Low body weight is a risk factor for proteinuria in multiracial Southeast Asian pediatric population

Ethnicity and IgA nephropathy: worldwide differences in epidemiology, timing of diagnosis, clinical manifestations, management and prognosis

Immunoglobulin A nephropathy (IgAN), the most common primary glomerulonephritis, is one of the major causes of end-stage renal disease. Significant variances in epidemiology, clinical manifestation, timing of diagnosis, management and renal prognosis of IgAN have been reported worldwide. The incidence of IgAN is the most frequent in Asia, followed by Europe, and lower in Africa. Moreover, Asian patients show more frequent acute lesions in renal histology and present poorer renal outcomes compared with Caucasians. The comorbidities also show the difference between Asians and Caucasians. Although the frequency of gross hematuria with upper respiratory tract infection is not different, comorbidities with gastrointestinal diseases are reported to be higher in Europe. Recently, genetic studies for variant ethnic patients revealed widely ranging genetic risks in each ethnicity. A genetic risk score is most elevated in Asians, intermediate in Europeans and lowest in Africans, consistent with the disease prevalence of IgAN globally. Ethnic variance might be highly affected by the difference in genetic background. However, it is also essential to mention that the different timing of diagnosis due to variant urinary screening systems and the indication for renal biopsy in different countries may also contribute to these variances. The management of IgAN also varies internationally. Currently, several novel therapies based on the pathogenesis of IgAN are being assessed and are expected to become available soon. Further understanding the ethnic variance of IgAN might help establish individualized care for this disease. Here, we review the issues of ethnic heterogeneities of IgAN.

Birth Weight and Susceptibility to Chronic Kidney Disease

The worldwide prevalence of noncommunicable diseases (NCDs) is projected to increase substantially over the next few decades. Chronic kidney disease (CKD) is a key determinant of poor health outcomes for major NCD. Genetic predisposition and environmental exposures are contributory factors, but increasingly, it is being recognized that fetal development is also an important modulator of the NCD risk. Low birth weight (LBW) and CKD affect more disadvantaged populations and ethnic minorities and, therefore, causes a disproportionate burden on the poor. Human nephron number is highly variable and may range from under half a million to almost over two million. Significant variability is already present at birth, highlighting the importance of early nephrogenesis. Nearly 60% of nephrons are developed in the third-trimester of pregnancy. Nephron numbers increase in proportion to birth weight and gestational age. This wide-variability probably contributes to individual susceptibility to develop CKD where individuals with nephron numbers on the lower side of the spectrum are those at higher risk of developing kidney dysfunction at higher rate and progress more toward end-stage CKD. This article aims at discussing LBW and the susceptibility to CKD. Furthermore, in postnatal environment, the weight gain or change at adult life increases the metabolic demand and determines the phenotypic expression of disease along with the spectrum of nephron number. Hence, a cycle of hyperfiltration mechanism of these nephrons leads to proteinuria, glomerulo- sclerosis, and progressive development of larger glomeruli, a greater risk of proteinuria and progressive CKD. Therefore, LBW offspring are at risk of developing CKD (defined as albuminuria, a reduced glomerular filtration rate, or renal failure) in later life. Furthermore, the impact of prenatal programming is expected to be compounded with age, and the association of LBW with the risk of CKD seen in younger adults may become greater with age. It would be prudent, to adopt policies of intensified life-long surveillance of LBW people, anticipating this risk.

Retrospective cohort study of individuals born with low birthweight: implications for screening practices

Background

Previous studies have established an association between low birthweight (LBW) and future kidney disease, but few have explored the progression of kidney dysfunction through the pediatric years leading up through adolescence and young adulthood.

Methods

To better understand the temporal effects of birthweight on kidney disease progression, we conducted a retrospective cohort study comparing the glomerular filtration rate (GFR) between LBW (<2500 grams) and normal birthweight (NBW) infants who were admitted to the neonatal intensive care unit (NICU) at our institution from 1992 to 2006.

