The global challenge of chronic kidney disease

The Role of Superb Microvascular Imaging and Shear Wave Elastography in the Prediction of Hemorrhage Complications After Renal Parenchyma Biopsy

OBJECTIVES

The aim of study was to evaluate the diagnostic utility of the renal parenchyma elasticity with the shear wave elastography (SWE) and microvascularization with the superb microvascular imaging (SMI) technique before kidney biopsy and to predict the complication of hemorrhage before kidney biopsy.

METHODS

A total of 75 patients were included in the prospective study. Before the biopsy, vascularity features of the kidney parenchyma in the area to be biopsied were assessed by SMI and parenchymal stiffness by SWE and were examined by 2 independent radiologists.

RESULTS

A statistically significant difference was found in the SMI and SWE values between the groups with and without hematoma and hematuria when compared with the Student t test and Mann-Whitney U test ( P < 0.05). The SWE hardness cutoff value, which maximizes the prediction of the development of hematuria, was found to be 18.40 kPa, and the sensitivity and specificity values were 84.4% and 62.8%, respectively. In SMI vascularity index values, the cutoff value was found to be 0.247410800 kPa, and sensitivity and specificity values were 81.3% and 83.7%, respectively. The cutoff value of the SMI vascularity index values that maximized the prediction of hematoma development was 0.297009650, and the sensitivity and specificity values were 87% and 87%, respectively.

CONCLUSIONS

We believe that evaluating and standardizing the microvascularization and elasticity of the kidney parenchyma before a percutaneous kidney biopsy will be potentially useful as a guiding method in the prediction of postbiopsy hemorrhage development.

Raman Multi-Omic Snapshots of Koshihikari Rice Kernels Reveal Important Molecular Diversities with Potential Benefits in Healthcare

This study exploits quantitative algorithms of Raman spectroscopy to assess, at the molecular scale, the nutritional quality of individual kernels of the Japanese short-grain rice cultivar Koshihikari in terms of amylose-to-amylopectin ratio, fractions of phenylalanine and tryptophan aromatic amino acid residues, protein-to-carbohydrate ratio, and fractions of protein secondary structures. Statistical assessments on a large number of rice kernels reveal wide distributions of the above nutritional parameters over nominally homogeneous kernel batches. This demonstrates that genetic classifications cannot catch omic fluctuations, which are strongly influenced by a number of extrinsic factors, including the location of individual grass plants within the same rice field and the level of kernel maturation. The possibility of collecting nearly real-time Raman "multi-omic snapshots" of individual rice kernels allows for the automatic (low-cost) differentiation of groups of kernels with restricted nutritional characteristics that could be used in the formulation of functional foods for specific diseases and in positively modulating the intestinal microbiota for protection against bacterial infection and cancer prevention.

Mechanisms underlying acupuncture therapy in chronic kidney disease: A narrative overview of preclinical studies and clinical trials

Chronic kidney disease (CKD) is associated with high incidence, low awareness, and high disability rates among the population. Moreover, the disease significantly affects the physical and mental health of patients. Approximately 25% of patients with CKD develop end-stage renal disease (ESRD) within 20 years of diagnosis and have to rely on renal replacement therapy, which is associated with high mortality, heavy economic burden, and symptoms including fatigue, pain, insomnia, uremia pruritus, and restless leg syndrome. Currently, the means to delay the progress of CKD are insufficient; therefore, developing strategies for delaying CKD progression has important practical implications. In recent years, more and more people are accepting the traditional Chinese medical technique "acupuncture." Acupuncture has been shown to improve the uncomfortable symptoms of various diseases through stimulation (needling, medicinal moxibustion, infrared radiation, and acupressure) of acupoints. Its application has been known for thousands of years, and its safety and efficacy have been verified. As a convenient and inexpensive complementary therapy for CKD, acupuncture has recently been gaining interest among clinicians and scientists. Nevertheless, although clinical trials and meta-analysis findings have demonstrated the efficacy of acupuncture in reducing albuminuria, improving glomerular filtration rate, relieving symptoms, and improving the quality of life of patients with CKD, the underlying mechanisms involved are still not completely understood. Few studies explored the correlation between acupuncture and renal pathological diagnosis. The aim of this study was to conduct a literature review summarizing the currently known mechanisms by which acupuncture could delay the progress of CKD and improve symptoms in patients with ESRD. This review help provide a theoretical basis for further research regarding the influence of acupuncture on renal pathology in patients with CKD, as well as the differences between specific therapeutic mechanisms of acupuncture in different renal pathological diagnosis. The evidence in this review indicates that acupuncture may produce marked effects on blocking and reversing the critical risk factors of CKD progression (e.g., hyperglycemia, hypertension, hyperlipidemia, obesity, aging, and anemia) to improve the survival of patients with CKD via mechanisms including oxidative stress inhibition, reducing inflammatory effects, improving hemodynamics, maintaining podocyte structure, and increasing energy metabolism.

Detection of urinary cystatin-c in IUGR neonates by immunoblot SDS-PAGE

BACKGROUND

it is known that intrauterine growth retardation (IUGR) represents a risk factor for the deterioration of renal function as it can adversely impact on the number of nephrons developed in the kidney during nephrogenesis. An interesting molecule is the Cystatin-C (cyst-C): it is considered to have the potency to detect both glomerular and proximal renal injury. Recently, using a quantitative EIA cyst-C detection kit, we found increased levels of cyst-C in the urine of neonates with IUGR. Since cyst-C molecules can be present in both monomer and/or polymer forms, the purpose of this study is to investigate in which forms this molecule is present in the urine of IUGR neonates by Immunoblot SDS-PAGE in order to verify if the presence or absence of a particular type of cyst-C conformation can give more information about the renal functioning.

METHODS

urine samples were collected from 64 neonates with IUGR, and 86 healthy controls defined as appropriate for gestational age (AGA). Urinary cyst-C was investigated by the Immunoblot SDS-PAGE.

RESULTS

in all urine samples, SDS-PAGE analysis showed a reactivity of the IgG anti cyst-C with a complex of about 70 kDa. The monomer form at 13 KDa appeared in 78% of IUGR neonates and in 12% of AGA neonates.

CONCLUSIONS

this study revealed the presence of monomer cyst-C in the urine of IUGR neonates, and suggests an insufficient and/or non-compensatory reabsorption by tubular cells. Monomeric cyst-C can be considered an early biochemical marker to identify and to select IUGR neonates who need to be monitored for risk of renal injury.

Relation Between Dietary Carotenoid Intake, Serum Concentration, and Mortality Risk of CKD Patients Among US Adults: National Health and Nutrition Examination Survey 2001–2014

Background

Current evidence on the relationship between carotenoids and chronic kidney disease (CKD) patients are limited and controversial.

Methods

Data were obtained from the Nutrition and Health Examination Survey (NHANES) database and the NHANES Linked Mortality File, both from a nationally representative sample. Dietary intake was assessed through 24-h dietary recall, and information was available both on dietary and serum α-carotene, β-carotene, β-cryptoxanthin, lycopene, and lutein/zeaxanthin (combined) through the NHANES cycles used. We used multivariable Cox proportional hazards regression models to estimate the risk for all-cause mortality associated with carotene intakes and serum levels, adjusting for potential confounding factors.

Results

Of the 6,095 CKD participants, 1,924 subjects died (mean follow-up time, 8.1 years). After eliminating all the confounding factors, we found that high levels of total carotene (HR = 0.85, 95% CI, 0.75-0.97, P = 0.011) intakes at baseline were significantly associated with a lower risk of death. And the serum concentrations of carotenoid were also showing that a-carotene (HR = 0.77, 95%CI, 0.65–0.92, P = 0.002), beta-cryptoxanthin (HR = 0.83, 95%CI, 0.70–0.98, P = 0.019), lycopene (HR = 0.77, 95% CI, 0.65–0.91, P = 0.002), and lutein + zeaxanthin (HR = 0.82, 95% CI, 0.70–0.96, P = 0.002) was significantly associated with decreased all-cause mortality of CKD patients. The associations remained similar in the sensitivity analyses.

Conclusion

Findings suggest that high-level carotene dietary intake and the serum concentration were associated with a lower risk of mortality in the CKD population.

