Nephron NEWS
Nephron NEWS
Nephron NEWS
(Updated on Aug.06.2010)
Issue 6,2010 [August, 2010]
I strongly encourage the readers of Nephron Digest to engage in a dialogue by emailing me to discuss issues of global nephrological interest. These would be addressed by expert members of the editorial board of Nephron. Also readers are encouraged to request topics that they would like to be updated upon through the Mini Review series of Nephron Clinical Practice.Besides reading Nephron Digest, I hope you are enjoying a great World Cup 2010.
Professor Meguid El Nahas, PhD, FRCP
Editor, Nephron Clinical Practice
nephron@sheffield.ac.uk
m.el-nahas@sheffield.ac.uk
Digest of issue 116/3/2010
An Update and Practical Guide to Renal Stone Management (N. Johri and colleagues, UK and Australia; Nephron Clin Pract 2010;116:c159-c171) This mini review covers aspects of epidemiology, genetics, and pathophysiology of renal stone disease and gives clear guidance on its management, merits of ESWL, endoscopic and surgical removal as well as medical management and dietary recommendations. Kidney stone disease is highly prevalent in emerging economies and is likely to increase globally with the ongoing epidemic of obesity (M.J. Semins et al., J Urol 2010;183:571-575). Nephrologists worldwide therefore need to familiarize themselves with aspects of diagnosis and management of kidney stone disease.
Clinical Transformation: The Key to Green Nephrology (A. Connor and colleagues, UK; Nephron Clin Pract 2010;116:c200-c206) The authors bring ecology to nephrology in a challenging review on 'green nephrology'. Clearly, nephrology practice cannot avoid the tide of green practices and energy conservation. In fact, energy conservation is likely to impact on general population health including causes and complications of CKD (P. Wilkinson et al., Lancet 2009;374:1917-1929). This challenge is similar to other major public health issues in that it requires to be clearly defined, evidence gathered, theories developed, alliances built, policies formulated and actions taken. Facts need to inform trends! All too often in nephrology, trends are followed before they are supported by strong evidence?!
Selective Strategy for Urethral Catheterization in Febrile Young Girls to Confirm Urinary Tract Infection Diagnosis (C. Runel-Belliard and co-authors, France and UK; Nephron Clin Pract 2010;116:c235-c240) This original article reports an approach to identify non-toilet-trained febrile girls at high risk for UTIs to restrict urethral catheterizations (UCs) to this high-risk group of patients. Absence of another source of fever on examination and the child's unusual behavior were found to be independent predictors of UTI. The authors propose a clinical decision model to selectively identify young febrile girls at high risk of UTI warranting UC in order to avoid unnecessary UCs.
Moderate Chronic Kidney Disease in Women Is Associated with Fracture Occurrence Independently of Osteoporosis (S. Kinsella and co-authors, Ireland; Nephron Clin Pract 2010;116:c256-c262) The authors draw attention to the increased risk of fractures in CKD; the adjusted odds ratios of any prior fracture for eGFR 75-89, 60-74 and 30-59 were 1.0 (reference), 1.2 (0.9-1.6) and 1.4 (1.0-1.9), respectively, adjusting simultaneously for age, T score, risk factors and treatment for osteoporosis. Moderate CKD is associated with increased morbidity and all-cause mortality (Chronic Kidney Disease Prognosis Consortium. Lancet 2010;375:2073-2081). Fractures, especially in elderly women suffering from CKD, can only increase poor outcomes.
For previous issues of Nephron Digest or to sign up for future issues, click here. For submission of articles, sign-ups to ToC Alerts or to recommend Nephron Clinical Practice to your librarian, please go to the journal's homepage..
© S. Karger AG - Medical and Scientific Publishers
Allschwilerstrasse 10, P.O. Box, CH-4009 Basel (Switzerland)
Tel. +41 61 306 1200, Fax +41 61 306 1234, publications@karger.ch.
