Volume 4 Issue 10, October 2008

Lymphocyte depletion has recently been adopted to allow immunosuppression minimization or even to achieve donor-specific tolerance in transplant recipients. The long-term aim of such therapy is to minimize toxic effects associated with standard immunosuppression, but this beneficial effect is offset by the potential toxicity of the global depletion of lymphocytes and, in some cases, monocytes and neutrophils. This Viewpoint summarizes current data on depletion strategies in kidney transplantation, typically in the setting of induction treatment.

Inhibitors of vascular endothelial growth factor, such as bevacizumab, are a promising approach to the treatment of tumors and other angiogenesis-dependent conditions. However, it is becoming increasingly obvious that these drugs can have serious adverse effects including proteinuria, hypertension and thrombotic microangiopathy. This Viewpoint evaluates current evidence to argue that these adverse effects are probably elicited by inhibition of nitric oxide production in the renal vasculature.

The blood-pressure response to antihypertensive medications varies between ethnic groups. Whether ethnicity determines the outcomes of patients with hypertensive kidney disease is less clear. Here, authors from the US examine key ethnic variations in hypertensive chronic kidney disease and proffer their pharmacologic and lifestyle recommendations for blood-pressure control in this setting, with an emphasis on African Americans. The authors highlight the need for adequate representation of minority populations in future studies, in order to improve the evidence base for these recommendations.

This Review will help physicians to make the best case-by-case decisions when treating the three most common types of primary glomerulonephritis that progress to end-stage renal disease—membranous nephropathy, focal segmental glomerulosclerosis and IgA nephropathy. The authors systematically assess the benefits of reducing proteinuria in each of these diseases, and then place these benefits in the context of the early and late adverse effects of currently available therapies.

This Review sets out the case for updating the nomenclature of inherited salt-losing tubulopathies. The author argues that the so-called 'Bartter-like syndromes' constitute a diverse group of diseases whose only common feature is hyperaldosteronism secondary to a salt leak along the distal nephron. Since there is considerable phenotypic overlap between some of these syndromes, he outlines a more logical classification based on the exact location of the defective ion transporter or channel in the distal nephron.

The role of antineutrophil cytoplasmic antibodies (ANCA) in the development of the pauci-immune vasculitide Churg–Strauss syndrome is unclear. Chemmalakuzhy et al. report the case of a 36-year-old man diagnosed with Churg–Strauss syndrome, whose presentation was notable for two atypical features: first, the absence of asthma and second, the presence of glomerulonephritis in the absence of ANCA. The latter observation challenges current thinking about the role of ANCA in the pathogenesis of the syndrome.

In this Case Study, Iwatani and colleagues describe two cases of valvular injury associated with noninfective endocarditis in patients with proteinase 3 antineutrophil cytoplasmic antibody-associated glomerulonephritis. Diagnosis, treatment and management of such cases is discussed, and the importance of distinguishing between noninfective and infective endocarditis is emphasized.