Sarah Pressman Lovinger

CHICAGO — Measures of soluble fms-like tyrosine kinase 1 (sFlt-1), a circulating antiangiogenic protein secreted in excess by the placentas of women with preeclampsia, may prove to be a screening test for preeclampsia.

“Looking to the future, I have a lot of faith in blocking sFlt-1” as a possible treatment for preeclampsia, Dr. Sharon Maynard said in an interview after her presentation at a meeting on clinical nephrology sponsored by the National Kidney Foundation. The first phase I trial of an agent that blocks sFlt-1 will begin next year. If shown to be safe and effective, a potential treatment could be available within 3–4 years.

The ability to prevent and treat preeclampsia has long eluded medicine, said Dr. Maynard, a nephrologist at George Washington University. Most studies have addressed preventive therapies for preeclampsia: calcium, antioxidants, aspirin, magnesium, and blood pressure control.

Several small studies initially suggested that calcium supplementation could help prevent preeclampsia, but the findings did not hold up in later studies. Outcomes were comparable in one large trial that randomized more than 4,500 healthy nulliparous women to calcium or placebo (N. Engl. J. Med.1997;337:69–76). A subgroup analysis of these data indicated women with low baseline calcium levels may derive some benefit from supplements. A World Health Organization-sponsored trial of 5,000 women with low baseline calcium levels also revealed a lower risk of preeclampsia and neonatal death.

Antioxidants similarly failed to hold up to the rigors of a controlled trial in 2,395 women. In fact, the gravid women taking antioxidant supplements had a greater risk of low-birth-weight babies and stillbirths.

The data on aspirin in this population are “the most confusing of all,” noted Dr. Maynard. Although three large randomized controlled trials of 12,000 high-risk women found no differences with aspirin versus placebo, results were mixed in a subsequent metaanalysis of 51 trials involving 36,500 women. A Cochrane analysis showed that benefits were seen in small studies, but not in large ones. “I am really concerned that there may be no benefit at all,” she said.

Although magnesium has not been shown to prevent preeclampsia, it should be used “across the board. [It] clearly cuts the risk of seizures in half,” said Dr. Maynard.

CHICAGO — Measures of soluble fms-like tyrosine kinase 1 (sFlt-1), a circulating antiangiogenic protein secreted in excess by the placentas of women with preeclampsia, may prove to be a screening test for preeclampsia.

“Looking to the future, I have a lot of faith in blocking sFlt-1” as a possible treatment for preeclampsia, Dr. Sharon Maynard said in an interview after her presentation at a meeting on clinical nephrology sponsored by the National Kidney Foundation. The first phase I trial of an agent that blocks sFlt-1 will begin next year. If shown to be safe and effective, a potential treatment could be available within 3–4 years.

The ability to prevent and treat preeclampsia has long eluded medicine, said Dr. Maynard, a nephrologist at George Washington University. Most studies have addressed preventive therapies for preeclampsia: calcium, antioxidants, aspirin, magnesium, and blood pressure control.

Several small studies initially suggested that calcium supplementation could help prevent preeclampsia, but the findings did not hold up in later studies. Outcomes were comparable in one large trial that randomized more than 4,500 healthy nulliparous women to calcium or placebo (N. Engl. J. Med.1997;337:69–76). A subgroup analysis of these data indicated women with low baseline calcium levels may derive some benefit from supplements. A World Health Organization-sponsored trial of 5,000 women with low baseline calcium levels also revealed a lower risk of preeclampsia and neonatal death.

Antioxidants similarly failed to hold up to the rigors of a controlled trial in 2,395 women. In fact, the gravid women taking antioxidant supplements had a greater risk of low-birth-weight babies and stillbirths.

The data on aspirin in this population are “the most confusing of all,” noted Dr. Maynard. Although three large randomized controlled trials of 12,000 high-risk women found no differences with aspirin versus placebo, results were mixed in a subsequent metaanalysis of 51 trials involving 36,500 women. A Cochrane analysis showed that benefits were seen in small studies, but not in large ones. “I am really concerned that there may be no benefit at all,” she said.

Although magnesium has not been shown to prevent preeclampsia, it should be used “across the board. [It] clearly cuts the risk of seizures in half,” said Dr. Maynard.

CHICAGO — Measures of soluble fms-like tyrosine kinase 1 (sFlt-1), a circulating antiangiogenic protein secreted in excess by the placentas of women with preeclampsia, may prove to be a screening test for preeclampsia.

“Looking to the future, I have a lot of faith in blocking sFlt-1” as a possible treatment for preeclampsia, Dr. Sharon Maynard said in an interview after her presentation at a meeting on clinical nephrology sponsored by the National Kidney Foundation. The first phase I trial of an agent that blocks sFlt-1 will begin next year. If shown to be safe and effective, a potential treatment could be available within 3–4 years.

The ability to prevent and treat preeclampsia has long eluded medicine, said Dr. Maynard, a nephrologist at George Washington University. Most studies have addressed preventive therapies for preeclampsia: calcium, antioxidants, aspirin, magnesium, and blood pressure control.

Several small studies initially suggested that calcium supplementation could help prevent preeclampsia, but the findings did not hold up in later studies. Outcomes were comparable in one large trial that randomized more than 4,500 healthy nulliparous women to calcium or placebo (N. Engl. J. Med.1997;337:69–76). A subgroup analysis of these data indicated women with low baseline calcium levels may derive some benefit from supplements. A World Health Organization-sponsored trial of 5,000 women with low baseline calcium levels also revealed a lower risk of preeclampsia and neonatal death.

Antioxidants similarly failed to hold up to the rigors of a controlled trial in 2,395 women. In fact, the gravid women taking antioxidant supplements had a greater risk of low-birth-weight babies and stillbirths.

The data on aspirin in this population are “the most confusing of all,” noted Dr. Maynard. Although three large randomized controlled trials of 12,000 high-risk women found no differences with aspirin versus placebo, results were mixed in a subsequent metaanalysis of 51 trials involving 36,500 women. A Cochrane analysis showed that benefits were seen in small studies, but not in large ones. “I am really concerned that there may be no benefit at all,” she said.

Although magnesium has not been shown to prevent preeclampsia, it should be used “across the board. [It] clearly cuts the risk of seizures in half,” said Dr. Maynard.

CHICAGO — Tight blood pressure control is crucial in caring for pregnant women with diabetic nephropathy, but medication management must factor in potential fetal risks, Dr. Phyllis August said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

In reviewing the management strategies for pregnant women with pre-existing diabetic nephropathy and lupus nephropathy, she noted that the most effective management begins even before conception. Yet even though preconception counseling can improve outcomes, physicians typically care for gravid women who already have significant disease.

“Overall, the outcome in pregnancy is related to the baseline blood pressure and level of renal function at the beginning of pregnancy,” said Dr. August, professor of medicine at the Weil Medical College of Cornell University, New York.

ACE inhibitors and angiotensin-receptor blockers (ARBs) are vital in the treatment of diabetic nephropathy in women who are trying to conceive, but these agents are potentially quite harmful to the developing fetus, she noted.

To derive the maximal benefit from these medications, Dr. August suggested switching to a safer agent (such as methyldopa or labetalol) as soon as a patient misses her menstrual period. “The overwhelming evidence for the adverse effects of ACE inhibitors and ARBs relates to second and third trimester exposure,” she said.

Dr. August also recommended performing a cardiac evaluation before conception in women with long-standing type 1 diabetes.

“Significant renal disease is associated with preeclampsia and renal complications,” she noted. Chronic kidney disease also increases the risk of intrauterine growth retardation and pre-term birth.

In the past, women with diabetic nephropathy tended to have a high rate of maternal complications, including overt nephropathy, hypertension, and death due to unrecognized coronary artery disease.

However, the outcomes for pregnant women with diabetic nephropathy have improved. A recent study detected no difference in the rate of decline in renal function between a group of women with diabetic nephropathy who became pregnant and another group that did not.

