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Sample records for advanced ckd patients

  1. A Simple Tool to Predict ESRD Within 1 Year in Elderly Patients with Advanced CKD

    PubMed Central

    Drawz, Paul E.; Goswami, Puja; Azem, Reem; Babineau, Denise C.; Rahman, Mahboob

    2013-01-01

    BACKGROUND/OBJECTIVES Chronic kidney disease (CKD) is common in older patients; currently, no tools are available to predict the risk of end-stage renal disease (ESRD) within 1 year. The goal of this study was to develop and validate a model to predict the 1 year risk for ESRD in elderly subjects with advanced CKD. DESIGN Retrospective study SETTING Veterans Affairs Medical Center PARTICIPANTS Patients over 65 years of age with CKD with an estimated (eGFR) less than 30mL/min/1.73m2. MEASUREMENTS The outcome was ESRD within 1 year of the index eGFR. Cox regression was used to develop a predictive model (VA risk score) which was validated in a separate cohort. RESULTS Of the 1,866 patients in the developmental cohort, 77 developed ESRD. Risk factors for ESRD in the final model were age, congestive heart failure, systolic blood pressure, eGFR, potassium, and albumin. In the validation cohort, the C index for the VA risk score was 0.823. The risk for developing ESRD at 1 year from lowest to highest tertile was 0.08%, 2.7%, and 11.3% (P<0.001). The C-index for the recently published Tangri model in the validation cohort was 0.780. CONCLUSION A new model using commonly available clinical measures shows excellent ability to predict the onset of ESRD within the next year in elderly subjects. Additionally, the Tangri model had very good predictive ability. Patients and physicians can use these risk models to inform decisions regarding preparation for renal replacement therapy in patients with advanced CKD. PMID:23617782

  2. Phase I Study of CKD-516, a Novel Vascular Disrupting Agent, in Patients with Advanced Solid Tumors

    PubMed Central

    Oh, Do-Youn; Kim, Tae-Min; Han, Sae-Won; Shin, Dong-Yeop; Lee, Yun Gyoo; Lee, Keun-Wook; Kim, Jee Hyun; Kim, Tae-You; Jang, In-Jin; Lee, Jong-Seok; Bang, Yung-Jue

    2016-01-01

    Purpose CKD-516 is a newly developed vascular disrupting agent. This phase I dose-escalation study of CKD-516 was conducted to determine maximum-tolerated dose (MTD), safety, pharmacokinetics, and preliminary antitumor efficacy in patients with advanced solid tumors. Materials and Methods Patients received CKD-516 intravenously on D1 and D8 every 3 weeks, in a standard 3+3 design. Safety was evaluated by National Cancer Institute Common Terminology Criteria for Adverse Events ver. 4.02 and response was assessed by Response Evaluation Criteria in Solid Tumor ver. 1.1. Results Twenty-three patients were treated with CKD-516 at seven dosing levels: 1 mg/m2/day (n=3), 2 mg/m2/day (n=3), 3.3 mg/m2/day (n=3), 5 mg/m2/day (n=3), 7 mg/m2/day (n=3), 9 mg/m2/day (n=6), and 12 mg/m2/day (n=2). Mean age was 54 and 56.5% of patients were male. Two dose-limiting toxicities, which were both grade 3 hypertension, were observed in two patients at 12 mg/m2/day. The MTD was determined as 12 mg/m2/day. Most common adverse events were gastrointestinal adverse events (diarrhea, 34.8% [30.4% grade 1/2, 13.0% grade 3]; nausea, 21.7% [all grade 1/2]; vomiting, 21.7% [all grade 1/2]), myalgia (17.4%, all grade 1/2), and abdominal pain (21.7% [21.7% grade 1/2, 4.3% grade 3]). The pharmacokinetic study showed the dose-linearity of all dosing levels. Among 23 patients, six patients (26.1%) showed stable disease. Median progression-free survival was 39 days (95% confidence interval, 37 to 41 days). Conclusion This study demonstrates feasibility of CKD-516, novel vascular disrupting agent, in patients with advanced solid tumor. MTD of CKD-516 was defined as 12 mg/m2/day on D1 and D8 every 3 weeks. PMID:25715767

  3. Epidemiology and Challenges to the Management of Advanced CKD.

    PubMed

    Hazzan, Azzour D; Halinski, Candice; Agoritsas, Sofia; Fishbane, Steven; DeVita, Maria V

    2016-07-01

    Advanced CKD is a period of CKD that differs greatly from earlier stages of CKD in terms of treatment goals. Treatment during this period presents particular challenges as further loss of kidney function heralds the need for renal replacement therapy. Successful management during this period increases the likelihood of improved transitions to ESRD. However, there are substantial barriers to optimal advanced CKD care. In this review, we will discuss advanced CKD definitions and epidemiology and outcomes. PMID:27324673

  4. Recent advances in understanding the pathogenesis of atherosclerosis in CKD patients.

    PubMed

    Shah, Sudhir V; Shukla, Ashutosh M; Bose, Chhanda; Basnakian, Alexei G; Rajapurkar, Mohan

    2015-03-01

    A need exists for developing new therapies to improve cardiovascular outcomes in end-stage kidney disease. Three new areas that address novel pathophysiological mechanisms and/or therapeutic approaches toward cardiovascular events in chronic kidney disease patients include the use of an anti-inflammatory agent, the role of catalytic iron, and protein carbamylation. In preliminary studies, hydroxychloroquine, which has multiple anti-inflammatory properties, preserved vascular compliance for the aorta and major vessels, as well as reduced the extent of severity of atherosclerosis in ApoE-/- mice. The ability of iron to rapidly and reversibly cycle between 2 oxidation states makes iron potentially hazardous by enabling it to participate in the generation of powerful oxidant species. We have shown that high catalytic iron in the general population is associated with a 4-fold increase in prevalent cardiovascular disease (CVD), even after accounting for traditional risk factors. In addition, the highest levels of catalytic iron are present in dialysis patients and, more specifically, patients with prevalent CVD have several-fold higher catalytic iron levels compared with controls without CVD. These data suggest the utility of iron chelators for preventing and treating CVD in patients with chronic kidney disease and should be further investigated. Carbamylation of proteins results from nonenzymatic chemical modification by isocyanic acid derived from urea and an alternative route, the myeloperoxidase-catalyzed oxidation of thiocyanate. We have shown carbamylated low-density lipoprotein to have all the major biological effects relevant to atherosclerosis including endothelial cell injury, increased expression of cell adhesion molecules, and vascular smooth muscle cell proliferation. In 2 separate clinical studies, plasma levels of carbamylated protein independently predicted an increased risk of CVD and death. PMID:25556310

  5. Adult Height in Patients with Advanced CKD Requiring Renal Replacement Therapy during Childhood

    PubMed Central

    Harambat, Jérôme; Bonthuis, Marjolein; van Stralen, Karlijn J.; Ariceta, Gema; Battelino, Nina; Bjerre, Anna; Jahnukainen, Timo; Leroy, Valérie; Reusz, György; Sandes, Ana R.; Sinha, Manish D.; Groothoff, Jaap W.; Combe, Christian; Jager, Kitty J.; Verrina, Enrico; Schaefer, Franz

    2014-01-01

    Summary Background and objectives Growth and final height are of major concern in children with ESRD. This study sought to describe the distribution of adult height of patients who started renal replacement therapy (RRT) during childhood and to identify determinants of final height in a large cohort of RRT children. Design, setting, participants, & measurements A total of 1612 patients from 20 European countries who started RRT before 19 years of age and reached final height between 1990 and 2011 were included. Linear regression analyses were performed to calculate adjusted mean final height SD score (SDS) and to investigate its potential determinants. Results The median final height SDS was −1.65 (median of 168 cm in boys and 155 cm in girls). Fifty-five percent of patients attained an adult height within the normal range. Adjusted for age at start of RRT and primary renal diseases, final height increased significantly over time from −2.06 SDS in children who reached adulthood in 1990–1995 to −1.33 SDS among those reaching adulthood in 2006–2011. Older age at start of RRT, more recent period of start of RRT, cumulative percentage time on a functioning graft, and greater height SDS at initiation of RRT were independently associated with a higher final height SDS. Patients with congenital anomalies of the kidney and urinary tract and metabolic disorders had a lower final height than those with other primary renal diseases. Conclusions Although final height remains suboptimal in children with ESRD, it has consistently improved over time. PMID:24178977

  6. Conservative Care of the Elderly CKD Patient: A Practical Guide.

    PubMed

    Raghavan, Divya; Holley, Jean L

    2016-01-01

    Palliative care is a branch of medicine dedicated to the relief of symptoms experienced during the course of illness. Renal palliative medicine or kidney supportive care is an evolving branch of nephrology, which incorporates the principles of palliative care into the care of CKD and ESRD (dialysis, transplant, and conservatively managed) patients. Conservative (non-dialytic) management is a legitimate option for frail, elderly CKD patients in whom dialysis may not lead to an improvement in quality or duration of life. Patients with advanced CKD have a high symptom burden that often worsens before death. Palliative or supportive care by visiting nurses, palliative care programs, or knowledgeable CKD programs should be routine for conservatively managed CKD patients. Decision-making about dialysis or conservative management requires patients and families be given information on prognosis, quality of life on dialysis, and options for supportive care. Advance care planning is the process by which these issues can be explored. In addition to advance care planning, because patients with ESRD have a high symptom burden, this needs to be addressed. Patients with ESRD have a high symptom burden, which needs to be addressed in any treatment plan. Common symptoms include pain, fatigue, insomnia, pruritus, anorexia, and nausea. Symptoms appear to increase as the patient nears death, and this must be anticipated. Recommendations for management are discussed in the article. Hospice care should be offered to all patients who are expected to die within the next 6 months, and supportive care should be provided to all CKD patients managed conservatively or with dialysis. PMID:26709063

  7. Epidemiology of CKD Regression in Patients under Nephrology Care

    PubMed Central

    Borrelli, Silvio; Leonardis, Daniela; Minutolo, Roberto; Chiodini, Paolo; De Nicola, Luca; Esposito, Ciro; Mallamaci, Francesca; Zoccali, Carmine; Conte, Giuseppe

    2015-01-01

    Chronic Kidney Disease (CKD) regression is considered as an infrequent renal outcome, limited to early stages, and associated with higher mortality. However, prevalence, prognosis and the clinical correlates of CKD regression remain undefined in the setting of nephrology care. This is a multicenter prospective study in 1418 patients with established CKD (eGFR: 60–15 ml/min/1.73m²) under nephrology care in 47 outpatient clinics in Italy from a least one year. We defined CKD regressors as a ΔGFR ≥0 ml/min/1.73 m2/year. ΔGFR was estimated as the absolute difference between eGFR measured at baseline and at follow up visit after 18–24 months, respectively. Outcomes were End Stage Renal Disease (ESRD) and overall-causes Mortality.391 patients (27.6%) were identified as regressors as they showed an eGFR increase between the baseline visit in the renal clinic and the follow up visit. In multivariate regression analyses the regressor status was not associated with CKD stage. Low proteinuria was the main factor associated with CKD regression, accounting per se for 48% of the likelihood of this outcome. Lower systolic blood pressure, higher BMI and absence of autosomal polycystic disease (PKD) were additional predictors of CKD regression. In regressors, ESRD risk was 72% lower (HR: 0.28; 95% CI 0.14–0.57; p<0.0001) while mortality risk did not differ from that in non-regressors (HR: 1.16; 95% CI 0.73–1.83; p = 0.540). Spline models showed that the reduction of ESRD risk associated with positive ΔGFR was attenuated in advanced CKD stage. CKD regression occurs in about one-fourth patients receiving renal care in nephrology units and correlates with low proteinuria, BP and the absence of PKD. This condition portends better renal prognosis, mostly in earlier CKD stages, with no excess risk for mortality. PMID:26462071

  8. Cardiovascular Complications in CKD Patients: Role of Oxidative Stress

    PubMed Central

    Gosmanova, Elvira O.; Le, Ngoc-Anh

    2011-01-01

    Starting with the early stages, patients with chronic kidney disease (CKD) experience higher burden of cardiovascular disease (CVD). Moreover, CVD complications are the major cause of mortality in CKD patients as compared with complications from chronic kidney failure. While traditional CVD risk factors, including diabetes, hypertension, hyperlipidemia, obesity, physical inactivity, may be more prevalent among CKD patients, these factors seem to underestimate the accelerated cardiovascular disease in the CKD population. Search for additional biomarkers that could explain the enhanced CVD risk in CKD patients has gained increasing importance. Although it is unlikely that any single nontraditional risk factor would fully account for the increased CVD risk in individuals with CKD, oxidative stress appears to play a central role in the development and progression of CVD and its complications. We will review the data that support the contribution of oxidative stress in the pathogenesis of CVD in patients with chronic kidney failure. PMID:21253517

  9. Are currently GFR estimating equations and standard Kt/V value adequate for advanced chronic kidney disease (CKD) frail elderly patients?

    PubMed

    Musso, Carlos G; Alvarez-Gregori, Joaquin; Jauregui, Jose; Núñez, Juan F Macías

    2015-07-01

    Chronic kidney disease (CKD) elderly patients have a reduced glomerular filtration rate (GFR) due to the combination of ageing and chronic nephropathy damage. This situation is very important to be taken into account in order to prescribe an adequate medication and dialysis dose in this aged group. Besides, cognitive and urinary incontinence problems make difficult to obtain an adequate 24-h urine collection in order to evaluate creatinine clearance in this group. Thus, a reliable GFR estimating equation would be very useful for assisting elderly CKD patients. Additionally, Kt/V is the main parameter currently used for dosing dialysis in stage V CKD young and elderly patients. However, frailty and sarcopenia are prevalent disorders usually suffered by old people, who also present many physiological changes that could make GFR estimating equations and standard Kt/V value to become unreliable in this particular group. In conclusion, based on all these facts, it seems crucial for clinical geriatric nephrology to carefully evaluate how reliable current GFR estimating equations are, as well as which would be an adequate Kt/V value in CKD frail elderly patients. PMID:25993909

  10. Iron Therapy Challenges for the Treatment of Nondialysis CKD Patients.

    PubMed

    Locatelli, Francesco; Mazzaferro, Sandro; Yee, Jerry

    2016-07-01

    The clinical consequences of untreated, severe anemia in patients with nondialysis CKD can be significant, but disparities exist in the anemia treatment guidelines and position papers issued from working groups and associations across the world. These differ in hemoglobin target and iron levels and their emphasis on various iron markers and other clinical outcomes. Not surprisingly, disparities are observed in anemia treatment strategies among patients with nondialysis CKD across different areas of the world. Over the past decade, the prescription and dosage of both iron therapies and erythropoiesis-stimulating agents have shifted, with notable regional differences observed. Moreover, there is ongoing debate regarding oral versus intravenous administration of iron. Compared with oral iron therapy, which often leads to gastrointestinal adverse events, low patient adherence, and low efficacy, intravenous iron administration has been associated with potential serious adverse events, such as anaphylaxis. New iron-based compounds and drugs currently under development are reviewed to describe their potential benefits in the treatment of anemia in patients with CKD. New oral compounds, including iron-based phosphate binders, heme iron polypeptide, and liposomal iron, show different rates of absorption with possibly different efficacy and improved tolerability. These new potential therapies offer health care providers additional anemia treatment options for their patients with CKD; however, the management of anemia in the CKD population continues to present challenges that require prospective studies to identify the optimal iron therapy for patients. PMID:27185524

  11. Patient-Reported and Actionable Safety Events in CKD

    PubMed Central

    Ginsberg, Jennifer S.; Zhan, Min; Diamantidis, Clarissa J.; Woods, Corinne; Chen, Jingjing

    2014-01-01

    Patients with CKD are at high risk for adverse safety events because of the complexity of their care and impaired renal function. Using data from our observational study of predialysis patients with CKD enrolled in the Safe Kidney Care study, we estimated the baseline frequency of adverse safety events and determined to what extent these events co-occur. We examined patient-reported adverse safety incidents (class I) and actionable safety findings (class II), conditioned on participant use of drugs that might cause such an event, and we used association analysis as a data-mining technique to identify co-occurrences of these events. Of 267 participants, 185 (69.3%) had at least one class I or II event, 102 (38.2%) had more than one event, and 48 (18.0%) had at least one event from both classes. The adjusted conditional rates of class I and class II events ranged from 2.9 to 57.6 per 100 patients and from 2.2 to 8.3 per 100 patients, respectively. The most common conditional class I and II events were patient-reported hypoglycemia and hyperkalemia (serum potassium>5.5 mEq/L), respectively. Reporting of hypoglycemia (in patients with diabetes) and falling or severe dizziness (in patients without diabetes) were most frequently paired with other adverse safety events. We conclude that adverse safety events are common and varied in CKD, with frequent association between disparate events. Further work is needed to define the CKD “safety phenotype” and identify patients at highest risk for adverse safety events. PMID:24556352

  12. Vascular Calcification in Patients with Nondialysis CKD over 3 Years

    PubMed Central

    Molina, Pablo; Cerverón, M. Jesús; Vila, Rocío; Bover, Jordi; Nieto, Javier; Barril, Guillermina; Martínez-Castelao, Alberto; Fernández, Elvira; Escudero, Verónica; Piñera, Celestino; Adragao, Teresa; Navarro-Gonzalez, Juan F.; Molinero, Luis M.; Castro-Alonso, Cristina; Pallardó, Luis M.; Jamal, Sophie A.

    2015-01-01

    Background and objectives Vascular calcification (VC) is common in CKD, but little is known about its prognostic effect on patients with nondialysis CKD. The prevalence of VC and its ability to predict death, time to hospitalization, and renal progression were assessed. Design, setting, participants, & measurements The Study of Mineral and Bone Disorders in CKD in Spain is a prospective, observational, 3-year follow-up study of 742 patients with nondialysis CKD stages 3–5 from 39 centers in Spain from April to May 2009. VC was assessed using Adragao (AS; x-ray pelvis and hands) and Kauppila (KS; x-ray lateral lumbar spine) scores from 572 and 568 patients, respectively. The primary end point was death. Secondary outcomes were hospital admissions and appearance of a combined renal end point (beginning of dialysis or drop >30% in eGFR). Factors related to VC were assessed by logistic regression analysis. Survival analysis was assessed by Cox proportional models. Results VC was present in 79% of patients and prominent in 47% (AS≥3 or KS>6). Age (odds ratio [OR], 1.05; 95% confidence interval [95% CI], 1.02 to 1.07; P<0.001), phosphorous (OR, 1.68; 95% CI, 1.28 to 2.20; P<0.001), and diabetes (OR, 2.11; 95% CI, 1.32 to 3.35; P=0.002) were independently related to AS≥3. After a median follow-up of 35 months (interquartile range=17–36), there were 70 deaths (10%). After multivariate adjustment for age, smoking, diabetes, comorbidity, renal function, and level of phosphorous, AS≥3 but not KS>6 was independently associated with all-cause (hazard ratio [HR], 2.07; 95% CI, 1.07 to 4.01; P=0.03) and cardiovascular (HR, 3.46; 95% CI, 1.27 to 9.45; P=0.02) mortality as well as a shorter hospitalization event–free period (HR, 1.14; 95% CI, 1.06 to 1.22; P<0.001). VC did not predict renal progression. Conclusions VC is highly prevalent in patients with CKD. VC assessment using AS independently predicts death and time to hospitalization. Therefore, it could be a useful

  13. [Is it possible to-predict fracture in CKD patients?].

