Establishing a renal management clinic in China: initiative, challenges, and opportunities

Cardiovascular health metrics and diabetic nephropathy: a nationally representative cross-sectional study

BACKGROUND

The pathogenesis of diabetic nephropathy is well-documented to be multifactorial. However, research available on the association between cardiovascular health and diabetic nephropathy is limited. Thus, this study aimed to investigate these potential associations and provide guidance for disease prevention.

METHODS

We applied Life's Essential 8 (LE8) identified by the American Heart Association, which integrates multiple health behaviors and health factors to measure cardiovascular health. This study covered 4207 adults with diabetes from the National Health and Nutrition Examination Survey spanning 2007-2018. Weighted regression models assessed the estimated effect of LE8 score on the prevalence of diabetic nephropathy as well as their corresponding clinical indicators. Weighted restricted cubic spline models discussed the possible nonlinear dose-response relationships further. Subgroup analyses clarified the effects of other covariates on correlations.

RESULTS

After adjusting for all covariates, participants with moderate or high cardiovascular health showed a decreased prevalence of diabetic nephropathy (odds ratio [OR]:0.52; 95% confidence interval [CI]:0.42-0.63), and also a decrease in the urinary albumin-to-creatinine ratio [UACR] (β: - 0.83; 95% CI:- 1.00 to - 0.65). The prevalence of diabetic nephropathy and the level of UACR tended to decrease linearly as the total LE8 score increased (P for nonlinear > 0.05). Subgroup analyses showed that the effects of increased overall LE8 score and the specific cardiovascular health construct varied across age and obesity strata.

CONCLUSION

Elevated overall LE8 score was significantly associated with a lower prevalence of diabetic nephropathy in U.S. adults, and the effects of the specific cardiovascular health construct on diabetic nephropathy and their corresponding clinical indicators varied. In all, maintaining good cardiovascular health by refining LE8 metrics may help reduce the adverse effects.

Update on Existing Care Models for Chronic Kidney Disease in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Approximately 78% of chronic kidney disease (CKD) cases reside in low- and middle-income countries (LMICs). However, little is known about the care models for CKD in LMICs.

OBJECTIVE

Our objective was to update a prior systematic review on CKD care models in LMICs and summarize information on multidisciplinary care and management of CKD complications.

DESIGN

We searched MEDLINE, EMBASE, and Global Health databases in September 2020, for papers published between January 1, 2017, and September 14, 2020. We used a combination of search terms, which were different iterations of CKD, care models, and LMICs. The World Bank definition (2019) was used to identify LMICs.

SETTING

Our review included studies published in LMICs across 4 continents: Africa, Asia, North America (Mexico), and Europe (Ukraine). The study settings included tertiary hospitals (n = 6), multidisciplinary clinics (n = 1), primary health centers (n = 2), referral centers (n = 2), district hospitals (n = 1), teaching hospitals (n = 1), regional hospital (n = 1), and an urban medical center (n = 1).

PATIENTS

Eighteen studies met inclusion criteria, and encompassed 4679 patients, of which 4665 were adults. Only 9 studies reported mean eGFR which ranged from 7 to 45.90 ml/min/1.73 m2.

MEASUREMENTS

We retrieved the following details about CKD care: funding, urban or rural location, types of health care staff, and type of care provided, as defined by Kidney Disease Improving Global Outcomes (KDIGO) guidelines for CKD care.

METHODS

We included studies which met the following criteria: (1) population was largely adults, defined as age 18 years and older; (2) most of the study population had CKD, and not end-stage kidney disease (ESKD); (3) population resided in an LMIC as defined by the World Bank; (4) manuscript described in some detail a clinical care model for CKD; (5) manuscript was in either English or French. Animal studies, case reports, comments, and editorials were excluded.

RESULTS

Eighteen studies (24 care models with 4665 patients) met inclusion criteria. Out of 24 care models, 20 involved interdisciplinary health care teams. Twenty models incorporated international guidelines for CKD management. However, conservative kidney management (management of kidney failure without dialysis or renal transplant) was in a minority of models (11 of 24). Although there were similarities between all the clinical care models, there was variation in services provided and in funding arrangement; the latter ranged from comprehensive government funding (eg, Sri Lanka, Thailand), to out-of-pocket payments (eg, Benin, Togo).

