Special Sections

The burden of renal disease is continuing to increase not only in the U.S. population but worldwide, as comorbidity factors such as obesity and diabetes become more prevalent (1). This year, the CDC estimates that more than 10 percent of adults in the United States, approximately 20 million people, may have chronic kidney disease (CKD) in varying degrees of severity, with many people being unaware that they either have CKD or are at increased risk of developing it (2).

Kidney Watch 2017

Leaving ASN Kidney Week 2016, I was excited to integrate new knowledge and thoughts into processes to improve the care and outcomes of patients with advanced CKD.

We cannot discuss too much or focus in too much detail on the issues when it comes to the historic transition of power and influence post-election. Much has been said about radically changing the government, and health care has been in the crosshairs throughout the election and in planning for transition. Governance and policy will be all important in 2017. Although there is limited detailed conversation about how change will occur, there surely will be new policy and rules.

After several years of declining interest, the future of nephrology as a career choice continues to be uncertain. Preliminary results from the Nephrology Match AY 2017 revealed a continuing trend toward unfilled nephrology tracks, with almost no change from AY 2016 (95 vs. 93 filled tracks). Programs may face the difficult choice of trying to recruit post-match or perhaps reducing program size and recruiting either more attending nephrologists or physician extenders including physician assistants or nurse practitioners.

The likely repeal of the Affordable Care Act (ACA) early in the Trump administration has placed patients who gained coverage through the legislation and the ACA’s value-based kidney care initiatives in limbo.

The Trump administration and Republican leaders in Congress are vowing to quickly repeal the ACA when they take power in January 2017. The repeal is expected to allow a 2–3 year grace period for parts of the ACA to continue. After that time, Republicans are expected to replace the ACA with their own legislation.

Kidney Week 2016

Chicago—Wider use of intensive control of systolic blood pressure could save the lives of as many as 32,145 individuals with chronic kidney disease each year, estimated a study presented at Kidney Week 2016.

Chicago—Too little and poor quality sleep are associated with a greater risk of kidney failure, according to results from the Chronic Renal Insufficiency Cohort Study (CRIC) presented at Kidney Week 2016.

While sleep disorders are common in patients with chronic kidney disease (CKD), how poor sleep may affect disease progression is not clear, according to the study’s lead author Ana C. Ricardo, MD, MPH, an assistant professor in the division of nephrology at the University of Illinois College of Medicine at Chicago.

Use of palliative care among patients with end stage renal disease (ESRD) has increased steadily since 2004, but use among minority patients lags behind whites, according to a study presented at Kidney Week 2016.

Chicago—Stem cells from patients with polycystic kidney disease have been coaxed into growing into kidney-like structures, which may aid researchers studying the disease, according to a study presented at Kidney Week 2016.

Ryuji Morizane, MD, PhD, an instructor and scientist in the Brigham and Women’s Hospital Renal Division in Boston, and his colleagues presented data on how they grew the kidney-like structures, called kidney organoids. They also described the features of the kidney organoids and the disease features they recreate.

Smoking may partly counteract the benefits of treatment with angiotensin converting enzyme inhibitors (ACE inhibitors) for patients with chronic kidney disease (CKD), according to a study presented at Kidney Week 2016.

Smoking has been linked to worsening kidney decline, but the exact mechanisms are unclear, according to lead author Bethany Roehm, MD, of Tufts Medical Center in Boston.

A safe, inexpensive pre-transplant intervention can reduce graft loss and mortality, according to late-breaking trial results presented during Kidney Week 2016.

Lifestyle factors, particularly higher body mass index (BMI), appear to explain the lower risk of end stage renal disease (ERSD) in women compared with men, according to data from the Chronic Renal Insufficiency Cohort (CRIC) Study presented at Kidney Week 2016.

Kidney Care and Depression

What do you mean my kidneys are failing?” “What is dialysis?” “Am I going to die?” “This can’t be happening to me.” “What about my family?” “I am afraid….” The diagnosis of kidney disease is a life-changing event for individuals and their families. Their entire world has just changed. They have lost their safe and secure view of their own sense of good health and well-being. Their sense of the future is not as certain. They are in crisis and grief.

Creative arts therapy is a form of psychotherapy that draws on the creative process along with traditional talk therapy to facilitate personal growth, insight, and resilience. Because chronic illnesses, such as ESRD and chronic kidney disease, can have psychosocial and spiritual effects on one’s mind, body, and relationships, art therapy as a treatment modality can be used to supplement traditional medical approaches to help one seek balance, wholeness, and self-actualization instead of just focusing on the cure.

Having recently experienced an excellent meeting on mental health, chronic kidney disease (CKD), and ESRD, I wanted to offer some thoughts about the extraordinary role that psychology and people play in the course of this illness and its treatment. I commend the Rogosin Institute for convening a marvelous group of leaders from various parts of the country to deliberate on these issues.

Approximately one in five women and one in 10 men will suffer from depression over the course of their lives (1). Chronic illness generally confers an even greater risk for depression. Patients with chronic kidney disease (CKD) and in particular, those who are on hemodialysis (HD) are at a relatively high risk for depression.

Patients who need dialysis for the treatment of ESRD have a high burden of disease because they have numerous coexisting illnesses (such as diabetes and congestive heart failure), high health care utilization with frequent hospitalizations and high rates of readmission, and a very high daily pill burden. The dialysis regimen adds further to this burden, because patients have to make significant changes in their day-to-day lives, including in their diets, to accommodate the treatment schedules and minimize risks to their health.

Major depression is a complicating comorbid diagnosis in a variety of chronic medical conditions, but may be a particular diagnostic and treatment challenge to the patient with end stage renal disease (ESRD). New Medicare guidelines mandate that dialysis providers must screen for depression, and soon they will be required to document a treatment plan. This new requirement is forcing kidney care providers to seriously consider the best approaches to accurately diagnose and treat patients on dialysis once they have been identified as having depression.

Telehealth and EHRs

Almost 25 years after the Texas Telemedicine Project, one of the first major telemedicine initiatives, we are still trying to determine where and how telemedicine fits into modern nephrology.

Search engines are one of the first places many Americans turn when looking for health information, according to a 2013 survey by the Pew Research Center. But what they may not know is that the data from these searches is collected by the search engine and is increasingly being used for health research and public health surveillance.

Electronic health records (EHRs) have made it much easier for physicians treating patients with chronic kidney disease (CKD) to collect data, including glomerular filtration rate (GFR), creatinine, blood pressure, cholesterol, anemia, and bone health, said Joseph Nally, MD, Director of the Center for Chronic Kidney Disease at the Cleveland Clinic. But they don’t always make it easy for physicians to use the data to improve patient care.

Patients with chronic kidney disease who also have chronic obstructive pulmonary disease (COPD) have a 41% increased risk of death, according to a recently published study that relied on electronic health records (EHRs) (Navaneethan SD, et al. Am J Nephrol 2016; 43:39–46).

The finding is part of a growing body of evidence demonstrating the power of EHR-based studies to help elucidate the many factors that contribute to poor outcomes for patients with CKD. The technology is also being used to help test ways to improve their care.

A new rule from the Centers for Medicare & Medicaid Services (CMS) would extend access to CMS claims data to support quality improvement efforts. But the increased access to personally identifiable claims—including to for-profit companies—may pose privacy risks for patients.

Kidney 2.0

Understanding the true value of a scholar’s research and output is no small feat. Although it’s fairly straightforward to track the number of publications or total dollar amount of awarded funding, it can be a greater challenge to assess the reach of scholarly efforts and determine how others are utilizing the research results.

The Journal of the American Medical Association has reported that one in nine Americans now have chronic kidney disease, and that figure is believed to be growing. At the same time many publications (among them, Kidney News) are tracking a drop in the number of nephrologists entering the field, and others have documented the strain on those already practicing as dialysis resources are stretched thin.

Twitter has taken the world by storm. No one could have predicted that just 6 years after its inception Twitter would have 300 million users generating 300 million messages every day (1). If you are among the uninitiated, you should become familiar with how Twitter works and why it’s one of the most popular micro-blogging websites in the world.

Kidney Week 2015

A team of investigators led by Morgan Grams, MD, of the CKD Prognosis Consortium recently developed equations to help predict potential kidney donors’ lifetime risk of end stage renal disease (ESRD) on the basis of their demographic and health characteristics before kidney donation.

Exposure to lead during pregnancy was linked with higher blood pressure in young children in a study presented at Kidney Week 2015. Exposure to lead during infancy did not seem to impact later blood pressure.

Despite evidence supporting hypertension in overweight and obese adolescents as risk factors for heart disease, high blood pressure is underdiagnosed in these teenagers. New research presented at Kidney Week examined the extent of the underdiagnosis.

