The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression and graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research. This summary includes a brief description of methodology and the complete guideline recommendations but does not include the rationale and references for each recommendation, which are published elsewhere.

No abstract

No abstract

Transplant candidates are permitted to register on multiple waiting lists. We examined multiple-listing practices and outcomes, using data on 81 481 kidney and 26 260 liver candidates registered between 7/1/95 and 6/30/00. Regression models identified factors associated with multiple-listing and its effect on relative rates of transplantation, waiting list mortality, kidney graft failure, and liver transplant mortality. Overall, 5.8% (kidney) and 3.3% (liver) of candidates multiple-listed. Non-white race, older age, non-private insurance, and lower educational level were associated with significantly lower odds of multiple-listing. While multiple-listed, transplantation rates were significantly higher for nearly all kidney and liver candidate subgroups (relative rate [RR] = = 1.42-2.29 and 1.82-7.41, respectively). Waiting list mortality rates were significantly lower while multiple-listed for 11 kidney subgroups (RR = = 0.22-0.72) but significantly higher for 7 liver subgroups (RR = = 1.44-5.93), suggesting multiple-listing by healthier kidney candidates and sicker liver candidates. Graft failure was 10% less likely among multiple-listed kidney recipients. Multiple-and single-listed liver recipients had similar post-transplant mortality rates. Although specific factors characterize those transplant candidates likely to multiple-list, transplant access is significantly enhanced for almost all multiple-listed kidney and liver candidates.

Hypertension is common in CKD, and is a risk factor for faster progression of kidney disease and development and worsening of CVD. Some antihypertensive agents also slow the progression of kidney disease by mechanisms in addition to their antihypertensive effect. 1.1 Antihypertensive therapy should be used in CKD to: 1.1.a Lower blood pressure (A); 1.1.b Reduce the risk of CVD, in patients with or without hypertension (B) (see Guideline 7); 1.1.c Slow progression of kidney disease, in patients with or without hypertension (A) (see Guidelines 8, 9,10). 1.2 Modifications to antihypertensive therapy should be considered based on the level of proteinuria during treatment (C) (see Guidelines 8, 9, 10,11). 1.3 Antihypertensive therapy should be coordinated with other therapies for CKD as part of a multi-intervention strategy (A). 1.4 If there is a discrepancy between the treatment recommended to slow progression of CKD and to reduce the risk of CVD, individual decision-making should be based on risk stratification (C). BACKGROUND The Joint National Committee (JNC) for Prevention, Detection, Evaluation and Treatment of High Blood Pressure issues regular reports that are meant to provide guidance for primary-care clinicians. The seventh report (JNC 7), issued in 2003, suggests stratification of risk for CVD in individuals with high blood pressure to determine the intensity of treatment. Individuals at highest risk should receive most intensive treatment, including prompt pharmacological therapy, a lower blood pressure goal, and use of specific antihypertensive agents for "compelling indications," including CKD. 5,5a Hypertension is common in CKD, affecting 50% to 75% of individuals. The Work Group for this K/DOQI Guideline on Hypertension and Antihypertensive Agents in CKD proposes recommendations for all patients with CKD, whether or not they have hypertension. Guideline 1 reviews the goals of antihypertensive therapy; multi-intervention strategies for CKD; and possible discrepancies between goals of slowing progression of CKD and reducing CVD risk. It concludes with a review of key recommendations of the guidelines and compares the recommendations to those made by the JNC 7, as well as with previous reports by the NKF and ADA. Limitations, implementation issues, and research recommendations are covered in subsequent guidelines. RATIONALE Definitions Antihypertensive therapy includes lifestyle modifications and pharmacological therapy that reduce blood pressure, in patients with or without hypertension. Lifestyle modifications include changes in diet, exercise, and habits that may slow the progression of CKD or lower the risk of CVD. These guidelines focus specifically on lifestyle modifications that lower blood pressure. Lifestyle modifications are discussed in more detail in Guideline 6. Pharmacological therapy includes selection of antihypertensive agents and blood pressure goals. Antihypertensive agents are defined as agents that lower blood pressure and are usually prescribed to hypertensive individuals for this pu...