letter to the editor
excretion in patients are necessary to understand the mechanism by which statins counteract the drop of urine osmolality in Li-induced NDI. 1.
2.
3.
4.
Kwon TH, Laursen UH, Marples D et al. Altered expression of renal AQPs and Na þ transporters in rats with lithium-induced NDI. Am J Physiol Renal Physiol 2000; 279: F552–F564. Rojek A, Nielsen J, Brooks HL et al. Altered expression of selected genes in kidney of rats with lithium-induced NDI. Am J Physiol Renal Physiol 2005; 288: F1276–F1289. Procino G, Milano S, Carmosino M et al. Combination of secretin and fluvastatin ameliorates the polyuria associated with X-linked nephrogenic diabetes insipidus in mice. Kidney Int 2014; 86: 127–138. Elie D, Segal M, Low N et al. Statins in the prevention of lithium-associated diabetes insipidus: preliminary findings. Kidney Int 2015; 87: 862.
Giuseppe Procino1, Serena Milano1, Maria C. Nicoletti1, Monica Carmosino1 and Maria Svelto1
recommendations to transplantation candidates, we may thus consider the global approach to cope with the cardiac evaluation of kidney transplant candidates and designing randomized controlled trial to assess the efficacy of the current practice. 1. 2.
3.
4.
1
Department of Biosciences, Biotechnologies and Biofarmaceutics, University of Bari, Bari, Italy Correspondence: Giuseppe Procino, Department of Biosciences, Biotechnologies and Biofarmaceutics, University of Bari, 70126 Bari, Italy. E-mail: [email protected]
5.
Kidney International (2015) 87, 862–863; doi:10.1038/ki.2014.412
Cardiovascular evaluation of potential transplant recipient: from non-US perspective Very recently Hart et al.1 published a review paper on cardiovascular risk assessment in kidney transplantation. Independently, in the same time a complimentary review appeared.2 As current guidelines for pretransplant cardiovascular evaluation in asymptomatic kidney transplant are based on expert opinion, we took another approach and focused predominantly on the appropriate testing with possible benefits and limitations. Hart et al.1 cited only US-based guidelines, whereas we took a non-US approach and went through available guidelines. Fortunately, in 2014, two guidelines, which may be relevant to the cardiac evaluation of potential kidney transplant recipients, were published by the European Society of Cardiology.3,4 The new 2014 European Society of Cardiology/European Society of Anaesthesiology Guidelines assess the surgical risk of patients undergoing kidney transplantation as intermediate (1–5%).3 The major breakthrough is devoted to the surgery in patients on dual antiplatelet therapy. From the clinical perspectives, in a case of urgency for transplantation––i.e., lack of vascular access––patients do not need to be kept inactive on the waiting list because of dual antiplatelet therapy.4 The world of evidence based medicine is worth to discuss as Wang et al.5 provide a systematic review of test accuracy for coronary artery disease in kidney transplant candidates. As the discrepancies among existing guidelines and the unique clinical characteristics of dialysis patients raise questions about the applicability of the available Kidney International (2015) 87, 857–864
Hart A, Weir MR, Kasiske BL. Cardiovascular risk assessment in kidney transplantation. Kidney Int 2015; 87: 527–534. Ma"yszko J, Bachorzewska-Gajewska H, Tomaszuk-Kazberuk A et al. Cardiovascular disease and kidney transplantation: evaluation of potential transplant recipient. Pol Arch Med Wewn 2014; 124: 608–616. Authors/Task Force Members, Windecker S, Kolh P et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35: 2541–2619. Authors/Task Force Members, Kristensen SD, Knuuti J, Saraste A et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: the Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35: 2383–2431. Wang LW, Fahim MA, Hayen A et al. Cardiac testing for coronary artery disease in potential kidney transplant recipients. Cochrane Database Syst Rev 2011; 12: CD008691.
