Trends in incidence of end-stage renal disease in Japan, 1983-2000: age-adjusted and age-specific rates by gender and cause

Use of Histologic Parameters to Predict Glomerular Disease Progression: Findings From the China Kidney Biopsy Cohort Study

RATIONALE & OBJECTIVE

Challenges in achieving valid risk prediction and stratification impede treatment decisions and clinical research design for patients with glomerular diseases. This study evaluated whether chronic histologic changes, when complementing other clinical data, improved the prediction of disease outcomes across a diverse group of glomerular diseases.

STUDY DESIGN

Multicenter retrospective cohort study.

SETTING & PARTICIPANTS

4,982 patients with biopsy-proven glomerular disease who underwent native biopsy at 8 tertiary care hospitals across China in 2004-2020.

NEW PREDICTORS & ESTABLISHED PREDICTORS

Chronicity scores depicted as 4 categories of histological chronic change, as well as baseline clinical and demographic variables.

OUTCOME

Progression of glomerular disease defined as a composite of kidney failure or a ≥40% decrease in estimated glomerular filtration rate from the measurement at the time of biopsy.

ANALYTICAL APPROACH

Multivariable Cox proportional hazard models. The performance of predictive models was evaluated by C statistic, time-dependent area under the receiver operating characteristic curve (AUROC), net reclassification index, integrated discrimination index, and calibration plots.

RESULTS

The derivation and validation cohorts included 3,488 and 1,494 patients, respectively. During a median of 31 months of follow-up, a total of 444 (8.9%) patients had disease progression in the 2 cohorts. For prediction of the 2-year risk of disease progression, the AUROC of the model combining chronicity score and the Kidney Failure Risk Equation (KFRE) in the validation cohort was 0.76 (95% CI, 0.65-0.87); in comparison with the KFRE model (AUROC, 0.68 [95% CI, 0.56-0.79]), the combined model was significantly better (P = 0.04). The combined model also had a better fit, with a lower Akaike information criterion and a significant improvement in reclassification as assessed by the integrated discrimination improvements and net reclassification improvements. Similar improvements in predictive performance were observed in subgroup and sensitivity analyses.

LIMITATIONS

Selection bias, relatively short follow-up, lack of external validation.

CONCLUSIONS

Adding histologic chronicity scores to the KFRE model improved the prediction of kidney disease progression at the time of kidney biopsy in patients with glomerular diseases.

PLAIN-LANGUAGE SUMMARY

Risk prediction and stratification remain big challenges for treatment decisions and clinical research design for patients with glomerular diseases. The extent of chronic changes is an important component of kidney biopsy evaluations in glomerular disease. In this large multicenter cohort including 4,982 Chinese adults undergoing native kidney biopsy, we evaluated whether histologic chronicity scores, when added to clinical data, could improve the prediction of disease prognosis for a diverse set of glomerular diseases. We observed that adding histologic chronicity scores to the kidney failure risk equation improved the prediction of kidney disease progression at the time of kidney biopsy in patients with glomerular diseases.

Long-term prolonged-release tacrolimus outcomes in living donor kidney transplantation: The Japan Academic Consortium of Kidney Transplantation study-II

OBJECTIVES

To evaluate the 10-year efficacy and safety of a prolonged-release tacrolimus-based combination immunosuppressive regimen on longer-term outcomes in living donor kidney transplantation.

METHODS

Data from Japanese living donor kidney transplant recipients (n = 410) maintained on continuous prolonged-release tacrolimus-based immunosuppression from 2009-2013 were analyzed with a median follow-up of 9.9 years.

RESULTS

A prolonged-release, tacrolimus-based combination regimen provided death-censored graft failure and all-cause death rates at 10 years of 7.0% and 6.8%, respectively. In multivariable analyses, acute and chronic rejection and 'throughout' (new-onset plus preexisting) diabetes mellitus were risk factors for death-censored graft failure. Recipient age ≥ 65 years, throughout diabetes mellitus and malignancy were common risk factors for all-cause death. Throughout diabetes mellitus was the most common risk factor for both death-censored graft failure and all-cause death. Additional analyses showed 10-year cumulative rates of death-censored graft failure were 14.0% and 5.4% for recipients with or without preexisting diabetes mellitus, respectively (log-rank test: p = 0.009). All-cause death rates were 12.7% and 5.4% in the preexisting and non-diabetes mellitus groups, respectively (log-rank test: p = 0.023).

CONCLUSIONS

In this real-world, retrospective, living donor kidney transplantation study, a prolonged-release tacrolimus-based immunosuppressive combination regimen provided 10-year death-censored graft failure rates of 14.0% and 5.4% in diabetes mellitus and non-diabetes mellitus patients, respectively; Similarly, 10-year all-cause death rates were 12.7% and 5.4% in diabetes mellitus and non-diabetes mellitus patients, respectively. To our knowledge, the data in this study are the first to provide 10-year transplant outcomes in living donor kidney transplant recipients under prolonged-release tacrolimus-based regimen.

Trends in the incidence of renal replacement therapy by type of primary kidney disease in Japan, 2006-2020

AIM

Age-standardized incidence of end stage kidney disease requiring renal replacement therapy (RRT) has stabilized in men and declined in women in Japan since 1996. However, recent trends by primary kidney disease are unknown. The present study aimed to examine recent trends in incidence rates of RRT by primary kidney disease in Japan.

METHODS

Numbers of incident RRT patients aged ≥20 years by sex and primary kidney disease from 2006 to 2020 were extracted from the Japanese Society of Dialysis Therapy registry. Using the census population as the denominator, annual incidence rates of RRT were calculated and standardized to the WHO World Standard Population (2000-2025). Average annual percentage change (AAPC) and corresponding 95% confidence intervals (CIs) were calculated for trends using Joinpoint regression analysis.

RESULTS

From 2006 to 2020, the crude number of incident RRT patients due to nephrosclerosis increased by 132% for men and 62% for women. Age-standardized incidence rates of RRT due to nephrosclerosis increased significantly, by 3.3% (95% CI: 2.9-3.7) and 1.4% (95% CI: 0.8-1.9) per year for men and women, respectively. The AAPC of chronic glomerulonephritis (-4.4% [95% CI: -5.3 to -3.8] for men and -5.1% [95% CI: -5.5 to -4.6] for women) and diabetic nephropathy (-0.6% [95% CI: -0.9 to -0.3] for men and -2.8% [95% CI: -3.1 to -2.6] for women) significantly decreased from 2006 to 2020.

CONCLUSION

Incident RRT due to chronic glomerulonephritis and diabetic nephropathy decreased, while the number and incident rates of RRT due to nephrosclerosis increased, from 2006 to 2020 in Japan.

Changes in metabolic parameters and adverse kidney and cardiovascular events during glomerulonephritis and renal vasculitis treatment in patients with and without diabetes mellitus

BACKGROUND

Cardiovascular disease causes significant morbidity and mortality in patients with glomerulonephritis, which is increasingly diagnosed in older individuals who may have diabetes mellitus (DM). We evaluated the impact of DM on metabolic profile, renal and cardiovascular outcomes during treatment and follow-up of individuals with glomerulonephritis.

METHODS

We performed a retrospective cohort study of 601 consecutive adults with biopsy-proven glomerulonephritis for factors associated with kidney failure, hospitalization for cardiovascular events, and death. Biopsies with isolated diabetic nephropathy were excluded.

RESULTS

The median patient age was 49.8 years (36.7-60.9 years) with estimated glomerular filtration rate of 56.7 mL/min/1.73 m2 (27.7-93.2 mL/min/1.73 m2). DM was present in 25.4%. The most frequent diagnoses were minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS) (29.5%), lupus nephritis (21.3%), immunoglobulin A (IgA) nephropathy (19.1%), and membranous nephropathy (12.1%). The median follow-up was 38.8 months (interquartile range [IQR], 26.8-55.8 months). Among 511 individuals with lupus nephritis, anti-neutrophil cytoplasmic antibody-associated vasculitis, MCD/FSGS, membranous nephropathy, and IgA nephropathy, 52 (10.2%) developed kidney failure at a median 16.4 months (IQR, 2.3-32.2 months), while 29 (5.7%) had cardiovascular-related hospitalizations at 12.9 months (IQR, 4.8-31.8 months) and 31 (6.1%) died at 13.5 months (IQR, 2.5-42.9 months) after diagnosis. Cox regression analysis found that baseline DM was independently associated with kidney failure (adjusted hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.06-4.05, p = 0.03) and cardiovascular-related hospitalization (adjusted HR, 2.69; 95% CI, 1.21-5.98, p = 0.02) but not with mortality.

