Risk Factors for Anemia in Patients with Chronic Renal Failure: A Systematic Review and Meta-Analysis

Anaemia and quality of life in chronic kidney disease: a consensus document from the European Anaemia of CKD Alliance

Anaemia is common in chronic kidney disease (CKD) and has a significant impact on quality of life (QoL), work productivity and outcomes. Current management includes oral or intravenous iron and erythropoiesis-stimulating agents (ESAs), to which hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) have been recently added, increasing the available therapeutic options. In randomised controlled trials, only intravenous iron improved cardiovascular outcome, while some ESAs were associated with increased adverse cardiovascular events. Despite therapeutic advances, several challenges and unmet needs remain in the current management of anaemia of CKD. In particular, clinical practice does not include an assessment of QoL, which prompted a group of European nephrologists and representatives of patient advocacy groups to revisit the current approach. In this consensus document, the authors propose a move towards a more holistic, personalised and long-term approach, based on existing evidence. The focus of treatment should be on improving QoL without increasing the risk of adverse cardiovascular events, and tailoring management strategies to the needs of the individual. In addition, the authors discuss the suitability of a currently available anaemia of CKD-specific health-related QoL measure for inclusion in the routine clinical management of anaemia of CKD. The authors also outline the logistics and challenges of incorporating such a measure into electronic health records and how it may be used to improve QoL for people with anaemia of CKD.

Shenkang injection combined with alprostadil for chronic renal failure: A systematic review and meta-analysis

Objective

To systematically evaluate the clinical efficacy and safety of Shenkang injection (SKI) combined with alprostadil in the treatment of chronic renal failure (CRF).

Method

Randomized controlled trials (RCTs) of Shenkang injection combined with alprostadil in CRF treatment were investigated by retrieving a total of 7 databases including CNKI, Wanfang database, VIP, CBM, PubMed, Embase and Cochrane Library, with the search time ranging from 2012 to now. Revman 5.2 software was used for data analysis, and Cochrane bias risk tool was used to evaluate the quality of the included literature. The final results were represented by relative risk (RR), mean difference (MD) and 95% confidence interval (95% CI).

Results

A total of 20 RCTs and 1,573 patients were included in this study. Meta-analysis showed that the overall response rate (ORR) of the treatment group was superior to the control group [RR = 0.20, 95% CI (0.16, 0.25), P < 0.00001]. Compared with the control group, the treatment group achieved favorable improvement in terms of the creatinine clearance rate (Ccr) [MD = 9.48, 95% CI (8.73, 10.24), P < 0.00001], serum creatinine (Scr) [MD = −55.12, 95% CI (−63.42, −46.82), P < 0.00001], quantitative urine protein (Upro) [MD = −0.48, 95% CI (−0.53, −0.43), P < 0.00001], and blood urea nitrogen (BUN) [MD=-3.73, 95% CI (−4.08, −3.3) 7, P < 0.00001]. There was no statistical difference in the incidence of adverse reactions in each group.

Conclusion

Currently, Shenkang injection combined with alprostadil has been widely used in clinical treatment of CRF due to the certain effect superior to other methods. However, its specific efficacy and safety need to be further verified through numerous large-scale clinical trials.

Prevalence, incidence, and treatment of anaemia in patients with non-dialysis-dependent chronic kidney disease: findings from a retrospective real-world study in Italy

BACKGROUND

Limited data are available on the epidemiology and clinical management of anaemia in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD).

METHODS

This retrospective observational study was based on records from databases of five Local Health Units across Italy. Adults with reported NDD-CKD stage 3a-5 between 1 January 2014 and 31 December 2016 were identified. Annual prevalence and incidence of anaemia (age- and sex-standardised) and clinical management (erythropoiesis-stimulating agents [ESAs], intravenous [IV] iron, and blood transfusions) were evaluated. Eligibility for ESAs was defined by ≥ 2 records of Hb < 10 g/dL, or < 11 g/dL over 6 months.