Jolanta Mal-yszko1, Hanna Bachorzewska-Gajewska2, Anna Tomaszuk-Kazberuk3, Joanna Matuszkiewicz-Rowinska4, Magdalena Durlik5 and Slawomir Dobrzycki2 1
2nd Department of Nephrology, Medical University of Bialystok, Bialystok, Poland; 2Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland; 3Department of Cardiology, Medical University of Bialystok, Bialystok, Poland; 4Department of Nephrology, Internal Medicine and Dialysis Therapy, Warsaw Medical University, Warsaw, Poland and 5 Department of Nephrology and Transplantation Medicine, Warsaw Medical University, Warsaw, Poland Correspondence: Jolanta Malyszko, 2nd Department of Nephrology, Medical University, M. Sklodowskiej-Curie 24a, 15-276 Bialystok, Poland. E-mail [email protected] Kidney International (2015) 87, 863; doi:10.1038/ki.2014.420
The Authors Reply: We appreciated the opportunity to read the excellent review by Malyszko et al.1 that was not available at the time of our submission.2 The authors correctly point out in their letter3 that our review, which was intended to illustrate the large variation in guideline recommendations even within a single country, cites only US-based guidelines. The 2014 European Society of Cardiology Guidelines cited by Malyszko et al. very closely mirror the American Heart Association Guidelines published in 2007.4,5 We agree with the authors’ call for fewer guidelines and a more uniform global approach; in fact, Kidney Disease, Improving Global Outcomes (KDIGO) and the Transplantation Society are currently collaborating on a global guideline for the evaluation of potential transplant recipients. However, any guideline on screening asymptomatic kidney transplant candidates will continue to rely on mixed observational data that cannot provide a definitive answer as to whether 863
letter to the editor
screening for cardiovascular disease in asymptomatic kidney transplant recipients improves outcomes. We agree with Malyszko et al. that ‘There are no definitive data at this time for or against screening for myocardial ischemia among kidney transplantation candidates who are free of active cardiac conditions.’1 We do not agree that detailed cardiac evaluation for the asymptomatic candidate has been proven to outweigh the risks of this evaluation, and renew our call for a randomized controlled trial to assess whether the current practice of screening is beneficial. 1.
2. 3.
4.
5.
Ma"yszko J, Bachorzewska-Gajewska H, Tomaszuk-Kazberuk A et al. Cardiovascular disease and kidney transplantation: evaluation of potential transplant recipient. Pol Arch Med Wewn 2014; 124: 608–616. Hart A, Weir MR, Kasiske BL. Cardiovascular risk assessment in kidney transplantation. Kidney Int 2015; 87: 527–534. Ma"yszko J, Bachorzewska-Gajewska H, Tomaszberuk A et al. Cardiovascular evaluation of potential transplant recipient: from non-US perspective. Kidney Int 2015; 87: 863. Authors/Task Force Members, Windecker S, Kolh P, Alfonso F et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35: 2541–2619. Fleisher LB, Brown J, Calkins K et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2007; 50: e159–e242.
Allyson Hart1,2, Matthew R. Weir3 and Bertram L. Kasiske1,2 1
Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota, USA; 2School of Medicine, University of Minnesota, Minneapolis, MN, USA and 3Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA Correspondence: Allyson Hart, Department of Nephrology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, Minnesota 55415, USA. E-mail: [email protected]
demonstrate that PCS in non-uremic concentrations is one of the metabolites associated with poor renal outcome. Does this mean that accelerated renal disease progression in diabetic nephropathy is due to toxic metabolites, including PCS? There are at least three other explanations to explain this observation. First, as renal clearance of PCS is mainly due to tubular secretion, high PCS levels may merely reflect renal proximal tubulopathy.2 Indeed, progressors presented with significantly higher albuminuria, which either may be a consequence or a cause of proximal tubulopathy. Second, PCS serum levels and urinary excretion rates are also substantially higher in diabetic versus nondiabetic chronic kidney disease patients (Meijers et al., CJASN 2010)3 and high PCS levels may contribute to insulin resistance, rendering the host more susceptible to development of more severe diabetes and its complications.4 Finally, high PCS may point to a disturbed and potentially deleterious gut microbial metabolism. As pharmacological (e.g., acarbose) and dietary interventions (e.g., fiber intake) may differentially affect microbial metabolism and PCS levels, they should be accounted for.5 Untargeted metabolomics will show us numerous intriguing associations. Even when in alignment with existing literature, such as for PCS, these associations may or may not point toward a causal relationship. As always, good science generates more questions. 1.
