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| This Month in AJKD | Lowering Postdialysis Conductivity to Increase Sodium RemovalManlucu et al, pages 69-76; and Depner & Ing, pages 1-4.
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Some have suggested that the focus on solute control in hemodialysis has been at the expense of attending to fluid control. Interdialytic fluid accumulation clearly is harmful, yet over the past 30 years these levels have not decreased. Aggressive fluid removal is often performed in hemodialysis, and in order to avoid intradialytic complications, high dialysate sodium concentrations are used. However, these high sodium concentrations create a negative cycle, leading to further increases in extracellular volume between dialysis sessions. In this issue, Manlucu et al showed that it is possible to accomplish a stepwise decrease in postdialysis plasma sodium levels (calculated as end-of-session plasma conductivity) over 4 phases, by using dialysate conductivity measurement cells and a biofeedback software system. The decrease in postdialysis plasma sodium levels was accompanied by decreases in extracellular water, blood pressure, and interdialytic weight gain. In an editorial, Drs Depner and Ing believe the key to these results is the stepwise nature of the reduction, and although most clinics do not have the biofeedback technology employed here, the principles can be applied in general with the potential of minimizing adverse effects of lowering serum sodium values abruptly while achieving the full benefit.
| Obstetric Outcome in Pregnant Women on Long-term DialysisLuders et al, pages 77-85; and Hou, pages 5-6.
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Most published reports suggest that intensified hemodialysis regimens in pregnant women result in better pregnancy outcomes; however, the small number of patients investigated is a limitation of all existing studies. In this issue, Luders et al analyzed maternal and fetal outcomes of 52 pregnancies in women undergoing maintenance hemodialysis in a single center and their relationship with various clinical, laboratory, and hemodialysis parameters. The study reported an 87% overall rate of successful delivery. Preeclampsia was the most important factor for adverse outcomes and was associated with a poor prognosis compared with pregnancies without preeclampsia. In an editorial, Dr Hou commends Luders et al for pointing out the potential benefits of carefully measuring residual kidney function in women who conceive after starting dialysis, and the importance of prevention of preeclampsia when treating pregnant women on hemodialysis.
| Blood Type and Allocation of Deceased Donor KidneysKayler & Segev, pages 95-101; and Scandling & Norman, pages 7-9.
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The current deceased donor kidney allocation system allows allocation of type A donor kidneys to type AB recipients, a practice Drs Kayler and Segev believe may be unfair and inefficient. In this issue, they examine United Network for Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN) data between 1995 and 2004 to determine the extent of disparities in waiting times and concurrent differences in recovery, discard, live donor, and deceased donor transplant rates. They found that type AB candidates had a 1.5-fold greater chance of receiving deceased donor kidney transplants than blood group A candidates, leading to significantly shorter median waiting time for deceased-donor transplant. Discard rates of type AB kidneys were 1.7-fold greater than for other blood types for both expanded criteria and standard criteria donors. In an editorial, Drs Scandling and Norman suggest that a refinement of UNOS policy to restrict the transplant of blood type A deceased-donor kidneys only into blood type A candidates would correct these apparent disparities in organ allocation.
| Nephrology Training in the 21st CenturyParker, pages 132-142.
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In the twentieth century, postgraduate nephrology training evolved from an apprenticeship model to a more formal fellowship where self-directed study by the trainee was emphasized, and competence to practice nephrology was presumed in part on the basis of adequate exposure to curriculum. In this issue, Dr Parker reviews the literature on nephrology training in the 20th century to determine if it is possible to measure whether the recent adaptation of trends in medical education produces better nephrologists. His review shows that while recent efforts are underway to create common evaluation and assessment tools specifically in the field of interventional nephrology, nephrology as a whole is lacking in systematic and uniform mechanisms for establishing competence, and there is a dearth of publications on educational techniques and outcomes in nephrology training. Dr Parker calls for educational initiatives that can be measured, validated, and reported to the nephrology training community for critical evaluation and then applied to the training of 21st century nephrologists.
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| | AJKD News | AJKD congratulates Statistical Editor Chris Schmid, PhD, on being elected a Fellow in the American Statistical Association. ASA Fellows are nominated by peers for outstanding contributions to the field. This is a great honor, as the number of annual recipients may be no more than one-third of 1% of ASA members. To have your next publication benefit from expert statistical review, consider submitting your work to AJKD.
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