This Month in AJKD

Article Outline

• Shifting Timing of Antihypertensive Therapy to Reduce Nocturnal Blood Pressure
• Improving GFR Estimation from Serum Creatinine
• Treatment of US Children on Long-term Dialysis
• Treatment of PD-Associated Peritonitis

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Shifting Timing of Antihypertensive Therapy to Reduce Nocturnal Blood Pressure 

See Minutolo et al, pages 908-917 and Rahman and Appel, pages 901-903.

Individuals without a decline in nocturnal blood pressure (“non-dipping”, defined as absence of a 10% or greater decrease in blood pressure at night) have greater cardiovascular morbidity and mortality and an increased risk of kidney failure. In this issue, Minutolo et al perform an 8-week uncontrolled trial on 32 chronic kidney disease patients without a decline in nocturnal blood pressure to determine whether shifting the timing of 1 antihypertensive drug from morning to evening restores nocturnal dipping. They found that after the medication shift, the night-day ratio of mean ambulatory blood pressure (ABP) decreased in 93.7% of the patients, with dipping restored in 87.5%. This decrease in nocturnal blood pressure was not associated with an increase in daytime ABP and was independent from number and class of medications that were shifted. An accompanying editorial by Drs Rahman and Appel stresses the importance of testing whether lowering nocturnal blood pressure can retard the progression of chronic kidney disease and prevent cardiovascular complications.

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• Blood pressure before drug shift (solid line) and after drug shift (dotted line).

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Improving GFR Estimation from Serum Creatinine 

See Selvin et al, pages 918-926 and Imai et al, pages 927-937.

The estimated glomerular filtration rate (GFR) has become an important decision tool in clinical medicine. Accurate GFR estimation requires calibration of serum creatinine and appropriate terms for ethnicity. In this issue, Selvin et al study serum creatinine measurements in NHANES III (1988-1994) and NHANES (1999-2000, 2001-2002, and 2003-2004), using a creatinine assay traceable to gold standard reference methods. The authors find that the differences in serum creatinine measurements in NHANES III and 1999-2000 from standard creatinine would result in large differences in estimates of kidneyfunction (10-20%), and provide updated calibration constants. Their results should allow more accurate estimates of chronic kidney disease in the population and of trends over time.

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Also in this issue, Imai et al report on the accuracy of the Modification of Diet in Renal Disease (MDRD) Study equation in Japan. They compared measured GFR from urinary clearance of inulin to estimated GFR using the 4-variable MDRD Study equation and new equations developed from their study population. When the 4-variable MDRD Study equation was adjusted with a coefficient (0.741) it performed with significantly lower bias and higher accuracy than the MDRD Study equation.

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Treatment of US Children on Long-term Dialysis 

See Fadrowski et al, pages 958-966.

The 2005 Centers for Medicare & Medicaid Services End-Stage Renal Disease Clinical Performance Measures (CPM) project was the first study of its kind to include both children on hemodialysis (HD) and on peritoneal dialysis (PD), and therefore is the first that adequately assesses quality measures for these patents. In this issue, Fadrowski et al examined and compared demographic and clinical characteristics among the children receiving long-term dialysis. The authors found that a large proportion of children had hemoglobin, serum albumin, and/or Kt/V values outside the recommended targets. In addition, children on HD were significantly more likely to have a mean hemoglobin less than 10 g/dL than those on PD (19% versus 14%, P<0.05), and were more likely than those receiving PD to have a mean serum albumin greater than or equal to the recommended target.

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Treatment of PD-Associated Peritonitis 

See Wiggins et al, pages 967-988.

Peritonitis is a frequent complication of peritoneal dialysis (PD). However, there is little consensus about the best treatment for peritonitis, particularly in terms of the type of antimicrobial therapy and route of administration. In this issue, Wiggins et al perform a systematic review of 36 randomized clinical trials involving treatments for PD peritonitis, comprising approximately 2000 patients. While they were not able to identify a superior antibiotic regimen, the authors found that intermittent and continuous antibiotic dosing were equivalent treatment strategies. Their review also revealed a paucity of evidence underlying many widely used and accepted practices in the treatment of peritonitis, and they recommend clinical trials to determine best treatment practices.

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