Results

Age at follow-up ranged 1–26 years old. GFR was found to be significantly lower in participants born with LBW than those born with NBW, with a mean difference of 5.5 mL/min/1.73m² (P < 0.01). These differences were found in the adolescent and young adult age group over 9 years of age, specifically in the extremely low birthweight group (ELBW) whose birthweight was less than 1000 grams.

Conclusions

We recommend screening for CKD in ELBW individuals starting at the age of 9 years old, regardless of their previous medical history.

Individual and Environmental Factors Associated with Proteinuria in Korean Children: A Multilevel Analysis

Proteinuria is a significant sign of childhood renal disorders. However, little is known about how sociodemographic and environmental factors are related to the presence of proteinuria among children and adolescents. This paper focuses on the prevalence of proteinuria and its risk factors among children and adolescents. This study conducted a secondary analysis of data from the 2016 Sample Schools Raw Data of Health Examination for School Students (SSRDHESS). Data collected from 27,081 students who had undergone a health screening were analyzed using Chi-square tests, independent t-tests, and multilevel logistic regression analysis. The prevalence of proteinuria was higher in the thin group than in the normal weight group (adjusted odds ratio (aOR) = 1.77; 95% confidence interval (CI) = 1.34–2.33) and lower in the overweight/obese group (aOR = 0.64; 95% CI = 0.51–0.80). Additionally, those in metropolitan and small–medium sized cities had a proteinuria prevalence about 1.5-fold higher than that of those in rural areas (95% CI = 1.08–2.02, 95% CI = 1.19–1.92, respectively). Proteinuria was associated with environmental pollution, including smoking rate, ambient particulate matter and heavy metals in drinking water (aOR = 1.10; 95% CI = 1.01–1.20; aOR = 1.06; 95% CI = 1.01–1.11, aOR = 1.001; 95% CI = 1.0001–1.0015). These results suggest that to improve health management effectiveness, kidney disease prevention efforts for children and adolescents should focus on geographical area and environmental pollution, as well as body weight as individual factors.

Effect of birth weight on adulthood renal function: A bias-adjusted meta-analytic approach

While the association between low birth weight (LBW; <2500 g) and development of adult chronic renal disease (CKD) is inconsistently reported, less information is available regarding association of high birth weight (HBW; ≥4000 g) with CKD. We undertook a systematic review and meta-analysis on studies published before 30 September 2015 and report associations between birth weight and renal function. Blood (glomerular filtration rate (GFR)) and urine (microalbuminuria/albumin excreation rate (AER)/urinary albumin creatinine ratio (ACR)) parameters were used to define CKD. Three different effect size estimates were used (odds ratio, regression coefficient and mean difference). The odds of developing CKD in the life course among those born LBW was 1.77 (95% CI: 1.42, 2.20) times and 1.68 (1.27, 2.33) times, assessed by blood and urine parameters respectively. Higher risk was also observed among Asian and Australian populations (blood: OR 2.68; urine: OR 2.28), individuals aged ≤30 years (blood: OR 2.30; urine: OR 1.26), and ≥50 years (blood: OR 3.66; urine: OR 3.10), people with diabetes (blood: OR 2.51), and aborigines (urine: OR 2.32). There was no significant association between HBW and CKD. For every 1 kg increase in BW, the estimated GFR increased by 2.09 mL/min per 1.73 m(2) (1.33-2.85), and it was negatively associated with LogACR (ß -0.07, 95% CI: -0.14, 0.00). LBW inborn had lower mean GFR -4.62 (-7.10, -2.14) compared with normal BW. Findings of this study suggest that LBW increased the risk of developing CKD, and HBW did not show any significant impact.