2. 3.
Kidney International (2015) 87, 863–864; doi:10.1038/ki.2014.422 4. 5.
The metabolomics grail: promising although not yet holy To the Editor: We read with interest the paper by Niewczas et al.,1 and would like to offer the following comments. Although the era of metabolome-wide association studies is still to arrive, the study by Niewczas et al.1 is a substantial step in this direction. Although p-cresyl sulfate (PCS) is a wellestablished nephro-vascular toxin, the authors are the first to
864
Niewczas MA, Sirich TL, Mathew AV et al. Uremic solutes and risk of endstage renal disease in type 2 diabetes: metabolomic study. Kidney Int 2014; 85: 1214–1224. Masereeuw R, Mutsaers HA, Toyohara T et al. The kidney and uremic toxin removal: glomerulus or tubule? Semin Nephrol 2014; 34: 191–208. Meijers BK, Claes K, Bammens B et al. p-Cresol and cardiovascular risk in mild-to-moderate kidney disease. Clin J Am Soc Nephrol 2010; 5: 1182–1189. Koppe L, Pillon NJ, Vella RE et al. p-Cresyl sulfate promotes insulin resistance associated with CKD. J Am Soc Nephrol 2013; 24: 88–99. Evenepoel P, Bammens B, Verbeke K et al. Acarbose treatment lowers generation and serum concentrations of the protein-bound solute p-cresol: a pilot study. Kidney Int 2006; 70: 192–198.
Ruben Poesen1, Pieter Evenepoel1 and Bjo¨ rn Meijers1 1 Department of Microbiology and Immunology, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium Correspondence: Bjo¨ rn Meijers, Division of Internal Medicine, Department of Nephrology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium. E-mail: [email protected]
Kidney International (2015) 87, 864; doi:10.1038/ki.2014.396
Kidney International (2015) 87, 857–864
excretion in patients are necessary to understand the mechanism by which statins counteract the drop of urine osmolality in Li-induced NDI. 1.
2.
3.
4.
Kwon TH, Laursen UH, Marples D et al. Altered expression of renal AQPs and Na þ transporters in rats with lithium-induced NDI. Am J Physiol Renal Physiol 2000; 279: F552–F564. Rojek A, Nielsen J, Brooks HL et al. Altered expression of selected genes in kidney of rats with lithium-induced NDI. Am J Physiol Renal Physiol 2005; 288: F1276–F1289. Procino G, Milano S, Carmosino M et al. Combination of secretin and fluvastatin ameliorates the polyuria associated with X-linked nephrogenic diabetes insipidus in mice. Kidney Int 2014; 86: 127–138. Elie D, Segal M, Low N et al. Statins in the prevention of lithium-associated diabetes insipidus: preliminary findings. Kidney Int 2015; 87: 862.
Giuseppe Procino1, Serena Milano1, Maria C. Nicoletti1, Monica Carmosino1 and Maria Svelto1
recommendations to transplantation candidates, we may thus consider the global approach to cope with the cardiac evaluation of kidney transplant candidates and designing randomized controlled trial to assess the efficacy of the current practice. 1. 2.
3.
4.
1
Department of Biosciences, Biotechnologies and Biofarmaceutics, University of Bari, Bari, Italy Correspondence: Giuseppe Procino, Department of Biosciences, Biotechnologies and Biofarmaceutics, University of Bari, 70126 Bari, Italy. E-mail: [email protected]
5.
