Kidney Dis Research Articles

Apolipoprotein G1 and G2 Variants May Partially Explain a Higher Prevalence of Lupus-Nephritis ESRD in African Americans

African Americans suffer from lupus-related kidney failure at higher rates compared with individuals without recent African ancestry [Byrne C et al. Am J Kidney Dis 1994; Satko SG et al. Kidney Int Suppl 2005]. This article presents findings from A National Consortium to Explore the Genotypic Basis for End-Stage Renal Disease in Lupus [1RC2-AR058951; P01-AR049084; P01-AI083194].

Reclassification of Cardiovascular Risk in Patients With Normal Myocardial Perfusion Imaging Using Heart Rate Response to Vasodilator Stress

Previous studies have shown that patients with normal vasodilator myocardial perfusion imaging (MPI) findings remain at a greater risk of future cardiac events than patients with normal exercise MPI findings. The aim was to assess improvement in risk classification provided by the heart rate response (HRR) in patients with normal vasodilator MPI findings when added to traditional risk stratification. We retrospectively studied 2,000 patients with normal regadenoson or adenosine MPI findings. Risk stratification was performed using Adult Treatment Panel III framework. Patients were stratified by HRR (percentage of increase from baseline) into tertiles specific to each vasodilator. All-cause mortality and cardiac death/nonfatal myocardial infarction (MI) ≤2 years from the index MPI were recorded. During follow-up, 11.8% patients died and 2.7% patients experienced cardiac death/nonfatal MI in the adenosine and regadenoson groups, respectively. The patients who died had a greater Framingham risk score (12 ± 4 vs 11 ± 4, p= 0.009) and lower HRR (22± 16 vs 32 ± 21, p <0.0001). In an adjusted Cox model, the lowest tertile HRR was associated with an increased risk of mortality (hazard ratio 2.1) and cardiac death/nonfatal MI (hazard ratio 2.9; p <0.01). Patients in the highest HRR tertile, irrespective of the Adult Treatment Panel III category, were at low risk. When added to the Adult Treatment Panel III categories, the HRR resulted in net reclassification improvement in mortality of 18% and cardiac death/nonfatal MI of 22%. In conclusion, a blunted HRR to vasodilator stress was independently associated with an increased risk of cardiac events and overall mortality in patients with normal vasodilator MPI findings. The HRR correctly reclassified a substantial proportion of these patients in addition to the traditional risk classification models and identified patients with normal vasodilator MPI findings, who had a truly low risk of events.

Oral bisphosphonate use in the elderly is not associated with acute kidney injury

Intravenous bisphosphonates can cause acute kidney injury; however, this risk was not found with oral bisphosphonates in randomized clinical trials with restrictive eligibility criteria. In order to provide complementary safety data, we studied the risk of acute kidney injury in a population-based cohort of 122,727 patients aged 66 years and older discharged from hospital following a new fragility fracture and no history of bisphosphonate use in the prior year. Bisphosphonate treatment was identified within 120 days after discharge and event rates were measured from 90 days of therapy initiation. The primary outcome was hospitalization with acute kidney injury with secondary outcomes of new nephrology consultation and, in a subset of patients with laboratory values, acute kidney injury was defined as an increase in serum creatinine. We identified 18,286 bisphosphonate users and 104,441 non-users with a mean age of 81 years. Of 5772 patients with laboratory values, 40% had chronic kidney disease (eGFR <60 ml/min per 1.73 m(2)). Overall, there was no statistically significant difference in the risk of acute kidney injury among bisphosphonate users compared to non-users (adjusted odds ratio 1.03), and no significant differences in other outcomes or in subgroups of patients with baseline chronic kidney disease. Thus, in this older population-based cohort, oral bisphosphonate use was not associated with acute kidney injury.

