Chronic kidney disease as a cardiovascular risk factor: lessons from kidney donors

Nurse-led clinical activity in kidney transplantation care in Spain: A cross-sectional observational study

OBJECTIVES

To explore the presence of specialist outpatient nursing activity in care for kidney transplant recipients in Spain and to determine the level of competence development of this activity according to the Advanced Practice Nurse model.

DESIGN

Descriptive, cross-sectional study.

PARTICIPANTS AND MEASUREMENTS

All outpatient nurses specialising in renal transplantation in the 39 transplant hospitals in Spain were included. To fulfil the study objectives, an ad hoc questionnaire and the 'Advanced Practice Nurse Role Definition Instrument (IDREPA)' were administered to assess the nurses' level of competence development.

RESULTS

Of the facilities included in the study, 25 (64.1%) had posttransplant nursing activity, 13 (33.3%) had pretransplant nursing activity and 11 (28.2%) had nursing activity involving kidney donor candidates. Twenty-seven specialist nurse's offices were identified. The results of the IDREPA reflect the presence of advanced practice in the domains of 'expert care planning' and 'comprehensive care'. Three (11.1%) nurses met all criteria for advanced nursing practice.

CONCLUSION

The results on specialised outpatient nursing activity at the 39 transplantation facilities in Spain indicate a low presence of this type of activity, with an even lower presence of advanced practice nurses.

IMPLICATIONS FOR CLINICAL PRACTICE

Management teams should consider investing in the quality of care provided by advanced nurse practice to ensure that suitable treatment is provided and better clinical outcomes are obtained.

Resveratrol ameliorates the behavioural and molecular changes in rats exposed to uninephrectomy: role of hippocampal SIRT1, BDNF and AChE

Subtle memory and cognitive changes may occur in uninephrectomized (Unix) patients long before the development of chronic kidney disease, such changes may be unnoticed. The dietary polyphenol, Resveratrol, displayed various neuroprotective effects, its role in chronic kidney disease is an area of intense studies. This work was designed to investigate the behavioural and molecular changes that may occur following 7 months of Unix in rats, and to determine whether Resveratrol intake can improve such pathology. Male Wistar rats were divided into three groups: sham operated, Unix and Unix group treated with Resveratrol (20 mg/kg/day). Rats were subjected to series of behavioural testing, different biochemical parameters along with RT-PCR and immunohistochemistry of the hippocampal tissue to track the development of functional or structural brain changes. Anxiety behaviour and reduced spatial memory performance were observed in rats 7 months post-nephrectomy; these deficits were remarkably reversed with Resveratrol. Among the species typical behaviour, burrowing was assessed; it showed significant impairment post-nephrectomy. Resveratrol intake was almost able to increase the burrowing behaviour. Decreased SIRT1 in immune-stained sections, oxidative stress, inflammatory changes, and increased AChE activity in hippocampal homogenates were found in Unix rats, and Resveratrol once more was capable to reverse such pathological changes. This work has investigated the occurrence of behavioural and structural brain changes 7 months following Unix and underlined the importance of Resveratrol to counterbalance the behavioural impairment, biochemical and brain pathological changes after uninephrectomy. These findings may raise the possible protective effects of Resveratrol intake in decreased kidney function.

Necesidades asistenciales en el estudio de personas candidatas a donantes de riñón

Objetivos: Describir las necesidades asistenciales del candidato a donante de riñón; sus características sociodemográficas y clínicas; y analizar los resultados desde una perspectiva de género.Material y Método: Estudio observacional descriptivo transversal. Se recogieron datos clínicos; sociodemográficos; y el número y tipo de visitas y pruebas realizadas durante el año 2020.Resultados: Se incluyeron 60 candidatos a donantes de riñón (n=37 mujeres; 61,67%) con una media de 51,98±14,50 años y una mediana de 2,5 [RIQ (0,69-5,29)] meses de estudio. 16 (26,67%) fueron aptos para la donación, correspondiendo al 14,16% de la actividad en Trasplante Renal (TR) del centro de referencia. Se requirieron 757 visitas (20,60% de la actividad) de las que 341 (45,05%) fueron visitas con la enfermera. Se requirieron 423 pruebas (19,60% de la actividad) durante el estudio. Se identificó una media de 1,87±1,35 factores de riesgo cardiovascular en la muestra analizada, siendo de 1,56±0,81 en los que finalmente fueron donantes. Más mujeres (n=12; 75%) que hombres (n=4; 25%) fueron finalmente donantes renales.Conclusiones: El estudio del candidato a donante de riñón es complejo e implica el doble de actividad que en el de los candidatos a receptores de trasplante renal. El proceso finaliza en donación en el 27% de los candidatos estudiados. La enfermera concentra el 45% de las visitas que se requieren. Es necesario explorar estrategias para optimizar el proceso de estudio. Hay diferencias de género en cuanto a la predisposición para estudiarse voluntariamente como candidata a donante renal.

