Hemodialysis.com

Hemodialysis research, author interviews, dialysis updates and information on chronic kidney disease and end stage renal failure.

Editor: Marie Benz, MDinfo@hemodialysis.com

December 6 2012

For Informational Purposes Only: Not for Specific Medical Advice.

Read more interviews on Hemodialysis.com

Medical Disclaimer | Terms and Conditions

• The contents of the Hemodialysis.com Site, such as text, graphics, images, and other material contained on the Hemodialysis.com Site ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on the Hemodialysis.com Site!

• If you think you may have a medical emergency, call your doctor or 911 immediately. Hemodialysis.com does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by Hemodialysis.com or other Eminent Domains Inc (EDI) websites, EDI employees, others appearing on the Site at the invitation of Hemodialysis.com or EDI, or other visitors to the Site is solely at your own risk.

• The Site may contain health- or medical-related materials that are sexually explicit. If you find these materials offensive, you may not want to use our Site. The Site and the Content are provided on an "as is" basis.

Hemodialysis.com

Experiences of Care Among Medicare Beneficiaries With ESRD: Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey Results

Hemodialysis.com Author Interview: Marc N. Elliott, PhD, RAND Corporation, 1776 Main St,Santa Monica, CA 90401-3208

• Hemodialysis.com Editor Marie Benz: What are the main findings of the study?• Dr. Elliott: • Medicare beneficiaries with ESRD reported better experiences of care than non-ESRD beneficiaries for 7 of 10 patient

experience measures -rating of care, rating of physician, rating of prescription drug plan, getting prescription drugs, getting needed care, customer service, and getting care quickly. However, the magnitude of these differences between ESRD and non-ESRD beneficiaries is small (<3 points difference on a scale of 0-100). Beneficiaries with ESRD did not report worse experiences of care than their non-ESRD counterparts on any of the 10 measures.

• Among ESRD beneficiaries, black Medicare beneficiaries indicated poorer experiences than white beneficiaries for 6 of 10 measures (rating of care, rating of physician, rating of specialist, rating of prescription drug plan, getting prescription drugs, and physician communication).

Also among ESRD beneficiaries, those without a high school degree were more likely to report worse experiences than high school graduates.

• Hemodialysis.com: Were any of the findings unexpected? • Dr. Elliott: • It may be surprising that, on average, beneficiaries with ESRD did not report worse care experiences than non-ESRD

beneficiaries for any of the 10 measures examined, though there is some evidence that this can occur in other settings with longstanding patient-physician relationships that arise in the treatment of chronic conditions such as ESRD.

Experiences of Care Among Medicare Beneficiaries With ESRD: Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey ResultsHemodialysis.com Author Interview: Marc N. Elliott, PhD, RAND Corporation, 1776 Main St,Santa Monica, CA 90401-3208(cont)

• Hemodialysis.com: What should clinicians and patients take away from your report? • Dr. Elliott: • Given that black ESRD patients and those without a high school degree report worse experiences than other ESRD

patients, clinicians may want to make extra efforts to communicate effectively with such ESRD patients and ensure that their needs are met.

Ensuring that discussions and materials are appropriate for the health literacy levels of all patients may be an important consideration.

• Hemodialysis.com: What recommendations do you have for future research as a result of this study? • Dr. Elliott: • Further research that explores the reasons why Medicare beneficiaries with ESRD tend to report better experiences of

care than those without ESRD is needed. Also needed is research that further examines disparities in experiences of care by race/ethnicity and education, including the reasons behind such disparities.

The CMS-sponsored In-Center Hemodialysis CAHPS Survey, which began implementation as of late 2012, could be a source of data for additional research.

• Reference:• Experiences of Care Among Medicare Beneficiaries With ESRD: Medicare Consumer Assessment of Healthcare Providers

and Systems (CAHPS) Survey Results

Charlotte A.M. Paddison, Marc N. Elliott, Amelia M. Haviland, Donna O. Farley, Georgios Lyratzopoulos, Katrin Hambarsoomian, Jacob W. Dembosky, Martin O. RolandAmerican Journal of Kidney Diseases - 23 November 2012 (10.1053/j.ajkd.2012.10.009)

Comparison of alteplase (tissue plasminogen activator) high-dose vs. low-dose protocol in restoring hemodialysis catheter function: The ALTE-DOSE study

Hemodialysis.com Author Interview: Dr. A. Kadri Chief of Medicine Hotel Dieu- Grace Hospital Windsor, Ontario

• Hemodialysis.com Editor Marie Benz: What are the main findings of the study?• Dr. Kadri:• Prior to this study, it was not entirely clear according to the available literature, what the optimal dose of TPA

was for catheter malfunction.

