Kidney International Research Articles

Serving as a reviewer

There is broad agreement that peer review remains Submitted to Biomedical Journals” adopted by an international committee of medical journal editors in 1988 the best method of assessing scientific manuscripts. Many readers of and contributors to Kidney International as that have subsequently been revised and expanded [2–4], and now most journals provide a web site with detailed well as all other biomedical journals may be asked by the editors to serve as reviewers of manuscripts that have instructions for authors. Some journals require that the been submitted for publication. Serving as a reviewer is a abstract contain sections presenting the background, vital effort in the advancement of biomedical knowledge. methods, results and conclusions of the study, while othReviewing is equivalent in importance to planning, comers require only a summary paragraph. The body of the pleting and reporting original research, and demands the manuscript then provides, sequentially, the background same high standards of honesty and care. and rationale for the research, the subjects of the study, It has been said that reviewing requires idealism bethe study design, the methods including the statistical cause the time and skill devoted to the effort does not, analyses if needed, the results including tables of data generally, provide a monetary reward or academic recogand graphics, a discussion, sources of support, acknowlnition [1]. Nevertheless, the request to serve as a reedgments and references. Some journals also require a viewer implies recognition by the editors of the selected statement regarding the contribution of each author to reviewer as a competent, careful and critical biomedical the planning of the study, the performance of the study scientist. Additionally, many journals annually recognize and the writing of the report. their reviewers by publication of a list of the names of Authors need to utilize care and judgment in deciding the individuals who have served as reviewers during the whether to present data in tables, graphs, other types of preceding year. Some reviewers are further recognized figures or text. An unnecessary graph or figure may utiby appointment to the editorial boards of journals. lize excessive space, but a well-prepared graph may effecThe reviewer is obligated both to the editors retively save space. When graphs are used, authors should questing the review and, even more significantly, to the take care to assure that lettering, symbols and lines within authors of the manuscript. This overview considers some graphs of data are sufficiently large and distinct to remain aspects of the review process that may provide assistance. clearly legible when necessarily reduced in size in order to meet columnor page-width limitations when printed. The manuscript should be carefully checked to assure THE AUTHOR(S) appropriate grammatical usage and spelling. If the auThe review process begins with the authors’ preparathors are not fluent in the language in which the manution of the report of the research. The review and publiscript is written, they should have the manuscript read cation even of significant new data that have broad bioand appropriately edited for correct usage by someone medical importance may be needlessly delayed if a who is fluent. Even if authors are writing in their native manuscript is poorly written. Authors should make cerlanguage, it is generally helpful to have one or more tain that they precisely comply with the requirements of colleagues read the manuscript before submission to asthe journal to which their manuscript is submitted with sure clear communication [5]. If the manuscript necessarrespect to the style of the manuscript. Many journal ily refers to another report by the authors that has been adhere to the “Uniform Requirements for Manuscripts accepted for publication but has not yet appeared, the authors must enclose a copy of the typescript of that report with the manuscript as reviewers should or will

Identifying and addressing potentially preventable causes of renal allograft loss

Identifying and addressing potentially preventable causes of renal allograft loss

Frequency of administration of recombinant human erythropoietin for anaemia of end-stage renal disease in dialysis patients.

