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Abstract
Life with a solitary functioning kidney (SFK) may be different from that when born with two kidneys. Based on the hyperfiltration hypothesis, a SFK may lead to glomerular damage with hypertension, albuminuria and progression towards end-stage renal disease. As the prognosis of kidney donors was considered to be very good, having a SFK has been considered to be a benign condition. In contrast, our research group has demonstrated that being born with or acquiring a SFK in childhood results in renal injury before adulthood in over 50% of those affected. Most congenital cases will be detected during antenatal ultrasound screening, but up to 38% of cases of unilateral renal agenesis are missed. In about 25-50% of cases of antenatally detected SFK there will be signs of hypertrophy, which could indicate additional nephron formation and is associated with a somewhat reduced risk of renal injury. Additional renal and extrarenal anomalies are frequently detected and may denote a genetic cause for the SFK, even though for the majority of cases no explanation can (yet) be found. The ongoing glomerular hyperfiltration results in renal injury, for which early markers are lacking. Individuals with SFK should avoid obesity and excessive salt intake to limit additional hyperfiltration. As conditions like hypertension, albuminuria and a mildly reduced glomerular filtration rate generally do not result in specific complaints but may pose a threat to long-term health, screening for renal injury in any individual with a SFK would appear to be imperative, starting from infancy. With early treatment, secondary consequences may be diminished, thereby providing the optimal life for anyone born with a SFK.
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102
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Inker LA, Koraishy FM, Goyal N, Lentine KL. Assessment of Glomerular Filtration Rate and End-Stage Kidney Disease Risk in Living Kidney Donor Candidates: A Paradigm for Evaluation, Selection, and Counseling. Adv Chronic Kidney Dis 2018; 25:21-30. [PMID: 29499883 DOI: 10.1053/j.ackd.2017.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/12/2017] [Accepted: 09/13/2017] [Indexed: 12/27/2022]
Abstract
Living donor kidney transplantation is the preferred treatment option for ESRD. However, recent data suggest a small increase in the long-term risk of kidney failure in living kidney donors when compared to healthy nondonors. These data have led to a need for reconsideration of how donor candidates are evaluated and selected for donation. A Kidney Disease: Improving Global Outcomes (KDIGO) work group completed a comprehensive clinical practice guideline for evaluation of living kidney donor candidates in 2017, based on systematic evidence review, de novo evidence generation, and expert opinion. Central to the evaluation framework is assessment of glomerular filtration rate (GFR), which is used to screen for kidney disease and aid the prediction of long-term kidney failure risk after donation. Accurate estimation of the level of GFR and risk of kidney failure, and communication of estimated risks, can support evidence-based donor selection and shared decision-making. In this review, we discuss approaches to optimal GFR estimation in the donor evaluation process, long-term risk projection, and risk communication to donor candidates, integrating recommendations from the new KDIGO guideline, other recent literature, and experience from our own research and practice. We conclude by highlighting topics for further research in this important area of transplant medicine.
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103
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Cheng XS, Glassock RJ, Lentine KL, Chertow GM, Tan JC. Donation, Not Disease! A Multiple-Hit Hypothesis on Development of Post-Donation Kidney Disease. CURRENT TRANSPLANTATION REPORTS 2017; 4:320-326. [PMID: 29201600 PMCID: PMC5691123 DOI: 10.1007/s40472-017-0171-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Purpose of Review The risks following living kidney donation has been the subject of rigorous investigation in the past several decades. How to utilize the burgeoning new knowledge base to better the risk assessment, education, and health maintenance of donors is unclear. We review the physiologic and epidemiologic evidences on the post-donation state and submit a multiple-hit hypothesis to reconcile the finite elevation in risk of kidney disease after donation with the benign course of most kidney donors. Recent Findings The risk of end-stage kidney disease is higher in kidney donors compared to similarly healthy non-kidney donors. Nonetheless, post-donation kidney disease is uncommon and arises mostly in the setting of other “hits”—either a “first hit” present at birth or a “second hit” acquired later in life. Summary The transplant community’s focus should be directed toward (1) personalized risk assessment to inform consent before donation and (2) preventing and treating development of “second hits” following kidney donation.
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Affiliation(s)
- Xingxing S. Cheng
- Division of Nephrology, Department of Medicine, Stanford University, 750 Welch Road, Suite 200, Mail code 5785, Palo Alto, CA 94304 USA
| | - Richard J. Glassock
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA USA
| | - Krista L. Lentine
- Division of Nephrology, Saint Louis University Center for Abdominal Transplantation, Saint Louis, MO USA
| | - Glenn M. Chertow
- Division of Nephrology, Department of Medicine, Stanford University, 750 Welch Road, Suite 200, Mail code 5785, Palo Alto, CA 94304 USA
| | - Jane C. Tan
- Division of Nephrology, Department of Medicine, Stanford University, 750 Welch Road, Suite 200, Mail code 5785, Palo Alto, CA 94304 USA
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104
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Ibrahim HN, Berglund DM, Jackson S, Vock DM, Foley RN, Matas AJ. Renal Consequences of Diabetes After Kidney Donation. Am J Transplant 2017; 17:3141-3148. [PMID: 28681494 PMCID: PMC5693658 DOI: 10.1111/ajt.14416] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 06/12/2017] [Accepted: 07/01/2017] [Indexed: 01/25/2023]
Abstract
Whether diabetes after kidney donation is associated with an accelerated GFR decay in the remaining kidney has not been studied. We determined the incidence of diabetes in kidney donors, and compared GFR change over time in diabetic to nondiabetic donors, in addition to the effect of diabetes mellitus (DM) on the development of proteinuria, hypertension, and end-stage renal disease (ESRD). Of the 4014 donors, 309 (7.7%) developed diabetes at a median age of 56.0 years and after a median of 18 years after donation. The difference in annual estimated GFR (eGFR) change between diabetic and nondiabetic donors in the 7 years before the development of DM was -0.08 mL/min/year; p = 0.51. After DM development, the difference was -1.10 mL/min/year for diabetic donors with hypertension and proteinuria, p < 0.001; -0.19 for diabetic donors with hypertension but no proteinuria, p = 0.29; -0.75 mL/min/year for diabetic donors with proteinuria but no hypertension, p = 0.19; and -0.09 mL/min/year for diabetic donors without proteinuria or hypertension, p = 0.63. When DM was considered as a time-dependent covariate, it was associated with the development of proteinuria (hazard ratio [HR] 2.65, 95% confidence interval [CI] 1.89-3.70; p < 0.001) and hypertension (HR 2.19, 95% CI 1.74-2.75; p < 0.001). It was not, however, associated with ESRD. eGFR decline after DM development exceeds that of nondiabetic donors only in diabetic donors with concomitant proteinuria and hypertension.