In a study that looked at the frequency and severity of early complications after living kidney donation, African Americans had a 26% increased risk of experiencing any complication and a 56% increased risk of experiencing major complications, after appropriate adjustment was made for other factors.

New research presented at ASN Kidney Week 2015 found that use of proton pump inhibitors (PPIs) is associated with increased risk for chronic kidney disease (CKD). PPIs are commonly used to treat acid reflux, stomach ulcers, and other acid-related gastrointestinal conditions.

In one study, PPI users were between 20% and 50% more likely to develop CKD than non-PPI users, even after accounting for baseline differences between users and non-users.

Twenty-seven percent of kidney donors surveyed in a recent study reported at Kidney Week developed new-onset hypertension after donation.

Many African Americans with uncontrolled hypertension do not have recommended food choices in their homes. They also often do not have adequate discussions with their doctors about diet, especially the Dietary Approaches to Stop Hypertension (DASH) diet, according to findings from two studies presented at ASN Kidney Week 2015.

The DASH diet is recommended for the treatment of hypertension, especially among African Americans.

A new streamlined approach for early detection and treatment of acute kidney injury (AKI) reduced mortality by 23 percent in a pilot study presented at ASN Kidney Week 2015 (1). AKI is frequently encountered in the hospital setting, complicating approximately 20 percent of cardiac surgeries worldwide. The STOP-AKI protocol—a combination of electronic alerts, a standardized intervention bundle, and staff and patient engagement—is a replicable model that could help to reduce the global burden of AKI.

The late-breaking clinical trials presented at ASN Kidney Week 2015 featured research that could help advance patient care in a wide range of clinical areas—from uremic pruritus in dialysis patients to acute kidney injury (AKI) in the hospital setting to the next frontier in renal replacement therapy. Although some trial outcomes were unfavorable or unexpected, Lynda Szczech, MD, FASN, told ASN Kidney News they still provide an important contribution to the medical literature and clinical care. “Negative trials have value too.

Patients who received kidney transplants survived longer than age-matched patients who underwent home hemodialysis in two studies presented at Kidney Week.

Previous studies found that kidney failure patients on long-term dialysis tend to die earlier than patients who receive kidney transplants, but none of the studies considered death rates in US patients using alternative forms of dialysis such as home hemodialysis.

Living kidney or kidney-pancreas donation rates were highest among Caucasians followed by Hispanics and Asians in a study that looked at the impact of organ transplant candidates’ socioeconomic environment on living donation rates. The findings were reported by Douglas Keith, MD, of the University of Virginia Medical Center at Kidney Week 2015.

Renal Week 2009: News and Analysis

Steven C. Hebert, MD, the board-certified nephrologist and physician-scientist responsible for “breaking open the black box of tubule cells,” was honored at an ASN symposium featuring four former colleagues, who described recent studies that build upon Hebert’s pioneering research on the thick ascending limb’s function and dysfunction in kidney disease.

Recurrent lupus nephritis is uncommon in lupus patients who receive a kidney transplant, but the condition often leads to allograft failure with an increased risk of death after transplantation. That was the finding of a study presented recently at Renal Week.

Interventional Nephrology

Hemodialysis (HD) sustains life for those with ESRD. Currently, nearly 400,000 individuals in the United States receive HD as management of ESRD (1). Sustainable vascular access that provides high-volume blood flow rates (Qb) above 300 mL/min is essential, whether through arteriovenous autologous fistulas, synthetic grafts, or tunneled dialysis catheters (TDCs) (2). Unfortunately, the overwhelming majority of incident patients begin HD treatments with a TDC: 82 percent, according to the most recent data from the U.S.

Over the past four decades, ultrasonography has become an indispensable tool because of its safety, availability, and low cost. Accordingly, many specialties have incorporated ultrasonography into their core training programs for visualization of relevant organs and guidance of procedures (e.g., echocardiograms in cardiovascular medicine, pelvic ultrasounds in gynecology and obstetrics, thyroid ultrasounds in endocrinology, abdominal ultrasounds in trauma and emergency medicine).

Interventional nephrology has become a growing and distinct discipline within nephrology. The first two articles in this special section deal with everyday issues that practicing nephrologists, dialysis nurses, and technicians encounter.

In “The PICC Conundrum: Vein Preservation and Venous Access,” Dr. Pflederer provides background on the increasing use of PICC lines and how their use impacts CKD patients who will require vascular access. Indeed, Dr. Pflederer’s article may serve as a resource for developing a PICC line use policy.

The incidence of ESRD is increasing, with a current prevalence of over half a million patients in the United States. Most ESRD patients are treated with hemodialysis (HD) and the number of patients receiving peritoneal dialysis (PD) has steadily declined over the past several decades. According to the U.S. Renal Data System 2011 annual report, approximately 7 percent of patients were being treated with PD at the end of 2009, reflecting gross underuse of this form of therapy (1).

Peripherally inserted central venous catheters (PICC lines) are being used with increasing frequency in the hospital and outpatient settings for patients who require venous access. Originally intended as a less invasive way to obtain long-term central venous access, PICC lines are now being used for a growing number of indications. Patients who require an extended course of antibiotics or other medications were often chosen to have a PICC line placed after treatment was begun with a peripheral intravenous (IV ) catheter.

Nephrologists enjoy an unusually close and extended relationship with their patients, often lasting decades through the evolution of chronic kidney disease to the eventual long-term management of ESRD. Their unique perspective on the importance of dialysis access has led to an intense interest in the field, resulting in the emergence of a distinct discipline within nephrology: interventional nephrology.

Interventional nephrology is in the midst of an exponential growth phase, with data from the U.S. Renal Data System suggesting that at least 25 percent of total vascular access procedure costs are billed by nephrologists (1).

Kidney Watch 2016

The past several years have seen a decline in the number of applicants for nephrology fellowship positions with about half of all programs having unfilled slots. It is anticipated that a further decline will be found for the current recruiting season.

Imagine putting your meal on a special plate. Its built-in scales and cameras identify your food and its quantity, and then send nutritional information to your smartphone. It may sound like science fiction, but such a product will be shipping soon! Now add a twist for patients. If you have diabetes, an app could tell you how much insulin to take. If you want to lose a few pounds, your phone may alert you to calorie intake.

Patients and physicians have new choices for treating hyperkalemia in 2016. The FDA recently approved patiromer calcium sorbitex (Relypsa, Redwood City, CA) and will likely reach a decision on sodium zirconium cyclosilicate (ZS-9) (ZS Pharma, San Mateo, CA) this year.

Ever since deceased donor kidney transplantation became practical and accessible to all, several competing factors have shaped the kidney allocation system (KAS) in the US. On one hand, scientific progress has allowed vastly improved preservation techniques, and cross-matching has made it possible to increase the allograft half-life significantly. On the other hand, there continues to be a moral obligation to achieve equitability and fairness in organ allocation practices.

After the signing into law of the Affordable Care Act in 2010, the Centers for Medicare & Medicaid Services developed the idea of accountable care organizations (ACOs) as a way to improve health care outcomes while controlling costs. ACOs are legal entities composed of physicians, other providers, clinics, and hospitals, with shared governance toward providing patient care. The idea is to share risk in the management of a given population toward providing high-quality, cost-effective care.

As health care moves forward in defining a system of accountable and valued care, aligning health care cost inflation with overall economic growth, and ensuring access to appropriate evidence-based services for all, physicians are being called upon to break down many barriers to achieving accountable valued care. These include right-sizing our outsized delivery system, correcting unwarranted variations in care, decreasing unnecessary health care spending, and improving patient-centered outcomes.

Happy New Year from Kidney News. We are delighted to provide you comprehensive coverage of what is new and influential in the world of kidney disease. Please look for major innovations in how we present information and news stories in upcoming editions. We welcome your input into how we can best serve your need for information and communication, and can always be reached at kidneynews@asn-online.org.

Be on the lookout for increased use of SGLT-2 inhibitors in 2016 after a recent study published in the New England Journal of Medicine demonstrated a lower composite rate of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke in high risk type 2 diabetics (n = 7020) treated with empagliflozin compared to placebo.

Health Literacy: Enhancing Patient Engagement

During the past 3 years, we at Dialysis Clinic, Inc., have focused on providing care for all patients with kidney disease with the goal to reach out to them, wherever they are, and work with them to empower them to live the life they want to live, without allowing kidney disease to get in the way of their life dreams. For most patients with kidney disease, the best way to have optimal quality of life is to avoid dialysis. Therefore, our primary goal for treating patients with chronic kidney disease (CKD) is to avoid dialysis or delay its start.

ASN Kidney News gratefully acknowledges the editor of this special section, Kidney News Editorial Board member Glenda Payne, MS, RN, CNN, for her contributions to the issue.

