News & Views in 2010

The cardiac evaluation and management of patients with stage 4 or 5 chronic kidney disease prior to renal transplantation is a collaborative effort between nephrologists and cardiologists. Concerns exist, however, that contrast-induced acute kidney injury occurring as a consequence of coronary angiography has the potential to hasten the progression to dialysis before transplantation.

In 2003, the International Society of Nephrology and the International Diabetes Federation launched a campaign to highlight the global pandemic of type 2 diabetes and diabetic kidney disease. It aimed to alert governments, health organizations, health-care providers, doctors, and patients to the increasing health and socioeconomic problems associated with diabetic kidney disease and its sequelae, end-stage renal disease. Today, 7 years later, the same message is even more urgent.

Masked hypertension—which is present in about 25% of adult patients initially classified as normotensive—is associated with left ventricular hypertrophy and is a well-documented marker of cardiovascular risk in adults. A recent study has found that masked hypertension is also an important and underdiagnosed cardiovascular risk factor in children.

Kidney transplant recipients and their health-care providers have access to an ever-expanding amount of information to aid decision-making in family planning. But are untargeted statistical databases an adequate tool for achieving this goal?

A major challenge to the success of transplantations is ensuring that patients take their immunosuppressive drugs regularly, as nonadherence is a major risk factor for poor clinical outcomes. Optimal transplantation care must include adherence-enhancing interventions as part of regular patient management.

Childhood-onset minimal-change nephrotic syndrome—usually considered a relatively benign disorder confined to childhood—is increasingly being appreciated to continue into adulthood in a sizeable minority of patients. Despite generally excellent preservation of kidney function, treatment-related morbidity may be considerable in these patients.

Acute kidney injury is a common syndrome associated with increased morbidity and mortality, but academic advances in this field are hindered by the lack of a universally accepted definition. Two classification schemes—the AKIN and the RIFLE criteria—have been proposed, but uncertainty remains as to whether their performance is comparable.

A number of concerns have prevented the widespread use of pediatric en bloc kidneys for transplantation in adults. New evidence suggests that some of these concerns could be unfounded and that en bloc pediatric kidneys might perform as well, or even better, than grafts from traditional donors.

The optimal blood pressure target for the protection of kidney function in children with chronic kidney disease is controversial. The ESCAPE trial has now shown, however, that lowering the blood pressure target to below the 50^th percentile slows pediatric chronic kidney disease progression.

Increased use of kidneys from expanded-criteria donors (ECDs) for both single and dual kidney transplantation has led to controversy over the criteria for selecting appropriate organs. Although several selection criteria have been proposed to determine the 'transplantability' of ECD kidneys, comprehensive clinical and histological assessment before transplantation remains necessary.

Despite the epidemic of cardiovascular disease among patients with end-stage renal disease, recent findings demonstrate that the pediatric community needs to make greater efforts to control the known modifiable risk factors.

Preliminary findings suggest that oral sodium bicarbonate administration could become a major addition to the armamentarium of renoprotective measures for individuals with chronic kidney disease.

Evidence supporting the renal benefits of angiotensin-converting-enzyme inhibitors and angiotensin II receptor blockers in elderly patients without proteinuria is lacking. However, until such data are available, if tolerated, these medications should continue to be used in this patient population because of their potent effect on blood pressure.

Retrospective data analysis suggests that revascularization provides no benefit over medical treatment in patients with severe kidney disease who experience non-ST-elevation myocardial infarction. But are these results the consequence of treatment bias and/or a failure to address poorly understood risk factors?

Warfarin, an anticoagulant that reduces the risk of stroke in the general population, might be associated with an increased risk of stroke in hemodialysis patients with atrial fibrillation. This finding raises important questions about the role of warfarin in the management of patients with atrial fibrillation who are undergoing dialysis.

Kidney transplantation is well known to increase survival and improve quality of life over conventional dialysis therapies. But are contemporary, intensive dialysis therapies, such as nocturnal home hemodialysis, associated with outcomes as good as those obtained with deceased donor transplantation?

In patients at low risk of renal disease and with low levels of albuminuria, administration of renin–angiotensin system inhibitors does not seem to offer renal benefits and might cause adverse renal effects. In these patients, renin–angiotensin system inhibition should be implemented judiciously, with doses titrated to individual needs and with careful monitoring of kidney function.

The Framingham hypertension risk score developed in the US has been validated in a large group of London-based civil servants. The score is therefore a useful tool for estimating the short-term risk of developing hypertension in a European population.

Extending the duration of cytomegalovirus prophylaxis to 6 months in virus-seronegative organ recipients who receive transplants from seropositive donors decreases the risk of cytomegalovirus disease. But is prophylaxis extension the best approach to preventing late-onset cytomegalovirus disease?