A Clinical Approach to the Treatment of Chronic Hypernatremia

Hypernatremia is a commonly encountered electrolyte disorder occurring in both the inpatient and outpatient settings. Community-acquired hypernatremia typically occurs at the extremes of age, whereas hospital-acquired hypernatremia affects patients of all age groups. Serum sodium concentration is linked to water homeostasis, which is dependent on the thirst mechanism, arginine vasopressin, and kidney function. Because both hypernatremia and the rate of correction of hypernatremia are associated with significant morbidity and mortality, prompt effective treatment is crucial. Chronic hypernatremia can be classified into 3 broad categories, hypovolemic, euvolemic, and hypervolemic forms, with each form having unique treatment considerations. In this teaching case, we provide a clinically based quantitative approach to the treatment of both hypervolemic and hypovolemic hypernatremia, which occurred in the same patient during the course of a prolonged illness.

Detecting reduced renal function in children: comparison of GFR-models and serum markers

The aim of this study was to compare the ability of renal indicators [serum creatinine (SCr), cystatin C (SCysC)] and glomerular filtration rate (GFR)-models to discriminate normal and reduced renal function. As a single cut-off level will always lead to false classifications, we propose using two cut-off levels, dividing renal function into normal or reduced, with an intermediate "gray zone" of indeterminable results. Glomerular filtration rate was measured by plasma clearance of (51)Cr-EDTA (13.7-147.4 mL/min/1.73 m(2)) in 119 children (age range 2.3-14.9 years). Reduced renal function was defined as a GFR of <82 mL/min/1.73 m(2). SCr, SCysC, age-normalized creatinine (SCr-ratio), and eight published GFR-models were compared for their ability to correctly classify renal function as normal or reduced. Cut-off levels were determined so as to give 99 % certainty outside the gray zone. The multivariable GFR-models by Schwartz et al. (J Am Soc Nephrol 2009; 20:629-637) and Zappitelli et al. (Am J Kidney Dis 2006; 48:221-230) and two models by Andersen et al. [Am J Kidney Dis 2012; 59(1):50-57: body cell mass (BCM)-model and Weight-model] performed significantly better than all other variables (P < 0.01), with the BCM-model performing the best (P < 0.05). The SCr-based Schwartz formula and SCr-ratio both performed better than SCr and SCysC. Among the 119 children enrolled in this study and the renal indicators tested, the BCM-model had the best diagnostic performance in terms of screening for normal or reduced renal function, and the SCr-ratio was a superior diagnostic tool to both SCr and SCysC.

Need for exercise among patients with hypertension and renal disease (Nephros trial) randomized controlled trial: preliminary results

1. Jaber BL, Madias NE. Progression of chronic kidney disease: can it be prevented or arrested? Am J Med. 2005; 118:1323-30. 2. Glassock RJ, Winearls C. Ageing and the glomerular filtration rate: truths and consequences. Trans Am Clin Climatol Assoc. 2009; 120:419-28. 3.. Stengel B, Tarver-Carr ME, Powe NR, Eberhardt MS, Brancati FL. Lifestyle factors, obesity and the risk of chronic kidney disease. Epidemiology. 2003; 14:479-87. 4. Robinson-Cohen C, Katz R, Mozaffarian D, Dalrymple LS, de Boer I, Sarnak M, et al. Physical activity and rapid decline in kidney function among older adults. Arch Intern Med. 2009; 169:2116-23. 5. Johansen KL and Painter P. Exercise in individuals with CKD. Am J Kidney Dis 2012; 59(1): 126-134. The study has not yet been finalized, these patients should be evaluated after eight weeks of the end of the intervention. The study protocol suggests a sample of 60 patients in each group, whose goal is intended to be reached later this year. Perhaps this is why some results were not different between groups, by the lack of power. However, at this point, the physical capacity tests already have shown a significant beneficial effect of exercise in this group of patients. These tests aimed at assessing dynamic balance, which is important in tasks that require quick maneuvering, such as go to the bathroom or answer the phone. There is still a scarcity of data relating to the effect of physical exercise among the most numerous group of individuals with kidney disease i.e. patients undergoing conservative treatment. In particular, there is a lack of randomized controlled studies. This study will help fill this gap. REFERENCES: Chronic kidney disease is an important public health threat. Such patients present high morbidity and mortality. There is some evidence that exercise interventions may be beneficial to chronic kidney disease patients, but previous studies included only end-stage patients, which are submitted to the dialysis treatment. This study aims to evaluate the effect of exercise on kidney function and other risk factors for cardiovascular disease among patients with chronic hypertensive kidney disease who are not undergoing dialysis. The participants were located through screening of hypertensive patients attended within the public healthcare. Eligible individuals were those with low glomerular filtration rate, measured by MDRD. The randomization was done in fixed-size blocks of six individuals. At baseline, informations on demographic and socioeconomic characteristics, behavioral, anthropometric measures, blood pressure and quality-of-life were collected, also laboratory tests were performed. The intervention consisted of three weekly physical exercise sessions, lasting 60 minutes each, with a total duration of 16 weeks. The patients in both groups (intervention and control) were evaluated at the end of the intervention (16th week) and will be reassessed in the 8th week after termination.The outcomes were kidney function progression rate, functional capacity, blood pressure and laboratory. The t test was used. A two-tailed significance was level of 5%. The analyses were of intention to treat.

