Viewpoint

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  • In this Viewpoint, we asked three individuals who have been affected by kidney failure for their views on the importance of understanding the drivers of kidney disease and, on a personal level, what they hope might be achieved with this information.

    • Keith D. Brown
    • Catherine Campbell
    • Glenda V. Roberts
    Viewpoint
  • Here, four leading researchers discuss key considerations related to women's kidney health, including specific risk factors, the main challenges and barriers to care and policies and systems that could be implemented to improve the kidney health of women and their offspring.

    • Gloria E. Ashuntantang
    • Vesna D. Garovic
    • Liz Lightstone
    Viewpoint
  • Here, five leading researchers describe changes in the epidemiology of obesity-related kidney disease, advances in current understanding of the mechanisms involved and current approaches to the management of affected patients.

    • Niels Olsen Saraiva Câmara
    • Kunitoshi Iseki
    • Kumar Sharma
    Viewpoint
  • In this Viewpoint, six leading researchers reflect on progress made in their specialist field of paediatric kidney disease. They provide their insight as to the direction research will take in future years, and comment on areas in which additional research or initiatives are required to improve renal outcomes and patient care for the paediatric and neonatal population.

    • John F. Bertram
    • Stuart L. Goldstein
    • Bradley A. Warady
    Viewpoint
  • In this Viewpoint, five members of theNature Reviews Nephrologyadvisory board reflect on the progress and frustrations of the past decade in basic and clinical nephrology research. They comment on areas where effort and money should be invested and the challenges that remain to be overcome, as well as give their predictions for progress in the next decade.

    • Jürgen Floege
    • Robert H. Mak
    • Pierre Ronco
    Viewpoint
  • In many low-to-middle income countries (LMICs) access to essential medications is limited and the number of clinical trials conducted is small because of regulatory issues and a lack of infrastructure. In this article,Nature Reviews Nephrologyasks three experts their opinions on how to improve drug access and increase the numbers of clinical trials conducted in LMICs.

    • Ikechi G. Okpechi
    • Charles R. Swanepoel
    • Francois Venter
    Viewpoint
  • Lower blood concentrations of protein-bound solutes have been directly linked to better outcomes in patients on dialysis. Studies indicate that clearance of protein-bound solutes is more efficient in patients on hemodialysis than in those on peritoneal dialysis; however, paradoxically, the circulating levels of these solutes are lower in patients on peritoneal dialysis. Vanholder and colleagues consider possible explanations for this discrepancy, such as differences in intestinal generation or metabolism of these molecules.

    • Raymond Vanholder
    • Natalie Meert
    • Sunny Eloot
    Viewpoint
  • Studies have shown that rituximab, a chimeric monoclonal antibody that targets the CD20 antigen of B cells, might be a valuable alternative to current therapies for idiopathic membranous nephropathy. In this Viewpoint article, Ruggenenti and colleagues discuss the use of rituximab in idiopathic membranous nephropathy and reason that titrating rituximab therapy to CD20+cell counts might be an effective way of limiting patient exposure to rituximab without reducing the efficacy of treatment, and would also substantially reduce treatment costs.

    • Piero Ruggenenti
    • Paolo Cravedi
    • Giuseppe Remuzzi
    Viewpoint
  • The role of aldosterone in the progression of kidney dysfunction, via its actions on mineralocorticoid receptors, is increasingly recognized. The authors of this Viewpoint outline the beneficial effects that have been seen in animal and human studies of mineralocorticoid receptor blockade in various forms of kidney disease. They predict that low daily doses of the aldosterone blocker spironolactone—an inexpensive, generic medication with few and easily recognizable adverse effects—might one day become the renal equivalent of 'baby' aspirin.

    • Andrew S Bomback
    • Abhijit V Kshirsagar
    • Philip J Klemmer
    Viewpoint
  • 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.

    • Scott D Cohen
    • Paul L Kimmel
    Viewpoint
  • This Viewpoint attempts to counter the arguments presented by Cravedi et al. in this issue of Nature Clinical Practice Nephrology. Although β-cell islet transplantation is not yet a widely viable treatment for type 1 diabetes, AM James Shapiro argues that the procedure's shortcomings are not insurmountable and that now is not the time for a moratorium on clinical research. Enhancing the mass of the initial islet engraftment, which would alleviate many of the present challenges, could be achieved in ongoing trials, and remarkable progress with xenotransplantation and human embryonic stem cells foreshadows the possibility of a renewable islet cell source.

