Reconciling Systolic Blood Pressure Intervention Trial with Eighth Joint National Commission: a nuanced view of optimal hypertension control in the chronic kidney disease population.

PURPOSE OF REVIEW: Universally lowering blood pressure (BP) may adversely affect some populations especially in the older population. Recent landmark trials revealed cardiovascular benefits of tight controlling systolic BP (SBP) more than several recent BP targets. Implementing the evidence from the studies and guidelines in some populations is reviewed. RECENT FINDINGS: Eighth Joint National Commission (JNC-8) on hypertension issued conservative guidelines that provided an evolutionary change to BPcontrol in the elderly. However, intensive BP control with SBP < 120 mmHg in Systolic Blood Pressure Intervention Trial (SPRINT) focuses on the improvement of cardiovascular and cerebrovascular outcomes. Although increasingly guidelines are trending toward the SPRINT results, it is noteworthy that not all populations show a favorable outcome with intensive BP control given hypotensive risks to memory, kidney function, orthostasis, and morbidity risks. SUMMARY: Some populations may benefit from implementing the more intensive SBP target, whereas others such as elderly hypertensive patients may benefit from a more liberal SBP target. In the spirit of 'Primum non Nocere', we call for and suggest that a marriage of both SPRINT and JNC-8 recommendations be undertaken to champion the most cardiovascular protections for the greatest number of patients possible whereas preventing complications in vulnerable populations such as the elderly. Among the chronic kidney disease (CKD) population, SBP < 120 mmHg may not necessarily lead to favorable CKD outcomes.

A2/A2B Deceased Donor Kidney Transplantation Using A2 Titers Improves Access to Kidney Transplantation: A Single-Center Study.

Rationale & Objective: The option for A2/A2B deceased donor kidney transplantation was integrated into the kidney allocation system in 2014 to improve access for B blood group waitlist candidates. Despite excellent reported outcomes, center uptake has remained low across the United States. Here, we examined the effect of implementing an A2/A2B protocol using a cutoff titer of ≤1:8 for IgG and ≤1:16 for IgM on blood group B kidney transplant recipients at a single center. Study Design: Retrospective observational study. Setting & Participants: Blood group B recipients of deceased donor kidney transplants at a single center from January 1, 2019, to December 2022. Exposure: Recipients of deceased donor kidney transplants were analyzed based on donor blood type with comparisons of A2/A2B versus blood group compatible. Outcomes: One-year patient survival, death-censored allograft function, primary nonfunction, delayed graft function, allograft function as measured using serum creatinine levels and estimated glomerular filtration rate at 1 year, biopsy-proven rejection, and need for plasmapheresis. Analytical Approach: Comparison between the A2/A2B and compatible groups were performed using the Fisher test or the χ2 test for categorical variables and the nonparametric Wilcoxon rank-sum test for continuous variables. Results: A total of 104 blood type B patients received a deceased donor kidney transplant at our center during the study period, 49 (47.1%) of whom received an A2/A2B transplant. Waiting time was lower in A2/A2B recipients compared with blood group compatible recipients (57.9 months vs 74.7 months, P = 0.01). A2/A2B recipients were more likely to receive a donor after cardiac death (24.5% vs 1.8%, P < 0.05) and experience delayed graft function (65.3% vs 41.8%). There were no observed differences in the average serum creatinine level or estimated glomerular filtration rate at 1 month, 3 months, and 1 year post kidney transplantation, acute rejection, or primary nonfunction. Limitations: Single-center study. Small cohort size limiting outcome analysis. Conclusions: Implementation of an A2/A2B protocol increased transplant volumes of blood group B waitlisted patients by 83.6% and decreased the waiting time for transplantation by 22.5% with similar transplant outcomes.

Recipient blood type is one of the main determinants of waiting time to receive a deceased donor kidney transplant. Patients with blood type B have some of the longest waiting times for a kidney in the United States. Minorities comprise a large percentage of blood group B waitlist patients, contributing to observed racial differences in kidney transplantation rates. In this study, accepting an A2/A2B incompatible kidney resulted in receiving a kidney transplant almost 18 months earlier compared with receiving a blood group compatible kidney. No differences in outcomes were seen by accepting A2/A2B kidneys.

Comparing the Fried frailty phenotype versus the Veterans Affairs frailty index among dialysis dependent patients.

INTRODUCTION: Frailty in dialysis patients is a modifiable disease state which can increase mortality if left untreated but remains underdiagnosed as frailty evaluations can be arduous or time consuming. We evaluate the agreement between a clinical frailty construct (Fried frailty phenotype, FFP) against and an electronic health record-based Veterans Affairs Frailty Index (VAFI) and their association with mortality. METHODS: A retrospective cohort analysis of 764 participants from the ACTIVE/ADIPOSE study was performed. Frailty as measured by VAFI and FFP was obtained and Kappa statistic estimating concordance between the two scores were calculated. Differences in mortality risk were analyzed according to presence or absence of frailty. FINDINGS: When assessing agreement between the VAFI and FFP, the kappa statistic was 0.09 (95% confidence interval [CI] 0.02-0.16) suggesting a low level of agreement. Frailty was independently associated with higher mortality risk (hazards ratio [HR] 1.40-1.42 in fully adjusted models depending upon frailty construct). Discordantly frail patients by construct had a higher risk of mortality though this was not statistically significant after adjustment. However, concordantly frail patients had much higher mortality risk compared to concordantly nonfrail (adjusted HR 2.08, 95% CI 1.44-3.01). DISCUSSION: Poor agreement between constructs is likely reflective of the multifactorial definition of frailty. While further longitudinal studies are needed to determine if the VAFI would be beneficial in the reassessment of frailty, it may be beneficial as a cue for further frailty testing (e.g., with FFP) with the combination of multiple frail constructs providing improved prognostic information.