Chronic kidney disease in Asia

The Etiology of Advanced Chronic Kidney Disease in Southeast Asia: A Meta-analysis

INTRODUCTION

Chronic kidney disease (CKD) etiology varies greatly between developed and developing countries. In addition, differences in underlying pathogenesis and therapeutic options affect the progression towards advanced-CKD. This meta-analysis aims to identify the etiology of advanced-CKD in Southeast Asia.

METHODS

A systematic search in four electronic-databases and complementary search on national kidney registries and repository libraries was conducted until July 20, 2023. The risk of bias was assessed using Newcastle-Ottawa Scale for observational studies and Version-2 of Cochrane for intervention studies. A random-effects model was used to estimate pooled prevalence. The protocol is registered in the International Prospective Register of Systematic Reviews PROSPERO; Registration ID:CRD42022300786.

RESULTS

We analyzed 81 studies involving 32,834 subjects. The pooled prevalence of advanced-CKD etiologies are diabetic kidney disease (DKD) 29.2% (95%CI 23.88-34.78), glomerulonephritis 20.0% (95%CI 16.84-23.38), hypertension 16.8% (95%CI 14.05-19.70), other 8.6% (95%CI 6.97-10.47), unknown 7.5% (95%CI 4.32-11.50), and polycystic kidney disease 0.7% (95%CI 0.40-1.16). We found a significant increase in DKD prevalence from 21% (9.2%, 95%CI 0.00-33.01) to 30% (95%CI 24.59-35.97) before and after the year 2000. Among upper-middle-income and high-income countries, DKD is the most prevalent (26.8%, 95%CI 21.42-32.60 and 38.9%, 95%CI 29.33-48.79, respectively), while glomerulonephritis is common in lower-middle-income countries (33.8%, 95%CI 15.62-54.81).

CONCLUSION

The leading cause of advanced-CKD in Southeast Asia is DKD, with a substantial proportion of glomerulonephritis. An efficient screening program targeting high-risk populations (diabetes mellitus and glomerulonephritis) is needed, with the aim to delay CKD progression.

Maturation and Patency Rates in Basilic Transposition Arteriovenous Fistula Under Regional Versus General Anesthesia: A Single-Center, Retrospective, Observational Study

Background Basilic transposition arteriovenous fistula (BT AVF) is a viable option for dialysis-dependent patients, which can be performed under either general or regional anesthesia. Regional anesthesia is reported to cause vascular dilatation during the perioperative period, leading to improved fistula success. Regional anesthesia is also considered safe as compared to general anesthesia in terms of hemodynamic stability. Limited and conflicting data are available comparing regional versus general anesthesia in terms of fistula maturation and patency. We aimed to compare the maturation, one-year patency rates, and complication rates in patients undergoing single-stage BT AVF in regional versus general anesthesia. Methods This retrospective observational study was conducted on patients undergoing single-stage BT AVF from January 2016 to December 2019. Patients were divided into regional (RA) vs. general anesthesia (GA) groups and compared in terms of maturation, one-year patency, and perioperative complication rates. Results Out of 152 patients, 110 (72.37%) were in GA while 42 (27.63%) were in the RA group. Elderly, female, diabetic, ischemic heart disease, and American Society of Anesthesiologists (ASA) class IV patients were more in the RA group. Other comorbid and vascular access-related factors were comparable between the groups. A trend toward higher maturation rates (97.6% vs. 92.1%) and one-year patency rates (62.5% vs. 56.6%) was observed in the RA vs. GA group, however, the difference did not attain statistical significance, p=0.359 and p=0.327, respectively. The rate of access abandonment was higher in the GA group (43.4% vs. 37.5%). The most prevalent cause of abandonment was death in the RA group while it was access failure in the GA group. Overall complication rates were comparable between both groups (20.2 % vs. 17.5%, p=0.816). Conclusion Regional anesthesia is a useful technique with potentially improved maturation and patency rates. Nevertheless, an assumed benefit of regional anesthesia in terms of anesthesia-related complications was not observed.

