1
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Carvalho JP, Marques A, Abreu F, Pintão S. Comparison of GFR measurement with a two-blood sample technique using [99mTc]Tc-DTPA vs. creatinine-based equations in potential kidney donors. J Bras Nefrol 2023; 45:344-349. [PMID: 36445202 PMCID: PMC10697154 DOI: 10.1590/2175-8239-jbn-2022-0105en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/28/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Accurate determination of glomerular filtration rate (GFR) is crucial for selection of kidney donors. Nuclear medicine methods are considered accurate in measuring GFR but are not always easily available. The four-variable Modification of Diet in Renal Disease (MDRD4), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), and Full Age Spectrum (FAS) formulas are common equations for estimating GFR and are recommended for initial assessment of kidney donors. The aim of this study was to evaluate the performance of these GFR estimation equations compared with technetium-99m diethylenetriaminepentaacetic acid ([99mTc]Tc-DTPA) clearance. METHODS We compared GFR estimation by [99mTc]Tc-DTPA clearance using a two-blood sample method with estimation by MDRD4, CKD-EPI, and FAS creatinine-based equations in a population of healthy potential kidney donors. RESULTS A total of 195 potential kidney donors (68.2% female; mean age 49 years, range 21-75 years) were included in this study. Mean [99mTc]Tc-DTPA measured GFR (mGFR) was 101.5 ± 19.1 mL/min/1.73 m2. All three equations underestimated the GFR value measured by [99mTc]Tc-DTPA (MDRD4: -11.5 ± 18.8 mL/min/1.73 m2; CKD-EPI: -5.0 ± 17.4 mL/min/1.73 m2; FAS: -8.3 ± 17.4 mL/min/1.73 m2). Accuracy within 30% and 10% of the measured GFR value was highest for CKD-EPI. CONCLUSION The CKD-EPI equation showed better performance in estimating GFR in healthy potential kidney donors, proving to be a more accurate tool in the initial assessment of kidney donors. However, creatinine-based equations tended to underestimate kidney function. Therefore, GFR should be confirmed by another method in potential kidney donors.
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Affiliation(s)
- José Pedro Carvalho
- Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz,
Serviço de Medicina Nuclear, Carnaxide, Lisboa, Portugal
| | - Andreia Marques
- Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz,
Serviço de Medicina Nuclear, Carnaxide, Lisboa, Portugal
| | - Fernando Abreu
- Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz,
Serviço de Medicina Nuclear, Carnaxide, Lisboa, Portugal
| | - Sophia Pintão
- Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz,
Serviço de Medicina Nuclear, Carnaxide, Lisboa, Portugal
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2
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McArdle Z, Singh R, Bielefeldt-Ohmann H, Moritz K, Denton K, Schreuder M. Beneficial effects of brief early life angiotensin-converting enzyme inhibition wane with time in sheep with solitary functioning kidney. Clin Sci (Lond) 2023; 137:603-615. [PMID: 37018071 PMCID: PMC10116343 DOI: 10.1042/cs20220811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/26/2023] [Accepted: 04/05/2023] [Indexed: 04/23/2023]
Abstract
A child with a congenital solitary functioning kidney (SFK) may develop kidney disease from early in life due to hyperfiltration injury. Previously, we showed in a sheep model of SFK that brief angiotensin-converting enzyme inhibition (ACEi) early in life is reno-protective and increases renal functional reserve (RFR) at 8 months of age. Here we investigated the long-term effects of brief early ACEi in SFK sheep out to 20 months of age. At 100 days gestation (term = 150 days) SFK was induced by fetal unilateral nephrectomy, or sham surgery was performed (controls). SFK lambs received enalapril (SFK+ACEi; 0.5 mg/kg, once daily, orally) or vehicle (SFK) from 4 to 8 weeks of age. At 8, 14 and 20 months of age urinary albumin excretion was measured. At 20 months of age, we examined basal kidney function and RFR via infusion of combined amino acid and dopamine (AA+D). SFK+ACEi resulted in lower albuminuria (∼40%) at 8 months, but not at 14 or 20 months of age compared with vehicle-SFK. At 20 months, basal GFR (∼13%) was lower in SFK+ACEi compared with SFK, but renal blood flow (RBF), renal vascular resistance (RVR) and filtration fraction were similar to SFK. During AA+D, the increase in GFR was similar in SFK+ACEi and SFK animals, but the increase in RBF was greater (∼46%) in SFK+ACEi than SFK animals. Brief ACEi in SFK delayed kidney disease in the short-term but these effects were not sustained long-term.
