Management of obesity in kidney transplant candidates and recipients: A clinical practice guideline by the DESCARTES Working Group of ERA

The clinical practice guideline Management of Obesity in Kidney Transplant Candidates and Recipients was developed to guide decision-making in caring for people with end-stage kidney disease (ESKD) living with obesity. The document considers the challenges in defining obesity, weighs interventions for treating obesity in kidney transplant candidates as well as recipients and reflects on the impact of obesity on the likelihood of wait-listing as well as its effect on transplant outcomes. It was designed to inform management decisions related to this topic and provide the backdrop for shared decision-making. This guideline was developed by the European Renal Association's Developing Education Science and Care for Renal Transplantation in European States working group. The group was supplemented with selected methodologists to supervise the project and provide methodological expertise in guideline development throughout the process. The guideline targets any healthcare professional treating or caring for people with ESKD being considered for kidney transplantation or having received a donor kidney. This includes nephrologists, transplant physicians, transplant surgeons, general practitioners, dialysis and transplant nurses. Development of this guideline followed an explicit process of evidence review. Treatment approaches and guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation approach. Limitations of the evidence are discussed and areas of future research are presented

A roadmap for optimizing chronic kidney disease patient care and patient-oriented research in the Eastern European nephrology community

Chronic kidney disease (CKD) is a major health problem because of its high prevalence, associated complications and high treatment costs. Several aspects of CKD differ significantly in the Eastern European nephrology community compared with Western Europe because of different geographic, socio-economic, infrastructure, cultural and educational features. The two most frequent aetiologies of CKD, DM and hypertension, and many other predisposing factors, are more frequent in the Eastern region, resulting in more prevalent CKD Stages 3-5. Interventions may minimize the potential drawbacks of the high prevalence of CKD in Eastern Europe, which include several options at various stages of the disease, such as raising public, medical personnel and healthcare authorities awareness; early detection by screening high-risk populations; preventing progression and CKD-related complications by training health professionals and patients; promoting transplantation or home dialysis as the preferred modality; disseminating and implementing guidelines and guided therapy and encouraging/supporting country-specific observational research as well as international collaborative projects. Specific ways to significantly impact CKD-related problems in every region of Europe through education, science and networking are collaboration with non-nephrology European societies who have a common interest in CKD and its associated complications, representation through an advisory role within nephrology via national nephrology societies, contributing to the training of local nephrologists and stimulating patient-oriented research. The latter is mandatory to identify country-specific kidney disease-related priorities. Active involvement of patients in this research via collaboration with the European Kidney Patient Federation or national patient federations is imperative to ensure that projects reflect specific patient needs.Peer reviewe

Nephrology and Public Policy Committee propositions to stimulate research collaboration in adults and children in Europe

The strengths and the limitations of research activities currently present in Europe are explored in order to outline how to proceed in the near future. Epidemiological and clinical research and public policy in Europe are generally considered to be comprehensive and successful, and the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) is playing a key role in the field of nephrology research. The Nephrology and Public Policy Committee (NPPC) aims to improve the current situation and translation into public policy by planning eight research topics to be supported in the coming 5 years by ERA-EDTA.Peer reviewe

The genetic architecture of membranous nephropathy and its potential to improve non-invasive diagnosis

Membranous Nephropathy (MN) is a rare autoimmune cause of kidney failure. Here we report a genome-wide association study (GWAS) for primary MN in 3,782 cases and 9,038 controls of East Asian and European ancestries. We discover two previously unreported loci, NFKB1 (rs230540, OR = 1.25, P = 3.4 × 10-12) and IRF4 (rs9405192, OR = 1.29, P = 1.4 × 10-14), fine-map the PLA2R1 locus (rs17831251, OR = 2.25, P = 4.7 × 10-103) and report ancestry-specific effects of three classical HLA alleles: DRB1*1501 in East Asians (OR = 3.81, P = 2.0 × 10-49), DQA1*0501 in Europeans (OR = 2.88, P = 5.7 × 10-93), and DRB1*0301 in both ethnicities (OR = 3.50, P = 9.2 × 10-23 and OR = 3.39, P = 5.2 × 10-82, respectively). GWAS loci explain 32% of disease risk in East Asians and 25% in Europeans, and correctly re-classify 20-37% of the cases in validation cohorts that are antibody-negative by the serum anti-PLA2R ELISA diagnostic test. Our findings highlight an unusual genetic architecture of MN, with four loci and their interactions accounting for nearly one-third of the disease risk

Living unrelated-commercial-kidney transplantation: when there is no chance to survive