Low-Protein Diet: History and Use of Processed Low-Protein Rice for the Treatment of Chronic Kidney Disease

The epidemiology of chronic kidney disease (CKD) shows increasing trends in prevalence and mortality and has become the leading health problem worldwide. Reducing the amount of proteins ingested from rice is an easy way to control the total intake of proteins, saving energy sources, particularly in rice-eating countries. In Japan, low-protein white rice had been developed, but the taste and function were not satisfactory for CKD patients. We reviewed the brief history of low-protein dietary therapy for renal diseases and the recent development of low-protein processed brown rice (LPBR). The new LPBR is characterized by a low-protein content, the same energy content as white rice, low potassium and phosphorus contents, and high amounts of dietary fibers, γ-oryzanol, and antioxidant activity. Dietary fibers and γ-oryzanol would stabilize intestinal microbiota and improve uremic dysbiosis and leaky gut syndrome. All these features suggest that the health benefits of LPBR extend to preventing CKD progression and enhancing the quality of life (QOL) of patients with CKD.

Involvement of the effect of renal hypoperfusion medications on vancomycin trough concentration: A secondary analysis using a retrospective observational data

This study examined the association between vancomycin (VCM) trough concentration and confounding factors including renal hypoperfusion medications which include angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, loop/thiazide diuretics, or non-steroidal anti-inflammatory drugs. This secondary analysis included patients aged >15 years who were administered VCM intravenously between June 2015 and August 2017 at the Tokyo Women's Medical University Medical Center East. We investigated predictors for three (initial, mean, and final) dose-normalized VCM trough concentration (dose-normalized VCM_trough ) as outcome using a multiple linear regression analysis. In total, 208 patients were analysed (use of loop/thiazide diuretics: 48 [23%]). Multiple linear regression analysis revealed that the initial dose-normalized VCM_trough was negatively correlated with estimated glomerular filtration rate (eGFR) (p = 0.028) and positively correlated with the use of loop/thiazide diuretics (p = 0.003). Meanwhile, there was a positive correlation between the mean dose-normalized VCM_trough and age (p = 0.023). The mean dose-normalized VCM_trough was negatively correlated with eGFR (p < 0.001) and serum albumin (p < 0.001). The final dose-normalized VCM_trough was positively associated with age (p = 0.034) and negatively associated with eGFR (p = 0.032) and serum albumin (p = 0.007). Clinicians should closely monitor VCM trough concentration while receiving VCM and loop/thiazide diuretics.

Hepatocellular carcinoma in patients with renal dysfunction: Pathophysiology, prognosis, and treatment challenges

The population of patients with hepatocellular carcinoma (HCC) overlaps to a high degree with those for chronic kidney disease (CKD) and end-stage renal disease (ESRD). The degrees of renal dysfunction vary, from the various stages of CKD to dialysis-dependent ESRD, which often affects the prognosis and treatment choice of patients with HCC. In addition, renal dysfunction makes treatment more difficult and may negatively affect treatment outcomes. This study summarized the possible causes of the high comorbidity of HCC and renal dysfunction. The possible mechanisms of CKD causing HCC involve uremia itself, long-term dialysis status, immunosuppressive agents for postrenal transplant status, and miscellaneous factors such as hormone alterations and dysbiosis. The possible mechanisms of HCC affecting renal function include direct tumor invasion and hepatorenal syndrome. Finally, we categorized the risk factors that could lead to both HCC and CKD into four categories: Environmental toxins, viral hepatitis, metabolic syndrome, and vasoactive factors. Both CKD and ESRD have been reported to negatively affect HCC prognosis, but more research is warranted to confirm this. Furthermore, ESRD status itself ought not to prevent patients receiving aggressive treatments. This study then adopted the well-known Barcelona Clinic Liver Cancer guidelines as a framework to discuss the indicators for each stage of HCC treatment, treatment-related adverse renal effects, and concerns that are specific to patients with pre-existing renal dysfunction when undergoing aggressive treatments against CKD and ESRD. Such aggressive treatments include liver resection, simultaneous liver kidney transplantation, radiofrequency ablation, and transarterial chemoembolization. Finally, focusing on patients unable to receive active treatment, this study compiled information on the latest systemic pharmacological therapies, including targeted and immunotherapeutic drugs. Based on available clinical studies and Food and Drug Administration labels, this study details the drug indications, side effects, and dose adjustments for patients with renal dysfunction. It also provides a comprehensive review of information on HCC patients with renal dysfunction from disease onset to treatment.

MR Elastography of the Abdomen: Experimental Protocols

Application of MRE for noninvasive evaluation of renal fibrosis has great potential for noninvasive assessment in patients with chronic kidney disease (CKD). CKD leads to severe complications, which require dialysis or kidney transplant and could even result in death. CKD in native kidneys and interstitial fibrosis in allograft kidneys are the two major kidney fibrotic pathologies where MRE may be clinically useful. Both these conditions can lead to extensive morbidity, mortality, and high health care costs. Currently, biopsy is the standard method for renal fibrosis staging. This method of diagnosis is painful, invasive, limited by sampling bias, exhibits inter- and intraobserver variability, requires prolonged hospitalization, poses risk of complications and significant bleeding, and could even lead to death. MRE based methods can potentially be useful to noninvasively detect, stage, and monitor renal fibrosis, reducing the need for renal biopsy. In this chapter, we describe experimental procedure and step by step instructions to run MRE along with some illustrative applications. We also includes sections on how to perform data quality check and analysis methods.This publication is based upon work from the COST Action PARENCHIMA, a community-driven network funded by the European Cooperation in Science and Technology (COST) program of the European Union, which aims to improve the reproducibility and standardization of renal MRI biomarkers.

The validation of immunoblot SDS-PAGE as a qualitative and quantitative method for the determination of urinary Cystatin C in neonates

INTRODUCTION

The quantitative determination of urinary Cystatin C (cyst-C) associated with the qualitative analysis of its polymorphisms is an excellent method for early identification of newborns predisposed to renal function impairment. PETIA, PENIA and EIA are the immunometric methods used for the quantitative determination of cyst-C in human biologic fluid but they have limitations and do not allow qualitative analysis. The present study is a validation of Immunoblot SDS-PAGE for the qualitative and quantitative analysis of urinary cyst-C.

METHODS

Urine was collected from neonates in the nursey at S. Maria della Misericordia Hospital. Urinary cyst-C was investigated by the immunoblot SDS-PAGE and by reading of optical density.

RESULTS

The qualitative analysis showed two different molecular forms: a reactivity at about 70 KDa in all samples and a reactivity at 13 KDa in a limited number of samples. This analysis allows the correlation of the polymorphisms of cyst-C with specific alterations of renal function in newborns. The quantitative analysis is specific, sensitive and accurate. In fact the coefficient of variation for assay precision was 10% and for assay accuracy was ±10%, the detection limit was 0.009 ng/ µL and the calibration line has satisfactory linearity (range 0.02-0.3 ng/ µL). The stability of urinary cyst-C was acceptable, even without the use of protease inhibitors, as long as the assay was performed on freshly recruited urine or immediately after thawing the samples, which had been stored for up to six months.

CONCLUSION

Immunoblot SDS-PAGE analysis is a valid method of obtaining a qualitative and quantitative analysis of urinary cyst-C. This method presents unique information about a previously unknown 70 KDa cyst-C form. The assay may offer potential diagnostic information not available with immunometric method.

Quality of Life of End Stage Renal Disease Patients Undergoing Dialysis in Southern Part of Kerala, India: Financial Stability and Inter-dialysis Weight Gain as Key Determinants

Background: Quality of Life (QoL) reflects the quality and outcome of healthcare along with key indicators of performance such as mortality and morbidity.

Objective: The aim of the study was to measure the QoL among patients with End Stage Renal Disease (ESRD) on maintenance hemodialysis and to understand various correlates of QoL.

Methods: A total of 95 ESRD patients from three dialysis centres in Southern districts of Kerala were interviewed. QoL was measured using vernacular version of World Health Organization Quality Of Life – Brief Version (WHOQOL-BREF) questionnaire.

Results: The mean age of the patients was 56.2 ± 13 years and 73.7% were males. Mean converted scores for overall QoL was 42.37 ± 21.3 and Health-related QoL (HRQoL) was 43.3 ± 18.3, indicating poor QoL. Males had significantly higher physical domain scores (p < 0.03). Occupation, income and Socio-economic Status (SES) influenced overall HRQoL while better income and higher SES predicted better scores in psychological and environmental domains.

Conclusion: Patients with better control over inter-dialysis weight gain (≤1600 g) had significantly higher scores. This study highlights the importance of using QoL tools in assessing the QoL of patients and the factors contributing to it.

