News & Views

The new Oxford classification of IgA nephropathy has been developed as a pathological classification system to reliably predict the risk of disease progression. Future studies need to demonstrate the value of this classification in directing individualized therapeutic decisions for patients with IgA nephropathy.

Two observational studies report opposite effects of glitazones on clinical outcomes in patients with ESRD. Given the limited reliability of such studies in the assessment of moderate effects of treatment, however, findings in these articles should prompt the generation of hypotheses rather than dictate changes in clinical practice.

Use of ABO-incompatible renal transplants from living donors has proven a viable and practical transplantation strategy. The protocols devised through the Johns Hopkins Incompatible Kidney Transplant Program could result in the most rapid escalation of access to organs in the modern era of transplantation.

Two recent reports in the American Journal of Transplantation focus on the maternal and fetal outcomes of pregnancies in kidney donors and provide tantalizing, if somewhat worrisome, observations. The findings also leave us with several important unanswered questions.

Although ALMS, the largest prospective, randomized, controlled study comparing mycophenolate mofetil to intravenous cyclophosphamide for the initial treatment of severe lupus nephritis, failed to achieve its primary end point of mycophenolate superiority, mycophenolate plus corticosteroids has become the accepted standard of care. Are we really beyond cyclophosphamide for severe lupus nephritis?

Identifying patients at risk of end-stage renal disease relying only on measurement of both glomerular filtration rate and albuminuria could greatly decrease the number of patients flagged for renal surveillance without increasing the risk of overlooking high-risk individuals.

Defining the dose of a new renoprotective drug with the optimal benefit-to-risk ratio is an important consideration for drug developers and physicians. Have we learned from past experiences?

ONTARGET showed that dual renin–angiotensin system blockade prevents microalbuminuria but facilitates transient renal function impairment in nonproteinuric patients with atherosclerotic vascular disease or diabetes. These findings should not be used as an excuse not to optimize renin–angiotensin system inhibition and target urinary protein in patients with proteinuric nephropathies.

In patients with hypertension in hemodialysis, dry-weight reduction by additional ultrafiltration leads to decreases in systolic and diastolic blood pressure. Ultrafiltration combined with daily dietary salt restriction should, therefore, be recommended to these patients, even in the absence of clinical signs of volume overload.

Mortality rates of patients with low levels of serum albumin, a marker of malnutrition and inflammation, are lower when hemodialysis is performed with high-flux membranes than with low-flux membranes.

Determining the optimal method for preserving deceased-donor kidneys is crucial for improving long-term transplant success. A randomized, controlled trial has compared two methods—hypothermic machine perfusion and cold storage preservation.

Candesartan doses in excess of the recommended antihypertensive maxima have been reported to lead to greater reductions of proteinuria than the advised doses. High-dose angiotensin-converting-enzyme inhibitors, however, are at least as effective as high-dose angiotensin blockers and less expensive. Angiotensin-converting-enzyme inhibition is thus the first-line strategy to halt kidney disease progression.

An observational study suggests that administration of phosphorus binders dramatically improves survival rates in patients on incident hemodialysis—even in those without hyperphosphatemia. Randomized clinical trials should drive changes in the relevant clinical practice.

Regardless of baseline blood pressure, treatment with a combination of an angiotensin-converting enzyme inhibitor and a diuretic decreases incidence of renal events in patients with type 2 diabetes. The combination therapy approach could be the key to achieving renoprotection.

In participants of the CONVERT trial, which enrolled recipients of kidney transplants, conversion of immunosuppressive therapy from calcineurin inhibitors to sirolimus did not improve renal function. More importantly, the intervention was detrimental among patients with impaired kidney function and/or proteinuria. Sirolimus conversion resulted, however, in lower rates of malignancy.

Autosomal-dominant polycystic kidney disease is characterized by the development and expansion of cysts, which ultimately results in kidney failure. The rate of this expansion can now be quantified within a short period of time, which has implications for assessing the risk of renal failure in affected patients.

Cinacalcet is an effective treatment for secondary hyperparathyroidism in patients on dialysis. Until now, no randomized, placebo-controlled, long-term trial has tested this drug in individuals with chronic kidney disease who are not receiving dialysis.

One of the early products of the Chronic Kidney Disease in Children (CKiD) study has been an updated equation for estimating GFR in children on the basis of demographic and laboratory parameters. This formula is comparable in form and performance to the MDRD equations for adults in clinical trials first published a decade ago.

An analysis of the US kidney transplant waiting list suggests that recording a potential recipient as 'inactive', during which time he or she cannot be offered a donor organ, is becoming increasingly common and is not in patients' best interests.

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.