Transplantation is the best treatment of end-stage renal disease (ESRD); however, organ shortage is a reality. Deceased donor organ donation is inadequate; hence, the number of patients on the waiting lists is increasing progressively. Since many ESRD patients do not have living genetically related donors, living unrelated transplantation is considered. These transplantations offer excellent graft and patient survival rates if practiced in conventional situations, while the results are not so favorable or even poor in unconventional transplantations, which mostly take place in developing countries. Ethical aspects of living unrelated transplantation are more complicated than the medical side due to concern of commercialization. Making payment to the donors has been considered strictly as nonethical by many authors, while some others suggest reopening previous debates for kidney sales. The latter claim that if exploitation of donors is avoided, the reward (or payment) to the donor can be morally justified. Apart from these controversies, it is uniformly accepted that commercial transplantation is certainly unethical when brokers are involved or the aim is just profit for transplant physicians, because the main reason in favor of organ sales is improving the quality of life of the patients and the donors, not the brokers or the physicians. All these theoretical ethical arguments in the Western countries turn out to become vital concerns in developing countries, because transplantation is the cheapest renal replacement therapy. Recently, it has been suggested that organ shortage problems can partly be solved by establishing controlled donor compensation programs in these countries, which may also prevent exploitation of the donors. However, it is impossible to suggest a uniform solution for all countries because of deep differences in economical status as well as social and cultural values. Thus, every country should build its own ethical standards for commercial transplantation

Prevention and Treatment of AKI during Various Disasters

Acute kidney injury (AKI) is frequent, and shows wide variation with regards to the spectrum, etio-pathogenesis and management strategies after natural (e.g., earthquakes) and man-made disasters (e.g., wars). The most important pathogenetic mechanisms in AKI during earthquakes are crush injury-related hypovolemia and myoglobinuria. Therefore, the most effective preventive measures are early and energetic fluid resuscitation (especially isotonic saline due to medical and logistic advantages) and also avoiding nephrotoxic medications. When preventive measures fail and intrarenal AKI develops, dialysis is lifesaving, with a preference towards intermittent hemodialysis due to medical and logistic advantages during disasters. During wars, the most important man-made disaster, prerenal, intrarenal and postrenal AKI may develop both at the battlefield and also in the field- or tertiary care-hospital setting. Overall, pathogenesis and management strategies of AKI in war victims are similar with those of AKI in general and in natural disasters. Logistic planning after disasters is vital for providing the most effective treatment. If patients cannot be coped with locally, either help should be asked from, or, alternatively, patients should be referred to, other regions or countries. Importantly, nephrology units in and around disaster-prone areas should be prepared for disasters for a sudden influx of AKI victims after disasters

Disasters, children and the kidneys

Following disasters, children are physically, psychologically and socially more vulnerable than adults; consequently, their morbidity and mortality are higher. The risks are especially high for orphans and unaccompanied children who are separated from their families, making them frequently victims of human trafficking, slavery, drug addiction, crime or sexual exploitation. Education of children and families about disaster-related risks and providing special protection in disaster preparedness plans may mitigate these threats. Kidney disease patients, both paediatric and adult, are extra vulnerable during disasters, because their treatment is dependent on technology and functioning infrastructure. Acute kidney injury, chronic kidney disease patients not on dialysis and dialysis and transplant patients are faced with extensive problems. Overall, similar treatment principles apply both for adults and paediatric kidney patients, but management of children is more problematic, because of substantial medical and logistic difficulties. To minimize drawbacks, it is vital to be prepared for renal disasters. Preparedness plans should address not only medical professionals, but also patients and their families. If problems cannot be coped with locally, calling for national and/or international help is mandatory. This paper describes the spectrum of disaster-related problems in children and the specific features in treating acute and chronic kidney disease in disasters

Management of Crush Syndrome Casualties after Disasters

After direct impact of the trauma, crush syndrome is the second most frequent cause of death after mass disasters. However, since crush syndrome is quite rare in daily practice, mistakes are frequent in the treatment of these cases. This paper summarizes the etiopathogenesis of traumatic rhabdomyolysis and of crush syndrome-based acute kidney injury. The clinical and laboratory features, prophylaxis, and treatment of crush cases are described as well. The importance of early and energetic fluid resuscitation is underlined for prophylaxis of acute kidney injury. Since there is chaos, and an overwhelming number of victims, logistic drawbacks create a specific problem in the treatment of crush victims after mass disasters. Potential solutions for logistic hurdles and disaster preparedness scenarios have also been provided in this review article

Moderator's view: Pretransplant weight loss in dialysis patients: cum grano salis

A high Body Mass Index (BMI) predicts delayed graft function, all cause and cardiovascular death after transplantation but such risk excess is apparently confined to patients included in studies performed before 2000. Perhaps with the exception of morbid obesity (BMI > 40), clinical outcomes in transplanted obese patients are definitely better than in listed dialysis patients who don't receive a renal transplant. Furthermore the new Scientific Registry of Transplant Recipients (SRTR) risk calculator incorporates BMI into the prediction model of the global risk for the graft's and patient's survival appropriately framing the risk of obesity in a multi-dimensional risk context. In the aggregate, available knowledge suggests that clinical decisions on weight loss before transplantation should be context specific. Renal transplant patients from living donors have substantial better survival in comparison to well matched dialysis patients listed for the same intervention at all BMI categories. Therefore renal transplantation in obese patients with a living donor may be prioritized. The attitude of fully informed obese patients at accepting the risk driven by transplantation, the experience of the surgical team with obese patients (including also robotic surgery) are of obvious importance. Renal transplantation should be timely considered when reasonable attempts at weight loss failed or appear overtly unrealistic. Transplantation in morbidly obese patients with BMI > 40, a category where the survival advantage of transplantation vs dialysis is probably small and still uncertain, particularly so in African-Americans, should be deferred until significant weight loss is achieved