Advances in Chronic Kidney Disease RSS feed: Current Issue. The purpose of Advances Chronic Kidney Disease is to provide in-depth, scholarly review articles about the care and management of persons with early kidney disease and kidney failure, as well as those at risk for kidney disease. Emphasis is on articles related to the early identification of kidney disease; prevention or delay in progression of kidney disease; the multidisciplinary case management of patients with chronic kidney disease or kidney failure, organ effects of kidney disease; epidemiology and outcomes research in chronic kidney disease; benefits and complications of the primary treatment methods, dialysis and transplantation; technical aspects of the delivery of uremia therapy; care of the critically ill patient with kidney failure in the intensive care setting; new therapies for kidney failure; and health care research in chronic kidney disease. The full spectrum of basic science through clinical care is covered in these reviews. Clinical care issues stress the multidisciplinary team approach to the care of kidney patients. Topics covered will be of interest to practicing nephrologists (pediatric and adult), nephrology fellows (pediatric and adult), nurses, technicians, dietitians, and social workers caring for patients with kidney disease. Each bimonthly issue of Advances in Chronic Kidney Disease presents focused review articles devoted to a single topic of current importance in clinical nephrology and related fields. 2009 Issues, Vol. 16 January Nephrolithiasis David S. Goldfarb & Michael J. Choi March Anemia and Iron Management in All Stages of CKD Kamyar Kalantar-Zadeh & Csaba P. Kovesdy May Home Dialysis Christopher Chan & Charmaine Lok July ESRD and Kidney Transplantation in the Non-Renal Transplant Recipient Connie Davis September Interventional Nephrology Arif Asif November Exercise and Physical Functioning in CKD Kirsten Johansen and Patricia Painterhttp://www.ackdjournal.org/?rss=yesElsevier Inc.en © 2010 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved. Advances in Chronic Kidney Disease1548-5595171January 2010 © 2010 National Kidney Foundation, Inc. Published by Elsevier Inc All rights reserved. healthpermissions@elsevier.comhttp://www.ackdjournal.org/article/PIIS1548559509001888/abstract?rss=yesI saw an HIV-positive patient for proteinuria recently. During the usual history taking, the patient essentially recounted his long sojourn with HIV including an early period of HIV unawareness; ensuing “dark” years when many friends were lost; and hope inspired by long-term survivors, medical progress, and successful drug trials. He was also discouraged by recidivism of unsafe sexual practices that might promote disease dissemination.The HIV-Associated Nephrologist: Advice Straight From the HAARTJerry Yee10.1053/j.ackd.2009.09.003Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Editorial12http://www.ackdjournal.org/article/PIIS1548559509001487/abstract?rss=yesIn 2007, the worldwide prevalence of human immunodeficiency virus (HIV) infection was 33 million, with 2.7 million incident cases and 2 million deaths. The global burden of CKD in the HIV population is difficult to estimate, but proteinuria is relatively common and is associated with increased rates of death, hospitalization, and AIDS-defining illness. Proteinuria, in turn, often predicts the onset of HIV-associated nephropathy (HIVAN) which, untreated, almost always progresses to ESRD. On the other hand, ESRD in HIV-infected patients is no longer a death sentence, and outcomes are favorable for both dialysis and kidney transplantation. In this issue of Advances in Chronic Kidney Disease, a group of internationally renowned thought leaders presents the latest synthesis of the epidemiology, biochemistry, genetics, and pharmacotherapy of HIV and kidney disease for the benefit of the practicing nephrologist.HIV Through a Nephrologist's LensJames E. Novak, Lynda A. Szczech10.1053/j.ackd.2009.07.012Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Guest Editorial34http://www.ackdjournal.org/article/PIIS154855950900158X/abstract?rss=yesDespite recent improvements in the efficacy, safety, tolerability, and convenience of antiretroviral therapy for patients, the management of HIV infection remains complex for clinicians. Multiple studies have shown better clinical outcomes and lower cost of care when HIV-infected patients are managed by experts. However, generalists are frequently involved in the care of patients with HIV infection, in many cases providing primary care in collaboration with an HIV expert. Generalists also play a critical role in the diagnosis and prevention of HIV infection. Generalists managing HIV-infected patients should be aware of the components of the initial patient evaluation. They should be familiar with the general principles of antiretroviral therapy and opportunistic infection prevention. They should be able to recognize antiretroviral toxicity and should be aware of common drug-drug interactions involving antiretroviral agents.What Does the Generalist Need to Know About HIV Infection?Joel E. Gallant10.1053/j.ackd.2009.08.003Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Articles518http://www.ackdjournal.org/article/PIIS1548559509001657/abstract?rss=yesNephrologists