Nephrology Now

Dialysate Sodium Concentration and the Association with Interdialytic Weight Gain, Hospitalization, and Mortality

Nephrology Now editors — Sat, 28 Jan 2012 08:32:30 +0000

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.

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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

Nephrology Now editors — Sat, 28 Jan 2012 08:31:32 +0000

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.

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Sodium Intake, ACE Inhibition, and Progression to ESRD

Nephrology Now editors — Sat, 28 Jan 2012 08:30:01 +0000

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 ESRD, independent of BP control.

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Decongestive Treatment of Acute Decompensated Heart Failure: Cardiorenal Implications of Ultrafiltration and Diuretics

Nephrology Now editors — Sat, 28 Jan 2012 08:28:56 +0000

This review discusses the role of diuretics and ultrafiltration in acute decompensated heart failure.

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Focal Segmental Glomerulosclerosis

Nephrology Now editors — Sat, 28 Jan 2012 08:27:20 +0000

FSGS accounts for appoximately 40% of adult nephrotic syndrome. This review provides an approaches to the diagnosis and management of this disease.

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The PROMISE Study: A Phase 2b Multicenter Study of Voclosporin (ISA247) Versus Tacrolimus in De Novo Kidney Transplantation

Nephrology Now editors — Sat, 28 Jan 2012 08:25:59 +0000

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 will be needed to show whether voclosporin is an improvement over tacrolimus.

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Specificity of Histological Markers of Long-Term CNI Nephrotoxicity in Kidney-Transplant Recipients Under Low-Dose Cyclosporine Therapy

Nephrology Now editors — Sat, 28 Jan 2012 08:24:58 +0000

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.

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Infectious complications in kidney-transplant recipients desensitized with rituximab and intravenous immunoglobulin

Nephrology Now editors — Sat, 28 Jan 2012 08:23:37 +0000

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.

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Impact of Early Conversion From Tacrolimus to Sirolimus on Chronic Allograft Changes in Kidney Recipients on Rapid Steroid Withdrawal

Nephrology Now editors — Sat, 28 Jan 2012 08:21:27 +0000

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 post-transplant.

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Novartis announces termination of ALTITUDE study

Nephrology Now editors — Fri, 23 Dec 2011 04:24:00 +0000

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 patients were unlikely to benefit from aliskiren added in addition to standard therapy. More importantly, the aliskiren arm had more frequent adverse events, including non-fatal stroke, renal complications, hyperkalemia and hypotension.

The peer reviewed publication has not yet been published. The full text link provides the Novartis press release.

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Urinary Sodium and Potassium Excretion and Risk of Cardiovascular Events

Nephrology Now editors — Fri, 23 Dec 2011 04:09:01 +0000

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 of stroke was less likely with higher potassium excretion.

Accompanying Editorial “Urinary Sodium and Cardiovascular Disease Risk: Informing Guidelines for Sodium Consumption”
http://jama.ama-assn.org/content/306/20/2262.extract

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Bedtime Dosing of Antihypertensive Medications Reduces Cardiovascular Risk in CKD

Nephrology Now editors — Fri, 23 Dec 2011 04:06:59 +0000

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

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Coiled Versus Straight Peritoneal Dialysis Catheters: A Randomized Controlled Trial and Meta-analysis

Nephrology Now editors — Fri, 23 Dec 2011 04:00:53 +0000

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.

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CKD–Mineral and Bone Disorder: Core Curriculum 2011

Nephrology Now editors — Fri, 23 Dec 2011 04:00:02 +0000

This AJKD Core Curriculum article nicely covers the challenging topic of bone mineral metabolism in chronic kidney disease.

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Meta-Analysis of Calcineurin-Inhibitor-Sparing Regimens in Kidney Transplantation

Nephrology Now editors — Fri, 23 Dec 2011 03:58:50 +0000

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 was associated with improved graft survival, use of mTOR inhibitors such as belatacept were associated with worse graft survival.

Free full text kindly provided by the American Society of Nephrology.

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Antibody Removal Before ABO-Incompatible Renal Transplantation: How Much Plasma Exchange Is Therapeutic?

Nephrology Now editors — Fri, 23 Dec 2011 03:56:54 +0000

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 it was felt that transplantation could safely proceed. It also found a starting antibody level above which desensitization was unlikely to be successful.

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Association of Pretransplant Serum Phosphorus with Posttransplant Outcomes

Nephrology Now editors — Fri, 23 Dec 2011 03:55:52 +0000

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 outcomes.

Free full text kindly provided by the American Society of Nephrology.

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Outcome of treated and untreated asymptomatic bacteriuria in renal transplant recipients

Nephrology Now editors — Fri, 23 Dec 2011 03:53:49 +0000

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 suggests that most cases of asymptomatic bactiuria should be managed conservatively.

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Mycophenolate versus Azathioprine as Maintenance Therapy for Lupus Nephritis

Nephrology Now editors — Tue, 29 Nov 2011 07:50:42 +0000

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 the mycophenolate mofetil arm and the rate of withdrawal due to adverse events was higher with azathioprine than with mycophenolate mofetil.

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Risk of Pneumocystis jiroveci pneumonia in patients long after renal transplantation

Nephrology Now editors — Tue, 29 Nov 2011 07:37:43 +0000

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, and a higher number of other infectious episodes. Review of lymphocytes counts after the early post-transplant period may identify patients at an increased risk of Pneumocystis and other infectious complications.

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Screening and Follow-Up of Living Kidney Donors: A Systematic Review of Clinical Practice Guidelines

Nephrology Now editors — Tue, 29 Nov 2011 07:36:57 +0000

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, there were variations in the suggested assessment, medical contraindications and post-transplant follow-up. The variations in guidelines reflect the absence of solid literature on which to base recommendations, and highlight the need for further research.

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Treatment of Kidney Transplant Recipients With ACEi/ARB and Risk of Respiratory Tract Cancer: A Collaborative Transplant Study Report

Nephrology Now editors — Tue, 29 Nov 2011 07:35:33 +0000

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. This was not a randomized controlled trial, and this study cannot determine whether the risks of ACE-I/ARB use in high-risk patients would outweigh their potential benefit.

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Terminal Complement Inhibition Decreases Antibody-Mediated Rejection in Sensitized Renal Transplant Recipients

Nephrology Now editors — Tue, 29 Nov 2011 07:34:10 +0000

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 a lower rate of transplant glomerulopathy in the eculizumab-treated patients.

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Cullen and Grey Turner signs in idiopathic perirenal hemorrhage

Nephrology Now editors — Tue, 29 Nov 2011 07:32:47 +0000

This brief report describes and provide images of Cullen and Grey Turner signs in perirenal hemorrhage.

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Use of Electron-Beam Sterilized Hemodialysis Membranes and Risk of Thrombocytopenia

Nephrology Now editors — Tue, 29 Nov 2011 07:32:00 +0000

This cohort study identified exposure to e-beam sterilized dialyzers as an etiologic agent contributing to significant post-dialytic thrombocytopenia.

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Pregnancy Outcomes in Women with Chronic Kidney Disease: A Systematic Review

Nephrology Now editors — Tue, 29 Nov 2011 07:30:41 +0000

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 fetal outcomes were reported in nine studies and were approximately two times higher in women with CKD. These included IUGR, low birth weight and premature births.

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Exercise training for adults with chronic kidney disease.

Nephrology Now editors — Tue, 29 Nov 2011 07:28:50 +0000

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.

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Survival advantage of hemodialysis relative to peritoneal dialysis in patients with end-stage renal disease and congestive heart failure

Nephrology Now editors — Tue, 29 Nov 2011 07:26:52 +0000

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 (75.9 vs 72.5 years of age, p <0.001) and the enrolled patients were stratified by modality at day 90.

Accompanying editorial: Choice of dialysis modality.

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Current Therapy for IgA Nephropathy

Nephrology Now editors — Tue, 29 Nov 2011 07:25:40 +0000

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

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The effects of frequent nocturnal home hemodialysis: the Frequent Hemodialysis Network Nocturnal Trial

Nephrology Now editors — Tue, 29 Nov 2011 07:22:25 +0000

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.

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Prolonged disease-free remission following rituximab and low-dose cyclophosphamide therapy for renal ANCA-associated vasculitis

Nephrology Now editors — Tue, 29 Nov 2011 07:20:48 +0000

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 patients relapsed at a median of 30 months. Adverse events included one severe drug reaction and one serious infection. This regimen may be considered in the creation of steroid minimizing regimen.

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Intensive Diabetes Therapy and Glomerular Filtration Rate in Type 1 Diabetes

Nephrology Now editors — Sun, 13 Nov 2011 00:32:17 +0000

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) studies. The study showed a decrease in the risk of decline in eGFR to < 60 ml/min (as measured by the CKD-EPI equation) in the group that received intensive diabetes therapy versus those that received conventional diabetes therapy. There was a trend (p =0.10) to reduced incidence of end-stage renal disease in the intensive therapy group. The benefits of intensive therapy persisted after adjustments were made for glycated hemoglobin and albumin excretion.

Free full text available courtesy of the New England Journal of Medicine for a short time.

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Late Breaking Clinical Trials at ASN 2011 – FISH study and more

Nephrology Now editors — Sun, 13 Nov 2011 00:11:38 +0000

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 in Hemodialysis Grafts (FISH) Study

This randomized- controlled trial compared fish oil versus placebo in primary AVG graft potency. There was no significant difference in the primary outcome of proportion of patients with loss of native graft patency at 12 months. However, there was a significant difference in rates of loss of patency and thrombosis. More interestingly, however, were the results of the secondary outcomes: there was a significnat decrease in time to first cardiovascular event as well as a decrease in mean systolic blood pressure in the fish oil group. Bleeding event rates were the same in both groups.

Judith M. Hoogendijk-van den Akker et al. Reduced Rate of Cutaneous Squamous Cell Carcinomas after Conversion to Sirolimus-Based Immunosuppression in Stable Renal Transplant Recipients: A Randomized, Prospective, Open-Label Multicenter Study

This randomized, prospective, open-label mutlicenter study compared conventional immunosupprezsion versus a sirolimus- based regimen in stable renal transplant patients with biopsy proven cutaneous squamous cell carcinoma. The intention to treat results showed a significant difference in the recurrence rate of developing subsequent squamous cell carcinoma (HR 0.62 (0.39 – 0.97), p = 0.038) as well a significant decrease in the total number of squamous cell carcinomas (RR 0.47 (0.29-0.76), p = 0.002).

Ashima Gulati et al. Multicenter Randomized Controlled Trial Comparing Efficacy of Tacrolimus to Intravenous Cyclophosphamide in Children with Steroid Resistant Nephrotic Syndrome

Five centres in India participated in this trial of children with steroid resistant nephrotic syndrome defined as no response to prednisone 2 mg/kg after 4 weeks of treatment. In addition to prednisone, patients were treated with either tacrolimus or intravenous cyclophosphamide. The primary outcome of the rate of complete or partial remission at 6 months was statistically different between the groups – 83% in the tacrolimus group vs 46% in the cyclophosphamide group (p < 0.001). There was also a statistically significant difference in the secondary outcome of maintaining remission at 12 months in favor of the tacrolimus group (53% vs 15%, p < 0.01). There was also less risk of treatment failure or severe infection in the tacrolimus group.