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Nephron NEWS
(Updated on Jul.08.2010)
Issue 5,2010 [July, 2010]
I strongly encourage the readers of Nephron Digest to engage in a dialogue by emailing me to discuss issues of global nephrological interest. These would be addressed by expert members of the editorial board of Nephron. Also readers are encouraged to request topics that they would like to be updated upon through the Mini Review series of Nephron Clinical Practice.Besides reading Nephron Digest, I hope you are enjoying a great World Cup 2010.
Professor Meguid El Nahas, PhD, FRCP
Editor, Nephron Clinical Practice
nephron@sheffield.ac.uk
m.el-nahas@sheffield.ac.uk
Digest of issue 116/2/2010
Dual RAS Therapy Not on Target, but Fully Alive (H.J. Lambers Heerspink, D. de Zeeuw, The Netherlands; Nephron Clin Pract 2010;116:c137-c142) The ONTARGET renal analysis suggests that the use of dual-agent RAS leads to increased renal risk. This led to vivacious discussions about the benefits and risks of dual-agent RAS in patients with nephropathy. Lambers Heerspink and de Zeeuw review the ONTARGET trial design and interpretation, and offer implications for novel trials.
The Kidney Evaluation and Awareness Program in Sheffield (KEAPS): A Community-Based Screening for Microalbuminuria in a British Population (A. Bello et al., UK; Nephron Clin Pract 2010;116:c95-c103) report the outcome of the KEAPS epidemiological study, a community-based screening program for microalbuminuria. As in other European studies, the authors found a high prevalence of individuals with microalbuminuria (~7%), but note a significant percentage who became negative upon re-testing. This highlights the issue of CKD screening and detection studies based on single testing that invariably overestimate the prevalence of microalbuminuria and, consequently, CKD. The authors also find that the majority of those testing positive have underlying predisposing disease such as hypertension, diabetes or obesity, or are elderly. This study adds credence to the argument for targeted screening of those at risk. In those, microalbuminuria may reflect Cardio-Kidney-Damage (C-K-D; El Nahas, Kidney Int 2010;78:14-18).
Targeted Screening of Adult First-Degree Relatives for Chronic Kidney Disease and Its Risk Factors (S. Bagchi et al., India; Nephron Clin Pract 2010;116:c128-c136) report their findings in first-degree relatives (FDRs) of patients with CKD. They detected new cases of hypertension (21.5%), diabetes mellitus (2.0%), impaired fasting glucose (22.4%) and hypercholesterolemia (18.8%). 5.9% had proteinuria (?1+). 61.2% of FDRs had eGFR in stage 1, 34.7% in stage 2, 3.6% in stage 3, and 0.5% in stage 4-5. 8.6% had CKD (88.5% were unaware). As with the above report from Sheffield, this study implies that first-degree relatives of CKD patients should also be included in a comprehensive targeted screening program. But more importantly, it reminds readers of the prevalence of undiagnosed hypertension and diabetes in communities. This has to be the major screening target of programs aimed at detecting and reducing the impact of chronic non-communicable disease on morbidity and mortality worldwide.
Section on 'Kidney Disease and Population Health' (K.J. Van Stralen and colleagues, The Netherlands and Italy; Nephron Clin Pract 2010;116:c143-c147). The authors discuss the definition and role of confounders in data interpretation and clinical studies. They remind readers of the criteria needed to define a confounder: 1) The variable needs to be associated with the exposure. 2) The variable needs to be associated with the outcome or disease. 3) The variable should not be an intermediate variable in the causal pathway between exposure and outcome. Only if all three criteria are fulfilled is the variable under question a confounder.
For previous issues of Nephron Digest or to sign up for future issues, click here. For submission of articles, sign-ups to ToC Alerts or to recommend Nephron Clinical Practice to your librarian, please go to the journal's homepage..
