Special Sections

Health Disparities in Kidney Disease

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%) (1) and making it a major public health problem in the United States.

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 (13). Although these forces have been attributed to pertain to many glomerular diseases, the processes are particularly described in diabetic nephropathy, in which podocyte loss may be a downstream effect (4).

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 (1). Unfortunately, many patients, particularly those of minority extraction, do not get this early referral benefit, as noted in the previous section. Current evidence-based progression-specific treatment approaches in CKD include treating BP to acceptable goals, blockade of the renin-angiotensinogen aldosterone system (RAAS), and controlling metabolic acidosis. Trials of antioxidants by the use of bardoxolone, an inhibitor of oxidative stress that failed phase 3 clinical trials, was associated with worsened albuminuria and heart failure (2). Antagonists of inflammation, renal fibrosis, extracellular matrix deposition, and endothelin 1 have not yielded any meaningful clinical application. Interestingly, antagonists of the mineralocorticoid receptor have demonstrated reduced albuminuria but have been associated with high blood potassium levels, which may limit their use in patients with advanced CKD (3). Of the progression-specific treatment approaches, the RAAS system and BP control exhibit significant racial disparities, as detailed below.

Kidney transplantation is the renal replacement therapy (RRT) of choice for most patients with ESRD because it is associated with improved survival and improved quality of life, and it is less expensive than dialysis. The process leading to transplantation is complex, with multiple necessary steps that must be completed before transplantation. Despite improvement in outcomes, disparity across the board in the transplantation process continues to be a major problem.

Smooth transition from CKD stage 5 to renal replacement therapy (RRT) remains a challenge. This transition period bears a high risk for mortality (1); hence, it requires a multidisciplinary pre-ESRD team approach (2) to address all aspects of care aimed at improving survival and providing adequate patient education about transplantation, in-center hemodialysis (HD), and home-based therapies (3).

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.

Opioids and Kidney Diseases

/kidneynews/10_7/12/graphic/12f1.jpgAdding to previous studies suggesting that illicit drug use is associated with the development of chronic kidney disease (CKD), new research indicates that it may also put patients with established CKD at elevated risk of disease progression and early death.

The Centers for Medicare & Medicaid Services (CMS) released the “CMS Roadmap to Address the Opioid Epidemic” in June 2018 (1). CMS stated at the time that “although some progress has been made in efforts to combat the opioid epidemic, the latest data from the Centers for Disease Control and Prevention (CDC) indicate the crisis is not slowing down” (2).

Highlights of the crisis are:

When Kidney News went to print, the U.S. House of Representatives had passed H.R. 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. Passed with bipartisan support, H.R. 6 combines provisions from more than 50 bills approved individually by the House.

The bill is designed to help overall efforts to combat the opioid crisis by advancing treatment and recovery initiatives, bolstering prevention efforts, and trying to counter deadly illicit synthetic drugs like fentanyl.

Policymakers and public health officials are sounding the alarm about the opioid overdose crisis nationwide. More than 115 people die each day due to opioid-related drug overdoses, and the Department of Health and Human Services (HHS) Secretary Alex Azar has made combatting this epidemic one of his top priorities.

An uptick of thrombotic microangiopathy (TMA) cases with a presentation similar to that of a rare blood disorder, thrombotic thrombocytopenic purpura, at Wake Forest Baptist Health in Winston-Salem, North Carolina, tipped off hematologist Peter Miller, MD, that something unusual was going on. An assistant professor at Wake Forest University, Miller had read a report from the U.S.

Women and Kidney Diseases

This year’s World Kidney Day falls on International Women’s Day, offering the nephrology community an excellent time to reflect on the theme, “Kidneys & Women’s Health: Include, Value, Empower.”

What progress have we made in addressing women’s kidney health? Why do so many unanswered questions remain? Most important, how do we as nephrologists currently care for women with chronic kidney disease (CKD)? How do we empower them?

