Prevention of chronic kidney and vascular disease: Toward global health equity—The Bellagio 2004 Declaration

Prevalence of chronic kidney disease and associated factors among patients with chronic illness in Ethiopia: A systematic review and meta-analysis

Objective:

The main aim of this systematic review and meta-analysis is to provide summarized evidence on the prevalence of chronic kidney disease and associated factors among patients with chronic illness in Ethiopia.

Method:

Databases of MEDLINE/PubMed, Embase, Google Scholar, CINAHL, Cochrane library, and ScienceDirect were searched. In addition, gray literatures were searched manually from university repositories. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used to select potential studies. Microsoft Excel 2013 sheet template was used to extract data. The quality of included studies was assessed by utilizing the Newcastle-Ottawa Scale. STATA software version 14.0 is used to compute the estimated pooled prevalence and associated factors of chronic kidney disease.

Result:

Twelve articles that fulfilled the inclusion criteria were included. The pooled estimate of chronic kidney disease among patients with chronic illnesses in Ethiopia is 21.71% (95% confidence interval: 17.67, 25.74). The highest prevalence of chronic kidney disease among patients with chronic illnesses is from Oromia (32.55% (confidence interval: 19.91, 45.19)). Glomerular filtration rate showed a comparable pooled prevalence from Cockroft-Gault and MDRD methods; 22.38% (confidence interval: 15.83, 28.92), 22.18 (confidence interval: 18.01, 26.34), respectively. Hypertensives become more likely to have chronic kidney disease compared with normotensive patients, (odds ratio = 3.01, 95% confidence interval: 1.33, 6.81).

Conclusion:

Prevalence of chronic kidney disease among chronic illness patients was significantly high. Hypertension is significantly associated with chronic kidney disease. Hence, we recommend that continuous screening of possible risk factors and proper follow-up and management strategies should be designed.

Atorvastatin Improves Hepatic Lipid Metabolism and Protects Renal Damage in Adenine-Induced Chronic Kidney Disease in Sprague-Dawley Rats

Objective

Chronic kidney disease (CKD), including nephrotic syndrome, is a major cause of cardiovascular morbidity and mortality. The literature indicates that CKD is associated with profound lipid disorders largely due to the dysregulation of lipoprotein metabolism which further aggravates the progression of kidney disease. The present study sought to determine the efficacy of atorvastatin treatment on hepatic lipid metabolism and renal tissue damage in CKD rats.

Methods

Serum, hepatic and faecal lipid contents and the expression and enzyme activity of molecules involved in cholesterol and triglyceride metabolism, along with kidney function, were determined in untreated adenine-induced CKD, atorvastatin-treated CKD (10 mg/kg/day oral for 24 days) and control rats.

Key Findings

CKD resulted in metabolic dyslipidaemia, renal insufficiency, hepatic lipid accumulation, upregulation of 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase, acyl-CoA cholesterol acyltransferase-2 (ACAT2) and the downregulation of LDL receptor protein, VLDL receptor, hepatic lipase, lipoprotein lipase (LPL), lecithin–cholesterol acyltransferase (LCAT) and scavenger receptor class B type 1 (SR-B1). CKD also resulted in increased enzymatic activity of HMG-CoA reductase and ACAT2 together with decreased enzyme activity of lipase and LCAT. Atorvastatin therapy attenuated dyslipidaemia, renal insufficiency, reduced hepatic lipids, HMG-CoA reductase and ACAT2 protein abundance and raised LDL receptor and lipase protein expression. Atorvastatin therapy decreased the enzymatic activity of HMG-CoA reductase and increased enzymatic activity of lipase and LCAT.

Conclusions

Atorvastatin improved hepatic tissue lipid metabolism and renal function in adenine-induced CKD rats.

Chronic treatment of curcumin improves hepatic lipid metabolism and alleviates the renal damage in adenine-induced chronic kidney disease in Sprague-Dawley rats

Background

Chronic kidney disease (CKD), including nephrotic syndrome, is a major cause of cardiovascular morbidity and mortality. The literature indicates that CKD is associated with profound lipid disorders due to the dysregulation of lipoprotein metabolism which progresses kidney disease. The objective of this study is to evaluate the protective effects of curcumin on dyslipidaemia associated with adenine-induced chronic kidney disease in rats.

Methods

Male SD rats (n = 29) were divided into 5 groups for 24 days: normal control (n = 5, normal diet), CKD control (n = 6, 0.75% w/w adenine-supplemented diet), CUR 50 (n = 6, 50 mg/kg/day curcumin + 0.75% w/w adenine-supplemented diet), CUR 100 (n = 6, 100 mg/kg/day curcumin + 0.75% w/w adenine-supplemented diet), and CUR 150 (n = 6, 150 mg/kg/day curcumin + 0.75% w/w adenine-supplemented diet). The serum and tissue lipid profile, as well as the kidney function test, were measured using commercial diagnostic kits.

Results

The marked rise in total cholesterol, low-density lipoprotein (LDL) cholesterol, very low-density lipoprotein (VLDL) cholesterol, triglycerides and free fatty acids in serum, as well as hepatic cholesterol, triglyceride and free fatty acids of CKD control rats were significantly protected by curcumin co-treatment (at the dose of 50, 100 and 150 mg/kg). Furthermore, curcumin significantly increased the serum high-density lipoprotein (HDL) cholesterol compared to the CKD control rats but did not attenuate the CKD-induced weight retardation. Mathematical computational analysis revealed that curcumin significantly reduced indicators for the risk of atherosclerotic lesions (atherogenic index) and coronary atherogenesis (coronary risk index). In addition, curcumin improved kidney function as shown by the reduction in proteinuria and improvement in creatinine clearance.

Conclusion

The results provide new scientific evidence for the use of curcumin in CKD-associated dyslipidaemia and substantiates the traditional use of curcumin in preventing kidney damage.