can serve many important functions for HIV-infected patients, including identifying risks for developing kidney disease, detecting and diagnosing kidney disease, distinguishing antiretroviral-induced kidney injury from kidney disease in the setting of antiretroviral therapy, comanaging the clinical course and complications of CKD, and preparing patients for dialysis and/or transplantation. The epidemiology of kidney disease in HIV informs us for these functions by describing the natural history of disease, its frequent occurrence in high-risk communities, and its potential causes. Risk factors that drive CKD in HIV are black race, hypertension, diabetes, HIV viral replication with low CD4 cell counts, high viral load or acquired immune deficiency syndrome–defining conditions, and antiretroviral agents with nephrotoxic potential. The prevalence of these risk factors in any population determines the magnitude of the problem, which can range from as low as 2% to as high as 30%. Recent research focuses on kidney health in HIV. Important links between HIV viral replication and glomerular filtration rate, even in patients with normal kidney function, are now being reported. A review of these data provides the foundation for a better understanding of kidney disease and, hopefully, better treatment for patients with HIV.HIV and CKD EpidemiologyJonathan A. Winston10.1053/j.ackd.2009.08.006Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Articles1925http://www.ackdjournal.org/article/PIIS1548559509001505/abstract?rss=yesWith improved survival afforded by highly active antiretroviral therapy (HAART), CKD has emerged as one of the primary comorbid conditions affecting HIV-infected individuals. Although CKD in HIV-infected individuals is classically thought of as a consequence of advanced HIV infection such as in the case of HIV-associated nephropathy, several factors likely contribute to the development CKD in HIV infection. These factors include genetic predisposition, age-related decline in kidney function, HAART-related metabolic changes, exposure to multiple nephrotoxic medications, and concurrent conditions such as hepatitis C or illicit drug use. Similar to the general population, proteinuria and impaired kidney function are associated with faster progression to acquired immune deficiency syndrome and death. Given the prevalence and impact of kidney disease on the course of HIV infection and its management, current guidelines recommend screening all HIV-infected individuals for kidney disease. This review focuses on the current guidelines for kidney disease screening and discusses traditional as well as promising strategies for detecting CKD in this vulnerable population.Screening for Chronic Kidney Disease in HIV-Infected PatientsMichelle M. Estrella, Derek M. Fine10.1053/j.ackd.2009.07.014Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Articles2635http://www.ackdjournal.org/article/PIIS1548559509001724/abstract?rss=yesHIV-associated nephropathy (HIVAN) is one of the leading causes of ESRD in HIV-1–seropositive patients. Patients typically present with heavy proteinuria and chronic renal failure with pathologic findings of collapsing focal segmental glomerulosclerosis (FSGS). The disease is caused by direct infection of renal epithelial cells by HIV-1 in a genetically susceptible host. The genetic factors responsible for the susceptibility to HIVAN among blacks include a noncoding variant in the podocyte-expressed gene nonmuscle myosin, heavy chain 9 (MYH9) as well as other genes yet to be identified. Podocyte and tubular dysfunction results from the expression of viral genes, in particular nef and vpr, and the subsequent dysregulation of numerous host factors, including critical signaling pathways, inflammatory mediators, and others. The identification of these factors has the potential to provide novel therapeutic targets to prevent and treat this important disease.The Pathogenesis of HIV-Associated NephropathyLewis Kaufman, Susan E. Collins, Paul E. Klotman10.1053/j.ackd.2009.08.012Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Articles3643http://www.ackdjournal.org/article/PIIS1548559509001578/abstract?rss=yesHIV-associated nephropathy (HIVAN) is a leading cause of ESRD in African Americans. The HIV-1 virus infects podocytes, cells integral to formation of the glomerular filtration barrier, often leading to focal segmental glomerulosclerosis. HIVAN is typically a complication of late-stage HIV infection, associated with low CD4 cell counts and elevated serum HIV RNA levels. Highly active antiretroviral therapy is partially protective and has altered the natural history of HIV-associated kidney disease. Nonetheless, HIVAN remains an important public health concern among HIV-infected African Americans. Although polymorphisms in the MYH9 gene on chromosome 22 are strongly associated with HIVAN, as well as with idiopathic focal segmental glomerulosclerosis and global glomerulosclerosis (historically labeled “hypertensive nephrosclerosis”), the majority of HIV-infected patients who are genetically at risk from MYH9 do not appear to develop severe kidney disease. Therefore, we postulate that additional environmental exposures and/or inherited factors are necessary to initiate human HIVAN. Gene-environment interactions have