Editorials
Treatment of Diabetic Nephropathy: Changing Landscapes and New Horizons
Until the early 19th century, diabetes mellitus (DM) was regarded as a disease of the kidney, in which one of the signs was that of an increase in the volume of urine and wasting. Only after the identification of glucose in blood and urine in the late 18th century was it recognized as a metabolic disorder. It was noted in parallel that patients with DM may show presence of coagulable urine containing albumin as a sign of kidney disease. After the advent of availability of insulin in the early 1920s, which led to increased survival, diabetic nephropathy became more apparent.A New Therapeutic Era in the Management of Diabetic Kidney Disease
Diabetic kidney disease (DKD) is the most common cause of end-stage kidney disease (ESKD) worldwide. After 2 decades of negative trials, in the last few years there has been a major and welcome shift in the therapeutic options to treat DKD. Nephrologists will be in the forefront of implementation of these new therapies as well as in the education of their colleagues and patients on the benefits and possible side effects of these novel therapies.The Ultrasound-Augmented Physical Exam for Nephrologists: Beyond the Kidney
Recent developments in handheld ultrasound technology, including cloud-based image archiving, artificial intelligence–enhanced image guidance, and the development of the capacitive micromachined ultrasound transducer—a microchip alternative to conventional piezoelectrics—are driving down the cost of ultrasound devices and facilitating image acquisition for novice learners. These technologic adaptations lower the barrier for entry and accelerate an already burgeoning trend of adoption of point-of-care ultrasound (POCUS) among medical providers.Home Hemodialysis
This special issue of ACKD on home hemodialysis (HHD) represents a timely reflection on the state of HHD in the United States. President Trump's executive order of July 2019 (Advancing American Kidney Health Initiative) laid out an ambitious agenda for expanding the use of home dialysis and preemptive kidney transplantation in the United States. This issue is a compendium of articles that are wide in their breadth and scope, representing an attempt to address a variety of issues involved in implementing such a complex and difficult task.Dialysis: Please Try This at Home!
Yes, in 2021, we are able to say that the quality of life and freedom to do the things we love can be possible while on dialysis. A special mention to the photograph on the cover of this issue dedicated to home hemodialysis (see credits in the issue), which exemplifies that.Nephrology Critical Care: A Darwinian Evolution
While hospitals across the nation continue to expand their capacity to care for critically ill patients, the practice of medicine in the intensive care unit (ICU) has evolved from being solo intensivist-driven to a multidisciplinary care model. The latter involves a myriad of clinicians as well as pharmacists, physical therapists, nutritionists, and subspecialists that usher a diverse and complementary expertise.1 Among many subspecialists in the ICU, the nephrologist serves as an invaluable asset in many commonly encountered conditions, including electrolyte/acid-base derangements and most notably acute kidney injury (AKI).COVID-19 and the Kidney Community: Coalescing in Crisis
The coronavirus disease 2019 (COVID-19) pandemic has led to significant changes to the practice of kidney medicine. The ability to provide acute dialysis is strained due to high rates of acute kidney injury (AKI), which occurs in up to 30% to 40% of hospitalized patients. The presence of AKI in the setting of COVID-19 is associated with high morbidity and mortality.1 Figure 1 illustrates various manifestations of COVID-19 in the kidney. The need for social distancing has resulted in a shift to outpatient telemedicine for many patients with kidney disease.Reenvisioning the Adult Nephrology Workforce: The Future of Kidney Care in the United States
The cover image in this issue of Advances in Chronic Kidney Disease illustrates the various components (pieces) that make up the nephrology workforce. Although our nephrology community strives to complete this puzzle, these pieces are dynamic and constantly evolving. It is up to our community to react to changes in kidney care to ensure our workforce is able to provide optimal care for patients with kidney disease.Future of Nephrology Workforce: Reimagining Educational Value
The definition of this term states “people engaged in or available for work in any enterprise or company”. Should we be satisfied in simply creating the future workforce? Or should we redefine in how we even articulate what the future of our profession may look like? Should we not be raising the bar to say that we want to nurture the next generation of compassionate and astute clinicians, scientists, and leaders? If so, then we need to reimagine how to do that and tread with caution as we pass on the knowledge to that generation.Dialysis Access: The Future Is Already Here
At the time of this writing, we are in the midst of a full-blown pandemic – the likes of which none of us have seen in our lifetimes. It is in times such as these that our profession and the care of our patients is seen through an unfiltered lens. The American Society of Diagnostic and Interventional Nephrology and the Vascular Access Society of the Americas in an effort to protect the mainstay of our patients' access to adequate dialytic care came together to publish a joint statement in March of 2020 sharing that maintaining dialysis accesses “will be instrumental in maintaining health and survival for patients with end-stage kidney disease (ESKD) as well as protecting hospitals from an eventual wave of high urgency/emergency procedures to deal with lost dialysis accesses.” Dialysis access truly is the lifeline of our patients – the infamous “Achilles Heel,” and in these dire times, our patients' need for a reliable, low-risk access becomes blatantly obvious.Interventional Nephrology: What, Who, Why?