CONCLUSION

DM was strongly associated with kidney failure and hospitalization for cardiovascular events in patients with biopsy-proven glomerulonephritis.

The mediating effect of resilience between family functioning and mental well-being in hemodialysis patients in Japan: a cross-sectional design

Background

End-stage kidney disease is highly prevalent worldwide. Currently, one of the most effective treatment modalities is dialysis therapy, which leads to serious side effects. Furthermore, psychiatric illnesses are prevalent among dialysis patients. Recently, researchers asserted that psychological resilience and family support could be helpful to maintain or improve patients’ mental well-being. Therefore, the purpose of this study was to examine the mediating effects of resilience on the relationship between family functioning and mental well-being in these patients.

Methods

To investigate the aim of this study, a cross-sectional design was employed. A total of 110 hemodialysis patients, who were receiving outpatient treatment from dialysis units at the University of Fukuoka and St. Maria Health Care Center in Japan, participated. Only the patients who met the criteria and who were willing to participate in this 30-min study were given The General Health Questionnaire-12, Conner-Davidson Resilience Scale, and Family Assessment Device. Structural Equation Modeling (SEM) was performed to test the hypothesis that resilience would mediate the relationship between each subscale of family functioning, namely, cohesion, adaptability, communication, and mental well-being. Then Sobel’s test was employed to examine the indirect effect.

Results

The results of the SEM showed that the model had an acceptable fit (RMSEA = .077; CFI = .93; and IFI = .94). According to the results, resilience fully mediated the relationship between family functioning, specifically family adaptability and communication, and mental health well-being of the dialysis patients. However, family cohesion was not associated with resilience.

Conclusions

The present study revealed that higher family adaptability and communication resulted in greater resilience, thus associated with better mental health. Given that poor mental health among dialysis patients is significantly associated with a decreased likelihood to adhere to treatment plans, it may lead to a significant risk to therapeutic compliance. As such, patients may experience detrimental consequences, such as death. This study showed that in order to maintain healthy mental well-being, developing resilience is a vital factor for hemodialysis patients.

Hippo signaling-a central player in cystic kidney disease?

Cystic transformation of kidney tissue is a key feature of various disorders including autosomal dominant polycystic kidney disease (ADPKD), autosomal recessive polycystic kidney disease (ARPKD), and disorders of the nephronophthisis spectrum (NPH). While ARPKD and NPH typically affect children and adolescents, pediatric onset of ADPKD is less frequently found. While both ADPKD and ARPKD are characterized by formation of hundreds of cysts accompanied by hyperproliferation of tubular epithelia with massive renal enlargement, NPH patients usually show kidneys of normal or reduced size with cysts limited to the corticomedullary border. Recent results suggest the hippo pathway to be a central regulator at the crossroads of the renal phenotype in both diseases. Hippo signaling regulates organ size and proliferation by keeping the oncogenic transcriptional co-activators Yes associated protein 1 (YAP) and WW domain containing transcription regulator 1 (TAZ) in check. Once this inhibition is released, nuclear YAP/TAZ interacts with TEAD family transcription factors and the consecutive transcriptional activation of TEA domain family members (TEAD) target genes mediates an increase in proliferation. Here, we review the current knowledge on the impact of NPHP and ADPKD mutations on Hippo signaling networks. Furthermore, we provide an outlook towards potential future therapeutic strategies targeting Hippo signaling to alleviate cystic kidney disease.

Synergistic impact of pre-diabetes and immunosuppressants on the risk of diabetes mellitus during treatment of glomerulonephritis and renal vasculitis

Background

Glomerulonephritis is often treated with kidney-saving, but potentially diabetogenic immunosup­pressants such as glucocorticosteroids and calcineurin inhibitors. Unfortunately, there are little data on dysglycemia before and after diagnosis and during treatment of glomerulonephritis. We aimed to evaluate the occurrence and risk factors for pre-diabetes and incident diabetes among non-diabetic patients with glomerular disease with or without treatment with immunosuppressants.

Methods

A single-center, retrospective cohort study was performed on 229 non-diabetic immunosuppressant-naïve adults diagnosed with glomerulonephritis and renal vasculitis. Patients with known diabetes and prior immunosuppressant treatment were excluded. Outcomes of new-onset pre-diabetes and new-onset diabetes were defined according to American Diabetic Association criteria.

Results

Pre-diabetes was present pre-biopsy in 74 of the 229 patients (32.3%). During the median follow-up of 34.0 (23.3-47.5) months, 29 patients (12.7%) developed new-onset diabetes and 58 (25.3%) had new-onset pre-diabetes. Immunosuppressive therapy in patients with pre-existing pre-diabetes was associated with increased odds of new-onset diabetes compared to those without either risk factor (26.0% versus 5.0%; odds ratio, 6.67; 95% confidence interval [CI], 1.41 to 31.64), P = 0.02).

Conclusion

New-onset diabetes after immunosuppressant treatment occurred in one-quarter of patients with glomerulonephritis and pre-existing pre-diabetes. Physicians should screen for pre-diabetes when planning treatment with immunosuppressants, as its presence significantly increases the risk of diabetes mellitus.

Diagnostic of Early Onset Polycystic Kidney Disease in Neonates

Polycystic kidney disease represented by autosomal dominant polycystic kidney disease (ADPKD) and autosomal recessive polycystic kidney disease (ARPKD) have a major impact of mortality in children. We conducted a study of a premature infant with an estimated gestation date of 32 weeks with a presumptive prenatal diagnosis of right polycystic kidney. A 28-year-old primigravida with pre-eclampsia was admitted at the gynecology unit of Clinical Emergency County Hospital of Craiova. The clinical examination revealed a large abdominal distention due probably to the right polycystic kidney, suspected on prenatal ultrasound and radiography. The preterm neonate undergone right nephrectomy 5 days after birth. Histopathology of the kidney was performed in the Pathology Department of the Emergency County Hospital of Craiova and in the Center for Microscopic Morphology and Immunology of U.M.F. of Craiova. Microscopy revealed dilated cysts lined by simple cuboidal or flattened epithelium, and islets of remnant kidney parenchyma separated by edematous stroma. Immunohistochemistry for CD34 revealed incomplete blood arcades which did not seem to be in contact with all the tubular elements of the parenchyma, when compared to a control age-matched kidney. The patient had a favorable postoperative evolution, she was clinically stable on discharge from the hospital with a follow-up strategy including genetic testing.

Polycystic kidney disease

Cystic kidneys are common causes of end-stage renal disease, both in children and in adults. Autosomal dominant polycystic kidney disease (ADPKD) and autosomal recessive polycystic kidney disease (ARPKD) are cilia-related disorders and the two main forms of monogenic cystic kidney diseases. ADPKD is a common disease that mostly presents in adults, whereas ARPKD is a rarer and often more severe form of polycystic kidney disease (PKD) that usually presents perinatally or in early childhood. Cell biological and clinical research approaches have expanded our knowledge of the pathogenesis of ADPKD and ARPKD and revealed some mechanistic overlap between them. A reduced 'dosage' of PKD proteins is thought to disturb cell homeostasis and converging signalling pathways, such as Ca²⁺, cAMP, mechanistic target of rapamycin, WNT, vascular endothelial growth factor and Hippo signalling, and could explain the more severe clinical course in some patients with PKD. Genetic diagnosis might benefit families and improve the clinical management of patients, which might be enhanced even further with emerging therapeutic options. However, many important questions about the pathogenesis of PKD remain. In this Primer, we provide an overview of the current knowledge of PKD and its treatment.

Chronic Kidney Disease, Gender, and Access to Care: A Global Perspective

Little is known regarding the ways in which chronic kidney disease (CKD) prevalence and progression differ between the sexes. Still less is known regarding how social disparities between men and women may affect access to care for CKD. In this review, we briefly describe biological sex differences, noting how these differences currently do not influence CKD management recommendations. We then describe what is known within the published literature regarding differences in CKD epidemiology between sexes; namely prevalence, progression, and access to treatment throughout the major world regions. We highlight that health care expenditure and social gender disparities ultimately may determine whether women have equitable access to care for CKD and end-stage kidney disease. Among many high- and low-income settings, women more often donate and are less likely to receive kidney transplants when compared with men. Research is needed urgently to elucidate the reasons behind these disparities, as well as to develop CKD treatment strategies tailored to women's unique health care needs.