Aging and Renal Disease: Old Questions for New Challenges

Chronic kidney disease (CKD) is a growing problem among aging population, and the number of individuals at risk of end stage renal disease is rising. Part of the reason lies in incomplete understanding of the pathways underlying renal aging and kidney disease, as well as insufficient delivery of evidence-based treatment to elderly patients with CKD. This review aims to address these unsolved issues by delineating updated mechanisms of renal senescence and summarizing recent findings on key clinical aspects of CKD in the elderly. Challenges and obstacles in caring for older people with CKD are discussed, with an emphasis on modification of risk factors, prevention of acute kidney injury, stabilization of progression and decision on dialysis initiation.

ACE Inhibitor/Angiotensin Receptor Blocker Use Patterns in Advanced CKD and Risk of Kidney Failure and Death

Rationale & Objective

The use of renin-angiotensin system (RAS) inhibitors is standard of care in people with early to moderate chronic kidney disease (CKD). Less is known regarding the efficacy of RAS inhibitors in very advanced CKD. In this study, we describe patterns of use of RAS inhibitors and associations of these patterns of use with risk for CKD progression and mortality in patients with advanced CKD.

Study Design

Propensity-matched cohort study.

Settings & Participants

We identified 678 participants who were enrolled in the multicenter Chronic Renal Insufficiency Cohort (CRIC) Study with estimated glomerular filtration rates (eGFRs) < 30 mL/min/1.73 m² at the baseline visit.

Exposure

Use of RAS inhibitors within the first year after the baseline visit, characterized by 4 patterns of use: never users, always users, dynamic users, and new users.

Outcome(s)

Progression to end-stage renal disease (ESRD) and all-cause mortality.

Analytical Approach

We generated propensity scores and matched participants in the always users group with a 1:1 ratio with a participant from the other 3 groups, matching by age, sex, race, diabetes, hypertension, systolic blood pressure, eGFR, urinary protein-creatinine ratio, and serum potassium level. Cox models were used to test the association of patterns of RAS inhibitor use with risk for kidney failure and death.

Results

Of the 678 participants with eGFRs < 30 mL/min/1.73 m², 57% were identified as always users of RAS inhibitors during the 1 year, 23% as never users, 13% as dynamic users, and 7% as new users. We found no differences in risk for ESRD across patterns of RAS inhibitor use (never users [HR, 1.09; 95% CI, 0.71-1.67], dynamic users [HR, 1.46; 95% CI, 0.83-2.55], new users [HR, 0.78; 95% CI, 0.33-1.84] vs the always users reference group). Similarly, there was no association of patterns of RAS inhibitor use with death (never users [HR, 1.02; CI, 0.74-1.40], dynamic users [HR, 1.23; 95% CI, 0.80-1.90], new users [HR, 1.10; 95% CI, 0.63-1.92] vs always users).

Limitations

Observational study.

Conclusions

Use of RAS inhibitors in patients with eGFRs < 30 mL/min/1.73 m² is heterogeneous.^.We found no difference in risk for progression to ESRD or mortality across patterns of RAS inhibitor use. Further research is required to identify optimal prescribing strategies of RAS inhibitors during advanced stages of CKD.

Exercise interventions on patients with end-stage renal disease: a systematic review

Objective:

This study aimed to conduct an up-to-date systematic review of the literature to evaluate the effects of exercise on fatigue, anxiety, depression, physical activity, and quality of life (QOL) in patients with end-stage renal disease.

Data sources:

We searched PubMed (October 2018), Embase (from 1966 to October 2018), Web of Science (from 1900 to October 2018), The Cochrane Library (October 2018), and references of papers.

Methods:

This study includes randomized controlled trials that analyzed the combined effects of exercise intervention on patients with end-stage renal disease. Two reviewers independently screened the retrieved records, extracted data, and assessed the risk of bias for inclusion in the study. The effects of exercise intervention were conducted in the meta-analysis using RevMan 5.3 software.

Results:

A total of 614 participants were included in 13 randomized controlled studies. The study revealed that exercise can improve fatigue, anxiety, depression, physical activity, and QOL. The effect value results were as follows: (1) fatigue, −0.97 (95% confidence interval (CI) −1.32 to −0.62, P < 0.00001); (2) anxiety, −0.78 (95% CI −1.17 to −0.39, P < 0.0001); (3) depression, −0.85 (95% CI −1.13 to −0.56, P < 0.00001) (4) physical activity, 38.15 (95% CI 21.20 to 55.10, P < 0.0001); (5) QOL, the physical component of the 36-item Short-Form Health Survey (SF-36), 4.73 (95% CI 1.92 to 7.54, P = 0.0010); and (6) the mental component of the SF-36, 3.42 (95% CI 0.27 to 6.56, P = 0.03).

