News & Views in 2010

A new pathologic classification scheme for diabetic nephropathy, in which only glomerular lesions are used to classify renal damage associated with either type 1 or type 2 diabetes, has been developed in association with the Renal Pathology Society. Given the heterogeneity of the renal lesions underlying diabetic nephropathy and the complex natural history of the disease, this scheme is not yet ready for clinical application but should be considered an important first step towards the development of a clinically useful classification system.

The management of patients with hemolytic uremic syndrome is challenging, and strategies for accurate diagnosis and effective treatment are needed. Intensive research over the past several years has revealed dysregulation of the complement system to be the main underlying cause of the syndrome, making this system the target of promising novel diagnostic and treatment strategies.

Individuals with chronic kidney disease (CKD) are more likely to die of cardiovascular causes than progress to end-stage renal disease. A recent report on a large, contemporary cohort highlights the high rates of CKD among patients with acute coronary syndromes, the poor outcomes associated with CKD, and the ongoing gap between evidence and practice in this population.

The ASCEND study was a large, international trial that aimed to assess the effects of avosentan on diabetic nephropathy. To the disappointment of the nephrology community who had anticipated that the trial would demonstrate beneficial effects of this treatment, ASCEND was terminated early owing to excessive rates of adverse events, such as congestive heart failure associated with avosentan use.

Acute kidney injury seems to have sequelae long beyond the index hospitalization. A new study suggests that even after adjusting for the impact of subsequent chronic kidney disease, acute kidney injury is associated with an increased risk of death.

Data are lacking on the impact of acute kidney injury (AKI) in children admitted to an intensive care unit. Schneider and colleagues have now performed a large-scale assessment of the use of the RIFLE criteria for characterizing AKI in children and have determined the mortality and morbidity associated with AKI in this patient group.

A Dutch study has evaluated the outcomes after transplantation of kidneys from pediatric patients after cardiac death. Such programs instigate ethical debate regarding the classification of donors, and raise questions about the suitability of protocols for determining when an individual can be declared dead, and thus, can donate their organs.

The survival advantages associated with renal replacement therapy might be counterbalanced by its negative effects on quality of life. Cohen et al. have proposed a simple mortality prediction model to help physicians discuss prognosis and individualized palliative care with patients on maintenance hemodialysis, to enable patients and their families make informed treatment decisions.

A new comorbidity index predicts the risk of mortality in patients with end-stage renal disease (ESRD). This index, which was developed using data from a large US database, is an important tool for observational research in patients with ESRD, but its value in patient populations other than dialysis populations in the US needs to be validated.

Medication errors frequently occur in the treatment of patients with renal insufficiency and can cause serious adverse events. Although computerized systems that adjust the drug dose on the basis of a patient's glomerular filtration rate can reduce the incidence and severity of drug prescription errors, other variables can also affect the susceptibility of patients with renal dysfunction to drug toxicity.

A recent study demonstrated the superiority of prednisone plus ramipril in preventing progression of IgA nephropathy compared with ramipril alone in a group of patients at high risk of progressive renal damage. However, future clinical trials need to clarify whether more aggressive supportive therapy may match the benefits of immunosuppression.

Although anemia is a well-known risk factor for the development of cardiovascular disease in patients with chronic kidney disease, a number of prospective clinical trials have shown that treatment of anemia does not improve cardiovascular outcomes. The primary findings of TREAT, the largest trial to date investigating anemia treatment in patients with chronic kidney disease, have been eagerly awaited.

Although the value of proteinuria measurement in the assessment and monitoring of patients with lupus nephritis is well recognized, the best method for measuring proteinuria is uncertain at present. Fine et al. have sought to define the optimal urine collection period that provides accurate proteinuria data while minimizing inconvenience for the patient.

The risk of peritonitis associated with infections of the peritoneal catheter exit site can be reduced by the use of proper exit-site care, such as the routine administration of prophylactic antibiotics at the exit site. Studies that demonstrate the efficacy of such an approach or similar approaches continue to be published.

The findings of a secondary analysis of the CHOIR trial—which evaluated the beneficial and harmful effects of anemia correction with epoetin alfa in patients with chronic kidney disease and diabetes mellitus or heart failure—threaten to undermine the importance of anemia therapy in patients with chronic kidney disease.

Results of a recent case–control study confirm that HIV positivity is far from a contraindication for performing a kidney biopsy. Nevertheless, this procedure is not without risk of complications, and, regardless of HIV status, the decision of whether to perform it must be made keeping in mind the therapeutic benefits the individual patient is likely to obtain.

The abstract of the RENAL Replacement Therapy study concludes that in critically ill patients with acute kidney injury, treatment with higher-intensity continuous renal replacement therapy did not reduce mortality. However, the real news is that survival and recovery of renal function might depend on how therapy is provided.

Are selective endothelin-receptor antagonists really an important new advance for treating patients with treatment-resistant hypertension? The evidence from a recent study leaves us with some uncertainty.

Blockade of the renin–angiotensin system has beneficial effects in patients with diabetic nephropathy; however, this treatment can induce aldosterone breakthrough and thus become ineffective. New data indicate that aldosterone breakthrough develops even when maximal doses of an angiotensin-converting-enzyme inhibitor are administered to patients with diabetic nephropathy.

Recent randomized, controlled trials suggest that B-cell-depletion therapy with rituximab effectively induces remission in anti-neutrophil-cytoplasmic-antibody-associated vasculitis but is ineffective in patients with lupus nephritis or nonrenal systemic lupus erythematosus with moderate-to-severe disease activity.