Pan-risk factor for a comprehensive cardiovascular health management

Cardiovascular diseases (CVDs) have become the leading cause of death in China. CVDs are mainly caused by multiple well-known modifiable risk factors that are affected by socioeconomic and environmental determinants, lifestyle and behavioral choices, and familial and genetic predispositions. With more risk factors proved to be associated with CVD occurrence, the concept "pan-risk factor" is proposed in this review to indicate all discovered and yet-to-be-discovered CVD risk factors for comprehensive primary prevention of CVD. Recognizing more factors and their roles in CVD development and progression is the first step in reducing the ever-increasing burden of CVD. This review is an overview of the pan-risk factor whose associations with CVD outcomes have been established. Along with the accumulation of scientific evidence, an increasing number of risk factors will be discovered and included in the list of pan-risk factors.

Cardiovascular Effects of Unilateral Nephrectomy in Living Kidney Donors at 5 Years

Supplemental Digital Content is available in the text.

Kidney donation reduces renal function by ≈30% allowing study of the cardiovascular effects of a reduced estimated glomerular filtration rate without comorbidities. We report 5-year results of a longitudinal, parallel-group, blinded end-point study of living kidney donors (n=50) and healthy controls (n=45). The primary end point, left ventricular mass, was measured using cardiac magnetic resonance. Secondary end points, 24-hour ambulatory blood pressure, and pulse wave velocity were measured using validated blood pressure monitors and the SphygmoCor device. Effect sizes were calculated as differences between change from baseline in the donor and control groups. In donors, estimated glomerular filtration rate was 95±15 mL/min per 1.73 m2 at baseline (predonation) and 67±14 mL/min per 1.73 m2 at 5 years. In controls, there was a −1±2 mL/min per 1.73 m2 decline per annum. Change in left ventricular mass at 5 years was not significantly different between donors and controls (mean difference, +0.40 g [95% CI, −4.68 to 5.49] P=0.876), despite an initial increase in mass in donors compared with controls at 12 months. Pulse wave velocity, which increased in donors at 12 months, returned to levels not different from controls at 5 years (mean difference, −0.24 m/s [95% CI, −0.69 to 0.21]). Change in ambulatory systolic blood pressure was not different in donors compared with controls (mean difference, +1.91 mm Hg [95% CI, −2.72 to 6.54]). We found no evidence that the reduction in estimated glomerular filtration rate after kidney donation was associated with a change in left ventricular mass detectable by magnetic resonance imaging at 5 years.

Prevalence, Mechanisms, Treatment, and Complications of Hypertension Postliving Kidney Donation

Living kidney donors represent a unique population of patients. Potential donors are selected based on the belief that their preoperative fitness is likely to mitigate the risks of long- and short-term harm following uninephrectomy. Studies performed on postdonation outcomes have largely focused on mortality and the risk of end-stage renal failure, but have also investigated secondary outcomes such as cardiovascular morbidity and hypertension. It has been postulated that hypertension is a possible outcome of living kidney donation. A variety of studies have been conducted to investigate the prevalence, epidemiology, mechanisms, treatment strategies, and long-term ramifications of hypertension postdonation. These studies are heterogeneous in their population, design, methodology, and outcome measures and have presented contradicting outcomes. Additionally, the absence of a well-matched control group has made it challenging to interpret and generalise the reported findings. As such, it is not possible to definitively conclude that hypertension occurs at a higher rate among donors than the general population. This article will review the evidence of postdonation hypertension prevalence, mechanisms, treatment, and complications.

Coronary flow velocity reserve and inflammatory markers in living kidney donors

BACKGROUND

Coronary microvascular dysfunction is prevalent in chronic kidney disease (CKD), and may contribute to the development of myocardial dysfunction in CKD. Coronary flow velocity reserve (CFVR) is a marker of coronary microvascular function and falls with increasing CKD stage. Living kidney donors have renal function consistent with early stage CKD and concern has been raised about their cardiovascular risk. No studies to date have investigated the presence of coronary microvascular dysfunction in living kidney donors.

METHODS

25 healthy controls and 23 living kidney donors were recruited and underwent assessment with transthoracic echocardiography, Doppler CFVR, myocardial contrast echocardiography and serum multiplex immunoassay panels.

RESULTS

Doppler CFVR was significantly reduced in living kidney donors compared to controls (mean CFVR 3.4 ± 0.7 vs 3.8 ± 0.6, mean difference 0.4 95% confidence interval 0.03-0.8, p =.036). Quantitative myocardial contrast echocardiography showed a trend towards reduced coronary flow reserve in living kidney donors. Compared to controls, living kidney donors had higher serum high sensitivity C reactive peptide (hsCRP) and lower levels of uromodulin.

