This Month in AJKD

Article Outline

• ARBs and Cardiovascular Events in Hemodialysis
• NGAL in Acute Kidney Injury
• Statins to Slow the Progression of Kidney Disease
• High-Flux Hemofiltration Versus Low-Flux Hemodialysis
• Older Living Donors and Older Transplant Recipients

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ARBs and Cardiovascular Events in Hemodialysis 

See Suzuki et al, pages 501-506; and Toto, pages 400-402.

Cardiovascular disease (CVD) is the leading cause of mortality in patients on hemodialysis, but the effects of treatment with angiotensin receptor blockers (ARBs) in these patients is not known. In this issue, Suzuki et al perform an open-label randomized trial among patients at 5 centers aged 30 to 80 years receiving hemodialysis 2 to 3 times weekly for 1 to 5 years (n = 180) to compare ARB treatment versus treatment without ARBs. Overall, there were 93 (52%) fatal and nonfatal CVD events (primary end points) and 63 (35%) fatal events (secondary endpoints). There were significantly fewer primary endpoints in the ARB group, but the difference in all cause mortality was not significant. An editorial by Dr Toto reviews the difficulty in interpreting this “positive” clinical trial.

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NGAL in Acute Kidney Injury 

See Wagener et al, pages 425-433; Bolignano et al, pages 595-605; and Devarajan, pages 395-399.

A few recent studies have shown that urinary neutrophil gelatinase–associated lipocalin (NGAL) could be a useful biomarker to detect kidney injury. In this issue, Wagener et al measured pre and postoperative (0, 3, 18, and 24 hours post surgery) NGAL levels in a large, heterogeneous cohort of adult cardiac surgical patients from a single center (n = 426). The patients that developed acute kidney injury (AKI), defined as a rise in serum creatinine concentration, had significantly greater urinary NGAL values at the end of surgery and 3 hours later, but the area under the receiver operator curve was only 0.603 (95% CI; 0.533 to 0.674; P = 0.003), indicating poor predictive ability. However, the early urinary NGAL values correlated better with cardiopulmonary bypass and aortic cross-clamp times than did changes in serum creatinine, suggesting that urinary NGAL may reflect kidney injury during cardiac surgery better than changes in serum creatinine. A review by Bolignano et al and an editorial by Dr Devarajan further elucidate the potential benefits and shortcomings of NGAL as a biomarker for predicting AKI.

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Statins to Slow the Progression of Kidney Disease 

See Rahman et al, pages 412-424; and Tonelli, pages 391-394.

While dyslipidemia is common in patients with CKD, the effect of statin therapy on kidney disease progression is unclear. In this issue, Rahman et al performed a post-hoc analysis of 10,060 moderately hypercholesterolemic and hypertensive patients enrolled in the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial, Lipid Lowering Trial (ALLHAT-LLT), a prospective randomized trial that compared pravastatin therapy versus usual care. They found that after 6 years, total cholesterol levels decreased in both the pravastatin (−20.7%) and usual care (−11.2%) groups with no significant differences in rates of end-stage renal disease, composite end points of end-stage renal disease and 50% or 25% decrease in estimated glomerular filtration rate (eGFR), or rate of change in eGFR, with findings consistent across eGFR strata. The authors conclude that the study suggest statins do not slow the progression of kidney disease. An editorial by Dr Tonelli asserts that closer scrutiny of the design and conduct of the ALLHAT trial (such as drop-in and drop-out effects) may explain the negative result.

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High-Flux Hemofiltration Versus Low-Flux Hemodialysis 

See Santoro et al, pages 507-518; and Depner, pages 403-406.

Santoro et al compare on-line high-flux hemofiltration (HF) with ultrapure low-flux hemodialysis (HD) in a small, centrally randomized trial (20 centers, 32 patients). They found that there was significant improvement in survival with HF compared with HD (78% versus 57%, respectively) at 3 years of follow up after allowing for the effects of age (P = 0.05). They also observed increased end of treatment Kt/V and decreased body mass index in the HD group, while the HF group showed decreased β₂-microglobulin levels, length of hospital stay, and trends of intradialytic acute hypotension. An editorial by Dr Depner reviews differences between filtration and dialysis and calls for a larger study.

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Older Living Donors and Older Transplant Recipients 

See Gill et al, pages 541-552.

Increasing numbers of elderly patients are on waiting lists for kidney transplants. In this issue, Gill et al used data from OPTN/UNOS from 1996 to 2004 to compare outcomes among 23,754 transplant recipients older than 60 years who received transplants from older living donors (OLD) with those from other sources. They found that transplantations from older living donors were associated with inferior 3-year graft survival rates (85.7%) than younger living donors (YLD) and had superior graft survival compared with standard criteria (SCD) and extended criteria (ECD) deceased donor options. Based on these results, the authors suggest that older living donors be considered as a transplant option for elderly patients.

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