Uwe Querfeld et al. A Randomized Cross-Over Muticenter Trial of Mycophenolate Mofetil versus Cyclosporin A in Children with Frequently Relapsing Nephrotic Syndrome

This German crossover designed study looked at children with frequently relapsing nephrotic syndrome and randomized them to 12 months of either cyclosporine or MMF. After 12 months, they were crossovered to the other group and treated for another 12 months. Therefore, both groups received 12 months of each agent. The primary outcome of frequency of relapses during both years of treatment showed that cyclosporine was superior to MMF (85 % vs 64% with no relapses). The investigators hypothesized that this was due to the lower MMF exposure and suggest that a higher MMF level should be targeted.

Ian H. de Boer et al. Effects of Intensive Diabetes Therapy on Glomerular Filtration Rate in Type 1 Diabetes: Results from the DCCT/EDIC [Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study]

Click here to learn more about this trial, simultaneously published online in the New England Journal of Medicine, in order to coincide with the presentation at the ASN.

Ravi I. Thadhani et al. Vitamin D Therapy and Cardiac Structure, Function, and Cardiovascular Events.

PRIMO is an industry sponsored study designed to test whether oral paricalcitriol at 2 ug po od for 48 weeks would reduce LV hypertrophy, diastolic dysfunction, biomarkers of cardiac dysfunction, and/or cardiac events. Patients were enrolled if they had mild to moderate LV dysfunction, GFR 15-60 ml/min per 1.73 m2, and iPTH 50 to 300 ng/L. 811 patients were screened and 227 were enrolled (115 paricalcitriol; 112 placebo). In the treatment group, iPTH reduced from to baseline level to approximately 30 ng/L but there was no signficant reduction in LVMI (left ventricular mass index). In fact, the placebo group tended to have a lower LVMI than the treatment group. Diastolic dysfuncion and biomarkers were also not difference. Of note, there were fewer cardiac events in the treatment group (1 vs which reached statistical signficance (p=0.034).

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Long Interdialytic Interval and Mortality among Patients Receiving Hemodialysis

Nephrology Now editors — Sun, 09 Oct 2011 06:31:08 +0000

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.

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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)

Nephrology Now editors — Sun, 09 Oct 2011 06:25:22 +0000

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.

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2011 Prevention in Renal Disease Conference

Nephrology Now editors — Sun, 09 Oct 2011 06:24:02 +0000

Watch all sessions from the 2011 Prevention in Renal Disease Conference.
http://ukidney.com/prevention-in-renal-disease-conference-toronto-11-dp1

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iPhone App ‘Calculate by QxMD’ adds PD Content

Nephrology Now editors — Sun, 09 Oct 2011 06:23:10 +0000

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

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New DaVita Peritoneal Dialysis Webinar Series

Nephrology Now editors — Sun, 09 Oct 2011 06:20:21 +0000

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 place Nov. 4 at 2 p.m. Register now!

Additional webinar topics include:

Kidney Transplants and PD Patients – Optimizing PD Treatments to Ensure Candidacy for Transplantation
Home Hemodialysis as the Continuum of the PD Spectrum – The Effective Transition of PD Patients to HHD
Successfully Starting Incident Crashers on PD
Cruise Control – Quality Parameters and Tips on Keeping Patients on the Therapy
- Part 1 of 3: 90 days to six months
- Part 2 of 3: six months to one year
- Part 3 of 3: more than one year

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Podocyte disorders: core curriculum 2011

Nephrology Now editors — Sun, 09 Oct 2011 06:18:34 +0000

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.

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Clinical practice. Chronic hypertension in pregnancy.

Nephrology Now editors — Sun, 09 Oct 2011 06:17:28 +0000

This is an excellent review on the management of pre-existing hypertension in the setting of pregnancy.

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Persistent Asymptomatic Isolated Microscopic Hematuria in Israeli Adolescents and Young Adults and Risk for End-Stage Renal Disease

Nephrology Now editors — Sun, 09 Oct 2011 06:15:41 +0000

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 low, the results of this paper are a warning against complacency and reinforce the need for longitidunal follow up of such patients.

See associated editorial:
Has the Time Come to Include Urine Dipstick Testing in Screening Asymptomatic Young Adults?
http://jama.ama-assn.org/cgi/content/full/306/7/764

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Predialysis nephrology care of older patients approaching end-stage renal disease.

Nephrology Now editors — Sun, 09 Oct 2011 06:14:10 +0000

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 Nephrology Care of Older Patients Approaching End-Stage Renal Disease”
http://archinte.ama-assn.org/cgi/content/full/171/15/1378?etoc

Is Predialysis Nephrology Care Worthwhile?
http://archinte.ama-assn.org/cgi/content/full/171/15/1317?etoc

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The Impact of Conversion From Prograf to Generic Tacrolimus in Liver and Kidney Transplant Recipients With Stable Graft Function

Nephrology Now editors — Sun, 09 Oct 2011 06:12:44 +0000

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 kidney and liver transplant recipients on Prograf (tacrolimus) were converted to a generic formulation. Renal and liver function remained stable after conversion, and there were no episodes of acute rejection, but almost 40% of patients needed an adjustment in their drug dose. Also, this was a non-randomized, non-placebo-controlled study, with short follow-up, and assessing only a single generic formulation.

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Randomized trial of immunosuppressive regimens in renal transplantation

Nephrology Now editors — Sun, 09 Oct 2011 06:11:18 +0000

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 receptor antibody and maintenance steroids. With a median of eight years of follow-up, acute rejection rates were lowest and renal function best in the tacrolimus/MMF group. This study supports the tacrolimus/MMF combination as the immunosuppressive regimen of choice in renal transplantation.

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Autoantibodies Specific for the Phospholipase A2 Receptor in Recurrent and De Novo Membranous Nephropathy

Nephrology Now editors — Sun, 09 Oct 2011 06:09:09 +0000

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 was detected in only half of patients in their cohort who experienced recurrence.

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Graft Loss Due to Recurrent Lupus Nephritis in Living-Related Kidney Donation

Nephrology Now editors — Sun, 09 Oct 2011 06:08:01 +0000

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 kindly provided by the American Society of Nephrology.

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Cardiac Survival after Pre-emptive Coronary Angiography in Transplant Patients and Those Awaiting Transplantation

Nephrology Now editors — Sun, 09 Oct 2011 06:03:25 +0000

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 underwent revascularization, whether or not they were subsequently transplanted, had superior survival to those who declined revascularization.

Free full text kindly provided by American Society of Nephrology.

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Monoclonal Gammopathy of Undetermined Significance Does Not Affect Outcomes in Patients Undergoing Solid Organ Transplants

Nephrology Now editors — Sun, 09 Oct 2011 06:00:04 +0000

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.

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Conversion of Long-Term Kidney Transplant Recipients From Calcineurin Inhibitor Therapy to Everolimus: A Randomized, Multicenter, 24-Month Study

Nephrology Now editors — Sun, 09 Oct 2011 05:59:02 +0000

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 greater than five years, which suggests that any benefit that mTOR inhibitors may provide require their initiation relatively early post-transplant.

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Circulating urokinase receptor as a cause of focal segmental glomerulosclerosis

Nephrology Now editors — Sun, 09 Oct 2011 05:57:43 +0000

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 a soluble form of the podocyte urokinase receptor (suPAR) is found in high levels in patients with recurrent FSGS post-transplant. They also demonstrate that in vitro and in mouse models that suPAR can cause proteinuria and change of FSGS.

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Selection Bias Explains Apparent Differential Mortality between Dialysis Modalities

Nephrology Now editors — Sat, 06 Aug 2011 05:53:26 +0000

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 who started dialysis electively as outpatients.

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Moderate dietary sodium restriction added to angiotensin converting enzyme inhibition compared with dual blockade in lowering proteinuria and blood pressure: randomised controlled trial

Nephrology Now editors — Sat, 06 Aug 2011 05:52:14 +0000

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 of proteinuria and blood pressure. Hard clinical endpoints were not examined in this study.

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Monitoring and Managing Graft Health in the Kidney Transplant Recipient

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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 role in long-term graft outcomes as acute rejection has decreased in importance thanks to current immunosuppressive protocols.

Free full text kindly provided by the American Society of Nephrology

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Desensitization in HLA-Incompatible Kidney Recipients and Survival

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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 at various levels of risk: CDC-positive crossmatch, flow cytometry=positive crossmatch, or detection of donor-specific antibody. Outcomes were compared to two groups of matched controls, one who had remained on the transplant waiting list, and a second that was subsequently transplanted. Patient survival in the desensitization group was superior to the other two groups, even after more than five years of follow-up.

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Nephrology Now editors — Sat, 06 Aug 2011 05:45:26 +0000

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 +/- an interleukin-2 receptor antibody. MPA exposure was higher in the high-dose arm, and rejection rates were lower. There were no differences in patient or graft survival, follow-up was only for six months, and these results may not apply to patients treated with tacrolimus or a lymphocyte-depleting antibody.

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The ORION Study: Comparison of Two Sirolimus-Based Regimens versus Tacrolimus and Mycophenolate Mofetil in Renal Allograft Recipients

Nephrology Now editors — Sat, 06 Aug 2011 05:39:12 +0000

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Nephrology Now editors — Sat, 25 Jun 2011 00:01:54 +0000

Free full text available for several days only.

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Nephrology Now editors — Thu, 16 Jun 2011 23:48:39 +0000

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Research Suggests a Novel Cell-Based Therapy for Chronic Kidney Disease and CKD-Associated Heart Failure

Nephrology Now editors — Wed, 15 Jun 2011 23:01:32 +0000

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 mortality, diminished quality of life and heath care expenditure [1]. Despite its importance and increasing prevalence, little progress in its treatment has been made over the past 20 years, with blood pressure reduction and blockade of the renin-angiotensin system still the mainstays of therapy.

Patients with CKD are not only at high risk of developing heart failure, but frequently have heart failure with preserved left ventricular ejection fraction [2]. These patients with CKD and diastolic dysfunction are a highly prevalent population that is faced with a particularly poor prognosis [2]. Importantly, in contrast to patients with reduced left ventricular ejection fraction, there is no evidence-based treatment for those with preserved ejection fraction in which RCTs failed to show a beneficial effect for either ACE inhibitors [3] or angiotensin receptor blockers [4,5]. Additional therapies are therefore needed.

The importance of fibrovascular injury in mediating progression of renal and cardiac injury in CKD

Renal and cardiac biopsy studies of animals and patients with progressive CKD demonstrate progressive capillary loss and fibrosis in both organs [6,7]. These two inter-related pathological features are thought to contribute to progressive injury and dysfunction in the kidney and heart in CKD [8].

Bone marrow-derived early outgrowth cells (EOCs)The bone marrow harbours novel cell populations with potent tissue protective and regenerative properties [9]. Named for their early appearance in culture (7 – 10 days) when peripheral blood mononuclear cells [10] or whole bone marrow cells [11,12] are grown in endothelial culture medium, early outgrowth cells (EOCs) have been shown to exert potent pro-angiogenic [13,14,15] and anti-fibrotic [12,16] effects in various disease models.