Because this is a very expensive medication some centers were using low dose TPA (1mg per port) as a cost saving measure as there was no clear information that higher dose TPA (2mg per port) was more effective in resolving catheter malfunction in the dialysis population. Prior to our study, we reviewed the available literature and there was some suggestion that 1 mg dosing might be as effective as 2-mg dosing of TPA for catheter malfunction.

Our study suggests that the 2-mg dose seems to be superior in resolving catheter malfunction and prolonging catheter survival in this population.

Importantly, this seems to be independent of the frequency and total TPA dose during the life of the catheter ie.

• A single 2-mg dose is more effective than repeatedly administering 1 mg doses in treating catheter malfunction.

• Hemodialysis.com: Were any of the findings unexpected? • Dr. Kadri:• I must admit, these findings were a bit surprising in that our center has been using 1 mg dosing as a cost saving

measure as there was no clear evidence that 2-mg dosing with superior.

Comparison of alteplase (tissue plasminogen activator) high-dose vs. low-dose protocol in restoring hemodialysis catheter function: The ALTE-DOSE study

Hemodialysis.com Author Interview: Dr. A. Kadri Chief of Medicine Hotel Dieu- Grace Hospital Windsor, Ontario Continued

• Hemodialysis.com: What should clinicians and patients take away from your report? • Dr. Kadri:• I think it is important to realize that the available data at this point seems to suggest that 2-mg dosing may be

more effective in restoring catheter function and prolonging catheter survival in the dialysis population than 1 mg dosing of TPA.

To date, we believe this is the largest analysis regarding this issue. It should be noted however that this is a retrospective analysis and further investigation is definitely warranted in our opinion.

• Hemodialysis.com: What recommendations do you have for future research as a result of this study? • Dr. Kadri:• I believe it would be an extremely worthwhile endeavor to embark on a prospective, randomized clinical trial

analyzing this issue.

It would be of great importance in the dialysis community given the enormous cost of TPA. • Reference:• Comparison of alteplase (tissue plasminogen activator) high-dose vs. low-dose protocol in restoring hemodialysis

catheter function: The ALTE-DOSE study

Yaseen, O., El-Masri, M. M., El Nekidy, W. S., Soong, D., Ibrahim, M., Speirs, J. W. and Kadri, A. (2012), Comparison of alteplase (tissue plasminogen activator) high-dose vs. low-dose protocol in restoring hemodialysis catheter function: The ALTE-DOSE study. Hemodialysis International. doi: 10.1111/hdi.12004

End-stage renal failure due to amyloidosis: outcomes in 490 ANZDATA registry cases.Hemodialysis.com Author Interview: Professor David JohnsonMB BS (Hons), FRACP, PhD (Syd), PSMMetro South and Ipswich Nephrology & Transplant Services (MINTS)

• Hemodialysis.com Editor Marie Benz: What are the main findings of the study?• The main findings of the study were that, compared to patients with end-stage renal failure

secondary to other causes, those with end-stage renal failure due to amyloidosis experienced inferior survival on dialysis (median 2.09 vs 4.45 years, respectively), inferior first renal allograft survival (median 4.55 vs 10.7 years) and inferior patient survival following renal transplantation (median 6.03 vs 16.8 years).

53 (13.8%) of amyloidosis patients on dialysis died of amyloidosis-related complications and 16.4% of amyloidosis patients undergoing renal transplantation experienced amyloidosis recurrence in the renal allograft.

• Hemodialysis.com: Were any of the findings unexpected? • Previous small observational cohort studies had observed inferior survival of amyloidosis patients

on dialysis compared with that of patients with other causes of end-stage renal failure.

