Volume 5 Issue 5, May 2009

The discovery that antibodies to a bacterial antigen can cross-react with a mammalian protein to cause pauci-immune necrotizing and crescentic glomerulonephritis opens up new possibilities for the diagnosis and treatment of this condition.

How can we improve the diagnostic value of donor kidney graft biopsies and the management of renal transplant recipients? A recent study developed a morphologic scoring system—the Maryland Aggregate Pathology Index—to help predict long-term renal graft survival from preimplantation donor organ biopsy findings.

A recent report showed that hypophosphatemia is common in children undergoing continuous renal replacement therapy, and that adding phosphate to the replacement and dialysate solutions significantly reduced the incidence of this complication. Should such supplementation be routinely performed?

A recent study reported that combination therapy with sirolimus plus either tacrolimus or ciclosporin resulted in effective immunosuppression in high-risk renal allograft recipients. Does such combination therapy really represent an advance in immunosuppressive therapy for these individuals?

Antineutrophil cytoplasmic antibody-associated vasculitides are usually treated with a combination of high-dose corticosteroids and cyclophosphamide therapy to induce remission, commonly followed by maintenance treatment with a less-toxic immunosuppressant. Azathioprine and methotrexate are both options for maintenance therapy, but whether one of these immunosuppressants is superior to the other is unclear.

Trials that compared sodium bicarbonate and sodium chloride for the prevention of contrast-induced acute kidney injury have yielded highly conflicting results. The authors of a recent meta-analysis endeavored to provide a definitive assessment of the relative efficacy of these two intravenous fluids.

Our understanding of post-infectious glomerulonephritis has evolved considerably since the condition was thought to be merely a benign consequence of streptococcal infection, characterized by pure endocapillary proliferation. This Review highlights the current status of post-infectious glomerulonephritis worldwide, with a particular focus on acute post-streptococcal glomerulonephritis. The authors, from Chulalongkorn University in Thailand, cover the epidemiology, presentation, pathology, pathogenesis, treatment and outcomes of this condition.

Lithium is the first-line therapy for the control of bipolar affective disorder. However, this monovalent cation can have several adverse effects on the kidney, namely tubular dysfunction (particularly nephrogenic diabetes insipidus), chronic nephropathy and hypercalcemia. This Review describes the presentation, pathophysiology and treatment of these complications. The authors review the clinical and experimental evidence that the principal cell of the collecting duct is the primary target for the nephrotoxic effects of lithium, and that these effects are characterized by the dysregulation of aquaporin 2.

Antineutrophil cytoplasmic autoantibody-associated vasculitides such as Wegener granulomatosis and microscopic polyangiitis are an important cause of renal failure. Current treatment strategies based on cyclophosphamide have improved patient survival, but are associated with considerable morbidity. In this Review, Pallan and colleagues discuss the current treatment strategies and describe how the continually growing understanding of disease pathogenesis is enabling the development of novel targeted therapies.

Authors from the University of Alberta, Canada describe the epidemiology of cardiovascular disease in patients with stage 3–5 chronic kidney disease (CKD), excluding renal transplant recipients. They outline the relevant cardiovascular risk factors, both traditional and nontraditional, and consider the implications of this knowledge for the optimal management of cardiovascular risk in the CKD setting. Opportunities for further research are briefly discussed.

Prakash and colleagues highlight the case of a 60-year-old man who was referred to a nephrology clinic with an elevated serum creatinine level. Investigations revealed that he had been taking a herbal remedy containing a large amount of lead. Following discontinuation of the remedy and several sessions of lead chelation, his creatinine level declined. This case highlights the need for clinicians to consider lead in the differential diagnosis and prognosis of patients with chronic kidney disease.