Conclusion:

Exercise intervention is more effective in fatigue, anxiety, depression, physical activity, and QOL. However, large-scale randomized controlled trials are needed to confirm the appropriate types of exercise and optimal time for patients with end-stage renal disease.

Acupuncture Application in Chronic Kidney Disease and its Potential Mechanisms

Chronic kidney disease (CKD) is an increasing major public health problem worldwide. The number of CKD patients on hemodialysis is growing rapidly as well. Acupuncture technique is one of the traditional Chinese medicine methods and has been used in a variety of diseases. Nowadays, the clinical application of acupuncture technique for CKD patients has become the focus for its effectiveness and security. In this paper, we will review the therapeutic effects and mechanisms of different acupuncture techniques for CKD patients. In patients with CKD, acupuncture improves renal function, reduces proteinuria, controls hypertension, corrects anemia, relieves pain, and controls many hemodialysis-related complications such as uremic pruritus, insomnia and fatigue. The mechanisms are related to the regulation of sympathetic nerve and the activation of bioactive chemicals. In conclusion, acupuncture is proved to be beneficial for CKD patients. More research, however, is needed to verify the potential mechanisms.

Prevalence and related risk factors of chronic kidney disease among adults in Luxembourg: evidence from the observation of cardiovascular risk factors (ORISCAV-LUX) study

BACKGROUND

Evidence on stages of renal impairment and related risk factors in Luxembourg is lacking. This study aimed to assess the prevalence of chronic kidney disease (CKD) and identify potential correlates among the general population, using the recent definition suggested by the Kidney Disease Improving Global Outcomes guidelines.

METHODS

Data analysed from 1361 participants aged 18-69 years, enrolled in the Observation of Cardiovascular Risk Factors in Luxembourg (ORISCAV-LUX) study, 2007-08. Descriptive and multivariable logistic regression analyses were performed to identify demographic, socio-economic, behavioural, and clinical factors associated with CKD, defined as a single estimated glomerular filtration rate (eGFR) measure <60 ml/min/1.73m² and/or urinary albumin: creatinine ratio (ACR) > 30 mg/g.

RESULTS

Overall, 6.3% had CKD, including 4.4% and 0.7% with moderate and severe macroalbuminuria respectively. 0.1% had kidney failure (eGFR < 15 ml/min/1.73 m²). CKD was higher among subjects with primary education and risk increased significantly with age; the odd ratio was more than 2-fold higher among participants aged 50-69 years. Hypertension and diabetes were associated with more than 3-fold and 4-fold higher risks of CKD [adjusted odd ratio (AOR 3.46 (95%CI 1.92, 6.24), P < 0.001] and [AOR 4.45 (2.18, 9.07), P < 0.001] respectively. Increased physical activity measured as total MET-hour/week was independently associated with a lower odds of CKD (P = 0.035).

CONCLUSION

The national baseline prevalence estimate of CKD, a neglected public health problem, stresses the benefit of early detection particularly in high-risk subjects with associated cardiovascular pathologies (e.g. hypertension, diabetes), to prevent and defray costs related to eventual complications.

Associations of estimated glomerular filtration rate and blood urea nitrogen with incident coronary heart disease: the Dongfeng-Tongji Cohort Study

Estimated glomerular filtration rate (eGFR) has been reported to be associated with risk of incident coronary heart disease (CHD), and blood urea nitrogen (BUN) has been shown to be a strong predictor of mortality in patients with heart failure (HF). However, such epidemiological evidence from Chinese population was still limited. We used Cox proportional-hazards regression models to investigate the associations of eGFR and BUN with risk of incident CHD in the prospective Dongfeng-Tongji (DFTJ) cohort. After fully adjusted for potential confounders, a 10-unit decline in eGFR was associated with higher risk for CHD (hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.01-1.09); compared with individuals with normal eGFR levels (eGFR ≥ 90 ml/min per 1.73 m2), individuals with a mild-to-severe eGFR decline (15 to 60 ml/min per 1.73 m2) were at significantly greater risk for CHD (HR 1.25, 95% CI 1.05-1.48; P = 0.011). Compared with individuals in the lowest tertile of BUN, those in the highest tertile were at significantly greater risk for CHD (HR 1.17, 95% CI 1.03-1.33; P = 0.014). In conclusion, a mild-to-severe decline in eGFR or a raised level of BUN might be associated with increased risk of incident CHD in middle-aged and elderly Chinese populations.

