Reviews & Analysis

Home haemodialysis offers increased flexibility over in-centre haemodialysis for adopting different dialysis regimes aimed at improving solute removal. In this Review, Vanholder et al. discuss strategies that can improve haemodialysis adequacy in the home setting. The authors examine vascular access, reaching dialysis adequacy targets, increasing dialyser pore size, increasing dialysis frequency, and increasing dialysis duration, and also discuss the idea of the wearable artificial kidney.

Ongoing research continues to show only moderate accuracy of all methods of measuring proteinuria in pregnant women with hypertension. We need to change traditional thinking so that emphasis on the detection or quantitation of proteinuria is not greater than emphasis on other clinical or laboratory features in the diagnosis or management of pre-eclampsia.

Abramowitz et al. report that the albumin-adjusted and full anion gaps are independent predictors of all-cause mortality after adjusting for estimated glomerular filtration rate (eGFR). This finding raises the question as to whether subtle changes in tubular function could identify patients at increased risk of adverse outcomes, even in those with eGFR >60 ml/min/1.73 m².

Studies of the association between BMI and complications after transplantation have reported variable results. BMI may be a deficient measure of obesity; therefore, a better measure of obesity and improved definition and follow-up of complications related to obesity may strengthen the estimation of post-transplantation risk in obese patients.

The link between chimerism and tolerance is well established. In a rhesus macaque study, Ramakrishnan et al. show that the type of chimerism might have an important effect on tolerance to kidney allografts, pointing to a critical role of donor T-cell production for success. These findings could directly impact clinical efforts to induce tolerance to allografts.

A study by Bojan et al. of neonates and infants who received peritoneal dialysis for the treatment of acute kidney injury following cardiac surgery revealed that the early initiation of dialysis was associated with a significantly decreased mortality rate compared with delayed dialysis.

A survey of seven countries has found a striking difference in dialysis reimbursement policies, even when data were adjusted for gross domestic product per capita. Although increased reimbursement is perceived to be a valuable incentive for certain treatments, this perception is not supported by current data and alternative strategies to promote home-based dialysis should be pursued.

In a new study, Schwartz and colleagues have investigated the best way to estimate glomerular filtration rate (GFR) in children. Having already improved GFR estimation with the use of creatinine-based equations, the investigators now propose a more precise method for cystatin C measurement. The precision of a GFR equation will strongly depend on the analytical precision of the biological variables included.

The American College of Rheumatology recently published guidelines for the screening, treatment, and management of lupus nephritis. How will or should these guidelines impact our current daily practice?

In the past decade there has been renewed interest in the benefits of intensive home haemodialysis over conventional in-centre dialysis and specialist units. The authors of this Review highlight some of the hurdles that need to be overcome in order for home-based therapy to be a more widely available treatment option for end-stage renal disease.

Atrial fibrillation and chronic kidney disease (CKD) frequently coexist and confer an increased risk of stroke. Novel anticoagulants are attractive options over warfarin but undergo renal clearance to varying degrees, and therefore require special consideration in patients with CKD. Recent studies also challenge the benefits of warfarin anticoagulation for atrial fibrillation patients undergoing haemodialysis. This Review discusses the data relating to anticoagulation in patients with atrial fibrillation and CKD and highlights the need for further studies to delineate the optimal use of new anticoagulant agents in patients with CKD.

Several immunosuppressive treatments have demonstrated their efficacy in idiopathic membranous nephropathy, but spontaneous remission does develop in more than 30% of patients. The availability of a validated biomarker that is easy to measure and able to accurately predict long-term outcomes would be very helpful for tailoring treatment of the disease to the individual.

Dialysis, particularly haemodialysis, is associated with an increased risk of cardiovascular disease. A new study confirms that hypokalaemia confers an excess cardiovascular risk and contributes disproportionately to the high risk of death in patients on peritoneal dialysis, which may partially account for the fact that observed cardiac risk is similar for patients on peritoneal dialysis and haemodialysis.

Lupus nephritis is the most common severe manifestation of the autoimmune disease systemic lupus erythematosus. Although conventional immunosuppressive therapy can increase survival, this approach is associated with considerable adverse effects. In this Review, Gregersen and Jayne discuss the available and future approaches to deplete B-cell populations and the current evidence for the therapeutic use of B cell depletion therapies in lupus nephritis, derived from case studies and clinical trials.

In a new study, Porcheray et al. provide evidence that a single antibody generated by alloimmunization can recognize multiple antigens in a paradigm-changing fashion. Although these results require confirmation, the presence of polyreactive antibody may offer an explanation as to why some patients with a single sensitizing event develop a wide breadth of panel-reactive antibody.

The deterioration of the peritoneal membrane during peritoneal dialysis is a serious problem as it leads to technique failure. The factors that have attracted the most attention as culprits in peritoneal membrane deterioration are those related to the peritoneal dialysis fluid itself, such as pH, glucose, and glucose degradation products. This Review focuses on the other factors-many of them modifiable-that can affect peritoneal membrane quality and could be targeted to preserve the peritoneal membrane.

The use of statins as a line of primary prevention in individuals at low risk of cardiovascular events is an area of debate. The most recent meta-analysis from the Cholesterol Treatment Trialists' (CTT) Collaboration suggests that present guidelines for prescribing statin therapy may need to be reconsidered.

Previous studies have indicated that ablation of renal sympathetic nerves reduces blood pressure in patients with resistant hypertension and preserved renal function. Hering et al. have now investigated the efficacy and safety of this procedure in patients with moderate to severe chronic kidney disease.

A defect in urine-concentrating ability is discernable in patients with autosomal dominant polycystic kidney disease (ADPKD) before any decline in glomerular filtration rate, and is associated with elevated concentrations of vasopressin and copeptin. This defect is 'urea-selective' and accordingly, the urine-to-plasma ratio of urea concentration could be a clinically relevant early marker of renal dysfunction in patients with ADPKD.

Socioeconomic status, race and ethnicity contribute to the variability in incidence and progression of kidney disease, access to treatment and health outcomes. In this Review, Patzer and McClellan discuss the multifactorial associations between poverty, race and kidney disease at the individual and community level that are fundamental to the occurrence and outcomes of disease.