The kidney plays a central role in the regulation of arterial blood pressure. A large body of experimental and physiological evidence indicates that renal control of extracellular volume and renal ...perfusion pressure are closely involved in maintaining the arterial circulation and blood pressure. Renal artery perfusion pressure directly regulates sodium excretion-a process known as pressure natriuresis-and influences the activity of various vasoactive systems such as the renin-angiotensin-aldosterone system. As a result, many researchers argue that identifying any marked rise in blood pressure requires resetting of the relationship between arterial blood pressure and urinary sodium excretion, which can occur by an array of systemic or local mechanisms. Almost all of the monogenic forms of hypertension affect sites in the kidney associated with sodium handling and transport. Experimental models of spontaneous hypertension, such as the Dahl salt-sensitive rat, have been used to study the effects of kidney transplantation on blood pressure. Results from studies of kidney transplantation indicate that pressure sensitivity to sodium intake 'follows' the kidney, meaning that the recipient of a 'salt-resistant kidney' acquires sodium resistance, and that the recipient of a 'salt-sensitive kidney' acquires pressure sensitivity. The examples above and discussed in this Review demonstrate that it should come as no surprise that most disorders that affect the kidney or the renal vasculature commonly lead to secondary forms of hypertension.
The number of kidney after liver transplants (KALT) increased after the implementation of the United Network of Organ Sharing (UNOS) safety net policy, but the effects of the policy on KALT outcomes ...remain unknown. Using the UNOS database, we identified KALT between 60 and 365 days from liver transplant from January 1, 2010, to December 31, 2020. The main outcome was 1- and 3-year patient, liver, and kidney graft survival. Secondary outcomes included 6-month and 1-year acute rejection (AR) of liver and kidney, and 1-year kidney allograft function. Of the 256 KALT, 90 were pre-policy and 166 post-policy. Compared to pre-policy, post-policy 1- and 3-year liver graft survival was higher (54% and 54% vs. 86% and 81%, respectively, p <0.001), while 1- and 3-year kidney graft survival (99% and 75% vs. 92% and 79%, respectively, p =0.19), and 1- and 3-year patient survival (99% and 99% vs. 95% and 89%, respectively, p =0.11) were not significantly different. Subgroup analysis revealed similar trends in patients with and without renal failure at liver transplant. Liver AR at 6 months was lower post-policy (6.3% vs. 18.3%, p =0.006) but was similar (10.5% vs. 13%, p =0.63) at 1 year. Kidney AR was unchanged post-policy at 6 months and 1 year. Creatinine at 1 year did not differ post-policy versus pre-policy (1.4 vs. 1.3 mg/dL, p =0.07) despite a higher proportion of deceased donors, higher Kidney Donor Profile Index, and longer kidney cold ischemia time post-policy ( p <0.05 for all). This 3-year follow-up after the 2017 UNOS policy revision demonstrated that the safety net implementation has resulted in improved liver outcomes for patients who underwent KALT with no increased AR of the liver or the kidney allografts.
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Pre-orthotopic heart (OHT) serum creatinine correlates with post-OHT outcomes, but there is limited information on the relationship between pre-OHT estimated glomerular filtration rate (eGFR) and ...adjusted short- and long-term survival and renal outcomes post-OHT.
Using the United Network of Organ Sharing (UNOS) database we estimated pre-OHT eGFR using the Modification of Diet in Renal Disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations in patients aged ≥18 years who underwent OHT between 1988 and 2013. Patients were stratified into 5 eGFR categories (≥90, 60 to 89, 45 to 59, 30 to 44 and <30 ml/min/1.73 m
) using each equation. The primary outcome was to determine whether pre-OHT eGFR independently predicted post-OHT mortality.
A total of 30,090 patients were included in the study; of these, 46.1% and 39.9% had an eGFR <60 ml/min/1.73 m
by MDRD and CKD-EPI, respectively. Compared with eGFR ≥90 ml/min/1.73 m
, the adjusted hazard ratio of mortality was 1.09 (95% confidence interval CI 1.02 to 1.26) for eGFR 45 to 59 ml/min/1.73 m
, 1.22 (95% CI -1.23 to 1.31) for eGFR 30 to 44 ml/min/1.73 m
and 1.55 (95% CI 1.41 to 1.70) for eGFR <30 ml/min/1.73 m
by MDRD. There was no advantage for CKD-EPI over MDRD in determining post-OHT mortality. Pre-OHT eGFR by either equation was predictive of post-OHT end-stage renal disease (ESRD) and the need for kidney transplantation, with the highest risk in those with pre-OHT eGFR <30 ml/min/1.73 m
by either equation.
