ISN Education has asked ISN Leaders from around the world to weigh in on their favorite educational pieces published in 2016. Their responses will be published as part of an exclusive editorial series in the lead up to WCN 2017.

Ce webinar de l'ISN est consacré à l'hyperparathyroïdie secondaire à l'insuffisance rénale – pathogénie et traitement.
Les objectifs du webinar seront de

  1. Comprendre la pathogénie de l'hyperparathyroïdie secondaire de la MRC.
  2. Placer cette complication dans le contexte des TMO-MRC.
  3. Définir les conséquences cliniques de l'hyperparathyroïdie secondaire.
  4. Choisir le traitement le plus adapté et connaître ses avantages et inconvénients.

This webinar is part of the ISN Dialysis Webinar Series. 

Protein energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with adverse clinical outcomes, especially in individuals receiving maintenance dialysis therapy. A multitude of factors can affect the nutritional and metabolic status of CKD patients requiring a combination of therapeutic maneuvers to prevent or reverse protein and energy depletion. These include optimizing dietary nutrient intake, appropriate treatment of metabolic disturbances such as metabolic acidosis, systemic inflammation, and hormonal deficiencies, and prescribing optimized dialytic regimens. In patients where oral dietary intake from regular meals cannot maintain adequate nutritional status, nutritional supplementation, administered orally, enterally, or parenterally, is shown to be effective in replenishing protein and energy stores. In clinical practice, the advantages of oral nutritional supplements include proven efficacy, safety, and compliance. Anabolic strategies such as anabolic steroids, growth hormone, and exercise, in combination with nutritional supplementation or alone, have been shown to improve protein stores and represent potential additional approaches for the treatment of PEW. Appetite stimulants, anti-inflammatory interventions, and newer anabolic agents are emerging as novel therapies. While numerous epidemiological data suggest that an improvement in biomarkers of nutritional status is associated with improved survival, there are no large randomized clinical trials that have tested the effectiveness of nutritional interventions on mortality and morbidity.

The complement cascade is a vital component of both the innate and adaptive immune systems. Complement activation also contributes to the pathogenesis of many diseases, however, and the kidney is particularly susceptible to complement-mediated injury. Drugs that block complement activation can rapidly reduce tissue inflammation and also attenuate the adaptive immune response to foreign and tissue antigens. Eculizumab is a monoclonal antibody that prevents the cleavage of C5. It has been approved for the treatment of atypical hemolytic uremic syndrome, and it has been used in selected patients with other kidney diseases. Many additional drugs are also in development for blocking the complement cascade, including new monoclonal antibodies, recombinant proteins, small molecules, and small interfering RNA agents. Validation of these new drugs as effective treatments for kidney diseases faces several challenges. Many complement-mediated kidney diseases are rare, so it is not feasible to test all of the new drugs in numerous different rare diseases. The onset and course of the diseases are heterogeneous; many of these diseases also carry a lifelong risk of recurrence, and it is not clear how long complement inhibition must be maintained. In spite of these challenges, new therapeutic options for targeting the complement system will likely become available in the near future and may prove useful for treating patients with kidney disease.

The purpose of this review is to examine the evidence supporting the application of plasma exchange in renal disease. Our review focuses on the following 6 most common renal indications for plasma exchange based on 2014 registry data from the Canadian Apheresis Group: (i) thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome; (ii) renal transplantation, (iii) anti–neutrophil cytoplasm antibodies–associated vasculitis, (iv) cryoglobulinemia, (v) focal segmental glomerulosclerosis, and (vi) Goodpasture syndrome. The rarity of these diseases and their rapid, often fatal course mean that randomized controlled studies of plasma exchange are rarely conducted. Although evidence from an adequately powered randomized controlled trial supports the use of plasma exchange to treat thrombotic thrombocytopenic purpura, the use of plasma exchange to treat other renal diseases is only supported by observational and mechanistic studies. Larger well-designed trials are needed to clarify the potential role of plasma exchange in renal disease. Growing international collaboration will improve the quality of future studies in this area.

KDIGO Logo transparentThis webinar is part of a Webinar Series organised with KDIGO.

The webinar will aim to:

  • Understand challenges in diagnosing and treating rare diseases affecting the kidneys.
  • Identifying issues in common in rare diseases affecting the kidneys.
  • Apply common issues to action in patient care.

This presentation was given by John Kellum, Director of Center for Critical Care Nephrology, USA. It was presented during the CRRT Conference 2016: "Updates in ICU Medicine: Controversies, Challenges and Solutions," held in San Diego from 16-19 February 2016.

This presentation was given by Mark Okusa from the Division of Nephrology, University of Virginia in Charlottesville, VA, USA. It was presented during the CRRT Conference 2016: "Updates in ICU Medicine: Controversies, Challenges and Solutions," held in San Diego from 16-19 February 2016.

This presentation was given by Paul Wischmeyer from the Department of Anesthesiology and Pediatrics at University of Colorado School of Medicine in Denver, Colorado. It was presented during the CRRT Conference 2016: "Updates in ICU Medicine: Controversies, Challenges and Solutions," held in San Diego from 16-19 February 2016.

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