The impact of diabetes on the association between alcohol intake and the risk of end-stage kidney disease in the Singapore Chinese Health Study

BACKGROUND

The relationship between alcohol intake and end-stage kidney disease (ESKD) risk is controversial. Moreover, while evidence has shown that the relationship between alcohol and atherosclerosis may be modified by diabetes, whether this applies to ESKD is unknown.

METHODS

We examined these associations in the Singapore Chinese Health Study, a prospective cohort of 63 257 adults aged 45 to 74 years. Information on alcohol intake, diet, lifestyle factors, and medical history was collected at recruitment. We identified 1217 ESKD cases via linkage with the Singapore Renal Registry after a mean follow-up of 17.5 years. Cox regression models were used to estimate hazard ratios (HRs) and 95% CI of ESKD.

RESULTS

Among the participants without diabetes at baseline, monthly to weekly drinking was associated with a decreased risk of ESKD (HR 0.69; 95% CI, 0.54-0.87) compared to nondrinkers. In contrast, this association was attenuated and not significant among those with diabetes (HR 0.82; 95% CI, 0.58-1.16; P_interaction = .19). Comparatively, alcohol intake of ≥2 drinks per day was significantly associated with an increased risk of ESKD compared to nondrinkers among those with diabetes (HR 2.00; 95% CI, 1.14-3.53) but not among those without diabetes (HR 0.91; 95% CI, 0.53-1.56; P_interaction = .01). The risk of ESKD among those with diabetes and who also consumed ≥2 drinks per day was increased by nearly 12-fold compared to nondrinkers without diabetes (HR 11.6; 95% CI, 6.73-19.9).

CONCLUSION

Low-dose drinking is associated with a reduced risk of ESKD among individuals without diabetes. However, joint exposure to heavy drinking and diabetes is associated with a substantially higher risk of ESKD.

Sex related differences in the pathogenesis of organ fibrosis

The development of organ fibrosis has garnered rising attention as multiple diseases of increasing and/or high prevalence appear to progress to the chronic stage. Such is the case for heart, kidney, liver, and lung where diseases such as diabetes, idiopathic/autoimmune disorders, and nonalcoholic liver disease appear to notably drive the development of fibrosis. Noteworthy is that the severity of these pathologies is characteristically compounded by aging. For these reasons, research groups and drug companies have identified fibrosis as a therapeutic target for which currently, there are essentially no effective options. Although a limited body of published studies are available, most literature indicates that in multiple organs, premenopausal women are protected from developing severe forms of fibrosis suggesting an important role for sex hormones in mitigating this process. Investigators have implemented relevant animal models of organ disease linked to fibrosis supporting in general, these observations. In vitro studies and transgenic animals models have also been used in an attempt to understand the role that sex hormones and related receptors play in the development of fibrosis. However, in the setting of chronic disease in some organs such as the heart older (postmenopausal) women within a few years can quickly approach men in disease severity and develop significant degrees of fibrosis. This review summarizes the current body of relevant literature and highlights the imperative need for a major focus to be placed on understanding the manner in which sex and the presence or absence of related hormones modulates cell phenotypes so as to allow for fibrosis to develop.

A Systematic Review of Screening Tests for Chronic Kidney Disease: An Accuracy Analysis

This systematic review was conducted to assess the diagnostic accuracy of chronic kidney disease screening tests in the general population. MEDLINE, EMBASE, Web of Science, Scopus, The Cochrane Library and ProQuest databases were searched for English-language publications up to November 2016. Two reviewers independently screened studies and extracted study data in standardized tables. Methodological quality was assessed using the QUADAS-2 tool. Sensitivity and specificity of all available screening methods were identified through included studies. Ten out of 1349 screened records included for final analysis. Sensitivities of the dipstick test with a cutoff value of trace were ranged from 37.1% to 69.4% and specificities from 93.7% to 97.3% for the detection of ACR>30 mg/g. The diagnostic sensitivities of the UAC>10 mg/dL testing was shown to vary from 40% to 87%, and specificities ranged from 75% to 96%. While the sensitivities of ACR were fluctuating between 74% and 90%, likewise the specificities were between 77% and 88%. Sensitivities for C-G, Grubb and Larsson equations were 98.9%, 86.2%, and 70.1% respectively. In the meantime the study showed specificities of 84.8%, 84.2% and 90.5% respectively for these equations. Individual studies were highly heterogeneous in terms of target populations, type of screening tests, thresholds used to detect CKD and variations in design. Results pointed to the superiority of UAC and dipstick over the other tests in terms of all parameters involved. The diversity of methods and thresholds for detection of CKD, necessitate considering the cost parameter along with the effectiveness of tests to scale-up an efficient strategy.

Factors affecting medication adherence among pre-dialysis chronic kidney disease patients: a systematic review and meta-analysis of literature

BACKGROUND

Medication adherence plays an essential role in slowing the progression of chronic kidney disease (CKD). This review aims to summarise factors affecting medication adherence among these pre-dialysis CKD patients.

METHODS

A systematic review of the literature was performed in Medline®, Embase®, SCOPUS® and CINAHL®. Peer-reviewed, English language articles which evaluated factors associated with medication adherence among pre-dialysis CKD patients were included. Meta-analysis was performed to assess the pooled medication adherence rates across studies. Factors identified were categorised using the World Health Organization's five dimensions of medication adherence (condition, patient, therapy, health-system, and socio-economic domains).

RESULTS

Of the 3727 articles reviewed, 18 articles were included. The pooled adherence rate across studies was 67.4% (95% CI 61.4-73.3%). The most studied medication class was anti-hypertensives (55.6%). A total of 19 factors and 95 sub-factors related to medication adherence were identified. Among condition-related factors, advanced CKD was associated with poorer medication adherence. Patient-related factors that were associated with lower medication adherence included misconceptions about medication and lack of perceived self-efficacy in medication use. Therapy-related factors which were associated with poorer medication adherence included polypharmacy while health system-based factors included loss of confidence in the physician. Socioeconomic factors such as poor social support and lower education levels were associated with poorer medication adherence.

CONCLUSION

Factors associated with poor medication adherence among pre-dialysis CKD patients were highlighted in this review. This will aid clinicians in designing interventions to optimise medication adherence among pre-dialysis CKD patients.

Pre-procedural shear wave elastography on prediction of hemorrhage after percutaneous real-time ultrasound-guided renal biopsy

PURPOSE

To evaluate the relationship between renal elasticity which was determined with shear wave elastography (SWE) and hemorrhage in patients who undergone percutaneous renal parenchyma biopsy (PRB).

MATERIALS AND METHODS

In total, 60 patients who were performed ultrasound-guided PRB after the B-mode ultrasonography and SWE assessment were recruited in this study. All patients' serum creatinine, blood urea nitrogen and coagulation tests before PRB were obtained from medical records. The patients were divided into two groups who did and did not develop hemorrhage after PRB. We investigated whether there was any statistically significant difference between the two groups in terms of laboratory findings, B-mode ultrasonographic measurements and SWE measurements.

RESULTS

Of the 60 patients, 23 (38.3%) had post-procedure hemorrhage and 37 (61.7%) had not. Mean hemorrhage size was 17.04 mm (7-50 mm). The mean value of renal cortical shear wave velocity of all patients was 1.91 m/s (0.96-3.57 m/sn). Patients with post-procedure hemorrhage had significantly lower mean shear wave velocity compared with patients with no hemorrhage (p < 0.05). ROC curve analysis suggested that the optimum SWV cutoff point for hemorrhage presence was 1.21 m/sn, with 39.1% sensitivity and 97.3% specificity. There was no other statistically significant demographic, ultrasonographic or laboratory value differences between two groups.

CONCLUSION

Although shear wave velocities have low sensitivity for hemorrhage after renal biopsy, high specificity and statistically significant difference in hemorrhage and non-hemorrhage group suggest that patients who have lower renal cortical shear wave velocity have a tendency to hemorrhage after PRB.

Temporal trends of incident diabetes mellitus and subsequent outcomes in patients receiving kidney transplantation: a national cohort study in Taiwan

BACKGROUND

Allograft kidney transplantation has become a treatment of choice for patients with end-stage renal disease (ESRD), and post-transplant diabetes mellitus (PTDM) has been associated with impaired patient and graft survival. Taiwan has the highest incidence and prevalence rates of ESRD with many recipients and candidates of kidney transplantation. However, information about the epidemiologic features of PTDM in Taiwan is incomplete. Therefore, we aimed to investigate the prevalence and incidence of PTDM with subsequent patient and graft outcomes.

