Renoprotection: one or many therapies?

Association between systolic blood pressure and target organ damage in naturally occurring cases of systemic hypertension in the dog

Chronic elevation in the systolic blood pressure (SBP) adversely affects the lifespan in the dog by causing injury to the eye, heart, kidney and brain. Understanding the association between SBP and target organ damage (TOD) helps in risk categorization and treatment planning. Therefore, a prospective study was undertaken to find the association between SBP and renal resistive index (RI) in naturally occurring cases of canine systemic hypertension. Based on the ACVIM guidelines 2018, dogs (n=135) were categorized into four risk groups of SBP, viz., A (minimal), B (low), C (moderate), and D (high). Ophthalmoscopy and echocardiography were used to assess ocular and cardiac changes, respectively. Nephrosonography, urinalysis, and RI were used to assess kidney damage. Odds ratio (OR) was used to quantify the risk of TOD for different categories of SBP. One-way Anova with Tukey's post-hoc test was used to test the effect of different SBP risk groups on urine protein creatinine ratio (UPC) and RI as well as the effect of number of TOD on the RI. Pearson's correlation test was done to see the relation of SBP with UPC and RI. Tortuous retinal vessels were common in group B with an OR of 11 (95% CI: 0.59-207). Retinal hemorrhage and left ventricular hypertrophy were common in group D with an OR of 13 (95% CI: 0.67-234) and 11 (95% CI: 0.61-207), respectively. A significant strong positive correlation of SBP with UPC (R2=0.65) and RI (R2=0.58) was observed. The renal RI significantly increased when the number of TOD was ≥ 2. It was concluded that SBP and RI are associated with the number and severity of TOD and might be valuable in risk classification in hypertensive dogs.

[Multidisciplinary team model for patients with oral cancer and systemic diseases: an expert consensus]

Large general hospitals currently play an increasingly important role in the diagnosis and treatment for acute critical patients and difficult diseases because of the development of dual referral system and hierarchical diagnosis, as well as the formation of medical treatment alliance. Patients with oral cancers are often associated with systemic diseases, which increases the complexity of the condition. Thus, meeting the demand through the traditional single medical model is difficult. As such, a multidisciplinary team (MDT) model has been proposed and has achieved a good clinical effect. To standardize the application of this model, we organized an event in which relevant experts discussed and formulated a consensus to provide standardized suggestions on the MDT process and the diagnosis and treatment of common systemic diseases as reference for clinical practice.

Management and treatment of glomerular diseases (part 1): conclusions from a kidney disease: improving global outcomes (KDIGO) controversies conference

The Kidney Disease: Improving Global Outcomes (KDIGO) initiative organized a Controversies Conference on glomerular diseases in November 2017. The conference focused on the 2012 KDIGO guideline with the aim of identifying new insights into nomenclature, pathogenesis, diagnostic work-up, and, in particular, therapy of glomerular diseases since the guideline’s publication. It was the consensus of the group that most guideline recommendations, in particular those dealing with therapy, will need to be revisited by the guideline-updating Work Group. This report covers general management of glomerular disease, IgA nephropathy, and membranous nephropathy.

Management and treatment of glomerular diseases (part 1): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

The Kidney Disease: Improving Global Outcomes (KDIGO) initiative organized a Controversies Conference on glomerular diseases in November 2017. The conference focused on the 2012 KDIGO guideline with the aim of identifying new insights into nomenclature, pathogenesis, diagnostic work-up, and, in particular, therapy of glomerular diseases since the guideline's publication. It was the consensus of the group that most guideline recommendations, in particular those dealing with therapy, will need to be revisited by the guideline-updating Work Group. This report covers general management of glomerular disease, IgA nephropathy, and membranous nephropathy.

Usefulness of urinary parameters in advanced chronic kidney disease

This review discusses the diagnostic value of urinary parameters in the setting of advanced chronic kidney disease and we present the key concepts that summarise the suggestions of the manuscript.

URINARY VOLUME

The amount of fluid intake may be a non-established risk factor for CKD. For these patients, a urinary output ≥2-3 l/day is a reasonable proposal. This recommendation is not applicable to patients with cardiorenal syndrome or fluid overload risk. NA: This determination is very useful to monitor salt intake. Reducing urinary Na<120 mEq/day (≅salt intake≤5-6g) is a reasonable objective.

URINARY UREA NITROGEN (UUN)

This parameter is useful to estimate protein intake (Maroni BJ equation). A protein intake between 48-72g (0.8-0.9g/kg/day according to weight) is equivalent to UUN 7-10g/day approximately.

ACID LOAD AND POTASSIUM

Acid load reduction may be an additional strategy in the nutritional management of this population. It may be estimated indirectly from a diet survey or by measuring the elimination of UUN and K_ur. The limits of this recommendation have not been established, but we propose a cautious and prudent diet of fruit and vegetables.

PHOSPHORUS

There is a significant positive correlation between phosphorus and protein, both in dietary records and urine elimination. Based on this information, we suggest a urinary P excretion<800mg/day or<600mg/day for patients with GFR<25ml/min or<15ml/min, respectively.

CONCLUSION

Urinary parameters provide sensitive and useful knowledge for clinical practice, provide information about the dietary habits of patients and the adherence to our recommendations.