Hemodialysis versus peritoneal dialysis: an observational study in two international centers

INTRODUCTION

Given that it is difficult to randomize end-stage renal disease (ESRD) patients to either hemodialysis (HD) or peritoneal dialysis (PD), differences between these renal replacement therapy (RRT) modalities are of major interest and remain controversial.

METHODS

All data on maintenance dialysis patients during 2009 to 2013 in the Renji Hospital in Shanghai, China and in the San Bortolo Hospital in Vicenza, Italy were selected. Patients who changed their therapy from HD to PD or PD to HD during this study were excluded.

RESULTS

919 maintenance dialysis patients were included in the present study, including 509 patients on HD and 410 on PD. During the 5-year follow-up, mean arterial pressure (MAP) was higher in HD patients. The level of serum HCO3- was significantly better in PD patients than in HD patients. Phosphate was significantly higher in HD patients than in PD patients. With respect to lipid metabolism, triglyceride, total cholesterol and LDL were significantly higher in PD patients. Serum protein and albumin were higher in HD patients than in PD patients. Overall, 236 patients died (25.7%); 150 (16.3%) on HD and 86 (9.4%) on PD. The main cause of death in HD and PD patients was cerebral vascular disease and infection, respectively. After adjusting for dialysis vintage, the Kaplan-Meier patient survival was similar between HD and PD patients.

CONCLUSIONS

Based on 5 years of data, we demonstrate that lipid metabolism and nutritional status were better in HD patients. However, blood pressure control, acid-base balance, phosphate (P) control were better in PD patients. The main cause of death in HD and PD was cerebral vascular disease and infection, respectively. Considering the dialysis vintage, the Kaplan-Meier patient survival was similar between HD and PD patients.

The Role of Early Diagnosis of Hepatorenal Cystic (HRC) Syndrome in Children-Clinical Trial

ABSTRACT: The hepatorenal cystic (HRC) syndrome is a heterogeneous group of severe monogenic conditions that may be detected before birth. Effective programme evaluation of children with HRC syndrome is a systematic way to identify the renal and urinary tract malformations which represent the most common cause of end-stage renal disease (ESRD). We conducted a study involving 50 patients, who were between 3 months and 16 years of age, with multiple admissions in the Nephrology Department of “Maria Sklodowska Curie” Children Emergency Hospital from Bucharest, during 6 years (April 14th 2010-October 24th 2016), to evaluate the HRC syndrome. The admission symptomatology was mainly represented by the nephrology evaluation which was essential in the management of children’s polycystic kidney disease. For example, a premature infant (gestational age=32 weeks) with positive heredo-collateral history (mother and grandmother were diagnosed with polycystic kidney disease), was tested positive for cystic renal disease after the fetal morphology was performed. It was also done a genetic determination for the presence of PKD1 and PKD2 mutations which are specific to autosomal dominant polycystic kidney disease-ADPKD. However, the genetic test was negative and a postnatal nephrological evaluation was performed using renal ultrasound. The image revealed autosomal recessive polycystic kidney disease-ARPKD. This study emphasizes the importance of an early diagnosis (prenatal, neontal, postnatal) correlated with the admission symptoms and also with the genetic diagnosis (mutations of PKD1 and PKD2).

Is Stem Cell Transplantation Ready for Prime Time in Diabetic Polyneuropathy?

Diabetic polyneuropathy (DPN) is the most common complication that emerges early in patients who have diabetes. Curative treatment for overt or symptomatic DPN has not been established, requiring much effort to explore new modalities. Thus, the use of various kinds of stem cells as a potential therapeutic option for DPN is of particular interest. The beneficial effects were proposed to be attributed to either cytokine released from transplanted stem cells or the differentiation of stem cells to substitute the damaged peripheral nerve. Furthermore, based on the concept that humoral factors secreted from stem cells play a pivotal role in tissue regeneration, the utilization of conditioned medium derived from the stem cell culture serves as a novel tool for regenerative therapy. However, many questions have not been yet answered to determine whether stem cell therapy is essential in clinical application of DPN. In this report, we review the current status of preclinical studies on stem cell therapy for DPN and discuss future prospects.

Long-Term Exposure to Air Pollution and Increased Risk of Membranous Nephropathy in China

The effect of air pollution on the changing pattern of glomerulopathy has not been studied. We estimated the profile of and temporal change in glomerular diseases in an 11-year renal biopsy series including 71,151 native biopsies at 938 hospitals spanning 282 cities in China from 2004 to 2014, and examined the association of long-term exposure to fine particulate matter of <2.5 μm (PM_2.5) with glomerulopathy. After age and region standardization, we identified IgA nephropathy as the leading type of glomerulopathy, with a frequency of 28.1%, followed by membranous nephropathy (MN), with a frequency of 23.4%. Notably, the adjusted odds for MN increased 13% annually over the 11-year study period, whereas the proportions of other major glomerulopathies remained stable. During the study period, 3-year average PM_2.5 exposure varied among the 282 cities, ranging from 6 to 114 μg/m³ (mean, 52.6 μg/m³). Each 10 μg/m³ increase in PM_2.5 concentration associated with 14% higher odds for MN (odds ratio, 1.14; 95% confidence interval, 1.10 to 1.18) in regions with PM_2.5 concentration >70 μg/m³ We also found that higher 3-year average air quality index was associated with increased risk of MN. In conclusion, in this large renal biopsy series, the frequency of MN increased over the study period, and long-term exposure to high levels of PM_2.5 was associated with an increased risk of MN.

The Telmisartan Renoprotective Study from Incipient Nephropathy to Overt Nephropathy – Rationale, Study Design, Treatment Plan and Baseline Characteristics of the Incipient to Overt: Angiotensin II Receptor Blocker, Telmisartan, Investigation on Type 2 Diabetic Nephropathy (INNOVATION) Study

We planned the INNOVATION study to determine whether telmisartan, an angiotensin-2-receptor blocker, delays the progression of renal disease from incipient nephropathy to overt nephropathy in hypertensive or normotensive Japanese patients with type 2 diabetes mellitus. The INNOVATION study is a randomized, double-blind, placebo-controlled trial. Eligible patients must have incipient nephropathy (defined as a urinary albumin to creatinine ratio of 100-300 mg/g creatinine) and a serum creatinine concentration of < 1.5 mg/dl for men and < 1.3 mg/dl for women. Patients who need treatment with angiotensin II receptor blockers or angiotensin-converting enzyme inhibitors are excluded. Eligible patients are randomly assigned to three groups: telmisartan titrated to 40 mg; telmisartan titrated to 80 mg; or placebo. The primary endpoint is the time from baseline visit to first detection of overt nephropathy (defined by a urinary albumin to creatinine ratio that is > 300 mg/g creatinine and 30% higher than the baseline on at least two consecutive visits). A total of 1855 patients have been enrolled from 160 study centres. In 527 randomized patients (28.4% of the enrolled patients), mean (SD) urinary albumin to creatinine ratio and serum creatinine concentration at baseline were 173.3 (47.2) mg/g creatinine and 0.78 (0.19) mg/dl. Sixty-eight per cent of the patients had hypertension at baseline. Mean (SD) systolic and diastolic blood pressures at baseline were 137.1 (14.6) and 77.5 (10.3) mmHg. The INNOVATION study will determine whether telmisartan, an angiotensin II receptor blocker, provides clinical benefits in hypertensive or normotensive patients with diabetes mellitus and diabetic nephropathy.

The Role of Gender in Chronic Kidney Disease

Chronic kidney disease (CKD) is a common disease worldwide and is associated with high rates of morbidity and mortality. This review discusses several aspects of the relationship between gender and CKD. While the prevalence of CKD tends to be higher in women, the disease is more severe in men, who also have a higher prevalence of end-stage renal disease. Most of the evidence in the current literature suggests a higher progression rate and mortality risk of CKD in men compared with women, except in post-menopausal women and diabetic patients. However, the decrease in glomerular filtration rate and the increase in the level of albuminuria are more prominent mortality risk factors among women. Sex hormones are thought to play a major role in the biological mechanisms associated with variability in CKD prevalence and characteristics between men and women. Animal studies have demonstrated the harmful influence of testosterone and protective influence of oestrogen on several biological processes that are involved in kidney injury. However, the role of sex hormones in explaining gender-related differences in CKD in humans has not yet been established. In summary, gender has an important influence on several aspects of CKD. Further research is needed to find additional gender-related characteristics in CKD and to identify the mechanisms of sexual dimorphism in CKD.