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Affiliation(s)
- Hassan N. Ibrahim
- Division of Renal Diseases and Hypertension, Houston Methodist Hospital, University of Minnesota
| | - Danielle M. Berglund
- Informatics Services for Research and Reporting, Fairview, University of Minnesota
| | - Scott Jackson
- Informatics Services for Research and Reporting, Fairview, University of Minnesota
| | | | - Robert N. Foley
- Division of Renal Diseases and Hypertension, University of Minnesota
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105
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Kwon HJ, Kim DH, Jang HR, Jung SH, Han DH, Sung HH, Park JB, Lee JE, Huh W, Kim SJ, Kim YG, Kim DJ, Oh HY. Predictive Factors of Renal Adaptation After Nephrectomy in Kidney Donors. Transplant Proc 2017; 49:1999-2006. [PMID: 29149951 DOI: 10.1016/j.transproceed.2017.09.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/01/2017] [Accepted: 09/02/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite compensatory hyperfiltration in remaining nephrons following donor nephrectomy, some donors show impaired renal adaptation and low estimated glomerular filtration rate (eGFR). We investigated the factors predicting early renal adaptation after nephrectomy and identified kidney donors at risk of inadequate renal adaptation. METHODS A total of 265 living kidney donors from 2010 to 2013 were retrospectively analyzed. Renal function was serially followed for 6 months after the operation. Regression analyses were performed to identify the independent predictors of low eGFR (eGFR <60 mL/min/1.73 m2) and impaired renal adaptation (%Modification of Diet in Renal Disease [MDRD] <66% of baseline eGFR). RESULTS A total of 148 donors belonged to the low eGFR group, and changes in eGFR (ΔeGFR) at postoperative (PO) 1 day and 1 month were identified as independent predictors of low eGFR. Impaired renal adaptation was related to age, ΔeGFR PO 2-3 days, and ΔeGFR PO 1 month. Early renal adaptation was associated with age, male gender, and residual kidney computerized tomography angiography (CTA) volume. The best sensitivity and specificity were obtained with a cutoff value of ΔeGFR 31 at PO 1 day and 1 month for predicting low eGFR and with a value of ΔeGFR 27 at PO 2-3 days and 1 month for predicting impaired renal adaptation. CONCLUSIONS Our study showed that the degree of early renal adaptation determines subsequent renal function in kidney donors. Closer monitoring and management may be required in old or male donors with small residual CTA kidney volume as well as donors with persistent ΔeGFR >27 within 1 month of nephrectomy.
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Affiliation(s)
- H J Kwon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - D H Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - H R Jang
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - S-H Jung
- Biostatics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - D H Han
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - H H Sung
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - J B Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - J E Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - W Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - S J Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Y-G Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - D J Kim
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - H Y Oh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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106
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Birendra R, John NT, Duhli N, Devasia A, Kekre N, Manojkumar R. Histopathological analysis of the non - tumour parenchyma following radical nephrectomy: can it predict renal functional outcome? Int Braz J Urol 2017; 43:655-660. [PMID: 28379664 PMCID: PMC5557441 DOI: 10.1590/s1677-5538.ibju.2016.0417] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 11/19/2016] [Indexed: 11/23/2022] Open
Abstract
Introduction Radical nephrectomy (RN), a recommended treatment option for patients with Renal cell carcinoma (RCC) leads to an inevitable decline in global renal function. Pathological changes in the non-tumour parenchyma of the kidney may help predict the function of the remaining kidney. Materials and Methods Aim of this prospective, observational study was to find histopathological factors in the non-tumor renal parenchyma that could predict the decline in global renal function postoperatively and its association with co-morbidities like diabetes (DM). Data of consecutive patients undergoing RN from December-2013 to January-2015 was collected. Non-tumor parenchyma of the specimen was reported by a dedicated histopathologist. eGFR was calculated using Cockcroft-Gault formula before the surgery and at last follow up of at least 12 months. Results 73 RN specimens were analyzed. Mean follow up was 12.3 months. The mean decrease in eGFR was 22% (p=.0001). Percent decrease in eGFR did not show association with any of the histopathological parameters studied. DM was significantly associated with decrease in percent eGFR (p<0.05) and increase in arteriolar hyalinosis (p=0.004), Glomerulosclerosis (p=0.03) and Interstitial fibrosis/ Tubular atrophy (p=.0001). Maximum size of the tumor showed a negative correlation with percentage change in eGFR (p=.028). Conclusion Histological parameters in the non-tumour portion of the RN specimen may not be able to predict renal function outcome over a short follow up. However, presence of DM was associated with adverse pathological changes and significant decrease in renal function postoperatively.
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Affiliation(s)
- Rana Birendra
- Department of Urology, Christian Medical College, Vellore
| | | | | | - Antony Devasia
- Department of Urology, Christian Medical College, Vellore
| | - Nitin Kekre
- Department of Urology, Christian Medical College, Vellore
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107
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Steiner RW. Invited response to "Hyperfiltration After Donation and Living Kidney Donor Risk". Am J Transplant 2017; 17:2992. [PMID: 28742953 DOI: 10.1111/ajt.14445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- R W Steiner
- Department of Nephrology, University of California Medical Center San Diego, San Diego, CA, USA
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108
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Kanzaki G, Puelles VG, Cullen-McEwen LA, Hoy WE, Okabayashi Y, Tsuboi N, Shimizu A, Denton KM, Hughson MD, Yokoo T, Bertram JF. New insights on glomerular hyperfiltration: a Japanese autopsy study. JCI Insight 2017; 2:94334. [PMID: 28978800 DOI: 10.1172/jci.insight.94334] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 08/24/2017] [Indexed: 12/15/2022] Open
Abstract
It has been suggested that low nephron number contributes to glomerular hypertension and hyperperfusion injury in progressive chronic kidney disease (CKD). The incidence of CKD in Japan is among the highest in the world, but the reasons remain unclear. We estimated total nephron (glomerular) number (NglomTOTAL) as well as numbers of nonsclerosed (NglomNSG) and globally sclerosed glomeruli (NglomGSG), and the mean volume of nonsclerosed glomeruli (VglomNSG) in Japanese normotensive, hypertensive, and CKD subjects and investigated associations between these parameters and estimated glomerular filtration rate (eGFR). Autopsy kidneys from age-matched Japanese men (9 normotensives, 9 hypertensives, 9 CKD) had nephron number and VglomNSG estimated using disector/fractionator stereology. Subject eGFR, single-nephron eGFR (SNeGFR), and the ratio SNeGFR/VglomNSG were calculated. NglomNSG in Japanese with hypertension (392,108 ± 87,605; P < 0.001) and CKD (268,043 ± 106,968; P < 0.001) was less than in normotensives (640,399 ± 160,016). eGFR was directly correlated with NglomNSG (r = 0.70, P < 0.001) and inversely correlated with VglomNSG (r = -0.53, P < 0.01). SNeGFR was higher in hypertensives than normotensives (P = 0.03), but was similar in normotensives and CKD, while the ratio SNeGFR/VglomNSG was similar in normotensives and hypertensives but markedly reduced in CKD. Nephron number in Japanese with hypertension or CKD was low. This results in a higher SNeGFR in hypertensives compared with normotensive and CKD subjects, but lowered SNeGFR/VglomNSG in CKD subjects, suggesting that changes in GFR are accommodated by glomerular hypertrophy rather than glomerular hypertension. These findings suggest glomerular hypertrophy is a dominant factor in maintenance of GFR under conditions of low nephron number.
