News & Views in 2011

Non-communicable diseases (NCDs) are taking center stage in global health policy. Intensive lobbying by the International Society of Nephrology has gained recognition for chronic kidney disease (CKD) as a major NCD. Continuing advocacy is needed for the health risk of CKD to be understood and opportunities for prevention and treatment grasped.

For predicting complications related to chronic kidney disease, endogenous filtration markers such as cystatin C and creatinine perform as well, if not better, than measured glomerular filtration rate (GFR). Measured GFR by clearance of an inert exogenous marker may still be the gold standard measure of GFR, but determining GFR may not answer the right clinical question.

A recent study has reviewed records of patients on thrice-weekly hemodialysis and shown that serious and fatal complications—including overall and cardiac mortality, as well as hospitalization for cardiovascular reasons—are more frequent on the last day of the long interdialytic interval than on other days.

General severity of illness scores lack high predictive accuracy for mortality in patients with acute kidney injury (AKI). Using the Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network database, Demirjian et al. identified 21 independent predictors of mortality and developed an accurate scoring system for outcomes in patients with AKI requiring renal replacement therapy.

A recent report from the Alberta Kidney Disease Network demonstrates that high estimated glomerular filtration rate is associated with an increased risk of all-cause mortality in both young and elderly individuals, as well as in those with and without proteinuria. Potential explanations and implications of these findings are discussed.

Whether erythropoiesis-stimulating agents (ESAs) administered in high doses could be harmful is a subject of intense interest. A recent trial has studied the relationship between hemoglobin level, ESA dose and outcomes in Japanese patients on hemodialysis. Here, we review the findings and the possible impact on clinical anemia treatment.

A new report suggests that differences in albuminuria might contribute to disparities in susceptibility to nephropathy in African American and white individuals. Interpretation of this finding requires consideration of renal histology, clinical trials and genetic studies. These factors indicate that a far more complex scenario is likely to exist than previously thought.

For patients who undergo desensitization treatment to reduce or neutralize circulating donor-specific anti-HLA antibodies prior to transplantation, survival is lower than for unsensitized patients. However, a new study suggests that for sensitized patients, desensitization and transplantation might be better than remaining on dialysis or waiting for a compatible kidney transplant.

A recent analysis from a French registry indicates that in incident patients with end-stage renal disease and congestive heart failure, peritoneal dialysis has a higher mortality risk than hemodialysis. Whether the results of this study should alter the choice of dialysis modality in such patients is debatable.

Frequent nocturnal hemodialysis has emerged as a promising option for patients, with some studies demonstrating that it improves clinical outcomes. However, the negative results of a recent randomized trial have cast some doubt on whether nocturnal home hemodialysis has any advantages over conventional hemodialysis.

Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular disease. Following publication of the results from the SHARP trial, are we any closer to knowing whether statins are beneficial for preventing cardiovascular events in patients with CKD, particularly those on dialysis?

Estimating renal function in the normal to high range is challenging, and even more so in critically ill patients. An analysis of commonly used equations for estimating renal function demonstrates that these formulae might not be accurate in this setting, which has important implications for drug dosing.

The ASCERTAIN study has confirmed previous findings that conversion from calcineurin inhibitors to mammalian target of rapamycin (mTOR) inhibitors does not seem to improve glomerular filtration rate in renal transplant recipients, although it does seem beneficial in patients with better renal function at baseline. Questions remain regarding the role of mTOR inhibitors in kidney transplantation.

Recent clinical studies with bardoxolone methyl have demonstrated improvements in the glomerular filtration rate of diabetic patients with chronic kidney disease (CKD). Although its mechanism of action is uncertain, the persisting effects of bardoxolone methyl in this challenging group of patients are a source of optimism for the management of CKD.

Pre-emptive kidney transplantation (PKT) is considered the best treatment for advanced chronic renal failure. Transplantation done too early can cause premature transplantation risks; done too late, the recipient might be exposed to the complications of chronic kidney disease. Thus, a major question arises: when is the best time for PKT?

Circulating anti-phospholipase A₂ receptor (PLA₂R) antibodies have been identified as an immunological marker of disease activity in patients with idiopathic membranous nephropathy. A simple assay has been developed to detect anti-PLA₂R antibodies in serum. Now, we can monitor the response to drugs and adapt therapy in daily clinical practice.

Self-monitoring of blood pressure at home is widely used and regarded as an effective tool to improve long-term management and control of hypertension. A new meta-analysis assessing the utility of home blood pressure monitoring supported by telecommunication shows that this system has the potential to further improve the care of patients with hypertension.

Levels of glycated albumin seem to predict mortality and hospitalization more accurately than does levels of glycated hemoglobin in patients with diabetes mellitus who are on dialysis. Should we be measuring glycated albumin instead of glycated hemoglobin in this group of patients?

According to a recent study, the renoprotective effect of losartan is partly owing to its ability to reduce levels of serum uric acid. This finding, along with supporting evidence from cohort studies, points to lowering of serum uric acid levels as a potential method to prevent end-stage renal disease in patients with diabetes mellitus.

A recent retrospective study has shown that statins can reduce the incidence of acute kidney injury in elderly patients undergoing major elective surgery. However, more data, preferably from randomized controlled trials, are required before a change in practice can be recommended.