Enigmas abound in the clinical care and research related to acute kidney injury (AKI). Unfortunately, little conversion of research findings to changes in patient care has occurred.

Investigators who are designing clinical trials and preclinical studies have realized that results found in males do not always hold true in females, and that there are clear differences in the sexes that should be considered when preventing and treating a wide variety of health issues. Kidney researchers also note that because female physiology is optimized for successful reproduction—which entails large fluctuations in vascular, hemodynamic, and renal function—it’s likely that female kidneys have important differences from those of males.

Studies have shown gender disparities in care for many chronic diseases, and ESRD is no exception.

Studies from the early 2000s suggested that women had lower rates of hemodialysis initiation using an arteriovenous fistula (AVF), the preferred hemodialysis vascular access. A recent study in Hemodialysis International analyzed gender-related differences in AVF use at dialysis initiation, including variations between ESRD regional networks.

The risk of developing CKD is at least as high in women as in men, and possibly higher. Yet the number of women receiving dialysis is lower than the number of men, and women are more likely to donate kidneys but less likely to receive transplants.

The March 2018 World Kidney Day theme, “Kidneys & Women’s Health: Include, Value, Empower,” aims to shine a light on issues of equitable healthcare access for women with kidney diseases worldwide.

“There’s no doubt that my wife and I waited too long to have that discussion, and part of that is—my wife is very quiet … we’ve been married for 55 years. So we never really had that discussion. And before I realized, it was kind of too late.” (interview 6, man, health care proxy for patient with cognitive impairment) (1).

What are the barriers to palliative care for those with kidney diseases? How do I respond when my patient says they want to stop dialysis? These are among the questions addressed in the September 2017 special section on palliative care. We continue the discussion here, with articles on hospice access, integrating advance care planning into the care of patients with kidney diseases and kidney failure, and nephrologists’ attitudes toward palliative care.

The US dialysis population is growing faster than the number of new nephrologists. At the same time, our population is aging, and there is a shortage of geriatricians. Beyond efforts to expand the nephrology and geriatrics workforces, it is also extremely important to pursue interdisciplinary collaboration. How can we ensure that older adults receiving dialysis receive quality care for their geriatric conditions? How can geriatricians be great partners in managing older adults with chronic kidney disease?

Can I stop dialysis?” asked my 88-year-old wheelchair-bound patient on a late fall afternoon. I squinted my eyes to block not only the streaming sunlight but my reaction: one of bewilderment.

In this issue, Kidney News Editorial Board member Edgar Lerma, MD, interviewed Christian T. Sinclair, MD, this month’s special section editor, about palliative care in kidney disease. Dr. Sinclair is Assistant Professor in the Division of Palliative Medicine at the University of Kansas Health System in Kansas City, KS. We hope you enjoy this introduction to palliative care in nephrology, as well as the set of articles that follow. More articles will appear in the next issue.

Patient-reported outcomes in patients with chronic kidney disease (CKD)/ESRD have assumed increasing importance during recent years, because these factors also play a vital role in affecting outcomes, as do traditional survival determinants. A comprehensive understanding of measurements coming directly from patients is expected to assist physicians in improving patient care and facilitate patients in optimizing their decision-making processes.

Psychologic concerns are prominent in chronic illness, such as ESRD, in which patients face significant morbidity, mortality, and complex treatment decisions. However, these symptoms are often not recognized or effectively treated. Because rates of depression and anxiety increase in this population, there is a need for interdisciplinary team collaboration among nephrology, palliative care, and mental health. Here, we present a guide tailored to the kidney care team for identifying and managing depressive and anxious symptoms in ESRD patients.

Offering patients life-prolonging treatments while at the same time improving their quality of life is a balancing act. With time, we learn that more care is not necessarily good care, that not every test or treatment available to the patient is needed, and that, at times, they may cause more harm than good.

Patients with ESRD experience a high degree of symptom burden—physical symptom burden akin to patients with advanced cancer, along with emotional and spiritual suffering. In addition, ESRD patients on maintenance dialysis have the highest levels of medicalization at the end of life, surpassing what is experienced by their counterparts with other advanced chronic illnesses (1). Although high-intensity health care at the end of life may be goal concordant for a minority of patients, it is not on a population level.