The impact of out-of-pocket costs on treatment commencement and adherence in chronic kidney disease: a systematic review

Chronic kidney disease (CKD) is a significant and growing driver of the global non-communicable diseases (NCD) burden, responsible for 1.2 million deaths in 2016. While previous research has estimated the out-of-pocket costs of CKD treatment and resulting levels of catastrophic health expenditures, less is known about the impact of such costs on access to, and maintenance of, care. Our study seeks to fill this gap by synthesizing available evidence on cost as a determinant of CKD treatment discontinuation. We searched for studies which considered the financial burden of treatment and medication for CKD patients and the extent to which this burden was associated with patients forgoing or discontinuing treatment. We identified 14 relevant studies, 5 from high-income countries and 9 from low-middle income countries. All suggest that cost adversely influences adherence to CKD medication and dialysis treatment. In poorer countries, those entering treatment programs were typically diagnosed late, under-dialysed and suffered very high levels of mortality. Identified studies present consistent findings regardless of study context: cost is barrier to treatment and a driver of non-adherence and discontinuation, with poorer households worst affected. This is in line with previous research. Major gaps in the literature remain, however, in relation to differential impact of the cost burden on men and women, the coping strategies of poor households and the effect of insurance coverage.

Expenses of the Brazilian Public Healthcare System with chronic kidney disease

INTRODUCTION

The prevalence of chronic kidney disease (CKD) is increasing worldwide, with costs that can be impeditive.

OBJECTIVE

To establish the expenses of the Brazilian Public Healthcare System (SUS), with hospitalizations due to CKD and related diseases; evaluating expenses with renal replacement therapy (RRT).

METHODS

We have assessed the values paid by the SUS in the triennium 2013-2015, for estimating annual expenses with CKD treatment and hospitalization, associated diseases, and exams.

RESULTS

There was an increase in hospitalization by all causes in Brazil during this triennium. CKD and associated diseases corresponded to 1.82% and 5.79% of hospitalizations due to all causes in Brazil, and 2.87% and 10.10% of all expenses, respectively. Kidney grafts from deceased donors corresponded to 76% of hospitalizations and 80% of expenses with transplantation. There was a decrease in transplantation from living donors. There was an increase in the number of exams of 11.94% and of 10.95% in the expenses. There was a decrease in the number of procedures and expenses in intermittent peritoneal dialysis (IPD) and related procedures; but other procedures increased. Hemodialysis (3 weekly sessions) corresponded to 95.96% of procedures and 96.07% of expenses with dialysis in general.

CONCLUSION

Renal diseases and some of the main related diseases corresponded to 12.97% of the expenses in the triennium 2013-2015, and RRT to more than 5% of the SUS expenses with medium and high complexity healthcare. Such high expenses determine great concerns on the future maintenance of treatment for stage-5 CKD in Brazil and countries in similar or worse conditions of development.

The effectiveness and safety of angiotensin-converting enzyme inhibition or receptor blockade in vascular diseases in patients with hemodialysis

Patients with end-stage renal disease (ESRD) who are on hemodialysis have high risk of vascular diseases. Our study sought to examine whether angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin type 1 receptor blockers (ARBs) could reduce the frequencies of cardiovascular and cerebrovascular events in patients receiving hemodialysis using the medication possession ratio (MPR) method of analysis.This retrospective cohort study identified cases of ESRD with dialysis from the National Health Insurance Research Database between 1999 and 2006, and used Cox-regression methods to evaluate risk of poor outcomes. Primary outcomes, including death from any cause, and secondary outcomes, including admission for stroke, myocardial infarction, and heart failure, were examined.Compared to the nonuser group, the adjusted HRs for mortality of the nonadherence group and the adherence group were 0.81 (95% CI: 0.76-0.86) and 0.98 (95% CI: 0.86-1.13), respectively. Cardiovascular events were more frequent in patients with ESRD receiving ACEIs /ARBs than in nonusers. Compared with nonusers, the hazard of secondary outcome significantly increased in the nonadherence group or adherence group in 10 years follow-up.Compared with patients with diabetes or chronic kidney disease, patients on hemodialysis may not experience the same cardiovascular and cerebrovascular benefits from ACEIs/ARBs use.

Spanish version of the Kidney Disease Knowledge Survey (KiKS) in Peru: cross-cultural adaptation and validation

INTRODUCTION

Chronic kidney disease (CKD) affects 50 million people globally. Several studies show the importance of implementing interventions that enhance patients’ knowledge about their disease. In 2011 the Kidney Disease Knowledge Survey (KiKS) was developed: a questionnaire that assesses the specific knowledge about chronic kidney disease in pre-dialysis patients.

OBJECTIVE

To translate to Spanish, culturally adapt and validate the Kidney Disease Knowledge Survey questionnaire in a population of patients with pre-dialysis chronic kidney disease.

METHODS

We carried out a Spanish translation and cross-cultural adaptation of the Kidney Disease Knowledge Survey questionnaire. Subsequently, we determined its validity and reliability. We determined the validity through construct validity; and reliability by evaluating its internal consistency and its intra-observer reliability (test-retest).

RESULTS

We found a good internal consistency (Kuder-Richardson = 0.85). The intra-observer reliability was measured by the intra-class correlation coefficient that yielded a value of 0.78 (95% CI: 0.5-1.0). This value indicated a good reproducibility; also, the mean difference of -1.1 test-retest SD 6.0 (p = 0.369) confirms this finding.

CONCLUSION

The translated Spanish version of the Kidney Disease Knowledge Survey is acceptable and equivalent to the original version; it also has a good reliability, validity and reproducibility. Therefore, it can be used in a population of patients with pre-dialysis chronic kidney disease.

Pharmacoeconomic evaluation of hospitalised pre-dialysis and dialysis patients: A comparative study

BACKGROUND

The progression of chronic kidney disease (CKD) can be attributed to various factors, including lack of medical services, delayed referral, lack of awareness about the disease, drugs, and financial support.

AIMS

To compare the pharmacoeconomic-related direct medical and non-medical costs among hospitalised pre-dialysis and dialysis patients.

METHODS

A prospective observational study was conducted on the inpatients admitted to the Department of Nephrology. Patients undergoing maintenance dialysis or initiated on renal replacement therapy were included in the dialysis patients group and other CKD patients in the pre-dialysis group. The data pertaining to the pharmacoeconomic-related direct medical and non-medical costs were collected from the patient records, medical bills, and other relevant sources.

RESULTS

Out of 100 patients, 43 were in the pre-dialysis group and 57 were in the dialysis group. The median direct medical costs (INR 4,731.62, USD $76.47) for dialysis group patients were significantly higher than for the pre-dialysis group (INR 1,820.95, USD $29.43). The median direct non-medical costs (INR 550, USD $8.88) for pre-dialysis group patients were not significantly higher than for the dialysis group (INR 480, USD $7.75).

