A clone-directed approach may improve diagnosis and treatment of proliferative glomerulonephritis with monoclonal immunoglobulin deposits.

The optimal treatment for the monoclonal gammopathies of renal significance is not known, but there is consensus among experts that treatment should be specific for the underlying clone. The majority of patients with proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) do not have an identifiable clone, and prior studies have found poor renal outcomes for patients with PGNMID treated with a variety of regimens. Here we present a retrospective case series of 19 patients with PGNMID with a more uniform, clone-directed approach. A circulating paraprotein was detected in 37% of patients, and the overall clone detection rate was 32%. Treatment was directed at the underlying clone or, for patients without a detectable clone, empirically prescribed to target the hypothesized underlying clone. Of the 16 patients who underwent treatment, the overall renal response rate was 88%, and 38% of patients experienced complete renal response (proteinuria reduction to under 0.5 gm/24 hours) with initial treatment. All patients were End Stage Renal Disease-free at last follow-up (median 693 days after diagnosis), and treatment was well tolerated. Thus, a clone-directed approach may lead to novel, targeted treatment strategies that could significantly improve outcomes for patients with PGNMID.

Antidiabetic Therapy in End-Stage Renal Disease.

There has been substantial growth in the variety of available antidiabetic agents during the last decade and a half. The role of these newer agents in patients with diabetes and end-stage renal disease (ESRD) population, and their relative benefits and risks in this population compared to patients without ESRD are not yet clear. This stems from the altered state of glucose homeostasis in ESRD, which places patients at high risk for hypoglycemia and, in certain situations, hyperglycemia. In addition, there is a dearth of evidence to support a benefit of tight glycemic control on either micro- or macrovascular outcomes in ESRD patients; furthermore, the metrics by which glycemic control is conventionally measured are less valid in ESRD. In this review, we will discuss noninsulin and insulin-based therapies as well as unique challenges, contraindications, advantages, and disadvantages to their use in ESRD. We will also review issues pertinent to both hemodialysis (HD) and peritoneal dialysis (PD) patients.

Incidence and management of percutaneous transluminal angioplasty-induced venous rupture in the "fistula first" era.

PURPOSE: Percutaneous transluminal angioplasty (PTA)-induced venous rupture is a common complication of hemodialysis access interventions. The authors sought to determine if venous rupture rates and management differed between grafts and fistulas, and in the fistula subset, between transposed and nontransposed fistulas. MATERIALS AND METHODS: Patients experiencing venous rupture during hemodialysis PTA over a 5-year period were identified. Of 1,985 hemodialysis interventions, 75 ruptures occurred in 69 patients (46 women) with a mean age of 63 years (range, 31-88 y). Rupture rates, proportion of successful treatments, and treatment type and number (ie, balloon tamponade, stent, covered stent) were determined. RESULTS: Rupture was more common in fistulas overall (5.6%, 39 of 693) compared with grafts (2.8%, 36 of 1,292; P = .002), in transposed (10.7%, 20 of 187) compared with nontransposed fistulas (3.8%, 19 of 506; P = .001), and in transposed fistulas compared with grafts (P = .0001). There was no significant difference between nontransposed fistulas and grafts. Treatment success (ie, resolution of extravasation) was the same among groups: 69% (27 of 39) in fistulas overall, 70% (14 of 20) in transposed fistulas, 68% (13 of 19) in nontransposed fistulas, and 72% (26 of 36) in grafts. There was a greater need for stents in grafts (38.9%, 14 of 36) compared with fistulas (12.8%, five of 39; P = .003). CONCLUSIONS: PTA-induced rupture is more common in fistulas than grafts, and this effect seems nearly entirely driven by transposed fistulas. Although rupture treatment in fistulas of all types yielded similar success to grafts, and graft ruptures were more difficult to treat than fistula ruptures, the high rupture rates in transposed fistulas attest to the increased difficulty of treating this subset of fistulas.

Quinine--a tonic too bitter for hemodialysis-associated muscle cramps?

Hemodialysis patients are susceptible to muscle cramps, both during dialysis sessions as well as in the interdialytic interval. These cramps are often very painful, disruptive to the dialysis treatment, and adversely affect quality of life. There is no well-defined means of preventing or treating these cramps. Quinine sulfate has been used with apparent success in some patients, but the Food and Drug Administration recently ordered the cessation of marketing of unapproved quinine formulations and advised consumers to avoid "off-label" use of quinine for cramps. We review the causes and consequences of hemodialysis-associated cramps, and discuss possible preventive measures and treatments.