However, there had not been a large, comprehensive, multi-centre evaluation of the clinical outcomes of amyloidosis patients on dialysis. Furthermore, information on renal transplant outcomes was extremely limited and conflicting, with some studies favouring transplantation for these individuals and other studies not. The present study clearly demonstrates that the dialysis and renal transplant outcomes of amyloidosis patients are poor.

End-stage renal failure due to amyloidosis: outcomes in 490 ANZDATA registry cases.Hemodialysis.com Author Interview: Professor David JohnsonMB BS (Hons), FRACP, PhD (Syd), PSMMetro South and Ipswich Nephrology & Transplant Services (MINTS)

Continued

• Hemodialysis.com: What should clinicians and patients take away from your report? • Amyloidosis is associated with poor patient survival following dialysis and/or renal

transplantation, poor renal allograft survival and a significant incidence of disease recurrence in the allograft. An appreciable proportion of amyloid ESRF patients die of amyloidosis complications.

• Hemodialysis.com: What recommendations do you have for future research as a result of this study?

• Future studies should examine dialysis and renal transplant outcomes amongst patients with different subtypes of amyloidosis (AL, AA or other types).

• Reference:• End-stage renal failure due to amyloidosis: outcomes in 490 ANZDATA registry cases.• Tang W, McDonald SP, Hawley CM, Badve SV, Boudville N, Brown FG, Clayton PA, Campbell

SB, de Zoysa JR, Johnson DW.1 ANZDATA Registry, Adelaide, SA, Australia.Nephrol Dial Transplant. 2012 Nov 25. [Epub ahead of print]

Uremic Versus Idiopathic Restless Legs Syndrome: Impact on Aspects Related to Quality of LifeHemodialysis.com Author Interview: Christoforos D. Giannaki PhD Department of Life and Health Sciences University of Nicosia Cyprus

• Hemodialysis.com Editor Marie Benz: What are the main findings of the study?• Restless legs syndrome (RLS) is very common in the hemodialysis population.

Briefly, RLS is characterized by an irresistible urge to move the legs, usually accompanied by unpleasant sensations.

The syndrome’s symptoms begin or worsen during rest periods and mainly in the night, whereas a temporary relief occurs by movement. We found that the patients with uremic RLS seem to experience lower levels of quality of life, have an increased score in depression symptoms, and report more severe RLS symptoms compared with the patients with idiopathic RLS. In addition, the patients with both types of RLS were found to experience significantly lower quality of life levels compared with healthy non-RLS individuals.

• Hemodialysis.com: Were any of the findings unexpected?

• We found no significant differences in sleep quality between the uremic and the idiopathic RLS patients. We believe that the lack of significant differences may be due to the lack of an overnight polysomnographic evaluation which is considered the gold standard technique for the assessment of sleep parameters as well as due to the low number of patients involved in the study.

Uremic Versus Idiopathic Restless Legs Syndrome: Impact on Aspects Related to Quality of LifeHemodialysis.com Author Interview:

Christoforos D. Giannaki PhD Department of Life and Health Sciences University of Nicosia CyprusContinued

• Hemodialysis.com: What should clinicians and patients take away from your report? • Severity of the RLS symptoms is greater in the uremic patients compared to the idiopathic patients.

Similarly, quality of life and depression score appeared to be worst in the uremic RLS patients compared to the idiopathic ones.

Taking into account the high prevalence as well as the great negative impact of RLS in the hemodialysis patients’ overall health and quality of life parameters, the syndrome should receive special attention both by the nephrologists and the hemodialysis patients.

• Hemodialysis.com: What recommendations do you have for future research as a result of this study? • The comparison of more health related parameters between the two RLS group of patients.

Examination of the efficacy of pharmacological and non-pharmacological treatment options in hemodialysis patients with RLS.

• Reference:• Uremic Versus Idiopathic Restless Legs Syndrome: Impact on Aspects Related to Quality of Life• Gkizlis V, Giannaki CD, Karatzaferi C, Hadjigeorgiou GM, Mihas C, Koutedakis Y, Stefanidis I, Sakkas GK.

Uremic Versus Idiopathic Restless Legs Syndrome: Impact on Aspects Related to Quality of Life. ASAIO J. 58(6):607-611. 2012

Fibroblast growth factor 23 and soluble klotho in children with Chronic Kidney DiseaseHemodialysis.com Authors' Interview: Dr. Rukshana Shroff, Research Registrar, Nephrourology Unit, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.

