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What's new in nephrology and hypertension

Last literature review version 17.3: September 2009  |  This topic last updated: October 16, 2009   (More)

The following represent additions to UpToDate since the last version that were considered by the authors and editors to be of particular interest. The new material described below represents a small subset of the updating that has been performed, since approximately 40 percent of the topic reviews are updated during each four-month cycle.

GLOMERULAR DISEASE AND VASCULITIS

A major antigen for idiopathic membranous nephropathy has been identified. Circulating antibodies to the M type phospholipase A2 receptor have been identified in 26 of 37 patients with idiopathic membranous nephropathy but not in patients with secondary membranous nephropathy, patients with proteinuric conditions other than membranous nephropathy or in healthy control patients [1]. (See "Causes and diagnosis of membranous nephropathy", section on 'Phospholipase A2 receptor'.)

A mechanism used by neutrophils to defend against invading pathogens may contribute to the pathogenesis of ANCA-associated vasculitis. Webs of decondensed chromatin, called neutrophil extracellular traps (NETs), are typically released into the extracellular space in the setting of a bacterial or fungal infection. NETs are also released by ANCA-stimulated neutrophils, contain PR3 and MPO autoantigens, and co-localize with PR3 and MPO in the kidneys of patients with ANCA-associated vasculitis [2]. (See "Pathogenesis of Wegener's granulomatosis and related vasculitides", section on 'NET formation'.)

Although IgA nephropathy is the most common glomerular disease worldwide, there has been little or no consensus on its pathologic classification. A new histological classification, called the Oxford classification of IgA nephropathy, has been issued by the International IgA Nephropathy Network and the Renal Pathology Society [3,4]. (See "Clinical presentation and diagnosis of IgA nephropathy", section on 'Oxford classification of IgA Nephropathy'.)

HYPERTENSION

The Cardio-Sis trial compared the effects of tight blood pressure control (with a target of less than 130 mmHg) and usual blood pressure control (with a target of less than 140 mmHg) among patients with established cardiovascular disease or at least one additional cardiovascular risk factor [5]. The prevalence of left ventricular hypertrophy was lower and there was a reduction in the risk of new onset atrial fibrillation and coronary revascularization among patients who had the lower blood pressure target. (See "Choice of antihypertensive drug and blood pressure goal in patients at increased risk for a cardiovascular event", section on 'Cardio-Sis trial'.)

FLUID AND ELECTROLYTES

Hyponatremia is common in hospitalized patients. A prospective cohort study that included over 95,000 patients showed that even mild hyponatremia is associated with increased mortality during hospitalization and at one and five years [6]. (See "Manifestations of hyponatremia and hypernatremia", section on 'Clinical manifestations of chronic hyponatremia'.)

Among patients with refractory ascites, a randomized controlled trial found a benefit from infusion of small volume hypertonic saline plus furosemide [7]. More studies are needed before such therapy should be considered. (See "Treatment of diuretic-resistant ascites in patients with cirrhosis".)

In a meta-analysis of 11 clinical reports, nearly one out of every ten patients receiving cetuximab for treatment of advanced cancer developed hypokalemia, often severe, during therapy [8]. Periodic monitoring of serum potassium levels is warranted in patients receiving cetuximab. (See "Chemotherapy and renal insufficiency", section on 'EGFR pathway inhibitors'.)

ACUTE AND CHRONIC KIDNEY DISEASE

Because of concerns about the data, UpToDate has previously recommended not relying on the COOPERATE trial when making decisions about using combination therapy with ACE inhibitors and ARBs in treating patients with chronic kidney disease; however, some clinicians were still using this combination based on results from COOPERATE. Lancet has now formally retracted its publication of the COOPERATE trial [9]. (See "Antihypertensive therapy and progression of nondiabetic chronic kidney disease", section on 'Combination of ACE inhibitors and ARBs'.)

Although bicarbonate supplementation preserves renal function in experimental models of chronic kidney disease, a beneficial effect had not been demonstrated in humans. In a randomized trial, treatment with oral bicarbonate slowed progression of chronic kidney disease and improved nutritional status of patients with creatinine clearances between 15 and 30 mL/min per 1.73m2 [10]. (See "Treatment of metabolic acidosis in chronic kidney disease", section on Decreased progression of chronic kidney disease and.) (See "Overview of the management of chronic kidney disease in adults", section on 'Metabolic acidosis'.)