METHODS

Using the Taiwan National Health Insurance Research Database (NHIRD), 3663 kidney recipients between 1997 and 2011 were enrolled. We calculated the cumulative incidences of diabetes mellitus (DM) after transplantation. Cox proportional hazards model with competing risk analysis was used to calculate the hazard ratio (HR) and 95% confidence intervals (CI) between three targeted groups (DM, PTDM, non-DM). The outcomes of primary interest were the occurrence of graft failure excluding death with functioning graft, all-cause mortality, death with functioning graft and major adverse cardiovascular events (MACE) including myocardial infarction (MI), cerebrovascular accident (CVA) and congestive heart failure (CHF). Subgroup analysis for graft failure excluding death with functioning graft, MACE and all-cause mortality was performed, and interaction between PTDM and recipient age was examined.

RESULTS

Of 3663 kidney transplant recipients, 531 (14%) had pre-existing DM and 631 (17%) developed PTDM. Compared with non-DM group, the PTDM and DM groups exhibited higher risk of graft failure excluding death with functioning graft (PTDM: HR 1.65, 95% CI 1.47-1.85; DM: HR 1.33, 95% CI 1.18-1.50), MACE (PTDM: HR 1.51, 95% CI 1.31-1.74; DM: HR 1.64, 95% CI 1.41-1.9), all-cause mortality (PTDM: HR 1.79, 95% CI 1.59-2.01; DM: HR 2.03, 95% CI 1.81-2.18), and death with functioning graft (PTDM: HR 1.94, 95% CI 1.71-2.20; DM: HR 1.94, 95% CI 1.71-2.21). Both PTDM and DM groups had increased cardiovascular disease-related mortality (PTDM: HR 2.14, 95% CI 1.43-3.20, p < 0.001; DM: HR 1.89, 95% CI 1.25-2.86, p = 0.002), cancer-related mortality (PTDM: HR 1.56, 95% CI 1.18-2.07, p = 0.002; DM: HR 1.89, 95% CI 1.25-2.86, p = 0.027), and infection-related mortality (PTDM: HR 1.47, 95% CI 1.14-1.90, p = 0.003; DM: HR 2.25, 95% CI 1.77-2.84, p < 0.001) compared with non-DM group. The subgroup analyses showed that the add-on risks of MACE and mortality from PTDM were mainly observed in patients who were younger and those without associated comorbidities including atrial fibrillation, cirrhosis, CHF, and MI. Age significantly modified the association between PTDM and MACE (p_interaction < 0.01) with higher risk in recipients with PTDM aged younger than 55 years (adjusted HR 1.64, 95% CI 1.40-1.92, p < 0.001). A trend (p_interaction = 0.06) of age-modifying effect on the association between PTDM and all-cause mortality was also noted with higher risk in recipients with PTDM aged younger than 55 years.

CONCLUSIONS

In the present population-based study, the incidence of PTDM peaked within the first year after kidney transplantation. PTDM negatively impacted graft and patient outcomes. The magnitude of cardiovascular and survival disadvantages from PTDM were more pronounced in recipients aged less than 55 years. Further trials to improve prediction of PTDM and to prevent PTDM are warranted.

Pulse Pressure and the Risk of End-Stage Renal Disease Among Chinese Adults in Singapore: The Singapore Chinese Health Study

Background Although hypertension is an established risk factor for chronic kidney disease, less is known about the relationship of pulse pressure (PP), a measure of arterial stiffness, with chronic kidney disease. We investigated the association of systolic blood pressure (BP), diastolic BP, PP, and mean arterial pressure with the risk of end-stage renal disease (ESRD) in the prospective population-based Singapore Chinese Health Study. Methods and Results We used data from 30 636 participants who had BP measured at ages 46 to 85 years during follow-up I interviews between 1999 and 2004. Information on lifestyle factors was collected at recruitment from 1993 to 1998, and selected factors were updated at follow-up I. We identified 463 ESRD cases over an average 11.3 years of follow-up I by linkage with the nationwide Singapore Renal Registry. Cox proportional hazards regression models were used to assess the relations between different BP indexes and ESRD risk. Each BP index was positively associated with ESRD when studied individually. However, when PP was included as a covariate, systolic and diastolic BP and mean arterial pressure were no longer associated with ESRD. Conversely, PP remained significantly associated with ESRD risk in a dose-dependent manner (Ptrend<0.001) after adjusting for systolic or diastolic BP. Compared with the lowest group (<45 mm Hg) of PP, the hazard ratio was 5.25 (95% CI, 3.52-7.84) for the highest group (≥85 mm Hg). The association between hypertension and ESRD risk was attenuated and no longer significant after adjusting for PP. Conclusions Our findings provide a basis for targeting reduction of arterial stiffness to decrease ESRD risk.

Long-term incense use and the risk of end-stage renal disease among Chinese in Singapore: the Singapore Chinese health study

BACKGROUND

Experimental studies have shown that exposure to incense burning may have deleterious effects on kidney function and architecture. However, the association between chronic exposure to incense smoke and risk of end-stage renal disease (ESRD) has not been reported in epidemiologic studies.

METHODS

We investigated this association in the Singapore Chinese Health Study, a prospective population-based cohort of 63,257 Chinese men and women of 45-74 years of age in Singapore during recruitment from 1993 to 1998. Information on the practice of incense burning at home, diet, lifestyle and medical history was collected at baseline interviews. ESRD cases were identified through linkage with the nationwide Singapore Renal Registry through 2015. We used Cox proportional hazards regression analysis to estimate hazard ratio (HR) and 95% confidence interval (CI) of ESRD associated with domestic incense burning.

RESULTS

Among cohort participants, 76.9% were current incense users. After an average 17.5 years of follow-up, there were 1217 incident ESRD cases. Compared to never users, the multivariable-adjusted HR for ESRD risk was 1.05 (95% CI, 0.80 to 1.38) for former users and 1.26 (95% CI, 1.02 to1.57) for current users of incense. In analysis by daily or non-daily use and duration, the increased ESRD risk was observed in daily users who had used incense for > 20 years; HR was 1.25 (95% CI, 1.07 to 1.46). Conversely, the risk was not increased in those who did not use incense daily or who had used daily but for ≤20 years.

CONCLUSIONS

Our findings demonstrate that long-term daily exposure to domestic incense burning could be associated with a higher risk of ESRD in the general population.

Designing and Implementing an ANFIS Based Medical Decision Support System to Predict Chronic Kidney Disease Progression

Background and objective: Chronic kidney disease (CKD) has a covert nature in its early stages that could postpone its diagnosis. Early diagnosis can reduce or prevent the progression of renal damage. The present study introduces an expert medical decision support system (MDSS) based on adaptive neuro-fuzzy inference system (ANFIS) to predict the timeframe of renal failure. Methods: The core system of the MDSS is a Takagi-Sugeno type ANFIS model that predicts the glomerular filtration rate (GFR) values as the biological marker of the renal failure. The model uses 10-year clinical records of newly diagnosed CKD patients and considers the threshold value of 15 cc/kg/min/1.73 m² of GFR as the marker of renal failure. Following the evaluation of 10 variables, the ANFIS model uses the weight, diastolic blood pressure, and diabetes mellitus as underlying disease, and current GFR_(t) as the inputs of the predicting model to predict the GFR values at future intervals. Then, a user-friendly graphical user interface of the model was built in MATLAB, in which the user can enter the physiological parameters obtained from patient recordings to determine the renal failure time as the output. Results: Assessing the performance of the MDSS against the real data of male and female CKD patients showed that this decision support model could accurately estimate GFR variations in all sequential periods of 6, 12, and 18 months, with a normalized mean absolute error lower than 5%. Despite the high uncertainties of the human body and the dynamic nature of CKD progression, our model can accurately predict the GFR variations at long future periods. Conclusions: The MDSS GUI could be useful in medical centers and used by experts to predict renal failure progression and, through taking effective actions, CKD can be prevented or effectively delayed.

