1
|
Chouhan AS, Kaple M, Hingway S. A Brief Review of Diagnostic Techniques and Clinical Management in Chronic Kidney Disease. Cureus 2023; 15:e49030. [PMID: 38116359 PMCID: PMC10728575 DOI: 10.7759/cureus.49030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 11/18/2023] [Indexed: 12/21/2023] Open
Abstract
Given its increasing incidence and detrimental effects on life expectancy and quality of life, chronic kidney disease (CKD) is a significant worldwide health concern. This review article provides a complete summary of current information on the diagnosis and management of CKD, focusing on recent advances and innovative approaches. The article discusses the most current findings on CKD risk assessment, emphasizing the need for early diagnosis utilizing better biomarkers and predictive models. A rigorous examination of diagnostic tools such as albumin-to-creatinine ratio (ACR) in urine and glomerular filtration rate (GFR) highlights their importance in determining CKD phases and etiologies. In terms of therapy, the study explores evidence-based techniques to reduce the development of CKD, such as enhanced blood pressure control, glycemic management in diabetic patients, dietary changes, and renin-angiotensin-aldosterone system (RAAS) blocking. Novel therapeutic approaches, including antifibrotic and precision medicine, are evaluated regarding their potential to revolutionize CKD treatment. The study also underlines the need for multidisciplinary therapy and patient education to achieve the best possible CKD patient outcomes. It also highlights the financial and social effects of CKD, highlighting the importance of early treatment to lower medical expenses and enhance the patient's standard of living. Finally, this review article provides a comprehensive update on CKD diagnosis and treatment, highlighting present successes alongside future potential. It is a valuable resource for healthcare professionals, academics, and policymakers who want to improve CKD treatment methods and patient outcomes.
Collapse
Affiliation(s)
- Anant Shourya Chouhan
- Medicine and Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Meghali Kaple
- Medicine and Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Snehlata Hingway
- Medicine and Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| |
Collapse
|
2
|
Wolf U, Ghadir H, Drewas L, Neef R. Underdiagnosed CKD in Geriatric Trauma Patients and Potent Prevention of Renal Impairment from Polypharmacy Risks through Individual Pharmacotherapy Management (IPM-III). J Clin Med 2023; 12:4545. [PMID: 37445580 DOI: 10.3390/jcm12134545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
The aging global patient population with multimorbidity and concomitant polypharmacy is at increased risk for acute and chronic kidney disease, particularly with severe additional disease states or invasive surgical procedures. Because from the expertise of more than 58,600 self-reviewed medications, adverse drug reactions, drug interactions, inadequate dosing, and contraindications all proved to cause or exacerbate the worsening of renal function, we analyzed the association of an electronic patient record- and Summaries of Product Characteristics (SmPCs)-based comprehensive individual pharmacotherapy management (IPM) in the setting of 14 daily interdisciplinary patient visits with the outcome: further renal impairment with reduction of eGFR ≥ 20 mL/min (redGFR) in hospitalized trauma patients ≥ 70 years of age. The retrospective clinical study of 404 trauma patients comparing the historical control group (CG) before IPM with the IPM intervention group (IG) revealed a group-match in terms of potential confounders such as age, sex, BMI, arterial hypertension, diabetes mellitus, and injury patterns. Preexisting chronic kidney disease (CKD) > stage 2 diagnosed as eGFR < 60 mL/min/1.73 m2 on hospital admission was 42% in the CG versus 50% in the IG, although in each group only less than 50% of this was coded as an ICD diagnosis in the patients' discharge letters (19% in CG and 21% in IG). IPM revealed an absolute risk reduction in redGFR of 5.5% (11 of 199 CG patients) to 0% in the IPM visit IG, a relative risk reduction of 100%, NNT 18, indicating high efficacy of IPM and benefit in improving outcomes. There even remained an additive superimposed significant association that included patients in the IPM group before/beyond the 14 daily IPM interventions, with a relative redGFR risk reduction of 0.55 (55%) to 2.5% (5 of 204 patients), OR 0.48 [95% CI 0.438-0.538] (p < 0.001). Bacteriuria, loop diuretics, allopurinol, eGFR ≥ 60 mL/min/1.73 m2, eGFR < 60 mL/min/1.73 m2, and CKD 3b were significantly associated with redGFR; of the latter, 10.5% developed redGFR. Further multivariable regression analysis adjusting for these and established risk factors revealed an additive, superimposed IPM effect on redGFR with an OR 0.238 [95% CI 0.06-0.91], relative risk reduction of 76.2%, regression coefficient -1.437 including patients not yet visited in the IPM period. As consequences of the IPM procedure, the IG differed from the CG by a significant reduction of NSAIDs (p < 0.001), HCT (p = 0.028) and Würzburger pain drip (p < 0.001), and significantly increased prescription rate of antibiotics (p = 0.004). In conclusion, (1) more than 50% of CKD in geriatric patients was not pre-recognized and underdiagnosed, and (2) the electronic patient records-based IPM interdisciplinary networking strategy was associated with effective prevention of further periinterventional renal impairment and requires obligatory implementation in all elderly patients to urgently improve patient and drug safety.
Collapse
Affiliation(s)
- Ursula Wolf
- Pharmacotherapy Management, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Hassan Ghadir
- Medical Clinic II, University Hospital Schleswig-Holstein, Lübeck Campus, 23562 Lübeck, Germany
| | - Luise Drewas
- Internal Medicine Clinic II, Martha-Maria Hospital Halle-Dölau, 06120 Halle (Saale), Germany
| | - Rüdiger Neef
- Department of Orthopedics, Trauma and Reconstructive Surgery, Division of Geriatric Traumatology, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
| |
Collapse
|
3
|
Sodium zirconium cyclosilicate and metabolic acidosis: Potential mechanisms and clinical consequences. Biomed Pharmacother 2023; 158:114197. [PMID: 36916426 DOI: 10.1016/j.biopha.2022.114197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/23/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023] Open
Abstract
Metabolic acidosis is frequent in chronic kidney disease (CKD) and is associated with accelerated progression of CKD, hypercatabolism, bone disease, hyperkalemia, and mortality. Clinical guidelines recommend a target serum bicarbonate ≥ 22 mmol/L, but metabolic acidosis frequently remains undiagnosed and untreated. Sodium zirconium cyclosilicate (SZC) binds potassium in the gut and is approved to treat hyperkalemia. In clinical trials with a primary endpoint of serum potassium, SZC increased serum bicarbonate, thus treating CKD-associated metabolic acidosis. The increase in serum bicarbonate was larger in patients with more severe pre-existent metabolic acidosis, was associated to decreased serum urea and was maintained for over a year of SZC therapy. SZC also decreased serum urea and increased serum bicarbonate after switching from a potassium-binding resin in normokalemic individuals. Mechanistically, these findings are consistent with SZC binding the ammonium ion (NH4+) generated from urea by gut microbial urease, preventing its absorption and, thus, preventing the liver regeneration of urea and promoting the fecal excretion of H+. This mechanism of action may potentially result in benefits dependent on corrected metabolic acidosis (e.g., improved well-being, decreased catabolism, improved CKD mineral bone disorder, better control of serum phosphate, slower progression of CKD) and dependent on lower urea levels, such as decreased protein carbamylation. A roadmap is provided to guide research into the mechanisms and clinical consequences of the impact of SZC on serum bicarbonate and urate.
Collapse
|
4
|
Shi H, Su X, Yan B, Li C, Wang L. Effects of oral alkali drug therapy on clinical outcomes in pre-dialysis chronic kidney disease patients: a systematic review and meta-analysis. Ren Fail 2022; 44:106-115. [PMID: 35176947 PMCID: PMC8865123 DOI: 10.1080/0886022x.2021.2023023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Metabolic acidosis accelerates the progression of chronic kidney disease (CKD) and increases the mortality rate. Whether oral alkali drug therapy benefits pre-dialysis CKD patients is controversial. We performed a meta-analysis of the effects of oral alkali drug therapy on major clinical outcomes in pre-dialysis CKD patients. METHODS We systematically searched MEDLINE using the Ovid, EMBASE, and Cochrane Library databases without language restriction. We included all eligible clinical studies that involved pre-dialysis CKD adults and compared those who received oral alkali drug therapy with controls. RESULTS A total of 18 eligible studies, including 14 randomized controlled trials and 4 cohort studies reported in 19 publications with 3695 participants, were included. Oral alkali drug therapy led to a 55% reduction in renal failure events (relative risk [RR]: 0.45; 95% confidence interval [CI]: 0.25-0.82), a rate of decline in the estimated glomerular filtration rate (eGFR) of 2.59 mL/min/1.73 m2 per year (95% CI, 0.88-4.31). There was no significant effect on decline in eGFR events (RR: 0.34; 95% CI: 0.09-1.23), proteinuria (standardized mean difference: -0.32; 95% CI: -1.08 to 0.43), all-cause mortality events (RR: 0.90; 95% CI: 0.40-2.02) and cardiovascular (CV) events (RR: 1.03; 95% CI: 0.32-3.37) compared with the control groups. CONCLUSION Based on the available and low-to-moderate certainty evidence, oral alkali drug therapy might potentially reduce the risk of kidney failure events, but no benefit in reducing all-cause mortality events, CV events, decline in eGFR and porteninuria.
Collapse
Affiliation(s)
- Honghong Shi
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaole Su
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Bingjuan Yan
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Chunfang Li
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China.,Division of Nephrology, Shanxi Cardiovascular Hospital, Taiyuan, China
| | - Lihua Wang
- Division of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| |
Collapse
|
5
|
Cheng F, Li Q, Wang J, Wang Z, Zeng F, Zhang Y. The Effects of Oral Sodium Bicarbonate on Renal Function and Cardiovascular Risk in Patients with Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Ther Clin Risk Manag 2021; 17:1321-1331. [PMID: 34908841 PMCID: PMC8665881 DOI: 10.2147/tcrm.s344592] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/30/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Oral sodium bicarbonate is often used to correct acid-base disturbance in patients with chronic kidney disease (CKD). However, there is little evidence on patient-level benign outcomes to support the practice. METHODS We conducted a systematic review and meta-analysis to examine the efficacy and safety of oral sodium bicarbonate in CKD patients. A total of 1853 patients with chronic metabolic acidosis or those with low-normal serum bicarbonate (22-24 mEq/L) were performed to compare the efficacy and safety of oral sodium bicarbonate in patients with CKD. RESULTS There was a significant increase in serum bicarbonate level (MD 2.37 mEq/L; 95% CI, 1.03 to 3.72) and slowed the decline in estimated glomerular filtration rate (eGFR) (MD -4.44 mL/min per 1.73 m2, 95% CI, -4.92 to -3.96) compared with the control groups. The sodium bicarbonate lowered T50-time, an indicator of vascular calcification (MD -20.74 min; 95% CI, -49.55 to 8.08); however, there was no significant difference between the two groups. In addition, oral sodium bicarbonate dramatically reduced systolic blood pressure (MD -2.97 mmHg; 95% CI, -5.04 to -0.90) and diastolic blood pressure (MD -1.26 mmHg; 95% CI, -2.33 to -0.19). There were no statistically significant body weight, urine pH and mean mid-arm muscle circumference. CONCLUSION Treatment of metabolic acidosis with sodium bicarbonate may slow the decline rate of kidney function and potentially significantly improve vascular endothelial function in patients with CKD. PROSPERO REGISTRATION NUMBER CRD42020207185.