These 2 words can mean different things from a patient's or a provider's perspective. For the patient, it is a “lifeline” to undergo a life-sustaining treatment, day after day, and lack of an optimal access can literally be a death sentence. Whether be it lack of achieving or maintaining the vascular access.O Complement, Where Aren't Thou
The innate immune system represents the oldest arm of mammalian host defense, of which the complement cascade is of paramount importance. Complement serves several roles, including direct cellular killing, tagging of foreign and self-debris for cell-mediated clearance, and modulation of the adaptive immune response. The Human Genome Organization Gene Nomenclature Committee recognizes 56 proteins within the complement pathway. Given this complexity, most medical students and clinicians devote little time to understanding the intricacies of the cascade.Poisoning, Toxicology, and the Nephrologist
In 2017, the American Association of Poison Control Centers reported more than 2.1 million human toxic exposures across the United States. In fact, toxic exposures with serious outcomes have increased every year since 2000.1 Although the 3208 resulting or related deaths were far fewer than the total referrals and interventions, concerns remain. Most reported exposures were due to a few classes of prescription medications (analgesics, sedative/hypnotics, antipsychotics, antidepressants) or readily available cleaning or personal care products.Toxicology and Kidney: Not so Innocent Bystander
Patients are exposed to numerous prescribed and over-the-counter medications. Unfortunately, drugs remain a relatively common cause of acute and chronic kidney injury. By some estimates, up to 1-in-3 cases of acute kidney injury (AKI) can be attributed to the effect of prescribed drugs and endogenous/exogenous toxins. However, establishing causality in drug-induced kidney disease is challenging and requires knowledge of the biological plausibility of the agent, mechanism of injury, time course, and assessment of competing risk factors.Advances in Chronic Kidney Disease as Syntopicon
Advances in Chronic Kidney Disease began its life under the aegis of Allen R. Nissenson as the first Editor-in-Chief of Advances in Renal Replacement Therapy.1 Dr. Nissenson's expressed desire was for A-R-R-T to become the “art” of renal replacement therapy. He explicitly stated this aspiration, echoing the enthusiastic prose of Dr. Seuss, in his inaugural editorial in April 1994, “The ARRT of Uremia Therapy.”1 Instrumental to the journal's conception was much the effort of Garabed Eknoyan—a long-time advisor-contributor to the National Kidney Foundation in so many ways.Cardiovascular Calcifications Among Patients With Uremia: Answers to Hard Questions
A 56-year-old woman with long-standing history of diabetes mellitus and end-stage renal disease is evaluated for severely painful indurations covering both thighs. She is obese and has been on warfarin therapy for atrial fibrillation. A skin biopsy obtained from the indurated area demonstrates calcifications involving subcutaneous arterioles and adjacent adipocytes. A diagnosis of uremic calciphylaxis is made. Prior radiological examinations demonstrate diffuse arterial and valvular calcifications involving coronary, mesenteric, carotid, femoral and aortic beds, and mitral and tricuspid valves.Lupus Nephritis: Breaking the Lull
Systemic lupus erythematosus (SLE) has a prevalence of 241 per 100,000 people in the United States.1 Young women are disproportionately affected and disease burden is highest in blacks and lowest in whites in studies that report data by race.1 Up to 75% of SLE patients will develop kidney disease, which is often asymptomatic and detected only by urinalysis. Pathologic classification of lupus nephritis (LN) is based on the location and degree of glomerular involvement coupled with the activity and chronicity of histologic changes.Lupus Nephritis: How Far Have We Come, and Where Are We Headed?
