The introduction of novel immunosuppressive agents over the last two decades and the improvement of our diagnostic tools for early detection of antibodymediated injury offer us an opportunity, if not a mandate, to better match the immunosuppression needs of the individual patients with side effects of the therapy. However, immunosuppressive regimens in the majority of programs remain mostly protocol-driven, with relatively little inter-program heterogeneity in certain areas of the world. Emerging data showing different outcomes with a particular immunosuppressive strategy in populations with varying immunological risks underscore a real potential for "personalized medicine" in renal transplantation. Studies demonstrating marked differences in the adverse-effect profiles of individual drugs including the risk for viral infections, malignancy and renal toxicity call for a paradigm shift away from a "one size fits all" approach to an individually tailored immunosuppressive therapy for renal transplant recipients, assisted by both screening for predictors of graft loss and paying close attention to dose or class-related adverse effects. Our paper explores some of the opportunities during the care of these patients. Potential areas of improvements may include: (1) a thorough assessment of immunological and metabolic risk profile of each renal transplant recipient; (2) screening for predictors of graft loss and early signs of antibody-mediated rejection with donor-specific antibodies, protocol biopsies and proteinuria (including close follow up of adverse effects with dose adjustments or conversions as necessary); and (3) increased awareness of the possible link between poor tolerance of a given drug at a given dose and non-adherence with the prescribed regimen. Altogether, these considerations may enable the most effective use of the drugs we already

Decades after the introduction of chronic maintenance hemodialysis, the optimal means of quantifying dialysis dose remains controversial. Differences of opinion in the international dialysis community lead to substantial diversity in everyday clinical practice. Several studies suggest that the well-recognized international mortality differences in hemodialysis populations may result from these divergent approaches to dialysis care. One of the main areas of divergence is the different degree of reliance on dialysis clearance when prescribing dialysis. The "clearance approach" implies that treatment quality is primarily dependent on efficient removal of uremic toxins as estimated by dialytic urea clearance. Urea can be rapidly removed by high efficiency dialysis in a relatively short time. The main alternative to this strategy is the "time approach" based on the recognition that longer or more frequent dialysis provides benefits beyond increasing urea removal. Some of the putative benefits are more effective volume and blood pressure control, better maintenance of hemodynamic stability because of slower ultrafiltration and removal of uremic toxins that do not behave like urea. Recently, chronic inflammation has been proposed to be an important predictor of outcome in dialysis patients. Inflammatory markers are commonly elevated in chronic renal failure and levels of these seem to correlate with malnutrition, maintenance of residual renal function, and volume control. The relationships between dialysis clearance, treatment time, chronic inflammation, volume control, and hemodynamic stability are explored in this review. We propose that a better understanding of these complex relationships may provide opportunities for improving outcomes of maintenance hemodialysis patients.

J Clin Hypertens (Greenwich). Liddle syndrome (LS) is an autosomal dominant disorder due to a gain‐of‐function mutation in the epithelial Na+ channel and is perceived to be a rare condition. A cross‐sectional study of 149 hypertensive patients with hypokalemia (<4 mmol/dL) or elevated serum bicarbonate (>25 mmol/dL) was conducted at a Veterans’ Administration Medical Center Hypertension Clinic in Shreveport, LA. Data on demographics, blood pressure, and select blood tests were collected and expressed as percentages for categoric variables and as mean ± standard deviation (SD) for continuous variables. Patients were diagnosed with likely LS when the plasma renin activity (PRA) was <0.35 μU/mL/h and the aldosterone was <15 ng/dL and likely primary hyperaldosteronism (PHA) with PRA <0.35 μU/mL/h and aldosterone level >15 ng/dL. The cohort included predominantly elderly (67.1±13.4 years), male (96%), and Caucasian (57%) patients. The average blood pressure was 143.8/79.8 mm Hg±27.11/15.20 with 3.03±1.63 antihypertensive drugs. Based on the above criteria, 9 patients (6%) satisfied the criteria for likely LS and 10 patients (6.7%) were diagnosed with likely PHA. In this hypothesis‐generating study, the authors detected an unusually high prevalence of biochemical abnormalities compatible with likely LS syndrome from Northwestern Louisiana, approaching that of likely PHA. J Clin Hypertens (Greenwich). 2010;12:856–860.

The prevalence of end‐stage renal disease continues to increase in the United States with commensurate need for renal replacement therapies. Hemodialysis continues to be the predominant modality, though less than 2% of these patients will receive hemodialysis in their own home. While home modalities utilizing peritoneal dialysis have been growing, home hemodialysis (HHD) remains underutilized despite studies showing regression in left ventricular mass, improved quality of life, reduced depressive symptoms, and decreased postdialysis recovery time. To increase penetration of HHD will require a proactive approach from both physicians and dialysis networks to address barriers both in the system and on the level of the patients and families. We are reviewing these issues with a focus on the state of Mississippi.

Introduction: Achieving euvolemia is one of the major challenges when treating end‐stage renal disease (ESRD) patients receiving maintenance renal replacement therapy. Fluid overload is recognized as an independent predictor of mortality in ESRD, but its association with chronic inflammation is less well explored especially in chronic maintenance hemodiafiltration. Methods: We performed a cross‐sectional study of 87 prevalent ESRD patients receiving chronic maintenance hemodiafiltration (vintage 66.5 ± 57.1 months) with bioimpedance analysis to characterize the degree of percent overhydration (OH%). We also compared the levels of inflammatory markers, including C‐reactive protein (CRP), serum albumin, neutrophil/lymphocyte ratio (NLR), and hemoglobin red cell distribution width (RDW) for the overhydrated (OH% ≥ 15%) versus euvolemic (OH% < 15%) groups. Linear regression analysis was performed to explore relationships between the degree of OH and inflammatory indicators. Findings: The cohort represented an all‐European population with a mean age of 60.9 ± 14.7 years and prevalence of diabetes mellitus of 27%. The entire cohort's OH% was 14.9% ± 5.1% (range −11.1% to 39.0%); further, the <15% group of patients’ OH% was 8.0% ± 8.5% versus 20.9% ± 5.1% in the OH% ≥ 15% group (P < 0.0001). Forty‐seven patients (53%) were overhydrated by traditional criteria (OH% ≥15%) and 20 patients (23%) were severely overhydrated (OH% > 20%). The euvolemic (OH% <15%) versus severely overhydrated (OH% > 20%) groups had significant differences in markers of inflammation: CRP (9.8 ± 10.6 vs. 21.5 ± 21.6 mg/L, P < 0.006), serum albumin (37.6 ± 02.9 vs. 34.5 ± 5.3 g/L, P < 0.004), and NLR (3.06 ± 1.25 vs. 3.92 ± 2.04; P < 0.004). On linear regression, significant correlations were found between OH% and CRP (r = 0.2899, P < 0.006), serum albumin (r = −0.3670; P < 0.0005), RDW (r = 0.2992; P < 0.005), and NLR (r = 0.2900; P < 0.006). Discussion: In a prevalent hemodiafiltration cohort, OH was common and correlated with several inflammatory markers.