Collapse
Affiliation(s)
- Fang Cheng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, People’s Republic of China
| | - Qiang Li
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, People’s Republic of China
| | - Jinglin Wang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, People’s Republic of China
| | - Zhendi Wang
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Fang Zeng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, People’s Republic of China
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, People’s Republic of China
| |
Collapse
|
6
|
Bai Y, Xu J, Yang S, Zhang H, He L, Zhou W, Cheng M, Zhang S. The intermediate-conductance calcium-activated potassium channel KCa3.1 contributes to alkalinization-induced vascular calcification in vitro. J Clin Lab Anal 2021; 35:e23854. [PMID: 34313357 PMCID: PMC8373358 DOI: 10.1002/jcla.23854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 05/03/2021] [Accepted: 05/13/2021] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE In order to find new strategies for the prevention of vascular calcification in uremic individuals especially treated by dialysis and develop novel therapeutic targets in vascular calcification, we explore the role of KCa3.1 in alkalinization-induced VSMCs calcification in vitro. METHOD Rat VSMCs calcification model was established by beta-glycerophosphate (β-GP, 10 mM) induction. The pH of Dulbecco's modified Eagle's medium (DMEM) was adjusted every 24 h with 10 mM HCl or 10 mM NaHCO3 . The mineralization was measured by Alizarin Red staining and O-cresolphthalein complex one method. mRNA and protein expression were detected by RT-PCR and Western blot or immunofluorescence. Ca2+ influx was measured by Elisa. RESULT The results indicated that alkalization induced an increase in Ca2+ influx to enhance VSMCs calcification. Furthermore, the increase of calcification was associated with the expression of KCa3.1 via advanced expression of osteoblastic differentiation markers alkaline phosphatase (ALP) and Runt-related transcription factor 2 (Runx2). Blocking KCa3.1 with TRAM-34 or shRNA vector can significantly lowered the effects of calcification in the activity of ALP and Runx2 expression. CONCLUSION Together all, our studies suggested that alkalinization can promote vascular calcification by upregulating KCa3.1 channel and enhancing osteogenic/chondrogenic differentiation by upregulating Runx2. The specific inhibitor TRAM-34 and KCa3.1-shRNA ameliorated VSMCs calcification by downregulating KCa3.1.
Collapse
MESH Headings
- Alkaline Phosphatase/metabolism
- Animals
- Aorta/drug effects
- Aorta/metabolism
- Aorta/pathology
- Calcinosis/chemically induced
- Calcinosis/drug therapy
- Calcinosis/metabolism
- Calcium/metabolism
- Cells, Cultured
- Core Binding Factor Alpha 1 Subunit/metabolism
- Glycerophosphates/toxicity
- Intermediate-Conductance Calcium-Activated Potassium Channels/antagonists & inhibitors
- Intermediate-Conductance Calcium-Activated Potassium Channels/genetics
- Intermediate-Conductance Calcium-Activated Potassium Channels/metabolism
- Male
- Muscle, Smooth, Vascular/chemistry
- Muscle, Smooth, Vascular/cytology
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/metabolism
- Pyrazoles/pharmacology
- Rats, Sprague-Dawley
- Rats
Collapse
Affiliation(s)
- Yaling Bai
- Hebei Clinical Research Center for Chronic Kidney Disease, Hebei Key Laboratory of Vascular Calcification in Kidney Disease, Departments of NephrologyThe Fourth Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Jinsheng Xu
- Hebei Clinical Research Center for Chronic Kidney Disease, Hebei Key Laboratory of Vascular Calcification in Kidney Disease, Departments of NephrologyThe Fourth Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Shuo Yang
- Hebei Clinical Research Center for Chronic Kidney Disease, Hebei Key Laboratory of Vascular Calcification in Kidney Disease, Departments of NephrologyThe Fourth Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Huiran Zhang
- Hebei Clinical Research Center for Chronic Kidney Disease, Hebei Key Laboratory of Vascular Calcification in Kidney Disease, Departments of NephrologyThe Fourth Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Lei He
- Hebei Clinical Research Center for Chronic Kidney Disease, Hebei Key Laboratory of Vascular Calcification in Kidney Disease, Departments of NephrologyThe Fourth Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Wei Zhou
- Hebei Clinical Research Center for Chronic Kidney Disease, Hebei Key Laboratory of Vascular Calcification in Kidney Disease, Departments of NephrologyThe Fourth Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Meijuan Cheng
- Hebei Clinical Research Center for Chronic Kidney Disease, Hebei Key Laboratory of Vascular Calcification in Kidney Disease, Departments of NephrologyThe Fourth Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Shenglei Zhang
- Hebei Clinical Research Center for Chronic Kidney Disease, Hebei Key Laboratory of Vascular Calcification in Kidney Disease, Departments of NephrologyThe Fourth Hospital of Hebei Medical UniversityShijiazhuangChina
| |
Collapse
|
7
|
Abstract
BACKGROUND/OBJECTIVES Western diet is characterized by a high acid load that could generate various degrees of metabolic acidosis, of which at least the stronger forms are known to contribute to the progression of chronic kidney disease (CKD). The aim of this study was to estimate the potential renal acid load (PRAL) and acid base status in CKD patients attended at the Children's Hospital J.M. de los Ríos in Caracas, Venezuela from April 2015 to February 2016. SUBJECTS/METHODS Twenty-seven children with CKD were included. Diet composition was evaluated by a food frequency questionnaire and a 24-h intake reminder. PRAL was calculated by the Remer and Manz method. Laboratory tests included serum creatinine, electrolytes and venous gases. RESULTS Protein intake was above recommendations in 21 patients (78.6%). Average vegetable and fruit intake was 0.4 and 1.5 servings per day, respectively. Mean PRAL was 16 ± 10.7 mEq/day. PRAL correlated positively with energy (p = 0.005), protein (p = 0.001) and fat intake (p = 0.0001), daily servings of dairy (p = 0.04) meat (p = 0.001) and cereals (0.001) and negatively with vegetable intake (p = 0.04). Serum pH and bicarbonate were 7.3 ± 0.08 and 20.46 ± 4.5 mEq/L, respectively. Twenty-one patients (80.7%) with metabolic acidosis were treated with sodium bicarbonate. CONCLUSIONS Dietary pattern of Venezuelan children with CKD may constitute a risk factor for the progression of the disease by promoting metabolic acidosis via unfavorable dietary acid loads. PRAL should be assessed as a valuable guide for nutritional counseling in children with CKD.
Collapse
|
8
|
Liu W, Li L, Zhang X, Dong H, Lu M. Efficacy and Safety of Veverimer in the Treatment of Metabolic Acidosis Caused by Chronic Kidney Disease: A Meta-analysis. Front Pharmacol 2021; 12:643128. [PMID: 33995050 PMCID: PMC8117340 DOI: 10.3389/fphar.2021.643128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/15/2021] [Indexed: 11/13/2022] Open
Abstract
Metabolic acidosis is a common complication of chronic kidney disease (CKD). Veverimer is an orally administrated, free amine polymer with high capacity and binding selectivity to hydrochloric acid from the gastrointestinal tract. This study pooled the current evidence of the efficacy and safety of veverimer for the treatment of metabolic acidosis associated with CKD. We conducted a systematic literature search on PubMed, Embase, and Cochrane Central for relevant randomized controlled trials (RCTs) in June 2020. In this study, three RCTs with 548 patients were included in our analysis. The analysis revealed that veverimer was associated with increased bicarbonate level of patients (weight mean difference [WMD] 3.08, 95% confidence interval [CI] [2.40, 3.77], p < 0.001) and improved physical function compared with placebo measured by Kidney Disease and Quality of Life Short Form 36, question 3 (physical functioning domain) (KDQoL-PFD) score (WMD 5.25, 95% CI [1.58, 8.92], p = 0.005). For safety outcomes, both groups exhibited similar risks for developing headache, diarrhea, flatulence, and hyperkalemia. In conclusion, current clinical evidence indicates that veverimer is efficacious and safe against metabolic acidosis related to CKD compared with placebo. Further research comparing long-term veverimer use with traditional alkali therapy is needed.
Collapse
Affiliation(s)
- Wenlin Liu
- Department of Nephrology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Lili Li
- Department of Nephrology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Xuemei Zhang
- Department of Nephrology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Haonan Dong
- Department of Nephrology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Miaomiao Lu
- Department of Nephrology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| |
Collapse
|
9
|
Tantisattamo E, Murray V, Obi Y, Park C, Catabay CJ, Lee Y, Wenziger C, Hsiung JT, Soohoo M, Kleine CE, Rhee CM, Kraut J, Kovesdy CP, Kalantar-Zadeh K, Streja E. Association of Pre-ESRD Serum Bicarbonate with Post-ESRD Mortality in Patients with Incident ESRD. Am J Nephrol 2021; 52:304-317. [PMID: 33895727 DOI: 10.1159/000513855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Serum bicarbonate or total carbon dioxide (CO2) concentrations decline as chronic kidney disease (CKD) progresses and rise after dialysis initiation. While metabolic acidosis accelerates the progression of CKD and is associated with higher mortality among patients with end stage renal disease (ESRD), there are scarce data on the association of CO2 concentrations before ESRD transition with post-ESRD mortality. METHODS A historical cohort from the Transition of Care in CKD (TC-CKD) study includes 85,505 veterans who transitioned to ESRD from October 1, 2007, through March 31, 2014. After 1,958 patients without follow-up data, 3 patients with missing date of birth, and 50,889 patients without CO2 6 months prior to ESRD transition were excluded, the study population includes 32,655 patients. Associations between CO2 concentrations averaged over the last 6 months and its rate of decline during the 12 months prior to ESRD transition and post-ESRD all-cause, cardiovascular (CV), and non-CV mortality were examined by using hierarchical adjustment with Cox regression models. RESULTS The cohort was on average 68 ± 11 years old and included 29% Black veterans. Baseline concentrations of CO2 were 23 ± 4 mEq/L, and median (interquartile range) change in CO2 were -1.8 [-3.4, -0.2] mEq/L/year. High (≥28 mEq/L) and low (<18 mEq/L) CO2 concentrations showed higher adjusted mortality risk while there was no clear trend in the middle range. Consistent associations were observed irrespective of sodium bicarbonate use. There was also a U-shaped association between the change in CO2 and all-cause, CV, and non-CV mortality with the lowest risk approximately at -2.0 and 0.0 mEq/L/year among sodium bicarbonate nonusers and users, respectively, and the highest mortality was among patients with decline in CO2 >4 mEq/L/year. CONCLUSION Both high and low pre-ESRD CO2 levels (≥28 and <18 mEq/L) during 6 months prior to dialysis transition and rate of CO2 decline >4 mEq/L/year during 1 year before dialysis initiation were associated with greater post-ESRD all-cause, CV, and non-CV mortality. Further studies are needed to determine the optimal management of CO2 in patients with advanced CKD stages transitioning to ESRD.
Collapse
Affiliation(s)
- Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Victoria Murray
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Yoshitsugu Obi
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Christina Park
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Christina J Catabay
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Yuji Lee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Cachet Wenziger
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Jui-Ting Hsiung
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Melissa Soohoo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Carola-Ellen Kleine
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Connie M Rhee
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Jeffrey Kraut
- Fielding School of Public Health at UCLA, Los Angeles, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| | - Elani Streja
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, School of Medicine, University of California Irvine, Orange, California, USA
| |
Collapse
|
10
|
Morooka H, Yamamoto J, Tanaka A, Inaguma D, Maruyama S. Relationship between mortality and use of sodium bicarbonate at the time of dialysis initiation: a prospective observational study. BMC Nephrol 2021; 22:118. [PMID: 33823813 PMCID: PMC8025509 DOI: 10.1186/s12882-021-02330-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/30/2021] [Indexed: 11/28/2022] Open
Abstract
Background Patients with chronic kidney disease often experience metabolic acidosis. Whether oral sodium bicarbonate can reduce mortality in patients with metabolic acidosis has been debated for years. Hence, this study was conducted to evaluate the utility of sodium bicarbonate in patients who will undergo dialysis therapy. In this study, we investigated the effect of oral sodium bicarbonate therapy on mortality in patients with end-stage kidney disease (ESKD) initiated on dialysis therapy. Methods We conducted an observational study of patients when they started dialysis therapy. There were 17 centres participating in the Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis. Data were available on patients’ sex, age, use of sodium bicarbonate, drug history, medical history, vital data, and laboratory data. We investigated whether patients on oral sodium bicarbonate for more than three months before dialysis initiation had a better prognosis than those without sodium bicarbonate therapy. The primary outcome was defined as all-cause mortality. Results The study included 1524 patients with chronic kidney disease who initiated dialysis between October 2011 and September 2013. Among them, 1030 were men and 492 women, with a mean age of 67.5 ± 13.1 years. Of these, 677 used sodium bicarbonate and 845 did not; 13.6% of the patients in the former group and 21.2% of those in the latter group died by March 2015 (p < 0.001). Even after adjusting for various factors, the use of sodium bicarbonate independently reduced mortality (p < 0.001). Conclusions The use of oral sodium bicarbonate at the time of dialysis initiation significantly reduced all-cause mortality in patients undergoing dialysis therapy. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02330-0.