Although the benefits of recombinant human erythropoietin (rHu EPO) administration in dialysis patients have been demonstrated the optimal frequency regimen has not as yet been established. Treatment with rHu EPO is expensive, there is therefore a need for optimising the efficiency of its administration. The objectives of this review were to assess the effects of different frequency regimens of rHu EPO administration in dialysis patients in terms of i) effectiveness (correction of anaemia, quality of life and freedom from adverse events) ii) efficiency (optimal resource use) of different rHu EPO dose regimen policies. We searched MEDLINE (1980 to May Week 3 2001), EMBASE (1984 to Week 24 2001), BIOSIS (1985 to January 1997), CINAHL (1982 to October 1997), The Cochrane Library (Issue 1, 1997), CHEMABS (1984 to November 1996), SIGLE (1980 to June 1996), CRIB (10th edition, 1995), UK NRR (14th consolidation, September 1996), RSC ( 1980 to February 1997), HealthSTAR (1995 to October 1997), IBSS (1984 to July 1997), NEED (July 1997) and reference lists of relevant articles. We contacted biomedical companies and investigators in the field and we hand searched Kidney International (including all supplements but excluding all conference proceedings except for 1994) July 1983 to May 1997 inclusive. The Internet was also searched on: August 1997. We had also identified some studies from a previous broad search for all randomised controlled trials (RCTs) relevant to the management of end-stage renal disease. Date of the most recent search: June 2001. All randomised or quasi randomised controlled trials comparing different frequencies of rHu EPO administration in dialysis patients. Subgroup analyses were performed comparing haemodialysis and CAPD patients and also subcutaneous and intravenous administration. Only published data were used. Data were abstracted by a single investigator on to a standard form. The data abstracted were relevant to the predetermined outcome measures: measures of correction of anaemia, rHu EPO dose, quality of life measures, adverse events, number of withdrawals from study, mortality. Where appropriate, a summary relative risk (RR) was calculated for dichotomous data and a weighted mean difference (WMD) or standardised mean difference (SMD) for continuous data. Eight studies met our inclusion criteria. When once a week administration was compared with twice weekly there was no significant difference in the ability to maintain the target haemoglobin (RR 1.00, 95% CI 0.42 to 2.40). Mean haemoglobin after twelve weeks of therapy was not different between the two groups (WMD -0.21g/dl, 95% CI -0.98 to 0.56). No difference was found in mean haemoglobin or haematocrit at the end of any studies which compared once with thrice weekly administration of rHu EPO (SMD -0.31, 95% CI -0.67 to 0.06). A single study which compared once with more that thrice weekly administration showed no significant difference in mean haemoglobin at the end of the maintenance phase (mean difference -0.2g/dl, 95% CI -0.65 to 0.25). The dosage of erythropoietin required by those on haemodialysis receiving rHu EPO once weekly was just significantly more (WMD 12.0 U/kg, 95% CI 0.24 to 23.76) than those receiving it twice weekly but the confidence interval is wide. No such difference was found for CAPD patients nor when the results were combined (WMD 5.15 U/kg, 95% CI -3.74 to 14.05). The result was not significant when comparing once weekly with thrice weekly administration (WMD 10.00 U/kg, 95% CI -80.87 to 100.87). There was no difference in the frequency of adverse events between any of the groups studies. There is no significant difference between once weekly versus thrice weekly subcutaneous administration of rHu EPO. Once weekly administration of rHu EPO would require an additional 12U/kg/week for patients on haemodialysis, however this is based on one very small study. The cost of this additional hRu EPO nee, however this is based on one very small study. The cost of this additional hRu EPO needs to assessed, in particular with regard to patient preference and compliance.

Introduction

This issue of Kidney International contains a series of reviews and articles on current research presented at the International Society of Nephrology Forefronts in Nephrology meeting on “Nitric Oxide and Renal Inflammation,” which took place at St. John's College, Cambridge, United Kingdom, on August 2–5, 2001. This international symposium was held approximately 20 years after the groundbreaking discovery of endothelium-derived relaxing factor (EDRF) by Robert Furchgott. The opening keynote lecture was by Salvador Moncada, who first demonstrated that EDRF is nitric oxide (NO), and the talk focused on the fundamental biology of NO. He emphasized how identifying the degree and duration of target exposure to NO, which arises due to differing activities of the NO synthase isoforms, is essential for understanding the pathophysiological effects of in vivo NO production. In the following four sessions the biology of endothelial NO synthase, inducible NO synthase, and diverse aspects of NO and renal diseases were highlighted by the leading experts in the field. Two major roles for NO were discussed in detail, cell-cell communication and cytotoxicity, and data from in vivo work were presented supporting the hypothesis that pathology arises due to imbalance between constitutive and induced NO production. The therapeutic challenge of how and when to manipulate these NO pathways, however, is still open and will require additional intense research efforts. About 50 scientists from 10 countries participated in the symposium. The meeting provided a forum for established investigators as well as young researchers in the field to participate openly in discussions, exchange views and have their work critically analyzed by experts. The relaxed atmosphere of one of the most traditional colleges in the U.K. opened the way for new contacts and collaborations among the participants. We believe that the articles compiled in this issue of the journal provide the current status of research in the field of NO biology in renal inflammatory diseases and will point to new directions for future studies. We are grateful to the many scientists who contributed their papers for this issue. We thank the International Society of Nephrology for generously supporting this event in Cambridge and the editors of Kidney International for the opportunity to publish this work.

