Chapter 1: Definition and classification of CKD

A comparison of anxiety and depression between pre-dialysis chronic kidney disease patients and hemodialysis patients using hospital anxiety and depression scale

Objective:

Tocompare frequency of anxiety and depression between pre-dialysis chronic kidney disease (CKD) and hemodialysis patients (ESRD) in Pakistan.

Methods:

This study was conducted in an out-patient department and hemodialysis unit of Sharif Medical City Hospital. Inclusion criteria included age above 18 years and a diagnosis of CKD including both pre-dialysis CKD and ESRD patients. Patients were screened for anxiety and depression using hospital anxiety and depression scale (HADS).

Results:

A total of 156 patients were included in the study. Out of these patients, 81 (51.9%) had ESRD and 75 (48.1%) had pre-dialysis CKD. Mean age of all patient was 47.3±18.3 years, 96 (61.5%) were males and 60 (38.5%) were females. Median duration of renal disease was 16 months (IQR 8-36 months). Anxiety and depression were present in 111 (71.2%) and 113 (72.4%) of all patients respectively. Moderate to severe anxiety and depression were present in 54 (34.6%) and 60 (38.5%) patients respectively. In multiple logistic regression model, after adjusting for other variables, ESRD vs. pre-dialysis CKD was significantly associated with moderate to severe depression (AOR 2.26 (1.1-5.1).

Conclusion:

Both anxiety and depression are common in pre-dialysis CKD and ESRD patients. Patients with ESRD have higher frequency of depression compared to pre-dialysis CKD patients.

Risk assessment of environmental exposure to heavy metals in mothers and their respective infants

Exposure to heavy metals can cause renal injury, which has been well documented in occupational exposure. Studies of low exposure in the general population, however, are still scarce, particularly for vulnerable populations such as mothers and young children. This study evaluated exposure to heavy metals, and biomarkers of renal function and oxidative stress in 944 lactating mothers and their infants and investigated the role of the interaction between heavy metals and oxidative stress in altering renal function. Mother and infant urine samples were analyzed to measure mercury (Hg), cadmium (Cd), and lead (Pb) concentrations for determining body-burden exposure; N-acetyl-β-d-glucosaminidase (NAG), α₁-microglobulin (α₁-MG), albumin (ALB), and creatinine (Cr) concentrations for determining early renal injury; and 8-hydroxy-2-deoxyguanosine (8-OHdG) and malondialdehyde (MDA) concentrations for determining oxidative stress. The median concentrclearlyations in mothers presented as μg/g Cr (infants as μg/l) for Hg, Cd, and Pb were 0.695 (0.716), 0.322 (0.343), and 3.97 (5.306) respectively. The mothers and their infants had clearly been exposed to heavy metals and had levels higher than the reference values reported for the general populations of USA, Germany, and Canada. Multiple regression analyses clearly demonstrated associations between urinary heavy metals in quartiles and several renal and oxidative biomarkers in mothers and to a lesser extent their infants. ß coefficients for urinary excretions of MDA, 8-OHdG, ALB, α₁-MG, NAG, and Cr in mothers were high in the highest quartile of Hg (1.183-51.29μg/g Cr or 1.732-106.95μg/l), Cd (0.565-765.776μg/g Cr or 0.785-1347.0μg/l), and Pb (6.606-83.937μg/g Cr or 9.459-80.826μg/l), except Pb was not associated with ALB. Infants in the highest Pb quartile (9.293-263.098μg/l) had the highest ß coefficients of urinary excretion of MDA, 8-OHdG, ALB, NAG, and Cr. Significant increasing trend in biomarkers across the quartiles of the three metals was seen in both mothers and infants (p_trend <0.001). A receiver operating characteristic analysis supported the predictive abilities of the four renal biomarkers in discriminating between low versus high metal quartiles. The interaction between heavy metals and oxidative stress contributed to the high excretions of renal biomarkers, but the mechanism remains unclear. These findings add to the limited evidence that low exposure to heavy metals in the general population is associated with alterations in renal function that could eventually progress to renal damage if exposure continues and that children are more susceptible due to the immaturity of their body organs.

Refining the Policy for Timing of Kidney Transplant Waitlist Qualification

BACKGROUND

Earlier qualification for the kidney transplant waitlist expedites transplant and is therefore associated with improved outcomes. U.S. Organ Procurement and Transplantation Network policies state that "measured or calculated creatinine clearance or glomerular filtration rate less than or equal to 20 mL/min" triggers waitlist time accrual. The choice of qualification method is somewhat arbitrary, and the policy implies that decline in renal function is monotonic.

METHODS

(1) We used survival analysis to quantify temporal differences in waitlist qualification by applying 3 kidney-function-estimating equations (Cockcroft-Gault, Modification of Diet in Renal Disease study, Chronic Kidney Disease Epidemiology Collaboration) to serial creatinine measurements from 3 patient cohorts: 1 of waitlisted patients at a major U.S. academic center and 2 national, multicenter cohorts of chronic kidney disease patients (African American Study of Kidney Disease and Hypertension, Modification of Diet in Renal Disease). (2) Survival analysis assessed whether requiring patients to demonstrate persistently reduced renal function on 2 occasions at least 90 days apart would meaningfully change qualification order.

RESULTS

On average, time to waitlist qualification would be delayed on the order of 1 to 2 years by using calculated creatinine clearance (per the Cockcroft-Gault equation). Compared with current policy, requiring demonstration of persistently reduced renal function delayed qualification by 0.6 to 2.1 years and caused 40% to 50% of patients to switch the order in which they qualify by 6 months or more.

CONCLUSIONS

The kidney transplantation policies should be revised, such that timing of waitlist qualification is more standardized. We suggest that mention of using calculated creatinine clearance be dropped from the Organ Procurement and Transplantation Network policy wording and the units to quantify kidney function be changed to mL/min per 1.73 m2. Some consideration should be given to whether requiring persistently reduced renal function would better identify patients most likely to benefit from earlier waitlist qualification.

Effect of Kidney Dysfunction on Cerebral Cortical Thinning in Elderly Population

Chronic kidney disease has been linked to cognitive impairment and morphological brain change. However, less is known about the impact of kidney functions on cerebral cortical thickness. This study investigated the relationship between kidney functions and global or lobar cerebral cortical thickness (CTh) in 259 non-demented elderly persons. Forty-three participants (16.7%) had kidney dysfunction, which was defined as either a glomerular filtration rate (GFR) of <60 ml/min/1.73 m² or presence of proteinuria. Kidney dysfunction was associated with lower global (β = −0.05, 95% CI = −0.08 to −0.01) as well as frontal, parietal, temporal, occipital, and insular lobar CTh. In the stratified analysis, the associations were more pronounced in women, APOEε4 non-carriers, and participants with a lower cognitive score. Besides, kidney dysfunction significantly increased the risk of cortical thinning, defined as being the lowest CTh tertile, in the insular lobe (adjusted odds ratio = 2.74, 95% CI = 1.31−5.74). Our results suggested that kidney dysfunction should be closely monitored and managed in elderly population to prevent neurodegeneration.

Study of Neutrophil-lymphocyte Ratio as Novel Marker for Diabetic Nephropathy in Type 2 Diabetes

INTRODUCTION

Diabetic nephropathy (DN) is a microvascular complication of diabetes. DN is clinically manifested as an increase in urine albumin excretion. Total white blood cell count is a crude but sensitive indicator of inflammation and studied in many cardiac and noncardiac diseases as an inflammatory marker such as acute myocardial infarction, stroke, and heart failure. In this study, the association of neutrophil-lymphocyte ratio (NLR) with DN is studied.