Collapse
Affiliation(s)
- Hikaru Morooka
- Division of Nephrology, Nagoya University Hospital, Tsurumaicho, 65, Showa Ward, Nagoya, Aichi, Japan
| | | | - Akihito Tanaka
- Division of Nephrology, Nagoya University Hospital, Tsurumaicho, 65, Showa Ward, Nagoya, Aichi, Japan.
| | - Daijo Inaguma
- Division of Internal Medicine, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Shoichi Maruyama
- Division of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
11
|
Quade BN, Parker MD, Occhipinti R. The therapeutic importance of acid-base balance. Biochem Pharmacol 2021; 183:114278. [PMID: 33039418 PMCID: PMC7544731 DOI: 10.1016/j.bcp.2020.114278] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/06/2020] [Indexed: 02/06/2023]
Abstract
Baking soda and vinegar have been used as home remedies for generations and today we are only a mouse-click away from claims that baking soda, lemon juice, and apple cider vinegar are miracles cures for everything from cancer to COVID-19. Despite these specious claims, the therapeutic value of controlling acid-base balance is indisputable and is the basis of Food and Drug Administration-approved treatments for constipation, epilepsy, metabolic acidosis, and peptic ulcers. In this narrative review, we present evidence in support of the current and potential therapeutic value of countering local and systemic acid-base imbalances, several of which do in fact involve the administration of baking soda (sodium bicarbonate). Furthermore, we discuss the side effects of pharmaceuticals on acid-base balance as well as the influence of acid-base status on the pharmacokinetic properties of drugs. Our review considers all major organ systems as well as information relevant to several clinical specialties such as anesthesiology, infectious disease, oncology, dentistry, and surgery.
Collapse
Affiliation(s)
- Bianca N Quade
- Department of Physiology and Biophysics, The State University of New York, The University at Buffalo, Buffalo, NY 14203, USA
| | - Mark D Parker
- Department of Physiology and Biophysics, The State University of New York, The University at Buffalo, Buffalo, NY 14203, USA; Department of Ophthalmology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA; State University of New York Eye Institute, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Rossana Occhipinti
- Department of Physiology and Biophysics, Case Western Reserve University, School of Medicine, Cleveland, OH 44106, USA.
| |
Collapse
|
12
|
Hultin S, Hood C, Campbell KL, Toussaint ND, Johnson DW, Badve SV. A Systematic Review and Meta-Analysis on Effects of Bicarbonate Therapy on Kidney Outcomes. Kidney Int Rep 2020; 6:695-705. [PMID: 33732984 PMCID: PMC7938083 DOI: 10.1016/j.ekir.2020.12.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/16/2020] [Accepted: 12/17/2020] [Indexed: 12/22/2022] Open
Abstract
Aim Preclinical studies suggest treatment of metabolic acidosis may slow chronic kidney disease (CKD) progression. This systematic review aimed to summarize evidence from randomized controlled trials (RCTs) concerning the benefits and risks of bicarbonate therapy on kidney outcomes. Methods Medline, EMBASE, and Cochrane databases were searched for RCTs with ≥3 months’ follow-up in patients with CKD (estimated glomerular filtration rate [eGFR] ≤60 ml/min per 1.73 m2 and/or proteinuria) comparing the effects of sodium bicarbonate with placebo/no study medication on kidney outcomes. The primary outcome was change from baseline to last measurement in kidney function measured as either eGFR or creatinine clearance. Treatment effects were summarized using random-effects meta-analysis. Results Fifteen trials (2445 participants, median follow-up 12 months) were eligible for inclusion. Compared with placebo or no study medication, sodium bicarbonate retarded the decline in kidney function (standardized mean difference [SMD]: 0.26; 95% confidence interval [CI]: 0.13–0.40; I2 = 50%, low certainty evidence), and reduced the risk of end-stage kidney failure (risk ratio [RR]: 0.53; 95% CI 0.32–0.89; I2 = 69%, low certainty evidence). The effect of sodium bicarbonate on proteinuria (SMD: −0.09; 95% CI −0.27 to 0.09; I2 = 28%, very low certainty evidence), systolic blood pressure (weighted mean difference [WMD]: −0.57 mm Hg; 95% CI −2.32 to 1.18; I2 = 0%, low certainty evidence), all-cause death (RR: 0.81; 95% CI: 0.39–1.68; I2 = 30%; very low certainty evidence) and edema (RR: 1.16; 95% CI: 0.90–1.50; I2 = 28%; low certainty evidence) were uncertain. Conclusion Sodium bicarbonate may slow CKD progression. Adequately powered randomized trials are required to evaluate the benefits and risks of sodium bicarbonate in CKD.
Collapse
Affiliation(s)
- Sebastian Hultin
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.,University of Sydney, Sydney, Australia.,Department of Nephrology, St George Hospital, Sydney, Australia
| | - Chris Hood
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.,Department of Nephrology, Middlemore Hospital, Auckland, New Zealand
| | - Katrina L Campbell
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.,Healthcare Excellence and Innovation, Metro North Hospital and Health Service, Brisbane, Australia
| | - Nigel D Toussaint
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.,Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia
| | - Sunil V Badve
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, Australia.,Department of Nephrology, St George Hospital, Sydney, Australia.,The George Institute for Global Health, University of New South Wales Medicine, Sydney, Australia
| |
Collapse
|
13
|
Boschmann M, Kaiser N, Klasen A, Klug L, Mähler A, Michalsen A, Vormann J, Werner T, Stange R. Effects of dietary protein-load and alkaline supplementation on acid-base balance and glucose metabolism in healthy elderly. Eur J Clin Nutr 2020; 74:48-56. [PMID: 32873957 DOI: 10.1038/s41430-020-0695-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND/OBJECTIVES Metabolism is controlled by macro- and micronutrients. Protein-rich diets should lead to latent acidosis at tissue level with further negative implications. Food supplements with alkaline salts are available and popular pretending to prevent these changes. SUBJECTS/METHODS Within a randomised double-blind placebo-controlled trial we tested the hypotheses that (1) a 4-week protein-rich diet induces a latent tissue acidosis and (2) an alkaline supplement can compensate this. Acid-base balance and important metabolic parameters were determined before and after 4 weeks of supplementation by peripheral blood samples, indirect calorimetry and muscle microdialysis before and after a protein-rich test meal. RESULTS Fourty volunteers were randomised 1:1 to either verum or placebo supplements. Protein-rich diet by itself did not significantly affect acid-base balance. Alkaline supplementation increased plasma bicarbonate concentration without changing pH. Postprandial increases in serum glucose and insulin tended to be lower for verum vs. placebo. Resting and postprandial energy metabolism, and carbohydrate and fat oxidation did not differ significantly before and after supplementation in both groups. In muscle, postprandial glucose uptake and aerobic glucose oxidation were significantly higher for verum. In addition, verum significantly increased serum magnesium concentrations. CONCLUSIONS Four weeks of protein-rich diet did not significantly influence acid-base balance. However, alkaline supplementation improved systemic and tissue acid-base parameters and oxidative glucose metabolism.
Collapse
Affiliation(s)
- Michael Boschmann
- Experimental and Clinical Research Center (ECRC) - a joint co-operation between Charité - Universitätsmedizin Berlin and Max Delbrueck Center for Molecular Medicine, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Nikoletta Kaiser
- Experimental and Clinical Research Center (ECRC) - a joint co-operation between Charité - Universitätsmedizin Berlin and Max Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Anja Klasen
- Experimental and Clinical Research Center (ECRC) - a joint co-operation between Charité - Universitätsmedizin Berlin and Max Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Lars Klug
- Experimental and Clinical Research Center (ECRC) - a joint co-operation between Charité - Universitätsmedizin Berlin and Max Delbrueck Center for Molecular Medicine, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Anja Mähler
- Experimental and Clinical Research Center (ECRC) - a joint co-operation between Charité - Universitätsmedizin Berlin and Max Delbrueck Center for Molecular Medicine, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Andreas Michalsen
- Department for Internal and Integrative Medicine, Charité - Universitätsmedizin Berlin and Immanuel Krankenhaus, Berlin, Germany
| | | | - Tanja Werner
- NuOmix Research k.s. Applied Nutriomic Research, Martin, Slovakia
| | - Rainer Stange
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany. .,Department for Internal and Integrative Medicine, Charité - Universitätsmedizin Berlin and Immanuel Krankenhaus, Berlin, Germany.
| |
Collapse
|
14
|
Brown DD, Roem J, Ng DK, Reidy KJ, Kumar J, Abramowitz MK, Mak RH, Furth SL, Schwartz GJ, Warady BA, Kaskel FJ, Melamed ML. Low Serum Bicarbonate and CKD Progression in Children. Clin J Am Soc Nephrol 2020; 15:755-765. [PMID: 32467307 PMCID: PMC7274283 DOI: 10.2215/cjn.07060619] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 04/09/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Studies of adults have demonstrated an association between metabolic acidosis, as measured by low serum bicarbonate levels, and CKD progression. We evaluated this relationship in children using data from the Chronic Kidney Disease in Children study. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The relationship between serum bicarbonate and a composite end point, defined as 50% decline in eGFR or KRT, was described using parametric and semiparametric survival methods. Analyses were stratified by underlying nonglomerular and glomerular diagnoses, and adjusted for demographic characteristics, eGFR, proteinuria, anemia, phosphate, hypertension, and alkali therapy. RESULTS Six hundred and three participants with nonglomerular disease contributed 2673 person-years of follow-up, and 255 with a glomerular diagnosis contributed 808 person-years of follow-up. At baseline, 39% (237 of 603) of participants with nonglomerular disease had a bicarbonate level of ≤22 meq/L and 36% (85 of 237) of those participants reported alkali therapy treatment. In participants with glomerular disease, 31% (79 of 255) had a bicarbonate of ≤22 meq/L, 18% (14 of 79) of those participants reported alkali therapy treatment. In adjusted longitudinal analyses, compared with participants with a bicarbonate level >22 meq/L, hazard ratios associated with a bicarbonate level of <18 meq/L and 19-22 meq/L were 1.28 [95% confidence interval (95% CI), 0.84 to 1.94] and 0.91 (95% CI, 0.65 to 1.26), respectively, in children with nonglomerular disease. In children with glomerular disease, adjusted hazard ratios associated with bicarbonate level ≤18 meq/L and bicarbonate 19-22 meq/L were 2.16 (95% CI, 1.05 to 4.44) and 1.74 (95% CI, 1.07 to 2.85), respectively. Resolution of low bicarbonate was associated with a lower risk of CKD progression compared with persistently low bicarbonate (≤22 meq/L). CONCLUSIONS In children with glomerular disease, low bicarbonate was linked to a higher risk of CKD progression. Resolution of low bicarbonate was associated with a lower risk of CKD progression. Fewer than one half of all children with low bicarbonate reported treatment with alkali therapy. Long-term studies of alkali therapy's effect in patients with pediatric CKD are needed.
Collapse
Affiliation(s)
- Denver D. Brown
- Division of Pediatric Nephrology, Children’s National Hospital, Washington, DC
| | - Jennifer Roem
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Derek K. Ng
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kimberly J. Reidy
- Division of Pediatric Nephrology, The Children’s Hospital at Montefiore, Bronx, New York
| | - Juhi Kumar
- Division of Pediatric Nephrology, Weill Cornell Medicine, New York, New York
| | | | - Robert H. Mak
- Division of Pediatric Nephrology, Rady Children’s Hospital San Diego, University of California San Diego, San Diego, California
| | - Susan L. Furth
- Division of Pediatric Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - George J. Schwartz
- Division of Pediatric Nephrology, University of Rochester, Rochester, New York
| | - Bradley A. Warady
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri
| | - Frederick J. Kaskel
- Division of Pediatric Nephrology, The Children’s Hospital at Montefiore, Bronx, New York
| | - Michal L. Melamed
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
15
|
Nguyen ITN, Klooster A, Minnion M, Feelisch M, Verhaar MC, van Goor H, Joles JA. Sodium thiosulfate improves renal function and oxygenation in L-NNA-induced hypertension in rats. Kidney Int 2020; 98:366-377. [PMID: 32605800 DOI: 10.1016/j.kint.2020.02.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 02/12/2020] [Accepted: 02/13/2020] [Indexed: 12/12/2022]
Abstract
Sodium thiosulfate, a reversible oxidation product of hydrogen sulfide, has vasodilating and anti-oxidative properties, making it an attractive agent to alleviate damaging effects of hypertension. In experimental settings, inhibition of nitric oxide synthase causes hypertension, renal dysfunction and damage. We hypothesized that thiosulfate would attenuate renal injury and improve renal function, hemodynamics and the efficiency of oxygen utilization for sodium reabsorption in hypertensive renal disease. Additionally, thiosulfate co-administration would further improve these variables when compared to inhibiting the renin-angiotensin system alone. Nitric oxide synthase was inhibited in Sprague Dawley rats by administering N-ω-nitro-L-arginine (L-NNA) in the food for three weeks. After one week, rats were split into two groups; without and with thiosulfate in the drinking water. In a parallel study, rats given N-ω-nitro-L-arginine and the angiotensin converting enzyme inhibitor lisinopril at a relatively low dose in their food were divided into two groups; without and with thiosulfate in the drinking water. Treatment with thiosulfate alleviated hypertension (mean 190 vs. 229 mmHg), lowered plasma urea (mean 11.3 vs. 20.0 mmol/L) and improved the terminal glomerular filtration rate (mean 503 vs. 260 μl/min/100 gbw), effective renal plasma flow (mean 919 vs. 514 μl/min/100 gbw) and oxygen utilization for sodium reabsorption (mean 14.3 vs. 8.6 μmol/μmol). Combining thiosulfate with lisinopril further lowered renal vascular resistance (mean 43 vs. 63 mmHg/ml/min/100 gbw) and prevented glomerulosclerosis. Thus, our results suggest that thiosulfate has therapeutic potential in hypertensive renal disease and might be of value when added to standard antihypertensive therapies.
