News & Views in 2014

New research suggests that rigorous blood pressure control is beneficial in early autosomal dominant polycystic kidney disease (ADPKD). Although a positive effect on the rate of decline of estimated glomerular filtration rate remains to be demonstrated, this study is likely to change current treatment strategies for young patients with ADPKD.

New data suggest that aortic stiffness results in the transmission of excessive flow pulsatility to the renal microcirculation. Further understanding of the mechanisms that regulate the relationship between large arteries and the renal microcirculation could lead to new strategies to protect the kidneys from increased blood pressure load owing to systemic hypertension.

A new study demonstrates that knockdown of miR-193a in human parietal epithelial cells induces their differentiation into podocytes. Inhibition of miR-193a in a model of nephrotoxic nephritis resulted in reduced proteinuria and crescent formation. These data suggest that promoting differentiation of parietal progenitors into podocytes has potential therapeutic relevance.

A new study shows that statin therapy before diagnosis of diabetes mellitus is not associated with an increased risk of microvascular disease and might even be beneficial for retinopathy and neuropathy. These data suggest a potential protective effect of statins in specific complications, which should be further investigated in randomized controlled trials.

A 6-year follow-up study of the ADVANCE trial participants reports that intensive glycaemic control is renoprotective—but does not reduce mortality—in patients with type 2 diabetes mellitus. By contrast, a post hoc analysis of the ACCORD trial suggests that intensive glycaemic control might increase mortality in patients with diabetic nephropathy.

It is now accepted that climate change is occurring as a result of human activity and that it will have potentially devastating effects on health. Nephrologists are likely to see a changing spectrum of disease as a consequence of climate change and are ideally placed to lead mitigating strategies in health-care provision.

Findings from the ARISE and TRISS trials indicate that protocolized therapy might be no better than contemporary management for patients in intensive care, and that in the absence of coronary disease a haemoglobin level of 70 g/l should be the new trigger for transfusion in patients with sepsis.

FDA approval of the first device to use novel biomarkers of kidney damage to assess risk of acute kidney injury (AKI) potentially brings forward diagnosis of moderate-to-severe AKI to a time frame that could enable early intervention. Although the device awaits greater scrutiny, its approval marks the beginning of a new era.

A new study has reported a molecular signature of T-cell-mediated rejection in human kidney transplant biopsy samples that is enriched for effector T cells, interferon-γ and macrophages. Inhibitors of T-cell activation, such as CTLA4 and PDL1, were also prominent, raising the possibility that these immunological constrains could be harnessed by therapies for treating rejection.

Desensitization therapy enables HLA-incompatible transplantation. However, desensitized patients have an increased risk of antibody-mediated rejection, and the presence of donor-specific antibodies (DSAs) is associated with poor outcomes. A new study has assessed the effect of rituximab induction on DSA production in kidney transplant recipients with high immunological risk.

A new population-based study of a Norwegian registry containing data on more than 5 million individuals has confirmed the existence of powerful familial clustering of complex aetiologies of end-stage renal disease. Novel strategies for identifying additional nephropathy risk genes will benefit from such large familial registries.

A new study suggests that peritoneal dialysis achieves a favourable mortality outcome compared with haemodialysis for the first 2 years of treatment. However, registry-based comparisons of mortality outcomes in patients with end-stage renal disease on either renal replacement modality are often fraught with complications.

In the general population, risk of cardiovascular disease is inversely associated with HDL-cholesterol levels. However, a new post hoc analysis of data from the German Diabetes Dialysis study reports no correlation between HDL cholesterol and mortality among patients on dialysis—a phenomenon that the authors attribute to HDL dysfunction.

Although intradialytic hypertension is associated with all-cause mortality, the mechanisms that underlie this phenomenon are not well understood. Now, Nongnuch et al. report that post-dialysis hypertension is associated with extracellular fluid overload, and suggest that patients with this condition might benefit from increased dialysis session length or frequency.

The KDIGO recommendation for blood pressure management in patients with chronic kidney disease and proteinuria is based partly on underpowered subgroup and post hoc analyses. New observational data, however, demonstrate that lower blood pressure goals may be harmful in this group of patients.

Should poor-quality kidneys be allocated to elderly recipients? A new study has determined that kidney recipients aged ≥70 years have similar outcomes regardless of donor-organ quality, with the exception of the lowest-quintile quality organs. These data can help physicians advise their elderly patients to decide whether or not to accept a kidney offer.

Podocyturia in patients with pre-eclampsia has been widely documented, but the underlying pathology is unknown. A new study highlights the glomerular histological alterations in a unique Dutch cohort of deceased patients with pre-eclampsia. The results suggest an important, albeit controversial, role of parietal epithelial cells in this context.

The PREDIAN trial investigated the renoprotective effects of pentoxifylline, in addition to renin–angiotensin system blockade, in patients with type 2 diabetes mellitus and chronic kidney disease. This promising approach resulted in a reduction in the rate of decline in estimated glomerular filtration rate and a significant decrease in albuminuria.

Two recent population-based studies reported higher death rates in patients given metoprolol tartrate than in those given atenolol. These observations contrast with those of a US study in which patients with known cardiovascular disease were excluded, suggesting that indication bias or residual confounding might account for the difference in findings.

Despite uncertainty in the KDIGO guidelines, new research has shown that they can accurately identify acute kidney injury in critically ill patients who have a high risk of mortality. Future refinements to AKI definitions will require biomarkers, and robust assessments in prospective studies.