Renal transplant recipients have an increased risk of non-melanoma skin cancer (NMSC) compared to in the general population. Here, we show polygenic risk scores (PRS) calculated from genome-wide association studies (GWAS) of NMSC in a general, nontransplant setting, can predict risk of, and time to posttransplant skin cancer. Genetic variants, reaching predefined P-value thresholds were chosen from published squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) nontransplant GWAS. Using these GWAS, BCC and SCC PRS were calculated for each sample across three European ancestry renal transplant cohorts (n = 889) and tested as predictors of case:control status and time to NMSC posttransplant. BCC PRS calculated at P-value threshold 1 × 10 was the most significant predictor of case:control status of NMSC posttransplant (OR = 1.61; adjusted P = .0022; AUC [full model adjusted for clinical predictors and PRS] = 0.81). SCC PRS at P-value threshold 1 × 10 was the most significant predictor of time to posttransplant NMSC (adjusted P = 9.39 × 10 ; HR = 1.41, concordance [full model] = 0.74). PRS of nontransplant NMSC is predictive of case:control status and time to NMSC posttransplant. These results are relevant to how genomics can risk stratify patients to help develop personalized treatment regimens.

Chronic kidney disease (CKD) is an increasingly common public health concern with a global prevalence of ~10% 1 . This disease now ranks as the 12th leading cause of death worldwide 1 . CKD results from a heterogeneous group of conditions that lead to a progressive and irreversible impairment in kidney function. It is defined as a reduction in estimated glomerular filtration rate (eGFR) to <60 ml/min/1.73 m 2 and/or the presence of markers of kidney damage on at least two occasions at least 3 months apart 2 .CKD is independently associated with cardiovascular disease 3 . As eGFR decreases, the risks of major cardiovascular events, cardiovascular mortality and all-cause mortality increase 4 . Importantly, patients with stage 1-3 CKD (eGFR >30 ml/min/1.73 m 2 ) are more likely to die from cardiovascular disease than they are to reach kidney failure 4,5 and around 50% of patients with kidney failure die from cardiovascular causes 6 . Not only are cardio vascular events more common in patients with CKD, but outcomes following such events are worse than in the general population 7 . Almost 8% of global cardiovascular deaths in 2017 were attributable to CKD 1 .Hypertension is both a cause and a consequence of CKD. As kidney function declines, blood pressure rises, and more than 85% of patients with CKD are hypertensive 8 . Thus, reducing blood pressure in CKD is a key therapeutic strategy that not only slows the progression to kidney failure but also reduces cardiovascular risk 9 . However, more than 30% of patients with CKD require four or more antihypertensive agents to achieve adequate blood pressure control and up to 50% never reach their target blood pressure 8 . Uncontrolled hypertension promotes the development of left ventricular hypertrophy (LVH). The prevalence of LVH increases as kidney function declines and it is present in ~50% of patients with an eGFR of <25 ml/min/1.73 m 2 (ref. 10 ). Alongside hypertension and LVH, arterial stiffness, endothelial dysfunction and proteinuria are characteristic features of CKD and important independent predictors of cardiovascular disease 4,[11][12][13][14] .Current evidence-based management of CKD is limited to blockers of the renin-angiotensin-aldosterone system (RAAS) that slow CKD progression 4,8 . Sodiumglucose co-transporter 2 (SGLT2) inhibitors, which were originally developed for the treatment of type 2 diabetes mellitus (T2DM), have also now been shown to improve kidney and cardiovascular end points in patients with and without T2DM 15,16 . However, an urgent unmet need remains for novel treatments 17 . The ideal therapy would provide direct renoprotection and reduce proteinuria, while also offering broad cardiovascular protection. The apelin system has exciting therapeutic potential in this regard. In this Review, we focus on current

Hypertension is a significant and increasing global health issue. It is a leading cause of cardiovascular disease and premature death worldwide due to its effects on end organs, and through its associations with chronic kidney disease, diabetes mellitus and obesity. Despite current management strategies, many patients do not achieve adequate blood pressure (BP) control. Hypertension-related cardiovascular mortality rates are rising in tandem with the increasing global prevalence of chronic kidney disease, diabetes mellitus and obesity. Improving BP control must therefore be urgently prioritised. Strategies include utilising existing antihypertensive agents more effectively, and using treatments developed for co-existing conditions (such as sodium-glucose cotransporter 2 inhibitors for diabetes mellitus) that offer additional BP-lowering and cardiovascular benefits. Additionally, novel therapeutic agents that target alternative prohypertensive pathways and that offer broader cardiovascular protection are under development, including dual angiotensin receptor-neprilysin inhibitors. Nonpharmacological strategies such as immunotherapy are also being explored. Finally, advancing knowledge of the human genome and molecular modification technology may usher in an exciting new era of personalised medicine, with the potential to revolutionise the management of hypertension.