A foremost goal of American medicine for the 21st century to improve the quality of health care is individualized, patient-centered care. The recommended means to achieve this care is shared decision-making, a conversation process in which the physician communicates information to the patient about diagnosis, prognosis, and treatment options and the patient communicates to the physician about his or her history, values, and treatment preferences. Together, the two share responsibility in reaching a common understanding of the patient’s preferred treatment course.

Effective communication is necessary when providing medical care but can prove challenging when attempting to match patients’ values to therapies. Nephrologists often participate in difficult conversations with patients and their families, most commonly involving dialysis in patients with chronic kidney disease (CKD) and ESRD. Despite this, most nephrologists and nephrology fellows do not feel prepared for these difficult conversations (13).

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.

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.

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.

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.

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

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

Diabetic Nephropathy

Diabetic nephropathy (DN)—the progressive decline in renal function usually accompanied by proteinuria, hypertension, and declining glomerular filtration rate (GFR)—is a major complication of longstanding diabetes. After 15–25 years of diabetes, approximately 25–40 percent of patients with type 1 diabetes mellitus (T1DM) will ultimately develop signs of renal involvement. According to the USRDS database, diabetic nephropathy is the single most important cause of end stage renal disease (ESRD) in the United States, Japan, and Europe.

New-onset diabetes after transplantation (NODAT) affects up to 50 percent of nondiabetic patients post-kidney transplant depending on the type of study (retrospective versus prospective), the patient population, frequency of sampling, posttransplantation complications, the immunosuppression regimen, duration of follow-up, and diagnostic criteria.

Are common causes of progressive kidney disease regulated by genes?

Many common diseases, including nephropathy, cluster in families, and genetic variants seem likely to regulate disease pathogenesis (1). Until recently, convincing evidence that common disease genes exist has been lacking.

Many therapies exist to treat diabetic kidney disease (DKD). Some have been proven to delay the progression of chronic kidney disease (CKD), while others have not been rigorously tested in a controlled way. This article summarizes the major clinical findings that direct DKD treatment and outlines the progress of ongoing trials whose results will direct care.

By the end of 2007, over 500,000 Americans were afflicted with end stage renal disease (ESRD), and almost 368,000 patients were undergoing dialysis therapy. Diabetes remains the most common cause of ESRD and accounts for over one-half of all new dialysis patients in the United States. Diabetic dialysis patients have poorer outcomes in general compared to nondiabetics. As a result, clinicians and researchers alike are searching for ways to improve outcomes of these patients.

Translational Research: Where do We Go from Here?

Would you bet $25 to win $100?

We would gladly take the bet if the chance of winning were 96 percent. We certainly would not change our minds if the odds dropped to 94 percent. However, many scientists make different decisions on the basis of the p values inherent in this example—whether p = 0.04 or p = 0.06.

Idiopathic nephrotic syndrome (INS) affects 16 per 100,000 children and is one of the most common acquired childhood kidney diseases. INS often runs a relapsing course in children, even in the children who respond to prednisone therapy. As a result, these children often have a prolonged clinical course. Because of the burden of this condition—augmented by the significant complications associated with INS and its treatments in children—childhood INS remains an intimidating challenge for children, families, and medical professionals.


The kidney maintains a proper fluid and electrolyte balance in our body, plays a major role in regulating blood pressure, and filters out waste products from the bloodstream for excretion from the body as urine. In addition, it is the source of the hormone erythropoietin and the active form of vitamin D. How has animal research contributed to treatment of kidney failure?

In 1971, I was diagnosed with kidney failure. Although I didn’t know it, my life had taken a new path. With a husband to love and support me, and a new baby daughter to raise, I had to pull myself together and get on with life.

