Nephrology Now

KDIGO Clinical Practice Guidelines for AKI
These extensive clinical practice guidelines provide by KDIGO are intended to assist decision-making in the area of acute kidney injury. Related Articles: KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder (CKD–MBD) Stage IV Chronic Kidney Disease Perioperative acute kidney injury: risk factors, recognition, management, and [...]
Comparing Cardiac Surgery in Peritoneal Dialysis and Hemodialysis Patients: Perioperative Outcomes and Two-Year Survival
This small observational study suggests that PD patients who require cardiac surgery do not experience more complications or worse 2-year survival as compared to HD patients. It also sugggests that 2-year survival for dialysis patients after cardiac surgery is acceptable. Related Articles: Similar Outcomes With Hemodialysis and Peritoneal Dialysis in Patients With End-Stage Renal Disease [...]
Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease
This study surveyed patients with stage 3-5 CKD in Australia to assess factors which influence patients to choose dialysis versus conservative care. Dialysis was more likely to be chosen if patients felt it increased life expectancy, would be given the choice of time to dialyze (evening rather than day only) or would receive subsidized transport. [...]
Effects of Antiplatelet Therapy on Mortality and Cardiovascular and Bleeding Outcomes in Persons With Chronic Kidney Disease: A Systematic Review and Meta-analysis
This systematic review and meta-analysis was designed to summarize the effects of antiplatelet treatment on cardiovascular events, mortality and bleeding in patients with CKD. The results showed that serious bleeding was increased while there was no benefit on all-cause CV mortality or myocardial infarction in patients with CKD. In patients with stable or absent cardiovascular [...]
Updated Labelling for Pradax Regarding Kidney Function and Risk of Bleeding
These notes are taken from the changes to the Canadian product monograph for the anticoagulant Pradax (dabigatran etexilate) which have been updated to include new recommendations regarding renal function. Given that renal impairment is a risk factor for bleeding with Pradax®: Prior to initiation of treatment, renal function should be assessed in all patients to [...]
Membranoproliferative Glomerulonephritis — A New Look at an Old Entity
MPGN accounts for approximately 10% of cases of glomerulonephritis. This article nicely reviews the causes, pathogenesis and clinical management. Related Articles: Allograft Failure in Kidney Transplant Recipients with Membranoproliferative Glomerulonephritis Calcium Kidney Stones Stage IV Chronic Kidney Disease
Benefits of regular walking exercise in advanced pre-dialysis chronic kidney disease
This prospective study of 40 patients with stage 4-5 CKD assessed the benefits of 6 months of regular walking. Self-reported improvements were noted in exercise tolerance, quality of life and uremic symptoms. While more studies need to be done with larger patient populations to understand the nature and mechanism of these benefits, this study does [...]
Likelihood of Starting Dialysis after Incident Fistula Creation
This analysis of administrative data estimated the risk of fistula non-use in predialysis patients with a fistula. Eighty-one percent of patients initiated dialysis; 9% of patients died without receiving dialysis, and 10% of patients remained predialysis. These results suggest that a fistula is used in the majority of patients in whom it is created. Related [...]
Correction of Postkidney Transplant Anemia Reduces Progression of Allograft Nephropathy
In this randomized controlled trial, use of erythropoietin in renal transplant recipients to normalize hemoglobin to normal levels (130-150 g/L) resulted in less decline in graft function, less graft failure and fewer deaths compared to maintaining hemoglobin in the range recommended by current renal guidelines (105-115 g/L). This is a surprising result, as there have [...]
Understanding the Causes of Kidney Transplant Failure: The Dominant Role of Antibody-Mediated Rejection and Nonadherence
Understanding the causes of renal allograft failure is key in improving long-term graft survival. In this study, for-cause biopsies were analyzed, and outcomes were related to the biopsy finding. Notably, acute T-cell mediated cellular rejection rarely led to graft loss. In contrast, all patients who experienced graft loss demonstrated some degree of antibody-mediated rejection on [...]
A Randomized Trial With Steroids and Antithymocyte Globulins Comparing Cyclosporine/Azathioprine Versus Tacrolimus/Mycophenolate Mofetil (CATM2) in Renal Transplantation
In the last few years, the tacrolimus and mycophenolic acid has become the most popular therapy used in renal transplant, rather than the older cyclosporine and azathioprine combination. These authors conducted a randomized controlled trial to see whether the use of lymphocyte-depleting induction therapy would give equivalent results between these two drug regimens. In fact, [...]
Very early steroid withdrawal or complete avoidance for kidney transplant recipients: a systematic review
There have been a number of randomized controlled trials over the last few years comparing early corticosteroid withdrawal post-renal transplant to long-term low-dose steroids. This meta-analysis found nine randomized controlled trials using modern immunosuppression protocols to assess the impact of early steroid withdrawal. Patients received tacrolimus or cyclosporine; mycophenolic acid or an mTOR inhibitor; and [...]
World Kidney Day 2012: The Global Role of Kidney Transplantation
This article reflects on the success of kidney transplantation for the therapy of ESRD to commemorate World Kidney Day on March 8, 2012. Related Articles: Liver-kidney transplantation to cure atypical hemolytic uremic syndrome. Bundled Payment for ESRD — Including ESAs in Medicare’s Dialysis Package A Predictive Model for Progression of Chronic Kidney Disease to Kidney [...]
