Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention

Risk factors for chronic kidney diseases may include periodontal diseases, as estimated by the correlations of plasma pentraxin-3 levels: a case-control study

BACKGROUND

Pentraxins are classical mediators of inflammation and markers of acute-phase reactions. Pentraxin-3 (PTX3) is believed to be a true independent indicator of disease activity. It has been associated with clinical outcomes in incident chronic kidney disease (CKD) and periodontal diseases. Periodontitis is lately being considered as a risk factor for CKD. However, no data are available on elevated PTX3 in patients with CKD associated with periodontitis.

METHOD

Sixty subjects were divided into three groups (n = 20) based on glomerular filtration rate (GFR) and periodontal parameters: healthy (group-1), CKD (group-2), and CKD with periodontitis (group-3). Plasma samples obtained from each patient were quantified for PTX3 using Enzyme-linked Immunosorbent Assay (ELISA).

RESULTS

Both patient groups with CKD had higher plasma PTX3 concentrations than control subjects. However, there was no significant difference between the two groups (groups 2 and 3). In all groups, plasma PTX3 correlated positively with periodontal parameters. Group 3 patients had higher concentrations of PTX3 (6.338 ng/ml) than group 2 (5.41 ng/ml) and group 1 (1.835 ng/ml).

CONCLUSIONS

Within the limits of the present study, the difference in plasma PTX3 levels between groups 2 and 3 was not found to be statistically significant (P > 0.05). However, as PTX3 values correlated positively with periodontal parameters, this model could contribute to identifying individuals with periodontitis at high risk of CKD. Thus, periodontal disease could serve as a risk factor for developing CKD. Further large-scale studies nullifying the confounders for CKD are warranted to confirm positive results.

Uraemic serum induces dysfunction of vascular endothelial cells: role of ubiquitin-proteasome pathway

The ubiquitin-proteasome pathway (UPP) has been indicated to contribute to dysfunction of endothelial cells (ECs). Nevertheless, the relationship between UPP and vascular complications of uraemia remains unknown. We aimed to determine whether the UPP is activated in vascular ECs when cultured with uraemic serum, and to examine the role of the UPP on dysfunction of ECs in uraemia. Rabbit aortic endothelial cells (RAECs) were cultured with normal serum or different concentrations of uraemic serum. The expression of the ubiquitin-activating enzyme (E1), an indicator of the UPP, was detected by real-time RT-PCR and Western blot; proteasome activity was determined by fluorescence spectrophotometry; and nuclear factor-κB (NF-κB) activity and expression, as well as tumour necrosis factor-α (TNF-α) expression, were also detected. We found that the expression of E1 and the activities of three kinds of proteasomes were increased significantly in RAECs after incubation with uraemic serum. Proliferation of RAECs was increased significantly by incubation with 3-15% uraemic serum but decreased markedly when incubated with uraemic serum above 15% (increased apoptosis). Incubation of RAECs with uraemic serum induced increased NF-B DNA-binding activity and nuclear translocation of NF-κB, decreased nitric oxide production and increased expression of TNF-α, which is the final effector of inflammatory activation of cells. All of these responses in RAECs were suppressed by the specific proteasome inhibitor, MG132. The inhibition of inflammatory responses by MG132 was further supported by a parallel experiment with pyrrolidine dithiocarbamate, a specific inhibitor of κNF-B. These findings suggest that the UPP was activated in RAECs by administration of uraemic serum, and played a pivotal role in the dysfunction of vascular ECs, such as inflammatory activation.

Insulin resistance, inflammation, and vascular disease in nondiabetic predialysis chronic kidney disease patients

BACKGROUND

Chronic kidney disease (CKD) is associated with high cardiovascular morbidity and mortality, which is not fully explained by traditional risk factors; hence, the interest in nontraditional risk factors such as inflammation and insulin resistance (IR). Though IR is shown in nondiabetic CKD, its association with vascular disease and inflammation in this population is unknown, and is what this study aims to investigate.

HYPOTHESIS

IR and inflammation are related to vascular disease in nondiabetic predialysis CKD patients.

METHODS

We studied carotid-artery intima-media thickness (IMT) and endothelial function (brachial artery flow mediated dilation [FMD]) in 35 nondiabetic predialysis patients with stage 3-5 CKD and 35 age- and gender-matched controls. Insulin resistance was measured using the homeostasis model assessment for insulin resistance score (HOMA-IR), inflammation by high-sensitivity CRP (hsCRP), and their relationship with FMD and IMT.

RESULTS

Patients with CKD showed reduced FMD (3.34 ± 2.14% vs. 5.27 ± 1.78%, P<0.001) and increased IMT (0.78 ± 0.22 mm vs. 0.64 ± 0.16 mm, P = 0.003) compared with controls. The CKD patients had a higher HOMA-IR (2.20 ± 1.08 vs. 1.13 ± 0.64, P<0.001) and hsCRP (3.25 ± 5.47 mg/L vs. 1.10 ± 1.85 mg/L [median ± interquartile range], P = 0.02). In the study population, HOMA-IR was directly related to hsCRP. After adjusting for traditional risk factors, high HOMA-IR and hsCRP were significantly related to decreased FMD (adjusted β = -0.44, 95% confidence interval [CI]: -1.55 to -0.08, P = 0.003 and adjusted β = -0.51, 95% CI: -0.51 to -0.15, P = 0.001) and increased IMT (adjusted β = 0.62, 95% CI: 0.54-1.90, P = 0.001 and adjusted β = 0.43, 95% CI: 0.08-0.57, P = 0.011), respectively.

CONCLUSIONS

Subjects with systemic inflammation were more insulin-resistant, and in nondiabetic predialysis CKD, IR and systemic inflammation were independently associated with endothelial dysfunction and atherosclerosis.

The urine albumin-to-creatinine ratio: assessment of its performance in the renal transplant recipient population

BACKGROUND AND OBJECTIVES

Microalbuminuria predicts graft loss and death in the renal transplant population. Measurement of the urinary albumin-to-creatinine ratio (UACR) is recommended for its detection. There is uncertainty regarding the optimal UACR cutoff values. Few studies have examined the accuracy of UACR in the general population and none have been conducted in renal transplant recipients. The aim of this study is to determine the performance of UACR in the renal transplant population.

DESIGN, SETTING, PARTICIPANTS & MEASUREMENTS

Renal transplant recipients with a daily urinary albumin excretion rate of up to 300 mg accurately carried out a 24-hour urine collection and provided a morning urine sample for the measurement of albuminuria and UACR. The performance measures of UACR for the detection of microalbuminuria (30 to 300 mg/d) were calculated using different cutoffs.

RESULTS

Median albuminuria was 23 mg/d, and median UACR was 17 mg/g. The area under the receiver-operating characteristic curve was 0.94 in men and 0.98 in women. The optimal cutoff was 21 mg/g in men and 24 mg/g in women. In men, the 30-, 17-, and 21-mg/g cutoffs provided a sensitivity of 0.79, 0.89, and 0.87. In women, the 30-, 25-, and 24-mg/g cutoffs provided a sensitivity of 0.90, 0.97, and 1.0.