My blood pressure was much too high, and soon I entered a clinical trial at the University of Washington in Seattle. The new blood pressure medicine being tested in the trial worked well for me. It slowed my kidney failure and kept me off dialysis for several years, much longer than had been projected.

Acute Kidney Injury

Over the past few years, and for appropriate reasons, the field of acute kidney injury (AKI) has evolved at a rapid pace. Even the name acute renal failure (ARF) was changed to AKI, and ICD-9 codes adopted AKI in October 2008. The primary reason for the change in nomenclature was the repeated observation that pharmacological therapy of AKI has been unsuccessful despite proven benefits seen in preclinical studies.

Acute kidney injury (AKI) is a frequent complication in critically ill patients and is associated with a high mortality rate. Continuous renal replacement therapy (CRRT) represents a spectrum of dialysis modalities developed in the 1980s specifically for the management of critically ill patients with AKI who could not tolerate traditional intermittent renal replacement therapy (IRRT). Over the years, CRRT has found widespread use and acceptance due to its ability to provide effective volume and metabolic control in hemodynamically unstable patients.

The main therapeutic intervention for treatment of acute renal failure (ARF), extracorporeal renal replacement therapy (RRT) was introduced over half a century ago. RRT has changed the natural history of this disorder from a devastating condition that almost invariably led to the patient’s demise, to a manageable complication. Unfortunately, further improvement in survival rates among patients with ARF have at best been incremental, with mortality rates remaining unacceptably high (13).

Recent and important advances in acute kidney injury (AKI) research have focused primarily on: ( i) derivation and validation of multidimensional AKI definitions and classification systems, e.g., RIFLE (Risk, Injury, and Failure (1), pRIFLE (2), or the Acute Kidney Injury Network (AKIN) (3) definitions; (ii) demonstrating that even small serum creatinine increases (e.g., > 0.3 mg/dL) can be associated with increased patient mortality (4); and (iii) discovery and validation of novel urinary bioma

Special Section

The kidney community has devoted a great deal of effort to building consensus regarding the definition of acute kidney injury (AKI). This has resulted in RIFLE classification and AKI network (AKIN) criteria focused on changes in serum creatinine (SCr) and rate of urine production. These changes in SCr are important and have been shown to be predictive of outcome in a number of studies.

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.


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.


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.

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.

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 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.

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.

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.

Stones and Bones

Arterial calcification is a common problem in advanced kidney disease and contributes to the high prevalence of cardiovascular disease. There are two forms: neointimal calcification, associated with atherosclerosis, and medial calcification. The former is not exclusive to renal failure and occurs in anyone with atherosclerosis. It is unclear whether this has any clinical significance other than being a convenient marker of atherosclerosis. Medial calcification is independent of atherosclerosis and is strongly linked with chronic kidney disease (CKD).

Phosphate is a true uremic toxin. Cross-sectional studies in patients undergoing dialysis uniformly demonstrate an increased risk of mortality with increasing phosphate levels. The population-attributable risk of mortality in dialysis patients is markedly greater for phosphate than anemia or urea reduction ratio.

Of longstanding interest to nephrologists, vitamin D has now become a hot topic in the general medical and lay literature. While the beneficial effects of vitamin D on mineral metabolism have been appreciated for a century, a burgeoning body of literature attests to a multitude of other effects including modulation of the immune system, anti-infectious and anti-neoplastic effects, anti-proteinuric effects, antagonism of the renin angiotensin system with attendant cardiovascular benefits, and insulin-sensitizing effects.

One might think that rare diseases are rare. But if one were to combine all the rare diseases that affect Americans, the overall prevalence is not rare at all. In fact, 30 million Americans, or roughly 10 percent of the population, are affected by a rare disease. Many of these disorders are severe and lead to a significant effect on people’s lives and life expectancy.

The Nephrology Workforce Crisis

To facilitate the matching of internal medicine residents with nephrology fellowship training programs, nephrology first participated in the Electronic Residency Application Services (ERAS) in 2006 and the Medical Specialties Matching Program (MSMP) in 2007. MSMP—part of the larger National Residency Matching Program—is a service that pairs residents with available fellowship positions. Currently, 10 internal medicine specialties participate in MSMP (Table 6.1).