CONCLUSION

There was a significant difference in the median direct total costs between pre-dialysis and dialysis patients. The number of medications per prescription and length of hospital stay are the factors that influence the median direct total costs.

Depression and quality of life in relation to decreased glomerular filtration rate among adults with hypertension in rural northeast China

BACKGROUND/AIMS

We aim to investigate the extent to which depression and quality of life might be associated with decreased glomerular filtration rate (GFR) in a large hypertensive population in rural Northeast China.

METHODS

A total of 5566 hypertensive participants aged 35 years and older were screened with a stratified cluster multistage sampling scheme in rural areas of Liaoning Province during 2012-2013. Decreased GFR was defined as estimated GFR <60 ml/min/1.73 m2.

RESULTS

The overall prevalence of decreased GFR was 3.2%. In the multivariable regression model, participants with moderate or greater depression had a greater risk for having a decreased GFR (OR: 1.739, 95%CI: 1.004 to 3.014) after full adjustment. Every -point increase of all the domains in WHOQOL-BREF, except for physical and environment domains, was significantly related to a lower risk for decreased GFR adjusting for age, gender and race. However, after fully adjustment, only social relations remained significant (OR: 0.899, 95%CI: 0.820 to 0.985). Increasing in total scores of WHOQOL-BREF was a protective factor against decreased GFR after fully adjustment.

CONCLUSION

We found that moderate or greater depression and lower quality of life were associated with higher risks for developing decreased GFR.

Self-reported sleep duration is associated with reduced glomerular filtration rate among adults with hypertension: a population-based study from rural northeast China

Short sleep duration has been found recently to be a predictor of proteinuria. However, population-based investigations addressing the association between self-reported sleep duration and glomerular filtration rate (GFR) among hypertensive patients are lacking. We therefore sought to investigate the extent to which self-reported sleep duration might be associated with reduced GFR in a large hypertensive population in rural northeast China. A total of 5555 hypertensive participants, aged ≥35 years, in rural areas of Liaoning Province, China, were screened between January 2012 and August 2013, using a stratified, cluster multi-stage sampling scheme. Anthropometric measurements, self-reported sleep duration, blood biochemical indexes and other health-related variables were collected by medically trained personnel. Reduced GFR was defined as the estimated GFR (eGFR) < 60 mL min(-1) 1.73 m(2). On average, participants slept for 6.9 ± 1.6 h per night. Mean self-reported sleep duration decreased with eGFR (P < 0.001). For both genders, a lower prevalence of reduced GFR was observed among participants who slept ≤6 h per night in total. In the multivariable regression model, after adjustments for age, gender, ethnicity, lifestyle factors, clinical correlates, depressive symptoms and general quality of life, participants who slept for 6 h or less per night were associated with a higher risk of reduced GFR [odds ratio (OR: 1.70, 95% confidence interval (CI): 1.05-2.73] compared with the reference group (self-reported sleep duration >7 and ≤8 h day(-1) ). We concluded that short self-reported sleep duration (≤6 h per night) was related significantly to an increased risk of reduced GFR in a hypertensive population. This novel risk factor should be taken into consideration during daily management of hypertension to prevent chronic kidney disease.

Expert opinion of nephrologists about the effectiveness of low-protein diet in different stages of chronic kidney disease (CKD)

No clinical trials have specifically explored the benefits of low-protein diet in patients with different stages of chronic kidney disease (CKD) 3B. In the absence of RCTs, expert opinion may be a valid surrogate to estimate treatment effectiveness. A questionnaire-based survey of a large sample of nephrologists from Southern Italy was conducted to explore benefits of low-protein diet (LPD) in delaying dialysis entry in different CKD stages. For the case vignettes describing eight different patient profiles with various CKD stages, nephrologists reported expected benefits as time delay of dialysis entry. Information was collected through questionnaires filled by 88 nephrologists from different Southern Italian hospitals. On average, nephrologists estimated the highest delay in starting dialysis due to LPD in stages 3B (15 months) and 3A (14 months), and the lowest for 5 stage (3 months). According to opinion of a large sample of Southern Italian nephrologists, low-protein diet may be more efficacious if started in CKD stage 3B than 4 and 5.

Characteristics of South African patients presenting with kidney disease in rural KwaZulu-Natal: a cross sectional study

Background

Diabetes mellitus is the leading cause of end-stage renal disease (ESRD) globally. Diabetes and human immunodeficiency virus (HIV), both prevalent in South Africa, have not been reported as significant causes of ESRD.

Methods

We evaluated chronic kidney disease (CKD) and cardiovascular disease risk factors in a cross-sectional study of 302 patients (165 females/ 137 males) at a CKD clinic in rural northern KwaZulu-Natal. We included all CKD outpatient clinic attendees and excluded acute renal failure patients. Demographic, clinical and laboratory data collected were analyzed with Stata11 software. Logistic regression analysis was used to determine factors associated with advanced CKD and results expressed as the odds ratio with the 95% confidence interval [OR (95% CI)].

Results

Of 302 patients analyzed, 290 (96%) were black African. Mean age ± SD was 47.1 ± 17.0 years. Approximately 86.4% of females and 54.5% of males were overweight/ obese. Dyslipidaemia was observed in 47.9% females and 29.2% males (P < 0.001). Estimated glomerular filtration rate (eGFR) was <30 ml/min/1.73 m² in 50.6% patients. CKD risk factors observed were: hypertension (77.8%), diabetes (29.8%), HIV (28.5%), glomerulonephritis (7.0%) and tubulointerstitial diseases (5.6%). Independent factors associated with eGFR <30 ml/min/1.73 m² at presentation were: HIV [OR = 2.4 (1.3-4.2), P = 0.004] and hypertension [OR = 2.3 (1.3-4.2), P = 0.007].

Conclusion

Diabetes and HIV are prevalent in CKD patients at primary/regional level healthcare in South Africa. With registry data lacking, dedicated CKD clinics at lower healthcare levels may provide valuable data on CKD epidemiology including changes in aetiology. Primary healthcare practitioners are faced with advanced CKD patients in resource-poor settings, with limited opportunity for upward referral hence the need for nephrology outreach programs.