RESULTS

Overall, 101,143 individuals with NDD-CKD (3a-5) recorded between 2014 and 2016 were identified, of whom 40,020 (39.6%) were anaemic. Prevalence of anaemia was 33.8% in 2016 and incidence of anaemia was stable (11.4-12.4%) from 2014 to 2016. Prevalence and incidence of anaemia increased with CKD stage. Among eligible patients, 12.8% with Hb < 11 g/dL and 15.5% with Hb < 10 g/dL received ESAs, and the proportion treated increased with CKD stage. Among ESA-treated patients with at least 2 years of follow up, 18.4% and 19.3% received IV iron in the Hb < 11 and < 10 g/dL groups, respectively, and 16.5% and 19.4% received blood transfusions. Corresponding proportions for the overall anaemic cohort were 9.0% and 11.3%, respectively.

CONCLUSIONS

Anaemia is a significant issue in patients with NDD-CKD. Low rates of ESA treatment indicate a potential treatment gap and suggest that anaemia may not be adequately controlled in many patients.

[Anemia and quality of life of chronic kidney disease patients on renal replacement therapy by programmed hemodialysis]

AIM

To study relationship between anemia and health-related quality of life (HRQOL) of chronic kidney disease stage 5 patients (CKD) undergoing renal replacement therapy by programmed hemodialysis.

MATERIALS AND METHODS

The study was conducted on the basis of dialysis centers/departments in Moscow. The Russian-language version of the KDQOL-SF^TM questionnaire, validated in Russia, was used to assess the HRQOL of patients on hemodialysis. A total of 723 patients were interviewed. Hemoglobin (Hb) levels were assessed in 442 patients based on outpatient records. To identify the relationship between Hb level and HRQOL scales, a correlation analysis was performed, as well as a HRQOL analysis in the three groups differing in hemoglobin levels (<100; 100-120 and >120 g/l). Statistical data processing was carried by SPSS.22 and using parametric and nonparametric statistical methods.

RESULTS

Correlation relationship was revealed between Hb and HRQOL of patients on hemodialysis on the scales "symptoms/problems", "pain", "vital activity, energy" and "total physical component of health". According to the scales "symptoms/problems" and "vital activity, energy", higher rates were noted among patients with Hb higher than the target level, which confirms the recommendations concerning the possibility of achieving higher Hb among individual patients who have not serious concomitant diseases and cardiovascular complications in order to improve their quality of life.

CONCLUSION

HRQOL assessment is important tool for planning and evaluating the effectiveness of anemia drug therapy among patients with CKD on hemodialysis.

Social, political and legal determinants of kidney health: Perspectives from lower- and middle-income countries with a focus on India

The social determinants of health (SDoH) are the non-medical factors that influence kidney health outcomes directly or indirectly in a substantial manner and include conditions in which people are born, grow, work, live, and age. Many such challenges in lower- and middle- income countries have an unfavourable impact on kidney health. These conditions potentially influence economic policies and systems, development agendas, social norms, social policies, and political systems. In addition, many political and legal factors also determine and modify the ultimate outcome in patients with kidney disease. Legal factors that ensure universal health care, promote gender and racial equality, prevent malpractices and regulate strict laws in the field of kidney transplantation are the paramount determinants for the provision of necessary kidney care. Converging lines of evidence have supported the impact of social variables such as socioeconomic resources, social inclusion, housing conditions, educational attainment, and financial status on kidney health, particularly affect vulnerable and disadvantaged groups and result in challenges in kidney care delivery. Furthermore, the climate is an important SDoH that plays a crucial role in the occurrence, prevalence, and progression of kidney diseases as highlighted by the presence of higher prevalence of chronic kidney disease in hot tropical countries. The rising incidence of water and vector-borne diseases causing acute kidney injury is another consequence of disruptive environmental and climate change which is detrimental to kidney health. Political risk factors such as conflict also have a devastating influence on kidney health. The relationship between SDoH and kidney health outcomes requires more clarity. Gaps in the current knowledge need to be identified to inform the development of appropriate interventions to address upstream socio-economic risk factors for kidney disease.

The Change of Aqueous Humor Cytokine Levels after Anti-VEGF in Diabetic Macular Edema: A Systematic Review and Meta-Analysis

Background

Diabetic macular edema (DME) is a vision-threatening complication that severely impairs vision, and VEGF has a certain improvement effect on it as a growth factor.

Objective

To assess the alterations of different aqueous humor cytokine concentrations after intravitreal antivascular endothelial growth factor (VEGF) treatment for diabetic macular edema (DME).