LIMITATIONS

These include (1) lack of detail on CKD care in many of the studies, (2) small number of included studies, (3) using a different definition of care model from the original Stanifer et al paper, and (4) using the KDIGO Guidelines as the standard for defining a CKD care model.

CONCLUSIONS

Most of the CKD models of care include the key elements of CKD care. However, access to such care depends on the funding mechanism available. In addition, few models included conservative kidney management, which should be a priority for future investment.

TRIAL REGISTRATION

Not applicable.

Multidisciplinary Chronic Kidney Disease Clinic Practices: A Scoping Review

Background:

Multidisciplinary chronic kidney disease (CKD) clinics improve patient outcomes but their optimal design is unclear.

Objective:

To perform a scoping review to identify and describe current practices (structure, function) associated with multidisciplinary CKD clinics.

Design:

Scoping review.

Setting:

Databases included Medline, EMBASE, Cochrane, and CINAHL.

Patients:

Patients followed in multidisciplinary CKD clinics globally.

Measurements:

Multidisciplinary CKD clinic composition, entry criteria, follow-up, and outcomes.

Methods:

We systematically searched the literature to identify randomized controlled trials, non-randomized interventional studies, or observational studies of multidisciplinary CKD clinics defined by an outpatient setting where two or more allied health members (with or without a nephrologist) provided longitudinal care to 50 or more adult or pediatric patients with CKD. Included studies were from 2002 to present. Searches were completed on August 10, 2018. Title, abstracts, and full texts were screened independently by two reviewers with disagreements resolved by a third. We abstracted data from included studies to summarize multidisciplinary CKD clinic team composition, entry criteria, follow-up, and processes.

Results:

40 studies (8 randomized controlled trials and 32 non-randomized interventional studies or observational studies) involving 23 230 individuals receiving multidisciplinary CKD care in 12 countries were included. Thirty-eight focused on adults (27 with CKD, 10 incident dialysis patients, one conservative therapy) while two studies focused on adolescents or children with CKD. The multidisciplinary team included a mean of 4.6 (SD 1.5) members consisting of a nephrologist, nurse, dietician, social worker, and pharmacist in 97.4%, 86.8%, 84.2%, 57.9%, and 42.1% of studies respectively. Entry criteria to multidisciplinary CKD clinics ranged from glomerular filtration rates of 20 to 70 mL/min/1.73m² or CKD stages 1 to 5 without any proteinuria or risk equation-based criteria. Frequency of follow-up was variable by severity of kidney disease. Team member roles and standardized operating procedures were infrequently reported.

Limitations:

Unstandardized definition of multidisciplinary CKD care, studies limited to CKD defined by glomerular filtration rate, and lack of representation from countries other than Canada, Taiwan, the United States, and the United Kingdom.

Conclusions:

There is heterogeneity in multidisciplinary CKD team composition, entry criteria, follow-up, and processes with inadequate reporting of this complex intervention. Additional research is needed to determine the best model for multidisciplinary CKD clinics.

Trial registration:

Not applicable.

Chronic kidney disease care models in low- and middle-income countries: a systematic review

Introduction

The number of persons with chronic kidney disease (CKD) living in low- and middle-income countries (LMIC) is increasing rapidly; yet systems built to care for them have received little attention. In order to inform the development of scalable CKD care models, we conducted a systematic review to characterise existing CKD care models in LMICs.

Methods

We searched PubMed, Embase and WHO Global Health Library databases for published reports of CKD care models from LMICs between January 2000 and 31 October 2017. We used a combination of database-specific medical subject headings and keywords for care models, CKD and LMICs as defined by the World Bank.

Results

Of 3367 retrieved articles, we reviewed the full text of 104 and identified 17 articles describing 16 programmes from 10 countries for inclusion. National efforts (n=4) focused on the prevention of end-stage renal disease through enhanced screening, public awareness campaigns and education for primary care providers. Of the 12 clinical care models, nine focused on persons with CKD and the remaining on persons at risk for CKD; a majority in the first category implemented a multidisciplinary clinic with allied health professionals or primary care providers (rather than nephrologists) in lead roles. Four clinical care models used a randomised control design allowing for assessment of programme effectiveness, but only one was assessed as having low risk for bias; all four showed significant attenuation of kidney function decline in the intervention arms.