Objectives Anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) is a rare autoimmune disorder that commonly involves the kidney. Early identification of kidney involvement, assessing treatment-response and predicting outcome are important clinical challenges. Here, we assessed the potential utility of interval kidney biopsy in AAV. Methods In a tertiary referral centre with a dedicated vasculitis service, we identified patients with AAV who had undergone interval kidney biopsy, defined as a repeat kidney biopsy (following an initial biopsy showing active AAV) undertaken to determine the histological response in the kidney following induction immunosuppression. We analysed biochemical, histological and outcome data, including times to kidney failure and death for all patients. Results We identified 57 patients with AAV who underwent at least one interval kidney biopsy (59 interval biopsies in total; median time to interval biopsy ∼130 days). Of the 59 interval biopsies performed, 24 (41%) patients had clinically suspected active disease at time of biopsy which was confirmed histologically in only 42% of cases; 35 (59%) patients were in clinical disease-remission, and this was correct in 97% of cases. The clinician’s impression was incorrect in 1 in 4 patients. Hematuria at interval biopsy did not correlate with histological activity. Interval biopsy showed fewer acute lesions and more chronic damage compared to initial biopsy and led to immunosuppressive treatment-change in 75% (44/59) of patients. Clinical risk prediction tools tended to operate better using interval biopsy data. Conclusion Interval kidney biopsy is useful for determining treatment-response and subsequent disease management in AAV. It may provide better prognostic information than initial kidney biopsy and should be considered for inclusion into future clinical trials and treatment protocols for patients with AAV.

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Aims Chronic kidney disease (CKD) is common and cardiovascular disease (CVD) is its commonest complication. The apelin system is a potential therapeutic target for CVD but data relating to apelin in CKD are limited. We examined expression of the apelin system in human kidney, and investigated apelin and Elabela/Toddler (ELA), the endogenous ligands for the apelin receptor, in patients with CKD. Methods Using autoradiography, immunohistochemistry and enzyme‐linked immunosorbent assay, we assessed expression of apelin, ELA and the apelin receptor in healthy human kidney, and measured plasma apelin and ELA in 155 subjects (128 patients with CKD, 27 matched controls) followed up for 5 years. Cardiovascular assessments included blood pressure, arterial stiffness (pulse wave velocity) and brachial artery flow‐mediated dilation. Surrogate markers of endothelial function (plasma asymmetric dimethylarginine and endothelin‐1) and inflammation (C‐reactive protein and interleukin‐6) were measured. Results The apelin system was expressed in healthy human kidney, throughout the nephron. Plasma apelin concentrations were 60% higher in women than men (6.48 [3.62–9.89] vs. 3.95 [2.02–5.85] pg/mL; P < .0001), and increased as glomerular filtration rate declined (R = −0.41, P < .0001), and albuminuria rose (R = 0.52, P < .0001). Plasma apelin and ELA were associated with vascular dysfunction. Plasma apelin associated independently with a 50% decline in glomerular filtration rate at 5 years. Conclusion We show for the first time that the apelin system is expressed in healthy human kidney. Plasma apelin is elevated in CKD and may be a potential biomarker of risk of decline in kidney function. Clinical studies exploring the therapeutic potential of apelin agonism in CKD are warranted.

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Eosinophilic granulomatosis with polyangiitis (EGPA) is a form of ANCA-associated vasculitis (AAV). Clinical trials demonstrating the efficacy of mycophenolate mofetil (MMF) for remission induction in AAV excluded patients with EGPA. Despite this, MMF is commonly used in these patients. The objective of this study was to evaluate, for the first time, the effectiveness and tolerance of MMF in EGPA remission induction. A retrospective, two-center, real-world study was conducted in patients with EGPA who received MMF in addition to prednisolone for newly diagnosed or relapsing disease between 2009 and 2019. Baseline, 3-, 6- and 12-month outcome data were extracted from electronic health records. The primary outcome was disease remission, defined as a Birmingham Vasculitis Activity Score of 0 at 6 months. Secondary outcomes included disease relapse, median prednisolone dose at 12 months and drug tolerance. In total, 15 patients (73% male, median age 57) with EGPA (11 newly diagnosed/4 relapsing) were identified. At 6 months, 67% had achieved disease remission. At 12 months, this was maintained (66.7%) and 4 patients had relapsed. All but one patient remained on MMF at study completion and all patients tolerated MMF. Our real-world data suggest that MMF is an effective and well-tolerated agent for achieving disease remission in EGPA. A future randomized controlled trial of MMF in this neglected orphan disease is now warranted.