Responding to concerns about the future of the nephrology workforce, the ASN is currently establishing a Workforce Committee. “A key goal of the ASN Strategic Plan is to advance patient care and research in kidney disease by strengthening the pipeline of clinicians, researchers, and educators,” explains ASN President Joseph V. Bonventre, MD, PhD, FASN.

The ASN Workforce Committee will help the society meet this goal by

From boom to bust, the projections for the physician workforce in the United States reverse every 20 years. In the 1960s, experts projected a shortage of 40,000 physicians by 1975. During the 1980s and 1990s, some of the same experts predicted a surplus of up to 165,000 physicians by 2000. A few years ago, the country was expected to face a shortage of 55,000 physicians by 2020 (1).

In contrast to adult nephrology, pediatric nephrology significantly increased its number of USMG fellows in recent years (1, 2). From 2002 to 2009, the number of pediatric nephrology fellows grew from 65 to 123, and the number of USMGs in pediatric nephrology fellowships jumped from 31 to 71, bringing USMGs up to 57.7 percent of the total from 47.4 percent.

As mounting evidence makes the waning interest in nephrology obvious to all of us, we must ask, “Why have we been asleep behind the wheel?” The accompanying articles in this special issue of ASN Kidney News detail many of the problems that have finally gotten our attention.

Interest in nephrology as a career among United States medical graduates (USMGs) is declining—and has been on the decline for the better part of a decade. From 2002 to 2009, all internal medicine subspecialties increased the number of available positions, with the exception of geriatric medicine (which shrank overall) (1, 2).

The workforce crisis hitting the field of nephrology extends beyond physicians to nurses, nurse practitioners, and physician assistants (PAs), who are often on the front lines in the battle against kidney disease. Nurses and nurse practitioners provide essential services to patients with kidney disease, working in hospitals, dialysis centers, and homes. They help bridge the growing gap between the number of patients with kidney disease and the availability of nephrologists.

As is the case with many chronic diseases in the United States, chronic kidney disease (CKD) is on the rise. The recent recognition of CKD as a public health problem may be driving patients to nephrologists at earlier stages. At least 26 million Americans have some stage of CKD (Figure 3.1), and minority populations are disproportionately affected.

Topics in Transplantation

Speakers at a “Controversies in Organ Transplant Policy” session at Renal Week 2010 described a range of issues affecting both kidney donors and recipients.

In recent years, the 60- to 80-year-old age group on the kidney transplant waiting list has increased dramatically, decreasing their chances of ever receiving a kidney. Yet studies show that even those older than 70 can decrease their chance of death and increase the length of their life with a kidney transplant.

Unrelated living donors in the United States have increased to the point where they were the most common category in 2009, most likely because of swaps and chains, said Gabriel Danovitch, medical director for the Kidney and Pancreas Transplant Program at the University of California, Los Angeles.

Three years ago, Garet Hil’s daughter’s kidneys failed, and he and his family entered a desperate race to find a living donor for her, including asking 100 family and friends to be tested and entering into every paired organ exchange program that existed in the United States. After several months of angst, they found that Hil’s 23-year-old nephew was a compatible match.

Kidney transplants are being performed in an era when higher-risk donor organs are being used. One could expect, given this scenario, that posttransplant renal function and graft survival would be adversely affected.

Refreshingly, recent studies show that kidney transplant function in the United States has improved in recent years, as has also graft survival.

The call had come. A donor was identified for 18-year-old Tim. His path to transplantation was not the smoothest, but in many ways, it was perhaps quite typical. He had received a diagnosis of Alport syndrome at a young age. Throughout his adolescence, his engagement was poor. He had received immunosuppressive therapy for a few years, with fluctuant drug levels. He often sat through appointments without his hearing aids and would provide very little independent information.