Cervical cancer and the global health agenda: Insights from multiple policy-analysis frameworks

Cervical cancer is the second leading cause of cancer deaths for women globally, with an estimated 88% of deaths occurring in the developing world. Available technologies have dramatically reduced mortality in high-income settings, yet cervical cancer receives considerably little attention on the global health policy landscape. The authors applied four policy-analysis frameworks to literature on global cervical cancer to explore the question of why cervical cancer may not be receiving the international attention it may otherwise warrant. Each framework explores the process of agenda setting and discerns factors that either facilitate or hinder policy change in cases where there is both a clear problem and a potential effective solution. In combination, these frameworks highlight a number of crucial elements that may be needed to raise the profile of cervical cancer on global health agendas, including improving local (national or sub-national) information on the condition; increasing mobilisation of affected civil society groups; framing cervical cancer debates in ways that build upon its classification as a non-communicable disease (NCD) and an issue of women's rights; linking cervical cancer screening to well-funded services such as those for HIV treatment in some countries; and identifying key global policy windows of opportunity to promote the cervical cancer agenda, including emerging NCD global health discussions and post-2015 reviews of the Millennium Development Goals.

Angiotensin II receptor blocker partially ameliorated intrarenal hypoxia in chronic kidney disease patients: a pre-/post-study

Chronic intrarenal hypoxia has been regarded as a pathogenic factor of progressive renal damage. However, the lack of available human data has impeded the progress in this field. In this work, blood oxygen level-dependent magnetic resonance imaging was used to determine intrarenal oxygen status pre- and post-angiotensin receptor blockade (olmesartan) treatment in normal subjects, diabetic chronic kidney disease (CKD) patients and non-diabetic CKD patients. The mean R2*, which represents intrarenal oxygenation, was significantly lower in the control group than in the CKD group (12.42 ± 0.53 /s vs 18.89 ± 3.15 /s, P < 0.01), indicating the presence of intrarenal hypoxia in the CKD patients. The olmesartan treatment induced a 16.2 ± 7.7% decrement of the mean R2* in CKD patients, suggesting that this drug had an intrarenal hypoxia ameliorating effect.

Use of complementary markers in assessing glycaemic control in people with diabetic kidney disease undergoing iron or erythropoietin treatment

AIMS

HbA(1c) values are unreliable in patients with diabetes who have chronic kidney disease who receive iron and/or erythropoiesis stimulating agents. The study aimed to evaluate the utility of the complementary glycaemic markers glycated albumin, fructosamine and 1,5 anhydroglucitol in this group of patients.

METHODS

A prospective study of patients with Type 2 diabetes and chronic kidney disease stage IIIB/IV undergoing intravenous iron or erythropoiesis-stimulating agent therapy. Glycaemic control was monitored using HbA(1c), seven-point daily glucose thrice weekly, continuous glucose monitoring, glycated albumin, fructosamine and 1,5 anhydroglucitol.

RESULTS

Fifteen patients [9 men; median age 72 years (interquartile range 68-74), follow-up period (16.4 ± 3.7 weeks)] received parenteral iron; 15 patients [11 men; 70 years (interquartile range 62-75), (17.3 ± 3.3 weeks)] received erythropoiesis-stimulating agent. HbA(1c) fell following treatment with both iron [57 mmol/mol (7.4%) to 53 mmol/mol (7.0%), P < 0.001] and erythropoiesis-stimulating agent [56 mmol/mol (7.3%) to 49 mmol/mol (6.6%), P = 0.01] despite mean blood glucose remaining unchanged (iron: 9.55 to 9.71 mmol/l, P = 0.07; erythropoiesis-stimulating agent: 8.72 to 8.78 mmol/l, P = 0.89). Unlike HbA1c , the glycated albumin, fructosamine and 1,5 anhydroglucitol levels did not change following iron [glycated albumin (16.8 to 16.3%, P = 0.10); fructosamine (259.5 to 256 μmol/l, P = 0.89); 1,5 anhydroglucitol (54.2 to 50.9 μmol/l, P = 0.89)] or erythropoiesis-stimulating agent [glycated albumin (17.9 to 17.5%, P = 0.29), fructosamine (324.3 to 306.0 μmol/l, P = 0.52), 1,5 anhydroglucitol (58.2 to 46.7 μmol/l, P = 0.35)]. Despite this, HbA(1c) was consistently the marker most closely related to mean blood glucose before and after each treatment (R range 0.7-0.88).

CONCLUSIONS

These data indicate that HbA(1c) was statistically most closely related to mean blood glucose, but clinical trends in glycaemia in patients undergoing iron or erythropoiesis-stimulating agent therapy are likely best assessed by including one of these additional glycaemic markers.

Long-term visit-to-visit office blood pressure variability increases the risk of adverse cardiovascular outcomes in patients with chronic kidney disease

Long-term visit-to-visit blood pressure (BP) variability predicts a high risk for cardiovascular events in patients with essential hypertension. Whether long-term visit-to-visit BP variability holds the same predictive power in predialysis patients with chronic kidney disease (CKD) is unknown. Here we tested the relationship between long-term visit-to-visit office BP variability and a composite end point (death and incident cardiovascular events) in a cohort of 1618 patients with stage 2-5 CKD. Visit-to-visit systolic BP variability was significantly and independently related to baseline office, maximal, and average systolic BPs, age, glucose, estimated glomerular filtration rate, and albumin, and to the number of visits during the follow-up. Both the standard deviation of systolic BP (hazard ratio: 1.11, 95% confidence interval: 1.01-1.20) and the coefficient of variation of systolic BP (hazard ratio: 1.15, 95% confidence interval: 1.02-1.29) were significant predictors of the combined end point independent of peak and average systolic BP, cardiovascular comorbidities, Framingham risk factors, and CKD-related risk factors. Antihypertensive treatment (β-blockers and sympatholytic drugs) significantly abrogated the excess risk associated with high systolic BP variability. Thus, large visit-to-visit systolic BP variability in patients with CKD predicts a higher risk of death and nonfatal cardiovascular events independent of underlying BP levels.

Identification of a multistate continuous-time nonhomogeneous Markov chain model for patients with decreased renal function

OBJECTIVES

Markov chain models are frequently used to study the clinical course of chronic diseases. The aim of this article is to adopt statistical methods to describe the time dynamics of chronically ill patients when 2 kinds of data sets--fully and partially observable data are available.

MODEL

We propose a 6-state continuous-time Markov chain model for the progression of chronic kidney disease (CKD), where little is known about the transitions between the disease stages. States 1 to 3 of the model correspond to stages III to V of chronic kidney disease in the Kidney Disease Outcomes Quality Initiative (KDOQI) CKD classification. States 4 and 5 relate to dialysis and transplantation (renal replacement therapy), respectively. Death is the (absorbing) state 6.

