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  • Perspective

    Penny Wise, Pound Foolish? Coverage Limits on Immunosuppression after Kidney Transplantation

    As a treatment for end-stage renal disease (ESRD), kidney transplantation is superior to dialysis for improving patient survival rates and quality of life. Its long-term success, however, requires ongoing treatment with immunosuppressive drugs. Ironically, although many of the pivotal discoveries…

    • February 16, 2012
    • Gill J.S. and Tonelli M.
    • N Engl J Med 2012; 366:586 - 589
    • Free Full Text

    Since U.S. kidney-transplant recipients don't benefit from a coherent funding policy for immunosuppressive drugs, thousands of them are at risk for allograft failure and premature death. Ensuring lifetime access to these medications would save lives and money.

  • Images in Clinical Medicine

    Tophaceous Gout

    Figure 1.

    • January 19, 2012
    • Samaras N. and Rossi C.
    • N Engl J Med 2012; 366:e6
    • Free Full Text

    A 74-year-old woman with chronic renal failure was admitted for diarrhea and functional impairment. She was noted to have a tender, soft swelling of the medial and distal phalanx of the right index finger (Panel A). She had no history of joint ...

  • Review Article

    Medical Progress: Focal Segmental Glomerulosclerosis

    Focal segmental glomerulosclerosis accounts for approximately 20% of cases of the nephrotic syndrome in children and 40% of such cases in adults, with an estimated incidence of 7 per 1 million. It is the most common primary glomerular disorder causing end-stage renal disease in the United States,…

    • December 22, 2011
    • D'Agati V.D., Kaskel F.J., Falk R.J.
    • N Engl J Med 2011; 365:2398 - 2411
    • CME

    Focal segmental glomerulosclerosis, which is characterized by progressive glomerular scarring, accounts for about 20% of cases of the nephrotic syndrome in children and 40% in adults. This review considers current approaches to diagnosis and management of the disease.

  • Original Article

    Intensive Diabetes Therapy and Glomerular Filtration Rate in Type 1 Diabetes

    An impaired glomerular filtration rate (GFR) is the final common pathway of diabetic kidney disease. Once the GFR is impaired, cardiovascular disease events and progression to end-stage renal disease occur at unacceptably high rates, even with proven medical management.– This underscores the need…

    • December 22, 2011
    • The DCCT/EDIC Research Group
    • N Engl J Med 2011; 365:2366 - 2376
    • CME

    Persons with type 1 diabetes are at high risk for kidney disease. In this study, intensive diabetes therapy administered early in the course of type 1 diabetes reduced the long-term risk of an impaired glomerular filtration rate.

  • Original Article

    INF2 Mutations in Charcot–Marie–Tooth Disease with Glomerulopathy

    Charcot–Marie–Tooth disease refers to a heterogeneous group of inherited chronic peripheral motor and sensory neuropathies. Affected persons typically present with progressive distal-muscle weakness and atrophy, reduced tendon reflexes, and foot and hand deformities. Three…

    • December 22, 2011
    • Boyer O., Nevo F., Plaisier E., et al.
    • N Engl J Med 2011; 365:2377 - 2388

      The authors report that INF2 mutations are present in patients with focal segmental glomerulosclerosis (FSGS) associated with Charcot–Marie–Tooth neuropathy. The findings provide insight into mechanisms linking formin proteins to podocyte and Schwann-cell function.

    • Correspondence

      Combined C3b and Factor B Autoantibodies and MPGN Type II

      To the Editor: Membranoproliferative glomerulonephritis (MPGN) type II (MPGN II), also called dense-deposit disease, is a rare glomerular disease that often progresses to end-stage renal disease. MPGN II is associated with complement because of systemic C3 activation and deposition of C3 cleavage…

      • December 15, 2011
      • N Engl J Med 2011; 365:2340 - 2342
      • Free Full Text

      This letter describes two unrelated patients with membranoproliferative glomerulonephritis type 2 and autoantibodies to the two individual components of C3 convertase, factor B and C3. These autoantibodies enhance C3 convertase activity, probably leading to nephritis.

    • Case Records of the Massachusetts General Hospital

      Case 30-2011 — A 62-Year-Old Woman with Renal Failure

      Presentation of Case. Dr. Kyle Staller (Medicine): A 62-year-old woman was admitted to this hospital because of renal failure. The patient had an autoimmune overlap syndrome with polymyositis, treated with prednisone and mycophenolate mofetil, but had been in her usual health until 6 weeks before…

      • September 29, 2011
      • Cunningham J., Harisinghani M.G., Taheri D.
      • N Engl J Med 2011; 365:1233 - 1243
      • CME

      A 62-year-old woman with autoimmune overlap syndrome and polymyositis presented to this hospital with anemia, thrombocytopenia, and acute renal failure. Four days before admission, she was found on the floor of her home, confused and minimally conversant.