Lupus nephropathy can be quite challenging for both patients and physicians, Dr. August noted. “There is a poor outcome when the disease is active at conception,” she said. A high percentage of patients—as many as 50%–80%—will experience a disease flare during pregnancy if they have active disease at conception. On the other hand, only 10%–40% of women who are in remission at conception will have a flare.

Physicians may safely use azathioprine to treat pregnant women with lupus nephritis. Dr. August also advocated delivery during the third trimester in gravid women whose lupus nephritis is deteriorating quickly. The mother's condition often improves quickly after delivery.

Women with lupus and antiphospholipid antibody syndrome are also at higher risk of fetal loss, arterial and venous thrombosis, renal vasculitis, and preeclampsia. Women with this syndrome may benefit from taking low-molecular-weight heparin, with or without aspirin.

Although the outlook has improved for women with certain types of chronic kidney disease who wish to bear children, the chance of a good pregnancy outcome in women with end-stage renal disease on dialysis remains poor.

Women on dialysis who do get pregnant have a high incidence of adverse outcomes such as second trimester pregnancy loss, prematurity, and congenital abnormalities. For these women, attempting pregnancy “should never be encouraged,” Dr. August said.

CHICAGO — Tight blood pressure control is crucial in caring for pregnant women with diabetic nephropathy, but medication management must factor in potential fetal risks, Dr. Phyllis August said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

In reviewing the management strategies for pregnant women with pre-existing diabetic nephropathy and lupus nephropathy, she noted that the most effective management begins even before conception. Yet even though preconception counseling can improve outcomes, physicians typically care for gravid women who already have significant disease.

“Overall, the outcome in pregnancy is related to the baseline blood pressure and level of renal function at the beginning of pregnancy,” said Dr. August, professor of medicine at the Weil Medical College of Cornell University, New York.

ACE inhibitors and angiotensin-receptor blockers (ARBs) are vital in the treatment of diabetic nephropathy in women who are trying to conceive, but these agents are potentially quite harmful to the developing fetus, she noted.

To derive the maximal benefit from these medications, Dr. August suggested switching to a safer agent (such as methyldopa or labetalol) as soon as a patient misses her menstrual period. “The overwhelming evidence for the adverse effects of ACE inhibitors and ARBs relates to second and third trimester exposure,” she said.

Dr. August also recommended performing a cardiac evaluation before conception in women with long-standing type 1 diabetes.

“Significant renal disease is associated with preeclampsia and renal complications,” she noted. Chronic kidney disease also increases the risk of intrauterine growth retardation and pre-term birth.

In the past, women with diabetic nephropathy tended to have a high rate of maternal complications, including overt nephropathy, hypertension, and death due to unrecognized coronary artery disease.

However, the outcomes for pregnant women with diabetic nephropathy have improved. A recent study detected no difference in the rate of decline in renal function between a group of women with diabetic nephropathy who became pregnant and another group that did not.

Lupus nephropathy can be quite challenging for both patients and physicians, Dr. August noted. “There is a poor outcome when the disease is active at conception,” she said. A high percentage of patients—as many as 50%–80%—will experience a disease flare during pregnancy if they have active disease at conception. On the other hand, only 10%–40% of women who are in remission at conception will have a flare.

Physicians may safely use azathioprine to treat pregnant women with lupus nephritis. Dr. August also advocated delivery during the third trimester in gravid women whose lupus nephritis is deteriorating quickly. The mother's condition often improves quickly after delivery.

Women with lupus and antiphospholipid antibody syndrome are also at higher risk of fetal loss, arterial and venous thrombosis, renal vasculitis, and preeclampsia. Women with this syndrome may benefit from taking low-molecular-weight heparin, with or without aspirin.

Although the outlook has improved for women with certain types of chronic kidney disease who wish to bear children, the chance of a good pregnancy outcome in women with end-stage renal disease on dialysis remains poor.

Women on dialysis who do get pregnant have a high incidence of adverse outcomes such as second trimester pregnancy loss, prematurity, and congenital abnormalities. For these women, attempting pregnancy “should never be encouraged,” Dr. August said.

CHICAGO — Tight blood pressure control is crucial in caring for pregnant women with diabetic nephropathy, but medication management must factor in potential fetal risks, Dr. Phyllis August said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

In reviewing the management strategies for pregnant women with pre-existing diabetic nephropathy and lupus nephropathy, she noted that the most effective management begins even before conception. Yet even though preconception counseling can improve outcomes, physicians typically care for gravid women who already have significant disease.

“Overall, the outcome in pregnancy is related to the baseline blood pressure and level of renal function at the beginning of pregnancy,” said Dr. August, professor of medicine at the Weil Medical College of Cornell University, New York.

ACE inhibitors and angiotensin-receptor blockers (ARBs) are vital in the treatment of diabetic nephropathy in women who are trying to conceive, but these agents are potentially quite harmful to the developing fetus, she noted.

To derive the maximal benefit from these medications, Dr. August suggested switching to a safer agent (such as methyldopa or labetalol) as soon as a patient misses her menstrual period. “The overwhelming evidence for the adverse effects of ACE inhibitors and ARBs relates to second and third trimester exposure,” she said.

Dr. August also recommended performing a cardiac evaluation before conception in women with long-standing type 1 diabetes.

“Significant renal disease is associated with preeclampsia and renal complications,” she noted. Chronic kidney disease also increases the risk of intrauterine growth retardation and pre-term birth.

In the past, women with diabetic nephropathy tended to have a high rate of maternal complications, including overt nephropathy, hypertension, and death due to unrecognized coronary artery disease.

However, the outcomes for pregnant women with diabetic nephropathy have improved. A recent study detected no difference in the rate of decline in renal function between a group of women with diabetic nephropathy who became pregnant and another group that did not.

Lupus nephropathy can be quite challenging for both patients and physicians, Dr. August noted. “There is a poor outcome when the disease is active at conception,” she said. A high percentage of patients—as many as 50%–80%—will experience a disease flare during pregnancy if they have active disease at conception. On the other hand, only 10%–40% of women who are in remission at conception will have a flare.

Physicians may safely use azathioprine to treat pregnant women with lupus nephritis. Dr. August also advocated delivery during the third trimester in gravid women whose lupus nephritis is deteriorating quickly. The mother's condition often improves quickly after delivery.

Women with lupus and antiphospholipid antibody syndrome are also at higher risk of fetal loss, arterial and venous thrombosis, renal vasculitis, and preeclampsia. Women with this syndrome may benefit from taking low-molecular-weight heparin, with or without aspirin.

Although the outlook has improved for women with certain types of chronic kidney disease who wish to bear children, the chance of a good pregnancy outcome in women with end-stage renal disease on dialysis remains poor.

Women on dialysis who do get pregnant have a high incidence of adverse outcomes such as second trimester pregnancy loss, prematurity, and congenital abnormalities. For these women, attempting pregnancy “should never be encouraged,” Dr. August said.

CHICAGO — Tight blood pressure control is crucial in caring for pregnant women with lupus nephropathy, but medication management must factor in potential fetal risks, Dr. Phyllis August said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

In reviewing the management strategies for pregnant women with preexisting lupus nephropathy and diabetic nephropathy, Dr. August noted that the most effective management begins even before conception. Even though preconception counseling can improve outcomes, physicians typically care for gravid women who already have significant disease.

“Overall, the outcome in pregnancy is related to the baseline blood pressure and level of renal function at the beginning of pregnancy,” said Dr. August, professor of medicine at the Weil Medical College of Cornell University, New York.

ACE inhibitors and angiotensin-receptor blockers (ARBs) are vital in the treatment of lupus or diabetic nephropathy in women who are trying to conceive, but these agents are potentially quite harmful to the developing fetus, she noted.

Switching to a safer agent (such as methyldopa or labetalol) as soon as a patient misses her menstrual period to get the greatest benefit. “The overwhelming evidence for the adverse effects of ACE inhibitors and ARBs relates to second- and third- trimester exposure,” she said.