Review: double bag or Y-set systems reduce peritonitis in patients on continuous ambulatory peritoneal dialysis

. Daly C, Campbell M, Cody J, et al. Double bag or Y-set versus standard transfer systems for continuous ambulatory peritoneal dialysis in end-stage renal disease . Cochrane Database Syst...

Recombinant human erythropoietin for chronic renal failure anaemia in pre-dialysis patients.

Treatment with recombinant human erythropoietin (rHu EPO) in dialysis patients has been shown to be highly effective in terms of correcting anaemia and improving quality of life. There is debate concerning the benefits of rHu EPO use in pre-dialysis patients. There is a concern that rHu EPO may accelerate the deterioration in renal function, however the opposing view is that if rHu EPO is as effective in pre-dialysis patients that by improving the patients sense of well-being the onset of dialysis could be delayed. To assess the effects of rHu EPO use in pre-dialysis patients with renal anaemia. We searched MEDLINE (1980 to May Week 3 2001), EMBASE (1984 to Week 24 2001), BIOSIS (1985 to January 1997), CINAHL (1982 to October 1997), The Cochrane Library (Issue 1, 1997), CHEMABS (1984 to November 1996), SIGLE (1980 to June 1996), CRIB (10th edition, 1995), UK NRR (14TH consolidation, September 1996), RSC ( 1980 to February 1997), HealthSTAR (1995 to October 1997), IBSS (1984 to July 1997), NEED (July 1997) and reference lists of relevant articles. We contacted biomedical companies and investigators in the field and we hand searched Kidney International (including all supplements but excluding all conference proceedings except for 1994) July 1983 to May 1997 inclusive. The internet was also searched on: August 1997. We had also identified some studies from a previous broad search for all randomised controlled trials (RCTs) relevant to the management of end-stage renal disease. Date of the most recent search: June 2001. RCTs or quasi-RCTs comparing the use of rHu EPO with no rHu EPO or placebo in pre-dialysis patients. Only published data were used. Data were abstracted by a single investigator onto a standard form. A sample of the data abstracted was double-checked by another reviewer. The data abstracted were relevant to the predetermined outcome measures. Some authors were contacted to clarify how patients were allocated to groups. All authors from included studies were contacted for missing information. Twelve studies with a total of 232 participants met the inclusion criteria and where possible data from these were summated by meta-analyses (Peto's Odds Ratio (OR) and Weighted Mean Difference (WMD)). The majority of the trials included small numbers and were of short duration (8-10 weeks) with the exception of three trials. There was a marked improvement in haemoglobin (mean difference 2.3g/dL, 95% CI 1.37 to 3.23) and haematocrit (WMD 9.92%, 95% CI 8.78 to 11.05) with the treatment and a decrease in the number of patients requiring blood transfusion (OR 0.25, 95% CI 0.09 to 0.69). The data from all studies which reported quality of life or exercise capacity demonstrated an improvement in the rHu EPO group. None of the measures of progression of renal disease (when a summary statistic was calculated) demonstrated a statistically significant difference. Though the requirement for antihypertensive treatment appears to be increased by rHu EPO (OR 1.84, 95% CI 1.02 to 3.32), there was no other statistically significant increase in adverse events. Based on the limited current evidence, decisions therefore have to be made on whether the putative benefits in terms of quality of life identified in the review are worth the extra costs of pre-dialysis rHu EPO. This review has shown that treatment with rHu EPO in pre-dialysis patients corrects anaemia and avoids the requirement for blood transfusions. There are also improvements in quality of life and exercise capacity. There may be increased hypertension. Most of the trials were not of sufficient duration to assess the effects of rHu EPO on progression of renal disease. In the long term, questions still remain about whether pre-dialysis rHu EPO either speeds up or delays the onset of dialysis. Thus there is insufficient evidence on the total costs and benefits of treating pre-dialysis patients with rHu EPO.