PATIENTS AND METHODS

It is an observational cross-sectional study. Totally 115 diagnosed type 2 diabetes mellitus patients were registered in this study. NLR was calculated by analyzing differential leukocyte count in complete blood picture. Albuminuria was tested by MICRAL-II TEST strips by dipstick method.

RESULTS

Totally 115 diabetic patients were registered. About 56 patients had DN and 59 had normal urine albumin. Mean NLR for a normal group is 1.94 ± 0.65 and in DN group is 2.83 ± 0.85 which was highly significant (P < 0.001). Estimated glomerular filtration rate (P = 0.047) and serum glutamate pyruvate transaminase (P < 0.001) were also significant.

CONCLUSION

The results of our study show that there was a significant relation between NLR and DN. Therefore, NLR may be considered as a novel surrogate marker of DN in early stages.

Incidence and predictors of excessive warfarin anticoagulation in patients with atrial fibrillation-The EWA study

Vitamin K antagonist warfarin is widely used in clinical practice and excessive anticoagulation is a well-known complication of this therapy. Little is known about permanent and temporary predictors for severe overanticoagulation. The aim of this study was to investigate the occurrence and predicting factors for episodes with very high (≥9) international normalized ratio (INR) values in warfarin treated patients with atrial fibrillation (AF). Excessive Warfarin Anticoagulation (EWA) study screened all patients (n = 13618) in the Turku University Hospital region with an INR ≥2 between years 2003–2015. Patients using warfarin anticoagulation for AF with very high (≥9) INR values (EWA Group) were identified (n = 412 patients) and their characteristics were compared to a control group (n = 405) of AF patients with stable INR during long-term follow-up. Over 20% (n = 92) of the EWA patients had more than one event of very high INR and in 105 (25.5%) patients EWA led to a bleeding event. Of the several temporary and permanent EWA risk factors observed, strongest were excessive alcohol consumption in 9.6% of patients (OR 24.4, 95% CI 9.9–50.4, p<0.0001) and reduced renal function (OR 15.2, 95% CI 5.67–40.7, p<0.0001). Recent antibiotic or antifungal medication, recent hospitalization or outpatient clinic visit and the first 6 months of warfarin use were the most significant temporary risk factors for EWA. Excessive warfarin anticoagulation can be predicted with several permanent and temporary clinical risk factors, many of which are modifiable.

Vascular Access Site for Renal Replacement Therapy in Acute Kidney Injury: A Post hoc Analysis of the ATN Study

Background

Acute kidney injury requiring renal replacement therapy (RRT) in the intensive care unit portends a poor prognosis. The decisions regarding dialysis catheter placement is based mainly on physician discretion with little evidence to support the choice of dialysis catheter location.

Methods

The Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network Study was a multicenter, prospective, randomized trial of intensive vs. less intensive RRT in critically ill patients with AKI. We assessed the association of dialysis catheter location with dialysis catheter-related outcomes including catheter-related complications, mortality, dialysis dependence, and dialysis dose delivered.

Results

Of the 1,124 patients enrolled in the ATN study, catheter data were available in 1,016 (90.39%) patients. A total of 91 (8.96%) subclavian, 387 (38.09%) internal jugular, and 538 (52.95%) femoral dialysis catheters were inserted. The femoral group was younger (58.39 ± 16.27), had greater bleeding tendency [lower platelet count (96.00 ± 109.35) with higher INR (2.01 ± 2.19)], and had a higher baseline sequential organ failure assessment score on admission (14.59 ± 3.61) compared to the other two groups. Dialysis catheter-related complications were low in this study with no significant difference in the rates of complications among all catheter locations. Mortality and dialysis dependence was lowest in the subclavian group, while the dose of dialysis delivered (Kt/V) remained lowest in the femoral group, after propensity score and center adjustments.

Conclusion

Patient characteristics influence the choice of dialysis catheter location with a tendency to place femoral catheters in younger, sicker, and more coagulopathic patients. There were no statistically significant differences in complication rates among the three catheter locations, although femoral catheters may be associated with a lower delivered dose of dialysis during intermittent hemodialysis.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier NCT00076219.

Arterial spin labeling MRI is able to detect early hemodynamic changes in diabetic nephropathy

PURPOSE

To investigate whether arterial spin labeling (ASL) MRI could detect renal hemodynamic impairment in diabetes mellitus (DM) along different stages of chronic kidney disease (CKD).

MATERIALS AND METHODS

Three Tesla (3T) ASL-MRI was performed to evaluate renal blood flow (RBF) in 91 subjects (46 healthy volunteers and 45 type 2 diabetic patients). Patients were classified according to their estimated glomerular filtration rate (eGFR) as group I (eGFR > 60 mL/min/1.73 m² ), group II (60 ≥ eGFR>30 mL/min/1.73 m² ), or group III (eGFR ≤ 30 mL/min/1.73 m² ), to determine differences depending on renal function. Studies were performed at 3T using a 12-channel flexible body array combined with the spine array coil as receiver.

RESULTS

A 28% reduction in cortical RBF was seen in diabetics in comparison with healthy controls (185.79 [54.60] versus 258.83 [37.96] mL/min/100 g, P < 3 × 10^-6 ). Differences were also seen between controls and diabetic patients despite normal eGFR and absence of overt albuminuria (RBF [mL/min/100 g]: controls=258.83 [37.96], group I=208.89 [58.83], P = 0.0018; eGFR [mL/min/1.73 m² ]: controls = 95.50 [12.60], group I = 82.00 [20.76], P > 0.05; albumin-creatinine ratio [mg/g]: controls = 3.50 [4.45], group I = 17.50 [21.20], P > 0.05). A marked decrease in RBF was noted a long with progression of diabetic nephropathy (DN) through the five stages of CKD (χ²  = 43.58; P = 1.85 × 10^-9 ). Strong correlation (r = 0.62; P = 4 × 10^-10 ) was obtained between RBF and GFR estimated by cystatin C.

CONCLUSION

ASL-MRI is able to quantify early renal perfusion impairment in DM, as well as changes according to different CKD stages of DN. In addition, we demonstrated a correlation of RBF quantified by ASL and GFR estimated by cystatin C.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1810-1817.

Insulin Resistance and Chronic Kidney Disease in Patients with Type 1 Diabetes Mellitus

Background and Aims. Diabetes mellitus (DM) is a chronic disease which can evolve towards devastating micro- and macrovascular complications. DM is the most frequent cause of chronic kidney disease (CKD). Insulin resistance plays an important role in the natural history of type 1 diabetes. The purpose of the study was to determine the prevalence of CKD in T1DM and the correlation with insulin resistance (IR) in patients with CKD. Materials and Methods. The study was conducted over a period of three years (2010-2013) and included patients with DM registered in the Clinical Centre of Diabetes, Nutrition and Metabolic Diseases of Dolj county. The study design was an epidemiological, transversal, noninterventional type. Finally, the study group included 200 subjects with type 1 DM. Insulin resistance (IR) was estimated by eGDR. The subjects with eGDR ≤ 7.5 mg/kg/min were considered with insulin resistance. Results. CKD was found in 44% of the patients. Analyzing statistically the presence of CKD, we found highly significant differences between patients with CKD and those without CKD regarding age and sex of the patients, the duration of diabetes, glycosylated hemoglobin (HbA1c), the estimated glucose disposal rate (eGDR), and the presence of hypertension, dyslipidemia, and hyperuricaemia. In patients with CKD, age and diabetes duration are significantly higher than in those who do not have this complication. CKD is more frequent in males than in females (50.9% men versus 34.5% women, p = 0.022). From the elements of metabolic syndrome, high blood pressure, hyperuricemia, and dyslipidemia are significantly increased in diabetic patients with CKD. eGDR value (expressed as mg·kg^-1·min^-1) is lower in patients with CKD than in those without CKD (15.92 versus 6.42, p < 0.001) indicating the fact that patients with CKD show higher insulin resistance than those without CKD. Conclusions. This study has shown that insulin resistance is associated with an increased risk of CKD, but, due to the cross-sectional design, the causal relationship cannot be assessed. However, the existence of this causality and the treatment benefit of insulin resistance in type 1 diabetes are issues for further discussion.