A large simulation study found a high concordance rate between the Cockcroft-Gault and MDRD Study equations using a standardized creatinine assay for the estimate of renal function for the purposes of drug dosing [11]. The National Kidney Disease Education Program has recommended that either equation may be used for the purposes of drug dosing. (See "Assessment of kidney function: Serum creatinine; BUN; and GFR", section on 'Drug dosing'.)

The Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guidelines for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD) were published [12]. (See "Management of secondary hyperparathyroidism and mineral metabolism abnormalities in dialysis patients", section on KDIGO guidelines and other topic reviews.)

A new parenteral iron preparation, ferumoxytol (Feraheme), has been approved by the United States Food and Drug Administration for the treatment of iron deficiency in patients with anemia due to chronic kidney disease [13]. (See "Use of iron preparations in hemodialysis patients", section on 'Ferumoxytol'.)

The benefit of iso-osmolal compared to low osmolal nonionic contrast agents in preventing contrast nephropathy is not known. A meta-analysis of 16 randomized trials showed that the iso-osmolal contrast agent, iodixanol, was associated with a reduction in risk of contrast nephropathy among patients with chronic kidney disease when compared to a single low osmolal agent, iohexol, but not when compared to all other nonionic low osmolal contrast agents that were tested [14]. (See "Prevention of contrast-induced nephropathy", section on 'Nonionic iso-osmolal agents'.)

DIALYSIS

The survival benefit due to preserved residual renal function among hemodialysis patients is not known. In a large observational 15-year study, survival was significantly better among patients with preserved residual renal function versus those without such function [15]. (See "Kt/V and the adequacy of hemodialysis", section on 'Residual renal function'.)

Although nocturnal hemodialysis is associated with marked benefits on quality of life and better blood pressure control, its effect on survival compared with conventional hemodialysis regimens had not been shown. A matched control study found similar patient survival among those undergoing maintenance nocturnal hemodialysis and recipients of deceased donor kidney transplants [16]. (See "Outcomes associated with nocturnal hemodialysis", section on 'Survival'.)

TRANSPLANTATION

Among kidney transplant recipients, a systematic review found that calcium channel blockers were the most effective antihypertensive agents [17]. (See "Hypertension after renal transplantation", section on 'Calcium channel blockers'.)

The success of renal transplantation is predicated, in part, on the recovery of the deceased donor kidney. A well-designed randomized open label trial of 264 deceased donors and 487 renal transplants found that low-dose dopamine administered to deceased donors was associated with a decreased requirement for dialysis post-transplantation in the recipient of a donor kidney [18]. (See "Deceased and living donor renal allograft recovery", section on 'deceased donor kidneys'.)

GENETIC DISEASES

Close attention to family history may allow the prediction of the causative mutation among patients with autosomal dominant polycystic kidney disease (ADPKD). This was shown in a study of 484 patients from 90 families with well-characterized ADPKD mutations. The presence of at least one family member who developed end stage renal disease before age 55 predicted an ADPKD type 1 mutation with positive predictive value of 100 percent. The presence of at least one family member who reached 70 years of age without end stage renal disease predicted an ADPKD type 2 mutation with positive predictive value of 100 percent [19]. (See "Course and treatment of autosomal dominant polycystic kidney disease", section on 'Predicting genotype'.)

NEPHROLITHIASIS

The Dietary Approaches to Stop Hypertension (DASH) diet (which is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein) lowers the risk for kidney stones among men, older women, younger women, high body mass index (BMI) individuals, and low BMI individuals [20]. The DASH diet is therefore a reasonable option in the attempt to reduce the risk of stone recurrence. (See "Risk factors for calcium stones in adults", section on 'Dietary risk factors'.)

PEDIATRIC NEPHROLOGY

In a study of two-month-old infants with moderate unilateral hydronephrosis, 94 percent of infants had resolution of their hydronephrosis by 12 to 14 months of age [21]. Resolution was defined as two consecutive ultrasounds that demonstrated a renal pelvic diameter less than or equal to 5 mm. (See "Postnatal management of antenatal hydronephrosis", section on 'Moderate and mild unilateral hydronephrosis'.)