Cholesterol in Vascular and Valvular Calcification

In the early 1990s, the late Jeff Hoeg had the foresight to ask whether vascular calcification relates to the duration and severity of exposure to cholesterol. In a group of homozygous hyperlipidemic patients for whom detailed records of cholesterol levels were available over a long period of time, he and his colleagues found that coronary calcification scores by ultrafast computed tomographic scanning correlated significantly with the cholesterol year product.1 Studies that lack long-term cholesterol history may miss a correlation between lipids and calcification, because current treatments so dramatically change cholesterol levels as to make them unrepresentative of long-term exposure. See p 1927 In the present issue of Circulation , Pohle et al2 successfully overcame these difficulties by studying the rate of change in calcification as a function of change in lipid levels, excluding patients in whom treatment was altered during the study period. These investigators found that both coronary calcification and aortic valve calcification progress more rapidly in subjects with levels of LDL >130 mg/dL. This finding dovetails with those of Callister et al,3 who discovered that patients who successfully lowered their cholesterol levels with lipid-lowering agents significantly reduced the progression of coronary calcification. In a large population of young subjects, the risk factor that correlated most significantly with coronary calcification was LDL cholesterol.4 This relation was stronger than the correlation with age, smoking, fasting insulin, blood pressure, or male sex.4 In another study of asymptomatic outpatients, LDL cholesterol was the only risk factor correlating with progression of coronary calcification by electron-beam computed tomography over an 18-month period.5 The correlation of LDL cholesterol exposure to valvular and vascular calcification raises the possibility of a mechanistic role, which is also supported by in vitro studies. Two groups …

Kidney Internationalgoes electronic

We are pleased to announce that, beginning in January 2002 Kidney International will begin accepting manuscript submissions online from authors. Authors will be able to submit their manuscripts for review via a secure Web site using the Manuscript Central™ system. Manuscript Central™ will handle all the steps of the review process online (submissions, tracking, review) through a Web browser, so the system will be accessible from anywhere in the world. An author will simply create an account on the Web site, enter some basic information about the manuscript, and upload the text and images. Upon submission, the paper will be immediately available to the Editorial Office and the process of peer review. Editors and reviewers will have access to the manuscript online for evaluation, and authors, reviewers, and editors will correspond via e-mail. User-specific accounts will be established for all users of the Web site to ensure security. Only reviewers and editors who have been assigned to a particular manuscript will be able to view that manuscript online. For those authors who have not previously submitted manuscripts online, DON'T worry. Detailed, step-by-step instructions for preparing manuscripts and image files for submission will be posted on the Web site, and technical help will be available online, by e-mail, or by telephone. The most obvious advantage of using electronic capabilities in manuscript submission and review is the speed in which manuscripts can be processed, considerably reducing the time from their initial submission to publication. Because every step will be accomplished online, there will be no need for numerous photocopies of the manuscript or hard copies of figures when submitting materials to Manuscript Central.™ In addition, the savings in time and cost in terms of postal or courier submissions cannot be overemphasized. A final benefit of the Manuscript Central™ system is the ability for authors to log on and check the status of their papers during the review process. Remember, however, to follow the guidelines in the Instructions for Authors for submitting accepted manscripts for production, including originals of figures suitable for reproduction. This is an important step into the 21st century, and one that the Editors of Kidney International hope will help us better serve the international nephrology community by delivering the latest cutting-edge research and information each month. In our opinion, taking the review process of our journal online is an essential next step to keep Kidney International the leader in our field. Please look for additional information in next month's issue. We look forward to this exciting new change and hope that you will as well.

Comparison of cellulose, modified cellulose and synthetic membranes in the haemodialysis of patients with end-stage renal disease.

Comparison of cellulose, modified cellulose and synthetic membranes in the haemodialysis of patients with end-stage renal disease.

Quantitation of dialysis: historical perspective.