Kidney International (2015) 87, 862–863; doi:10.1038/ki.2014.412
Cardiovascular evaluation of potential transplant recipient: from non-US perspective Very recently Hart et al.1 published a review paper on cardiovascular risk assessment in kidney transplantation. Independently, in the same time a complimentary review appeared.2 As current guidelines for pretransplant cardiovascular evaluation in asymptomatic kidney transplant are based on expert opinion, we took another approach and focused predominantly on the appropriate testing with possible benefits and limitations. Hart et al.1 cited only US-based guidelines, whereas we took a non-US approach and went through available guidelines. Fortunately, in 2014, two guidelines, which may be relevant to the cardiac evaluation of potential kidney transplant recipients, were published by the European Society of Cardiology.3,4 The new 2014 European Society of Cardiology/European Society of Anaesthesiology Guidelines assess the surgical risk of patients undergoing kidney transplantation as intermediate (1–5%).3 The major breakthrough is devoted to the surgery in patients on dual antiplatelet therapy. From the clinical perspectives, in a case of urgency for transplantation––i.e., lack of vascular access––patients do not need to be kept inactive on the waiting list because of dual antiplatelet therapy.4 The world of evidence based medicine is worth to discuss as Wang et al.5 provide a systematic review of test accuracy for coronary artery disease in kidney transplant candidates. As the discrepancies among existing guidelines and the unique clinical characteristics of dialysis patients raise questions about the applicability of the available Kidney International (2015) 87, 857–864
Hart A, Weir MR, Kasiske BL. Cardiovascular risk assessment in kidney transplantation. Kidney Int 2015; 87: 527–534. Ma"yszko J, Bachorzewska-Gajewska H, Tomaszuk-Kazberuk A et al. Cardiovascular disease and kidney transplantation: evaluation of potential transplant recipient. Pol Arch Med Wewn 2014; 124: 608–616. Authors/Task Force Members, Windecker S, Kolh P et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35: 2541–2619. Authors/Task Force Members, Kristensen SD, Knuuti J, Saraste A et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: the Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35: 2383–2431. Wang LW, Fahim MA, Hayen A et al. Cardiac testing for coronary artery disease in potential kidney transplant recipients. Cochrane Database Syst Rev 2011; 12: CD008691.
Jolanta Mal-yszko1, Hanna Bachorzewska-Gajewska2, Anna Tomaszuk-Kazberuk3, Joanna Matuszkiewicz-Rowinska4, Magdalena Durlik5 and Slawomir Dobrzycki2 1
2nd Department of Nephrology, Medical University of Bialystok, Bialystok, Poland; 2Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland; 3Department of Cardiology, Medical University of Bialystok, Bialystok, Poland; 4Department of Nephrology, Internal Medicine and Dialysis Therapy, Warsaw Medical University, Warsaw, Poland and 5 Department of Nephrology and Transplantation Medicine, Warsaw Medical University, Warsaw, Poland Correspondence: Jolanta Malyszko, 2nd Department of Nephrology, Medical University, M. Sklodowskiej-Curie 24a, 15-276 Bialystok, Poland. E-mail [email protected] Kidney International (2015) 87, 863; doi:10.1038/ki.2014.420
The Authors Reply: We appreciated the opportunity to read the excellent review by Malyszko et al.1 that was not available at the time of our submission.2 The authors correctly point out in their letter3 that our review, which was intended to illustrate the large variation in guideline recommendations even within a single country, cites only US-based guidelines. The 2014 European Society of Cardiology Guidelines cited by Malyszko et al. very closely mirror the American Heart Association Guidelines published in 2007.4,5 We agree with the authors’ call for fewer guidelines and a more uniform global approach; in fact, Kidney Disease, Improving Global Outcomes (KDIGO) and the Transplantation Society are currently collaborating on a global guideline for the evaluation of potential transplant recipients. However, any guideline on screening asymptomatic kidney transplant candidates will continue to rely on mixed observational data that cannot provide a definitive answer as to whether 863
letter to the editor
screening for cardiovascular disease in asymptomatic kidney transplant recipients improves outcomes. We agree with Malyszko et al. that ‘There are no definitive data at this time for or against screening for myocardial ischemia among kidney transplantation candidates who are free of active cardiac conditions.’1 We do not agree that detailed cardiac evaluation for the asymptomatic candidate has been proven to outweigh the risks of this evaluation, and renew our call for a randomized controlled trial to assess whether the current practice of screening is beneficial. 1.
2. 3.
4.
5.