EOCs exert powerful renal and cardiac protective effects in experimental CKD

Intra-venous EOC infusion attenuates renal and cardiac damage and dysfunction

As shown in our Study Design depicted in Figure 1, using the 5/6 subtotal nephrectomy (SNX) rat as a model of progressive experimental CKD that develops diastolic dysfunction, we demonstrated that a single intra-venous infusion of 106 EOCs significantly attenuated the progressive capillary loss and fibrosis that occurs in the kidney and heart of animals with established experimental CKD (Figures 2 – 4) [12].

Figure 1. Study Design

Rats were randomized to either 5/6 subtotal nephrectomy surgery (SNX) to induce the onset of chronic kidney disease or sham surgery. 4 weeks post-surgery, at a time when CKD is established, SNX animals were further randomized to receive: (1) an intra-venous injection of 106 EOCs, (2) an intra-aortic injection of 106 EOCs, or (3) an intra-venous injection of phosphate-buffered saline 12

Figure 2. Renal fibrosis is attenuated by EOC therapy in the SNX rat.

Tubulointerstitial fibrosis was assessed following immunolabelling for Type IV collagen 8 weeks post-surgery. (A – C) Representative cortical tubulointerstitial images. Original magnification x 160. (A) Sham animal. (B) SNX animal. (C) SNX – EOC animal. (D) Type IV collagen % positivity. * p < 0.05 vs. sham operated animals. † p < 0.05 vs. SNX animals. Glomerulosclerosis was assssed on PAS-stained kidney sections at 8 weeks post-surgery. (E – G) Representative glomerular images. Original magnification x 400. (E) Sham animal. (F) SNX animal. (G) SNX – EOC animal. (H) Glomerulosclerosis index (GSI). * p < 0.05 vs. sham operated animals. † p < 0.05 vs. SNX animals {12}

Figure 3. Renal capillary density loss is attenuated by EOC therapy in the SNX rat.

(A – C) Kidney sections were immunolabelled with JG-12 antibody, which recognizes a glomerular endothelial cell antigen. Representative JG-12 immunostained images. Original magnification x 400. (A) Sham animal. (B) SNX animal. (C) SNX – EOC animal. (D) % positive area for JG-12 immunostaining per glomerulus. (E – G) Representative fluorescence microangiography (FMA) images of glomeruli. The autofluorescence of the surrounding renal cortex was captured and pseudocolourized red. The green fluorescence of the infused beads outlines microvascular structures. Original magnification x 40. (E) Sham animal. (F) SNX animal. (G) SNX – EOC animal. (H – J) Representative FMA images of peritubular capillaries. Each image is a flattened Z-stack of a 100 m section taken with a confocal microscope. Original magnification x 75. (H) Sham animal. (I) SNX animal. (J) SNX – EOC animal. * p < 0.05 vs. sham operated animals. † p < 0.05 vs. SNX animals 12

Figure 4. Cardiac fibrosis is attenuated by EOC therapy in the SNX rat.

(A – C) Representative picrosirius red stained heart sections at 8 weeks post-surgery. Original magnification x 160. (A) Sham animal. (B) SNX animal. (C) SNX – EOC animal. (D) Quantitative cardiac fibrosis analysis. * p < 0.05 vs. sham operated animals. † p < 0.05 vs. SNX animals. Abbreviations: PSR: picrosirius red [12

Importantly, these changes were associated with preservation of organ function, as manifested by a reduction in plasma creatinine, urinary protein excretion, and left ventricular (LV) end-diastolic pressure-volume relationship, a measure of LV stiffness (Figures 5 – 6) [12].

Figure 5. Deterioration of renal function is reduced by intra-vascular EOC therapy in the SNX rat.

(A) Plasma creatinine. (B) Urinary protein excretion 12

Figure 6. Left ventricular stiffness is reduced in SNX rats by EOC therapy.

SNX rats develop progressive left ventricular stiffness (diastolic dysfunction) that manifests itself as an increased left ventricular end-diastolic pressure volume relationship (LV EDPVR). This phenotype mimics a common and high risk CKD patient population. Using gold standard invasive cardiac catherization techniques, we measured the pressure and volume within the left ventricle throughout the cardiac cycle under varying preload conditions 8 weeks post-surgery to generate pressure-volume loops. Left ventricular end diastolic pressure volume relationship (LV EDPVR), a measure of passive LV relaxation, is represented by the slope of the tangent of the base of each PV loop (green lines). (A) Sham animal. (B) SNX animal. (C) SNX – EOC animal. (D) Quantitative analysis. * p < 0.05 vs. sham operated animals. † p < 0.05 vs. SNX animals 12

EOCs mediate their benefits from remote locations in the body

To test whether the beneficial effects of EOC infusion are dependent upon EOC delivery to the kidney and heart, we compared the effects of intra-arterial versus intra-venous EOC infusion. Interestingly, both the renal and cardiac tissue protective effects of EOC infusion were observed regardless of route of intravascular administration (Figure 7) [12].

To determine where the EOCs localize post-infusion, we fluorescently labeled the EOCs, and infused them into SNX rats. Despite the dramatic structural and functional benefits seen upon EOC infusion in the kidney and heart, very few labeled cells were found in either organ, contrasting with their relative abundance in the liver and spleen [Figure 8] [12].

Figure 7. EOC therapy improves renal and cardiac outcomes regardless of route of administration (intravenous vs. intra-arterial).

(A) Proteinuria. (B) Systolic blood pressure. (C) Glomerulosclerosis. (D) Glomerular endothelial (JG-12) immunostaining. (E) Tubulointerstitial type IV collagen immunostaining. (F) Left ventricular end diastolic pressure-volume relationship. (G) Myocyte cross-sectional area. (H) Cardiac interstitial fibrosis. Abbreviations: SNX – iv: 5/6 nephrectomy (SNX) animal treated with intravenous EOC infusion. SNX – ia: SNX animal treated with intra-arterial EOC infusion. BP: blood pressure. LV EDPVR: left ventricular end diastolic pressure-volume relationship. PSR: picrosirius red 12

Figure 8. Following infusion, EOCs do not localize to the kidney or heart, but rather to the liver.

10X6 fluorescently labeled EOCs were infused intra-venously into SNX rats 4 weeks post-surgery, and organs harvested 4 days post-cell infusion to determine EOC localization. EOCs were found in significant numbers in the liver, but not in the kidney or heart. (A – C): Representative confocal microscopy images of kidney, heart, and liver respectively at 4 days post-EOC infusion. Original magnification x 20. (a) Kidney cortex. (b) Heart. (c) Liver. (d) Time course of EOC retention in kidney, heart, and liver. n = 3 animals per time point. * p < 0.05 vs. kidney 12

Conclusion

The results of our studies are the first to demonstrate that EOC infusion may significantly attenuate the renal and cardiac injury that accumulates as CKD progresses. Given the marked morbidity and mortality associated with CKD, we believe that our data may form the preclinical foundation for clinical trials of EOC therapy for CKD and CKD-associated heart failure.

References

1. (2010) USRDS Annual Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda.
2. Parfrey PS, Harnett JD, Barre PE (1991) The natural history of myocardial disease in dialysis patients. J Am Soc Nephrol 2: 2-12.
3. Cleland JG, Tendera M, Adamus J, Freemantle N, Polonski L, et al. (2006) The perindopril in elderly people with chronic heart failure (PEP-CHF) study. Eur Heart J 27: 2338-2345.
4. Yusuf S, Pfeffer MA, Swedberg K, Granger CB, Held P, et al. (2003) Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. Lancet 362: 777-781.
5. Massie BM, Carson PE, McMurray JJ, Komajda M, McKelvie R, et al. (2008) Irbesartan in patients with heart failure and preserved ejection fraction. N Engl J Med 359: 2456-2467.
6. Amann K, Breitbach M, Ritz E, Mall G (1998) Myocyte/capillary mismatch in the heart of uremic patients. J Am Soc Nephrol 9: 1018-1022.
7. Kelly DJ, Zhang Y, Gow R, Gilbert RE (2004) Tranilast attenuates structural and functional aspects of renal injury in the remnant kidney model. J Am Soc Nephrol 15: 2619-2629.
8. Fine LG, Norman JT (2008) Chronic hypoxia as a mechanism of progression of chronic kidney diseases: from hypothesis to novel therapeutics. Kidney Int 74: 867-872.
9. Rafii S, Lyden D (2003) Therapeutic stem and progenitor cell transplantation for organ vascularization and regeneration. Nat Med 9: 702-712.
10. Asahara T, Murohara T, Sullivan A, Silver M, van der Zee R, et al. (1997) Isolation of putative progenitor endothelial cells for angiogenesis. Science 275: 964-967.
11. Asahara T, Masuda H, Takahashi T, Kalka C, Pastore C, et al. (1999) Bone marrow origin of endothelial progenitor cells responsible for postnatal vasculogenesis in physiological and pathological neovascularization. Circ Res 85: 221-228.
12. Yuen DA, Connelly KA, Advani A, Liao C, Kuliszewski MA, et al. (2010) Culture-Modified Bone Marrow Cells Attenuate Cardiac and Renal Injury in a Chronic Kidney Disease Rat Model via a Novel Antifibrotic Mechanism. PLoS One 5: e9543.
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0009543
13. Kalka C, Masuda H, Takahashi T, Kalka-Moll WM, Silver M, et al. (2000) Transplantation of ex vivo expanded endothelial progenitor cells for therapeutic neovascularization. Proc Natl Acad Sci U S A 97: 3422-3427.
14. Murohara T, Ikeda H, Duan J, Shintani S, Sasaki K, et al. (2000) Transplanted cord blood-derived endothelial precursor cells augment postnatal neovascularization. J Clin Invest 105: 1527-1536.
15. Kocher AA, Schuster MD, Szabolcs MJ, Takuma S, Burkhoff D, et al. (2001) Neovascularization of ischemic myocardium by human bone-marrow-derived angioblasts prevents cardiomyocyte apoptosis, reduces remodeling and improves cardiac function. Nat Med 7: 430-436.
16. Nakamura T, Torimura T, Sakamoto M, Hashimoto O, Taniguchi E, et al. (2007) Significance and therapeutic potential of endothelial progenitor cell transplantation in a cirrhotic liver rat model. Gastroenterology 133: 91-107 e101.

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Recipient Risk Factors Associated With Delayed Graft Function: A Paired Kidney Analysis

Nephrology Now editors — Mon, 25 Apr 2011 05:46:12 +0000

Delayed graft function (DGF) after transplant is related to donor, perioperative and recipient factors. This registry study is a paired kidney analysis, where one kidney from a deceased donor experienced DGF and the other did not. This analysis identifies several recipient and perioperative risk factors for DGF, some of which are modifiable, such as obesity, cold ischemia time and waiting time on dialysis.

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Impact of Dialysis Modality on Survival after Kidney Transplant Failure

Nephrology Now editors — Mon, 25 Apr 2011 05:44:11 +0000

For patients with native kidney disease, initiation of dialysis with peritoneal dialysis is associated with improved survival compared to hemodialysis. This Canadian-based registry study compared patients whose transplant failed and returned to dialysis. In contrast to native kidney disease, there was no difference in patient survival between those who started peritoneal dialysis versus hemodialysis.