    PubMed

    Tsukamoto, Yusuke

    2016-09-01

    Routine examination of bone mineral density(BMD)by DXA(dual energy X-ray absorptiometry)is useful to predict bone fracture in both CKD nondialysis and dialysis patients. The cutoff value of BMD to predict bone fracture is different between genders and its predictive power is better in patients with lower serum PTH levels than higher counterpart. Increase in serum bone specific alkaline phosphatase is a better predictor of the bone fracture than serum PTH levels. PMID:27561344

  14. [Sarcopenia or uremic myopathy in CKD patients].

    PubMed

    Chauveau, Philippe; Moreau, Karine; Lasseur, Catherine; Fouque, Denis; Combe, Christian; Aparicio, Michel

    2016-04-01

    Often underestimated or misunderstood in chronic renal failure (CRF), muscle wasting is nevertheless common and concerns about 50% of dialysis patients. The consequences of this myopathy on quality of life and outcomes of patients are unfavorable, identical to those observed in sarcopenia in elderly subjects with sarcopenia. The similarities between the two situations also concern the symptoms, the underlying muscle damages and the pathogenic mechanisms and may be partly explained by the frequently high age of ESRD patients. Skeletal muscle involvement should be systematically investigated in the IRC patient as in the elderly with sarcopenia to propose as early as possible a treatment of which physical activity and nutritional interventions are the mainstay. PMID:26598033

  15. Association of advanced age with concentrations of uraemic toxins in CKD.

    PubMed

    Rroji, Merita; Eloot, Sunny; Dhondt, Annemie; Van Biesen, Wim; Glorieux, Griet; Neirynck, Nathalie; Vandennoortgate, Nele; Liabeuf, Sophie; Massy, Ziad; Vanholder, Raymond

    2016-02-01

    To our knowledge, there are no studies on advanced chronic kidney disease (CKD) analysing the impact of ageing on serum concentrations of uraemic toxins while adjusting for renal function. Knowledge of this feature, however, could influence prognostic assessment and therapeutic decision-making, e.g. about when to start dialysis or how intensive it should be. Indeed, the slowing down of metabolism with age may result in lower uraemic toxin concentrations, hence reducing their toxic effects. In this case, a later start of dialysis or less intensive dialysis may become justified in an already fragile population that might enjoy a better quality of life without a survival disadvantage with conservative treatment. We assessed the impact of advancing age on uraemic solute concentrations [blood, urea, nitrogen (BUN), uric acid, creatinine, asymmetric and symmetric dimethylarginine (ADMA and SDMA), β2-microglobulin and a large array of protein-bound solutes] by matching 126 maintenance haemodialysis patients subdivided into two age-groups, younger vs. older (using the median as cut-off: 72 years). Concentrations were compared after age stratification and were matched with patient and dialysis characteristics. In addition, 93 non-dialysed CKD patients (median as cut-off: 70 years), with a comparable average estimated glomerular filtration rate (eGFR) between younger and older age-groups, were analysed. In haemodialysis patients, carboxy-methyl-furanpropionic acid (CMPF) levels were markedly higher and BUN and uric acid borderline lower in the older age-group. All other solutes showed no difference. At multifactor analysis, the concentration of several uraemic toxins was associated with residual renal function and protein intake in the overall haemodialysis group and the younger group, but the association with most solutes, especially those protein-bound, was lost in the older age-group. No differences were found in non-dialysed CKD patients. It was concluded that in this

  16. CKD and Its Risk Factors among Patients with Cystinuria

    PubMed Central

    Prot-Bertoye, Caroline; Lebbah, Saïd; Daudon, Michel; Tostivint, Isabelle; Bataille, Pierre; Bridoux, Franck; Brignon, Pierre; Choquenet, Christian; Cochat, Pierre; Combe, Christian; Conort, Pierre; Decramer, Stéphane; Doré, Bertrand; Dussol, Bertrand; Essig, Marie; Gaunez, Nicolas; Joly, Dominique; Le Toquin-Bernard, Sophie; Méjean, Arnaud; Meria, Paul; Morin, Denis; N’Guyen, Hung Viet; Noël, Christian; Normand, Michel; Pietak, Michel; Ronco, Pierre; Saussine, Christian; Tsimaratos, Michel; Friedlander, Gérard; Traxer, Olivier; Knebelmann, Bertrand

    2015-01-01

    Background and objectives Cystinuria is an autosomal recessive disorder affecting renal cystine reabsorption; it causes 1% and 8% of stones in adults and children, respectively. This study aimed to determine epidemiologic and clinical characteristics as well as comorbidities among cystinuric patients, focusing on CKD and high BP. Design, setting, participants, & measurements This retrospective study was conducted in France, and involved 47 adult and pediatric nephrology and urology centers from April 2010 to January 2012. Data were collected from 442 cystinuric patients. Results Median age at onset of symptoms was 16.7 (minimum to maximum, 0.3–72.1) years and median diagnosis delay was 1.3 (0–45.7) years. Urinary alkalinization and cystine-binding thiol were prescribed for 88.8% and 52.2% of patients, respectively, and 81.8% had at least one urological procedure. Five patients (1.1%, n=4 men) had to be treated by dialysis at a median age of 35.0 years (11.8–70.7). Among the 314 patients aged ≥16 years, using the last available plasma creatinine, 22.5% had an eGFR≥90 ml/min per 1.73 m2 (calculated by the Modification of Diet in Renal Disease equation), whereas 50.6%, 15.6%, 7.6%, 2.9%, and 0.6% had an eGFR of 60–89, 45–59, 30–44, 15–29, and <15, respectively. Among these 314 patients, 28.6% had high BP. In multivariate analysis, CKD was associated with age (odds ratio, 1.05 [95% confidence interval, 1.03 to 1.07]; P<0.001), hypertension (3.30 [1.54 to 7.10]; P=0.002), and severe damage of renal parenchyma defined as a past history of partial or total nephrectomy, a solitary congenital kidney, or at least one kidney with a size <10 cm in patients aged ≥16 years (4.39 [2.00 to 9.62]; P<0.001), whereas hypertension was associated with age (1.06 [1.04 to 1.08]; P<0.001), male sex (2.3 [1.3 to 4.1]; P=0.003), and an eGFR<60 ml/min per 1.73 m2 (2.7 [1.5 to 5.1]; P=0.001). Conclusions CKD and high BP occur frequently in patients with cystinuria and

  17. Differential impact of peripheral endothelial dysfunction on subsequent cardiovascular events following percutaneous coronary intervention between chronic kidney disease (CKD) and non-CKD patients.

    PubMed

    Tabata, Noriaki; Hokimoto, Seiji; Akasaka, Tomonori; Arima, Yuichiro; Sakamoto, Kenji; Yamamoto, Eiichiro; Tsujita, Kenichi; Izumiya, Yasuhiro; Yamamuro, Megumi; Kojima, Sunao; Kaikita, Koichi; Ogawa, Hisao

    2016-07-01

    Chronic kidney disease (CKD) status might modify the predictive effect of peripheral endothelial dysfunction on cardiovascular events after percutaneous coronary intervention (PCI). The aim of this study was to examine the differential effect of peripheral endothelial dysfunction on clinical outcome after PCI between CKD and non-CKD patients. We conducted a cohort study of 435 patients following PCI. CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m(2). Peripheral endothelial dysfunction was examined using reactive hyperemia-peripheral arterial tonometry index (RHI), and we divided patients into low- and high-natural logarithmic RHI (Ln-RHI) group. The endpoint was a composite of cardiovascular death, nonfatal myocardial infarction, ischemic stroke, hospitalization due to unstable angina pectoris, and coronary revascularization. A total of 56 patients had a cardiovascular event. Patients who suffered a cardiovascular event had significantly lower Ln-RHI than other patients in the non-CKD group (0.46 ± 0.18 versus 0.60 ± 0.25; P = 0.002). Kaplan-Meier analysis demonstrated a significantly higher probability of cardiovascular events in low Ln-RHI patients in the non-CKD group (log-rank test: P = 0.003). Multivariate Cox proportional hazards analysis identified Ln-RHI as an independent and significant predictor of future cardiovascular events in the non-CKD group (HR: 0.096; 95 % CI 0.02-0.47; P = 0.004) but not in the CKD group. There was a differential effect of peripheral endothelial dysfunction on clinical outcome after PCI between CKD and non-CKD patients, and peripheral endothelial dysfunction significantly correlates with subsequent cardiovascular events after PCI in non-CKD patients. PMID:26164597

  18. [New Developments in CKD-MBD. Imbalance of myocardial oxygen supply and demand in CKD patients with cardiovascular calcification].

    PubMed

    Joki, Nobuhiko; Hayashi, Toshihide

    2014-12-01

    Cardiovascular calcification is well known as an important factor for poor prognosis in CKD patients. It is not well understood why even no significant narrowing the presence of vascular calcification have a great impact for tissue ischemia, especially myocardial ischemia. Many studies have demonstrated that the presence of coronary calcification, aortic calcification, arterial calcification and aortic valve calcification is susceptible to induce an imbalance of myocardial oxygen supply and demand. PMID:25423922

  19. Controversies Regarding Lipid Management and Statin Use for Cardiovascular Risk Reduction in Patients With CKD.

    PubMed

    Markossian, Talar; Burge, Nicholas; Ling, Benjamin; Schneider, Julia; Pacold, Ivan; Bansal, Vinod; Leehey, David; Stroupe, Kevin; Chang, Alex; Kramer, Holly

    2016-06-01

    Adults with chronic kidney disease (CKD) are at heightened risk for dying of cardiovascular disease. Results from randomized clinical trials of statin drugs versus placebo demonstrate that statin drugs or statin plus ezetimibe reduce the absolute risk for coronary heart disease and mortality among adults with non-dialysis-dependent CKD. The Kidney Disease: Improving Global Outcomes 2013 clinical practice guideline for lipid management in CKD recommends that adults 50 years or older with non-dialysis-dependent CKD be treated with a statin or statin plus ezetimibe regardless of low-density lipoprotein cholesterol levels. However, at least 9 guidelines published during the last 5 years address lipid management for primary and secondary prevention of atherosclerotic cardiovascular disease, and not all guidelines address the utility of lipid-lowering therapy in adults with CKD. Because most patients with CKD receive most of their clinical care from non-nephrologists, differences in recommendations for lipid-lowering therapy for cardiovascular disease prevention may negatively affect the clinical care of adults with CKD and cause confusion for both patients and providers. This review addresses the identification and management of lipid levels in patients with CKD and discusses the existing controversies regarding testing and treatment of lipid levels in the CKD population. PMID:26943983

  20. Life-Time Risk, Screening and The Cost of Cardiovascular Comorbidities in CKD Patients.

    PubMed

    Zoccali, Carmine; Abd ElHafeez, Samar; Dounousi, Evangelia; Anastasi, Rossana; Tripepi, Giovanni; Mallamaci, Francesca

    2015-01-01

    CKD is a problem of epidemic dimension. The risk of death and cardiovascular complications in this condition is of the same order of that by myocardial infarction, which qualifies CKD as "risk equivalent". Calculations made on the basis of the epidemiological data of the MONICA-Augsburg study and analyses of the costs of myocardial infarction in a large health insurance company in Germany show that the economic burden of cardiovascular comorbidities with CKD in this country is substantial. These estimates, which may be valid also for other large member states of the European Community, represent a call for studies looking at the cost-effectiveness of preventive interventions aimed at reducing the risk for CKD and at lowering the concerning incidence rate of death and disability due to CKD-triggered cardiovascular complications in CKD patients. PMID:27442374

  1. Association of low potassium diet and folic acid deficiency in patients with CKD

    PubMed Central

    Hassan, Kamal

    2015-01-01

    Background Most of the folic acid sources are rich also in potassium. Patients with chronic kidney disease (CKD) usually receive a low potassium diet. We investigated the possibility of an association between low potassium diet and folic acid deficiency. Methods In total, 128 CKD patients participated in this cross-sectional study. Sixty-four patients with CKD grades 1 and 2 were on an unrestricted potassium diet when enrolled in the study, and 64 patients with CKD grades 3 and 4 had received instructions to restrict their intake of potassium at least 6 months before enrollment in the study. Subjects were evaluated for daily intake of folic acid (DIFA), daily intake of potassium (DIK), and serum folic acid levels (SFA). Results DIFA correlated with the estimated glomerular filtration rate, the DIK, and the SFA (P<0.001). SFA correlated with the estimated glomerular filtration rate (P<0.001). Mean DIFA and mean SFA were lower among patients with CKD grades 3 and 4 than among those with CKD grades 1 and 2 (P<0.001). The mean DIFA in patients with folic acid deficiency was lower than that in those with SFA ≥7.1 nmol/L (P<0.001). There was lower SFA and threefold greater frequency of folic acid deficiency among patients with CKD grades 3 and 4 who had received instructions to restrict their intake of potassium than among patients with CKD grades 1 and 2 who were on an unrestricted potassium diet. Conclusion A potassium-restricted diet offered to patients with CKD grades 3 and 4 may be associated with folic acid deficiency. Serum levels of folic acid should be investigated before starting potassium restriction in patients with CKD grades 3 and 4, in order to identify individuals with folic acid deficiency or with marginal serum levels who should receive folic acid replacement therapy. PMID:26056461

  2. A Retrospective Case-Control Analysis of the Outpatient Expenditures for Western Medicine and Dental Treatment Modalities in CKD Patients in Taiwan

    PubMed Central

    Huang, Ren-Yeong; Lin, Yuh-Feng; Kao, Sen-Yeong; Shieh, Yi-Shing; Chen, Jin-Shuen

    2014-01-01

    Background To determine if expenditures for dentistry (DENT) correlate with severity of chronic kidney disease (CKD). Methods A total of 10,457 subjects were enrolled from January 2008 to December 2010, divided into three groups: healthy control (HC) group (n = 1,438), high risk (HR) group (n = 3,392), and CKD group (n = 5,627). Five stages were further categorized for the CKD group. OPD utilization and expenditures for western medicine (WM), DENT, and TCM (traditional Chinese medicine) were analyzed retrospectively (2000–2008) using Taiwan's National Health Insurance Research Database. Three major areas were analyzed among groups CKD, HR and HC in this study: 1) demographic data and medical history; 2) utilization (visits/person/year) and expenditures (9-year cumulative expenditure, expenditure/person/year) for OPD services in WM, DENT, and TCM; and 3) utilization and expenditures for dental OPD services, particularly in dental filling, root canal and periodontal therapy. Results OPD utilization and expenditures of WM increased significantly for the CKD group compared with the HR and HC groups, and increased steadily along with the severity of CKD stages. However, overall DENT and TCM utilization and expenditures did not increase for the CKD group. In comparison among different CKD stages, the average expenditures and utilization for DENT including restorative filling and periodontal therapy, but not root canal therapy, showed significant decreases according to severity of CKD stage, indicating less DENT OPD utilization with progression of CKD. Conclusions Patients with advanced CKD used DENT OPD service less frequently. However, the connection between CKD and DENT service utilization requires further study. PMID:24533085

  3. Educating Patients about CKD: The Path to Self-Management and Patient-Centered Care.

    PubMed

    Narva, Andrew S; Norton, Jenna M; Boulware, L Ebony

    2016-04-01

    Patient education is associated with better patient outcomes and supported by international guidelines and organizations, but a range of barriers prevent widespread implementation of comprehensive education for people with progressive kidney disease, especially in the United States. Among United States patients, obstacles to education include the complex nature of kidney disease information, low baseline awareness, limited health literacy and numeracy, limited availability of CKD information, and lack of readiness to learn. For providers, lack of time and clinical confidence combine with competing education priorities and confusion about diagnosing CKD to limit educational efforts. At the system level, lack of provider incentives, limited availability of practical decision support tools, and lack of established interdisciplinary care models inhibit patient education. Despite these barriers, innovative education approaches for people with CKD exist, including self-management support, shared decision making, use of digital media, and engaging families and communities. Education efficiency may be increased by focusing on people with progressive disease, establishing interdisciplinary care management including community health workers, and providing education in group settings. New educational approaches are being developed through research and quality improvement efforts, but challenges to evaluating public awareness and patient education programs inhibit identification of successful strategies for broader implementation. However, growing interest in improving patient-centered outcomes may provide new approaches to effective education of people with CKD. PMID:26536899

  4. To Your Health: NLM update transcript - Salt linked to heart disease among CKD patients

    MedlinePlus

    ... transcript072516.html To Your Health: NLM update Transcript Salt linked to heart disease among CKD patients : 07/ ... kidney disease - and eat a diet high in salt - comparatively increase their odds of a heart attack ...

  5. Cardiovascular risk in chronic kidney disease (CKD): the CKD-mineral bone disorder (CKD-MBD).

    PubMed

    Hruska, Keith A; Choi, Eric T; Memon, Imran; Davis, T Keefe; Mathew, Suresh

    2010-04-01

    Recent advances in our understanding of the excess mortality of chronic kidney disease (CKD) due to cardiovascular complications, obtained through observational studies, demonstrate that vascular calcification and hyperphosphatemia are major cardiovascular risk factors. Mechanistic studies demonstrate that these two risk factors are related and that hyperphosphatemia directly stimulates vascular calcification. The role of hyperphosphatemia in stimulating vascular calcification in CKD is associated with a block to the skeletal reservoir function in phosphate balance due to excess bone resorption. This has led to the realization that renal osteodystrophy is linked to vascular calcification by disordered mineral homeostasis (phosphate) and that a multiorgan system fails in CKD, leading to cardiovascular mortality. In children with renal disease, the multiorgan system fails, just as in adults, but the outcomes have been less well studied, and perceptions of differences from adults are possibly incorrect. Vascular calcification and cardiovascular mortality are less prevalent among pediatric patients, but they are present. However, CKD-induced vascular disease causes stiffness of the arterial tree causing, in turn, systolic hypertension and left ventricular hypertrophy as early manifestations of the same pathology in the adult. Because of the role of the skeleton in these outcomes, renal osteodystrophy has been renamed as the CKD mineral bone disorder (CKD-MBD). This review, which focuses on the pediatric patient population, describes our current state of knowledge with regards to the pathophysiology of the CKD-MBD, including the new discoveries related to early stages of CKD. As a new necessity, cardiovascular function issues are incorporated into the CKD-MBD, and new advances in our knowledge of this critical component of the disorder will lead to improved outcomes in CKD. PMID:19898875

  6. Contrast-Induced Nephropathy After Computed Tomography in Stable CKD Patients With Proper Prophylaxis

    PubMed Central

    Park, Sehoon; Kim, Myoung-Hee; Kang, Eunjeong; Park, Seokwoo; Jo, Hyung Ah.; Lee, Hajeong; Kim, Sun Moon.; Lee, Jung Pyo.; Oh, Kook-Hwan; Joo, Kwon Wook.; Kim, Yon Su.; Kim, Dong Ki.