Acupuncture and related interventions for symptoms of chronic kidney disease

BACKGROUND

People living with chronic kidney disease (CKD) experience a range of symptoms and often have complex comorbidities. Many pharmacological interventions for people with CKD have known risks of adverse events. Acupuncture is widely used for symptom management in patients with chronic diseases and in other palliative care settings. However, the safety and efficacy of acupuncture for people with CKD remains largely unknown.

OBJECTIVES

We aimed to evaluate the benefits and harms of acupuncture, electro-acupuncture, acupressure, moxibustion and other acupuncture-related interventions (alone or combined with other acupuncture-related interventions) for symptoms of CKD. In particular, we planned to compare acupuncture and related interventions with conventional medicine, active non-pharmacological interventions, and routine care for symptoms of CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Specialised Register up to 28 January 2016 through contact with the Information Specialist using search terms relevant to this review. We also searched Korean medical databases (including Korean Studies Information, DBPIA, Korea Institute of Science and Technology Information, Research Information Centre for Health Database, KoreaMed, the National Assembly Library) and Chinese databases (including the China Academic Journal).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that investigated the effects of acupuncture and related point-stimulation interventions with or without needle penetration that involved six sessions or more in adults with CKD stage 3 to 5, regardless of the language and type of publication. We excluded studies that used herbal medicine or co-interventions administered unequally among the study groups.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed risk of bias. We calculated the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratio (RR) for dichotomous outcomes. Primary outcomes were changes in pain and depression, and occurrence of serious of adverse events.

MAIN RESULTS

We included 24 studies that involved a total of 1787 participants. Studies reported on various types of acupuncture and related interventions including manual acupuncture and acupressure, ear acupressure, transcutaneous electrical acupuncture point stimulation, far-infrared radiation on acupuncture points and indirect moxibustion. CKD stages included pre-dialysis stage 3 or 4 and end-stage kidney disease on either haemodialysis or peritoneal dialysis.None of the included studies assessed pain outcomes, nor formally addressed occurrence of serious adverse events, although three studies reported three participant deaths and three hospitalisations as reasons for attrition. Three studies reported minor acupuncture-related harms; the remainder did not report if those events occurred.All studies were assessed at high or unclear risk of bias in terms of allocation concealment. Seventeen studies reported outcomes measured for only two months.There was very low quality of evidence that compared with routine care, manual acupressure reduced scores of the Beck Depression Inventory score (scale from 0 to 63) (3 studies, 128 participants: MD -4.29, 95% CI -7.48 to -1.11, I(2) = 0%), the revised Piper Fatigue Scale (scale from 0 to 10) (3 studies, 128 participants: MD -1.19, 95% CI -1.77 to -0.60, I(2) = 0%), and the Pittsburgh Sleep Quality Index (scale from 0 to 21) (4 studies, 180 participants: MD -2.46, 95% CI -4.23 to -0.69, I(2) = 50%).We were unable to perform further meta-analyses because of the paucity of data and problems with clinical heterogeneity, such as different interventions, comparisons and timing of outcome measurements.

AUTHORS' CONCLUSIONS

There was very low quality of evidence of the short-term effects of manual acupressure as an adjuvant intervention for fatigue, depression, sleep disturbance and uraemic pruritus in patients undergoing regular haemodialysis. The paucity of evidence indicates that there is little evidence of the effects of other types of acupuncture for other outcomes, including pain, in patients with other stages of CKD. Overall high or unclear risk of bias distorts the validity of the reported benefit of acupuncture and makes the estimated effects uncertain. The incomplete reporting of acupuncture-related harm does not permit us to assess the safety of acupuncture and related interventions. Future studies should investigate the effects and safety of acupuncture for pain and other common symptoms in patients with CKD and those undergoing dialysis.