CONCLUSIONS

These data show that in the renal transplant population, lower gender-specific cutoffs should be used for the detection of microalbuminuria than the recommended 30-mg/g cutoff. These data support the need for a reappraisal of the 30-mg/g cutoff for the detection of microalbuminuria.

Usefulness of the resistive index in renal Doppler ultrasonography as an indicator of vascular damage in patients with risks of atherosclerosis

BACKGROUND

Chronic kidney disease (CKD) is caused by various risk factors of cardiovascular disease (CVD). The estimated glomerular filtration rate (eGFR) is commonly used for the evaluation of the renal function in patients with CKD; however, it is difficult to assess the pathogenesis of CKD and predict the renal prognosis accurately using only eGFR. The resistive index (RI) in renal Doppler ultrasonography (RDU) is thought to be a good indicator of renal vascular resistance caused by atherosclerosis. In the present study, we investigated whether RI could be used to evaluate the pathogenesis of renal damage and predict the renal prognosis and investigated the correlation between RI and blood pressure (BP) fluctuations in patients with or without hypertension.

METHODS

The total study population included 194 patients (mean age: 66.2 years), who underwent RDU in our hospital ward between February 2009 and July 2010. We investigated the correlation between RI and multiple clinical parameters, including ambulatory blood pressure monitoring (ABPM).

RESULTS

RI significantly correlated with age, eGFR, diastolic BP, pulse pressure and level of albuminuria. Patients with diabetes mellitus (DM) showed a significantly higher RI than patients without DM, although their eGFR was similar; thus, DM might accelerate renal vascular damage and RI could detect earlier changes of vascular damage proceeding the time eGFR is reduced. Regarding ABPM, patients with a larger morning surge [systolic blood pressure (SBP) in the early morning--lowest SBP during sleep] showed a significantly higher RI.

CONCLUSIONS

The present study indicated that RI might be very useful for the evaluation of very early renal damage more effectively than eGFR and that diurnal BP change might be partly due to the progression of atherosclerotic change in the kidney evaluated by RI.

Elevated serum parathyroid hormone is a cardiovascular risk factor in moderate chronic kidney disease

INTRODUCTION

Over 8% of adults in the United States are estimated to have moderate (stages 3 and 4) chronic kidney disease (CKD), which is increasingly recognized as one of the independent predictors for cardiovascular (CV) disease and related mortality. Secondary hyperparathyroidism with elevated serum intact parathyroid hormone (iPTH) is associated with increased CV mortality in end-stage renal disease and this relationship is unclear in moderate CKD.

METHODS

Medical records of 196 patients at Harry S. Truman Memorial Veterans Hospital with stages 3 and 4 CKD (glomerular filtration rate, GFR 16-59 ml/min/1.73 m(2)) who had iPTH levels determined from 4/2006 to 9/2007 were reviewed. CV event was defined as occurrence of any of the following during follow-up: myocardial infarction, stroke, coronary/carotid/peripheral artery revascularization, and death due to CV reasons.

RESULTS

During median follow-up of 27.2 months, 48 patients had CV events, while 148 patients did not. iPTH was elevated (156.43 ± 107.49) for patients who had CV events compared with those without (109.12 ± 86.54, P = 0.003). Among the covariates studied in the multivariate analysis including history of vascular disease, 25-OH Vit D, corrected calcium, phosphorus levels, calcium-phosphorus product, and GFR, iPTH level was found to have a positive association with CV events during follow-up period (odds ratio = 1.3 for 50 pg/ml change in iPTH, 95% CI: 1.03-1.55, P = 0.02)). Cardiovascular disease history was the only other significant variable with estimated odds ratio of 5.9 (P = 0.002).

CONCLUSION

iPTH level in patients with stages 3 and 4 CKD is associated with increased incidence of cardiovascular events independent of calcium-phosphorous level.

Cystatin C and albuminuria as risk factors for development of CKD stage 3: the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

The growing burden and morbidity of chronic kidney disease (CKD) warrant effective strategies for identifying those at increased risk. We examined the association of cystatin C level and albuminuria with the development of CKD stage 3.

STUDY DESIGN

Prospective observational study.

SETTING & PARTICIPANTS

5,422 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m(2).

PREDICTOR

Participants were categorized into 4 mutually exclusive groups: the presence or absence of microalbuminuria (albumin-creatinine ratio >17 and >25 μg/mg in men and women, respectively) in those with or without cystatin C level ≥1.0 mg/L.

OUTCOMES & MEASUREMENTS

Incident CKD stage 3 was defined as eGFR <60 mL/min/1.73 m(2) at the third or fourth visit and an annual decrease >1 mL/min/1.73 m(2). Poisson regression was used to evaluate incident rate ratios in unadjusted and adjusted analyses that include baseline eGFR.

RESULTS

Mean age was 61 years, 49% were men, 38% were white, 11% had diabetes, 13.7% had cystatin C level ≥1 mg/L, 8.4% had microalbuminuria, and 2.7% had cystatin C level ≥1 mg/L with microalbuminuria. 554 (10%) participants developed CKD stage 3 during a median follow-up of 4.7 years, and adjusted incidence rate ratios were 1.57 (95% CI, 1.19-2.07), 1.37 (95% CI, 1.13-1.66), and 2.12 (95% CI, 1.61-2.80) in those with microalbuminuria, cystatin C level ≥1 mg/L, and both, respectively, compared with those with neither.

LIMITATIONS

Relatively short follow-up and absence of measured GFR.

CONCLUSIONS

Cystatin C level and microalbuminuria are independent risk factors for incident CKD stage 3 and could be useful as screening tools to identify those at increased risk.

Quantitative and qualitative urinary cellular patterns correlate with progression of murine glomerulonephritis

The kidney is a nonregenerative organ composed of numerous functional nephrons and collecting ducts (CDs). Glomerular and tubulointerstitial damages decrease the number of functional nephrons and cause anatomical and physiological alterations resulting in renal dysfunction. It has recently been reported that nephron constituent cells are dropped into the urine in several pathological conditions associated with renal functional deterioration. We investigated the quantitative and qualitative urinary cellular patterns in a murine glomerulonephritis model and elucidated the correlation between cellular patterns and renal pathology.

Urinary cytology and renal histopathology were analyzed in BXSB/MpJ (BXSB; glomerulonephritis model) and C57BL/6 (B6; control) mice. Urinary cytology revealed that the number of urinary cells in BXSB mice changed according to the histometric score of glomerulonephritis and urinary albumin; however, no correlation was detected for the levels of blood urea nitrogen and creatinine. The expression of specific markers for podocytes, distal tubules (DTs), and CDs was detected in BXSB urine. Cells immunopositive for Wilms tumor 1 (podocyte marker) and interleukin-1 family, member 6 (damaged DT and CD marker) in the kidney significantly decreased and increased in BXSB versus B6, respectively. In the PCR array analysis of inflammatory cytokines and chemokines, Il10, Cxcl2, C3, and Il1rn showed relatively higher expression in BXSB kidneys than in B6 kidneys. In particular, the highest expression of C3 mRNA was detected in the urine from BXSB mice. Furthermore, C3 protein and mRNA were localized in the epithelia of damaged nephrons.

