2011 Most-Read Articles in Nephrology

Carol Peckham


December 08, 2011

In This Article

Editor's Note:

The following are the Medscape features and news most read by nephrologists in 2011 to date.

10. Rapid Fluid Removal During Dialysis is Associated With Cardiovascular Morbidity and Mortality

The United States is home to more than 350,000 hemodialysis (HD) patients. Dialysis patients experience high rates of mortality, driven largely by an exceptionally high rate of cardiovascular (CV)-related mortality, which exceeds that of the general population by 10- to 20-fold. A study republished from Kidney International tested whether higher dialytic ultrafiltration rates are associated with greater all-cause and cardiovascular mortality, and hospitalization for cardiovascular disease. The study showed that among chronic HD patients, ultrafiltration rates >13 mL/h/kg are associated with increased all-cause mortality and even more so with CV mortality.

9. I'm Struggling to Live on $160,000 a Year: MD Lament

According to an article based on the Medscape Physician Compensation Report 2011 , a typical primary care doctor -- family physician or internist -- earns $160,000 after expenses but before taxes. Yet it's often not enough in a world where rising costs collide with stagnant reimbursements. Whereas most Americans would consider a $160,000 income a fortune, many physicians find it a challenge to live on that amount. Why can some manage easily while others are struggling to pay the bills?

8. New Lupus Drug Is Here; Now What About the Kidneys?

In this Medscape Viewpoint Lynda Szczech talks about belimumab, the first drug to be approved in several decades for treating systemic lupus erythematosus (SLE). Belimumab is a B-lymphocyte stimulator protein inhibitor that is thought to decrease the amount of abnormal B cells, which is hypothesized to be a mechanism of action in lupus. Dr. Szczech discusses the phase 3 trial published in The Lancet,[1] which found that patients who received belimumab experienced a benefit over those receiving placebo. She observes that "little information is provided in this initial report on how belimumab may have affected the course of those with established renal manifestations of their lupus."

7. Bardoxolone Improves Kidney Function in CKD Out to 1 Year

Bardoxolone methyl is synthesized from oleanolic acid, a compound found in olive trees, among other places. It has been shown to have anti-inflammatory and antioxidant effects in the cell. A Medscape Medical News story covered a study published in the New England Journal of Medicine showing that patients with advanced chronic kidney disease (CKD) and type 2 diabetes receiving bardoxolone continued to show improvements in their estimated glomerular filtration rates (eGFR) at 52 weeks.[2] For information on the upcoming BEACON trial, which will study bardoxolone in more than 2400 patients for longer than 2 years, view a recent conversation between George Bakris and Robert D. Toto.

6. When to Start Dialysis

Two stories based on the IDEAL study[3] were in the top 10, so both are included here in 6th place.

A position paper published in Nephrology Dialysis Transplantation is intended to be used in conjunction with the original 2002 European guideline on when to start dialysis and is updated following the IDEAL study. The 2002 guidance was not significantly changed. The evidence levels are increased by the studies published since 2002. The caution against using creatinine and creatinine clearance (CC) to guide dialysis start is strengthened. A caution that eGFR calculated by the modification of diet in renal disease (MDRD) method is not useful in determining need for dialysis has been added. The emphasis on using GFR of 6 mL/min/1.73m2 as an absolute lower limit to starting dialysis is made more vague. Support for establishing advanced CKD clinics has been added.

Another highly read article covering the IDEAL study was “Early” Dialysis Start Based on eGFR is no Longer Appropriate , republished from Nature Reviews Nephrology. It concluded with the hope that the IDEAL results, together with those from many observational studies, will help to reverse the epidemic of “early” start of dialysis.

5. Early Nephrology Care Useless? A Worrisome Conclusion

In his commentary Jeffrey Berns expressed concern about a study published in the Archives of Internal Medicine by Winkelmayer and colleagues[4] examining the impact of predialysis care on first-year mortality among patients who started dialysis between the years 1996 and 2007. The editor's note concluded that predialysis care did not show any improvements. Jeffrey Berns advised that readers look at the details. In fact, he said, "the study showed a 36% reduction in 1-year mortality associated with earlier nephrology care that occurred 90 days or more before the start of dialysis."

4. Cochrane Salt/Blood-Pressure Message Blasted in The Lancet

How significantly salt affects health has been challenged over the course of this year. For example, a Medscape news story covered the response to a meta-analysis published in the Cochrane Review[5] in which relative risks for all-cause mortality and cardiovascular mortality for both normotensives and hypertensives were only mildly to moderately reduced, and not to a statistically significant degree. In congestive heart failure patients, salt restriction actually significantly increased all-cause death. In a comment published in the July 30, 2011[6] issue of The Lancet, Dr. Feng J. He (Queen Mary University, London, United Kingdom) and Dr. Graham A. MacGregor (Wolfson Institute of Preventive Medicine, Barts, London) say that the meta-analysis and press release that accompanied it "reflect poorly on the reputation of the Cochrane Library and the authors."

3. Estimating Creatinine Clearance: A Meta-analysis

A meta-analysis republished from Pharmacotherapy to determine which body weight descriptor most accurately predicts measured creatinine clearance (and whether rounding serum creatinine concentration to 1 mg/dL when it is less than 1 mg/dL accurately predicts measured creatinine clearance. They concluded that using the Cockcroft-Gault equation with no body weight and actual serum creatinine concentration value most closely estimated measured creatinine clearance.

2. New Dosing Guidelines for Erythropoiesis-Stimulating Agents

In June, The US Food and Drug Administration (FDA) urged more conservative dosing guidelines for erythropoiesis-stimulating agents (ESAs) when used to treat anemia in patients with CKD. The recommendations are in response to clinical trials showing an increased risk for cardiovascular events, such as heart attack, stroke, thrombosis, and death, when ESAs are dosed to achieve a normal or nearly normal blood hemoglobin level. Medscape readers might be interested in a cross-Atlantic Skype debate on this issue between Ajay Singh, MD, and Francesco Locatelli, MD.