This month, KN Editorial Board member and special section editor Glenda Payne interviewed Cindy Brach, MPP, lead for health literacy at the Agency Healthcare Research and Quality, about ways nephrology professionals can recognize issues in health literacy and more effectively bridge communication gaps.

Health literacy research over the past 2 decades has shaped its definition, determined how it is assessed, and provided us with an initial understanding about how this concept significantly contributes to the connections among patients, families, health care providers, and health systems. We all strive to apply the most rigorous and contemporary evidence in the care of patients, and this is no different for practices related to health literacy.

In the ever-changing climate of health care, providers eagerly seek innovative approaches to actively engage patients and their families in their care. The Center for Advancing Health defines engagement as “actions individuals must take to obtain the greatest benefit from the health care services available to them.”

Proficiency in health literacy is a critical ingredient in the outcomes of both the prevention and the treatment of kidney disease. Unfortunately, according to a US Department of Education report, only 12 percent of Americans are proficient in health literacy (1).

With all this talk about health literacy (HL), do people even know what the term means? After the Health Literacy Roundtable in March 2015, a short questionnaire was administered to 22 patients and six staff members in an effort to determine what patients and staff know about HL. The patients and staff were first asked if they had heard the term “health literacy.” If they responded “yes,” they were asked to describe the term in their own words.

Chronic kidney disease (CKD) is a complex medical condition that requires multiple self-management strategies including the ability to understand, implement, and maintain clinical recommendations and self-care treatment strategies (1). Heart disease, diabetes mellitus, and nephropathies are among the top 10 causes of death, with rankings of 1, 7, and 9, respectively (2). CKD affects approximately 26 million American adults in the United States, whereas millions of others are at increased risk (3).

Hope Abides

Hope abides; therefore I abide.

Countless frustrations have not cowed me.

I am still alive, vibrant with life.

The black cloud will disappear,

The morning sun will appear once again

In all its supernal glory.

—by Sri Chinmoy Ghose

Kidney Week 2015 Plenary Sessions

Donald E. Ingber

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A founder of the emerging field of biologically inspired engineering will deliver a state-of-the-art lecture about “Human Organs on Chips,” on Sunday, Nov. 8.

Dontscho Kerjaschki

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Acclaimed researcher Dontscho Kerjaschki, MD, will receive the Homer W. Smith Award and deliver an address on “The Podocyte: From Periphery to Center Stage.“ Dr. Kerjaschki chairs the department of pathology at the Medical University of Vienna.

The Belding H. Scribner Award will be tendered to Glenn M. Chertow, MD, MPH, for his career-long contributions to the practice of nephrology.

Dr. Chertow is the Norman S. Coplon Satellite Healthcare Professor of Medicine and chief of the division of nephrology at Stanford University School of Medicine.

Janos Peti-Peterdi

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Janos Peti-Peterdi, MD, PhD, will receive the ASN-AHA Young Investigator Award for his groundbreaking research on CKD. He will describe his recent findings in an address: Renal Physiology Is Key to Understand and Augment Nephron Repair.

Mark L. Zeidel

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Mark L. Zeidel, MD, FASN, will receive the Robert G. Narins Award for his many contributions to medical education.

Corinne Antignac

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The genomics of focal segmental glomerulosclerosis (FSGS) will be the subject of the Michelle P. Winn, MD, Endowed Lectureship on Saturday, Nov. 7. The internationally recognized investigator Corinne Antignac, MD, PhD, will be the speaker.

Helen H. Hobbs

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An internationally known genetics researcher will deliver a state-of-the-art lecture on “Genetics of Cardiovascular Disease: Getting to the Heart of the Matter” on Friday, Nov. 6.

Isidro B. Salusky

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Isidro B. Salusky, MD, will share the results of his current research into the role of fibroblast growth factor 23 (FGF23) in the pathogenesis of chronic kidney disease (CKD) mineral and bone disorder as well as the impact of therapies to treat the disorder on FGF23 production.

Gerald I. Shulman

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A leading diabetes researcher will speak on “Cellular Mechanisms of Insulin Resistance: Implications for Obesity, Diabetes, and Metabolic Syndrome” at a state-of-the-art lecture on Saturday, Nov. 7.

Roger C. Wiggins

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ASN will recognize the wide-ranging contributions of Roger C. Wiggins, MB, BChir, with the presentation of the John P. Peters Award.

Ravi I. Thadhani

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Adaptive Trial Design for Acute Kidney Injury (AKI) Interventional Studies” is the title of the Robert W. Schrier, MD, Endowed Lectureship on Thursday, Nov. 5.

Shari M. Ling

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A federal government leader will discuss the “Brave New World in Payment and Care Delivery” in the Christopher R. Blagg, MD, Lectureship in Renal Disease and Public Policy on Thursday, Nov. 5.

Transplantation: Issues and Controversies

Titte Srinivas

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Jesse Schold

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The United States has the highest per capita cost of medical care in the world—medical care consumes 17 percent of the gross domestic product. Yet the United States ranks far from the top in most measures of health.

Basic

Wsilliam E. Mitch

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The American Society of Nephrology announces William E. Mitch, MD, as this year’s recipient of the John P. Peters Award. The award recognizes Dr. Mitch’s outstanding contributions to improving the lives of patients with kidney disease and to furthering the understanding of the kidney in health and disease.

Oliver Smithies

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The ASN welcomes Oliver Smithies, PhD, as he presents the Barry M. Brenner Endowed Lecture on “Gel Permeation in the Kidney” during Saturday’s Meeting-Within-a-Meeting on “Novel Insights of Glomerular Function and Structure (Controversies).” The session will be held from 1:30 to 3:30 p.m.

L. Darryl Quarles

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L Darryl Quarles, MD, will present the 6th Annual Jack W. Coburn Endowed Lecture on “FGF23 and its Receptors: Lessons from Studies in Mice.” He will give the lecture during the Basic and Clinical Science Symposium “CKD-MBD and Outcomes,” held Saturday, October 31, from 1:30 to 3:30 p.m.

Burton D. Rose

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In recognition of his work as a teacher, textbook author, and creator of UpToDate, a respected online educational resource for physicians, the American Society of Nephrology has selected Burton D. Rose, MD, to receive the 2009 Robert G. Narins Award. The award honors those who have made substantial contributions to education and teaching.

Are you overwhelmed by Renal Week’s many offerings and wonder where to head next? Or would you like to post a few words about findings at a session you just attended? Then join Twitter and help us Tweet the Week.

What is Twitter?

More than a decade ago, ASN recognized the importance of helping early-career faculty gain independent funding and initiated a grants program to help them transition from mentored trainee to independent investigator.

In 2009, the career development grants program for young investigators supported 16 renal researchers. The growth of this program reflects ASN’s commitment to helping young faculty develop promising research initiatives and share their findings with their colleagues.

Matthias Kretzler

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The American Society of Nephrology is delighted to present this year’s Young Investigator Award to Matthias Kretzler, MD, whose work to define the molecular mechanisms of kidney disease is helping to identify better ways to predict and treat it.

Bruce Beutler

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The ASN welcomes Bruce Beutler, MD, as he presents a state-of-the-art lecture, “Genetic Insights into the Innate Immune System,” during the Saturday, October 31, plenary session, which begins at 8 a.m. Dr. Beutler is professor and chair of the department of genetics at the Scripps Research Institute in La Jolla, Calif.

René Jan Maria Bindels

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René Jan Maria Bindels, PhD, a physiology professor and researcher studying renal transport systems, is this year’s recipient of the Homer W. Smith Award. With this award, the American Society of Nephrology recognizes those who have made outstanding contributions to understanding how kidneys function in normal and diseased states.

Bernard Lo

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Bernard Lo, MD, will present the 8th Christopher R. Blagg Endowed Lecture on “How to Identify and Manage Conflicts,” during the Public Policy Forum, “Conflicts of Interest in Medicine.” The forum will be held from 1:30 to 3:30 p.m. on Thursday, October 29.

Tony Pawson

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The ASN invites Tony Pawson, PhD, to present a state-of-the-art lecture on “Signal Transduction Mechanisms in the Kidney” during the plenary session on Sunday, November 1, from 8:30 to 9:30 a.m.

Barry M. Brenner

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Barry M. Brenner, MD, will receive the Robert G. Narins Award on Friday, November 19.

Dr. Brenner is director emeritus of the renal division of Brigham and Women’s Hospital and Samuel A. Levine Professor of Medicine at Harvard Medical School in Boston.

The award honors those who have made substantial contributions to education and teaching.

Novel Nephrology

Merriam-Webster’s online dictionary defines the adjective “novel” as

  1. new and not resembling something formerly known or used, or
  2. original or striking, especially in conception or style.