METHODS AND DATA

The model can be investigated and identified using Kolmogorov's forward equations and the methods of survival analysis. Age dependency, covariates in the form of the Cox regression, and unobservable risks of transition (frailties) can be included in the model. We applied our model to a data set consisting of all 2097 patients from all renal centers in a region in North Rhine-Westphalia (Germany) in 2005-2010.

RESULTS

We compared transitions and relative risks to the few data published and found them to be reasonable. For example, patients with diabetes had a significantly higher risk for disease progression compared with patients without diabetes.

CONCLUSIONS

In summary, modeling may help to quantify disease progression and its predictors when only partially observable prospective data are available.

Statins in the management of dyslipidemia associated with chronic kidney disease

The cause of death in the majority of patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) is accelerated cardiovascular disease and not renal failure per se, suggesting a role for statin therapy in this setting. During the past 6 years three large, randomized, placebo-controlled studies of three different statins have been conducted in the dialysis population-but two of these studies did not demonstrate any benefits of statin therapy, and the third study showed only marginally positive results. To understand why statins have failed to reduce cardiovascular events in patients with ESRD, the basic mechanisms underlying the pathogenesis of dyslipidemia in CKD must be critically examined. The observed negative results in the clinical trials of statin therapy might also reflect the biomarkers and targets that were chosen to be evaluated. The characteristics of dyslipidemia in patients with CKD not yet requiring dialysis treatment differ markedly from those of individuals with established ESRD and form the basis for therapeutic recommendations. The potential adverse effects associated with statin therapy are important to consider in the management of dyslipidemia in patients with CKD.

Novel targets for immunotherapy in glomerulonephritis

Glomerulonephritis is a common cause of chronic kidney disease and end stage renal failure. Current therapy relies on variably effective, nonspecific and toxic immunosuppression. Recent insights into underlying biology and disease pathogenesis in human glomerulonephritis combined with advances in the fields of inflammation and autoimmunity promise a cadre of novel targeted interventions. This review highlights the therapeutic potential of two antigens, alpha3 (IV)NC1 collagen and podocyte neutral endopeptidase, and two cell signaling and effector molecules, IgG Fc receptors and complement, judged to be particularly amenable to therapeutic manipulation in man. It is anticipated that continued dissection of pathogenesis in the diverse disorders that comprise the glomerulonephritides will provide the basis for individualized disease-specific therapy.

The role of obesity in kidney disease: recent findings and potential mechanisms

Obesity epidemic is in rise in almost every industrialized country and continues to be a growing problem worldwide. In fact, obesity per se has been recognized as a chronic disease. Consequently, there has been a cascade of metabolic changes initiated by the markedly risen prevalence that contributes to the increased incidence of diabetes, hypertension, and cardiovascular disease. Moreover, obesity is also associated with an increased risk of chronic kidney disease (CKD). The majority of the studies indicate a direct relationship between body mass index (BMI) and CKD risk. Moreover, current evidence emphasized the fact that central obesity measurements, such as waist circumference, could be a better predictor of CKD progression and mortality than BMI. The detrimental effects of obesity on kidney outcome have been recognized in nondialysis-dependent (NDD)-CKD patients. However, survival in overweight or obese CKD patients undergoing maintenance hemodialysis is paradoxically opposed compared with the general population. This "reverse epidemiology," however, is valid mainly for the inflammated end-stage renal disease (ESRD) patients. In fact, renal transplant recipients with higher BMI have inferior patient and graft survival compared to patients with lower BMI. This review also provides perspectives concerning the mechanisms associated with obesity, such as the renin-angiotensin-aldosterone system (RAAS) activation, and the role of leptin, adiponectin, fetuin-A, and adipose tissue, as factors that contribute to the development of CKD. Prevention strategies for CKD patients are also discussed and should be considered by clinicians.

Burden of CKD, proteinuria, and cardiovascular risk among Chinese, Mongolian, and Nepalese participants in the International Society of Nephrology screening programs

BACKGROUND

In 2007, the International Society of Nephrology funded the Kidney Disease Data Center database to house data from sponsored programs aimed at preventing chronic kidney disease and its complications in developing nations. This study compares baseline characteristics and burden of illness among participants from centers in China, Mongolia, and Nepal. An important secondary objective is to show the feasibility of screening for chronic kidney disease and its major risk factors in a diverse group of lower income settings.

STUDY DESIGN

Cross-sectional screening study.

SETTING & PARTICIPANTS

Participants from Nepal (n = 8,398), China (n = 1,999), and Mongolia (n = 997). Screening was open to the public for participants in China and Nepal; referral from a general practitioner was required for participants in Mongolia.

OUTCOMES

Estimated glomerular filtration rate (eGFR), proteinuria, hypertension, diabetes, obesity, cardiovascular risk.

MEASUREMENT

Demographic and clinical data were collected prospectively using a standard format. Blood and urine specimens were provided according to local protocol.

RESULTS

Of 11,394 participants, decreased eGFR (<60 mL/min/1.73 m(2)) was present in 7.3%-14% of participants across centers; proteinuria (≥1+) on dipstick (2.4%-10%), hypertension (26%-36%), diabetes (3%-8%), and obesity (body mass index ≥30 kg/m(2); 2%-20%) were all common. Predicted 5-year cardiovascular risk ≥10% ranged from 20%-89%. Numbers needed to screen to detect a new case of eGFR <60 mL/min/1.73 m(2), hypertension, or diabetes were 2.6 (95% CI, 2.5-2.7), 3.4 (95% CI, 3.1-3.7), and 4.7 (95% CI, 3.3-8.0) for Nepal, China, and Mongolia, respectively.

LIMITATIONS

May not be representative of the general population.

CONCLUSIONS

The acceptable diagnostic yield of abnormalities across these 3 diverse settings suggests that trials of targeted screening and intervention are feasible and warranted in such countries.