also been proposed as necessary for the initiation of HIVAN in murine models. It is important that these novel risk factors be identified because prevention of environmental exposures and targeting of additional gene products may reduce the risk for HIVAN, even among those harboring 2 risk alleles in MYH9.Gene-Gene and Gene-Environment Interactions in HIV-Associated Nephropathy: A Focus on the MYH9 Nephropathy Susceptibility GeneMarina Núñez, Anita M. Saran, Barry I. Freedman10.1053/j.ackd.2009.08.002Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Articles4451http://www.ackdjournal.org/article/PIIS1548559509001645/abstract?rss=yesHIV-associated nephropathy (HIVAN) is a largely distinctive phenotype induced by HIV-1 infection and is the most recognized and detrimental kidney disease in HIV-infected patients. Host and viral characteristics have been implicated in the pathogenesis of HIVAN that may explain its exclusive predilection to patients of African descent. In untreated patients, the disorder is clinically manifested by an acute decline in kidney function, most often in conjunction with high-grade proteinuria and uncontrolled HIV-1 infection. Histologically, proliferating glomerular epithelial cells are the prominent feature of the disease. Data have evolved over the past decade suggesting that highly active antiretroviral therapy (HAART) can change the natural history of HIVAN, not only by preventing its development but also by halting its progression once developed. Consequently, with the widespread use of HAART, the prevalence of HIVAN is declining in Western countries. In contrast, the epidemiology of the disease is not well defined in the poorest areas in the world, which bear a disproportionate share of the HIV-1 epidemic's burden. Corticosteroids and inhibition of the renin-angiotensin axis are recommended as adjunctive agents in treating patients with established HIVAN and are potentially helpful in delaying the need for renal replacement therapy. However, the long-term value and potential risks of using corticosteroids in this population are unclear.Diagnosis and Natural History of HIV-Associated NephropathyMohamed G. Atta10.1053/j.ackd.2009.08.005Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Articles5258http://www.ackdjournal.org/article/PIIS1548559509001712/abstract?rss=yesAntiretroviral therapy (ART) preserves kidney function in patients with human immunodeficiency virus (HIV)-associated nephropathy (HIVAN). Emerging data also document substantial renal benefits of ART in the general HIV-infected population, which is associated in part with suppression of HIV-1 viral replication. The extent to which the response to ART differs in persons with HIVAN compared with those with other HIV-associated kidney disorders is unknown. Beneficial effects of corticosteroids and angiotensin-converting enzyme inhibitors on kidney function also are suggested by retrospective cohort studies and uncontrolled trials of patients with HIVAN. Underexposure to ART or inadequate ART dosing in HIV-infected patients with CKD may curtail the optimal benefits that may be derived from this therapy.The Treatment of HIV-Associated NephropathyRobert C. Kalayjian10.1053/j.ackd.2009.08.013Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Articles5971http://www.ackdjournal.org/article/PIIS1548559509001335/abstract?rss=yesThe widespread introduction of highly active antiretroviral therapy (HAART) in the mid-1990s dramatically altered the course of human immunodeficiency virus (HIV) infection, with improvements in survival and reductions in the incidence of AIDS-defining illnesses. Although antiretroviral therapy has been shown to reduce the incidence of both AIDS-defining and non-AIDS conditions, long-term exposure to HAART may also be associated with significant toxicity. This article reviews the potential nephrotoxicity of specific antiretroviral agents and the impact of antiretroviral therapy on related metabolic disorders. The antiretroviral agents most strongly associated with direct nephrotoxicity include the nucleotide reverse transcriptase inhibitor, tenofovir, and the protease inhibitor indinavir, although other agents have been implicated less frequently. Tenofovir and related nucleotide analogs have primarily been associated with proximal tubular dysfunction and acute kidney injury, whereas indinavir is known to cause nephrolithiasis, obstructive nephropathy, and interstitial nephritis. Kidney damage related to antiretroviral therapy is typically reversible with early recognition and timely discontinuation of the offending agent, and nephrologists should be familiar with the potential toxicity of these agents to avoid delays in diagnosis.Antiretroviral Medications: Adverse Effects on the KidneyJennifer Jao, Christina M. Wyatt10.1053/j.ackd.2009.07.009Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Articles7282http://www.ackdjournal.org/article/PIIS1548559509001748/abstract?rss=yesA spectrum of kidney diseases in HIV-infected patients has been reported both before and after the introduction of highly active antiretroviral therapy (HAART). Kidney syndromes affecting HIV-infected patients include CKD as well as proteinuria, nephrotic syndrome, and acute nephritic syndrome. Thrombotic microangiopathy should be considered in patients