Both definitions apply to the topics covered in this special section, which include noninvasive or minimally invasive diagnostic techniques as well as new interventions to treat disease, all of which can be performed by nephrologists.

Special Section

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The work lives of most pediatric nephrologists differ significantly from those of our internal medicine colleagues in all aspects of the career pathway. Changing patient and trainee demographics and expectations have spurred a renewed interest in evaluation of our current training processes with an eye toward the future.

The United States will face a shortage of nephrologists during the next decade. This shortfall will occur despite the fact that the number of nephrology fellows nearly doubled during the past 20 years, from 460 in 1987 to 863 in 2008 (1,2). The current disparities—by ethnicity, socioeconomic status, and geographical location—among patients with kidney disease will worsen as a result of this shortage.

For years, international medical graduates (IMGs) have comprised a significant percentage of the fellows in nephrology training programs who prepare to provide treatment to the rapidly growing population of patients suffering from kidney disease. In the 2006–2007 school year, physicians trained in foreign institutions constituted 47 percent of the fellowship class, an increase over the historic low of 38 percent in 2002–2003, and a return to the high percentages posted in the late 1990s.

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U.S. nephrology training program directors (TPDs) are increasingly joining forces to meet many of today’s current challenges. These efforts are spearheaded by the American Society of Nephrology’s (ASN) TPD executive committee. The committee consists of members elected by the TPD community to serve three-year terms, and is led by the ASN Education Director for Nephrology Fellowships.

These are certainly interesting times for nephrology education. As the number of patients with chronic kidney disease increases, the number of trainees seeking careers in nephrology is not keeping pace. The nephrology workforce forms the ASN, so this month we examine personnel issues, including changes in the education of nephrologists-to-be and those maintaining certification. Other topics of interest include international medical graduates, women, transplant nephrologists, and pediatric nephrologists.

In 2007, only 21 percent of practicing nephrologists were women, and females filled 36 percent of nephrology training slots. We asked three women to talk about gender issues in the profession.

Although cardiologists and nephrologists have debated for years about the relative contributions of the vasculature and the kidney to the pathogenesis of hypertension, new data have emerged that may recast essential hypertension as an autoimmune disease. These studies do not discount the importance of vascular tone and regulation of intravascular volume in the determination of blood pressure.

For this issue's focus on hypertension, we have assembled a small portfolio of articles describing recent provocative advances in the study of hypertension.

Most people with chronic kidney disease (CKD) have high blood pressure. Treatment of hypertension in patients with CKD is considered critical to prevent CKD progression and related cardiovascular events. However, questions remain about the appropriate BP goal. Most evidence indicates there is no benefit of treating to a goal any lower than 140/90 mm Hg, but there is some suggestion that such a goal may be appropriate for patients with albuminuria.

Hypertension is a common condition that is a significant risk factor for development of other cardiovascular diseases. The prevalence of hypertension is higher in men than women until after menopause, when the prevalence reverses and is higher in women. In addition, more women die of cardiovascular disease each year than do men.

In the United States we are currently experiencing the phenomenon of the “graying of America,” whereby the population is growing older and the proportion of those 65 years and older is rapidly increasing. Data from the U.S. Census Bureau predict that the number of individuals 65 years and older will double in the next 20 years. Most of this growth is happening in the “oldest old”—that is, 85 years and older.

Updates in Dialysis

In 2015, the overwhelming majority of patients with treated ESRD in the United States are treated with in-center hemodialysis (CHD), whereas peritoneal dialysis (PD) is the predominant modality used by home dialysis patients. Overall, this is not markedly different from the historical distribution of modality use: most patients use CHD. However, not only has the observed historical decline in percentages of patients using PD (1995–2009) stabilized, but the percentage of those using PD has actually been increasing since 2010 (1).

Continuous renal replacement therapy (CRRT) is relatively young; the first continuous venovenous CRRT systems were deployed widely in the late 1990s. The early machines were an enormous improvement over continuous arteriovenous systems. However, the early machines did not have the corresponding accessories available, and many nephrologists can recall “brewing” lactate-buffered dialysis and replacement solutions to operate CRRT in the early days. Some of us even resorted to using peritoneal dialysate in CRRT.

Although the physical and chemical concepts of diffusion and convection are well known, dialysis has been carried out mainly by diffusion during its first four decades. This form of dialysis, hemodialysis (HD), has ensured the survival of millions of patients with advanced kidney disease worldwide and has met the increasing needs generated in the 50 years since dialysis was considered for long-term renal replacement therapy.

1983–1988: Technology and bioengineering

Scope of the problem

Hemodialysis vascular access is without question the lifeline for the more than 400,000 patients undergoing hemodialysis in the United States. Unfortunately, because of the high incidence of dialysis vascular access dysfunction, it is also the “Achilles heel” of hemodialysis (1, 2). There are currently three main forms of permanent dialysis vascular access, each of which have their pros and cons.

ASN Kidney News gratefully acknowledges the editor of this special section, Kidney News Editorial Board member Edgar V. Lerma, MD, FASN, for his contributions to this issue.

Kidney Week 2014

Could differences in air quality contribute to the observed regional variations in chronic kidney disease (CKD)? A study presented at Kidney Week 2014 finds a higher prevalence of recognized CKD in counties of the United States with higher particulate air pollution.

Epidemiologist Jennifer L. Bragg-Gresham, PhD, of the University of Michigan and colleagues evaluated differences in pollutant levels—specifically, fine particles smaller than 2.5 µm (PM2.5)—as potentially contributing to regional differences in CKD prevalence.

Research presented at Kidney Week 2014 highlights dietary factors affecting kidney disease outcomes—including a study reporting that a “healthy diet” and lower sodium intake are associated with a reduced risk of major renal outcomes. Another report draws attention to the potentially high levels of potassium added to some “reduced-sodium” foods.

A total of 27 late-breaking clinical trials were presented at ASN Kidney Week 2014 in Philadelphia. These studies detailed new understandings and innovations in multiple therapeutic areas, including acute kidney injury (AKI), autosomal dominant polycystic kidney disease (ADPKD), dialysis, and diabetic nephropathy. This article highlights some of the leading science presented at the oral plenary High-Impact Clinical Trials session that potentially could influence the clinical approach of kidney health professionals in the United States and beyond.

Patients with stage 3 to 4 chronic kidney disease (CKD) assigned to an exercise/rehabilitation intervention have better maintenance of kidney function at one-year follow-up, according to preliminary research presented at Kidney Week 2014.

Kidney Disease Biomarkers

There has been considerable interest in studying novel biomarkers in chronic kidney disease (CKD) beyond the conventional clinical indices, such as serum creatinine, blood urea nitrogen, and urine protein or urine albumin. The motivation for this is similar to what has been outlined in other articles in this issue of ASN Kidney News.

Evolution of the biomarker concept

The search for biomarkers in body fluids is evolving into a broader quest for molecular phenotyping of tissue and disease reclassification. The original biomarker concept was too limited, failing to recognize that the interpretation of the molecular changes in body fluids requires a molecular understanding of the diseased tissue.

ASN Kidney News gratefully acknowledges KN Editorial Board member Edgar Lerma for his contribution as editor of this special section.

Cirrhosis is a major contributor to the burden of disease in society, and much of the morbidity and mortality associated with cirrhosis is due to the complications of portal hypertension. Acute kidney injury (AKI) is a frequent complication in patients with cirrhosis, occurring in up to 20 percent of hospitalized patients (1). Despite the high rate of AKI in this patient population, there is often a delay in early diagnosis of AKI.

A biomarker is defined as a characteristic that can be objectively measured and evaluated as an indicator of normal biologic or pathogenic processes of pharmacological responses to a therapeutic intervention (1). Examples of biomarkers are proteins; lipids; microRNAs; genomic, metabolomic, or proteomic patterns; imaging determinations; electrical signals; and cells present on a urinalysis. This issue will focus primarily on serum and urine proteins.

Over the past decade there has been an explosion of research investigating biomarkers of acute kidney injury (AKI). The research was borne out of the desire to replace serum creatinine, and in part urine output, as for a variety of reasons both serve as suboptimal tools in the diagnosis of acute renal tubular injury. The biomarker movement has been assisted by internationally accepted, standardized, consensus definitions of AKI.

Renal insufficiency is prevalent and clinically relevant in the setting of congestive heart failure. When admitted for acute decompensation, on average 1 out of 5 patients has a rise in serum creatinine, 1 out of 10 requires some form of dialysis, and 1 out of 20 requires long-term renal replacement therapies (1). These startling observations highlight the fact that adequate renal function plays a pivotal role in the clinical stability of heart failure.