Treatment of chronic kidney disease
This article reviews the therapeutic options to delay the progression of chronic kidney disease. Related Articles: Update in Nephrology Pediatrics: Blood pressure target for renoprotection in children Stage IV Chronic Kidney Disease
Choosing peritoneal dialysis reduces the risk of invasive access interventions
This prospective multicentre Canadian study followed 369 dialysis patients for an average of 1.3 years (224 patients chose PD and 145 chose HD). The authors found that the PD group required fewer access interventions to maintain dialysis access (2.5 versus 3.1 interventions per patient, adjusted odds ratio of 0.79 for PD versus HD, P = [...]
Randomized Controlled Trial Comparing Mupirocin and Polysporin Triple Ointments in Peritoneal Dialysis Patients: The MP3 Study
This double-blind multicentre RCT studied the effectiveness of topical Polysporin Triple ointment as compared to mupirocin to peritoneal dialysis catheter exit sites. Twice the number of patients experienced redness at the exit site in the Polysporin Triple group (14 versus 6, P=0.10) with a higher rate of fungal exit site infection (0.07 versus 0.01; P=0.02) [...]
Three-Year Outcomes from BENEFIT, a Randomized, Active-Controlled, Parallel-Group Study in Adult Kidney Transplant Recipients
BENEFIT is a randomized controlled trial comparing two different doses of belatacept, a costimulatory blocker, to standard therapy with cyclosporine in de novo kidney transplant patients. Earlier results from this study showed a higher acute rejection rate with belatacept. Nonetheless, at three years, renal function was significantly better in belatacept-treated patents. Related Articles: Switching from [...]
Ureteral Stents Are Associated With Reduced Risk of Ureteral Complications After Kidney Transplantation: A Large Single Center Experience
Insertion of a double-J stent into the transplant ureter at the time of surgery reduces the risk of ureteric stricture. In this single-centre study, the decision to insert a ureteral stent or not was made by surgeons at the time of transplantation. There was a significant reduction in the risk of stricture, but only in [...]
Recurrent Dense Deposit Disease After Renal Transplantation: An Emerging Role for Complementary Therapies
Membranoproliferative glomerulonephritis type II, or dense deposit disease, is a rare type of renal disease caused by excessive complement deposition in the kidney. It is also associated with a high rate of recurrence post-transplant. In this case report, a patient developed recurrent dense deposit disease shortly after transplant. Despite aggressive treatment, renal function worsened and [...]
Testosterone deficiency is a cause of anemia and reduced responsiveness to erythropoiesis-stimulating agents in men with chronic kidney disease
This observational study assessed a) the association between testosterone levels and hemoglobin in nondialysed CKD Stages 1-5 ESA-naive male patients as well as the association between testosterone levels and ESA dose in ESA-treated males undergoing hemodialysis. CKD patients with lower testosterone values were 5.3 times more likely to be anemic. In patients undergoing HD, higher [...]
Dialysate Sodium Concentration and the Association with Interdialytic Weight Gain, Hospitalization, and Mortality
This analysis of observational DOPPS data examined the impact of reduced dialysate sodium on clinical outcomes. While lowering dialysate sodium was associated with lower interdialytic weight gain, it was also associated with increased hospitalization. No mortality benefit was associated with reduced dialysate sodium. Related Articles: Fatal and Nonfatal Outcomes, Incidence of Hypertension, and Blood Pressure [...]
The effect of combination treatment with aliskiren and blockers of the renin-angiotensin system on hyperkalaemia and acute kidney injury: systematic review and meta-analysis
In the wake of the termination of the Altitude study, this meta-analysis identifies an increase risk of hyperkalemia but not acute kidney injury in the combination of aliskiren and angiotensin converting enzyme inhibitors or angiotensin receptor blockers. Related Articles: Treatment of Kidney Transplant Recipients With ACEi/ARB and Risk of Respiratory Tract Cancer: A Collaborative Transplant Study [...]
Sodium Intake, ACE Inhibition, and Progression to ESRD
The impact of sodium intake on clinical outcomes has recently come under some scrutiny and the topic is surrounded by debate. In this retrospective analysis of the REIN study, patients with non-diabetic CKD who had high dietary salt (>14 g daily) had a blunted antiproteinuric effect from ACE inhibitor therapy and increase the risk for [...]
Decongestive Treatment of Acute Decompensated Heart Failure: Cardiorenal Implications of Ultrafiltration and Diuretics
This review discusses the role of diuretics and ultrafiltration in acute decompensated heart failure. Related Articles: Diuretic Strategies in Patients with Acute Decompensated Heart Failure Therapeutic Strategies for Heart Failure in Cardiorenal Syndromes The time course of peritoneal transport parameters in peritoneal dialysis patients who develop encapsulating peritoneal sclerosis.
Focal Segmental Glomerulosclerosis
FSGS accounts for appoximately 40% of adult nephrotic syndrome. This review provides an approaches to the diagnosis and management of this disease. Related Articles: Atypical Hemolytic–Uremic Syndrome Dementia and cognitive impairment in ESRD: diagnostic and therapeutic strategies Podocyte disorders: core curriculum 2011
The PROMISE Study: A Phase 2b Multicenter Study of Voclosporin (ISA247) Versus Tacrolimus in De Novo Kidney Transplantation
Voclosporin is a new calcineurin inhibitor being assessed for transplantation. In this dose-ranging non-inferiority trial, three therapeutic levels of voclosporin were compared to tacrolimus in new renal transplant recipients. The incidence of acute rejection was similar in all voclosporin groups compared to tacrolimus. The incidence of diabetes increased in the higher-dose voclosporin group. Further studies [...]
