The role of kidney biopsy in heart transplant candidates with kidney disease.

BACKGROUND: Kidney disease is common in patients with advanced heart failure and can result from intrinsic parenchymal disease or to reversible hemodynamic factors. Distinguishing the two is difficult but is important when selecting patients who will benefit from combined heart and kidney transplantation (HKT) versus heart transplantation (OHT) alone. The goal of this study was to characterize kidney biopsy findings in this population and follow the outcome of patients based on the biopsy results. METHODS: Thirty heart transplant candidates with an estimated glomerular filtration rate less than 40 mL/min or proteinuria greater than 500 mg/day or a history of amyloidosis underwent kidney biopsies between June 2001 and March 2009. The renal pathologic diagnosis as well as the percent tubular atrophy and interstitial fibrosis on renal biopsy were assessed. RESULTS: Proteinuria and glomerular filtration rate at the time of evaluation for heart transplant did not correlate with the degree of fibrosis on biopsy. On the basis of the biopsy results, nine patients were listed for OHT and eight patients were listed for HKT. One patient originally triaged to receive OHT and was listed for HKT due to subsequent worsening of renal function. Eight patients received OHT, none required dialysis during a median follow-up period of 18 months. CONCLUSIONS: Renal biopsy provides useful diagnostic information to differentiate intrinsic renal disease from renal hypoperfusion and helps guide the decision for OHT alone versus combined HKT.

Combined heart-kidney transplantation: a review of recipient selection and patient outcomes.

Elevated serum creatinine is a common finding among patients awaiting heart transplantation because of reduced renal perfusion in the setting of severe heart failure as well as overlapping risk factors for chronic kidney disease and heart disease. Patients with significant renal dysfunction preoperatively have worse outcomes with heart transplantation alone compared with those with normal renal function or those with renal dysfunction who undergo combined heart-kidney transplantation. Optimizing organ distribution and patient outcomes after cardiac transplantation requires appropriate recipient selection, including deciding which patients will benefit from combined heart-kidney transplantation. This review focuses on the evaluation of patients with chronic kidney disease awaiting heart transplantation and the outcomes of combined heart-kidney transplantation.

Antiepileptic drugs and bone metabolism.

Anti-epileptic medications encompass a wide range of drugs including anticonvulsants, benzodiazepines, enzyme inducers or inhibitors, with a variety effects, including induction of cytochrome P450 and other enzyme, which may lead to catabolism of vitamin D and hypocalcemia and other effects that may significantly effect the risk for low bone mass and fractures. With the current estimates of 50 million people worldwide with epilepsy together with the rapid increase in utilization of these medications for other indications, bone disease associated with the use of anti-epileptic medications is emerging as a serious health threat for millions of people. Nevertheless, it usually goes unrecognized and untreated. In this review we discuss the pathophysiologic mechanisms of bone disease associated with anti-epileptic use, including effect of anti-epileptic agents on bone turnover and fracture risk, highlighting various strategies for prevention of bone loss and associated fractures a rapidly increasing vulnerable population.