Pre-OHT eGFR was independently associated with mortality, ESRD and kidney transplantation after OHT. There was no advantage of CKD-EPI over MDRD in determining post-OHT mortality or renal outcomes.
Monkeypox is a rapidly spreading infection worldwide and is a public health concern, especially with newly reported fatality cases. The characteristics and disease course of monkeypox infection in ...transplant recipients remain elusive because no case reports have been published detailing its clinical presentation and outcome in this population. We report a case of a kidney transplant recipient who developed end-stage renal disease secondary to HIV-associated nephropathy and manifested monkeypox infection after kidney transplantation. The patient had severe clinical manifestations, including disseminated vesicular skin rash, diffuse mucosal involvement, urine retention, proctitis, and bowel obstruction. We also highlight several clinical considerations regarding the use of tecovirimat, a novel antiviral therapy with activity against orthopoxviruses that has been used in the United States to treat monkeypox infection.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
Simultaneous liver kidney (SLK) transplant protects against acute cellular rejection. In 2017, UNOS implemented a “safety net” policy to allow patients with renal recovery to avoid renal ...transplantation. Whether kidney after liver transplantation (KALT) increases the risk of rejection is unknown.
Methods
We performed a retrospective analysis of the Organ Procurement and Transplantation Network (OPTN) database of adult patients who received liver transplant, SLK or KALT between 2010 and 2020. We examined rejection of the liver within 6 months and 1 year of the liver transplant, as well as rejection of the kidney within 6 months and 1 year of receiving the kidney, as well as patient and graft loss.
Results
Sixty‐six thousand seventy‐nine patients were transplanted; 60 168 with liver transplant alone, 5627 with SLK, and 284 with KALT. Acute or chronic liver rejection rates within 6 or 12 months were statistically higher in the KALT group (10.0% and 10.9%) compared to the SLK group (6.1% and 7.5%), but comparable to the LTA group (9.3% and 11.1%). Kidney rejection and graft survival rates were not different. Liver graft survival was worse in KALT than SLK or LTA (Kaplan‐Meier estimates .61 vs. .89 and .90), but these patients were more ill at the time of transplantation. KDPI and LDRI scores were notably lower in the SLK than KALT group. Patient survival was not clinically different between the groups.
Conclusion
KALT does not increase the risk of acute or chronic kidney rejection. SLK has a lower risk of early liver rejection, but this effect diminishes by one year to being not clinically different compared to KALT. Given that KALT is immunologically safe, and potentially avoids unnecessary renal graft use, it should be preferred over SLK.
Brief summary
Patients undergoing sequential kidney after liver transplant do not have an increased risk of liver or kidney rejection when compared to liver transplant alone or simultaneous liver and kidney transplant.
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Acute kidney injury (AKI) in the setting of cirrhosis (hepatorenal syndrome HRS–AKI) is a severe and often fatal complication of end‐stage liver disease. The goals of treatment are to reverse renal ...failure and prolong survival in patients who are critically ill. However, interventions have limited efficacy, and mortality rates remain high. In the United States, the mainstay of pharmacologic therapy consists of the off‐label use of vasoconstrictive agents in combination with plasma expanders, a strategy that produces modest effects. Liver transplantation is the ultimate solution but is only an option in a minority of patients because contraindications to transplantation are common and organ availability is limited. Renal replacement therapy is a temporary option but is known to confer an extremely poor short‐term prognosis in patients with HRS‐AKI and at best serves as a bridge to liver transplantation for the minority of patients who are transplantation candidates. The high mortality rate associated with HRS‐AKI in the United States is a reflection of the suboptimal standard of care. Improved therapeutic options to treat HRS‐AKI are sought. Terlipressin is a drug approved in Europe for treatment of HRS‐AKI and supported by recommendations for first‐line therapy by some liver societies and experts around the world. This review article will discuss the substantial unmet medical need associated with HRS‐AKI and the potential benefits if terlipressin was approved in the United States.
https://wileyhealth.myabsorb.com/onlineCourses/e2064352-f2f6-4a2e-9cd5-88839e562b84
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