Specificity of Histological Markers of Long-Term CNI Nephrotoxicity in Kidney-Transplant Recipients Under Low-Dose Cyclosporine Therapy
Arteriolar hyalinosis has been considered as the hallmark of calcineurin-inhibitor toxicity. In this retrospective study, renal biopsies were compared between patients who did and did not receive cyclosporine. No histologic lesion, including arteriolar hyalinosis, was seen exclusively in cyclosporine-treated patients. The accompanying editorial discusses the need to develop specific markers of calcineurin-inhibitor toxicity. Related Articles: [...]
Infectious complications in kidney-transplant recipients desensitized with rituximab and intravenous immunoglobulin
Patients who are desensitized prior to renal transplant require more intensive immunosuppression compared to average-risk patients. In this single-centre, non-randomized study, the use of rituximab was not associated with an increased risk of bacterial, viral or fungal infections. Related Articles: Incidence and Predictive Factors for Infectious Disease after Rituximab Therapy in Kidney-Transplant Patients Troponin I [...]
Impact of Early Conversion From Tacrolimus to Sirolimus on Chronic Allograft Changes in Kidney Recipients on Rapid Steroid Withdrawal
This randomized controlled trial assessed the effect of conversion from tacrolimus to sirolimus at one month post-transplant. In comparison to other such trials of early conversion to an mTOR inhibitor, this trial was notable for including protocol biopsies. Conversion to sirolimus did not affect the frequency of chronic changes seen on biopsy at one year [...]
Novartis announces termination of ALTITUDE study
Novartis announced the termination of the ALTITUDE study in high-risk patients with diabetes and renal impairment. The study was designed to determine if aliskiren could reduce cardiovascular and renal morbidity and mortality, compared with placebo, when added to conventional treatment (including ACEi or ARB). Based on the recommendation from the Data Monitoring committee, it was felt [...]
Urinary Sodium and Potassium Excretion and Risk of Cardiovascular Events
An observational analysis of cohorts from the ONTARGET and TRANSCEND trials looked at the association of urinary sodium and potassium with CV events and mortality. Sodium excretion and CV events showed a J-shaped relationship: sodium excretion of < 3 g and >7 g per day was associated with an increased risk of CV events. Risk [...]
Bedtime Dosing of Antihypertensive Medications Reduces Cardiovascular Risk in CKD
This open-label single-center trial examines the impact on cardiovascular events in hypertensive patients with CKD treated with ≥1 hypertension medication at bedtime vs taking all anti-hypertensive medications upon waking. See the accompanying editorial: http://jasn.asnjournals.org/content/22/12/2152.full Free full text kindly provided by the American Society of Nephrology Related Articles: Staphylococcus aureus Infections in Hemodialysis: What a Nephrologist [...]
Coiled Versus Straight Peritoneal Dialysis Catheters: A Randomized Controlled Trial and Meta-analysis
While the included RCT failed to show any significant difference between PD catheter type, the meta-analysis also performed suggests that coiled catheters may be more prone to migration and dysfunction than straight catheters. Related Articles: Effect of Telmisartan on Renal Outcomes: A Randomized Trial. ASN 2010 Late Breaking Clinical Trial Results | SHARP, Preclot, more [...]
CKD–Mineral and Bone Disorder: Core Curriculum 2011
This AJKD Core Curriculum article nicely covers the challenging topic of bone mineral metabolism in chronic kidney disease. Related Articles: Kidney Development: Core Curriculum 2011 Nutritional Considerations in Kidney Disease: Core Curriculum 2010 Home Hemodialysis, Daily Hemodialysis, and Nocturnal Hemodialysis: Core Curriculum 2009
Meta-Analysis of Calcineurin-Inhibitor-Sparing Regimens in Kidney Transplantation
This is a meta-analysis of papers using a variety of approaches to reduce the toxicity of calcineurin inhibitors (CnI) in renal transplantation. Papers include a variety of approaches, such as CnI minimization, delayed introduction and avoidance. All strategies showed improvements in graft function. However, while CnI minimization or use of newer agents such as belatacept [...]
Antibody Removal Before ABO-Incompatible Renal Transplantation: How Much Plasma Exchange Is Therapeutic?
Desensitization protocols to allow for transplantation across the ABO-blood barrier have become accepted in renal transplantation over the last decade. Plasma exchange is a frequent part of these protocols, and physically removes the antibodies from the circulation. This single-centre cohort study looked at the number of plasma exchange sessions required to reach a threshold where [...]
Association of Pretransplant Serum Phosphorus with Posttransplant Outcomes
Both hypo- and hyperphosphatemia are associated with an increased risk of death in dialysis patients. In this large registry study, severe hyperphosphatemia was associated with increased risk of death. More moderate hyperphosphatemia was associated with graft failure after kidney transplantation. This shows the importance of phosphate management in patients pre-transplant, as it will affect post-transplant [...]