This article is an attempt to provide a historical perspective to the ongoing attempts to quantify dialysis therapy. It is immediately apparent that motivated chemists, physicists, engineers, mathematicians, and other scientists from all over the world have greatly aided this effort. Dialysis, described by Graham in 1861, was furthered by Abel et al. and Hass before World War I. Willem Kolff attempted to evaluate mass removed and Alwall used a solute extraction ratio. However, the concept of "clearance" and "dialysance" awaited the studies of Wolf et al. in 1951. This classic work describes most of the information concerning actual dialyzer performance known today. A. S. Michaels provided the equations leading to the KoA/Ro/A concept in 1966 which only very recently required updating. The interaction of diffusion and convection is complex and was studied by Villarroel in 1977 and recently by Jaffrin. L. W. Henderson studied and described hemofiltration and hemodiafiltration from 1967-1975. Efforts to relate the patient's outcome to the dialyzer's performance have been difficult and ongoing since 1971; the Babb-Scribner Square meter-hour (which included the expression "Kt/V"); the Kopp et al. Liter-Kilogram concept; 1972 Kjellstrand clearance * time/kg or Liter. A NIH sponsored conference on the Adequacy of Dialysis in Monterey, California in March of 1974 was focused somewhat on the "middle molecule" theory of uremic toxicity, but contained a presentation by Sargent and Gotch on the possibilities of urea kinetic modeling. They developed iterative computer programs to obtain the best estimates of the required variables. At about this same time, Teschan, Ginn et al. published a series of neurofunctional tests and EEG power spectra analyses which most convincingly showed that dialysis two times a week was inadequate, and that dialysis delivered three times a week at urea clearance equal to body water volume was required to normalize these abnormalities: a major contribution! The National Cooperative Dialysis Study reported in Kidney International, 1983, was either misunderstood or ignored by most practitioners. The mechanistic analysis of the study by Gotch and Sargent appeared in 1985 and indicated that at adequate protein intake a Kt/V >0.8 yielded better patient survival. In 1982 Malchesky reported the Direct Dialysis Quantification (DDQ) based on calculations from the total mass removed in the dialysate. Although cumbersome, it avoids many errors including the effect of hematocrit and other factors on dialyzer clearance and many consider it to be "the gold standard." The 1990s were characterized by the development of many simple logarithmic equations to estimate Kt/V and eKt/V suitable for spreadsheets which could be used for CQI by individual units. These are primarily by J. T. Daugirdas and coworkers, Smye and Tattersall. In 1991 the Urea Reduction Ratio (URR) was introduced by Lowrie, who in 1999 suggested that Kt and V (as indicator of lean body mass) were independent predictors of survival. Peritoneal dialysis: Although performed before and immediately after World War II, almost all of the basic quantification mechanistics and data are found in the publications of S. T. Boen (1964). New quantifiers, the Mass Transport Area Coefficient (MTAC) or Pyle-Popovich model, the Henderson-Nolph, and Garred models, were compared by Waniewski. Gotch announced a PD modeling program which suggested that a weekly PKt/V at 2.1 was needed to supply the same urea removal as a Kt/V of 3.6, but warned that both were sensitive to decreased time.