Of all the organ domains involved in systemic lupus erythematosus (SLE), renal disease is associated with the greatest morbidity and mortality. Relative age-adjusted mortality in SLE patients with renal disease compared to those without is greater at every level of renal involvement and stage of CKD.1,2 Recent data show decreased trends in the burden of end-stage renal disease (ESRD) due to lupus nephritis (LN) in the United States. However, greater than 50% of SLE patients will develop LN and an unacceptably high number (up to 44% of patients with class III or IV LN) progress to ESRD by 15 years requiring renal replacement therapy in the form of dialysis or kidney transplant.Erythropoiesis-Stimulating Agents and Cancer: Myth or Truth
Erythropoiesis-stimulating agents (ESAs) have been implicated in causing cancer progression. This belief has been largely based on trials in the early 2000s of ESA use in malignancy with high hemoglobin (Hgb) targets and large ESA doses to attain the targets. More recent trials using ESA doses with Hgb targets similar to current goal levels in CKD have not confirmed this increased risk of cancer progression for most malignancies.Anemia Treatment After 30 Years of Erythropoietic Stimulating Agents: No Longer Business as Usual?
The publication date of this issue of ACKD, July-August 2019, is almost exactly 30 years after the approval by the Food and Drug Administration (FDA) of epoetin alfa in June 1989. There has been considerable evolution in the treatment of anemia in patients with CKD since that time despite the fact that erythropoietic stimulating agents (ESAs) remain the mainstay of that therapy. In the 1990s, we discovered the necessity of adequate iron supplementation to achieve the targeted erythropoietic response to ESAs.Eradicating the Viral Triad in Hemodialysis Units
In this issue of Advances in Chronic Kidney Diseases, Dr James Novak as Guest Editor has curated a collection of manuscripts from a cadre of nephrologists whose curiosity includes the viral nephropathies. The authors present a well-researched group of articles that comprehensively review the vast majority of contemporary viral disorders with which most nephrologists will engage at some point in their careers. However, the bulk of nephrologists will be concerned with 3 viruses more than others, hepatitis C virus (HCV), hepatitis B virus (HBV), and the human immunodeficiency virus-1 (HIV).Warning: Kidney Virus Detected
The variety of genes on the planet in viruses exceeds, or is likely to exceed, that in all of the rest of life combined. —Edward O. Wilson In 1993, the number of viruses that infected vertebrates, specifically mammals, was estimated at 1,000,000 and 320,000, respectively.1 By 2012, 219 human virus species had been identified, with 3–4 novel viruses projected to emerge each year from mammalian and avian reservoirs.2 Advances in genetics during the past few decades have facilitated the detection of more and more occult viruses, previously unrecognized within the human genome, the accumulation of which is collectively known as the human virome.Dr. Conn Lives on: Insights Into Screening and Genetics of Primary Aldosteronism
This issue of Advances in Chronic Kidney Disease features an old standard, hypertension. This topic is reviewed periodically. This time, Dr. Kausik Umanath has taken up the gauntlet to press forward our collective mission to diagnose and treat this most fundamental medical problem early, accurately, and efficiently. In this issue, the variegation of the pathophysiology of hypertension will be revealed along with its treatments. In Dr. Umanath's Guest Editorial, you will see a glimpse of what is contained within, but first, a story.Hypertension: A Common but Complex Condition
Hypertension is a common condition known to cause significant cardiovascular events including death, stroke, and heart failure.1,2 Our understanding of the pathogenesis and optimal approaches to therapy has evolved tremendously over the past 50 years.3 Despite these advances, only 50% of individuals achieve blood pressure control according to National Health and Nutrition Examination Surveys 2015-2016 data.4 Hypertension remains a significant global health problem, and in this issue of Advances in Chronic Kidney Disease, we have put together a set of manuscripts covering several key issues in both the pathogenesis and management of hypertension.The Many Faces of Infection in CKD: Evolving Paradigms, Insights, and Novel Therapies
In 1961, Schreiner was the first to note unique susceptibility to infection among patients with kidney failure.1 It was assumed that general debility from chronic uremia increased the risk of infection; thus, it was postulated that reversal of the uremic state would reduce the risk of infection.2 Unfortunately, kidney replacement therapy has not reduced the problem of infection; it has only changed the paradigm.3 Dialysis superimposes myriad new problems onto patients already suffering relentless deterioration from underlying multisystem disease and poor wound healing.