Outcome Comparisons Between Patients on Peritoneal Dialysis With and Without Polycystic Kidney Disease: A Nationwide Matched Cohort Study

Polycystic kidney disease (PCKD) is the most common hereditary cause of end-stage renal disease. The complications associated with this disease may affect the performance of peritoneal dialysis (PD). The aim of this study was to compare the outcomes between patients on PD with PCKD and without PCKD.We extracted an incident cohort of adult (≥ 20 years old) patients on long-term PD from the Taiwan National Health Insurance Research Database. Patients with PCKD were identified by specific diagnosis codes. We recorded baseline comorbidities, socioeconomic status, timing of referral to a nephrologist, prior hemodialysis history before PD, and the type of PD modalities. We compared the risk of death, technique failure, peritonitis, hospitalization, and outpatient visiting as well as overall medical expenditure between the patients with PCKD and a groups of patients without PCKD who were propensity-score matched (1:3). The analysis was carried out by various Cox regression models that considered competing risk and time-varying coefficients. We enrolled 139 patients with PCKD and 7739 patients without PCKD who started long-term PD between 1999 and 2010. Patients with PCKD were less comorbid and more often treated with automated PD. In the propensity-score matched analysis, both overall survival and technique survival did not differ between the patients and the result was similar for hospitalization and peritonitis after adjusting for the application of automated PD. Furthermore, the overall annual medical expenditures were similar between the patients with and without PCKD. PD patients with PCKD are comparable to PD patients without PCKD in terms of risk of death, peritonitis, technique failure, and hospitalization in the present study. Furthermore, the medical expenses of the 2 groups after initiation of PD are also indistinguishable.

Japanese society for dialysis therapy renal data registry-a window through which we can view the details of Japanese dialysis population

The Japanese Society for Dialysis Therapy (JSDT) collects the clinical data from all the facilities to create a nation-wide registry system named JSDT Renal Data Registry (JRDR). This survey was begun in 1966 as a form of facility survey. Patient survey started in 1983. More than 95% of facilities respond to the survey on the basis of voluntary work of facility staffs. Therefore, JRDR has the longest history and the most comprehensive coverage. As for the prevalent patients, 304,856 patients are treated by dialysis therapy in Japan as of the year 2011. The demographics of the Japanese dialysis population have been markedly changing in terms of age, primary diagnoses and dialysis vintage. The mean age of prevalent population reaches 66.55 years at the end of 2011. The increase in the numbers of dialysis population is due to the growth of those older than 65 years old. Patients with the vintage longer than 20 years account for 8% of the entire population. Around 38 thousands patients started their dialysis treatments, whereas 31 thousands deceased. The disease burden of cardiovascular diseases as well as infection is substantial due to the demographic changes. Many evidences have been reported from the data obtained from JRDR to date. These findings covers a wide range of dialysis practice and are utilized for the development of JSDT guidelines. Therefore, JRDR has provided indispensable and fundamental data of Japanese dialysis population.

Screening with urinary dipsticks for reducing morbidity and mortality

BACKGROUND

Urinary dipsticks are sometimes used for screening asymptomatic people, and for case-finding among inpatients or outpatients who do not have genitourinary symptoms. Abnormalities identified on screening sometimes lead to additional investigations, which may identify serious disease, such as bladder cancer and chronic kidney disease (CKD). Urinary dipstick screening could improve prognoses due to earlier detection, but could also lead to unnecessary and potentially invasive follow-up testing and unnecessary treatment.

OBJECTIVES

We aimed to quantify the benefits and harms of screening with urinary dipsticks in general populations and patients in hospitals.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register to 8 September 2014 through contact with the Trials Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

Randomised controlled trials and other study types that compared urinary dipstick screening with no dipstick screening were eligible for inclusion. We searched for studies that investigated the use of urinary dipsticks for detecting haemoglobin, protein, albumin, albumin-creatinine ratio, leukocytes, nitrite, or glucose, alone or in any combination, and in any setting. We planned to exclude studies conducted in patients with urinary disorders.

DATA COLLECTION AND ANALYSIS

It was planned that two authors would independently extract data from included studies and assess risk of bias using the Cochrane risk of bias tool. However, no studies met our inclusion criteria.

MAIN RESULTS

Literature searches to 8 September 2014 yielded 4298 records, of which 4249 were excluded following title and abstract assessment. There were 49 records (44 studies) eligible for full text assessment; of these 18 studies were not RCTs and 26 studies compared interventions or controls that were not relevant to this review. Thus, no studies were eligible for inclusion.

AUTHORS' CONCLUSIONS

We found no evidence to assess the benefits and harms of screening with urinary dipsticks, which remain unknown.

Mapping end-stage renal disease (ESRD): spatial variations on small area level in northern France, and association with deprivation

BACKGROUND

Strong geographic variations in the incidence of end-stage renal disease (ESRD) are observed in developed countries. The reasons for these variations are unknown. They may reflect regional inequalities in the population's sociodemographic characteristics, related diseases, or medical practice patterns. In France, at the district level, the highest incidence rates have been found in the Nord-Pas-de-Calais region. This area, with a high population density and homogeneous healthcare provision, represents a geographic situation which is quite suitable for the study, over small areas, of spatial disparities in the incidence of ESRD, together with their correlation with a deprivation index and other risk factors.

METHODS

The Renal Epidemiology and Information Network is a national registry, which lists all ESRD patients in France. All cases included in the Nord-Pas-de-Calais registry between 2005 and 2011 were extracted. Adjusted and smoothed standardized incidence ratio (SIR) was calculated for each of the 170 cantons, thanks to a hierarchical Bayesian model. The correlation between ESRD incidence and deprivation was assessed using the quintiles of Townsend index. Relative risk (RR) and credible intervals (CI) were estimated for each quintile.

RESULTS

Significant spatial disparities in ESRD incidence were found within the Nord-Pas-de-Calais region. The sex- and age-adjusted, smoothed SIRs varied from 0.66 to 1.64. Although no correlation is found with diabetic or vascular nephropathy, the smoothed SIRs are correlated with the Townsend index (RR: 1.18, 95% CI [1.00-1.34] for Q2; 1.28, 95% CI [1.11-1.47] for Q3; 1.30, 95% CI [1.14-1.51] for Q4; 1.44, 95% CI [1.32-1.74] for Q5).

CONCLUSION

For the first time at this aggregation level in France, this study reveals significant geographic differences in ESRD incidence. Unlike the time of renal replacement care, deprivation is certainly a determinant in this phenomenon. This association is probably independent of the patients' financial ability to gain access to healthcare.

ESRD from autosomal dominant polycystic kidney disease in the United States, 2001-2010

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is amenable to early detection and specialty care. Thus, while important to patients with the condition, end-stage renal disease (ESRD) from ADPKD also may be an indicator of the overall state of nephrology care.

STUDY DESIGN

Retrospective cohort study of temporal trends in ESRD from ADPKD and pre-renal replacement therapy (RRT) nephrologist care, 2001-2010 (n = 23,772).

SETTING & PARTICIPANTS

US patients who initiated maintenance RRT from 2001 through 2010 (n = 1,069,343) from US Renal Data System data.

PREDICTOR

ESRD from ADPKD versus from other causes for baseline characteristics and clinical outcomes; interval 2001-2005 versus 2006-2010 for comparisons of cohort of patients with ESRD from ADPKD.

OUTCOMES

Death, wait-listing for kidney transplant, kidney transplantation.

MEASUREMENTS

US census data were used as population denominators. Poisson distribution was used to compute incidence rates (IRs). Incidence ratios were standardized to rates in 2001-2002 for age, sex, and race/ethnicity. Patients with and without ADPKD were matched to compare clinical outcomes. Poisson regression was used to calculate IRs and adjusted HRs for clinical events after inception of RRT.

RESULTS

General population incidence ratios in 2009-2010 were unchanged from 2001-2002 (incidence ratio, 1.02). Of patients with ADPKD, 48.1% received more than 12 months of nephrology care before RRT; preemptive transplantation was the initial RRT in 14.3% and fistula was the initial hemodialysis access in 35.8%. During 4.9 years of follow-up, patients with ADPKD were more likely to be listed for transplantation (IR, 11.7 [95% CI, 11.5-12.0] vs 8.4 [95% CI, 8.2-8.7] per 100 person-years) and to undergo transplantation (IR, 9.8 [95% CI, 9.5-10.0] vs 4.8 [95% CI, 4.7-5.0] per 100 person-years) and less likely to die (IR, 5.6 [95% CI, 5.4-5.7] vs 15.5 [95% CI, 15.3-15.8] per 100 person-years) than matched controls without ADPKD.

