Reviews & Analysis

Renal pathological changes seen in individuals with the zoonotic disease leptospirosis include interstitial nephritis and tubular necrosis. With a particular emphasis on the role of hemodynamics, this author from Thailand examines the pathogenesis of renal dysfunction in leptospirosis. The utility of dopamine in this setting is contrasted with its effects in renal dysfunction of other etiologies.

There is a high false-positive rate for certain serologies in patients with HIV infection. Here, Hernandez and colleagues reinforce several salient points relating to the management of HIV-seropositive patients with renal disease. The case clearly highlights the importance of kidney biopsy; aggressive immunosuppressive therapy in the setting of HIV-infection should be avoided unless a diagnosis of autoimmune disease is confirmed.

This Review integrates discussion of well-established mechanisms that are known to underlie the 'fetal origins hypothesis' of hypertension with examination of mechanisms for which data continue to emerge. Set in the context of implications for public health, the authors suggest that monitoring the blood pressure, renal function and body weight of at-risk children might help to reduce the likelihood of kidney and cardiovascular disease developing in later life.

It is essential that community-based nephrologists and primary care physicians, who are increasingly involved in the management of stable renal allograft recipients, are familiar with new-generation immunosuppressive drugs. This comprehensive article by Arjang Djamali and colleagues is a guide to the pharmacokinetics, dosing, drug–drug interactions and adverse effects of the mainstays of modern immunosuppression; calcineurin inhibitors, antimetabolites, mTOR inhibitors and corticosteroids.

It is estimated that up to 30% of people who regularly receive hemodialysis for kidney failure suffer from a depressive disorder. Depression can compromise treatment compliance, and modulate the immunological and nutritional status of patients. In this thorough and balanced overview, the authors explore this understudied issue, drawing attention to the problems associated with detection of depression and effective management in hemodialysis populations.

The Iranian model of kidney transplantation, whereby donors are paid by a government-sponsored agency, has eliminated the waiting list completely. Elsewhere, black markets for kidneys encourage exploitation of the poor and harm both donors and recipients. As the buying and selling of organs increases relentlessly despite legislation, this author argues that failure to regulate these practices could be considered unethical.

Seven single gene mutations are known to cause hypertension, generally by affecting electrolyte transport in the distal nephron, or synthesis or activity of mineralocorticoid hormones. These relatively uncommon disorders should be considered when young patients with a family history of high blood pressure present with severe or refractory hypertension. This article guides clinicians through identification of these defects, their associated laboratory findings, and recommended treatments.

This short article is an introduction to the histology of damage to transplanted kidneys caused by active BK virus infection. Aimed at trainee pathologists and nephrologists wishing to enhance their understanding of the histological basis of the diseases they manage, this beautifully illustrated paper describes the key features, differential diagnosis and clinical implications of this increasingly frequent complication.

Are polymorphisms of the G protein-coupled receptor kinase GRK4 the key to developing new tools for the diagnosis and management of essential hypertension? Here, Felder and Jose explore the therapeutic potential of manipulating this protein, which regulates the activity of the dopamine-1 receptor. The role of GRK4 is set in the context of the contributions of the dopaminergic and renin–angiotensin systems to the pathogenesis of hypertension.

These authors present their controversial opinion that the evidence for a specific renoprotective effect of renin–angiotensin blockade, independent of blood-pressure control, is more ambiguous and the magnitude of any such effect much smaller than is often claimed. Data from several large trials of renin–angiotensin blockers and elegant renal cross-transplantation experiments in mice are proffered in support of their theory.

Authors from the University of Heidelberg present a provocative and comprehensive Review of the issues involved in management of hypertension in patients with type 2 diabetic nephropathy. After examining the relationships between the renin–angiotensin system (RAS), proteinuria and hypertension, Ritz and Dikow focus on controversies such as the effect of RAS blockade beyond blood-pressure reduction, and optimal doses of drugs that inhibit RAS.

When stimulated by pathogens or endogenous ligands, Toll-like receptors (TLRs) initiate production of myriad cytokines. Long known to reside on cells of the innate immune system, 10 of 11 TLRs have now been shown to be expressed in human kidney. Data supporting a role for these renal TLRs in a variety of conditions, including sepsis-induced acute renal failure, ischemic injury, and rejection of allografts, are presented.

Here, the concept of a self-perpetuating cyclical interaction between outcomes of oxidative stress (such as production of reactive oxygen species and depletion of antioxidants) and inflammatory mediators (such as cytokines), driving initiation and progression of hypertension, is presented. Experimental evidence to support operation of such a cycle is outlined, and the therapeutic implications of targeting the interactions therein are discussed.

Could the shortage of transplantable kidneys in the developed world be reduced by allowing willing individuals to sell their organs? To answer this question, the authors examine the outcomes of patients who have received paid kidneys, and the financial compensation and postoperative care received by their donors. Adoption of commercial kidney transplantation in the Western world would have inevitable knock-on effects in developing countries, they argue.

The ideal vascular access for hemodialysis would have a long functional life, facilitate blood flow sufficient to achieve dialysis prescription, and have a low rate of associated complications. This Review assesses the success with which available forms of access fulfill these criteria. The discussion is set in the context of the 2000 K/DOQI dialysis access guidelines and data published in the past 5 years.

Few studies have specifically addressed treatment of cardiovascular disease in kidney transplantees. As such, extrapolation from trials in other patient populations forms the basis for current management regimens. Here, the etiology of, and major risk factors for, cardiovascular complications in renal transplant recipients are reviewed. Evidence for risk factor-specific interventions for left ventricular hypertrophy, congestive heart failure and ischemic heart disease in this population is also appraised.

Parasites are an under-recognized cause of serious complications following organ and tissue transplantation. This comprehensive overview of the infectious species most commonly encountered in immunocompromised graft recipients—including protozoa, such as malaria and leishmania, and nematodes—aims to increase clinicians' index of suspicion when presented with pyrexial illness in this patient population. Routes of infection, key clinical characteristics, diagnostic techniques and treatments are discussed.