The effect of frequent hemodialysis on nutrition and body composition: Frequent Hemodialysis Network Trial

We investigated the effects of frequency of hemodialysis on nutritional status by analyzing the data in the Frequent Hemodialysis Network Trial. We compared changes in albumin, body weight and composition among 245 patients randomized to 6- or 3-times per week in-center hemodialysis (Daily Trial) and 87 patients randomized to 6-times per week nocturnal or 3-times per week conventional hemodialysis, performed largely at home (Nocturnal Trial). In the Daily Trial, there were no significant differences between groups in changes in serum albumin or the equilibrated protein catabolic rate by 12 months. There was a significant relative decrease in pre-dialysis body weight of 1.5 ± 0.2 kg in the 6 times per week group at one month, but this significantly rebounded by 1.3 ± 0.5 kg over the remaining 11 months. Extracellular water decreased in the 6 times per week compared to the 3 per week hemodialysis group. There were no significant between-group differences in phase angle, intracellular water or body cell mass. In the Nocturnal Trial, there were no significant between-group differences in any study parameter. Any gain in “dry” body weight corresponded to increased adiposity rather than muscle mass but was not statistically significant. Thus, frequent in-center hemodialysis reduced extracellular water but did not increase serum albumin or body cell mass while frequent nocturnal hemodialysis yielded no net effect on parameters of nutritional status or body composition.

Mycophenolate and lower graft function reduce the seroresponse of kidney transplant recipients to pandemic H1N1 vaccination

In late 2009 transplant organizations recommended that kidney recipients be vaccinated for pandemic H1N1 influenza (pH1N1); however, the vaccine efficacy was unknown. We had offered a monovalent non-adjuvanted pH1N1 vaccine to transplant recipients. Here we compared the pre- and post-vaccination seroresponses of 151 transplant recipients to that of 71 hemodialysis patients and 30 healthy controls. Baseline seroprotection was similar between groups but was significantly different at 1 month (44, 56, and 87%, respectively). Seroconversion was significantly less common for transplant recipients (32%) than dialysis patients (45%) and healthy controls (77%). After adjusting for age and gender, dialysis patients were significantly more likely (2.7-fold) to achieve new seroprotection than transplant recipients. The likelihood of seroprotection in transplant recipients was significantly reduced by mycophenolate use (adjusted odds ratio 0.24), in a dose-dependent manner, and by reduced eGFR (adjusted odds ratio 0.16 for worst to best). Seroprotection and geometric mean antibody titers increased substantially in 49 transplant recipients who subsequently received the 2010 seasonal influenza vaccine. Thus, patients requiring renal replacement therapy had reduced seroresponses to vaccination with the monovalent vaccine compared with healthy controls. Transplant recipient responses were further reduced if they were receiving mycophenolate or had significantly lower graft function.

