10 (more) unanswered questions in nephrology, CKD and transplantation
In this article, we will describe 10 (more) unanswered questions in nephrology, CKD and transplantation.
CKD
1. Why are we not deprescribing in nephrology?
In the era of deprescribing, there is recognition that polypharmacy is common in nephrology, and an issue for many of our patients.
Generally nephrology is a ‘tablet pushing and restrictive’ specialty. We see the answer to a problem as starting (yet) another tablet [“docs .. CKD patients take on average 8 tablets .. yes .. 8. And you still cannot make them well. Really!?” CKDEx Ed], fluid or dietary restriction.
The new tablet/restriction is portrayed as a wonder drug/treatment that will stop something frightening. But many have not been shown to be effective in advanced CKD (statins are a good example).
Why have we not attempted to determine which drugs can be stopped, in whom and at what stage of the disease?
[“Yeah. And when was the last time you recommended missing tablets or dialysis, and more steaks, crisps and beer? The average survival on dialysis is 5 years, let us have some fun, docs.” Ed].
2. Why are many drugs for CKD unpalatable?
E.g. calcium carbonate, which is used as a phosphate binder. More palatable medications need to be found. [“Would you take 2 (chalky) phosphate binders three times a day? Exactly.” Ed].
3. Why are target parameters the same for all people with CKD?
Even though there are guidelines for most renal variables (GFR/creatinine, Kt/V, haemoglobin and blood pressure), we don’t know the right ‘value’ for an individual, and in what context (i.e. it may change during the progression of CKD). It makes no sense. Perhaps it is to make our lives easier, e.g. say everyone needs a BP of 130/80 and Hb of 110 g/L.
Dialysis
4. Why is infection still a problem in peritoneal dialysis?
Peritoneal dialysis is complicated by both peritonitis and exit site infections. Both can limit the lifespan of the technique. They have been an issue since the late 1970s when PD started in the USA/Canada. Little progress has been made on them. Why have better less infectious techniques not been found?
5. Why do patients on peritoneal dialysis feel full and bloated?
Peritoneal dialysis is also complicated by feeling full and bloating. Even though the reason seems obvious (the 2L of extra fluid in the abdomen), is that the only reason? There is little research on, or treatment for, this issue. Why not?
6. Why do people on haemodialysis still have low blood pressure episodes on dialysis?
Low blood pressure (sometimes called ‘crashing’) can occur when too much fluid is removed from the blood during treatment. This causes BP to drop, causing nausea and dizziness. Sometimes patients become unconscious.
It is a very unpleasant experience for patients that requires rapid action from dialysis nurses. We need ways of preventing this issue. Little research is on-going.
7. Why do AV fistulas (AVFs) and grafts (AVGs) have a limited lifespan on haemodialysis?
We need better surgical techniques so AVF/AVGs can last longer, or an alternative can be found. Again little research is on-going.
Transplantation
8. Why is the average life span of a kidney transplant still so low?
The average life span for a deceased donor transplant is 10 years, and 15 years for a living transplant. Why? Hence many younger patients will need two or more transplants. Why cannot we make one kidney last a patient’s lifetime? More research needs to be done.
Transplant patient (not just kidney) survival – is also still not great.
Why? Again, we don’t know. It may be due to damage to the heart before dialysis starts (or before the transplant, if you go straight to a transplant). We need strategies to prolong life, as well as kidney life.
9. Why do we still prescribe nephrotoxic immunosuppression?
We continue to have the dilemma that tacrolimus (one of the mainstays of immunosuppression) is itself nephrotoxic – and so toxic to the transplanted kidney. Better alternatives are required.
10. Why is donation of kidneys for transplantation still inadequate for the need? There would be copious potential donors if we were willing to organise non-heart beating deceased donor transplantation. Xenotransplantation has been a research area for 30-40 years. It is still far from a clinical entity. Why? We need to make more effort to use available organs. New strategies are needed to improve transplant rates.
OK OK. To be frank .. when was the last major breakthrough in nephrology?
Bit of uncomfortable coughing .. [“well doctors? Well?? Speak up” CKDEx Ed]. The truth is .. the truth is .. that there has not been, readers, a major breakthrough since the advent of EPO in the late 1980s/early 1990s. This is disappointing. We are truly sorry.
We need to work harder, especially in the area of multicentre and multi-country trials. There is not enough co-operation between units in the UK and between countries. There is no excuse for this issue.
Other medical specialities, including cardiology and haematology, work much better together. There is too much arrogance and competition within the specialty of nephrology and renal transplantation. This does not help us answer the questions above (and in the linked article). It does not help the patients.
Summary
We have described 10 (more) unanswered questions in nephrology, CKD and transplantation. We hope you have found them interesting.
It is disappointing the answers to such fundamental questions are still unknown. More co-operation is required in the world of nephrology and transplantation.
Why not try to answer one of the questions above? When was your last paper published? [“that includes the CKDEx team” Ed].
Other resources
10 unanswered questions in CKD, nephrology and transplantation (linked article)
10 unanswered questions in kidney transplantation (another linked article)
What we know and don’t know about women and CKD (Piccoli, 2018)
Levin, 2022 emphasises that interventional studies of the value of specific diets in individuals with CKD are few.
Last Reviewed on 17 April 2024