Combination Therapy of Prednisone and ACE Inhibitor Versus ACE-Inhibitor Therapy Alone in Patients With IgA Nephropathy: A Randomized Controlled Trial
, 20 October 2008
Jicheng Lv, Hong Zhang, Yuqing Chen, Guangtao Li, Lei Jiang, Ajay K. Singh, Haiyan Wang
American Journal of Kidney Diseases
January 2009 (Vol. 53, Issue 1, Pages 26-32) Abstract |
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IgA Nephropathy: A Disease in Search of a Large-Scale Clinical Trial to Reliably Inform Practice
Giovanni F.M. Strippoli, Ausilia Maione, Francesco P. Schena, G. Tognoni, Jonathan C. Craig
American Journal of Kidney Diseases
January 2009 (Vol. 53, Issue 1, Pages 5-8) Full Text |
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Blood Pressure and Mortality Risk on Peritoneal Dialysis
, 25 November 2008
Udaya P. Udayaraj, Retha Steenkamp, Fergus J. Caskey, Chris Rogers, Dorothea Nitsch, David Ansell, Charles R.V. Tomson
American Journal of Kidney Diseases
January 2009 (Vol. 53, Issue 1, Pages 70-78) Abstract |
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Blood Pressure and Mortality Risk in Patients Treated by Peritoneal Dialysis
Philip G. Zager, Mark R. Rohrscheib
American Journal of Kidney Diseases
January 2009 (Vol. 53, Issue 1, Pages 9-11) Full Text |
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Effect of a Vascular Access Nurse Coordinator to Reduce Central Venous Catheter Use in Incident Hemodialysis Patients: A Quality Improvement Report
, 22 September 2008
Kevan Roy Polkinghorne, Mechelle Seneviratne, Peter G. Kerr
American Journal of Kidney Diseases
January 2009 (Vol. 53, Issue 1, Pages 99-106) Abstract |
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Add-Ons
Patterns of Use of Vascular Catheters for Hemodialysis in Children in the United States
, 28 October 2008
Jeffrey J. Fadrowski, Wenke Hwang, Alicia M. Neu, Barbara A. Fivush, Susan L. Furth
American Journal of Kidney Diseases
January 2009 (Vol. 53, Issue 1, Pages 91-98) Abstract |
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Obesity Management in Adults With CKD
Holly Kramer, Katherine R. Tuttle, David Leehey, Amy Luke, Ramon Durazo-Arvizu, David Shoham, Richard Cooper, Srinvisan Beddhu
American Journal of Kidney Diseases
January 2009 (Vol. 53, Issue 1, Pages 151-165) Full Text |
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Prednisone and ACE Inhibitor Combination Therapy for IgA Nephropathy
See Lv et al, pages 26-32; and Strippoli et al, pages 5-8.
Recent studies have shown that both steroids and angiotensin-converting enzyme (ACE) inhibitors may improve GFR decline and proteinuria in patients with immunoglobulin A (IgA) nephropathy. In this issue, Lv et al conduct a randomized controlled trial to investigate the combined effects of the glucocorticosteroid prednisone and the ACE inhibitor cilazapril versus ACE inhibition alone in 63 patients with IgA nephropathy. The risk of “kidney survival,” estimated on the basis of a 50% increase in serum creatinine concentration from baseline, was significantly lower with combination therapy than with ACE inhibition alone (1 of 33 events in the combination group versus 7 of 30 in the ACE inhibitor group; relative risk, 0.13; 95% confidence interval, 0.02 to 0.99). At 24 months after trial initiation, kidney survival was 96.6% in the combination therapy group versus 75.7% in the ACE inhibition alone group (P = 0.001). Those in the combination therapy group also had a more rapid and stable reduction in proteinuria than those in the ACE inhibition alone group. An editorial by Dr Strippoli discusses the important findings in this study and agrees with the authors' assessment that a much larger, confirmatory study needs to be conducted before firm conclusions can be drawn.
Blood Pressure and Mortality Risk in Peritoneal Dialysis
See Udayaraj et al, pages 70-78; and Zager and Rohrscheib, pages 9-11.
It is uncertain whether the association between blood pressure (BP) and mortality in incident peritoneal dialysis (PD) patients is similar to the general population, where higher blood pressure levels are associated with worse outcomes, or is similar to the hemodialysis population, where normal-appearing blood pressure levels are associated with increased mortality. In this issue, Udayaraj et al examine the association of BP and mortality in 2,770 incident PD patients in England and Wales. Systolic BP, diastolic BP, mean arterial pressure, and pulse pressure were measured in the first 6 months of renal replacement therapy, and the association between blood pressure and all-cause mortality was assessed using time-stratified Cox regression models. In fully adjusted analyses, higher systolic BP, diastolic BP, mean arterial pressure, and pulse pressure all were associated with lower 1-year mortality; however both higher systolic BP and pulse pressure were associated with increased late mortality (years 6 and beyond). In order to select only the healthiest dialysis patients, the authors performed a subgroup analysis of patients placed on the transplant wait list within 6 months of starting renal replacement therapy. Unlike the wider PD population, higher systolic BP, diastolic BP, mean arterial pressure, and pulse pressure were not protective against mortality in the first year. An editorial by Zager and Rohrscheib place this finding into the context of both the hemodialysis population and the general population.
See Polkinghorne et al, pages 99-106; and Fadrowski et al, pages 91-98.
In this issue, Polkinghorne et al assess factors leading to initiating hemodialysis with a central venous catheter rather than a fistula and describe their quality improvement plan, which utilized a nurse coordinator and an algorithm to prioritize surgical schedules to increase the proportion of hemodialysis patients initiating with a fistula from 56% to 75%. In another article related to catheter use in children, Fadrowski et al examined 1,284 prevalent hemodialysis patients enrolled in the 2001 to 2003 ESRD Clinical Performance Measures (CPM) projects to identify the reasons for the high use of vascular catheters. They note that there may be technical barriers related to anatomical factors. Additionally, while attributing some of the high use to expeditious transplantation, they also note that only one-third of patients with a vascular catheter underwent transplantation within 1 year, which indicates that interventions to decrease vascular catheter use in this population may be possible.
Management of obesity remains a challenge in all populations. Obesity is associated with a host of adverse outcomes in the general population, but with improved survival in patients with kidney failure treated by dialysis. In this issue's In Practice feature, Kramer et al provide an overview of the definition of overweight and obesity in the general population, discuss the identification and management of obesity in patients with chronic kidney disease, including lifestyle, pharmacologic, and surgical therapies. In addition, the authors examine the potential analytic problems in observational studies which try to determine body mass index (BMI) thresholds for mortality in populations with CKD.
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