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Affiliation(s)
- Zoe McArdle
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Reetu R. Singh
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Helle Bielefeldt-Ohmann
- School of Chemistry & Molecular Biosciences, The University of Queensland, St Lucia, Queensland, Australia
| | - Karen M. Moritz
- Child Health Research Centre and School of Biomedical Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Kate M. Denton
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
- Correspondence: Kate M. Denton ()
| | - Michiel F. Schreuder
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
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Prediction of Renal Function in Living Kidney Donors and Recipients of Living Donor Kidneys Using Quantitative Histology. Transplantation 2023; 107:264-273. [PMID: 35883240 DOI: 10.1097/tp.0000000000004266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Living kidney donors (LKDs) are at increased risk of chronic kidney disease, whereas transplant recipients experience progressive reduction of graft function. We examined the predictive value of quantitative stereology on renal function in LKDs and recipients of living donor kidneys, based on perioperative biopsies from the donated kidney. METHODS Cortex volume of both donor kidneys was determined by contrast-enhanced computed tomography and single-kidney glomerular filtration rate (GFR) by 51 chrome-EDTA clearance together with renography. Glomerular density was used to estimate total glomeruli number in addition to glomerular volume, glomerular sclerosis, kidney fibrosis, and arteriole dimensions. GFR measurements were repeated 1 y after transplantation in both LKDs and recipients. Associations between GFR at follow-up and cortex volume and histomorphometric parameters after adjustment of age, gender, body mass index, smoking status, 24-h blood pressure, and single-kidney GFR were examined. RESULTS We included 49 LKDs (age, 51 ± 12 y) and 51 recipients (age, 44 ± 13 y). At follow-up, GFR was 71 ± 16 mL/min in LKDs and 61 ± 18 mL/min in recipients with hyperfiltration being more prominent in LKDs (30.4%) as compared to recipients (16.4%; P < 0.05). One-year GFR in donors correlated to cortex volume ( P < 0.001) but not to any histological parameters, whereas GFR in recipients correlated to the amount of interstitial fibrosis ( P < 0.01) but not to other histological parameters or cortex volume. CONCLUSIONS Kidney cortex volume, but not renal histology parameters, predicts 1-y renal outcome in LKDs. In contrast, the amount of interstitial fibrosis, but not cortex volume, predicts 1-y graft function in recipients.
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Carvalho JP, Marques A, Abreu F, Pintão S. Comparação da medição da TFG com uma técnica com duas amostras de sangue usando [99mTc]Tc-DTPA vs. equações baseadas em creatinina em potenciais doadores de rim. J Bras Nefrol 2022. [DOI: 10.1590/2175-8239-jbn-2022-0105pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RESUMO Introdução: Determinar precisamente a taxa de filtração glomerular (TFG) é crucial para seleção de doadores de rim. Métodos de medicina nuclear são considerados precisos na medição da TFG, mas nem sempre estão facilmente disponíveis. As fórmulas Modification of Diet in Renal Disease de 4 variáveis (MDRD4), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), e Full Age Spectrum (FAS) são equações comuns para estimar a TFG, sendo recomendadas para avaliação inicial dos doadores. Este estudo visou avaliar o desempenho destas equações de estimativa da TFG em comparação com o clearance do tecnécio-99m-ácido dietilenotriaminopentacético ([99mTc]Tc-DTPA). Métodos: Comparamos a TFG por clearance de [99mTc]Tc-DTPA usando um método com duas amostras de sangue com estimativa da TFG pelas equações MDRD4, CKD-EPI e FAS baseadas em creatinina em uma população de potenciais doadores saudáveis. Resultados: Incluiu-se 195 potenciais doadores de rim (68,2% mulheres; idade média de 49 anos, intervalo 21–75 anos). A TFG média medida por [99mTc]Tc-DTPA foi 101,5 ± 19,1 mL/min/1,73m2. As três equações subestimaram o valor da TFG medida por [99mTc]Tc-DTPA (MDRD4: –11,5 ± 18,8 mL/min/1,73 m2; CKD-EPI: –5,0 ± 17,4 mL/min/1,73 m2; FAS: –8,3 ± 17,4 mL/min/1,73 m2). A precisão dentro de 30% e 10% do valor da TFG medida foi maior para CKD-EPI. Conclusão: A equação CKD-EPI mostrou melhor desempenho na estimativa da TFG em potenciais doadores de rim saudáveis, revelando-se uma ferramenta mais precisa na avaliação inicial dos doadores. Entretanto, equações baseadas em creatinina tendem a subestimar a função renal. Portanto, a TFG deve ser confirmada por outro método em potenciais doadores.
