News & Views in 2010

The optimal blood-pressure goals to prevent progression of chronic kidney disease (CKD) remain controversial. The results of the AASK cohort study provide additional support for more aggressive blood-pressure control (<130/90 mmHg) in proteinuric but not nonproteinuric patients with hypertensive CKD.

Available evidence suggests that rituximab may be safe and effective for the treatment of refractory antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Two studies now show that rituximab is not less effective than cyclophosphamide for treating ANCA-associated vasculitides. Should rituximab be the new standard of care for patients with ANCA-associated vasculitis?

Two new vasopressin antagonists, conivaptan and tolvaptan have recently been licensed for the treatment of hyponatremia in the USA. Their safety and clinical effectiveness seems promising, but high costs and the lack of data regarding their use in symptomatic patients call for further studies to clarify their future clinical role.

Patients with end-stage renal disease have a heightened risk of cardiovascular morbidity and mortality. Cardiac arrest causes around one-quarter of deaths in this population, and a recent study has investigated whether echocardiographic parameters and serum biomarkers can be used to predict the risk of sudden cardiac death in patients on peritoneal dialysis.

Two trials recently reported in the New England Journal of Medicine report that use of mammalian target of rapamycin inhibitors does little to halt the progression of autosomal dominant polycystic kidney disease. Do these therapies still have a future in the treatment of this disease?

One recent trial failed to show any beneficial effect of homocysteine lowering using vitamin B therapy on survival and cardiovascular events in patients with end-stage renal disease, and results of another study in patients with early-stage diabetic nephropathy actually suggested that vitamin B therapy has harmful effects. Do these findings mark the end of the era of studies investigating homocysteine lowering in patients with chronic kidney disease?

The randomized, controlled IDEAL study reports no survival advantage of 'early' dialysis initiation and data from this study support an estimated glomerular filtration rate of around 7 ml/min/1.73 m² as a guideline for dialysis initiation. The results of the IDEAL study supplement data from eight observational studies involving over 1.2 million patients which showed a comorbidity-adjusted incremental survival disadvantage of 'early' dialysis initiation.

Several randomized clinical trials with short-term follow-up have shown that patients on hemodialysis with prophylactic antibiotic catheter locks have reduced catheter-related bacteremia. However, the long-term safety of such locks remains a subject of ongoing debate. Landry et al. now report that prophylactic gentamicin catheter locks can promote the emergence of gentamicin-resistant bacteremia during long-term use.

Major efforts are underway to expand the available pool of organ donors and increase the supply of transplantable kidneys to shorten transplant waiting lists for patients with end-stage renal disease (ESRD). Snoeijs et al. now report that kidneys from donors after cardiac death improve survival of patients with ESRD who are on a transplant waiting list.

The possible cardioprotective and renoprotective effects of statins in patients with chronic kidney disease remain an unsolved enigma for clinicians and researchers in the field of nephrology. Do the recently published AURORA and JUPITER studies shed light on this controversy?

Non-melanoma skin cancer occurs at an alarmingly high rate in transplant recipients, causing considerable morbidity and sometimes even mortality. A recent prospective clinical study performed by nephrologists and dermatologists at the Johann Wolfgang Goethe University in Frankfurt suggests that switching renal transplant recipients with skin lesions onto the mTOR inhibitor sirolimus might keep non-melanoma skin cancer in check.

Prerenal azotemia is a common occurrence in hospitalized patients and is generally easier to define in clinical practice than in clinical research. Monitoring the duration of acute kidney injury and biomarkers of kidney function might help distinguish prerenal azotemia from acute tubular necrosis in both clinical practice and research settings.

The Oxford classification of IgA nephropathy identified four histological features with adequate reproducibility and clinical relevance to predict renal outcome in patients with IgA nephropathy. Does the predictive value of biopsy lesions apply across a range of patient ages?

The clinical management of chronic kidney disease leads to an inevitable interplay between recommended therapies and the hazards of impaired renal function. Disturbances in potassium level are a common byproduct of this interaction and can increase the risk of adverse safety outcomes in patients with chronic kidney disease.

Changes in serum creatinine concentration are used to define acute kidney injury after the intravascular administration of iodinated contrast media, but less is known about the short-term increases in levels of cystatin C after angiography. A new study investigates whether cystatin C is a reliable marker of contrast-induced acute kidney injury after angiography.

Many clinical guidelines recommend thiazide diuretics as first-line treatment for hypertension, even in individuals with mild chronic kidney disease (CKD). However, results from the ACCOMPLISH trial add to growing evidence that thiazide-based therapy does not retard progression of CKD. Re-evaluation of the role of these agents in the management of hypertension in patients with CKD might be appropriate.

The results of a large observational study seem to confirm an association between early initiation of dialysis and increased mortality that is not fully explained by the presence of comorbidities and other confounding variables. However, this paradoxical association may be an artifact resulting from the inaccuracy of using plasma creatinine levels to estimate glomerular filtration rates in patients with severely impaired renal function.

Almost 25 years after recombinant human erythropoietin first became available to treat anemia in patients with chronic kidney disease, the optimal use of erythropoiesis-stimulating agents (ESAs) is as unclear as ever. One reason for this uncertainty is that the risks associated with correction of anemia using ESAs could be either related to patients' hemoglobin levels or to off-target effects of these agents.

Low pre-dialysis blood pressure is associated with an increased risk of mortality, but whether a high blood pressure level affects outcomes among patients on dialysis—as it does in the general population—is unclear. A recent study has found that higher systolic blood pressure measurements obtained outside the dialysis unit are associated with an increased risk of death, but that standard blood pressure recording in the dialysis unit has limited usefulness as a prognostic indicator.

A recent randomized clinical trial concluded that implantation of a stent graft plus angioplasty was superior to angioplasty alone for the treatment of stenosis at the venous anastomosis of an arteriovenous graft. However, concerns regarding the reliability of the results of this trial suggest that additional investigations are necessary.