Methods

We searched PubMed, EMBASE, and the Cochrane Library from inception up to May 2022 for studies evaluating the alterations of different aqueous humor cytokine concentrations after intravitreal anti-VEGF treatment for diabetic macular edema. The estimates from eligible studies were meta-analyzed by the Hartung-Knapp/Sidik-Jonkman random-effects method. Egger's regression test was used to determine the publications' bias. A 95% confidence interval was calculated across studies. The analysis was performed using STATA™ Version 15 software.

Results

Nine eligible studies involving a total of 209 eyes for our systematic review were identified through our search strategy. The mean differences in 1-month and 2-month changes of VEGF were 110.681 pg/ml (P < 0.001) and 283.474 pg/ml (P=0.003), respectively. The mean difference in 2-month changes of interleukin 6 (IL-6) was -24.784 pg/ml (P=0.037). The mean difference in 3-month changes of central macular thickness was 130.372 μm (P < 0.001).

Conclusions

Intravitreal injection of anti-VEGF exerts a protective effect on macular edema secondary to diabetic retinopathy by affecting various cytokine concentrations, especially reducing aqueous VEGF concentrations and interleukin 6 in patients with DME.

Nursing Countermeasures of Continuous Renal Replacement Treatment in End-Stage Renal Disease with Refractory Hypotension in the Context of Smart Health

This work is aimed at exploring the nursing strategies and effects of continuous renal replacement therapy (CRRT) for end-stage renal disease (ESRD) with refractory hypotension under the background of smart health. 40 ESRD patients with refractory hypotension who received CRRT treatment were enrolled as the research objects and were randomly rolled into the intervention group and the control group, with 20 cases in each group. Patients in the control group received routine nursing, and those in the intervention group received individualized nursing. The incidence of hypotension, dry body weight, serous cavity effusion, renal function indicators (blood urea nitrogen (BUN) and creatinine (Cre)), and patient satisfaction were compared between the two groups. The results showed that the probability of hypotension in the intervention group was 9.38%, which was lower than that in the control group (34.38%). The probability of early termination of dialysis in the intervention group was 0%, which was lower than that in the control group (18.75%), and the difference was statistically significant (P < 0.05). The decreases of BUN and Cre in the intervention group were significantly greater than those in the control group, and the differences were statistically significant (P < 0.05). The proportion of water growth less than 10% during dialysis in the intervention group was 98.44%, which was greater than that in the control group (93.45%), and the difference was statistically significant (P < 0.05). The ultrafiltration volume after dialysis in the intervention group was 2850 ± 400 mL, which was greater than that in the control group 2350 ± 350 mL. After intervention, the proportion of patients with pleural effusion in the intervention group was 10% less than that in the control group (20%), and the difference was statistically significant (P < 0.05). The satisfaction rate of the intervention group was 97.66%, which was higher than that of the control group (65.63%). In conclusion, individualized nursing was more helpful to the recovery of ESRD patients with refractory hypotension treated with CRRT than routine nursing.

Changes of Intestinal Flora and Lymphocyte Subsets in Patients with Chronic Renal Failure

OBJECTIVE

To explore the changes of intestinal flora and lymphocyte subsets in patients with chronic renal failure (CRF).

METHODS

60 CRF patients who were treated from June 2018 to June 2019 were selected; 60 healthy persons were selected as the control group. 16S rDNA was used to detect the expression of Lactobacillus, Enterobacteriaceae, Enterococcus, Bacteroides, Clostridium, and Bifidobacterium in the feces of the two groups. Illumina Miseq sequencing (Solexa sequencing technology) method was used to analyze the structural differences and species diversity of intestinal flora, including species richness index (Chao) and diversity index (Shannon, Simpson). Flow cytometry was used to detect the levels of lymphocytes and their subgroups of the two groups. Pearson correlation analysis was used to analyze the correlation between Chao and lymphocyte subsets.

RESULTS

The number of Enterobacteriaceae and Enterococcus in CRF group were higher than those in the control group (P < 0.05), while the Lactobacillus, Bacteroides, Clostridium, and Bifidobacterium were opposite (P < 0.05). The Simpson index of the CRF group was lower than that of the control group, while the Chao index and Shannon index were opposite (P < 0.05). The levels of CD3+, CD4+, CD8+, and CD4+/CD8+ in the CRF group were lower than those in the control group, while the levels of CD14+, CD19+, and CD16+/CD56+ were opposite (P < 0.05). The intestinal flora Chao index of CRF group was negatively correlated with the levels of CD3+, CD4+, and CD8+ (r = -0.692, P=0.019; r = -0.669, P=0.021; r = -0.603, P=0.028). The intestinal flora Chao of CRF group is positively correlated with the level of CD14+ and CD16+/CD56+ (r = 0.615, P=0.026; r = 0.758, P=0.016).

