Reply to: “Chronic kidney disease (CKD) and NAFLD: Time for awareness and screening”
Authors: Alina M. Allen, W. Ray Kim, Julie K. Heimbach, Andrew D. Rule
Journal: Journal of Hepatology (2014)

Chronic kidney disease (CKD) and NAFLD: Time for awareness and screeningJournal of HepatologyVol. 62Issue 4PreviewWe read with interest the article by Allen et al. reporting on the high prevalence and associated mortality of chronic kidney disease (CKD), in patients who had undergone liver transplantation [1]. Full-Text PDF Open AccessChronic kidney disease and associated mortality after liver transplantation – A time-dependent analysis using measured glomerular filtration rateJournal of HepatologyVol. 61Issue 2PreviewThe accuracy of creatinine-based estimated GFR (eGFR) in assessing the prevalence of chronic kidney disease (CKD) and associated mortality after liver transplantation (LTx) is unknown. Using measured GFR (mGFR) by iothalamate clearance, we determined the prevalence of the entire spectrum of renal dysfunction and the impact of CKD on mortality after LTx. Full-Text PDF We appreciate the comments of Musso et al. related to our manuscript “Chronic kidney disease and associated mortality after liver transplantation - a time-dependent analysis using measured glomerular filtration rate” [[1]Allen A.M. Kim W.R. Therneau T.M. Larson J.J. Heimbach J.K. Rule A.D. Chronic kidney disease and associated mortality after liver transplantation–a time-dependent analysis using measured glomerular filtration rate.J Hepatol. 2014; 61: 286-292Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar]. The authors call attention to the accumulating evidence of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) as a risk factor for chronic kidney disease (CKD). As NASH cirrhosis is emerging as the most common cause of liver transplantation (LT) [[2]Charlton M.R. Burns J.M. Pedersen R.A. et al.Frequency and outcomes of liver transplantation for nonalcoholic steatohepatitis in the United States.Gastroenterology. 2011; 141: 1249-1253Abstract Full Text Full Text PDF PubMed Scopus (859) Google Scholar], the incidence of subsequent CKD may increase. Whether the changing trends in the etiology of end-stage liver disease requiring transplantation will impact the risk of CKD post LT remains to be determined. The anticipated decline of hepatitis C as a main cause of end-stage liver disease will reduce the prevalence of well-defined HCV-associated kidney diseases, such as cryoglobulinemia and membranoproliferative glomerulopathy [[3]Fabrizi F. Plaisier E. Saadoun D. Martin P. Messa P. Cacoub P. Hepatitis C virus infection, mixed cryoglobulinemia, and kidney disease.Am J Kidney Dis. 2013; 61: 623-637Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar]. On the other hand, the increasing prevalence of obesity and NASH is likely to offset this effect. A growing number of observations have linked NASH to the development of CKD [[4]Targher G. Chonchol M.B. Byrne C.D. CKD and nonalcoholic fatty liver disease.Am J Kidney Dis. 2014; 64: 638-652Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar]. While the exact mechanism of this association is unclear, both share common cardiometabolic risk factors and the ultimate clinical consequence of increased risk for cardiovascular morbidity and mortality. Efforts to minimize the comorbidity burden associated with NAFLD may consequently decrease the risk of developing CKD. Once CKD develops, we agree that statins and angiotensin receptor blockers are helpful in select patients [[5]Qaseem A. Hopkins Jr., R.H. Sweet D.E. Starkey M. Shekelle P. et al.Screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease: a clinical practice guideline from the American College of Physicians.Ann Intern Med. 2013; 159: 835-847Crossref PubMed Scopus (118) Google Scholar]. Unfortunately, more effective treatments for preventing CKD progression are still needed. Indeed, a GFR decline into stage 3 CKD (moderately decreased GFR) is the expected consequence of normal aging [[6]Glassock R.J. Rule A.D. The implications of anatomical and functional changes of the aging kidney: with an emphasis on the glomeruli.Kidney Int. 2012; 82: 270-277Abstract Full Text Full Text PDF PubMed Scopus (201) Google Scholar] and the American College of Physicians does not recommend routine screening for moderately decreased GFR in the absence of risk factors [[5]Qaseem A. Hopkins Jr., R.H. Sweet D.E. Starkey M. Shekelle P. et al.Screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease: a clinical practice guideline from the American College of Physicians.Ann Intern Med. 2013; 159: 835-847Crossref PubMed Scopus (118) Google Scholar]. However, liver transplantation is an unequivocal risk factor and monitoring for CKD is warranted. The evolving epidemiology of end-stage liver disease presents new challenges for the transplant community. Optimization of long term outcomes of liver transplant recipients may be improved with vigilant management of pre and posttransplant metabolic syndrome and careful adjustment of the immunosuppression regimen. In order to improve the medical care in this population, we fully agree that renal function should be an investigated endpoint for randomized trials of novel treatments for NASH. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript. The underlying research reported in the study was funded by the NIH Institutes of Health – United States.