Intensive renal support in critically ill patients with acute kidney injury did not decrease mortality, improve recovery of kidney function, or reduce the rate of nonrenal organ failure as compared with less-intensive therapy involving a defined dose of intermittent hemodialysis three times per week and continuous renal-replacement therapy at 20 ml per kilogram per hour. (ClinicalTrials.gov number, NCT00076219.)

SummaryBackground and objectives Octogenarians frequently require maintenance hemodialysis (HD) for treatment of stage renal disease ESRD. Although the Fistula First Initiative recommends creating an arteriovenous fistula as the preferred dialysis access method, vascular access selection should be based on life expectancy and functional status at treatment initiation. Results Thirty-seven octogenarian patients selected HD and two selected peritoneal dialysis. Among the 37 HD patients, 29 initiated dialysis with a tunneled cuffed catheter, 6 with an arteriovenous fistula, and 2 with an arteriovenous graft. Three patients regained renal function after an average 112 days and one was lost to follow-up. Of the 33 remaining on HD, 8 required nursing home admission and 25 were discharged home after initiating HD. Among these 33, 19 died and 14 remained on HD at the end of study period. Days on dialysis (mean Ϯ SEM) before death in those discharged to a nursing facility versus home were 52.6 Ϯ 14.7 versus 386.1 Ϯ 90.7 (P Ͻ 0.05), respectively.Conclusions Vascular access planning should include assessment of functional status and life expectancy in octogenarian HD patients.

Despite more aggressive treatment of diabetes, hypertension, and hyperlipidemia, the incidence and prevalence rates of end-stage renal disease (ESRD) continue to increase worldwide. The likelihood of developing chronic kidney disease in an individual is determined by interactions between genes and the environment. Familial clustering of nephropathy has repeatedly been observed in all population groups studied and for multiple etiologies of kidney disease. A three- to nine-fold greater risk of ESRD is observed in individuals with a family history of ESRD. Marked racial variation in the familial aggregation of kidney disease exists, with high rates in African American, Native American, and Hispanic American families. Disparate etiologies of nephropathy aggregate within African American families, as well. These data have led several investigators to search for genes linked to diabetic and other forms of nephropathy. Evidence for linkage to kidney disease has been detected and replicated at several loci on chromosomes 3q (types 1 and 2 diabetic nephropathy), 10q (diabetic and nondiabetic kidney disease), and 18q (type 2 diabetic nephropathy). Multicenter consortia are currently recruiting large numbers of multiplex diabetic families with index cases having nephropathy for linkage and association analyses. In addition, large-scale screening studies are underway, with the goals of better defining the overall prevalence of chronic kidney disease, as well as educating the population about risk factors for nephropathy, including family history. Given the overwhelming burden of kidney disease worldwide, it is imperative that we develop a clearer understanding of the pathogenesis of nephropathy so that individuals at risk can be identified and treated at earlier, potentially reversible, stages of their illness.

Background and Purpose-Calcified arterial plaque has been proposed as a subclinical marker of atherosclerosis. We compared it to a well-validated surrogate-carotid intimal medial thickness (IMT). Methods-Calcified arterial plaque was measured in 2 vascular beds (coronary and carotid) by computed tomography, and common carotid artery IMT was measured by B-mode ultrasonography, in 438 participants. Results-Calcium was positively associated with IMT (rϭ0.36 for coronary and rϭ0.45 for carotid, both PϽ0.0001).Correlations were attenuated with adjustment for age, sex, and diabetes. Conclusions-Calcified plaque in the coronary and carotid arteries is moderately associated with subclinical atherosclerosis.( Patients and MethodsThe sample consisted of families with Ն2 siblings concordant for type 2 diabetes (T2DM). Unaffected siblings were also recruited. Individuals with previous vascular surgeries were excluded.Calcified plaque was measured in the coronary arteries and carotid bifurcation with single and multidetector row computed tomography (CT) (General Electric CTi, LightSpeed QXi) capable of 500 ms temporal resolutions. 4,5 Images were obtained during suspended respiration and with electrocardiogram gating at 50% of the RR interval. The SmartScore software package (GE Advantage Windows) provided a calcium mass score using a 90-Hounsfield unit threshold. The calcium mass score was used because of reduced variability. 6 For this report, calcified plaque burden was summed for the coronary arteries and for the carotid bifurcation (common, bulb, internal, and external), which was then averaged for the left and right sides.High-resolution B-mode carotid ultrasonography was performed using a 7.5-MHz transducer and a Biosound Esaote (AU5) machine. Scans were performed of the near and far walls of the distal 10-mm portion of the common carotid artery (CCA) at 5 predefined interrogation angles on each side. The mean value of up to 20 the CCA IMT values is reported here.Partial Pearson correlation coefficients, adjusted for age, sex, and diabetes, were computed to test for an association between IMT and the log of vascular calcium plus 1; statistical significance was assessed using generalized estimating equations to account for familial correlation. This report focuses primarily on 438 white participants; 88 black participants were excluded from most analyses because of small sample size. ResultsMean values in the 438 white participants were: age, 61 years (range 34 to 83); body mass index, 32 kg/m 2 ; and low-density lipoprotein, 2.8 mmol/L. Prevalence of T2DM was 80%; hypertension, 77%; smoking, 20%; and history of cardiovascular disease, 22%. Calcified plaque was present in the expected pattern with lower quantities observed in persons aged younger than 60 years compared with those aged 60 years or older, and in women compared with men (Table 1). Prevalence of detectable calcified plaque was high for the coronary arteries in all groups (Ն85%) and lower for the carotid arteries in the group younger than 60 years.Common c...

Vascular access for hemodialysis has a long and rich history. This article highlights major innovations and milestones in the history of angioaccess for hemodialysis. Advances in achievement of lasting hemodialysis access, swift access transition, immediate and sustaining access to vascular space built the momentum at different turning points of access history and shaped the current practice of vascular access strategy. In the present era, absent of large‐scale clinical trials to validate practice, the ever‐changing demographic and comorbidity makeup of the dialysis population pushes against stereotypical angioaccess goals. The future of hemodialysis vascular access would benefit from proper randomized clinical trials and acclimatization to clinical contexts.