LIMITATIONS

Retrospective nonexperimental registry-based study of associations; cause-and-effect relationships cannot be determined.

CONCLUSIONS

Although outcomes on dialysis therapy are better for patients with ADPKD than for those without ADPKD, access to predialysis nephrology care and nondeclining ESRD rates may be a cause for concern.

Azilsartan improves glycemic status and reduces kidney damage in zucker diabetic fatty rats

BACKGROUND

Azilsartan medoxomil (AZL-M), an angiotensin II receptor blocker, demonstrates antihypertensive and organ protective effects in hypertension. We investigated the efficacy of AZL-M to ameliorate metabolic syndrome and kidney damage associated with type 2 diabetes using Zucker diabetic fatty (ZDF) rats.

METHODS

ZDF rats were treated with vehicle or AZL-M for 8 weeks. Zucker diabetic lean (ZDL) rats were used as controls. Urine and plasma samples were collected for biochemical analysis, and kidney tissues were used for histopathological and immunohistopathological examination at the end of the 8-week protocol.

RESULTS

ZDF rats were diabetic with hyperglycemia and impaired glucose tolerance, and AZL-M ameliorated the diabetic phenotype. ZDF rats were hypertensive compared with ZDL rats (181±6 vs. 129±7mm Hg), and AZL-M decreased blood pressure in ZDF rats (116±7mm Hg). In ZDF rats, there was marked renal damage with elevated proteinuria, albuminuria, nephrinuria, 2-4-fold higher tubular cast formation, and glomerular injury compared with ZDL rats. AZL-M treatment reduced renal damage in ZDF rats. ZDF rats demonstrated renal inflammation and oxidative stress with elevated urinary monocyte chemoattractant protein 1 excretion, renal infiltration of macrophages, and elevated kidney malondialdehyde levels. AZL-M reduced oxidative stress and inflammation in ZDF rats.

CONCLUSIONS

Overall, we demonstrate that AZL-M attenuates kidney damage in type 2 diabetes. We further demonstrate that anti-inflammatory and antioxidative activities of AZL-M contribute to its kidney protective action.

Role of elevated serum uric acid levels at the onset of overt nephropathy in the risk for renal function decline in patients with type 2 diabetes

AIMS/INTRODUCTION

Despite the use of intensive therapies, declining renal function is often observed during the overt nephropathy stage of type 2 diabetes. We aimed at investigating the role of serum uric acid (SUA) levels at the onset of overt nephropathy in the risk of renal function decline in type 2 diabetes patients.

MATERIALS AND METHODS

The present cohort study included 290 type 2 diabetes patients who were followed from the onset of overt nephropathy. The relationship between SUA and declining renal function was assessed using Cox regression models after adjusting for known risk factors.

RESULTS

Over a median 4.8-year follow-up period, 85 patients (4.9/100 person-years) showed serum creatinine (Cr) doubling with a total cumulative incidence of 71.9% at 20 years of follow up. The highest SUA tertile resulted in significantly a higher incidence (7.7/100 person-years) and cumulative incidence at 20 years (85.7%) than the middle (3.9/100 person-years, 54.2%) and lowest (3.0/100 person-years, 55.5%) tertiles. The univariate Cox hazard model resulted in significant risks for Cr doubling related to female sex, short diabetes duration, smoking and elevated levels of low-density lipoprotein cholesterol (LDL-c), glycated hemoglobin and SUA tertiles. SUA tertiles remained statistically significant in the multivariate model (highest vs lowest hazard ratio 2.68, 95% confidence interval 1.48-5.00, P = 0.0009).

CONCLUSIONS

Elevated SUA levels within the normal range (men >6.3 mg/dL, women >5.1) at the onset of overt nephropathy resulted in an increased risk for declining renal function in type 2 diabetes patients.

Analysis of data from the ERA-EDTA Registry indicates that conventional treatments for chronic kidney disease do not reduce the need for renal replacement therapy in autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is a major cause of end-stage kidney failure, but is often identified early and therefore amenable to timely treatment. Interventions known to postpone the need for renal replacement therapy (RRT) in non-ADPKD patients have also been tested in ADPKD patients, but with inconclusive results. To help resolve this we determined changes in RRT incidence rates as an indicator for increasing effective renoprotection over time in ADPKD. We analyzed data from the European Renal Association-European Dialyses and Transplant Association Registry on 315,444 patients starting RRT in 12 European countries between 1991 and 2010, grouped into four 5-year periods. Of them, 20,596 were due to ADPKD. Between the first and last period the mean age at onset of RRT increased from 56.6 to 58.0 years. The age- and gender-adjusted incidence rate of RRT for ADPKD increased slightly over the four periods from 7.6 to 8.3 per million population. No change over time was found in the incidence of RRT for ADPKD up to age 50, whereas in recent time periods the incidence in patients above the age of 70 clearly increased. Among countries there was a significant positive association between RRT take-on rates for non-ADPKD kidney disease and ADPKD. Thus, the increased age at onset of RRT is most likely due to an increased access for elderly ADPKD patients or lower competing risk prior to the start of RRT rather than the consequence of effective emerging renoprotective treatments for ADPKD.

Proteinuria, (99m) Tc-DTPA Scintigraphy, Creatinine-, Cystatin- and Combined-Based Equations in the Assessment of Chronic Kidney Disease

Background. Precise estimation of the glomerular filtration rate (GFR) and the identification of markers of progression are important. We compared creatinine, cystatin, and combined CKD-EPI equations with ^99mTc-DTPA scintigraphy to measure GFR and proteinuria as markers of progression. Methods. Cross-sectional, observational study including 300 subjects. CKD was classified by ^99mTc-DTPA scintigraphy. Determinations. Creatinine, 24-hour creatinine clearance, cystatin, Hoek formula, and creatinine, cystatin, and combined CKD-EPI equations. Results. In the global assessment, creatinine CKD-EPI and combined CKD-EPI equations yielded the highest correlations with ^99mTc-DTPA: ρ = 0.839, P < 0.0001 and ρ = 0.831, P < 0.0001. Intergroup analysis versus ^99mTc-DTPA: control G, creatinine clearance ρ = 0.414, P = 0.013; G3, combined CKD-EPI ρ = 0.5317, P < 0.0001; G4, Hoek ρ = 0.618, P < 0.0001, combined CKD-EPI ρ = 0.4638, P < 0.0001; and G5, creatinine clearance ρ = 0.5414, P < 0.0001, combined CKD-EPI ρ = 0.5288, P < 0.0001. In the global assessment, proteinuria displayed the highest significant correlations with cystatin (ρ = 0.5433, P < 0.0001) and cystatin-based equations (Hoek: ρ = −0.5309, P < 0.0001). When GFR < 60 mL/min: in stage 3, proteinuria-cystatin (ρ = 0.4341, P < 0.0001); proteinuria-Hoek (ρ = −0.4105, P < 0.0001); in stage 4, proteinuria-cystatin (ρ = 0.4877, P < 0.0001); proteinuria-Hoek (ρ = −0.4877, P = 0.0026). Conclusions. At every stage of GFR < 60 mL/min, cystatin-based equations displayed better correlations with ^99mTc-DTPA. Proteinuria and cystatin-based equations showed strong associations and high degrees of correlation.

Renal replacement therapy in ADPKD patients: a 25-year survey based on the Catalan registry

Background

Some 7-10% of patients on replacement renal therapy (RRT) are receiving it because of autosomal dominant polycystic kidney disease (ADPKD). The age at initiation of RRT is expected to increase over time.

Methods

Clinical data of 1,586 patients (7.9%) with ADPKD and 18,447 (92.1%) patients with other nephropathies were analysed from 1984 through 2009 (1984–1991, 1992–1999 and 2000–2009).

Results

The age at initiation of RRT remained stable over the three periods in the ADPKD group (56.7 ± 10.9 (mean ± SD) vs 57.5 ± 12.1 vs 57.8 ± 13.3 years), whereas it increased significantly in the non-ADPKD group (from 54.8 ± 16.8 to 63.9 ± 16.3 years, p < 0.001). The ratio of males to females was higher for non-ADPKD than for ADPKD patients (1.6–1.8 vs 1.1–1.2). The prevalence of diabetes was significantly lower in the ADPKD group (6.76% vs 11.89%, p < 0.001), as were most of the co-morbidities studied, with the exception of hypertension. The survival rate of the ADPKD patients on RRT was higher than that of the non-ADPKD patients (p < 0.001).