    2016-01-01

    Abstract Conflicting data have been reported on the clinical significance of contrast-induced nephropathy after CT scan (CT-CIN). In addition, the epidemiologic characteristics and clinical outcomes of CT-CIN following proper prophylactic intervention remain elusive. We examined the incidence, risk factors, and outcomes of CT-CIN in stable chronic kidney disease (CKD) patients using data collected from our outpatient CT-CIN prophylaxis program conducted between 2007 and 2014. The program recruited patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 using an electronic health record-based pop-up alert system and provided an identical protocol of CIN prophylaxis to all patients. A total of 1666 subjects were included in this study, and 61 of the 1666 subjects (3.7%) developed CT-CIN. Multivariate analysis showed that baseline eGFR, diabetes mellitus, and low serum albumin were significant risk factors for CT-CIN. The generalized additive model analysis revealed a nonlinear relationship between the baseline eGFR and the risk of CT-CIN. In this analysis, the risk of CT-CIN began to increase below an eGFR threshold of 36.8 mL/min/1.73 m2. To assess the outcomes of CT-CIN, patients with and without CT-CIN were compared after propensity score-based 1:2 matching. CT-CIN did not increase the mortality rate of patients. However, patients with CT-CIN were significantly more likely to start dialysis within 6 months of follow-up, but not after those initial 6 months. CT-CIN developed in only a small number of stable CKD patients who received proper prophylactic intervention, and the risk of CT-CIN was increased in patients with more advanced CKD. Despite the low incidence, CT-CIN conferred a non-negligible risk for the initiation of dialysis in the acute period, even after prophylaxis. PMID:27149474

  7. Understanding CKD among patients with T2DM: prevalence, temporal trends, and treatment patterns—NHANES 2007–2012

    PubMed Central

    Wu, Bingcao; Bell, Kelly; Stanford, Amy; Kern, David M; Tunceli, Ozgur; Vupputuri, Suma; Kalsekar, Iftekhar; Willey, Vincent

    2016-01-01

    Objective To describe the estimated prevalence and temporal trends of chronic kidney disease (CKD) treatment patterns, and the association between CKD and potential factors for type 2 diabetes mellitus (T2DM) in different demographic subgroups. Research design and methods This was a cross-sectional analysis of adults with T2DM based on multiple US National Health and Nutrition Examination Survey (NHANES) datasets developed during 2007–2012. CKD severity was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 guidelines using the CKD Epidemiology Collaboration (CKD-EPI) equation: mild to moderate=stages 1–3a; moderate to kidney failure=stages 3b–5. Multivariable logistic regression analyses were performed to assess the associations between CKD and potential factors. Results Of the adult individuals with T2DM (n=2006), age-adjusted CKD prevalence was 38.3% during 2007–2012; 77.5% were mild-to-moderate CKD. The overall age-adjusted prevalence of CKD was 40.2% in 2007–2008, 36.9% in 2009–2010, and 37.6% in 2011–2012. The prevalence of CKD in T2DM was 58.7% in patients aged ≥65 years, 25.7% in patients aged <65 years, 43.5% in African-Americans and Mexican-Americans, and 38.7% in non-Hispanic whites. The use of antidiabetes and antihypertensive medications generally followed treatment guideline recommendations. Older age, higher hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and having hypertension were significantly associated with CKD presence but not increasing severity of CKD. Conclusions CKD continued to be prevalent in the T2DM population; prevalence remained fairly consistent over time, suggesting that current efforts to prevent CKD could be improved overall, especially by monitoring certain populations more closely. PMID:27110365

  8. Uremic Retention Solute Indoxyl Sulfate Level Is Associated with Prolonged QTc Interval in Early CKD Patients

    PubMed Central

    Tang, Wei-Hua; Wang, Chao-Ping; Chung, Fu-Mei; Huang, Lynn L. H.; Yu, Teng-Hung; Hung, Wei-Chin; Lu, Li-Fen; Chen, Po-Yuan; Luo, Ching-Hsing; Lee, Kun-Tai; Lee, Yau-Jiunn; Lai, Wen-Ter

    2015-01-01

    Total mortality and sudden cardiac death is highly prevalent in patients with chronic kidney disease (CKD). In CKD patients, the protein-bound uremic retention solute indoxyl sulfate (IS) is independently associated with cardiovascular disease. However, the underlying mechanisms of this association have yet to be elucidated. The relationship between IS and cardiac electrocardiographic parameters was investigated in a prospective observational study among early CKD patients. IS arrhythmogenic effect was evaluated by in vitro cardiomyocyte electrophysiological study and mathematical computer simulation. In a cohort of 100 early CKD patients, patients with corrected QT (QTc) prolongation had higher IS levels. Furthermore, serum IS level was independently associated with prolonged QTc interval. In vitro, the delay rectifier potassium current (IK) was found to be significantly decreased after the treatment of IS in a dose-dependent manner. The modulation of IS to the IK was through the regulation of the major potassium ion channel protein Kv 2.1 phosphorylation. In a computer simulation, the decrease of IK by IS could prolong the action potential duration (APD) and induce early afterdepolarization, which is known to be a trigger mechanism of lethal ventricular arrhythmias. In conclusion, serum IS level is independently associated with the prolonged QTc interval in early CKD patients. IS down-regulated IK channel protein phosphorylation and the IK current activity that in turn increased the cardiomyocyte APD and QTc interval in vitro and in the computer ORd model. These findings suggest that IS may play a role in the development of arrhythmogenesis in CKD patients. PMID:25893644

  9. Prevalence and Risk Factors of CKD in Chinese Patients with Periodontal Disease

    PubMed Central

    Chen, Wei; Liang, Mengjun; Luo, Wei; Wu, Xianfeng; Ruan, Yiping; Wang, Jie; Xu, Ricong; Zhan, Xiaojiang; Yu, Jianwen; Tan, Jiaqing; Dong, Xiuqing; Zhang, Jincai; Yu, Xueqing

    2013-01-01

    Background Periodontal disease is common among adults and is associated with an increasing risk of chronic kidney disease (CKD). We aimed to investigate the prevalence and risk factors of CKD in patients with periodontal disease in China. Methods In the current cross-sectional study, patients with periodontal disease were included from Guangdong Provincial Stomatological Hospital between March 2011 and August 2011. CKD was defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, the presence of albuminuria, or hematuria. All patients with periodontal disease underwent a periodontal examination, including periodontal probing pocket depth, gingival recession, and clinical attachment level by Florida Probe. They completed a questionnaire and had blood and urine samples taken. The adjusted prevalence of indicators of kidney damage was calculated and risk factors associated with CKD were analyzed. Results A total of 1392 patients with periodontal disease were invited to participate this study and 1268 completed the survey and examination. After adjusting for age and sex, the prevalence of reduced eGFR, albuminuria, and hematuria was 2.7% (95% CI 1.7–3.7), 6.7% (95% CI 5.5–8.1) and 10.9% (95% CI 9.2–12.5), respectively. The adjusted prevalence of CKD was 18.2% (95% CI 16.2–20.3). Age, male, diabetes, hypertension, history of CKD, hyperuricemia, and interleukin-6 levels (≥7.54 ng/L) were independent risk factors for reduced eGFR. Female, diabetes, hypertension, history of CKD, hyperuricemia, high level of cholesterol, and high sensitivity C-reactive protein (hsCRP) (≥1.03 mg/L) and TNF-α levels (≥1.12 ng/L) were independently associated with an increased risk of albuminuria. Female, lower education (CKD were independent risk factors for hematuria. Conclusions 18.2% of Chinese patients with periodontal disease have proteinuria, hematuria, or reduced eGFR, indicating the presence of kidney damage. Whether

  10. Competitive Interaction Between Fibroblast Growth Factor 23 And Asymmetric Dimethylarginine in Patients With CKD

    PubMed Central

    Tripepi, Giovanni; Kollerits, Barbara; Leonardis, Daniela; Yilmaz, Mahamut Ilker; Postorino, Maurizio; Fliser, Danilo; Mallamaci, Francesca; Kronenberg, Florian

    2015-01-01

    Both fibroblast growth factor 23 (FGF-23) and asymmetric dimethylarginine (ADMA) are associated with progression of CKD. We tested the hypothesis that ADMA and FGF23 are interactive factors for CKD progression in a cohort of 758 patients with CKD in Southern Europe (mean eGFR±SD, 36±13 ml/min per 1.73 m2) and in a central European cohort of 173 patients with CKD (MMKD study, mean eGFR, 64±39 ml/min per 1.73 m2). In the first cohort, 214 patients had renal events (decrease in eGFR of >30%, dialysis, or kidney transplantation) during a 3-year follow-up. Both intact FGF-23 and ADMA predicted the incidence rate of renal events in unadjusted and adjusted analyses (P<0.001). There was a strong competitive interaction between FGF-23 and ADMA in the risk of renal events (P<0.01 in adjusted analyses); the risk associated with raised ADMA levels was highest in patients with low FGF-23 levels. These results were confirmed in the MMKD cohort, in which FGF-23 level was again an effect modifier of the relationship between plasma ADMA level and renal events (doubling of baseline serum creatinine, dialysis, or kidney transplantation) in the adjusted analyses (P<0.01). Furthermore, in the MMKD cohort there was a parallel, independent competitive interaction between symmetric dimethylarginine level and c-terminal FGF-23 level for the risk for renal events (P=0.001). These findings indicate that the association of ADMA level with the risk of CKD progression is modified by FGF-23 level and provide further evidence that dysregulation of the nitric oxide system is involved in CKD progression. PMID:25150156

  11. Clinical implications of the CKD epidemiology collaboration (CKD-EPI) equation compared with the modification of diet in renal disease (MDRD) study equation for the estimation of renal dysfunction in patients with cardiovascular disease.

    PubMed

    Tarantini, Luigi; Barbati, Giulia; Cioffi, Giovanni; McAlister, Finlay Aleck; Ezekowitz, Justin Adrian; Mazzone, Carmine; Faganello, Giorgio; Russo, Giulia; Franceschini Grisolia, Enrico; Di Lenarda, Andrea

    2015-12-01

    The CKD-EPI equation is more accurate than the MDRD equation in the general population. We performed this study to establish whether chronic kidney disease (CKD) is commonly recognized by clinicians and whether the CKD-EPI equation improves prognosis estimation in patients with chronic cardiovascular disease (CVD). We analyzed data on 12394 CVD patients consecutively examined at the Cardiovascular Center of Trieste (Italy) between November 2009 and October 2013. The outcomes were all-cause death and a composite outcome of death/hospitalization for CV events (D+cvH). CKD-EPI formula reclassified 1786 (14.4 %) patients between KDIGO categories compared to the MDRD: 2.3 % (n = 280) placed in a lower risk and 12.1 % (n = 1506) into a higher risk group. CKD, defined as eGFR-CKD-EPI formula <60 ml/min, was present in 3083 patients (24.9 %) but not recognized by clinicians in 1946 (63.1 % of patients with CKD). The lack of recognition of CKD was inversely proportional to the KDIGO class for both equations. There were 986 deaths and 2726 D+cvH during 24 months follow-up. The incidence of death and D+cvH was about twice as high in patients with unrecognized CKD than in those with normal renal function (31 % vs. 17.1 %, aHR: 1.35, 95 % CI: 1.15 to 1.60), even in those patients with eGFR-MDRD >60 but eGFR-CKD-EPI formula <60 (31.1 % vs 17.1 %, p < 0.001). CKD-EPI equation provides more accurate risk stratification than MDRD equation in patients with CVD. CKD was unrecognized in nearly two-thirds of these patients but clinical outcomes were similar in those for patients with recognized CKD. PMID:26123617

  12. Association of Walking with Survival and RRT Among Patients with CKD Stages 3–5

    PubMed Central

    Chen, I-Ru; Wang, Su-Ming; Liang, Chih-Chia; Kuo, Huey-Liang; Chang, Chiz-Tzung; Liu, Jiung-Hsiun; Lin, Hsin-Hung; Wang, I-Kuan; Yang, Ya-Fei; Huang, Chiu-Ching

    2014-01-01

    Background and objectives Patients with CKD can benefit from an increase in physical activity. Walking is one of the most common exercises in patients with CKD; however, the association of walking with outcomes in patients with CKD is not clear. This study investigated the association of walking with overall mortality and RRT in patients with CKD stages 3–5. Design, setting, participants, & measurements All patients with CKD stages 3–5 in the CKD program of China Medical University Hospital from June 2003 to May 2013 were enrolled. The risks of overall mortality and RRT were analyzed using competing-risks regressions. Results A total of 6363 patients (average age, 70 years) during a median of 1.3 (range=0.6–2.5) years of follow-up were analyzed. There were 1341 (21.1%) patients who reported walking as their most common form of exercise. The incidence density rate of overall mortality was 2.7 per 100 person-years for walking patients and 5.4 for nonwalking ones. The incidence density rate of RRT was 22 per 100 person-years for walking patients and 32.9 for nonwalking ones. Walking, independent of patients’ age, renal function, and comorbidity, was linked to lower overall mortality and lower RRT risk in the multivariate competing-risks regression. The adjusted subdistribution hazard ratio (SHR) of walking was 0.67 (95% confidence interval [95% CI], 0.53 to 0.84; P<0.001) for overall mortality and 0.79 (95% CI, 0.73 to 0.85; P<0.001) for the risk of RRT. The SHRs of overall mortality were 0.83, 0.72, 0.42, and 0.41 for patients walking 1–2, 3–4, 5–6, and ≥7 times per week, and the SHRs of RRT were 0.81, 0.73, 0.57, and 0.56, respectively. Conclusions Walking is the most popular form of exercise in patients with CKD and is associated with lower risks of overall mortality and RRT. The benefit of walking is independent of patients’ age, renal function, and comorbidity. PMID:24832096

  13. Chronic Kidney Disease (CKD) Treatment Burden Among Low-Income Primary Care Patients

    PubMed Central

    Kahn, Linda S.; Vest, Bonnie M.; Madurai, Nethra; Singh, Ranjit; York, Trevor R.M.; Cipparone, Charlotte W.; Reilly, Sarah; Malik, Khalid S.; Fox, Chester H.

    2015-01-01

    Objective This study explored the self-management strategies and treatment burden experienced by low income US primary care patients with chronic kidney disease. Methods Semi-structured interviews were conducted with 34 patients from two primary care practices on Buffalo’s East Side, a low-income community. Qualitative analysis was undertaken using an inductive thematic content analysis approach. We applied Normalization Process Theory (NPT) to the concept of treatment burden to interpret and categorize our findings. Results The sample was predominantly African-American (79%) and female (59%). Most patients (79%) had a diagnosis of Stage 3 CKD. Four major themes were identified corresponding to NPT and treatment burden: (1) Coherence – making sense of CKD; (2) Cognitive participation – enlisting support and organizing personal resources; (3) Collective action – self-management work; and (4) Reflexive monitoring – further refining chronic illness self-care in the context of CKD. For each component we identified barriers hindering patients’ ability to accomplish the necessary tasks. Conclusions Our findings highlight the substantial treatment burden faced by inner-city primary care patients self-managing CKD in combination with other chronic illnesses. Health care providers’ awareness of treatment burden can inform the development of person-centered care plans that can help patients to better manage their chronic illnesses. PMID:25416418

  14. Utility of Traditional Circulating and Imaging-Based Cardiac Biomarkers in Patients with Predialysis CKD

    PubMed Central

    Colbert, Gates; Jain, Nishank; de Lemos, James A.

    2015-01-01

    Cardiac biomarkers, such as cardiac troponin T (cTnT), brain natriuretic peptide (BNP), and N-terminal-pro-BNP (NT-pro-BNP), are commonly used to diagnose acute coronary syndrome and congestive heart failure exacerbation in symptomatic patients. Levels of these biomarkers are frequently chronically elevated in asymptomatic patients with ESRD who are receiving maintenance dialysis. Other imaging biomarkers commonly encountered in nephrologists’ clinical practice, such as coronary artery calcium measured by computed tomography, left ventricular hypertrophy, and carotid intima-media thickness, are also frequently abnormal in asymptomatic patients with ESRD. This article critically reviews the limited observational data on associations between cTnT, BNP, NT-pro-BNP, coronary artery calcium, left ventricular hypertrophy, and carotid intima-media thickness with cardiovascular events and death in non–dialysis-dependent patients with CKD. Although sufficient evidence suggests that these biomarkers may be used for prognostication, the diagnostic utility of cTnT, BNP, and NT-pro-BNP remain challenging in patients with CKD. Decreased renal clearance may affect the plasma levels of these biomarkers, and upper reference limits were originally derived in patients without CKD. Until better data are available, higher cutoffs, or a rise in level compared with previous values, have been proposed to help distinguish acute myocardial infarction from chronic elevations of cTnT in symptomatic patients with CKD. Additionally, it is not known whether these biomarkers are modifiable and amenable to interventions that could change hard clinical outcomes in patients with CKD not yet undergoing long-term dialysis. PMID:25403922

  15. Effects of the Use of Non-Calcium Phosphate Binders in the Control and Outcome of Vascular Calcifications: A Review of Clinical Trials on CKD Patients

    PubMed Central

    Bolasco, Piergiorgio

    2011-01-01

    Vascular calcifications produce a high impact on morbidity and mortality rates in patients affected by chronic kidney disease and mineral bone disorder (CKD-MBD). Effects are manifested from the more advanced stages of CKD (stages 3-4), particularly in patients undergoing dialysis (CKD5D). In recent years, a large number of therapeutic options have been successfully used in the treatment of secondary hyperparathyroidism (SHPT), despite eliciting less marked effects on nonbone calcifications associated with CKD-MBD. In addition to the use of Vitamin D and analogues, more recently treatment with calcimimetic drugs has also been undertaken. The present paper aims to analyze comparative and efficacy studies undertaken to assess particularly the impact on morbidity and mortality rates of non-calcium phosphate binders. Moreover, the mechanism of action underlying the depositing of calcium and phosphate along blood vessel walls, irrespective of the specific contribution provided in reducing the typical phosphate levels observed in CKD largely at more advanced stages of the disease, will be investigated. The aim of this paper therefore is to evaluate which phosphate binders are characterised by the above action and the mechanisms through which these are manifested. PMID:21716706

  16. Left Atrial Volume and Adverse Cardiovascular Outcomes in Unselected Patients with and without CKD

    PubMed Central

    Hee, Leia; Nguyen, Tuan; Whatmough, Melinda; Descallar, Joseph; Chen, Jack; Kapila, Shruti; French, John K.