© S. Karger AG - Medical and Scientific Publishers
Allschwilerstrasse 10, P.O. Box, CH-4009 Basel (Switzerland)
Tel. +41 61 306 1200, Fax +41 61 306 1234, publications@karger.ch.
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Nephron NEWS
(Updated on Jun.02.2010)
Issue 4,2010 [May, 2010]
I strongly encourage the readers of Nephron Digest to engage in a dialogue by emailing me to discuss issues of global nephrological interest. These would be addressed by expert members of the editorial board of Nephron. Also readers are encouraged to request topics that they would like to be updated upon through the Mini Review series of Nephron Clinical Practice.Professor Meguid El Nahas, PhD, FRCP
Editor, Nephron Clinical Practice
nephron@sheffield.ac.uk
m.el-nahas@sheffield.ac.uk
Digest of issue 116/1/2010
Treatment of Primary Systemic Vasculitis with the Inosine Monophosphate Dehydrogenase Inhibitor Mycophenolic Acid (T.F. Hiemstra, R.B. Jones, D.R.W. Jayne, UK; Nephron Clin Pract 2010;116:c1-c10) This minireview focuses on recent developments in the use of salts of mycophenolic acid (mycophenolate mofetil and mycophenolate sodium) in systemic vasculitis associated with antineutrophil cytoplasmic autoantibodies (ANCA+ vasculitis, AASV). The authors review the promise of these agents in this type of vasculitis and caution against premature enthusiasm. They remind the readers that these agents have not yet achieved first-line treatment status. Trials are underway (MYCYC and IMPROVE) that may confirm their potential in inducing remission and maintaining it, respectively. Meanwhile, it is important to remember that steroids and cyclophosphamide are considered the "treatment of choice" in AASV. However, the potential toxicity of cyclophosphamide, especially in older patients, warrants the search for alternatives. It is intriguing that cyclophosphamide was never compared, or shown to be superior, to another old-fashioned antimetabolite, azathioprine, in inducing remission in AASV. This shows that "treatments of choice" are often based on "expert" opinions and/or bias and not always on sound clinical evidence. Without strong evidence I have always favoured azathioprine over cyclophosphamide in older patients (>65years) with AASV. Perhaps another example of bias over evidence!
Chronic Kidney Disease in Older People: Physiology, Pathology or Both? (A.H. Abdelhafiz et al., UK; Nephron Clin Pract 2010;116:c19-c24) In this review, the authors explore the true nature of CKD in older people. Emphasis is on whether age-related changes in kidney function are physiological or pathological. It is concluded that CKD in the elderly, which constitutes the bulk of the so-called CKD "epidemic", is merely the reflection of vascular ageing and consequent kidney damage with microalbuminuria and reduced GFR. The kidney is one of many affected target organs along with the heart, brain and eyes. A recent publication coins the term Cardio-Kidney-Damage (C-K-D) to describe this entity (El Nahas, Kidney Int advance online publication 5 May 2010; doi: 10.1038/ki.2010.123). This may be a preferable term to "disease" as otherwise older people would be plagued with so many diseases; heart disease, kidney disease, lung disease, brain disease, hearing disease, eye disease, not to mention hair disease - for those who also lose their hair! Ageing after all can be cruel.
Nephrology Guidelines Synopsis
In this issue, Dr. Arif Khwaja has started his review of current nephrology guidelines by summarising and commenting upon two KDIGO guidelines.
Chronic Kidney Disease-Mineral and Bone Disorder KDIGO Guidelines (A. Khwala, UK; Nephron Clin Pract 2010;116:c25-c26. For a summary, see table:
KDIGO Guidelines for Care of the Kidney Transplant Recipient (A. Khwala, UK; Nephron Clin Pract 2010;116:c27-c28. For a summary, see table:
For previous issues of Nephron Digest or to sign up for future issues, click here. For submission of articles, sign-ups to ToC Alerts or to recommend Nephron Clinical Practice to your librarian, please go to the journal's homepage..