The relevance of antigen binding to the pathogenicity of lupus autoantibodies

Although lupus autoantibodies provide diagnostic value, discordance between serum levels and nephritis poses mechanistic questions. Krishnan and co-workers report that only those that crossreact with basement membrane components produce immune deposits. Thus, other glomerular binding properties probably define where deposits form. Thereafter, Fc- and complement-mediated events influence disease expression. Clearly other factors determine the ultimate phenotype; however, the findings provide insights into the variable disease patterns in lupus nephritis.

Use of ≥ 1 antihypertensive drug at bedtime reduced CV events more than use of all drugs in the morning in CKD

ACP Journal Club19 June 2012Use of ≥ 1 antihypertensive drug at bedtime reduced CV events more than use of all drugs in the morning in CKDArjun D. Sinha, MD, Rajiv Agarwal, MDArjun D. Sinha, MDIndiana University School of Medicine, Division of Nephrology and, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA (A.D.S., R.A.)Search for more papers by this author, Rajiv Agarwal, MDIndiana University School of Medicine, Division of Nephrology and, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA (A.D.S., R.A.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-156-12-201206190-02008 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Source CitationHermida RC, Ayala DE, Mojón A, Fernández JR. Bedtime dosing of antihypertensive medications reduces cardiovascular risk in CKD. J Am Soc Nephrol. 2011;22:2313-21. https://pubmed.ncbi.nlm.nih.gov/22025630Clinical Impact RatingsGIM/FP/GP: Hospitalists: Cardiology: Nephrology: References1 Minutolo R, Gabbai FB, Borrelli S, et al. Changing the timing of antihypertensive therapy to reduce nocturnal blood pressure in CKD: an 8-week uncontrolled trial. Am J Kidney Dis. 2007;50:908-17. [PMID: 18037091]. Google Scholar2 Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000;342:145-53. [PMID: 10639539] Google Scholar3 Svensson P, de Faire U, Sleight P, Yusuf S, Ostergren J. Comparative effects of ramipril on ambulatory and office blood pressures: a HOPE substudy. Hypertension. 2001;38:E28-32. [PMID: 11751742] Google Scholar Author, Article, and Disclosure InformationAffiliations: Indiana University School of Medicine, Division of Nephrology and, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA (A.D.S., R.A.)This article was published at Annals.org on 5 June 2012. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited ByManagement of Hypertension in People with Diabetes Mellitus: Translating the 2012 Canadian Hypertension Education Program Recommendations into Practice 19 June 2012Volume 156, Issue 12Page: JC6-8KeywordsCardiovascular disease riskChronic kidney diseaseCoronary revascularizationDrugsHeart failureHypertensionIschemic strokeMyocardial infarctionTransient ischemic attacks ePublished: 19 June 2012 Issue Published: 19 June 2012 CopyrightCopyright © 2012 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...

Double-edged sword: a p53 regulator mediates both harmful and beneficial effects in experimental acute kidney injury

Acute kidney injury triggers activation of innate immune responses and of proapoptotic programs such as the p53 pathway. Mulay et al. examine the effects of blocking murine double minute-2 (mdm2), a negative regulator of p53, using a novel chemotherapeutic agent, nutlin-3a, in mouse ischemia-reperfusion injury. Their results indicate that mdm2 promotes renal regeneration by limiting p53-mediated apoptosis but also enhances early inflammation by facilitating DNA binding of nuclear factor-κB independently of p53.

PARTIALLY HYDROLYZED GUAR GUM INTAKE AMELIORATES CONSTIPATION, IMPROVES NUTRITIONAL STATUS AND REDUCES INDOXYLSULFURIC ACID IN DIALYSIS PATIENTS.