Contrast-induced acute kidney injury (CI-AKI) is a common condition that is associated with serious, adverse short- and long-term outcomes. Despite substantial advancements in our understanding of CI-AKI, the capacity to effectively risk-stratify patients, diagnose incipient renal injury before elevations in serum creatinine (SCr) manifest, and identify patients at highest risk for adverse downstream events is limited.

Clinicians view kidney disease as a continuum where kidney failure results from a combination of patient susceptibility factors (diabetes, hypertension, or low nephron mass) combined with episodes of kidney injury (acute kidney injury [AKI]). Clinicians use traditional biomarkers such as serum creatinine, urine output, and albumin as indices of kidney function to diagnose, prognosticate, implement therapy, and monitor progression. These traditional biomarkers are far from ideal.

Diet and Nutrition for CKD Management

Clinicians are trained to review prescription drugs with patients during their clinic visits and hospital admissions. However, less emphasis is placed on appropriate review and documentation of foods and nutrients that are known or suspected to interact with medications. This scenario places kidney disease patients at significant risk, given the 10 to 12 different medications that are typically prescribed (1).

According to the 2007 National Health Interview survey, fish oil is the most popular dietary supplement used by adult Americans (1). This follows on the heels of decades of well-publicized basic science and clinical research into the biology of long-chain omega-3 fatty acids—the major active ingredient in fish oil—and their influence on a variety of disease processes.

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Individuals at high risk for the development of chronic kidney disease (CKD), or who already have the disease, are frequently encouraged by their health care providers to follow a “healthful” diet. Such a diet may be particularly difficult to follow if the recommended foods cannot be easily acquired—a situation that individuals living in poverty often face.

Phosphorus levels are elevated in patients with chronic kidney disease due to decreased urinary excretion. Higher levels of blood phosphorus are associated with increased mortality in patients on dialysis, patients with kidney disease not yet on dialysis, and in the general population. In animal studies, adding phosphorus to the diet causes calcification of arteries and progression of kidney disease.

Medical nutrition therapy (MNT) or dietary counseling in chronic kidney disease (CKD), provided by a registered dietitian (RD), is critical for patients with CKD. It may improve health outcomes, enhance quality of life, and help delay kidney disease progression (1). Additionally, MNT may help prevent or treat complications, including malnutrition, metabolic acidosis, hyperkalemia, mineral imbalance/bone disorders, anemia, and cardiovascular disease (2).

Phosphorus levels are elevated in patients with chronic kidney disease due to decreased urinary excretion. Higher levels of blood phosphorus are associated with increased mortality in patients on dialysis, patients with kidney disease not yet on dialysis, and in the general population. In animal studies, adding phosphorus to the diet causes calcification of arteries and progression of kidney disease.

Clinicians are trained to review prescription drugs with patients during their clinic visits and hospital admissions. However, less emphasis is placed on appropriate review and documentation of foods and nutrients that are known or suspected to interact with medications. This scenario places kidney disease patients at significant risk, given the 10 to 12 different medications that are typically prescribed (1).

According to the 2007 National Health Interview survey, fish oil is the most popular dietary supplement used by adult Americans (1). This follows on the heels of decades of well-publicized basic science and clinical research into the biology of long-chain omega-3 fatty acids—the major active ingredient in fish oil—and their influence on a variety of disease processes.

Individuals at high risk for the development of chronic kidney disease (CKD), or who already have the disease, are frequently encouraged by their health care providers to follow a “healthful” diet. Such a diet may be particularly difficult to follow if the recommended foods cannot be easily acquired—a situation that individuals living in poverty often face.

Kidney Week 2013

A Mediterranean diet may be beneficial for not only heart health, but kidney health as well. This is the conclusion of a new long-term study presented at Kidney Week 2013 that found individuals following a regimen similar to a Mediterranean diet reduced their risk for developing chronic kidney disease (CKD) and for rapid decline in kidney function. Although the diet’s heart health benefits have received public attention, it has been unknown if this diet confers any nephroprotective effects.

New research on the sodium-chloride cotransporter (NCC) and its mechanisms provides a clearer understanding of how a typical Western diet—high in sodium and low in potassium—could promote hypertension. In a study presented at Kidney Week 2013, Andrew Terker, an MD/PhD student at the Oregon Health & Science University, and coworkers found this diet profile may play a role in the development of hypertension in an NCC-dependent manner.

A dipstick that uses the saliva of an individual with suspected acute kidney injury (AKI) can quickly and accurately detect and diagnose AKI, without the need for laboratory facilities. The novel test strip, described in research presented at ASN Kidney Week (1), could help preserve the kidney health of millions of individuals in developing countries and help first responders in natural disaster zones make a fast diagnosis to help save kidney function and lives.

Meditation could be a valuable, low-cost, nonpharmacologic intervention for reducing blood pressure and adrenaline levels in patients with chronic kidney disease (CKD) according to research presented at Kidney Week 2013. Because CKD patients have a higher risk for cardiovascular disease, in part due to increased sympathetic nervous system activity, Jeanie Park, MD, of Emory University School of Medicine and her colleagues (1) investigated the technique to determine if it could help control hypertension and reduce this risk.

Results of a late-breaking clinical trial presented at Kidney Week 2013 show that atenolol-based antihypertensive therapy may be superior to lisinopril-based therapy in preventing cardiovascular morbidity and all-cause hospitalizations among maintenance dialysis patients. The trial was terminated early in September by the data safety monitoring committee when it became clear that lisinopril was associated with an increased risk for cardiovascular events.

For the first time, ASN partnered with the American Kidney Fund (AKF) to kick off Kidney Week with a free kidney health screening and public awareness event. Kidney Action Day was held at downtown Atlanta’s Underground and featured fitness, nutrition, and health education in addition to screenings and advice from volunteer health professionals from local institutions including Emory University School of Medicine.

Hypertension: The Good Bad and Unknown

Renal denervation is an emerging and promising new therapy for resistant hypertension. Although 54 percent of all hypertension is “uncontrolled” (1), not all uncontrolled hypertension is considered resistant. The American Heart Association (AHA) definition of resistant hypertension is BP above goal on at least three antihypertensive medications of different classes, one of which is a diuretic, or BP that requires four or more medications to get to goal.

The Living Kidney Donor

The use of living donors for kidney transplantation in the United States has become increasingly common, with recipients of a living donor kidney demonstrating better outcomes and shorter waiting times. Substantial differences exist between transplant centers in their choice of protocols and exclusion criteria for potential living donors.

The expansion of kidney transplantation from living donors over the last several decades has included greater racial and ethnic diversification of the donor population. In the United States, the fraction of non-white living kidney donors rose from 24 percent in 1988 to 30 percent in 2011, representing more than 1700 donors. Currently, 12 percent of living kidney donors in the United States are African American and 13 percent are Hispanic.

In 1995, Ratner, Kavoussi, and colleagues at Johns Hopkins University revolutionized live kidney donor transplantation through the development of the laparoscopic donor nephrectomy (1). Since then, the number of live donor transplants in the United States doubled, the number of live donors who are not biologically related to the recipient rose by more than fivefold, and the proportion of donor nephrectomies performed laparoscopically (or laparoscopically assisted) neared 100 percent.

Transplantation from a living kidney donor provides the best outcomes in recipients with end stage renal disease. However, our knowledge regarding the effects of kidney donation on long-term mental and physical health of the living donor remains incomplete. Published data are largely derived from single-center retrospective studies in young, healthy, and mostly white populations (1), whereas donors in today’s environment are increasingly older, larger, racially diverse, and medically complex (2).

The increasing prevalence of end stage renal disease (ESRD) has led to a steady growth in the kidney transplant waiting list, rapidly outpacing the availability and transplantation of organs from deceased donors. Interestingly, although overall living donation rates have remained relatively static over the last several years the one exception is a rise in the number of living non-spouse unrelated donors, including altruistic donors.

KDIGO: A Promise Unfilled

The World Health Organization defines anemia in adults and children older than 15 years as a hemoglobin concentration (Hb) <13.0 g/dL in male individuals and <12.0 g/dL in female individuals. In children aged 1.5 to 5 years anemia is defined as Hb <11 g/dL, in those 5 to 12 years as <11.5 g/dL, and in those 12 to 15 years as <12 g/dL (1).

The KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients was the third Kidney Disease: Improving Global Outcomes (KDIGO) guideline, published in November 2009 as a supplement to the American Journal of Transplantation. This guideline addressed a broader set of issues than did the previous two guidelines (for hepatitis C and bone and mineral disease). The guideline was written for clinicians (doctors, nurses, coordinators, and pharmacists) providing care to patients who have received a transplant.