Mandy Wan Lead Paediatric Research Pharmacist | London & South East MCRN Local Research Network

• Hemodialysis.com Editor Marie Benz: What are the main findings of the study?• Our study shows that even in a population of children with well-controlled serum

phosphate, high fibroblast growth factor 23 (FGF23) and low soluble-klotho (s-klotho) levels are seen with progressive decline in estimated glomerular filtration rate (eGFR).

No association was seen between serum phosphate or PTH and FGF23, but FGF23 showed a positive association with serum calcium levels. FGF23 levels increased over a 12 months period, particularly in children with CKD stage 3b.

• Our multivariate regression analysis demonstrated a strong relationship between FGF23 and eGFR, whereas the association between s-klotho and eGFR as observed in univariate analysis was lost following adjustment for confounders.

• Hemodialysis.com: Were any of the findings unexpected? • We found novel associations between FGF23 and serum calcium as well as 25-

hydroxyvitamin D [25(OH)D]: there was a positive association between FGF23 and serum calcium, and 25(OH)D deficiency was associated with higher FGF23 levels.

Also, this study is the first to report on s-klotho levels in children with CKD, suggesting that low 25(OH)D and high PTH are associated with s-klotho deficiency in CKD.

Fibroblast growth factor 23 and soluble klotho in children with Chronic Kidney DiseaseHemodialysis.com Authors' Interview: Dr. Rukshana Shroff, Research Registrar, Nephrourology Unit, Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.

Mandy Wan Lead Paediatric Research Pharmacist | London & South East MCRN Local Research Network Continued

• Hemodialysis.com: What should clinicians and patients take away from your report? • Our report adds to the emerging data, which suggests progressive increase in FGF23 production starting at the

earliest stage of chronic kidney disease (CKD), and that FGF23 may be a key contributor to the disturbances in mineral and bone metabolism in patients with CKD. Equally, one must not forget s-klotho and its potential involvement in this pathophysiologic process which may or may not be dependent of FGF23.

• The potential association between calcium levels and high FGF23 suggest that mechanisms other than phosphate and PTH regulate FGF23 levels, and careful attention to maintaining normocalcaemia must be emphasized.

Importantly, our data shows a potential association with 25(OH)D levels, highlighting yet another role of FGF23 in cardiovascular health.

• Hemodialysis.com: What recommendations do you have for future research as a result of this study? • A positive correlation between serum calcium and FGF23 suggests that the calcaemic effects of activated vitamin D

analogues and calcium-based phosphate binders need to be examined in future randomised controlled trials.

The effect of 25(OH)D on FGF23 should be investigated to further explore the therapeutic role of 25(OH)D. Furthermore, additional research is required to examine FGF23-klotho mediated signaling before s-klotho levels in CKD patients can be accurately interpreted.

• Reference:• Fibroblast growth factor 23 and soluble klotho in children with chronic kidney disease• Mandy Wan,Colette Smith, Vanita Shah, Ambrose Gullet,

David Wells, Lesley Rees, and Rukshana Shroff• Nephrol. Dial. Transplant. first published online November 23, 2012 doi:10.1093/ndt/gfs411

Biofeedback dialysis for hypotension and hypervolemia: a systematic review and meta-analysisHemodialysis.com Author Interview: Gihad Nesrallah, MD, M.Sc.(c), FRCPC

• Hemodialysis.com Editor Marie Benz: What are the main findings of the study?• Hypotension on dialysis is a major source of patient discomfort, and may contribute

to organ damage and premature death in dialysis patients.

Biofeedback systems may improve blood pressure stability during hemodialysis by creating a better match between the rate of fluid removal and the replacement of blood volume from the body's tissues during dialysis.

This systematic review and meta-analysis found that across 8 randomized studies of biofeedback dialysis, there was a large and consistent improvement in the frequency of blood pressure drops during dialysis.

• Hemodialysis.com: Were any of the findings unexpected? • The findings are not altogether unexpected. Several small studies have suggested

improved blood pressure stability with biofeedback for many years.

The consistency of this treatment effect across a number of randomized studies was not expected, and suggests a true treatment effect.