Dialysis patients often develop constipation and changes in intestinal bacterial flora. Indoxylsulfuric acid (IS) levels rise as glomerular filtration decreases, and patients with renal failure have high IS. Elevated IS is also caused by increased indole due to altered intestinal flora (Takayama et al, Am J Kidney Dis. 2003). We investigated whether administering partially hydrolyzed guar gum (PHGG) (Sunfiber: a product of Taiyokagaku Co., Ltd., Japan) ameliorates constipation and improves nutritional status in dialysis patients, while decreasing IS levels. Thirty-five patients on maintenance dialysis (mean age, 71 ± 9; male/female= 22/13) ingested PHGG (10 g/day) for 6 weeks. Defecation was scored before and after PHGG intake using a modified Constipation Assessment Scale-Long Term (Japanese version). Nutritional status was rated according to the Geriatric Nutritional Risk Index (GNRI) before and after PHGG intake. IS was measured in 8 patients taking PHGG orally for 24 weeks, for comparison with those in 8 patients not on PHGG. Constipation scores decreased from 7.9 to 5.0 (p 〈.01) and GNRI increased from 95.0 ± 5.0 to 95.9 ± 5.7 (p 〈.05), reflecting amelioration of constipation and improved nutritional status. The ratio of IS after to that before PHGG intake was calculated to analyze the magnitude of IS change. The ratio in patients not on PHGG was 1.2 ± 0.3, i.e. IS rose, while that in patients taking PHGG was significantly reduced (0.8 ± 0.3, p 〈.05). Our results indicate PHGG consumption to ameliorate constipation and improve nutritional status, and that continued intake reduces IS, in dialysis patients.

Roflumilast enhances the renal protective effects of retinoids in an HIV-1 transgenic mouse model of rapidly progressive renal failure

Retinoic acid decreases proteinuria and glomerulosclerosis in several animal models of kidney disease by protecting podocytes from injury. Our recent in vitro studies suggest that all-trans retinoic acid induces podocyte differentiation by activating the retinoic acid receptor-α (RARα)/cAMP/PKA/CREB pathway. When used in combination with all-trans retinoic acid, an inhibitor of phosphodiesterase 4 further enhanced podocyte differentiation by increasing intracellular cAMP. Additionally, we found that Am580, a specific RARα agonist, has similar renal protective effects as all-trans retinoic acid in a rederived colony of HIV-1 transgenic mice with rapidly progressive renal failure (HIV-Tg) that mimics human HIV-associated nephropathy. Treatment with either the inhibitor of phoshodiesterase 4, roflumilast, or Am580 significantly reduced proteinuria, attenuated kidney injury, and improved podocyte differentiation in these HIV-Tg mice. Additional renal protective effects were found when roflumilast was combined with Am580. Consistent with the in vitro data, glomeruli from HIV-Tg mice treated with both Am580 and roflumilast had more active phosphorylated CREB than with either agent alone. Thus, phosphodiesterase 4 inhibitors could be used in combination with RARα agonists to provide additional renal protection.

The MDRD study: the surprises Proteinuria and blood pressure get attention

Journal of Renal NursingVol. 4, No. 3 From The ArchiveThe MDRD study: the surprises Proteinuria and blood pressure get attentionNeil TurnerNeil TurnerSearch for more papers by this authorNeil TurnerPublished Online:29 Sep 2013https://doi.org/10.12968/jorn.2012.4.3.159AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleReferencesKlahr S, Levey AS, Beck GJ et al. (1994) The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. New Engl J Med 330(13):877–884 Crossref, Google ScholarMenon V, Kopple JD, Wang X et al. (2009) Effect of a very low protein diet on outcomes: long-term follow-up of the MDRD study. Am J Kidney Dis 53(2): 208–217 Crossref, Google Scholar FiguresReferencesRelatedDetails 1 May 2012Volume 4Issue 3ISSN (print): 2041-1448ISSN (online): 2052-2894 Metrics History Published online 29 September 2013 Published in print 1 May 2012 Information© MA Healthcare LimitedPDF download