Collapse
Affiliation(s)
- Isabel T N Nguyen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Astrid Klooster
- Department of Pathology and Medical Biology, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Magdalena Minnion
- Clinical and Experimental Sciences, Faculty of Medicine, Southampton General Hospital and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Martin Feelisch
- Clinical and Experimental Sciences, Faculty of Medicine, Southampton General Hospital and Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Harry van Goor
- Department of Pathology and Medical Biology, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Jaap A Joles
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands.
| |
Collapse
|
16
|
Navaneethan SD, Shao J, Buysse J, Bushinsky DA. Effects of Treatment of Metabolic Acidosis in CKD: A Systematic Review and Meta-Analysis. Clin J Am Soc Nephrol 2019; 14:1011-1020. [PMID: 31196951 PMCID: PMC6625635 DOI: 10.2215/cjn.13091118] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 05/04/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Metabolic acidosis is associated with progression of CKD and has significant adverse effects on muscle and bone. A systematic review and meta-analysis was conducted to evaluate the benefits and risks of metabolic acidosis treatment with oral alkali supplementation or a reduction of dietary acid intake in those with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS MEDLINE, Embase, and Cochrane CENTRAL were searched for relevant trials in patients with stage 3-5 CKD and metabolic acidosis (<22 mEq/L) or low-normal serum bicarbonate (22-24 mEq/L). Data were pooled in a meta-analysis with results expressed as weighted mean difference for continuous outcomes and relative risk for categorical outcomes with 95% confidence intervals (95% CIs), using a random effects model. Study quality and strength of evidence were assessed using Cochrane risk of bias and the Grading of Recommendations Assessment, Development and Evaluation criteria. RESULTS Fourteen clinical trials were included (n=1394 participants). Treatment of metabolic acidosis with oral alkali supplementation or a reduction of dietary acid intake increased serum bicarbonate levels (14 studies, 1378 patients, mean difference 3.33 mEq/L, 95% CI, 2.37 to 4.29) and resulted in a slower decline in eGFR (13 studies, 1329 patients, mean difference -3.28 ml/min per 1.73 m2, 95% CI, -4.42 to -2.14; moderate certainty) and a reduction in urinary albumin excretion (very-low certainty), along with a reduction in the risk of progression to ESKD (relative risk, 0.32; 95% CI, 0.18 to 0.56; low certainty). Oral alkali supplementation was associated with worsening hypertension or the requirement for increased antihypertensive therapy (very-low certainty). CONCLUSIONS Low-to-moderate certainty evidence suggest that oral alkali supplementation or a reduction in dietary acid intake may slow the rate of kidney function decline and potentially reduce the risk of ESKD in patients with CKD and metabolic acidosis.
Collapse
Affiliation(s)
- Sankar D. Navaneethan
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Jun Shao
- Tricida, Inc., South San Francisco, CA; and
| | | | - David A. Bushinsky
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| |
Collapse
|
17
|
Ahmed AR, Lappin D. Oral alkali therapy and the management of metabolic acidosis of chronic kidney disease: A narrative literature review. World J Nephrol 2018; 7:117-122. [PMID: 30324086 PMCID: PMC6181870 DOI: 10.5527/wjn.v7.i6.117] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 08/05/2018] [Accepted: 08/30/2018] [Indexed: 02/06/2023] Open
Abstract
Chronic metabolic acidosis is a common complication seen in advanced chronic kidney disease (CKD). There is currently no consensus on its management in the Republic of Ireland. Recent trials have suggested that appropriate active management of metabolic acidosis through oral alkali therapy and modified diet can have a deterring impact on CKD progression. The potential benefits of treatment include preservation of bone health and improvement in muscle function; however, present data is limited. This review highlights the current evidence, available primarily from randomised control trials (RCTs) over the last decade, in managing the metabolic acidosis of CKD and outlines ongoing RCTs that are promising. An economic perspective is also briefly discussed to support decision-making.
Collapse
Affiliation(s)
- Adeel Rafi Ahmed
- Department of Nephrology, University Hospital Galway, Galway H91YR1, Ireland
| | - David Lappin
- Department of Nephrology, University Hospital Galway, Galway H91YR1, Ireland
| |
Collapse
|
18
|
Retarding progression of chronic kidney disease: use of modalities that counter acid retention. Curr Opin Nephrol Hypertens 2018; 27:94-101. [PMID: 29140821 DOI: 10.1097/mnh.0000000000000386] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Acid retention because of chronic kidney disease (CKD) increases tissue acidity and accelerates progression of CKD, whereas reduction in acid retention slows progression of CKD. Herein, we describe the mechanisms through which increased tissue acidity worsens CKD, modalities for countering acid retention and their impact on progression of CKD, and current recommendations for therapy. RECENT FINDINGS Studies in animals and humans show that increased tissue acidity raises the renal levels of endothelin, angiotensin II, aldosterone, and ammoniagenesis, thereby worsening renal fibrosis and causing progression of CKD. Measures that counter acid retention, such as providing alkali or modifying the quantity or type of dietary protein, reduce the levels of endothelin, angiotensin II, aldosterone, and ammoniagenesis, slowing progression of CKD. Alkali can be provided as NaHCO3, sodium citrate, or base in fruits and vegetables. A serum [HCO3] of 24-26 mEq/l is targeted, because higher values can be associated with adverse consequences. SUMMARY Insights into the mechanisms through which increased tissue acidity mediates progression of CKD and the beneficial impact of ameliorating positive acid balance underlie our recommendation for modalities that counter acid retention in CKD.
Collapse
|
19
|
Vanholder R, Van Laecke S, Glorieux G, Verbeke F, Castillo-Rodriguez E, Ortiz A. Deleting Death and Dialysis: Conservative Care of Cardio-Vascular Risk and Kidney Function Loss in Chronic Kidney Disease (CKD). Toxins (Basel) 2018; 10:E237. [PMID: 29895722 PMCID: PMC6024824 DOI: 10.3390/toxins10060237] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/11/2018] [Indexed: 02/07/2023] Open
Abstract
The uremic syndrome, which is the clinical expression of chronic kidney disease (CKD), is a complex amalgam of accelerated aging and organ dysfunctions, whereby cardio-vascular disease plays a capital role. In this narrative review, we offer a summary of the current conservative (medical) treatment options for cardio-vascular and overall morbidity and mortality risk in CKD. Since the progression of CKD is also associated with a higher cardio-vascular risk, we summarize the interventions that may prevent the progression of CKD as well. We pay attention to established therapies, as well as to novel promising options. Approaches that have been considered are not limited to pharmacological approaches but take into account lifestyle measures and diet as well. We took as many randomized controlled hard endpoint outcome trials as possible into account, although observational studies and post hoc analyses were included where appropriate. We also considered health economic aspects. Based on this information, we constructed comprehensive tables summarizing the available therapeutic options and the number and kind of studies (controlled or not, contradictory outcomes or not) with regard to each approach. Our review underscores the scarcity of well-designed large controlled trials in CKD. Nevertheless, based on the controlled and observational data, a therapeutic algorithm can be developed for this complex and multifactorial condition. It is likely that interventions should be aimed at targeting several modifiable factors simultaneously.
Collapse
Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Steven Van Laecke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Francis Verbeke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | | | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain.
| |
Collapse
|
20
|
Dietary Treatment of Metabolic Acidosis in Chronic Kidney Disease. Nutrients 2018; 10:nu10040512. [PMID: 29677110 PMCID: PMC5946297 DOI: 10.3390/nu10040512] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 04/14/2018] [Accepted: 04/17/2018] [Indexed: 01/19/2023] Open
Abstract
Chronic kidney disease and reduced glomerular filtration rate are risk factors for the development of chronic metabolic acidosis. The prevention or correction of chronic metabolic acidosis has been found to slow progression of chronic kidney disease. Dietary composition can strongly affect acid–base balance. Major determinants of net endogenous acid production are the generation of large amounts of hydrogen ions, mostly by animal-derived protein, which is counterbalanced by the metabolism of base-producing foods like fruits and vegetables. Alkali therapy of chronic metabolic acidosis can be achieved by providing an alkali-rich diet or oral administration of alkali salts. The primary goal of dietary treatment should be to increase the proportion of fruits and vegetables and to reduce the daily protein intake to 0.8–1.0 g per kg body weight. Diet modifications should begin early, i.e., even in patients with moderate kidney impairment, because usual dietary habits of many developed societies contribute an increased proportion of acid equivalents due to the high intake of protein from animal sources.
Collapse
|
21
|
Hu JR, Coresh J. The public health dimension of chronic kidney disease: what we have learnt over the past decade. Nephrol Dial Transplant 2017; 32:ii113-ii120. [PMID: 28206632 DOI: 10.1093/ndt/gfw416] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 11/05/2016] [Indexed: 11/13/2022] Open
Abstract
Much progress has been made in chronic kidney disease (CKD) epidemiology in the last decade to establish CKD as a condition that is common, harmful and treatable. The introduction of the new equations for estimating glomerular filtration rate (GFR) and the publication of international reference standards for creatinine and cystatin measurement paved the way for improved global estimates of CKD prevalence. The addition of albuminuria categories to the staging of CKD paved the way for research linking albuminuria and GFR to a wide range of renal and cardiovascular adverse outcomes. The advent of genome-wide association studies ushered in insights into genetic polymorphisms underpinning some types of CKD. Finally, a number of new randomized clinical trials and meta-analyses have informed evidence-based guidelines for the treatment and prevention of CKD. In this review, we discuss the lessons learnt from epidemiological investigations of the staging, etiology, prevalence and prognosis of CKD between 2007 and 2016.
Collapse
Affiliation(s)
- Jiun-Ruey Hu
- Department of Spine Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Josef Coresh
- Department of Epidemiology, John Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
22
|
Noraee N, Fathi M, Golestani Eraghi M, Dabbagh A, Massoudi N. The Effect of Intraoperative Alkali Treatment on Recovery from Atracurium-Induced Neuromuscular Blockade in Renal Transplantation: A Randomized Trial. Anesth Pain Med 2017; 7:e42660. [PMID: 28920046 PMCID: PMC5554426 DOI: 10.5812/aapm.42660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/05/2016] [Accepted: 12/26/2016] [Indexed: 11/16/2022] Open
Abstract
Background Intraoperative care and anesthesia method in patients undergoing allograft renal transplantation surgery are very necessary. Acid-base imbalance can alter neuromuscular blockade and recovery time. Objectives The aim of the present study was to investigate the effect of acid-base balance on atracurium blockade in renal transplantation. Methods In this randomized-controlled trial, 31 end-stage renal disease (ESRD) patients undergoing renal transplantation were randomly assigned into two equal groups. The case group received intravenous sodium bicarbonate based on base excess in the first ABG sample, while the control group received sterile water for injection during the interval between anesthesia and beginning of surgery. Arterial blood gas (ABG) sample was drawn first prior to surgery and again at declamping time. Train-of-four (TOF) was measured before anesthesia and repeatedly after declamping time until acceptable recovery (TOF 3 of 4). The time of achieving TOF 3 was recorded and compared between the groups. Results There was no significant difference in blood pH between the groups in the first evaluation (P = 0.649). The pH and base excess (BE) in the case group significantly increased after the intervention. There was a significant decrease in after-surgery measurement of pH in the control group (P = 0.011). The mean time to achieve TOF = 3 was 23.75 ± 5.32 and 41.80 ± 5.2 minutes after declamping in the case and control groups, respectively. Patients in the sodium bicarbonate group achieved TOF = 3 significantly faster than the control group. Conclusions Based on our results, intraoperative alkali and acid-base imbalance treatment can reduce neuromuscular blockade and recovery time, and it can be regarded as a potential casual factor to enhance transplantation outcome.
