Volume 6 Issue 2, February 2010

The optimal blood pressure target for the protection of kidney function in children with chronic kidney disease is controversial. The ESCAPE trial has now shown, however, that lowering the blood pressure target to below the 50^th percentile slows pediatric chronic kidney disease progression.

Increased use of kidneys from expanded-criteria donors (ECDs) for both single and dual kidney transplantation has led to controversy over the criteria for selecting appropriate organs. Although several selection criteria have been proposed to determine the 'transplantability' of ECD kidneys, comprehensive clinical and histological assessment before transplantation remains necessary.

Childhood-onset minimal-change nephrotic syndrome—usually considered a relatively benign disorder confined to childhood—is increasingly being appreciated to continue into adulthood in a sizeable minority of patients. Despite generally excellent preservation of kidney function, treatment-related morbidity may be considerable in these patients.

Acute kidney injury is a common syndrome associated with increased morbidity and mortality, but academic advances in this field are hindered by the lack of a universally accepted definition. Two classification schemes—the AKIN and the RIFLE criteria—have been proposed, but uncertainty remains as to whether their performance is comparable.

A number of concerns have prevented the widespread use of pediatric en bloc kidneys for transplantation in adults. New evidence suggests that some of these concerns could be unfounded and that en bloc pediatric kidneys might perform as well, or even better, than grafts from traditional donors.

The selection of a specific dialysis modality can have important consequences in terms of survival and quality of life. In this Review, Lameire and Van Biesen compare the epidemiology of peritoneal dialysis with that of hemodialysis and describe some of the major differences that exist in the global utilization of these two dialysis modalities. The authors describe a number of medical and nonmedical factors, including economic, educational and psychological factors that influence dialysis modality choice.

Individuals with diabetic nephropathy experience sequential abnormalities in oxygen metabolism, partly as a result of chronic hypoxia. Toshio Miyata and Charles van Ypersele de Strihou discuss molecules involved in the defense against hypoxia, especially oxygen sensors, and novel methods of inhibiting such molecules.

The defining characteristic of autosomal dominant polycystic kidney disease is the progressive formation and enlargement of large numbers of renal cysts, which in most patients eventually leads to end-stage renal disease. In this Review, Bae and Grantham examine the evidence that supports a prognostic role for imaging-based measurements of volume and rate of enlargement of cysts and of whole kidneys for patients with autosomal dominant polycystic kidney disease.

Intravenous fluids are widely administered to patients who have, or are at risk of, acute kidney injury (AKI), but deleterious consequences of overzealous fluid therapy are increasingly being recognized. This Review describes the problems of fluid management in acquired AKI, and discusses the need to balance the competing needs of adequate fluid resuscitation, the avoidance of progressively positive fluid balances (which can lead to extracellular volume expansion and organ edema), and the possibility of overzealous fluid removal (which can lead to hypovolemic AKI).

This article reports the case of a 49-year-old woman who presented to hospital with symptoms associated with severe hyponatremia. For the previous 6 years, she had been treated for lumbago with lumbar facet joint injections of triamcinolone acetonide every 10–12 weeks. Laboratory analyses and nonresponse to the corticotropin-releasing-hormone-stimulation test led to the conclusion that triamcinolone acetonide treatment had caused the development of secondary adrenal insufficiency, which in turn had led to upregulation of antidiuretic hormone and the development of hyponatremia.