Dr. August also recommended performing a cardiac evaluation before conception in women with long-standing lupus or type 1 diabetes. “Significant renal disease is associated with preeclampsia and renal complications,” she noted. Chronic kidney disease also increases the risk of intrauterine growth retardation and preterm birth.

Lupus nephropathy can be quite challenging for both patients and physicians, Dr. August noted. “There is a poor outcome when the disease is active at conception,” she said.

A high percentage of patients—as many as 50%–80%—will experience a disease flare during pregnancy if they have active disease at conception. On the other hand, only 10%–40% of women who are in remission at conception will have a flare.

Physicians may safely use azathioprine to treat pregnant women with lupus nephritis. Dr. August also advocated delivery during the third trimester in gravid women whose lupus nephritis is deteriorating quickly.

The mother's condition often improves quickly after delivery.

Women with lupus and antiphospholipid antibody syndrome are also at higher risk of fetal loss, arterial and venous thrombosis, renal vasculitis, and preeclampsia. Women with this syndrome may benefit from taking low-molecular-weight heparin, with or without aspirin.

Although the outlook has improved for women with certain types of chronic kidney disease who wish to bear children, the chance of a good pregnancy outcome in women with end-stage renal disease on dialysis remains poor. Women who become pregnant while on dialysis have a high incidence of adverse outcomes such as second-trimester pregnancy loss, prematurity, and congenital abnormalities. These women “should never be encouraged” to get pregnant, Dr. August said.

CHICAGO — Tight blood pressure control is crucial in caring for pregnant women with lupus nephropathy, but medication management must factor in potential fetal risks, Dr. Phyllis August said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

In reviewing the management strategies for pregnant women with preexisting lupus nephropathy and diabetic nephropathy, Dr. August noted that the most effective management begins even before conception. Even though preconception counseling can improve outcomes, physicians typically care for gravid women who already have significant disease.

“Overall, the outcome in pregnancy is related to the baseline blood pressure and level of renal function at the beginning of pregnancy,” said Dr. August, professor of medicine at the Weil Medical College of Cornell University, New York.

ACE inhibitors and angiotensin-receptor blockers (ARBs) are vital in the treatment of lupus or diabetic nephropathy in women who are trying to conceive, but these agents are potentially quite harmful to the developing fetus, she noted.

Switching to a safer agent (such as methyldopa or labetalol) as soon as a patient misses her menstrual period to get the greatest benefit. “The overwhelming evidence for the adverse effects of ACE inhibitors and ARBs relates to second- and third- trimester exposure,” she said.

Dr. August also recommended performing a cardiac evaluation before conception in women with long-standing lupus or type 1 diabetes. “Significant renal disease is associated with preeclampsia and renal complications,” she noted. Chronic kidney disease also increases the risk of intrauterine growth retardation and preterm birth.

Lupus nephropathy can be quite challenging for both patients and physicians, Dr. August noted. “There is a poor outcome when the disease is active at conception,” she said.

A high percentage of patients—as many as 50%–80%—will experience a disease flare during pregnancy if they have active disease at conception. On the other hand, only 10%–40% of women who are in remission at conception will have a flare.

Physicians may safely use azathioprine to treat pregnant women with lupus nephritis. Dr. August also advocated delivery during the third trimester in gravid women whose lupus nephritis is deteriorating quickly.

The mother's condition often improves quickly after delivery.

Women with lupus and antiphospholipid antibody syndrome are also at higher risk of fetal loss, arterial and venous thrombosis, renal vasculitis, and preeclampsia. Women with this syndrome may benefit from taking low-molecular-weight heparin, with or without aspirin.

Although the outlook has improved for women with certain types of chronic kidney disease who wish to bear children, the chance of a good pregnancy outcome in women with end-stage renal disease on dialysis remains poor. Women who become pregnant while on dialysis have a high incidence of adverse outcomes such as second-trimester pregnancy loss, prematurity, and congenital abnormalities. These women “should never be encouraged” to get pregnant, Dr. August said.

CHICAGO — Tight blood pressure control is crucial in caring for pregnant women with lupus nephropathy, but medication management must factor in potential fetal risks, Dr. Phyllis August said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

In reviewing the management strategies for pregnant women with preexisting lupus nephropathy and diabetic nephropathy, Dr. August noted that the most effective management begins even before conception. Even though preconception counseling can improve outcomes, physicians typically care for gravid women who already have significant disease.

“Overall, the outcome in pregnancy is related to the baseline blood pressure and level of renal function at the beginning of pregnancy,” said Dr. August, professor of medicine at the Weil Medical College of Cornell University, New York.

ACE inhibitors and angiotensin-receptor blockers (ARBs) are vital in the treatment of lupus or diabetic nephropathy in women who are trying to conceive, but these agents are potentially quite harmful to the developing fetus, she noted.

Switching to a safer agent (such as methyldopa or labetalol) as soon as a patient misses her menstrual period to get the greatest benefit. “The overwhelming evidence for the adverse effects of ACE inhibitors and ARBs relates to second- and third- trimester exposure,” she said.

Dr. August also recommended performing a cardiac evaluation before conception in women with long-standing lupus or type 1 diabetes. “Significant renal disease is associated with preeclampsia and renal complications,” she noted. Chronic kidney disease also increases the risk of intrauterine growth retardation and preterm birth.

Lupus nephropathy can be quite challenging for both patients and physicians, Dr. August noted. “There is a poor outcome when the disease is active at conception,” she said.

A high percentage of patients—as many as 50%–80%—will experience a disease flare during pregnancy if they have active disease at conception. On the other hand, only 10%–40% of women who are in remission at conception will have a flare.

Physicians may safely use azathioprine to treat pregnant women with lupus nephritis. Dr. August also advocated delivery during the third trimester in gravid women whose lupus nephritis is deteriorating quickly.

The mother's condition often improves quickly after delivery.

Women with lupus and antiphospholipid antibody syndrome are also at higher risk of fetal loss, arterial and venous thrombosis, renal vasculitis, and preeclampsia. Women with this syndrome may benefit from taking low-molecular-weight heparin, with or without aspirin.

Although the outlook has improved for women with certain types of chronic kidney disease who wish to bear children, the chance of a good pregnancy outcome in women with end-stage renal disease on dialysis remains poor. Women who become pregnant while on dialysis have a high incidence of adverse outcomes such as second-trimester pregnancy loss, prematurity, and congenital abnormalities. These women “should never be encouraged” to get pregnant, Dr. August said.

Hand bone loss as noted on a dual-energy absorptiometry scan may make earlier diagnosis of rheumatoid arthritis possible in patients with joint pain, reported Dr. Paul Emery and his colleagues at the University of Leeds, (England).

Dual-energy absorptiometry (DXA) scans in 74 patients with undifferentiated arthritis lasting less than 12 months showed significant changes in hand bone mineral density (BMD) in patients who were eventually diagnosed with rheumatoid arthritis (RA), Dr. Emery and his colleagues reported.

“This longitudinal study supports the view that hand BMD loss, even at the earliest stages of the disease process, is related to measures of disease activity and severity in rheumatoid arthritis,” the investigators wrote (Ann. Rheum. Dis. 2006;65:736–40).

The study participants were mostly women (88%), with an average age of 44 years. They underwent serial BMD measurements of the hands, femoral neck, and spine (L2–L4) using serial DXA scans at baseline, and at 3, 6, and 12 months, the investigators reported.

None of the patients had received disease-modifying drugs or prednisone prior to the start of the study.

Patients had ongoing diagnostic tests for RA during the study period. Thirteen patients were eventually diagnosed as having RA, 19 patients were determined to have inflammatory nonrheumatoid joint disorders, and the remaining 42 patients were diagnosed with noninflammatory joint disorders, Dr. Emery and his fellow investigators reported.

The results revealed that at 12-month follow-up, none of the patient groups sustained significant bone loss at the femoral neck and spine.

