Simultaneous liver-kidney versus liver transplantation alone in patients with end-stage liver disease and kidney dysfunction not on dialysis.

BACKGROUND: Since implementation of the Model for End-stage Liver Disease (MELD), the number of simultaneous liver-kidney transplantations (SLKT) has increased in the United States. However, predictors and survival benefit of SLKT compared to liver transplantation alone (LTA) are not well defined. METHODS: Organ Procurement and Transplantation Network data of patients with end-stage liver disease (ESLD) with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2) who had not been on dialysis while on the waiting list and underwent liver transplantation between 2002 and 2008 were analyzed. To identify predictors of undergoing SLKT versus LTA, multiple logistic regression analysis was performed. Cox proportional hazards regression analysis was used to assess the association between SLKT and post-liver transplant patient and graft survival. RESULTS: The study cohort comprised 5443 patients; 262 (5%) underwent SLKT and 5181 (95%) underwent LTA. Adjusting for potential confounders, patients who underwent SLKT were 34% less likely to die after liver transplantation than those who underwent LTA (hazard ratio [HR] = 0.66, P = .012) and 33% less likely to have liver graft failure than those who underwent LTA (HR = 0.67, P = .010). Among those who underwent SLKT, 1-, 3-, and 5-year kidney graft survival probabilities were 88%, 80%, and 77%, respectively. Black race and diabetes were associated with a higher likelihood of SLKT versus LTA; female sex, a higher eGFR, and higher MELD score reduced the likelihood of SLKT. CONCLUSIONS: Among those with ESLD and kidney dysfunction not on dialysis, post-liver transplant patient and liver graft survivals of patients who underwent SLKT were superior to those of patients who underwent LTA. Whether this reflects differences in the two groups that could not be adjusted in survival models or a specific effect of kidney dysfunction cannot be established.

Racial and ethnic differences in incident myocardial infarction in end-stage renal disease patients: The USRDS.

African Americans have a greater risk of cardiovascular disease (CVD) than Caucasians in early chronic kidney disease; however, limited data describe racial and ethnic differences in the risk of incident myocardial infarction (MI) among patients with end-stage renal disease (ESRD). We conducted a prospective, observational cohort study among 271 102 incident dialysis patients receiving renal replacement therapy enrolled in the United States Renal Data System (USRDS) for whom Medicare was the primary insurer between 1995 and 2000. The incidence and risk of any MI (non-fatal or fatal) estimated by Cox proportional hazards models was the primary outcome of interest. Of those with prevalent CVD at baseline (118 708), 14 849 had an incident non-fatal MI compared with 9926 events for those without prevalent CVD (152 394). Patients with prevalent CVD had higher crude rates of combined fatal and non-fatal MI (99.3/1000 person-years vs 42.9/1000 person-years) compared with those without prevalent CVD. Among those with prevalent CVD, African Americans (adjusted relative risk (aRR)=0.65, 95% confidence interval (CI):0.62-0.68), Asian Americans (aRR=0.74, 95% CI: 0.66-0.83), and Hispanics (aRR=0.72, 95% CI: 0.68-0.77) were 26-35% less likely to have an incident MI compared to Caucasians. Similarly, among those without prevalent CVD, racial/ethnic minorities were 26-42% less likely to have an incident MI compared to Caucasians. We conclude that in a national setting where comparable access to dialysis and associated medical care, exist, racial/ethnic minorities were found to have a lower risk of non-fatal and fatal MI than Caucasians.

Inflammation and dyslipidemia in nephropathy: an epidemiologic perspective.

The association of dyslipidemia and inflammatory markers with decreased renal function has been reported in several large epidemiologic studies. In this issue, Lin et al examine these associations among middle-aged and older type 2 diabetes, a population at high risk for chronic kidney disease. Their findings support a role for these factors in the pathogenesis of progressive renal disease.

Gender and the progression of renal disease.

Many studies of chronic renal disease have reported that men have a more rapid progression of renal insufficiency. However, other studies have found no differences between the sexes, and the true effect of sex on chronic renal disease remains a topic of controversy. There is evidence that women with non-diabetic renal diseases experience a slower progression, but in diabetic renal disease, the effect of gender is not yet established. Sex hormones may mediate the effects of gender on chronic renal disease, through alterations in the renin--angiotensin system, reduction in mesangial collagen synthesis, the modification of collagen degradation, and upregulation of nitric oxide synthesis.