    • Original Article

      Long Interdialytic Interval and Mortality among Patients Receiving Hemodialysis

      Although some progress has been made in the past two decades, survival rates among patients receiving hemodialysis in the United States remain among the lowest in the world. As in most countries, maintenance hemodialysis in the United States is typically performed three times per week, with two 1…

      • September 22, 2011
      • Foley R.N., Gilbertson D.T., Murray T., Collins A.J.
      • N Engl J Med 2011; 365:1099 - 1107

        Patients receiving thrice-weekly hemodialysis have two 1-day intervals and one 2-day interval between treatments. This study shows that the risks of death and cardiovascular events leading to hospital admission are increased during the long (2-day) interdialytic interval.

      • Case Records of the Massachusetts General Hospital

        Case 29-2011 — A 66-Year-Old Woman with Cardiac and Renal Failure

        Presentation of Case. Dr. Jason E. Faris (Medicine): A 66-year-old woman was admitted to this hospital because of cardiac and renal failure. The patient had been well until approximately 6 months earlier, when dyspnea on exertion and leg edema developed. A diagnosis of congestive heart failure was…

        • September 22, 2011
        • Raje N.S., Steele D.J.R., Lawrimore T.M., Johri A.M., Sohani A.R.
        • N Engl J Med 2011; 365:1129 - 1138
        • CME

        Cardiac and renal failure developed in a 66-year-old woman. Echocardiography suggested infiltrative cardiomyopathy, lytic bone lesions were seen on imaging, and elevated serum free light chains were detected. A diagnostic procedure was performed.

      • Original Article

        Bardoxolone Methyl and Kidney Function in CKD with Type 2 Diabetes

        Diabetes mellitus is a major cause of chronic kidney disease (CKD) worldwide. The complications of CKD (e.g. cardiovascular disease and death) occur before kidney failure develops and are independent of known risk factors (i.e. hypertension and proteinuria). Although CKD progression is slowed by…

        • July 28, 2011
        • Pergola P.E., Raskin P., Toto R.D., et al.
        • N Engl J Med 2011; 365:327 - 336
        • Free Full Text

        Adults with type 2 diabetes and CKD were assigned to receive bardoxolone methyl at a dose of 25 mg, 75 mg, or 150 mg once daily or placebo. Drug treatment was associated with improved estimated GFR, a finding that persisted throughout the 52-week treatment period.

      • Correspondence

        Eosinophil Granule Protein Localization in Eosinophilic Endomyocardial Disease

        To the Editor: A 70-year-old man with chronic renal disease, splenomegaly, and eosinophilia presented with transient weakness in the left arm, visual disturbances, disequilibrium, and anomia. Magnetic resonance imaging of the brain showed findings consistent with numerous, small embolic strokes.…

        • July 14, 2011
        • N Engl J Med 2011; 365:187 - 188
        • Free Full Text

        In this case report, eosinophilic endomyocardial disease was diagnosed in a patient on the basis of immunohistochemical evidence of eosinophil granule protein deposition in the heart, even in the absence of eosinophilic infiltration on cardiac biopsy.

      • Perspective

        Survivors — Dialysis, Immigration, and U.S. Law

        Santiago is in the ER again. He sits in a special row of 20 patients, all of whom are waiting for one result: the potassium. Is it high enough today? Two days ago he was here, and it was only 6 meq per liter. We discharged him. Right now his chest hurts, and he is short of breath. Nothing new, and…

        • June 9, 2011
        • Raghavan R. and Nuila R.
        • N Engl J Med 2011; 364:2183 - 2185
        • Free Full Text

        Santiago, one of 6000 undocumented U.S. residents with end-stage renal disease, is in the ER again. He sits among 20 patients, all waiting for one result: the potassium. Will it be high enough today to earn him one of the 12 chairs in the dialysis unit?

      • Images in Clinical Medicine

        Calcified Vasa Deferentia

        Figure 1.

        • May 26, 2011
        • Banerji J.S. and Devasia A.
        • N Engl J Med 2011; 364:2043
        • Free Full Text

        A 60-year-old man with advanced diabetic nephropathy and secondary hyperparathyroidism underwent radiographic imaging of the abdomen and pelvis as part of an evaluation for nephrolithiasis.