CONCLUSION

There are intestinal flora disorder and the imbalance of immune function in CRF patients, which are mainly manifested in the change of intestinal flora structure, the increase of richness and diversity of intestinal flora, and the decrease of lymphocyte subgroups. There is correlation between the imbalance of intestinal colony and the imbalance of immune function.

The Impact of Intravenous Iron Supplementation on Hematinic Parameters and Erythropoietin Requirements in Hemodialysis Patients

INTRODUCTION

Anemia is one of the most common complications of chronic kidney disease (CKD). As a result of the side effects of high doses of recombinant human erythropoietin (rhEPO) and the differences in the standard dose of the injectable iron, this study aimed to evaluate the effect of high and low intravenous iron supplementation on hematinic parameters and EPO requirements in patients under hemodialysis.

METHODS

This multicenter, randomized, double-blind clinical trial was conducted on 60 patients with CKD admitted to Sina and 29 Bahman hospitals in Tabriz, Iran in 2019-2020 to undergo hemodialysis. In the two studied groups, low (100 mg/week) and high (400 mg/week) doses of iron were administered and subjects were followed up for 6 months. The incidence of acute myocardial ischemia, stroke, and mortality during 6 months was recorded.

RESULTS

The required rhEPO dosage (mg/week) to maintain hemoglobin levels between 10 and 12 g/dL in the high-dose iron group was significantly decreased during the follow-up period (52,129.03 ± 23,810 vs. 45,760 ± 20,978.71, P ≤ 0.028). Transferrin saturation (TSAT) index had a significant upward trend after iron injection and significant correlations with the serum levels of Fe (r ≥ 0.353, P ≤ 0.007), ferritin (r ≥ 0.315, P ≤ 0.016), and total iron binding capacity (r ≥ 0.219, P < 0.050) during the follow-up period in the studied groups.

CONCLUSION

High-dose intravenous iron (400 mg/week) can reduce the mean dose of rhEPO requirements and increase the TSAT index over a period of 6 months in hemodialysis patients. High-dose IV iron administration can decrease cardiovascular events in hemodialysis patients with iron deficiency anemia.

Magnitude and factors associated with anemia among diabetic patients in Ethiopia: A systematic review and meta-analysis

Background:

In Ethiopia, diabetes is estimated to affect about half a million people. About 35% of individuals with diabetes are complicated by microvascular diseases like retinopathy, nephropathy, cardiovascular, and anemia. Even though there are some studies conducted on prevalence and associated factors of anemia in diabetic patients, their findings were variable. Therefore, this meta-analysis is aimed to determine the pooled prevalence and factors associated with anemia among diabetic patients.

Methods:

PubMed, CINAHL, POPLINE, ScienceDirect, African Journals Online, and Google Scholar were systematically searched to identify related studies. The heterogeneity of studies was assessed using Cochran’s Q test and I² tests. A random-effects model was used to estimate the pooled prevalence of anemia among diabetic patients in Ethiopia. Publication bias was evaluated by employing Egger’s tests.

Results:

After reviewing 503 articles, 6 articles fulfilled inclusion criteria and remained for the final meta-analysis. The pooled prevalence of anemia among diabetic patients was 24.81% (95% confidence interval: 19.38–30.25). Age greater than 60 years old (pooled odds ratio, 95% confidence interval: 3.73 (2.23–6.77)), glomerular filtration rate less than 60 mL/min/1.73 m² (pooled odds ratio, 95% confidence interval: 12.65 (8.71–18.37)), and being diabetic for more than 10 years (pooled odds ratio, 95% confidence interval: 10.21 (7.00–15.04)) were found to be determinants of anemia among diabetic patients in Ethiopia.

Conclusion:

Overall, one in four diabetic patients develops anemia in Ethiopia. Age, glomerular filtration rate, and duration of being diabetic are factors significantly associated with the occurrence of anemia in diabetic patients.