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Affiliation(s)
- Go Kanzaki
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Anatomy and Developmental Biology, School of Biomedical Sciences, Monash University, Melbourne, Victoria, Australia.,Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Victor G Puelles
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Anatomy and Developmental Biology, School of Biomedical Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Aachen, Germany
| | - Luise A Cullen-McEwen
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Anatomy and Developmental Biology, School of Biomedical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Wendy E Hoy
- Centre for Chronic Disease, The University of Queensland, Brisbane, Australia
| | - Yusuke Okabayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Kate M Denton
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, School of Biomedical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Michael D Hughson
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - John F Bertram
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Anatomy and Developmental Biology, School of Biomedical Sciences, Monash University, Melbourne, Victoria, Australia
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109
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Affiliation(s)
| | - Richard J Glassock
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
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110
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Ernandez T, Udwan K, Chassot A, Martin PY, Feraille E. Uninephrectomy and apical fluid shear stress decrease ENaC abundance in collecting duct principal cells. Am J Physiol Renal Physiol 2017; 314:F763-F772. [PMID: 28877879 DOI: 10.1152/ajprenal.00200.2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Acute nephron reduction such as after living kidney donation may increase the risk of hypertension. Uninephrectomy induces major hemodynamic changes in the remaining kidney, resulting in rapid increase of single-nephron glomerular filtration rate (GFR) and fluid delivery in the distal nephron. Decreased sodium (Na) fractional reabsorption after the distal tubule has been reported after uninephrectomy in animals preserving volume homeostasis. In the present study, we thought to specifically explore the effect of unilateral nephrectomy on epithelial Na channel (ENaC) subunit expression in mice. We show that γ-ENaC subunit surface expression was specifically downregulated after uninephrectomy, whereas the expression of the aldosterone-sensitive α-ENaC and α1-Na-K-ATPase subunits as well as of kidney-specific Na-K-Cl cotransporter isoform and Na-Cl cotransporter were not significantly altered. Because acute nephron reduction induces a rapid increase of single-nephron GFR, resulting in a higher tubular fluid flow, we speculated that local mechanical factors such as fluid shear stress (FSS) were involved in Na reabsorption regulation after uninephrectomy. We further explore such hypothesis in an in vitro model of FSS applied on highly differentiated collecting duct principal cells. We found that FSS specifically downregulates β-ENaC and γ-ENaC subunits at the transcriptional level through an unidentified heat-insensitive paracrine basolateral factor. The primary cilium as a potential mechanosensor was not required. In contrast, protein kinase A and calcium-sensitive cytosolic phospholipase A2 were involved, but we could not demonstrate a role for cyclooxygenase or epoxygenase metabolites.
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Affiliation(s)
- T Ernandez
- Service of Nephrology, University Hospital of Geneva , Geneva , Switzerland.,Department of Cell Physiology and Metabolism, University Medical Center , Geneva , Switzerland
| | - K Udwan
- Department of Cell Physiology and Metabolism, University Medical Center , Geneva , Switzerland
| | - A Chassot
- Department of Cell Physiology and Metabolism, University Medical Center , Geneva , Switzerland
| | - P-Y Martin
- Service of Nephrology, University Hospital of Geneva , Geneva , Switzerland
| | - E Feraille
- Department of Cell Physiology and Metabolism, University Medical Center , Geneva , Switzerland
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111
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Geraci S, Chacon-Caldera J, Cullen-McEwen L, Schad LR, Sticht C, Puelles VG, Bertram JF, Gretz N. Combining new tools to assess renal function and morphology: a holistic approach to study the effects of aging and a congenital nephron deficit. Am J Physiol Renal Physiol 2017; 313:F576-F584. [PMID: 28490528 DOI: 10.1152/ajprenal.00329.2015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 04/28/2017] [Accepted: 05/09/2017] [Indexed: 01/17/2023] Open
Abstract
Recently, new methods for assessing renal function in conscious mice (transcutaneous assessment) and for counting and sizing all glomeruli in whole kidneys (MRI) have been described. In the present study, these methods were used to assess renal structure and function in aging mice, and in mice born with a congenital low-nephron endowment. Age-related nephron loss was analyzed in adult C57BL/6 mice (10-50 wk of age), and congenital nephron deficit was assessed in glial cell line-derived neurotrophic factor heterozygous (GDNF HET)-null mutant mice. Renal function was measured through the transcutaneous quantitation of fluorescein isothiocyanate-sinistrin half-life (t1/2) in conscious mice. MRI was used to image, count, and size cationic-ferritin labeled glomeruli in whole kidneys ex vivo. Design-based stereology was used to validate the MRI measurements of glomerular number and mean volume. In adult C57BL/6 mice, older age was associated with fewer and larger glomeruli, and a rightward shift in the glomerular size distribution. These changes coincided with a decrease in renal function. GNDF HET mice had a congenital nephron deficit that was associated with glomerular hypertrophy and exacerbated by aging. These findings suggest that glomerular hypertrophy and hyperfiltration are compensatory processes that can occur in conjunction with both age-related nephron loss and congenital nephron deficiency. The combination of measurement of renal function in conscious animals and quantitation of glomerular number, volume, and volume distribution provides a powerful new tool for investigating aspects of renal aging and functional changes.
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Affiliation(s)
- Stefania Geraci
- Medical Research Centre, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jorge Chacon-Caldera
- Computer Assisted Clinical Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; and
| | - Luise Cullen-McEwen
- Cardiovascular Program, Monash Biomedicine Discovery Institute, and Department of Anatomy and Developmental Biology, Monash University, Melbourne, Victoria, Australia
| | - Lothar R Schad
- Computer Assisted Clinical Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; and
| | - Carsten Sticht
- Medical Research Centre, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Victor G Puelles
- Cardiovascular Program, Monash Biomedicine Discovery Institute, and Department of Anatomy and Developmental Biology, Monash University, Melbourne, Victoria, Australia
| | - John F Bertram
- Cardiovascular Program, Monash Biomedicine Discovery Institute, and Department of Anatomy and Developmental Biology, Monash University, Melbourne, Victoria, Australia
| | - Norbert Gretz
- Medical Research Centre, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany;
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112
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Lentine KL, Kasiske BL, Levey AS, Adams PL, Alberú J, Bakr MA, Gallon L, Garvey CA, Guleria S, Li PKT, Segev DL, Taler SJ, Tanabe K, Wright L, Zeier MG, Cheung M, Garg AX. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation 2017; 101:S1-S109. [PMID: 28742762 PMCID: PMC5540357 DOI: 10.1097/tp.0000000000001769] [Citation(s) in RCA: 194] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/20/2017] [Indexed: 12/17/2022]
Abstract
The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.