    2014-01-01

    Background and objectives Patients with CKD have increased cardiovascular morbidity and mortality. This study investigated the prognostic value of common clinical echocardiographic parameters. Design, setting, participants, & measurements There were 289 unselected consecutive patients who had a transthoracic echocardiogram between January and June 2003. Patients with stage 3 or 4 CKD (n=49) were compared with those with eGFR≥60 ml/min per 1.73 m2, n=240). Left ventricular volume, ejection fraction and mass, left atrial volume, and function parameters were measured. The primary endpoint, determined a priori, was a composite of cardiac death, myocardial infarction, and congestive cardiac failure. Results Patients were followed for a median 5.6 years. The incidence of the primary endpoint was higher in patients with CKD (29% versus 12%, P=0.001), who were older and had a higher prevalence of hypertension and ischemic heart disease. Indexed left ventricular mass (LVMI) and left atrial volume (LAVI) were higher in patients with CKD. Furthermore, patients with LAVI>32 ml/m2 had significantly lower event-free survival than patients with normal (<28 ml/m2) or mildly dilated LAVI (28–32 ml/m2) (P<0.001). Multivariate analysis showed that age (odds ratio [OR], 1.19; 95% confidence interval [95% CI], 1.08 to 1.31; P=0.001) and LVMI (OR, 3.66; 95% CI, 2.47 to 5.41; P<0.001) were independently associated with LAVI>32 ml/m2. Multivariate Cox regression analysis demonstrated that CKD (hazard ratio [HR], 1.13; 95% CI, 1.01 to 1.26; P=0.04), hypertension (HR, 2.18; 95% CI, 1.05 to 4.54; P=0.04), and a larger LAVI (HR, 1.35; 95% CI, 1.02 to 1.77; P=0.04) were independent predictors of the primary endpoint. Conclusions Patients with CKD were at higher risk for cardiovascular events. LAVI was significantly larger in the CKD group and was a predictor of adverse cardiac events. PMID:24923578

  17. How do We Manage Coronary Artery Disease in Patients with CKD and ESRD?

    PubMed

    Choi, Hoon Young; Park, Hyeong Cheon; Ha, Sung Kyu

    2014-12-01

    Chronic kidney disease (CKD) has been shown to be an independent risk factor for cardiovascular events. In addition, patients with pre-dialysis CKD appear to be more likely to die of heart disease than of kidney disease. CKD accelerates coronary artery atherosclerosis by several mechanisms, notably hypertension and dyslipidemia, both of which are known risk factors for coronary artery disease. In addition, CKD alters calcium and phosphorus homeostasis, resulting in hypercalcemia and vascular calcification, including the coronary arteries. Mortality of patients on long-term dialysis therapy is high, with age-adjusted mortality rates of about 25% annually. Because the majority of deaths are caused by cardiovascular disease, routine cardiac catheterization of new dialysis patients was proposed as a means of improving the identification and treatment of high-risk patients. However, clinicians may be uncomfortable exposing asymptomatic patients to such invasive procedures like cardiac catheterization, thus noninvasive cardiac risk stratification was investigated widely as a more palatable alternative to routine diagnostic catheterization. The effective management of coronary artery disease is of paramount importance in uremic patients. The applicability of diagnostic, preventive, and treatment modalities developed in nonuremic populations to patients with kidney failure cannot necessarily be extrapolated from clinical studies in non-kidney failure populations. Noninvasive diagnostic testing in uremic patients is less accurate than in nonuremic populations. Initial data suggest that dobutamine echocardiography may be the preferred diagnostic method. PCI with stenting is a less favorable alternative to CABG, however, it has a faster recovery time, reduced invasiveness, and no overall mortality difference in nondiabetic and non-CKD patients compared with CABG. CABG is associated with reduced repeat revascularizations, greater relief of angina, and increased long term

  18. Calcifying circulating cells: an uncharted area in the setting of vascular calcification in CKD patients.

    PubMed

    Cianciolo, Giuseppe; Capelli, Irene; Cappuccilli, Maria; Schillaci, Roberto; Cozzolino, Mario; La Manna, Gaetano

    2016-04-01

    Vascular calcification, occurring during late-stage vascular and valvular disease, is highly associated with chronic kidney disease-mineral and bone disorders (CKD-MBD), representing a major risk factor for cardiovascular morbidity and mortality. The hallmark of vascular calcification, which involves both media and intima, is represented by the activation of cells committed to an osteogenic programme. Several studies have analysed the role of circulating calcifying cells (CCCs) in vascular calcification. CCCs are bone marrow (BM)-derived cells with an osteogenic phenotype, participating in intima calcification processes and defined by osteocalcin and bone alkaline phosphatase expression. The identification of CCCs in diabetes and atherosclerosis is the most recent, intriguing and yet uncharted chapter in the scenario of the bone-vascular axis. Whether osteogenic shift occurs in the BM, the bloodstream or both, is not known, and also the factors promoting CCC formation have not been identified. However, it is possible to recognize a common pathogenic commitment of inflammation in atherosclerosis and diabetes, in which metabolic control may also have a role. Currently available studies in patients without CKD did not find an association of CCCs with markers of bone metabolism. Preliminary data on CKD patients indicate an implication of mineral bone disease in vascular calcification, as a consequence of functional and anatomic integrity interruption of BM niches. Given the pivotal role that parathyroid hormone and osteoblasts play in regulating expansion, mobilization and homing of haematopoietic stem/progenitors cells, CKD-MBD could promote CCC formation. PMID:26985381

  19. Usability of a CKD Educational Website Targeted to Patients and Their Family Members

    PubMed Central

    Zuckerman, Marni; Fink, Wanda; Hu, Peter; Yang, Shiming; Fink, Jeffrey C.

    2012-01-01

    Summary Background and objectives Web-based technology is critical to the future of healthcare. As part of the Safe Kidney Care cohort study evaluating patient safety in CKD, this study determined how effectively a representative sample of patients with CKD or family members could interpret and use the Safe Kidney Care website (www.safekidneycare.org), an informational website on safety in CKD. Design, setting, participants, & measurements Between November of 2011 and January of 2012, persons with CKD or their family members underwent formal usability testing administered by a single interviewer with a second recording observer. Each participant was independently provided a list of 21 tasks to complete, with each task rated as either easily completed/noncritical error or critical error (user cannot complete the task without significant interviewer intervention). Results Twelve participants completed formal usability testing. Median completion time for all tasks was 17.5 minutes (range=10–44 minutes). In total, 10 participants had greater than or equal to one critical error. There were 55 critical errors in 252 tasks (22%), with the highest proportion of critical errors occurring when participants were asked to find information on treatments that may damage kidneys, find the website on the internet, increase font size, and scroll to the bottom of the webpage. Participants were generally satisfied with the content and usability of the website. Conclusions Web-based educational materials for patients with CKD should target a wide range of computer literacy levels and anticipate variability in competency in use of the computer and internet. PMID:22798537

  20. [The expanding concept of CKD-MBD].

    PubMed

    Komaba, Hirotaka

    2016-09-01

    Almost seven years have passed since the publication of the KDIGO clinical practice guideline on chronic kidney disease-mineral and bone disorder(CKD-MBD). During this period, several new medications for osteoporosis that may be applicable to patients with CKD have become available. Clinical studies have also shown the utility of bone mineral density to assess fracture risk in CKD. These new data charges us with the task of reconciling the concept of renal osteodystrophy(ROD)and osteoporosis in CKD. This review summarize the recent advances in the management of bone disease in CKD and the key points raised during the discussion for the KDIGO guideline revision, and address the problems to be solved in future. PMID:27561339

  1. "Dietaly": practical issues for the nutritional management of CKD patients in Italy.

    PubMed

    D'Alessandro, Claudia; Piccoli, Giorgina Barbara; Calella, Patrizia; Brunori, Giuliano; Pasticci, Franca; Egidi, Maria Francesca; Capizzi, Irene; Bellizzi, Vincenzo; Cupisti, Adamasco

    2016-01-01

    Evidence exists that nutritional therapy induces favorable metabolic changes, prevents signs and symptoms of renal insufficiency, and is able to delay the need of dialysis. Currently, the main concern of the renal diets has turned from the efficacy to the feasibility in the daily clinical practice.Herewith we describe some different dietary approaches, developed in Italy in the last decades and applied in the actual clinical practice for the nutritional management of CKD patients.A step-wise approach or simplified dietary regimens are usually prescribed while taking into account not only the residual renal function and progression rate but also socio-economic, psychological and functional aspects.The application of the principles of the Mediterranean diet that covers the recommended daily allowances for nutrients and protein (0.8 g/Kg/day) exert a favorable effect at least in the early stages of CKD. Low protein (0.6 g/kg/day) regimens that include vegan diet and very low-protein (0.3-0.4 g/Kg/day) diet supplemented with essential amino acids and ketoacids, represent more opportunities that should be tailored on the single patient's needs.Rather than a structured dietary plan, a list of basic recommendations to improve compliance with a low-sodium diet in CKD may allow patients to reach the desired salt target in the daily eating.Another approach consists of low protein diets as part of an integrated menu, in which patients can choose the "diet" that best suits their preferences and clinical needs.Lastly, in order to allow efficacy and safety, the importance of monitoring and follow up of a proper nutritional treatment in CKD patients is emphasized. PMID:27473183

  2. Pilot Study of a Physician-Delivered Education Tool to Increase Patient Knowledge About CKD

    PubMed Central

    Nunes, Julie Wright; Greene, Jane; Wallston, Kenneth; Eden, Svetlana; Shintani, Ayumi; Elasy, Tom; Rothman, Russell; İkizler, T. Alp; Cavanaugh, Kerri

    2013-01-01

    Background Limited research exists on physician-delivered education interventions. We examined the feasibility and impact of an educational tool on facilitating physician-patient kidney disease communication. Study Design Pilot feasibility clinical trial with a historical control to examine effect size on patient knowledge and structured questions to elicit physician and patient feedback. Setting & Participants Adults with chronic kidney disease (CKD) stages 1–5, seen in nephrology clinic. Intervention One page educational worksheet, reviewed by physicians with patients. Outcomes Kidney knowledge between patient groups and provider/patient feedback. Measurements Patient kidney knowledge was measured using a previously validated questionnaire compared between patients receiving the intervention (April–October 2010) and a historical cohort (April–October 2009). Provider input was obtained using structured interviews. Patient input was obtained through survey questions. Patient characteristics were abstracted from the medical record. Results 556 patients were included, with 401 patients in the historical cohort, and 155 receiving the intervention. Mean age was 57 ± 16 (SD) years, with 53% male, 81% White, and 78% CKD stages 3–5. Compared to the historical cohort, patients receiving the intervention had higher adjusted odds of knowing they had CKD (adjusted OR, 2.20; 95% CI, 1.16–4.17; p=0.01), knowing their kidney function (adjusted OR, 2.25; 95% CI, 1.27–3.97; p=0.005), and knowing their stage of CKD (adjusted OR, 3.22; 95% CI, 1.49–6.92; p=0.003). Physicians found the intervention tool easy and feasible to integrate into practice and 98% of patients who received the intervention recommended it for future use. Limitations Study design did not randomize patients for comparison and enrollment was performed in clinics at one center. Conclusions In this pilot study, a physician delivered education intervention was feasible to use in practice, and was

  3. Assessed value of high-sensitivity cardiac troponin T for cardiovascular disease among CKD patients.

    PubMed

    Sun, Li; Tan, Xiao; Cao, Xuesen; Zou, Jianzhou

    2016-06-01

    Objective To analyze the relationship between serum high-sensitivity cardiac troponin T (hs-cTnT) and cardiovascular disease (CVD) among non-dialysis chronic kidney disease (CKD) patients, and to further explore its value of evaluating and predicting CVD in this population. Methods Five hundred and fifty-seven non-dialysis CKD patients were involved in this cross-sectional study. The relationship between serum hs-cTnT and CVD was analyzed using comparison between groups and regression analysis, and its value on assessing cardiac structure and function was evaluated by ROC curves. Results Median level of hs-cTnT was 13 (7-29) ng/L, with 1.7% undetectable, 46.4% greater than 99th percentile of the general population. Multivariate analysis suggested that compared with the lowest quartile of hs-cTnT, the highest quartile was approximately six times as likely to develop into LVH (OR, 6.515; 95% CI, 3.478-12.206, p < 0.05) and 18 times as likely to progress to left ventricular diastolic dysfunction(OR, 18.741; 95% CI, 2.422-145.017, p < 0.05). And Ln cTnT level had a more modest association with LVEF (OR, -1.117; 95% CI, -5.839 to -0.594; p < 0.05). When evaluated as a screening test, the area under the curve of ROC curves for hs-cTnT was 0.718, 0.788 and 0.736, respectively (p < 0.05). With a specificity of 90% as a diagnostic criterion, the value of hs-cTnT to evaluate LVH, LVEF < 50%, left ventricular diastolic dysfunction increased across CKD stages, from CKD 1 stage to CKD 5 stage. Conclusions In CKD non-dialysis population, hs-cTnT and NT-proBNP were valuable for evaluating LVH, left ventricular systolic dysfunction and left ventricular diastolic dysfunction. PMID:26984066

  4. Can ACE inhibitors and angiotensin receptor blockers be detrimental in CKD patients?

    PubMed

    Onuigbo, Macaulay A C

    2011-01-01

    Current epidemiological data from the USA, Europe, Asia and the Indian subcontinent, Africa, the Far East, South America, the Middle East and Eastern Europe all point to the increasing incidence of renal failure encompassing acute kidney injury (AKI), chronic kidney disease (CKD) and end-stage renal disease (ESRD). While the explanations for these worldwide epidemics remain speculative, it must be acknowledged that these increases in AKI, CKD and ESRD, happening worldwide, have occurred despite the universal application of strategies of renoprotection over the last 2 decades, more especially the widespread use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). We note that many of the published large renin-angiotensin-aldosterone system (RAAS) blockade randomized controlled trials, upon which current evidence-based practice for the increasing use of ACEIs and ARBs for renoprotection derived from, have strong deficiencies that have been highlighted over the years. From reports in the literature, there is an increasing association of exacerbations of renal failure with ACEIs and ARBs, more so in the older hypertensive patient, >65 years old. The biological plausibility for ACEI and ARB to protect the kidneys against a background of potential multiple pathogenetic pathways to account for CKD progression appears to be not very defensible. We reviewed the literature along these lines and submit that ACEIs and ARBs often cause unrecognized significant worsening renal failure in CKD patients, sometimes irreversible, and that more caution is required regarding their use, especially in the older hypertensive patients, with likely ischemic hypertensive nephropathy. Given the increasing association of concomitant RAAS blockade with worsening renal failure following exposure to iodinated contrast, during acute illness, in the perioperative period and following lower bowel preparations prior to colonoscopy, we submit that, preferably

  5. Epidemiology, Diagnosis, and Management of Depression in Patients With CKD

    PubMed Central

    Hedayati, S. Susan; Finkelstein, Fredric O.

    2011-01-01

    CASE PRESENTATION A 58-year-old Hispanic man who has been dialysis dependent for 2 years because of diabetic nephropathy reports depressive symptoms during dialysis rounds. For the past 6 weeks, he has had reduced energy and difficulty sleeping and concentrating. He reports a loss of interest in his usual hobbies and family activities and notes an increasing sense of feeling worthless and guilty. He denies suicidal ideation. Medical history includes diabetic retinopathy and neuropathy, coronary artery disease treated with 4-vessel coronary artery bypass grafting 3 years ago, ischemic cardiomyopathy with an ejection fraction of 30%, and cerebrovascular disease. His wife recently has been given a diagnosis of breast cancer. His medications are aspirin, metoprolol, lisinopril, simvastatin, sevelamer, and epoetin alfa. His blood pressure is 130/75 mm Hg, pulse is 65 beats/min, and cardiac and pulmonary examination results are unremarkable. He is interviewed by the social worker in the dialysis unit, who diagnoses clinical depression by using standard Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM IV) criteria. The patient refuses to discuss his problems with the social worker and declines further psychiatric evaluation. His nephrologist discusses a trial of antidepressant medication, but the patient refuses to use additional medication. During the next month, the patient presents with greater interdialytic weight gains and begins to come late for dialysis sessions. He then presents to a dialysis session reporting dyspnea and orthopnea and is found to have a 10-kg weight gain. On physical examination, blood pressure is 196/96 mm Hg and he has increased jugular venous pressure and bibasilar crackles. He is admitted to the hospital with a diagnosis of congestive heart failure. PMID:19592143

  6. The "phosphorus pyramid": a visual tool for dietary phosphate management in dialysis and CKD patients.

    PubMed

    D'Alessandro, Claudia; Piccoli, Giorgina B; Cupisti, Adamasco

    2015-01-01

    Phosphorus retention plays a pivotal role in the onset of mineral and bone disorders (MBD) in chronic kidney disease (CKD). Phosphorus retention commonly occurs as a result of net intestinal absorption exceeding renal excretion or dialysis removal. The dietary phosphorus load is crucial since the early stages of CKD, throughout the whole course of the disease, up to dialysis-dependent end-stage renal disease.Agreement exits regarding the need for dietary phosphate control, but it is quite challenging in the real-life setting. Effective strategies to control dietary phosphorus intake include restricting phosphorus-rich foods, preferring phosphorus sourced from plant origin, boiling as the preferred cooking procedure and avoiding foods with phosphorus-containing additives. Nutritional education is crucial in this regard.Based on the existing literature, we developed the "phosphorus pyramid", namely a novel, visual, user-friendly tool for the nutritional education of patients and health-care professionals. The pyramid consists of six levels in which foods are arranged on the basis of their phosphorus content, phosphorus to protein ratio and phosphorus bioavailability. Each has a colored edge (from green to red) that corresponds to recommended intake frequency, ranging from "unrestricted" to "avoid as much as possible".The aim of the phosphorus pyramid is to support dietary counseling in order to reduce the phosphorus load, a crucial aspect of integrated CKD-MBD management. PMID:25603926

  7. [Teriparatide:benefit and safety for bone disease in CKD patients undergoing hemodialysis].