The authors of the Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline for acute kidney injury (1) are often asked two important questions: “Who is the guideline for?” and “Is acute kidney injury (AKI) preventable?”

During the 1980s and 1990s, the focus of dealing with disorders of bone and mineral metabolism was predominantly “bone centric,” with parathyroid hormone (PTH) the main culprit and calcium the primary regulator of PTH. The term “renal osteodystrophy” was generally used to encompass these disorders. The focus of therapy was to maintain relatively high serum calcium concentrations in order to suppress PTH, which would presumably result in normal bone.

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In 1995, the National Kidney Foundation spearheaded the development of the first broadly accepted clinical practice guidelines in nephrology, the Kidney Disease Outcomes Quality Initiative (KDOQI).

First published in 1997, these “guidelines” made a significant impact in the quality of care for kidney patients in the United States and across the world.

Glomerulonephritis (GN)—including both primary and secondary variants in aggregate—remains one of the most common types of kidney disease that progresses to end stage renal disease (ESRD). However, this fact alone seriously underestimates the extent of the problem associated with GN. Many cases of the disease begin early in life and can have a devastating effect both on the individual and their families.

Hepatitis C virus (HCV) affects approximately 4 million Americans, and can trigger, share risk factors for, or result from CKD. Besides causing glomerulonephritis, HCV is associated with diabetes, a CKD precursor. End stage renal disease (ESRD) is a risk factor for HCV, transmitted via transfusions or transplantation in the era preceding its identification. The estimated HCV prevalence among U.S. CKD patients is 10 percent, several-fold higher than the general population, and is presumed to increase with CKD stage, with demographic variation.

Geriatric Nephrology

“If you really want to do something, you’ll find a way. If you don’t, you’ll find an excuse.”

—Jim Rohn, American entrepreneur, author, and motivational speaker

One of the major challenges for today’s society is the growth of the elderly population. By 2030, the age segment over 65 years will have nearly doubled, and the incidence of multiple age-associated disorders is predicted to increase in parallel. Age-associated changes of the kidney are important not only because normal aging alters renal function, but also because of the high frequency of ESRD in the elderly population (1).

We are aging and living longer. This fact could be attributed to improved technology, medical advances, and the increased number and aging of the baby boomers. It is estimated that the number of elderly will be up to 2 billion by the year 2050 (1). This increase in the number of elderly is mirrored by an increase in medical problems such as acute and chronic kidney disease. This requires coordinated care by multiple specialties, with geriatricians and nephrologists playing a key role in the treatment of these patients.

In the United States, chronic kidney disease (CKD)—defined by reduced GFR <60 mL/min per 1.73 m2, or presence of kidney damage—is very common in the elderly population. The prevalence of CKD is estimated to be 46.8 percent in those older than 70 years (1). However, the significance of reduced GFR in the elderly has been debated, and some suggest that reduced GFR is secondary to (expected) age-related changes in kidney function and is not evidence of true kidney disease.

Hypertension remains a growing problem in our aging population. Recent data from the National Health and Nutrition Examination Survey (NHANES) estimate that almost one-third of the adult population meets the criteria for hypertension (1). Furthermore, the prevalence increases with age; 65 percent of individuals over the age of 60 are hypertensive. Approximately three-quarters of the population with diagnoses of hypertension require some form of pharmacologic therapy, and the percentage is as high as 82 percent among individuals over the age of 60.

Chronic kidney disease (CKD) is a prevalent disease in the United States that disproportionately affects the elderly. The national prevalence is approximately 15 percent and reaches nearly 50 percent in adults aged 70 years and older (1). CKD stages 1 and 2 are characterized by a GFR >60 mL/min/1.73 m2, and dose adjustments are usually indicated only for drugs that have a narrow therapeutic index, such as aminoglycosides and vancomycin.

Diabetes mellitus is the most common cause of chronic kidney disease (CKD) and kidney failure (1). More than one quarter of the United States population over age 65 has diabetes (2), and 37 percent of them have an eGFR <60 mL/min/1.73 m2 (3).

The United States ESRD population is aging. Patients over the age of 65 have the highest adjusted prevalence of ESRD (Figure 1) (1). As a result of these demographics, nephrology providers are now faced with the task of recognizing and treating not only the burdens of ESRD but also morbidities associated with geriatric syndromes (Table 1). Prognosis for the elderly encompasses survival as well as effects on quality of life (QOL), cognition, functional status, and time lost from being with family.

Dialysis: Change is Online

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Three times a week, in a plain red-brick building near the Pentagon City mall in Arlington, a machine keeps me alive.

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The National Kidney Foundation’s (NKF) Kidney Early Evaluation Program (KEEP) provides comprehensive health risk appraisals to assess kidney function and key risk factors for chronic kidney disease (CKD), including hypertension and diabetes. Since 1997, this rapidly expanding program has screened more than 125,000 individuals. About 20,000 people were screened in 2008 alone.

Renal Week 2008

Women who want to bear children in the future need not worry about the risks of donating a kidney before pregnancy, researchers have found.

Urban and rural physicians involved in kidney transplantation have different perceptions about various aspects of the procedure, including when it should be done in the course of end stage renal disease (ESRD) and for which patients.

Wait times for kidney transplants throughout the United States vary widely, so that some individuals can receive a deceased donor’s kidney within just one year while others must wait up to a decade. Researchers are investigating the issues related to organ allocation inequities and are searching for ways to remedy them.

A combination of steroids and a blood pressure-lowering drug better prevents end stage renal disease (ESRD) than a blood pressure-lowering drug alone, researchers suggest.

A newly developed equation provides more accurate estimates of glomerular filtration rate (GFR) than do other measures, according to new research. The equation is different from other measures because it was developed on the basis of findings from pooled databases, rather than from a single study.

Hemodialysis patients who were more physically active had less postdialysis fatigue (PDF) compared with less active patients in a study of patients undergoing maintenance hemodialysis thrice weekly. The amount of physical activity on the day after dialysis was most predictive of PDF, whereas the level of activity on the day of dialysis was not.

Older age and wasting are risk factors for severe bacterial infections among patients with stage 5 chronic kidney disease (CKD), according to findings from a study by researchers at the Karolinska Instutet in Stockholm. Patients with a central dialysis catheter at the initiation of dialysis were more prone to infection, and patients with a particular single nucleotide polymorphism in the gene for interleukin-1β (IL-1β) were at markedly increased risk.

Kidney stones are an important risk factor for chronic kidney disease (CKD), researchers found when they studied the records of all residents of Olmstead County, Minn., over a 20-year span.

Kidney stones are known to lead to CKD in patients with rare genetic diseases, but their role as a risk factor for CKD in the general population had been less clear. Researchers generally thought that complications of kidney stones only rarely cause CKD; however, few long-term studies looked at the question.

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Exercise may benefit patients with end stage renal disease (ESRD) by improving their functional independence, resistance to disability, and survival of acute stressors.

Kidney function in obese kidney donors remains strong one year after donation, although long-term effects on renal function are uncertain, said Peter Reese and his colleagues at the University of Pennsylvania-Philadelphia at a Renal Week session.

As transplant centers work to maximize appropriate live donor transplantation, uncertainties remain concerning the potential risks of accepting kidneys from donors with obesity or other risk factors for future kidney disease. Also unclear are risks obese donors may face during and after the surgical procedure.

Low levels of potassium in the diet may be as important a contributor to high blood pressure as high levels of sodium—especially among African-Americans—researchers have found.

“Lowering salt or sodium in the diet to lower blood pressure is relatively well known, but more publicity on increasing dietary potassium is needed,” said lead author Susan Hedayati, MD, at the University of Texas Southwestern Medical Center in Dallas and the Dallas VA Medical Center.

Uremic pruritis, or itch, can significantly diminish quality of life and interfere with sleep, work, and social interactions for a large proportion of hemodialysis patients, according to findings from two poster presentations at the ASN annual meeting.

Drug-eluting stents provide the best one-year survival for patients with kidney disease who also must be treated for heart disease, but bypass surgery provides the best long-term survival, according to a study by Charles Herzog, MD, and Craig Solid, MS, of the Cardiovascular Special Studies Center at the United States Renal Data System (USRDS) in Minneapolis, Minn.

Depression is common among individuals on dialysis for kidney disease, but researchers have found that behavioral therapy can significantly improve these patients’ quality of life.

Patients undergoing hemodialysis are taxed both physically and mentally, and 20–30 percent become depressed. Many of these individuals are at increased risk of becoming hospitalized, developing other diseases, and even dying.

Kidney transplants lead to improved mental performance in people with kidney disease, new research shows.

Individuals with chronic kidney disease often suffer from cognitive impairment, but it is unclear to what extent outside factors such as age and medication play a role.