The role of an integrated care model for kidney disease in the development of peritoneal dialysis: a single-center experience in China

Peritoneal dialysis plays a crucial role in the integrated care of patients with end-stage renal disease (ESRD). In this paper, we retrospectively analyzed the quality indicators of peritoneal dialysis (PD) in 712 patients from our center who underwent PD between 2004 and 2011. In 43% of patients, follow-up was undertaken every 3 months at our outpatient department, and 54% patients were followed up by both our hospital and other local hospitals. The patient survival rate at 1, 3 and 5 years was 96.3%, 85.4% and 76.2%, respectively. The technique survival (excludes death/transplantation) at 1, 3 and 5 years was 95.1%, 87.7% and 79.6%, respectively. Fluid overload occurred in 29.2% of patients and was one of the major reasons for discontinuing PD. The peritonitis rate in our center decreased to 0.16 episodes/year in 2011. In addition, since our center is one of the largest integrated-treatment centers for ESRD in China, we have developed a multilevel care program in Zhejiang Province, which resulted in rapid growth of PD in our province in recent years.

Distribution of and factors contributing to chronic kidney disease in a middle-aged working population

OBJECTIVES

To clarify the distribution of chronic kidney disease (CKD) and the factors contributing to its development and progression in middle-aged Japanese workers/employees.

METHODS

This was a retrospective study involving 3,964 men and 2,698 women aged 35-64 years in 2009 who had been followed-up until 2003. Data on proteinuria determined with a dipstick and glomerular filtration rate estimated from serum creatinine concentration (eGFR) were collected in the annual health check-ups.

RESULTS

Proteinuria was detected in 2.9 and 1.1 % of the men and women, respectively, and total CKD was detected in 16.0 and 16.1 % of the men and women respectively. Moderate or severe CKD associated a high risk of cardiovascular diseases and end-stage kidney disease was found mostly in the male subjects [2.0 (men) vs. 0.6 % (women)]. High-risk CKD was found in 3.3 % of the men aged 55-64 years. A body mass index (BMI) of ≥30, hypertension, diabetes mellitus (DM), current smoking and some job types were independently related to the development of proteinuria, while age, BMI, hypertriglyceridemia, and job types were related to total CKD. The development of high-risk CKD was related to preceding mild CKD signs of reduced eGFR and proteinuria as well as to hypertension, DM, smoking, and job type.

CONCLUSIONS

Chronic kidney disease was found in 16 % of middle-aged workers with an equal prevalence in both sexes, while high-risk CKD was found mostly in men, of whom 3.3 % were aged 55-64 years. Obesity, hypertension, DM, smoking and some job types were related to the development and progression of CKD.

Role of asymmetrical dimethylarginine in the progression of renal disease

Asymmetric dimethylarginine (ADMA) is a naturally occurring amino acid found in tissues and cells that circulates in plasma and is excreted in urine. It inhibits nitric oxide synthases (NOs) and produces considerable cardiovascular biological effects. Several studies have suggested that plasma concentrations of ADMA provide a marker of risk for endothelial dysfunction and cardiovascular disease. In animal and in population studies ADMA has been associated with progression of CKD. Several mechanisms may be involved in this association, such as compromise of the integrity of the glomerular filtration barrier and development of renal fibrosis. This review summarizes the existing literature on the biology and physiology of ADMA focusing on its role in the progression of renal disease.

Effects of exercise on kidney function among non-diabetic patients with hypertension and renal disease: randomized controlled trial

Background

Chronic kidney disease is an important public health threat. Such patients present high morbidity and mortality due to cardiovascular disease, with low quality of life and survival, and also high expenditure resulting from the treatment. Arterial hypertension is both a cause and a complication of kidney disease; also, arterial hypertension is a risk factor for cardiovascular disease among patients with kidney diseases. There is some evidence that exercise interventions may be beneficial to chronic kidney disease patients, but previous studies included only end-stage patients, i.e. those undergoing dialysis. This study aims to evaluate the effect of exercise on kidney function, quality of life and other risk factors for cardiovascular disease among non-diabetic chronic hypertensive kidney disease patients who are not undergoing dialysis.