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Affiliation(s)
| | | | | | | | - Josefina Alberú
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | | | | | - Dorry L. Segev
- Johns Hopkins University, School of Medicine, Baltimore, MD
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113
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Affiliation(s)
- Karen A Griffin
- From the Hines VA Hospital, IL; and Loyola University Medical Center, Maywood, IL.
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114
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Denic A, Mathew J, Lerman LO, Lieske JC, Larson JJ, Alexander MP, Poggio E, Glassock RJ, Rule AD. Single-Nephron Glomerular Filtration Rate in Healthy Adults. N Engl J Med 2017; 376:2349-2357. [PMID: 28614683 PMCID: PMC5664219 DOI: 10.1056/nejmoa1614329] [Citation(s) in RCA: 209] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The glomerular filtration rate (GFR) assesses the function of all nephrons, and the single-nephron GFR assesses the function of individual nephrons. How the single-nephron GFR relates to demographic and clinical characteristics and kidney-biopsy findings in humans is unknown. METHODS We identified 1388 living kidney donors at the Mayo Clinic and the Cleveland Clinic who underwent a computed tomographic (CT) scan of the kidney with the use of contrast material and an iothalamate-based measurement of the GFR during donor evaluation and who underwent a kidney biopsy at donation. The mean single-nephron GFR was calculated as the GFR divided by the number of nephrons (calculated as the cortical volume of both kidneys as assessed on CT times the biopsy-determined glomerular density). Demographic and clinical characteristics and biopsy findings were correlated with the single-nephron GFR. RESULTS A total of 58% of the donors were women, and the mean (±SD) age of the donors was 44±12 years. The mean GFR was 115±24 ml per minute, the mean number of nephrons was 860,000±370,000 per kidney, and the mean single-nephron GFR was 80±40 nl per minute. The single-nephron GFR did not vary significantly according to age (among donors <70 years of age), sex, or height (among donors ≤190 cm tall). A higher single-nephron GFR was independently associated with larger nephrons on biopsy and more glomerulosclerosis and arteriosclerosis than would be expected for age. A higher single-nephron GFR was associated with a height of more than 190 cm, obesity, and a family history of end-stage renal disease. CONCLUSIONS Among healthy adult kidney donors, the single-nephron GFR was fairly constant with regard to age, sex, and height (if ≤190 cm). A higher single-nephron GFR was associated with certain risk factors for chronic kidney disease and certain kidney-biopsy findings. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases.).
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Affiliation(s)
- Aleksandar Denic
- From the Divisions of Nephrology and Hypertension (A.D., J.M., L.O.L., J.C.L., A.D.R.), Biomedical Statistics and Informatics (J.J.L.), and Epidemiology (A.D.R.) and the Department of Laboratory Medicine and Pathology (J.C.L., M.P.A.), Mayo Clinic, Rochester, MN; the Department of Nephrology, Cleveland Clinic, Cleveland (E.P.); and the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (R.J.G.)
| | - Jerry Mathew
- From the Divisions of Nephrology and Hypertension (A.D., J.M., L.O.L., J.C.L., A.D.R.), Biomedical Statistics and Informatics (J.J.L.), and Epidemiology (A.D.R.) and the Department of Laboratory Medicine and Pathology (J.C.L., M.P.A.), Mayo Clinic, Rochester, MN; the Department of Nephrology, Cleveland Clinic, Cleveland (E.P.); and the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (R.J.G.)
| | - Lilach O Lerman
- From the Divisions of Nephrology and Hypertension (A.D., J.M., L.O.L., J.C.L., A.D.R.), Biomedical Statistics and Informatics (J.J.L.), and Epidemiology (A.D.R.) and the Department of Laboratory Medicine and Pathology (J.C.L., M.P.A.), Mayo Clinic, Rochester, MN; the Department of Nephrology, Cleveland Clinic, Cleveland (E.P.); and the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (R.J.G.)
| | - John C Lieske
- From the Divisions of Nephrology and Hypertension (A.D., J.M., L.O.L., J.C.L., A.D.R.), Biomedical Statistics and Informatics (J.J.L.), and Epidemiology (A.D.R.) and the Department of Laboratory Medicine and Pathology (J.C.L., M.P.A.), Mayo Clinic, Rochester, MN; the Department of Nephrology, Cleveland Clinic, Cleveland (E.P.); and the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (R.J.G.)
| | - Joseph J Larson
- From the Divisions of Nephrology and Hypertension (A.D., J.M., L.O.L., J.C.L., A.D.R.), Biomedical Statistics and Informatics (J.J.L.), and Epidemiology (A.D.R.) and the Department of Laboratory Medicine and Pathology (J.C.L., M.P.A.), Mayo Clinic, Rochester, MN; the Department of Nephrology, Cleveland Clinic, Cleveland (E.P.); and the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (R.J.G.)
| | - Mariam P Alexander
- From the Divisions of Nephrology and Hypertension (A.D., J.M., L.O.L., J.C.L., A.D.R.), Biomedical Statistics and Informatics (J.J.L.), and Epidemiology (A.D.R.) and the Department of Laboratory Medicine and Pathology (J.C.L., M.P.A.), Mayo Clinic, Rochester, MN; the Department of Nephrology, Cleveland Clinic, Cleveland (E.P.); and the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (R.J.G.)
| | - Emilio Poggio
- From the Divisions of Nephrology and Hypertension (A.D., J.M., L.O.L., J.C.L., A.D.R.), Biomedical Statistics and Informatics (J.J.L.), and Epidemiology (A.D.R.) and the Department of Laboratory Medicine and Pathology (J.C.L., M.P.A.), Mayo Clinic, Rochester, MN; the Department of Nephrology, Cleveland Clinic, Cleveland (E.P.); and the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (R.J.G.)
| | - Richard J Glassock
- From the Divisions of Nephrology and Hypertension (A.D., J.M., L.O.L., J.C.L., A.D.R.), Biomedical Statistics and Informatics (J.J.L.), and Epidemiology (A.D.R.) and the Department of Laboratory Medicine and Pathology (J.C.L., M.P.A.), Mayo Clinic, Rochester, MN; the Department of Nephrology, Cleveland Clinic, Cleveland (E.P.); and the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (R.J.G.)
| | - Andrew D Rule
- From the Divisions of Nephrology and Hypertension (A.D., J.M., L.O.L., J.C.L., A.D.R.), Biomedical Statistics and Informatics (J.J.L.), and Epidemiology (A.D.R.) and the Department of Laboratory Medicine and Pathology (J.C.L., M.P.A.), Mayo Clinic, Rochester, MN; the Department of Nephrology, Cleveland Clinic, Cleveland (E.P.); and the Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (R.J.G.)