Biofeedback dialysis for hypotension and hypervolemia: a systematic review and meta-analysisHemodialysis.com Author Interview: Gihad Nesrallah, MD, M.Sc.(c), FRCPCContinued

• Hemodialysis.com: What should clinicians and patients take away from your report? • Biofeedback dialysis has not received a great deal of attention over the last couple of decades

that it has been in use. Recently, more studies are suggesting that drops in blood pressure carry harmful effects, including heart and brain injury and loss of residual kidney function.

Clinicians should be mindful of the significant harm associated with hypotension on dialysis, and the need for strategies to improve hemodynamic stability during dialysis. Biofeedback software is now available on most commercially available dialysis machines, and clinicians should be aware of its potential utility in hypotension-prone patients.

• Hemodialysis.com: What recommendations do you have for future research as a result of this study?

• Larger studies with blinding of study participants and outcome adjudicators are needed to confirm these promising preliminary results, and to further evaluate the effects of biofeedback on more important patient outcomes, including quality of life, hospitalizations and survival.

• Reference:• Biofeedback dialysis for hypotension and hypervolemia: a systematic review and meta-analysis.

Nesrallah GE, Suri RS, Guyatt G, Mustafa RA, Walter SD, Lindsay RM, Akl EA.1Department of Medicine, The University of Western Ontario, London, Canada.Nephrol Dial Transplant. 2012 Nov 29. [Epub ahead of print]

Association between use of renin-angiotensin system antagonists and mortality in patients with heart failure and preserved ejection fraction.Hemodialysis.com Author Interview: Lars H. Lund, MD, PhD,

Associate Professor Dep. of Cardiology, Section for Heart FailureKarolinska University Hospital, N305 171 76 Stockholm Sweden

• Hemodialysis.com Editor Marie Benz: What are the main findings of the study?• In patients with heart failure and preserved ejection fraction, renin-

angiotensin system antagonists (ACE-inhibitors and ARBs) were associated with reduced mortality.

• Hemodialysis.com: Were any of the findings unexpected? • The findings wre unexpected in that they were in contrast to previous negative

randomized placebo-controlled trials.

But we believe these trials may have been underpowered and entailed considerable cross-over to active treatment, and there were signals toward benefit.

Therefore we hypothesized that in a larger, un-selective population, RAS-antagonists would in fact be associated with reduced mortality.

Association between use of renin-angiotensin system antagonists and mortality in patients with heart failure and preserved ejection fraction.Hemodialysis.com Author Interview: Lars H. Lund, MD, PhD,

Associate Professor Dep. of Cardiology, Section for Heart FailureKarolinska University Hospital, N305 171 76 Stockholm SwedenContinued

• Hemodialysis.com: What should clinicians and patients take away from your report? • In patients with heart failure and preserved ejection fraction, RAS-antagonists may be

considered, particularly with concomitant hypertension.

• Hemodialysis.com: What recommendations do you have for future research as a result of this study?

• Ideally, a large, publicly funded, randomized trial.

• Reference:• Association between use of renin-angiotensin system antagonists and mortality in pati

ents with heart failure and preserved ejection fraction.

Lund LH, Benson L, Dahlström U, Edner M.Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, SwedenJAMA. 2012 Nov 28;308(20):2108-17. doi: 10.1001/jama.2012.14785.

Serum uric acid, kidney volume and progression in autosomal-dominant polycystic kidney disease Hemodialysis.com Author Interview: Godela M. Fick-Brosnahan MD

Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO, USA

• Hemodialysis.com Editor Marie Benz: What are the main findings of the study?• The main finding is that ADPKD patients who had higher uric acid levels at their

study visit had an increased risk of reaching ESRD, independent of gender, body mass index and renal function (measured by the average of 2 in-hospital creatinine clearances).

They also had larger kidneys at their visit after adjusting for age, gender and creatinine clearance, and younger age at onset of hypertension.

• Hemodialysis.com: Were any of the findings unexpected?

• These findings were not entirely unexpected, however the effect of hyperuricemia on progression had never been studied in ADPKD.

Hyperuricemia has been associated with early onset of hypertension in the general population, as well as with initiation and progression of chronic kidney disease.