Evaluation of urine biomarkers of kidney injury in polycystic kidney disease

Progressive disruption of renal tubular integrity in the setting of increased cellular proliferation and apoptosis is a feature of ADPKD. Here we evaluated the effect of these processes on the expression of NGAL and IL-18, markers of tubular injury, in rodent models and in the cyst fluid and urine of patients with ADPKD. Two mouse models where Pkd2 was inactivated which resulted in early or adult onset cysts, were used to evaluate NGAL levels. Further, the Han:SPRD rat model of polycystic disease was used to study IL-18 levels. In four annual serial urine samples from 107 patients with ADPKD in the Consortium for Radiologic Imaging for the Study of Polycystic Kidney Disease (CRISP) study, NGAL and IL-18 excretion rates were determined in conjunction with measures of total kidney volume and estimated GFR (eGFR) by the MDRD equation. Kidneys from affected mice and rats showed prominent expression of NGAL and IL-18/IL-18R, respectively, in epithelial cells lining kidney cysts. In human ADPKD cyst fluid, both NGAL and IL-18 were elevated. In CRISP patients, the mean percentage increase in total kidney volume was 5.4 /year and the mean decline in eGFR 2.4 mL/min/year. The trend of increased mean urine NGAL and IL-18 over three years was statistically significant; however, there was no association of tertiles of IL-18 or quartiles of NGAL and the change in total kidney volume or eGFR over this period. Thus, urinary NGAL and IL-18 excretion are mildly and stably elevated in ADPKD, but do not correlate with changes in total kidney volume or kidney function. This may be due, in part, to the lack of communication between individual cysts and the urinary collecting system in this disorder.

Managing Patients With Chronic Kidney Disease

Over the past several years, major consensus has emerged about the management of chronic kidney disease (CKD) based on large-scale randomized treatment trials, most notably in diabetic nephropathy. 1 Brenner B.M. Cooper M.E. de Zeeuw D. et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001; 345: 861-869 Crossref PubMed Scopus (6092) Google Scholar The systematic staging of CKD based on estimates of kidney function is being expanded to include urinary albumin excretion, 2 Matshushita K. van der Velde M. Astor B. et al. Chronic Kidney Prognosis ConsortiumAssociation of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet. 2010; 375: 2073-2081 Abstract Full Text Full Text PDF PubMed Scopus (2731) Google Scholar , 3 Warnock D.G. Muntner P. McCullough P.A. et al. REGARDS InvestigatorsKidney function, albuminuria, and all-cause mortality in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study. Am J Kidney Dis. 2010; 56: 861-871 Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar and the direct relationship between severity of kidney disease (marked by reduced glomerular filtration rate [GFR]) and adverse outcomes has been emphasized. 4 Go A.S. Chertow G.M. Fan D. et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004; 351: 1296-1305 Crossref PubMed Scopus (8834) Google Scholar , 5 KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. Am J Kidney Dis. 2007; 49: S12-S154 Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar

Prospective Tracking of Pediatric Urology Consults: Knowing is Half the Battle

The planned clinical activity of pediatric urologists has been well described. However, little is known about nonscheduled work (eg consultation requests). We describe the unplanned clinical activity of pediatric urologists at a high volume academic medical center. Demographic data regarding inpatient, operating room and emergency department pediatric urology consults were prospectively entered into an internal database. Consults from July 2008 through June 2010 underwent retrospective chart abstraction to identify reasons for consultation. Bivariate and multivariate statistics were used to evaluate 1) temporal trends in unplanned clinical activity, and 2) patient and service specific factors associated with whether a consult was billable (ie seen by attending physician within 24 hours). During the study period 665 pediatric consults were obtained. Mean ± SD patient age was 8.4 ± 7.7 years. Nearly all consults were seen at the emergency department (51%) or the inpatient wards (47%). The most common primary diagnoses were infection, obstruction/hydronephrosis and neurogenic bladder. The number of consults per month decreased during the course of the academic year (r(2) = 0.1422). Nearly three fourths of consults were eligible for billing. The factors associated with consult eligibility for billing included specific attending physician (p = 0.03), location (p <0.0001) and house officer experience (p = 0.007). At our academic pediatric hospital we averaged nearly 1 unplanned pediatric urology consult per day. Several service specific factors (unrelated to patient diagnosis or acuity) were associated with whether the consult had the potential to generate revenue. Unplanned clinical activity is an important factor to consider when planning departmental funding, staffing and training.