These findings suggest that epithelial cells of the glomerulus, DT, and CD are dropped into the urine, and that these patterns are associated with renal pathology progression. We conclude that evaluation of urinary cellular patterns plays a key role in the early, noninvasive diagnosis of renal disease.

Are ACEI/ARBs associated with the decreased peritoneal protein clearance in long-term PD patients?

Objective. Peritoneal protein clearance (PrC) is recognized as a new marker of systemic endothelial dysfunction and predictor of mortality in patients on peritoneal dialysis (PD). Given that angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) could improve endothelial dysfunction in the general population, we aim to explore whether this benefit is present in the PD population.

METHODS

We analysed data from a PD cohort with data prospectively collected. The PrC, defined daily doses (DDDs) of ACEI/ARBs, as well as other clinical variables were recorded at baseline and then repeatedly measured at 3- to 6-month intervals till to death or censoring. A total of 156 patients were treated with ACEI/ARBs with 0.60 of median time-averaged DDDs, the untreated group consisted of 149 patients who received none of the above drugs during the follow-up.

RESULTS

The baseline and time-averaged PrC were 69.9 ± 34.7 mL/day and 75.2 ± 28.3 mL/day, respectively. Time-averaged PrC was an independent predictor of mortality adjusted for recognized confounders in a multivariate Cox regression model (P = 0.037). There were no significant differences in the time course of PrC (P = 0.82) and peritoneal protein loss (P = 0.83) between the ACEI/ARBs group and the untreated group after adjustment for age, gender, diabetes, baseline C-reactive protein, mean blood pressure and baseline PrC or baseline peritoneal protein loss in the generalized linear mixed model.

CONCLUSIONS

We conclude that ACEI/ARBs did not correlate with a decreased PrC in this observational study. The effect of higher doses of ACEI/ARBs needs to be determined in future interventional studys.

Oral activated charcoal adsorbent (AST-120) ameliorates extent and instability of atherosclerosis accelerated by kidney disease in apolipoprotein E-deficient mice

BACKGROUND

Accelerated atherosclerosis and increased cardiovascular events are not only more common in chronic kidney disease (CKD) but are more resistant to therapeutic interventions effective in the general population. The oral charcoal adsorbent, AST-120, currently used to delay start of dialysis, reduces circulating and tissue uremic toxins, which may contribute to vasculopathy, including atherosclerosis. We, therefore, investigated whether AST-120 affects CKD-induced atherosclerosis.

METHODS

Apolipoprotein E-deficient mice, a model of atherosclerosis, underwent uninephrectomy, subtotal nephrectomy or sham operation at 8 weeks of age and were treated with AST-120 after renal ablation. Atherosclerosis and its characteristics were assessed at 25 weeks of age.

RESULTS

Uninephrectomy and subtotal nephrectomised mice had significantly increased acceleration of atherosclerosis. AST-120 treatment dramatically reduced the atherosclerotic burden in mice with kidney damage, while there was no beneficial effect in sham-operated mice. The benefit was independent of blood pressure, serum total cholesterol or creatinine clearance. AST-120 significantly decreased necrotic areas and lessened aortic deposition of the uremic toxin indoxyl sulfate without affecting lesional macrophage or collagen content. Furthermore, AST-120 lessened aortic expression of monocyte chemoattractant protein-1, tumor necrosis factor-α and interleukin-1β messenger RNA.

CONCLUSIONS

AST-120 lessens the extent of atherosclerosis induced by kidney injury and alters lesion characteristics in apolipoprotein E-deficient mice, resulting in plaques with a more stable phenotype with less necrosis and reduced inflammation.

Pharmacist Web-based training program on medication use in chronic kidney disease patients: impact on knowledge, skills, and satisfaction

INTRODUCTION

Chronic kidney disease (CKD) patients are multimorbid elderly at high risk of drug-related problems. A Web-based training program was developed based on a list of significant drug-related problems in CKD patients requiring a pharmaceutical intervention. The objectives were to evaluate the impact of the program on community pharmacists' knowledge and skills and their satisfaction with the training.

METHODS

Pharmacists were randomized to the training program or the control group. Training comprised a 60-minute Web-based interactive session supported by a clinical guide. Pharmacists completed a questionnaire on knowledge (10 multiple-choice questions) and skills (2 clinical vignettes) at baseline and a second time within 1 month. Trained pharmacists completed a written satisfaction questionnaire. Semidirected telephone interviews were conducted with 8 trained pharmacists. Changes in knowledge and skills scores were compared between the groups.

RESULTS

Seventy pharmacists (training: 52; control: 18) were recruited; the majority were women with <15 years' experience. Compared with the control group, an adjusted incremental increase in the knowledge score (22%; 95% confidence interval [CI]: 16%-27%) and skills score (24%; 95% CI: 16%-33%) was observed in the training group. Most pharmacists (87%-100%) rated each aspect of the program "excellent'' or "very good." Additional training and adding a discussion forum were suggested to complement the program.

DISCUSSION

Pharmacists like the Web-based continuing education program. Over a short time span, the program improved their knowledge and skills. Its impact on their clinical practices and quality of medication use in CKD patients remains to be assessed.

Chronic kidney disease before and after partial nephrectomy

PURPOSE

We performed a multi-institutional retrospective cohort study to evaluate baseline renal function of patients who underwent partial nephrectomy for renal tumors, and determined rates of progression to higher stages of chronic kidney disease.

MATERIALS AND METHODS

The Modification of Diet in Renal Disease study equation was used to estimate glomerular filtration rate. Preoperative and postoperative serum creatinine values were obtained from patients who underwent partial nephrectomy at 6 institutions with a normal contralateral kidney, and had baseline chronic kidney disease stage I (estimated glomerular filtration rate greater than 90 ml/minute/1.73 m(2)), II (estimated glomerular filtration rate 60 to 89 ml/minute/1.73 m(2)) or III (estimated glomerular filtration rate 30 to 59 ml/minute/1.73 m(2)). The end point was change in chronic kidney disease stage at long-term followup (3 to 18 months). Multivariate logistic and Cox regression models tested the association of newly acquired chronic kidney disease stage III or greater with pertinent demographic, tumor and surgical factors.

RESULTS

For 1,228 patients with followup creatinine data at least 3 months after partial nephrectomy median baseline glomerular filtration rate was 74 ml/minute/1.73 m(2). At baseline 19%, 59% and 22% of patients had chronic kidney disease stage I, II and III, respectively. At long-term followup for patients with baseline chronic kidney disease stage I or II median postoperative glomerular filtration rate was 67 ml/minute/1.73 m(2) with 29% having progression to chronic kidney disease stage III or greater. Increasing age, female gender, increasing tumor size, clamping of the renal artery and vein, and lower preoperative estimated glomerular filtration rate were independently associated with newly acquired chronic kidney disease stage III or greater. The presence of comorbid conditions such as coronary artery disease, diabetes mellitus or hypertension did not independently predict an increased risk of higher chronic kidney disease stage.