Dipstick proteinuria level is significantly associated with pre-morbid and in-hospital functional status among hospitalized older adults: a preliminary study

Although chronic kidney disease (CKD) is associated with functional decline, whether proteinuria alone is associated with functional statuses over the course of acute illnesses independent of CKD is unclear. During 2014, we prospectively enrolled non-dialysis patients aged ≥65 years, and all participants underwent spot dipstick urinalysis on admission, divided into 3 groups according to the results (none, trace to 1 + , and 2 + or higher); functional status was evaluated using the pre-morbid and in-hospital Barthel index (BI) scores. Of 136 community-dwelling elderly patients enrolled (age 80.7 ± 8.2 years, with 19% having CKD), 17%, 57%, and 26% had no, trace to 1 + , or 2 + or higher proteinuria. Overall pre-morbid, on-admission, and on-discharge BI scores were 50.4 ± 41.9, 38.6 ± 31.8, and 38.7 ± 35.3, respectively with significant negative correlations with proteinuric severity on admission. Finally, multivariate linear stepwise regression analysis with backward variable selection found that dipstick proteinuric severity was significantly associated with pre-morbid, on-admission, and on-dischrage BI scores (p = 0.048, <0.01, and <0.01, respectively), independent of diabetes and CKD. This relationship between dipstick proteinuric levels and functional status of hospitalized elderly suggests an under-recognized association. Prospective evaluation of long-term outcome is needed.

Frequency of Hepatitis C in hospitalized patients with chronic kidney disease

Background and Objectives:

Hepatitis C and chronic kidney disease (CKD) are major global health problems and are highly prevalent in Pakistan. There is limited information on prevalence of hepatitis C in patients with CKD not yet on dialysis. The objective of this study was to determine the frequency of hepatitis C in hospitalized chronic kidney disease patients at a tertiary care center in Pakistan.

Methods:

The study design was cross-sectional in nature. Patients between ages of 20-80 years with CKD not previously on renal replacement therapy and who were admitted to nephrology ward at a tertiary care facility were included. Hepatitis C was tested using 3^rd generation enzyme linked immunosorbent assay (ELISA). Hepatitis C RNA was tested by polymerase chain reaction (PCR) in patients with positive ELISA.

Results:

A total of 180 patients were included in the study. Mean age of patients was 48.7±14.9 years. Of all patients, 105 (58.3%) were males and 75 (41.7%) were females, 152 (84.4%) had hypertension, 113 (62.8%) had diabetes mellitus and 26 (14.9%) had known cardiovascular disease. Mean eGFR of patients was 11.4±9.4 ml/min/1.73 m2. Of all patients with CKD, 49 (27.2%) had hepatitis C test positive by ELISA. Hepatitis C PCR testing was done in 39 patients with hepatitis C ELISA positive status and 29 (74.4%) tested positive. Risk factors and clinical characteristics of patients with and without positive hepatitis C antibody by ELISA were similar.

Conclusion:

A significant proportion of hospitalized CKD patients have hepatitis C. Strict universal infection control measures should be implemented in nephrology wards to prevent transmission of hepatitis C infection.

Chronic Kidney Disease-Mineral Bone Disorder in Korean Patients: a Report from the KoreaN Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD)

This study examined the characteristics of biochemical parameters, bone diseases, and vascular calcification in Korean patients with chronic kidney disease (CKD) not yet on dialysis. Serum levels of fibroblast growth factor 23 (FGF23), intact parathyroid hormone (iPTH), 25-hydroxyvitamin D3 (25D), and 1,25-dihydroxyvitamin D3 (1,25D); lumbar spine, total hip, and femur neck bone mineral densities; and brachial-to-ankle pulse wave velocity (baPWV) representing vascular calcification were measured at baseline for 2,238 CKD patients in the KoreaN Cohort Study for Outcomes in Patients With CKD (KNOW-CKD). Increases in serum FGF23 and iPTH preceded changes in serum calcium and phosphate, similar to Western populations. However, the 25D and 1,25D levels decreased earlier than serum FGF23 or iPTH increased, with a decreased estimated glomerular filtration rate (eGFR) in Korean CKD patients. Vitamin D deficiency occurred in 76.7% of patients with CKD stage 1. Bone mineral densities were lowest in CKD stage 5 (lumbar spine, -0.64 ± 1.67; total hip, -0.49 ± 1.21; femur neck, -1.02 ± 1.25). Osteoporosis was more prevalent in patients with higher CKD stages. The mean baPWV, abdominal aortic calcification (AAC), and coronary calcium score also increased, with declined eGFR. In conclusion, a decline in serum vitamin D levels was observed in early CKD stages before significant increases of FGF23 and iPTH in the Korean CKD population compared with that in Western populations. Increased bone disease and vascular calcification occurred in early-stage CKD.

Nutritional Status in Adults with Predialysis Chronic Kidney Disease: KNOW-CKD Study

Adverse changes in nutrition are prevalent and are strong indicators of adverse outcomes in patients with chronic kidney disease (CKD). The International Society of Renal Nutrition and Metabolism (ISRNM) proposed a common nomenclature and diagnostic criteria to identify protein-energy wasting (PEW) in CKD patients. We examined the nutritional status in 1,834 adults with predialysis CKD enrolled in the KoreaN cohort study for Outcome in patients With Chronic Kidney Disease (KNOW-CKD) study. As there was a need for further understanding of nutritional status and associated factors in CKD, we evaluated the prevalence and associated factors of PEW in adults with predialysis CKD. The prevalence of PEW was about 9.0% according to ISRNM criteria and tended to increase with advanced stage in predialysis CKD. Those who concurrently had PEW, inflammation, and CVD were a small proportion (0.4%). In multivariate logistic regression model, PEW was independently associated with estimated glomerular filtration rate (eGFR) (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96-0.99), total CO₂ (OR, 0.93; 95% CI, 0.87-0.99), physical activity (OR, 0.43; 95% CI, 0.26-0.69), comorbid diabetes (OR, 1.68; 95% CI, 1.09-2.59), and high sensitivity C-reactive protein (hs-CRP) (OR, 1.03; 95% CI, 1.01-1.06). Our study suggests that PEW increases with advanced CKD stage. PEW is independently associated with renal function, low total CO₂, low physical activity, comorbid diabetes, and increased hs-CRP in adults with predialysis CKD.

The Prevalence and Management of Anemia in Chronic Kidney Disease Patients: Result from the KoreaN Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD)

Anemia is a common and significant complication of chronic kidney disease (CKD). However, its prevalence and current management status has not been studied thoroughly in Korea. We examined the prevalence of anemia, its association with clinical and laboratory factors, and utilization of iron agents and erythropoiesis stimulating agents using the baseline data from the large-scale CKD cohort in Korea. We defined anemia when hemoglobin level was lower than 13.0 g/dL in males and 12.0 g/dL in females, or received by erythropoiesis stimulating agents. Overall prevalence of anemia was 45.0% among 2,198 non-dialysis CKD patients from stage 1 to 5. Diabetic nephropathy (DN) as a cause, CKD stages, body mass index (BMI), smoking, leukocyte count, serum albumin, iron markers, calcium, and phosphorus concentration were identified as independent risk factors for anemia. Considering the current coverage of Korean National Health Insurance System, only 7.9% among applicable patients were managed by intravenous iron agents, and 42.7% were managed by erythropoiesis stimulating agents.

