Essentials of Liver Transplantation in the Setting of Acute Kidney Injury and Chronic Kidney Disease.

Kidney dysfunction is common among liver transplant candidates with decompensated cirrhosis and has a major impact on pre- and post-liver transplant survival. Updated definitions of acute kidney injury and criteria for the diagnosis of hepatorenal syndrome allow for early recognition and intervention, including early initiation of vasoconstrictor therapy for hepatorenal syndrome. The rise of the metabolic syndrome and nonalcoholic fatty liver disease as a cause of cirrhosis has coincided with an increase in intrinsic chronic kidney disease recognized in transplant candidates and recipients. Ultimately, the ability to accurately assess kidney function and associated risk is essential to decision-making in the context of transplantation, including selection of candidates for simultaneous liver and kidney transplantation.

Adverse Gastrointestinal Events With Sodium Polystyrene Sulfonate Use in Patients on Maintenance Hemodialysis: An International Cohort Study.

Background: There are concerns regarding the gastrointestinal (GI) safety of sodium polystyrene sulfonate (SPS), a medication commonly used in the management of hyperkalemia. Objective: To compare the risk of GI adverse events among users versus non-users of SPS in patients on maintenance hemodialysis. Design: International prospective cohort study. Setting: Seventeen countries (Dialysis Outcomes and Practice Patterns Study [DOPPS] phase 2-6 from 2002 to 2018). Patients: 50 147 adults on maintenance hemodialysis. Measurements: An adverse GI event defined by a GI hospitalization or GI fatality with SPS prescription compared with no SPS prescription. Methods: Overlap propensity score-weighted Cox models. Results: Sodium polystyrene sulfonate prescription was present in 13.4% of patients and ranged from 0.42% (Turkey) to 20.6% (Sweden) with 12.5% use in Canada. A total of 935 (1.9%) adverse GI events (140 [2.1%] with SPS, 795 [1.9%] with no SPS; absolute risk difference 0.2%) occurred. The weighted hazard ratio (HR) of a GI event was not elevated with SPS use compared with non-use (HR = 0.93, 95% confidence interval = 0.83-1.6). The results were consistent when examining fatal GI events and/or GI hospitalization separately. Limitations: Sodium polystyrene sulfonate dose and duration were unknown. Conclusions: Sodium polystyrene sulfonate use in patients on hemodialysis was not associated with a higher risk of an adverse GI event. Our findings suggest that SPS use is safe in an international cohort of maintenance hemodialysis patients.

Contexte: Des préoccupations sont soulevées quant à l'innocuité gastro-intestinale (GI) du sulfonate de polystyrène sodique (SPS), un médicament couramment utilisé dans la gestion de l'hyperkaliémie. Objectif: Comparer dans une population de patients sous hémodialyse d'entretien le risque d'effets indésirables gastro-intestinaux chez les utilisateurs du SPS par rapport aux patients non-utilisateurs. Conception: Étude de cohorte prospective internationale. Cadre: 17 pays (phases 2 à 6 de l'essai DOPPS [de 2002 à 2018]). Sujets: 50 147 adultes sous hémodialyse d'entretien. Mesures: La comparaison entre les événements gastro-intestinaux indésirables, définis par une hospitalisation ou un décès en lien avec un problème gastro-intestinal, selon que les patients avaient ou non une prescription de SPS. Méthodologie: Modèles de Cox pondérés par le score de propension au chevauchement. Résultats: Dans l'ensemble de la cohorte, 13,4 % des patients avaient une prescription de SPS; l'usage de SPS variait selon les pays entre 0,42 % (Turquie) et 20,6 % (Suède) avec 12,5 % au Canada. En tout, 935 (1,9 %) événements GI indésirables sont survenus dans l'ensemble de la cohorte, soit 140 (2,1 %) chez les patients avec prescription de SPS et 795 (1,9 %) chez les patients sans prescription de SPS (différence de risque absolue: 0,2 %). Le rapport de risque (RR) pondéré d'un événement GI n'était pas plus élevé avec l'utilisation de SPS (RR = 0,93; IC 95 %: 0,83-1,6). Les résultats étaient cohérents lorsque l'on a examiné séparément les événements gastro-intestinaux (hospitalisation et/ou décès). Limites: La dose et la durée du traitement par SPS étaient inconnues. Conclusion: L'utilisation de SPS chez les patients sous hémodialyse n'a pas été associée à un risque plus élevé d'événements indésirables d'origine gastro-intestinale. Nos résultats suggèrent que l'utilisation du SPS est sans danger dans la cohorte internationale de patients sous hémodialyse d'entretien étudiée.