CONCLUSIONS

Chronic kidney disease stage III or greater will develop postoperatively in approximately a third of patients with an estimated glomerular filtration rate greater than 60 ml/minute/1.73 m(2), and this progression is associated with definable demographic, tumor and surgical factors.

A population-based survey of Chronic REnal Disease In Turkey--the CREDIT study

Background. Chronic kidney disease (CKD) is a growing health problem worldwide that leads to end-stage kidney failure and cardiovascular complications. We aimed to determine the prevalence of CKD in Turkey, and to evaluate relationships between CKD and cardiovascular risk factors in a population-based survey.

Methods. Medical data were collected through home visits and interviews. Serum creatinine, blood glucose, total cholesterol, triglycerides, HDL, LDL and uric acid were determined from 12-h fasting blood samples, and spot urine tests were performed for subjects who gave consent to laboratory evaluation.

Results. A total of 10 872 participants were included in the study. The final analysis was performed on 10 748 subjects (mean age 40.5 ± 16.3 years; 55.7% women) and excluded 124 pregnant women. A low glomerular filtration rate (GFR) (< 60 mL/min/1.73 m²) was present in 5.2% of the subjects who were evaluated for GFR, while microalbuminuria and macroalbuminuria were observed in 10.2% and 2% of the subjects, respectively. The presence of CKD was assessed in subjects who gave consent for urinary albumin excretion measurement (n = 8765). The overall prevalence of CKD was 15.7%; it was higher in women than men (18.4% vs. 12.8%, P < 0.001) and increased with increasing age of the subjects. The prevalence of hypertension (32.7% in the general population), diabetes (12.7%), dyslipidaemia (76.3%), obesity (20.1%) and metabolic syndrome (31.3%) was significantly higher in subjects with CKD than subjects without CKD (P < 0.001 for all).

Conclusions. The prevalence of CKD in Turkey is 15.7%. Cardiovascular risk factors were significantly more prevalent in CKD patients.

Aspirin is beneficial in hypertensive patients with chronic kidney disease: a post-hoc subgroup analysis of a randomized controlled trial

OBJECTIVES

The purpose of this study was to determine the benefit and risk associated with antiplatelet therapy in the chronic kidney disease (CKD) population.

BACKGROUND

Cardiovascular and possibly bleeding risks are elevated in patients with CKD. The balance of benefit and harm associated with antiplatelet therapy remains uncertain.

METHODS

The HOT (Hypertension Optimal Treatment) study randomly assigned participants with diastolic hypertension to aspirin (75 mg) or placebo. Study treatment effects were calculated using univariate proportional hazards regression models stratified by baseline estimated glomerular filtration rate (eGFR) with trends tested by adding interaction terms. End points included major cardiovascular events, total mortality, and major bleeding.

RESULTS

The study included 18,597 participants treated for 3.8 years. Baseline eGFR was < 60 ml/min/1.73 m(2) in 3,619 participants. Major cardiovascular events were reduced by 9% (95% confidence interval [CI]: -9% to 24%), 15% (95% CI: -17% to 39%), and 66% (95% CI: 33% to 83%) for patients with baseline eGFR of ≥ 60, 45 to 59, and < 45 ml/min/1.73 m(2), respectively (p trend = 0.03). Total mortality was reduced by 0% (95% CI: -20% to 17%), 11% (95% CI: -31% to 40%), and 49% (95% CI: 6% to 73%), respectively (p trend = 0.04). Major bleeding events were nonsignificantly greater with lower eGFR (hazard ratio [HR]: 1.52 [95% CI: 1.11 to 2.08], HR: 1.70 [95% CI: 0.74 to 3.88], and HR: 2.81 [95% CI: 0.92 to 8.84], respectively; p trend = 0.30). Among every 1,000 persons with eGFR < 45 ml/min/1.73 m(2) treated for 3.8 years, 76 major cardiovascular events and 54 all-cause deaths will be prevented while 27 excess major bleeds will occur.

CONCLUSIONS

Aspirin therapy produces greater absolute reduction in major cardiovascular events and mortality in hypertensive patients with CKD than with normal kidney function. An increased risk of major bleeding appears to be outweighed by the substantial benefits.

Integrative bioinformatics analysis of proteins associated with the cardiorenal syndrome

The cardiorenal syndrome refers to the coexistence of kidney and cardiovascular disease, where cardiovascular events are the most common cause of death in patients with chronic kidney disease. Both, cardiovascular as well as kidney diseases have been extensively analyzed on a molecular level, resulting in molecular features and associated processes indicating a cross-talk of the two disease etiologies on a pathophysiological level. In order to gain a comprehensive picture of molecular factors contributing to the bidirectional interplay between kidney and cardiovascular system, we mined the scientific literature for molecular features reported as associated with the cardiorenal syndrome, resulting in 280 unique genes/proteins. These features were then analyzed on the level of molecular processes and pathways utilizing various types of protein interaction networks. Next to well established molecular features associated with the renin-angiotensin system numerous proteins involved in signal transduction and cell communication were found, involving specific molecular functions covering receptor binding with natriuretic peptide receptor and ligands as well known example. An integrated analysis of identified features pinpointed a protein interaction network involving mediators of hemodynamic change and an accumulation of features associated with the endothelin and VEGF signaling pathway. Some of these features may function as novel therapeutic targets.

Impact of microalbuminuria on incident stroke: a meta-analysis

BACKGROUND AND PURPOSE

Microalbuminuria, a marker of both kidney disease and endothelial dysfunction, may be associated with global vascular risk, but the nature and magnitude of the link between microalbuminuria and incident stroke has not been clearly defined. The purpose of this study was to assess the consistency and strength of the association of microalbuminuria with risk of stroke in prospective studies using meta-analysis.

METHODS

We conducted a systematic search of electronic databases and bibliographies for studies reporting a multivariate-adjusted estimate, represented as relative risk with 95% CI, of the association between microalbuminuria and stroke risk. Studies were excluded if a majority of study participants had established kidney disease or pre-eclampsia. Estimates were combined using a random-effect model.

RESULTS

We identified 12 studies, with a total of 48 596 participants and 1263 stroke events. Overall, presence of microalbuminuria was associated with greater stroke risk (relative risk, 1.92; 95% CI, 1.61 to 2.28; P < 0.001) after adjustment for established cardiovascular risk factors. There was evidence of significant heterogeneity in the magnitude of the association across studies (P for heterogeneity < 0.001, I² = 68%), which was partially explained by differences in study population, microalbuminuria definition, and different microalbuminuria-related risk among stroke subtypes. However, in stratified analyses, microalbuminuria was associated with increased risk of subsequent stroke in all subgroups (general population, diabetics, those with known stroke).