    • AM James Shapiro
    Viewpoint
  • 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.

    • Lynda A Szczech
    Viewpoint
  • The enthusiasm for pancreatic β-cell islet transplantation that followed the introduction of the 'Edmonton protocol' in 2000 has been tempered by evidence that the immunosuppressants used in the protocol might be nephrotoxic and that the resultant insulin independence is only short-term in most patients. Cravedi and colleagues analyze the risks and benefits of islet transplantation and argue that it should not be regarded as a general alternative to insulin replacement therapy for patients with type 1 diabetes mellitus.

    • Paolo Cravedi
    • Roslyn B Mannon
    • Giuseppe Remuzzi
    Viewpoint
  • The development of a wearable device that can replace conventional dialysis in patients needing chronic renal replacement therapy is not as far-fetched as it once was. Ronco et al. describe technological achievements, propose future research directions and discuss the clinical, technical and socioeconomic reasons for continuing the push to realize the wearable artificial kidney.

    • Claudio Ronco
    • Andrew Davenport
    • Victor Gura
    Viewpoint
  • Various strategies have been considered in attempts to improve the outcomes of dialysis patients. Such strategies include increasing dialysis dose, using alternative depuration methods, changing dialysis schedules and focusing on preventing or treating specific co-morbidities and complications. In this Viewpoint, Andreas Pierratos discusses the first three strategies, and concludes that he believes that a paradigm shift, a disruptive change-in the form of daily home nocturnal hemodialysis-is needed to improve dialysis outcomes.

    • Andreas Pierratos
    Viewpoint
  • Lymphocyte depletion has recently been adopted to allow immunosuppression minimization or even to achieve donor-specific tolerance in transplant recipients. The long-term aim of such therapy is to minimize toxic effects associated with standard immunosuppression, but this beneficial effect is offset by the potential toxicity of the global depletion of lymphocytes and, in some cases, monocytes and neutrophils. This Viewpoint summarizes current data on depletion strategies in kidney transplantation, typically in the setting of induction treatment.

    • Paolo Cravedi
    • Roslyn B Mannon
    • Giuseppe Remuzzi
    Viewpoint
  • Inhibitors of vascular endothelial growth factor, such as bevacizumab, are a promising approach to the treatment of tumors and other angiogenesis-dependent conditions. However, it is becoming increasingly obvious that these drugs can have serious adverse effects including proteinuria, hypertension and thrombotic microangiopathy. This Viewpoint evaluates current evidence to argue that these adverse effects are probably elicited by inhibition of nitric oxide production in the renal vasculature.

    • Jecko Thachil
    Viewpoint
  • Multifactorial approaches to the treatment of type 2 diabetes mellitus have proven more effective than any individual intervention alone in reducing the risk of cardiovascular complications. As the spread of diabetes and obesity accelerates worldwide, unhindered by lifestyle modification approaches, the authors of this Viewpoint propose an aggressive multifactorial strategy for treating patients who have one or more risk factors for the metabolic syndrome in an effort to prevent or delay the onset of diabetes.

    • Robert W Schrier
    • Yolanda E Bogaert
    Viewpoint
  • Although low-molecular-weight heparins (LMWHs) have largely replaced unfractionated heparin for the treatment of deep vein thrombosis and pulmonary embolism in the general population, sufficiently powered clinical studies on the use of LMWHs in patients with renal impairment are lacking. In this Viewpoint article, Gallieni and colleagues discuss reasons why LMWHs should be used with caution, at present, in patients with chronic kidney disease.

    • Maurizio Gallieni
    • Mario Cozzolino
    • Diego Brancaccio
    Viewpoint
  • According to the Kidney Disease Outcomes Quality Initiative guidelines, estimated glomerular filtration rate can be used to diagnose chronic kidney disease. The authors of this Viewpoint argue, however, that reliance on estimated glomerular filtration rates alone encourages an erroneous disregard of age, gender and other evidence of kidney disease, such as proteinuria. Consequently, mandatory reporting of estimated glomerular filtration rate leads to misdiagnosis of chronic kidney disease and to the unhelpful referral of healthy individuals to nephrologists.

    • Richard J Glassock
    • Christopher G Winearls
    Viewpoint