Conclusions

Overall, very few rigorous CKD care models have been reported from LMICs. While preliminary data indicate that national efforts or clinical CKD care models bolstering primary care are successful in slowing kidney function decline, limited data on regional causes of CKD to inform national campaigns, and on effectiveness and affordability of local programmes represent important challenges to scalability.

Improvement and influencing factors of blood pressure control by nephrologist referral in chronic kidney disease patients in China: a cohort study

PURPOSE

Hypertension is an independent risk factor for mortality in chronic kidney disease (CKD) and is suboptimally controlled worldwide. Therefore, this study aimed to examine the rate of BP control and the main barriers to achieving target BP, according to K/DOQI guidelines, in China.

METHODS

We performed a single-center, prospective cohort study. Two hundred and sixty CKD patients were referred by general physicians to nephrologists, and their BP was treated in accordance with K/DOQI guidelines for a 1-year follow-up. We evaluated improvement of BP target achievement and factors affecting BP control. We defined "not-at-goal" as persistence of systolic BP ≥ 130 mmHg and/or diastolic BP ≥ 80 mmHg after 1 year.

RESULTS

The BP decreased from 138 ± 12/84 ± 7 mmHg at baseline to 124 ± 13/73 ± 7 mmHg after 1 year. The rate of achieving the BP goal (<130/80 mmHg) increased from 25.4 to 61.5 %. The decrease in BP was associated with a significant reduction of proteinuria (median, 0.14 vs 0.06 g/24 h; P < 0.05). Logistic regression analysis identified proteinuria levels ≥1.0 g/24 h (odds ratio [OR]: 5.21; 95 % confidence interval [CI]: 1.37-19.77) and high basal systolic BP (OR: 2.17; 95 % CI: 1.25-3.77) and diastolic BP (OR: 6.62; 95 % CI: 2.03-21.60) as independent predictors of not-at-goal BP. Higher educational level was independently associated with at-goal BP (OR: 0.21; 95 % CI: 0.06-0.78).

CONCLUSIONS

In CKD patients, BP control is poor when managed by general physicians and may be improved after nephrologist referral. High basal BP and proteinuria levels ≥1.0 g/24 h are the main barriers that preclude the optimal control of BP.

Epidemiology and aetiology of dialysis-treated end-stage kidney disease in Libya

Background

The extent and the distribution of end stage kidney disease (ESKD) in Libya have not been reported despite provision of dialysis over 4 decades. This study aimed to develop the first comprehensive description of the epidemiology of dialysis-treated ESKD in Libya.

Methods

Structured demographic and clinical data were obtained regarding all adult patients treated at all maintenance dialysis facilities (n=39) in Libya from May to September 2009. Subsequently data were collected prospectively on all new patients who started dialysis from September 2009 to August 2010. Population estimates were obtained from the Libyan national statistics department. The age and gender breakdown of the population in each region was obtained from mid-2009 population estimates based on 2006 census data.

Results

The prevalence of dialysis-treated ESKD was 624 per million population (pmp). 85% of prevalent patients were aged <65 years and 58% were male. The prevalence of ESKD varied considerably with age with a peak at 55–64 years (2475 pmp for males; 2197 pmp for females). The annual incidence rate was 282 pmp with some regional variation and a substantially higher rate in the South (617 pmp). The most common cause of ESKD among prevalent and incident patients was diabetes. Other important causes were glomerulonephritis, hypertensive nephropathy and congenital or hereditary diseases.

Conclusions

Libya has a relatively high prevalence and incidence of dialysis-treated ESKD. As the country prepares to redevelop its healthcare system it is hoped that these data will guide strategies for the prevention of CKD and planning for the provision of renal replacement therapy.

Clinical characteristics and outcomes of rural patients with ESRD in Guangxi, China: one dialysis center experience

OBJECTIVES

End-stage renal disease (ESRD) is a serious public health problem in Guangxi, a province of south China. This prospective study evaluated the characteristics and outcome of rural patients with ESRD in a dialysis center of Guangxi, compared with urban patients in the same period.

METHODS

A total of 238 patients (96 rural and 142 urban) who enrolled in 2007 was included in this study and followed up for 1 year. Clinical data including patient basic information, clinical parameters, laboratory tests, data associated with dialysis and prognosis were evaluated and compared between rural and urban groups.