CONCLUSIONS

Microalbuminuria is strongly and independently associated with incident stroke risk. Future studies should explore whether microalbuminuria is just a risk marker or a modifiable risk factor for stroke.

Circulating levels of asymmetric dimethylarginine are an independent risk factor for left ventricular hypertrophy and predict cardiovascular events in pre-dialysis patients with chronic kidney disease

BACKGROUND

Several studies have related the circulating level of asymmetric dimethylarginine (ADMA) to cardiac remodeling and cardiovascular (CV) events in end-stage renal disease (ESRD) patients. Studies investigating this relationship in patients with pre-dialysis chronic kidney disease (CKD) are lacking.

METHODS

We enrolled 76 CKD patients (age, 46.7+/-14.3 years, 39 females) and 15 controls (age, 40.1+/-18.5 years, 6 females). Clinical parameters, blood biochemistry and echocardiographic findings were recorded, and plasma ADMA concentrations measured by high-performance liquid chromatography-mass spectrometry (HPLC-MS). Patients were prospectively followed up for a median of 15 (range, 6-24) months.

RESULTS

Plasma ADMA was significantly elevated in CKD patients compared with controls (41.56+/-12.76 microg/mL vs 17.12+/-7.09 microg/mL, P<0.001), and correlated with the left ventricular mass index (LVMI) (r=0.597, P<0.001). During follow-up, 25 patients experienced new CV events and their plasma ADMA level was significantly elevated (48.27+/-13.70 vs 34.91+/-6.38 in CV event-free patients, P<0.001). Cox regression analysis further confirmed that ADMA was an independent risk factor for CVD (HR=1.175, 95%CI[1.070-1.290], P=0.001).

CONCLUSION

Similar to findings in ESRD patients, elevated circulating levels of ADMA may increase the risk of LVH and CV events in pre-dialysis CKD patients.

Blood pressure level and kidney disease progression: do we really need to go to 130/80 mm Hg?

Current guidelines recommend a blood pressure goal of less than 130/80 mm Hg in patients with chronic kidney disease. Considerable epidemiologic observational data, post hoc analyses of clinical trials, and meta-analyses support this goal, particularly in patients with proteinuria. Although prospective clinical trials have not shown a clear benefit, recent data indicate that a longer duration of follow-up may be needed to assess the effects of different blood pressure goals. While we await the results of several ongoing and planned studies in this area, the current recommendations of a blood pressure goal less than 130/80 mm Hg appear reasonable.

Advances in glomerular filtration rate-estimating equations

PURPOSE OF REVIEW

Estimated glomerular filtration rate (eGFR) is now commonly reported by clinical laboratories. Here, we review the performance of current creatinine and cystatin C-based estimating equations as well as demonstration of their utility in public health and clinical practice.

RECENT FINDINGS

Lower levels of GFR are associated with multiple adverse outcomes, including acute kidney injury and medical errors. The new Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation improves performance and risk prediction compared with the Modification of Diet in Renal Disease study equation. Current cystatin C-based equations are not accurate in all populations, even in those with reduced muscle mass or chronic illness, in which cystatin C would be expected to outperform creatinine. eGFR reporting has led to a greater number of referrals to nephrologists, but the increased numbers do not appear to be excessive or burdensome. The Modification of Diet in Renal Disease study equation appears to be able to provide drug dosage adjustments similar to the Cockcroft-Gault equation.

SUMMARY

Estimated GFRs and their reporting can improve and facilitate clinical practice for chronic kidney disease. Understanding strengths and limitations facilitates their optimal use. Endogenous filtration markers, alone or in combination, which are less dependent on non-GFR determinants of the filtration markers, are necessary to lead to more accurate eGFRs.

Albuminuria and the risk of incident stroke and stroke types in older adults

BACKGROUND

The kidney biomarker that best reflects risk of stroke is unknown. We sought to evaluate the association of stroke with 3 kidney biomarkers: albuminuria, cystatin C, and glomerular filtration rate.

METHODS

These 3 biomarkers were determined in 3,287 participants without history of stroke from the Cardiovascular Health Study, a longitudinal cohort study of men and women age 65 years and older from 4 US communities. The biomarkers were albuminuria ascertained using urinary albumin-to-creatinine ratio (UACR) from morning spot urine, creatinine-based estimated glomerular filtration rate (eGFR), and cystatin C. Outcomes were incident stroke (any, ischemic, or hemorrhagic) during follow-up between 1996 and 2006.

RESULTS

A total of 390 participants had an incident stroke: 81% ischemic, 12% hemorrhagic, and 7% unclassified. In adjusted Cox regression models, UACR was more strongly related to any stroke, ischemic stroke, and hemorrhagic stroke than eGFR and cystatin C. The hazard ratio (HR) of any stroke comparing the top to bottom quintile of UACR was 2.10 (95% confidence interval [CI] 1.47-3.00), while HR for eGFR was 1.29 (95% CI 0.91-1.84) and for cystatin C was 1.22 (95% CI 0.85-1.74). When considering clinically relevant categories, elevated UACR was associated with increased hazard of any stroke and ischemic stroke regardless of eGFR or cystatin C categories.

CONCLUSIONS

UACR was the kidney biomarker most strongly associated with risk of incident stroke. Results in this elderly cohort may not be applicable to younger populations. These findings suggest that measures of glomerular filtration and permeability have differential effects on stroke risk.

Qualidade de vida: pacientes com insuficiência renal crônica no município de Caruaru, PE

RESUMO INTRODUÇÃO: Qualidade de vida é uma dimensão que tem sido amplamente investigada na saúde da população, independente da faixa etária. Uma condição crônica é um fator que interfere na realização das atividades da vida diária e na percepção de bem-estar individual, como é o caso dos pacientes em tratamento por hemodiálise. OBJETIVO: Descrever as características e analisar as possíveis associações entre a Insuficiência Renal Crônica (IRC) e a qualidade de vida em uma amostra representativa de pacientes com o agravo no município de Caruaru, PE. MÉTODO: A pesquisa foi realizada nos centros de tratamentos dialíticos na cidade de Caruaru, onde toda a população com IRC é atendida (n = 192), sendo 82 pacientes do Centro Regional de Hemodiálise do Agreste (CRHA) e 110 da clínica SOS Rim - Clínica Nefrológica de Caruaru. Para a composição da amostra foi realizado um censo e todos os pacientes cadastrados foram pré-selecionados inicialmente para o estudo. RESULTADOS: Verificou-se que a maioria dos participantes relatou algum grau de incômodo: dores musculares (69,4%), cãibras (89,8%), coceiras (67,3%), fraqueza muscular (73,5%), diminuição de líquido (91,8%), diminuição alimentar (85,7%) e capacidade de trabalhar (75,5%). Já quando questionados se o esforço físico interfere na sua qualidade de vida, este estudo revelou que 70,3% afirmam que sim. Em relação à saúde, 80,6% das pessoas dizem que a doença renal crônica interfere de forma negativa na qualidade de vida. CONCLUSÃO: Os dados indicam que pacientes com IRC apresentam diminuição na qualidade de vida graças a repercussões musculoesqueléticas, tais como cãibras, fraqueza muscular e esforço físico.