Outcome of treated and untreated asymptomatic bacteriuria in renal transplant recipients
Urinary tract infections (UTIs) are a common complication post-renal transplant. Asymptomatic bactiuria is a common finding, but whether antibiotic treatment it will reduce symptomatic urinary tract infections is unclear. In this single-centre cohort study, there was no difference in the rate of progression of asymptomatic bactiuria to symptomatic UTI between treated and untreated episodes. This [...]
Mycophenolate versus Azathioprine as Maintenance Therapy for Lupus Nephritis
This 3-year randomized controlled trial compared mycophenolate mofetil and azathioprine as maintenance therapy after induction of remission in lupus nephritis. Mycophenolate mofetil was superior to azathioprine in achieving the primary end point, time to treatment failure, time to renal flare and time to rescue therapy There was a trend to fewer serious adverse events in [...]
Risk of Pneumocystis jiroveci pneumonia in patients long after renal transplantation
Pneumocystis jiroveci pneumonia is a well-recognized complication after transplantation, and current guidelines recommend prophylaxis for three-six months post-transplant. In this study, nine patients who develop Pneumocystis pneumonia a median of 19 months post-transplant were compared to a group of control patients. Cases had significantly lower lymphocyte counts than controls, as well as lower CD4 counts, [...]
Screening and Follow-Up of Living Kidney Donors: A Systematic Review of Clinical Practice Guidelines
Careful screening of potential living kidney donors is crucial to ensure that only appropriate patients are allowed to donate, and keep the risk of donation to a minimum. This systematic review found nine different sets of guidelines about living donor evaluation published over the last fifteen years. While there was broad agreement in most areas, [...]
Treatment of Kidney Transplant Recipients With ACEi/ARB and Risk of Respiratory Tract Cancer: A Collaborative Transplant Study Report
Meta-analyses in the general population have suggested that ACE-inhibitors and angiotensin receptor blockers may increase the risk of cancer, particularly lung cancer. In this report from the international Collaborative Transplant Study, use of ACE-I or ARB as associated with a statistically significant increased risk of lung cancer, but only in patients with a smoking history. [...]
Terminal Complement Inhibition Decreases Antibody-Mediated Rejection in Sensitized Renal Transplant Recipients
There has been much interest in transplantation around eculizumab, a monoclonal antibody that blocks formation of the membrane attack complex of the complement cascade. In this single-centre, non-randomized study, patients with donor-specific antibody who were treated with eculizumab had a significantly lower rate of antibody-mediated rejection that a group of historical controls. There was also [...]
Cullen and Grey Turner signs in idiopathic perirenal hemorrhage
This brief report describes and provide images of Cullen and Grey Turner signs in perirenal hemorrhage. Related Articles: Intensive Diabetes Therapy and Glomerular Filtration Rate in Type 1 Diabetes Case Report, Hemodialysis: Atypical clinical presentation of H1N1 influenza in a dialysis patient Prediction of the severity and outcome of acute tubular necrosis based on continuity [...]
Use of Electron-Beam Sterilized Hemodialysis Membranes and Risk of Thrombocytopenia
This cohort study identified exposure to e-beam sterilized dialyzers as an etiologic agent contributing to significant post-dialytic thrombocytopenia. Related Articles: Contraindicated Medication Use in Dialysis Patients Undergoing Percutaneous Coronary Intervention Use of isoniazid chemoprophylaxis in renal transplant recipients Effect of Obesity on the Outcome of Kidney Transplantation: A 20-Year Follow-Up
Pregnancy Outcomes in Women with Chronic Kidney Disease: A Systematic Review
Thirteen observational studies were included in this systematic review of pregnant women with chronic kidney disease (CKD). Pregnant women on dialysis or with a history of transplantation were excluded. Adverse maternal outcomes were reported in twelve studies were approximately five times higher in women with CKD. These include gestational hypertension, preeclampsia and maternal mortality. Adverse [...]
Exercise training for adults with chronic kidney disease.
This systematic review identified evidence for significant beneficial effects of regular exercise on physical fitness, walking capacity, cardiovascular dimensions (e.g. BP and heart rate), health-related quality of life and some nutritional parameters in adults with chronic kidney disease. Related Articles: Benefits of regular walking exercise in advanced pre-dialysis chronic kidney disease Systematic Review: Vitamin D [...]
Survival advantage of hemodialysis relative to peritoneal dialysis in patients with end-stage renal disease and congestive heart failure
This prospective French Registry study finds that the adjusted hazard ratio for death in PD compared to the HD patients was significant at 1.48 for all enrolled patients started on dialysis with associated congestive heart failure. Of note, congestive heart failure was determined subjectively (not by left ventricular ejection fraction), the PD group was older [...]
Current Therapy for IgA Nephropathy
IgA nephropathy is a multi-faceted disease with many clinical presentations that are not always easy to manage. This review nicely summarizes the therapeutic options using four clinical scenarios of patients with IgA nephropathy. Free full text kindly provided by the American Society of Nephrology Related Articles: Enzyme Replacement Therapy and Fabry Nephropathy Staphylococcus aureus Infections [...]
The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial
This small randomized controlled trial comparing nocturnal home hemodialysis to conventional hemodialysis failed to show a benefit in any primary outcome (death or left ventricular mass, or, death or RAND Physical Health Composite). Patients in the nocturnal arm did have improved control of hyperphosphatemia and hypertension. Related Articles: In-Center Hemodialysis Six Times per Week versus [...]