Free full text kindly provided by ASN

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Naturally Occurring Higher Hemoglobin Concentration Does Not Increase Mortality among Hemodialysis Patients

Nephrology Now editors — Wed, 16 Mar 2011 06:02:33 +0000

This prospective, observational Dialysis Outcomes and Practice Patterns Study which examined 29,796 hemodialysis patients demonstrates and reassures that naturally occurring hemoglobin concentration >120 g/L is not associated with increased mortality.

Free full text kindly provided by American Society of Nephrology.

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Antihypertensive Treatment and Secondary Prevention of Cardiovascular Disease Events Among Persons Without Hypertension: A Meta-analysis

Nephrology Now editors — Wed, 16 Mar 2011 06:00:54 +0000

In this meta-analysis, antihypertensive treatment was associated with decreased risk of stroke, CHF, composite CVD events, and all-cause mortality in patients without hypertension, but with a clinical history of cardiovascular disease.

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Peritoneal Dialysis First: Rationale

Nephrology Now editors — Wed, 16 Mar 2011 05:59:25 +0000

This review discusses factors that contribute to peritoneal dialysis underutilization and suggests strategies to implement PD as a first-line therapy for dialysis treatment. In addition, it explores methods to maintain a strong PD program and avoid transfers to hemodialysis.

Free full text kindly provided by the American Society of Nephrology.

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Kidney March

Nephrology Now editors — Wed, 16 Mar 2011 05:58:20 +0000

Walk 3 days. 100 kilometers. From K Country to Calgary. Raise $2,200 for the fight against kidney disease. We are asking you to do the most you can possibly do – walk the furthest you’ve ever walked, raise the most money you’ve ever raised, and commit to truly making a difference. Walking 100 kilometres over 3 days is an intimidating feat; after all, we’re all just normal, everyday people. But, we believe the only time we can be brave is when we’re afraid. And we’re ready to be brave for this cause. Make the biggest difference you’ve ever made in your life and join us for Kidney March September 9-11, 2011.

Submitted by the Kidney Foundation of Canada

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Diuretic Strategies in Patients with Acute Decompensated Heart Failure

Nephrology Now editors — Wed, 16 Mar 2011 05:56:25 +0000

Among patients with acute decompensated heart failure, there were no significant differences in global assessment of symptoms or in renal function when diuretic therapy was administered by bolus versus continuous infusion or at high dose verus low dose.

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Cardiovascular and Renal Outcomes With Telmisartan, Ramipril, or Both in People at High Renal Risk: Results From the ONTARGET and TRANSCEND Studies.

Nephrology Now editors — Wed, 16 Mar 2011 05:55:12 +0000

This post hoc analysis examines the renal subgroups in the studies ONTARGET and TRANSCEND. The results do not support dual therapy over monotherapy in high-vascular risk patients with low glomerular filtration rate or albuminuria.

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Bundled Payment for ESRD — Including ESAs in Medicare’s Dialysis Package

Nephrology Now editors — Wed, 16 Mar 2011 05:54:06 +0000

This NEJM Perspective article discusses the implementation and implication of bundled Medicare reimbursement for ESRD therapy in the United States.

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Special Treatment — The Story of Medicare’s ESRD Entitlement

Nephrology Now editors — Wed, 16 Mar 2011 05:52:46 +0000

This historical review of the origins of ESRD coverage by the US Medicare program explains and summarizes how “…the moral cost of failing to provide lifesaving care was deemed to be greater than the financial cost of doing so.”

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Switching from Calcineurin Inhibitor-based Regimens to a Belatacept-based Regimen in Renal Transplant Recipients: A Randomized Phase II Study

Nephrology Now editors — Wed, 16 Mar 2011 05:51:38 +0000

This is another study assessing the role of belatacept, a costimulatory blocker in renal transplantation. As opposed to previous studies in de novo patients, this randomized controlled trial included patients 6 to 36 months post-transplant who continued on treatment with a calcineurininbitor or were switched to belatacept. There was a greater improvement in GFR after twelve months in the patients switched to belatacept. There were more rejections in the belatacept-treated patients, but no graft losses.

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Posttransplantation Encapsulating Peritoneal Sclerosis Contributes Significantly to Mortality after Kidney Transplantation

Nephrology Now editors — Wed, 16 Mar 2011 05:49:35 +0000

Encapsulating peritoneal sclerosis is a rare but serious complication of peritoneal dialysis. It has also been reported as appearing after transplantation in patients who were on PD pre-transplant. This retrospective multicenter study shows that post-transplant EPS is associated with a high rate of mortality, and may present many years after transplantation.

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Long-Term Renal Allograft Survival in the United States: A Critical Reappraisal

Nephrology Now editors — Wed, 16 Mar 2011 05:47:29 +0000

This study uses US transplant registry data to look at changes in both one-year and long-term graft survival post-transplant. This analysis shows that most of the improvement in recent years has been due to improvements in one-year graft survival. However, long-term graft loss rates have improved as well, although not as strikingly as short-term survival.

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Cardiovascular Disease Medications After Renal Transplantation: Results From the Patient Outcomes in Renal Transplantation Study

Nephrology Now editors — Wed, 16 Mar 2011 05:46:35 +0000

Renal transplantation reduces the risk of cardiovascular events compared to dialysis, but these patients remain a high-risk group. This large international registry study shows that use of common cardioprotective agents such as antiplatelets agents, statins, beta-blockers, ACE-inhibitors and ARBs is lower than would be expected, although their use has increased over time. Whether increased use of these medications can reduce death from cardiovascular disease post-transplant is unknown.

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Prevention of Dialysis Catheter Malfunction with Recombinant Tissue Plasminogen Activator

Nephrology Now editors — Tue, 08 Feb 2011 07:24:57 +0000

In this trial, patients undergoing long-term hemodialysis were randomized to a catheter-locking regimen of heparin (5000 U per milliliter) three times per week or recombinant tissue plasminogen activator (rt-PA) (1 mg in each lumen) instead of heparin once per week. Catheter malfunction occurred almost twice as often in the heparin only group and catheter-related bacteremia occurred less frequently (4.5%) in those assigned to the rt-PA group compared to those assigned to heparin only (13.0%).

Read the accompanying editorial “Tackling the Achilles’ Heel of Hemodialysis”
http://www.nejm.org/doi/full/10.1056/NEJMe1013952

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Short-term Outcomes of Induction Therapy With Tacrolimus Versus Cyclophosphamide for Active Lupus Nephritis: A Multicenter Randomized Clinical Trial

Nephrology Now editors — Tue, 08 Feb 2011 07:23:36 +0000

This multicenter noninferiority randomized controlled trial compared the efficacy and safety of tacrolimus versus intravenous cyclophosphamide as induction therapy for lupus nephritis. While limited by lack of blinding, small sample size, and short duration of follow-up, this study suggested that prednisone + tacrolimus achieved similar cumulative probabilities of complete remission and response than prednisone + cyclophosphamide after the 6-month induction period.

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Association between estimated glomerular filtration rate at initiation of dialysis and mortality

Nephrology Now editors — Tue, 08 Feb 2011 07:22:13 +0000

This study from the Canadian Organ Replacement Register looked at the trends in initiation of hemodialysis within Canada and compared the risk of death between patients with early and late initiation of dialysis. In keeping with other recent publications, this study showed that a higher glomerular filtration rate at initiation of dialysis was associated with an increased risk of death.

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Raloxifene, a selective estrogen receptor modulator, is renoprotective: a post-hoc analysis

Nephrology Now editors — Tue, 08 Feb 2011 07:21:26 +0000

This study is a post-hoc analysis of the Multiple Outcomes of Raloxifene Evaluation Trial, a double-masked, placebo-controlled randomized clinical trial of post-menopausal women with osteoporosis who were randomized to raloxifene or placebo. Compared with those in the placebo group, participants on raloxifene had a significantly slower yearly rate of decrease in eGFR.

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Dementia and cognitive impairment in ESRD: diagnostic and therapeutic strategies

Nephrology Now editors — Tue, 08 Feb 2011 07:20:02 +0000

This review nicely summarizes the diagnosis and management of cognitive impairment and dementia in dialysis patients.

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Tamoxifen is associated with lower mortality of encapsulating peritoneal sclerosis: results of the Dutch Multicentre EPS Study

Nephrology Now editors — Tue, 08 Feb 2011 07:16:55 +0000

This retrospective analysis of survival in patients with encapsulating peritoneal sclerosis suggests that mortality is significantly lower in tamoxifen-treated patients (45.8% vs 74.4%, P = 0.03).

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Early Catheter Removal Improves Patient Survival In Peritoneal Dialysis Patients with Fungal Peritonitis: Results of a Ninety-Four Episodes of Fungal Peritonitis at a Single Center

Nephrology Now editors — Tue, 08 Feb 2011 07:15:20 +0000

This single centre experience suggests a markedly lower mortality rate if patients with fungal peritonitis have their PD catheter removed within 24 hours, 12.8% vs 31.7% (p < 0.01).

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Human albumin for intradialytic hypotension in haemodialysis patients.

Nephrology Now editors — Tue, 08 Feb 2011 07:13:14 +0000

In this systematic review, no evidence was found to suggest that intravenous albumin is superior to normal saline for the treatment of symptomatic hypotension in maintenance haemodialysis patients with intradialytic hypotension.

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Intra-abdominal Hypertension and Abdominal Compartment Syndrome

Nephrology Now editors — Tue, 08 Feb 2011 07:11:31 +0000

This concise review discusses intra-abdominal hypertension and abdominal compartment syndrome as a potential cause of acute kidney injury in the critically ill.

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Belatacept-Based Regimens Versus a Cyclosporine A-Based Regimen in Kidney Transplant Recipients: 2-Year Results From the BENEFIT and BENEFIT-EXT Studies

Nephrology Now editors — Tue, 08 Feb 2011 07:09:25 +0000

This paper continues to follow patients from two randomized controlled trials comparing standard treatment with cyclosporine to a regime including belatacept, the fist costimulatory receptor blocker. Patient and graft survival were similar in both groups, with better renal function in the belatacept groups.

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Cost-Related Immunosuppressive Medication Nonadherence Among Kidney Transplant Recipients

Nephrology Now editors — Tue, 08 Feb 2011 07:08:27 +0000

The cost of immunosuppressive medications can be a barrier to medication adherence post-transplant. In this survey of transplant centers in the United States, most centers reported that they had patients who had difficulty paying for their immunosuppressive medications. The effects of this included graft losses and deaths. This has important implications for insurance coverage post-transplant, and suggests a relatively simple way to improve long-term transplant outcomes.

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Tacrolimus Once Daily (ADVAGRAF) Versus Twice Daily (PROGRAF) in De Novo Renal Transplantation: A Randomized Phase III Study

Nephrology Now editors — Tue, 08 Feb 2011 07:05:42 +0000

Advagraf is a once daily version of tacrolimus. This was randomized controlled non-inferiority trial comparing Advagraf to standard twice-daily tacrolimus. Patient and graft survival were not significantly different between the two groups. However, the difference in acute rejection episodes (higher with Advagraf) did not meet the non-inferiority threshold.

