BackgroundAfrican Americans have persistently poor access to living donor kidney transplants (LDKT). We conducted a small randomized trial to provide preliminary evidence of the effect of informational decision support and donor financial assistance interventions on African American hemodialysis patients’ pursuit of LDKT.MethodsStudy participants were randomly assigned to receive (1) Usual Care; (2) the Providing Resources to Enhance African American Patients’ Readiness to Make Decisions about Kidney Disease (PREPARED); or (3) PREPARED plus a living kidney donor financial assistance program. Our primary outcome was patients’ actions to pursue LDKT (discussions with family, friends, or doctor; initiation or completion of the recipient LDKT medical evaluation; or identification of a donor). We also measured participants’ attitudes, concerns, and perceptions of interventions’ usefulness.ResultsOf 329 screened, 92 patients were eligible and randomized to Usual Care (n = 31), PREPARED (n = 30), or PREPARED plus financial assistance (n = 31). Most participants reported interventions helped their decision making about renal replacement treatments (62%). However there were no statistically significant improvements in LDKT actions among groups over 6 months. Further, no participants utilized the living donor financial assistance benefit.ConclusionsFindings suggest these interventions may need to be paired with personal support or navigation services to overcome key communication, logistical, and financial barriers to LDKT.Trial registrationClinicalTrials.gov [NCT01439516] [August 31, 2011].

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Diabetes is associated with an inordinate burden of cardiovascular and renal disease, which is expected to accelerate during the next few decades. The relationship between the renin-angiotensin system (RAS) and diabetic macrovascular and microvascular disease is well established. The contribution of the tissue RAS in disease pathogenesis has recently been the focus of much interest, and has prompted investigators to explore the use of high-dose RAS inhibition with monotherapy or combination therapy to provide a more complete blockade of the actions of angiotensin II, beyond lowering blood pressure. There is now evidence to support this approach to maximize cardiovascular and renal protection. Optimal dosing strategies remain uncertain, but tissue specificity does not appear to be important if the doses of angiotensin-converting enzyme-I and angiotensin-receptor binders are high enough. The purpose of this review is to highlight our current understanding of the role of the tissue RAS in the pathogenesis of diabetic end-organ damage and ongoing strategies to interfere pharmacologically.

Hypertension is a leading risk factor for vascular dementia. With the increasing burden of dementia, prevention and delay of cognitive decline are becoming a priority. Recent clinical trials have demonstrated that patients taking antihypertensive medications have a reduced incidence of dementia and cognitive impairment. Calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers appear to offer significant neuroprotection, even beyond blood pressure reduction. Evidence is emerging that the angiotensin receptor blockers offer superior neuroprotection. This finding has been attributed to the unique property of sustained blockade of the AT1 receptor, combined with simultaneous activation of the AT2 receptors. The use of angiotensin receptor blockers as first-line therapy for hypertension and cognitive protection in the elderly should be strongly considered.

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