This Month in AJKD

Article Outline

• Focusing on CKD for World Kidney Day 2007
• New Model for Deceased Donor Kidney Allocation
• High Mortality Risk After Graft Failure
• Impact of KDOQI Clinical Practice Guidelines
• Proteinuria and Hypertension After Bevacizumab

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Focusing on CKD for World Kidney Day 2007 

See Levey et al, pages 175-179, and the following message from William G. Couser, MD (President, International Society of Nephrology) and Sudhir Shah, MD (President, International Federation of Kidney Foundations).

The International Society of Nephrology and the International Federation of Kidney Foundations, along with the joint World Kidney Day Steering Committee, strongly endorse this message from the 4 US kidney organizations to focus worldwide attention on World Kidney Day, March 8, 2007. As this article points out, chronic diseases are now the major cause of premature death worldwide. Chronic kidney disease and associated cardiovascular diseases account for a significant portion of the total. There is an urgent need for rational health care policies in both the developed and developing world that emphasize early detection and prevention of kidney disease. More information on how each of us can participate in World Kidney Day 2007 is available at www.worldkidneyday.org.

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New Model for Deceased Donor Kidney Allocation 

See Baskin-Bey et al, pages 284-293, and Danovitch and Bunnapradist, pages 180-182.

It is difficult to design a kidney allocation scheme that maximizes the use of available deceased donor kidneys. The current allocation system put in place by the United Network for Organ Sharing has been scrutinized by the transplant community because it does not include important factors associated with graft and recipient survival. In this issue, Baskin-Bey et al provide an alternate allocation system using a Recipient Risk Score, which considers age, diabetes mellitus, hypertension, angina, time on dialysis, presence of panel-reactive antibodies, and ethnicity for predicting survival. Using the Recipient Risk Score, in combination with a Deceased Donor Score, a separate prediction equation that estimates graft survival and function after transplantation, the authors propose an allocation system for deceased donor kidneys that could increase the annual rate of supply by 15%. An accompanying editorial by Danovitch and Bunnapradist provides a critique of the current allocation systems as well as the proposed Recipient Risk and Deceased Donor Score models.

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High Mortality Risk After Graft Failure 

See Rao et al, pages 294-300.

Advances in immunosuppression have led to improved short-term graft survival in kidney transplantation, but many patients still experience graft failure and resume dialysis. The effect of graft failure on mortality is not well known. In this issue, Rao et al use data from the Scientific Registry of Transplant Recipients to determine whether the mortality risk for dialysis patients after graft failure is higher than for similar patients who did not receive a transplant. The study demonstrates that patients who had transplant failure and returned to dialysis experienced 78% higher mortality relative to the transplant candidate group (p<0.0001); this hazard remained significantly elevated even after accounting for the marked increased risk of mortality immediately following graft failure. The authors emphasize the need for additional studies to clarify the mechanism of this increased risk as well as to devise strategies to decrease mortality in these patients.

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Impact of KDOQI Clinical Practice Guidelines 

See Wald et al, pages 257-266.

The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) regularly issues guidelines for various aspects of monitoring and managing chronic kidney disease. While the guidelines have received widespread attention, little is known about their impact on clinical practice. In this issue, Wald et al evaluate the effect of the KDOQI Guidelines for Bone Metabolism and Disease by comparing values for mineral metabolic indicators among patients treated by a large dialysis network during the 8 months before and after the October 2003 release of the guidelines. The post-release period showed a modest improvement in the number of patients achieving goal levels of serum calcium, serum phosphate, and calcium-phosphate product. The authors recommend further studies to evaluate whether achievement of the prescribed targets results in improved clinical outcomes.

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Proteinuria and Hypertension After Bevacizumab 

See Zhu et al, pages 186-193 and George et al, pages E23-E29, online only at www.ajkd.org.

Angiogenesis inhibitors have emerged as effective therapy in the treatment of many cancers. Bevacizumab, which targets the vascular endothelial growth factor (VEGF) signaling pathway, is one of the most widely used of these inhibitors. In this issue, Zhu et al report a significant dose-dependent increase in the risk for both proteinuria and hypertension in a meta-analysis of 7 trials (comprising 1850 patients) of bevacizumab in cancer patients. These findings stress the importance of monitoring for and managing these potential side effects. In an online-only case report, George et al highlight the same point, describing the development of nephrotic syndrome in a cancer patient on bevacizumab.

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