Albuminuria is a stronger predictor of renal disease progression and cardiovascular (CV) morbidity and mortality than is glomerular filtration rate (GFR), said George Bakris, MD, in his talk at the two-day program “CKD and CVD from the Vascular Viewpoint: Merging Basic and Clinical Sciences to Optimize Treatment” at Renal Week. Bakris stressed the need to monitor and reduce proteinuria to maximize risk reduction and said that blood pressure control is a key element in therapy.

Transition from Adolescent to Adult Care

“What is transition?” asked my colleague when I mentioned the topic of this article. As I began to explain the science and philosophy of the transition from pediatric to adult care my coworker’s expression became more thoughtful, although it was obvious that he didn’t know much about the topic. Later it became clear that there is a large amount of variability in different individuals’ knowledge of transition and in the effects of a rocky transition on those being transferred.

Kidney Watch 2015

Although last fall’s anxiety about the spread of the Ebola epidemic has receded, the outbreak continues in Africa. The possibility that U.S. hospitals will be treating more Ebola virus disease (EVD) cases cannot be discounted, and advance preparation is the key to coping with any infectious disease.

Patients’ access to specialized care before kidney failure develops varies significantly across the United States and among different racial groups. And perceived racial discrimination may have negative effects on kidney function.

Pre-ESRD nephrology care is crucial for optimizing the health of patients with this condition. How the United States and global kidney community ensure such care for the millions of people with kidney disease is crucial to stemming the disease’s growing prevalence.

Nearly two years after the Centers for Medicare and Medicaid Innovation (CMMI) announced the first-ever disease-specific innovation model, the first performance period of the ESRD Seamless Care Organizations (ESCO) program is slated to begin in January 2015. Large Dialysis Organization (LDO)-based ESCOs will be the first to participate in the program, followed by ESCOs operated by Small Dialysis Organizations (SDOs) in July 2015.

Suppose you’re seeing a new patient with kidney disease, high blood pressure, and high cholesterol. What if you could order a single lab test that would assess all known gene variants that might affect his response to common drugs—not just medications he’s currently taking, but also common drugs that may be prescribed in the future? That’s the approach being studied by The University of Chicago’s Center for Personalized Therapeutics and other centers nationwide.

The dust is still settling from the election of November 4, 2014, when Republicans gained control of both chambers of Congress. Whether a Republican Congress and a Democratic administration can work together to address the many domestic and foreign challenges confronting the country today is one of the biggest questions as we head into 2015.

In 2014, Congress made major gains toward finally repealing the broken sustainable growth rate (SGR). But, as of press time, Congress had failed to get legislation to repeal SGR over the line, meaning that physicians will again face pay cuts—and the hope of repeal—in 2015.

Insights from recent research into the nephrology workforce will inform discussions about nephrology’s future in 2015. Researchers from George Washington University (GWU) will continue their collaboration with the American Society of Nephrology (ASN) and expand upon their initial nephrology workforce research. Discussion of workforce trends and developments in the specialty is timely and has become more urgent after results of the Match for appointment year (AY) 2015–2016 were released on December 3, 2014.

Glomerular Disease

Pregnancy in Women with Glomerular and other Chronic Kidney Disease and the Need for International Collaboration

Patients with kidney disease are at increased maternal and fetal risk during pregnancy. In particular, glomerular-based kidney disease is overrepresented among younger patient populations and is therefore a common form of kidney disease that requires management during pregnancy. Potential untoward outcomes include progression of underlying renal dysfunction, worsening of urine protein excretion and hypertension, and untoward fetal outcomes including intrauterine growth restriction and preterm delivery.

Membranoproliferative glomerulonephritis (MPGN), also termed mesangiocapillary glomerulonephritis, is a diagnosis based on a glomerular injury pattern common to a heterogeneous group of diseases (1). MPGN is characterized by both an inflammatory (proliferative) and resolving (membrane) phase.

The therapy of proliferative lupus nephritis (LN) is generally divided into an initial phase of high-intensity immunosuppression to induce prompt clinical improvement, followed by a maintenance phase of lower-intensity immunosuppression to consolidate improvement into remission. Induction most often lasts 3 to 6 months, but maintenance lasts years and often indefinitely. The average duration of maintenance therapy in several recent randomized clinical trials was 3.5 years but ranged beyond 5 years.

The main goal of the Nephrotic Syndrome Study Network, NEPTUNE, is to build a translational research infrastructure for diseases manifesting as nephrotic syndrome (NS), which includes focal and segmental glomerulosclerosis (FSGS), minimal change disease (MCD), and membranous nephropathy (MN) (1). The network of investigators from 21 academic centers across the United States and Canada, and two patient interest groups, the NephCure Foundation and the Halpin Foundation, have worked closely together to study these rare glomerular diseases.

Advancing Understanding and Treatment of Glomerular Disease

Primary glomerular disease is an important cause of chronic and end stage renal disease

Chronic kidney disease (CKD) is increasingly recognized as a growing global challenge, affecting up to 16 percent of the adult population (1,2). Although the veritable explosion in type II diabetes is largely responsible for this growth in developed and many developing countries, primary glomerular disease continues to contribute meaningfully to the CKD epidemic (2). These diseases account for roughly 10 percent of CKD cases in the United States and up to 50 percent in other countries (3, 4). Primary glomerular diseases contribute to considerable morbidity, cost, and mortality.

In the past several years, major progress has been made in understanding the mechanisms underlying the development and progression of IgA nephropathy (IgAN). These advances have contributed to the generation of an ever-expanding catalog of measurable variables that provide diagnostic or prognostic information about IgAN. Such measures span the gamut from immune mediators and metabolites detectable in serum or urine, to genetic and epigenetic traits, to histologic features both traditional and novel.

The treatment of idiopathic membranous nephropathy (IMN) has been a matter of discussion for many years. Given the variable clinical course and potential toxicity of current regimens, the main issue nephrologists face at the moment are who to treat and with what regimen. Conservative management is justified for patients with subnephrotic proteinuria, inasmuch as spontaneous remission occurs more frequently in these patients, and their long-term prognosis is usually excellent.

2014 European Renal Association-European Dialysis and Transplant Association Congress

A novel compound in development, emapticap pegol (emapticap; NOX-E36, Noxxon Pharma), a drug with anti-inflammatory properties, may be the first disease-modifying drug for the nephropathy in type 2 diabetes mellitus (T2DM). In a presentation at the European Renal Association—European Dialysis and Transplant Association conference in Amsterdam in June, researchers presented evidence that emapticap had positive effects on the kidney that persisted for several weeks after the drug was stopped.

Better dental hygiene and oral health can lead to better overall outcomes for patients with end stage renal disease (ESRD). Researchers saw the effect regardless of the age at which patients initiated oral hygiene practices.

Poor oral health is a risk factor for cardiovascular and all-cause death among patients with chronic kidney disease (CKD). Compared to the general population, dialysis patients have more severe oral disease, and their uptake of dental health services is very low. But questions remain whether improving oral health would result in better outcomes.

Cinacalcet beats parathyroidectomy for improving survival of patients on chronic hemodialysis. The use of a vitamin D receptor activator (VDRA) along with cinacalcet produced additional survival benefit, researchers reported at the European Renal Association—European Dialysis and Transplant Association conference in Amsterdam in June.

ASN Kidney Week 2014

Beth C. Levine, MD
“Autophagy and Metabolic Diseases” is the title of a state-of-the-art lecture to be presented by one of the founders of the autophagy field on Sunday, Nov. 16.

Beth C. Levine, MD, is the director of the Center for Autophagy Research and the Charles Cameron Sprague Distinguished Chair in Biomedical Science at the University of Texas Southwestern.

Here's a list of 20 key takeaways about the American Society of Nephrology: its services, history, and much more.

Left: Tom Marino, Right: Jim McDermott
Two distinguished members of Congress will each receive a President’s Medal for championing the cause of kidney patients and research in a special presentation during the plenary session on Saturday, Nov. 15.

Reps. Jim McDermott (D-Wash.) and Tom Marino (R-Pa.) are the co-chairs of the Congressional Kidney Caucus, which Rep. McDermott co-founded in 2002.

Peter Igarashi

An expert on molecular mechanisms underlying kidney function will deliver the Robert W. Schrier, MD, Endowed Lectureship on the topic “MicroRNAs that Slow Cyst Progression” on Thursday, Nov. 13.

Peter Igarashi, MD, FASN, is professor of internal medicine and pediatrics at the University of Texas Southwestern Medical Center in Dallas, where he holds the Robert Tucker Hayes Distinguished Chair in Nephrology. Dr. Igarashi is also director of the University of Texas Southwestern O’Brien Kidney Research Core Center.

