Volume 4 Issue 9, September 2008

Multifactorial approaches to the treatment of type 2 diabetes mellitus have proven more effective than any individual intervention alone in reducing the risk of cardiovascular complications. As the spread of diabetes and obesity accelerates worldwide, unhindered by lifestyle modification approaches, the authors of this Viewpoint propose an aggressive multifactorial strategy for treating patients who have one or more risk factors for the metabolic syndrome in an effort to prevent or delay the onset of diabetes.

Although low-molecular-weight heparins (LMWHs) have largely replaced unfractionated heparin for the treatment of deep vein thrombosis and pulmonary embolism in the general population, sufficiently powered clinical studies on the use of LMWHs in patients with renal impairment are lacking. In this Viewpoint article, Gallieni and colleagues discuss reasons why LMWHs should be used with caution, at present, in patients with chronic kidney disease.

Proteinuria and the underlying glomerulosclerosis seem to be reversible. Could such reversal be achieved by targeting endothelin via the ET_Areceptor? This Review begins with a summary of the mechanisms involved in the development of glomerulosclerosis—particularly those responsible for podocyte injury—and continues with an evaluation of the growth-promoting and vasoconstricting properties of endothelin. Finally, the findings of preclinical and clinical studies of endothelin receptor antagonists in proteinuric renal disease are summarized.

Considerable progress has been made over the past few years in understanding the pathogenesis of pre-eclampsia. In particular, the contribution of the circulating antiangiogenic factors soluble fms-like tyrosine kinase 1 and endoglin to the vascular and glomerular dysfunction of pre-eclampsia has been recognized. Inspired by these findings, Alexandre Hertig and colleagues from France, the US and Switzerland propose an updated and standardized protocol for the post-delivery follow-up of women with pregnancy-induced hypertension or pre-eclampsia.

This Review analyzes the changing face of acute kidney injury in children in terms of etiology, incidence, diagnosis, treatment and long-term outcomes. The evidence base for conservative management of pediatric acute kidney injury (with agents such as diuretics, nesiritide and fenoldopam) is assessed, and the author offers advice on the optimal timing and modality of renal replacement therapy.

Dialysis units are facing a growing number of patients who disrupt the smooth functioning of the unit and even jeopardize the health and safety of other patients and staff. Here, authors from West Virginia University outline a set of ethical principles that can assist dialysis staff to deal with difficult or disruptive patients while meeting their ethical obligations to other patients. These principles can also be used to identify the limited situations in which involuntary patient discharge from a dialysis unit is ethically justified.