Comparative Efficacy and Safety of Therapies in IgA Nephropathy: A Network Meta-analysis of Randomized Controlled Trials

The present study aims to compare the relative efficacy and safety of different interventions for IgA nephropathy (IgAN) with proteinuria more than 1 g/d by using network meta-analysis. We searched PubMed, Embase, and the Cochrane Library for studies compared the rate of clinical remission and/or end-stage renal disease (ESRD) and/or serious adverse events in IgAN patients with proteinuria (>1 g/d). The surface under the cumulative ranking area (SUCRA) was calculated to rank the interventions. A total of 21 randomized controlled trials with 1822 participants were included for the comparisons of 7 interventions. The rank of the most effective treatments to induce clinical remission was renin−angiotensin system inhibitors (RASi) plus urokinase, steroid plus tonsillectomy, and RASi plus steroid with a SUCRA of 0.912, 0.710, and 0.583, respectively. As for the prevention of ESRD or doubling of serum creatinine, RASi plus steroid (SUCRA 0.012) was the most effective, followed by RASi (SUCRA 0.282) and steroid (SUCRA 0.494), leaving mycophenolate mofetil as the least effective (SUCRA 0.644). There was no statistical difference among all interventions in the occurrence of serious adverse events. The current network meta-analysis demonstrated for the first time that RASi plus steroid is probably the best therapeutic choice, not only for reducing proteinuria but also for maintaining long-term renal protection.

Uric acid causes kidney injury through inducing fibroblast expansion, Endothelin-1 expression, and inflammation

Background

Uric acid (UA) plays important roles in inducing renal inflammation, intra-renal vasoconstriction and renal damage. Endothelin-1 (ET-1) is a well-known profibrotic factor in the kidney and is associated with fibroblast expansion. We examined the role of hyperuricemia conditions in causing elevation of ET-1 expression and kidney injury.

Methods

Hyperuricemia was induced in mice using daily intraperitoneal injection of uric acid 125 mg/Kg body weight. An NaCl injection was used in control mice. Mice were euthanized on days-7 (UA7) and 14 (UA14). We also added allopurinol groups (UAL7 and UAL14) with supplementation of allopurinol 50 mg/Kg body weight orally. Uric acid and creatinine serum were measured from blood serum. Periodic Acid Schiff (PAS) and Sirius Red staining were done for glomerulosclerosis, tubular injury and fibrosis quantification. mRNA expression examination was performed for nephrin, podocin, preproEndothelin-1 (ppET-1), MCP-1 and ICAM-1. PDGFRβ immunostaining was done for quantification of fibroblast, while α-SMA immunostaining was done for localizing myofibroblast. Western blot analysis was conducted to quantify TGF-β1, α-SMA and Endothelin A Receptor (ETAR) protein expression.

Results

Uric acid and creatinine levels were elevated after 7 and 14 days and followed by significant increase of glomerulosclerosis and tubular injury score in the uric acid group (p < 0.05 vs. control). Both UA7 and UA14 groups had higher fibrosis, tubular injury and glomerulosclerosis with significant increase of fibroblast cell number compared with control. RT-PCR revealed down-regulation of nephrin and podocin expression (p < 0.05 vs. control), and up-regulation of MCP-1, ET-1 and ICAM-1 expression (p < 0.05 vs. control). Western blot revealed higher expression of TGF-β1 and α-SMA protein expression. Determination of allopurinol attenuated kidney injury was based on reduction of fibroblast cell number, inflammation mediators and ppET-1 expression with reduction of TGF-β1 and α-SMA protein expression.

Conclusions

UA induced glomerulosclerosis, tubular injury and renal fibrosis with reduction of podocyte function and inflammatory mediator elevation. ET-1 and fibroblast expansion might modulate hyperuricemia induced renal fibrosis.

The Envy of Scholars: Applying the Lessons of the Framingham Heart Study to the Prevention of Chronic Kidney Disease

During the past 50 years, a dramatic reduction in the mortality rate associated with cardiovascular disease has occurred in the US and other countries. Statistical modeling has revealed that approximately half of this reduction is the result of risk factor mitigation. The successful identification of such risk factors was pioneered and has continued with the Framingham Heart Study, which began in 1949 as a project of the US National Heart Institute (now part of the National Heart, Lung, and Blood Institute). Decreases in total cholesterol, blood pressure, smoking, and physical inactivity account for 24%, 20%, 12%, and 5% reductions in the mortality rate, respectively. Nephrology was designated as a recognized medical professional specialty a few years later. Hemodialysis was first performed in 1943. The US Medicare End-Stage Renal Disease (ESRD) Program was established in 1972. The number of patients in the program increased from 5,000 in the first year to more than 500,000 in recent years. Only recently have efforts for risk factor identification, early diagnosis, and prevention of chronic kidney disease (CKD) been undertaken. By applying the approach of the Framingham Heart Study to address CKD risk factors, we hope to mirror the success of cardiology; we aim to prevent progression to ESRD and to avoid the cardiovascular complications associated with CKD. In this paper, we present conceptual examples of risk factor modification for CKD, in the setting of this historical framework.