    PubMed

    Yamamoto, Suguru; Ei, Isei; Narita, Ichiei

    2016-09-01

    Teriparatide, 1-34 parathyroid hormone, is one of effective treatments for osteoporosis. Teriparatide shows an anabolic effect for bone formation, as a result, increases bone mineral density as well as prevention of fractures in the general population. On the other hand, there are a few report about the effect of teriparatide on increase of bone mineral density in maintenance hemodialysis patients. In addition to CKD-MBD, osteoporosis is also an important pathological change in ESRD patients, therefore its safety and efficacy should be discussed in more detail. PMID:27561345

  8. Pro-inflammatory cytokines and bone fractures in CKD patients. An exploratory single centre study

    PubMed Central

    2012-01-01

    Background Pro-inflammatory cytokines play a key role in bone remodeling. Inflammation is highly prevalent in CKD-5D patients, but the relationship between pro-inflammatory cytokines and fractures in CKD-5D patients is unclear. We studied the relationship between inflammatory cytokines and incident bone fractures in a cohort of CKD-5D patients. Methods In 100 CKD-5D patients (66 on HD, 34 on CAPD; males:63, females:37; mean age: 61 ± 15; median dialysis vintage: 43 months) belonging to a single renal Unit, we measured at enrolment bone metabolic parameters (intact PTH, bone and total alkaline phosphatase, calcium, phosphate) and inflammatory cytokines (TNF-α, IL-6, CRP). Patients were followed-up until the first non traumatic fracture. Results During follow-up (median: 74 months; range 0.5 -84.0) 18 patients experienced fractures. On categorical analysis these patients compared to those without fractures had significantly higher intact PTH (median: 319 pg/ml IQ range: 95–741 vs 135 pg/ml IQ: 53–346; p = 0.04) and TNF-α levels (median: 12 pg/ml IQ: 6.4-13.4 vs 7.8 pg/ml IQ: 4.6-11; p = 0.02). Both TNF-α (HR for 5 pg/ml increase in TNF-α: 1.62 95% CI: 1.05-2.50; p = 0.03) and intact PTH (HR for 100 pg/ml increase in PTH: 1.15 95% CI: 1.04-1.27; p = 0.005) predicted bone fractures on univariate Cox’s regression analysis. In restricted (bivariate) models adjusting for previous fractures, age, sex and other risk factors both PTH and TNF-α maintained an independent association with incident fractures. Conclusions In our bivariate analyses TNF-α was significantly associated with incident fractures. Analyses in larger cohorts and with adequate number of events are needed to firmly establish the TNF α -fracture link emerged in the present study. PMID:23043229

  9. Promoting functioning and well-being in older CKD patients: review of recent evidence.

    PubMed

    Kutner, Nancy G

    2008-01-01

    Osteoporosis, falls, sleep difficulty, cognitive impairment, and depressed mood are major clinical concerns in the geriatric population that are physiologically and psychologically based and are often interrelated. All of these issues have implications for patients' daily functioning and quality of life (QOL). This review synthesizes recent evidence about these prominent issues in geriatric care and related implications for care of older patients with chronic kidney disease (CKD). Recent evidence about pre-dialysis and dialysis treatment strategies that may help to optimize management of older patients is also considered. Although elderly patients often report better psychosocial adjustment to dialysis than do younger patients, physical functioning and cognitive functioning losses challenge the QOL of many elderly persons. Early management of CKD and attention to anemia, consideration of the benefits of peritoneal dialysis compared with hemodialysis, and inclusion of some form of exercise or regular physical activity in routine care provide key opportunities to enhance the functioning and well-being of older patients. PMID:18787971

  10. Effects of a Renal Rehabilitation Exercise Program in Patients with CKD: A Randomized, Controlled Trial

    PubMed Central

    Rossi, Ana P.; Burris, Debra D.; Lucas, F. Leslie; Crocker, Gail A.

    2014-01-01

    Background and objectives Patients with CKD have a high prevalence of cardiovascular disease associated with or exacerbated by inactivity. This randomized, controlled study investigated whether a renal rehabilitation exercise program for patients with stages 3 or 4 CKD would improve their physical function and quality of life. Design, setting, participants, & measurements In total, 119 adults with CKD stages 3 and 4 were randomized, and 107 of these patients proceeded to usual care or the renal rehabilitation exercise intervention consisting of usual care plus guided exercise two times per week for 12 weeks (24 sessions). Physical function was determined by three well established performance-based tests: 6-minute walk test, sit-to-stand test, and gait-speed test. Health-related quality of life was assessed by the RAND 36-Item Short Form Health Survey. Results At baseline, no differences in self-reported level of activity, 6-minute walk test, and sit-to-stand test scores were observed between the usual care (n=48) and renal rehabilitation exercise (n=59) groups, although baseline gait-speed test score was higher in the renal rehabilitation exercise group (P<0.001). At follow-up, the renal rehabilitation exercise group but not the usual care group showed significant improvements in the 6-minute walk test (+210.4±266.0 ft [19% improvement] versus −10±219.9 ft; P<0.001), the sit-to-stand test (+26.9±27% of age prediction [29% improvement] versus +0.7±12.1% of age prediction; P<0.001), and the RAND-36 physical measures of role functioning (P<0.01), physical functioning (P<0.01), energy/fatigue levels (P=0.01), and general health (P=0.03) and mental measure of pain scale (P=0.04). The renal rehabilitation exercise regimen was generally well tolerated. Conclusions A 12-week/24-session renal rehabilitation exercise program improved physical capacity and quality of life in patients with CKD stages 3 and 4. Longer follow-up is needed to determine if these findings will

  11. Cardiac Resynchronization Therapy in CKD: A Systematic Review

    PubMed Central

    Garg, Neha; Thomas, George; Jackson, Gregory; Rickard, John; Nally, Joseph V.; Tang, W.H. Wilson

    2013-01-01

    Summary Background Cardiac resynchronization therapy (CRT) confers morbidity and mortality benefits to selected patients with heart failure. This systematic review examined effects of CRT in CKD patients (estimated GFR [eGFR] <60 ml/min per 1.73 m2). Design, setting, participants, & measurements MEDLINE and Scopus (from 1990 to December 2012) and conference proceedings abstracts were searched for relevant observational studies and randomized controlled trials (RCTs). Studies comparing the following outcomes were included: (1) CKD patients with and without CRT and (2) CKD patients with CRT to non-CKD patients with CRT. Mortality, eGFR, and left ventricular ejection fraction data were extracted and pooled when appropriate using a random-effects model. Results Eighteen studies (14 observational studies and 4 RCTs) were included. There was a modest improvement in eGFR with CRT among CKD patients (mean difference 2.30 ml/min per 1.73m2; 95% confidence interval, 0.33 to 4.27). Similarly, there was a significant improvement in left ventricular ejection with CRT in CKD patients (mean difference 6.24%; 95% confidence interval, 3.46 to 9.07). Subgroup analysis of three RCTs reported lower rates of death or hospitalization for heart failure with CRT (versus other therapy) in the CKD population. Survival outcomes of CKD patients (compared with the non-CKD population) with CRT differed among observational studies and RCTs. Conclusions CRT improves left ventricular and renal function in the CKD population with heart failure. Given the increasing use of cardiac devices, further studies examining the effects of CRT on mortality in CKD patients, particularly those with advanced kidney disease, are warranted. PMID:23660183

  12. Inflammation, Endothelial Dysfunction and Increased Left Ventricular Mass in Chronic Kidney Disease (CKD) Patients: A Longitudinal Study

    PubMed Central

    Dounousi, Evangelia; Jager, Kitty J.; Papagianni, Aikaterini; Pappas, Konstantinos; Siamopoulos, Kostas C.; Zoccali, Carmine; Tsakiris, Dimitrios

    2015-01-01

    Introduction Within this longitudinal study we investigated the association of inflammation markers C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-α (TNFα) and endothelial dysfunction markers intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) with left ventricular mass indexed for height2·71 (LVMI) in hypertensive predialysis CKD patients. Material and Methods From 2004 to 2005, 182 incident consecutive adult patients from the outpatient CKD clinics of two hospitals in Greece with CKD and hypertension or using antihypertensive medication, were included. Of these, 107 patients underwent CRP (mg/l) and LVMI (g/height2·71) measurements annually for three years. Results In the longitudinal analyses, using linear mixed modeling, a higher IL-6 (ß = 1.9 (95%ci:0.38;3.5), inflammation score based on CRP, IL-6 and TNF-α (ß = 5.0 (95%ci:0.72; 9.4) and VCAM-1 (ß = 0.01 (95%ci:0.005;0.02) were associated with higher LVMI. These models were adjusted for age, gender and primary renal disease, and for confounders that on top changed the beta with ≥10%, i.e. diuretic use (for IL-6 and inflammation score). Conclusion The results suggest that in predialysis CKD patients, inflammation as well as endothelial dysfunction may play an important role towards the increase in LVMI. PMID:26398099

  13. Assessing Glomerular Filtration Rate in Hospitalized Patients: A Comparison Between CKD-EPI and Four Cystatin C-Based Equations

    PubMed Central

    de la Torre, Judith; Ramos, Natalia; Quiroz, Augusto; Garjau, Maria; Torres, Irina; Azancot, M. Antonia; López, Montserrat; Sobrado, Ana

    2011-01-01

    Summary Background and objectives A specific method is required for estimating glomerular filtration rate GFR in hospitalized patients. Our objective was to validate the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and four cystatin C (CysC)–based equations in this setting. Design, setting, participants, & measurements This was an epidemiologic, cross-sectional study in a random sample of hospitalized patients (n = 3114). We studied the accuracy of the CKD-EPI and four CysC-based equations—based on (1) CysC alone or (2) adjusted by gender; (3) age, gender, and race; and (4) age, gender, race, and creatinine, respectively—compared with GFR measured by iohexol clearance (mGFR). Clinical, biochemical, and nutritional data were also collected. Results The CysC equation 3 significantly overestimated the GFR (bias of 7.4 ml/min per 1.73 m2). Most of the error in creatinine-based equations was attributable to calculated muscle mass, which depended on patient's nutritional status. In patients without malnutrition or reduced body surface area, the CKD-EPI equation adequately estimated GFR. Equations based on CysC gave more precise mGFR estimates when malnutrition, extensive reduction of body surface area, or loss of muscle mass were present (biases of 1 and 1.3 ml/min per 1.73 m2 for equations 2 and 4, respectively, versus 5.9 ml/min per 1.73 m2 for CKD-EPI). Conclusions These results suggest that the use of equations based on CysC and gender, or CysC, age, gender, and race, is more appropriate in hospitalized patients to estimate GFR, since these equations are much less dependent on patient's nutritional status or muscle mass than the CKD-EPI equation. PMID:21852668

  14. Albuminuria Is an Appropriate Therapeutic Target in Patients with CKD: The Pro View

    PubMed Central

    Gansevoort, Ron T.

    2015-01-01

    The presence of elevated levels of albuminuria is associated with an increased risk of progressive renal function loss over time. This association is found in various pathophysiological conditions, including diabetic nephropathy, hypertensive nephropathy, and various primary renal diseases, but also, the general, otherwise healthy population. Emerging data report that elevated albuminuria causes tubulointerstitial damage through activation of proinflammatory mediators, which ultimately leads to a progressive decline in renal function. Nowadays, various drugs are available that decrease the rate of GFR loss in patients with kidney disease. Well known are renin-angiotensin-aldosterone system inhibitors, but there are also other drugs and interventions, like intensive glucose control, anti-inflammatory agents (pentoxifylline), or a low-protein diet. These interventions have an additional effect beyond their original target, namely lowering albuminuria. Analyses from clinical trials show that the reduction in albuminuria observed during the first months of treatment with these drugs correlates with the degree of long-term renal protection: the larger the initial reduction in albuminuria, the lower the risk of ESRD during treatment. In addition, in treated patients, residual albuminuria is again the strongest risk marker for renal disease progression. These observations combined provide a strong argument that albuminuria is an appropriate therapeutic target in patients with CKD. PMID:25887073

  15. Hepcidin Response to Iron Therapy in Patients with Non-Dialysis Dependent CKD: An Analysis of the FIND-CKD Trial.

    PubMed

    Gaillard, Carlo A; Bock, Andreas H; Carrera, Fernando; Eckardt, Kai-Uwe; Van Wyck, David B; Bansal, Sukhvinder S; Cronin, Maureen; Meier, Yvonne; Larroque, Sylvain; Roger, Simon D; Macdougall, Iain C

    2016-01-01

    Hepcidin is the key regulator of iron homeostasis but data are limited regarding its temporal response to iron therapy, and response to intravenous versus oral iron. In the 56-week, open-label, multicenter, prospective, randomized FIND-CKD study, 626 anemic patients with non-dialysis dependent chronic kidney disease (ND-CKD) and iron deficiency not receiving an erythropoiesis stimulating agent were randomized (1:1:2) to intravenous ferric carboxymaltose (FCM), targeting higher (400-600μg/L) or lower (100-200μg/L) ferritin, or to oral iron. Serum hepcidin levels were measured centrally in a subset of 61 patients. Mean (SD) baseline hepcidin level was 4.0(3.5), 7.3(6.4) and 6.5(5.6) ng/mL in the high ferritin FCM (n = 17), low ferritin FCM (n = 16) and oral iron group (n = 28). The mean (SD) endpoint value (i.e. the last post-baseline value) was 26.0(9.1),15.7(7.7) and 16.3(11.0) ng/mL, respectively. The increase in hepcidin from baseline was significantly smaller with low ferritin FCM or oral iron vs high ferritin FCM at all time points up to week 52. Significant correlations were found between absolute hepcidin and ferritin values (r = 0.65, p<0.001) and between final post-baseline increases in both parameters (r = 0.70, p<0.001). The increase in hepcidin levels over the 12-month study generally mirrored the cumulative iron dose in each group. Hepcidin and transferrin saturation (TSAT) absolute values showed no correlation, although there was an association between final post-baseline increases (r = 0.42, p<0.001). Absolute values (r = 0.36, p = 0.004) and final post-baseline increases of hepcidin and hemoglobin (p = 0.30, p = 0.030) correlated weakly. Baseline hepcidin levels were not predictive of a hematopoietic response to iron therapy. In conclusion, hepcidin levels rose in response to either intravenous or oral iron therapy, but the speed and extent of the rise was greatest with intravenous iron targeting a higher ferritin level. However neither the

  16. Hepcidin Response to Iron Therapy in Patients with Non-Dialysis Dependent CKD: An Analysis of the FIND-CKD Trial

    PubMed Central

    Gaillard, Carlo A.; Bock, Andreas H.; Carrera, Fernando; Eckardt, Kai-Uwe; Van Wyck, David B.; Bansal, Sukhvinder S.; Cronin, Maureen; Meier, Yvonne; Larroque, Sylvain; Roger, Simon D.; Macdougall, Iain C.

    2016-01-01

    Hepcidin is the key regulator of iron homeostasis but data are limited regarding its temporal response to iron therapy, and response to intravenous versus oral iron. In the 56-week, open-label, multicenter, prospective, randomized FIND-CKD study, 626 anemic patients with non-dialysis dependent chronic kidney disease (ND-CKD) and iron deficiency not receiving an erythropoiesis stimulating agent were randomized (1:1:2) to intravenous ferric carboxymaltose (FCM), targeting higher (400–600μg/L) or lower (100–200μg/L) ferritin, or to oral iron. Serum hepcidin levels were measured centrally in a subset of 61 patients. Mean (SD) baseline hepcidin level was 4.0(3.5), 7.3(6.4) and 6.5(5.6) ng/mL in the high ferritin FCM (n = 17), low ferritin FCM (n = 16) and oral iron group (n = 28). The mean (SD) endpoint value (i.e. the last post-baseline value) was 26.0(9.1),15.7(7.7) and 16.3(11.0) ng/mL, respectively. The increase in hepcidin from baseline was significantly smaller with low ferritin FCM or oral iron vs high ferritin FCM at all time points up to week 52. Significant correlations were found between absolute hepcidin and ferritin values (r = 0.65, p<0.001) and between final post-baseline increases in both parameters (r = 0.70, p<0.001). The increase in hepcidin levels over the 12-month study generally mirrored the cumulative iron dose in each group. Hepcidin and transferrin saturation (TSAT) absolute values showed no correlation, although there was an association between final post-baseline increases (r = 0.42, p<0.001). Absolute values (r = 0.36, p = 0.004) and final post-baseline increases of hepcidin and hemoglobin (p = 0.30, p = 0.030) correlated weakly. Baseline hepcidin levels were not predictive of a hematopoietic response to iron therapy. In conclusion, hepcidin levels rose in response to either intravenous or oral iron therapy, but the speed and extent of the rise was greatest with intravenous iron targeting a higher ferritin level. However neither the

  17. A public health perspective on CKD and obesity.

    PubMed

    McClellan, William M; Plantinga, Laura C

    2013-11-01

    End-stage renal disease (ESRD) is a growing health burden for global populations, which has generated keen interest in interventions to prevent or delay the progression of its antecedent chronic kidney disease (CKD). There are biologically plausible mechanisms that link increased adiposity to pathways of kidney injury, animal models of obesity-related kidney disease and specific glomerular disease that is observed in extremely obese humans. Further, individuals with progressive kidney disease and incident ESRD are more obese than their counterparts in the general population. These observations raise the consideration that population-based policies targeted at delaying progressive CKD should recommend interventions for treatment of obesity in these individuals. We examine this proposition first by describing the public health infrastructure that exists to translate CKD public health policy, illustrating it by examples familiar to the practicing nephrologist. Next, we suggest that, despite the evidence supporting an association between increased body weight and progressive CKD, it is premature to contemplate public health recommendations for weight reduction in CKD patients. This prematurity reflects the lack of strong evidence that reduction in body weight delays or prevents the progression of CKD and persistent uncertainty about the direction of the association between obesity and mortality in individuals with advanced kidney failure. We conclude by noting that this position is not that of therapeutic nihilism but rather a caution to approach weight management in CKD on an individual, patient-to-patient basis, and an emphasis for further randomized clinical trials to resolve these uncertainties. PMID:24179014

  18. Association of FMO3 Variants and Trimethylamine N-Oxide Concentration, Disease Progression, and Mortality in CKD Patients.