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Posttransplant Recurrence of Primary Glomerulonephritis

Nephrology Now editors — Tue, 08 Feb 2011 07:04:26 +0000

As the incidence of graft loss due to acute rejection decreases, recurrence of glomerulonephritis post-transplant has become more common. This review covers the incidence, mechanisms and treatment of four types of primary glomerulonephritis: IgA nephropathy, focal segmental glomerulosclerosis, membranous nephropathy and membranoproliferative glomerulonephritis.

Full text kindly provided by the American Society of Nephrology.

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Immunosuppression with Belatacept-Based, Corticosteroid-Avoiding Regimens in De Novo Kidney Transplant Recipients

Nephrology Now editors — Tue, 08 Feb 2011 07:01:59 +0000

This randomized-controlled study continues work being done to define the place of the co stimulatory blocker belatacept in renal transplantation. This trial compared three regimens of rapid corticosteroid withdrawal, two of which avoided calcineurin inhibitors by using belatacept. Rejection rates were low at one year, and renal function was better in patients on belatacept instead of tacrolimus.

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Allograft Failure in Kidney Transplant Recipients with Membranoproliferative Glomerulonephritis

Nephrology Now editors — Tue, 08 Feb 2011 07:01:02 +0000

Data on recurrence of membranoproliferative glomerulonephritis (MPGN) post-transplant is limited. This registry-based study looks separately at the impact of MPGN type I and II on graft and patient survival, compared to transplant recipient with other forms of glomerulonephritis and other causes of end-stage renal disease.

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C1q-Fixing Human Leukocyte Antigen Antibodies Are Specific for Predicting Transplant Glomerulopathy and Late Graft Failure After Kidney Transplantation

Nephrology Now editors — Tue, 08 Feb 2011 07:00:16 +0000

Detection of donor-specific anti-HLA antibodies by flow cytometry of antigen-coated beads is more sensitive than the older complement-dependent cytotoxicity test performed on lymphocytes. However, flow cytometry cannot distinguish between antibodies that can fix complement or not, which may be an important marker in determining whether or not an antibody will cause antibody-mediated rejection. In this retrospective study, the development of donor-specific antibodies that can fix the complement component C1q was associated with a high risk of transplant glomerulopathy.

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Transporting Live Donor Kidneys for Kidney Paired Donation: Initial National Results

Nephrology Now editors — Tue, 08 Feb 2011 06:58:59 +0000

Living-donor paired exchange programs may match pairs from different centers, requiring some patients to travel in order to perform the transplant. An alternative is to perform the donor nephrectomy and then transport the kidney. This review of practices in the United States showed excellent renal function and no episodes of delayed graft function. This practice may encourage some donors who did not wish to travel to participate in such exchange programs.

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Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial

Nephrology Now editors — Mon, 27 Dec 2010 06:40:04 +0000

In this randomized controlled trial, catheter-based renal denervation successfully reduced blood pressure in those patients with treatment-resistant hypertension. Office-based blood pressure measurements in the renal denervation group reduced by 32/12 mm Hg, while they did not differ from baseline in the control group.

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Broadening Options for Long-term Dialysis in the Elderly (BOLDE): differences in quality of life on peritoneal dialysis compared to haemodialysis for older patients

Nephrology Now editors — Mon, 27 Dec 2010 06:35:34 +0000

This cross-sectional, multi-centred study assessed quality of life in 140 patients over the age of 65 years on PD or HD. The two groups were demographically closely matched with overall results showing a similar, if not better, quality of life in those patients on PD as compared to HD.

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Fungal Peritonitis in Peritoneal Dialysis Patients: Successful Prophylaxis with Fluconazole, as Demonstrated by Prospective Randomized Control Trial

Nephrology Now editors — Mon, 27 Dec 2010 06:34:34 +0000

This randomized controlled trial compared oral fluconazole 200 mg given every 2nd day versus placebo in patients being treated for PD peritonitis, exit site infection or tunnel infection. A statistically significant reduction in secondary fungal peritonitis was noted in patients on prophylaxis.

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Acetaminophen Increases Blood Pressure in Patients With Coronary Artery Disease.

Nephrology Now editors — Mon, 27 Dec 2010 06:33:37 +0000

In this small randomized, double-blind, placebo-controlled, crossover study, acetaminophen was documented to increased ambulatory blood pressure in patients with coronary artery disease.

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Routine Preoperative Vascular Ultrasound Improves Patency and Use of Arteriovenous Fistulas for Hemodialysis: A Randomized Trial

Nephrology Now editors — Mon, 27 Dec 2010 06:32:46 +0000

In this randomized controlled trial, patients going for arteriovenous fistula creation were randomized to pre-operative review of vascular ultrasound versus routine care. The intervention group had a significantly lower rate of immediate access failure. While primary AVF survival at 1 year was not statistically different, assisted primary AVF survival at 1 year was significantly better for the intervention group.

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What’s new in hypertension 2010?

Nephrology Now editors — Mon, 27 Dec 2010 06:30:02 +0000

This review summarizes clinically important publications in hypertension between Oct 2008 and Nov 2010.

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Updates on the Treatment of Lupus Nephritis

Nephrology Now editors — Mon, 27 Dec 2010 06:28:57 +0000

This excellent review of lupus nephritis focuses on summarizing the most effective treatment for this condition while limiting therapy-induced toxicity.

Free full text kindly provided by ASN.

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Tubular Transport: Core Curriculum 2010

Nephrology Now editors — Mon, 27 Dec 2010 06:27:12 +0000

This addition to the AJKD Core Curriculum reviews the physiology of renal tubular transport.

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Outcomes of Kidney Transplantation in HIV-Infected Recipients

Nephrology Now editors — Mon, 27 Dec 2010 06:25:56 +0000

Although originally considered an absolute contraindication to transplantation, the advent of HAART therapy has now made renal transplantation a viable option for selected HIV-positive patients with end-stage renal disease. This study reports the experience in a non-randomized trial of patients who were HIV-positive and received a renal transplant. Graft survival was lower than that for all transplant recipients, but was better than survival among patients older than 65, another high-risk group. There was a surprisingly high incidence of acute rejection among HIV-positive transplant recipients.

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Intestinal radiopacities in chronic renal failure

Nephrology Now editors — Mon, 27 Dec 2010 06:25:49 +0000

This CT abdomen image shows an incidental finding of deposition of lanthanum carbonate in the small and large intestine.

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Fibrosis with Inflammation at One Year Predicts Transplant Functional Decline

Nephrology Now editors — Mon, 27 Dec 2010 06:23:13 +0000

Interstitial fibrosis is commonly seen in renal transplant biopsies as early as three months post-transplant. More concerning is the finding of fibrosis along with subclinical inflammation, i.e. inflammation found on a protocol biopsy not accompanied by a rise in serum creatinine. This cohort study with up to five years of follow-up shows that the combination of fibrosis and subclinical inflammation is associated with a decline in GFR and lower graft survival.

Free full text kindly provided by ASN.

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Long-Term Follow-up of a Randomized Trial Comparing Laparoscopic and Mini-Incision Open Live Donor Nephrectomy

Nephrology Now editors — Mon, 27 Dec 2010 06:20:27 +0000

Increasing numbers of living donor transplants are performed laparoscopically, in order to minimize patient discomfort and improved the cosmetic result. This is the long-term (six years) follow-up of a randomized controlled study of patients who underwent either laparoscopic nephrectomy or open nephrectomy with a “mini-incision.” Quality of life in both groups was similar, and there was no difference in long-term donor renal function between groups.

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Informing the Debate: Rates of Kidney Transplantation in Nations With Presumed Consent

Nephrology Now editors — Mon, 27 Dec 2010 06:18:53 +0000

In order to improve organ donation rates, some countries have adopted a policy of presumed consent (“opt out”), where citizens must explicitly state they do not wish to be a donor if they were to become brain dead or a suitable candidate for donation after cardiac death. In this paper, the authors compare the rate of organ donation among countries with presumed consent to those where citizens must explicit agree to be organ donors. Countries with presumed consent had higher deceased organ donation rates, but lower rates of living donation. Adoption of a presumed consent policy may have unexpected consequences on the overall rate of transplantation.

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ASN 2010 Late Breaking Clinical Trial Results | SHARP, Preclot, more

Nephrology Now editors — Mon, 22 Nov 2010 03:33:21 +0000

The late breaking clinical trials session from the 2010 American Society of Nephrology meeting was held on November 20, 2010. The following are summaries of the clinical trial results. Where available, links to additional online resources are included. Access to the full details of these studies awaits publication in peer reviewed journals.

The Sharp Collaborative Group. Should We Reduce LDL Cholesterol in Patients with Chronic Kidney Disease? The Results of the Study of Heart and Renal Protection (SHARP)

In this eagerly awaiting trial, patients with CKD (men with Cr ≥1.7 mg/dL (150 µmol/L) or women with Cr ≥1.5 mg/dL (130 µmol/L), no history of myocardial infarction or coronary revascularization and clinical uncertainty if lipid lowering therapy was warranted, patients were randomized to lipid lowering therapy (simvastatin or simvastatin/ezetimibe) vs placebo (see slide 4 of the powerpoint presentation to view the complex details of randomization).

The primary outcome (major atherosclerotic events defined as a composite of coronary death, MI, non-haemorrhagic stroke, or any revascularization) was reduced by 17%. See the slide below. Similar reductions were noted in both patients on dialysis and those with CKD but not yet on dialysis. No difference was seen in side effects including those related to muscle/liver toxicity and malignancy.

View the online resource web site

View the slides presented at the 2010 ASN Meeting

Brenda Hemmelgarn et al. Prevention of Dialysis Catheter Lumen Occlusion with RT-PA versus Heparin (Preclot): A Randomized Trial

In this randomized controlled trial (see published trial design) looking at central venous catheters (CVC) in hemodialysis patients, patients were randomized to receive rt-PA 1 mg per lumen once per week to lock their CVC post dialysis or heparin 5,000 units per ml after each dialysis session. The rt-PA arm resulted in a significant reduction in catheter malfunction (primary outcome) and bacteremia (secondary outcome). No signficant difference in bleeding events were noted between arms.

Prospective Randomized Trials of More Frequent Hemodialysis: The Frequent Hemodialysis Network (FHN)

Trials of Daily In-Center and Nocturnal Home Hemodialysis

Nathan W. Levin et al for the ‘Daily’ Study

As reported in the New England Journal of Medicine paper released to coincide with the oral presentation, this randomized controlled trial comparing conventional thrice weekly dialysis to frequent “daily” dialysis revealed that more frequent dialysis resulted in improvement in the composite outcomes of death or change in left ventricular mass and death or change in a physical-health composite score but prompted more frequent interventions related to vascular access.

Michael Rocco et al for the ‘Nocturnal’ Study.

This randomized controlled trial comparing conventional thrice weekly dialysis to nocturnal dialysis failed to show that frequent, nocturnal dialysis resulted in improvements in the composite outcomes of death or change in left ventricular mass, or death or change in a physical-health composite score.