A prediction model for the risk of incident chronic kidney disease

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Burden of chronic kidney disease: an international perspective

CKD is associated with increased cardiovascular mortality and a loss of disability-adjusted life years. Diseases of the genitourinary system were responsible for 928,000 deaths and 14,754,000 disability-adjusted life years in 2004. However, the absence of kidney registries in most of the low- and middle-income countries has made it difficult to ascertain the true burden of CKD in these countries. The global increase in the incidence and prevalence of CKD is being driven by the global increase in the prevalence of diabetes mellitus, hypertension, obesity, and aging. Most patients in low- and middle-income countries die because they cannot access renal replacement therapy because of the exorbitant cost. Community surveys have shown that the number of people with end-stage kidney disease is just the tip of the "CKD iceberg." The preventive strategies to stem the tide of CKD should involve educating the population on how to prevent renal disease; identifying those at risk of developing CKD; raising the awareness of the general public, policy makers, and health care workers; modifying the lifestyle of susceptible individuals; detecting early stage of CKD; arresting or hindering the progression of disease; and creating facilities for global assistance.

Surveillance of chronic kidney disease around the world: tracking and reining in a global problem

In recent years, there has been a general recognition of the importance of tackling noncommunicable chronic diseases throughout the world and not just in developed nations. Chronic kidney disease (CKD) is increasingly recognized as a public health threat, based on its high prevalence, rising incidence, associated complications, and cost. It is imperative that nations develop screening and surveillance programs related to CKD. This article provides a global perspective on existing and emerging CKD surveillance efforts. A variety of programs are described, ranging from cross-sectional screening studies to determine CKD prevalence; targeted screening of high-risk populations presenting for voluntary testing; to more systematic surveillance within the scope of integrated health care systems in many developed nations. The choice of surveillance programs for many countries will depend on available resources and competing health care priorities. Integration with surveillance programs for other major chronic diseases such as diabetes, hypertension, and obesity is highly desirable and could be a key to the prevention of CKD. Finally, we propose the model of integrated health systems as one that is perhaps best suited to systematic, longitudinal surveillance of many chronic diseases, a model based on a national electronic health care record with linkage across primary care and hospital-based programs. Robust health education efforts and timely dissemination strategies will remain the key to the success of disease surveillance. It is gratifying to note that more and more countries are developing and adopting CKD surveillance programs as part of national disease prevention strategies.

Therapeutic potential of endothelin receptor antagonists for chronic proteinuric renal disease in humans

Diabetes and arterial hypertension continue to be the main causes of chronic renal failure in 2010, with a rising prevalence in part due to the worldwide obesity epidemic. Proteinuria is a main feature of chronic renal disease and mediated by defects in the glomerular filtration barrier and is as a good predictor of cardiovascular events. Indeed, chronic renal disease due to glomerulosclerosis is one of the important risk factors for the development of coronary artery disease and stroke. Glomerulosclerosis develops in response to inflammatory activation and increased growth factor production. Preclinical and first preliminary clinical studies provide strong evidence that endogenous endothelin-1 (ET-1), a 21-amino-acid peptide with strong growth-promoting and vasoconstricting properties, plays a central role in the pathogenesis of proteinuria and glomerulosclerosis via activation of its ET(A) subtype receptor involving podocyte injury. These studies have not only shown that endothelin participates in the disease processes of hypertension and glomerulosclerosis but also that features of chronic renal disease such as proteinuria and glomerulosclerosis are reversible processes. Remarkably, the protective effects of endothelin receptors antagonists (ERAs) are present even on top of concomitant treatments with inhibitors of the renin-angiotensin system. This review discusses current evidence for a role of endothelin for proteinuric renal disease and podocyte injury in diabetes and arterial hypertension and reviews the current status of endothelin receptor antagonists as a potential new treatment option in renal medicine.

Cost-effectiveness of screening and optimal management for diabetes, hypertension, and chronic kidney disease: a modeled analysis

OBJECTIVES

Chronic kidney disease is, increasingly, both a contributor to premature deaths and a financial burden to the health system, and is estimated to affect between 10% and 15% of the adult population in Western countries. Hypertension and, in particular diabetes, are significant contributors to the global burden of chronic kidney disease. Although it might increase costs, screening for, and improved management of, persons at increased risk of progressive kidney disease could improve health outcomes. We therefore sought to estimate the costs and health outcomes of alternative strategies to prevent end-stage kidney disease, compared with usual care.

METHODS

A Markov model comparing: 1) intensive management versus usual care for patients with suboptimally managed diabetes and hypertension; and 2) screening for and intensive treatment of diabetes, hypertension, and proteinuria versus usual care was developed. Intervention effectiveness was based on published meta-analyses and randomized controlled trial data; costs were measured from a central health-care funder perspective in 2008 Australian dollars ($A), and outcomes were reported in quality-adjusted life-years (QALYs).

RESULTS

Intensive treatment of inadequately controlled diabetes was both less costly (an average lifetime saving of $A133) and more effective (with an additional 0.075 QALYs per patients) than conventional management. Intensive management of hypertension had an incremental cost-effectiveness ratio (ICER) $A2588 per QALY gained. Treating all known diabetics with angiotensin-converting enzyme (ACE) inhibitors was both less costly (an average lifetime saving of $A825 per patient) and more effective than current treatment (resulting in 0.124 additional QALYs per patient). Primary care screening for 50- to 69-year-olds plus intensive treatment of diabetes had an ICER of $A13,781 per QALY gained. Primary care screening for hypertension (between ages 50 and 69 years) plus intensive blood pressure management had an ICER of $A491 per QALY gained. Primary care screening for proteinuria (between ages 50 and 69 years) combined with prescription of an ACE inhibitor for all persons showing proteinuria and all known diabetics had an ICER of $A4793 per QALY gained.

CONCLUSIONS

Strategies combining primary care screening of 50- to 69-year-olds for proteinuria, diabetes, and hypertension followed by the routine use of ACE inhibitors, and optimal treatment of diabetes and hypertension, respectively, have the potential to reduce death and end-stage kidney disease and are likely to represent good value for money.

Glomerulonephritis and managing the risks of chronic renal disease

The rising global burden of chronic renal disease, the high cost of providing renal replacement therapies, and renal disease also being a risk factor for cardiovascular disease is increasing focus on renal disease prevention. This article focuses on the aspects of renal disease (specifically poststreptococcal glomerulonephritis [PSGN] and chronic kidney disease [CKD]) in Indigenous populations in Australia, New Zealand, Canada, and the United States that diverge from those typically seen in the general population of those countries. The spectrum of renal and many other diseases seen in Indigenous people in developed countries is similar to that seen in developing countries. Diseases like PSGN that have largely disappeared in developed countries still occur frequently in Indigenous people. CKD during the childhood years is due to congenital anomalies of the kidney and urinary tract in up to 70% of cases and occurs later in polycystic kidney disease and childhood-onset diabetes. Several risk factors for CKD in adulthood are already present in childhood.