Latent association between low urine pH and low body weight in an apparently healthy population

Low urine pH, a plausible predictor for chronic kidney disease and metabolic disorders, is often observed in obese individuals. However, the association between low urine pH and low body weight is equivocal. We examined clinical parameters including urine pH and body mass index (BMI) in a cross-sectional study of 3629 apparently healthy Japanese adults aged 25-80 years who underwent a health-screening check-up. Urine pH was lower and the prevalence of proteinuria was significantly higher in subjects with BMI of ≥ 27.0 kg/m(2) compared with those with BMI of 21.0-22.9 kg/m(2). By contrast, hematuria was more prevalent in subjects with BMI of ≤ 20.9 kg/m(2). Logistic regression analysis showed that BMI of ≥ 27.0 kg/m(2) was significantly associated with low urine pH (≤ 5.5), which remained significant after adjustment for relevant confounders including age, sex, proteinuria, estimated glomerular filtration rate, urine density, hematuria, smoking status, and daily alcohol drinking. However, the association disappeared after further adjustment for serum uric acid. In contrast, the association between low urine pH and BMI of ≤ 19.0 kg/m(2) was significant after adjustment for age and sex and rather strengthened by the further adjustment for serum uric acid. In conclusion, low urine pH may be independently associated with low BMI. However, the underlying mechanisms of low urine pH in low body weight may differ from those in high body weight.

A community-based cross-sectional and longitudinal study uncovered asymptomatic proteinuria in Japanese adults with low body weight

Although proteinuria is highly prevalent in obese individuals, the association between proteinuria and low body weight is equivocal. In this study we determine whether low body weight is more strongly associated with proteinuria compared with normal weight. The association between body mass index (BMI) and proteinuria was examined in a cross-sectional study of 62,582 asymptomatic individuals aged 20-70 years without known kidney diseases recruited, based on the results of medical checkups in 1999. We also examined the incidence of recurrent or nonrecurrent proteinuria in an 8-year longitudinal analysis of 12,493 individuals without proteinuria at baseline. The prevalence of proteinuria showed a J-shaped relationship with BMI. Multivariate regression analysis showed that BMI of 27.0 kg/m(2) and above or 18.9 kg/m(2) and less was significantly associated with proteinuria relative to BMI 21.0-22.9 kg/m(2), even after adjusting for relevant cardiometabolic risk factors. In the longitudinal study, similar J-shaped relationships between the incident rates of proteinuria and baseline BMI groups were observed at post-baseline checkups. Baseline BMI 27.0 kg/m(2) and above was associated with significantly greater risk for recurrent and nonrecurrent proteinuria, whereas BMI 18.9 kg/m(2) and less was only associated with nonrecurrent proteinuria. Thus, obesity and low body weight may be associated with different types of proteinuria independent of cardiometabolic risk factors.

U-shaped association between body mass index and proteinuria in a large Japanese general population sample

BACKGROUND

There is little data on the association between body mass index (BMI) and proteinuria.

METHODS

This was a cross-sectional cohort study assessing the association between BMI and proteinuria in a large Japanese population. Using a nationwide health check-up database of 212,251 Japanese aged >20 years with no pre-existing cardiovascular diseases (185,183 men, median age 66 years; 127,068 women, median age 65 years), we examined the association between BMI and proteinuria (≥ 1+ on dipstick).

RESULTS

Subjects were divided into 11 subgroups by BMI grading in 1 kg/m(2) intervals from 18.5-27.5 kg/m(2). A BMI of approximately 22 ± 0.5 kg/m(2) was considered optimal for Japanese; therefore, this subgroup was set as a reference when logistic analysis was applied. Age, waist circumference, height, weight, smoking and drinking habits, use of medications such as antihypertensive, antidiabetic, or antihyperlipidemic, as well as proteinuria, estimated glomerular filtration rate (eGFR), chemistry data, and blood pressure levels were significantly different between subgroups in both genders. The odds ratio for proteinuria showed a U-shape in men and women, even after adjustment for significant covariates such as age, waist circumference, systolic blood pressure, eGFR, fasting plasma glucose, triglyceride, low-density lipoprotein, antihypertensive use, antidiabetic use, antihyperlipidemic use, and lifestyle factors (smoking and drinking). Gender differences were also prominent--a BMI <20.4 kg/m(2) was significantly associated with proteinuria in men compared to a BMI <18.4 kg/m(2) in women. On the other hand, a BMI ≥ 25.5 kg/m(2) was also significantly associated with proteinuria in men compared to a BMI ≥ 22.5 kg/m(2) in women.