Left ventricular dysfunction as a risk factor for cardiovascular and noncardiovascular hospitalizations in African Americans

BACKGROUND

A substantial portion of the public health burden of heart failure is due to hospitalizations, many of which are for causes other than cardiovascular disease. We assessed whether left ventricular (LV) systolic dysfunction was associated with increased risk of both cardiovascular and noncardiovascular hospitalizations in a community sample of African Americans.

METHODS

African American participants from the Jackson, MS, site of the Atherosclerosis Risk in Communities (ARIC) study who underwent echocardiography were followed for 12 years. Hospitalization rates among individuals with and without LV systolic dysfunction were compared using negative binomial regression.

RESULTS

Among 2,416 participants with echocardiograms, LV systolic dysfunction was found in 61 (2.5%). Participants with LV dysfunction experienced 366 hospitalizations, a rate of 1.27 per person-year, compared with 0.25 per person-year among individuals without LV dysfunction. The incidence rate ratio adjusted for demographics, comorbidities, and other risk factors was 3.11 (95% CI 2.22-4.35). The adjusted rate ratios were 4.76 (95% CI 2.90-7.20) for cardiovascular and 2.67 (95% CI 1.82-3.90) for noncardiovascular diagnoses, with similar findings in the subset of individuals with asymptomatic LV dysfunction. The percentage attributable risks for hospitalizations were 87% and 74% for cardiovascular and noncardiovascular causes (79% and 63% after adjustment).

CONCLUSIONS

African American individuals with LV dysfunction are at an increased risk of hospitalization due to a wide range of causes, with noncardiovascular hospitalizations accounting for nearly half the increased risk. To the extent that estimates of risk focus on cardiovascular morbidity, they may underestimate the true health burden of LV dysfunction.

Rate of ESRD exceeds mortality among African Americans with hypertensive nephrosclerosis

In several studies, patients with CKD seemed to be at greater risk for dying from cardiovascular disease (CVD) than reaching ESRD. The purpose of this study was to compare incident ESRD rates with rates of total mortality, CVD death, and a CVD composite (CVD mortality and CVD hospitalization) among participants who had hypertensive nephrosclerosis and were enrolled in the African American Study of Kidney Disease and Hypertension (AASK). The study period included the AASK trial phase (1996 through 2001) and a subsequent cohort phase (2002 through 2007). The AASK enrolled 1094 participants. Of the 764 participants who completed the trial phase without an event, 691 (90%) enrolled in the cohort phase. During 11 years of follow-up, there were 59 CVD-related deaths and 118 non-CVD-related deaths. The rate of ESRD (3.9/100 patient-years) was significantly higher than the rates of total mortality (2.2/100 patient-years), CVD mortality (0.8/100 patient-years), and the CVD composite (3.2/100 patient-years). The incidence rate ratio of ESRD to CVD mortality was 5.0. The rate of ESRD consistently exceeded the various mortality rates across most of the subgroups defined by age, gender, income, education, previous CVD, baseline urine protein excretion, and baseline estimated GFR. In conclusion, AASK participants were more likely to reach ESRD than to die.

Relationship between kidney function and risk of asymptomatic peripheral arterial disease in elderly subjects

BACKGROUND

Limited data exist regarding the relationship between kidney function and incident asymptomatic peripheral arterial disease (PAD).

METHODS

The study population consisted of 2881 participants of the Intervention Project on Cerebrovascular Diseases and Dementia in the Community of Ebersberg, Bavaria, a community-based cohort of elderly individuals. Kidney function was calculated as creatinine clearance (Ccr) estimated by the Cockcroft-Gault formula. Incident PAD was defined as a new onset of ankle-brachial index < 0.9 assessed at regular examinations among those with an ankle brachial pressure index (ABPI) ≥ 0.9 at baseline. Relative risks (RR) for PAD were compared across declining kidney function quartiles.

RESULTS

Mean serum concentration of creatinine and Ccr were 0.82 ± 0.31 mg/dL and 78 ± 21 mL/min/1.73 m(2). After 6 years of follow-up, 478 (17%) participants developed incident asymptomatic PAD. After adjustment for demographic factors and cardiovascular risk factors, lower Ccr quartiles were directly associated with a higher risk of PAD. Compared with participants in quartile 1 (> 89 mL/min/1.73 m(2)), the adjusted RR (95% CI) for PAD were 1.01 (0.88-1.19) for quartile 2 (75-89 mL/min/1.73 m(2)), 1.05 (0.93-1.23) for quartile 3 (64-75 mL/min/1.73 m(2)) and 1.10 (1.01-1.44) for quartile 4 (< 64 mL/min/1.73 m(2); P = 0.009 for trend). Cardiovascular events as a function of baseline Ccr and incident PAD showed that most vascular events occurred in participants with Ccr < 60 mL/min/1.73 m(2) at baseline and incident PAD (log-rank test, P = 0.0018).

CONCLUSIONS

Lower kidney function is associated with incident asymptomatic PAD. In addition, the combination of impaired kidney function and incident PAD better predicts cardiovascular outcomes.

Early intervention strategies to lower cardiovascular risk in early nephropathy: focus on dyslipidemia

Patients with chronic kidney disease (CKD) are at high cardiovascular risk and we can consider them to have a risk equivalent to coronary heart disease, putting them into the high-risk category. A mixed dyslipidemia with high triglyceride levels; low high-density lipoprotein (HDL) levels; and small, dense low-density lipoprotein (LDL) particles is a common pattern in patients with CKD, contributing to their high cardiovascular disease (CVD) risk. A treatment strategy to reduce LDL cholesterol to the current high-risk category goals reduces risk similar to patients without CKD. Emerging evidence suggests that targeting non-HDL cholesterol can have the potential to bring about further CVD risk reduction. Non-HDL cholesterol should be a secondary target for all patients with CKD. Further studies are needed to determine the magnitude of the risk reduction we can expect to gain by targeting non-HDL cholesterol and the most effective way to treat this target.

An assessment of cholesterol goal attainment in patients with chronic kidney disease

BACKGROUND

Patients with chronic kidney disease (CKD) are at significant risk for cardiovascular disease (CVD). The National Kidney Foundation developed clinical practice guidelines (Kidney Disease Outcomes Quality Initiative) for targeting low-density lipoprotein cholesterol (LDL-C) goals.

OBJECTIVE

This study evaluated the extent to which these guidelines were adhered to among patients with CKD and to examine factors associated with the attainment of LDL-C goals.

METHODS

In this cross-sectional study we evaluated patients with a glomerular filtration rate of 15 to 59 mL/min per 1.73 m². Patients with previous CVD, who were receiving dialysis, or were post kidney transplant were excluded. Administrative databases were used to determine the percentage of patients with a fasting lipid profile performed within the previous year, the percentage who attained a LDL-C goal less than 100 mg/dL, and to determine lipid-lowering medications prescribed. Logistic regression analysis was used to identify factors associated with LDL-C goal attainment.