Methods

The participants will be located through screening hypertensive patients attended within the public healthcare network in Pelotas, a city in south of Brazil. Eligible individuals will be those with glomerular filtration rate between 15 and 59 ml/min x 1.73 m². The randomization will be done in fixed-size blocks of six individuals such that 75 participants will be allocated to each group. At baseline, information on demographic, socioeconomic, behavioral, anthropometric, blood pressure and quality-of-life variables will be collected, and laboratory tests will be performed. The intervention will consist of three weekly physical exercise sessions lasting 60–75 minutes each, with a total duration of 16 weeks. The outcomes will be the kidney function progression rate, quality of life, blood pressure, lipid profile, hemoglobin level, ultrasensitive C-reactive protein level, and ankle-arm index. The patients in both groups (intervention and control) will be reassessed and compared partway through the study (8^th week), at the end of the intervention (16^th week) and in the 8^th week after the end of the intervention.

Discussion

There is still a scarcity of data relating to the effect of physical exercise among the most numerous group of individuals with kidney disease, i.e. patients undergoing conservative treatment. In particular, there is a lack of randomized controlled studies. This study will help fill this gap.

Left ventricular dysfunction due to diffuse multiple vessel coronary artery spasm can be concealed in dilated cardiomyopathy

AIMS

Many patients with idiopathic dilated cardiomyopathy (DCM) have been diagnosed on the basis of the exclusion of significant coronary stenosis and the presence of left ventricular (LV) dysfunction. In the present study, we investigated the possibility that coronary multispasm is one of the mechanisms leading to diffuse idiopathic DCM-like LV dysfunction.

METHODS AND RESULTS

Forty-two patients with severely depressed LV function but without significant coronary stenosis were enrolled (baseline LV ejection fraction, 33 ± 11%). An acetylcholine (ACh) provocation test was performed at the time of coronary angiography. In patients with a positive ACh provocation test (n = 20), coronary angiography revealed multivessel diffuse coronary spasm with marked electrocardiogram changes. In patients with a negative ACh provocation test (n = 22), significant findings compatible with idiopathic DCM were more frequently observed on magnetic resonance imaging (MRI) or in LV biopsies compared with the ACh-positive group (MRI, 73% vs. 12%; and LV biopsy, 71% vs. 0%, respectively; P < 0.01). In the ACh-positive group, LV function significantly improved after the administration of calcium channel blockers (LV ejection fraction, 34 ± 12% vs. 54 ± 10%; and brain natriuretic peptide, 803 ± 482 pg/mL vs. 69 ± 84 pg/mL, at baseline and 1 year, respectively; P < 0.01).

CONCLUSIONS

Our results raise the possibility that patients with LV dysfunction due to repeated coronary multispasm are being diagnosed as idiopathic DCM, and that calcium channel blockers may prove to be a promising therapeutic strategy in those patients.

Genome-wide association and functional follow-up reveals new loci for kidney function

Chronic kidney disease (CKD) is an important public health problem with a genetic component. We performed genome-wide association studies in up to 130,600 European ancestry participants overall, and stratified for key CKD risk factors. We uncovered 6 new loci in association with estimated glomerular filtration rate (eGFR), the primary clinical measure of CKD, in or near MPPED2, DDX1, SLC47A1, CDK12, CASP9, and INO80. Morpholino knockdown of mpped2 and casp9 in zebrafish embryos revealed podocyte and tubular abnormalities with altered dextran clearance, suggesting a role for these genes in renal function. By providing new insights into genes that regulate renal function, these results could further our understanding of the pathogenesis of CKD.

Uncertain etiologies of proteinuric-chronic kidney disease in rural Sri Lanka

The global prevalence of chronic kidney disease (CKD) of uncertain etiology may be underreported. Community-level epidemiological studies are few due to the lack of national registries and poor focus on the reporting of non-communicable diseases. Here we describe the prevalence of proteinuric-CKD and disease characteristics of three rural populations in the North Central, Central, and Southern Provinces of Sri Lanka. Patients were selected using the random cluster sampling method and those older than 19 years of age were screened for persistent dipstick proteinuria. The prevalence of proteinuric-CKD in the Medawachchiya region (North Central) was 130 of 2600 patients, 68 of 709 patients in the Yatinuwara region (Central), and 66 of 2844 patients in the Hambantota region (Southern). The mean ages of these patients with CKD ranged from 44 to 52 years. Diabetes and long-standing hypertension were the main risk factors of CKD in the Yatinuwara and Hambantota regions. Age, exceeding 60 years, and farming were strongly associated with proteinuric-CKD in the Medawachchiya region; however, major risk factors were uncertain in 87% of these patients. Of these patients, 26 underwent renal biopsy; histology indicated tubulointerstitial disease. Thus, proteinuric-CKD of uncertain etiology is prevalent in the North Central Province of Sri Lanka. In contrast, known risk factors were associated with CKD in the Central and Southern Provinces.