Collapse
Affiliation(s)
- Navid Noraee
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Fathi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Majid Golestani Eraghi
- Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Dabbagh
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nilofar Massoudi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding author: Nilofar Massoudi, MD, Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. E-mail:
| |
Collapse
|
23
|
Liu XY, Gao XM, Zhang N, Chen R, Wu F, Tao XC, Li CJ, Zhang P, Yu P. Oral Bicarbonate Slows Decline of Residual Renal Function in Peritoneal Dialysis Patients. Kidney Blood Press Res 2017; 42:565-574. [PMID: 29032379 DOI: 10.1159/000479641] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 02/07/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Metabolic acidosis is a common consequence of end-stage renal disease (ESRD) which may result in a substantial adverse outcome. The effect of oral bicarbonate on the preservation of residual renal function (RRF) in peritoneal dialysis (PD) patients has been rarely reported. METHODS We randomly assigned 40 continuous ambulatory peritoneal dialysis (CAPD) patients to the oral bicarbonate group or placebo group at a 1: 1 ratio. All enrollments were followed for a duration of 104 weeks. We took residual creatinine clearance (CCr), a measure of residual renal function (RRF), as the primary outcome. Residual CCr was calculated as the average of urea and creatinine clearance from a 24-hour urine collection. RESULTS Thirteen patients in the placebo group and 15 patients in the treatment group completed the 104 weeks of follow-up with a comparable dropout rate (placebo group: 35% vs treatment group: 25%). Compared with the placebo group, serum bicarbonate in treatment group was significantly increased at each time point, and oral bicarbonate resulted in a slower declining rate of residual CCr (F=5.113, p=0.031). Baseline residual CCr at enrollment also had a significant effect on residual CCr (F=168.779, P<0.001). Charlson Comorbidity Index which was adopted to calculate a comorbidity score had no significant effect on residual CCr loss (F=0.168, P=0.685). CONCLUSION Oral bicarbonate may have a RRF preserving effect in CAPD patients, and a normal to high level of serum bicarbonate (≥24mmol/L) may be appropriate for RRF preservation.
Collapse
Affiliation(s)
- Xiang-Yang Liu
- Department of Diabetic Nephropathy Hemodialysis, Key Laboratory of Hormones and Development (Ministry of Health), Tianjin Key Laboratory of Metabolic Diseases, Tianjin Metabolic Diseases Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Xiu-Mei Gao
- Department of Nephrology, Chinese PLA No. 254 Hospital, Tianjin, China
| | - Ning Zhang
- Department of Endocrinology, Chinese PLA No. 254 Hospital, Tianjin, China
| | - Rui Chen
- Department of Diabetic Nephropathy Hemodialysis, Key Laboratory of Hormones and Development (Ministry of Health), Tianjin Key Laboratory of Metabolic Diseases, Tianjin Metabolic Diseases Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Feng Wu
- Department of Endocrinology, Chinese PLA No. 254 Hospital, Tianjin, China
| | - Xin-Chao Tao
- Department of Nephrology, Chinese PLA No. 254 Hospital, Tianjin, China
| | - Chun-Jun Li
- Department of Endocrinology, Key Laboratory of Hormones and Development (Ministry of Health), Tianjin Key Laboratory of Metabolic Diseases, Tianjin Metabolic Diseases Hospital & Tianjin Institute of Endocrinology, Tianjin Medical Universtiy, Tianjin, China
| | - Ping Zhang
- Department of Nephrology, Chinese PLA No. 254 Hospital, Tianjin, China
| | - Pei Yu
- Department of Diabetic Nephropathy Hemodialysis, Key Laboratory of Hormones and Development (Ministry of Health), Tianjin Key Laboratory of Metabolic Diseases, Tianjin Metabolic Diseases Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| |
Collapse
|
24
|
Goraya N, Wesson DE. Management of the Metabolic Acidosis of Chronic Kidney Disease. Adv Chronic Kidney Dis 2017; 24:298-304. [PMID: 29031356 DOI: 10.1053/j.ackd.2017.06.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/27/2017] [Indexed: 01/31/2023]
Abstract
Subjects with CKD and reduced glomerular filtration rate are at risk for chronic metabolic acidosis, and CKD is its most common cause. Untreated metabolic acidosis, even in its mildest forms, is associated with increased mortality and morbidity and should therefore be treated. If reduced glomerular filtration rate or the tubule abnormality causing chronic metabolic acidosis cannot be corrected, it is typically treated with dietary acid (H+) reduction using Na+-based alkali, usually NaHCO3. Dietary H+ reduction can also be accomplished with the addition of base-producing foods such as fruits and vegetables and limiting intake of H+-producing foods like animal-sourced protein. The optimal dose of Na+-based alkali that prevents the untoward effects of metabolic acidosis while minimizing adverse effects and the appropriate combination of this traditional therapy with dietary strategies remain to be determined by ongoing studies. Recent emerging evidence supports a phenomenon of H+ retention, which precedes the development of metabolic acidosis by plasma acid-base parameters, but further studies will be needed to determine how best to identify patients with this phenomenon and whether they too should be treated with dietary H+ reduction.
Collapse
|
25
|
Kramer H. Kidney Disease and the Westernization and Industrialization of Food. Am J Kidney Dis 2017; 70:111-121. [DOI: 10.1053/j.ajkd.2016.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 11/01/2016] [Indexed: 01/12/2023]
|
26
|
Fleig S, Patecki M, Schmitt R. [Chronic kidney disease : What is currently available for treatment?]. Internist (Berl) 2016; 57:1164-1171. [PMID: 27844096 DOI: 10.1007/s00108-016-0150-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Chronic kidney disease is common in the general population with an estimated prevalence of roughly 2 million in Germany. Typically, chronic kidney disease is progressive and in the terminal stage the patients require dialysis or kidney transplantation. In many cases the disease remains silent for a long time but early stages are already associated with increasing morbidity and mortality. Therefore early detection is very important. In recent years several new concepts have been introduced that might help to slow the progression of chronic kidney disease or improve the accompanying risks. Here, we want to provide a nephrologist's perspective on the current guidelines for the treatment and prevention of chronic kidney disease. We summarize which diagnostic approaches are useful for general practitioners and we take a pragmatic look at the existing opportunities for combating renal functional decline. We also shed light on established measures to minimize the risk of comorbidities.
Collapse
Affiliation(s)
- S Fleig
- Klinik für Nieren- und Hochdruckerkrankungen, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - M Patecki
- Klinik für Nieren- und Hochdruckerkrankungen, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - R Schmitt
- Klinik für Nieren- und Hochdruckerkrankungen, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| |
Collapse
|
27
|
Mani NS, Ginier E. An Evidence-Based Approach to Conducting Systematic Reviews on CKD. Adv Chronic Kidney Dis 2016; 23:355-362. [PMID: 28115078 DOI: 10.1053/j.ackd.2016.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 10/28/2016] [Accepted: 11/14/2016] [Indexed: 11/11/2022]
Abstract
With the growing need to integrate best evidence to inform clinical care, systematic reviews have continued to flourish. Although this type of review is integral to the synthesis of evidence-based information, systematic reviews are often conducted omitting well-established processes that ensure the validity and replicability of the study; elements of which are integral based on standards developed by the Cochrane Collaboration and the National Academy of Medicine. This review article will share best practices associated with conducting systematic reviews on the topic of CKD using an 8-step process and an evidence-based approach to retrieving and abstracting data. Optimal methods for conducting systematic review searching will be described, including development of appropriate search strategies and utilization of varied resources including databases, grey literature, primary journals, and handsearching. Processes and tools to improve research teams' coordination and efficiency, including integration of systematic review protocols and sophisticated software to streamline data management, will be investigated. In addition to recommended strategies for surveying and synthesizing CKD literature, techniques for maneuvering the complex field of Nephrology will also be explored.
Collapse
|
28
|
A High Content Screening Assay to Identify Compounds with Anti-Epithelial-Mesenchymal Transition Effects from the Chinese Herbal Medicine Tong-Mai-Yang-Xin-Wan. Molecules 2016; 21:molecules21101340. [PMID: 27735870 PMCID: PMC6273035 DOI: 10.3390/molecules21101340] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 09/29/2016] [Accepted: 10/06/2016] [Indexed: 12/29/2022] Open
Abstract
Chronic kidney disease (CKD) is a worldwide health problem with growing prevalence in developing countries. Renal tubular epithelial-mesenchymal transition (EMT) is a critical step and key factor in the development of this condition. Renal tubulointerstitial fibrosis is a basic pathological change at the later stages of the disease. Therefore, blocking the development of EMT could be a critical factor in curing CKD. We have established a cell-based high-content screening (HCS) method to identify inhibitors of EMT in human proximal tubular epithelial (HK-2) cells by automatic acquisition and processing of dual-fluorescent labeled images. With the aid of chromatographic separation and mass spectrometry, we achieved the rapid and reliable screening of active compounds from the Chinese herbal medicine Tong-Mai-Yang-Xin-Wan (TMYX) for treating EMT. Five fractions were found to exert anti-EMT activity and were further identified by liquid chromatography coupled with tandem mass spectrometry. Glycyrrhizic acid, glyasperin A, and licorisoflavan A were found to inhibit EMT. The proposed approach was successfully applied to screen active compounds from TMYX on TGF-β1-stimulated HK-2 cells and may offer a new means for identifying lead compounds for treating EMT from registered Chinese herbal medicines.
Collapse
|
29
|
Paul Chubb SA, Davis WA, Peters KE, Davis TME. Serum bicarbonate concentration and the risk of cardiovascular disease and death in type 2 diabetes: the Fremantle Diabetes Study. Cardiovasc Diabetol 2016; 15:143. [PMID: 27716263 PMCID: PMC5054557 DOI: 10.1186/s12933-016-0462-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 09/29/2016] [Indexed: 12/18/2022] Open
Abstract
Background Serum bicarbonate is associated with mortality, heart failure (HF) and progression of renal failure in studies of healthy people and patients with chronic kidney disease, but the significance of these observations in unselected patients with diabetes in the general population is unknown. The aim of this study was to determine whether serum bicarbonate was associated with mortality and cardiovascular disease risk in type 2 diabetes. Methods Baseline serum bicarbonate was available for 1283 well-characterized community-based patients (mean ± SD age 64.1 ± 11.3 years, 48.7 % males) from the longitudinal observational Fremantle Diabetes Study followed for a mean of 12 years. Associations between serum bicarbonate and mortality, coronary heart disease (CHD) and incident HF were analysed using Cox proportional hazards regression. Results Serum bicarbonate was independently and negatively associated with incident CHD. For each 1 mmol/L increase in bicarbonate, the hazard ratio for CHD was 0.95 (95 % confidence interval 0.92–0.99) after adjustment for age as time scale, age at baseline, sex, English fluency, diabetes duration, loge(serum triglycerides), loge(urinary albumin: creatinine ratio), peripheral sensory neuropathy and peripheral arterial disease. There were no independent associations between serum bicarbonate and all-cause mortality [0.98 (0.95–1.004)] or incident HF [0.99 (0.95–1.03)]. Conclusions Serum bicarbonate was a significant independent predictor of incident CHD but not death or HF in community-based patients with type 2 diabetes. This supports intervention trials of bicarbonate replacement in type 2 patients at risk of CHD and who have a low serum bicarbonate concentration. Electronic supplementary material The online version of this article (doi:10.1186/s12933-016-0462-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- S A Paul Chubb
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, WA, 6959, Australia.,PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Wendy A Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, WA, 6959, Australia
| | - Kirsten E Peters
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, WA, 6959, Australia
| | - Timothy M E Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, PO Box 480, Fremantle, WA, 6959, Australia.
| |
Collapse
|
30
|
Controversial issues in CKD clinical practice: position statement of the CKD-treatment working group of the Italian Society of Nephrology. J Nephrol 2016; 30:159-170. [PMID: 27568307 DOI: 10.1007/s40620-016-0338-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 07/12/2016] [Indexed: 01/13/2023]
Abstract
This position paper of the study group "Conservative treatment of Chronic Kidney Disease-CKD" of the Italian Society of Nephrology addresses major practical, unresolved, issues related to the conservative treatment of chronic renal disease. Specifically, controversial topics from everyday clinical nephrology practice which cannot find a clear, definitive answer in the current literature or in nephrology guidelines are discussed. The paper reports the point of view of the study group. Concise and practical advice is given on several common issues: renal biopsy in diabetes; dual blockade of the renin-angiotensin-aldosterone system (RAAS); management of iron deficiency; low protein diet; dietary salt intake; bicarbonate supplementation; treatment of obesity; the choice of conservative therapy vs. dialysis. For each topic synthetic statements, guideline-style, are reported.