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Larsen T, See EJ, Holmes N, Bellomo R. Estimating baseline kidney function in hospitalised adults with acute kidney injury. Nephrology (Carlton) 2022; 27:588-600. [PMID: 35471640 PMCID: PMC9325517 DOI: 10.1111/nep.14047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 11/26/2022]
Abstract
AIM Baseline serum creatinine values are required to diagnose acute kidney injury but are often unavailable. We evaluated four conventional equations to estimate creatinine. We then developed and validated a new equation corrected by age and gender. METHODS We retrospectively examined adults who, at first hospital admission, had available baseline creatinine data and developed acute kidney injury ≥ 24 hours after admission. We split the study population: 50% (derivation) to develop a new linear equation and 50% (validation) to compare against conventional equations for bias, precision, and accuracy. We stratified analyses by age and gender. RESULTS We studied 3,139 hospitalised adults (58% male, median age 71). Conventional equations performed poorly in bias and accuracy in patients aged < 60 or ≥ 75 (68% of the study population). The new linear equation had less bias and more accuracy. There were no clinically significant differences in precision. The median (95% confidence interval) difference in creatinine values estimated via the new equation minus measured baselines was 0.9 (-3.0, 5.9) and -0.5 (-7.0, 3.7) μmol/L in female patients 18-60 and 75-100, and -1.5 (-4.2, 2.2) and -7.8 (-12.7, -3.6) μmol/L in male patients 18-60 and 75-100 respectively. The new equation improved reclassification of KDIGO AKI stages compared to the MDRD II equation by 5.0%. CONCLUSION Equations adjusted for age and gender are less biased and more accurate than unadjusted equations. Our new equation performed well in terms of bias, precision, accuracy, and reclassification.
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Affiliation(s)
- Thomas Larsen
- Data Analytics Research Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Heidelberg, Australia.,Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Emily J See
- Department of Critical Care, University of Melbourne, Melbourne, Australia.,Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Department of Nephrology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Nephrology, Royal Children's Hospital, Melbourne, Australia
| | - Natasha Holmes
- Data Analytics Research Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Heidelberg, Australia.,Department of Infectious Diseases, Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- Data Analytics Research Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Heidelberg, Australia.,Department of Critical Care, University of Melbourne, Melbourne, Australia.,Department of Intensive Care, Austin Hospital, Heidelberg, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Parkville, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
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6
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McArdle Z, Singh R, Bielefeldt-Ohmann H, Moritz K, Schreuder M, Denton K. Brief Early Life Angiotensin Converting Enzyme Inhibition Offers Reno-Protection in Sheep with a Solitary Functioning Kidney at 8 Months of Age. J Am Soc Nephrol 2022; 33:1341-1356. [PMID: 35351818 PMCID: PMC9257814 DOI: 10.1681/asn.2021111534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/18/2022] [Indexed: 11/03/2022] Open
Abstract
Background: Children born with a solitary functioning kidney (SFK) are predisposed to develop hypertension and kidney injury. Glomerular hyperfiltration and hypertrophy contribute to the pathophysiology of kidney injury. Angiotensin converting enzyme inhibitors (ACEi) can mitigate hyperfiltration and may be therapeutically beneficial in reducing progression of kidney injury in SFK. Methods: SFK was induced in male sheep fetuses at 100 days gestation (term=150 day). Between 4-8 weeks of age, SFK lambs received enalapril (SFK+ACEi; 0.5mg/kg/day, once daily, orally) or vehicle (SFK). At 8 months we examined whether SFK+ACEi reduced elevation in blood pressure (BP) and improved basal kidney function, renal functional reserve (RFR; glomerular filtration rate (GFR) response to combined amino acid and dopamine infusion), GFR response to nitric oxide synthase (NOS) inhibition and basal nitric oxide (NO) bioavailability (basal urinary total nitrate+nitrite (NOx)). Results: SFK+ACEi prevented albuminuria, resulted in lower basal GFR (16%), higher renal blood flow (~22%), and lower filtration fraction ( 35%), but similar BP compared to ~ vehicle-treated SFK sheep. Together with greater recruitment of RFR (~14%) in SFK+ACEi animals than SFK, this indicates reduction in glomerular hyperfiltration-mediated kidney dysfunction. During NOS inhibition, the decrease in GFR ( 14%) was greater among SFK+ACEi than among SFK animals. Increased ( 85%) basal urinary total NOx in SFK+ACEi animals compared to SFK indicates elevated NO bioavailability likely contributing to improvements in kidney function and prevention of albuminuria. Conclusions: Brief and early ACEi in SFK is associated with reduced glomerular hyperfiltration-mediated kidney disease up to 8 months of age in a sheep model.
