Volume 5 Issue 1, January 2009

Should renal biopsy be performed in all patients with both HIV infection and kidney disease? In this Viewpoint, Dr Szczech argues that, given its efficacy against conditions like HIV-associated nephropathy, antiretroviral therapy should be implemented before biopsy is considered. Only when suppression of viral replication fails to improve renal function does the case for biopsy become more compelling. In any event, much as with HIV-negative patients with renal disease, empiric therapy should be implemented before renal biopsy is undertaken.

Here, Cohen and Kimmel attempt to counter the arguments presented by Lynda Szczech in the preceding Viewpoint. They point out that HIV-associated kidney disease exists in various forms that have different treatment requirements and that renal biopsy is necessary to establish the exact diagnosis. They argue, furthermore, that the efficacy and safety of highly active antiretroviral therapy against HIV-associated nephropathy is questionable and that such treatment should not, therefore, be initiated empirically.

The authors of this Review propose a new paradigm for the treatment of secondary hyperparathyroidism in chronic kidney disease. They argue that calcitriol deficiency in this setting is simply an adaptive response, and that the primary therapeutic approach (after phosphate control) should be administration of calcimimetics. The actions of fibroblast growth factor 23, the dominant role of the calcium-sensing receptor in regulating parathyroid gland function and the results of clinical trials of cinacalcet and vitamin D analogs are cited in support of their contention.

Nephrologists are actively looking for ways to improve the outcomes of patients on dialysis. To this end, a number of alternative dialysis strategies, involving longer and/or more-frequent sessions, are being investigated. Here, authors with experience of prolonged hemodialysis outline the beneficial effects of such strategies on cardiovascular complications, phosphate balance, nutrition, survival and other factors, and highlight the barriers preventing more-widespread adoption of these regimens.

Immunosuppression renders patients with renal transplants particularly susceptible to vaccine-preventable diseases; however, the use of recommended vaccines before and after transplantation is suboptimal because of fears of toxicity or allograft rejection, which are generally unfounded. The authors of this Review describe the general tenets of immunization in patients who are scheduled for or who have undergone kidney transplantation, and they discuss the efficacy, safety, dosage and timing of vaccination for the relevant diseases and the need for post-vaccination monitoring in this setting.

In this issue, Vilayur et al. describe the case of a patient with monoclonal gammopathy and glomerulopathy associated with chronic lymphocytic leukemia (CLL). Although 'conventional; immunosuppression with cyclophosphamide and prednisone was unsuccessful, two courses of rituximab reversed the clinical manifestations of CLL-associated glomerulopathy, and resulted in complete clearance of the glomerular deposits.