However, patients who were eventually diagnosed with RA had significant hand BMD loss at 12 months, compared with the other patient groups.

In patients diagnosed with RA, hand BMD loss was 4.27%; the inflammatory non-RA group had a 0.49% loss; and the noninflammatory joint disorder group had a BMD loss of 0.87%, the investigators reported.

Hand bone loss as noted on a dual-energy absorptiometry scan may make earlier diagnosis of rheumatoid arthritis possible in patients with joint pain, reported Dr. Paul Emery and his colleagues at the University of Leeds, (England).

Dual-energy absorptiometry (DXA) scans in 74 patients with undifferentiated arthritis lasting less than 12 months showed significant changes in hand bone mineral density (BMD) in patients who were eventually diagnosed with rheumatoid arthritis (RA), Dr. Emery and his colleagues reported.

“This longitudinal study supports the view that hand BMD loss, even at the earliest stages of the disease process, is related to measures of disease activity and severity in rheumatoid arthritis,” the investigators wrote (Ann. Rheum. Dis. 2006;65:736–40).

The study participants were mostly women (88%), with an average age of 44 years. They underwent serial BMD measurements of the hands, femoral neck, and spine (L2–L4) using serial DXA scans at baseline, and at 3, 6, and 12 months, the investigators reported.

None of the patients had received disease-modifying drugs or prednisone prior to the start of the study.

Patients had ongoing diagnostic tests for RA during the study period. Thirteen patients were eventually diagnosed as having RA, 19 patients were determined to have inflammatory nonrheumatoid joint disorders, and the remaining 42 patients were diagnosed with noninflammatory joint disorders, Dr. Emery and his fellow investigators reported.

The results revealed that at 12-month follow-up, none of the patient groups sustained significant bone loss at the femoral neck and spine.

However, patients who were eventually diagnosed with RA had significant hand BMD loss at 12 months, compared with the other patient groups.

In patients diagnosed with RA, hand BMD loss was 4.27%; the inflammatory non-RA group had a 0.49% loss; and the noninflammatory joint disorder group had a BMD loss of 0.87%, the investigators reported.

Hand bone loss as noted on a dual-energy absorptiometry scan may make earlier diagnosis of rheumatoid arthritis possible in patients with joint pain, reported Dr. Paul Emery and his colleagues at the University of Leeds, (England).

Dual-energy absorptiometry (DXA) scans in 74 patients with undifferentiated arthritis lasting less than 12 months showed significant changes in hand bone mineral density (BMD) in patients who were eventually diagnosed with rheumatoid arthritis (RA), Dr. Emery and his colleagues reported.

“This longitudinal study supports the view that hand BMD loss, even at the earliest stages of the disease process, is related to measures of disease activity and severity in rheumatoid arthritis,” the investigators wrote (Ann. Rheum. Dis. 2006;65:736–40).

The study participants were mostly women (88%), with an average age of 44 years. They underwent serial BMD measurements of the hands, femoral neck, and spine (L2–L4) using serial DXA scans at baseline, and at 3, 6, and 12 months, the investigators reported.

None of the patients had received disease-modifying drugs or prednisone prior to the start of the study.

Patients had ongoing diagnostic tests for RA during the study period. Thirteen patients were eventually diagnosed as having RA, 19 patients were determined to have inflammatory nonrheumatoid joint disorders, and the remaining 42 patients were diagnosed with noninflammatory joint disorders, Dr. Emery and his fellow investigators reported.

The results revealed that at 12-month follow-up, none of the patient groups sustained significant bone loss at the femoral neck and spine.

However, patients who were eventually diagnosed with RA had significant hand BMD loss at 12 months, compared with the other patient groups.

In patients diagnosed with RA, hand BMD loss was 4.27%; the inflammatory non-RA group had a 0.49% loss; and the noninflammatory joint disorder group had a BMD loss of 0.87%, the investigators reported.

CHICAGO — With the goal of preventing renal complications in type 1 diabetics, nephrologists have begun to focus on subtle increases in nighttime blood pressure as a risk factor for the subsequent development of overt nephropathy.

“It is a concept we are pioneering, a very promising approach,” Dr. Daniel Batlle said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

In a prospective study, he and his associates followed 75 young type 1 diabetics without microalbuminuria at baseline for 5 years. After 2 years, none of the subjects had developed any urinary protein, but 18% of the subjects went on to develop microalbuminuria. In those who developed microalbuminuria, the mean systolic pressure during sleep increased significantly (from 109.9 to 114.9 mm Hg). This group had elevated systolic blood pressure only at night (Kidney Int. 2003;63:2319–30).

This line of research is a departure from the classic reasoning that blood pressure does not start to increase until overt proteinuria occurs in diabetics, noted Dr. Batlle, chairman of the nephrology department at Northwestern University, Chicago.

No specific treatments for mild nocturnal hypertension have been developed, but a 5-year National Institutes of Health study of 300–400 patients should shed more light on the importance of nocturnal hypertension in diabetics, said Dr. Batlle, the study's principal investigator. “Systolic [hypertension] seems to be a more powerful predictor that diastolic,” he added.

Nephrologists have long considered microalbuminuria to be the best marker for predicting progression of renal disease, but more recent studies have shown that the cumulative incidence of overt nephropathy in patients with type 1 diabetes and microalbuminuria is only about 25%. “So obviously, microalbuminuria is not as good a predictor as we thought,” he explained.

In addition to microalbuminuria, researchers also have considered histology and genetics in the search for a marker for an increased risk of nephropathy. Renal biopsies of 170 type 1 diabetics with albuminuria that regressed in some patients but progressed in others revealed that a wider glomerular basement membrane could lead to the development of proteinuria (Diabetes 2005;54:2164–71).

Researchers have not yet shed light on the genetic nature of proteinuria. “We don't have a good genetic marker,” Dr. Batlle said. A family history of nephropathy confers the greatest risk of microalbuminuria.

CHICAGO — With the goal of preventing renal complications in type 1 diabetics, nephrologists have begun to focus on subtle increases in nighttime blood pressure as a risk factor for the subsequent development of overt nephropathy.

“It is a concept we are pioneering, a very promising approach,” Dr. Daniel Batlle said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

In a prospective study, he and his associates followed 75 young type 1 diabetics without microalbuminuria at baseline for 5 years. After 2 years, none of the subjects had developed any urinary protein, but 18% of the subjects went on to develop microalbuminuria. In those who developed microalbuminuria, the mean systolic pressure during sleep increased significantly (from 109.9 to 114.9 mm Hg). This group had elevated systolic blood pressure only at night (Kidney Int. 2003;63:2319–30).

This line of research is a departure from the classic reasoning that blood pressure does not start to increase until overt proteinuria occurs in diabetics, noted Dr. Batlle, chairman of the nephrology department at Northwestern University, Chicago.

No specific treatments for mild nocturnal hypertension have been developed, but a 5-year National Institutes of Health study of 300–400 patients should shed more light on the importance of nocturnal hypertension in diabetics, said Dr. Batlle, the study's principal investigator. “Systolic [hypertension] seems to be a more powerful predictor that diastolic,” he added.

Nephrologists have long considered microalbuminuria to be the best marker for predicting progression of renal disease, but more recent studies have shown that the cumulative incidence of overt nephropathy in patients with type 1 diabetes and microalbuminuria is only about 25%. “So obviously, microalbuminuria is not as good a predictor as we thought,” he explained.

In addition to microalbuminuria, researchers also have considered histology and genetics in the search for a marker for an increased risk of nephropathy. Renal biopsies of 170 type 1 diabetics with albuminuria that regressed in some patients but progressed in others revealed that a wider glomerular basement membrane could lead to the development of proteinuria (Diabetes 2005;54:2164–71).

Researchers have not yet shed light on the genetic nature of proteinuria. “We don't have a good genetic marker,” Dr. Batlle said. A family history of nephropathy confers the greatest risk of microalbuminuria.