Pablo E. Pergola et al. Effect of Bardoxolone Methyl on Renal Function in Patients with Chronic Kidney Disease (CKD) and Type 2 Diabetes Mellitus

This report documented clinical outcomes at 24 weeks from a 52 week trial comparing bardoxolone methyl vs placebo in patients with diabetes and chronic kidney disease. 227 patients with eGFR ranging from 20-45 ml/min were randomized. At 24 weeks, those in the treatment arm experienced an increase in eGFR of 10.1% (p < 0.0001) compared to placebo. Side effects such as muscle spasms, nausea, anorexia and hypomagnesemia were significantly more common in the active treatment arm. Formal measurement of GFR, hard clinical endpoints and eGFR response to drug withdrawal were not reported.

Howard Trachtman et al. Results of the Multicenter FSGS Clinical Trial in Children and Young Adults

In this randomized controlled trial of cyclosporine vs mycophenolate mofetil + dexamethasone in children and young adults with steroid resistant focal segmental glomerulosclerosis, no difference was found in the primary outcome of partial or complete remission of proteinuria. Of note, the rate of complete remission was low in both arms and disease relapse was frequent after drug withdrawal.

Steven Fishbane et al. Primary Safety and Efficacy Results from Four Phase 3 Randomized, Active-controlled, Open-label Studies of Hematide/Peginesatide among CKD Dialysis and Nondialysis Patients

This presentation included pooled analysis of 4 distinct studies, 2 completed in patients on dialysis (EMERALD 1 and 2) and 2 completed in CKD patients not yet on dialysis (PEARL 1 and 2). In the pooled analysis of these 4 trials designed to test for non-inferiority in correcting or maintaining haemoglobin in the target range, the primary efficacy endpoint met the statistical criteria for non-inferiority. While the safety endpoint met the criteria for non-inferiority in the pooled analysis, subgroup analysis of non-dialysis patients (PEARL trials) revealed the frequency of events was higher in the peginesatide group than the comparator group. Such a difference was not seen in the subgroup on dialysis.

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In-Center Hemodialysis Six Times per Week versus Three Times per Week

Nephrology Now editors — Sun, 21 Nov 2010 05:50:24 +0000

In this randomized controlled trial comparing conventional thrice weekly dialysis to frequent “daily” dialysis, more frequent dialysis resulted in improvement in the composite outcomes of death or change in left ventricular mass and death or change in a physical-health composite score but prompted more frequent interventions related to vascular access

This paper was presented at the American Society of Nephrology today (November 20, 2010) and simultaneously released online at NEJM.org.

Free full text kindly provided by the New England Journal of Medicine.

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“Daily” Dialysis — Lessons from a Randomized, Controlled Trial

Nephrology Now editors — Sat, 20 Nov 2010 23:19:54 +0000

This editorial provides critical analysis of the paper “In-Center Hemodialysis Six Times per Week versus Three Times per Week”.

Free full text provided by the New England Journal of Medicine.

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Mycophenolate Mofetil vs Azathioprine for Remission Maintenance in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Randomized Controlled Trial

Nephrology Now editors — Tue, 09 Nov 2010 05:03:29 +0000

In this publication by the EUVAS group, mycophenolate mofetil was found to be less effective than azathioprine for maintaining disease remission in ANCA-associated vasculitis.

Free full text provided by JAMA.

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Therapeutic Interventions for Systemic Vasculitis

Nephrology Now editors — Tue, 09 Nov 2010 05:02:35 +0000

This editorial provides critical analysis and commentary on the article ‘Mycophenolate Mofetil vs Azathioprine for Remission Maintenance in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Randomized Controlled Trial’.

Free full text provided by JAMA.

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Rejection of the Kidney Allograft

Nephrology Now editors — Tue, 09 Nov 2010 05:01:09 +0000

This article summarizes the current understanding of mechanisms of rejection, including both cellular and antibody-mediated rejection.

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Long-Term Experience With Kidney Transplantation From Hepatitis C-Positive Donors Into Hepatitis C-Positive Recipients

Nephrology Now editors — Tue, 09 Nov 2010 05:00:01 +0000

Donors with hepatitis C virus (HCV) have often not been used for kidney transplants because of concerns of infecting the recipient with hepatitis C. This paper reports long-term outcomes of transplanting HCV+ kidneys into HCV+ recipients. There was no difference in patient or graft survival among recipients of HCV+ or HCV- kidneys, and very few deaths due to liver disease.

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Analysis of factors that affect outcome after transplantation of kidneys donated after cardiac death in the UK: a cohort study

Nephrology Now editors — Tue, 09 Nov 2010 04:58:48 +0000

Donation after donors undergo cardiac death is a growing source of kidney transplant. These kidneys have a higher fate of delayed graft function. This UK registry study found 5-year graft function and survival of kidneys from donors after cardiac death were similar to that from brain-dead donors.

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Policy Statement of Canadian Society of Transplantation and Canadian Society of Nephrology on Organ Trafficking and Transplant Tourism

Nephrology Now editors — Tue, 09 Nov 2010 04:56:59 +0000

The Istanbul Declaration was an international statement condemning the practices of organ trafficking and transplant tourism. This paper outlines an approach for physicians to counsel patients about the risks of commercial renal transplantation beforehand, physicians’ duties towards a patient who wishes to proceed with a commercial transplant, and their responsibilities once a patient returns seeking care. Although developed in the context of the Canadian health-care system, many of the principles advocated here are applicable in other countries.

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Similar Outcomes With Hemodialysis and Peritoneal Dialysis in Patients With End-Stage Renal Disease

Nephrology Now editors — Mon, 01 Nov 2010 22:46:20 +0000

In one of the largest retrospective observational studies comparing dialysis modality and survival, the authors compared the survival of 620 020 incident Hemodialysis patients and 64 046 incident Peritoneal Dialysis patients treated in The United States between 1996-2004. The authors demonstrated improving survival for PD patients with similar survival compared to HD patients in a more recent cohort (2002-2004) compared to inferior survival for PD patients in prior cohorts (1996-1998) and (1999-2001). The authors used a fairly novel technique to simultaneously adjust for both the propensity for PD and HD treatment among patients, and to diminish any bias resulting from consistently higher rates of kidney transplantation among PD patients relative to HD patients.

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ACLASTA (zoledronic acid 5mg/100mL) solution for intravenous infusion – Association with renal dysfunction

Nephrology Now editors — Mon, 01 Nov 2010 22:44:59 +0000

Novartis in collaboration with Health Canada, is notifying healthcare professionals and the public of reports of renal impairment and renal failure requiring dialysis or with fatal outcome that occurred in patients with history of renal impairment or other risk factors receiving ACLASTA (zoledronic acid).

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Pharmacist-Physician Comanagement of Hypertension and Reduction in 24-Hour Ambulatory Blood Pressures

Nephrology Now editors — Mon, 01 Nov 2010 22:44:18 +0000

This prospective, cluster-randomized, controlled clinical trial examined the impact of pharmacist-primary care physician collaborative management of hypertension. Patients receiving the intervention achieved greater reduction in 24-hour BP and a high rate of BP control.

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Antiplatelet agents for the prevention of arteriovenous fistula and graft thrombosis: a meta analysis.

Nephrology Now editors — Mon, 01 Nov 2010 22:43:22 +0000

This meta-analysis suggests that antiplatelet agents reduce the rate of thrombosis in arteriovenous fistulas but not arteriovenous grafts.

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Patient Awareness and Initiation of Peritoneal Dialysis

Nephrology Now editors — Mon, 01 Nov 2010 22:38:01 +0000

In a cohort of 1621 dialysis patients surveyed between 2005-2007 as part of The United States Renal Data System Comprehensive Dialysis Study, the authors found that although 61% of subjects surveyed had Peritoneal Dialysis discussed with them prior to dialysis initiation, only 10.9% of such informed patients chose PD. After adjustment for patient characteristics and comorbid conditions, the study found large geographic variation in PD use across the United States as well as large variation in PD use by dialysis provider. The authors conclude that further study is needed to understand the factors responsible for dialysis modality selection among US dialysis patients.

See the accompanying editorial
http://archinte.ama-assn.org/cgi/content/full/archinternmed.2010.370v1?etoc

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Management of Poisonings: Core Curriculum 2010

Nephrology Now editors — Mon, 01 Nov 2010 22:36:47 +0000

This addition to the AJKD Core Curriculum series reviews the management of poisionings, as it pertains to Nephrology practice.

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Screening for encapsulating peritoneal sclerosis in patients on peritoneal dialysis: role of CT scanning.

Nephrology Now editors — Mon, 01 Nov 2010 22:35:32 +0000

In this retrospective cohort study, these authors evaluated CT scans in 20 patients 3 months prior to the development of encapsulating peritoneal sclerosis (EPS) compared to the CT scans of 20 control PD patients. Using a validated EPS-CT scoring system, the authors were unable to demonstrate any differences in the CT scans of patients 3 months prior to the development of EPS compared to controls. The authors conclude that , based on existing evidence, the use of routine CT scans in screening for EPS is not justified.

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Management of patients with acute hyperkalemia

Nephrology Now editors — Mon, 01 Nov 2010 22:34:02 +0000

This case-based systematic review nicely summarizes the available therapeutic options for management of acute hyperkalemia.

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Cinacalcet hydrochloride treatment significantly improves all-cause and cardiovascular survival in a large cohort of hemodialysis patients

Nephrology Now editors — Mon, 01 Nov 2010 22:32:57 +0000

This observational study utilizing USRDS data showed a survival benefit associated with the use of cinacalcet in those patients receiving intravenous vitamin D. The authors indicate that “definitive proof, however, of a survival advantage awaits the performance of randomized clinical trials.”

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Therapeutic Strategies for Heart Failure in Cardiorenal Syndromes

Nephrology Now editors — Mon, 01 Nov 2010 22:31:51 +0000

This comprehensive review discusses therapeutic strategies treatment options for the management of patients with heart failure and decreased kidney function.

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Five-Year Safety and Efficacy of Belatacept in Renal Transplantation

Nephrology Now editors — Mon, 01 Nov 2010 22:30:37 +0000

Belatacept is the first costimulation blocker to be assessed in renal transplantation. Its mechanism of action is different from other immunosuppressive medications, and has been evaluated as a primary immunosuppressive agent in place of cyclosporine. This paper is an observational study extending the follow-up of the original randomized controlled trial. Although belatacept must be given intravenously on a monthly basis, it was well-accepted by patients, well-tolerated, and provided stable graft function over time.

Free full text kindly provided by the American Society of Nephrology

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Similar Outcomes for Canadian Renal Transplant Recipients Followed Up in Transplant Centers and Satellite Clinics

Nephrology Now editors — Mon, 01 Nov 2010 22:27:15 +0000

How long-term follow-up of renal transplant patients should be structured is an important question. The increasing numbers of long-term transplant recipients place an increasing strain on the transplant programs that follow them, and many patients live far from their transplant centre. In this observational study, patients who had their care transferred to a satellite (non-transplant) centre had similar renal function and management of cardiovascular risk factors as patients who continued to be followed in the transplant centre.