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115
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de Souza Rodrigues T, Amorim de Albuquerque AL, de Oliveira Cosme FA, de Oliveira JAMG, Magalhães I, Teles F, Pedrosa AF. Evaluation of renal function in a specific population of living kidney donors. J Ren Care 2017; 43:114-120. [PMID: 28233463 DOI: 10.1111/jorc.12198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The increase in candidates for kidney transplant has led to growth in the number of living donor transplants. Therefore, studies that adequately evaluate the possible long-term consequences of elective transplant nephrectomy are needed. OBJECTIVE To evaluate the possible long-term adverse effects of transplant nephrectomy on the renal function of living kidney donors. DESIGN A cross-sectional study. PARTICIPANTS Thirty-three living kidney donors registered in the transplant programme of a centre in Alagoas, Brazil. MEASUREMENTS Demographic characteristics, anthropometric measures, clinical data and biomarkers (creatinine, eGFR, microalbuminuria, cholesterol and triglycerides) were measured. Creatinine clearance was calculated using the Cockcroft-Gault and Modification of Diet in Renal Disease formulae. RESULTS Of the 33 individuals, 63.63% were female, and the median age was 45 years. Additionally, 24.24% of these individuals had altered blood pressure, 39.39% had altered abdominal circumference (AC) and 36.36% were obese, with a body mass index ≥30. Furthermore, 33.33% of these individuals had elevated triglyceride levels. The average eGFR was 97.33 (33.03-175.9) ml/min/1.73 m2 (CG) and 84.14 (29.4-131) ml/min/1.73 m2 (MDRD). The microalbuminuria level was altered in 12.12% patients. CONCLUSION Kidney donation is unquestionably a safe procedure. However, a better understanding of the long-term consequences of living donor kidney transplantation is still needed. This knowledge may have important implications for the follow-up of these patients. Our study has demonstrated a non-negligible presence of an early marker of glomerular injury and a decrease in the GFR of some patients, thereby reinforcing the proposal for long-term follow-up of living kidney donors.
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Affiliation(s)
| | | | | | | | | | - Flávio Teles
- Alagoas State University of Health Science, Maceió, Alagoas, Brazil.,School of Medicine, Federal University of Alagoas, Maceió, Alagoas, Brazil
| | - André Falcão Pedrosa
- Alagoas State University of Health Science, Maceió, Alagoas, Brazil.,School of Medicine, Federal University of Alagoas, Maceió, Alagoas, Brazil
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116
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Narasimhamurthy M, Smith LM, Machan JT, Reinert SE, Gohh RY, Dworkin LD, Merhi B, Patel N, Beland MD, Hu SL. Does size matter? Kidney transplant donor size determines kidney function among living donors. Clin Kidney J 2017; 10:116-123. [PMID: 28638611 PMCID: PMC5469570 DOI: 10.1093/ckj/sfw097] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 08/16/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Kidney donor outcomes are gaining attention, particularly as donor eligibility criteria continue to expand. Kidney size, a useful predictor of recipient kidney function, also likely correlates with donor outcomes. Although donor evaluation includes donor kidney size measurements, the association between kidney size and outcomes are poorly defined. METHODS We examined the relationship between kidney size (body surface area-adjusted total volume, cortical volume and length) and renal outcomes (post-operative recovery and longer-term kidney function) among 85 kidney donors using general linear models and time-to-chronic kidney disease data. RESULTS Donors with the largest adjusted cortical volume were more likely to achieve an estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 over a median 24-month follow-up than those with smaller cortical volumes (P <0.001), had a shorter duration of renal recovery (1.3-2.2 versus 32.5 days) and started with a higher eGFR at pre-donation (107-110 versus 91 mL/min/1.73 m2) and immediately post-nephrectomy (∼63 versus 50-51 mL/min/1.73 m2). Similar findings were seen with adjusted total volume and length. CONCLUSIONS Larger kidney donors were more likely to achieve an eGFR ≥60 mL/min/1.73 m2 with renal recovery over a shorter duration due to higher pre-donation and initial post-nephrectomy eGFRs.
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Affiliation(s)
- Meenakshi Narasimhamurthy
- Division of Kidney Disease and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Lachlan M. Smith
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Jason T. Machan
- Biostatistics Core, Lifespan Hospital System, Departments of Orthopedic and Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Steven E. Reinert
- Lifespan Information Services, Lifespan Hospital System, Providence, RI, USA
| | - Reginald Y. Gohh
- Division of Renal Transplantation, Department of Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Lance D. Dworkin
- Division of Kidney Disease and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Basma Merhi
- Division of Kidney Disease and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Nikunjkumar Patel
- Division of Kidney Disease and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Michael D. Beland
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Susie L. Hu
- Division of Kidney Disease and Hypertension, Department of Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
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117
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Wang X, Garrett MR. Nephron number, hypertension, and CKD: physiological and genetic insight from humans and animal models. Physiol Genomics 2017; 49:180-192. [PMID: 28130427 DOI: 10.1152/physiolgenomics.00098.2016] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The kidneys play a vital role in the excretion of waste products and the regulation of electrolytes, maintenance of acid-base balance, regulation of blood pressure, and production of several hormones. Any alteration in the structure of the nephron (basic functional unit of the kidney) can have a major impact on the kidney's ability to work efficiently. Progressive decline in kidney function can lead to serious illness and ultimately death if not treated by dialysis or transplantation. While there have been numerous studies that implicate lower nephron numbers as being an important factor in influencing susceptibility to developing hypertension and chronic kidney disease, a direct association has been difficult to establish because of three main limitations: 1) the large variation in nephron number observed in the human population; 2) no established reliable noninvasive methods to determine nephron complement; and 3) to date, nephron measurements have been done after death, which doesn't adequately account for potential loss of nephrons with age or disease. In this review, we will provide an overview of kidney structure/function, discuss the current literature for both humans and other species linking nephron deficiency and cardio-renal complications, as well as describe the major molecular signaling factors involved in nephrogenesis that modulate variation in nephron number. As more detailed knowledge about the molecular determinants of nephron development and the role of nephron endowment in the cardio-renal system is obtained, it will hopefully provide clinicians the ability to accurately identify people at risk to develop CKD/hypertension and lead to a shift in patient care from disease treatment to prevention.