Ma"yszko J, Bachorzewska-Gajewska H, Tomaszuk-Kazberuk A et al. Cardiovascular disease and kidney transplantation: evaluation of potential transplant recipient. Pol Arch Med Wewn 2014; 124: 608–616. Hart A, Weir MR, Kasiske BL. Cardiovascular risk assessment in kidney transplantation. Kidney Int 2015; 87: 527–534. Ma"yszko J, Bachorzewska-Gajewska H, Tomaszberuk A et al. Cardiovascular evaluation of potential transplant recipient: from non-US perspective. Kidney Int 2015; 87: 863. Authors/Task Force Members, Windecker S, Kolh P, Alfonso F et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35: 2541–2619. Fleisher LB, Brown J, Calkins K et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2007; 50: e159–e242.
Allyson Hart1,2, Matthew R. Weir3 and Bertram L. Kasiske1,2 1
Division of Nephrology, Hennepin County Medical Center, Minneapolis, Minnesota, USA; 2School of Medicine, University of Minnesota, Minneapolis, MN, USA and 3Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA Correspondence: Allyson Hart, Department of Nephrology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, Minnesota 55415, USA. E-mail: [email protected]
demonstrate that PCS in non-uremic concentrations is one of the metabolites associated with poor renal outcome. Does this mean that accelerated renal disease progression in diabetic nephropathy is due to toxic metabolites, including PCS? There are at least three other explanations to explain this observation. First, as renal clearance of PCS is mainly due to tubular secretion, high PCS levels may merely reflect renal proximal tubulopathy.2 Indeed, progressors presented with significantly higher albuminuria, which either may be a consequence or a cause of proximal tubulopathy. Second, PCS serum levels and urinary excretion rates are also substantially higher in diabetic versus nondiabetic chronic kidney disease patients (Meijers et al., CJASN 2010)3 and high PCS levels may contribute to insulin resistance, rendering the host more susceptible to development of more severe diabetes and its complications.4 Finally, high PCS may point to a disturbed and potentially deleterious gut microbial metabolism. As pharmacological (e.g., acarbose) and dietary interventions (e.g., fiber intake) may differentially affect microbial metabolism and PCS levels, they should be accounted for.5 Untargeted metabolomics will show us numerous intriguing associations. Even when in alignment with existing literature, such as for PCS, these associations may or may not point toward a causal relationship. As always, good science generates more questions. 1.
2. 3.
Kidney International (2015) 87, 863–864; doi:10.1038/ki.2014.422 4. 5.
The metabolomics grail: promising although not yet holy To the Editor: We read with interest the paper by Niewczas et al.,1 and would like to offer the following comments. Although the era of metabolome-wide association studies is still to arrive, the study by Niewczas et al.1 is a substantial step in this direction. Although p-cresyl sulfate (PCS) is a wellestablished nephro-vascular toxin, the authors are the first to
864
Niewczas MA, Sirich TL, Mathew AV et al. Uremic solutes and risk of endstage renal disease in type 2 diabetes: metabolomic study. Kidney Int 2014; 85: 1214–1224. Masereeuw R, Mutsaers HA, Toyohara T et al. The kidney and uremic toxin removal: glomerulus or tubule? Semin Nephrol 2014; 34: 191–208. Meijers BK, Claes K, Bammens B et al. p-Cresol and cardiovascular risk in mild-to-moderate kidney disease. Clin J Am Soc Nephrol 2010; 5: 1182–1189. Koppe L, Pillon NJ, Vella RE et al. p-Cresyl sulfate promotes insulin resistance associated with CKD. J Am Soc Nephrol 2013; 24: 88–99. Evenepoel P, Bammens B, Verbeke K et al. Acarbose treatment lowers generation and serum concentrations of the protein-bound solute p-cresol: a pilot study. Kidney Int 2006; 70: 192–198.
Ruben Poesen1, Pieter Evenepoel1 and Bjo¨ rn Meijers1 1 Department of Microbiology and Immunology, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium Correspondence: Bjo¨ rn Meijers, Division of Internal Medicine, Department of Nephrology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium. E-mail: [email protected]
Kidney International (2015) 87, 864; doi:10.1038/ki.2014.396
Kidney International (2015) 87, 857–864
