Blockade of the renin-angiotensin system: better late than never

Chronic kidney disease management: comparison between renal transplant recipients and nontransplant patients with chronic kidney disease

BACKGROUND/AIM

Renal transplant recipients (RTR) and patients with native chronic kidney disease (CKD) have similar complications. It is not known how the management of CKD in RTR differs from that of patients with native CKD. This study compares the management of complications related to CKD between RTR and patients with native CKD.

METHODS

Cross-sectional study of all RTR with stage 4 or 5 CKD (n = 72). The control group consisted of 72 native CKD patients matched by glomerular filtration rate (within 2 ml/min/1.73 m(2)). Multivariate logistic regression analysis was performed to account for potential confounding variables.

RESULTS

Multivariate analysis revealed RTR to more likely have uncontrolled hypertension (adjusted odds ratio AOR 3.8; 95% confidence interval CI 1.3-10.7), less likely to be on angiotensin-converting enzyme inhibitors (AOR 0.11; 95% CI 0.04-0.32), more likely to be anemic and not be on erythropoietin (AOR 6.4; 95% CI 0.99-41.9), and more likely to have dyslipidemia and not be on statin (AOR 4.3; 95% CI 1.4-13.4).

CONCLUSIONS

This study suggests that the management of non-RTR in a multidisciplinary CKD clinic differs significantly from the CKD management in a traditional transplant clinic. A disease management approach like a multidisciplinary clinic may be an appropriate model for the future.

Patients With Biallelic Mutations in the Chloride Channel Gene CLCNKB: Long-Term Management and Outcome

BACKGROUND

Little information on the management and long-term follow-up of patients with biallelic mutations in the chloride channel gene CLCNKB is available.

METHODS

Long-term follow-up was evaluated from 5.0 to 24 years (median, 14 years) after diagnosis in 13 patients with homozygous (n = 10) or compound heterozygous (n = 3) mutations.

RESULTS

Medical treatment at last follow-up control included supplementation with potassium in 12 patients and sodium in 2 patients and medical treatment with indomethacin in 9 patients. At the end of follow-up, body height was 2.0 standard deviation score or less in 6 patients; 2 of these patients had growth hormone deficiency. Body weight (<or=2.0 standard deviation score in 6 patients) significantly increased (P < 0.05) at the end of follow-up in comparison to values at diagnosis. Nonpostural persistent proteinuria was present in 6 patients, and 4 patients had a glomerular filtration rate less than 75 mL/min/1.73 m(2) (<1.25 mL/s).

CONCLUSION

These data show that some patients with biallelic mutations in the chloride channel gene CLCNKB tend to present with pathological proteinuria and impaired kidney function after a median follow-up of 14 years, and growth retardation is common and sometimes related to growth hormone deficiency in these patients.

A randomized trial comparing losartan with amlodipine as initial therapy for hypertension in the early post-transplant period

BACKGROUND

Blockade of the renin-angiotensin-aldosterone system in the early post-transplant period remains controversial. Angiotensin II-receptor blockers (ARB) have many benefits to the patient with chronic kidney disease and these benefits may also apply to the renal transplant recipient (RTR). Additionally, there are theoretical benefits of ARB use in RTR. This study was designed to investigate the safety of early ARB use after renal transplantation.

METHODS

RTR with serum creatinine levels <3.0 mg/dl were randomized to receive either ARB (n = 29) or calcium-channel blocker (CCB; n = 27) as initial therapy for post-transplant hypertension. Differences in potassium, creatinine and haemoglobin concentrations were compared at baseline, 3, 6 and 12 months after transplantation.

RESULTS

Withdrawal from the assigned treatment was high: 12 in the ARB group (due to hyperkalaemia in six) and 17 in the CCB group (due to intractable oedema in seven and post-transplant erythrocytosis requiring an angiotensin-converting enzyme inhibitor in seven). There were no differences in blood pressure, haemoglobin or creatinine concentration at any time-points. Mean potassium concentrations were only slightly higher in the ARB vs CCB group (range: 4.2-4.3 vs 3.7-3.8 mEq/l, respectively, but clinically significant) and the number of patients with potassium values >6.0 mEq/l was higher in ARB (n = 7) vs CCB (n = 1).

CONCLUSIONS

These data suggest that hyperkalaemia is the major complication that occurs with the use of ARB in the immediate post-transplant period. ARB use does not affect renal function or complicate the post-transplant management of RTR. Other than reducing the incidence of post-transplant erythrocytosis, ARB use does not cause an excess incidence of anaemia. Strategies to reduce the risk of hyperkalaemia may allow increased use of ARB immediately after kidney transplantation.