Viewpoint in 2007

The authors proffer their response to the question previously posed by Joanne Bargman inNature Clinical Practice Nephrology: “Why are rheumatologists treating lupus nephritis?” They argue that rheumatologists are often the first point of call for patients presenting with systemic lupus erythematosus, and that they are also more adept than nephrologists at assessing certain extrarenal manifestations of the disease. Thus, the rheumatologist is ideally placed to design and monitor treatment, with the aid of a nephrologist.

Screening for chronic kidney disease in patients with diabetes should encompass not only testing for albuminuria, but also the subsequent diagnostic procedures and interventions. Otherwise, what is the purpose of testing? The authors of this Viewpoint highlight the inadequacies of current screening practices, and argue that detection of increased urinary albumin excretion in a patient with diabetes should be a call to action.

Since the publication of the CHOIR and CREATE study results, tremendous attention has focused on the cardiovascular effects of anemia correction in patients with chronic kidney disease. Less publicized has been the finding of a potentially higher risk of progression to end-stage renal disease among patients assigned to a higher hemoglobin target. Ajay K Singh examines whether the sum of evidence indicates a harmful or a beneficial effect of anemia correction on the progression of kidney disease.

In the second of two opposing Viewpoints, these authors from the Greenslopes and Princess Alexandra Hospital Hypertension Units in Brisbane, Australia, describe why, who, and how they screen for primary aldosteronism. They argue that diagnosing (using a stepwise selective approach) and curing or specifically treating aldosterone excess is good for the patient and inexpensive compared with potentially lifelong and less-effective nonspecific antihypertensive therapy.

This, the first of two opposing Viewpoints, sets out the arguments against screening for primary aldosteronism. The author, from the Western General Hospital in Edinburgh, UK, asserts that the majority of individuals with a high aldosterone:renin ratio have a normal plasma aldosterone level. Physicians should, therefore, focus on optimizing the excretion of salt and water in hypertensive patients rather than on expensive tests to detect an aldosterone-secreting adenoma.

This Viewpoint puts forward the intriguing hypothesis that vitamin K is a modifiable risk factor for vascular calcification in patients on dialysis. Reports linking vitamin K with regulation of vascular calcification via the actions of matrix GLA protein are set in the context of the authors' own data on the incidence of subclinical vitamin K deficiency and the use of the vitamin K antagonist warfarin in the dialysis setting.

Since the first successful transplantations were performed around 50 years ago, the lack of improvement in long-term graft survival and the risks associated with immunosuppressive therapy have made the ability to induce tolerance a burning desire among transplantation immunobiologists. These authors outline the considerable challenges that stand in the way of this goal, and proffer their opinion on which strategies are most likely to succeed.

Earlier this year, the FDA responded to the findings of CHOIR and several other studies by issuing a Public Health Advisory about the risks associated with erythropoiesis-stimulating agents, and introducing a black box warning to the labeling of these drugs. In this Viewpoint, Ajay K Singh responds to some of the criticisms that have been leveled at CHOIR and offers some practical advice for implementing the FDA's guidance.

A group chaired by a rheumatologist recently published a consensus document inArthritis and Rheumatismthat codified definitions of renal responses and non-responses to therapy in patients with lupus nephritis. In this Viewpoint, the co-director of a renal-rheumatology lupus clinic argues that nephrologists have a key role to play in the diagnosis and treatment of lupus nephritis, and that they should not allow rheumatologists to take over the management of this condition.

For clinicians treating chronic conditions such as end-stage renal disease (ESRD), the quality of patients' lives is an important consideration. This Viewpoint highlights the ways in which health-related quality of life can be measured in ESRD (e.g. with generic instruments that facilitate comparisons with the general population and between countries), and the difficulties of such measurement. The authors offer their suggestions of how best to obtain and use this information to improve the care and outcomes of patients with ESRD.

In formulating a clear and succinct answer to the question posed by this Viewpoint, the authors highlight several important considerations. They discuss how the choice of induction agent, the presence of risk factors for relapse and the definition of remission can influence the timing of the switch to maintenance therapy and/or the duration of maintenance treatment in patients with ANCA-associated vasculitis.

Focusing largely on end-stage renal disease, this Viewpoint outlines some echocardiographic indices of left ventricular function, and examines their prognostic value in chronic kidney disease. Recommendations are provided for optimal indexing of estimates of left ventricular mass to body size in this population. The role of echocardiography as an outcome measure in interventional studies and in the longitudinal monitoring of cardiac risk are also briefly considered.

The author of this counterpoint argues that the results of recently published randomized clinical trials call into question the assumption that continuous renal replacement therapy is inherently superior to intermittent hemodialysis for patients in the intensive care unit with severe acute kidney injury. The second half of his article examines why this might be. Has intermittent hemodialysis become safer and more efficacious? Might continuous renal replacement therapy be less safe and/or efficacious than previously thought?

The first of this pair of 'pro/con' Viewpoints sets out the case for the superiority of continuous renal replacement therapy over intermittent hemodialysis in critically ill patients with acute kidney injury. Forming the basis of the author's argument is the notion that by attempting to correct in a few minutes physiological derangements that have developed over hours or days, intermittent hemodialysis is aggressive and unphysiological; by contrast, continuous renal replacement therapy corrects derangements gently and slowly, like the native kidneys.

The US National High Blood Pressure Education Program currently advocates diuretics as first-line treatment for all patients with hypertension, based mainly on the findings of ALLHAT. This Viewpoint identifies several flaws in the design of ALLHAT that call into question the validity of its conclusions. The authors argue that by encouraging use of angiotensin-converting-enzyme inhibitors and calcium channel blockers in ways that are not the standard of care, the trial likely exaggerated the benefits of diuretics in this setting.

Taking into account the danger of provoking osmotic demyelination by causing an overly rapid rise in the plasma sodium level, these authors from the University of Toronto offer their recommendations for correcting chronic hyponatremia. They highlight the importance of avoiding a substantial water diuresis, and discuss three key clinical settings where such a diuresis can occur.