Reviews & Analysis

The frequency with which central venous catheters are used as permanent access for maintenance hemodialysis is likely to increase in the future as the dialysis population ages and the quality of peripheral vasculature concomitantly declines. It is, therefore, essential that clinicians who manage dialysis patients stay abreast of the latest recommendations for prevention and treatment of catheter-related blood stream infections. This timely Review covers risk factors as well as data that underlie current best practice.

A team from King's College London presents an overview of the role of complement activation and complement regulatory proteins in kidney injury. They extend their discussion beyond immune-complex-mediated glomerular diseases such as lupus nephritis and membranoproliferative glomerulonephritis to other forms of renal injury in which complement has a role, such as atypical hemolytic uremic syndrome and graft rejection. Their concise and easy to read article includes a discussion of the therapeutic potential of manipulating complement inhibition.

Here, Krisper and Stauber analyze the relative efficiency, clinical outcomes, safety and potential indications of two different 'liver dialysis' systems. Despite their 'experimental' status, the Molecular Adsorbents Recirculating System (MARS^®) and Prometheus^®, developed by Gambro and Fresenius Medical Care, respectively, are increasingly used to treat patients with severe hepatic failure. Preliminary data are promising, and large-scale randomized trials with the aim of proving a survival benefit are underway.

Focusing largely on end-stage renal disease, this Viewpoint outlines some echocardiographic indices of left ventricular function, and examines their prognostic value in chronic kidney disease. Recommendations are provided for optimal indexing of estimates of left ventricular mass to body size in this population. The role of echocardiography as an outcome measure in interventional studies and in the longitudinal monitoring of cardiac risk are also briefly considered.

Decreased libido, difficulty becoming aroused and achieving orgasm, erectile and ejaculatory dysfunction, and lack of vaginal lubrication are common problems that have a substantial impact on the quality of life of people with chronic kidney disease. This guide to the assessment and management of sexual dysfunction in renal patients emphasizes the multifactorial nature of such problems, and the need for medical teams to initiate discussion of sexual issues as part of routine care.

Kinins are endogenous vasodilators, through which at least some of the beneficial cardiovascular effect of ACE inhibitors is exerted. In the past 15 years, development of new research tools has contributed to the generation of many genetic, biochemical and clinical data. Here, these new findings are brought together to illustrate the potential for manipulation of the kallikrein–kinin system to ameliorate hypertension and its complications, including cardiac hypertrophy and renal failure.

The author of this counterpoint argues that the results of recently published randomized clinical trials call into question the assumption that continuous renal replacement therapy is inherently superior to intermittent hemodialysis for patients in the intensive care unit with severe acute kidney injury. The second half of his article examines why this might be. Has intermittent hemodialysis become safer and more efficacious? Might continuous renal replacement therapy be less safe and/or efficacious than previously thought?

The first of this pair of 'pro/con' Viewpoints sets out the case for the superiority of continuous renal replacement therapy over intermittent hemodialysis in critically ill patients with acute kidney injury. Forming the basis of the author's argument is the notion that by attempting to correct in a few minutes physiological derangements that have developed over hours or days, intermittent hemodialysis is aggressive and unphysiological; by contrast, continuous renal replacement therapy corrects derangements gently and slowly, like the native kidneys.

Epigenetic, or nonheritable, mechanisms that regulate gene expression are potentially reversible. In this short article, authors involved in identification of the chemokine RANTES (CCL5) outline the complex pathways that control its expression and thereby influence movement of immune cells, with a focus on T lymphocytes. Rational design of agents based on this knowledge could have a beneficial impact on various forms of nephritis and nephropathy, transplant rejection and acute renal failure.

More widespread use of kidneys from cadavers who have suffered irreversible circulatory arrest has the potential to reduce the shortfall between supply and demand of organs for transplantation. In the Netherlands, kidneys from this source now account for almost 50% of cadaveric-donor renal grafts. Here, Dutch authors review outcomes data from studies of non-heartbeating donation (or donation after cardiac death) and relate their own considerable experience with this form of transplantation.

The complex interplay between the multiple pathogenic factors that underlie uremic bleeding syndrome is yet to be fully elucidated. As such, guidelines on management of this complication of chronic renal failure are lacking. Here, data from clinical trials of dialysis, erythropoietin, cryoprecipitate, desmopressin and conjugated estrogens have been used to develop a treatment algorithm. This decision aid is accompanied by answers to questions that commonly arise during management of uremic bleeding.

The US National High Blood Pressure Education Program currently advocates diuretics as first-line treatment for all patients with hypertension, based mainly on the findings of ALLHAT. This Viewpoint identifies several flaws in the design of ALLHAT that call into question the validity of its conclusions. The authors argue that by encouraging use of angiotensin-converting-enzyme inhibitors and calcium channel blockers in ways that are not the standard of care, the trial likely exaggerated the benefits of diuretics in this setting.

Immunosuppressive drugs, metabolic disorders and immobilization are factors that contribute to an increased incidence of scoliosis, vertebral fractures and back pain in pediatric transplant recipients. Here, a team from Helsinki University Central Hospital review historical data on orthopedic complications in this patient population, and provide updated recommendations for prevention, assessment and management based on their own extensive research and clinical experience.

Daniel Batlle and colleagues present an approach to the diagnosis and evaluation of hyponatremia that is based on the often-underused concept of electrolyte-free water clearance. Illustrated by a case vignette, this approach is set in the context of emerging evidence supporting the utility of vasopressin receptor antagonists in the management of hyponatremia. The pharmacology, mechanism of action, and efficacy data for drugs of this class are reviewed.