Conclusions

Over time neither changes in age nor alterations in male to female ratio have occurred among ADPKD patients who have started RRT, probably because of the impact of unmodifiable genetic factors in the absence of a specific treatment.

Increased risk of hip fracture among Japanese hemodialysis patients

Incidence of hip fracture in dialysis patients is significantly higher than that in the general population. As information is lacking about Asian dialysis patients, we compared the incidence of hip fracture in hemodialysis patients with that in the general population in Japan. We conducted a retrospective cohort study using panel data from the Japanese Society for Dialysis Therapy registry. The study included patients without history of hip fracture who received hemodialysis three times per week as of December 31, 2007. We compared the observed number of hip fractures to the expected number derived from a national survey, and calculated standardized incidence ratios (SIRs) and the incidence rate difference. Subgroup analysis was performed according to vintage and diabetic status. During the one-year study period, 1,437 hip fractures were recorded in the 128,141 hemodialysis patients (61.9 % male). The overall incidence was 7.57 and 17.43 per 1,000 person-years in men and women, respectively. The SIRs for male and female patients were 6.2 [95 % confidence interval (CI) 5.7-6.8] and 4.9 (95 % CI 4.6-5.3) compared to the general population, and remained nearly constant until 16 years vintage, but increased steeply thereafter. The incidence rate difference of hip fracture increased with age. The SIRs for diabetics of both genders were higher than those for non-diabetics. Our study provides additional evidence that hip fracture risk among Asian dialysis patients is also significantly higher than in the general population.

Epidemiology of autosomal-dominant polycystic kidney disease: an in-depth clinical study for south-western Germany

BACKGROUND

As we emerge into the genomic medicine era, the epidemiology of diseases is taken for granted. Accurate prevalence figures, especially of rare diseases (RDs, ≤50/100,000), will become even more important for purposes of health care and societal planning. We noticed that the numbers of affected individuals in regionally established registries for mainly hereditary RDs do not align with published estimated and expected prevalence figures. We therefore hypothesized that such non-population-based means overestimate RDs and sought to address this by recalculating prevalence for an important 'common' hereditary disease, autosomal-dominant polycystic kidney disease (ADPKD) whereby presumed-prevalence is 100-250/100,000 METHODS: The Else-Kroener-Fresenius-ADPKD-Study in south-west Germany with a population of 2,727,351 inhabitants was established with the cooperation of all nephrology centres. Furthermore, general practitioners, internists, urologists, human geneticists and neurosurgery centres were contacted with questionnaires for demographic, family and kidney function data. Germline-mutation screening of susceptibility genes PKD1 and PKD2 was offered. Official population data for 2010 were used for overall and kidney function-adjusted prevalence estimations.

RESULTS

A total of 891 subjects, 658 index-cases and 233 relatives, aged 10-89 (mean 52), were registered, with >90% response rate, 398 by nephrologists and 493 by non-nephrologists. Molecular-genetic analyses contributed to confirmation of the diagnosis in 57%. The overall prevalence of ADPKD was 32.7/100,000 reaching a maximum of 57.3/100,000 in the 6th decade of life.

CONCLUSIONS

Prevalence of ADPKD is overestimated by 2- to 5-fold and close to the limit of RDs which may be of broad clinical, logistic and policy implications.

Burden and management of chronic kidney disease in Japan: systematic review of the literature

Background

Chronic kidney disease (CKD) is a common disorder with increasing prevalence worldwide. This systematic literature review aims to provide insights specific to Japan regarding the burden and treatment of CKD.

Methods

We reviewed English and Japanese language publications from the last 10 years, reporting economic, clinical, humanistic, and epidemiologic outcomes, as well as treatment patterns and guidelines on CKD in Japan.

Results

This review identified 85 relevant articles. The prevalence of CKD was found to have increased in Japan, attributable to multiple factors, including better survival on dialysis therapy and a growing elderly population. Risk factors for disease progression differed depending on CKD stage, with proteinuria, smoking, hypertension, and low levels of high-density lipoprotein commonly associated with progression in patients with stage 1 and 2 disease. Serum albumin levels and hemoglobin were the most sensitive variables to progression in patients with stage 3 and 5 disease, respectively. Economic data were limited. Increased costs were associated with disease progression, and with peritoneal dialysis as compared with either hemodialysis or combination therapy (hemodialysis + peritoneal dialysis) treatment options. Pharmacological treatments were found potentially to improve quality of life and result in cost savings. We found no reports of treatment patterns in patients with early-stage CKD; however, calcium channel blockers were the most commonly prescribed antihypertensive agents in hemodialysis patients. Treatment guidelines focused on anemia management related to dialysis and recommendations for peritoneal dialysis treatment and preventative measures. Few studies focused on humanistic burden in Japanese patients; Japanese patients reported greater disease burden but better physical functioning compared with US and European patients.

Conclusion

A dearth of evidence regarding the earlier stages of kidney disease presents an incomplete picture of CKD disease burden in Japan. Further research is needed to gain additional insight into CKD in Japan.

Association between Urinary N-Acetyl-Beta-D-Glucosaminidase and Microalbuminuria in Diabetic Black Africans

Diabetes mellitus is the commonest cause of ESRD worldwide and third most common cause in Nigeria. Recent reports from Nigeria indicate the prevalence of diabetic nephropathy as an aetiology of ESRD is increasing necessitating early diagnosis of diabetic nephropathy. We measured the urinary excretion of N-acetyl-beta-D-glucosaminidase (NAG), NAG/creatinine ratio, urinary protein-creatinine ratio and calculated eGFR in 30 recently diagnosed nonhypertensive diabetics and 67 controls. The age and sex distribution, systolic blood pressure, serum and urinary creatinine were similar for both groups. There was higher urinary excretion of NAG (304 versus 184 μmol/h/L, P < 0.001) and NAG/creatinine ratio (21.2 versus 15.7 μmol/h/L/mmolCr, P < 0.001) in the diabetics than controls. There was a strong correlation between NAG/creatinine ratio and albumin/creatinine ratio (r = 0.74, P < 0.001). A multivariate linear regression model showed a significant linear relationship between NAG/creatinine ratio and albumin/creatinine ratio after adjusting for the effect of blood pressure, age, sex, and serum creatinine. The strong association found between albumin/creatinine ratio and NAG/creatinine ratio perhaps indicates the need for further investigation of the clinical utility of NAG/creatinine ratio as a screening tool for early nephropathy in African diabetics.

Polycystic kidney disease: a 2011 update

PURPOSE OF REVIEW

The review will examine clinically relevant advances in the area of polycystic kidney disease (PKD), mainly focusing on autosomal dominant polycystic kidney disease (ADPKD). Discussion will focus on predicting the course of ADPKD, clinical trials and new research endeavors.

RECENT FINDINGS

During the past several years PKD research has been one of the most prolific areas in investigative nephrology. Research endeavors have focused on decreasing cyst proliferation and cyst fluid formation based on an understanding of the pathophysiology of these processes. If cysts can be prevented from growing, kidney function can be better preserved.

SUMMARY

Progression of this most common inherited kidney disorder can be altered by understanding that cysts are the disease in ADPKD. Assessing total kidney volume and noting its relationship to glomerular filtration rate is key in predicting the course of the disease and will aid in the evaluation of the new research initiatives that are designed to stop cyst proliferation and fluid secretion into the kidney cysts. The role of biomarkers is an advancement in predicting PKD progression and can potentially be used in evaluation of treatments for this disease. Complications of PKD alter the course and prognosis; hence management approaches will be addressed.

Low birth weight is associated with earlier onset of end-stage renal disease in Danish patients with autosomal dominant polycystic kidney disease

Low-birth-weight individuals have a higher risk of hypertension and end-stage renal disease (ESRD). Here we investigated whether low birth weight was associated with earlier onset of ESRD in patients with autosomal dominant polycystic kidney disease (ADPKD). In collaboration with all Danish departments of nephrology, 307 of 357 patients with ADPKD and ESRD born and living in Denmark were recruited. We were able to analyze complete data of 284 patients obtained from both hospital medical files and midwife protocols in the Danish State Archives. Multivariable linear regression adjusted for birth weight, adult height, mean arterial pressure, gender, birth decade, and type of antihypertensive treatment showed that for every kilogram increase in birth weight, the age at onset of ESRD significantly increased by 1.7 years. Male gender and increased mean arterial pressure were both associated with earlier onset of ESRD. Patients treated with renin-angiotensin system blockade or calcium channel blockers during follow-up had significantly later onset of ESRD by 4.3 years and 2.1 years, respectively. Treatment with beta-blockade or a diuretic was not associated with the age at onset of ESRD. Thus, low birth weight may contribute to considerable phenotypic variability in the progression of renal disease between individuals with ADPKD.

