ASN Live Update 2010: Cirrhosis and the Kidney

Th The Kidney in Liver Disease
Garcia-Tsao, MD
Take home points
1.      Pre liver transplant creatinine affects even post transplant survival of patient( based on data)
2.      Patients with Crt >1.0 pretransplant do worse post transplant
3.      Why is the serum crt low in cirrhosis( falsely): Decreased synthesis, malnutrition, less muscle mass, hyperbilirubenemia, and dilutational
4.      AKI can be divided in pre renal, renal and post renal causes in cirrhosis
5.      Pre renal causes are GI bleed, diarrhea usually due to lactulose, and hepatorenal syndrome(HRS)
6.      HRS is not volume responsive
7.      Intre renal causes  are ATN and GNs
8.      Post renal are rare
9.      20% of patients with cirrhosis in hospital have kidney injury( 19% is AKI and 1% is CKD). 68% of all are pre renal.  Of all pre renal most are volume responsive.
10.     In a study comparing pre renal ( diarrhea and GI bleed) causes and HRS, HRS has the lowest Na, lowest Mean arterial pressure and highest mortality
11.     Two things that make HRS worse worse splanchnic vasodilation and worse decrease in effective blood volume
12.     HRS-1 is aki, HRS2 is usually a chronic renal injury.  HRS -1 is a diagnosis of exclusion.  20% of AKI in cirrhosis, usually followed by infection and kidney is really not injured. 
13.     Diagnosis includes stopping all volume depleting agents first , looking for infection, giving IV Albumin 1g/kg qd or bid and if still no response in 48 hours, then check a cvp to see ifvolume replete and renal us, if all normal, then HRS Is diagnosed
14.     There is no data or studies on using bladder pressure in cirrhotics to date to discuss intra abdominal HTN

ASN Live updates from nephrology on demand

Check out the link for live updates from NOD at
http://blog.ecu.edu/sites/nephrologyondemand/?p=5161

ASN Live Update 2010:when do to combined liver-kidney transplants?

When to do a combined Liver and Kidney Transplant?
Take home points from Dr.Aklin's talk1.      After the introduction of MELD scoring system, the crt was in that and that led to increase number of combined liver and kidney transplants from 2% to 6%
2.      Who gets combined: ESRD with Cirrhosis, ESLD with GFR<30, ESLD +AKI+>8 weeks on HD, ESLD + biopsy proven >30% IFTA and >30% glomerulosclerosis
3.      After Introduction of MELD, the outcomes of Liver and kidney combined were worse , not donor related, perhaps recipient related as they were sicker. Now if MELD>23, they do worse and surgeons think twice before a combined liver kidney
4.      A biopsy proven way of deciding if you want to do a kidney and liver was suggested.  Interestingly they found that the most common biopsy finding was GN and DM being top, followed by MPGN, FSGS and IgA nephropathy
5.      >30% had biopsy complications, especially inr>1.5
6.      Interesting GN found after liver transplant alone( some sort of nodular GN, as it looks like DM nephropathy but they don’t have DM and never develop it)

Diet and CKD - Historical Interest

http://www.ncbi.nlm.nih.gov/pubmed/5939526
Check out the above article.It has one of the oldest classifications of CKD and use of protein diet breakdown for a diet used in CKD.

The Kidney Transplant in HIV patients- the NEJM study

Kidney Transplantation was rare in HIV+ cases few years ago and now many centers have developed protocols that have allowed this to happen with relatively good outcomes.
No prospective studies were ever done in this matter for rejection rates, outcome measures and so forth,
This month in NEJM 2010, a nice multi center study takes a look at this particular question. The investigators evaluated 150 patients for close to 2 years, multicenter fashion, non randomized prospective fashion.
The mean graft survival was 90% at one year and 3 years was 73.7%.  The ones that didn't do well were the ones with rejection episodes, use of thymoglobulin, and non living donors.  The rejection rate was higher than expected, close to 31% at 1 year and 41% in 3 years.

This study shows that graft survival is good but the rejection rates are high still and needs some work. Perhaps the drug interaction with HAART therapy play a role in the fluctuation of perhaps CNI levels and higher rejection risk or the immunosuppresive agents we have now are not the ideal ones for an immunodeficiency diseases model?


ref:
http://www.nejm.org/doi/full/10.1056/NEJMoa1001197
http://www.ncbi.nlm.nih.gov/pubmed/19776780

ASN 2010 Live Update - Careers in nephrology

CAREERS IN NEPHROLOGY

Academic Nephrology: Job Security, Diversity, lifestyle advantages (Division of labor), opportunities for multidisciplinary interventional studies (e.g. CKD-CVD) ,opportunity to be part of translational research team, reward of teaching endeavors

Clinical Nephrology: Integration of care of CKD patients with PCP’s through the PCMH (Patient centered medical health) concept, need for outcomes research related to new reimbursement strategies, addition to workforce

New Concepts  PCMH (Patient centered medical health) CKD to be one of the major chronic disease to model  for the PCMH and the Nephrologist as a PCMH-N( Neighbor) This being an attempt to lay ground work for coordinated care of CKD patients by attempting to do the following : Better collaboration for consultation , information exchange and evidence based decision making , PCP’s to continue to manage CKD due to HTN and DM and nephrologists to adhere to diagnosis and management of specific Glomerular diseases , Nephrologists developing systems for PCP’s to ensure  early detection of CKD
GUIDELINES FOR JOB IN ACADEMIC NEPHROLOGY 

Have a plan at least for next five years; Negotiate Contract;Ask About promotion guidelines; Apply for Grants ( Sure shot way to secure dedicated research  time!);Have more than one Mentor;Don’t move too quickly into leadership roles; Don’t take up assignments that others will not !

Reported by ITI YADAV, MD

What Dialysis Modality you would want? Survey

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