Collapse
|
31
|
Rubio-Aliaga I, Wagner CA. Regulation and function of the SLC38A3/SNAT3 glutamine transporter. Channels (Austin) 2016; 10:440-52. [PMID: 27362266 DOI: 10.1080/19336950.2016.1207024] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Isabel Rubio-Aliaga
- a Institute of Physiology, the National Center for Competence in Research NCCR Kidney, University of Zurich , Zurich , Switzerland
| | - Carsten A Wagner
- a Institute of Physiology, the National Center for Competence in Research NCCR Kidney, University of Zurich , Zurich , Switzerland
| |
Collapse
|
32
|
Vassalotti JA, Centor R, Turner BJ, Greer RC, Choi M, Sequist TD. Practical Approach to Detection and Management of Chronic Kidney Disease for the Primary Care Clinician. Am J Med 2016; 129:153-162.e7. [PMID: 26391748 DOI: 10.1016/j.amjmed.2015.08.025] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 08/05/2015] [Accepted: 08/06/2015] [Indexed: 12/21/2022]
Abstract
A panel of internists and nephrologists developed this practical approach for the Kidney Disease Outcomes Quality Initiative to guide assessment and care of chronic kidney disease (CKD) by primary care clinicians. Chronic kidney disease is defined as a glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) and/or markers of kidney damage for at least 3 months. In clinical practice the most common tests for CKD include GFR estimated from the serum creatinine concentration (eGFR) and albuminuria from the urinary albumin-to-creatinine ratio. Assessment of eGFR and albuminuria should be performed for persons with diabetes and/or hypertension but is not recommended for the general population. Management of CKD includes reducing the patient's risk of CKD progression and risk of associated complications, such as acute kidney injury and cardiovascular disease, anemia, and metabolic acidosis, as well as mineral and bone disorder. Prevention of CKD progression requires blood pressure <140/90 mm Hg, use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for patients with albuminuria and hypertension, hemoglobin A1c ≤7% for patients with diabetes, and correction of CKD-associated metabolic acidosis. To reduce patient safety hazards from medications, the level of eGFR should be considered when prescribing, and nephrotoxins should be avoided, such as nonsteroidal anti-inflammatory drugs. The main reasons to refer to nephrology specialists are eGFR <30 mL/min/1.73 m(2), severe albuminuria, and acute kidney injury. The ultimate goal of CKD management is to prevent disease progression, minimize complications, and promote quality of life.
Collapse
Affiliation(s)
- Joseph A Vassalotti
- Icahn School of Medicine at Mount Sinai, New York, NY; National Kidney Foundation, Inc, New York, NY.
| | - Robert Centor
- University of Alabama at Birmingham School of Medicine
| | | | - Raquel C Greer
- Johns Hopkins University School of Medicine, Baltimore, Md
| | - Michael Choi
- Johns Hopkins University School of Medicine, Baltimore, Md
| | | | | |
Collapse
|
33
|
Lee SM, Kim SE, Kim EB, Jeong HJ, Son YK, An WS. Lactate Clearance and Vasopressor Seem to Be Predictors for Mortality in Severe Sepsis Patients with Lactic Acidosis Supplementing Sodium Bicarbonate: A Retrospective Analysis. PLoS One 2015; 10:e0145181. [PMID: 26692209 PMCID: PMC4686961 DOI: 10.1371/journal.pone.0145181] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/30/2015] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Initial lactate level, lactate clearance, C-reactive protein, and procalcitonin in critically ill patients with sepsis are associated with hospital mortality. However, no study has yet discovered which factor is most important for mortality in severe sepsis patients with lactic acidosis. We sought to clarify this issue in patients with lactic acidosis who were supplementing with sodium bicarbonate. MATERIALS AND METHODS Data were collected from a single center between May 2011 and April 2014. One hundred nine patients with severe sepsis and lactic acidosis who were supplementing with sodium bicarbonate were included. RESULTS The 7-day mortality rate was 71.6%. The survivors had higher albumin levels and lower SOFA, APACHE II scores, vasopressor use, and follow-up lactate levels at an elapsed time after their initial lactate levels were checked. In particular, a decrement in lactate clearance of at least 10% for the first 6 hours, 24 hours, and 48 hours of treatment was more dominant among survivors than non-survivors. Although the patients who were treated with broad-spectrum antibiotics showed higher illness severity than those who received conventional antibiotics, there was no significant mortality difference. 6-hour, 24-hour, and 48-hour lactate clearance (HR: 4.000, 95% CI: 1.309-12.219, P = 0.015) and vasopressor use (HR: 4.156, 95% CI: 1.461-11.824, P = 0.008) were significantly associated with mortality after adjusting for confounding variables. CONCLUSIONS Lactate clearance at a discrete time point seems to be a more reliable prognostic index than initial lactate value in severe sepsis patients with lactic acidosis who were supplementing with sodium bicarbonate. Careful consideration of vasopressor use and the initial application of broad-spectrum antibiotics within the first 48 hours may be helpful for improving survival, and further study is warranted.
Collapse
Affiliation(s)
- Su Mi Lee
- Department of Internal Medicine, Dong-A University, Busan, Korea
| | - Seong Eun Kim
- Department of Internal Medicine, Dong-A University, Busan, Korea
| | - Eun Bin Kim
- Department of Internal Medicine, Dong-A University, Busan, Korea
| | - Hyo Jin Jeong
- Department of Internal Medicine, Dong-A University, Busan, Korea
| | - Young Ki Son
- Department of Internal Medicine, Dong-A University, Busan, Korea
| | - Won Suk An
- Department of Internal Medicine, Dong-A University, Busan, Korea
- Institute of Medical Science, Dong-A University College of Medicine, Busan, Korea
- * E-mail:
| |
Collapse
|
34
|
Abstract
Chronic kidney disease (CKD) is associated with significant morbidity and mortality, impacted not alone by progression to end-stage kidney disease, but also by the high associated incidence of cardiovascular events and related mortality. Despite our current understanding of the pathogenesis of CKD and the treatments available, the reported incidence of CKD continues to rise worldwide, and is often referred to as the silent public healthcare epidemic. The significant cost to patient wellbeing and to the economy of managing the later stages of CKD have prompted efforts to develop interventions to delay the development and progression of this syndrome. In this article, we review established and novel agents that may aid in delaying the progression of CKD and improve patient outcomes.
Collapse
Affiliation(s)
- Frank Ward
- St Vincent's University Hospital, Dublin 4, Ireland
| | - John Holian
- St Vincent's University Hospital, Dublin 4, Ireland
| | - Patrick T Murray
- School of Medicine, University College Dublin, Health Sciences Centre, Dublin 4, Ireland
| |
Collapse
|
35
|
Citarda S, Hanf W, Vrigneaud L, Bataille S, Gosselin M, Beaume J, Dariane C, Madec FX, Larceneux F, Fiard G, Bertocchio JP. [Mineral-based alkaline waters' prescription in France: Patients are the key point for both nephrologists and urologists]. Nephrol Ther 2015; 12:38-47. [PMID: 26563589 DOI: 10.1016/j.nephro.2015.07.471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/17/2015] [Indexed: 11/25/2022]
Abstract
Alkali therapy is frequently used during chronic kidney disease and nephrolithiasis: nephrologists and urologists are the key operators. Very few is known about the underlying conditions of such a prescription: the aim of this study was to delineate those determinants. We conducted a prospective survey where French nephrologists and urologists were involved. Responders were without gender distinction and principally nephrologists. Prescription frequency was associated with gender (women), specialty (nephrologists), indications and perceived efficiency. Urologists prescribe more often during nephrolithiasis and nephrologists during chronic kidney disease. Urologists were more expert (by scoring on mineral-based alkaline waters compositions knowledge). By multivariate analysis, prescription frequency is associated with gender (women), indications and perceived efficiency by prescribers, which is itself influenced by feedback from patients. These results could have been influenced by a huge representation of nephrologists but foster physicians to go on listening to feedback from patients, due to a lack of clinical trials on the efficiency of mineral-based alkaline waters in such a field. Finally, physicians' education (especially young nephrologists) on mineral-based alkaline waters should be intensified.
Collapse
Affiliation(s)
- Salvatore Citarda
- Centre associatif lyonnais de dialyse (CALYDIAL), 51, rue Yvours, 69540 Irigny, France; Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France
| | - William Hanf
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Service de néphrologie, centre hospitalier Alpes-Léman, 74130 Contamine-sur-Arve, France
| | - Laurence Vrigneaud
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Service de médecine interne et néphrologie, centre hospitalier de Valenciennes, avenue Desandrouin, 59300 Valenciennes, France
| | - Stanislas Bataille
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Institut phocéen de néphrologie, clinique Bouchard, 13006 Marseille, France
| | - Morgane Gosselin
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Service de néphrologie et transplantation rénale, CHRU La Cavale-Blanche, boulevard Tanguy-Prigent, 29609 Brest, France
| | - Julie Beaume
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Service de dialyse, HIA Sainte-Anne, boulevard Sainte-Anne, 83000 Toulon, France
| | - Charles Dariane
- Service d'urologie, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75908 Paris, France; Association française des urologues en formation, Maison de l'urologie, 11, rue Viète, 75017 Paris, France
| | - François-Xavier Madec
- Association française des urologues en formation, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service de chirurgie infantile, hôpital Mère-Enfant, 38, boulevard Jean-Monnet, 44093 Nantes, France
| | - Fabrice Larceneux
- Dauphine recherches en management, UMR CNRS 7088, université Paris Dauphine, place du Maréchal-de-Lattre-de-Tassigny, 75016 Paris, France
| | - Gaëlle Fiard
- Association française des urologues en formation, Maison de l'urologie, 11, rue Viète, 75017 Paris, France; Service d'urologie, CHU de Grenoble, laboratoire TIMC-IMAG, CNRS, université Grenoble-Alpes, 38000 Grenoble, France
| | - Jean-Philippe Bertocchio
- Club des jeunes néphrologues, 11, rue Auguste-Mourcou, 59000 Lille, France; Service d'explorations fonctionnelles rénales et métaboliques, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75908 Paris, France.
| |
Collapse
|
36
|
Kraut JA, Madias NE. Metabolic Acidosis of CKD: An Update. Am J Kidney Dis 2015; 67:307-17. [PMID: 26477665 DOI: 10.1053/j.ajkd.2015.08.028] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 08/01/2015] [Indexed: 01/02/2023]
Abstract
The kidney has the principal role in the maintenance of acid-base balance. Therefore, a decrease in renal ammonium excretion and a positive acid balance often leading to a reduction in serum bicarbonate concentration are observed in the course of chronic kidney disease (CKD). The decrease in serum bicarbonate concentration is usually absent until glomerular filtration rate decreases to <20 to 25mL/min/1.73 m(2), although it can develop with lesser degrees of decreased kidney function. Non-anion gap acidosis, high-anion gap acidosis, or both can be found at all stages of CKD. The acidosis can be associated with muscle wasting, bone disease, hypoalbuminemia, inflammation, progression of CKD, and increased mortality. Administration of base may decrease muscle wasting, improve bone disease, and slow the progression of CKD. Base is suggested when serum bicarbonate concentration is <22 mEq/L, but the target serum bicarbonate concentration is unclear. Evidence that increments in serum bicarbonate concentration > 24 mEq/L might be associated with worsening of cardiovascular disease adds complexity to treatment decisions. Further study of the mechanisms through which metabolic acidosis contributes to the progression of CKD, as well as the pathways involved in mediating the benefits and complications of base therapy, is warranted.
