Articles in 2009

A prehypertension classification of blood pressure, encompassing a blood pressure range previously regarded to be normal that has been associated with an increased risk of hypertension mortality compared with lower blood pressure, has been established. In this Review, Pimenta and Oparil discuss the epidemiology of prehypertension, the relationship with cardiovascular morbidity and mortality, and the treatment of prehypertensive patients.

Disturbances in bone metabolism are common in patients after renal transplantation and represent important causes of morbidity and mortality. This Review discusses the etiological factors that contribute to bone metabolic disturbances in renal transplant recipients—pre-existing renal osteodystrophy, the effects of transplant-specific therapies on bone metabolism, and the effects of reduced renal function after transplantation. The clinical implications of bone disease in these patients are also considered.

Induction therapy with rabbit anti-thymocyte globulin is preferable to induction with daclizumab in renal transplant recipients at high immunological risk. These findings provide additional support to the idea that personalized immunosuppressive regimens should be developed in renal transplant recipients.

In patients on hemodialysis with a history of failure to respond to hepatitis B vaccination, intradermal revaccination is more effective than repeat intramuscular vaccination. Intradermal vaccine administration might become the standard of care for high-risk patients.

Several surprising findings indicate that pharmacological blocking of the multifunctional enzyme mTOR fosters distinct differentiation programs in different immunocompetent cells. These data might lead to a striking change in our view of the role that mTOR inhibition should have in immunosuppressive therapy for allogeneic transplant recipients.

Vitamin D insufficiency is endemic amongst renal transplant recipients, as it is in other individuals with chronic diseases, both within and beyond nephrology. Few data exist to guide vitamin D replacement strategies, but indirect evidence points to likely skeletal, and possibly extraskeletal, benefits from supplementation.

In vitro evidence suggests that immune complex formation in IgA nephropathy is determined by the sugar content of the IgA1 hinge region. Absence of galactose residues in this region renders the IgA1 molecule immunogenic.

Proof has at last been provided that idiopathic membranous nephropathy is caused by autoantibodies to proteins expressed by podocytes. The discovery that autoantibodies to the M-type secretory phospholipase A2 receptor were present in most individuals affected by the condition opens a new era for the management of membranous nephropathy.

In this Case Study, Hladunewich and colleagues describe the case of a woman with a twin pregnancy with a single fetal demise who presented earlier than 20 weeks' gestation with severe nephrotic syndrome, hypertension and renal insufficiency. The authors describe how aberrant levels of anti-angiogenic and angiogenic factors helped confirm the diagnosis of pre-eclampsia in this complex renal presentation, allowing for the rapid discontinuation of unnecessary immunosuppressive agents and the avoidance of the potential risks inherent with diagnostic renal biopsy.

Vitamin D has long been understood to be a key player in the control of bone metabolism through the regulation of calcium and phosphate homeostasis; however, growing evidence suggests this hormone may also have an important role in the progressive loss of renal function. In this Review, the authors discuss the pathogenic consequence of vitamin D deficiency on the kidney and describe the renoprotective potential of vitamin D analogues for patients with kidney disease.

According to the 'lipid nephrotoxicity hypothesis', hyperlipidemia resulting from physiological compensatory synthesis of lipoproteins in response to urinary loss of albumin can itself cause or aggravate glomerular and tubulointerstitial disease. Ruan and colleagues discuss the evidence on the mutual influence that dysregulation of lipid homeostasis and renal disease exert on each other and how such evidence confirms, qualifies and modifies the lipid nephrotoxicity hypothesis.

Proteomic research has the potential to provide disease biomarkers to clinical practice and insight into pathological mechanisms. In this Review, Welberry Smith and colleagues present an overview of the state of the art of proteomic analysis applied to the study of kidney diseases and discuss future directions of this research field and likely developments.