High prevalence of undiagnosed chronic kidney disease among at-risk population in Kinshasa, the Democratic Republic of Congo

Background

There is limited knowledge of Chronic Kidney Disease (CKD) among high risk populations, especially in the developing countries. We report our study of testing for CKD in at-risk subjects.

Methods

In a cross-sectional study, 527 people from primary and secondary health care areas in the city of Kinshasa were studied from a random sample of at-risk out-patients with hypertension, diabetes, obesity, or HIV+. We measured blood pressure (BP), blood glucose level, proteinuria, body mass index, and estimated glomerular filtration rate (eGFR by MDRD equation) using calibrated creatinine levels based on one random measurement. The associations between health characteristics, indicators of kidney damage (proteinuria) and kidney function (<60 ml/min/1.73 m²) were also examined.

Results

The prevalence of CKD in this study was 36%, but only 12% were aware of their condition. 4% of patients had stage 1 CKD, 6% stage 2, 18% stage 3, 2% stage 4, and 6% had stage 5. 24 hour quantitative proteinuria (>300 mg/day) was found in 19%. In those with the at-risk conditions, the % of CKD was: 44% in patients with hypertension, 39% in those with diabetes; 16% in the obese and 12% in those who were HIV+. 82% of those with a history of diabetes had elevated serum glucose levels at screening (≥ 126 mg/dl). Only 6% of individuals with hypertension having CKD had reduced BP to lower than 130/80 mmHg. In multivariate analysis, diabetes, proteinuria and hypertension were the strongest determinants of CKD 3+.

Conclusion

It appears that one out of three people in this at-risk population has undiagnosed CKD and poorly controlled CKD risk factors. This growing problem poses clear challenges to this developing country. Therefore, CKD should be addressed through the development of multidisciplinary teams and improved communication between traditional health care givers and nephrology services. Attention to CKD risk factors must become a priority.

Screening for kidney disease in children on World Kidney Day in Jalisco, Mexico

World Kidney Day (WKD) is intended to raise awareness and increase detection of chronic kidney disease (CKD), but most emphasis is placed on adults rather than children. We examined yield of screening for CKD and hypertension among poor children in Mexico. On WKD (2006, 2007), children (age < 18 years) without known CKD were invited to participate at two screening stations. We measured body mass index (BMI), blood pressure, and serum creatinine, and performed dipstick urinalysis. The Schwartz equation was used to estimate glomerular filtration rate (GFR; reduced GFR defined as < 60 ml/min per 1.73 m(2)). Proteinuria and hematuria were defined by a reading of >or= 1+ protein or blood on dipstick. Hypertension was defined by gender, age, and height-specific norms. In total, 240 children were screened (mean age 8.9 +/- 4.1 years; 44.2% male). Proteinuria and hematuria were detected in 38 (16.1%) and 41 (17.5%), respectively; 15% had BMI > 95th percentile for age. Reduced GFR was detected in four (1.7%) individuals. Systolic hypertension was more prevalent in younger children (age 0-8 years, 19.6%; age 9-13 years, 7.1%; age 14-17 years, 5.3%) suggesting a possible white-coat effect. Hematuria, proteinuria, hypertension and obesity were frequently detected among children in a community based screening program in Mexico. This form of screening might be useful in identifying children with CKD and hypertension in developing nations.

Report of the Asian Forum of Chronic Kidney Disease Initiative (AFCKDI) 2007. "Current status and perspective of CKD in Asia": diversity and specificity among Asian countries

The Japanese Society of Nephrology (JSN) sponsored the Asian Forum of CKD Initiative (AFCKDI) 2007 with the support of the International Society of Nephrology-Commission for Global Advancement in Nephrology (ISN-COMGAN), Asian Pacific Society of Nephrology (APSN), the Kidney Disease: Improving Global Outcome (KDIGO) and other national societies of nephrology in the Asian Pacific region on 27-28 May 2007 in Hamamatsu City, Japan. An international organising committee was established by leading experts of the CKD initiative. The main objective of this forum was to clarify the current status and perspectives of CKD and to promote coordination, collaboration and integration of initiatives in the Asian Pacific region. The forum received 56 papers from 16 countries; it began with the symposium "A Challenge to CKD in the world" and was followed by the ISN-COMGAN affiliated workshop "Current status and perspective of CKD in Asia". The second day was dedicated to discussion on the evaluation, surveillance and intervention in CKD in this area. At the end of the forum, we decided on the future plan as follows: (1) The AFCKDI will provide opportunities annually or biannually for every person who promotes CKD initiatives in the Asian Pacific region to join together and build consensus for action; (2) the second forum will be held in Kuala Lumpur on 4 May 2008 at the time of the 11th Asian Pacific Congress of Nephrology (APCN). Zaki Morad, President of the 11th APCN, will host the second forum; (3) the International Organising Committee (IOC) of the 1st AFCKDI will continue its function by adding other experts, including the organisers of the APCN; (4) the AFCKDI is not an organisation by itself, nor does it belong to any society, but is organised by each host national society of nephrology. The IOC will assist the domestic committee for the success of the forum and will assure the continuation of the mission; (5) in order to organise the forum and promote CKD initiatives in the Asia Pacific region, the AFCKDI will look for support by both national and international societies. The AFCKDI will keep an intimate and mutual relation with the ISN, APSN and KDIGO.

Prevalence and awareness of CKD among African Americans: the Jackson Heart Study

BACKGROUND

Chronic kidney disease (CKD) leads to end-stage renal disease and is a growing epidemic throughout the world. In the United States, African Americans have an incidence of end-stage renal disease 4 times that of whites.

STUDY DESIGN

Cross-sectional to examine the prevalence and awareness of CKD in African Americans.

SETTING & PARTICIPANTS

Observational cohort in the Jackson Heart Study (JHS).

PREDICTOR

CKD was defined as an estimated glomerular filtration rate less than 60 mL/min/1.73 m(2), the presence of albuminuria, or dialysis therapy.

OUTCOMES & MEASUREMENTS

Data from the JHS were analyzed. Medical history, including disease awareness and drug therapy, anthropometric measurements, and serum and urine samples, were obtained from JHS participants at the baseline visit. Associations between CKD prevalence and awareness and selected demographic, socioeconomic, health care access, and disease status parameters were assessed by using logistic regression models.