Prolonged disease-free remission following rituximab and low-dose cyclophosphamide therapy for renal ANCA-associated vasculitis
This study of twenty-three patients presenting or relapsing with ANCA-associated vasculitis were treated with two pulses of rituximab 2 weeks apart, six biweekly doses of cyclophosphamide and a tapering course of oral steroids. They were subsequently put on a maintenance regimen of low-dose steroids and azathioprine. All patients achieved clinical remission within six weeks. Five [...]
Intensive Diabetes Therapy and Glomerular Filtration Rate in Type 1 Diabetes
This paper was published online in the New England Journal of Medicine paper in order to coincide with the oral presentation at the 2011 American Society of Nephrology meeting. This report describes renal follow-up of Type 1 diabetic patients enrolled in the DCCT (Diabetes Control and Complications Trial) and EDIC (Epidemiology of Diabetes Interventions and Complications) [...]
Late Breaking Clinical Trials at ASN 2011 – FISH study and more
The late breaking clinical trials session from the 2011 American Society of Nephrology meeting was held on November 12, 2011. The following are summaries of some of the clinical trial results. Access to the full details of these studies awaits publication in peer reviewed journals. Charmaine E. Lok et al. The Fish Oil Inhibition of Stenosis [...]
Long Interdialytic Interval and Mortality among Patients Receiving Hemodialysis
This administrative study using USRDS data demonstrated an increased risk of all-cause mortality and admissions to hospital due to cardiovascular events during the long (2 day) interdialytic interval. This study alludes to the benefit of more frequent hemodialysis and suggests that current dialysis scheduling may need to be revisited. Related Articles: Cardiovascular and noncardiovascular [...]
Acetylcysteine for Prevention of Renal Outcomes in Patients Undergoing Coronary and Peripheral Vascular Angiography: Main Results From the Randomized Acetylcysteine for Contrast-Induced Nephropathy Trial (ACT)
This randomized trial of over 2300 patients undergoing coronary and peripheral vascular angiography failed to show that acetylcysteine reduces the risk of contrast-induced acute kidney injury, need for dialysis or mortality. This study contributes to the growing body of literature suggesting the lack of benefit of using NAC in the prevention of contrast-induced nephropathy. Related [...]
2011 Prevention in Renal Disease Conference
Watch all sessions from the 2011 Prevention in Renal Disease Conference. http://ukidney.com/prevention-in-renal-disease-conference-toronto-11-dp1 Related Articles: Prevention in Renal Disease Conference 2009 8th Annual Prevention in Renal Disease 9th Annual Conference on Prevention in Renal Disease
iPhone App ‘Calculate by QxMD’ adds PD Content
The app ‘Calculate by QxMD’ now includes: Access Care and Complications Guide PD Prescription Calculator & Guide ISPD & CSN Guidelines MATCH D – Home Dialysis Patient Selection tool General Nephrology Calculators Learn more http://www.qxmd.com/peritoneal-dialysis-management-tools-added-to-calculate-by-qxmd Download now http://itunes.apple.com/app/calculate-medical-calculator/id361811483?mt=8 Related Articles: iPhone Nephrology Clinical Calculator A Predictive Model for Progression of Chronic Kidney Disease to Kidney [...]
New DaVita Peritoneal Dialysis Webinar Series
A new series of DaVita’s peritoneal dialysis (PD) webinars began in October and will continue on the first Friday of each month. The clinically focused webinars will be presented by physician experts in home dialysis. The next webinar, The Pros and Cons of CAPD vs. CCPD, is hosted by Dr Tom Tucker and will take [...]
Podocyte disorders: core curriculum 2011
This paper provides point form review of normal and pathological glomerular function, as well as major types of podocyte disorders including minimal change disease, membranous nephropathy and FSGS. Related Articles: Circulating urokinase receptor as a cause of focal segmental glomerulosclerosis Posttransplant Recurrence of Primary Glomerulonephritis Autoantibodies Specific for the Phospholipase A2 Receptor in Recurrent and De [...]
Clinical practice. Chronic hypertension in pregnancy.
This is an excellent review on the management of pre-existing hypertension in the setting of pregnancy. Related Articles: Management of hypertensive disorders during pregnancy: summary of NICE guidance Vitamins C and E to Prevent Complications of Pregnancy-Associated Hypertension Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomised [...]
Persistent Asymptomatic Isolated Microscopic Hematuria in Israeli Adolescents and Young Adults and Risk for End-Stage Renal Disease
This study linked an ESRD registry to retrospective medical data for persons aged 16-25 examined for military fitness. It showed that persistent asymptomatic microscopic hematuria was associated with an increased risk of ESRD, with an adjusted hazard ratio of 18.5 [95% CI, 12.4-27.6]. While the absolute risk of ESRD in patients with microscopic hematuria remains [...]
Predialysis nephrology care of older patients approaching end-stage renal disease.
This retrospective study failed to demonstrate significant improvements in 1-year survival rates after dialysis initiation despite a trend to earlier nephrology consultation in older adults with chronic kidney disease. The accompanying editorials ask questions about the role and benefit of predialysis care. Editorials Earlier Nephrology Consultation Is Not Associated With Improved Survival: Comment on “Predialysis [...]