Diabetic nephropathy amelioration by a low-dose sitagliptin in an animal model of type 2 diabetes (Zucker diabetic fatty rat)

This study was performed to assess the effect of chronic low-dose sitagliptin, a dipeptidyl peptidase 4 inhibitor, on metabolic profile and on renal lesions aggravation in a rat model of type-2 diabetic nephropathy, the Zucker diabetic fatty (ZDF) rat. Diabetic and obese ZDF (fa/fa) rats and their controls ZDF (+/+) were treated for 6 weeks with vehicle (control) or sitagliptin (10 mg/kg/bw). Blood/serum glucose, HbA1c, insulin, Total-c, TGs, urea, and creatinine were assessed, as well as kidney glomerular and tubulointerstitial lesions (interstitial fibrosis/tubular atrophy), using a semiquantitative rating from 0 (absent/normal) to 3 (severe and extensive damage). Vascular lesions were scored from 0-2. Sitagliptin in the diabetic rats promoted an amelioration of glycemia, HbA1c, Total-c, and TGs, accompanied by a partial prevention of insulinopenia. Furthermore, together with urea increment prevention, renal lesions were ameliorated in the diabetic rats, including glomerular, tubulointerstitial, and vascular lesions, accompanied by reduced lipid peroxidation. In conclusion, chronic low-dose sitagliptin treatment was able to ameliorate diabetic nephropathy, which might represent a key step forward in the management of T2DM and this serious complication.

Improved prognosis in patients with autosomal dominant polycystic kidney disease in Denmark

BACKGROUND AND OBJECTIVES

The introduction of new therapies, including agents that block the renin-angiotensin system, may have affected progression of autosomal dominant polycystic kidney disease (ADPKD). We investigated whether the age when reaching ESRD and survival during renal replacement therapy in Danish patients with ADPKD changed from January 1, 1990, through December 31, 2007.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

According to the Danish National Registry on Regular Dialysis and Transplantation, 693 patients with ADPKD reached ESRD in the study period. The 18 years were divided into three consecutive 6-year intervals.

RESULTS

The incidence of reaching ESRD for patients with ADPKD increased from 6.45 per million people in 1990 through 1995 to 7.59 per million people in 2002 through 2007, and the mean age at onset of ESRD increased by 4.7 years. The age-adjusted male-to-female ratio for onset of ESRD changed from 1.6 to 1.1, indicating a trend toward similar progression in both genders. From onset of ESRD, a Cox regression analysis to compare the first and second 6-year intervals, adjusted for age, gender, and treatment modality, showed that patient survival improved by 38%. Although NS, a similar trend was found during the second and third time intervals.

CONCLUSIONS

This study demonstrates that in Danish patients with ADPKD, the prognosis had significantly improved during the study period. Furthermore, the results indicate that male gender may be losing its importance as a risk factor for progression in ADPKD.

Asian leadership in chronic kidney disease

Asian Pacific countries include those with the highest incidence of renal failure in the world, the richest and poorest economies and unparalleled diversity of economy, culture and geography. From this come many challenges, but also a strong basis for the introduction of strategies to combat renal diseases. With a rapidly developing scientific community, Asia needs to accept the challenge of becoming a global leader in nephrology in the near future.

Agents in development for the treatment of diabetic nephropathy

BACKGROUND

Nephropathy is a major cause of morbidity and mortality in diabetic patients. Current treatments include optimization of glycemic and blood pressure control, but more innovative strategies are needed for the prevention and treatment of diabetic nephropathy.

OBJECTIVES

To review emerging therapies for diabetic nephropathy.

METHODS

This paper discusses the molecular mechanisms of diabetic nephropathy and the potential therapeutic interventions.

RESULTS/CONCLUSION

New therapies, including those targeting the accumulation of advanced glycation end products (AGEs) and reactive oxygen species (ROS) generation, are likely to feature in future treatment regimens. Other approaches that at this stage do not appear to be progressing include the glycosaminoglycan sulodexide and the protein kinase C-beta (PKC-beta) inhibitor, ruboxistaurin.

Incidence, prevalence and mortality trends of dialysis end-stage renal disease in Taiwan from 1990 to 2001: the impact of national health insurance

BACKGROUND

Incident and prevalent (I&P) rates in dialysis end-stage renal disease (ESRD) patients in Taiwan increased rapidly following the launch of National Health Insurance (NHI) in 1995. Our aim was to explore the impact of NHI on the status and trends of ESRD epidemiology in Taiwan.

METHODS

This study was conducted using retrospective cohort analysis of data collected from the Taiwan national dialysis registry.

RESULTS

From 1990 to 2001, I&P rates of ESRD patients increased 2.6 times from 126 to 331 per million populations (pmp) and 3.46 times from 382 to 1322 pmp, respectively. Increasing ESRD was seen in patients who were middle-aged, elderly and who had diabetic nephropathy as their primary renal disease. The mean age of I&P patients increased by 7.2 years and 7.1 years, respectively. All of these parameters increased markedly in 1995, the year of NHI implementation. First-year mortality decreased to 7.8 per 1000 patient-months in 1994, and then increased to 18.0 in 2001. The cumulative survival rate of the elderly subgroup (age >65) in the incident 1990-1994 cohort was greater than in the 1995-1999 cohort. These data indicated that NHI implementation significantly influenced the inflow and the mortality of ESRD patients.

CONCLUSION

In addition to presenting ESRD epidemiology in Taiwan, this study demonstrated that NHI implementation stimulated the growth of treated ESRD populations. Preventive plans mounted against chronic kidney diseases will be essential to reduce the growth of ESRD patient numbers and consequent economic burdens.

Kidney disease screening program in Japan: history, outcome, and perspectives

In the early 1970s, mandatory kidney disease screening was started with urinalysis in the Japanese health examination program for all workers and school-age children. In 1983, nationwide urinalysis screening in adults aged > or = 40 yr was mandated in the community-based health examination program. Because glomerulonephritis was an endemic disease and the leading cause of end-stage renal disease in Japan until 1997, the urinalysis in the annual health examination program aimed for early detection of glomerulonephritis and early referral of patients to physicians. To the programs, measurement of serum creatinine was added for detection of chronic kidney disease in 1992 for adults aged > or = 40 yr. Kidney disease screening and early intervention brought reduction of progressive glomerulonephritis or an increase in remission. Thus, in children and adults aged < or = 45 yr, the number of patients with end-stage renal disease from glomerulonephritis has declined, and the mean age of patients with new end-stage renal disease has increased significantly. In 1998, the leading cause of end-stage renal disease was shifted from glomerulonephritis to diabetic nephropathy as a result of lifestyle changes in the Japanese population; however, the present comprehensive kidney disease screening in the health examination program for detection of glomerulonephritis must be continued, because even in 2005, 27.3% of newly developed end-stage renal disease was from glomerulonephritis. An additional kidney disease screening program should also be established to target patients with high risk for diabetes, hypertension, and metabolic syndrome, because 42% of newly introduced renal replacement cases were from diabetic nephropathy in 2005.

Present state of diabetes management in the elderly, Japan

A recent dramatic increase in elderly patients with diabetes mellitus has made the proper management of the disease in this population more important. Here, we discuss the present status of diabetes management in the elderly in Japan. As a characteristic feature of elderly persons, body weight reduction is difficult, because of the profound adaptive reduction in resting energy expenditure under calorie restriction in the elderly. However, hyperglycemia increases the risk for diabetic complications, except proliferative retinopathy, similarly in elderly and non-elderly. Of note, there is marked clinical heterogeneity in this generation in the following aspects: duration, complication status (past aspect), insulin secretion, insulin sensitivity, familial support and physical exercise/activity (present aspect), as well as the expected lifespan (future aspect). This heterogeneity among the elderly should render diabetes treatment diverse, and in fact, one of the largest surveys in Japan demonstrated significant diversity in diabetes management in the elderly. In Japan, thus, the present management of diabetes in the elderly is considerably diverse, reflecting the clinical heterogeneity among elderly patients with diabetes. Further clinical evidence is awaited for the establishment of proper and safe management of diabetes in the elderly.

