Kidney Function

The growth of the undocumented immigrant population in the United States has been explosive. The absence of a uniform policy regarding health care for this population has created a unique problem for nephrologists. How should provision of care for undocumented immigrants with end-stage renal disease be delivered and compensated? This problem is exacerbated by the multiple complex laws that govern delivery of and payment for care, as well as that state regulations vary widely and are not easily understood. Furthermore, the ethical and moral commitments of providers to ensure adequate and appropriate care for any patient whose life is at stake, irrespective of his or her immigration status, place nephrologists in a difficult position. This review focuses on the scope of this problem, relevant case law and legislation, current care and payment models, the response of nephrology groups, and ethical dilemmas inherent in caring for this vulnerable population. Recommendations for further study, including convening of a consensus conference, are discussed.

Glomerulonephritis is the primary cause of end-stage renal disease (ESRD) in a substantial proportion of patients and includes antineutrophil cytoplasmic antibody (ANCA)-associated small-vessel vasculitis. Although recognition and treatment of ANCA-associated vasculitis (AAV) has improved, the diagnosis can be difficult to make. In 1 study, the diagnosis was missed (before ANCA testing was performed) in 43% of patients. It is estimated that 20%-40% of patients with AAV will progress to kidney failure requiring replacement therapy. It is important to be aware of the diagnosis before transplant to provide patient counseling and monitor allograft function closely in the postoperative period because the relapse rate can be significant. In a pooled analysis by Nachman et al, the overall recurrence rate was 17%. We present a case of a patient with reported “focal sclerosing nephropathy” and an acute increase in serum creatinine level shortly after transplant who was noted to have crescentic glomerulonephritis with the absence of immune complexes on allograft biopsy. This case shows the importance of confirming the cause of ESRD before transplant and the role of allograft biopsy in identifying the causes of decreased kidney function.

Steroid withdrawal implies the discontinuation of steroid administration post-transplant and needs to be differentiated from steroid avoidance, in which steroids are administered only in the event of rejection. Steroid avoidance has never been popular in the United States, although it has been applied in European countries. Many patients who avoid steroids end up receiving them for rejection anyway. Steroid withdrawal is a more tempting ploy that may be considered in select patients, although the anxiety associated with withdrawal (for both the patients and their physicians) has understandably dampened its popularity. Steroid withdrawal should be considered only in patients who are at least several months post-transplant, have not suffered recent or recurrent rejections, have excellent graft function, and are receiving relatively high doses of cyclosporine. There is some evidence that African-American transplant recipients may not be good candidates for withdrawal.

A clear-cut benefit of withdrawal, in terms of certain steroid-related side effects (bone disease, hyperlipidemia, etc) has not been demonstrated. There may be long-term deterioration in graft function in steroid withdrawn patients, who should be forewarned.