CHICAGO — With the goal of preventing renal complications in type 1 diabetics, nephrologists have begun to focus on subtle increases in nighttime blood pressure as a risk factor for the subsequent development of overt nephropathy.

“It is a concept we are pioneering, a very promising approach,” Dr. Daniel Batlle said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

In a prospective study, he and his associates followed 75 young type 1 diabetics without microalbuminuria at baseline for 5 years. After 2 years, none of the subjects had developed any urinary protein, but 18% of the subjects went on to develop microalbuminuria. In those who developed microalbuminuria, the mean systolic pressure during sleep increased significantly (from 109.9 to 114.9 mm Hg). This group had elevated systolic blood pressure only at night (Kidney Int. 2003;63:2319–30).

This line of research is a departure from the classic reasoning that blood pressure does not start to increase until overt proteinuria occurs in diabetics, noted Dr. Batlle, chairman of the nephrology department at Northwestern University, Chicago.

No specific treatments for mild nocturnal hypertension have been developed, but a 5-year National Institutes of Health study of 300–400 patients should shed more light on the importance of nocturnal hypertension in diabetics, said Dr. Batlle, the study's principal investigator. “Systolic [hypertension] seems to be a more powerful predictor that diastolic,” he added.

Nephrologists have long considered microalbuminuria to be the best marker for predicting progression of renal disease, but more recent studies have shown that the cumulative incidence of overt nephropathy in patients with type 1 diabetes and microalbuminuria is only about 25%. “So obviously, microalbuminuria is not as good a predictor as we thought,” he explained.

In addition to microalbuminuria, researchers also have considered histology and genetics in the search for a marker for an increased risk of nephropathy. Renal biopsies of 170 type 1 diabetics with albuminuria that regressed in some patients but progressed in others revealed that a wider glomerular basement membrane could lead to the development of proteinuria (Diabetes 2005;54:2164–71).

Researchers have not yet shed light on the genetic nature of proteinuria. “We don't have a good genetic marker,” Dr. Batlle said. A family history of nephropathy confers the greatest risk of microalbuminuria.

CHICAGO — Tight blood pressure control is crucial in caring for pregnant women with diabetic nephropathy, but medication management must factor in potential fetal risks, Dr. Phyllis August said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

In reviewing the management strategies for pregnant women with pre-existing diabetic nephropathy and lupus nephropathy, she noted that the most effective management begins even before conception. Yet even though preconception counseling can improve outcomes, physicians typically care for gravid women who already have significant disease.

“Overall, the outcome in pregnancy is related to the baseline blood pressure and level of renal function at the beginning of pregnancy,” said Dr. August, professor of medicine at the Weill Medical College of Cornell University, New York.

ACE inhibitors and angiotensin-receptor blockers (ARBs) are vital in treating diabetic nephropathy in women who are trying to conceive, but these agents are potentially harmful to the developing fetus, she noted.

To derive the maximal benefit from these medications, Dr. August suggesting switching to a safer agent (such as methyldopa or labetalol) as soon as a patient misses her menstrual period. “The overwhelming evidence for the adverse effects of ACE inhibitors and ARBs relates to second and third trimester exposure,” she said.

Dr. August also recommended performing a cardiac evaluation before conception in women with long-standing type 1 diabetes.

“Significant renal disease is associated with preeclampsia and renal complications,” she noted. Chronic kidney disease also increases the risk of intrauterine growth retardation and preterm birth.

In the past, women with diabetic nephropathy tended to have a high rate of maternal complications, including overt nephropathy, hypertension, and death due to unrecognized coronary artery disease.

But outcomes for pregnant women with diabetic nephropathy have improved. One study detected no difference in the rate of decline in renal function between a group of women with diabetic nephropathy who became pregnant and another that did not.

Lupus nephropathy can be challenging for patients and physicians, Dr. August noted. “There is a poor outcome when the disease is active at conception,” she said. A high percentage of patients—as many as 50%–80%—will experience a disease flare during pregnancy if they have active disease at conception. On the other hand, only 10%–40% of women who are in remission at conception will have a flare.

Azathioprine can be safely used to treat pregnant women with lupus nephritis. Dr. August also advocated delivery during the third trimester in gravid women whose lupus nephritis is deteriorating quickly. The mother's condition often improves quickly after delivery.

Women with lupus and antiphospholipid antibody syndrome are also at higher risk of fetal loss, arterial and venous thrombosis, renal vasculitis, and preeclampsia. Women with this syndrome may benefit from taking low-molecular-weight heparin, with or without aspirin.

Although the outlook has improved for women with certain types of chronic kidney disease who wish to bear children, the chance of a good pregnancy outcome in women with end-stage renal disease on dialysis remains poor.

Women on dialysis who get pregnant have a high incidence of adverse outcomes such as second trimester pregnancy loss, prematurity, and congenital abnormalities. For these women, attempted pregnancy “should never be encouraged,” Dr. August said.

CHICAGO — Tight blood pressure control is crucial in caring for pregnant women with diabetic nephropathy, but medication management must factor in potential fetal risks, Dr. Phyllis August said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

In reviewing the management strategies for pregnant women with pre-existing diabetic nephropathy and lupus nephropathy, she noted that the most effective management begins even before conception. Yet even though preconception counseling can improve outcomes, physicians typically care for gravid women who already have significant disease.

“Overall, the outcome in pregnancy is related to the baseline blood pressure and level of renal function at the beginning of pregnancy,” said Dr. August, professor of medicine at the Weill Medical College of Cornell University, New York.

ACE inhibitors and angiotensin-receptor blockers (ARBs) are vital in treating diabetic nephropathy in women who are trying to conceive, but these agents are potentially harmful to the developing fetus, she noted.

To derive the maximal benefit from these medications, Dr. August suggesting switching to a safer agent (such as methyldopa or labetalol) as soon as a patient misses her menstrual period. “The overwhelming evidence for the adverse effects of ACE inhibitors and ARBs relates to second and third trimester exposure,” she said.

Dr. August also recommended performing a cardiac evaluation before conception in women with long-standing type 1 diabetes.

“Significant renal disease is associated with preeclampsia and renal complications,” she noted. Chronic kidney disease also increases the risk of intrauterine growth retardation and preterm birth.

In the past, women with diabetic nephropathy tended to have a high rate of maternal complications, including overt nephropathy, hypertension, and death due to unrecognized coronary artery disease.

But outcomes for pregnant women with diabetic nephropathy have improved. One study detected no difference in the rate of decline in renal function between a group of women with diabetic nephropathy who became pregnant and another that did not.

Lupus nephropathy can be challenging for patients and physicians, Dr. August noted. “There is a poor outcome when the disease is active at conception,” she said. A high percentage of patients—as many as 50%–80%—will experience a disease flare during pregnancy if they have active disease at conception. On the other hand, only 10%–40% of women who are in remission at conception will have a flare.

Azathioprine can be safely used to treat pregnant women with lupus nephritis. Dr. August also advocated delivery during the third trimester in gravid women whose lupus nephritis is deteriorating quickly. The mother's condition often improves quickly after delivery.

Women with lupus and antiphospholipid antibody syndrome are also at higher risk of fetal loss, arterial and venous thrombosis, renal vasculitis, and preeclampsia. Women with this syndrome may benefit from taking low-molecular-weight heparin, with or without aspirin.

Although the outlook has improved for women with certain types of chronic kidney disease who wish to bear children, the chance of a good pregnancy outcome in women with end-stage renal disease on dialysis remains poor.

Women on dialysis who get pregnant have a high incidence of adverse outcomes such as second trimester pregnancy loss, prematurity, and congenital abnormalities. For these women, attempted pregnancy “should never be encouraged,” Dr. August said.