Emerging drugs for chronic kidney disease

INTRODUCTION

Chronic kidney disease (CKD) is a worldwide health problem. Despite remarkable headway in slowing the progression of kidney diseases, the incidence of end-stage renal disease (ESRD) is increasing in all countries with a severe impact on patients and society. The high incidence of diabetes and hypertension, along with the aging population, may partially explain this growth. Currently, the mainstay of pharmacological treatment for CKD, aiming to slow progression to ESRD are ACE inhibitors and angiotensin II receptor blockers for their hemodynamic/antihypertensive and anti-inflammatory/antifibrotic action. However, novel drugs would be highly desirable to effectively slow the progressive renal function loss.

AREAS COVERED

Through the search engines, PubMed and ClinicalTrial.gov, the scientific literature was reviewed in search of emerging drugs in Phase II or III trials, which appear to be the most promising for CKD treatment.

EXPERT OPINION

The great expectations for new drugs for the management of CKD over the last decade have unfortunately not been met. Encouraging results from preliminary studies with specific agents need to be tempered with caution, given the absence of consistent and adequate data. To date, several agents that showed great promise in animal studies have been less effective in humans.

Effect of add-on pentoxifylline on proteinuria in membranous glomerulonephritis: a 6-month placebo-controlled trial

BACKGROUND

Membranous glomerulonephritis (MGN) may cause proteinuria as the main complication and is a strong risk factor for end-stage renal disease. Current therapeutic regimens provide only partial renoprotection. Data derived from both animal and human studies provide a scientific basis for the use of pentoxifylline as an antiproteinuric agent.

OBJECTIVE

This study was designed to evaluate the antiproteinuric effect of add-on pentoxifylline therapy in non-diabetic patients with MGN.

STUDY DESIGN

This was a double-blind, placebo-controlled trial.

SETTING

Non-diabetic patients with histologically proven MGN and urinary protein excretion (UPE) > 500 mg/24 h, entered a 6-month study period. Enrolled patients were selected from a university and three private clinics.

INTERVENTION

Patients were assigned to one of the two treatment groups: pentoxifylline 400 mg two or three times a day, or matching placebo.

MAIN OUTCOME MEASURES

Baseline and follow-up assessments included estimated glomerular filtration rate (eGFR) and UPE. Differences in the changes in variables within the placebo and pentoxifylline treatment groups during the study period were assessed using Friedman's test.

RESULTS

Treatment with pentoxifylline for 6 months resulted in a significant reduction of mean UPE (p < 0.001) along with a slight, non-significant increase of eGFR, in comparison to the mean UPE and eGFR increase in the placebo group.

CONCLUSION

This study showed that add-on therapy of pentoxifylline in MGN was beneficial, and could be considered as a potential new therapeutic indication for the drug in such kidney diseases.

Combination therapy an ACE inhibitor and an angiotensin receptor blocker for IgA nephropathy: a meta-analysis

OBJECTIVE

The pathogenesis of IgA nephropathy (IgAN) is still unknown. Combination therapy with angiotensin-converting enzyme inhibitors (ACEIs) plus angiotensin receptor blockers (ARBs) might provide more benefits to IgAN patients. We conducted a systematic review to assess the efficacy of combination therapy for IgAN.

METHODS

The MEDLINE, EMBASE, the Cochrane Library and article reference lists were searched for randomised clinical trials (RCTs) which involved combination therapy ACEI plus ARB in only one arm. A meta-analysis was performed on the outcomes of proteinuria and renal function in IgAN patients.

RESULTS

Six RCTs involving 109 patients were included in the review. Combined treatment with ACEI plus ARB was more effective than with ACEI/ARB alone for reducing daily proteinuria. This did not translate into an improvement in GFR. Patients receiving ACEI plus ARB therapy did not have an increased risk of hyperkalemia.

CONCLUSIONS

The current cumulative evidence suggests that combination therapy ACEI plus ARB may provide more benefits to IgAN patients for reducing daily proteinuria. Long-term effects of these agents on renal outcomes, and safety need to be established.

Role of TWEAK in lupus nephritis: a bench-to-bedside review

There is significant unmet need in the treatment of lupus nephritis (LN) patients. In this review, we highlight the role of the TWEAK/Fn14 pathway in mediating key pathologic processes underlying LN involving both glomerular and tubular injury, and thus the potential for renal protection via blockade of this pathway. The specific pathological mechanisms of TWEAK - namely promoting inflammation, renal cell proliferation and apoptosis, vascular activation and fibrosis - are described, with supporting data from animal models and in vitro systems. Furthermore, we detail the translational relevance of these mechanisms to clinical readouts in human LN. We present the opportunity for an anti-TWEAK therapeutic as a renal protective agent to improve efficacy relative to current standard of care treatments hopefully without increased safety risk, and highlight a phase II trial with BIIB023, an anti-TWEAK neutralizing antibody, designed to assess efficacy in LN patients. Taken together, targeting the TWEAK/Fn14 axis represents a potential new therapeutic paradigm for achieving renal protection in LN patients.