Identification of HnRNP-A2/B1 as a Target Antigen of Anti-Endothelial Cell IgA Antibody in Behçet's Disease

Behçet's disease (BD) is a chronic, multisystemic vasculitis that theoretically affects all sizes and types of blood vessels. Although pathogenesis remains enigmatic, endothelial cells are believed to be the primary target in this disease. We detected the target protein using western blotting and immunoprecipitation and determined the amino-acid sequence of the peptide by liquid chromatography-matrix assisted laser desorption/ionization-tandem time-of-flight analysis (LC-MALDI-TOF/TOF). Serum reactivity against the recombinant target protein was analyzed by immunoblotting. Serum reactivity against streptococcal 65-kD heat shock protein (hsp-65) and the recombinant target protein was investigated by ELISA. The 36-40-kD protein band that was obtained from immunoprecipitation, which was analyzed by LC-MALDI-TOF/TOF, exhibited the amino-acid sequences of heterogeneous nuclear ribonucleoproteins A2/B1 (hnRNP-A2/B1). Reactivity of serum IgA against human recombinant hnRNP-A2/B1 was detected in 25 of 30 BD patients (83.3%), 4 of 30 systemic lupus erythematosus patients (13.3%), 8 of 30 rheumatoid arthritis patients (26.7%), 9 of 30 Takayasu's arteritis patients (30%), 6 of 30 healthy controls (20%), and none of 30 IgA nephropathy patients. Optical densities obtained from ELISAs against the recombinant human hnRNP-A2/B1 were correlated with those against the recombinant streptococcal hsp-65.JID JOURNAL CLUB ARTICLE: For questions, answers, and open discussion about this article, please go to http://www.nature.com/jid/journalclub.

Quiz Page February 2012: Acute Kidney Injury in an Adolescent With a Family History of Autoimmune Disorders

Quiz Page February 2012: Acute Kidney Injury in an Adolescent With a Family History of Autoimmune Disorders

Nutrition Supplementation and Chronic Kidney Disease: What Are the Options?

LOWSERUMALBUMIN and low protein intake are independently associated with increased risk of mortality in the hemodialysis and peritoneal dialysis populations. In a hypothetical theoretical model, interventions to improve serum albumin by just 0.2 g/dL in 50% of all dialysis patients with albumin levels less than 3.5 g/dL were projected to potentially save 1,400 lives and decrease hospitalizations by 6,300 per year. However, dialysis patients may underestimate the importance of these factors in their overall health at the onset of dialysis. One of these factorsmay include being overwhelmed with information from various health care practitioners, including physicians, nurses, dietitians, and social workers. Nutrition counseling focused on increasing protein intake is often undertaken in the face of many obstacles. Some of these obstacles may include lack of patient readiness to make changes in food intake, inadequate monetary funds, dysgeusia, poor gastrointestinal function, poor appetite, depression, and low energy levels between dialysis treatments. As a result, nutritional supplementation has become a routine part of life for many dialysis patients. Given that mortality rises significantly as albumin levels decrease below 3.8 g/dL, it is important for the dietitian to start implementing nutritional supplementation in the earlier stages of malnutrition. In general, oral supplementation is the first and most frequently used nutrition intervention, followed or supplemented by enteral