The Outcome of Tapered Steroid Regimen When Used to Treat Acute Borderline Cellular Rejection After Kidney Transplant: A Single-Center Experience.

Background: Treatment of acute borderline cellular rejection (BCR) after kidney transplant has shown mixed results with no consensus on the necessity and modality of interventions. Methods: The emphasis of our study was to assess the histopathologic response when BCR of kidney transplant is being treated with rapid steroid regimen. We analyzed all diagnosed acute BCR between 2018 and 2020. Patients were divided to a treatment responder group (RG) and non-responder group (NRG). All diagnosed BCR were treated with rapid steroid regimen and followed by a biopsy to assess response. Demographic data, recipients' comorbidities and clinical data, donor type, and induction immunosuppression regimen data were collected. Results: Ninety-one patients had acute BCR and were treated with rapid steroid followed by a repeat biopsy. Sixty-three (69%) patients showed persistence BCR and were considered NRG. Age, gender, and race were similar between the two groups. Class I and II calculated panel reactive antibodies were similar between the groups. No significant difference in the median serum creatinine (SCr) was noted between the groups. RG and NRG had a median SCr of 1.6 mg/dL (1.2 - 2.1) and 1.5 mg/dL (1.4 - 2.0), respectively (P < 0.79). The median SCr at the time of the follow-up biopsy was not different between the groups: SCr of 1.6 mg/dL (1.2 - 2.0) vs. 1.4 mg/dL (1.2 - 2.2) for the RG and NRG, respectively (P < 0.93). Conclusion: When rapid steroid regimen was used to treat acute BCR after kidney transplant, only smaller number of patients showed response based on the histology evaluation of the follow-up post-treatment biopsies.

Multidisciplinary Team versus a "Phosphate-Counting" App for Serum Phosphate Control: A Randomized Controlled Trial.

Background: Hyperphosphatemia is almost universal in well-nourished patients with ESKD treated with dialysis due to an imbalance between dietary intake and phosphate removal via residual kidney function and dialysis. Although food phosphate content can vary dramatically between meals, the current standard is to prescribe a fixed dose of phosphate binder that may not match meal phosphate intake. The primary objective of our study was to determine if the use of an app that matches phosphate binder dose with food phosphate content would be associated with an improvement in serum phosphate and a reduction in calcium carbonate intake compared with the multidisciplinary renal team. Methods: Eighty patients with ESKD treated with peritoneal dialysis at a tertiary care hospital in Canada were randomized to the standard of care for serum phosphate management (multidisciplinary renal team) versus the OkKidney app. Serum phosphate was measured at baseline and then monthly for 3 months with adjustments to phosphate management as deemed necessary by the multidisciplinary team (control) or the phosphate binder multiplier in the OkKidney app (intervention) on the basis of the laboratory values. The primary analysis was an unpaired t test of the serum phosphate at study completion. Results: The participants were 56 (±14) years old, and 54% were men; the most common cause of ESKD was diabetes mellitus. The serum phosphate values were 1.96 (0.41) and 1.85 (0.44) mmol/L in the control and intervention groups, respectively, at the end of 3 months (P=0.30). The median elemental daily dose of calcium carbonate did not differ between the groups at study completion (587 mg [309-928] versus 799 mg [567-1183], P=0.29). Conclusions: The OkKidney app was associated with similar but not superior serum phosphate control to the standard of care, which included renal dietician support. Clinical Trial registry name and registration number: US National Library Medicine ClinicalTrials.gov, NCT01643486.