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Cold Machine Perfusion Versus Static Cold Storage of Kidneys Donated After Cardiac Death: A UK Multicenter Randomized Controlled Trial

Nephrology Now editors — Mon, 01 Nov 2010 22:08:02 +0000

A previous randomized controlled trial showed that machine perfusion was associated with a lower rate of delayed graft function and improved graft survival one year post-transplant. This trial was limited to donation after cardiac death donors. In contrast to the earlier study, there was no difference in DGF, renal function, patient of graft survival rates between the two methods of preservation.

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Inflammation in Areas of Tubular Atrophy in Kidney Allograft Biopsies: A Potent Predictor of Allograft Failure

Nephrology Now editors — Mon, 01 Nov 2010 22:06:30 +0000

The current criteria used to evaluate renal biopsies bases the diagnosis of acute cellular rejection on inflammation and tubulitis only in the areas of non-atrophic tissue. However, changes in atrophic areas have been ignored. In this observational study, inflammation in atrophic tissue was a strong predictor of graft failure. This was true even after adjusting for acute rejection in the non-atrophic tissue as well as changes of fibrosis and atrophy.

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Erythropoietic Response and Outcomes in Kidney Disease and Type 2 Diabetes

Nephrology Now editors — Mon, 01 Nov 2010 22:05:16 +0000

This study assessed the relationship between initial responsiveness to darbepoetin alfa and outcomes in patients with chronic kidney disease and type 2 diabetes mellitus. A poor initial hematopoietic response was associated with an increased risk of death or cardiovascular events.

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Perceived barriers to guidelines in peritoneal dialysis

Nephrology Now editors — Mon, 01 Nov 2010 22:03:46 +0000

Subscribers to NephrologyNow.com, were invited to participate in an online study to identify perceived barriers to evidence-based medicine (EBM) and measurement of continuous quality indicators (CQI) in the practice of peritoneal dialysis. It was noted that international variation in guideline adherence may be influenced by a country’s healthcare expenditure, physician’s PDA use and experience, and size of PD practice. This may impact future guideline development and implementation.Thank you to all Nephrology Now subscribers who participated and made this study possible.

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Nephrologist required in Trail, BC

Nephrology Now editors — Mon, 27 Sep 2010 21:25:56 +0000

Nephrologist required in Trail, BC. In Trail, the nephrology program supports an 8 station hemodialysis unit, 5 community dialysis units and home-based care with PD and home hemodialysis. Learn more at about this position http://bit.ly/936eYN or contact us at 1-877-5522-9722 / physicianrecruitment@interiorhealth.ca

Find out more about the exceptional lifestyle in Trail, BC. http://bit.ly/cKNufo

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Intensive Blood-Pressure Control in Hypertensive Chronic Kidney Disease

Nephrology Now editors — Mon, 27 Sep 2010 21:23:58 +0000

This follow-up to the AASK study followed a large patient cohort after the completion of the randomized controlled trial. The original AASK randomized controlled trial examined anti-hypertensive choice and blood pressure control intensity in African-Americans with hypertensive renal disease. The cohort study targeted a blood pressure of <130/80. While the study failed to show that intensive blood pressure control had an impact on kidney disease progression, it suggested that there may be specific benefit in the highly proteinuric subgroup.

View the editorial
http://www.nejm.org/doi/full/10.1056/NEJMe1007783

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Peritoneal Dialysis-Related Infections Recommendations: 2010 Update | NOW FREE FULL TEXT

Nephrology Now editors — Mon, 27 Sep 2010 21:22:23 +0000

This update from the ISPD focuses on the treatment of exit-site & tunnel infections as well as peritonitis. Guidelines regarding prevention of PD-related infections will be covered in a separate ISPD position statement.

Free full text kindly provided by the International Society of Peritoneal Dialysis.

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Clinical Practice Guidelines For Peritoneal Access – NOW FREE FULL TEXT

Nephrology Now editors — Mon, 27 Sep 2010 21:20:09 +0000

This clinical practice guideline provides recommendations for best practice in creating peritoneal access.

Free full text kindly provided by the International Society of Peritoneal Dialysis.

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Survey Regarding Initiation of Renal Replacement Therapy for Acute Kidney Injury.

Nephrology Now editors — Mon, 27 Sep 2010 21:17:11 +0000

You are invited to participate in a survey to learn more about attitudes and practice patterns regarding the timing of initiation of renal replacement therapy (RRT) in critically ill patients with AKI in Canada.

www.surveymonkey.com/s/timing_renal_replacement_therapy
(The survey should take no more than 15 minutes to complete.)

The primary objective of this survey is to aid in the design and planning of a future clinical trial assessing the impact of timing of RRT in critically ill patients with AKI.

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Management of hypertensive disorders during pregnancy: summary of NICE guidance

Nephrology Now editors — Mon, 27 Sep 2010 21:16:02 +0000

This is a comprehensive summary of management of hypertension in pregnancy based on the best available evidence where it exists.

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The time course of peritoneal transport parameters in peritoneal dialysis patients who develop encapsulating peritoneal sclerosis.

Nephrology Now editors — Mon, 27 Sep 2010 21:14:54 +0000

This single centre retrospective cohort study examined longitudinal changes in small solute transport and other peritoneal membrane characteristics of 12 patients prior to the development of encapsulating peritoneal sclerosis (EPS) compared to 21 vintage-matched controls who did not develop EPS but did develop peritoneal ultrafiltration failure. No differences in the time course of small solute transport characteristics or peritoneal ultrafiltration capacity was seen between the two groups. The authors conclude that early functional peritoneal membrane changes alone cannot delineate between patients who develop simple ultrafiltration failure vs those destined to develop EPS.

This suggests that routine monitoring of peritoneal membrane function does not have a role in the early detection of EPS.

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Steroid Pretreatment of Organ Donors to Prevent Postischemic Renal Allograft Failure A Randomized, Controlled Trial

Nephrology Now editors — Mon, 27 Sep 2010 21:12:37 +0000

Steroids are frequently given to neurologically-deceased donors prior to organ procurement. They may also prevent an inflammatory response in the kidney, which is known to play a role in the development of delayed graft function post-transplant. This blinded, randomized controlled trial compared steroid treatment to placebo. Although markers of inflammation were suppressed, steroids did not change the rate of delayed graft function or renal function in the early post-transplant period.

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The Impact of Timing of Maximal Crystalloid Hydration on Early Graft Function During Kidney Transplantation

Nephrology Now editors — Mon, 27 Sep 2010 21:11:07 +0000

Perioperative volume status and hypotension can lead to delayed graft function post-transplant. Mannitol and crystalloids are evidence-based strategies to reduce DGF rates, while furosemide and albumin have not been shown to decrease the risk. In this small, single-center blinded randomized controlled trial, a strategy of crystalloid administration to a target central venous pressure resulted in better intraoperative blood pressure, less use of pressors and furosemide and a faster fall in serum creatinine. This study highlights the importance of perioperative fluid management on outcomes post-transplant.

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A Systematic Review on Steroid Withdrawal Between 3 and 6 Months After Kidney Transplantation

Nephrology Now editors — Mon, 27 Sep 2010 21:08:08 +0000

Rapid steroid withdrawal within 1 week of transplantation is associated with an increased incidence of acute rejection, and no clear reduction in side effects or cardiovascular disease risk. This paper combines all studies of steroid withdrawal at an intermediate time point post-transplant in patients treated with cyclosporine or tacrolimus, mycophenolic acid and no antibody induction. It showed no increase in graft loss or death with steroid withdrawal. Interestingly, it showed an increased rate of acute rejection in cyclosporine-treated patients, but not tacrolimus. These results need to be confirmed with larger studies.

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Topics in Transplantation Medicine for General Nephrologists

Nephrology Now editors — Mon, 27 Sep 2010 21:04:29 +0000

This paper is aimed at the general nephrologist with brief updates on a variety of topics in transplantation nephrology. These include issues relating to immunosuppression; BK infection; cardiovascular risks and benefits of transplantation; pregnancy; malignancy; and vaccinations.

Full text kindly provided by the American Society of Nephrology.

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Peritoneo-scrotal shunting diagnosed by Tc-99m DTPA SPECT/CT imaging

Nephrology Now editors — Mon, 27 Sep 2010 20:59:20 +0000

Related Articles: Nephrogenic Systemic Fibrosis: Suspected Causative Role of Gadodiamide Used for Contrast-Enhanced Magnetic Resonance Imaging. Effect of allopurinol on blood pressure of adolescents with newly diagnosed essential hypertension: a randomized trial. Screening for encapsulating peritoneal sclerosis in patients on peritoneal dialysis: role of CT scanning.

Calcium Kidney Stones

Nephrology Now editors — Mon, 27 Sep 2010 20:57:46 +0000

This clinical practice feature reviews the common clinical problem of calcium stones. It begins with a case and then highlights various treatment strategies as well as reviews formal guidelines.

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Is There Any Reason to Stent Atherosclerotic Renal Artery Stenosis?

Nephrology Now editors — Fri, 20 Aug 2010 17:44:18 +0000

This is commentary on the ASTRAL study (Revascularization versus medical therapy for renal artery stenosis. N Engl J Med. 2009;361(20):1953-1962.) discusses trial findings, limitations and implications for practice.

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Indications for renal revascularization—the landscape after the ASTRAL study

Nephrology Now editors — Fri, 20 Aug 2010 17:43:07 +0000

This review discusses the implications of the STAR and ASTRAL studies on management of atherosclerotic renovascular disease and highlight an important study in progress, CORAL. The authors summarize that “until completion of the CORAL study, it is prudent to restrict the endovascular intervention to only patients with tight RAS of the single functioning kidney or with bilateral lesions in patients with recurrent pulmonary oedema or when arterial hypertension is refractory to medication with rapid deterioration of kidney function.”

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Guidelines for the prevention and management of Mycobacterium tuberculosis infection and disease in adult patients with chronic kidney disease.

Nephrology Now editors — Fri, 20 Aug 2010 17:41:41 +0000

Theses guidelines have been prepared by British Thoracic Society Standards of Care Committee and Joint Tuberculosis Committee.

Free full text kindly provided through the British Thoracic Society website.

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Perioperative acute kidney injury: risk factors, recognition, management, and outcomes

Nephrology Now editors — Fri, 20 Aug 2010 17:40:05 +0000

This clinical review nicely summarizes how to manage acute kidney injury perioperatively, including recognizing and preventing common pitfalls in this setting.

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The CLEAR Study: A 5-day, 3-g Loading Dose of Mycophenolate Mofetil versus Standard 2-g Dosing in Renal Transplantation

Nephrology Now editors — Fri, 20 Aug 2010 17:38:44 +0000

Although mycophenolate mofetil (MMF) is prescribed at a standard dose for all patients, there are studies showing that there is a level of MMF exposure at which the risk of acute rejection is reduced. Some studies have compared therapeutic drug monitoring to fixed doses of MMF. In contrast, this open-label multicenter randomized controlled trial compared two different fixed doses of MMF in the first five days post-transplant. Higher MMF dosing early post-transplant showed a trend towards fewer acute rejection and graft loss at six months, but did not reach statistical significance.

Free full text kindly provided by the American Society of Nephrology.