A wide array of ethical issues comes into play regarding renal transplantation after prior solid organ transplantation. They include concerns about prevention and access. One must first understand the scope of the problem. The prevalence of chronic kidney disease (CKD) among prior non–renal organ transplant (NRTx) recipients is between 80 percent and 100 percent for those who survive three years. The more advanced stages of CKD, types IV and V, occur in 5–20 percent of patients by five years after NRTx, and they vary according to the type of transplant.

Outcomes of kidney transplants and the rate of deterioration in posttransplant kidney function in the United States have improved in recent years. This news provides optimism to patients awaiting transplants, their caregivers, and their families, as well as the assurance that they are waiting for a transplant that has a durable lifespan and function. These gains are particularly tied to advances in patient selection and medical management of the many complexities posed by renal transplantation.

Geriatric Kidney Care

Chronic kidney disease (CKD) is a relatively common condition in the older American population. An estimated 26 million people in the United States are reported to have CKD. As the population of Americans 65 and older grows, so does the incidence of CKD. Evidence now indicates that kidney disease and aging carry a significant risk for cardiovascular complications and sudden death.

The end stage renal disease (ESRD) end-of-life coalition was developed by a diverse group of individuals committed to patient-centered end-of-life care for ESRD patients, their families, and their health care providers.

In the United States, the number of end stage renal disease (ESRD) patients on maintenance dialysis has increased 20 percent in the last decade to 1700 per million, and 100,000 new cases are added every year. The largest increase in both incident and prevalent cases of ESRD has been in individuals ≥65, with rates three- to fourfold higher compared with younger individuals (Figure 1). Nearly 50 percent of all patients on dialysis are ≥65.

Hypertension is common in people 60 and older. With increasing age, it is more likely that someone will experience hypertension and die of coronary heart disease even in the prehypertension range (1, 2) (Figure 1). According to the National Health and Nutrition Examination Survey (NHANES) 1999 to 2006, approximately 67 percent of adults in the United States 60 and older had hypertension, a 10 percent increase from NHANES 1988 to 2004 (3).

In the United States, as in many other developed countries, the incidence of treated end stage renal disease (ESRD) increases with advancing age; the highest rates are observed in individuals between the ages of 75 and 79 (Figure 1) (1). There is concern, however, that the functional rehabilitation of elderly dialysis patients is often unsatisfactory and the gain in life expectancy with renal replacement therapy is rather modest.

Chronic kidney disease (CKD) is likely to be the most common condition managed by practicing nephrologists in elderly patients attending a nephrology clinic. Why? Because the majority of individuals with renal disease are 65 or older (Figure 1) and CKD is the most common renal disease in the older individual.

Figure 1.

Prevalence of CKD in NHANES 1988–-1994 and 1999–2004 by age group (reprinted from JAMA, 2007)

Elderly persons frequently experience acute kidney injury (AKI). Although studies describing its incidence in this population are difficult to compare because definitions of AKI vary dramatically from study to study, it is clear that the elderly are at the very highest risk for developing the condition. Indeed, Feest and coworkers (1) demonstrated that there is a three- to eightfold progressive, age-dependent increase in the frequency of development of community-acquired AKI in patients over 60.

U.S. census data show that the population of individuals over 65 in the United States is growing rapidly and is expected to double over the next 20 years. This means that current fellows can expect to see an increasing number of older patients in professional practice. Average life expectancy is currently around 75.2 years for men and 80.4 years for women, and continues to rise. During the 1990s, the fastest growing population was that of individuals over 85, with 38 percent annual growth, and this group is the largest consumer of health care services.

Kidney 2.0

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.

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.

Kidney Week 2015

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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

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).

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.

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).

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.

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).

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.

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.

Pregnancy and the Kidney

The Nobel Laureate Joseph Murray provided the first report of pregnancy in a transplant recipient (1). Since that time, over 16,000 pregnancies have been documented in the world literature (2). Many more pregnancies have clearly occurred, now that pregnancy after transplantation is commonplace and is rarely reported. The data about pregnancy in transplant recipients come from case reports and registry reports, but these sources underrepresent the population of transplant recipients who have become pregnant (2).