CONCLUSIONS

This is the first study of CFVR in living kidney donors. We have shown that the modest drop in estimated glomerular filtration rate in living kidney donors is associated with lower values of Doppler CFVR compared to controls, suggesting that isolated reductions in renal function may lead to altered microvascular function. The increase in hsCRP and reduction in uromodulin suggests that chronic subclinical inflammation may contribute to altered microvascular function in this population.

Changes in Blood Pressure and Arterial Hemodynamics following Living Kidney Donation

BACKGROUND AND OBJECTIVES

The Effect of a Reduction in GFR after Nephrectomy on Arterial Stiffness and Central Hemodynamics (EARNEST) study was a multicenter, prospective, controlled study designed to investigate the associations of an isolated reduction in kidney function on BP and arterial hemodynamics.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Prospective living kidney donors and healthy controls who fulfilled criteria for donation were recruited from centers with expertise in vascular research. Participants underwent office and ambulatory BP measurement, assessment of arterial stiffness, and biochemical tests at baseline and 12 months.

RESULTS

A total of 469 participants were recruited, and 306 (168 donors and 138 controls) were followed up at 12 months. In the donor group, mean eGFR was 27 ml/min per 1.73 m² lower than baseline at 12 months. Compared with baseline, at 12 months the mean within-group difference in ambulatory day systolic BP in donors was 0.1 mm Hg (95% confidence interval, -1.7 to 1.9) and 0.6 mm Hg (95% confidence interval, -0.7 to 2.0) in controls. The between-group difference was -0.5 mm Hg (95% confidence interval, -2.8 to 1.7; P=0.62). The mean within-group difference in pulse wave velocity in donors was 0.3 m/s (95% confidence interval, 0.1 to 0.4) and 0.2 m/s (95% confidence interval, -0.0 to 0.4) in controls. The between-group difference was 0.1 m/s (95% confidence interval, -0.2 to 0.3; P=0.49).

CONCLUSIONS

Changes in ambulatory peripheral BP and pulse wave velocity in kidney donors at 12 months after nephrectomy were small and not different from controls.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

NCT01769924 (https://clinicaltrials.gov/ct2/show/NCT01769924).

Pomegranate juice improves cardiometabolic risk factors, biomarkers of oxidative stress and inflammation in hemodialysis patients: a randomized crossover trial

BACKGROUND

Pomegranate has antioxidant, cardioprotective and anti-inflammatory properties. We designed a crossover study aimed at determining if consumption of pomegranate juice (PJ) improves lipid profile and oxidative and inflammatory biomarkers of hemodialysis patients. Forty-one hemodialysis patients were randomly assigned to one of two groups: PJ-treated group receiving 100 mL of natural PJ immediately after their dialysis session three times a week and the control group receiving the usual care. After 8 weeks, a 4-week washout period was established and then the role of the groups was exchanged. Lipid profile, blood pressure and oxidative and inflammatory biomarkers were measured before and after each sequence.

RESULTS

Based on the results of intention-to-treat analysis, triglycerides were decreased in PJ condition and increased in the controls. Conversely, high-density lipoprotein cholesterol was increased in PJ and decreased in the control group. Total and low-density lipoprotein cholesterol did not significantly change in either condition. Systolic and diastolic blood pressure significantly decreased in PJ condition. Total antioxidant capacity increased in PJ condition (P < 0.001) and decreased in the controls (P < 0.001). Conversely, malondialdehyde and interleukin-6 decreased in PJ (P < 0.001) and increased in the control group (P ≤ 0.001). The changes of these biomarkers were significantly different between the two conditions.

CONCLUSIONS

Eight-week PJ consumption showed beneficial effects on blood pressure, serum triglycerides, high-density lipoprotein cholesterol, oxidative stress and inflammation in hemodialysis patients. © 2019 Society of Chemical Industry.

Heart-kidney interactions: mechanistic insights from animal models

Pathological changes in the heart or kidney can instigate the release of a cascade of cardiorenal mediators that promote injury in the other organ. Combined dysfunction of heart and kidney is referred to as cardiorenal syndrome (CRS) and has gained considerable attention. CRS has been classified into five distinct entities, each with different major pathophysiological changes. Despite the magnitude of the public health problem of CRS, the underlying mechanisms are incompletely understood, and effective intervention is unavailable. Animal models have allowed us to discover pathogenic molecular changes to clarify the pathophysiological mechanisms responsible for heart-kidney interactions and to enable more accurate risk stratification and effective intervention. Here, this article focuses on the use of currently available animal models to elucidate mechanistic insights in the clinical cardiorenal phenotype arising from primary cardiac injury, primary renal disease with special emphasis of chronic kidney disease-specific risk factors, and simultaneous cardiorenal/renocardiac dysfunction. The development of novel animal models that recapitulate more closely the cardiorenal phenotype in a clinical scenario and discover the molecular basis of this condition will be of great benefit.