CONCLUSIONS

We found that BMI levels were associated with proteinuria in a U-shaped manner and showed marked gender differences. Health guidance should not only focus on higher BMI subjects, but also on thin subjects, in terms of the prevention of chronic kidney disease.

Urinary screening for detection of renal abnormalities in asymptomatic school children

Background

Urinary screening tests for early detection of renal diseases in asymptomatic school children and adolescents are important in the detection of silent renal diseases.

Objectives

The purpose of the study was to determine the prevalence of occult renal diseases by dipstick test (reagent strips) in asymptomatic Nepalese children.

Patients and Methods

A total of 2,243 school children, aged 5–15 years, were screened for urinary abnormalities using dipstick test screening. The children who tested positive in the first screening were re-tested after 2–4 weeks.

Results

In the first screening, 123 children (5.5%) tested positive for isolated hematuria and proteinuria and for combined hematuria and proteinuria. Of these children, 16 (0.71%) cases tested positive in a second screening. Subsequently, 1 child from the secondary screening group was lost to follow up, 5 tested normal and 10 revealed abnormalities. Glomerulonephritis was the most commonly detected disorder (50%).

Conclusions

Urinary screening was found to be useful in identifying occult renal diseases in asymptomatic children. Urinary screening would therefore not only help in early detection but also in the prevention of the deterioration of renal function later in life.

Dipstick urinalysis screening of healthy neonates

BACKGROUND

Renal disease may accidentally be discovered during urinalysis. This study was conducted to examine the usefulness of dipstick urinalysis screening in healthy neonates for the diagnosis of underlying renal disease and to study the magnitude of abnormal urinalysis in apparently healthy neonates.

METHODS

In this descriptive study, voided urine samples were obtained from 400 apparently healthy neonates and tested using urine dipstick. The reaction of dipstick strip was read visually by a trained nurse. In cases with an abnormal urine analysis, a second screen test was performed within a week, and for those with persistent abnormalities, complete diagnostic tests were done.

RESULTS

On the first urinalysis, 375 (94%) subjects were normal and 25 (6%) had abnormalities: 23 had proteinuria (5.75%), one was blood positive (0.25%), and one was both protein and blood positive (0.25%). Male neonates had a higher proportion of proteinuria than female neonates (p=0.038). In the second examination, proteinuria was found in five (1.25%) neonates, but the proportion of other abnormalities did not change. In follow-up investigations, ureteropelvic junction obstruction and vesicoureteral reflux were recognized in two infants who had blood-positive or combined blood- and protein-positive results on their first tests.

CONCLUSION

The findings of this study show that dipstick test during neonatal period could be used for early diagnosis of renal diseases.

Early influences on cardiovascular and renal development

The hypothesis that a developmental component plays a role in subsequent disease initially arose from epidemiological studies relating birth size to both risk factors for cardiovascular disease and actual cardiovascular disease prevalence in later life. The findings that small size at birth is associated with an increased risk of cardiovascular disease have led to concerns about the effect size and the causality of the associations. However, recent studies have overcome most methodological flaws and suggested small effect sizes for these associations for the individual, but an potential important effect size on a population level. Various mechanisms underlying these associations have been hypothesized, including fetal undernutrition, genetic susceptibility and postnatal accelerated growth. The specific adverse exposures in fetal and early postnatal life leading to cardiovascular disease in adult life are not yet fully understood. Current studies suggest that both environmental and genetic factors in various periods of life may underlie the complex associations of fetal growth retardation and low birth weight with cardiovascular disease in later life. To estimate the population effect size and to identify the underlying mechanisms, well-designed epidemiological studies are needed. This review is focused on specific adverse fetal exposures, cardiovascular adaptations and perspectives for new studies.

Is low birth weight an antecedent of CKD in later life? A systematic review of observational studies

BACKGROUND

There has been considerable interest in the hypothesis that low birth weight may be a marker of impaired nephrogenesis and that this is causally related to chronic kidney disease (CKD).

STUDY DESIGN

Systematic review and meta-analysis of observational studies.

SETTING & POPULATION

Studies of the relationship between birth weight and CKD published before February 1, 2008, were identified by using electronic searches.