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Affiliation(s)
- Zoe McArdle
- Z McArdle, Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Clayton, Australia
| | - Reetu Singh
- R Singh, Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Clayton, Australia
| | - Helle Bielefeldt-Ohmann
- H Bielefeldt-Ohmann, School of Veterinary Science, The University of Queensland, Gatton, Australia
| | - Karen Moritz
- K Moritz, Child Health Research Centre and School of Biomedical Sciences, The University of Queensland, Saint Lucia, Australia
| | - Michiel Schreuder
- M Schreuder, Department of Pediatric Nephrology , Amalia Children's Hospital, Nijmegen, Netherlands
| | - Kate Denton
- K Denton, Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Clayton, Australia
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7
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Bleyer AJ. Factors that lead to dialysis as the preferred treatment modality for patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2022; 31:180-184. [PMID: 34954719 DOI: 10.1097/mnh.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe forces that lead to dialysis as the preferred treatment modality for patients with chronic kidney disease. RECENT FINDINGS Although chronic dialysis is life-saving and the only option available for many individuals, treatment of the underlying causes of kidney disease and transplantation may be preferable options for many patients. Factors that favor dialysis instead of treatment of underlying kidney disease or transplantation include lack of proper diagnosis, lack of proper treatment of underlying kidney disease, poor compliance, lack of consideration for transplantation, early initiation of dialysis therapy, and financial incentives. New developments that may reverse this trend include genetic panels that improve diagnosis of kidney disease, new methods of transplantation, and legislation that will encourage kidney transplantation. SUMMARY By recognizing factors that favor dialysis over other therapies, nephrologists may be better able to provide care to their patients and prevent dialysis, researchers may be able to focus on research that will prevent the need for dialysis, and professional societies may work to prevent unneeded dialysis.
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Affiliation(s)
- Anthony J Bleyer
- Section on Nephrology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, North Carolina, USA
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8
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Abstract
An exploration of the normal limits of physiologic responses and how these responses are lost when the kidney is injured rarely occurs in clinical practice. However, the differences between "resting" and "stressed" responses identify an adaptive reactiveness that is diminished before baseline function is impaired. This functional reserve is important in the evaluation of prognosis and progression of kidney disease. Here, we discuss stress tests that examine protein-induced hyperfiltration, proximal tubular secretion, urea-selective concentration defects, and acid retention. We discuss diseases in which these tests have been used to diagnose subclinical injury. The study and follow-up of abnormal functional reserve may add considerable understanding to the natural history of CKD.