Supersonic Shear Wave Ultrasonography for Assessing Tissue Stiffness in Native Kidney

Recent years have brought shear wave elastography to the attention of nephrologists as a non-invasive method for detecting kidney fibrosis and, therefore, as a potential tool for reducing the need for kidney biopsy. Few studies are performed on native kidney. We aimed to compare cortical stiffness, assessed by measuring Young's modulus (YM, kPa) with SuperSonic Imaging technology, in patients with various degrees of chronic kidney disease (CKD) compared with healthy individuals. Cortical stiffness was measured by two operators, in different sessions, in 32 patients with CKD stages 3-5 and 20 healthy individuals. Comparison between mean YM values in CKD and those in controls and also between the different stages of CKD was our primary objective. The influence of other possible confounders on YM readings was also investigated and analyzed. Mean YM was significantly greater in CKD patients than in controls. Estimated YM was not able to differentiate the stages of CKD, except stage 5. Intra-subject variability was greater in CKD than in controls. Body mass index was the most important confounder in multiple analyses, in both the CKD and control groups. Our results highlight a positive correlation between increased cortical stiffness and presence of CKD. Further studies are needed to validate this method for implementation in daily clinical practice.

The epidemiology of chronic kidney disease and the association with non-communicable and communicable disorders in a population of sub-Saharan Africa

In sub-Saharan Africa (SSA), epidemiological data for chronic kidney disease (CKD) are scarce. We conducted a prospective cross-sectional study including 952 patients in an outpatient clinic in Tanzania to explore CKD prevalence estimates and the association with cardiovascular and infectious disorders. According to KDIGO, we measured albumin-to-creatinine ratio and calculated eGFR using CKD-EPI formula. Factors associated with CKD were calculated by logistic regression. Venn diagrams were modelled to visualize interaction between associated factors and CKD. Overall, the estimated CKD prevalence was 13.6% (95% CI 11-16%). Ninety-eight patients (11.2%) (95% CI 9-14%) were categorized as moderate, 12 (1.4%) (95% CI 0-4%) as high, and 9 (1%) (95% CI 0-3%) as very high risk according to KDIGO. History of tuberculosis (OR 3.75, 95% CI 1.66-8.18; p = 0.001) and schistosomiasis (OR 2.49, 95% CI 1.13-5.18; p = 0.02) were associated with CKD. A trend was seen for increasing systolic blood pressure (OR 1.02 per 1 mmHg, 95% CI 1.00-1.03; p = 0.01). Increasing BMI (OR 0.92 per 1kg/m2, 95% CI 0.88-0.96; p = <0.001) and haemoglobin (OR 0.82 per 1g/dL, 95% CI 0.72-0.94; p = 0.004) were associated with risk reduction. Diabetes was associated with albuminuria (OR 2.81, 95% CI 1.26-6.00; p = 0.009). In 85% of all CKD cases at least one of the four most common factors (hypertension, diabetes, anaemia, and history of tuberculosis or schistosomiasis) was associated with CKD. A singular associated factor was found in 61%, two in 14%, and ≥3 in 10% of all CKD cases. We observed a high prevalence estimate for CKD and found that both classical cardiovascular and neglected infectious diseases might be associated with CKD in a semi-rural population of SSA. Our finding provides further evidence for the hypothesis that the "double burden" of non-communicable and endemic infectious diseases might affect kidney health in SSA.

Acupuncture Application in Chronic Kidney Disease and its Potential Mechanisms

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

Reducing costs at the end of life through provider incentives for hospice care: A retrospective cohort study

BACKGROUND

Costs of medical care have been found to be highest at the end of life.

AIM

To evaluate the effect of provider reimbursement for hospice care on end-of-life costs.

DESIGN

The policy expanded access to hospice care for end-stage renal disease patients, a policy previously limited to cancer patients only. This study employed a difference-in-differences analysis using a generalized linear model. The main outcome is inpatient expenditures in the last 30 days of life.

SETTING/PARTICIPANTS

A cohort of 151,509 patients with chronic kidney disease or cancer, aged 65 years or older, who died between 2005 and 2012 in the National Health Insurance Research Database, which contains all enrollment and inpatient claims data for Taiwan.

RESULTS

Even as end-of-life costs for cancer are declining over time, expanding hospice care benefits to end-stage renal disease patients is associated with an additional reduction of 7.3% in end-of-life costs per decedent, holding constant patient and provider characteristics. On average, end-of-life costs are also high for end-stage renal disease (1.88 times higher than those for cancer). The cost savings were larger among older patients-among those who died at 80 years of age or higher, the cost reduction was 9.8%.

CONCLUSION

By expanding hospice care benefits through a provider reimbursement policy, significant costs at the end of life were saved.

Strengthening Renal Registries and ESRD Research in Africa

In Africa, the combination of noncommunicable diseases, infectious diseases, exposure to environmental toxins, and acute kidney injury related to trauma and childbirth are driving an epidemic of chronic kidney disease and end-stage renal disease (ESRD). Good registry data can inform the planning of renal services and can be used to argue for better resource allocation, audit the delivery and quality of care, and monitor the impact of interventions. Few African countries have established renal registries and most have failed owing to resource constraints. In this article we briefly review the burden of chronic kidney disease and ESRD in Africa, and then consider the research questions that could be addressed by renal registries. We describe examples of the impact of registry data and summarize the sparse primary literature on country-wide renal replacement therapy in African countries over the past 20 years. Finally, we highlight some initiatives and opportunities for strengthening research on ESRD and renal replacement therapy in Africa. These include the establishment of the African Renal Registry and the availability of new areas for research. We also discuss capacity building, collaboration, open-access publication, and the strengthening of local journals, all measures that may improve the quantity, visibility, and impact of African research outputs.

Optical coherence tomography and computer-aided diagnosis of a murine model of chronic kidney disease

Chronic kidney disease (CKD) is characterized by a progressive loss of renal function over time. Histopathological analysis of the condition of glomeruli and the proximal convolutional tubules over time can provide valuable insights into the progression of CKD. Optical coherence tomography (OCT) is a technology that can analyze the microscopic structures of a kidney in a nondestructive manner. Recently, we have shown that OCT can provide real-time imaging of kidney microstructures in vivo without administering exogenous contrast agents. A murine model of CKD induced by intravenous Adriamycin (ADR) injection is evaluated by OCT. OCT images of the rat kidneys have been captured every week up to eight weeks. Tubular diameter and hypertrophic tubule population of the kidneys at multiple time points after ADR injection have been evaluated through a fully automated computer-vision system. Results revealed that mean tubular diameter and hypertrophic tubule population increase with time in post-ADR injection period. The results suggest that OCT images of the kidney contain abundant information about kidney histopathology. Fully automated computer-aided diagnosis based on OCT has the potential for clinical evaluation of CKD conditions.

Multiparametric Quantitative Ultrasound Imaging in Assessment of Chronic Kidney Disease

OBJECTIVES

To evaluate the value of multiparametric quantitative ultrasound imaging in assessing chronic kidney disease (CKD) using kidney biopsy pathologic findings as reference standards.

METHODS

We prospectively measured multiparametric quantitative ultrasound markers with grayscale, spectral Doppler, and acoustic radiation force impulse imaging in 25 patients with CKD before kidney biopsy and 10 healthy volunteers. Based on all pathologic (glomerulosclerosis, interstitial fibrosis/tubular atrophy, arteriosclerosis, and edema) scores, the patients with CKD were classified into mild (no grade 3 and <2 of grade 2) and moderate to severe (at least 2 of grade 2 or 1 of grade 3) CKD groups. Multiparametric quantitative ultrasound parameters included kidney length, cortical thickness, pixel intensity, parenchymal shear wave velocity, intrarenal artery peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive index. We tested the difference in quantitative ultrasound parameters among mild CKD, moderate to severe CKD, and healthy controls using analysis of variance, analyzed correlations of quantitative ultrasound parameters with pathologic scores and the estimated glomerular filtration rate (GFR) using Pearson correlation coefficients, and examined the diagnostic performance of quantitative ultrasound parameters in determining moderate CKD and an estimated GFR of less than 60 mL/min/1.73 m² using receiver operating characteristic curve analysis.

RESULTS

There were significant differences in cortical thickness, pixel intensity, PSV, and EDV among the 3 groups (all P < .01). Among quantitative ultrasound parameters, the top areas under the receiver operating characteristic curves for PSV and EDV were 0.88 and 0.97, respectively, for determining pathologic moderate to severe CKD, and 0.76 and 0.86 for estimated GFR of less than 60 mL/min/1.73 m² . Moderate to good correlations were found for PSV, EDV, and pixel intensity with pathologic scores and estimated GFR.