Conversion to everolimus in maintenance liver transplant patients: a multicenter, retrospective analysis

Data on the conversion of patients to everolimus after liver transplantation are sparse. A multicenter, retrospective study followed 240 maintenance liver transplant patients to analyze the current indications for everolimus conversion, the employed regimens and exposure levels, and the impact on efficacy and safety. The mean time from transplantation to the introduction of everolimus was 4.9 ± 5.2 years. The mean everolimus trough level was 7.3 ± 4.1 ng/mL at month 1 and 8.1 ± 4.7 ng/mL at month 12. At 12 months, 61.6% of the patients were no longer receiving calcineurin inhibitor (CNI) therapy. The mean estimated glomerular filtration rate (eGFR) according to the Cockcroft-Gault formula was 64.2 ± 30.0 mL/minute on day 0 and 68.4 ± 32.5 mL/minute at month 12 (P = 0.007). Among patients with baseline serum creatinine levels ≥ 130 μmol/L, the eGFR values were 44.3 ± 15.7 mL/minute on day 0 and 53.7 ± 26.0 mL/minute at month 12 (P = 0.003). Four patients (1.6%) developed mild or moderate biopsy-proven acute rejection. Adverse events led to everolimus discontinuation in 12.9% of the patients. After the initiation of everolimus, the mean white blood cell count decreased significantly, and the total cholesterol and triglyceride levels increased significantly. In this retrospective analysis of the largest cohort of maintenance liver transplant patients analyzed after their conversion to everolimus, more than 60% of the patients were kept free of CNIs with a very low risk of acute rejection and with an acceptable safety profile. Randomized trials in which maintenance liver transplant patients are switched to everolimus in response to clinical indications or preemptively are warranted.

A phase 1, single-dose study of fresolimumab, an anti-TGF-β antibody, in treatment-resistant primary focal segmental glomerulosclerosis

Primary focal segmental glomerulosclerosis (FSGS) is a disease with poor prognosis and high unmet therapeutic need. Here, we evaluated the safety and pharmacokinetics of single-dose infusions of fresolimumab, a human monoclonal antibody that inactivates all forms of transforming growth factor-β (TGF-β), in a phase I open-label, dose-ranging study. Patients with biopsy-confirmed, treatment-resistant, primary FSGS with a minimum estimated glomerular filtration rate (eGFR) of 25  ml/min per 1.73  m(2), and a urine protein to creatinine ratio over 1.8  mg/mg were eligible. All 16 patients completed the study in which each received one of four single-dose levels of fresolimumab (up to 4  mg/kg) and was followed for 112 days. Fresolimumab was well tolerated with pustular rash the only adverse event in two patients. One patient was diagnosed with a histologically confirmed primitive neuroectodermal tumor 2 years after fresolimumab treatment. Consistent with treatment-resistant FSGS, there was a slight decline in eGFR (median decline baseline to final of 5.85 ml/min per 1.73  m(2)). Proteinuria fluctuated during the study with the median decline from baseline to final in urine protein to creatinine ratio of 1.2  mg/mg with all three Black patients having a mean decline of 3.6  mg/mg. The half-life of fresolimumab was ∼14 days, and the mean dose-normalized Cmax and area under the curve were independent of dose. Thus, single-dose fresolimumab was well tolerated in patients with primary resistant FSGS. Additional evaluation in a larger dose-ranging study is necessary.

Novel therapies for resistant focal segmental glomerulosclerosis (FONT) phase II clinical trial: study design

Background

The lack of adequate randomized clinical trials (RCT) has hindered identification of new therapies that are safe and effective for patients with primary focal segmental glomerulosclerosis (FSGS), especially in patients who fail to respond to corticosteroids and immunosuppressive therapies. Recent basic science advances have led to development of alternative treatments that specifically target aberrant pathways of fibrosis which are relevant to disease progression in FSGS. There is a need for a flexible Phase II study design which will test such novel antifibrotic strategies in order to identify agents suitable for phase III testing.

Methods/Design

The Novel Therapies for Resistant Focal Segmental Glomerulosclerosis (FONT) project is a multicenter Phase I/II RCT designed to investigate the potential efficacy of novel therapies for resistant FSGS. Adalimumab and galactose will be evaluated against conservative therapy consisting of the combination of lisinopril, losartan and atorvastatin. The sample size is defined to assure that if one of the treatments has a superior response rate compared to that of the other treatments, it will be selected with high probability for further evaluation. Comparison of primary and secondary endpoints in each study arm will enable a choice to be made of which treatments are worthy of further study in future Phase III RCT.

Discussion

This report highlights the key features of the FONT II RCT including the two-step outcome analysis that will expedite achievement of the study objectives. The proposed phase II study design will help to identify promising agents for further testing while excluding ineffective agents. This staged approach can help to prevent large expenditures on unworthy therapeutic agents in the management of serious but rare kidney diseases

Trial Registration

ClinicalTrials.gov, NCT00814255

Effects of an exercise program on blood biochemical values and exercise stage of chronic kidney disease patients

BACKGROUND

Chronic kidney disease (CKD) patients face a relatively high risk of cardiovascular disease morbidity and mortality. A healthy lifestyle facilitated by participation in a regular exercise regimen may prevent or retard conditions commonly associated with CKD, including hypertension, hyperlipidemia, and diabetes.

PURPOSE

This study examined the effect of a tailored exercise program on blood biochemical values and other exercise-related variables in CKD patients.