SELECTION CRITERIA

All studies that had collected data for birth weight and kidney function at greater than 12 months of age were eligible for inclusion, except for studies of extremely low-birth-weight infants, very premature infants, or toxic exposure in utero. STUDY FACTOR: Birth weight.

OUTCOMES

CKD defined as albuminuria, low estimated glomerular filtration rate (<60 mL/min/1.73 m(2) or < 10th centile for age/sex), or end-stage renal disease.

RESULTS

We analyzed 31 relevant cohort or case-control studies with data for 49,376 individuals and data for 2,183,317 individuals from a single record-linkage study. Overall, 16 studies reported a significant association between low birth weight and risk of CKD and 16 observed a null result. The combination of weighted estimates from the 18 studies for which risk estimates were available (n = 46,249 plus 2,183,317 from the record linkage study) gave an overall odds ratio (OR) of 1.73 (95% confidence interval [CI], 1.44 to 2.08). Combined ORs were consistent in magnitude and direction for risks of albuminuria (OR, 1.81; 95% CI, 1.19 to 2.77), end-stage renal disease (OR, 1.58; 95% CI, 1.33 to 1.88), or low estimated glomerular filtration rate (OR, 1.79; 95% CI, 1.31 to 2.45).

LIMITATIONS

A reliance on published estimates and estimates provided on request rather than individual patient data and the possibility of reporting bias.

CONCLUSIONS

Existing data indicate that low birth weight is associated with subsequent risk of CKD, although there is scope for additional well-designed population-based studies with accurate assessment of birth weight and kidney function and consideration of important confounders, including maternal and socioeconomic factors.

Screening for CKD in children: a global controversy

This review addresses the relevance of urinary screening for chronic kidney disease (CKD) in children. Ambiguity about screening children exists because of the uncertainty as to whether early detection of renal disorders in childhood will lead to effective interventions and reduction in the number of individuals who subsequently progress to ESRD. A related concern is whether the adoption of urinary screening programs is cost effective. The most common method that is used for screening children for CKD involves the measurement of spot samples of urine for hematuria and or proteinuria. Although mass screening is now well established in Japan, Taiwan, and Korea, there appears to be movement away from mass screening to detect CKD in children and adolescents in North America and Europe. In December 2007, the American Academy of Pediatrics published their latest recommendations, in which no urinalyses were recommended at any age during childhood. The second issue addressed in this review is the reporting of estimated glomerular filtration rates (GFR) in children by clinical laboratories.

Chronic kidney disease prevention in Singapore

In consideration of the epidemiologic basis for screening and surveillance, a comprehensive program for chronic kidney disease prevention was initiated in Singapore by the National Kidney Foundation Singapore (NKF Singapore) in 1997. Reasons for developing this include the rising rate of end-stage renal disease in the country, and the projected escalation because of the increase in chronic diseases that lead to end-stage renal disease (ESRD) such as diabetes mellitus and hypertension. Presented are progress and preliminary findings of this program, as well as that of the parallel initiative of Singapore's Ministry of Health. The NKF Singapore program incorporates primary, secondary and tertiary approaches to the prevention of chronic kidney disease. These include the population-based screening for early chronic kidney disease and chronic diseases that are associated with kidney disease and the implementation of disease management programs that aim to improve the multi-faceted care of patients with chronic diseases that lead to ESRD, including the development of community-based "Prevention Centers." The screening program identified risk factors for proteinuria, including the Malay race, increasing age, family history of kidney disease, and higher levels of systolic and diastolic BP even within the normal ranges. Longitudinal follow-up of both prevention programs are critical to provide evidence for the efficacy of such screening and intervention programs in improving chronic kidney disease outcomes, while reducing the cost of care.

Hypertension and kidney disease in Asia

PURPOSE OF REVIEW

Communicable diseases were traditionally the major cause of public health concern in Asian countries, most of which were less developed. With industrialization and associated lifestyle changes during the past few decades, however, noncommunicable diseases similar to those that affect Western societies have emerged in Asian countries. The purpose of the review was to examine recent evidence about the burden and factors associated with hypertension and chronic kidney disease (CKD) in Asian countries.