Evaluation of the Chronic Kidney Disease Epidemiology Collaboration equation for estimating the glomerular filtration rate in multiple ethnicities

An equation from the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) provides more accurate estimates of the glomerular filtration rate (eGFR) than that from the modification of diet in renal disease (MDRD) Study, although both include a two-level variable for race (Black and White and other). Since creatinine generation differs among ethnic groups, it is possible that a multilevel ethnic variable would allow more accurate estimates across all groups. To evaluate this, we developed an equation to calculate eGFR that includes a four-level race variable (Black, Asian, Native American and Hispanic, and White and other) using a database of 8254 patients pooled from 10 studies. This equation was then validated in 4014 patients using 17 additional studies from the United States and Europe (validation database), and in 1022 patients from China (675), Japan (248), and South Africa (99). Coefficients for the Black, Asian, and Native American and Hispanic groups resulted in 15, 5, and 1% higher levels of eGFR, respectively, compared with the White and other group. In the validation database, the two-level race equation had minimal bias in Black, Native American and Hispanic, and White and other cohorts. The four-level ethnicity equation significantly improved bias in Asians of the validation data set and in Chinese. Both equations had a large bias in Japanese and South African patients. Thus, heterogeneity in performance among the ethnic and geographic groups precludes use of the four-level race equation. The CKD-EPI two-level race equation can be used in the United States and Europe across a wide range of ethnicity.

Current status of estimated glomerular filtration rate (eGFR) equations for Asians and an approach to create a common eGFR equation

CKD is now recognized as life-threatening disease and various countermeasures are implemented worldwide. The most important step to overcome CKD is early detection and evaluation. Equation for estimating GFR is the necessary tool for this step. This is also useful to follow-up CKD patients in routine clinical settings. Currently, most commonly used equation is original and re-expressed MDRD formula. For Asians, ethnic co-efficient is needed when applying these formulas. Ethnic co-efficient is different among Asian countries. Recently, different original equations have been developed in several Asian countries. At the present time, it is not clear to develop a single common eGFR equation fit for Asians. There are several factors that affect GFR estimation. These include ethnicity, reference method to measure GFR, method of creatinine measurement and calibration. Towards the future, Asian collaborative study is necessary to validate and standardize eGFR equations.

A prediction model for the risk of incident chronic kidney disease

BACKGROUND

Chronic kidney disease is a health burden for the general population. We designed a cohort study to construct prediction models for chronic kidney disease in the Chinese population.

METHODS

A total of 5168 participants were followed up during a median of 2.2 (interquartile range, 1.5-2.9) years, and 190 individuals (3.7%) developed chronic kidney disease, defined by a glomerular filtration rate of less than 60 mL/min/1.73 m(2).

RESULTS

We developed a point system to estimate chronic kidney disease risk at 4 years using the following variables: age (8 points), body mass index (2 points), diastolic blood pressure (2 points), and history of type 2 diabetes (1 point) and stroke (4 points) for the clinical model, with the addition of uric acid (2 points), postprandial glucose (1 point), hemoglobin A1c (1 point), and proteinuria 100 mg/dL or greater (6 points) for the biochemical model. Similar discrimination measures were found between the clinical model (area under the receiver operating characteristic curve, 0.768; 95% confidence interval (CI), 0.738-0.798) and the biochemical model (area under the receiver operating characteristic curve, 0.765; 95% CI, 0.734-0.796). The area under the receiver operating characteristic curve of the clinical model was 0.667 (95% CI, 0.631-0.703) for the external validation data from community-based cohort participants. The optimal cutoff value for the clinical model was set as 7, with a sensitivity of 0.76 and a specificity of 0.66.

CONCLUSION

We constructed a clinical point-based model to predict the 4-year incidence of chronic kidney disease. This prediction tool may help to target Chinese subjects at risk of developing chronic kidney disease.