METHODS

A total of 94 subjects diagnosed with CKD by a nephrology outpatient clinic at a medical center in northern Taiwan participated in this quasi-experimental study. Subjects were randomly divided into an experimental group (n = 45) or a control group (n = 49). Experimental group subjects agreed to join a 3-month exercise program. Individual guidance was given remotely to the experimental group over the telephone during the second and the third months following initiation of the exercise intervention. Both groups completed the pretest and posttest forms of the Stages of Exercise Questionnaire, and blood biochemical data were obtained from patient medical files. Data were analyzed using analysis of covariance.

RESULTS

The preexercise cholesterol values (from 198.03 +/- 43.52 to 160.97 +/- 37.39 mg/dl) of the experimental group differed significantly from their postexercise values. Also, the number of subjects in the experimental group who reported exercising regularly rose from 57.8% pretest to 75.6% posttest. However, changes in red blood cell count, hemoglobin, hematocrit, and blood sugar were all insignificant in the experimental group. No significant change in any of these items was detected in the control group. The cholesterol value of the experimental group (158.75 mg/dl) was significantly lower than that of the control group (177.29 mg/dl) after applying analysis of covariance, using the pretest results of both groups as the covariate.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The developed exercise program was found to reduce cholesterol levels in CKD patients effectively, to encourage more patients to do exercise regularly, and to offer clinical nursing staff an approach to encourage and teach CKD patients to exercise.

Hyperuricemia as a risk factor for progressive renal insufficiency after coronary intervention in patients with chronic kidney disease

The development of renal insufficiency after percutaneous coronary intervention (PCI) is associated with increases in morbidity and mortality. Recent studies have reported that hyperuricemia (HU) results in hypertension, intrarenal vascular disease, and renal injury. We postulated that HU contributes to progressive renal disease after PCI. We studied 139 patients with chronic kidney disease (CKD) undergoing elective PCI including 59 HU patients. We assessed the relationship between HU and the development of renal insufficiency after PCI by estimating traditional contrast-induced nephropathy (CIN) and persistent postprocedural nephropathy (PPN) defined as an increase in creatinine ≥0.2 mg/dl of the baseline value 2 weeks after procedure. CIN and PPN were seen in 6.5 and 28.8% respectively. The incidence of PPN was higher in HU patients than in non-HU patients (p < 0.001) although the incidence of CIN was not significantly different between the two groups. PPN was more frequently observed in hyperuricemic patients irrespective of association with hypertension (with and without hypertension, p < 0.001 and p = 0.034, respectively). By univariate analysis, HU and hypertension are associated with PPN although there was no significant predictor of CIN in this study. Multivariate analysis showed HU and hypertension were independent predictors of PPN. HU is a predictor of slow and mild development of renal insufficiency after PCI in patients with CKD.

Potential new therapeutic agents for diabetic kidney disease

Diabetic nephropathy is the leading cause of end-stage renal disease, and both the incidence and prevalence of diabetic nephropathy continue to increase. Currently, various treatment regimens and combinations of therapies provide only partial renoprotection. It is obvious that new approaches are desperately needed to retard the progression of diabetic nephropathy. Recently, a number of new agents have been described that have the potential to delay the progression of diabetic kidney disease and minimize the growing burden of end-stage renal disease. These include inhibitors and breakers of advanced glycation end products, receptor antagonists for advanced glycation end products, protein kinase C inhibitors, NADPH (reduced nicotinamide adenine dinucleotide phosphate) oxidase inhibitors, glycosaminoglycans, endothelin receptor antagonists, antifibrotic agents, and growth factor inhibitors. This review addresses these promising new therapeutic agents for delaying the progression of diabetic kidney disease.

A clinical comparative study of the management of chronic renal failure with Punarnavadi compound

India like any other country is facing a silent epidemic of chronic renal failure (CRF)- a facet of the health transition associated with industrialization partly fuelled by increase in sedentary lifestyle, low birth weight and malnutrition. Increasing figures by many folds seen is posing a difficult situation to overcome with respect to economy and health of the working and earning population of the nation. There is an urgent need to explore, highlight new interventions and modify modifiable risk factors as a basis for treatment strategies to prevent the development and progression of CRF. The present study was taken up to evaluate the role of trial formulation tab. Punarnavadi compound in the management of chronic renal failure. This was an open clinical comparative study in controlled circumstances wherein 67 patients were studied for two months in three groups- Group A (allopathic control), Group B (ayurvedic control) and Group C (ayurvedic test). It was a multi-centric study; patients were registered from Anandababa charitable dialysis centre, Jamnagar, Kayachikitsa O.P.D. of I.P.G.T. and R.A. Jamnagar and P. D. Patel Ayurveda hospital, Nadiad. Results were assessed on 15 parameters using Students (paired) 't' test. Group A patients showed comparatively better results in eight parameters- weight, platelet count, serum urea, serum uric acid, serum sodium, potassium, chloride and total proteins. Parameter Hemoglobin% showed better results in Group B patients and in Group C patients comparatively better results in six parameters viz.- quality of life (breathlessness, weakness, general functional capacity), total count, serum creatinine and serum calcium - were observed. Throughout the study, trial drug tab. Punarnavadi compound did not show any adverse drug reaction. The results of this study will help in developing a cheap and safe treatment for the management of CRF.