About 5 percent of pregnancies suffer complications from abnormal placental development. The process of placentation begins when blastocysts adhere to the uterine endometrium, forming a lineage of epithelial cells termed the invasive extravillous cytotrophoblast, which then invades the uterine wall to create the decidua, transforming the spiral arteries into a low-resistance uteroplacental circulation.

Pre-eclampsia is a systemic syndrome occurring in the second half of pregnancy, with cardinal manifestations of hypertension and proteinuria. Pre-eclampsia is one of the most common glomerular diseases in the world; it affects approximately 3–5 percent of all pregnancies. Although careful obstetric management—including antihypertensive medications and seizure prophylaxis with intravenous magnesium—is important for the treatment of pre-eclampsia, delivery of the neonate and placenta remains the only definitive treatment.

During pregnancy, the development of acute renal failure is especially daunting because two lives are involved and at risk. The outcomes of acute kidney injury (AKI), as in other settings, can be quite poor, with significant morbidity and mortality rates of 20–30 percent.

Healthy kidneys—healthy pregnancy

A healthy pregnancy—a baby born at term, with minimal untoward physical consequences to the mother—is the ideal outcome and indeed, when it occurs, is nothing short of a miracle.

The Kidney Cardiac Link

interaction between chronic kidney disease (CKD) and cardiovascular disease (CVD), termed the cardiorenal syndrome (CRS), is characterized by enhanced risk of atherosclerosis and uremia-related myocardial disorders (Figure 1). While milder degrees of renal impairment (CKD stages 1–3) are associated with accelerated risk of atherosclerotic events, a uremia-specific cardiomyopathy characterizes the more severe and advanced stages of renal dysfunction and end stage renal disease (ESRD) (stages 4, 5, and ESRD) (Figure 1).

Figure 1. Guanylyl cyclase (GC) pathways, activation of cGMP as their second messenger

anemia is common in congestive heart failure (CHF) and is associated with increased mortality, morbidity, and progressive renal failure. The two most common causes of the anemia are associated renal failure, which causes depression of erythropoietin production in the kidney, and excessive cytokine production, which can also cause depression of erythropoietin production in the kidney as well as depression of the erythropoietic response in bone marrow.

renal dysfunction is a common and often progressive complication of heart failure (Figure 1). Renal function is—to use a descriptive term—“twitchy” in the patient with heart failure. It can change relating to patient volume status, concomitant medications, and adequacy of pump function, with all factors influenced by the background level of renal function.

most cardiologists consider the coexistence of heart failure and chronic kidney disease (CKD) (1) or worsening of renal function (WRF) defined as an increase in serum creatinine >0.3 mg/dL (2) during treatment of acute decompensated heart failure (ADHF) as a reasonable working definition of cardiorenal syndrome (CRS).

the interaction between the heart and the kidney is well known. Congestive cardiac failure can be tied to acute renal failure with prerenal origin or, if it is sustained in time, to renal failure. Chronic cardiac disease and chronic kidney disease can both lead to chronic disturbances in the other organ. Lindner et al. published work describing the association between hemodialysis and accelerated atherosclerosis (1).


Cardiac and renal diseases are common and frequently coexist, adding to the complexity and costs of care, and ultimately, to increased morbidity and mortality (1).

Cardiorenal syndrome can be defined as a pathophysiological state in which primary dysfunction of one organ (the heart or the kidney) induces or exacerbates dysfunction of the other. Cardiorenal syndrome occurs through multiple mechanisms that demonstrate the complex interaction between the two organs.

Kidney Watch 2016

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.

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.

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.

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.

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.

Kidney Week 2015 Plenary Sessions

Janos Peti-Peterdi


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.

Donald E. Ingber


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.

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.

Roger C. Wiggins


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

Corinne Antignac


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.

Gerald I. Shulman


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.