    PubMed

    Robinson-Cohen, Cassianne; Newitt, Richard; Shen, Danny D; Rettie, Allan E; Kestenbaum, Bryan R; Himmelfarb, Jonathan; Yeung, Catherine K

    2016-01-01

    Elevated levels of circulating pro-atherogenic uremic solutes, particularly trimethylamine N-oxide (TMAO), have been implicated in cardiovascular disease development in patients with chronic kidney disease (CKD). TMAO is generated from trimethylamine (TMA) via metabolism by hepatic flavin-containing monooxygenase isoform 3 (FMO3). We determined the functional effects of three common FMO3 variants at amino acids 158, 308, and 257 on TMAO concentrations in a prospective cohort study and evaluated associations of polymorphisms with CKD progression and mortality. Each additional minor allele at amino acid 158 was associated with a 0.38 μg/mL higher circulating TMAO (p = 0.01) and with faster rates of annualized relative eGFR decline. Participants with 0, 1 and 2 variant alleles averaged an eGFR loss of 8%, 12%, and 14% per year, respectively (p-for trend = 0.05). Compared to participants with the homozygous reference allele, heterozygous and homozygous variant participants had a 2.0-fold (95% CI: 0.85, 4.6) and 2.2-fold (95% CI: 0.89, 5.48) higher risk of mortality, respectively (p-for-trend = 0.04). No associations with clinical outcomes were observed for allelic variants at amino acids 257 or 308. Understanding the contribution of genetic variation of FMO3 to disease progression and all-cause mortality can guide recommendations for diet modification or pharmacotherapy in CKD patients at increased risk of adverse outcomes. PMID:27513517

  19. Association of FMO3 Variants and Trimethylamine N-Oxide Concentration, Disease Progression, and Mortality in CKD Patients

    PubMed Central

    Robinson-Cohen, Cassianne; Newitt, Richard; Shen, Danny D.; Rettie, Allan E.; Kestenbaum, Bryan R.; Himmelfarb, Jonathan; Yeung, Catherine K.

    2016-01-01

    Elevated levels of circulating pro-atherogenic uremic solutes, particularly trimethylamine N-oxide (TMAO), have been implicated in cardiovascular disease development in patients with chronic kidney disease (CKD). TMAO is generated from trimethylamine (TMA) via metabolism by hepatic flavin-containing monooxygenase isoform 3 (FMO3). We determined the functional effects of three common FMO3 variants at amino acids 158, 308, and 257 on TMAO concentrations in a prospective cohort study and evaluated associations of polymorphisms with CKD progression and mortality. Each additional minor allele at amino acid 158 was associated with a 0.38 μg/mL higher circulating TMAO (p = 0.01) and with faster rates of annualized relative eGFR decline. Participants with 0, 1 and 2 variant alleles averaged an eGFR loss of 8%, 12%, and 14% per year, respectively (p-for trend = 0.05). Compared to participants with the homozygous reference allele, heterozygous and homozygous variant participants had a 2.0-fold (95% CI: 0.85, 4.6) and 2.2-fold (95% CI: 0.89, 5.48) higher risk of mortality, respectively (p-for-trend = 0.04). No associations with clinical outcomes were observed for allelic variants at amino acids 257 or 308. Understanding the contribution of genetic variation of FMO3 to disease progression and all-cause mortality can guide recommendations for diet modification or pharmacotherapy in CKD patients at increased risk of adverse outcomes. PMID:27513517

  20. Aldosterone blockade in CKD: emphasis on pharmacology.

    PubMed

    Schwenk, Michael H; Hirsch, Jamie S; Bomback, Andrew S

    2015-03-01

    Besides its epithelial effect on sodium retention and potassium excretion in the distal tubule, aldosterone promotes inflammation and fibrosis in the heart, kidneys, and blood vessels. As glomerular filtration rate falls, aldosterone is inappropriately elevated relative to extracellular fluid expansion. In addition, studies in CKD patients on angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and/or direct renin inhibitors have shown that aldosterone levels paradoxically rise in approximately 30% to 40% of patients on these renin-angiotensin system-blocking drugs. Hence, there is interest in using mineralocorticoid receptor blockers that directly target the inflammatory and fibrotic effects of aldosterone in CKD patients. This interest, however, is tempered by a number of unresolved issues, including the safety of using such drugs in advanced CKD and ESRD populations, and the potential for differences in drug efficacy according to race and ethnicity of patient populations. A better understanding of mineralocorticoid receptor blocker pharmacology should help inform future research directions and clinical practice decisions as to how best to use these agents in CKD. PMID:25704349

  1. A Longitudinal Study of Left Ventricular Function and Structure from CKD to ESRD: The CRIC Study

    PubMed Central

    Keane, Martin; Delafontaine, Patrice; Dries, Daniel; Foster, Elyse; Gadegbeku, Crystal A.; Go, Alan S.; Hamm, L. Lee; Kusek, John W.; Ojo, Akinlolu O.; Rahman, Mahboob; Tao, Kaixiang; Wright, Jackson T.; Xie, Dawei; Hsu,, Chi-yuan

    2013-01-01

    Summary Background and objectives Abnormal left ventricular structure and function are associated with increased risk of adverse outcomes among patients with CKD and ESRD. A better understanding of changes in left ventricular mass and ejection fraction during the transition from CKD to ESRD may provide important insights to opportunities to improve cardiac outcomes. Design, setting, participants, & measurements This was a longitudinal study of a subset of participants of the Chronic Renal Insufficiency Cohort who were enrolled from 2003 to 2007 and followed through January of 2011. Participants were included if they had serial echocardiograms performed at advanced CKD (defined as estimated GFR<20 ml/min per 1.73 m2) and again after ESRD (defined as need for hemodialysis or peritoneal dialysis). Results A total of 190 participants (44% female, 66% black) had echocardiograms during advanced CKD and after ESRD. Mean (SD) estimated GFR at advanced CKD was 16.9 (3.5) ml/min per 1.73 m2. Mean (SD) time between the advanced CKD echocardiogram and ESRD echocardiogram was 2.0 (1.0) years. There was no significant change in left ventricular mass index (62.3–59.5 g/m2.7, P=0.10) between advanced CKD and ESRD; however, ejection fraction significantly decreased (53%–50%, P=0.002). Interactions for age, race, dialysis modality, and diabetes status were not significant (P>0.05). Conclusions Mean left ventricular mass index did not change significantly from advanced CKD to ESRD; however, ejection fraction declined during this transition period. Although left ventricular mass index is fixed by advanced stages of CKD, ejection fraction decline during more advanced stages of CKD may be an important contributor to cardiovascular disease and mortality after dialysis. PMID:23411431

  2. Contrast-Induced Nephropathy After Computed Tomography in Stable CKD Patients With Proper Prophylaxis: 8-Year Experience of Outpatient Prophylaxis Program.

    PubMed

    Park, Sehoon; Kim, Myoung-Hee; Kang, Eunjeong; Park, Seokwoo; Jo, Hyung Ah; Lee, Hajeong; Kim, Sun Moon; Lee, Jung Pyo; Oh, Kook-Hwan; Joo, Kwon Wook; Kim, Yon Su; Kim, Dong Ki

    2016-05-01

    Conflicting data have been reported on the clinical significance of contrast-induced nephropathy after CT scan (CT-CIN). In addition, the epidemiologic characteristics and clinical outcomes of CT-CIN following proper prophylactic intervention remain elusive.We examined the incidence, risk factors, and outcomes of CT-CIN in stable chronic kidney disease (CKD) patients using data collected from our outpatient CT-CIN prophylaxis program conducted between 2007 and 2014. The program recruited patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m using an electronic health record-based pop-up alert system and provided an identical protocol of CIN prophylaxis to all patients.A total of 1666 subjects were included in this study, and 61 of the 1666 subjects (3.7%) developed CT-CIN. Multivariate analysis showed that baseline eGFR, diabetes mellitus, and low serum albumin were significant risk factors for CT-CIN. The generalized additive model analysis revealed a nonlinear relationship between the baseline eGFR and the risk of CT-CIN. In this analysis, the risk of CT-CIN began to increase below an eGFR threshold of 36.8 mL/min/1.73 m. To assess the outcomes of CT-CIN, patients with and without CT-CIN were compared after propensity score-based 1:2 matching. CT-CIN did not increase the mortality rate of patients. However, patients with CT-CIN were significantly more likely to start dialysis within 6 months of follow-up, but not after those initial 6 months.CT-CIN developed in only a small number of stable CKD patients who received proper prophylactic intervention, and the risk of CT-CIN was increased in patients with more advanced CKD. Despite the low incidence, CT-CIN conferred a non-negligible risk for the initiation of dialysis in the acute period, even after prophylaxis. PMID:27149474

  3. Managing Hypertension in Patients with CKD: A Marathon, Not a SPRINT.

    PubMed

    Chertow, Glenn M; Beddhu, Srinivasan; Lewis, Julia B; Toto, Robert D; Cheung, Alfred K

    2016-01-01

    In this manuscript, nephrologist-investigators from one of five Clinical Center Networks of the Systolic Blood Pressure Intervention Trial (SPRINT) provide background information and context on the intensity of anti-hypertensive therapy in conjunction with the release of detailed results from SPRINT's primary analysis. The authors highlight published evidence on the safety and efficacy of differing intensities of anti-hypertensive therapy in mild to moderate CKD, where SPRINT will help to inform practice, as well as where gaps in evidence will remain. The authors also challenge the nephrology community to renew its attention and efforts on hypertension clinical care and research. PMID:26553785

  4. Febuxostat for hyperuricemia in patients with advanced chronic kidney disease.

    PubMed

    Akimoto, Tetsu; Morishita, Yoshiyuki; Ito, Chiharu; Iimura, Osamu; Tsunematsu, Sadao; Watanabe, Yuko; Kusano, Eiji; Nagata, Daisuke

    2014-01-01

    Febuxostat is a nonpurine xanthine oxidase (XO) inhibitor, which recently received marketing approval. However, information regarding the experience with this agent among advanced chronic kidney disease (CKD) patients is limited. In the current study, we investigated the effects of oral febuxostat in patients with advanced CKD with asymptomatic hyperuricemia. We demonstrated, for the first time, that not only the serum levels of uric acid (UA) but also those of 8-hydroxydeoxyguanosine, an oxidative stress marker, were significantly reduced after six months of febuxostat treatment, with no adverse events. These results encouraged us to pursue further investigations regarding the clinical impact of lowering the serum UA levels with febuxostat in advanced CKD patients in terms of concomitantly reducing oxidative stress via the blockade of XO. More detailed studies with a larger number of subjects and assessments of the effects of multiple factors affecting hyperuricemia, such as age, sex, and dietary habits, would shed light on the therapeutic challenges of treating asymptomatic hyperuricemia in patients with various stages of CKD. PMID:25210423

  5. Association of Age and CKD with Prognosis of Myocardial Infarction

    PubMed Central

    Choi, Joon Seok; Kim, Min Jee; Kang, Yong Un; Kim, Chang Seong; Bae, Eun Hui; Ma, Seong Kwon; Ahn, Young-Keun; Jeong, Myung Ho; Kim, Young Jo; Cho, Myeong Chan; Kim, Chong Jin

    2013-01-01

    Summary Background and objectives CKD is a well known poor prognostic factor in myocardial infarction (MI). This study evaluated the prognostic significance of CKD, particularly in association with increasing age, in MI patients. Design, setting, participants, & measurements This study was based on a retrospective cohort, the Korean Acute Myocardial Infarction Registry. Patients with a discharge diagnosis of MI were analyzed to investigate the association of CKD with mortality risk according to age. A total of 11,268 patients (mean age 63.0±12.6 years) were included and followed for 1 year. Results In the full cohort, 26% of patients had CKD (n=2929). The prevalence of CKD was higher with advancing age. Eight hundred sixty-one patients (7.6%) died and the interaction for 1-year mortality between age strata and estimated GFR (eGFR) strata was significant (P<0.001). Within each age category, the absolute 1-year mortality was higher in patients with a low eGFR. However, the adjusted relative mortality risk for a low eGFR was lower with increasing age (adjusted hazard ratio [95% confidence interval] for 1-year mortality at eGFR <30 ml/min per 1.73 m2: 4.84 [1.93−12.15], 4.53 [2.42−8.47], 3.51 [2.42−5.09], and 3.30 [2.41−4.52] for patients aged <55, 55−64, 65−74, and ≥75 years compared with those with eGFR ≥60 ml/min per 1.73 m2, respectively). Conclusions For all age categories, the overall mortality was significantly higher as eGFR declined. The association of a lower eGFR with mortality was weaker with increasing age, indicating that the prognostic significance of CKD in MI patients is age dependent. PMID:23430208

  6. A practical approach to dietary interventions for nondialysis-dependent CKD patients: the experience of a reference nephrology center in Brazil.

    PubMed

    Cuppari, Lilian; Nerbass, Fabiana Baggio; Avesani, Carla Maria; Kamimura, Maria Ayako

    2016-01-01

    This paper describes the 30-year experience on nutritional management of non-dialysis dependent chronic kidney disease (CKD) patients in a public outpatient clinic located in the city of São Paulo, Brazil. A team of specialized dietitians in renal nutrition is responsible to provide individual dietary counseling for patients on stages 3 to 5 of CKD. Two different types of nutrition care protocols are employed depending on the level of renal function. For patients with CKD stage 3 a simplified nutritional assessment is performed and the main dietary focus is on the control of protein intake particularly from animal sources. A more complete nutritional assessment as well as a detailed dietary plan focusing not only on the control of protein but also on energy supply and on specific micronutrients is provided for patients on stages 4 or 5 of CKD. Practical approaches and tools used by the dietitians in our clinic for improving patient´s adherence to protein, sodium and potassium restriction while maintaining a healthy diet are described in detail in the sections of the article. PMID:27423180

  7. Approximation of Corrected Calcium Concentrations in Advanced Chronic Kidney Disease Patients with or without Dialysis Therapy

    PubMed Central

    Kaku, Yoshio; Ookawara, Susumu; Miyazawa, Haruhisa; Ito, Kiyonori; Ueda, Yuichiro; Hirai, Keiji; Hoshino, Taro; Mori, Honami; Yoshida, Izumi; Morishita, Yoshiyuki; Tabei, Kaoru

    2015-01-01

    Background The following calcium (Ca) correction formula (Payne) is conventionally used for serum Ca estimation: corrected total Ca (TCa) (mg/dl) = TCa (mg/dl) + [4 – albumin (g/dl)]; however, it is inapplicable to advanced chronic kidney disease (CKD) patients. Methods 1,922 samples in CKD G4 + G5 patients and 341 samples in CKD G5D patients were collected. Levels of TCa (mg/day), ionized Ca2+ (iCa2+) (mmol/l) and other clinical parameters were measured. We assumed the corrected TCa to be equal to eight times the iCa2+ value (measured corrected TCa). We subsequently performed stepwise multiple linear regression analysis using the clinical parameters. Results The following formula was devised from multiple linear regression analysis. For CKD G4 + G5 patients: approximated corrected TCa (mg/dl) = TCa + 0.25 × (4 – albumin) + 4 × (7.4 – pH) + 0.1 × (6 – P) + 0.22. For CKD G5D patients: approximated corrected TCa (mg/dl) = TCa + 0.25 × (4 – albumin) + 0.1 × (6 – P) + 0.05 × (24 – HCO3-) + 0.35. Receiver operating characteristic analysis showed the high values of the area under the curve of approximated corrected TCa for the detection of measured corrected TCa ≥8.4 mg/dl and ≤10.4 mg/dl for each CKD sample. Both intraclass correlation coefficients for each CKD sample demonstrated superior agreement using the new formula compared to the previously reported formulas. Conclusion Compared to other formulas, the approximated corrected TCa values calculated from the new formula for patients with CKD G4 + G5 and CKD G5D demonstrates superior agreement with the measured corrected TCa. PMID:26557841

  8. Urinary Creatinine Excretion, Bioelectrical Impedance Analysis, and Clinical Outcomes in Patients with CKD: The CRIC Study

    PubMed Central

    Xie, Dawei; Anderson, Amanda H.; Leonard, Mary B.; Reese, Peter P.; Delafontaine, Patrice; Horwitz, Edward; Kallem, Radhakrishna; Navaneethan, Sankar; Ojo, Akinlolu; Porter, Anna C.; Sondheimer, James H.; Sweeney, H. Lee; Townsend, Raymond R.; Feldman, Harold I.

    2014-01-01

    Background and objectives Previous studies in chronic disease states have demonstrated an association between lower urinary creatinine excretion (UCr) and increased mortality, a finding presumed to reflect the effect of low muscle mass on clinical outcomes. Little is known about the relationship between UCr and other measures of body composition in terms of the ability to predict outcomes of interest. Design, setting, participants, & measurements Using data from the Chronic Renal Insufficiency Cohort (CRIC), the relationship between UCr, fat free mass (FFM) as estimated by bioelectrical impedance analysis, and (in a subpopulation) whole-body dual-energy x-ray absorptiometry assessment of appendicular lean mass were characterized. The associations of UCr and FFM with mortality and ESRD were compared using Cox proportional hazards models. Results A total of 3604 CRIC participants (91% of the full CRIC cohort) with both a baseline UCr and FFM measurement were included; of these, 232 had contemporaneous dual-energy x-ray absorptiometry measurements. Participants were recruited between July 2003 and March 2007. UCr and FFM were modestly correlated (rho=0.50; P<0.001), while FFM and appendicular lean mass were highly correlated (rho=0.91; P<0.001). Higher urinary urea nitrogen, black race, younger age, and lower serum cystatin C level were all significantly associated with higher UCr. Over a median (interquartile range) of 4.2 (3.1–5.0) years of follow-up, 336 (9.3%) participants died and 510 (14.2%) reached ESRD. Lower UCr was associated with death and ESRD even after adjustment for FFM (adjusted hazard ratio for death per 1 SD higher level of UCr, 0.63 [95% confidence interval, 0.56 to 0.72]; adjusted hazard ratio for ESRD per 1 SD higher level of UCr, 0.70 [95% confidence interval, 0.63 to 0.75]). Conclusions Among a cohort of individuals with CKD, lower UCr is associated with death and ESRD independent of FFM as assessed by bioelectrical impedance analysis. PMID

  9. Patient Education and Support During CKD Transitions: When the Possible Becomes Probable.

    PubMed

    Green, Jamie A; Boulware, L Ebony

    2016-07-01

    Patients transitioning from kidney disease to kidney failure require comprehensive patient-centered education and support. Efforts to prepare patients for this transition often fail to meet patients' needs due to uncertainty about which patients will progress to kidney failure, nonindividualized patient education programs, inadequate psychosocial support, or lack of assistance to guide patients through complex treatment plans. Resources are available to help overcome barriers to providing optimal care during this time, including prognostic tools, educational lesson plans, decision aids, communication skills training, peer support, and patient navigation programs. New models are being studied to comprehensively address patients' needs and improve the lives of kidney patients during this high-risk time. PMID:27324676

  10. Online CKD education for medical students, residents, and fellows: training in a new era.

    PubMed

    Bhasin, Bhavna; Estrella, Michelle M; Choi, Michael J

    2013-07-01

    CKD and its complications are associated with substantial morbidity and mortality. Studies have highlighted significant deficiencies in resident knowledge and awareness of CKD and its complications. There is a need to improve CKD education through medical school and residency. There is also a need to provide alternatives to traditional teaching methods to meet the challenges of learning in the context of work-hour restrictions and increasing workload among residents and fellows. Internet-based learning resources offer various educational tools, including websites, kidney blogs, online modules, and smartphone applications, which could potentially and efficiently advance CKD knowledge among medical trainees. In this review, we describe several online resources for CKD education that could be useful for medical students, residents, and fellows. Increased awareness of these tools and their utilization may significantly influence and hopefully improve the recognition and management of patients with CKD. Future studies may help evaluate the effectiveness of these online learning methods and their effect on CKD patient outcomes. In addition, in light of increased concern about nephrology workforce issues, the potential for these online tools to augment interest in nephrology careers should be investigated. PMID:23809287

  11. Sleep Quality, Mood, Alertness and Their Variability in CKD and ESRD

    PubMed Central

    Roumelioti, Maria-Eleni; Argyropoulos, Christos; Buysse, Daniel J.; Nayar, Harry; Weisbord, Steven D.; Unruh, Mark L.