Proteinuria and clinical outcomes in hypertensive patients

This narrative review focuses on outcomes related to proteinuria in hypertension (HT), and also examines the role of current and future therapeutic strategies. Proteinuria is an independent marker of renal and cardiovascular (CV) disease in hypertensive populations, particularly in high-risk groups such as diabetic patients. Effective blood pressure (BP) control and proteinuria management are associated with significant improvements in the risk of key adverse outcomes, although a causative relationship needs careful assessment. Available antihypertensives have varying effects on proteinuria reduction. Drugs affecting the renin system offer antiproteinuric and renoprotective effects that are probably at least partially independent of their BP effects. Economic evaluations of these interventions confirm their cost-saving benefits relative to other antihypertensives, but outcomes-based research is needed in some settings.

Oral cyclophosphamide for lupus glomerulonephritis: an underused therapeutic option

BACKGROUND AND OBJECTIVES

In our center, systemic lupus erythematosus nephritis is routinely treated with an oral cyclophosphamide (POCY) regimen. POCY is easy to administer and less expensive than intravenous cyclophosphamide (IVCY) as it is currently used in the United States; however, the use of POCY has declined in favor of IVCY. Our experience with POCY suggests that it is well tolerated and consistently associated with good long-term outcomes. Here we report this experience to build a case for maintaining POCY as a therapeutic option in lupus nephritis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This is a single-center, retrospective analysis of the outcome of 46 patients who had systemic lupus erythematosus with nephritis and were treated with POCY between 1995 and 2006. POCY was given for 2 to 4 mo at a dosage of 1.0 to 1.5 mg/kg ideal body weight. After completing POCY, the patients received either azathioprine or mycophenolate mofetil.

RESULTS

Median follow-up was 23.5 mo, and median duration of POCY was 4 mo (range 1 to 16 mo). Durable complete or partial remission of proteinuria was achieved in 32 (70%) patients, whereas 5 (11%) progressed to ESRD. Outcomes were comparable in black and white individuals. Adverse effects occurred in fewer than 10% of the cohort, and only four patients discontinued POCY.

CONCLUSIONS

These results suggest that sequential therapy of POCY followed by azathioprine or mycophenolate mofetil is comparable to IVCY regimens but that efficacy may not be affected by race.

Avaliação da relação proteína-creatinina urinária em gatos com doença renal crônica

Doença renal crônica (DRC) é a forma mais comum de doença renal em gatos. Vários fatores têm sido citados como importantes na progressão da doença, dentre eles a proteinúria. A relação proteína-creatinina (RPC) urinária em uma única amostra de urina apresenta boa correlação com a perda de proteína urinária em 24 horas. O objetivo dessa investigação foi determinar a RPC urinária em gatos com DRC adquirida naturalmente. A determinação da RPC foi realizada em nove gatos saudáveis (Grupo I) e em trinta gatos com DRC (Grupo II). Os gatos do Grupo I apresentaram RPC de 0,16±0,10 e os gatos do Grupo II apresentaram RPC de 0,53± 0,59. No Grupo II encontrou-se correlação positiva e significante da RPC com o nível de creatinina sérica. Os resultados deste estudo demonstram que a RPC urinária em gatos com DRC é bastante variável e que, à semelhança do que já havia sido previamente descrito, aproximadamente um terço dos gatos com DRC são considerados proteinúricos segundo critérios estabelecidos pela literatura (RPC urinária >0,4).

Elevated Serum Creatinine and a Normal Urinalysis: A Short Differential Diagnosis in the Etiology of Renal Failure

OBJECTIVE

The diagnosis of renal failure with a normal urinalysis represents a short differential diagnosis that has not been characterized in the literature. This study was designed to identify the specific disease states that encompass this interesting renal condition.

MATERIAL

The Regenstrief database, which is an electronic medical record containing inpatient laboratory and other clinical data for patients admitted to Wishard Memorial Hospital, was utilized to provide data for this study.

METHODS

The database was culled to provide data for hospitalized patients admitted between March 1, 1992, and March 1, 2001, with the concurrent findings of a serum creatinine greater than or equal to 2 mg/dL, a normal urinalysis, and diagnoses of obstructive uropathy, multiple myeloma, prerenal azotemia, hypertensive nephrosclerosis, interstitial nephritis, renal vascular disease, hypokalemic nephropathy, and hypercalcemia, as identified by their corresponding ICD-9 codes.

RESULTS

A search of the Regenstrief database yielded a total of 190,343 patient admissions. There were 515 patient admissions with renal failure and a concurrent normal urinalysis. The largest specific diagnostic categories within this group were hypertension and prerenal azotemia.

CONCLUSIONS

An elevated serum creatinine and normal urinalysis present a short differential for the etiologies of renal failure and include such entities as hypertensive nephrosclerosis, prerenal azotemia, obstructive nephropathy, interstitial nephritis, renal vascular disease, and various electrolyte abnormalities. An awareness of these specific disease states may lead to an earlier diagnosis and more effective treatment of renal failure.

ACEI/ARB therapy for IgA nephropathy: a meta analysis of randomised controlled trials

BACKGROUND

Published reports examining the efficacy of RAS blockers: angiotensin converting-enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB) agents for preserving renal function in IgA nephropathy (IgAN) have yielded conflicting results. To evaluate systematically the effects of ACEI/ARB agents on IgAN, we conducted a meta analysis of published randomised controlled trials (RCTs).