A Forty Year History 1960–2000

A Forty Year History 1960–2000

International Society of Nephrology

International Society of Nephrology

Correction for vol. 102, p. 2700; vol. 102, p. 3053

HomeCirculationVol. 103, No. 3 Free AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCorrectionPDF/EPUB Originally published23 Jan 2001https://doi.org/10.1161/01.CIR.103.3.476Circulation. 2001;103:476This article corrects the followingLimitation of Excessive Extracellular Matrix Turnover May Contribute to Survival Benefit of Spironolactone Therapy in Patients With Congestive Heart Failure In the article, “Limitation of Excessive Intracellular Matrix Turnover May Contribute to Survival Benefit of Spironolactone Therapy in Patients With Congestive Heart Failure: Insights from the Randomized Aldactone Evaluation Study (RALES),” by Zannad et al that appeared in a previous issue of the journal (Circulation. 2000;102:2700–2706 ), some sentences contained incorrect information.In Results, under Baseline Levels of ECM Turnover Markers (page 2702), the sentence: “However, ischemic heart disease (5.3 versus 4.7 μg/L for ischemic versus nonischemic, P=0.02) and baseline treatment with digoxin (4.7 versus 5.4 μg/L for on digoxin versus off digoxin, P=0.001) were independently associated with baseline PIIINP levels” should be replaced with the following:However, ischemic heart disease (5.3 versus 4.7 μg/L for ischemic versus nonischemic, P=0.02) and baseline treatment with digoxin (5.4 versus 4.7 μg/L for on digoxin versus off digoxin, P=0.001) were independently associated with baseline PIIINP levels.In addition, under Prognostic Significance of Serum Levels of ECM Turnover in the Discussion (page 2705), the statement, “On the other hand, we found that patients chronically treated with digitalis had a lower level of PIIINP. This is consistent with the finding that digoxin reduces death due to the progression of heart disease” should be replaced with the following:On the other hand, we found that patients chronically treated with digitalis had a higher level of PIIINP. This is inconsistent with the finding that digoxin reduces death due to the progression of heart disease.In the article by Nelson et al that appeared in a previous issue of the journal (Circulation. 2000;102:3053–3059), the order of authors in the author line was incorrect. The correct author list follows:Gregory S. Nelson, PhD; Ronald D. Berger, MD, PhD; Barry J. Fetics, MSE; Maurice Talbot, RN; Julio C. Spinelli, PhD; Joshua M. Hare, MD; David A. Kass, MD Previous Back to top Next FiguresReferencesRelatedDetailsCited By Bakris G, Vassalotti J, Ritz E, Wanner C, Stergiou G, Molitch M, Nesto R, Kaysen G and Sowers J (2010) National Kidney Foundation consensus conference on cardiovascular and kidney diseases and diabetes risk: an integrated therapeutic approach to reduce events, Kidney International, 10.1038/ki.2010.292, 78:8, (726-736), Online publication date: 1-Oct-2010. Williams E, Katholi R and Karambelas M (2006) Use and side-effect profile of spironolactone in a private cardiologist's practice, Clinical Cardiology, 10.1002/clc.4960290405, 29:4, (149-153), Online publication date: 1-Apr-2006. Related articlesLimitation of Excessive Extracellular Matrix Turnover May Contribute to Survival Benefit of Spironolactone Therapy in Patients With Congestive Heart Failure Faiez Zannad, et al. Circulation. 2000;102:2700-2706 January 23, 2001Vol 103, Issue 3 Advertisement Article InformationMetrics Copyright © 2001 by American Heart Associationhttps://doi.org/10.1161/01.CIR.103.3.476 Originally publishedJanuary 23, 2001 PDF download Advertisement

Evidence-based medicine in nephrology: identifying and critically appraising the literature.

Uncertainties about best management of end-stage renal disease (ESRD) are reflected in wide variations in practice. Systematic reviews aim to reduce uncertainty by strengthening the evidence base for clinical practice, allowing estimation of the benefits and risks of particular interventions, whilst minimizing the potential for bias. This paper describes the methods and conduct of six systematic reviews of aspects of the management of ESRD, and the yield in terms of trials found. Our methodology was based on that recommended by the Cochrane Collaboration (an international initiative set up to perform and disseminate systematic reviews of health care). It involved a systematic search of electronic databases and bibliographic reference lists, together with handsearching of Kidney International for studies relevant to the management of ESRD, followed by a systematic assessment of study quality. Around 12,000 abstracts were assessed which had been identified from electronic sources. Of these, 2085 (18%) were deemed to be reports of possible randomized or quasi-randomized controlled trials relevant to the management of ESRD. Three hundred and forty were relevant to the six specific reviews, and after assessment of the full manuscripts, 39 studies were finally included in our reviews. Reports of a further nine trials, which were identified from other sources, were also included. The broad search adopted allowed the parallel development of a register of trials of all aspects of the management of ESRD. This study has demonstrated that the methodology of systematic reviews, as promoted by the Cochrane Renal Group, is feasible but has significant resource implications. The development of a register of randomized controlled trials (RCTs) related to the management of ESRD will facilitate this form of research in the future.

Renal cell loss through cell suicide

Renal cell loss through cell suicide

Introduction

Introduction

Acute Rejection, type I (Interstitial)

y Dis. 2000;35(4):E13-E14 Fig 1. Tubulitis, ie, infiltration of tubular epithelium by lymphocytes, is the hallmark of type I interstitial acute rejection. Different classifications have been put forth for diagnosis of acute rejection. Among the most widely used are Banff, most recently revised in 1997 (published in Kidney International 1999), and CCTT (published in the Journal of the American Society of Nephrology 1998). The lower threshold for rejection by CCTT criteria is 5% of non-scarred parenchyma involved with tubulointerstitial lymphoplasmacytic infiltrate, with tubulitis in at least three tubules, with accompanying tubular injury, lymphocyte activation, and/or edema (at least 2 of these latter 3). In this biopsy, there is tubular injury, edema, and multiple lymphocytes infiltrating under the glomerular basement membrane. (Jones’ Silver Stain, original magnification 3400).