with kidney disease and typical clinical characteristics. As the HIV-infected population ages, there is increased concern regarding the incidence of vascular and metabolic disease, leading to an increased burden of CKD. Although HIV-associated nephropathy is still the major cause of nephrotic syndrome in HIV-infected patients, immune complex glomerulonephritis (ICGN) still comprises a substantial proportion of the disease burden, especially in people of European origin. Genetic investigations into the underpinnings of the various histologic expressions of HIV-associated kidney disease hold great promise. The single most important diagnostic test to differentiate various forms of kidney disease in HIV-infected patients is a kidney biopsy. The results of treating kidney disease in HIV-infected patients remain unclear, and properly designed randomized controlled trials of the treatment of ICGN with HAART and other approaches are desperately needed.CKD in HIV-Infected Patients Other Than HIV-Associated NephropathyAjay K. Rachakonda, Paul L. Kimmel10.1053/j.ackd.2009.09.001Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Articles8393http://www.ackdjournal.org/article/PIIS1548559509001633/abstract?rss=yesHIV infection is a common cause of ESRD, particularly among blacks. Advances in antiretroviral therapy have greatly improved the survival of HIV patients, including those with renal disease. Despite concerns about the risk of immunosuppressive medications for HIV patients, emerging studies have now reported acceptable short-term outcomes for eligible HIV recipients undergoing renal transplantation, and an ongoing multicenter clinical trial reported 1-year patient and graft survival similar to that of HIV-uninfected kidney recipients. In these studies, the interactions between calcineurin inhibitors and HIV medications that are also metabolized by the cytochrome P450 system required substantial dosing modifications and careful monitoring of calcineurin inhibitor trough levels. These studies also revealed an elevated risk of acute rejection of the kidney allograft but few reports of opportunistic infections or viremia that could not be controlled. Long-term follow-up studies will be important to examine these outcomes and the development of malignancy to fully evaluate the risk and benefits of kidney transplantation among HIV-positive recipients.Kidney Transplantation in Patients With HIV InfectionPeter P. Reese, Emily A. Blumberg, Roy D. Bloom10.1053/j.ackd.2009.08.004Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Articles94101http://www.ackdjournal.org/article/PIIS1548559509001736/abstract?rss=yesPatients infected with human immunodeficiency virus (HIV) often progress to ESRD. In the era of highly active antiretroviral therapy, the care of these patients has become increasingly complex as survival has improved. Patients infected with HIV who also have ESRD are at risk for critical interactions between medication regimens to treat both of these conditions. Within this population, hemo- and peritoneal dialysis as well as kidney transplantation are life sustaining but present a host of obstacles related to HIV monitoring and risk of transmission, access thrombosis, infection, and rejection. Knowledge of antiretroviral regimens, drug interactions, and HIV resistance as well as the management of ESRD in the presence of HIV infection will improve the care of these unique patients.Management of HIV-Infected Patients With ESRDJames E. Novak, Lynda A. Szczech10.1053/j.ackd.2009.08.014Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8Articles102110http://www.ackdjournal.org/article/PIIS1548559509001980/abstract?rss=yesThe article “Hyporesponsiveness to Erythropoietin: Causes and Management” (Elliott J, Mishler D, Agarwal R, Advances in Chronic Kidney Disease 16:94-100) contains an error in the article text. On page 98, the second sentence incorrectly referred to the drug rHuEpo beta instead of rHuEpo alpha. The corrected sentence: “Prompt recognition and avoidance of rHuEpo alpha, especially administration by the more immunogenic subcutaneous route, has led to fewer patients reported of this already rare disorder.”Erratum to Hyporesponsiveness to Erythropoietin: Causes and Management10.1053/j.ackd.2009.10.001Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8111111http://www.ackdjournal.org/article/PIIS1548559509001992/abstract?rss=yesThe editors of Advances in Chronic Kidney Disease would like to take the opportunity to thank the following article reviewers for 2009. Kenneth Abreo, MD, Shreveport, LA, USAArticle Reviewers for 200910.1053/j.ackd.2009.10.002Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8112112http://www.ackdjournal.org/article/PIIS154855950900202X/abstract?rss=yesMasthead10.1053/S1548-5595(09)00202-XAdvances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8FrontmatterA2A2http://www.ackdjournal.org/article/PIIS1548559509002031/abstract?rss=yesEditorial Board10.1053/S1548-5595(09)00203-1Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8FrontmatterA3A3http://www.ackdjournal.org/article/PIIS1548559509002043/abstract?rss=yesTable of Contents10.1053/S1548-5595(09)00204-3Advances in Chronic Kidney Disease 17, 1 (2010)2010-01-01Advances in Chronic Kidney Disease2010-01-01171S1548-5595(09)X0007-8FrontmatterA5A6