CHICAGO — Tight blood pressure control is crucial in caring for pregnant women with diabetic nephropathy, but medication management must factor in potential fetal risks, Dr. Phyllis August said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

In reviewing the management strategies for pregnant women with pre-existing diabetic nephropathy and lupus nephropathy, she noted that the most effective management begins even before conception. Yet even though preconception counseling can improve outcomes, physicians typically care for gravid women who already have significant disease.

“Overall, the outcome in pregnancy is related to the baseline blood pressure and level of renal function at the beginning of pregnancy,” said Dr. August, professor of medicine at the Weill Medical College of Cornell University, New York.

ACE inhibitors and angiotensin-receptor blockers (ARBs) are vital in treating diabetic nephropathy in women who are trying to conceive, but these agents are potentially harmful to the developing fetus, she noted.

To derive the maximal benefit from these medications, Dr. August suggesting switching to a safer agent (such as methyldopa or labetalol) as soon as a patient misses her menstrual period. “The overwhelming evidence for the adverse effects of ACE inhibitors and ARBs relates to second and third trimester exposure,” she said.

Dr. August also recommended performing a cardiac evaluation before conception in women with long-standing type 1 diabetes.

“Significant renal disease is associated with preeclampsia and renal complications,” she noted. Chronic kidney disease also increases the risk of intrauterine growth retardation and preterm birth.

In the past, women with diabetic nephropathy tended to have a high rate of maternal complications, including overt nephropathy, hypertension, and death due to unrecognized coronary artery disease.

But outcomes for pregnant women with diabetic nephropathy have improved. One study detected no difference in the rate of decline in renal function between a group of women with diabetic nephropathy who became pregnant and another that did not.

Lupus nephropathy can be challenging for patients and physicians, Dr. August noted. “There is a poor outcome when the disease is active at conception,” she said. A high percentage of patients—as many as 50%–80%—will experience a disease flare during pregnancy if they have active disease at conception. On the other hand, only 10%–40% of women who are in remission at conception will have a flare.

Azathioprine can be safely used to treat pregnant women with lupus nephritis. Dr. August also advocated delivery during the third trimester in gravid women whose lupus nephritis is deteriorating quickly. The mother's condition often improves quickly after delivery.

Women with lupus and antiphospholipid antibody syndrome are also at higher risk of fetal loss, arterial and venous thrombosis, renal vasculitis, and preeclampsia. Women with this syndrome may benefit from taking low-molecular-weight heparin, with or without aspirin.

Although the outlook has improved for women with certain types of chronic kidney disease who wish to bear children, the chance of a good pregnancy outcome in women with end-stage renal disease on dialysis remains poor.

Women on dialysis who get pregnant have a high incidence of adverse outcomes such as second trimester pregnancy loss, prematurity, and congenital abnormalities. For these women, attempted pregnancy “should never be encouraged,” Dr. August said.

CHICAGO — Guidelines developed for the first time by the Kidney Disease Outcomes Quality Initiative provide detailed information on how to improve clinical outcomes in patients who have both diabetes and chronic kidney disease, Dr. Robert Nelson said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

The guidelines emphasize tight control of glucose, blood pressure, and lipids, along with frequent monitoring of urinary protein in patients with this dual condition. Dr. Nelson of the National Institutes of Health in Phoenix offered a preview of the guidelines, which will be published in the American Journal of Kidney Diseases this fall.

The Kidney Disease Outcomes Quality Initiative guidelines recommend that people with type 1 diabetes undergo screening for diabetic kidney disease 5 years after diagnosis, and then annually. In type 2 diabetics, annual screening should begin at diagnosis.

Primary care physicians can easily follow these guidelines by obtaining spot urine samples for an albumin/creatinine ratio—at least two samples within 3 months, Dr. Nelson noted.

If the urine albumin/creatinine ratio exceeds 300 mg/g, a number that is consistent with macroalbuminuria, then the physician can diagnose diabetic kidney disease without doing a renal biopsy.

In addition, patients with microalbuminuria who also have retinopathy are considered to have diabetic kidney disease.

Clues to the diagnosis of nondiabetic kidney disease in diabetic patients include lack of diabetic nephropathy, a rapid decrease in glomerular filtration rate, and sudden onset of nephropathy.

Solid research evidence shows that the cornerstone of managing patients with diabetic kidney disease is maintaining a target hemoglobin A_1c of 7% or below, Dr. Nelson said, citing the Diabetes Control and Complications Trial (N. Engl. J. Med. 1993;329:977–86).

Physicians must also manage hypertension aggressively in patients with diabetic kidney disease. Both ACE inhibitors and angiotensin-receptor blockers (ARBs), often given with a diuretic, can help patients achieve the goal blood pressure of 130/80 mm Hg or lower.

“We believe that the efficacy of ACE inhibitors and ARBs are similar,” Dr. Nelson said.

Achieving the blood pressure goal is a very important preventive measure, and clinicians can use additional classes of antihypertensive medication as needed to meet this goal.

CHICAGO — Guidelines developed for the first time by the Kidney Disease Outcomes Quality Initiative provide detailed information on how to improve clinical outcomes in patients who have both diabetes and chronic kidney disease, Dr. Robert Nelson said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

The guidelines emphasize tight control of glucose, blood pressure, and lipids, along with frequent monitoring of urinary protein in patients with this dual condition. Dr. Nelson of the National Institutes of Health in Phoenix offered a preview of the guidelines, which will be published in the American Journal of Kidney Diseases this fall.

The Kidney Disease Outcomes Quality Initiative guidelines recommend that people with type 1 diabetes undergo screening for diabetic kidney disease 5 years after diagnosis, and then annually. In type 2 diabetics, annual screening should begin at diagnosis.

Primary care physicians can easily follow these guidelines by obtaining spot urine samples for an albumin/creatinine ratio—at least two samples within 3 months, Dr. Nelson noted.

If the urine albumin/creatinine ratio exceeds 300 mg/g, a number that is consistent with macroalbuminuria, then the physician can diagnose diabetic kidney disease without doing a renal biopsy.

In addition, patients with microalbuminuria who also have retinopathy are considered to have diabetic kidney disease.

Clues to the diagnosis of nondiabetic kidney disease in diabetic patients include lack of diabetic nephropathy, a rapid decrease in glomerular filtration rate, and sudden onset of nephropathy.

Solid research evidence shows that the cornerstone of managing patients with diabetic kidney disease is maintaining a target hemoglobin A_1c of 7% or below, Dr. Nelson said, citing the Diabetes Control and Complications Trial (N. Engl. J. Med. 1993;329:977–86).

Physicians must also manage hypertension aggressively in patients with diabetic kidney disease. Both ACE inhibitors and angiotensin-receptor blockers (ARBs), often given with a diuretic, can help patients achieve the goal blood pressure of 130/80 mm Hg or lower.

“We believe that the efficacy of ACE inhibitors and ARBs are similar,” Dr. Nelson said.

Achieving the blood pressure goal is a very important preventive measure, and clinicians can use additional classes of antihypertensive medication as needed to meet this goal.

CHICAGO — Guidelines developed for the first time by the Kidney Disease Outcomes Quality Initiative provide detailed information on how to improve clinical outcomes in patients who have both diabetes and chronic kidney disease, Dr. Robert Nelson said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

The guidelines emphasize tight control of glucose, blood pressure, and lipids, along with frequent monitoring of urinary protein in patients with this dual condition. Dr. Nelson of the National Institutes of Health in Phoenix offered a preview of the guidelines, which will be published in the American Journal of Kidney Diseases this fall.

The Kidney Disease Outcomes Quality Initiative guidelines recommend that people with type 1 diabetes undergo screening for diabetic kidney disease 5 years after diagnosis, and then annually. In type 2 diabetics, annual screening should begin at diagnosis.

Primary care physicians can easily follow these guidelines by obtaining spot urine samples for an albumin/creatinine ratio—at least two samples within 3 months, Dr. Nelson noted.

If the urine albumin/creatinine ratio exceeds 300 mg/g, a number that is consistent with macroalbuminuria, then the physician can diagnose diabetic kidney disease without doing a renal biopsy.