Collapse
Affiliation(s)
- Jeffrey A Kraut
- Medical and Research Services, VHAGLA Healthcare System, UCLA Membrane Biology Laboratory, Los Angeles, CA; Division of Nephrology, VHAGLA Healthcare System and David Geffen School of Medicine, Los Angeles, CA.
| | - Nicolaos E Madias
- Department of Medicine, Division of Nephrology, St. Elizabeth's Medical Center, Boston, MA; Department of Medicine, Tufts University School of Medicine, Boston, MA.
| |
Collapse
|
37
|
Johns TS, Yee J, Smith-Jules T, Campbell RC, Bauer C. Interdisciplinary care clinics in chronic kidney disease. BMC Nephrol 2015; 16:161. [PMID: 26458811 PMCID: PMC4603306 DOI: 10.1186/s12882-015-0158-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 10/04/2015] [Indexed: 12/13/2022] Open
Abstract
The burden of chronic kidney disease (CKD) is substantial, and is associated with high hospitalization rates, premature deaths, and considerable health care costs. These factors provide strong rationale for quality improvement initiatives in CKD care. The interdisciplinary care clinic (IDC) has emerged as one solution to improving CKD care. The IDC team may include other physicians, advanced practice providers, nurses, dietitians, pharmacists, and social workers—all working together to provide effective care to patients with chronic kidney disease. Studies suggest that IDCs may improve patient education and preparedness prior to kidney failure, both of which have been associated with improved health outcomes. Interdisciplinary care may also delay the progression to end-stage renal disease and reduce mortality. While most studies suggest that IDC services are likely cost-effective, financing IDCs is challenging and many insurance providers do not pay for all of the services. There are also no robust long-term studies demonstrating the cost-effectiveness of IDCs. This review discusses IDC models and its potential impact on CKD care as well as some of the challenges that may be associated with implementing these clinics.
Collapse
Affiliation(s)
- Tanya S Johns
- Department of Medicine, Division of Nephrology, Albert Einstein School of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467, USA.
| | - Jerry Yee
- Department of Internal Medicine, Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA.
| | | | - Ruth C Campbell
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, SC, USA.
| | - Carolyn Bauer
- Department of Medicine, Division of Nephrology, Albert Einstein School of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467, USA.
| |
Collapse
|
38
|
Schutte E, Lambers Heerspink HJ, Lutgers HL, Bakker SJ, Vart P, Wolffenbuttel BH, Umanath K, Lewis JB, de Zeeuw D, Gansevoort RT. Serum Bicarbonate and Kidney Disease Progression and Cardiovascular Outcome in Patients With Diabetic Nephropathy: A Post Hoc Analysis of the RENAAL (Reduction of End Points in Non–Insulin-Dependent Diabetes With the Angiotensin II Antagonist Losartan) Study and IDNT (Irbesartan Diabetic Nephropathy Trial). Am J Kidney Dis 2015; 66:450-8. [DOI: 10.1053/j.ajkd.2015.03.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 03/20/2015] [Indexed: 11/11/2022]
|
39
|
Witham MD, Band MM, Littleford RC, Avenell A, Soiza RL, McMurdo MET, Sumukadas D, Ogston SA, Lamb EJ, Hampson G, McNamee P. Does oral sodium bicarbonate therapy improve function and quality of life in older patients with chronic kidney disease and low-grade acidosis (the BiCARB trial)? Study protocol for a randomized controlled trial. Trials 2015; 16:326. [PMID: 26231610 PMCID: PMC4522127 DOI: 10.1186/s13063-015-0843-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 07/01/2015] [Indexed: 12/24/2022] Open
Abstract
Background Metabolic acidosis is more common with advancing chronic kidney disease, and has been associated with impaired physical function, impaired bone health, accelerated decline in kidney function and increased vascular risk. Although oral sodium bicarbonate is widely used to correct metabolic acidosis, there exist potential risks of therapy including worsening hypertension and fluid overload. Little trial evidence exists to decide whether oral bicarbonate therapy is of net benefit in advanced chronic kidney disease, particularly in older people who are most commonly affected, and in whom physical function, quality of life and vascular health are at least as important outcomes as decline in renal function. Methods/Design BiCARB is a multi-centre, double-blind, placebo controlled, randomised trial evaluating the clinical and cost-effectiveness of oral sodium bicarbonate in the management of older people with chronic kidney disease and severely reduced glomerular filtration rate (GFR) who have a mild degree of metabolic acidosis. The trial will recruit 380 patients from renal, Medicine for the Elderly, and primary care services across centres in the United Kingdom. Male and female patients aged 60 years and older with an estimated glomerular filtration rate of <30 mL/min/1.73 m2, not on dialysis, and with serum bicarbonate concentrations <22 mmol/L will be eligible for participation. The primary clinical outcome for the trial is the between-group difference in the Short Physical Performance Battery score at 12 months. Secondary outcomes include muscle strength, quality of life measured using the EQ-5D score and KDQoL tools, cost effectiveness, renal function, presence of albuminuria and blood pressure. Markers of bone turnover (25-hydroxyvitamin D, 1,25-hydroxyvitamin D, tartrate-resistant acid phosphatase-5b and bone-specific alkaline phosphatase) and vascular health (B-type natriuretic peptide) will be measured. Participants will receive a total of 24 months of either bicarbonate or placebo. The results will provide the first robust test of the overall clinical and cost-effectiveness of this commonly used therapy in older patients with severely reduced kidney function. Trial registration www.isrctn.com; ISRCTN09486651, registered 17 February 2012
Collapse
Affiliation(s)
- Miles D Witham
- Medical Research Institute, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Margaret M Band
- Tayside Clinical Trials Unit, University of Dundee / NHS Tayside, Dundee, UK.
| | | | - Alison Avenell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
| | - Roy L Soiza
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
| | - Marion E T McMurdo
- Medical Research Institute, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Deepa Sumukadas
- Medical Research Institute, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Simon A Ogston
- Epidemiology and Biostatistics Unit, University of Dundee, Dundee, UK.
| | - Edmund J Lamb
- Department of Clinical Biochemistry, East Kent NHS Trust, Canterbury, UK.
| | - Geeta Hampson
- Department of Chemical Pathology, Guy's and St Thomas' Hospitals, London, UK.
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK.
| | | |
Collapse
|
40
|
de-Brito Ashurst I, O'Lone E, Kaushik T, McCafferty K, Yaqoob MM. Acidosis: progression of chronic kidney disease and quality of life. Pediatr Nephrol 2015; 30:873-9. [PMID: 25085611 DOI: 10.1007/s00467-014-2873-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 05/23/2014] [Accepted: 05/30/2014] [Indexed: 11/25/2022]
Abstract
Metabolic acidosis (MA) is relatively common in patients with chronic kidney disease (CKD) particularly in stages 4 and 5. It is assumed to play a contributory role in the development of several complications including bone disease, skeletal muscle wasting, altered protein synthesis, and degradation. Recent evidence also suggests that even mild acidosis might play a role in progressive glomerular filtration rate loss. Experimental and clinical studies suggest that correction of acidosis by alkali therapy attenuates these complications and improves quality of life. Despite several recent small and single-center studies supporting this notion, more robust evidence is required with regard to the long-term benefits of alkali therapy, type of alkali supplements, and the optimal level of serum bicarbonate.
Collapse
Affiliation(s)
- Ione de-Brito Ashurst
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, Cardiovascular Biological Research Unit and William Harvey Research Institute, London, UK
| | | | | | | | | |
Collapse
|
41
|
Ori Y, Zingerman B, Bergman M, Bessler H, Salman H. The effect of sodium bicarbonate on cytokine secretion in CKD patients with metabolic acidosis. Biomed Pharmacother 2015; 71:98-101. [PMID: 25960222 DOI: 10.1016/j.biopha.2015.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 02/12/2015] [Indexed: 10/23/2022] Open
Abstract
The incidence of acidosis increases with the progression of chronic kidney disease (CKD). Correction of acidosis by sodium bicarbonate may slow CKD deterioration. Inflammation, which is common in CKD, may be related to acidosis. Whether the slower rate of GFR decline following the correction of acidosis is related to changes in inflammatory markers is unknown. The current study examined whether correcting CKD-acidosis affected inflammatory cytokines secretion. Thirteen patients with CKD 4-5 and acidosis were tested for cytokines secretion from peripheral-blood mononuclear cells at baseline and after one month of oral sodium bicarbonate. Following treatment with sodium bicarbonate there was no change in weight, blood pressure, serum creatinine, albumin, sodium, calcium, phosphate, PTH, hemoglobin and CRP. Serum urea decreased (134±10-116±8 mg/dl, P=0.002), potassium decreased (5.1±0.4-4.8±0.1 mequiv./l, P=0.064), pH increased (7.29±0.01-7.33±0.01, P=0.008), and serum bicarbonate increased (18.6±0.4 mequiv./l to 21.3±0.3 mequiv./l, P=0.001). The secretion of the anti-inflammatory cytokine IL-10 decreased (2.75±0.25 ng/ml to 2.29±0.21 ng/ml, P=0.041). There was no significant change in the secretion of the other pro-inflammatory and anti-inflammatory cytokines, including IL-1β, IL-2, IL-6, TNFα, IFNγ, IL-1ra. Thus, correcting acidosis in CKD with bicarbonate decreases IL-10 secretion. Its significance needs to be further investigated.
Collapse
Affiliation(s)
- Yaacov Ori
- Department of Nephrology and Hypertension, Rabin Medical Center-Hasharon Hospital, Petah-Tiqva, Israel; Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.
| | - Boris Zingerman
- Department of Nephrology and Hypertension, Rabin Medical Center-Hasharon Hospital, Petah-Tiqva, Israel; Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Michael Bergman
- Department of Nephrology and Hypertension, Rabin Medical Center-Hasharon Hospital, Petah-Tiqva, Israel; Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Hanna Bessler
- Laboratory for Immunology and Hematology Research, Rabin Medical Center-Hasharon Hospital, Petah-Tiqva, Israel; Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Hertzel Salman
- Department of Internal Medicine C, Rabin Medical Center-Hasharon Hospital, Petah-Tiqva, Israel; Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| |
Collapse
|
42
|
Jeong J, Kwon SK, Kim HY. Effect of bicarbonate supplementation on renal function and nutritional indices in predialysis advanced chronic kidney disease. Electrolyte Blood Press 2014; 12:80-7. [PMID: 25606047 PMCID: PMC4297707 DOI: 10.5049/ebp.2014.12.2.80] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 12/19/2014] [Indexed: 02/06/2023] Open
Abstract
Current practice guidelines recommend alkali therapy in patients with chronic kidney disease (CKD) and metabolic acidosis to prevent complications. This study aims to investigate the effect of oral sodium bicarbonate supplementation on the progression of renal function and nutritional indices in patients with predialysis advanced CKD. Forty patients with predialysis stage 5 CKD(estimated glomerular filtration rate, eGFR <15mL/min per 1.73m2) and 40 patients with stage 4 CKD (eGFR 15 to 30mL/min per 1.73m2) who had a total CO2 less than 22mEq/L were assigned into the bicarbonate treatment group or control group for 12 months. In stage 4 CKD, there were significant differences in the changes of eGFR during the study between the treatment group and the control group (-2.30±4.49 versus -6.58±6.32mL/min/1.73m2, p<0.05). However, in stage 5 CKD, there were no significant differences in the change of eGFR during the study between the two groups (-2.10±2.06 versus -3.23±1.95mL/min/1.73 m2).There were no significant differences in the changes of nutritional indices such as albumin, prealbumin, transferrin, total lymphocyte count (TLC), and Ondodera's prognostic nutritional index (OPNI) during the study between the two groups. In stage 5 CKD, there were significant differences in the changes of TLC and OPNI between the two groups. In conclusion, our results demonstrate that bicarbonate supplementation slows the rate of decline of renal function in stage 4 CKD and improves nutritional indices in stage 5 CKD. Alkali therapy in advanced CKD may have beneficial effect on renal function and malnutrition.