RESULTS

The prevalence of CKD in the JHS was 20%; CKD awareness was only 15.8%. Older participants had a greater prevalence, but also were more aware of CKD. Hypertension, diabetes, cardiovascular disease, hypercholesterolemia, hypertriglyceridemia, increasing age and waist circumference, and being single or less physically active were associated with CKD. Only advancing CKD stage was associated with awareness.

LIMITATIONS

Cross-sectional assessment, single urine measurement.

CONCLUSIONS

The JHS has a high prevalence and low awareness of CKD, especially in those with less severe disease status. This emphasizes the need for earlier diagnosis and increased education of health care providers and the general population.

How can we achieve global equity in provision of renal replacement therapy?

There is a significant emerging burden of chronic and end-stage kidney disease in low- and middle-income countries, driven by population ageing and the global epidemic of type 2 diabetes. Sufferers of end-stage kidney disease require ongoing dialysis or kidney transplantation to survive; however, in many low- and middle-income countries, treatment options are strictly limited or unaffordable. Low numbers of maintenance dialysis patients and transplant recipients reflect profound economic and service provision challenges for health-care systems in low- and middle-income countries in sustaining renal replacement therapy programmes. Underdeveloped organ donor and transplant programmes, health system and financing issues, ethical regulation of transplantation and the cost of pharmaceuticals commonly pose additional barriers to the delivery of efficient and cost-effective renal replacement therapy. Development of locally appropriate transplant programmes, effective use of nongovernmental sources of funding, service planning and cost containment, use of generic drugs and local manufacture of dialysis consumables have the potential to make life-saving renal replacement therapy available to many more in need. Select low- and middle-income countries demonstrate more equitable provision of renal replacement therapy is possible outside high-income countries. For other low- and middle-income countries, education, the development of good public policy and a supportive international environment are critical. Prevention of end-stage kidney disease, ideally as part of an integrated approach to chronic vascular diseases, must also be a key objective.

Socioeconomic disadvantage and kidney disease in the United States, Australia, and Thailand

OBJECTIVES

We sought to determine whether an elevated burden of chronic kidney disease is found among disadvantaged groups living in the United States, Australia, and Thailand.

METHODS

We used data on participants 35 years or older for whom a valid serum creatinine measurement was available from studies in the United States, Thailand, and Australia. We used logistic regression to analyze the association of income, education, and employment with the prevalence of chronic kidney disease (estimated glomerular filtration rate<60 mL/min/1.73 m(2)).

RESULTS

Age- and gender-adjusted odds of having chronic kidney disease were increased 86% for US Whites in the lowest income quartile versus the highest quartile (odds ratio [OR] = 1.86; 95% confidence interval [CI] = 1.27, 2.72). Odds were increased 2 times and 6 times, respectively, among unemployed (not retired) versus employed non-Hispanic Black and Mexican American participants (OR=2.89; 95% CI=1.53, 5.46; OR=6.62; 95% CI=1.94, 22.64. respectively). Similar associations were not evident for the Australian or Thai populations.

CONCLUSIONS

Higher kidney disease prevalence among financially disadvantaged groups in the United States should be considered when chronic kidney disease prevention and management strategies are created. This approach is less likely to be of benefit to the Australian and Thai populations.

Prevalence and factors associated with CKD: a population study from Beijing

BACKGROUND

Chronic kidney disease (CKD) is considered a serious worldwide public health problem, but data from developing countries are extremely limited.

STUDY DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

A representative sample of 13,925 adults in Beijing, China.

PREDICTORS

Age (18 to 39, 40 to 59, 60 to 69, and >70 years), sex, urban or rural area, history of chronic respiratory infection and cardiovascular disease, hepatitis B virus infection, smoking, family history (diabetes, hypertension, and CKD), nephrotoxic medications, central obesity, diabetic and hypertension status, and dyslipidemia.

OUTCOMES AND MEASUREMENTS

CKD was defined as estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) or markers of kidney damage. Glomerular filtration rate was estimated by using calibrated serum creatinine level and a formula specific for China. Persistent albuminuria and hematuria were considered markers of kidney damage.

RESULTS

The prevalence of CKD in adults in Beijing was 13.0% (95% confidence interval [CI], 11.9 to 14.2). It therefore was estimated that the number of adults in Beijing with CKD was 1.43 million. In subjects aged 18 to 39, 40 to 59, 60 to 69, and older than 70 years, prevalences of CKD were 10.0% (95% CI, 8.9 to 11.3), 14.2% (95% CI, 13.0 to 15.4), 20.8% (95% CI, 18.1 to 23.9), and 30.5% (95% CI, 26.6 to 34.7), respectively. Factors independently associated with decreased kidney function included older age (odds ratio [OR], 1.83; 95% CI, 1.51 to 2.22 per 10-year increase), nephrotoxic medications (OR, 2.19; 95% CI, 1.21 to 3.97), rural area (versus urban area; OR, 0.47; 95% CI, 0.28 to 0.78), history of cardiovascular disease (OR, 2.04; 95% CI, 1.24 to 3.38), high-density lipoprotein cholesterol level less than 40 mg/dL (OR, 3.00; 95% CI, 1.39 to 6.51), and hypertension status (with duration > 10 years; OR, 1.85; 95% CI, 1.19 to 2.88).

LIMITATIONS

Kidney function and indicators of kidney damage were based on single measurements.

CONCLUSIONS

CKD is a public health burden in Beijing.

Smoking: a risk factor for progression of chronic kidney disease and for cardiovascular morbidity and mortality in renal patients--absence of evidence or evidence of absence?

Although it is beyond any doubt that smoking is the number one preventable cause of death in most countries, smoking as an independent progression factor in renal disease has been questioned against the background of evidence-based criteria. This is because information from large, randomized, prospective studies that investigate the effects of smoking on renal function in healthy individuals as well as in patients with primary or secondary renal disease are lacking. Since 2003, a substantial number of clinical and experimental data concerning the adverse renal effects of smoking have been published, including large, prospective, population-based, observational studies. These more recent data together with evidence from experimental studies clearly indicate that smoking is a relevant risk factor, conferring a substantial increase in risk for renal function deterioration. This review summarizes the present knowledge about the renal risks of smoking as well as the increased cardiovascular risk caused by smoking in patients with chronic kidney disease. The conclusion is that smoking is an important renal risk factor, and nephrologists have to invest more efforts to motivate patients to stop smoking.