Correlates of Physical Functioning and Performance Across the Spectrum of Kidney Function

The aim of this study was to determine the extent to which poor physical functioning, low participation in physical activity, and muscle atrophy observed among patients on hemodialysis are evident in the earlier stages of chronic kidney disease (CKD). We enrolled adults in three groups: no CKD, Stages 3 to 4 CKD, and hemodialysis. Outcomes measured were physical activity, muscle size, thigh muscle strength, physical performance, and self-reported physical function. Patients with CKD had muscle area intermediate between the no CKD and hemodialysis groups, but they had low levels of physical activity that were similar to the hemodialysis group. Physical activity and muscle size were significantly associated with all outcomes. Kidney function was not significantly associated with muscle strength or physical performance after adjustment for physical activity and muscle size. In conclusion, interventions aimed to increase muscle mass and energy expenditure might have an impact on improving physical function of CKD patients.

Glycative Stress and Its Defense Machinery Glyoxalase 1 in Renal Pathogenesis

Chronic kidney disease is a major public health problem around the world. Because the kidney plays a role in reducing glycative stress, renal dysfunction results in increased glycative stress. In turn, glycative stress, especially that due to advanced glycated end products (AGEs) and their precursors such as reactive carbonyl compounds, exacerbates chronic kidney disease and is related to premature aging in chronic kidney disease, whether caused by diabetes mellitus or otherwise. Factors which hinder a sufficient reduction in glycative stress include the inhibition of anti-glycation enzymes (e.g., GLO-1), as well as pathogenically activated endoplasmic reticulum (ER) stress and hypoxia in the kidney. Promising strategies aimed at halting the vicious cycle between chronic kidney disease and increases in glycative stress include the suppression of AGE accumulation in the body and the enhancement of GLO-1 to strengthen the host defense machinery against glycative stress.

Long term renal survival in patients undergoing T-Cell depleted versus conventional hematopoietic stem cell transplants

Calcineurin inhibitor-sparing T cell depleted (TCD) hematopoietic stem cell transplants HSCTs are presumed less nephrotoxic than conventional HSCTs. We evaluated incidence and risk factors for kidney failure and chronic kidney disease (CKD) in 231 TCD and 212 conventional HSCT recipients. Kidney failure required a median glomerular filtration rate (GFR) <60 mL/min/1.73 m² for ≥ 100 days anytime after 180 days post-HSCT. Two year cumulative incidence (CI) of kidney failure was 42% in the conventional vs. 31% in the TCD group (p=0.005). TCD, age, acute kidney injury and number of toxic CNI levels all impacted on kidney failure, which was associated with increased all-cause mortality (hazard ratio 2.86 (95% CI: 1.88–4.36), p <0.001). Renal recovery occurred in 28% of kidney failure patients, while the remaining patients were defined to have chronic kidney disease (CKD). In those with baseline GFR>60 mL/min/1.73 m² only exposure to nephrotoxic medications was associated with CKD (p=0.033). In the myeloablative conditioning subgroup only total body irradiation was associated with CKD (p=0.013). Of all patients, five (1.13%) required dialysis. These results confirm an impact of TCD on kidney failure but not CKD for which other risk factors such as radiation or nephrotoxic drug exposure may play a role.

Prevalencia de Micro albuminuria en pacientes hipertensos no diabéticos

Introducción: Se ha demostrado que la presencia de micro albuminuria puede reflejar el desarrollo de enfermedad cardiovascular en pacientes con diabetes mellitus, este fenómeno también se ha observado en pacientes no diabéticos. Objetivo: Determinar la prevalencia de micro albuminuria en pacientes hipertensos no diabéticos tratados en la Consulta Externa del Hospital General San Juan de Dios. Métodos: Medición de micro albuminuria con tira reactiva urinaria Micral-Test® en 86 pacientes con hipertensión esencial de 1 a 10 años de evolución. Resultados: Se encontró una prevalencia total de micro albuminuria de 81%. Con ICC se encontró diferencia estadísticamente significativa entre el grupo de pacientes que presentó micro albuminuria con 99% de significancia. (p 0.03) IC 95%. No se encontró diferencia estadísticamente significativa entre los grupos de pacientes con y sin micro albuminuria con el resto de variables a estudio.

The prevalence of renal impairment in individuals seeking HIV testing in Urban Malawi

BACKGROUND

Chronic kidney disease (CKD) poses a major health threat to people living in low- and middle-income countries, especially when it is combined with HIV, antiretroviral treatment (ART) or communicable and non-communicable diseases. Data about the prevalence of CKD and its association with other diseases is scarce, particularly in HIV-negative individuals. This study estimated the prevalence of CKD in individuals who were either HIV-positive (and ART-naïve) or HIV-negative in an urban Malawian population.

METHODS

This cross-sectional study was conducted at a HIV Testing and Counselling Centre in Lilongwe, Malawi. Consecutive clients who were ≥18 years and consented to participate were enrolled over a 3-month period. Clients were screened for potential renal disease and other conditions. Their blood pressure was measured, urine examined via dipstick and albumin/creatinine ratio and blood drawn for creatinine, cystatin C and sero-markers for schistosomiasis. Estimated glomerular filtration (eGFR) rate was calculated using a cystatin C-based formula and classified according to the matching CKD stages by K/DOQI (The National Kidney Foundation Kidney Disease Outcome Quality Initiative). We performed a descriptive analysis and compared differences between HIV-positive (and ART naïve) and -negative participants.

RESULTS

Out of 381 consecutive clients who were approached between January and March 2012, 366 consented and 363 (48% female; 32% HIV-positive) were included in the analysis. Reasons for exclusion were missing samples or previous use of ART. HIV-positive and negative clients did not differ significantly with regard to age, sex or medical history, but they did differ for BMI-21.3 (±3.4) vs. 24 (±5.1), respectively (p < 0.001). Participants also differed with regard to serum cystatin C levels, but not creatinine. Reduced kidney function (according to CKD stages 2-5) was significantly more frequent 15.5 vs. 3.6%, respectively (p < 0.001) among HIV-positive clients compared to the HIV-negative group. Differences in renal function were most pronounced in the eGFR range 60-89 ml/min/1.73 m2 accompanied by proteinuria with results as 11.2% vs. 1.2%, respectively for clients who were HIV-positive vs. HIV-negative (p = 0.001).

CONCLUSIONS

Reduced glomerular filtration and/or proteinuria occurred in 15.5% of HIV-positive, and 3.6% of HIV-negative patients in this urban Malawian cohort. Since generalized renal monitoring is not feasible in Malawi or other resource-limited countries, strategies to identify patients at risk for higher stages of CKD and appropriate preventive measures are needed for both HIV-positive and HIV-negative patients.

Influencia de la Consulta de Enfermedad Renal Crónica avanzada en la elección de modalidad de terapia renal sustitutiva

Introducción: La enfermedad renal crónica constituye un problema de salud pública por su elevada incidencia y prevalencia, importante morbimortalidad y coste asistencial. Un aspecto fundamental para el paciente es la elección de modalidad de terapia sustitutiva renal. En este sentido, la consulta de enfermedad renal crónica avanzada o prediálisis, puede jugar un papel fundamental. Objetivo: Conocer producción científica sobre la influencia de la consulta de enfermedad renal crónica avanzada en la elección de modalidad de diálisis por parte del paciente. Metodología: Revisión bibliográfica para la que se realizaron búsquedas en las bases de datos de PubMed, Scielo, Science Direct, Proquest y Google Académico. Se analizaron los artículos que trataban la consulta prediálisis, variables que influyeran en la elección de modalidad de diálisis y satisfacción del paciente. Resultados: Se han revisado 25 artículos publicados en los años 2002-2014, de diseño observacional descriptivo y de cohortes. Se ha encontrado relación en la elección de las técnicas domiciliarias con la existencia de un programa de educación prediálisis, la información que ofrece enfermería, la entrada programada en diálisis, menor edad, menor comorbilidad y factores socioeconómicos o estructurales. Conclusion: Los factores que favorecen la elección de las técnicas de diálisis domiciliarias son la existencia de consulta de enfermedad renal crónica avanzada y la referencia oportuna del paciente a dicha consulta, ser joven, menor comorbilidad y la necesidad de contención de costes. Esta elección se ve perjudicada por factores estructurales. Las terapias domiciliarias producen mayor satisfacción en los pacientes.

