News & Views in 2012

The European Paediatric Dialysis Working Group has recently produced recommendations for the management of infants on dialysis. This document is timely because, despite the fact that such infants are increasingly being accepted onto renal replacement therapy programmes, most centres have very little experience in the care of this demanding group of patients.

Central venous catheters are currently the primary method of vascular haemodialysis access used by paediatric nephrologists in the USA. However, new data from Ma and colleagues suggest that in children who require chronic haemodialysis, arteriovenous fistulas might be a safer option.

Isakova et al. report that kidney transplant recipients on mammalian target of rapamycin (mTOR) inhibitors do not have a lower risk of allograft failure but do have a higher risk of death than those on calcineurin inhibitors. Careful consideration is, therefore, required before converting to mTOR inhibitors to preserve renal function.

A recent study reports that the combination of an angiotensin-receptor blocker (ARB) and a calcium-channel blocker (versus a high-dose ARB) is associated with improved blood pressure control and reduced cardiovascular, cerebrovascular and heart failure events in an elderly chronic kidney disease population. This finding raises the possibility of using fixed-dose drug combinations to improve efficacy and compliance of antihypertensive medications.

As granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) share histopathologic and clinical features, including the presence of antineutrophil cytoplasmic autoantibodies (ANCAs), patients with these syndromes are commonly labelled as having ANCA-associated vasculitis (AAV) and are subjected to similar treatments. A recent study suggests that dividing AAV into five classes based on disease phenotype provides better prognostic information than the classic division into GPA and MPA.

Data from the ARISTOTLE trial showed that apixaban, compared with warfarin, reduced the rates of stroke, death and major bleeding in patients with atrial fibrillation, regardless of renal function. Is the problem of balancing the risks of thromboembolism and bleeding in patients with atrial fibrillation and chronic kidney disease finally solved?

Surprising new randomized trial data showed no clinically relevant decrease in bone mineral density at various skeletal sites 12 months after kidney transplantation in patients receiving baseline calcitriol and calcium therapy as well as ibandronate or placebo. These data raise important questions regarding strategies to prevent bone loss after renal transplantation.

A new multinational cohort study reports that patients receiving daily haemodialysis had a significantly higher mortality rate than those receiving conventional thrice-weekly treatments. Other studies have suggested that daily haemodialysis has beneficial effects. What are patients and nephrologists to make of these conflicting findings?

The appropriate use of lipid-lowering therapy in patients with chronic kidney disease (CKD) remains unclear. The results of two recent, robust systematic reviews and meta-analyses of lipid-lowering therapy in patients with CKD seem to support the use of lipid-lowering therapy. But is the story more complex?

Surprising new data from Sever and colleagues suggest that in patients who have hypertension and cardiovascular disease risk factors, increased plasma renin activity is associated with future renal impairment but not with cardiovascular events or all-cause mortality. These novel data are important but difficult to explain.

Oral phosphate binder therapy is considered a 'tower of strength' in the ever-expanding armamentarium of drugs used to treat abnormal mineral metabolism in patients with chronic kidney disease (CKD) and use of these agents early in the course of CKD is gaining much interest. Recent data from a randomized controlled study by Block et al. challenge this strategy, raise doubts about its safety and indicate the need for additional studies of hard end points.

A recently published study suggests that sirolimus is an attractive treatment option for the prevention of secondary skin cancer in kidney transplant recipients. However, before we think about switching all patients with a previous skin cancer (or with any other malignancy) to sirolimus, we should have a closer look at the data.

The new KDIGO anaemia guidelines represent a bold, sensible, and patient-centred approach to anaemia management in patients with chronic kidney disease. Recommendations regarding haemoglobin targets, blood transfusions, and erythropoiesis-stimulating agent therapy are provided, and individualizing the management of anaemia is emphasized.

Cell hypertrophy is the only mechanism by which podocytes can cope with increased functional demands, whereas other glomerular cells can adapt by cell proliferation. In the setting of systemically stimulated glomerular growth, a 'mismatch' of inadequate podocyte hypertrophy and overall glomerular growth may lead to podocyte loss and development of focal segmental glomerulosclerosis.

Several management guidelines for lupus nephritis have been published this year. All of the guidelines provide clear and consistent recommendations, but although evidence-based, many of the recommendations are not supported by high-quality clinical data. The guidelines reveal these evidence gaps and are thus an important roadmap for future lupus nephritis clinical research.

German health-care providers should be applauded for their heroic efforts in facing the 2011 Escherichia coli O104:H4 outbreak. However, a unique opportunity was missed to compare the efficacy of antibiotics, plasma therapy and eculizumab therapy in a randomized study, and the open questions concerning the optimal treatment of severe Shiga-toxin-associated haemolytic uraemic syndrome remained unanswered.

Current dogma suggests that fluid overload—when associated with acute kidney injury (AKI)—is an independent risk factor for death. Although the volume status of the patient is important, there are other predictors of morbidity, mortality and the need for renal replacement therapy in patients with AKI.

For more than 20 years, Doppler ultrasound has been a valuable noninvasive imaging tool in the evaluation of several forms of kidney disease. Modifying the typical parameters used in clinical practice as shown in a study by Grün et al. may lead to a more kidney-specific Doppler value.

Ongoing research continues to show only moderate accuracy of all methods of measuring proteinuria in pregnant women with hypertension. We need to change traditional thinking so that emphasis on the detection or quantitation of proteinuria is not greater than emphasis on other clinical or laboratory features in the diagnosis or management of pre-eclampsia.

Abramowitz et al. report that the albumin-adjusted and full anion gaps are independent predictors of all-cause mortality after adjusting for estimated glomerular filtration rate (eGFR). This finding raises the question as to whether subtle changes in tubular function could identify patients at increased risk of adverse outcomes, even in those with eGFR >60 ml/min/1.73 m².