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Affiliation(s)
- Armando Armenta
- Department of Nephrology, National Institute of Cardiology “Ignacio Chavez,” Mexico City, Mexico
| | - Magdalena Madero
- Department of Nephrology, National Institute of Cardiology “Ignacio Chavez,” Mexico City, Mexico
| | - Bernardo Rodriguez-Iturbe
- Department of Nephrology, National Institute of Cardiology "Ignacio Chavez," Mexico City, Mexico .,Department of Nephrology and Mineral Metabolism, National Institute of Health Sciences and Nutrition "Salvador Zubirán," Mexico City, Mexico
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9
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van der Weijden J, Mahesh SV, van Londen M, Bakker SJ, Sanders JS, Navis G, Pol RA, Roodnat JI, Kho MM, Yakar D, Kwee TC, Nolte IM, Berger SP, De Borst MH. Early increase in single-kidney glomerular filtration rate after living kidney donation predicts long-term kidney function. Kidney Int 2022; 101:1251-1259. [DOI: 10.1016/j.kint.2022.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/30/2021] [Accepted: 01/11/2022] [Indexed: 10/19/2022]
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10
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Nephron overload as a therapeutic target to maximize kidney lifespan. Nat Rev Nephrol 2021; 18:171-183. [PMID: 34880459 DOI: 10.1038/s41581-021-00510-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2021] [Indexed: 12/27/2022]
Abstract
Kidney lifespan is a patient-oriented outcome that provides much needed context for understanding chronic kidney disease (CKD). Nephron endowment, age-associated decline in nephron number, kidney injury history and the intrinsic capacity of nephrons to adapt to haemodynamic and metabolic overload vary widely within the population. Defining percentiles of kidney function might therefore help to predict individual kidney lifespan and distinguish healthy ageing from progressive forms of CKD. In response to nephron loss, the remaining nephrons undergo functional and structural adaptations to meet the ongoing haemodynamic and metabolic demands of the organism. When these changes are no longer sufficient to maintain kidney cell homeostasis, remnant nephron demise occurs and CKD progression ensues. An individual's trajectory of glomerular filtration rate and albuminuria reflects the extent of nephron loss and adaptation of the remaining nephrons. Nephron overload represents the final common pathway of CKD progression and is largely independent of upstream disease mechanisms. Thus, interventions that efficiently attenuate nephron overload in early disease stages can protect remnant kidney cells and nephrons, and delay CKD progression. This Review provides a conceptual framework for individualized diagnosis, monitoring and treatment of CKD with the goal of maximizing kidney lifespan.
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11
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Montgomery JR, Brown CS, Zondlak AN, Walsh KW, Kozlowski JE, Pinsky AM, Herriman EA, Sussman J, Lu Y, Stein EB, Shankar PR, Sung RS, Woodside KJ. CT-measured Cortical Volume Ratio Is an Accurate Alternative to Nuclear Medicine Split Scan Ratio Among Living Kidney Donors. Transplantation 2021; 105:2596-2605. [PMID: 33950636 DOI: 10.1097/tp.0000000000003676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The 125I-iothalamate clearance and 99mTc diethylenetriamine-pentaacetic acid (99mTc-DTPA) split scan nuclear medicine studies are used among living kidney donor candidates to determine measured glomerular filtration rate (mGFR) and split scan ratio (SSR). The computerized tomography-derived cortical volume ratio (CVR) is a novel measurement of split kidney function and can be combined with predonation estimated GFR (eGFR) or mGFR to predict postdonation kidney function. Whether predonation SSR predicts postdonation kidney function better than predonation CVR and whether predonation mGFR provides additional information beyond predonation eGFR are unknown. METHODS We performed a single-center retrospective analysis of 204 patients who underwent kidney donation between June 2015 and March 2019. The primary outcome was 1-y postdonation eGFR. Model bases were created from a measure of predonation kidney function (mGFR or eGFR) multiplied by the proportion that each nondonated kidney contributed to predonation kidney function (SSR or CVR). Multivariable elastic net regression with 1000 repetitions was used to determine the mean and 95% confidence interval of R2, root mean square error (RMSE), and proportion overprediction ≥15 mL/min/1.73 m2 between models. RESULTS In validation cohorts, eGFR-CVR models performed best (R2, 0.547; RMSE, 9.2 mL/min/1.73 m2, proportion overprediction 3.1%), whereas mGFR-SSR models performed worst (R2, 0.360; RMSE, 10.9 mL/min/1.73 m2, proportion overprediction 7.2%) (P < 0.001 for all comparisons). CONCLUSIONS These findings suggest that predonation CVR may serve as an acceptable alternative to SSR during donor evaluation and furthermore, that a model based on CVR and predonation eGFR may be superior to other methods.
