This Month in AJKD

Article Outline

• Inaugural Features: In Translation and In Practice
• Neointimal Hyperplasia in Early AVF Failure
• Utility of Dialysis Quality Measures
• In the Literature: Statin Treatment and Sepsis

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Inaugural Features: In Translation and In Practice 

See Mistry et al, pages 855-864 and Lubowsky et al, pages 865-879.

AJKD is pleased to unveil 2 new features in this month’s issue: In Translation and In Practice. These features begin with clinical vignettes and cover areas vital to the practice of nephrology. In Translation articles offer authoritative, cutting-edge analyses of developments in basic science which have diagnostic or therapeutic implications in the clinical practice of nephrology. In this issue, Mistry et al describe the use of molecular genetics to evaluate patients with hereditary kidney disease, determine chromosomal regions of interest, and identify diagnoses.

The second new feature, In Practice, addresses the reality that many patients seen by kidney specialists have coexisting conditions cared for by primary care physicians and other specialists. Each article reviews a clinical topic in another discipline which affects kidney specialists daily. In this issue, Lubowsky et al provide an overview of how to manage glycemia in chronic kidney disease, including the proper use of hypoglycemic agents, as well as newer classes of agents.

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Neointimal Hyperplasia in Early AVF Failure 

See Roy-Chaudhury et al, pages 782-790 and Dember and Dixon, pages 696-699.

Arteriovenous fistulas (AVFs) are the preferred form of permanent dialysis access, but early AVF failure is a common clinical problem and its exact pathogenesis is unknown. In this issue, Roy-Chaudhury et al performed detailed histological, morphometric, and immunohistochemical analyses on stenotic venous segments from 4 patients with early AVF failure and found that all had significant luminal stenosis as a result of neointimal hyperplasia. Although neointimal hyperplasia has been shown to play a role in stenosis of AV grafts, this is the first time it has been found in patients with early AVF failure. The authors suggest that future therapies to address AVF failure should target this pathogenetic pathway. An accompanying editorial by Dember and Dixon comments on this finding and further examines the causes of early AVF failure.

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Utility of Dialysis Quality Measures 

See Spolter et al, pages 774-781 and Meyer and Miskulin, pages 691-695.

Although urea reduction ratio and hemoglobin level are both used as clinical performance measures (CPMs) to assess dialysis quality, it is not clear how well they correlate. In this issue, Spolter et al examined records from 18,000 patients dialyzed in 270 ESRD Network 5 facilities, and found that the association between these two CPMs was not strong. The adjusted mean urea reduction ratio was 0.91 ± 0.38 higher for each g/dL increment in hemoglobin (P<0.0001). The adjusted odds ratio of a facility failing to meet the urea reduction ratio quality threshold, if they missed the benchmark for hemoglobin, was 2.08 (P<0.0001), but area under the ROC curve was only 0.62. The authors suggest that based on this data, there exist distinct processes that determine the quality for each measure. In an accompanying editorial, Meyer and Miskulin discuss the variety of complex factors that come into play when examining dialysis quality, and the potential pitfalls of interpreting CPMs.

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In the Literature: Statin Treatment and Sepsis 

See Wanner, pages 700-702 and Goldfarb-Rumyantzev et al, pages 791-802.

Sepsis is second only to cardiovascular disease as the most common cause of death in hemodialysis patients. In a recent issue of the Journal of the American Medical Association, Gupta et al published a secondary analysis of a cohort study, Choices for Healthy Outcomes in Caring for ESRD (CHOICE), which found that statin use was strongly and independently associated with a reduction in the risk of hospitalization for sepsis. In this issue, Dr Wanner discusses this article in the context of the 4D randomized trial, in which 22% of patients died from sepsis, but there was no effect of statins on sepsis-related deaths. In a related article, Goldfarb-Rumyantzev et al analyze the association of lipid-modifying medications with clinical outcomes in a cohort study of long-term peritoneal dialysis patients. Wanner suggests that the evidence from these cohort studies is intriguing, but clinical trials are required to provide evidence for clinicians to change their practice.

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