Volume 56, Issue 6 , Pages A24-A26, December 2010
This Month in AJKD
Article Outline
- Remote Ischemic Preconditioning in AKI
- Cost-Effectiveness Analyses of CKD-Related Treatments
- Acute Rejection and New-Onset Diabetes After Transplant
- Optimizing HD Vascular Access
- Blood Pressure Control in CKD and Type 2 Diabetes
Remote Ischemic Preconditioning in AKI
See Venugopal et al, pages 1043-1049; and Zimmerman, pages 1019-1022.
Remote ischemic preconditioning (RIPC) is a phenomenon in which transient nonlethal ischemia applied to an organ or tissue protects another organ or tissue from subsequent lethal ischemic injury and represents a potential renoprotective strategy for patients undergoing cardiac surgery. In this issue, Venugopal et al analyze kidney outcomes from 2 randomized placebo-controlled trials of RIPC. Preconditioning was performed in 38 patients by applying a tourniquet cuff to induce three 5-minute episodes of arm ischemia followed by reperfusion while 40 controls had an uninflated cuff applied for 30 minutes. The authors demonstrated that the incidence of AKI was 25% in the control group and 11% in the RIPC group (P = 0.005). In an editorial, Dr Zimmerman asserts that larger trials assessing the association of RIPC before cardiac surgery with hard outcomes including need for dialysis, cardiovascular morbidity, and mortality are needed.
Cost-Effectiveness Analyses of CKD-Related Treatments
See Shireman et al, pages 1108-1116; Clement et al, pages 1050-1061; and Erickson & Winkelmayer, pages 1023-1025.
In this issue, 2 studies analyze the cost-effectiveness of common CKD-related treatments. Shireman et al examine the cost-effectiveness of treating hyperparathyroidism in dialysis patients with cinacalcet in combination with low-dose vitamin D analogues. Using data from the ACHIEVE trial, where cinacalcet was more effective than either paricalcitol or doxercalciferol in reaching biochemical targets associated with CKD–mineral bone disease, the authors found that a protocol with cinacalcet cost 35% more than a protocol employing flexible-dose vitamin D analogues ($5,852 vs $4,332). In the second article, Clement et al examine the cost-effectiveness of using erythropoietin-stimulating agents (ESAs) to achieve hemoglobin targets in anemic patients with CKD. They estimated incremental cost-effectiveness ratios from 4 different ESA strategies (no ESA with transfusions as needed, low-, intermediate-, and high-dose ESA). The estimated incremental cost-effectiveness ratio comparing a strategy without ESAs to a low-dose strategy was $96,270 per quality-adjusted life-year. In an editorial, Drs Erickson and Winkelmayer review the principles of cost-effectiveness analyses and place the results of these articles in context.
Acute Rejection and New-Onset Diabetes After Transplant
See Kuo et al, pages 1127-1139; and Klein & Brennan, pages 1026-1028.
In kidney transplantation, immunosuppressive medications decrease acute rejection but increase the frequency of new-onset diabetes after transplant (NODAT). In this issue, Kuo et al investigate the associations of NODAT and acute rejection with transplant outcomes. In 37,448 recipients with at least 1-year graft survival after transplant, pretransplant diabetes but not NODAT was the major predictor of all-cause and cardiovascular mortality, while acute rejection during the first year posttransplant was the major predictor of death-censored transplant failure. The major limitation was the short duration of follow-up, which precludes definitive conclusions. In an editorial, Drs Klein and Brennan conclude that acute rejection is likely a more important modifiable risk factor than NODAT.
Optimizing HD Vascular Access
See Goodkin et al, pages 1032-1042.
Fistulas are considered the optimal hemodialysis (HD) access. Much of the data supporting fistulas for dialysis access are derived from longitudinal cohorts, including the Dialysis Outcomes and Practice Patterns Study (DOPPS), dialysis provider databases, and the US Renal Data System. In this issue, Goodkin et al review the major findings from these and other sources, focusing on specific practices and characteristics associated with greater arteriovenous fistula use in dialysis facilities worldwide. Notable, and potentially underrecognized, factors include dialysis staff preferences, the emphasis placed on fistula primacy, and the number of fistulas created by surgeons during their surgical training. The authors conclude it is imperative that dialysis clinicians advocate actively for specific dialysis access types on behalf of individual patients, and that vascular surgery teaching programs supervise adequate numbers of fistula procedures for every trainee.
Blood Pressure Control in CKD and Type 2 Diabetes
See Weiss et al, pages 1062-1071; and Chang et al, pages 1029-1031.
Current CKD guidelines recommend a blood pressure target <130/80 mm Hg for all patients with CKD; however, it is unknown how lower achieved blood pressure may affect older adults with CKD. In this issue, Weiss et al examine the association of baseline systolic blood pressure (SBP) with cardiovascular disease hospitalization and all-cause mortality in community-dwelling older patients (≥75 years) with estimated GFR below 60 mL/min/1.73 m2. They found that baseline SBP below 130 mm Hg may predict poorer 5-year outcomes, while substantially elevated baseline SBP (>160 mm Hg) was associated with increased risk of cardiovascular hospitalizations but not mortality. In a related “In the Literature” editorial, Chang et al comment on the recently published results of the ACCORD trial on the effects of blood pressure control in type 2 diabetes, which showed that participants with type 2 diabetes at high risk of cardiovascular events did not have a significant decrease in the risk of composite cardiovascular events with intensive blood pressure control (SBP target <120 mm Hg vs <140 mm Hg), although a significant decrease in risk of stroke was observed. Chang et al conclude that clinicians will have to carefully weigh the perceived risks and benefits of blood pressure targets in patients with and without diabetes, CKD, or other comorbid conditions while waiting for results from future studies to guide practice.
PII: S0272-6386(10)01457-5
doi:10.1053/S0272-6386(10)01457-5
Volume 56, Issue 6 , Pages A24-A26, December 2010