RESULTS

Of the 4541 patients evaluated, 3157 (69.5%) had a fasting lipid profile performed within the previous year. Overall, 60.8% attained a LDL-C less than 100 mg/dL. Among patients at goal, 72.2% were taking lipid-lowering therapy compared with 37.9% of those not at goal (P < .01). Characteristics independently associated with LDL-C goal attainment were increasing age, male gender, increasing chronic disease score, history of diabetes, and statin use.

CONCLUSION

Although most patients were screened and attained LDL-C goal, there was room for improvement. Statin use was independently associated with LDL-C goal attainment. Future prospective studies should focus on evaluating clinical outcomes of lipid-lowering interventions within the CKD population.

Effect of kidney disease on acute coronary syndrome

Chronic kidney disease (CKD) is highly prevalent worldwide and is associated with an increased risk for adverse outcomes in patients hospitalized with acute coronary syndrome (ACS). In studies including thousands of patients admitted with myocardial infarction, CKD consistently determines a poorer prognosis for ACS patients. In contrast with CKD, information about the effect of acute kidney injury (AKI) on clinical outcomes after ACS is limited. Most data come from retrospective registry databank studies of nonconsecutive patients with a significant number of patients excluded from analyses. There are no prospective studies designed to determine whether AKI strictly diagnosed by the new the Acute Kidney Injury Network (AKIN) or RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease) criteria is a risk factor for death after ACS, and there are no data comparing the RIFLE and AKIN criteria for AKI diagnosis after myocardial infarction. This article reviews the most important data on CKD and ACS and the available data on AKI and ACS. The importance of obtaining an early serum creatinine level after admission for ACS and the importance of renal function monitoring during hospitalization are stressed.

Impact of age and overt proteinuria on outcomes of stage 3 to 5 chronic kidney disease in a referred cohort

BACKGROUND AND OBJECTIVES

Population-based studies have reported outcomes and risk factors for patients with chronic kidney disease (CKD), defined primarily by decreased estimated GFR (eGFR). They are characterized by old age, low proteinuria level, and stage 3 CKD. However, many patients referred to nephrologists are younger and have overt proteinuria and advanced CKD. This study evaluated the association between outcomes and those factors among referred CKD patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We retrospectively reviewed 461 referred patients with stage 3 to 5 CKD from January 2003 to December 2007. Key outcomes were death and ESRD. Patients were followed from the time of first serum creatinine measurement to December 2009.

RESULTS

The median age of subjects was 67.0 years, and median follow-up was 3.2 years. Overt proteinuria was present in 57.0% of subjects. For stage 3, 4, and 5 CKD, cumulative mortality and probability of ESRD at 3 years was 9.5 and 6.5%, 11.2 and 27.8%, and 16.5 and 79.1%, respectively. Using proportional-hazards regression models, age was a determinant for death, whereas overt proteinuria was strongly associated with ESRD. Among stage 3 CKD patients older than 65 years without overt proteinuria, the incidence of death before renal replacement therapy (RRT) was 2.8/100 patient-years and none had ESRD. In patients with advanced CKD and overt proteinuria, the incidence of ESRD was substantially higher than that of death before RRT.

CONCLUSIONS

Stratification by age, proteinuria level, and CKD stage could predict the competing outcomes of death before RRT and ESRD among CKD patients.

New evidence on pitavastatin: efficacy and safety in clinical studies

IMPORTANCE OF THE FIELD

Many clinical trials of pitavastatin have been done since its launch. New insights on pitavastatin from these trials are summarized and evaluated.

AREAS COVERED IN THIS REVIEW

The results of clinical studies using pitavastatin, from 2008 to 2009, the LIVES study, the JAPAN-ACS study, the CHIBA study, the PIAT study and Phase III clinical trials in the West are reviewed.

WHAT THE READER WILL GAIN

In the LIVES study, pitavastatin showed significant and continuous elevation of high-density lipoprotein cholesterol (HDL-C), estimated glomerular filtration rate (eGFR), as well as potential decrease in low-density lipoprotein cholesterol (LDL-C), in addition to long-term safety. Non-inferiority of pitavastatin against atorvastatin in the percentage change in plaque volume was proved in the JAPAN-ACS study. Also, comparable effects on LDL-C reduction rate of pitavastatin versus atorvastatin were confirmed in the CHIBA study and Phase III clinical trials in the West, and a greater increase in HDL-C was observed than with atorvastatin in the PIAT study.

TAKE HOME MESSAGE

Pitavastatin is a useful potent stain in raising HDL-C as well as in lowering of LDL-C, though a large-scale, clinical trial to confirm prevention of cardiovascular events is needed in the future.

Therapeutic strategies for heart failure in cardiorenal syndromes

Cardiorenal syndromes are disorders of the heart and kidneys whereby acute or long-term dysfunction in one organ may induce acute or long-term dysfunction of the other. The management of cardiovascular diseases and risk factors may influence, in a beneficial or harmful way, kidney function and progression of kidney injury. In this review, we assess therapeutic strategies and discuss treatment options for the management of patients with heart failure with decreased kidney function and highlight the need for future high-quality studies in patients with coexisting heart and kidney disease.

Chronic kidney disease and end-stage renal disease-a review produced to contribute to the report 'the status of health in the European union: towards a healthier Europe'

The Report on the Status of Health in the European Union (EUGLOREH) is a project aimed at describing health problems in member states of the European Community. This project is an effort of more than 170 European experts and the collaboration of the health authorities or institutions from all EU Member States, major intergovernmental, International and European Organizations and Agencies. In this report, for the first time special emphasis is given to chronic diseases. Chronic kidney disease (CKD) is increasingly recognized as a major public health problem. However, with some notable exceptions, until now this disease has received scarce attention both at European level and at member states level. In 2007, the ERA-EDTA Registry was invited to contribute to EUGLOREH. The Registry made a major effort to gather published and unpublished information on the epidemiology of CKD and ESRD and to provide a comprehensive overview on CKD and ESRD in European countries. The review was completed in early 2008 and included into the final EUGLOREH published in the WEB as of 20 March 2009.

Complement anaphylatoxin C5a contributes to hemodialysis-associated thrombosis

Thrombosis is a common complication of end-stage renal disease, particularly in patients on hemodialysis. Although substantial progress has been made in preventing thrombotic complications in various other groups of patients, the mechanisms of thrombosis during hemodialysis require clarification. In this report, we demonstrate that complement activation triggered by hemodialysis biomaterials, and the subsequent generation of the complement anaphylatoxin C5a, results in the expression of functionally active tissue factor (TF) in peripheral blood neutrophils. Because TF is a key initiator of coagulation in vivo, we postulate that the recurring complement activation that occurs during long-term hemodialysis contributes to thrombosis in dialyzed end-stage renal disease patients. Furthermore, we found that complement contributed to the induction of granulocyte colony-stimulating factor, which has been implicated in the pathogenesis of thrombosis in patients treated with the recombinant form of this molecule. Importantly, the inhibition of complement activation attenuated the TF expression and granulocyte colony-stimulating factor induction in blood passing through a hemodialysis circuit, suggesting that the complement system could become a new therapeutic target for preventing thrombosis in patients with chronic renal failure who are maintained on hemodialysis.