The role of primary care in the management of the chronic kidney disease population

With the recognition of the high prevalence of CKD and its associated morbidity and mortality, increasing attention has focused on how to optimally provide care to this population. An immediate concern is that the sheer size of the population with early-stage CKD will overwhelm the capacity of the current nephrology workforce. Thus, the burden of care for most CKD patients will likely have to fall on primary care physicians (PCPs). This article reviews the issues surrounding the role of primary care in the management of the CKD population. Topics covered include specific roles that PCPs can play in the care of CKD patients, barriers and challenges to PCP involvement, and a discussion of strategies to improve the care provided to CKD patients by PCPs.

Prevalence of chronic kidney disease in the Black Sea Region, Turkey, and investigation of the related factors with chronic kidney disease

We aimed to assess the prevalence of CKD in the Black Sea Region, Turkey, and to evaluate any relationship between age, gender, diabetes, obesity, hypertension, and CKD. This study was conducted in 70 different areas in Tokat Province in the Black Sea Region, in the northern part of Turkey. The estimated glomerular filtration rate (eGFR) was calculated from the serum creatinine using MDRD formulas. CKD-defined estimated GFR was lower than 60 mL/min/1.73 m(2). A total of 1,079 persons were included in this study (mean age 41.4+/-17 years [range: 18-95 years], 49.4% males, 50.6% living in an urban area). Of the 1,079 individuals, 5.28% were diabetic, 22.9% were obese, and 37.8% were hypertensive. CKD was found in 62 of them (5.75%). The prevalence of CKD was 5.58% in non-diabetics and 8.77% in diabetics. No significant differences were found between two groups. The prevalence of CKD was 3.77% in non-hypertensive individuals and 8.82% in hypertensive patients, and 4.46% in non-obese and 9.31% in obese. The evident significant differences were found between groups (p < 0.0001 and p = 0.004, respectively). The prevalence of CKD increased with age within our population. A salient observation was the markedly higher prevalence of CKD in females than males (p = 0.046). There was an inverse correlation between eGFR and age (r = 0.529, p < 0.0001). The overall prevalence of CKD was 5.75% in general population. The prevalence of CKD increased with age within our population. Age, gender, obesity and hypertension were found to be significant risk factors for development of CKD in our population.

Ethnic disparities in prevalence and impact of risk factors of chronic kidney disease

BACKGROUND

There is substantial heterogeneity in literature regarding the epidemiology for chronic kidney disease (CKD) in different Asian populations. We aimed to assess the prevalence and risk factors of CKD in a multi-ethnic Asian population in Singapore.

METHODS

We examined 4499 participants of Chinese, Malay and Indian ethnicity, aged 24-95 years, who participated in the Singapore Prospective Study Program. CKD was defined as an estimated glomerular filtration rate <60 ml/min/1.73 m(2) or the presence of micro/macroalbuminuria.

RESULTS

The age, sex-standardized prevalence of CKD was 12.8% (11.4%, 18.6% and 17.6% in Chinese, Malays and Indians). Older age and the presence of diabetes, hypertension and dyslipidaemia were significantly associated with CKD in all ethnic groups. Clinical, metabolic, socioeconomic and behavioral factors accounted for 68% and 78% of excess risk of CKD in Malays and in Indians, respectively. Diabetes (45%) and dyslipidaemia (16%) among Malays and hypertension among Indians (23%) had greater population-attributable risk of CKD.

CONCLUSIONS

The prevalence of CKD is high in all three major Asian ethnic groups, in particular Malays and Indians, but risk factors are similar to those reported from previous studies in Western populations. The association of modifiable risk factors with CKD emphasizes the need to screen and treat high-risk populations for early detection and prevention of CKD.

Analysis of multidisciplinary care models and interface with primary care in management of chronic kidney disease

Public policy efforts and education have led to an increased appreciation of the prevalence of chronic kidney disease (CKD) in general outpatient populations. The complexity of the care of individuals with established CKD has led to the development of multidisciplinary care models, which have been shown to improve the clinical outcomes of those with CKD. The interface between specialty and primary care in various systems remains necessary and desired, albeit a continuing challenge. This overview reviews various models of specialty care for CKD patients, including those that emphasize multidisciplinary team approaches, and highlight the essential role(s) of primary care physicians. Importantly, there is a need for improved definition of CKD populations and individuals, review and refinement of proposed care pathways, and the need to define essential elements of care for the patient. Models of care often are not subject to the same rigor that other interventions applied to this population are; nonetheless, we offer here a framework for establishing and evaluating care models for the CKD populations at various stages of disease and with various comorbidities.