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Lower blood concentrations of protein-bound solutes have been directly linked to better outcomes in patients on dialysis. Studies indicate that clearance of protein-bound solutes is more efficient in patients on hemodialysis than in those on peritoneal dialysis; however, paradoxically, the circulating levels of these solutes are lower in patients on peritoneal dialysis. Vanholder and colleagues consider possible explanations for this discrepancy, such as differences in intestinal generation or metabolism of these molecules.

'Middle molecules' (those in the molecular weight range of 500–60,000 Da, such as β₂-microglobulin), are not easily removed by dialysis and are believed to mediate some of the effects of the uremic syndrome. The authors of this Viewpoint argue that Kt/V_ureais flawed as a sole indicator of dialysis adequacy, and that we need new indices to quantify removal of these middle molecules in patients on dialysis.

The deterioration of the peritoneal membrane during peritoneal dialysis is a serious problem as it leads to technique failure. The factors that have attracted the most attention as culprits in peritoneal membrane deterioration are those related to the peritoneal dialysis fluid itself, such as pH, glucose, and glucose degradation products. This Review focuses on the other factors-many of them modifiable-that can affect peritoneal membrane quality and could be targeted to preserve the peritoneal membrane.

The selection of a specific dialysis modality can have important consequences in terms of survival and quality of life. In this Review, Lameire and Van Biesen compare the epidemiology of peritoneal dialysis with that of hemodialysis and describe some of the major differences that exist in the global utilization of these two dialysis modalities. The authors describe a number of medical and nonmedical factors, including economic, educational and psychological factors that influence dialysis modality choice.

A recent study has reviewed records of patients on thrice-weekly hemodialysis and shown that serious and fatal complications—including overall and cardiac mortality, as well as hospitalization for cardiovascular reasons—are more frequent on the last day of the long interdialytic interval than on other days.

Graft stenosis, which can lead to thrombosis, is a major problem in hemodialysis patients with arteriovenous grafts. Does anti-aggregation with dipyridamole and aspirin help to prolong the primary patency of vascular access grafts?

Home haemodialysis offers increased flexibility over in-centre haemodialysis for adopting different dialysis regimes aimed at improving solute removal. In this Review, Vanholder et al. discuss strategies that can improve haemodialysis adequacy in the home setting. The authors examine vascular access, reaching dialysis adequacy targets, increasing dialyser pore size, increasing dialysis frequency, and increasing dialysis duration, and also discuss the idea of the wearable artificial kidney.

The existence of several different definitions of acute renal failure makes it difficult to determine the true epidemiological characteristics of this condition. Nonetheless, there have been notable variations in its epidemiology during the past few decades. Norbert Lameire and colleagues present an overview of these changes and their causative factors, including geography, patient setting and ageing populations.

Patients with chronic kidney disease have elevated levels of carbamoylated proteins. Here the authors review the mechanisms of carbamoylation, the effects of this post-translational modification on renal function and strategies to reduce the carbamoylation load.

The treatment of chronic kidney disease (CKD) and end-stage renal disease (ESRD) is associated with immense societal costs, with particularly high expenditure for renal replacement therapy. This Review addresses the economic aspects of CKD and ESRD with a focus on approaches to prevent the conditions that contribute to CKD and its progression.

Working towards sustainable development is essential to tackle the rise in the global burden of non-communicable diseases, including kidney disease. Five years after the Sustainable Development Goal agenda was set, this Review examines the progress thus far, highlighting future challenges and opportunities, and explores the implications for kidney disease.