In addition, patients with microalbuminuria who also have retinopathy are considered to have diabetic kidney disease.

Clues to the diagnosis of nondiabetic kidney disease in diabetic patients include lack of diabetic nephropathy, a rapid decrease in glomerular filtration rate, and sudden onset of nephropathy.

Solid research evidence shows that the cornerstone of managing patients with diabetic kidney disease is maintaining a target hemoglobin A_1c of 7% or below, Dr. Nelson said, citing the Diabetes Control and Complications Trial (N. Engl. J. Med. 1993;329:977–86).

Physicians must also manage hypertension aggressively in patients with diabetic kidney disease. Both ACE inhibitors and angiotensin-receptor blockers (ARBs), often given with a diuretic, can help patients achieve the goal blood pressure of 130/80 mm Hg or lower.

“We believe that the efficacy of ACE inhibitors and ARBs are similar,” Dr. Nelson said.

Achieving the blood pressure goal is a very important preventive measure, and clinicians can use additional classes of antihypertensive medication as needed to meet this goal.

CHICAGO — As the demand for kidney transplants for patients with end-stage renal disease continues to increase, disparities in transplantation rates among U.S. minority populations continue.

Dr. Robert S. Gaston, a nephrologist whose transplant team at the University of Alabama, Birmingham, has performed more than 7,000 kidney transplants, said that thousands of people have asked him when they can have a transplant.

Most patients would prefer having a kidney transplant to remaining on dialysis.

“Patients will tell us a lot about therapeutic modalities if we'll listen to them,” Dr. Gaston said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

The prevalence of end-stage renal disease (ESRD) is four to five times greater in blacks than in whites, yet black and other minority patients do not undergo nearly as many transplants as white patients do. “White patients are 50% more likely to receive a transplant within 2 years of being wait-listed,” compared with other racial groups, Dr. Gaston said.

He cited 2002 data on ESRD prevalence that further underscore the disparities. At that time, more than 80% of the African American population with ESRD was on dialysis, while less than 20% had undergone a kidney transplant. At the same time, only 62% of the comparable white population was on dialysis, while 38% had received a kidney transplant.

All patients who might need a kidney transplant go through a process that involves a referral to a transplant center and a medical evaluation, Dr. Gaston explained. Patients who are approved after the evaluation are then placed on a waiting list. But the process goes more smoothly for some patients than others. “At each step along the pathway, the evaluation process can be challenging,” he said.

Dr. Gaston provided details on many of the barriers to transplantation that minority patients face.

First, fewer African American patients than white patients learn about the transplantation option.

In addition, the high cost of a transplant is also an important factor, and patients with higher-paying private insurance are much more likely to get a transplant than patients who have only Medicare.

Also, those ESRD patients who have been placed on multiple transplant lists have an increased likelihood of ultimately receiving a transplant. But African American patients are 70% less likely to be on multiple waiting lists.

Possibly the biggest obstacle to receiving a transplant is that minority patients have less access to living donors than white patients do. Dr. Gaston cited a study done at his institution that revealed that while 33% of white patients received a kidney from a living donor, only 13% of African American patients were able to undergo this type of transplant.

Ultimately, patients who receive a transplanted kidney from a living donor have the best outcomes. Studies show that the greatest survival benefit occurs in ESRD patients who receive a living donor transplant before starting dialysis.

Under the new organ allocation system, Dr. Gaston noted, transplant access for minorities has increased and overall outcomes have also improved.

Data show a 10.3% increase in renal transplants in black patients since the rules have changed by relaxing HLA matching requirements, said Friedrich K. Port, president of University Renal Research and Education Association in Ann Arbor, Mich.

CHICAGO — As the demand for kidney transplants for patients with end-stage renal disease continues to increase, disparities in transplantation rates among U.S. minority populations continue.

Dr. Robert S. Gaston, a nephrologist whose transplant team at the University of Alabama, Birmingham, has performed more than 7,000 kidney transplants, said that thousands of people have asked him when they can have a transplant.

Most patients would prefer having a kidney transplant to remaining on dialysis.

“Patients will tell us a lot about therapeutic modalities if we'll listen to them,” Dr. Gaston said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

The prevalence of end-stage renal disease (ESRD) is four to five times greater in blacks than in whites, yet black and other minority patients do not undergo nearly as many transplants as white patients do. “White patients are 50% more likely to receive a transplant within 2 years of being wait-listed,” compared with other racial groups, Dr. Gaston said.

He cited 2002 data on ESRD prevalence that further underscore the disparities. At that time, more than 80% of the African American population with ESRD was on dialysis, while less than 20% had undergone a kidney transplant. At the same time, only 62% of the comparable white population was on dialysis, while 38% had received a kidney transplant.

All patients who might need a kidney transplant go through a process that involves a referral to a transplant center and a medical evaluation, Dr. Gaston explained. Patients who are approved after the evaluation are then placed on a waiting list. But the process goes more smoothly for some patients than others. “At each step along the pathway, the evaluation process can be challenging,” he said.

Dr. Gaston provided details on many of the barriers to transplantation that minority patients face.

First, fewer African American patients than white patients learn about the transplantation option.

In addition, the high cost of a transplant is also an important factor, and patients with higher-paying private insurance are much more likely to get a transplant than patients who have only Medicare.

Also, those ESRD patients who have been placed on multiple transplant lists have an increased likelihood of ultimately receiving a transplant. But African American patients are 70% less likely to be on multiple waiting lists.

Possibly the biggest obstacle to receiving a transplant is that minority patients have less access to living donors than white patients do. Dr. Gaston cited a study done at his institution that revealed that while 33% of white patients received a kidney from a living donor, only 13% of African American patients were able to undergo this type of transplant.

Ultimately, patients who receive a transplanted kidney from a living donor have the best outcomes. Studies show that the greatest survival benefit occurs in ESRD patients who receive a living donor transplant before starting dialysis.

Under the new organ allocation system, Dr. Gaston noted, transplant access for minorities has increased and overall outcomes have also improved.

Data show a 10.3% increase in renal transplants in black patients since the rules have changed by relaxing HLA matching requirements, said Friedrich K. Port, president of University Renal Research and Education Association in Ann Arbor, Mich.

CHICAGO — As the demand for kidney transplants for patients with end-stage renal disease continues to increase, disparities in transplantation rates among U.S. minority populations continue.

Dr. Robert S. Gaston, a nephrologist whose transplant team at the University of Alabama, Birmingham, has performed more than 7,000 kidney transplants, said that thousands of people have asked him when they can have a transplant.

Most patients would prefer having a kidney transplant to remaining on dialysis.

“Patients will tell us a lot about therapeutic modalities if we'll listen to them,” Dr. Gaston said at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

The prevalence of end-stage renal disease (ESRD) is four to five times greater in blacks than in whites, yet black and other minority patients do not undergo nearly as many transplants as white patients do. “White patients are 50% more likely to receive a transplant within 2 years of being wait-listed,” compared with other racial groups, Dr. Gaston said.

He cited 2002 data on ESRD prevalence that further underscore the disparities. At that time, more than 80% of the African American population with ESRD was on dialysis, while less than 20% had undergone a kidney transplant. At the same time, only 62% of the comparable white population was on dialysis, while 38% had received a kidney transplant.

All patients who might need a kidney transplant go through a process that involves a referral to a transplant center and a medical evaluation, Dr. Gaston explained. Patients who are approved after the evaluation are then placed on a waiting list. But the process goes more smoothly for some patients than others. “At each step along the pathway, the evaluation process can be challenging,” he said.

Dr. Gaston provided details on many of the barriers to transplantation that minority patients face.

First, fewer African American patients than white patients learn about the transplantation option.

In addition, the high cost of a transplant is also an important factor, and patients with higher-paying private insurance are much more likely to get a transplant than patients who have only Medicare.