CONCLUSIONS

The PSV, EDV, and pixel intensity are valuable in determining moderate to severe CKD. The value of shear wave velocity in assessing CKD needs further investigation.

Gender Differences in the Progression of Experimental Chronic Kidney Disease Induced by Chronic Nitric Oxide Inhibition

Chronic kidney disease (CKD) is considered a public health problem, assuming epidemic proportions worldwide. In this context, the preponderance of CKD prevalence in male over age-matched female patients is of note. In the present study, we investigated the impact of the gender on the development of experimental CKD induced by chronic nitric oxide (NO) inhibition in Wistar male and female rats through the administration of L-NAME. CKD model induced by L-NAME is characterized by systemic vasoconstriction, resulting in severe hypertension, albuminuria, renal ischemia, glomerulosclerosis, interstitial expansion, and macrophage infiltration. After 30 days of CKD induction, male NAME rats exhibited remarkable albuminuria, augmented cortical histological damage, interstitial inflammation, and fibrosis. Age-matched female NAME rats showed significantly lower albuminuria, diminished glomerular ischemia, and glomerulosclerosis, as well as a significant reduction in the expression of α-smooth muscle actin renal interstitial Ang II+ cells. Thus, the present study demonstrated that female rats submitted to the NAME model developed less severe CKD than males. Female renoprotection could be promoted by both the estrogen anti-inflammatory activity and/or by the lack of testosterone, related to renin-angiotensin-aldosterone system hyperactivation and fibrogenesis. However, the influence of sex hormones on the progression of CKD needs to be further investigated.

Treatment adherence and perception in patients on maintenance hemodialysis: a cross - sectional study from Palestine

BACKGROUND

Adherence to diet recommendations, fluid restriction, prescribed medications, and attendance at hemodialysis (HD) sessions are essential for optimal and effective treatment of patients with end-stage renal disease. No data regarding this issue are available from Palestine. Therefore, this study was carried out to assess adherence to diet, fluid restriction, medications, and HD sessions.

METHODS

A cross-sectional study of HD patients at An-Najah National University Hospital was carried out during summer, 2016. Self-reported adherence behavior was obtained using a valid and reliable questionnaire (End-Stage Renal Disease Adherence Questionnaire: ESRD-AQ). Predialytic serum levels of potassium and phosphate were obtained as clinical indicator of diet and medication adherence respectively. In addition, interdialytic body weight (IDW) was also obtained from medical records and analyzed in relation to reported adherence of fluid restriction.

RESULTS

A total of 220 patients answered all questions pertaining to ESRD-AQ. The mean age ± standard deviation of participants was 56.82 ± 14.51 years. Dietary adherence was observed in 24% while that of fluid restriction adherence was observed in 31% of studied patients. Reported adherence to HD sessions was 52% while that for medications was 81%. Overall, 122 (55.5%) patients had good adherence, 89 (40.5%) had moderate adherence, and 9 (4.1%) had poor adherence behavior. Male patients had significantly higher overall adherence scores than females (p = 0.034). A significant correlation between reported diet adherence and serum pre-HD potassium level (p < 0.01) was observed. A significant correlation between reported fluid restriction adherence and IDW (p < 0.01) was also found. However, no significant correlation between reported adherence and pre-HD phosphate level. There was significant correlation between overall perception and overall adherence score (p < 0.001). Counselling of patients regarding importance of adherence modalities was lowest for "staying for the entire dialysis time". Multivariate analysis indicated that elderly male patients who were city residents had higher odds of having higher adherence score.

CONCLUSIONS

There was a good percentage of patients who had overall moderate or poor adherence. ESRD-AQ could be used to assess some aspects of HD adherence. Counselling and education of patients on HD are important to improve therapeutic outcome.

Association between metabolic syndrome and chronic kidney disease in a Chinese urban population

BACKGROUND

Few studies have examined the relationships between the prevalence of chronic kidney disease (CKD) and the metabolic risk factors in a developing country such as China, where genetic and environmental backgrounds differ from those in Western countries.

METHODS

The subjects of this cross-sectional study were the individuals from 18 to 92y. The metabolic syndrome (MetS) was defined based on the criteria of Adult Treatment Panel Third Report (ATP III), but using body mass index (BMI) instead of waist circumference. CKD was defined as decreased estimated glomerular filtration rate (eGFR<60mL/min/1.73m²) or presence of proteinuria (urine protein≥1+) assessed using dipstick method.

RESULTS

A total of 26,601 subjects (average age of 48.7y) were analyzed. Among them, the prevalence of the MetS and CKD was 36.4% and 3.0%, respectively. After adjustment for age, gender, cigarette smoking and alcohol drinking, the prevalence of CKD was significantly greater in subjects with than without MetS (OR 1.99, 95% CI 1.57-2.53, p<0.001). Multivariate-adjusted odd ratios for CKD in subjects with 3, 4 or 5 MetS components were 1.82 (95% CI 1.31-2.52, p<0.001), 2.92 (95% CI 2.09-4.09, p<0.001), and 3.07 (95% CI 1.67-5.67, p<0.001), respectively. After further adjustments were made for the other components of MetS, only high fasting glucose (OR 1.52, 95% CI 1.12-2.05) were significant risk factors for reduced renal function(eGFR<60mL/min/1.73m²). High blood pressure (OR 1.81, 95% CI 1,42-2.29), high triglycerides (OR 1.34, 95% CI 1.11-1.67) and high fasting glucose (OR 2.07, 95% CI 1.62-2.66) were significant risk factors for proteinuria.

CONCLUSIONS

MetS was highly prevalent in the middle-aged and elderly Chinese population in the city of Jinan. There was a graded relationship between the number of MetS components and risk of CKD. High fasting blood glucose levels were the main risk factor of reduced renal function. High blood pressure, high fasting blood glucose levels and high triglycerides were main risk factors for proteinuria.

Urinary extracellular vesicles. A promising shortcut to novel biomarker discoveries

Proteomic and genomic techniques have reached full maturity and are providing unforeseen details for the comprehensive understanding of disease pathologies at a fraction of previous costs. However, for kidney diseases, many gaps in such information remain to inhibit major advances in the prevention, treatment and diagnostics of these devastating diseases, which have enormous global impact. The discovery of ubiquitous extracellular vesicles (EV) in all bodily fluids is rapidly increasing the fundamental knowledge of disease mechanisms and the ways in which cells communicate with distant locations in processes of cancer spread, immunological regulation, barrier functions and general modulation of cellular activity. In this review, we describe some of the most prominent research streams and findings utilizing urinary extracellular vesicles as highly versatile and dynamic tools with their extraordinary protein and small regulatory RNA species. While being a highly promising approach, the relatively young field of EV research suffers from a lack of adherence to strict standardization and carefully scrutinized methods for obtaining fully reproducible results. With the appropriate guidelines and standardization achieved, urine is foreseen as forming a unique, robust and easy route for determining accurate and personalized disease signatures and as providing highly useful early biomarkers of the disease pathology of the kidney and beyond.

Kidney disease in Uganda: a community based study

Background

Chronic kidney disease (CKD) is a major cause of morbidity and mortality in Sub-Saharan Africa (SSA). The majority of studies on CKD in SSA have been conducted among HIV-infected populations and mainly from large health facilities. We determined the prevalence of CKD and its predictors among populations in communities in central Uganda.

Methods

A cross-sectional study was conducted in Wakiso district using multi-stage sampling. Data was collected on age, sex, socio-economic status, history of alcohol intake, diabetes mellitus, hypertension and smoking. Measurement of blood pressure, weight and height to determine body mass index (BMI) and investigations including HIV testing, fasting blood sugar, creatinine and urinalysis were conducted. Logistic regression was used to estimate the strength of the association between variables and the presence of CKD estimated using the Cockcroft Gault formula.

Results

A total of 955 participants aged 18–87 years were enrolled into the study. The median age was 31 years (Interquartile range 24–42) and majority (67%) were female. Up to 21.4% (204/955) had abnormal renal function with CKD stage 1 in 6.2% (59/955), stage 2 in 12.7% (121/955), stage 3 in 2.4% (23/955), CKD stage 4 in 0% and CKD stage 5 in 0.1% (1/995). Female gender OR 1.8 (95% Confidence Interval [CI] 1.2–2.8), age >30 years OR 2.2(95% CI 1.2–3.8) and high social economic status OR 2.1 (95% CI 1.3–3.6) were associated with increased risk of CKD while BMI > 25Kg/m² was protective against CKD OR 0.1 (95% CI 0.04–0.2). Traditional risk factors such as HIV-infection, diabetes mellitus, smoking and alcohol intake were not found to be significantly associated with CKD.