RECENT FINDINGS

Hypertension has become one of the leading causes of mortality in Asia. Although its prevalence continues to rise, it remains under-diagnosed and under-treated. CKD is becoming increasingly common mainly due to an increase in risk factors such as high blood pressure, diabetes, and obesity. Treatment of advanced CKD is overwhelmingly burdensome in a resource poor environment. Barriers to early detection of CKD in Asians include the fact that equations to estimate the glomerular filtration rate have not been validated in this population, and the uncertainty about appropriate glomerular filtration rate cutoff values to define CKD.

SUMMARY

Concerted efforts are needed to develop and implement cost-effective strategies for prevention and treatment of hypertension and CKD in Asian countries. More research is needed on these conditions in these populations.

Proteinuria in South Asian children: prevalence and determinants

Proteinuria in children is a marker of kidney disease and atherosclerosis, both which are known predictors of cardiovascular mortality. Recent evidence suggests that migrant South Asian populations living in the West may be at higher risk of kidney disease than native Caucasians. However, the determinants of proteinuria in South Asian children have not been explored. Previously, we reported ethnic variation in the prevalence of proteinuria in the adult population of Pakistan. However, it is not known whether ethnic predisposition to proteinuria appears during childhood or whether it is acquired later in life as a result of prolonged exposure to undiagnosed diabetes and hypertension. Analyses were based on a subset of data for 4977 children aged 5 to less than 15 years collected as part of the broad National Health Survey of Pakistan, conducted between 1990 and 1994. Proteinuria was defined as a dipstick positive for protein on a random urine sample. Ethnicity was reported as "mother-tongue", which is specific for each of the five major ethnic subgroups of Pakistan: Muhajir, Punjabi, Sindhi, Pashtun, and Baluchi. The overall prevalence (95% CI) of proteinuria in the children was 3.3% (2.7-3.9%). It was 6.2% in Sindhis, 3.6% in Muhajirs, 2.8% in Punjabis, 2.8% in Baluchis, and 1.0% in Pashtuns (p<0.001). In multivariable analyses, proteinuria was associated with greater height (p=0.007), urban dwelling (p=0.03), lower socioeconomic status (p=0.02), and certain ethnicities (p=0.005). The ethnic variation in proteinuria in South Asian children mirrors variation among ethnic groups in adults. This suggests variations in susceptibility or early exposure to causes of chronic kidney disease, rather than long-term exposure to undiagnosed diabetes or hypertension. Further studies are needed to determine factors in early life that may differentially predispose certain ethnic groups to proteinuria.

Ethnic differences and determinants of proteinuria among South Asian subgroups in Pakistan

BACKGROUND

Hypertension, diabetes, increasing age, and smoking are known risk factors for proteinuria. Prevalence of proteinuria is high in South Asians. However, ethnic subgroup differences and determinants of proteinuria within the South Asian population have not been explored.

METHODS

The National Health Survey of Pakistan conducted between 1990 and 1994 was used to explore ethnic subgroup variation in proteinuria. Distinct ethnic subgroups, the Muhajir, the Punjabi, the Sindhi, the Pashtun, and the Baluchi, were defined by mother tongue. We report results in individuals aged >or=15 years (N = 9442). Proteinuria was defined as dipstick positive for protein on random urine sample.

RESULTS

Increasing age, high consumption of meat, and presence of hypertension and diabetes were each independently associated with proteinuria. The age-standardized prevalence of proteinuria was 4.6% (4.2% to 5.1%) and varied among ethnic subgroups (P < 0.001). The highest was among the Sindhi (men 9.5%, women 10.3%), then the Muhajir (men 8.2%, women 4.7%), the Punjabi (men 3.2% women 3.5%), and lowest among the Baluchi (men 2.4%, women 4.2%) and the Pashtun (men 2.7%, women 1.2%). The ethnic differences persisted after adjusting for the above-mentioned sociodemographic, dietary, and clinical risk factors [adjusted odds ratio (OR) (95% CI)] were 6.42 (3.97 to 10.38) for the Sindhis, 3.58 (2.22 to 5.79) for the Muhajirs, 2.03 (1.25 to 3.29) for the Punjabis, and 1.75 (0.79 to 3.88) for the Baluchis compared to the Pashtuns).