Douglas A. Melton
Stem cells offer hope for treatment of a host of diseases, and diabetes could be one of the most important. The potential of “Stem Cells to Understand and Treat Diabetes” will be the subject of a state-of-the-art lecture by Douglas A. Melton, PhD, on Thursday, Nov. 13.

Dr. Melton is the Saris University Professor at Harvard. He is also an investigator at the Howard Hughes Medical Institute and co-chair of the department of stem cell and regenerative biology at the Harvard Stem Cell Institute. Dr.

Sharon M. Moe

We need to be proactive and positive in promoting nephrology to the public, students, politicians, and government. Nephrology offers physicians a rewarding career that combines the excitement of science and physiology, continuity of care and lasting relationships, and the opportunity to improve our patients’ lives. We are detail-oriented by necessity, but sometimes this attention to detail can become unnecessarily negative. I encourage everyone to think positively and embrace collaboration in research, innovation, education, and health care delivery across the kidney health spectrum. The ultimate goal is to improve the care of those with kidney disease.

Martin R. Pollak, MD
A leading researcher into the genetic basis of kidney disease will deliver the Barry M. Brenner, MD, Endowed Lectureship on Thursday, Nov. 13. Martin R. Pollak, MD, will speak on “APOL1 and Glomerular Disease.” Dr. Pollak is the chief of the renal division at Beth Israel Deaconess Medical Center in Boston. He is also professor of medicine at Harvard Medical School and an associate member of the Broad Institute.
Eske Willerslev

An internationally recognized researcher in the fields of ancient DNA and evolutionary biology will unveil some secrets that can be learned from history in a state-of-the-art lecture entitled “What We Can Learn from the Genetic Past” on Friday, Nov. 14.

Mary B. Leonard
Mary B. Leonard, MD, will present the Jack W. Coburn, MD, Endowed Lectureship on Friday, Nov. 13. Dr. Leonard’s topic will be “Frailty, Fractures, and the Bone-Muscle Connection in CKD.”
Chad A. Mirkin, PhD

Smaller and smaller particles are doing bigger and bigger things in all fields of science. A specialist in these tiny matters will deliver a state-of-the-art lecture on “Realizing the Promise of Nanomedicine” on Saturday, Nov. 15.

Allan J. Collins, MD
The Belding H. Scribner Award will be tendered to Allan J. Collins, MD, for his career-long contributions to the practice of nephrology.

Dr. Collins is professor of medicine at the University of Minnesota School of Medicine and Hennepin County Medical Center and director of the Chronic Disease Research Group of the Minneapolis Medical Research Foundation.

Josephine P. Briggs
ASN will recognize the wide-ranging contributions of Josephine P. Briggs, MD, with the presentation of the John P. Peters Award.

An accomplished researcher and physician, Dr. Briggs is director of the National Center for Complementary and Alternative Medicine at the National Institutes of Health (NIH).

Myles Wolf, MD, MMSc
The ASN-AHA Young Investigator Award will be presented to Myles Wolf, MD, MMSc, for his groundbreaking research on mineral metabolism. He will describe his recent findings in an address: “Mineral (Mal)Adaptation to Kidney Disease.”

Dr. Wolf is the Margaret Gray Morton Professor of Medicine at the Feinberg School of Medicine at Northwestern University in Chicago. He is the founding director of the Center for Translational Metabolism and Health and director of the physician-scientist training program at Feinberg.

Friedhelm Hildebrandt, MD

Acclaimed researcher Friedhelm Hildebrandt, MD, will receive the Homer W. Smith Award and deliver an address at Kidney Week on “Single-Gene Defects Elucidate Mechanisms of CKD.”

Dr. Hildebrandt is the Warren E. Grupe Professor of Pediatrics at Harvard Medical School and chief of the division of nephrology at Boston Children’s Hospital. He is also an investigator at the Howard Hughes Medical Institute.

Andrey S. Shaw, MD
Andrey S. Shaw, MD, will deliver the Michelle P. Winn, MD, Endowed Lectureship on the genetics of human focal and segmental glomerulosclerosis (FSGS) on Friday, Nov. 14.

Dr. Shaw is the Emil R. Unanue Professor of Pathology and Immunology and head of the division of immunobiology at Washington University School of Medicine in St. Louis. He is also an investigator of the Howard Hughes Medical Institute.

Stuart L. Linas, MD, FASN

Stuart L. Linas, MD, FASN, will receive the Robert G. Narins Award for his many contributions to medical education.

Dr. Linas is the Rocky Mountain Professor of Renal Research at the University of Colorado School of Medicine, where he has served on the faculty throughout his academic career. He has directed the renal fellowship program since 1984 and headed the section of hypertension within the division of renal diseases since 1994. He is also the chief of nephrology at Denver Health Medical Center.

ASN President-Elect Jonathan Himmelfarb, MD, FASN, Looks to the Year Ahead
Without a doubt the coming year will present many exciting opportunities and challenges for nephrology, and I anticipate that ASN will be right in the middle of the action.
Richard J. Baron

The president of the American Board of Internal Medicine (ABIM) will deliver the Christopher R. Blagg, MD, Lectureship in Renal Disease and Public Policy on the topic “Opportunities and Challenges: Attracting the Next Generation” on Thursday, Nov. 13.

In addition to leading ABIM, Richard J. Baron, MD, also heads the ABIM Foundation in Philadelphia. ABIM is a certifying board that works with 250,000 physicians in 19 specialties—about one in four practicing physicians in the United States. Dr. Baron leads a staff of 200.

Kidney Health Initiative

Despite the large number of Americans affected by kidney disease, few new drugs have been approved to treat it in the past decade. To address this issue and to ensure high-quality care for every patient with kidney disease, the American Society of Nephrology (ASN) and the U.S. Food and Drug Administration (FDA) formed a public–private partnership called the Kidney Health Initiative (KHI) in September 2012 to enhance patient safety and foster innovation.

Home Dialysis

Impact of the Prospective Payment System (PPS) on Home Hemodialysis

The vast majority of patients with end stage renal disease (ESRD) undergoing dialysis receive this care through a Medicare entitlement enacted in 1972. Up until 2011, payment for dialysis treatments included one payment for the basic treatment itself, including all of the associated costs, and a separate payment for injectable medications (primarily erythropoietin, vitamin D, and iron) and some laboratory tests.

Home Dialysis: Patient Selection and Psychosocial Support

Which patients might benefit from home dialysis? Clinically, virtually all of them—a fact that nephrologists know given that only 6 percent of them would choose standard in-center hemodialysis (HD), done in a clinic thrice weekly for 3 to 4 hours, if their own kidneys were to fail (1). There is clearly an enormous disconnect between knowledge and practice, inasmuch as more than 90 percent of American patients with kidney failure are prescribed the treatment most nephrologists would not choose for themselves.

Dialysis leads to massive changes in an individual’s lifestyle. This is especially true for in-center conventional hemodialysis (CHD), which necessitates that patients constantly travel back and forth to their dialysis facility at least three times a week.

Home hemodialysis (HHD) has emerged as an important alternative treatment option for patients with end stage renal disease. The renaissance of HHD is based in part on several established and potential clinical benefits. In addition, HHD also acts as a conduit for intensive hemodialysis, which is otherwise not feasible in the context of dialysis centers. Various considerations and implications of establishing and implementing HHD have already been covered in this issue of ASN Kidney News. The clinical benefits of HHD will be discussed and summarized here.

Various home dialysis systems available for consumer use.

In 1972, when the Medicare Act provided people in the United States with coverage for renal replacement therapy, 40 percent of patients were doing home hemodialysis (HHD). In 2003, only 0.7 percent of the dialysis population in this country were doing HHD. The Aksys Company was founded in January 1991 to develop an HHD machine that would be patient friendly; reduce the labor of setting up, putting on, and tearing down; provide ultrapure water; and reuse the dialyzer and blood tubing to reduce cost. Since then, the following advances in HHD devices have continued to evolve.

In 1972, when the Medicare Act provided people in the United States with coverage for renal replacement therapy, 40 percent of patients were doing home hemodialysis (HHD). In 2003, only 0.7 percent of the dialysis population in this country were doing HHD. The Aksys Company was founded in January 1991 to develop an HHD machine that would be patient friendly; reduce the labor of setting up, putting on, and tearing down; provide ultrapure water; and reuse the dialyzer and blood tubing to reduce cost. Since then, the following advances in HHD devices have continued to evolve.

When snake oil salesmen peddled their cure-alls, an undefended populace fell prey to the “best story,” the “best sell,” and the “most persuasive line.” Then, as remedy upon remedy failed to prove effective, to be safe, or to give value for money, greater scientific rigor was demanded of medical intervention. With statistical methods improving in parallel, “proof by clinical trial” emerged.