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Despite the substantial successes of kidney transplantation, this field continues to be hampered by the inability to monitor the intensity of the immunosuppressive regimens. As a result, chronic antibody-mediated rejection (under-immunosuppression), as well as drug-related toxicity, malignancies, and opportunistic infections (over-immunosuppression) continue to be the leading causes of allograft loss.
In addition, counter to all the predictions, the vast improvement in the early acute rejection rate has not resulted in similar improvement in long-term allograft survival. Serum creatinine, the traditional marker to monitor kidney function, is highly unreliable in predicting renal injury of any kind. Protocol kidney biopsies, in addition
Diet and other health tracking mobile applications have become a part of everyday life for many people, and patients with kidney disease are no exception. Patients can choose from numerous kidney nutrition apps available in app stores, but experts warn many contain misleading or inaccurate information and few have undergone rigorous testing to ensure they are safe and effective.
A growing number of clinicians are trying to change that by developing and rigorously testing apps that help kidney patients make dietary choices to optimize their health. In September 2018, the American Association of Kidney Patients (AAKP), the Veterans Transplantation Association,
Our top area to watch for 2019 is the advent of sodium glucose cotransporter 2 (SGLT2) inhibitors, oral anti-hyperglycemic agents that have been recently approved for the treatment of type 2 diabetes mellitus (T2DM).
Aside from their glucose-lowering effect, SGLT2 inhibitors have also been shown to reduce blood pressure, body weight, and albuminuria. These multiple beneficial metabolic effects have contributed, at least in part, to reductions in cardiovascular and renal outcomes observed in large cardiovascular outcome trials. As a result, the American Diabetes Association’s 2019 Standards of Medical Care in Diabetes (
The addition of anti-inflammatory and immunosuppressive drugs to the standard of care (SOC) treatment of systemic autoimmune disorders affecting the kidney has impressively improved outcomes over the past decades. Nonetheless, for example, the adjusted mortality rate of individuals with anti-neutrophil antibody (ANCA)–associated vasculitis is still 2.71 in comparison with the general population (
Uncontrolled disease activity and infectious complications are major risk factors for early mortality, but side effects of immunosuppression, and in particular corticosteroid therapy, increase long-term morbidity and mortality. Next to promoting the development of hypertension, osteoporosis, weight gain, and diabetes along with coronary heart disease
Immigration.
One of the most polarizing issues in the country was the topic of a special session devoted to Improving Care for Vulnerable Patients at ASN Kidney Week 2018. Speakers included Rajeev Raghavan, MD, FASN, associate professor of medicine/nephrology at Baylor College of Medicine; Valerie Luyckx, MD, Institute of Biomedical Ethics, Geneva, Switzerland; Lauren Stern, MD, assistant professor of medicine and nephrology at Boston University; and Jenny Shen, MD, assistant professor of medicine and nephrology at UCLA.
Understanding the issues surrounding the care of undocumented patients begins with numbers.
ESRD patients account for <1% of the Medicare population, yet they
Despite advances in the management of hypertension and diabetes—the two risk factors accounting for over 70% of all cases of chronic kidney disease (CKD)—the prevalence of CKD in the general population has risen from about 10% two decades ago to 14.8% in 2017, surpassing that of diabetes (9.4%) (
Minority populations disproportionately have hypertension and diabetes and consequently bear a disproportionate burden of CKD (
Smooth transition from CKD stage 5 to renal replacement therapy (RRT) remains a challenge. This transition period bears a high risk for mortality (
Often dubbed an options clinic, this team-based approach needs to be conducted when RRT is anticipated within a year, sufficient time being allowed for access placement and transplant evaluation (
Population-based screening and identification strategies for patients with CKD remain a challenge. Data from the Behavioral Risk Factors Surveillance System suggest that most patients with CKD do not know they have the condition. Screening strategies such as albuminuria and serum creatinine determinations are not widely used in the general population and are performed only on indication; hence, most patients with CKD go undetected, for several reasons.
First, although screening is indicated in patients with traditional risk factors for CKD, including diabetes, hypertension, older age, cardiovascular disease, history of acute kidney injury, and a family history of CKD, screening is generally
Many patients with CKD invariably experience progression, slow or fast, to later CKD stages and require renal replacement therapy at some point. Controlling the primary risk factors for CKD has been shown to slow progression of CKD but does not prevent the development of ESRD. The mechanisms underlying slow or fast progression of CKD are complex but are generally attributable to nephron loss from the primary disease, which sets a vicious circle of further nephron loss, characterized by hypertrophy and hyperfiltration of the remaining nephrons, intraglomerular hypertension, proteinuria, and toxicity of filtered proteins on tubular epithelial cells (
The best chance to slow or reverse the progression of chronic kidney disease (CKD) is in CKD stage 1, when GFR is still preserved. The strategy in stage 1 CKD is to control comorbidities (treat to target) and to perform risk assessment and intervention for cardiovascular disease (