Predictors of Renal Function Decline in Chinese Patients with Type 2 Diabetes Mellitus and in a Subgroup of Normoalbuminuria: A Retrospective Cohort Study

BACKGROUND

Risk factors related to renal function decline in type 2 diabetes mellitus (T2DM) remain uncertain. This study aimed to investigate risk factors in relation to renal function decline in patients with T2DM and in a subgroup of patients with normoalbuminuria.

METHODS

This study was a retrospective cohort study, which included 451 patients with T2DM aged 63 ± 14 years admitted to a tertiary hospital in Beijing, China, between April and December 2010 and followed up for 6-60 months. Endpoint was renal function decline, defined as estimated glomerular filtration rate less than 60 mL/min 1.73 m² or at least twofold increase of serum creatinine. Cox proportional hazards analysis was used to estimate hazard ratios (HRs) for candidate risk factors of renal function decline.

RESULTS

After a median follow-up of 3.3 years, 94 (20.8%) patients developed renal function decline. Increased age (HR, 1.045; 95% CI, 1.020-1.070), albuminuria (HR, 1.956; 95%CI, 1.271-3.011), mild renal dysfunction (HR, 4.521; 95%CI, 2.734-7.476), hyperfiltration (HR, 3.897; 95%CI, 1.572-9.663), and increased hemoglobin A1c (HR, 1.128; 95%CI, 1.020-1.249) were identified as major risk factors. Among a subgroup of 344 patients with normoalbuminuria at baseline, 53 (15.4%) patients developed renal function decline. Increased age (HR, 1.089; 95%CI, 1.050-1.129), mild renal dysfunction (HR, 4.667; 95%CI, 2.391-9.107), hyperfiltration (HR, 5.677; 95%CI, 1.544-20.872), smoking (HR, 2.886; 95%CI, 1.370-6.082), higher pulse pressure (HR, 1.022; 95%CI, 1.004-1.040), and increased fasting glucose (HR, 1.104; 95%CI, 1.020-1.194) were major risk factors.

CONCLUSIONS

Risk factors of diabetic renal impairment in T2DM should be screened and evaluated at an early stage of diabetes. Albuminuria, mild renal dysfunction, hyperfiltration, increased blood glucose, increased pulse pressure, and smoking were all predictors for diabetic renal impairment and interventions that focus on these risk factors may reduce further decline in renal function.

Impact of a Potassium-enriched, Chloride-depleted 5% Glucose Solution on Gastrointestinal Function after Major Abdominopelvic Surgery

Background

Gastrointestinal (GI) complications often delay recovery after radical cystectomy with urinary diversion. The authors investigated if perioperative administration of a potassium-enriched, chloride-depleted 5% glucose solution (G5K) accelerates recovery of GI function.

Methods

This randomized, parallel-group, single-center double-blind trial included 44 consecutive patients undergoing radical cystectomy and pelvic lymph node dissection with urinary diversion. Patients were randomized to receive either a G5K (G5K group) solution or a Ringer’s maleate solution (control group). Fluid management aimed for a zero fluid balance. Primary endpoint was time to first defecation. Secondary endpoints were time to normal GI function, need for electrolyte substitution, and renal dysfunction.

Results

Time to first defecation was not significantly different between groups (G5K group, 93 h [19 to 168 h] and control group, 120 h [43 to 241 h]); estimator of the group difference, −16 (95% CI, −38 to 6); P = 0.173. Return of normal GI function occurred faster in the G5K group than in the control group (median, 138 h [range, 54 to 262 h] vs. 169 h [108 to 318 h]); estimator of the group difference, −38 (95% CI, −74 to −12); P = 0.004. Potassium and magnesium were less frequently substituted in the G5K group (13.6 vs. 54.5% [P = 0.010] and 18.2 vs. 77.3% [P &lt; 0.001]), respectively. The incidence of renal dysfunction (Risk, Injury, Failure, Loss and End-stage kidney disease stage “risk”) at discharge was 9.1% in the G5K group and 4.5% in the control group; P = 1.000.

Conclusions

Perioperative administration of a G5K did not enhance first defecation, but may accelerate recovery of normal GI function, and reduces potassium and magnesium substitution after radical cystectomy and urinary diversion.

Effect of Diet on Serum Creatinine in Healthy Subjects During a Phase I Study

Creatinine is widely used as an indirect marker of renal function. However, interfering factors such as diet, exercise and problems with the assay can generate false results and misinterpretation of real kidney function. In this article, we report the dietary effects on serum creatinine during a phase I single dose escalation study and discuss the reasons why serum creatinine should be measured under fasting conditions.

The impact of renal angiomyolipoma on estimated glomerular filtration rate in patients with tuberous sclerosis complex

BACKGROUND

There is a growing concern that renal impairment may develop in patients with renal angiomyolipomas (AMLs) associated with tuberous sclerosis complex (TSC) as a consequence of the disease itself and/or the interventions to mitigate the risk of hemorrhage.

OBJECTIVE

To assess the estimated glomerular filtration rate (eGFR) in patients with bilateral renal AMLs and the impact of tumor burden and intervention on renal function.

DESIGN

Retrospective study.

SETTING

Urology department of a tertiary care hospital.

PATIENTS AND METHODS

All adult patients (>=18 years of age) with TSC-associated renal AMLs seen from October 1998 to June 2015. We included only patients with bilateral tumors or solitary kidneys at the last follow-up.

MAIN OUTCOME MEASURES

The eGFR, renal volume, and number and type of interventions.

RESULTS

We identified 12 patients (median age 27.6, interquartile range 23.7-39.9 years), a median follow-up period of 1266 days (33-3133), and a median renal size of 454.7 mL (interquartile range 344.7-1016.9 on the right side; 558.1 mL, interquartile range 253.7-1001.4 on the left). In 11 (91.7%) patients, the eGFR was > 60 mL/min/1.77 m2. Six patients had three total nephrectomies, one had a contralateral partial nephrectomy, and seven had selective arterial embolizations. Intervention was associated with a significantly reduced eGFR. The renal size did not correlate with the eGFR.

CONCLUSIONS

TSC-associated renal AMLs may attain a large size but normal renal function is maintained in 92% of patients. Interventions to mitigate the risk of hemorrhage are associated with decreased renal function.

LIMITATIONS

The renal size was used as a surrogate for tumor size. Other limitations were the limited number of patients and lack of split renal function testing.

Acute kidney injury in critically ill patients with haematological malignancies: results of a multicentre cohort study from the Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologie

BACKGROUND

Cancer patients are at high risk for acute kidney injury (AKI), which is associated with high morbidity and mortality. We sought to appraise the incidence, risk factors, and outcome of AKI in a large multicentre cohort study of critically ill patients with haematological malignancies.

METHODS

We used a retrospective analysis of a prospectively collected database. The study was carried out in 17 university or university-affiliated centres in France and Belgium between 2010 and 2012. AKI was defined according to the Acute Kidney Injury Network (AKIN) definition.

