Effect of intravenous iron on outcomes of acute kidney injury.

BACKGROUND: Little is known about benefit versus risk in treating iron deficiency anemia with intravenous (IV) iron in patients with acute kidney injury (AKI). Concerns about adverse outcomes may dissuade use and could contribute to greater use of red blood cell (RBC) transfusion. STUDY DESIGN AND METHODS: We performed a retrospective case-control study of patients with AKI who received IV iron (cases) compared to those with AKI without IV iron (controls). RESULTS: We identified 67 cases and 67 controls matched for age, stage of chronic kidney disease, and severity of anemia (hemoglobin [Hb], 7.7 ± 0.1 mg/dL vs. 7.5 ± 0.1 mg/dL; p = 0.47). Cases tended to be sicker with longer length of stay (27 + 4 days vs. 15 + 1.3 days; p = 0.003) and more intensive care unit days (13 + 2 days vs. 5 + 1 days; p = 0.003), more often with diagnosis of sepsis and greater number of antibiotics used (2.7 ± 0.3 vs. 1.8 ± 0.2; p = 0.02). Sepsis and AKI preceded use of IV iron. Despite greater illness severity, there was no difference in dialysis (38.8% vs. 34.3%; p = 0.59), mortality (24% vs. 21%; p = 0.679), or severity and/or recovery of AKI. Discharge Hb was similar (9.0 ± 0.1 mg/dL vs. 9.1 ± 0.1 mg/dL; p = 0.47). IV iron was used later in the stay and hence the cases also had more RBC transfusions. CONCLUSIONS: We were unable to find any adverse consequences of use of IV iron when used to treat anemia in patients with AKI in regard to recovery of AKI or mortality even in patients with a diagnosis of sepsis. Consideration of preemptive use of IV iron in AKI with severe anemia is warranted to determine if this would reduce RBC transfusion.

Effect of allopurinol on slowing allograft functional decline in kidney transplant recipients.

OBJECTIVES: Hyperuricemia may be a risk factor for graft loss in kidney transplant recipients. The purpose of this study was to evaluate the effects of allopurinol in kidney transplant recipients. MATERIALS AND METHODS: A single center retrospective case-control study was performed with kidney transplant recipients who were treated with allopurinol (54 patients) and a control group matched for time of transplant (± 3 months) and estimated glomerular filtration rate (54 patients). We evaluated the relation between allopurinol use and estimated glomerular filtration rate, graft survival, blood pressure, and number of anti-hypertensive drugs used. RESULTS: At the start of allopurinol therapy, mean serum uric acid level was greater in the allopurinol (476 ± 119 µmol/L) than control group (404 ± 125 µmol/L; P ≤ .001) and estimated glomerular filtration rate was similar between the 2 groups (allopurinol, 39 ± 16 mL/min; control, 38 ± 16 mL/min; not significant). At 1 year, mean estimated glomerular filtration rate was greater in the allopurinol than control group (allopurinol, 41 ± 15 mL/min; control, 36 ± 13 mL/min; P ≤ .04). At 2 years, mean serum uric acid level was significantly lower in the allopurinol (399 ± 101 µmol/L) than control group (452 ± 95 µmol/L; P ≤ .02). Graft survival, blood pressure, and antihypertensive requirements were similar between the groups. CONCLUSIONS: Allopurinol use is associated with preservation of estimated glomerular filtration rate in kidney transplant recipients. There may be potential benefit in treating asymptomatic hyperuricemia in kidney transplant recipients.

Belatacept : a new biological agent for maintenance immunosuppression in kidney transplantation.

INTRODUCTION: Over the past decades, calcineurin inhibitors (CNIs) have become the cornerstone of transplant immunosuppression. CNIs can exert negative effects on chronic allograft function along with cardiovascular (CV) and metabolic adverse effects. Belatacept , a selective co-stimulation blocker of T cells, is the first US FDA (06/2011) and EMEA (06/2011) approved biologic agent for maintenance immunosuppression in renal transplantation. AREAS COVERED: The authors critically reviewed the literature over the last few years comparing belatacept with current standard of maintenance immunosuppression including CNIs in kidney transplantation. EXPERT OPINION: Despite the increased incidence and severity of acute rejection with belatacept in Phase II and III studies, a better preservation of GFR and reduced incidence of chronic allograft nephropathy was observed as compared with CNIs. Patient and graft survivals were similar over 3- and 5-year follow-up post-transplantation. Incidence of adverse events were similar between the groups, but the risk of post-transplant lymphoproliferative disorder, predominantly involving CNS, was higher in Epstein-Barr virus seronegative recipients on belatacept, especially with a more intensive regimen. CV and metabolic end points were more favorable in belatacept versus CNI groups with similar incidences of diabetes after transplantation. Belatacept seems to be a promising drug for the future, but long-term outcomes are awaited.