    2010-01-01

    Background/Aims Little is known about the association of chronic kidney disease (CKD) with sleep quality, mood, and alertness. In this report, we assessed these symptoms among patients with advanced CKD (stages 4–5) and those with end-stage renal disease (ESRD) and compared them to healthy controls without known kidney disease. Methods Patients were recruited from local dialysis units, outpatient nephrology clinics and the Thomas E. Starzl Transplant Institute. Healthy control subjects matched for age, gender and race were drawn from an archival database. Daily symptoms of sleep quality, mood, and alertness were assessed by visual analogue scales of the Pittsburgh Sleep Diary. Health-related quality of life was assessed by the Short Form-36 instrument. Results Sixty-nine dialysis patients and 23patients with advanced CKD demonstrated worse scores in sleep quality, mood, and alertness (p < 0.001) than controls. In adjusted analyses, European-American race, dialysis dependency, younger age, and physical performance SF-36 components were significantly associated with poor sleep quality, mood and alertness (p < 0.05). The dialysis population demonstrated higher day-to-day variability in scores than either the advanced CKD patients or the controls. Conclusion Advanced CKD and dialysis dependency are associated with impaired and highly variable sleep quality, mood, and alertness. PMID:20090370

  12. Effect of high-protein supplemental therapy on subjective global assessment of CKD-5D patients.

    PubMed

    Yuvaraj, Anand; Vijayan, Madhusudan; Alex, Marina; Abraham, Georgi; Nair, Sanjeev

    2016-01-01

    Adequate nutrition in patients on hemodialysis is an important step for improving the quality of life. This prospective study was undertaken to monitor the nutritional status of patients who were given high-protein supplements on malnutrition inflammation score (MIS) and to correlate with biochemical parameters in maintenance hemodialysis (MHD) patients. This prospective study was conducted on 55 chronic kidney disease patients on MHD (37 women, 18 men), aged between 21 and 67 years. Of the 55 patients, 26 patients received high-protein commercial nutritional supplements, whereas 29 patients received high-protein kitchen feeding. Every patient had their MIS, 24-hour dietary recall, hand grip, mid arm circumference, triceps skin-fold thickness at 0, 3, and 6 months. Each of the above parameters was compared between the high-protein commercial nutritional supplement cohort and high-protein kitchen feeding cohort, and the data were analyzed. Of the 55 patients, 82.61% of patients on high-protein kitchen feeding group and 66.67% in high-protein commercial nutritional supplement group were nonvegetarian (P = 0.021). According to the MIS, improvement was observed in malnutrition status from 3- to 6-month period in 38.1% of patients in high-protein commercial supplement group, whereas only in 8.7% in high-protein kitchen feeding group (P = 0.04). Assessment showed improvement in malnutrition status with high-protein commercial nutritional supplement, which was marked in patients with age group >65 years (P = 0.03) and in those in whom serum albumin is <35 g/L (P = 0.02). Both high-protein kitchen feeding and high-protein commercial nutritional supplement cohorts were observed to have improvement in overall nutritional status. Older patients >65 years with lower serum albumin levels (<3.5 g/dL) were observed to have significant improvement in nutritional status with high-protein commercial nutritional supplements. PMID:26105085

  13. Niacin and progression of CKD.

    PubMed

    Streja, Elani; Kovesdy, Csaba P; Streja, Dan A; Moradi, Hamid; Kalantar-Zadeh, Kamyar; Kashyap, Moti L

    2015-05-01

    Niacin is the oldest drug available for the treatment of dyslipidemia. It has been studied extensively and tested in clinical trials of atherosclerotic cardiovascular disease prevention and regression in the general population, but not specifically in patients with chronic kidney disease (CKD), who are at extremely high residual risk despite current therapy. Despite the current controversy about recent trials with niacin, including their limitations, there may be a place for this agent in select patients with CKD with dyslipidemia. Niacin has a favorable unique impact on factors affecting the rate of glomerular filtration rate decline, including high-density lipoprotein (HDL) particle number and function, triglyceride levels, oxidant stress, inflammation and endothelial function, and lowering of serum phosphorus levels by reducing dietary phosphorus absorption in the gastrointestinal tract. These effects may slow glomerular filtration rate decline and ultimately improve CKD outcomes and prevent cardiovascular risk. This review presents the clinically relevant concept that niacin holds significant potential as a renoprotective therapeutic agent. In addition, this review concludes that clinical investigations to assess the effect of niacin (in addition to aggressive low-density lipoprotein cholesterol lowering) on reduction of cardiovascular events in patients with CKD with very low HDL cholesterol (or those with identified dysfunctional HDL) and elevated triglyceride levels need to be considered seriously to address the high residual risk in this population. PMID:25708553

  14. Diabetic Nephropathy and CKD—Analysis of Individual Patient Serum Creatinine Trajectories: A Forgotten Diagnostic Methodology for Diabetic CKD Prognostication and Prediction

    PubMed Central

    Onuigbo, Macaulay Amechi Chukwukadibia; Agbasi, Nneoma

    2015-01-01

    Creatinine is produced in muscle metabolism as the end-product of creatine phosphate and is subsequently excreted principally by way of the kidneys, predominantly by glomerular filtration. Blood creatinine assays constitute the most common clinically relevant measure of renal function. The use of individual patient-level real-time serum creatinine trajectories provides a very attractive and tantalizing methodology in nephrology practice. Topics covered in this review include acute kidney injury (AKI) with its multifarious rainbow spectrum of renal outcomes; the stimulating vicissitudes of the diverse patterns of chronic kidney disease (CKD) to end-stage renal disease (ESRD) progression, including the syndrome of rapid onset end stage renal disease (SORO-ESRD); the syndrome of late onset renal failure from angiotensin blockade (LORFFAB); and post-operative AKI linked with the role of intra-operative hypotension in patients with diabetes mellitus and suspected diabetic nephropathy with CKD. We conclude that the study of individual patient-level serum creatinine trajectories, albeit a neglected and forgotten diagnostic methodology for diabetic CKD prognostication and prediction, is a most useful diagnostic tool, both in the short-term and in the long-term practice of nephrology. The analysis of serum creatinine trajectories, both in real time and retrospectively, indeed provides supplementary superior diagnostic and prognostic insights in the management of the nephrology patient. PMID:26239680

  15. Acute kidney injury from cherry concentrate in a patient with CKD.

    PubMed

    Luciano, Randy L

    2014-03-01

    Nutraceuticals are supplements and medical foods that offer numerous health benefits. However, these substances may have adverse effects on multiple organ systems, leading to significant morbidity. I present a patient with chronic kidney disease who experienced hemodynamically mediated acute kidney injury and hyperkalemia after daily consumption of cherry concentrate. The method of injury was most likely cyclooxygenase inhibition by the compounds in cherries that mimic the mechanism of action of nonsteroidal anti-inflammatory medications. Ceasing cherry concentrate consumption led to improvements in both the patient's hyperkalemia and kidney injury. Physicians should be aware of the potentially harmful side effects of cherry concentrate and approach the use of cherry extract or concentrate with caution in patients with underlying kidney disease. PMID:24290246

  16. Audit-based education: a potentially effective program for improving guideline achievement in CKD patients.

    PubMed

    de Goeij, Moniek C M; Rotmans, Joris I

    2013-09-01

    The achievement of treatment guidelines in patients with chronic kidney disease is poor, and more efforts are needed to improve this. Audit-based education is a program that may contribute to this improvement. de Lusignana et al. investigated whether audit-based education is effective in lowering systolic blood pressure in a primary-care setting. Although the program is inventive and promising, several adjustments are needed before it can be applied as an effective strategy. PMID:23989357

  17. Should an Elderly Patient with Stage V CKD and Dementia Be Started on Dialysis?

    PubMed Central

    Ying, Irene; Levitt, Zoe

    2014-01-01

    The burden of cognitive impairment appears to increase with progressive renal disease, such that the prevalence of dementia among those starting dialysis, or those already established on dialysis, is high. The appropriateness of dialysis initiation in this population has been questioned, and current Renal Physician Association guidelines suggest forgoing dialysis in individuals who have dementia and lack awareness of self and environment. Patients are, however, also entitled to equal rights and respect, equal access to health care services, and an opportunity to engage in shared decision-making processes, particularly if there is concern over reversibility of disease. This article discusses, on the basis of principles of beneficence and nonmaleficence, the arguments in favor of and against dialysis use, and the process of determining an appropriate care plan. Factors discussed include the current societal trend toward a technological imperative, premature fatalism, survival benefits, and the implications of providing care to patients who are unable to express their tolerance for symptoms associated with the treatment or lack of treatment. PMID:24235287

  18. Combination therapy for hypertension in patients with CKD: a subanalysis of the Combination Therapy of Hypertension to Prevent Cardiovascular Events trial.

    PubMed

    Rakugi, Hiromi; Ogihara, Toshio; Umemoto, Seiji; Matsuzaki, Masunori; Matsuoka, Hiroaki; Shimada, Kazuyuki; Higaki, Jitsuo; Ito, Sadayoshi; Kamiya, Akira; Suzuki, Hiromichi; Ohashi, Yasuo; Shimamoto, Kazuaki; Saruta, Takao

    2013-11-01

    The Combination Therapy of Hypertension to Prevent Cardiovascular Events (COPE) trial was a multicenter, randomized, three-arm comparative study (N=3293) undertaken to determine the optimal combination therapy, based on the occurrence of cardiovascular events in patients treated with an angiotensin II receptor blocker (ARB), a β-blocker (BB) or a thiazide diuretic (TD) in addition to the calcium antagonist benidipine as baseline medication. This subanalysis was conducted to compare the efficacy of three combination therapies in a subset of 834 patients with chronic kidney disease (CKD) (287 patients treated with benidpine-ARB, 283 patients treated with benidipine-BB and 264 patients treated with benidipine-TD). The incidence of composite cardiovascular events as the primary end point did not differ among these three groups. The incidence of hard end points and cerebrovascular events among these groups did not differ either, although the incidence among all patients in the COPE trial was lower in the benidipine-TD group than in the benidipine-BB group. The incidence of new-onset diabetes mellitus was higher in the benidipine-TD group than in the benidipine-ARB group among patients with CKD. The estimated glomerular filtration rate (eGFR) was maintained even after 12 months of treatment in patients with a baseline eGFR <60 ml min(-1) per 1.73 m(2) regardless of the treatment group, although the eGFR decreased over time in all patients in the three groups. In conclusion, in patients with CKD, all of the tested combination therapies demonstrated comparable efficacy in terms of prevention of cardiovascular events as well as maintenance of eGFR. PMID:23864054

  19. Risk of liver injury after α-glucosidase inhibitor therapy in advanced chronic kidney disease patients

    PubMed Central

    Kao, Chih-Chin; Wu, Pei-Chen; Wu, Che-Hsiung; Chen, Li-kwang; Chen, Hsi-Hsien; Wu, Mai-Szu; Wu, Vin-Cent

    2016-01-01

    Although α-glucosidase inhibitors (AGIs) are commonly used for controlling postprandial blood glucose, AGIs-induced liver injuries have been reported. However, the relationship between AGIs and liver injuries in advanced chronic kidney disease (CKD) patients remains unexplored. In this nationwide case-control study, we recruited 1765 advanced diabetic CKD patients, who received AGIs therapy from January 1, 2000 to December 31, 2010 as the study sample and 5295 matched controls. Recent and former AGIs users were defined as patients who received the AGIs prescription for 30–60 d and 30–210 d before the event of liver injury. The risk of AGIs-induced liver injury was examined using time-dependent Cox proportional hazards model. Liver injury occurred in 3.9% of patients in the study group and 3.3% of patients in the control group. AGIs use did not increase the risk of liver injury in advanced CKD patients (P = 0.19). The stratified analysis indicated no increased risk of liver injury in all AGIs-using subgroups (all P > 0.05). The available evidence supports extending the use of AGIs without increasing the risk of liver injury in patients with advanced CKD. Additional randomized controlled trials are warranted to confirm our results. PMID:26751038

  20. Association of the receptor for advanced glycation end-products (RAGE) gene polymorphisms in Malaysian patients with chronic kidney disease

    PubMed Central

    Wong, Foo Nian; Chua, Kek Heng; Kuppusamy, Umah Rani; Wong, Chew Ming; Lim, Soo Kun

    2016-01-01

    Background: Chronic kidney disease (CKD) is a condition associated with progressive loss of kidney function and kidney damage. The two common causes of CKD are diabetes mellitus and hypertension. Other causes of CKD also include polycystic kidney disease, obstructive uropathy and primary glomerulonephritis. The receptor for advanced glycation end-products (RAGE) is a multi-ligand cell surface receptor of the immunoglobulin superfamily and it has been associated with kidney disease in both non-diabetic and diabetic patients. Presently, data on the association between RAGE polymorphisms and CKD in the Malaysian population is limited, while numerous studies have reported associations of RAGE polymorphisms with diabetic complications in other populations. The present study aims to explore the possibility of using RAGE polymorphisms as candidate markers of CKD in Malaysian population by using association analysis. Methods: A total of 102 non-diabetic CKD patients, 204 diabetic CKD patients and 345 healthy controls were enrolled in the study. DNA isolated from blood samples were subjected to genotyping of RAGE G82S, −374T/A, −429T/C, 1704G/T and 2184A/G polymorphisms using real-time polymerase chain reaction (PCR). The 63-bp deletion, a polymorphism in the RAGE gene promoter, was genotyped using conventional PCR method and visualized using agarose gel electrophoresis. The collective frequencies of genotypes with at least one copy of the minor alleles of the four polymorphisms were compared between the non-diabetic CKD patients, diabetic CKD patients and healthy controls. Results: After adjustment of age, gender and ethnic groups in binary logistic regression analysis, the G82S CT + TT genotypes were associated with non-diabetic CKD patients when compared with diabetic CKD patients (p = 0.015, OR = 1.896, 95% CI = 1.132–3.176). After further adjustment of CKD comorbidities, the G82S CT + TT genotypes were still associated with non-diabetic CKD patients when compared

  1. The French Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort study

    PubMed Central

    Stengel, Bénédicte; Combe, Christian; Jacquelinet, Christian; Briançon, Serge; Fouque, Denis; Laville, Maurice; Frimat, Luc; Pascal, Christophe; Herpe, Yves-Edouard; Deleuze, Jean-François; Schanstra, Joost; Pisoni, Ron L.; Robinson, Bruce M.; Massy, Ziad A.