Collapse
Affiliation(s)
- Jiwon Jeong
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Soon Kil Kwon
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hye-Young Kim
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| |
Collapse
|
43
|
Bürki R, Mohebbi N, Bettoni C, Wang X, Serra AL, Wagner CA. Impaired expression of key molecules of ammoniagenesis underlies renal acidosis in a rat model of chronic kidney disease. Nephrol Dial Transplant 2014; 30:770-81. [PMID: 25523450 DOI: 10.1093/ndt/gfu384] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 11/19/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Advanced chronic kidney disease (CKD) is associated with the development of renal metabolic acidosis. Metabolic acidosis per se may represent a trigger for progression of CKD. Renal acidosis of CKD is characterized by low urinary ammonium excretion with preserved urinary acidification indicating a defect in renal ammoniagenesis, ammonia excretion or both. The underlying molecular mechanisms, however, have not been addressed to date. METHODS We examined the Han:SPRD rat model and used a combination of metabolic studies, mRNA and protein analysis of renal molecules involved in acid-base handling. RESULTS We demonstrate that rats with reduced kidney function as evident from lower creatinine clearance, lower haematocrit, higher plasma blood urea nitrogen, creatinine, phosphate and potassium had metabolic acidosis that could be aggravated by HCl acid loading. Urinary ammonium excretion was highly reduced whereas urinary pH was more acidic in CKD compared with control animals. The abundance of key enzymes and transporters of proximal tubular ammoniagenesis (phosphate-dependent glutaminase, PEPCK and SNAT3) and bicarbonate transport (NBCe1) was reduced in CKD compared with control animals. In the collecting duct, normal expression of the B1 H(+)-ATPase subunit is in agreement with low urinary pH. In contrast, the RhCG ammonia transporter, critical for the final secretion of ammonia into urine was strongly down-regulated in CKD animals. CONCLUSION In the Han:SPRD rat model for CKD, key molecules required for renal ammoniagenesis and ammonia excretion are highly down-regulated providing a possible molecular explanation for the development and maintenance of renal acidosis in CKD patients.
Collapse
Affiliation(s)
- Remy Bürki
- Institute of Physiology and ZIHP, University of Zurich, Zurich, Switzerland
| | - Nilufar Mohebbi
- Institute of Physiology and ZIHP, University of Zurich, Zurich, Switzerland Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Carla Bettoni
- Institute of Physiology and ZIHP, University of Zurich, Zurich, Switzerland
| | - Xueqi Wang
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland Department of Nephrology, Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Andreas L Serra
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Carsten A Wagner
- Institute of Physiology and ZIHP, University of Zurich, Zurich, Switzerland
| |
Collapse
|
44
|
Che X, Xie Y, Wang C, Wang Q, Zhang M, Qi C, Ni Z, Mou S. Blood HCO3 - concentration predicts the long-term prognosis of acute kidney injury patients. Biomark Med 2014; 8:1219-26. [PMID: 25525982 DOI: 10.2217/bmm.14.91] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To evaluate the value of HCO3 - concentrations in long-term prognosis after acute kidney injury. Patients & methods: A total of 169 AKI patients were included in this study. At the 12‐month follow-up, the patients were divided into recovered and unrecovered groups. Results: The blood HCO3 - concentrations were significantly correlated with poor prognosis. The area under the curve for renal prognosis of 6 months later blood HCO3 - concentrations was 0.798. Combined HCO3 - and Scr level area under the curve was 0.952. Conclusion: The blood HCO3 - level was useful in evaluating renal prognosis of acute kidney injury patients. The combination of blood HCO3 - concentration and Scr level increased the accuracy of prediction.
Collapse
Affiliation(s)
- Xiajing Che
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
| | - Yuanyuan Xie
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
| | - Chunlin Wang
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
| | - Qin Wang
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
| | - Minfang Zhang
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
| | - Chaojun Qi
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
| | - Zhaohui Ni
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
| | - Shan Mou
- Department of Nephrology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, PR China
| |
Collapse
|
45
|
Adeva-Andany MM, Fernández-Fernández C, Mouriño-Bayolo D, Castro-Quintela E, Domínguez-Montero A. Sodium bicarbonate therapy in patients with metabolic acidosis. ScientificWorldJournal 2014; 2014:627673. [PMID: 25405229 PMCID: PMC4227445 DOI: 10.1155/2014/627673] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 09/05/2014] [Accepted: 09/19/2014] [Indexed: 01/18/2023] Open
Abstract
Metabolic acidosis occurs when a relative accumulation of plasma anions in excess of cations reduces plasma pH. Replacement of sodium bicarbonate to patients with sodium bicarbonate loss due to diarrhea or renal proximal tubular acidosis is useful, but there is no definite evidence that sodium bicarbonate administration to patients with acute metabolic acidosis, including diabetic ketoacidosis, lactic acidosis, septic shock, intraoperative metabolic acidosis, or cardiac arrest, is beneficial regarding clinical outcomes or mortality rate. Patients with advanced chronic kidney disease usually show metabolic acidosis due to increased unmeasured anions and hyperchloremia. It has been suggested that metabolic acidosis might have a negative impact on progression of kidney dysfunction and that sodium bicarbonate administration might attenuate this effect, but further evaluation is required to validate such a renoprotective strategy. Sodium bicarbonate is the predominant buffer used in dialysis fluids and patients on maintenance dialysis are subjected to a load of sodium bicarbonate during the sessions, suffering a transient metabolic alkalosis of variable severity. Side effects associated with sodium bicarbonate therapy include hypercapnia, hypokalemia, ionized hypocalcemia, and QTc interval prolongation. The potential impact of regular sodium bicarbonate therapy on worsening vascular calcifications in patients with chronic kidney disease has been insufficiently investigated.
Collapse
Affiliation(s)
- María M. Adeva-Andany
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - Carlos Fernández-Fernández
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - David Mouriño-Bayolo
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - Elvira Castro-Quintela
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| | - Alberto Domínguez-Montero
- Nephrology Division, Hospital General Juan Cardona, Avenida Pardo Bazán, s/n, Ferrol, 15406 A Coruña, Spain
| |
Collapse
|
46
|
Kawada N, Isaka Y, Rakugi H, Moriyama T. SCAD syndrome: A vicious cycle of kidney stones, CKD, and AciDosis. World J Clin Urol 2014; 3:113-118. [DOI: 10.5410/wjcu.v3.i2.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 05/23/2014] [Accepted: 06/20/2014] [Indexed: 02/06/2023] Open
Abstract
Cumulative evidence has shown that kidney stone formers are at high risk for developing end-stage renal disease (ESRD) and cardiovascular disease. The aim of this mini-review is to summarize the present knowledge about the close relationships among kidney stone formation, chronic kidney disease (CKD), and plasma and urine acidosis (SCAD). Part of the cause of the positive relationships between higher risk of developing ESRD and cardiovascular diseases in stone formers may be explained by inflammation and cell death due to the components of kidney stones. In CKD patients, acidic urine and loss of anti-crystallization factors may cause stone formation. Acidosis can promote tissue inflammation and may affect vascular tone. Correction of plasma and urine acidosis may improve renal and cardiovascular outcome of stone formers and CKD patients. More intensive and long-term interventions, which include correction of plasma and urine pH in patients with reduced renal function and correction of urine pH in patients with normal renal function, may be considered in treating patients with SCAD syndrome.
Collapse
|
47
|
Renal function after percutaneous coronary interventions depending on the type of hydration. Adv Med Sci 2014; 58:369-75. [PMID: 24285128 DOI: 10.2478/ams-2013-0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE The aim of our study was to evaluate renal function assessed by serum creatinine as well as novel biomarkers in 142 patients with stable coronary heart disease and normal serum creatinine undergoing percutaneous coronary interventions (PCI) depending on the type of hydration: physiological saline vs. sodium bicarbonate (1:1 randomization). MATERIALS AND METHODS Serum and urinary NGAL were evaluated before and after 8-12, and 24 hours after PCI. Serum cystatin C, serum creatinine, estimated glomerular filtration rate using different formulae were assessed before PCI, and 24 hours after the procedure. RESULTS Only 2 patients (2.8%) from the saline-hydrated group fulfilled the criteria for CI-AKI. In patients hydrated with sodium bicarbonate serum creatinine declined significantly (p<0.01). In patients hydrated with sodium bicarbonate a significant fall in serum NGAL after 8-12 hours was found. In sodium bicarbonate group cystatin C decreased non significantly after 8-12 hours, then returned to the baseline values. In patients hydrated with physiological saline serum NGAL before PCI and after 24 hours correlated positively with cystatin C and eGFR by CKD-EPI. In patients hydrated with sodium bicarbonate baseline serum NGAL correlated with NGAL baseline cystatin C and eGFR by CKD-EPI, similarly serum NGAL after 24 hours correlated with cystatin C. CONCLUSION We suggest to rather use sodium bicarbonate in a hydration protocol in patients undergoing PCI. However, the value of NGAL in this setting remains to be elucidated and volume expansion remain the unquestionable prevention methods of CI-AKI.
Collapse
|
48
|
Preventing the progression of chronic kidney disease: two case reports and review of the literature. Int Urol Nephrol 2014; 46:2167-74. [PMID: 24948202 DOI: 10.1007/s11255-014-0762-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 06/03/2014] [Indexed: 01/13/2023]
Abstract
A variety of therapeutic modalities are available to alter the abnormalities seen in patients with chronic kidney disease (CKD). A comprehensive plan can now be developed to slow the progression of CKD. Two clinical cases of delay in the need for renal replacement therapy are described. This delay was achieved by using recognized recommendations for optimal diabetes therapy (HbA1c target 7 %), goals for blood pressure levels, reduction of proteinuria, and the proper use of ACEI/ARB therapies. Recent recommendations include BP <140/90 mmHg for patients <60 years old and <150/90 mmHg for older patients unless they have CKD or diabetes. Limits on dietary sodium and protein intake and body weight reduction will decrease proteinuria. Proper treatment for elevated serum phosphorous and parathyroid hormone levels is now appreciated as well as the benefits of therapy for dyslipidemias and anemia. Concerns regarding unfavorable outcomes with excess ESA therapy have led to hemoglobin goals in the 10-12 g/dL range. Finally, new therapeutic considerations for the treatment of acidosis and hyperuricemia are presented with data available to suggest that increasing serum bicarbonate to >22 mmol/L is beneficial, while serum uric acid therapeutic goals are still uncertain. Also, two as yet insufficiently understood approaches to altering the course of CKD (FGF-23 level reduction and balancing gut microbiota) are noted.
Collapse
|
49
|
Chen W, Abramowitz MK. Metabolic acidosis and the progression of chronic kidney disease. BMC Nephrol 2014; 15:55. [PMID: 24708763 PMCID: PMC4233646 DOI: 10.1186/1471-2369-15-55] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 03/31/2014] [Indexed: 11/10/2022] Open
Abstract
Metabolic acidosis is a common complication of chronic kidney disease. Accumulating evidence identifies acidosis not only as a consequence of, but as a contributor to, kidney disease progression. Several mechanistic pathways have been identified in this regard. The dietary acid load, even in the absence of overt acidosis, may have deleterious effects. Several small trials now suggest that the treatment of acidosis with oral alkali can slow the progression of kidney disease.
Collapse
Affiliation(s)
| | - Matthew K Abramowitz
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
| |
Collapse
|
50
|
Brunkhorst R. [Mineral and bone disorder in chronic kidney disease : Critical appraisal of pharmacotherapy]. Internist (Berl) 2014; 55:334-9. [PMID: 24522558 DOI: 10.1007/s00108-014-3447-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Mineral and bone disorder (MBD) in chronic kidney disease (CKD) is associated with increased cardiovascular calcification and mortality. Pharmacological interventions for MBD in CKD are characterized by inconsistent data and a wide spectrum of (sometimes costly) treatment options. The objective of this article is a guideline-oriented overview of the differential indications for pharmacotherapy considering cost-effectiveness. CURRENT DATA The serum phosphate concentration in patients with CKD stages 3-5 with a glomerular filtration rate (GFR) of < 45 ml/min should be kept within the normal range. Currently, under consideration of cost-effectiveness, calcium-containing phosphate binders and combinations of calcium acetate with magnesium carbonate are the preferred treatment options. Phosphate binders free of calcium are indicated in patients with high normal or elevated serum calcium levels. Low vitamin D concentrations in CKD stages 3-5 should be treated under consideration of serum calcium and parathyroid hormone (PTH) with calcidiol (25-cholecalciferol) and in dialysis patients (CKD 5D) with calcitriol (1,25 dihydroxycholecalciferol, activated vitamin D). In CKD the PTH levels should be kept in the range of 2-9-times the upper limit of normal levels. This is achieved by administration of phosphate binding drugs, activated vitamin D, calcimimetic compounds and parathyroidectomy. In CKD stages 3-5 patients metabolic acidosis with < 22 mmol/l serum bicarbonate should be treated with oral sodium bicarbonate. CONCLUSION In MBD of CKD patients an individualized pharmacotherapy which is closely guideline-oriented is required in order to achieve cost-effectiveness.
Collapse
Affiliation(s)
- R Brunkhorst
- Innere Medizin und Nephrologie, Krankenhaus Oststadt, Podbielskistr. 380, 30659, Hannover, Deutschland,
| |
Collapse
|