News & Views in 2009

Blockade of the renin–angiotensin system does not seem to prevent early nephropathy in individuals with type 1 diabetes who are normoalbuminuric and normotensive, but both the angiotensin-converting-enzyme inhibitor enalapril and the angiotensin-receptor blocker losartan seem to retard retinopathy.

The automated reporting of estimated glomerular filtration rate has increased the number of patients being referred to nephrologists, but is chronic kidney disease being incorrectly diagnosed in individuals who have normal serum creatinine levels?

Primary hyperoxaluria eventually leads to end-stage renal disease and systemic oxalosis; if left untreated, it may be fatal. The outcome might be different if primary hyperoxaluria is diagnosed early, but when is 'early'?

The degree to which systolic blood pressure should be lowered in individuals with mild hypertension is unclear. The Cardio-Sis trial has investigated whether tight systolic blood pressure control is more beneficial than usual control in individuals with hypertension but without diabetes.

Small-scale clinical trials have provided encouraging evidence on the short-term orexigenic effects of subcutaneous ghrelin administration in malnourished dialysis patients. New treatment strategies to tackle the excess mortality of this patient group are urgently needed, but the strengths, shortcomings and unanswered questions related to ghrelin treatment need to be highlighted.

Induction therapy with rabbit anti-thymocyte globulin is preferable to induction with daclizumab in renal transplant recipients at high immunological risk. These findings provide additional support to the idea that personalized immunosuppressive regimens should be developed in renal transplant recipients.

In patients on hemodialysis with a history of failure to respond to hepatitis B vaccination, intradermal revaccination is more effective than repeat intramuscular vaccination. Intradermal vaccine administration might become the standard of care for high-risk patients.

Several surprising findings indicate that pharmacological blocking of the multifunctional enzyme mTOR fosters distinct differentiation programs in different immunocompetent cells. These data might lead to a striking change in our view of the role that mTOR inhibition should have in immunosuppressive therapy for allogeneic transplant recipients.

Vitamin D insufficiency is endemic amongst renal transplant recipients, as it is in other individuals with chronic diseases, both within and beyond nephrology. Few data exist to guide vitamin D replacement strategies, but indirect evidence points to likely skeletal, and possibly extraskeletal, benefits from supplementation.

In vitro evidence suggests that immune complex formation in IgA nephropathy is determined by the sugar content of the IgA1 hinge region. Absence of galactose residues in this region renders the IgA1 molecule immunogenic.

Proof has at last been provided that idiopathic membranous nephropathy is caused by autoantibodies to proteins expressed by podocytes. The discovery that autoantibodies to the M-type secretory phospholipase A2 receptor were present in most individuals affected by the condition opens a new era for the management of membranous nephropathy.

Atypical hemolytic uremic syndrome often progresses to end-stage renal disease and recurs after kidney transplantation, even with empiric plasma therapy. Guidelines on the treatment of this devastating disease have now been published, following a consensus conference in Bergamo, Italy.

As the population ages, more elderly people are developing kidney disease. Nephrologists are often reluctant to perform renal biopsy in elderly patients, but in many cases, the diagnostic benefits of this procedure outweigh the risks.

How long should we monitor patients for evidence of significant bleeding after percutaneous native kidney biopsy? Both cost and safety must be rigorously considered before recommending a new standard of care.

Uremic diabetics have better survival rates with a kidney transplant than on dialysis. Adding a pancreas graft induces insulin independence and if the graft survives for >1 year, risk-adjusted registry analyses show improved patient and graft survival. Overall, however, as survival is similar for kidney–pancreas and kidney transplants alone from deceased pancreas donors, many questions remain.

Graft stenosis, which can lead to thrombosis, is a major problem in hemodialysis patients with arteriovenous grafts. Does anti-aggregation with dipyridamole and aspirin help to prolong the primary patency of vascular access grafts?

The recent EUPHAS trial was stopped early because of reduced mortality in patients with sepsis treated with polymyxin B hemoperfusion. So should we rush to offer this technique to all patients with sepsis? Not quite so fast.

The new Oxford classification of IgA nephropathy has been developed as a pathological classification system to reliably predict the risk of disease progression. Future studies need to demonstrate the value of this classification in directing individualized therapeutic decisions for patients with IgA nephropathy.

Two observational studies report opposite effects of glitazones on clinical outcomes in patients with ESRD. Given the limited reliability of such studies in the assessment of moderate effects of treatment, however, findings in these articles should prompt the generation of hypotheses rather than dictate changes in clinical practice.

Use of ABO-incompatible renal transplants from living donors has proven a viable and practical transplantation strategy. The protocols devised through the Johns Hopkins Incompatible Kidney Transplant Program could result in the most rapid escalation of access to organs in the modern era of transplantation.