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Affiliation(s)
- Xuexiang Wang
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi; and
| | - Michael R Garrett
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi; and .,Department of Medicine (Nephrology) and Pediatrics (Genetics), University of Mississippi Medical Center, Jackson, Mississippi
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118
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Thorsen IS, Bleskestad IH, Jonsson G, Skadberg Ø, Gøransson LG. Neutrophil Gelatinase-Associated Lipocalin, Fibroblast Growth Factor 23, and Soluble Klotho in Long-Term Kidney Donors. NEPHRON EXTRA 2016; 6:31-39. [PMID: 27920796 PMCID: PMC5122995 DOI: 10.1159/000450621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background The best treatment for end-stage renal disease (ESRD) is kidney transplantation. Twenty-seven percent of transplantations in Norway are from living donors. Recent studies have shown an increased risk of ESRD and increased mortality in donors. The aim of this study was to determine if the levels of the new biomarkers neutrophil gelatinase-associated lipocalin (NGAL), soluble Klotho (sKlotho), and fibroblast growth factor 23 (FGF23) are changed in kidney donors with normal kidney function defined as an estimated glomerular filtration rate (eGFR) >60 ml/min/1.73 m2 compared to patients with chronic kidney disease (CKD) stages 3-5 and healthy controls. Methods This is a cross-sectional, observational, single-center study including 35 kidney donors with an eGFR ≥60 ml/min/1.73 m2 5 years after donation, 22 patients with CKD stage 3 (eGFR 30-59 ml/min/1.73 m2), 18 patients with CKD stage 4 (eGFR 15-29 ml/min/1.73 m2), 20 patients with CKD stage 5 (eGFR <15 ml/min/1.73 m2), and 35 controls comparing levels of biomarkers in long-term kidney donors with those in CKD patients and healthy controls. Results The level of log NGAL was significantly higher in donors than in healthy controls (2.02 ± 0.10 vs. 1.89 ± 0.10 ng/ml; p < 0.001), and the level increased with declining kidney function. The log FGF23 level was nonsignificantly higher in donors than in controls, but it significantly increased with declining kidney function. The log sKlotho levels were significantly lower in patients with CKD stages 4 and 5 than in controls, but no difference was revealed between controls and donors. Conclusion Kidney donors have significantly higher levels of NGAL than healthy controls after a median of 15 years (range 5-38). NGAL could be a valuable diagnostic marker in the future. FGF23 and sKlotho were not significantly different between donors and controls.
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Affiliation(s)
- Inga Strand Thorsen
- Department of Internal Medicine, Stavanger University Hospital, Stavanger, Norway
| | | | - Grete Jonsson
- Department of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | - Øyvind Skadberg
- Department of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | - Lasse Gunnar Gøransson
- Department of Internal Medicine, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway
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119
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Marconi L, Desai MM, Ficarra V, Porpiglia F, Van Poppel H. Renal Preservation and Partial Nephrectomy: Patient and Surgical Factors. Eur Urol Focus 2016; 2:589-600. [DOI: 10.1016/j.euf.2017.02.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 02/02/2017] [Accepted: 02/17/2017] [Indexed: 01/20/2023]
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120
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Quantification of Single-Kidney Function and Volume in Living Kidney Donors Using Dynamic Contrast-Enhanced MRI. AJR Am J Roentgenol 2016; 207:1022-1030. [DOI: 10.2214/ajr.16.16168] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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121
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Wormser C, Aronson LR. Perioperative morbidity and long-term outcome of unilateral nephrectomy in feline kidney donors: 141 cases (1998-2013). J Am Vet Med Assoc 2016; 248:275-81. [PMID: 26799104 DOI: 10.2460/javma.248.3.275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the outcome associated with unilateral nephrectomy in feline kidney donors. DESIGN Retrospective case series. ANIMALS 141 cats. PROCEDURES Medical records of cats that underwent nephrectomy for renal donation were reviewed for information on signalment, date of renal donation, results of blood and urine analyses, infectious disease history, anesthetic protocols, intra- and postoperative complications, and postoperative analgesic protocols. Long-term follow-up data were obtained via client telephone interview and review of referring veterinarian medical records. RESULTS All donors were healthy young adult cats with a median age of 1.5 years (range, 0.8 to 2 years). No cats died or were euthanized during the perioperative period. Intraoperative complications occurred in 2 cats, and postoperative complications occurred in 17. Median time from nephrectomy to hospital discharge was 3.6 days (range, 2 to 8 days). Long-term follow-up information was available for 99 cats, with a median interval between nephrectomy and follow-up of 10 years (range, 0.25 to 15 years). Six cats had a history of urinary tract disease including stable chronic kidney disease (n = 3), acute kidney injury (2), and cystitis (1). Nine cats were dead at follow-up; death was attributed to chronic renal failure in 2 and acute ureteral obstruction in 4. CONCLUSIONS AND CLINICAL RELEVANCE Feline donor nephrectomy had an acceptably low perioperative morbidity in this series. Most cats (84%) for which follow-up information was available had no associated long-term effects. However, a small subset (7%) developed renal insufficiency or died of urinary tract disease.
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122
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Kramers BJ, Kramers C, Lenders JWM, Deinum J. Effects of Treating Primary Aldosteronism on Renal Function. J Clin Hypertens (Greenwich) 2016; 19:290-295. [DOI: 10.1111/jch.12914] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 07/27/2016] [Accepted: 08/02/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Bart J. Kramers
- Department of Internal Medicine; Radboud University Medical Center; Nijmegen The Netherlands
| | - Cornelis Kramers
- Department of Internal Medicine; Radboud University Medical Center; Nijmegen The Netherlands
- Department of Pharmacology-Toxicology; Radboud University Medical Center; Nijmegen The Netherlands
| | - Jacques W. M. Lenders
- Department of Internal Medicine; Radboud University Medical Center; Nijmegen The Netherlands
- Department of Internal Medicine III; University Hospital Carl Gustav Carus; Technische Universität; Dresden Germany
| | - Jaap Deinum
- Department of Internal Medicine; Radboud University Medical Center; Nijmegen The Netherlands
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123
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Denic A, Lieske JC, Chakkera HA, Poggio ED, Alexander MP, Singh P, Kremers WK, Lerman LO, Rule AD. The Substantial Loss of Nephrons in Healthy Human Kidneys with Aging. J Am Soc Nephrol 2016; 28:313-320. [PMID: 27401688 DOI: 10.1681/asn.2016020154] [Citation(s) in RCA: 236] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/18/2016] [Indexed: 01/28/2023] Open
Abstract
Nephron number may be an important determinant of kidney health but has been difficult to study in living humans. We evaluated 1638 living kidney donors at Mayo Clinic (MN and AZ sites) and Cleveland Clinic. We obtained cortical volumes of both kidneys from predonation computed tomography scans. At the time of kidney transplant, we obtained and analyzed the sections of a biopsy specimen of the cortex to determine the density of both nonsclerotic and globally sclerotic glomeruli; the total number of glomeruli was estimated from cortical volume×glomerular density. Donors 18-29 years old had a mean 990,661 nonsclerotic glomeruli and 16,614 globally sclerotic glomeruli per kidney, which progressively decreased to 520,410 nonsclerotic glomeruli per kidney and increased to 141,714 globally sclerotic glomeruli per kidney in donors 70-75 years old. Between the youngest and oldest age groups, the number of nonsclerotic glomeruli decreased by 48%, whereas cortical volume decreased by only 16% and the proportion of globally sclerotic glomeruli on biopsy increased by only 15%. Clinical characteristics that independently associated with fewer nonsclerotic glomeruli were older age, shorter height, family history of ESRD, higher serum uric acid level, and lower measured GFR. The incomplete representation of nephron loss with aging by either increased glomerulosclerosis or by cortical volume decline is consistent with atrophy and reabsorption of globally sclerotic glomeruli and hypertrophy of remaining nephrons. In conclusion, lower nephron number in healthy adults associates with characteristics reflective of both lower nephron endowment at birth and subsequent loss of nephrons.