Serum uric acid, kidney volume and progression in autosomal-dominant polycystic kidney disease Hemodialysis.com Author Interview: Godela M. Fick-Brosnahan MD

Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO, USA

• Hemodialysis.com: What should clinicians and patients take away from your report? • The findings are preliminary since this was a retrospective analysis.

Therefore this article should not change general practice yet.

• Hemodialysis.com: What recommendations do you have for future research as a result of this study?

• An intervention trial of uric acid lowering is needed to examine whether this treatment slows the progression of ADPKD.

• Reference:

• Serum uric acid, kidney volume and progression in autosomal-dominant polycystic kidney disease

• Imed Helal, Kim McFann, Berenice Reed, Xiang-Dong Yan, Robert W. Schrier, and Godela M. Fick-Brosnahan

• Nephrol. Dial. Transplant. first published online December 4, 2012 doi:10.1093/ndt/gfs417

Temporal Changes in Incidence of Dialysis-Requiring AKI Hemodialysis.com Author's Interview: Dr. Hsu, Chi-yuan and Chi-yuan Hsu MD MS

Division of Nephrology, University of California-San Francisco, 521 Parnassus Avenue, C443, Box 0532, San Francisco, CA

• Hemodialysis.com Editor Marie Benz: What are the main findings of the study?• Dr. Raymond Hsu:

• The main finding is that severe cases of acute kidney injury, characterized as an abrupt decline in kidney function warranting initiation of acute dialysis therapy, are becoming more common in the United States, rising 10% per year and doubling over the past decade. Total number of in-hospital deaths associated with severe acute kidney injury more than doubled as well, from 18,000 in 2000 to nearly 39,000 in 2009. (Raymond Hsu)

• Hemodialysis.com: Were any of the findings unexpected?

• Dr. Chi-yuan Hsu:

• We expected to see some rise in the occurrence of severe acute kidney injury, but were surprised at how rapid the rate of rise was over the past decade.

• We were also somewhat surprised that only about 30% of the increase can be attributed to some of the commonly known causes of acute kidney injury, such as severe infections, ventilator use, acute heart failure, and cardiac catheterizations. Therefore, further research is needed to uncover the causes behind the rapid rise in acute kidney injury.

Temporal Changes in Incidence of Dialysis-Requiring AKI Hemodialysis.com Author's Interview: Dr. Hsu, Chi-yuan and Chi-yuan Hsu MD MS

Division of Nephrology, University of California-San Francisco, 521 Parnassus Avenue, C443, Box 0532, San Francisco, CA Continued

• Hemodialysis.com: What should clinicians and patients take away from your report? • Dr. Raymond Hsu:

• We hope that clinicians, researchers and the general public can gain a higher appreciation of the devastating impact of acute kidney injury that is comparable to other forms of acute organ injury, such as heart attack and stroke. Clinicians should pay close attention to identifying patients who are at risk for acute kidney injury--such as those with underlying chronic kidney disease, hypertension, diabetes, and elderly individuals--and judiciously manage those patients' fluid status, and reduce exposure to medications and procedures that may be toxic to the kidneys.

• Since individuals with baseline chronic kidney disease are the ones most likely to suffer acute kidney injury, those individuals should discuss carefully with their doctors the risk and benefits of procedures and interventions which may trigger acute kidney injury. They should communicate to all their providers such as surgeons or emergency room doctors that they do have underlying chronic kidney disease, so that appropriate decisions are made regarding procedures and medications in those settings.

• Hemodialysis.com: What recommendations do you have for future research as a result of this study?

• We certainly need more intervention trials on how to prevent acute kidney injury in specific high-risk settings.• We should also examine whether there are differences in the occurrence of acute kidney injury across geographic areas and different types

of healthcare systems to explore whether practice pattern differences may play a role in triggering acute kidney injury.• Because the overall incidence is rising, we also need to further study the longterm outcomes in individuals who survive severe acute kidney

injury and investigate strategies to prevent recurrence of acute kidney injury.

• Reference:• Temporal Changes in Incidence of Dialysis-Requiring AKI

Raymond K. Hsu, Charles E. McCulloch, R. Adams Dudley, Lowell J. Lo, and Chi-yuan HsuJASN ASN.2012080800; published ahead of print December 6, 2012doi:10.1681/ASN.2012080800