      • Editorial

        Preemptive Olmesartan for the Delay or Prevention of Microalbuminuria in Diabetes

        Patients with either type 1 or type 2 diabetes mellitus are at high risk for chronic kidney disease, which is usually first evident with the onset of microalbuminuria. There is overall consensus that agents that block the renin–angiotensin system — particularly angiotensin-converting–enzyme…

        • March 10, 2011
        • Ingelfinger J.R.
        • N Engl J Med 2011; 364:970 - 971

          Patients with either type 1 or type 2 diabetes mellitus are at high risk for chronic kidney disease, which is usually first evident with the onset of microalbuminuria. There is overall consensus that agents that block the renin–angiotensin system — ...

        • Original Article

          Olmesartan for the Delay or Prevention of Microalbuminuria in Type 2 Diabetes

          Diabetic nephropathy is an increasingly common cause of end-stage renal disease, and the development and rate of renal deterioration are most closely related to the patient's blood pressure. Guideline committees worldwide concur that the blood pressure in patients with diabetes and chronic kidney…

          • March 10, 2011
          • Haller H., Ito S., Izzo J.L., et al.
          • N Engl J Med 2011; 364:907 - 917
          • Free Full Text
          • CME

          This study investigated whether an angiotensin-receptor blocker (olmesartan) would delay microalbuminuria in patients with type 2 diabetes and normoalbuminuria. Olmesartan was associated with a delayed onset of microalbuminuria, even though blood pressure control in both groups was excellent.

        • Perspective

          Bundled Payment for ESRD — Including ESAs in Medicare's Dialysis Package

          In response to a congressional mandate, Medicare has introduced a more constrained method of paying for services covered by its end-stage renal disease (ESRD) program — a method with benefits and risks for patients and providers alike. In the Medicare Improvements for Patients and Providers Act…

          • February 17, 2011
          • Iglehart J.K.
          • N Engl J Med 2011; 364:593 - 595
          • Free Full Text

          Medicare has introduced a more constrained method of paying for services for end-stage renal disease (ESRD) — bundling together most dialysis services and establishing a fixed compensation amount for them, reducing incentives for overuse of drugs such as ESAs.

        • Perspective

          Special Treatment — The Story of Medicare's ESRD Entitlement

          In October 1972, Medicare, which had been enacted for the elderly in 1965, was extended to the disabled by the Social Security Amendments. One provision, added at the last minute, declared that persons with chronic renal disease who required hemodialysis or kidney transplantation "shall be deemed…

          • February 17, 2011
          • Rettig R.A.
          • N Engl J Med 2011; 364:596 - 598
          • Free Full Text

          In 1972, through a last-minute provision of the Social Security Amendments, Medicare coverage was extended specifically to people with end-stage renal disease requiring hemodialysis or kidney transplantation — an entitlement that has had significant consequences.

        • Images in Clinical Medicine

          Metastatic Pulmonary Calcification

          Figure 1.

          • December 23, 2010
          • Timmins S. and Hibbert M.
          • N Engl J Med 2010; 363:2547
          • Free Full Text

          A chest radiograph of a 47-year-old woman with a dry cough and mild exertional dyspnea showed poorly defined bilateral nodular opacities in the superior lung fields (Panel A). The patient had undergone renal transplantation at 23 years of age for an ...

        • Clinical Implications of Basic Research

          Proteinuria, the Podocyte, and Insulin Resistance

          Diabetic nephropathy is a chronic progressive disease that affects 20 to 40% of patients with diabetes mellitus. Clinical trials have shown that strict control of hyperglycemia and hypertension can slow the progression of diabetic nephropathy and that insulin resistance correlates with the onset…

          • November 18, 2010
          • Fornoni A.
          • N Engl J Med 2010; 363:2068 - 2069

            Diabetic nephropathy is a chronic progressive disease that affects 20 to 40% of patients with diabetes mellitus. Clinical trials have shown that strict control of hyperglycemia and hypertension can slow the progression of diabetic nephropathy and that ...

          • Original Article

            Erythropoietic Response and Outcomes in Kidney Disease and Type 2 Diabetes

            Erythropoiesis-stimulating agents (ESAs) have been credited with a reduced need for red-cell transfusion and improved quality of life for patients with end-stage kidney disease who have severe anemia. In patients with chronic kidney disease who do not require dialysis and have moderate anemia, the…

            • September 16, 2010
            • Solomon S.D., Uno H., Lewis E.F., et al.
            • N Engl J Med 2010; 363:1146 - 1155
            • Free Full Text

            This study assessed the relationship between initial responsiveness to darbepoetin alfa and outcomes in patients with chronic kidney disease and type 2 diabetes mellitus. A poor initial hematopoietic response was associated with an increased risk of death or cardiovascular events.

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          American Association for the Study of Liver Diseases

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          Contact AASLD, 1001 North Fairfax St., Suite 400, Alexandria, VA 22314; or call (703) 299-9766; or see http://www.aasld.org .

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