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Despite the epidemic of cardiovascular disease among patients with end-stage renal disease, recent findings demonstrate that the pediatric community needs to make greater efforts to control the known modifiable risk factors.
Kidney transplantation is well known to increase survival and improve quality of life over conventional dialysis therapies. But are contemporary, intensive dialysis therapies, such as nocturnal home hemodialysis, associated with outcomes as good as those obtained with deceased donor transplantation?
In patients at low risk of renal disease and with low levels of albuminuria, administration of renin–angiotensin system inhibitors does not seem to offer renal benefits and might cause adverse renal effects. In these patients, renin–angiotensin system inhibition should be implemented judiciously, with doses titrated to individual needs and with careful monitoring of kidney function.
Evidence supporting the renal benefits of angiotensin-converting-enzyme inhibitors and angiotensin II receptor blockers in elderly patients without proteinuria is lacking. However, until such data are available, if tolerated, these medications should continue to be used in this patient population because of their potent effect on blood pressure.
Extending the duration of cytomegalovirus prophylaxis to 6 months in virus-seronegative organ recipients who receive transplants from seropositive donors decreases the risk of cytomegalovirus disease. But is prophylaxis extension the best approach to preventing late-onset cytomegalovirus disease?
The Framingham hypertension risk score developed in the US has been validated in a large group of London-based civil servants. The score is therefore a useful tool for estimating the short-term risk of developing hypertension in a European population.
Preliminary findings suggest that oral sodium bicarbonate administration could become a major addition to the armamentarium of renoprotective measures for individuals with chronic kidney disease.
Warfarin, an anticoagulant that reduces the risk of stroke in the general population, might be associated with an increased risk of stroke in hemodialysis patients with atrial fibrillation. This finding raises important questions about the role of warfarin in the management of patients with atrial fibrillation who are undergoing dialysis.
Retrospective data analysis suggests that revascularization provides no benefit over medical treatment in patients with severe kidney disease who experience non-ST-elevation myocardial infarction. But are these results the consequence of treatment bias and/or a failure to address poorly understood risk factors?
A prehypertension classification of blood pressure, encompassing a blood pressure range previously regarded to be normal that has been associated with an increased risk of hypertension mortality compared with lower blood pressure, has been established. In this Review, Pimenta and Oparil discuss the epidemiology of prehypertension, the relationship with cardiovascular morbidity and mortality, and the treatment of prehypertensive patients.
Disturbances in bone metabolism are common in patients after renal transplantation and represent important causes of morbidity and mortality. This Review discusses the etiological factors that contribute to bone metabolic disturbances in renal transplant recipients—pre-existing renal osteodystrophy, the effects of transplant-specific therapies on bone metabolism, and the effects of reduced renal function after transplantation. The clinical implications of bone disease in these patients are also considered.
Intradialytic hypertension is not an uncommon complication in hemodialysis patients, and seems to be associated with adverse outcomes. This complex phenomenon is not well understood, and many uncertainties exist regarding its pathophysiologic mechanisms and appropriate treatment strategies. Many of the therapeutic approaches currently used come from expert recommendations rather than from the results of randomized clinical trials. In this Review, Locatelli et al. describe the possible pathophysiologic mechanisms of intradialytic hypertension, and consider potential treatment and management strategies.
Direct renin inhibition is a novel strategy for the blockade of the renin–angiotensin system. In this Review, Hollenberg discusses the evidence indicating that direct renin inhibitors might block the renin–angiotensin system in the kidney more effectively than either angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers. The author also discusses the therapeutic implications of this evidence and possible mechanisms that underlie the renal effects of direct renin inhibition.
The development of new biomarkers that enable the early diagnosis of acute kidney injury (AKI) should facilitate early intervention and reduce the mortality associated with this disease. In this Perspectives article, Robert Schrier discusses the need to develop interventions to attenuate or prevent AKI and the requirement for such interventions to selectively improve renal hemodynamics, increase tubular flow rates, and decrease inflammation without causing systemic vasodilation.