Conclusion

We found a high prevalence of kidney disease in central Uganda. Interestingly the traditional risk factors associated with CKD previously documented, were not associated with CKD.

Genome-Wide Association of Copy Number Polymorphisms and Kidney Function

Genome-wide association studies (GWAS) using single nucleotide polymorphisms (SNPs) have identified more than 50 loci associated with estimated glomerular filtration rate (eGFR), a measure of kidney function. However, significant SNPs account for a small proportion of eGFR variability. Other forms of genetic variation have not been comprehensively evaluated for association with eGFR. In this study, we assess whether changes in germline DNA copy number are associated with GFR estimated from serum creatinine, eGFRcrea. We used hidden Markov models (HMMs) to identify copy number polymorphic regions (CNPs) from high-throughput SNP arrays for 2,514 African (AA) and 8,645 European ancestry (EA) participants in the Atherosclerosis Risk in Communities (ARIC) study. Separately for the EA and AA cohorts, we used Bayesian Gaussian mixture models to estimate copy number at regions identified by the HMM or previously reported in the HapMap Project. We identified 312 and 464 autosomal CNPs among individuals of EA and AA, respectively. Multivariate models adjusted for SNP-derived covariates of population structure identified one CNP in the EA cohort near genome-wide statistical significance (Bonferroni-adjusted p = 0.067) located on chromosome 5 (876-880kb). Overall, our findings suggest a limited role of CNPs in explaining eGFR variability.

Icariin combined with human umbilical cord mesenchymal stem cells significantly improve the impaired kidney function in chronic renal failure

At present, the main therapy for chronic renal failure (CRF) is dialysis and renal transplantation, but neither obtains satisfactory results. Human umbilical cord mesenchymal stem cells (huMSCs) are isolated from the fetal umbilical cord which has a high self-renewal and multi-directional differentiation potential. Icariin (ICA), a kidney-tonifying Chinese Medicine can enhance the multipotency of huMSCs. Therefore, this work seeks to employ the use of ICA-treated huMSCs for the treatment of chronic renal failure. Blood urea nitrogen and creatinine (Cr) analyses showed amelioration of functional parameters in ICA-treated huMSCs for the treatment of CRF rats at 3, 7, and 14 days after transplantation. ICA-treated huMSCs can obviously increase the number of cells in injured renal tissues at 3, 7, and 14 days after transplantation by optical molecular imaging system. Hematoxylin-eosin staining demonstrated that ICA-treated huMSCs reduced the levels of fibrosis in CRF rats at 14 days after transplantation. Superoxide dismutase and Malondialdehyde analyses showed that ICA-treated huMSCs reduced the oxidative damage in CRF rats. Moreover, transplantation with ICA-treated huMSCs decreased inflammatory responses, promoted the expression of growth factors, and protected injured renal tissues. Taken together, our findings suggest that ICA-treated huMSCs could improve the kidney function in CRF rats.

miR-378 reduces mesangial hypertrophy and kidney tubular fibrosis via MAPK signalling

The regulatory role of a novel miRNA, miR-378, was determined in the development of fibrosis through repression of the MAPK1 pathway, miR-378 and fibrotic gene expression was examined in streptozotocin (STZ)-induced diabetic mice at 18 weeks or in unilateral ureteral obstruction (UUO) mice at 7 days. miR-378 transfection of proximal tubular epithelial cells, NRK52E and mesangial cells was assessed with/without endogenous miR-378 knockdown using the locked nucleic acid (LNA) inhibitor. NRK52E cells were co-transfected with the mothers against decapentaplegic homolog 3 (SMAD3) CAGA reporter and miR-378 in the presence of transforming growth factor-β (TGF-β1) was assessed. Quantitative polymerase chain reaction (qPCR) showed a significant reduction in miR-378 (P<0.05) corresponding with up-regulated type I collagen, type IV collagen and α-smooth muscle actin (SMA) in kidneys of STZ or UUO mice, compared with controls. TGF-β1 significantly increased mRNA expression of type I collagen (P<0.05), type IV collagen (P<0.05) and α-SMA (P<0.05) in NRK52E cells, which was significantly reduced (P<0.05) following miR-378 transfection and reversed following addition of the LNA inhibitor of endogenous miR-378 Overexpression of miR-378 inhibited mesangial cell expansion and proliferation in response to TGF-β1, with LNA-miR-378 transfection reversing this protective effect, associated with cell morphological alterations. The protective function of MAPK1 on miR-378 was shown in kidney cells treated with the MAPK1 inhibitor, selumetinib, which inhibited mesangial cell hypertrophy in response to TGF-β1. Taken together, these results suggest that miR-378 acts via regulation of the MAPK1 pathway. These studies demonstrate the protective function of MAPK1, regulated by miR-378, in the induction of kidney cell fibrosis and mesangial hypertrophy.

Low-protein diet for the prevention of renal failure

The prevalence of chronic kidney disease (CKD) is estimated to be 8-16% worldwide, and it is increasing. CKD is a risk factor for heart attack and stroke, and it can progress to kidney failure requiring dialysis or transplantation. Recently, diabetic nephropathy has become the most common cause of CKD. In Japan, the cumulative probability of requiring hemodialysis by the age 80 years is 1/50 in males and 1/100 in females. The number of patients under hemodialysis in Japan exceeded 320,000 in 2014, among which 38,000 were newcomers and 27,000 died.The annual medical costs of hemodialysis are 1.25 trillion yen in Japan, representing 4% of the total national medical expenditures in 2014. A low-protein diet (less than 0.5 g/kg b.wt.) is a very effective intervention. Low-protein rice (1/10 to 1/25 of the normal protein contents) is helpful to control the consumption of proteins, decreasing at the same time the intake of potassium and phosphate.Protein restriction is indicated as soon as the eGFR becomes lower than 60 ml/min/1.73 m² body surface, in order, to slow disease progression. The newly developed low-protein Indica rice is expected to help many CKD patients in China and Southeast Asia.

Longitudinal Serum Creatinine Levels in Relation to Graft Loss Following Renal Transplantation: Robust Joint Modeling of Longitudinal Measurements and Survival Time Data

BACKGROUND

Chronic kidney disease (CKD) is a major public health problem that may lead to end-stage renal disease (ESRD). Renal transplantation has become the treatment modality of choice for the majority of patients with ESRD. It is therefore necessary to monitor the disease progression of patients who have undergone renal transplantation. In order to monitor the disease progression, the continuous assessment of kidney function over time is considered.

OBJECTIVES

This study aimed to investigate the etiological role of recipient characteristics in serum creatinine changes within the follow-up period and in relation to the graft failure risk, as well as to evaluate whether or not the serum creatinine level represents an indicator of graft failure following renal transplantation.

METHODS

This retrospective cohort study was conducted at the department of nephrology, Baqiyatallah Hospital, Baqiyatallah University of Medical Sciences, between April 2005 and December 2008. The study involved 413 renal transplantation patients. The primary outcomes were the determination of the serum creatinine levels at each attendance and the time to graft failure. Robust joint modeling of the longitudinal measurements (serum creatinine level) and time-to-event data (time to graft failure) were used for the analysis in the presence of outliers in the serum creatinine levels. The data analysis was implemented in WinBUGS 1.4.3.

RESULTS

There was a positive association between the serum creatinine level and graft failure (HR = 5.13, P < 0.001). A one unit increase in the serum creatinine level suggests an increased risk of graft failure of up to 5.13 times. The serum creatinine level significantly decreased over time (95% CI: (-1.58, -1.08)). The recipient's age was negatively associated with the serum creatinine level (95% CI: (-0.02, -0.001)).

CONCLUSIONS

Graft failure is more likely to occur in patients with higher serum creatinine levels.