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Affiliation(s)
- John R Montgomery
- Department of Surgery, Section of Transplant Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI
| | - Craig S Brown
- Department of Surgery, Section of Transplant Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI
| | | | - Kevin W Walsh
- Medical School, University of Michigan, Ann Arbor, MI
| | | | | | - Emily A Herriman
- Department of Surgery, Section of Transplant Surgery, University of Michigan, Ann Arbor, MI
| | - Jeremy Sussman
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Yee Lu
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Erica B Stein
- Division of Abdominal Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI
| | - Prasad R Shankar
- Division of Abdominal Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI
- Michigan Radiology Quality Collaborative, University of Michigan, Ann Arbor, MI
| | - Randall S Sung
- Department of Surgery, Section of Transplant Surgery, University of Michigan, Ann Arbor, MI
| | - Kenneth J Woodside
- Department of Surgery, Section of Transplant Surgery, University of Michigan, Ann Arbor, MI
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12
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Azawi N, Jensen M, Jensen BL, Goetze JP, Bistrup C, Lund L. Functional adaptation after kidney tissue removal in patients is associated with increased plasma atrial natriuretic peptide concentration. Nephrol Dial Transplant 2021; 37:2138-2149. [PMID: 34792174 DOI: 10.1093/ndt/gfab327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Following nephrectomy, the remaining kidney tissue adapts by an increase in GFR. In rats, hyperfiltration can be transferred by plasma. We examined whether natriuretic peptides (ANP, BNP) increase in plasma proportionally with kidney mass reduction and, if so, whether the increase relates to an increase in GFR. METHODS Patients (n = 54) undergoing partial or total unilateral nephrectomy at two Danish centers were followed for one year in an observational study. Glomerular filtration rate was measured before, 3, and 12 months after surgery. Natriuretic propeptides (proANP and proBNP) and aldosterone were measured in plasma before and at 24 hours, five days, 21 days, three months, and 12 months. Cyclic GMP was determined in urine. RESULTS There was no baseline difference in GFR between total- and partial nephrectomy (90.1 mL/min ±14.6 vs. 82.9±18, p = 0.16). Single-kidney GFR increased after 3 and 12 months (12.0 and 11.9 ml/min/1.73m2, +23.3%). There was no change in measured GFR 3 and 12 months after partial nephrectomy. ProANP and proBNP increased 3-fold 24h after surgery and returned to baseline after five days. The magnitude of acute proANP and proBNP increases did not relate to kidney mass removed. ProANP, not proBNP, increased 12 months after nephrectomy. Plasma aldosterone and urine cGMP did not change. Urine albumin/creatine ratio increased transiently after partial nephrectomy. Blood pressure was similar between groups. CONCLUSION ANP and BNP increase acutely in plasma with no relation to degree of kidney tissue ablation. After 1year, only unilateral nephrectomy patients display increased plasma ANP which could support adaptation.
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Affiliation(s)
- Nessn Azawi
- Department of Urology, Zealand University Hospital, Roskilde, Denmark.,Institute of clinical medicine, Copenhagen University, Denmark
| | - Mia Jensen
- Cardiovascular and renal research, Institute of Molecular Medicine, University of Southern Denmark, Denmark
| | - Boye L Jensen
- Cardiovascular and renal research, Institute of Molecular Medicine, University of Southern Denmark, Denmark.,Department of Urology, Odense University Hospital, Odense, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Denmark
| | - Claus Bistrup
- Department of Nephrology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Denmark
| | - Lars Lund
- Department of Urology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Denmark
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13
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Arabi Z, Bukhari M, Hamad A, Altheaby A, Kaysi S. Practice Patterns in the Acceptance of Medically Complex Living Kidney Donors with Obesity, Hypertension, Family History of Kidney Disease, or Donor-Recipient Age Discrepancy. Avicenna J Med 2021; 11:172-184. [PMID: 34881200 PMCID: PMC8648409 DOI: 10.1055/s-0041-1736541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background To assess the practice patterns of the acceptance of medically complex living kidney donors (MCLKDs). Methods We distributed a survey to nephrologists and transplant surgeons (TS) across the world through major international transplant societies. The survey contained questions regarding obesity, abnormal blood glucose profile, mild hypertension, donor-recipient age discrepancy, or family history of kidney disease of unknown etiology. Results In total, 239 respondents from 29 countries (42% were nephrologists and 58% were TS). Most respondents would allow donations from obese donors, especially if they intended to lose weight but would be cautious if these donors had abnormal blood glucose or family history of diabetes mellitus. In hypertensive donors, future pregnancy plans mattered in decisions regarding the acceptance of female donors. Most respondents would allow young donors but would be more cautious if they had a future risk of hypertension or a family history of kidney disease of unknown etiology. They would also allow donations from an older person if prolonged waiting time was anticipated. We found multiple areas of consensus of practice among the diverse members of international transplant societies, with some interesting variations among nephrologists and TS. Conclusions This survey highlights the practice patterns of the acceptance of MCLKDs among the international community. In the absence of clear guidelines, this survey provides additional information to counsel kidney donors with these conditions.
