Volume 6 Issue 5, May 2010

The findings of a secondary analysis of the CHOIR trial—which evaluated the beneficial and harmful effects of anemia correction with epoetin alfa in patients with chronic kidney disease and diabetes mellitus or heart failure—threaten to undermine the importance of anemia therapy in patients with chronic kidney disease.

A recent study demonstrated the superiority of prednisone plus ramipril in preventing progression of IgA nephropathy compared with ramipril alone in a group of patients at high risk of progressive renal damage. However, future clinical trials need to clarify whether more aggressive supportive therapy may match the benefits of immunosuppression.

Although anemia is a well-known risk factor for the development of cardiovascular disease in patients with chronic kidney disease, a number of prospective clinical trials have shown that treatment of anemia does not improve cardiovascular outcomes. The primary findings of TREAT, the largest trial to date investigating anemia treatment in patients with chronic kidney disease, have been eagerly awaited.

Results of a recent case–control study confirm that HIV positivity is far from a contraindication for performing a kidney biopsy. Nevertheless, this procedure is not without risk of complications, and, regardless of HIV status, the decision of whether to perform it must be made keeping in mind the therapeutic benefits the individual patient is likely to obtain.

Although the value of proteinuria measurement in the assessment and monitoring of patients with lupus nephritis is well recognized, the best method for measuring proteinuria is uncertain at present. Fine et al. have sought to define the optimal urine collection period that provides accurate proteinuria data while minimizing inconvenience for the patient.

The risk of peritonitis associated with infections of the peritoneal catheter exit site can be reduced by the use of proper exit-site care, such as the routine administration of prophylactic antibiotics at the exit site. Studies that demonstrate the efficacy of such an approach or similar approaches continue to be published.

Aldosterone is a steroid hormone that is mainly recognized for its action on sodium reabsorption in the distal nephron of the kidney. In addition, however, aldosterone exerts other effects on the kidney, blood vessels and the heart, which can have pathophysiological consequences. In this Review, Briet and Schiffrin discuss the mechanisms of aldosterone-induced kidney and cardiovascular injury. The role of mineralocorticoid receptor antagonists in preventing the progression of chronic kidney disease and in the treatment of patients at high risk of cardiovascular events is also described.

Metabolic acidosis is a common acid–base disorder that can occur acutely (lasting minutes to several days) or chronically (lasting weeks to years). Both forms can have considerable adverse effects on cellular function and can contribute to increased morbidity and mortality. This Review summarizes current views on the pathogenesis, diagnosis, adverse effects, and management of different forms of metabolic acidosis.

Accelerated atherosclerosis is common in patients with chronic kidney disease (CKD). The association between CKD and atherosclerosis is in part driven by the downregulated synthesis of high-density lipoprotein (HDL) and an impairment of HDL antioxidant and anti-inflammatory activity. In this Review, Vaziri and colleagues discuss the mechanisms by which CKD adversely affects HDL level, activity and ability to mediate reverse lipid transport, and describe the mechanisms by which HDL dysregulation predisposes patients to atherosclerosis and CKD progression.

Finding a suitable donor kidney for renal transplant candidates who are allosensitized to human leukocyte antigen (HLA) can be challenging. In this Review, Gloor and Stegall discuss currently available strategies for screening and desensitization and new techniques that are under development. Treatments that target donor-specific antibodies have shown some success in reversing acute antibody-mediated rejection, a common complication in antibody-incompatible kidney transplantation. New treatments, such as anti-C5 antibody-mediated complement blockade and proteasome inhibitor-mediated plasma cell depletion, are promising therapeutic avenues.

New hypoglycemic agents that inhibit renal glucose reabsorption are valuable in the constant search for therapeutic tools that achieve glycemic control in patients with diabetes mellitus. In this Perspectives article, Amanda Mather and Carol Pollock discuss novel agents that inhibit the principal glucose transporter in the kidney, which can be added to the armamentarium against hyperglycemia.