© S. Karger AG - Medical and Scientific Publishers
Allschwilerstrasse 10, P.O. Box, CH-4009 Basel (Switzerland)
Tel. +41 61 306 1200, Fax +41 61 306 1234, publications@karger.ch.
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Nephron NEWS
(Updated on Apr.19.2010)
Issue 3,2010 [April , 2010]
I strongly encourage the readers of Nephron Digest to engage in a dialogue by emailing me to discuss issues of global nephrological interest. These would be addressed by expert members of the editorial board of Nephron. Also readers are encouraged to request topics that they would like to be updated upon through the Mini Review series of Nephron Clinical Practice.You are also invited to share with other readers your clinical experiences and research by submitting to Nephron manuscripts that reflect the practice of Nephrology in your country and region.
Nephron is also publishing a new series entitled The Opposite View. I would like to encourage readers and nephrologists who have clinical views at variance with the current dogma or trend to express them through the pages of Nephron. Clearly, the opposite views also need to be based on some facts and evidence!
Another new feature is the Nephron Forum: clinico-pathological conferences (CPC) held during national or regional meetings, discussed by young emerging nephrologists.
Finally, as Nephron aims to respond to readers' suggestions, please do not hesitate to make suggestions for topics or series as you feel appropriate.
Data from the UK Renal Registry: The full 2009 UKRR Report is now available as a free electronic supplement to Nephron.
Professor Meguid El Nahas, PhD, FRCP
Editor, Nephron Clinical Practice
nephron@sheffield.ac.uk
m.el-nahas@sheffield.ac.uk
Digest of issue 115/1/2010
Current Management of Atherosclerotic Renovascular Disease - What Have We Learned from ASTRAL? (C. Chrysochou, P.A. Kalra, UK; Nephron Clin Pract 2010;115:c73-c81. The authors of this paper review the ASTRAL trial and interpret its results, confirming that revascularization with or without stenting in patients with atherosclerotic renovascular disease is of little value in long-term blood pressure control or in affecting the course of CKD. The ASTRAL data is supported by the findings of the Dutch STAR study group (L. Bax et al. Ann Intern Med 2009;150:840-848). These findings are not surprising as patients suffering from atherosclerotic renovascular disease often have extensive intra-renal ischemic arteriolar and glomerular changes that are unlikely to be affected by interventions on large renal arteries.
Physical Exercise in Patients with Severe Kidney Disease (G.C. Kosmadakis et al., UK; Nephron Clin Pract 2010;115:c7-c16. This review is a reminder to nephrologists of a topic that has long been neglected, namely that of the value of exercise in CKD/ESRD patients. The authors review the evidence for the impact of lack of exercise on outcomes in ESRD patients on replacement therapy. Attention should be paid to tailoring the exercise programme to the patient's capabilities and underlying comorbidities.
Predictors of Declining Glomerular Filtration Rate in a Population-Based Chronic Kidney Disease Cohort (B.O. Erikson et al., Norway; Nephron Clin Pract 2010;115:c41-c50. In this study, a large cohort of elderly CKD patients was studied. The mean rate of decline in GFR was slower (1.5 ml/min/1.73 m2 /year) than in studies of selected patient groups. Male gender, diabetes, proteinuria and higher mean arterial pressure were independent predictors of a faster decline in GFR. Recent publications have focused on the interface between CKD in the elderly and the progression of underlying CVD. Determinants of progressive CVD and CKD are shared supporting the concept that CKD in the elderly is the reflection of vascular aging affecting a number of end-organs including the kidneys (El Nahas, Kidney Int 2010; in press).
