Reviews & Analysis

Identification of effective therapies for nephrotic syndrome is challenging. The pituitary adrenocorticotropic hormone (ACTH) has been shown to be renoprotective in patients with proteinuric neuropathies, but its mechanism of action is unknown. In this Perspectives, Runjun Gong provides an overview of the biophysiology of ACTH, the effects of ACTH on proteinuric renal diseases and the mechanisms likely to be involved in its therapeutic activity. The potential therapeutic role of ACTH for nephrotic glomerulopathies is also discussed.

Several studies have indicated that an intensive continuous renal replacement therapy (CRRT) dose has no benefit over a standard CRRT dose. However, treatment-related factors may have influenced these findings. In this article, Macedo et al. discuss the assumption that delivered dialysis dose is equivalent to the effluent volume and highlight the importance of assessing filter efficacy and dose parameters in patients receiving CRRT.

Use of thiazide diuretics leads to decreased urinary calcium excretion, which in turn reduces the recurrence rate of calcium-containing stones. Whether the hypocalciuria results from increased calcium reabsorption in the proximal or distal nephron is still a matter of debate. In this Perspectives article, the authors discuss the evidence supporting the hypocalciuric effects of NaCl cotransporter inhibition in the proximal and distal nephron.

Several mechanisms in critically ill patients make them susceptible to augmented renal clearance (ARC). The authors of this Perspectives article focus on the causes, risk factors and monitoring of ARC in these patients, and examine the clinical consequences of ARC with regard to achieving target therapeutic concentrations of renally excreted drugs.

Extensive rhabdomyolysis is often lethal unless treated immediately, owing to hypovolemic shock, hyperkalemia, acidosis and myoglobinuric acute kidney injury. In patients with rhabdomyolysis caused by muscle crush syndrome, the use of early fluid resuscitation at the scene of injury has reduced mortality from ∼100% to <20% over the past 70 years. In this article, Better and Abassi discuss the lifesaving and limb-saving potential of early vigorous fluid resuscitation in patients with extensive traumatic and nontraumatic rhabdomyolysis.

Attempts to achieve pharmacological suppression of the renin–angiotensin–aldosterone system (RAAS) fall short of complete success, owing to the existence of accessory enzyme pathways. In this article, the therapeutic targets and limitations of RAAS inhibition are discussed, and the use of combination therapy and the direct renin inhibitor, aliskiren, are described.

Although the relationship between asymptomatic hyperuricemia and chronic kidney disease is not fully understood, data from small studies indicate that reducing high serum urate level may slow disease progression. In this Perspectives article, Badve and colleagues propose that a multicenter pilot randomized controlled trial be performed to investigate the effects of uric-acid-lowering therapy in patients with CKD.