RESULTS

Of the 1011 patients admitted into the intensive care unit (ICU) during the study period, 1009 were included in this study. According to the AKIN definition, 671 patients (66.5%) developed an AKI during their ICU stay, of which 258 patients (38.4%) were AKI stage 1, 75 patients (11.2%) AKI stage 2 and 338 patients (50.4%) AKI stage 3. After adjustment for confounders, main adverse risk factors of AKI were older age, severity [non-renal Sequential Organ Failure Assessment (SOFA)], history of hypertension, tumour lysis syndrome, exposure to nephrotoxic agents and myeloma. Hospital mortality was 44.3% in patients with AKI and 25.4% in patients without AKI (P < 0.0001). After adjustment for confounders, AKI was independently associated with hospital mortality [OR 1.65 (95% CI 1.19-2.29)]. Overall, 271 patients required renal replacement therapy (RRT), of whom 57.2% died during their hospital stay as compared with 31.2% (P < 0.0001) in those not requiring RRT.

CONCLUSION

Two-thirds of critically ill patients with haematological malignancies developed AKI. Hospital mortality in this population of patients developing AKI or requiring RRT is close to that in general ICU population.

Risk of Hospital-Acquired Complications in Patients with Chronic Kidney Disease

BACKGROUND AND OBJECTIVES

Unintended injuries or complications in hospitalized patients are common, potentially preventable, and associated with adverse consequences, including greater mortality and health care costs. Patients with CKD may be at higher risk of hospital-acquired complications (HACs).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Adults from a population-based cohort (Alberta Kidney Disease Network) who were hospitalized from April 1, 2003, to March 31, 2008, made up the study cohort. Kidney function was defined using outpatient eGFR and proteinuria (protein-to-creatinine ratio or dipstick) in the year before index hospitalization. Comorbid conditions were identified using validated algorithms applied to administrative data. A specific diagnostic indicator was used to identify HACs. Complications were classified into clinically homogeneous groups and subclassified as potentially preventable (p-HACs) or always preventable (a-HACs). Multivariable logistic regressions models were used to examine the association of CKD with HACs, accounting for confounders.

RESULTS

Of 536,549 patients, 8.5% had CKD; those with CKD were older and more likely to be admitted for circulatory system diseases than those without CKD. In fully adjusted models, the odds ratio (OR) of any hospital complication in patients with CKD (reference: no CKD) was 1.19 (95% confidence interval [95% CI], 1.18 to 1.26); there was a graded relation between the risk of HACs and CKD severity, with an OR of 1.81 (95% CI, 1.51 to 2.17) in those with the most severe CKD (eGFR, 15-29 ml/min per 1.73 m(2) and proteinuria, >30 mg/mmol). Findings were similar for p-HACs (OR, 1.20 [95% CI, 1.16 to 1.24] and 1.78 [95% CI, 1.43 to 2.11], respectively). The a-HACs had similar point estimates.

CONCLUSIONS

The presence of CKD and its severity are associated with a higher risk of HACs, including those considered preventable. Targeted strategies to reduce complications in patients with CKD admitted to the hospital should be considered.

The next generation of therapeutics for chronic kidney disease

Chronic kidney disease (CKD) represents a leading cause of death in the United States. There is no cure for this disease, with current treatment strategies relying on blood pressure control through blockade of the renin-angiotensin system. Such approaches only delay the development of end-stage kidney disease and can be associated with serious side effects. Recent identification of several novel mechanisms contributing to CKD development - including vascular changes, loss of podocytes and renal epithelial cells, matrix deposition, inflammation and metabolic dysregulation - has revealed new potential therapeutic approaches for CKD. This Review assesses emerging strategies and agents for CKD treatment, highlighting the associated challenges in their clinical development.

Comparison between urine albumin-to-creatinine ratio and urine protein dipstick testing for prevalence and ability to predict the risk for chronic kidney disease in the general population (Iwate-KENCO study): a prospective community-based cohort study

Background

This study compared the combination of estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) vs. eGFR and urine protein reagent strip testing to determine chronic kidney disease (CKD) prevalence, and each method’s ability to predict the risk for cardiovascular events in the general Japanese population.

Methods

Baseline data including eGFR, UACR, and urine dipstick tests were obtained from the general population (n = 22 975). Dipstick test results (negative, trace, positive) were allocated to three levels of UACR (<30, 30–300, >300), respectively. In accordance with Kidney Disease Improving Global Outcomes CKD prognosis heat mapping, the cohort was classified into four risk grades (green: grade 1; yellow: grade 2; orange: grade 3, red: grade 4) based on baseline eGFR and UACR levels or dipstick tests.

Results

During the mean follow-up period of 5.6 years, 708 new onset cardiovascular events were recorded. For CKD identified by eGFR and dipstick testing (dipstick test ≥ trace and eGFR <60 mL/min/1.73 m²), the incidence of CKD was found to be 9 % in the general population. In comparison to non-CKD (grade 1), although cardiovascular risk was significantly higher in risk grades ≥3 (relative risk (RR) = 1.70; 95 % CI: 1.28–2.26), risk predictive ability was not significant in risk grade 2 (RR = 1.20; 95 % CI: 0.95–1.52). When CKD was defined by eGFR and UACR (UACR ≥30 mg/g Cr and eGFR <60 mL/min/1.73 m²), prevalence was found to be 29 %. Predictive ability in risk grade 2 (RR = 1.41; 95 % CI: 1.19–1.66) and risk grade ≥3 (RR = 1.76; 95 % CI: 1.37–2.28) were both significantly greater than for non-CKD. Reclassification analysis showed a significant improvement in risk predictive abilities when CKD risk grading was based on UACR rather than on dipstick testing in this population (p < 0.001).

Conclusions

Although prevalence of CKD was higher when detected by UACR rather than urine dipstick testing, the predictive ability for cardiovascular events from UACR-based risk grading was superior to that of dipstick-based risk grading in the general population.

Prevalence and Determinants of Chronic Kidney Disease Among Hypertensive Cameroonians According to Three Common Estimators of the Glomerular Filtration Rate

Hypertension is a risk factor for renal diseases, which, in turn, are precursors of hypertension. The authors assessed the prevalence and determinants of chronic kidney disease (CKD) among 336 hypertensive adult Cameroonians (mean age, 60.9±11.3 years; 63.4% women) at Yaoundé. Any participant with an estimated glomerular filtration rate <60 mL/min/1.73 m(2) regardless of the equation used (Cockcroft-Gault [CG], Modification of Diet in Renal Disease [MDRD], and Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]) and/or dipstick proteinuria was reviewed 3 months later. Participants presented a high prevalence of diabetes (18.5%), dyslipidemia (17.6%), gout/hyperuricemia (10.7%), overweight/obesity (68.8%), self-medication (37.5%), and alcohol consumption (33.3%). Hypertension was uncontrolled in 265 patients (78.9%). The prevalence of CKD was 49.7%, 50.0%, and 52.1% according to MDRD, CKD-EPI, and CG equations, respectively. Advanced age, adiposity, and severity of hypertension were determinants of CKD. Nearly half of the hypertensive patients had CKD regardless of the estimators used, predicted by well-known risk factors.

