Articles in 2009

ONTARGET showed that dual renin–angiotensin system blockade prevents microalbuminuria but facilitates transient renal function impairment in nonproteinuric patients with atherosclerotic vascular disease or diabetes. These findings should not be used as an excuse not to optimize renin–angiotensin system inhibition and target urinary protein in patients with proteinuric nephropathies.

In patients with hypertension in hemodialysis, dry-weight reduction by additional ultrafiltration leads to decreases in systolic and diastolic blood pressure. Ultrafiltration combined with daily dietary salt restriction should, therefore, be recommended to these patients, even in the absence of clinical signs of volume overload.

Mortality rates of patients with low levels of serum albumin, a marker of malnutrition and inflammation, are lower when hemodialysis is performed with high-flux membranes than with low-flux membranes.

Determining the optimal method for preserving deceased-donor kidneys is crucial for improving long-term transplant success. A randomized, controlled trial has compared two methods—hypothermic machine perfusion and cold storage preservation.

Zuber and colleagues from Paris describe a case of diabetes that developed after renal transplantation in a young, white, nonobese man. Genetic screening detected a newly described deletion in the gene encoding hepatocyte nuclear factor 1 homeobox B,HNF1B, indicating that mutations in HNF1Bmight account for some 'unexpected' cases of new-onset diabetes after transplantation. Minimization of tacrolimus exposure and withdrawal of steroids markedly reduced the patient's insulin requirement.

The term 'chronic allograft nephropathy' describes a clinical syndrome of proteinuria, hypertension and declining renal function, that is a major cause of late graft loss in renal transplant recipients. In this concise Review, authors from Korea discuss the contribution of immunological and non-immunological factors to the pathogenesis of chronic allograft nephropathy. In the absence of a definitive treatment protocol for the condition, they offer recommendations to minimize some of these underlying risk factors.

Heparin-induced thrombocytopenia (HIT) is a clinicopathologic syndrome in which one or more clinical events, usually thrombocytopenia or thrombosis, are temporally related to heparin administration and caused by HIT antibodies. This Review examines HIT from a renal perspective, discussing manifestations of HIT in patients on renal replacement therapy, the recent association of HIT with increased mortality in hemodialysis patients, newer aspects of HIT treatment in the renal patient, and heparin rechallenge in individuals who revert to antibody-negative status.

No large randomized, placebo-controlled trials have investigated whether the metabolic syndrome affects hard renal outcomes. In this Review, Varun Agrawal and colleagues evaluate the evidence of an association between the metabolic syndrome and chronic kidney disease and examine whether treatment of the syndrome improves renal outcomes. The authors conclude their discussion detailing the challenges of defining the metabolic syndrome and of selecting appropriate renal outcomes.

The fact that numerous systemic and renal disorders result in progressive proteinuria illustrates the importance of the glomerular filtration barrier. In this concise Review, authors from Stockholm provide an update on the structure and function of the glomerular filtration barrier and the pathogenesis of proteinuria, with a particular emphasis on the involvement of podocytes. The discussion encompasses newly identified pathogenic players, including TRPC6, phospholipase C ε, MYH9 and the urokinase receptor.

The nephrologist must consider several difficult questions when faced with a patient who has a new diagnosis of idiopathic membranous nephropathy (IMN). Here, authors from the National Institutes of Health corral the latest trial data to provide an update on the 'who', 'when' and 'how' of IMN treatment. They focus particularly on agents that have been studied as alternatives to cytotoxic drugs and ciclosporin, including mycophenolate mofetil, rituximab and adrenocorticotropic hormone.