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Affiliation(s)
| | | | - Harini A Chakkera
- Division of Nephrology and Hypertension, Mayo Clinic, Scottsdale, Arizona; and
| | | | | | | | - Walter K Kremers
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
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124
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Denic A, Lieske JC, Chakkera HA, Poggio ED, Alexander MP, Singh P, Kremers WK, Lerman LO, Rule AD. The Substantial Loss of Nephrons in Healthy Human Kidneys with Aging. J Am Soc Nephrol 2016. [PMID: 27401688 DOI: 10.1681/asn.201602154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Nephron number may be an important determinant of kidney health but has been difficult to study in living humans. We evaluated 1638 living kidney donors at Mayo Clinic (MN and AZ sites) and Cleveland Clinic. We obtained cortical volumes of both kidneys from predonation computed tomography scans. At the time of kidney transplant, we obtained and analyzed the sections of a biopsy specimen of the cortex to determine the density of both nonsclerotic and globally sclerotic glomeruli; the total number of glomeruli was estimated from cortical volume×glomerular density. Donors 18-29 years old had a mean 990,661 nonsclerotic glomeruli and 16,614 globally sclerotic glomeruli per kidney, which progressively decreased to 520,410 nonsclerotic glomeruli per kidney and increased to 141,714 globally sclerotic glomeruli per kidney in donors 70-75 years old. Between the youngest and oldest age groups, the number of nonsclerotic glomeruli decreased by 48%, whereas cortical volume decreased by only 16% and the proportion of globally sclerotic glomeruli on biopsy increased by only 15%. Clinical characteristics that independently associated with fewer nonsclerotic glomeruli were older age, shorter height, family history of ESRD, higher serum uric acid level, and lower measured GFR. The incomplete representation of nephron loss with aging by either increased glomerulosclerosis or by cortical volume decline is consistent with atrophy and reabsorption of globally sclerotic glomeruli and hypertrophy of remaining nephrons. In conclusion, lower nephron number in healthy adults associates with characteristics reflective of both lower nephron endowment at birth and subsequent loss of nephrons.
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Affiliation(s)
| | | | - Harini A Chakkera
- Division of Nephrology and Hypertension, Mayo Clinic, Scottsdale, Arizona; and
| | | | | | | | - Walter K Kremers
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
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126
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Lenihan CR, Myers BD, Tan JC. Glomerular Function and Structure in Living Donors: Lessons from Single Nephron Studies. CURRENT TRANSPLANTATION REPORTS 2016; 3:24-32. [PMID: 27004159 PMCID: PMC4779140 DOI: 10.1007/s40472-016-0092-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
One third of the kidney transplants performed in the USA come from living kidney donors. The long-term outcome of healthy individuals who donate kidneys is mostly excellent, although recent studies have suggested that living donation is associated with a small absolute increase in the risk of end stage renal failure. Much of our understanding about the progression of kidney disease comes from experimental models of nephron loss. For this reason, living kidney donation has long been of great interest to renal physiologists. This review will summarize the determinants of glomerular filtration and the physiology that underlies post-donation hyperfiltration. We describe the 'remnant kidney' model of kidney disease and the reasons why such progressive kidney disease very rarely ensues in healthy humans following uninephrectomy. We also review some of the methods used to determine glomerular number and size and outline their associations.
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Affiliation(s)
- Colin R. Lenihan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Bryan D. Myers
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
| | - Jane C. Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA USA
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127
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Addressing the ESRD Risks of the Young Living Kidney Donor: Putting “Normal for Now” into Practice. CURRENT TRANSPLANTATION REPORTS 2016. [DOI: 10.1007/s40472-016-0083-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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128
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Steiner RW. Moving closer to understanding the risks of living kidney donation. Clin Transplant 2015; 30:10-6. [DOI: 10.1111/ctr.12652] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2015] [Indexed: 01/09/2023]
Affiliation(s)
- Robert W. Steiner
- Center for Transplantation; University of California; San Diego CA USA
- Division of Nephrology; Department of Medicine; School of Medicine; University of California; San Diego CA USA
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129
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Longitudinal study of living kidney donor glomerular dynamics after nephrectomy. Kidney Int 2015. [DOI: 10.1038/ki.2015.329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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130
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Delanaye P, Mariat C, Glassock RJ. Safety of Living Kidney Donation: Another Brick in the Wall…and a Solid (Physiologic) One. Am J Kidney Dis 2015; 66:1-3. [DOI: 10.1053/j.ajkd.2015.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 04/08/2015] [Indexed: 01/28/2023]
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131
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Yee J. Set theory: nephrology ∩ urology. Adv Chronic Kidney Dis 2015; 22:253-5. [PMID: 26088067 DOI: 10.1053/j.ackd.2015.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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132
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Polichnowski AJ, Licea-Vargas H, Picken M, Long J, Bisla R, Williamson GA, Bidani AK, Griffin KA. Glomerulosclerosis in the diet-induced obesity model correlates with sensitivity to nitric oxide inhibition but not glomerular hyperfiltration or hypertrophy. Am J Physiol Renal Physiol 2015; 309:F791-9. [PMID: 26109088 DOI: 10.1152/ajprenal.00211.2015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 06/19/2015] [Indexed: 12/17/2022] Open
Abstract
The diet-induced obesity (DIO) model is frequently used to examine the pathogenesis of obesity-related pathologies; however, only minimal glomerulosclerosis (GS) has been reported after 3 mo. We investigated if GS develops over longer periods of DIO and examined the potential role of hemodynamic mechanisms in its pathogenesis. Eight-week-old male obesity-prone (OP) and obesity-resistant (OR) rats (Charles River) were administered a moderately high-fat diet for 5 mo. Radiotelemetrically measured blood pressure, proteinuria, and GS were assessed. OP (n=10) rats developed modest hypertension (142±3 vs. 128±2 mmHg, P<0.05) and substantial levels of proteinuria (63±12 vs. 12±1 mg/day, P<0.05) and GS (7.7±1.4% vs. 0.4±0.2%) compared with OR rats (n=8). Potential hemodynamic mechanisms of renal injury were assessed in additional groups of OP and OR rats fed a moderately high-fat diet for 3 mo. Kidney weight (4.3±0.2 vs. 4.3±0.1 g), glomerular filtration rate (3.3±0.3 vs. 3.1±0.1 ml/min), and glomerular volume (1.9±0.1 vs. 2.0±0.1 μm3×10(-6)) were similar between OP (n=6) and OR (n=9) rats. Renal blood flow autoregulation was preserved in both OP (n=7) and OR (n=7) rats. In contrast, Nω-nitro-L-arginine methyl ester (L-NAME) administration in conscious, chronically instrumented OP (n=11) rats resulted in 15% and 39% increases in blood pressure and renal vascular resistance, respectively, and a 16% decrease in renal blood flow. Minimal effects of L-NAME were seen in OR (n=9) rats. In summary, DIO-associated GS is preceded by an increased hemodynamic sensitivity to L-NAME but not renal hypertrophy or hyperfiltration.