Home blood pressure monitor use in patients with chronic kidney disease

Home blood pressure monitoring (HBPM) is recommended in patients with chronic kidney disease (CKD) and hypertension (HTN). However, little is known about the use and pattern of HBPM in CKD patients. A cross-sectional study was conducted in an out-patient nephrology clinic. A total of 285 patients participated in the study. Of all patients, 66% reported using HBPM. Self-reported compliance with BP medications (93.9% vs. 85.1%, p 0.03), exercise >3 days/week (45.9 vs. 26.3%, p <0.001) and dietary sodium restriction (85.6% vs. 71.6%, p < 0.001) were more common in HBPM users vs. non-HBPM users. Most patients with HBPM used upper arm cuff (82.3%), reported receiving education on correct use of HBPM (82.5%), had perception that home BP was controlled (75.4%) and believed that HBPM is helpful in managing hypertension (85.4%). Most common reason for not using HBPM was lack of advice by a physician (43.4%). HBPM use is common in patients with CKD and HTN. HBPM users are more likely to follow life-style and dietary modifications for blood pressure control.

KNOW-Ped CKD (KoreaN cohort study for outcomes in patients with pediatric CKD): Design and methods

Background

The global prevalence of chronic kidney disease (CKD) is increasing. In children, CKD exhibits unique etiologies and can have serious impacts on children’s growth and development. Therefore, an aggressive approach to preventing the progression of CKD and its complications is imperative. To improve the understanding and management of Asian pediatric patients with CKD, we designed and launched KNOW-Ped CKD (KoreaN cohort study for Outcome in patients With Pediatric Chronic Kidney Disease), a nationwide, prospective, and observational cohort study of pediatric CKD with funding from the Korean government.

Methods/design

From seven major centers, 450 patients <20 years of age with CKD stages I to V are recruited for the comprehensive assessment of clinical findings, structured follow-up, and bio-specimen collection. The primary endpoints include CKD progression, defined as a decline of estimated glomerular filtration rate by 50 %, and a requirement for renal replacement therapy or death. The secondary outcomes include the development of left ventricular hypertrophy or hypertension, impairment of growth, neuropsychological status, behavioral status, kidney growth, and quality of life.

Discussion

With this study, we expect to obtain more information on pediatric CKD, which can be translated to better management for the patients.

Trial registration

NCT02165878 (ClinicalTrials.gov), submitted on June 11, 2014.

Prediction of prevalence of chronic kidney disease in diabetic patients in countries of the European Union up to 2025

BACKGROUND

Diabetes and chronic kidney disease (CKD) are a growing burden for health-care systems. The prevalence of diabetes has increased constantly during the last decade, although a slight flattening of end-stage renal disease as a result of diabetes has been observed recently in some European countries. In this study, we project the prevalence of CKD in patients with diabetes in European countries up to the year 2025.

METHODS

We analysed the population with diabetes and development of nephropathy in 12 European countries, which we computed from models published previously and on data from the annual reports of the European Renal Association (1998-2011). The prevalence of CKD stage 5 in patients with diabetes up to the year 2025 was projected by the Lee-Carter algorithm. Those for stage 3 and 4 were then estimated by applying the same ratios of CKD prevalences as estimated in the Austrian population with diabetic nephropathy.

RESULTS

The estimated prevalence of CKD in patients with diabetes is expected to increase in all 12 countries up to the year 2025. For CKD stage 3, we estimate for Austria in 2025 a prevalence of 215 000 per million diabetic population (p.m.p.) (95% confidence interval 169 000, 275 000), for CKD4 18 600 p.m.p. (14 500, 23 700) and for CKD5 6900 p.m.p. (5400, 8900). The median prevalence in the considered countries is 132 900 p.m.p. (IQR: 118 500, 195 800), 11 500 (10 200, 16 900) and 4300 (3800, 6300) for CKD stages 3, 4 and 5, respectively. Altogether, these data predict in the years 2012-25 an annual increase of 3.2% in the prevalence of diabetic CKD stage 5.

CONCLUSIONS

Due to the increase in prevalence of diabetes and CKD5, the costs of renal therapy are expected to rise. We believe that these data may help health-care policy makers to make informed decisions.

Effect of low-dose spironolactone on resistant hypertension in type 2 diabetes mellitus: a randomized controlled trial in a sub-Saharan African population

Background

Low-dose spironolactone has been proven to be effective for resistant hypertension in the general population, but this has yet to be confirmed in type 2 diabetic (T2DM) patients. We assessed the efficacy of a low-dose spironolactone on resistant hypertension in a sub-Saharan African population of T2DM patients from Cameroon.

Methods

This was a four-week single blinded randomized controlled trial in 17 subjects presenting with resistant hypertension in specialized diabetes care units in Cameroon. They were randomly assigned to treatment with a daily 25 mg of spironolactone (n = 9) or to an alternative antihypertensive regimen (n = 8), on top of any ongoing regimen and prevailing lifestyle prescriptions. They were seen at the start of the treatment, then 2 and 4 weeks later. The primary outcome was change in office and self-measured blood pressure (BP) during follow-up, and secondary outcomes were changes in serum potassium, sodium, and creatinine levels.

Results

Compared with alternative treatment, low-dose spironolactone was associated with significant decrease in office systolic BP (−33 vs. −14 mmHg; p = 0.024), and in diastolic BP (−14 vs. −5 mmHg; p = 0.006). After 1 month of spironolactone, all the patients were controlled based on BP below 130/80 mmHg, with significant office BP reduction from 158 ± 17/86 ± 11 to 125 ± 11/72 ± 8, vs. 158 ± 8/94 ± 8 to 144 ± 17/89 ± 12 mmHg in the alternative treatment group. There was no significant variation in sodium and creatinine levels in both groups, but a mild increase of potassium levels in the spironolactone group.

Interpretation

Add-on low-dose spironolactone was effective in reducing BP to optimal levels in T2DM Cameroonian patients despite mild increase in serum potassium.

Trial registration ClinicalTrials.gov Identifier NCT02426099. Date of registration April 2015

Change in quality of life and one-year mortality risk in maintenance dialysis patients

BACKGROUND

Quality of life (QOL) is an important metric of high-quality dialysis care. QOL is commonly measured by the Short Form 36 Questionnaire (SF-36), which provides two summary scores: a mental component score (MCS) and a physical component score (PCS). Poor QOL is associated with mortality in dialysis patients. Small studies show that changes in QOL also predicts mortality. We investigated whether changes in QOL over time are associated with mortality in a large cohort of maintenance hemodialysis patients.

METHODS

This retrospective study was conducted in 1017 outpatient dialysis facilities. Over 10,000 hemodialysis patients completed two SF-36 surveys. We compared 1-year morality rates in those whose MCS or PCS increased or decreased ±5 vs. those whose did not.

RESULTS

For those who completed two surveys, mean score for PCS was unchanged, whereas MCS increased slightly (48.6 vs. 48.9, p = 0.05). Individual patients, however, showed marked variation. On the second survey, more than half of patients demonstrated a ± 5 point change in the PCS and/or MCS. After multivariate adjustment, a ≥ 5 decrease in MCS was associated with an increase in mortality (HR = 1.33, 95 % CI 1.18, 1.50).

CONCLUSIONS

Clinicians should be aware that many patients experience a significant change in both the MCS and PCS on dialysis. A MCS decrease of ≥5 was associated with increased mortality. More study is needed to determine whether this is a causal relationship. Physicians should evaluate root causes and seek to mitigate declines in QOL whenever possible.

Association between levels of pentraxin 3 and incidence of chronic kidney disease in the elderly

OBJECTIVE

Higher levels of the novel inflammatory marker pentraxin 3 (PTX3) predict cardiovascular mortality in patients with chronic kidney disease (CKD). Yet, whether PTX3 predicts worsening of kidney function has been less well studied. We therefore investigated the associations between PTX3 levels, kidney disease measures and CKD incidence.