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Affiliation(s)
- Ziad Arabi
- Department of the Organ Transplant Center, Division of Adult Transplant Nephrology, King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Muhammad Bukhari
- Department of Medicine, Division of Adult Nephrology, Taif University, Taif, Saudi Arabia
| | - Abdullah Hamad
- Department of Medicine, Division of Nephrology, Regional Medical Center of Orangeburg and Calhoun Counties, Orangeburg, South Carolina, United States
| | - Abdulrahman Altheaby
- Department of the Organ Transplant Center, Division of Adult Transplant Nephrology, King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Saleh Kaysi
- Department of Medicine, Division of Nephrology, CHU, Clermont-Ferrand, France
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14
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Brignone J, Assersen KB, Jensen M, Jensen BL, Kloster B, Jønler M, Lund L. Protection of kidney function and tissue integrity by pharmacologic use of natriuretic peptides and neprilysin inhibitors. Pflugers Arch 2021; 473:595-610. [PMID: 33844072 DOI: 10.1007/s00424-021-02555-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/03/2021] [Accepted: 03/06/2021] [Indexed: 12/11/2022]
Abstract
With variable potencies atrial-, brain-type and c-type natriuretic peptides (NP)s, best documented for ANP and its analogues, promote sodium and water excretion, renal blood flow, lipolysis, lower blood pressure, and suppress renin and aldosterone secretion through interaction predominantly with cGMP-coupled NPR-A receptor. Infusion of especially ANP and its analogues up to 50 ng/kg/min in patients with high risk of acute kidney injury (cardiac vascular bypass surgery, intraabdominal surgery, direct kidney surgery) protects kidney function (GFR, plasma flow, medullary flow, albuminuria, renal replacement therapy, tissue injury) at short term and also long term and likely additively with the diuretic furosemide. This documents a pharmacologic potential for the pathway. Neprilysin (NEP, neutral endopeptidase) degrades NPs, in particular ANP, and angiotensin II. The drug LCZ696, a mixture of the neprilysin inhibitor sacubitril and the ANGII-AT1 receptor blocker valsartan, was FDA approved in 2015 and marketed as Entresto®. In preclinical studies of kidney injury, LCZ696 and NPs lowered plasma creatinine, countered hypoxia and oxidative stress, suppressed proinflammatory cytokines, and inhibited fibrosis. Few randomized clinical studies exist and were designed with primary cardiac outcomes. The studies showed that LCZ696/entresto stabilized and improved glomerular filtration rate in patients with chronic kidney disease. LCZ696 is safe to use concerning kidney function and stabilizes or increases GFR. In perspective, combined AT1 and neprilysin inhibition is a promising approach for long-term renal protection in addition to AT1 receptor blockers in acute kidney injury and chronic kidney disease.