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Affiliation(s)
- Aaron J Polichnowski
- Department of Medicine, Loyola University, and Hines Veterans Affairs Hospital, Maywood, Illinois
| | - Hector Licea-Vargas
- Department of Medicine, Loyola University, and Hines Veterans Affairs Hospital, Maywood, Illinois
| | - Maria Picken
- Department of Pathology, Loyola University, Maywood, Illinois
| | - Jianrui Long
- Department of Electrical and Computer Engineering, Illinois Institute of Technology, Chicago, Illinois; and
| | - Rashmi Bisla
- Department of Medicine, Loyola University, and Hines Veterans Affairs Hospital, Maywood, Illinois
| | - Geoffrey A Williamson
- Department of Electrical and Computer Engineering, Illinois Institute of Technology, Chicago, Illinois; and
| | - Anil K Bidani
- Department of Medicine, Loyola University, and Hines Veterans Affairs Hospital, Maywood, Illinois
| | - Karen A Griffin
- Department of Medicine, Loyola University, and Hines Veterans Affairs Hospital, Maywood, Illinois;
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133
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Kanzaki G, Tsuboi N, Haruhara K, Koike K, Ogura M, Shimizu A, Yokoo T. Factors associated with a vicious cycle involving a low nephron number, hypertension and chronic kidney disease. Hypertens Res 2015; 38:633-41. [PMID: 26084263 DOI: 10.1038/hr.2015.67] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 12/15/2022]
Abstract
It has been reported that there is substantial variation in the nephron number between individuals. Previous studies using autopsy kidneys have demonstrated that a low nephron number, in relation to a low birth weight, may result in hypertension (HTN) and/or chronic kidney disease (CKD). However, recent studies have revealed that the association between a low nephron number and HTN is not a universal finding. This observation indicates that a low nephron number is unlikely to be the sole factor contributing to an elevated blood pressure. In addition to the nephron number, various genetic and congenital factors may contribute to increased susceptibility to HTN and/or CKD in a complex manner. Acquired factors, including aging, obesity and related metabolic abnormalities, and various causes of renal injury, may additionally promote further nephron loss. Such a vicious cycle may induce HTN and/or CKD via the common mechanisms of renal hemodynamic maladaptation.
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Affiliation(s)
- Go Kanzaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kotaro Haruhara
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Makoto Ogura
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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134
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Tan JC, Gordon EJ, Dew MA, LaPointe Rudow D, Steiner RW, Woodle ES, Hays R, Rodrigue JR, Segev DL. Living Donor Kidney Transplantation: Facilitating Education about Live Kidney Donation--Recommendations from a Consensus Conference. Clin J Am Soc Nephrol 2015; 10:1670-7. [PMID: 25908792 DOI: 10.2215/cjn.01030115] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The Best Practice in Live Kidney Donation Consensus Conference held in June of 2014 included the Best Practices in Living Donor Education Workgroup, whose charge was to identify best practice strategies in education of living donors, community outreach initiatives, commercial media, solicitation, and state registries. The workgroup's goal was to identify critical content to include in living kidney donor education and best methods to deliver educational content. A detailed summary of considerations regarding educational content issues for potential living kidney donors is presented, including the consensus that was reached. Educational topics that may require updating on the basis of emerging studies on living kidney donor health outcomes are also presented. Enhancing the educational process is important for increasing living donor comprehension to optimize informed decision-making.
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Affiliation(s)
- Jane C Tan
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California;
| | - Elisa J Gordon
- Center for Healthcare Studies and Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, and Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dianne LaPointe Rudow
- Recanati Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York
| | - Robert W Steiner
- Department of Medicine, University of California at San Diego, San Diego, California
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Rebecca Hays
- Transplant Center, University of Wisconsin Hospital, Madison, Wisconsin
| | - James R Rodrigue
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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135
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Abstract
Almost one-third of transplanted kidneys come from living donors, who sacrifice approximately 30% of their pre-donation glomerular filtration rate (GFR) after they experience compensatory hypertrophy and hyperfiltration in their remaining kidney. Although hyperfiltration can cause glomerular injury, many studies have suggested that donor nephrectomy itself does not cause long-term loss of GFR at a higher rate than what is seen in the normal aging population. However, when post-donation kidney diseases occur in an unfortunate few, recent studies suggest that GFR loss at donor nephrectomy increases the risk of eventual end-stage renal disease (ESRD). In this issue of the JCI, Lenihan and colleagues evaluated glomerular dynamics in a cohort of kidney donors prior to, within 1 year of, and several years after kidney donation. Their results suggest that adaptive hyperfiltration in the remaining kidney occurs without glomerular hypertension, furthering our understanding of the relatively benign renal outcomes for most living kidney donors.
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Affiliation(s)
- Roland C. Blantz
- Department of Medicine, School of Medicine, Division of Nephrology-Hypertension, UCSD, San Diego, California, USA
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
| | - Robert W. Steiner
- Department of Medicine, School of Medicine, Division of Nephrology-Hypertension, UCSD, San Diego, California, USA
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