This Month in AJKD

Article Outline

• Intradialytic Blood Pressure Increases and Mortality
• p-Cresyl Sulfate in Cardiovascular Disease
• Induction Antibody Therapy in Kidney Transplantation
• Dialysis Delivery in Canada and the United States

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Intradialytic Blood Pressure Increases and Mortality 

See Inrig et al, pages 881-890; and Sinha and Agarwal, pages 788-791.

Intradialytic increases in blood pressure can complicate the management of hypertension in hemodialysis patients, but the long-term consequences are uncertain. In this issue, Inrig et al analyze the 1,748 incident hemodialysis patients participating in the Dialysis Morbidity and Mortality Wave 2 Study to determine the relationship between blood pressure increases during hemodialysis and 2-year mortality. In this population, 12.2% had >10–mm Hg increases in systolic blood pressure, and, in adjusted analyses, each 10–mm Hg increase was associated with a 6% increased hazard of death. An editorial by Drs Sinha and Agarwal commends the authors for looking beyond conventional assessment of peridialytic blood pressure in hemodialysis patients and discusses possible explanations for the association between rising peridialytic blood pressure and mortality in these patients.

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p-Cresyl Sulfate in Cardiovascular Disease 

See Meijers et al, pages 891-901; and Winchester et al, pages 792-794.

The protein-bound uremic retention solute p-cresol has been independently associated with cardiovascular disease in hemodialysis patients, but the underlying mechanisms are unknown. In this issue, Meijers et al study the relationship between p-cresol and blood markers of endothelial dysfunction, including soluble P-selectin and endothelial microparticles, and also evaluate the direct effects of p-cresol and p-cresyl sulfate on endothelial cell cultures. In a cohort of 100 hemodialysis patients, they found that free serum p-cresol concentrations were directly associated with circulating endothelial microparticles, but not with soluble P-selectin concentration. In vitro, they noted that p-cresyl sulfate induced a dose-dependent increase in the shedding of endothelial microparticles by human umbilical vein endothelial cells. In a related editorial, Winchester et al suggest a clinical trial to test whether more effective lowering of p-cresyl sulfate levels with dialysis could prevent vascular disease in hemodialysis patients.

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Induction Antibody Therapy in Kidney Transplantation 

See Padiyar et al, pages 935-944.

Although use of antilymphocyte antibodies for induction therapy in kidney transplantation has varied over the years, induction antibodies are currently administered to more than 70% of kidney transplant recipients in the United States. However, which agents are used and which patients they are given to vary substantially between and within transplant centers. In this issue, Padiyar et al review the effectiveness of currently available antibody agents and discuss the costs and benefits of induction antibody therapy. While benefits include decreased incidence of acute rejection, delayed onset of rejection, and improved management of patients with delayed graft function, these benefits must be balanced against the expensive cost of the antibodies and a likely increased risk of subsequent infection and malignancy.

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Dialysis Delivery in Canada and the United States 

See Mendelssohn and Wish, pages 954-964.

Although the provision of health care differs vastly between Canada and the United States, delivery of dialysis care is far less divergent, reflecting the presence of a government-sponsored entitlement for end-stage renal disease in the United States that finance the majority of dialysis care. In this World Kidney Forum, Drs Mendelssohn and Wish examine the similarities and differences in dialysis delivery in these 2 countries, noting that while the dialysis system in the United States has undergone profound changes in the past 20 years that continue today, the system in Canada remains relatively unchanged over this time. The authors assert that the Canadian system is showing signs of suboptimal performance and express concern that this will continue to worsen. The authors identify strengths and weaknesses of each system and hope to catalyze discussion with their recommendations for improvement in both the US and Canadian systems. They conclude with a call for empirical methods to evaluate the impact of any new initiatives for dialysis delivery in both countries.

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