Red Meat Intake and Risk of ESRD

Randomized controlled trials suggest that protein restriction may retard the progression of CKD toward ESRD. However, the effects of dietary protein intake level and the food sources of dietary protein on the risk of ESRD in the general population remain unclear. We investigated these effects in the Singapore Chinese Health Study, a prospective population-based cohort that recruited 63,257 Chinese adults aged 45-74 years from 1993 to 1998. We collected habitual diet information via a validated semiquantitative food frequency questionnaire and identified ESRD via record linkage with a nationwide registry. In all, 951 cases of ESRD occurred over a mean follow-up of 15.5 years. Regarding total protein intake, compared with the lowest quartile, the three higher quartiles combined had a hazard ratio for ESRD of 1.24 (95% confidence interval [95% CI], 1.05 to 1.46), but the dose-dependent association across the quartiles was not statistically significant (P_trend=0.16). Red meat intake strongly associated with ESRD risk in a dose-dependent manner (hazard ratio for highest quartile versus lowest quartile,1.40 [95% CI, 1.15 to 1.71; P_trend<0.001]). Intake of poultry, fish, eggs, or dairy products did not associate with risk of ESRD. In substitution analysis, replacing one serving of red meat with other food sources of protein associated with a maximum relative risk reduction of 62.4% (95% CI, 33.1 to 78.9; P<0.01). Our study shows that red meat intake may increase the risk of ESRD in the general population and substituting alternative sources of protein may reduce the incidence of ESRD.

Inhibition of mitochondrial complex-1 restores the downregulation of aquaporins in obstructive nephropathy

Obstructive kidney disease is a common complication in the clinic. Downregulation of aquaporins (AQPs) in obstructed kidneys has been thought as a key factor leading to the polyuria and impairment of urine-concentrating capability after the release of kidney obstruction. The present study was to investigate the role of mitochondrial complex-1 in modulating AQPs in obstructive nephropathy. Following 7-day unilateral ureteral obstruction (UUO), AQP1, AQP2, AQP3, and vasopressin 2 (V₂) receptor were remarkably reduced as determined by qRT-PCR and/or Western blotting. Notably, inhibition of mitochondrial complex-1 by rotenone markedly reversed the downregulation of AQP1, AQP2, AQP3, and V₂ In contrast, AQP4 was not affected by kidney obstruction or rotenone treatment. In a separate study, rotenone also attenuated AQPs' downregulation after 48-h UUO. To study the potential mechanisms in mediating the rotenone effects on AQPs, we examined the regulation of the COX-2/microsomal prostaglandin E synthase (mPGES)-1/PGE₂/EP pathway and found that COX-2, mPGES-1, and renal PGE₂ content were all significantly elevated in obstructive kidneys, which was not affected by rotenone treatment. For EP receptors, EP₂ and EP₄ but not EP₁ and EP₃ were upregulated in obstructive kidneys. Importantly, rotenone strikingly suppressed EP₁ and EP₄ but not EP₂ and EP₃ receptors. However, treatment of EP₁ antagonist SC-51322 could not affect AQPs' reduction in obstructed kidneys. Collectively, these findings suggested an important role of mitochondrial dysfunction in modulating AQPs and V₂ receptor in obstructive nephropathy possibly via prostaglandin-independent mechanisms.

Ginsenoside Rg1 inhibits angiotensin II-induced podocyte autophagy via AMPK/mTOR/PI3K pathway

Recent researches have reported the extensive pharmacological activities of Ginsenoside Rg1 including antioxidant, anti-inflammatory, and anticancer properties. Furthermore Rg1 was also shown to protect various kinds of cells from self-digestion by its anti-autophagy activity. In previous studies, angiotensin II (Ang II), a key mediator of renin-angiotensin system, has been demonstrated to contribute to the progression of renal injury including abnormal autophagy. However, whether Rg1 can relieve Ang II-induced autophagy in podocyte as well as the underlying molecular mechanism remains to be elucidated. Here, we employed Ang II-treated podocyte as a model to investigate the effect of Rg1 on autophagy and the involved signal pathways. In the present study, we found that Ang II strongly promoted autophagy in immortalized mouse podocyte cells by observing the formation of autophagosomes and detecting the expression of autophagic marker, for example, LC3-II. Notably, compared to the Ang II-treated cells, treatment with Rg1 significantly inhibited the formation of autophagosomes and expression of autophagy-related proteins in Ang II pre-treated podocyte. Meanwhile, Rg1 downregulated the activity of AMPK and GSK-3β and upregulated the activity of P70S6K in Ang II-treated podocyte. In conclusion, these findings demonstrate that Ang II promotes autophagy in podocyte, and Rg1 effectively attenuates this process through AMPK/mTOR/PI3K pathway, suggesting that Rg1 may be beneficial to alleviate podocyte injury.

Measurement of glycated albumin in serum and plasma by LC-MS/MS

BACKGROUND

Diagnosis of diabetes and monitoring of long-term blood sugar are preferably done by measurement of glycated hemoglobin (HbA1c). Diabetic patients with end stage renal disease (ESRD) may have short-lived red blood cells due to hemodialysis (HD), and thus higher turnover of hemoglobin. The level of glycated hemoglobin (HbA1c) may be lower than expected for these patients, even at increased blood glucose, possibly making glycated albumin (GA) measurement a better alternative.

METHODS

The percentage of GA was measured by liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). Fast and efficient trypsin digestion of proteins in diluted serum or plasma resulted in a high number of proteotypic peptides from albumin, including KQTALVELVK which was detected both glycated and non-glycated by multiple reaction monitoring (MRM). The percentage of GA was estimated by neat peak area response of glycated peptide divided by the sum of glycated and non-glycated peptide.

RESULTS

Acceptable method reproducibility (6% CV), repeatability (2-6% CV), limit of quantification (0.75% GA), linearity (R(2) = 0.999) and recovery (79 ± 9%) was achieved without using calibration or isotope-labeled internal standard. GA was strongly correlated with HbA1c (r = 0.84) for patients without ESRD. The average ratio of GA/HbA1c was significantly higher (p = 0.0021) for ESRD patients (1.84 ± 0.38, n = 62) compared to other patients (1.67 ± 0.28, n = 225).

CONCLUSION

GA measurement by detecting glycation in KQTALVELVK with LC-MS/MS seems to be a useful supplement to HbA1c for detecting increased blood glucose in diabetic patients with ESRD.

Predicting Renal Failure Progression in Chronic Kidney Disease Using Integrated Intelligent Fuzzy Expert System

Background. Chronic kidney disease (CKD) is a covert disease. Accurate prediction of CKD progression over time is necessary for reducing its costs and mortality rates. The present study proposes an adaptive neurofuzzy inference system (ANFIS) for predicting the renal failure timeframe of CKD based on real clinical data. Methods. This study used 10-year clinical records of newly diagnosed CKD patients. The threshold value of 15 cc/kg/min/1.73 m² of glomerular filtration rate (GFR) was used as the marker of renal failure. A Takagi-Sugeno type ANFIS model was used to predict GFR values. Variables of age, sex, weight, underlying diseases, diastolic blood pressure, creatinine, calcium, phosphorus, uric acid, and GFR were initially selected for the predicting model. Results. Weight, diastolic blood pressure, diabetes mellitus as underlying disease, and current GFR_(t) showed significant correlation with GFRs and were selected as the inputs of model. The comparisons of the predicted values with the real data showed that the ANFIS model could accurately estimate GFR variations in all sequential periods (Normalized Mean Absolute Error lower than 5%). Conclusions. Despite the high uncertainties of human body and dynamic nature of CKD progression, our model can accurately predict the GFR variations at long future periods.

A renal registry for Africa: first steps

There is a dearth of data on end-stage renal disease (ESRD) in Africa. Several national renal registries have been established but have not been sustainable because of resource limitations. The African Association of Nephrology (AFRAN) and the African Paediatric Nephrology Association (AFPNA) recognize the importance of good registry data and plan to establish an African Renal Registry. This article reviews the elements needed for a successful renal registry and gives an overview of renal registries in developed and developing countries, with the emphasis on Africa. It then discusses the proposed African Renal Registry and the first steps towards its implementation. A registry requires a clear purpose, and agreement on inclusion and exclusion criteria, the dataset and the data dictionary. Ethical issues, data ownership and access, the dissemination of findings and funding must all be considered. Well-documented processes should guide data collection and ensure data quality. The ERA-EDTA Registry is the world's oldest renal registry. In Africa, registry data have been published mainly by North African countries, starting with Egypt and Tunisia in 1975. However, in recent years no African country has regularly reported national registry data. A shared renal registry would provide participating countries with a reliable technology platform and a common data dictionary to facilitate joint analyses and comparisons. In March 2015, AFRAN organized a registry workshop for African nephrologists and then took the decision to establish, for the first time, an African Renal Registry. In conclusion, African nephrologists have decided to establish a continental renal registry. This initiative could make a substantial impact on the practice of nephrology and the provision of services for adults and children with ESRD in many African countries.