Factors Predicting Mortality in Elderly Patients on Dialysis (U. Verdalles et al., Spain; Nephron Clin Pract 2010;115:c28-c34. This study concludes that age does not influence in itself mortality in elderly patients on dialysis. Outcomes were determined by patients' comorbidities as survival and hospitalization rates were directly correlated to the Charlson comorbidity index. Advanced age in itself should not be regarded as an excluding factor for starting dialysis. However, elderly patients often have higher co-morbidities with increased prevalence of diabetes and cardiovascular disease. This is supported by observations among elderly nursing home residents with ESRD in the US, where the initiation of dialysis was associated with a substantial and sustained decline in functional status (M. Kurella Tamura et al., N Engl J Med 2009;361:1539-1547)
Measures of Disease Frequency: Prevalence and Incidence (M. Noordzij et al.; Nephron Clin Pract 2010;115:c17-c20. This article is part of the new section 'Kidney Disease and Population Health'. This section is managed by Professor Carmine Zoccali and Dr. Kitty Jager and covers a range of statistical approaches the reader will find useful in the evaluation and design of clinical investigations in nephrology.
For previous issues of Nephron Digest or to sign up for future issues, click here. For submission of articles, sign-ups to ToC Alerts or to recommend Nephron Clinical Practice to your librarian, please go to the journal's homepage.
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Nephron NEWS
(Updated on Jan.14.2010)
Issue 1,2010 [January 12, 2010]
Nephron Digest wishes all its readers a Happy New YearProfessor Meguid El Nahas, PhD, FRCP
Editor, Nephron Clinical Practice
nephron@sheffield.ac.uk
m.el-nahas@sheffield.ac.uk
Digest of issue 114/2/2010
Ureteral Endometriosis: Rare and Underdiagnosed Cause of Kidney Dysfunction. Claudio Ponticelli and colleagues, Italy (Nephron Clin Pract 2010;114:c89-c94) draw attention to an unusual cause of ureteral obstruction and hydronephrosis in premenopausal women, namely ureteral endometriosis. They provide the reader with clues to diagnosis and recommend a high index of suspicion in those at risk. Moreover, they also supply recommendations for comprehensive monitoring, diagnosis and management. This minireview points to an uncommon and probably underdiagnosed cause of ureteral obstruction in young women.
Serum Cystatin C-Based Formulas for Prediction of Glomerular Filtration Rate. Radovan Hojs and colleagues, Slovenia (Nephron Clin Pract 2010;114:c118-c126) argue that most serum cystatin C-based GFR equations are reliable markers of GFR in patients with CKD; according to the authors, the simplest formula (100/cystatin C) could be accurate enough for GFR estimation in daily clinical practice. This observation is at variance with a publication that concluded that all eight cystatin C-based GFR estimating equations underestimated or overestimated GFR in a Chinese population (Sun, Y. et al., Nephrol Dial Transplant. 2009 Dec 27). Moreover, a Scandinavian study showed that intra-individual variance was greater for cystatin C than for creatinine in healthy subjects and CKD, thus recommending serum creatinine as the pref erred marker for serial monitoring of renal function in individuals with stable muscle mass (Reinhard, M. et al., Scand J Clin Lab Invest. 2009;69:831-836). These publications highlight the fact that knowledge of the merit and pitfalls of the various tools available to estimate GFR is essential for data interpretation (reviewed by White et al, Transplant Rev 2010;24:18-27).
Medication Compliance among Dialysis Patients. Ze'ev Katzir and colleagues, Israel (Nephron Clin Pract 2010;114:c151-c157) show that dialysis patients appear to benefit from comprehensive guidance about medication in terms of compliance. Nonadherence to oral medication in haemodialysis patients is still an underestimated but life-threatening behaviour (Schmid, H. et al., Eur J Med Res. 2009;14:185-190). A recent publication highlighted depression as a major contributor to non-adherence to medication in the dialysis population (Cukor, D. et al., Kidney Int. 2009;75:1223-1229). It is therefore important to take poor compliance very seriously and address a number of clinical, psychological, biochemical/haematological as well as pharmacological variables to optimise adherence to medication amongst patients on renal rep lacement therapy. These could be complemented by careful instructions, guidance and reinforcement at regular intervals.
For previous issues of Nephron Digest or to sign up for future issues, click here
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