Neil Boudville

BACKGROUND: Elevated serum urate levels are associated with progression of chronic kidney disease. Whether urate-lowering treatment with allopurinol can attenuate the decline of the estimated glomerular filtration rate (eGFR) in patients with chronic kidney disease who are at risk for progression is not known. METHODS: of body-surface area in the preceding year to receive allopurinol (100 to 300 mg daily) or placebo. The primary outcome was the change in eGFR from randomization to week 104, calculated with the Chronic Kidney Disease Epidemiology Collaboration creatinine equation. RESULTS: per year [95% CI, -1.18 to 0.97]; P = 0.85). Serious adverse events were reported in 84 of 182 patients (46%) in the allopurinol group and in 79 of 181 patients (44%) in the placebo group. CONCLUSIONS: In patients with chronic kidney disease and a high risk of progression, urate-lowering treatment with allopurinol did not slow the decline in eGFR as compared with placebo. (Funded by the National Health and Medical Research Council of Australia and the Health Research Council of New Zealand; CKD-FIX Australian New Zealand Clinical Trials Registry number, ACTRN12611000791932.).

BACKGROUND: The risk for hypertension after kidney donation remains uncertain. PURPOSE: To see whether normotensive adults who donate a kidney develop higher blood pressure and risk for hypertension compared with nondonor adults acting as control participants. DATA SOURCES: MEDLINE, EMBASE, and Science Citation Index were searched from 1966 until November 2005 for articles published in any language. Reference lists of pertinent articles were also reviewed. STUDY SELECTION: The authors selected studies involving 10 or more healthy normotensive adults who donated a kidney and in whom blood pressure was assessed at least 1 year later. DATA EXTRACTION: Two reviewers independently abstracted data on study and donor characteristics, blood pressure measurements, outcomes, and prognostic features. Comparison data were abstracted from donor studies with control participants. Thirty primary authors provided additional data. DATA SYNTHESIS: Forty-eight studies from 28 countries followed a total of 5145 donors. Before surgery, the average age of donors was 41 years, the average systolic blood pressure was 121 mm Hg, and the average diastolic blood pressure was 77 mm Hg for all studies. In controlled studies in which the average follow-up was at least 5 years after donation (range, 6 to 13 years), blood pressure was 5 mm Hg higher in donors than in control participants (the weighted mean for systolic blood pressure using 4 studies involving 157 donors and 128 control participants was 6 mm Hg [95% CI, 2 to 11 mm Hg], and the weighted mean for diastolic blood pressure using 5 studies involving 196 donors and 161 control participants was 4 mm Hg [CI, 1 to 7 mm Hg]). There was statistical heterogeneity among the 6 controlled studies that assessed hypertension; an increase in risk was noted in 1 study (relative risk, 1.9 [CI, 1.1 to 3.5]). LIMITATIONS: Most studies were retrospective and did not include control groups that were assembled and followed along with donors. Approximately one third of the donors had incomplete follow-up information. CONCLUSIONS: On the basis of the limited studies conducted to date, kidney donors may have a 5-mm Hg increase in blood pressure within 5 to 10 years after donation over that anticipated with normal aging. Future controlled, prospective studies with long periods of follow-up will better delineate safety and identify donors at lowest risk for long-term morbidity.

Lay summary The International Society for Peritoneal Dialysis last published a guideline on prescribing peritoneal dialysis (PD) in 2006. This focused on clearance of toxins and used a measure of waste product removal by dialysis using urea as an example. This guideline suggested that a specific quantity of small solute removal was needed to achieve dialysis `adequacy'. It is now generally accepted, however, that the well-being of the person on dialysis is related to many different factors and not just removal of specific toxins. This guideline has been written with the focus on the person doing PD. It is proposed that dialysis delivery should be `goal-directed'. This involves discussions between the person doing PD and the care team (shared decision-making) to establish care goals for dialysis delivery. The aims of these care goals are (1) to allow the person doing PD to achieve his/her own life goals and (2) to promote the provision of high-quality dialysis care by the dialysis team.Key recommendations 1. PD should be prescribed using shared decision-making between the person doing PD and the care team. The aim is to establish realistic care goals that (1) maintain quality of life for the person doing PD as much as possible by enabling them to meet their life goals, (2) minimize symptoms and treatment burden while (3) ensuring high-quality care is provided. 2. The PD prescription should take into account the local country resources, the wishes and lifestyle considerations of people needing treatment, including those of their families/caregivers', especially if providing assistance in their care. 3. A number of assessments should be used to help ensure the delivery of high-quality PD care. a. Patient reported outcome measures - this is a measure of how a person doing PD is experiencing life and his/her feeling of well-being. It should take into account the person's symptoms, impact of the dialysis regimen on the person's life, mental health and social circumstances. b. Fluid status is an important part of dialysis delivery. Urine output and fluid removed by dialysis both contribute to maintaining good fluid status. Regular assessment of fluid status, including blood pressure and clinical examination, should be part of routine care. c. Nutrition status should be assessed regularly through evaluation of the patient's appetite, clinical examination, body weight measurements and blood tests (potassium, bicarbonate, phosphate, albumin). Dietary intake of potassium, phosphate, sodium, protein, carbohydrate and fat may need to be assessed and adjusted as well. d. Removal of toxins. This can be estimated using a calculation called Kt/Vurea and/or creatinine clearance. Both are measures of the amount of dialysis delivered. There is no high-quality evidence regarding the need or benefit associated with the achievement of a specific target value for these measures. 4. The amount of kidney function that continues to remove waste products and the remaining urine volume should be known for all individuals doing PD. Management should focus on preserving this as long as possible. 5. For some people who require dialysis and who are old, frail or have a poor prognosis, there may be a quality of life benefit from a reduced dialysis prescription to minimize the burden of treatment. 6. In low and lower middle-income countries, every effort should be made to conform to the framework of these statements, taking into account resource limitations. 7. The principles of prescribing and assessing delivery of high-quality PD to children are the same as for adults. In all cases, the PD prescription should be designed to meet the medical, mental health social and financial needs of the individual child and family