Introduction

Introduction

Introduction

The last 20 years have seen major changes in the practice of critical care medicine. Initially sustained by emerging mechanical ventilation technology and the part-time dedication of interested anesthesiologists, it has gone on to become an established feature of all tertiary institutions, with dedicated and trained specialists, an expanding specific knowledge base, and ongoing research unique to its needs. Critical care medicine is now a well-established medical specialty with specific therapies, publications, practical and cognitive skills, and procedures. The development of intensive care units in particular has had major implications for the kind of surgery that can be performed routinely (such as coronary artery by-pass surgery) and for the type of patients (older and with significant chronic diseases) who can be successfully treated. The evolution of critical care medicine has also had significant implications for clinical nephrologists. One major development has to do with the nature, epidemiology, and management of severe acute renal failure (ARF). Severe ARF is now profoundly different in its epidemiology and associations from the disease seen by nephrologists 30 years ago. It is now seen predominantly in intensive care units, is usually associated with the dysfunction of other organs, and is often accompanied by sepsis. It is typically multifactorial, and has a very high mortality rate. The management of this type of ARF demands the application of complex knowledge and skills. Such knowledge and skills can come either from only a multidisciplinary approach in which nephrologist and intensivist work side by side to achieve optimal care for a given patient, or only from specialists originally from either field who have gone on to formally acquire training and expertise in both specialties. The time has come for the formal development of a specialty area called “Critical Care Nephrology.” The foundation for such an integrated approach has been hemofiltration therapy. Although originally developed to treat patients with end-stage renal disease, hemofiltration has rapidly grown as an important treatment for acute patients. From the original description of Peter Kramer in 1977 as a possible alternative to established techniques, today hemofiltration is a first choice technique for several clinical conditions, particularly multiple organ failure. The success of this technique, however, relies on a strong collaboration between the nephrologist and the intensive care specialist. There are important clinical reasons for collaborative care. Patients with renal failure are significantly more complex than 30 years ago. They almost always are elderly, have significant comorbidity, and have dysfunction of multiple organs. Renal failure cannot be viewed as a simple problem that will get better over time once the initial insult is gone and sufficient renal replacement therapy has been provided. Insights into such renal replacement therapy now reveal that the therapy itself may make a great deal of difference in the course of the disease. The use of continuous renal replacement therapy (CRRT) has partly redefined the indications for initiating dialytic therapy in the intensive care unit. It has expanded the possible role of blood purification in the management of critically ill patients, and it has widened the scope of interaction between the expertise of the nephrologist, the needs of the intensive care specialist, and their common goals for patient recovery. Critically ill patients keep dying at unacceptably high rates. Surely the answer to such a high mortality rate must be that physicians need to combine knowledge and expertise, be modest and collegial, and be constructive, nonconflictual, and interdisciplinary in their approach to patient care. In this issue of Kidney International, we collected the contributions presented as review and original articles at the Fourth International Congress on Hemofiltration held in Darmstadt, Germany on May 14th and 15th, 1999. The aim of this issue is to provide the scientific community with some of the latest contributions in the field of hemofiltration and multiple organ failure, providing a balanced mix between established knowledge and the newer results from clinical trials and basic research. We were able to assemble a group of outstanding scientists and clinicians who are actively involved in the treatment of critically ill patients with multiple organ failure. We hope this Supplement issue will serve as a tool for consultation and informative reading not only for experts, but also for the beginners of this field. We are grateful to our major sponsor, Hospal (Lyon, France), for supporting this meeting. We also appreciate the following sponsors: Baxter (McGaw Park, Illinois, USA), Braun (Melsungen, Germany), Fresenius Medical Care (Bad Homburg, Germany), Hoechst Marion Roussel (Bad Soden, Germany), Janssen-Cilag (Neuss, Germany), Ray-Med (Wiesbaden, Germany), and A. Schulz Lauterbach (Iserlohn, Germany).

Report from the Treasurer

Report from the Treasurer