Also, those ESRD patients who have been placed on multiple transplant lists have an increased likelihood of ultimately receiving a transplant. But African American patients are 70% less likely to be on multiple waiting lists.

Possibly the biggest obstacle to receiving a transplant is that minority patients have less access to living donors than white patients do. Dr. Gaston cited a study done at his institution that revealed that while 33% of white patients received a kidney from a living donor, only 13% of African American patients were able to undergo this type of transplant.

Ultimately, patients who receive a transplanted kidney from a living donor have the best outcomes. Studies show that the greatest survival benefit occurs in ESRD patients who receive a living donor transplant before starting dialysis.

Under the new organ allocation system, Dr. Gaston noted, transplant access for minorities has increased and overall outcomes have also improved.

Data show a 10.3% increase in renal transplants in black patients since the rules have changed by relaxing HLA matching requirements, said Friedrich K. Port, president of University Renal Research and Education Association in Ann Arbor, Mich.

CHICAGO — Maintaining a lower hemoglobin level may help prevent morbidity and mortality in patients with chronic kidney disease, according to a study of 1,432 patients randomized to two different hemoglobin goals.

Almost half of patients with stage 3–5 chronic kidney disease (CKD) have anemia, and nephrologists know that treating anemia with erythropoietin and iron “improves quality of life, well-being, exercise tolerance, and lowers the risk of transfusions,” said Dr. Ajay Singh, who presented late-breaking results of the Correction of Hemoglobin and Outcomes in Renal Insufficiency (CHOIR) study at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

A deficiency of erythropoietin, which is produced by the kidneys, is known to contribute to anemia. Iron deficiency also plays a role, noted Dr. Singh, director of the dialysis unit at Brigham and Women's Hospital, Boston.

But researchers have not yet elucidated the optimal target hemoglobin level for CKD patients. Dr. Singh and his associates conducted a randomized, controlled trial of 1,432 patients with CKD. The patients were randomized to one of two groups, with a target hemoglobin of either 13.5 g/dL or 11.3 g/dL. The groups had similar baseline characteristics: About half of those in each group had diabetes, and about one-third had hypertension.

Patients were followed weekly, for a median of 16 months, to assess how many in each group reached a primary composite end point of death, MI, stroke, or severe heart failure requiring hospital admission. Patients in both groups received an average dose of 8,000 U of erythropoietin subcutaneously every week. To achieve the hemoglobin levels specified in the trial, some patients were switched to every-other-week dosing.

Patients also received iron supplementation, as indicated, according to the standard of care.

The patients randomized to the lower hemoglobin level were significantly less likely to reach the primary composite end point, compared with those randomized to the higher hemoglobin level.

Further analysis of the data showed that death and heart failure were driving the composite end point, rather than an increased incidence of stroke or MI. No difference was seen between the groups in reaching the secondary composite end point: all-cause mortality, change in hemoglobin level or hematocrit, or development of heart failure.

The physiologic mechanisms underlying the findings have not yet been worked out. “The biologic mechanisms are unclear,” Dr. Singh said in an interview.

It is not yet known whether the poorer outcomes seen in the high-hemoglobin group were the result of the higher level of hemoglobin itself, the use of erythropoietin to achieve this higher hemoglobin level, or other factors. “It seems to be a phenomenon related to kidney disease,” he added.

CHICAGO — Maintaining a lower hemoglobin level may help prevent morbidity and mortality in patients with chronic kidney disease, according to a study of 1,432 patients randomized to two different hemoglobin goals.

Almost half of patients with stage 3–5 chronic kidney disease (CKD) have anemia, and nephrologists know that treating anemia with erythropoietin and iron “improves quality of life, well-being, exercise tolerance, and lowers the risk of transfusions,” said Dr. Ajay Singh, who presented late-breaking results of the Correction of Hemoglobin and Outcomes in Renal Insufficiency (CHOIR) study at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

A deficiency of erythropoietin, which is produced by the kidneys, is known to contribute to anemia. Iron deficiency also plays a role, noted Dr. Singh, director of the dialysis unit at Brigham and Women's Hospital, Boston.

But researchers have not yet elucidated the optimal target hemoglobin level for CKD patients. Dr. Singh and his associates conducted a randomized, controlled trial of 1,432 patients with CKD. The patients were randomized to one of two groups, with a target hemoglobin of either 13.5 g/dL or 11.3 g/dL. The groups had similar baseline characteristics: About half of those in each group had diabetes, and about one-third had hypertension.

Patients were followed weekly, for a median of 16 months, to assess how many in each group reached a primary composite end point of death, MI, stroke, or severe heart failure requiring hospital admission. Patients in both groups received an average dose of 8,000 U of erythropoietin subcutaneously every week. To achieve the hemoglobin levels specified in the trial, some patients were switched to every-other-week dosing.

Patients also received iron supplementation, as indicated, according to the standard of care.

The patients randomized to the lower hemoglobin level were significantly less likely to reach the primary composite end point, compared with those randomized to the higher hemoglobin level.

Further analysis of the data showed that death and heart failure were driving the composite end point, rather than an increased incidence of stroke or MI. No difference was seen between the groups in reaching the secondary composite end point: all-cause mortality, change in hemoglobin level or hematocrit, or development of heart failure.

The physiologic mechanisms underlying the findings have not yet been worked out. “The biologic mechanisms are unclear,” Dr. Singh said in an interview.

It is not yet known whether the poorer outcomes seen in the high-hemoglobin group were the result of the higher level of hemoglobin itself, the use of erythropoietin to achieve this higher hemoglobin level, or other factors. “It seems to be a phenomenon related to kidney disease,” he added.

CHICAGO — Maintaining a lower hemoglobin level may help prevent morbidity and mortality in patients with chronic kidney disease, according to a study of 1,432 patients randomized to two different hemoglobin goals.

Almost half of patients with stage 3–5 chronic kidney disease (CKD) have anemia, and nephrologists know that treating anemia with erythropoietin and iron “improves quality of life, well-being, exercise tolerance, and lowers the risk of transfusions,” said Dr. Ajay Singh, who presented late-breaking results of the Correction of Hemoglobin and Outcomes in Renal Insufficiency (CHOIR) study at a meeting on clinical nephrology sponsored by the National Kidney Foundation.

A deficiency of erythropoietin, which is produced by the kidneys, is known to contribute to anemia. Iron deficiency also plays a role, noted Dr. Singh, director of the dialysis unit at Brigham and Women's Hospital, Boston.

But researchers have not yet elucidated the optimal target hemoglobin level for CKD patients. Dr. Singh and his associates conducted a randomized, controlled trial of 1,432 patients with CKD. The patients were randomized to one of two groups, with a target hemoglobin of either 13.5 g/dL or 11.3 g/dL. The groups had similar baseline characteristics: About half of those in each group had diabetes, and about one-third had hypertension.

Patients were followed weekly, for a median of 16 months, to assess how many in each group reached a primary composite end point of death, MI, stroke, or severe heart failure requiring hospital admission. Patients in both groups received an average dose of 8,000 U of erythropoietin subcutaneously every week. To achieve the hemoglobin levels specified in the trial, some patients were switched to every-other-week dosing.

Patients also received iron supplementation, as indicated, according to the standard of care.

The patients randomized to the lower hemoglobin level were significantly less likely to reach the primary composite end point, compared with those randomized to the higher hemoglobin level.

Further analysis of the data showed that death and heart failure were driving the composite end point, rather than an increased incidence of stroke or MI. No difference was seen between the groups in reaching the secondary composite end point: all-cause mortality, change in hemoglobin level or hematocrit, or development of heart failure.

The physiologic mechanisms underlying the findings have not yet been worked out. “The biologic mechanisms are unclear,” Dr. Singh said in an interview.

It is not yet known whether the poorer outcomes seen in the high-hemoglobin group were the result of the higher level of hemoglobin itself, the use of erythropoietin to achieve this higher hemoglobin level, or other factors. “It seems to be a phenomenon related to kidney disease,” he added.