| | This Month in AJKD
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Mass Spectrometry–Based Proteomic Analysis of Urine in Acute Kidney Injury Following Cardiopulmonary Bypass: A Nested Case-Control Study
, 15 December 2008
Julie Ho, Malcolm Lucy, Oleg Krokhin, Kent Hayglass, Edward Pascoe, Gayle Darroch, David Rush, Peter Nickerson, Claudio Rigatto, Martina Reslerova
American Journal of Kidney Diseases
April 2009 (Vol. 53, Issue 4, Pages 584-595)
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Ironing Out the Pathogenesis of Acute Kidney Injury
Sangeeta Hingorani, Bruce A. Molitoris, Jonathan Himmelfarb
American Journal of Kidney Diseases
April 2009 (Vol. 53, Issue 4, Pages 569-571)
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Inflammation, Hemostasis, and the Risk of Kidney Function Decline in the Atherosclerosis Risk in Communities (ARIC) Study
, 25 December 2008
Lori D. Bash, Thomas P. Erlinger, Josef Coresh, Jane Marsh-Manzi, Aaron R. Folsom, Brad C. Astor
American Journal of Kidney Diseases
April 2009 (Vol. 53, Issue 4, Pages 596-605)
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Does Inflammation Fuel the Fire in CKD?
Dena E. Rifkin, Mark J. Sarnak
American Journal of Kidney Diseases
April 2009 (Vol. 53, Issue 4, Pages 572-575)
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The Effects of Dietary Patterns on Urinary Albumin Excretion: Results of the Dietary Approaches to Stop Hypertension (DASH) Trial
, 27 January 2009
David R. Jacobs, Myron D. Gross, Lyn Steffen, Michael W. Steffes, Xinhua Yu, Laura P. Svetkey, Lawrence J. Appel, William M. Vollmer, George A. Bray, Thomas Moore, Paul R. Conlin, Frank Sacks
American Journal of Kidney Diseases
April 2009 (Vol. 53, Issue 4, Pages 638-646)
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Effects of Dietary Modification on Albumin Excretion Rate
Mahboob Rahman, Michael C. Smith
American Journal of Kidney Diseases
April 2009 (Vol. 53, Issue 4, Pages 576-578)
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CKD as an Underrecognized Threat to Patient Safety
, 27 February 2009
Jeffrey C. Fink, Jeanine Brown, Van Doren Hsu, Stephen L. Seliger, Loreen Walker, Min Zhan
American Journal of Kidney Diseases
April 2009 (Vol. 53, Issue 4, Pages 681-688)
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Patients' Experiences and Perspectives of Living With CKD
, 12 February 2009
Allison Tong, Peter Sainsbury, Steven Chadban, Rowan G. Walker, David C. Harris, Stacy M. Carter, Bronwyn Hall, Carmel Hawley, Jonathan C. Craig
American Journal of Kidney Diseases
April 2009 (Vol. 53, Issue 4, Pages 689-700)
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Pathogenesis of Acute Kidney Injury  See Ho et al, pages 584-595; and Himmelfarb and colleagues, pages 569-571. Ho et al hypothesize in this issue of AJKD that urine proteomics could provide insight into the pathophysiological events in acute kidney injury (AKI) before the rise in serum creatinine. In a case-control design, they compared serial urinary proteomes of 22 patients with AKI and 22 patients without AKI before, during, and after cardiopulmonary bypass surgery. They found that, regardless of whether or not AKI developed, all patients had early evidence of tubular dysfunction and stress as demonstrated by β2-microglobulinuria in urine samples collected in the ICU. Although levels declined in both groups postoperatively, β2-microglobulin and its cleavage products resurged in AKI patients, and at the same time numerous unidentified peaks in the range of 3-5 kDa and 6-8 kDa appeared, suggesting a second phase of injury. Samples from patients who did not develop AKI tended to show a short-lived spike in levels of 2 low-molecular-weight factors at postoperative day 1. Although the 2.43-kDa factor could not be isolated, the 2.78-kDa peak was identified as hepcidin-25, the active form of a peptide involved in iron homeostasis. Given that hepcidin-25 upregulation would be expected to lead to iron trapping within cells, the authors speculate that this response may limit ischemia-reperfusion injury by sequestering iron free radicals. An editorial by Himmelfarb and colleagues extends the discussion of iron regulation in AKI pathogenesis, but cautions that validation of these findings in other cohorts is necessary given the high potential for false detection rates in proteomics studies. Inflammation, Hemostasis, and the Risk of Kidney Function Decline See Bash et al, pages 596-605; and Rifkin and Sarnak, pages 572-575. Inflammation and hemostasis may increase the risk of kidney function decline; however, data from prospective studies are sparse. In this issue, Bash et al examined markers of inflammation and hemostasis in the Atherosclerosis Risk in Communities (ARIC) Study, a prospective observational cohort (N = 14,854). After adjustment for traditional cardiovascular disease risk factors and baseline level of eGFR, they