Risk of developing low glomerular filtration rate or elevated serum creatinine in a screened cohort in Okinawa, Japan

There are no known predictors of renal dysfunction, particularly for a community-based screening. We evaluated the changes in serum creatinine (SCr) and glomerular filtration rate (GFR) among screenees who participated in the screening program of the Okinawa General Health Maintenance Association both in 1983 and 1993. A total of 4,662 screenees at least 30 years of age at the 1983 screening were analyzed to examine whether they developed high SCr (>or=1.4 mg/dl for men, >or=1.2 mg/dl for women) or low GFR (<60 ml/min/1.73 m2). Overall, mean GFR (mean+/-SD) decreased slightly from 72.7+/-11.7 ml/min/1.73 m2 to 70.8+/-15.0 ml/min/1.73 m2. In 1983, the prevalences of high SCr and low GFR were 3.6% and 13.2%, respectively, and in 1993, they were 8.1% and 24.2%, respectively. Among the variables studied, dipstick proteinuria was the strongest predictor: the adjusted odds ratio (95% CI) was 1.282 (1.076-1.527, p<0.01) for high SCr and 1.215 (1.116-1.322, p<0.01) for low GFR. Dipstick proteinuria was best for detecting subjects who might develop low GFR in a screening setting. In subjects without proteinuria, systolic blood pressure was a significant predictor for low GFR (the adjusted odds ratio [95% CI] was 1.015 [1.009-1.020, p<0.01]) and for high SCr (the adjusted odds ratio [95% CI] was 1.028 [1.016-1.040, p<0.01]). In conclusion, the present study suggests that a dipstick urine test for proteinuria and both systolic and diastolic blood pressure are useful to identify those who are at risk of developing high SCr and low GFR and consequently end-stage renal disease.

Autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease is the most prevalent, potentially lethal, monogenic disorder. It is associated with large interfamilial and intrafamilial variability, which can be explained to a large extent by its genetic heterogeneity and modifier genes. An increased understanding of the disorder's underlying genetic, molecular, and cellular mechanisms and a better appreciation of its progression and systemic manifestations have laid out the foundation for the development of clinical trials and potentially effective treatments.

Regulatory mechanism of "K+recycling" for Na +reabsorption in renal tubules

Hypertension is one of the predominant risk factors for the progression of renal impairment, and the most common disorder in industrialized societies. Because reduction of the systemic blood pressure in hypertension can halt the progression of renal impairment, it is imperative to appropriately control the systemic blood pressure. Recent genetic analysis has reconfirmed that renal maladjustment of Na(+)-homeostasis, which determines the extracellular fluid volume, is a key element in the pathogenesis of hypertension. The distal tubules adjust the net Na(+)-excretion according to Na(+)-ingestion and maintain the Na(+)-homeostasis. The distal convoluted tubules and the connecting tubules are the predominant sites for the adjustment in individuals with a modern lifestyle. In these tubules, Na(+)-reabsorption depends on "K(+)-recycling", which is conducted through K(+) channels. Because the functional expression of K(+) channels in these tubules is regulated by signal motifs for intracellular localization, the adjustment of "K(+)-recycling" through the modification of signal motifs could be a new target for the treatment of hypertension.

Olmesartan reducing incidence of endstage renal disease in diabetic nephropathy trial (ORIENT): rationale and study design

Diabetic nephropathy (DN) is a leading cause of endstage renal disease (ESRD) in Japan and Hong Kong. Asian patients are known to be more predisposed to DN and ESRD than Caucasians. Strict blood glucose and blood pressure control are key factors in prevention and treatment of DN. In the last decade, inhibition of the renin-angiotensin-aldosterone (RAA) system has been confirmed to reduce the incidence of cardiovascular complications in Caucasian patients with diabetes. Although the RENAAL study has demonstrated the beneficial effects of inhibition of the RAA system on prevention of ESRD and death in type 2 diabetic patients with overt proteinuria, only 17% of patients in this multicenter study were of Asian ethnicity. Given the predilection of Asian diabetic patients for renal complications and the rising burden of ESRD, there is a need to confirm these findings in a homogenous group of Asian patients. The ORIENT (Omesartan Reducing Incidence of Endstage Renal Disease in Diabetic Nephropathy Trial) is a randomized, double-blind, placebo-controlled study in Japan and Hong Kong to evaluate the renal protective benefits of olmesartan medoxomil in type 2 diabetic patients with overt proteinuria (urinary albumin to creatinine ratio > or =300 mg/g creatinine) and renal insufficiency (serum creatinine: 1.0-2.5 mg/dl). The study has a targeted enrollment of 400 Japanese and Hong Kong Chinese patients. The primary outcome is the composite endpoint of time to the first occurrence of doubling of serum creatinine, ESRD (serum creatinine more than 5.0 mg/dl, the need for chronic dialysis, or renal transplantation) or death. The average follow-up period is 4 years and the study ends in 2009.

Divergent trends in the incidence of end-stage renal disease due to Type 1 and Type 2 diabetes in Europe, Canada and Australia during 1998-2002

AIMS

To describe the variation in geographical distribution of end-stage renal disease (ESRD) due to Type 1 and Type 2 diabetes, and to calculate recent trends in incidence in predominantly white populations.

METHODS

Estimation of age- and sex-standardized incidence of ESRD by type of diabetes, and temporal trends, in population-based data for persons aged 30-44, 45-54 or 55-64 years newly treated for ESRD during 1998-2002 in eight countries or regions of Europe, and Non-Indigenous Canadians and Australians.

RESULTS

The incidence of ESRD due to Type 1 diabetes at age 30-44 years correlated with published rates of childhood-onset insulin dependent diabetes mellitus (P = 0.0025). ESRD due to Type 2 diabetes was uncommon before 45 years of age; in older persons, the highest rates (in Canada and Austria) were five times the lowest rates (in Norway and the Basque region). Rates of ESRD due to Type 1 diabetes fell, per year, by 6.4%[95% confidence interval (CI): 2.1-10.6%) in persons aged 30-44 years, and by 7.7% (95% CI: 2.4-12.7%] in those aged 45-54 years. In contrast, rates of ESRD due to Type 2 diabetes increased annually by 16% (95% CI: 5-28%) in the 30-44-year age group, 11% (95% CI: 6-16%) at 45-54 years, and 9% (95% CI: 5-14%) at 55-64 years.

CONCLUSIONS

Modern prevention has reduced progression of nephropathy to ESRD due to Type 1 diabetes, but the continuing rise of ESRD due to Type 2 diabetes represents a failure of current disease control measures that has serious public health implications.

Exploring Secular Trends in the Likelihood of Receiving Treatment for End-Stage Renal Disease

There is a limited understanding of the forces that drive the steady rise in the number of patients who receive treatment for ESRD. It was hypothesized that this is not simply due to increasing prevalence of chronic kidney disease (CKD) or changes in renal failure risk factors in the population from which ESRD cases develop. A noncurrent cohort study was conducted to quantify the change over time (per year) in the likelihood of receiving ESRD therapy in a cohort of 320,252 individuals who volunteered for health check-ups between 1964 and 1985. Initiation of ESRD treatment was ascertained using the US Renal Data System registry through 2000. A total of 1471 cases of ESRD were observed during 8,347,955 person-years of observation, with ESRD cases developing between 1973 and 2000. In unadjusted Cox proportional hazards analysis, individuals who were examined later in time had an 8% per year higher risk for progressing to receive treatment for ESRD (relative risk 1.08; 95% confidence interval 1.05 to 1.11). This temporal trend in risk for future ESRD associated with year of cohort entry (baseline examination) was not explained by increases over time in the prevalence of CKD or risk factors for renal failure. After adjustment for age, gender, race, diabetes, BP, body mass index, education level, smoking status, history of myocardial infarction, serum cholesterol, proteinuria, hematuria, and serum creatinine level, there remained an 8% per year increase in risk (relative risk 1.08; 95% confidence interval 1.06 to 1.11). Among individuals who were examined from the 1960s through the 1980s, those who were examined later were more likely to receive treatment for ESRD. This trend was not accounted for by increasing prevalence of baseline CKD or risk factors for renal failure. These findings should spur further research into other forces that drive the rise in treated ESRD.