METHODS

Cross-sectional associations between serum PTX3 levels, urinary albumin/creatinine ratio (ACR) and cystatin C-estimated glomerular filtration rate (GFR) were assessed in two independent community-based cohorts of elderly subjects: the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS, n = 768, 51% women, mean age 75 years) and the Uppsala Longitudinal Study of Adult Men (ULSAM, n = 651, mean age 77 years). The longitudinal association between PTX3 level at baseline and incident CKD (GFR <60 mL(-1) min(-1) 1.73 m(-2) was also analysed (number of events/number at risk: PIVUS 229/746, ULSAM 206/315).

RESULTS

PTX3 levels were inversely associated with GFR [PIVUS: B-coefficient per 1 SD increase -0.16, 95% confidence interval (CI) -0.23 to -0.10, P < 0.001; ULSAM: B-coefficient per 1 SD increase -0.09, 95% CI -0.16 to -0.01, P < 0.05], but not ACR, after adjusting for age, gender, C-reactive protein and prevalent cardiovascular disease in cross-sectional analyses. In longitudinal analyses, PTX3 levels predicted incident CKD after 5 years in both cohorts [PIVUS: multivariable odds ratio (OR) 1.21, 95% CI 1.01-1.45, P < 0.05; ULSAM: multivariable OR 1.37, 95% CI 1.07-1.77, P < 0.05].

CONCLUSIONS

Higher PTX3 levels are associated with lower GFR and independently predict incident CKD in elderly men and women. Our data confirm and extend previous evidence suggesting that inflammatory processes are activated in the early stages of CKD and drive impairment of kidney function. Circulating PTX3 appears to be a promising biomarker of kidney disease.

β2 -microglobulin normalization within 6 months of ibrutinib-based treatment is associated with superior progression-free survival in patients with chronic lymphocytic leukemia

BACKGROUND

A high pretreatment β2 -microglobulin (B2M) level is associated with inferior survival outcomes in patients with chronic lymphocytic leukemia. However, to the authors' knowledge, the prognostic and predictive significance of changes in B2M during treatment have not been reported to date.

METHODS

The authors analyzed 83 patients treated with ibrutinib-based regimens (66 with recurrent/refractory disease) and 198 treatment-naive patients who were treated with combined fludarabine, cyclophosphamide, and rituximab (FCR) to characterize changes in B2M and their relationship with clinical outcomes.

RESULTS

B2M rapidly decreased during treatment with ibrutinib; on multivariable analysis, patients who received FCR (odds ratio, 0.40; 95% confidence interval [95% CI], 0.18-0.90 [P = .027]) were less likely to have normalized B2M at 6 months than patients treated with ibrutinib. On univariable analysis, normalization of B2M was associated with superior progression-free survival (PFS) from the 6-month landmark in patients treated with ibrutinib-based regimens and FCR. On multivariable analysis, failure to achieve normalized B2M at 6 months of treatment was associated with inferior PFS (hazard ratio, 16.9; 95% CI, 1.3-220.0 [P = .031]) for patients treated with ibrutinib, after adjusting for the effects of baseline B2M, stage of disease, fludarabine-refractory disease, and del(17p). In contrast, in patients treated with FCR, negative minimal residual disease status in the bone marrow was the only variable found to be significantly associated with superior PFS (hazard ratio, 0.28; 95% CI, 0.12-0.67 [P = .004]).

CONCLUSIONS

Normalization of B2M at 6 months in patients treated with ibrutinib was found to be a useful predictor of subsequent PFS and may assist in clinical decision-making.

On the rationale of population screening for chronic kidney disease: a public health perspective

Unlike opportunistic screening, population screening is accompanied by stringent quality control measures and careful programme monitoring. Sufficient evidence for benefit together with acceptable harms and costs to society are needed before launching a programme. A screening programme is a complex process organized at the population level involving multiple actors of the health care system that should ideally be supervised by public health authorities and evaluated by an independent and trustful body. Chronic kidney disease is defined by reduced glomerular filtration rate and/or presence of kidney damage for at least three months. Chronic kidney disease is divided into 5 stages with stages 1 to 3 being usually asymptomatic. Chronic kidney disease affects one in ten adults worldwide and its prevalence sharply increases with age. Kidney function is measured using serum creatinine-based, and/or cystatin C-based, equations. Markers of renal function show high intra-individual and inter-laboratory variabilities, highlighting the need for standardized procedures. There is also large inter-individual variability in age-related kidney function decline. Despite these limitations, chronic kidney disease, as currently defined, has been consistently associated with high cardiovascular morbidity and mortality and high risk of end-stage renal disease. Major modifiable risk factors for chronic kidney disease are diabetes, hypertension, obesity and cardiovascular disease. Several treatment options, ranging from antihypertensive and lipid-lowering treatments to dietary measures, reduce all-cause mortality and/or end-stage renal disease in patients with stages 1-3 chronic kidney disease. So far, no randomized controlled trial comparing outcomes with and without population screening for stages 1-3 chronic kidney disease has been published. Population screening for stages 1-3 chronic kidney disease is currently not recommended because of insufficient evidence for benefit. Given the current and future burden attributable to chronic kidney disease, randomized controlled trials exploring benefits and harms of population screening are clearly needed to prioritize resource allocations.

[Terminal renal insufficiency and indication for kidney transplantation]

BACKGROUND

Terminal renal insufficiency is characterized by the need for renal replacement therapy for survival of the patient. In addition to several types of dialysis treatment, successful renal transplantation offers the best form of renal replacement therapy in terms of long-term patient survival and quality of life.

METHOD

Living donor renal transplantation offers the best conditions concerning quality of organ transplanted and graft survival.

CONCLUSION

The risk of complications associated with renal transplantation are manageable; however, these must be weighed against the potential benefits of successful transplantation.

Outcomes After Post-Traumatic AKI Requiring RRT in United States Military Service Members

BACKGROUND AND OBJECTIVES

Mortality and CKD risk have not been described in military casualties with post-traumatic AKI requiring RRT suffered in the Iraq and Afghanistan wars.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This is a retrospective case series of post-traumatic AKI requiring RRT in 51 military health care beneficiaries (October 7, 2001-December 1, 2013), evacuated to the National Capital Region, documenting in-hospital mortality and subsequent CKD. Participants were identified using electronic medical and procedure records.

RESULTS

Age at injury was 26±6 years; of the participants, 50 were men, 16% were black, 67% were white, and 88% of injuries were caused by blast or projectiles. Presumed AKI cause was acute tubular necrosis in 98%, with rhabdomyolysis in 72%. Sixty-day all-cause mortality was 22% (95% confidence interval [95% CI], 12% to 35%), significantly less than the 50% predicted historical mortality (P<0.001). The VA/NIH Acute Renal Failure Trial Network AKI integer score predicted 60-day mortality risk was 33% (range, 6%-96%) (n=49). Of these, nine died (mortality, 18%; 95% CI, 10% to 32%), with predicted risks significantly miscalibrated (P<0.001). The area under the receiver operator characteristic curve for the AKI integer score was 0.72 (95% CI, 0.56 to 0.88), not significantly different than the AKI integer score model cohort (P=0.27). Of the 40 survivors, one had ESRD caused by cortical necrosis. Of the remaining 39, median time to last follow-up serum creatinine was 1158 days (range, 99-3316 days), serum creatinine was 0.85±0.24 mg/dl, and eGFR was 118±23 ml/min per 1.73 m(2). No eGFR was <60 ml/min per 1.73 m(2), but it may be overestimated because of large/medium amputations in 54%. Twenty-five percent (n=36) had proteinuria; one was diagnosed with CKD stage 2.

CONCLUSIONS

Despite severe injuries, participants had better in-hospital survival than predicted historically and by AKI integer score. No patient who recovered renal function had an eGFR<60 ml/min per 1.73 m(2) at last follow-up, but 23% had proteinuria, suggesting CKD burden.