[Diagnosis, treatment and prevention of renal diseases in HIV infected patients. Recommendations of the Spanish AIDS Study Group/National AIDS Plan]

The incidence of opportunistic infections and tumours in HIV-infected patients has sharply declined in the HAART era. At the same time there has been a growing increase of other diseases not directly linked to immunodeficiency. Renal diseases are an increasing cause of morbidity and mortality among HIV-infected patients. In the general population, chronic renal failure has considerable multiorgan repercussions that have particular implications in patients with HIV infection. The detection of occult or subclinical chronic kidney disease is crucial since effective measures for delaying progression exist. Furthermore, the deterioration in glomerular filtration should prompt clinicians to adjust doses of some antiretroviral agents and other drugs used for treating associated comorbidities. Suppression of viral replication, strict control of blood pressure, dyslipidemia and diabetes mellitus, and avoidance of nephrotoxic drugs in certain patients are fundamental components of programs aimed to prevent renal damage and delaying progression of chronic kidney disease in patients with HIV. Renal transplantation and dialysis have also special implications in HIV-infected patients. In this article, we summarise the updated clinical practice guidelines for the evaluation, management and prevention of renal diseases in HIV-infected patients from a panel of experts in HIV and nephrologists on behalf of the Spanish AIDS Study Group (GESIDA) and the National AIDS Plan.

Hereditary fibrinogen A α-chain amyloidosis: phenotypic characterization of a systemic disease and the role of liver transplantation

Variants of fibrinogen A α-chain (AFib) cause the most common type of hereditary renal amyloidosis in Europe and, possibly, the United States as well. Variant fibrinogen is produced in the liver, and solitary renal allografts fail within 1 to 7 years with recurrent amyloidosis. We assessed 22 AFib patients for combined liver and kidney transplantation (LKT) and report the clinical features and outcome. Twenty-one had E526V and 1, the R554L variant. Coronary atherosclerosis was identified in 68% and systemic atheromatosis in 55%. Vascular atheroma excised at endarterectomy and endomyocardial biopsies contained purely variant fibrinogen amyloid. Half had autonomic neuropathy. Six of 9 patients who underwent LKT are alive (67%), with good allograft function and no amyloidosis at median 67 months (range, 33-155 months) of follow-up. Serial technetium-99m–labeled dimercaptosuccinic acid (99mTc-DMSA) renal scintigraphy in 2 cases of preemptive LKT demonstrated preserved native kidney residual function at 5 years. Four explanted livers were used successfully for domino transplantation. Fibrinogen amyloidosis is a systemic amyloid disease with visceral, vascular, cardiac, and neurologic involvement. LKT is curative; however, cardiovascular amyloidosis may preclude this option. Our data encourage evaluation of preemptive solitary liver transplantation early in the course of amyloid nephropathy to prevent hemodialysis and kidney transplantation.

Renal injury is associated with operative mortality after cardiac surgery for women and men

OBJECTIVES

The purpose of this study was to determine whether acute renal injury develops more frequently in women than in men after cardiac surgery and whether this complication is associated with operative mortality in women.

METHODS

Prospectively collected data were evaluated from 9461 patients undergoing coronary artery bypass graft surgery, cardiac valve surgery, or both (3080 women) and not receiving preoperative dialysis. The glomerular filtration rate was estimated by using the Modification of Diet in Renal Disease equations with the last plasma creatinine level before surgical intervention (baseline) and the highest level of the first postoperative week. The primary renal injury outcome was the composite end point of renal injury according to RIFLE criteria (estimated glomerular filtration rate decrease >50% from baseline value) or failure.

RESULTS

Thirty-day operative mortality and renal injury were more common in women than in men (5.9% vs 2.8%, P = .01; 5.1% vs 3.6%, P < .001, respectively). Nonetheless, patient sex was not independently associated with risk for renal injury when the baseline estimated glomerular filtration rate was included in multivariate modeling. Perioperative complications, intensive care unit length of stay, and mortality were more frequent for patients with than without renal injury (women, 20.6% vs 3.2%, P < .0001; men, 18.3% vs 2.2%, P < .001). Renal injury was independently associated with 30-day mortality for women (odds ratio, 3.96; 95% confidence interval, 1.86-8.44; P < .0001) and men (odds ratio, 4.05; 95% confidence interval, 2.19-7.48; P < .0001).

CONCLUSIONS

Postoperative renal injury is independently associated with 30-day mortality regardless of patient sex. Higher rates of renal injury in women compared with men might be explained in part by a higher prevalence of low estimated glomerular filtration rate before surgical intervention.

In vitro renal cortex elasticity and viscosity measurements with Shearwave Dispersion Ultrasound Vibrometry (SDUV) on swine kidney

Renal fibrosis threatens kidney viability and fibrosis has been associated with altered tissue structure affecting the biomechanical properties of the kidney, quantifiable as elasticity and viscosity. Importantly, early detection of renal fibrosis may guide therapy and eliminate invasive biopsy procedures. The ability to detect fibrosis early and monitor it regularly with sufficient sensitivity and specificity is an active area of research. A newly emerging method called Shearwave Dispersion Ultrasound Vibrometry (SDUV), that quantifies both elasticity and viscosity by evaluating dispersion of shear wave propagation speed versus its frequency, offers a potential tool to determine renal elasticity and viscosity in vivo. The purpose of this study was to evaluate the feasibility of SDUV for in vitro measurements of renal cortex elasticity and viscosity in the kidney.

The assessment of total cardiovascular risk in hypertensive subjects in primary care

BACKGROUND

Recently published guidelines emphasize that detection of any subclinical target organ damage in hypertensive subjects should be regarded as a sign of high cardiovascular risk.

AIM

To assess the ability of conventional multivariable cardiovascular disease risk prediction tools and high-sensitivity C-reactive protein (hs-CRP) to identify hypertensive subjects with target organ damage.

METHODS

Ankle-brachial index (ABI), estimated glomerular filtration rate (eGFR), electrocardiographically determined left ventricular hypertrophy (ECG-LVH), and base-line variables were measured in hypertensive subjects aged 45-70 years without established cardiovascular or renal disease or known diabetes.

RESULTS

Of the 495 subjects, 123 (24.8% (95% CI 21.1-28.9)) had ABI <1.00, 81 (16.4% (95% CI 13.2-19.9)) had ECG-LVH, and 41 (8.3% (95% CI 6.0-11.1)) had eGFR <60 mL/min/1.73 m(2). In patients with SCORE <5% or Framingham risk <20%, any sign of target organ damage was found in 46% and 49% of patients, respectively.

CONCLUSION

Assessment of ECG-LVH, ABI, and eGFR reclassifies a significant number of hypertensive patients to the high-risk category as compared to SCORE and Framingham risk prediction tools only.