found that the risk of incident CKD (defined as decline in eGFR) increased with increasing quartiles of white blood cell count, fibrinogen, von Willebrand factor, and factor VIIIc. A strong inverse association was found between serum albumin level and risk of CKD, while factor VIIc was not found to have a significant association. These findings are consistent with the hypothesis that inflammation and hemostasis are associated with an increased risk of CKD. An editorial by Drs Rifkin and Sarnak states that the important findings of this study should be replicated in a population with data on markers of kidney damage, such as albuminuria (which was not measured in the ARIC study), and the comparative importance of inflammation versus other risk factors should be assessed. Effects of Dietary Modification on Albumin Excretion Rate See Jacobs et al, pages 638-646; and Rahman and Smith, pages 576-578. Studies indicate that dietary modification can lower blood pressure. In this issue, Jacobs et al evaluated albumin excretion rate (AER) in an ancillary analysis of the Dietary Approaches to Stop Hypertension (DASH) Trial, a randomized trial of 378 individuals without diabetes and with prehypertension or stage I hypertension, comparing the effects of 3 controlled feeding arms: a control diet, a “fruit/vegetable” (FV) diet, or the DASH diet itself (18% energy from protein, with an emphasis on low-fat dairy products). They found that 285 individuals (76%) had very low albumin excretion rates (<7 mg/24 h), and, in this subgroup, the albumin excretion rate did not differ significantly among the 3 diet groups at the end of the 8-week study period. However, in the subgroup of participants with albumin excretion rates greater than 7 mg/24 h, albumin excretion rates were the lowest at the end of the study period in participants assigned to the FV diet (6.6 mg/24 h), compared with the DASH diet (11.7 mg/24 h) and the control diet (11.4 mg/24 h). An editorial by Drs Rahman and Smith discusses the 2 lines of thought these findings stimulate: (1) how do these findings relate to albuminuria as a marker of end-organ damage in hypertension, and (2) what are the implications of lowering urinary albumin excretion in patients with “normal” levels of urinary albumin excretion. CKD as an Underrecognized Threat to Patient Safety See Fink et al, pages 681-688. Chronic kidney disease (CKD) is underrecognized among patients in a health care system where improving patient safety is a high priority. In this issue, Fink et al review and discuss the unique attributes of CKD which make it a high-risk condition for patient safety mishaps. They point out that adverse safety events in this disease have the potential to contribute to disease progression; namely, accelerated loss of kidney function and an increased incidence of end-stage renal disease (ESRD). They also propose a framework for patient safety in CKD that highlights the need for disease-specific safety indicators that reflect unsafe practices and discuss the hypothesis that increased recognition of CKD will reduce disease-specific safety events, and in this way decrease the likelihood of adverse outcomes including an accelerated rate of kidney function loss and an increased incidence of ESRD. Patients' Experiences and Perspectives of Living With CKD See Tong et al, pages 689-700. Explicit incorporation of patients' values and preferences is important in health care decision making, though there is little data on this topic for patients with chronic kidney disease (CKD). In this issue, Tong et al conducted 9 focus groups (3 each for CKD stages 1 to 5, CKD stage 5D, and CKD stages 1T to 5T). Five major themes were identified: (1) personal meaning of CKD, (2) managing and monitoring health, (3) lifestyle consequences, (4) family impact, and (5) informal support structures. They report that patients had to adjust to the disruptive and permanent implications of the illness on their physical health, identity, emotions, family, lifestyle, relationships, and employment; the overwhelming fatigue, complex treatment regimens, side effects, and liquid and diet restrictions constrained patients' lives. Patients appreciated specialist care, but described the health care system as nonintegrated and believed they received insufficient information and psychosocial support. Choice of treatments was based on lifestyle, family impact, and physical comfort, seldom on clinical outcomes. Time was needed to comprehend the diagnosis, cope with uncertainty, integrate their treatment regimen into their daily routine, and reestablish a sense of normality in their lives. Tong et al suggest that providing information and psychosocial and practical support at a patient-specific, not organ-specific, level may maximize patient quality of life. PII: S0272-6386(09)00469-7 doi:10.1053/S0272-6386(09)00469-7 | |
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