RESUMO
Acute kidney injury (AKI) and chronic kidney disease (CKD) are common in patients awaiting liver transplantation, and both have a marked impact on the perioperative and long-term morbidity and mortality of liver transplant recipients. Consequently, we reviewed the epidemiology of AKI and CKD in patients with end-stage liver disease, highlighted strategies to prevent and manage AKI, evaluated the changing liver transplant waiting list's impact on kidney function, delineated important considerations in simultaneous liver-kidney transplant selection, and projected possible future transplant policy changes and outcomes. This review was assembled by experts in the field and endorsed by the American Society of Transplantation Liver and Intestinal Community of Practice and Board of Directors and provides practice-based recommendations for preservation of kidney function in patients with end-stage liver disease.
Assuntos
Intestinos , Falência Renal Crônica/prevenção & controle , Transplante de Fígado/efeitos adversos , Guias de Prática Clínica como Assunto/normas , Humanos , Falência Renal Crônica/etiologia , Sociedades CientíficasRESUMO
Although previous consensus recommendations have helped define patients who would benefit from simultaneous liver-kidney transplantation (SLK), there is a current need to reassess published guidelines for SLK because of continuing increase in proportion of liver transplant candidates with renal dysfunction and ongoing donor organ shortage. The purpose of this consensus meeting was to critically evaluate published and registry data regarding patient and renal outcomes following liver transplantation alone or SLK in liver transplant recipients with renal dysfunction. Modifications to the current guidelines for SLK and a research agenda were proposed.
Assuntos
Transplante de Rim/métodos , Transplante de Fígado/métodos , Guias de Prática Clínica como Assunto , Obtenção de Tecidos e Órgãos , Consenso , Feminino , Seguimentos , Rejeição de Enxerto , Sobrevivência de Enxerto , Humanos , Transplante de Rim/efeitos adversos , Transplante de Rim/mortalidade , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Masculino , Medição de Risco , Análise de Sobrevida , Resultado do Tratamento , Estados UnidosRESUMO
Consensus recommendations have been published to help better define those patients who would benefit from simultaneous liver-kidney transplantation (SLK). We conducted a survey of transplant centers that perform SLK (n = 88, 65% response rate) to determine practice patterns in the United States. The majority of centers (73%) stated that they use dialysis duration whereas only 30% of centers use acute kidney injury duration as a criterion for determining need for SLK. Dialysis duration >4 weeks was used by 32% of centers, >6 weeks by 37% and >8 weeks by 32% of centers. Glomerular filtration rate (GFR) was estimated using the modified diet in renal disease (MDRD)-4 equation in roughly half of centers whereas the MDRD-6 equation was used by only 6%. In patients with chronic kidney disease, GFR < 40 mL/min was used by 24% of centers as a criterion for SLK transplants instead of the recommended threshold of < 30 mL/min. Regional differences in practices were also observed. This survey demonstrates significant variation in the criteria used for SLK among transplant centers, with few centers following the current published recommendations, and emphasizes the need for evidence-based guidelines and uniformity in studying renal dysfunction in liver transplant candidates.
Assuntos
Falência Renal Crônica/cirurgia , Transplante de Rim/estatística & dados numéricos , Falência Hepática/cirurgia , Transplante de Fígado/estatística & dados numéricos , Feminino , Rejeição de Enxerto , Sobrevivência de Enxerto , Pesquisas sobre Atenção à Saúde , Humanos , Incidência , Falência Renal Crônica/complicações , Falência Renal Crônica/diagnóstico , Testes de Função Renal , Transplante de Rim/métodos , Transplante de Rim/mortalidade , Falência Hepática/complicações , Falência Hepática/diagnóstico , Testes de Função Hepática , Transplante de Fígado/métodos , Transplante de Fígado/mortalidade , Masculino , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/tendências , Cuidados Pré-Operatórios/métodos , Medição de Risco , Inquéritos e Questionários , Taxa de Sobrevida , Resultado do Tratamento , Estados UnidosRESUMO
Fluids are the only known method of attenuating renal injury. Furthermore, whether for hydration, resuscitation or renal replacement therapy, fluid prescriptions must be tailored to the fluid and electrolyte, cardiovascular status and residual renal function of the patient. Different fluids have significantly different effects both on volume expansion as well as on the electrolyte and acid-base balance; while controversial, different fluids may even influence renal function differently. This systematic review focuses on fluids for prevention and management of acute kidney injury. We have reviewed the available evidence and have made recommendations for clinical practice and future studies.
Assuntos
Injúria Renal Aguda/terapia , Hidratação , Diálise Renal/métodos , Injúria Renal Aguda/prevenção & controle , Animais , Bicarbonatos/uso terapêutico , Coloides/uso terapêutico , Hemofiltração , Hemoglobinas/uso terapêutico , Humanos , Manitol/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Rabdomiólise , Solução Salina Hipertônica , Desequilíbrio Hidroeletrolítico/diagnóstico , Desequilíbrio Hidroeletrolítico/terapiaRESUMO
Injury mechanisms activated by the hemodynamic adaptations to nephron loss are considered to represent a final common pathway that underlies the progressive nature of chronic renal disease. In this article, we review experimental evidence that the induction of cell adhesion molecule, cytokine and profibrotic growth factor gene expression and the resultant renal infiltration by inflammatory cells, especially macrophages, are important components of these common pathway mechanisms. Interventions aimed at inhibiting these mechanisms may offer new treatments for slowing or arresting the progression of chronic renal disease.
Assuntos
Hemodinâmica , Nefropatias/fisiopatologia , Animais , Moléculas de Adesão Celular/fisiologia , Doença Crônica , Citocinas/fisiologia , Progressão da Doença , Substâncias de Crescimento/fisiologia , Humanos , Nefropatias/terapiaRESUMO
Pharmacologic interruption of the renin-angiotensin system (RAS) with angiotensin-converting enzyme inhibitors (ACEI) is considered a standard therapeutic intervention for patients with chronic renal disease, regardless of whether systemic hypertension is present. The advent of orally active angiotensin receptor blockers (ARB) increases the number of therapeutic options for inhibiting the RAS in patients with chronic renal diseases. Clinical studies of ARB that can be compared with large-scale ACEI clinical trials have yet to be completed. More than a dozen experimental studies comparing ARB with ACEI suggest that the two classes of drugs share similar renoprotective properties. Like ACEI, ARB are effective antihypertensive and antiproteinuric agents, which greatly reduce glomerular and tubulointerstitial scarring. Although both reduce stimulation of the AT1 receptor, ARB lack the kinin-potentiating effects of ACEI. ARB may exert antifibrotic actions via the AT2 receptor, through increased levels of angiotensin II resulting from AT1 receptor blockade. Despite these pharmacologic distinctions, recent studies have not detected differences in renoprotection between ARB and ACEI. In the context of RAS inhibition, the magnitude of antihypertensive and antiproteinuric effects achieved appears to be the major determinant of renoprotection, not the class of drug used. Thus, experimental data suggest that ARB will fulfill their promise as effective agents to be used as mainstays in multifaceted clinical strategies designed to slow or arrest the progression of chronic renal disease. Confirmation of this view awaits the results of clinical trials.