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Affiliation(s)
- Juan Brignone
- Department of Urology, Aalborg University Hospital, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Kasper Bostlund Assersen
- Department of Cardiovascular and Renal Research, University of Southern Denmark, Odense, Denmark
| | - Mia Jensen
- Department of Cardiovascular and Renal Research, University of Southern Denmark, Odense, Denmark
| | - Boye L Jensen
- Department of Cardiovascular and Renal Research, University of Southern Denmark, Odense, Denmark
| | - Brian Kloster
- Department of Urology, Aalborg University Hospital, Aalborg, Denmark
| | - Morten Jønler
- Department of Urology, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Lund
- Department of Urology, Aalborg University Hospital, Aalborg, Denmark.,Department of Urology, Odense University Hospital, Odense, Denmark
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15
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Funamoto M, Osho AA, Li SS, Moonsamy P, Mohan N, Ong CS, Melnitchouk S, Sundt TM, Astor TL, Villavicencio MA. Factors Related to Survival in Low-Glomerular Filtration Rate Cohorts Undergoing Lung Transplant. Ann Thorac Surg 2021; 112:1797-1804. [PMID: 33421391 DOI: 10.1016/j.athoracsur.2020.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 10/25/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Historically, a glomerular filtration rate (GFR) of less than 50 mL/min per 1.73 m2 has been considered a contraindication to lung transplantation. Combined or sequential lung-kidney transplantation is an option for those with a GFR less than 30 mL/min per 1.73 m2. Patients with a GFR of 30 to 50 mL/min per 1.73 m2 are provided with no options for transplantation. This study explores factors associated with improved survival in patients who undergo isolated lung transplantation with a GFR of 30 to 50 mL/min per 1.73 m2. METHODS The United Network for Organ Sharing database was queried for adult patients undergoing primary isolated lung transplantation between January 2007 and March 2018. Regression models were used to identify factors associated with improved survival in lung recipients with a preoperative GFR of 30 to 50 mL/min per 1.73 m2. The propensity score method was used to match highly performing patients (outpatient recipients aged less than 60 years) with a GFR of 30 to 50 mL/min per 1.73 m2 with patients who had a GFR greater than 50 mL/min per 1.73 m2. Kaplan-Meier, Cox, and logistic regression analyses compared outcomes in matched populations. RESULTS A total of 21,282 lung transplantations were performed during the study period. Compared with patients with a GFR greater than 50 mL/min per 1.73 m2, survival was significantly worse for patients with a GFR of 30 to 50 mL/min per 1.73 m2. Multivariate analysis of patients with a GFR of 30 to 50 mL/min per 1.73 m2 demonstrated outpatient status and age less than 60 years to be predictive of superior survival. After propensity matching, survival of this highly performing subset with a GFR of 30 to 50 mL/min per 1.73 m2 was no different from that of patients with a normal GFR. CONCLUSIONS Outpatient recipients aged less than 60 years represent an optimal subset of patients with a GFR of 30 to 50 mL/min per 1.73 m2. Lung transplant listing should not be declined based only on a GFR less than 50 mL/min per 1.73 m2.
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Affiliation(s)
- Masaki Funamoto
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | - Asishana A Osho
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Selena S Li
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Philicia Moonsamy
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Navyatha Mohan
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Chin Siang Ong
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Todd L Astor
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Mauricio A Villavicencio
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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16
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Bellomo R, Evans RG. Renal functional reserve: from physiological phenomenon to clinical biomarker and beyond. Am J Physiol Regul Integr Comp Physiol 2020; 319:R690-R702. [PMID: 33074016 DOI: 10.1152/ajpregu.00237.2020] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Glomerular filtration rate (GFR) is acutely increased following a high-protein meal or systemic infusion of amino acids. The mechanisms underlying this renal functional response remain to be fully elucidated. Nevertheless, they appear to culminate in preglomerular vasodilation. Inhibition of the tubuloglomerular feedback signal appears critical. However, nitric oxide, vasodilator prostaglandins, and glucagon also appear important. The increase in GFR during amino acid infusion reveals a "renal reserve," which can be utilized when the physiological demand for single nephron GFR increases. This has led to the concept that in subclinical renal disease, before basal GFR begins to reduce, renal functional reserve can be recruited in a manner that preserves renal function. The extension of this concept is that once a decline in basal GFR can be detected, renal disease is already well progressed. This concept likely applies both in the contexts of chronic kidney disease and acute kidney injury. Critically, its corollary is that deficits in renal functional reserve have the potential to provide early detection of renal dysfunction before basal GFR is reduced. There is growing evidence that the renal response to infusion of amino acids can be used to identify patients at risk of developing either chronic kidney disease or acute kidney injury and as a treatment target for acute kidney injury. However, large multicenter clinical trials are required to test these propositions. A renewed effort to understand the renal physiology underlying the response to amino acid infusion is also warranted.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
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