METHODS

MEDLINE, EMBASE, the Cochrane Library and article reference lists were searched for RCTs that compared ACEI/ARB with placebo and any other antihypertensive agents or non-immunosuppressive agents for treating IgAN. The quality of the studies was evaluated with the method of intention to treat analysis and allocation concealment, as well as with the Jadad method. Meta analyses were performed on the outcomes of proteinuria and renal function in patients with IgAN.

RESULTS

Eleven RCTs involving 585 patients were included in the review. Seven trials used placebo/no treatment as controls. Four trials used other antihypertensive agents as controls. Overall, ACEI/ARB agents had statistically significant effects on protecting renal function(p < 0.00001) and reduction of proteinuria (p < 0.00001) when compared with control group. Tests for heterogeneity showed no difference in effect among the studies. Systolic and diastolic blood pressure, glomerular filtration rate (GFR), age, did not influence treatment response. ACEI/ARB agents were well tolerated.

CONCLUSIONS

The current cumulative evidence suggests that ACEI/ARB agents had statistically significant effects on protecting renal function and reduction of proteinuria in patients with IgAN when compared with control groups. ACEI/ ARB agents are a promising medication and should be investigated further.

Elevations in serum creatinine with RAAS blockade: why isn't it a sign of kidney injury?

PURPOSE OF REVIEW

The aim of this article is to review the pertinent physiology and pathophysiology of the renin-angiotensin-aldosterone system (RAAS), summarize the proven beneficial cardiovascular and renal effects of RAAS blockade, examine clinical situations in which RAAS blockade may induce reductions in glomerular filtration rate, and explore why increases in serum creatinine in the setting of angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) therapy do not necessarily signify the presence of clinically relevant kidney failure.

RECENT FINDINGS

RAAS inhibition appears to reduce the likelihood of atrial fibrillation. RAAS inhibition leads to improved insulin sensitivity and glycemic control, but does not appear to prevent diabetes. The beneficial effects of ACEi/ARB therapy extend to those with significant renal disease. Combination ACEi/ARB is safe, and reduces proteinuria more than either agent alone in patients with macroalbuminuric nephropathy. Acute deteriorations in renal function that result from RAAS inhibition are usually reversible.

SUMMARY

RAAS blockade exerts potent hemodynamic, antihypertensive, and antiinflammatory effects, and slows progression of kidney disease beyond that due to lowering of blood pressure. The benefit extends to those with advanced disease. In spite of established benefit, ACEi and ARB therapy remains underutilized, in part due to concerns about acute deteriorations in renal function that result from interruption of the RAAS.

New therapeutic strategies with combined renin-angiotensin system inhibitors for pediatric nephropathy

Renin-angiotensin system (RAS) inhibitors may delay progression of several chronic kidney diseases in adults. Two classes of RAS inhibitors--angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs)--have been shown to have renoprotective abilities. Despite their different mechanisms of action, these two drug classes appear to have comparable antiproteinuric and renoprotective properties. Preliminary investigations suggest that combination therapy with an ACE inhibitor and ARB offers additional benefit. Only a few studies with these drugs for treatment of pediatric nephrology have been conducted; however, their results are encouraging. Additional clinical trials are needed to confirm these results.

Relation of left ventricular hypertrophy to microalbuminuria and C-reactive protein in children and adolescents with essential hypertension

Microalbuminuria (MA) and C-reactive protein (CRP) levels are predictors of increased risk for left ventricular hypertrophy (LVH). Whether the strength of association between CRP and LVH is comparable to that of MA in hypertensive children is unknown. CRP and MA were measured in 64 children and adolescents with essential hypertension (HTN). In the entire population, CRP and MA showed positive relations with body mass index (BMI) (r = 0.30, p = 0.04 and r = 0.32, p = 0.04, respectively), systolic blood pressure (SBP) (r = 0.63, p = 0.03 and r = 0.58, p = 0.03, respectively), and LVH (r = 0.86, p < 0.001 and r = 0.81, p < 0.001, respectively). Patients with LVH (n = 23) had significantly higher BMI (p = 0.32), increased SBP (p = 0.031), and higher levels of CRP (p < 0.001) and MA (p < 0.001) compared with those without LVH. Multiple linear regression analysis demonstrated that CRP (r = 2.11, p < 0.001), MA (r = 1.94, p < 0.003), BMI (r = 0.53, p = 0.02), and SBP (r = 0.48, p = 0.04) were significantly associated with LVH. By analysis of covariance, CRP and MA were significantly different between patients who had LVH and those without LVH after adjustment for age, gender, BMI, SBP, SBP index, and diastolic blood pressure (p < 0.001 for the two markers). In conclusion, the strength of association between LVH and CRP is comparable to that of MA in children and adolescents with essential HTN.

Outpatient management of chronic kidney disease: proteinuria, anemia and bone disease as therapeutic targets

There is increasing emphasis on chronic kidney disease (CKD), owing to its prevalence and its association with cardiovascular risk. Important issues concerning treatment of CKD are delaying its progression, improving patients' quality of life, and decreasing related mortality. These issues can be addressed with certain therapeutic options, targeting proteinuria, anemia, and secondary hyperparathyroidism. The management options and possible benefits related to treatment of these complications of CKD are reviewed.

