Dialysis in the undocumented: The past, the present, and what lies ahead.

In many states undocumented immigrants with end stage renal disease (ESRD) do not have access to regular, thrice weekly dialysis. The term "compassionate dialysis" is used to describe dialysis that is provided on an emergent basis, when patients are in extremis from symptoms of volume overload or suffer from life-threatening electrolyte abnormalities. In this editorial, one particularly poignant anecdote is presented from the experience of one of the authors (AZF) as a nephrologist in Texas, a state where undocumented immigrants have faced difficulties in accessing regular dialysis. We then describe the legislation that allows the right to regular dialysis to be determined on a state by state basis. We offer some potential solutions to this challenging issue, and we describe the difficulties that lay ahead given the uncertain future of the Affordable Care Act.

Assessment and management of hypertension in transplant patients.

Hypertension in renal transplant recipients is common and ranges from 50% to 80% in adult recipients and from 47% to 82% in pediatric recipients. Cardiovascular morbidity and mortality and shortened allograft survival are important consequences of inadequate control of hypertension. In this review, we examine the epidemiology, pathophysiology, and management considerations of post-transplant hypertension. Donor and recipient factors, acute and chronic allograft injury, and immunosuppressive medications may each explain some of the pathophysiology of post-transplant hypertension. As observed in other patient cohorts, renal artery stenosis and adrenal causes of hypertension may be important contributing factors. Notably, BP treatment goals for renal transplant recipients remain an enigma because there are no adequate randomized controlled trials to support a benefit from targeting lower BP levels on graft and patient survival. The potential for drug-drug interactions and altered pharmacokinetics and pharmacodynamics of the different antihypertensive medications need to be carefully considered. To date, no specific antihypertensive medications have been shown to be more effective than others at improving either patient or graft survival. Identifying the underlying pathophysiology and subsequent individualization of treatment goals are important for improving long-term patient and graft outcomes in these patients.