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Kidneys from Donors after Cardiac Death Provide Survival Benefit

Nephrology Now editors — Fri, 20 Aug 2010 17:36:28 +0000

Donation after cardiac death (DCD) has become an important new source of deceased donor kidneys, but is associated with a higher risk of delayed graft function, itself a risk factor for acute rejection, graft loss and death. In this cohort study, recipients of a DCD kidney had improved survival compared to patients who remained on dialysis and waited longer to receive a kidney from a neurologically-deceased donor. This study confirms that DCD kidneys provide good outcomes to patients.

Free full text kindly provided by the American Society of Nephrology

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High Dose Epoetin Beta in the First Weeks Following Renal Transplantation and Delayed Graft Function: Results of the Neo-PDGF Study

Nephrology Now editors — Fri, 20 Aug 2010 17:33:29 +0000

Erythropoietin has nephroprotective effects in a variety of animal models, including against ischemia-reperfusion injury, which is an important element of delayed graft function. In this multi-center randomized trial, patients were randomized to four doses of erythropoietin or placebo in the first two weeks post-transplant. There ws no difference in the rate of delayed graft function or eGFR at 1 month post-transplant between the two groups.

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Thrombotic Microangiopathy After Kidney Transplantation

Nephrology Now editors — Fri, 20 Aug 2010 17:32:29 +0000

Thrombotic microangiopathy (TMA) is a rare but serious post-transplant complication. It can occur de novo or recurrent, especially in patients with complement factor abnormalities. This paper reviews the causes and risk factors for TMA, as well as strategies for prevention and treatment.

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9th Annual Conference on Prevention in Renal Disease

Nephrology Now editors — Fri, 20 Aug 2010 17:31:13 +0000

Dear colleagues:

9th Annual Conference on Prevention in Renal Disease- Toronto – October 1st & 2nd, 2010.

September 6th is the DEADLINE for early registration and abstract submission.

As in the past we will provide 50 scholarships to fellows/residents who will register early.

For details of the program and on-line registration please visit: www.nephroprevention.com

- Dimitrios Oreopoulos

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Invitation to Participate in Study on Initiation of Dialysis in Acute Kidney Injury

Nephrology Now editors — Fri, 20 Aug 2010 17:28:49 +0000

Researchers at University of Cincinnati are conducting a research survey to examine factors that may affect the timing of initiation of dialysis in patients with acute kidney injury (aka: acute renal failure) in ICU patients. This survey can be accessed by clicking on the link provided below. The survey will take less than 10 – 15 minutes of your time. The responses are not identifiable, and are being collected for research purposes only.

Survey Link: http://www.surveymonkey.com/s/Dialysis_Initiation_in_AKI_in_ICU_Survey

Thank you, and your participation is greatly appreciated.

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Rituximab versus Cyclophosphamide in ANCA-Associated Renal Vasculitis

Nephrology Now editors — Tue, 20 Jul 2010 07:46:28 +0000

This RCT did not find that a rituximab-based regimen was superior to standard intravenous cyclophosphamide for severe ANCA-associated vasculitis.

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Rituximab versus Cyclophosphamide for ANCA-Associated Vasculitis

Nephrology Now editors — Tue, 20 Jul 2010 07:45:22 +0000

This non-inferiority trial finds that rituximab therapy was not inferior to daily cyclophosphamide treatment for induction of remission in severe ANCA-associated vasculitis and may be superior in relapsing disease.
See the associated editorial.

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Daily oral sodium bicarbonate preserves glomerular filtration rate by slowing its decline in early hypertensive nephropathy

Nephrology Now editors — Tue, 20 Jul 2010 07:40:12 +0000

It has previously been demonstrated that oral sodium bicarbonate slows GFR decline in patients with low GFR. This 5-year RCT evaluated whether daily oral sodium bicarbonate slowed GFR decline in patients with hypertensive nephropathy with reduced but relatively preserved eGFR (mean 75 ml/min). The rate of eGFR decline was slower and eGFR was higher in patients given sodium bicarbonate than in those given placebo or sodium chloride. Both groups were treated with angiotensin-coverting enzyme inhibitors concurrently.

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High-dose renal replacement therapy for acute kidney injury: Systematic review and meta-analysis.

Nephrology Now editors — Tue, 20 Jul 2010 07:39:07 +0000

This meta-analysis examining high-dose renal replacement therapy in acute kidney injury did not show any improvement in patient survival or recovery of renal function.

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Trimethoprim-Sulfamethoxazole-Induced Hyperkalemia in Patients Receiving Inhibitors of the Renin-Angiotensin System: A Population-Based Study

Nephrology Now editors — Tue, 20 Jul 2010 07:37:57 +0000

This case control study suggests that older patients taking ACEIs or ARBs have a major increase in the risk of hyperkalemia-associated hospitalization when using trimethoprim-sulfamethoxazole.

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Switch to a Sirolimus-Based Immunosuppression in Long-Term Renal Transplant Recipients: Reduced Rate of (Pre-)Malignancies and Nonmelanoma Skin Cancer in a Prospective, Randomized, Assessor-Blinded, Controlled Clinical Trial

Nephrology Now editors — Tue, 20 Jul 2010 07:36:43 +0000

Early studies showed fewer new skin-cancers in patients randomized to sirolimus at the time of transplant. In this single-center trial, patients with a previous non-melanoma skin cancer were randomized to sirolimus or to continue on their current immunosuppression. There was fewer new skin cancers or premalignant lesions in the sirolimus group. This is a small study lasting only twelve months and speaks to the need for larger, longer trials.

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Everolimus Plus Reduced-Exposure CsA versus Mycophenolic Acid Plus Standard-Exposure CsA in Renal-Transplant Recipients

Nephrology Now editors — Tue, 20 Jul 2010 07:35:24 +0000

Everolimus is an mTOR inhibitor, in the same family as sirolimus. Previous studies combining mTOR inhibitors with usual dosing of calcineurin inhibitors showed worse renal function and graft survival, despite equal efficacy in preventing acute rejection as a calcineurin inhibitor/mycophenolic acid combination. In this RCT, everolimus at two different target levels was combined with low-dose cyclosporine and compared to usual-dose cyclosporine and mycophenolic acid. The everolimus combinations were non-inferior to cyclosporine and MPA for the primary endpoint of eGFR at twelve months post-transplant.

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Kidney and Recipient Weight Incompatibility Reduces Long-Term Graft Survival

Nephrology Now editors — Tue, 20 Jul 2010 07:34:19 +0000

Nephron mass plays an important role in providing adequate renal function, with loss of nephron mass a risk factor for later deterioration of renal function. In this study, a low ratio of the weight of the donor kidney before implantation to recipient weight was associated with worse long-term renal function and outcomes.

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Kidneys from Donors after Cardiac Death Provide Survival Benefit

Nephrology Now editors — Tue, 20 Jul 2010 07:32:13 +0000

Kidneys obtained from donors after cardiac death (DCD) have been increasing over the last several years. DCD kidneys have a higher risk for delayed graft function compared to kidneys obtained from standard kidneys from brain-dead donors (DBD). In this analysis of transplantation in the Netherlands, patients receiving a DCD kidney had improved survival compared to patients who waited longer on the transplant waiting list and then received a DBD kidney. This study supports the use of standard-criteria DCD kidneys.

Full text access kindly provided by the American Society of Nephrology.

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Cholesterol Lowering, Cardiovascular Diseases, and the Rosuvastatin – JUPITER Controversy A Critical Reappraisal

Nephrology Now editors — Tue, 20 Jul 2010 07:29:02 +0000

This article critically reviews the trial JUPITER which reported a substantial decrease in the risk of cardiovascular diseases among patients without coronary heart disease and with normal or low cholesterol levels. Concern was expressed that the trial was flawed as it was discontinued (according to prespecified rules) after fewer than 2 years of follow-up, with no differences between the 2 groups on the most objective criteria. The authors concluded that the results of the trial do not support the use of statin treatment for primary prevention of cardiovascular diseases, while raising concerning questions about the role of commercial sponsors.

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Update in Nephrology

Nephrology Now editors — Tue, 20 Jul 2010 07:10:01 +0000

This article highlights the findings of several key trials that were published in the field of chronic kidney disease in 2009.

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A Randomized, Controlled Trial of Early versus Late Initiation of Dialysis

Nephrology Now editors — Mon, 28 Jun 2010 06:02:01 +0000

This landmark clinical trial randomized CKD patients to a strategy of early (GFR 10-14 ml/min) vs late (GFR 5-7 ml/min) initiation of dialysis. After a median follow-upof 3.6 years, no difference was seen in mortality, cardiovascularevents, infections, or complications of dialysis. Careful note should be made that the majority of patient randomized to late initiation (76%) had to start dialysis at a GFR above 7 ml/min due to clinical indications. Read the accompanying editorial to learn more and please post your own comments on Nephrology Now.

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The Initiation of Renal-Replacement Therapy — Just-in-Time Delivery

Nephrology Now editors — Mon, 28 Jun 2010 05:52:44 +0000

This editorial provides insight into the interpretation of the article ‘A Randomized, Controlled Trial of Early versus Late Initiation of Dialysis‘.

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Nutritional Considerations in Kidney Disease: Core Curriculum 2010

Nephrology Now editors — Mon, 07 Jun 2010 04:16:27 +0000

This addition to the AJKD Core Curriculum series reviews nutritional considerations in the management of kidney disease.

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Superior survival of high transporters treated with automated versus continuous ambulatory peritoneal dialysis

Nephrology Now editors — Mon, 07 Jun 2010 04:14:59 +0000

APD is generally recommended for the management of high transporters, although there have been no adequate studies to date comparing the outcomes of APD and CAPD in this high risk group. In this study of patients receiving peritoneal dialysis, APD treatment was associated with superior survival and comparable death-censored technique survival, as compared to CAPD. There were no statistically significant differences in patient survival or death-censored technique survival between APD and CAPD for any other transport group, except for low transporters, who experienced a higher mortality rate on APD compared with CAPD.

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TREAT: Implications for Guideline Updates and Clinical Care

Nephrology Now editors — Mon, 07 Jun 2010 04:13:45 +0000

This editorial provides practical suggestions on how to translate the results of TREAT into clinical practice.

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Systematic Review: Erythropoiesis-Stimulating Agents in Patients With Chronic Kidney Disease

Nephrology Now editors — Mon, 07 Jun 2010 04:12:00 +0000

This meta-analysis confirms that targeting higher hemoglobin levels in CKD increases risks for stroke, hypertension, and vascular access thrombosis and probably increases risks for death, serious cardiovascular events, and end-stage renal disease.

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Anemia Management in Chronic Kidney Disease: Bursting the Hemoglobin Bubble

Nephrology Now editors — Mon, 07 Jun 2010 04:10:26 +0000

This editorial summarizes the management of anemia post-TREAT, but also asks critical questions that remain to be clarified in this important area.

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Randomized Clinical Trial of Long-Acting Somatostatin for Autosomal Dominant Polycystic Kidney and Liver Disease

Nephrology Now editors — Mon, 07 Jun 2010 04:08:39 +0000

In this small RCT of 12 months duration, octreotide slowed the progressive increase in liver and kidney volume in patients with polycystic kidney disease and polycystic liver disease. While the findings are encouraging and consistent with other studies, longer and larger clinical trials will be necessary to establish the long-term safety and efficacy of somatostatin analogs for ADPKD and/or ADPLD.

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