The Impact of Conversion From Prograf to Generic Tacrolimus in Liver and Kidney Transplant Recipients With Stable Graft Function
Most immunosuppressive agents used in transplantation will become available as generics in the next few years. This might significantly reduce the costs of transplantation, but there is concern that the pharmacokinetics of generic formulations will not be the same as the brand-name drug, resulting in either inadequate immunosuppression or excessive toxicity. In this paper, stable [...]
Randomized trial of immunosuppressive regimens in renal transplantation
Most randomized controlled trials of immunosuppressive regimens have follow-up of only one to three years, which may not be relevant in an era where average graft survival is a decade or more. This paper reports long-term results of a randomized controlled trial comparing tacrolimus/sirolimus, tacrolimus/mycophenolate mofetil and cyclosporine/sirolimus. All patients received induction with an interlukin-2 [...]
Autoantibodies Specific for the Phospholipase A2 Receptor in Recurrent and De Novo Membranous Nephropathy
An important recent story in glomerulonephritis has been the discovery of the anti-phospholipase A2 receptor antibodies (PLA2R Ab) in many patients with membranous nephropathy. This paper aims to relate the presence or absence of this antibody to the likelihood of recurrence. Patients with de novo membranous nephropathy did not produce PLA2R Ab. Surprisingly, the antibody [...]
Graft Loss Due to Recurrent Lupus Nephritis in Living-Related Kidney Donation
Recurrence of lupus nephritis is not uncommon, and treatment can be difficult. This retrospective cohort study using the UNOS registry examined the risk of graft loss among living-donor recipients of a kidney transplant. Surprisingly, patients who received a zero-mismatched kidney had the lowest incidence of graft loss due to recurrent lupus nephritis. Free full text [...]
Cardiac Survival after Pre-emptive Coronary Angiography in Transplant Patients and Those Awaiting Transplantation
Evaluation for cardiac ischemia is frequently part of the pre-transplant evaluation for renal transplant candidates, and frequently leads to angioplasty or bypass surgery. However, given the possibility of a long time period between cardiac evaluation and eventual transplant, it is unclear whether this reduces the risk of transplant surgery. In this single-centre study, patients who [...]
Monoclonal Gammopathy of Undetermined Significance Does Not Affect Outcomes in Patients Undergoing Solid Organ Transplants
Monoclonal gammopathy of unknown significance (MGUS) is often benign but can progress to myeloma in some cases. Whether immunosuppression increases the risk of progression is unknown. In this retrospective study, MGUS was not associated with progression to myeloma, amyloid or lymphoma post-transplant. MGUS should not be considered a contraindication to transplant. Related Articles: Outcomes of [...]
Conversion of Long-Term Kidney Transplant Recipients From Calcineurin Inhibitor Therapy to Everolimus: A Randomized, Multicenter, 24-Month Study
The ASCERTAIN study was a randomized controlled trial comparing three strategies: replacement of calcineurin inhibitor (CnI) with everolimus; addition of everolimus and CnI reduction; or CnI minimization. There was no difference in renal function, acute rejection rates or graft loss at 2 years. Of note, the mean time post-transplant of patients in this trial was [...]
Circulating urokinase receptor as a cause of focal segmental glomerulosclerosis
Recurrence of focal segmental glomerulosclerosis (FSGS) post-transplant can be dramatic and lead to graft loss. Several years ago, a “permeability factor” was discovered that seemed to cause recurrence, and could be removed by plasma exchange. However, until now, the nature of this factor has been unknown. In this set of experiments, the authors show that [...]
Selection Bias Explains Apparent Differential Mortality between Dialysis Modalities
This study shows that the previously explained difference in relative risk of death with peritoneal dialysis patients compared with those treated with hemodialysis is likely related to selection bias. No difference was found in the relative risk of mortality for peritoneal dialysis compared with hemodialysis among individuals who received ≥4 months of predialysis care and [...]
Moderate dietary sodium restriction added to angiotensin converting enzyme inhibition compared with dual blockade in lowering proteinuria and blood pressure: randomised controlled trial
This small randomized trial including patients with non-diabetic nephropathy looked at the addition of dietary sodium restriction or angiotensin receptor blockade (or their combination), in patients receiving background treatment with angiotensin converting enzyme (ACE) inhibition at maximum dose. Dietary sodium restriction to a level recommended in guidelines was more effective than dual blockade for reduction [...]
Monitoring and Managing Graft Health in the Kidney Transplant Recipient
This is an introduction to a collection of articles focusing on care of the healthy renal transplant recipient after the early post-transplant. The articles in this section focus on the components of a routine clinic visit, the metabolic syndrome, proteinuria and anemia. The focus is on recognizing and managing those factors that play an important [...]
Desensitization in HLA-Incompatible Kidney Recipients and Survival
For patients with high levels of anti-HLA antibodies, waiting times for a kidney transplant are significantly longer than average. Desensitization allows the barrier of a positive crossmatch to be overcome, but there are concerns related to the long-term risks of chronic antibody-mediated rejection. This paper reports an experienced centre’s results with a group of patients [...]
Improved Rejection Prophylaxis With an Initially Intensified Dosing Regimen of Enteric-Coated Mycophenolate Sodium in De Novo Renal Transplant Recipients
Previous studies have defined a therapeutic area under the curve for mycophenolic acid (MPA) in the early post-transplant period, although the majority of centers do not perform routine MPA monitoring. This paper presents results of a randomized controlled trial comparing an initial higher dose of MPA to standard dosing in patients treated with steroids, cyclosporine [...]