RESULTS

Glomerulonephritis was found to be the most common cause of ESRD in all the cohorts studied, with similar rates of 47.9 and 46.5% in the rural and urban patients, respectively. Compared to urban patients, the rural patients had significantly lower prevalence of diabetic nephropathy (8.3 vs. 24.6%, P < 0.001) and higher prevalence of obstructive uropathy (20.8 vs. 3.5%, P < 0.001); the rural patients were overall younger, with poorer financial supports, but with higher rates of late referrals, poorer renal functions as indicated by related laboratory tests including lower levels of GFR, serum hemoglobin, bicarbonate and Kt/V, but higher prevalence of very low GFR, severe metabolic acidosis, severe anemia and hyperkalemia, higher rate of not initiating dialysis, radial artery puncture and mortality. The cardiovascular events were found to be the most common cause of death in both rural and urban groups.

CONCLUSIONS

Glomerulonephritis was found to be the most common cause of ESRD in all the studied patients. The rural patients with ESRD in Guangxi had kidney disease in more advanced stage at the time of first visit to a nephrologist and higher rates of mortality after dialysis initiation, compared to urban patients.

Genetic variation of apolipoprotein E does not contribute to the lipid abnormalities secondary to childhood minimal change nephrotic syndrome

Minimal change nephrotic syndrome (MCNS) is a common progressive renal disorder occurring in childhood that is characterized by alterations of permselectivity at the glomerular capillary wall, resulting in its inability to restrict the urinary loss of protein. Hyperlipidemia (HLP) is not only an important clinical manifestation of MCNS but is also involved in cardiovascular disease and in progressive renal damage. ApoE is a polymorphic protein. Besides modulation of lipid metabolism, apoE can also elevate the sulfate-proteoglycan in glomerular filtration membrane and inhibit the proliferation of mesengial cells. The present study aimed mainly to determine whether genetic polymorphism of apoE is involved in the HLP secondary to childhood MCNS. Genomic DNA was extracted from 250 children diagnosed with MCNS and 200 healthy controls. ApoE genotype was determined by PCR-restriction fragment length polymorphism (RFLP) analysis. The fasting serum lipoprotein (a) [Lp(a)], total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein A1 (apoA1), and apoB were measured. Serum concentrations of Lp(a), TC, TG, HDL-C, nonHDL-C, LDL-C, and apoB were higher in the MCNS than in the control group (P < 0.05). No significant differences in genotypes and alleles frequencies were observed for the apoE Hha I restriction sites in MCNS patients as compared to controls (P > 0.05). No significant differences in serum lipid levels were observed for variant genotypes and alleles of apoE Hha I restriction site in both MCNS and healthy children (P > 0.05). Genetic variation of apoE does not contribute to the lipid abnormalities secondary to childhood MCNS.

Altered P-selectin and CD44 expression in the renal tissues and peripheral blood of children with IgA nephropathy

OBJECTIVE

To understand the role of P-selectin (CD62P) and CD44 in mediating immune inflammation in the nephrotic process of children with IgA nephropathy (IgAN), cooperative expression of CD62P and CD44 in peripheral blood and renal tissues of IgAN children was investigated and its association with changes of histopathologic, serologic, and urinary properties was tested.

MATERIAL AND METHODS

Forty-six IgAN children were divided into three groups according to pathologic grades and clinical features. Fifteen blood samples from normal children and four normal renal biopsy specimens were used as controls. Plasma level of CD62P was detected by double antibody sandwich immunoradiometric assay; ELISA was used to determine serum level of CD44. Expression of CD62P and CD44 in renal tissues was determined by immunohistochemistry.

RESULTS

Cooperative expression of CD62P and CD44 was detected in renal tissues and peripheral blood of IgAN children. Altered expression of CD62P and CD44 in peripheral blood significantly correlated not only with hematuria, proteinuria, serum cholesterol, and albumin, and with urine NAG and beta(2)-MG, but also with degree of tubulointerstitial injury in IgAN children.

CONCLUSION

The evidence supported CD62P and CD44 as initial and promoting factors mediating immune inflammation in the nephrotic process in IgAN children. The cooperative expression profiles of CD62P and CD44 in renal tissues and peripheral blood combined with serologic and urinary predictors may be important in diagnosis of progression in children with IgAN.