CONCLUSION

We conclude that unmeasured environmental or genetic factors account for ethnic variations in proteinuria, and deserve further study.

Taking a public health approach to the prevention of end-stage renal disease: the NKF Singapore Program

The National Kidney Foundation Singapore (NKFS) provides subsidized dialysis care to approximately 70% of the country's total end-stage renal disease (ESRD) population, based entirely on charitable donations. Because of the exponential increase in prevalent dialysis patients receiving care through the NKFS' chronic dialysis program, and with the anticipated epidemic rise in incident ESRD patients, an accelerated comprehensive strategy for the prevention of renal and its associated chronic diseases was developed. Presented is the NKFS' public health plan, which incorporates primary, secondary and tertiary approaches to the prevention of chronic kidney disease. Components of this comprehensive strategy include: screening populations at risk for the development and progression of renal disease, the documentation of existing standards of care for chronic diseases associated with renal disease, and the institution of disease management programs that facilitate the systematic management of patients with chronic diseases that lead to ESRD, including the development of community-based "Prevention Centers." Finally, longitudinal follow-up of the participating population is being performed in order to provide benchmarks for improvement and to determine future directions of the program. Such long-term monitoring also will facilitate the establishment of its efficacy in improving clinical outcomes, reducing the cost of care, and delaying the development and progression of chronic kidney disease.

Paradigms of public-private partnerships in end-stage renal disease care: the National Kidney Foundation Singapore

Novel forms of funding chronic renal replacement therapy and other chronic kidney disease programs are urgently required in order to address the increasing global burden of end-stage renal disease (ESRD). For areas of infectious disease control in less-developed countries, the formation of public-private partnerships has successfully yielded short-term improvement in clinical outcomes. This article reviews the concept of public-private partnerships and its various formats. We argue that similar partnerships play an important role in addressing the public health problem of chronic kidney disease. Through its establishment of numerous paradigms of partnerships with private for-profit corporations in building a nationwide chronic dialysis program and through partnerships with other non-governmental institutions and healthcare institutions in order to create a new entity characterized by a separate management structure, the NKFS has been able to provide chronic dialysis care to over 70% of the country's total ESRD population. This extensive network of partnerships is currently being applied as the NKFS continues to expand its programs to focus on the prevention of chronic kidney disease at a nationwide level.

Risk factors for proteinuria in a large, multiracial, southeast Asian population

The factors associated with proteinuria were examined in a large multiracial Asian population participating in a screening program aimed at the early detection of renal disease. Of 213,873 adults who participated, 189,117 with complete data were included. Malay race, increasing age, both extremes of body mass index (BMI), self-reported family history of kidney disease (FKD), and higher systolic and diastolic BP measurements (even at levels classified as being within the normal range) were independently associated with dipstick-positive proteinuria. The odds ratios (OR) for proteinuria increased progressively with age. There was a J-shaped relationship between BMI and proteinuria (OR of 1.3, 1.00, 1.3, 1.6, and 2.5 for BMI of < or =18.00, 23.00 to 24.99, 25.00 to 27.49, 27.50 to 29.99, and > or =30.00 kg/m(2), respectively, compared with BMI of 18.01 to 22.99 kg/m(2)). OR for proteinuria according to systolic and diastolic BP were significantly increased beginning at levels of 110 and 90 mmHg, respectively. In addition, the Malay race was associated with a significantly higher OR for proteinuria, compared with the Chinese race (OR of 1.3). Finally, FKD was significantly associated with proteinuria (OR of 1.7), whereas a family history of diabetes mellitus and a family history of hypertension were not. When family histories were analyzed by clustering, isolated FKD remained a significant determinant of proteinuria and the magnitude of the effect was not significantly different from that observed in the presence of a coexisting family history of diabetes mellitus or hypertension. This is the first study to evaluate factors associated with proteinuria in an Asian population. The epidemiologic study of renal disease in this population suggests that risk factors for renal disease might differ significantly among racial groups.