The ORION Study: Comparison of Two Sirolimus-Based Regimens versus Tacrolimus and Mycophenolate Mofetil in Renal Allograft Recipients
This randomized controlled trial in de novo renal transplant recipients compared a standard immunosuppressive protocol of daclizumab induction, tacrolimus, mycophenolate mofetil (MMF) and steroids, to either: sirolimus and tacrolimus, with tacrolimus discontinued by four months post-transplant, or sirolimus and MMF. The sirolimus and MMF group was stopped early due to a high incidence of acute [...]
Bardoxolone Methyl and Kidney Function in CKD with Type 2 Diabetes
Free full text available for several days only. This industry-sponsored phase 2 RCT examined the impact of bardoxolone methyl, an oral antioxidant inflammation modulator, on renal function in patients with CKD and diabetes. At 24 and 52 weeks, the intervention arms had improved eGFR compared to placebo. Hard clinical endpoints were not examined in this study. Related [...]
The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial
The SHARP study was a large randomized controlled trial which assessed the efficacy and safety of the combination of simvastatin plus ezetimibe in patient with moderate-to-severe kidney disease. Consistent with Nephrology Now’s report on the trial results as presented at the 2010 ASN meeting, the intervention arm had a 17% relative risk reduction in major [...]
Research Suggests a Novel Cell-Based Therapy for Chronic Kidney Disease and CKD-Associated Heart Failure
This Nephrology Now Research Showcase is submitted by Darren A. Yuen MD and Richard E. Gilbert MD PhD. Nephrology Now Research Showcases summarize important bodies of work in clinical or experimental Nephrology. Background New therapies are needed for CKD and its cardiovascular complications Chronic kidney disease (CKD) is a major cause of hospitalization, premature [...]
A Nurse-coordinated Model of Care versus Usual Care for Stage 3/4 Chronic Kidney Disease in the Community: A Randomized Controlled Trial
The CanPREVENT study was an unblinded randomized clinical trial that provided either usual care or nurse-coordinated and nephrologist-supported care for patient identified with CKD stages 3 and 4. While the clinical endpoints were no different between groups, the economic analysis published in the same issue of CJASN suggests the program was cost effective with better [...]
Desmopressin Acetate in Percutaneous Ultrasound-Guided Kidney Biopsy: A Randomized Controlled Trial
This double-blind randomized controlled trial of 162 patients with eGFR > 60 ml/min showed that desmopressin decreased the bleeding rate post-renal biopsy. Of note, the control group had a very high bleeding rate of approximately 30% which may not be representative of many centers’ experience. Related Articles: Raloxifene, a selective estrogen receptor modulator, is renoprotective: [...]
Kidney Development: Core Curriculum 2011
This AJKD core curriculum article discusses through the less commonly covered subject of kidney development from embroyonic stages to birth. Related Articles: CKD–Mineral and Bone Disorder: Core Curriculum 2011 Nutritional Considerations in Kidney Disease: Core Curriculum 2010 Toxic Nephropathies: Core Curriculum 2010
Hemodialysis Vascular Access Modifies the Association between Dialysis Modality and Survival
The question of early survival benefit in peritoneal dialysis is addressed in this study of CORR incident adult dialysis patients. By comparing the survival of incident PD patients with those who initiated HD with a central venous cathter or with a functional arteriovenous fistula or graft, it was determined that the use of CVCs in [...]
Maintenance Immunosuppression in Antineutrophil Cytoplasmic Antibody–Associated Vasculitis
This review provides commentary on the article ‘Mycophenolate mofetil vs azathioprine for remission maintenance in antineutrophil cytoplasmic antibody-associated vasculitis: a randomized controlled trial.’, authored by Hiemstra TF, Walsh M, Mahr A, et al for the European Vasculitis Study Group (EUVAS). Related Articles: Therapeutic Interventions for Systemic Vasculitis Mycophenolate versus Azathioprine as Maintenance Therapy for Lupus [...]
The Tumor Lysis Syndrome
This review nicely summarizes tumor lysis syndrome and its renal complications. Related Articles: Dementia and cognitive impairment in ESRD: diagnostic and therapeutic strategies Management of patients with acute hyperkalemia Perioperative acute kidney injury: risk factors, recognition, management, and outcomes
10th Annual Conference on Prevention in Renal Disease
Program details, faculty and on-line registration of the 10th Annual Conference on Prevention in Renal Disease (Toronto, September 16-17, 2011) are now available at www.nephroprevention.com Scholarships (waiving of early registration fee) will be given to the first 50 fellows/residents who will register. Prizes for the best three abstracts. Participation is limited to the first 300 [...]
Homocysteine-lowering and cardiovascular disease outcomes in kidney transplant recipients: primary results from the folic acid for vascular outcome reduction in transplantation trial
The FAVORIT study is the largest randomized controlled trial ever conducted in renal transplantation. It examined whether lowering homocysteine levels using folic acid, vitamin B6 and vitamin B12 would reduce cardiovascular events in a group of stable renal transplant patients. Although homocysteine levels were lowered, there was no difference in cardiovascular events, death or graft [...]
Alemtuzumab induction in renal transplantation
Alemtuzumab is a monoclonal antibody developed for treatment of lymphoma that profoundly depletes both T- and B-cells, and has been used off-label in transplantation. This randomized controlled trial compared alemtuzumab to induction with either thymoglobulin or basiliximab, and with rapid corticosteroid withdrawal. There were fewer acute rejections at one year with alemtuzumab compared to conventional [...]