Dontscho Kerjaschki


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.

Helen H. Hobbs


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


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.

Shari M. Ling


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.

Ravi I. Thadhani


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.

Mark L. Zeidel


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

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.

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).

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.

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.”

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.

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.

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).

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

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.

Transplantation: Issues and Controversies


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.

Titte Srinivas


Jesse Schold


Wsilliam E. Mitch


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.

Bernard Lo


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.

Matthias Kretzler


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


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


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.

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.

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?

L. Darryl Quarles


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.

Oliver Smithies


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.

Tony Pawson


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.

Burton D. Rose


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.

Barry M. Brenner


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

the American Society of Diagnostic and Interventional Nephrology (ASDIN) is dedicated to enhancing the quality of care that patients receive related to vascular access, peritoneal dialysis access, and ultrasonography. Established in 2000, the mission of ASDIN is to promote the appropriate application of new and existing procedures in order to improve the care of patients with kidney disease. Membership includes physicians, nurses, technicians, and administrators—all with interest in this specialized field.

acute kidney injury (AKI) often presents formidable risks to patients in critical care units, particularly those with associated multiorgan failure. Such patients are very likely to die in spite of the best efforts of providers. With this in mind, aggressive management of AKI using hemofiltration and/or dialytic therapy has evolved. Systems appropriate for use in pediatric patients are limited today.

recent advances in molecular diagnostics are making inroads in how we manage patients with kidney-related disorders. Techniques such as nucleic acid amplification and detection, genomic analysis, proteomics, and metabolomics have enabled development of several molecular diagnostic assays. These developments, in turn, affect the practice of various aspects of nephrology, such as management of acute kidney injury, chronic kidney disease (CKD) and its complications, as well as transplant nephrology.

Since its introduction in the early 1960s, ultrasonography has become an essential part of the workup and management of patients with kidney disease owing to its safety, low cost, and the ease of visualizing the kidneys, bladder, and blood vessels. Given ultrasonography’s simplicity and utility, it is curious it is not routinely performed by many nephrologists, considering that ultrasonography has become a standard procedure for many other specialists and subspecialists.

a mbulatory blood pressure monitoring (ABPM) is a noninvasive, automated method for measurement of brachial artery blood pressure (BP) in a nonclinical setting. The two major benefits of ABPM are that the measurements reflect the diurnal pattern of BP of the individual and that data are obtained outside the clinic or hospital setting. There are excellent reviews on use of ABPM in children and adults (13). This article will cover the basics of ABPM—methodology, applications, and indications.

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.

Medicine Online

Many physicians, health care extenders, and students increasingly use online educational resources. From databases to blogs, the amount of medical information one can access is growing exponentially. Unfortunately, much of this medical information is scattered on numerous websites, each designed for one specific audience only. As a result, physicians are learning and sharing information in isolation from medical trainees, nurses, students, and patients.

a transformation is occurring in science, specifically in the domains of health and medicine. Second generation Web technologies that facilitate interaction between users are changing the way health care professionals communicate with each other, as well as with patients, health consumers and bio- medical researchers.

Updates in Dialysis

1983–1988: Technology and bioengineering

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.

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.

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.

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).

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.

Kidney Week 2014

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.

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.

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.

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.

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.

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.

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

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.

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.


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).

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.

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.

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).

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.

Kidney Week 2013

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.

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.

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.

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.

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.

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.

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.

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).

KDIGO: A Promise Unfilled

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 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 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.


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

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.

“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

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).

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.

Dialysis: Change is Online


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.


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

Renal Week 2008

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.

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.

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.

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

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.

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.

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.

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.


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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Glomerular Disease

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.

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.

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.

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.

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 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.

2014 European Renal Association-European Dialysis and Transplant Association Congress

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.

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.

ASN Kidney Week 2014

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.

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.

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).

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.

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.

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.

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.

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.”
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.

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.

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.
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.

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.

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.
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.

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

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

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.

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.

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.

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.

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.

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 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.