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REFERENCES

  1. Beck, LH Jr, Bonegio, RG, Lambeau, G, et al. M-type phospholipase A2 receptor as target antigen in idiopathic membranous nephropathy. N Engl J Med 2009; 361:11.
  2. Kessenbrock, K, Krumbholz, M, Schonermarck, U, et al. Netting neutrophils in autoimmune small-vessel vasculitis. Nat Med 2009; 15:623.
  3. Cattran, DC, Coppo, R, Cook, HT, et al. The Oxford classification of IgA nephropathy: rationale, clinicopathological correlations, and classification. Kidney Int 2009; 76:534.
  4. Roberts, IS, Cook, HT, Troyanov, S, et al. The Oxford classification of IgA nephropathy: pathology definitions, correlations, and reproducibility. Kidney Int 2009; 76:546.
  5. Verdecchia, P, Staessen, JA, Angeli, F, et al. Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomised trial. Lancet 2009; 374:525.
  6. Waikar, SS, Mount, DB, Curhan, GC. Mortality after hospitalization with mild, moderate, and severe hyponatremia. Am J Med 2009; 122:857.
  7. Licata, G, Tuttolomondo, A, Licata, A, et al. Clinical Trial: High-dose furosemide plus small-volume hypertonic saline solutions vs. repeated paracentesis as treatment of refractory ascites. Aliment Pharmacol Ther 2009; 30:227.
  8. Cao, Y, Liu, L, Liao, C, et al. Meta-analysis of incidence and risk of hypokalemia with cetuximab-based therapy for advanced cancer. Cancer Chemother Pharmacol 2009; :.
  9. The Editors of The Lancet. Retraction—Combination treatment of angiotensin-II receptor blocker and angiotensin-converting-enzyme inhibitor in non-diabetic renal disease (COOPERATE): a randomised controlled trial. Lancet 2009; 374:1226.
  10. de Brito-Ashurst, I, Varagunam, M, Raftery, MJ, Yaqoob, MM. Bicarbonate supplementation slows progression of CKD and improves nutritional status. J Am Soc Nephrol 2009; 20:2075.
  11. Stevens, LA, Nolin, TD, Richardson, MM, et al. Comparison of drug dosing recommendations based on measured GFR and kidney function estimating equations. Am J Kidney Dis 2009; 54:33.
  12. KDIGO clinical practice guidelines for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Kidney Int 2009; 76(Suppl 113):S1.
  13. Feraheme prescribing information at www.feraheme.com/prescribing.html, June 2009.
  14. Reed, M, Meier, P, Tamhane, UU, et al. The relative renal safety of iodixanol compared with low-osmolar contrast media: a meta-analysis of randomized controlled trials. JACC Cardiovasc Interv 2009; 2:645.
  15. Vilar, E, Wellsted, D, Chandna, SM, et al. Residual renal function improves outcome in incremental haemodialysis despite reduced dialysis dose. Nephrol Dial Transplant 2009; 24:2502.
  16. Pauly, RP, Gill, JS, Rose, CL, et al. Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients. Nephrol Dial Transplant 2009; 24:2915.
  17. Cross, NB, Webster, AC, Masson, P, et al. Antihypertensive treatment for kidney transplant recipients. Cochrane Database Syst Rev 2009; :CD003598.
  18. Schnuelle, P, Gottmann, U, Hoeger, S, et al. Effects of donor pretreatment with dopamine on graft function after kidney transplantation: a randomized controlled trial. JAMA 2009; 302:1067.
  19. Barua, M, Cil, O, Paterson, AD, et al. Family history of renal disease severity predicts the mutated gene in ADPKD. J Am Soc Nephrol 2009; 20:1833.
  20. Taylor, EN, Fung, TT, Curhan, GC. DASH-style diet associates with reduced risk for kidney stones. J Am Soc Nephrol 2009; 20:2253.
  21. Mami, C, Paolata, A, Palmara, A, et al. Outcome and management of isolated moderate renal pelvis dilatation detected at postnatal screening. Pediatr Nephrol 2009; 24:2005.
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UpToDate performs a continuous review of over 430 journals and other resources. Updates are added as important new information is published. The literature review for version 17.3 is current through September 2009; this topic was last changed on October 16, 2009. The next version of UpToDate (18.1) will be released in March 2010.

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