Elevated Fibroblast Growth Factor 23 is a Risk Factor for Kidney Transplant Loss and Mortality
Fibroblast growth factor 23 (FGF 23) is a protein that is elevated in CKD and ESRD and is associated with increased risk of cardiovascular disease and death. In this single-center study, higher FGF 23 levels in a group of stable renal transplant patients were associated with a greater risk of mortality and graft failure. Whether [...]
Improving the Allocation System for Deceased-Donor Kidneys
This “Perspective” article and the accompanying piece Risk, Prognosis, and Unintended Consequences in Kidney Allocation look at a recent proposal to change the allocation of deceased donor kidneys in the United States. The new system would use models which estimates a patient’s risk of death and a kidney’s risk of graft failure, and then allocates [...]
Cytomegalovirus glycoprotein-B vaccine with MF59 adjuvant in transplant recipients: a phase 2 randomised placebo-controlled trial
The highest risk of cytomegalovirus (CMV) disease post-transplant is in seronegative recipients who receive a kidney from a seropositive donor. In this randomized controlled trial, a vaccine resulted in production of antibodies. Among those patients subsequently transplanted, CMV viremia responded to treatment with ganciclovir more quickly in vaccinated patients. Related Articles: Anti-Human Leukocyte Antigen and [...]
Associations of Pretransplant Serum Albumin with Post-Transplant Outcomes in Kidney Transplant Recipients
A low serum albumin level is a well-known predictor of morbidity and mortality among patients with chronic kidney disease. This study from a large US national dialysis chain followed patients who subsequently underwent transplant. A lower pre-transplant albumin level was associated with a higher risk of death, graft failure and also delayed graft function. Whether [...]
Effect of Obesity on the Outcome of Kidney Transplantation: A 20-Year Follow-Up
This study examined the effect of obesity pre-transplant, post-transplant obesity and early weight gain post-transplant on outcomes. An elevated BMI both pre-transplant and at 1 year post-transplant were associated with worse outcomes. More notably, the change in BMI during the first year post-transplant was also a significant risk factor for death and death-censored graft loss. [...]
Intravenous Erythropoietin in Patients With ST-Segment Elevation Myocardial Infarction: REVEAL: A Randomized Controlled Trial
This randomized controlled trial in non-CKD patients with STEMI examined the impact of a single intravenous bolus of epoetin alfa within 4 hours of PCI. The intervention group did not have any reduction in infarct size and was associated with higher rates of adverse cardiovascular events. Should this trial impact how Nephrologists prescribe ESA in CKD [...]
Fatal and Nonfatal Outcomes, Incidence of Hypertension, and Blood Pressure Changes in Relation to Urinary Sodium Excretion
In this controversial prospective observational study, reduced sodium excretion (a marker of sodium intake) was associated with increased mortality, rather than the expected opposite finding. Higher sodium excretion was, however, associated with increased systolic blood pressure. Please share your comments – does this research change your opinion about the impact of dietary sodium intake? Related [...]
Summary of Recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections
Given the large number of central venous catheters placed by Nephrologists, this clinical practice guideline reviews preventative strategies to reduce infections. Areas of focus include a) educating and training healthcare personnel who insert and maintain catheters; b) using maximal sterile barrier precautions during central venous catheter insertion; c) using a > 0.5% chlorhexidine skin preparation [...]
Olmesartan for the Delay or Prevention of Microalbuminuria in Type 2 Diabetes
This large randomized multicentre trial showed delayed onset of microalbuminuria in Type 2 diabetics with normoalbuminuria that were treated with olmesartan 40 mg daily as compared to the placebo group, but a higher rate of fatal cardiovascular events in those with preexisting heart disease. Editorial http://www.nejm.org/doi/full/10.1056/NEJMe1014147 UKidney Discussion http://qx.md/y Related Articles: Effect of Valsartan on [...]
Clinical Practice Guidelines and Recommendations on Peritoneal Dialysis Adequacy 2011
This set of guidelines, released by the Canadian Society of Nephrology (CSN), updates the last set of guidelines from 1999 and addresses key points in PD adequacy. Free full text access kindly provided by the Canadian Society of Nephrology Available for iPhone Available for iPad Available for Android Related Articles: Staphylococcus aureus Infections in Hemodialysis: [...]
A Predictive Model for Progression of Chronic Kidney Disease to Kidney Failure
The Kidney Failure Risk Equation is described, which offers a robust prediction model to determine the probability of renal replacement therapy (dialysis or transplant) in patients with baseline GFR of 10-60 ml/min. The results were first presented at the recent World Congress of Nephrology and a point of care calculator was simultaneously released as part [...]
Detection of Chronic Kidney Disease With Creatinine, Cystatin C, and Urine Albumin-to-Creatinine Ratio and Association With Progression to End-Stage Renal Disease and Mortality
This large prospective cohort study looked at the predictive power of adding cystatin C to the combination of creatinine and urine ACR. The study revealed improved predictive accuracy for all-cause mortality and end-stage renal disease. Related Articles: Correction of Postkidney Transplant Anemia Reduces Progression of Allograft Nephropathy Renal outcomes with different fixed-dose combination therapies in [...]