Immune modulating therapy for IgA nephropathy: rationale and evidence

Our current understanding of the initial pathogenetic steps in IgA nephropathy (IgAN) provides relatively limited rationale for immunosuppressive therapy. However, it is conceivable that immunosuppressive drugs might affect secondary inflammatory events triggered by glomerular immune deposits or even proteinuria per se. Some, but not all, randomized clinical trials on either corticosteroid monotherapy, mycophenolate mofetil monotherapy, or immunosuppressive combination therapy have provided evidence for a benefit on either surrogate parameters such as proteinuria or hard end points such as renal failure. The central problem of these studies is that most were designed in the 1980s or 1990s, when recommendations for supportive therapy were strikingly different from those of today. In the meantime an equal number of randomized clinical studies reporting a benefit of supportive therapy has been published only regarding patients with IgAN and, unfortunately, no head-to-head comparisons of these 2 approaches currently are available. Several ongoing clinical trials may help to resolve this dilemma. Until the data of such studies become available, a pragmatic approach is to first optimize supportive therapy and reserve immunosuppressive medication for those patients failing a supportive approach and remaining at risk for progressive loss of renal function.

Thiazide-induced subtle renal injury not observed in states of equivalent hypokalemia

Hydrochlorothiazide (HCTZ) is used to manage hypertension and heart failure; however, its side effects include mild hypokalemia, metabolic abnormalities, and volume depletion, which might have deleterious effects on renal and endothelial function. We studied whether HCTZ cause renal injury and/or altered vasoreactivity and if these changes are hypokalemia-dependent. Rats were given a normal diet or a diet moderately low in potassium K+ with or without HCTZ. Animals fed either a low K+ diet alone or HCTZ developed mild hypokalemia. There was no significant difference in systolic blood pressure in the different treatment groups. All three groups with hypokalemia had mild proteinuria; low K(+)-HCTZ rats had reduced creatinine clearance. HCTZ-treated rats displayed hypomagnesemia, hypertriglyceridemia, hyperglycemia, insulin resistance, and hyperaldosteronism. No renal injury was observed in the groups without HCTZ; however, increased kidney weight, glomerular ischemia, medullary injury, and cortical oxidative stress were seen with HCTZ treatment. Endothelium-dependent vasorelaxation was reduced in all hypokalemic groups and correlated with reduced serum K+, serum, and urine nitric oxide. Our results show that HCTZ is associated with greater renal injury for the same degree of hypokalemia as the low K+ diet, suggesting that factors such as chronic ischemia and hyperaldosteronism due to volume depletion may be responsible agents. We also found impaired endothelium-dependent vasorelaxation was linked to mild hypokalemia.

C-reactive protein and incident left ventricular hypertrophy in essential hypertension

Elevated C-reactive protein (CRP) levels have been associated with increased cardiovascular risk in hypertensive adults. The aim of this study was to determine whether plasma CRP level is more predictive of left ventricular hypertrophy (LVH) than is ambulatory blood pressure (BP) in hypertensive children. Baseline and 12-month follow-up measures of BP, body mass index (BMI), low-density lipoprotein/high density lipoprotein cholesterol, left ventricular mass (LVM), and CRP data collected from 48 newly diagnosed, untreated hypertensive children were analyzed. CRP was measured by a highly sensitive nephelometric method. Left ventricular mass index (LVMI) was calculated as LVM/height2.7, and LVH was defined as LVMI>38.6 g/m2.7 being the cut-point for the 95th percentile found in healthy children. Average systolic BP (SBP), diastolic BP (DBP), SBP index, and DBP index were calculated. All patients received hydrochlorothiazide therapy in combination with angiotensin converting enzyme inhibitor treatment. Five patients also had angiotensin receptor blocker therapy to reach the target BP (<95th percentile corrected for age and gender). In a multiple regression analysis, LMVI was correlated with CRP, BMI, SBP, and SBP index. CRP alone explained 77% of the variance of LVMI, whereas BMI, SBP, and SBP index explained only 1.3, 0.3, and 0.4% of the variance, respectively. CRP was also the most significant correlate of follow-up LVH. In conclusion, elevated CRP level is significantly associated with LVH in children with essential hypertension. BP reduction with renin-angiotensin system blocker and hydrochlorothiazide therapy reduces LVH while lowering CRP level.

Patient and technique survival on peritoneal dialysis in patients with failed renal allograft: a case-control study

Failed renal allograft is becoming one of the most frequent causes of dialysis initiation in countries with developed transplant programs. The majority of patients initiate hemodialysis (HD) as their next renal replacement modality and concerns about the success of peritoneal dialysis (PD) in this patient population has been expressed. We evaluated patient and technique outcome in a cohort of 494 patients in the United States who initiated PD after a failed renal allograft in the years 2000-2003, and compared the outcomes to those of two case-matched groups: patients new to dialysis or patients transferred from HD who started PD during the same period. Patients starting PD after a failed allograft had patient survival and technique survival similar to case-matched controls. Transplantation was lower in patients with failed allograft than controls. The high success of PD in patients with failed allograft suggests that it is beneficial to utilize this modality more frequently in this patient group than current practice.