    2014-01-01

    Background While much has been learned about the epidemiology and treatment of end-stage renal disease (ESRD) in the last 30 years, chronic kidney disease (CKD) before the end-stage has been less investigated. Not enough is known about factors associated with CKD progression and complications, as well as its transition to ESRD. We designed the CKD-renal epidemiology and information network (REIN) cohort to provide a research platform to address these key questions and to assess clinical practices and costs in patients with moderate or advanced CKD. Methods A total of 46 clinic sites and 4 renal care networks participate in the cohort. A stratified selection of clinic sites yields a sample that represents a diversity of settings, e.g. geographic region, and public versus for-profit and non-for-profit private clinics. In each site, 60–90 patients with CKD are enrolled at a routine clinic visit during a 12-month enrolment phase: 3600 total, including 1800 with Stage 3 and 1800 with Stage 4 CKD. Follow-up will continue for 5 years, including after initiation of renal replacement therapy. Data will be collected from medical records at inclusion and at yearly intervals, as well as from self-administered patient questionnaires and provider-level questionnaires. Patients will also be interviewed at baseline, and at 1, 3 and 5 years. Healthcare costs will also be determined. Blood and urine samples will be collected and stored for future studies on all patients at enrolment and at study end, and at 1 and 3 years in a subsample of 1200. Conclusions The CKD-REIN cohort will serve to improve our understanding of the biological, clinical and healthcare system determinants associated with CKD progression and adverse outcomes as well as of international variations in collaboration with the CKD Outcome and Practice Pattern Study (CKDopps). It will foster CKD epidemiology and outcomes research and provide evidence to improve the health and quality of life of patients with CKD and

  2. Tubular Secretion in CKD.

    PubMed

    Suchy-Dicey, Astrid M; Laha, Thomas; Hoofnagle, Andrew; Newitt, Rick; Sirich, Tammy L; Meyer, Timothy W; Thummel, Ken E; Yanez, N David; Himmelfarb, Jonathan; Weiss, Noel S; Kestenbaum, Bryan R

    2016-07-01

    Renal function generally is assessed by measurement of GFR and urinary albumin excretion. Other intrinsic kidney functions, such as proximal tubular secretion, typically are not quantified. Tubular secretion of solutes is more efficient than glomerular filtration and a major mechanism for renal drug elimination, suggesting important clinical consequences of secretion dysfunction. Measuring tubular secretion as an independent marker of kidney function may provide insight into kidney disease etiology and improve prediction of adverse outcomes. We estimated secretion function by measuring secreted solute (hippurate, cinnamoylglycine, p-cresol sulfate, and indoxyl sulfate) clearance using liquid chromatography-tandem mass spectrometric assays of serum and timed urine samples in a prospective cohort study of 298 patients with kidney disease. We estimated GFR by mean clearance of creatinine and urea from the same samples and evaluated associations of renal secretion with participant characteristics, mortality, and CKD progression to dialysis. Tubular secretion rate modestly correlated with eGFR and associated with some participant characteristics, notably fractional excretion of electrolytes. Low clearance of hippurate or p-cresol sulfate associated with greater risk of death independent of eGFR (hazard ratio, 2.3; 95% confidence interval, 1.1 to 4.7; hazard ratio, 2.5; 95% confidence interval, 1.0 to 6.1, respectively). Hazards models also suggested an association between low cinnamoylglycine clearance and risk of dialysis, but statistical analyses did not exclude the null hypothesis. Therefore, estimates of proximal tubular secretion function correlate with glomerular filtration, but substantial variability in net secretion remains. The observed associations of net secretion with mortality and progression of CKD require confirmation. PMID:26614381

  3. Prevalence of Metformin Use and the Associated Risk of Metabolic Acidosis in US Diabetic Adults With CKD

    PubMed Central

    Kuo, Chin-Chi; Yeh, Hung-Chieh; Chen, Bradley; Tsai, Ching-Wei; Lin, Yu-Sheng; Huang, Chiu-Ching

    2015-01-01

    with subclinical metabolic acidosis but not with severe metabolic acidosis. The propensity of serum bicarbonate-lowering effect was intensified in advanced CKD; however, such tendency was not associated with the risk of clinically defined acidosis. Our findings highlight a potential of cautious expansion of metformin use among CKD-3b patients with diabetes meriting further investigations. PMID:26705203

  4. An overview of advance care planning for patients with advanced chronic kidney disease: The basics.

    PubMed

    Wasylynuk, Betty Ann; Davison, Sara N

    2016-01-01

    As the number of Canadians living with end-stage kidney disease (ESKD) continues to grow, even higher numbers are living with advanced chronic kidney disease (CKD). Many of these people will eventually require renal replacement therapy (RRT), either dialysis or transplantation. More than 50% of patients starting RRT today are aged 65 or older, with the fastest growing group being patients 75 years and older. Despite advances to dialysis technology and dialysis care, the mortality rates remain high and dialysis patients' end-of-life care may not align with their preferences or values. Advance care planning (ACP) is an essential component of quality comprehensive kidney care. Kidney care teams develop strong relationships with their patients and are well positioned to integrate ACP into routine kidney care. This article defines ACP, outlines the essential components of ACP, and discusses the benefits, challenges, and special considerations of ACP. By enhancing the kidney care team's understanding of ACP, this article aims to assist in integrating ACP into routine kidney care for patients with advanced CKD. PMID:27215058

  5. Impact of prior CKD management in a renal care network on early outcomes in incident dialysis patients: a prospective observational study

    PubMed Central

    2013-01-01

    Background Effective therapeutic strategies are available to prevent adverse outcomes in patients with chronic kidney disease (CKD) but their clinical results are hindered by unplanned implementation. Coordination of care emerges as a suitable way to improve patient outcomes. In this study, we evaluated the effect of planned and coordinated patient management within a dedicated renal care network comparatively to standard renal care delivered in nephrology departments of teaching hospitals. Methods This observational matched cohort study included 40 patients with CKD stage 4–5 in the network group as compared with a control group of 120 patients matched for age, sex and diabetic status. Main outcome was a composite endpoint of death from cardiovascular cause and cardiovascular events during the first year after dialysis initiation. Results There was no difference between the two groups neither for the primary outcome (40% vs 41%) nor for the occurrence of death from cardiovascular cause or cardiovascular events. Whereas the proportion of patients requiring at least one hospitalization was identical (83.3% vs 75%), network patients experienced less individual hospitalizations than control patients (2.3±2.0 vs 1.6±1.7) during the year before dialysis start. Patients of the network group had a slower renal function decline (7.7±2.5 vs 4.9±1.1 ml/min/1,73m2 per year; p=0.04). Conclusions In this limited series of patients, we were unable to demonstrate a significant impact of the coordinated renal care provided in the network on early cardiovascular events in incident dialysis patients. However, during the predialysis period, there were less hospitalizations and a slower slope of renal function decrease. PMID:23425313

  6. High amylose resistant starch diet ameliorates oxidative stress, inflammation, and progression of chronic kidney disease (CKD)

    Technology Transfer Automated Retrieval System (TEKTRAN)

    Patients with advanced CKD exhibit profound changes in the composition and function of the gut microbiome. This is, in part, mediated by: I- heavy influx of urea in the intestinal tract leading to the dominance of urease-possessing bacteria and II- dietary restriction of potassium-rich fruits and ve...

  7. New Insights into Dialysis Vascular Access: What Is the Optimal Vascular Access Type and Timing of Access Creation in CKD and Dialysis Patients?

    PubMed

    Woo, Karen; Lok, Charmaine E

    2016-08-01

    Optimal vascular access planning begins when the patient is in the predialysis stages of CKD. The choice of optimal vascular access for an individual patient and determining timing of access creation are dependent on a multitude of factors that can vary widely with each patient, including demographics, comorbidities, anatomy, and personal preferences. It is important to consider every patient's ESRD life plan (hence, their overall dialysis access life plan for every vascular access creation or placement). Optimal access type and timing of access creation are also influenced by factors external to the patient, such as surgeon experience and processes of care. In this review, we will discuss the key determinants in optimal access type and timing of access creation for upper extremity arteriovenous fistulas and grafts. PMID:27401524

  8. Increased Synthesis of Liver Erythropoietin with CKD.

    PubMed

    de Seigneux, Sophie; Lundby, Anne-Kristine Meinild; Berchtold, Lena; Berg, Anders H; Saudan, Patrick; Lundby, Carsten

    2016-08-01

    Anemia of CKD seems to be related to impaired production of renal erythropoietin (Epo). The glycosylation pattern of Epo depends on the synthesizing cell and thus, can indicate its origin. We hypothesized that synthesis of Epo from nonkidney cells increases to compensate for insufficient renal Epo production during CKD. We determined plasma Epo levels and Epo glycosylation patterns in 33 patients with CKD before undergoing dialysis and nine patients with CKD undergoing dialysis. We compared these values with values obtained in healthy volunteers and other controls. Although patients with CKD before undergoing dialysis had median (interquartile range) Epo levels higher than those of healthy controls (13.8 IU/L; interquartile range, 10.0-20.7 IU/L versus 8.4 IU/L; interquartile range, 7.6-9.0 IU/L; P<0.01), these patients were moderately anemic (mean±SD; hemoglobin =118±17 g/L). Detected as the percentage of migrated isoforms (PMI), Epo glycosylation in patients with CKD before undergoing dialysis (PMI=36.1±11.7%) differed from that in healthy controls (PMI=9.2±3.8%; P<0.01) but not from that in umbilical cord plasma (PMI=53.9±10.6%; P>0.05), which contains mainly liver-derived Epo. Furthermore, glycosylation modification correlated with eGFR loss. These results suggest that patients with CKD maintain persistent Epo synthesis despite declining renal function, and this maintenance may result in part from increased liver Epo synthesis. PMID:26757994

  9. Randomized placebo-controlled dose-ranging and pharmacodynamics study of roxadustat (FG-4592) to treat anemia in nondialysis-dependent chronic kidney disease (NDD-CKD) patients

    PubMed Central

    Besarab, Anatole; Provenzano, Robert; Hertel, Joachim; Zabaneh, Raja; Klaus, Stephen J.; Lee, Tyson; Leong, Robert; Hemmerich, Stefan; Yu, Kin-Hung Peony; Neff, Thomas B.

    2015-01-01

    Background Roxadustat (FG-4592) is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor that stimulates erythropoiesis. This Phase 2a study tested efficacy (Hb response) and safety of roxadustat in anemic nondialysis-dependent chronic kidney disease (NDD-CKD) subjects. Methods NDD-CKD subjects with hemoglobin (Hb) ≤11.0 g/dL were sequentially enrolled into four dose cohorts and randomized to roxadustat or placebo two times weekly (BIW) or three times weekly (TIW) for 4 weeks, in an approximate roxadustat:placebo ratio of 3:1. Efficacy was assessed by (i) mean Hb change (ΔHb) from baseline (BL) and (ii) proportion of Hb responders (ΔHb ≥ 1.0 g/dL). Pharmacodynamic evaluation was performed in a subset of subjects. Safety was evaluated by adverse event frequency/severity. Results Of 116 subjects receiving treatment, 104 completed 4 weeks of dosing and 96 were evaluable for efficacy. BL characteristics for roxadustat and placebo groups were comparable. In roxadustat-treated subjects, Hb levels increased from BL in a dose-related manner in the 0.7, 1.0, 1.5 and 2.0 mg/kg groups. Maximum ΔHb within the first 6 weeks was significantly higher in the 1.5 and 2.0 mg/kg groups than in the placebo subjects. Hb responder rates were dose dependent and ranged from 30% in the 0.7 mg/kg BIW group to 100% in the 2.0 mg/kg BIW and TIW groups versus 13% in placebo. Conclusions Roxadustat transiently and moderately increased endogenous erythropoietin and reduced hepcidin. Adverse events were similar in the roxadustat and placebo groups. Roxadustat produced dose-dependent increases in blood Hb among anemic NDD-CKD patients in a placebo-controlled trial. Clinical Trials Registration Clintrials.gov #NCT00761657. PMID:26238121

  10. [Treatment of CKD-MBD targeting the parathyroid gland].

    PubMed

    Isozaki, Yudai; Komaba, Hirotaka

    2016-06-01

    Secondary hyperparathyroidism is a major component of chronic kidney disease-mineral and bone disorder(CKD-MBD)and has a considerable impact on morbidity and mortality through the development of high-turnover bone disease and vascular calcification. Thus, management of secondary hyperparathyroidism is important for improving the outcomes of CKD patients. Because there is a fundamental difference in the pathogenesis of secondary hyperparathyroidism between predialysis and dialysis patients, different therapeutic approach should be considered for each condition. In this article, we summarize the treatment of CKD-MBD for managing secondary hyperparathyroidism, with a particular focus on the difference between predialysis and dialysis stages of CKD. PMID:27230846

  11. Prevalence of Metformin Use and the Associated Risk of Metabolic Acidosis in US Diabetic Adults With CKD: A National Cross-Sectional Study.

    PubMed

    Kuo, Chin-Chi; Yeh, Hung-Chieh; Chen, Bradley; Tsai, Ching-Wei; Lin, Yu-Sheng; Huang, Chiu-Ching

    2015-12-01

    metabolic acidosis but not with severe metabolic acidosis. The propensity of serum bicarbonate-lowering effect was intensified in advanced CKD; however, such tendency was not associated with the risk of clinically defined acidosis. Our findings highlight a potential of cautious expansion of metformin use among CKD-3b patients with diabetes meriting further investigations. PMID:26705203

  12. Vitamin B(12) Immunoassay on Roche Elecsys 2010: Effects of High Excess Concentration of Serum Vitamin B(12) in CKD Patients on Parenteral Administration.

    PubMed

    Basu, Surupa; Chaudhuri, Subimal

    2011-10-01

    Vitamin B(12) being water soluble is excreted in the urine when administered in excess. The probability of finding an abnormally excess serum concentration would be almost surreal. We report a peculiar clinical situation that may impact the vitamin B(12) immunoassay on the Roche Elecsys 2010 due to excess analyte concentration. In separate episodes (Feb and June 2010), the Biochemistry laboratory of a tertiary-care hospital, Kolkata, India, encountered two critically ill patients with background chronic kidney disease (CKD), low urine output, and on cyanocoabalamin supplementation, who had serum vitamin B(12) concentrations far exceeding expected values; even post dialysis. The B(12) assays (pmol/l) were performed using electrochemiluminiscence immunoassay on Roche Elecsys 2010, the assay validity confirmed by concomitant quality control runs. The immunoassays failed to deliver results, flagged with "signal level below limit". Biotin therapy was ruled out as a possible interferent. In the first episode, re-assay of a repeat draw yielded same outcome; outsourcing on Immulite provided concentration of >738 pmol/l. Serial dilution gave result of >29520 pmol/l on Elecsys 2010. In the second, we gained from past experience. Vitamin B(12) concentration >59040 pmol/l was conveyed to the treating nephrologist the very day. The B(12) immunoassay on the Elecsys 2010 employs sequential incubation steps for competitive binding that is compromised in the event of abnormally excess B(12) concentration in patient sera akin to the prozone effect. This knowledge may be beneficial while assaying sera of CKD patients to avoid financial loss due unnecessary repeats and delay in turnaround time. PMID:23024480

  13. Implantable Cardioverter Defibrillators for Primary Prevention of Sudden Cardiac Death in CKD: A Meta-analysis of Patient-Level Data from 3 Randomized Trials

    PubMed Central

    Pun, Patrick H.; Al-Khatib, Sana M.; Han, Joo Yoon; Edwards, Rex; Bardy, Gust H.; Bigger, J. Thomas; Buxton, Alfred E.; Moss, Arthur J.; Lee, Kerry L.; Steinman, Richard; Dorian, Paul; Hallstrom, Al; Cappato, Riccardo; Kadish, Alan H.; Kudenchuk, Peter J.; Mark, Daniel B.; Hess, Paul L.; Inoue, Lurdes Y. T.; Sanders, Gillian D.

    2014-01-01

    Background The benefit of a primary prevention implantable cardioverter defibrillator (ICD) among patients with chronic kidney disease (CKD) is uncertain. Study Design Meta-analysis of patient-level data from randomized controlled trials. Setting & Population Patients with symptomatic heart failure and left ventricular ejection fraction of <35%. Selection Criteria for Studies From 7 available randomized control studies with patient level data, we selected studies with available data on important covariates. Studies without patient-level data on baseline eGFR were excluded. Intervention Primary prevention ICD versus usual care Outcomes Mortality, re-hospitalizations, and effect modification by estimated GFR (eGFR) Results We included data from the Multicenter Automatic Defibrillator Implantation Trial I (MADIT-I), MADIT-II, and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). 2,867 patients were included; 36.3% had at least stage 3 CKD (eGFR<60). The Kaplan-Meier estimate of the probability of death during follow-up was 43.3% among 1,334 patients receiving usual care and 35.8% among 1,533 ICD recipients. After adjustment for baseline differences, there was evidence that the survival benefit of ICDs in comparison to usual care depends on eGFR (posterior probability for null interaction p <0.001). The ICD was associated with survival benefit among patients with an eGFR ≥ 60 (adjusted HR (aHR)=0.49 [95% posterior credible interval (PCI) 0.24-0.95]) but not among patients with eGFR <60 (aHR = 0.80 [95% PCI 0.40-1.53]). eGFR did not modify the association between the ICD and re-hospitalizations. Limitations Few patients with eGFR <30 were available. Differences in trial-to-trial measurement techniques may lead to residual confounding. Conclusions Reductions in baseline eGFR decrease the survival benefit associated with the ICD. These findings should be confirmed by additional studies specifically targeting patients with varying levels of eGFR. PMID:24518128

  14. Social Determinants of Racial Disparities in CKD.

    PubMed

    Norton, Jenna M; Moxey-Mims, Marva M; Eggers, Paul W; Narva, Andrew S; Star, Robert A; Kimmel, Paul L; Rodgers, Griffin P

    2016-09-01

    Significant disparities in CKD rates and outcomes exist between black and white Americans. Health disparities are defined as health differences that adversely affect disadvantaged populations, on the basis of one or more health outcomes. CKD is the complex result of genetic and environmental factors, reflecting the balance of nature and nurture. Social determinants of health have an important role as environmental components, especially for black populations, who are disproportionately disadvantaged. Understanding the social determinants of health and appreciating the underlying differences associated with meaningful clinical outcomes may help nephrologists treat all their patients with CKD in an optimal manner. Altering the social determinants of health, although difficult, may embody important policy and research efforts, with the ultimate goal of improving outcomes for patients with kidney diseases, and minimizing the disparities between groups. PMID:27178804

  15. Arterial Remodeling Associates with CKD Progression

    PubMed Central

    Collin, Cédric; Karras, Alexandre; Laurent, Stéphane; Bozec, Erwan; Jacquot, Christian; Stengel, Bénédicte; Houillier, Pascal; Froissart, Marc; Boutouyrie, Pierre

    2011-01-01

    In CKD, large arteries remodel and become increasingly stiff. The greater pulsatile pressure reaching the glomerulus as a result of increased aortic stiffness could induce renal damage, suggesting that the stiffening and remodeling of large arteries could affect the progression of CKD. We measured carotid-femoral pulse wave velocity, aortic pressure and carotid remodeling and stiffness parameters in 180 patients with CKD (mean measured GFR, 32 ml/min per 1.73 m2) and followed them prospectively for a mean of 3.1 years. During follow-up, carotid stiffness significantly increased (+0.28 ± 0.05 m/s; P < 0.0001) but aortic stiffness did not. Carotid intima-media thickness decreased significantly during follow-up and the internal diameter of the carotid increased, producing increased circumferential wall stress (+2.08 ± 0.43 kPa/yr; P < 0.0001). In a linear mixed model, circumferential wall stress significantly associated with faster GFR decline after adjustment for risk factors of cardiovascular disease and progression of CKD. In a multivariable Cox model, carotid circumferential wall stress and pulse pressure independently associated with higher risk for ESRD. None of the arterial stiffness parameters associated with progression of CKD. In conclusion, maladaptive remodeling of the carotid artery and increased pulse pressure independently associate with faster decline of renal function and progression to ESRD. PMID:21493771

  16. Uric Acid as a Target of Therapy in CKD

    PubMed Central

    Jalal, Diana I.; Chonchol, Michel; Chen, Wei; Targher, Giovanni

    2012-01-01

    The prevalence of chronic kidney disease (CKD) has risen and will continue to rise in the United States and worldwide. This is alarming considering that CKD remains an irreversible condition and patients who progress to chronic kidney failure suffer reduced quality of life and high mortality rates. As such, it is imperative to identify modifiable risk factors to develop strategies to slow CKD progression. One such factor is hyperuricemia. Recent observational studies have associated hyperuricemia with kidney disease. In addition, hyperuricemia is largely prevalent in patients with CKD. Data from experimental studies have revealed several potential mechanisms by which hyperuricemia may contribute to the development and progression of CKD. In this manuscript we offer a critical review of the experimental evidence linking hyperuricemia to CKD, we highlight the gaps in our knowledge on the topic as it stands today, and we review the observational and interventional studies that have examined the potential nephro-protective effect of lowering uric acid in CKD patients . While uric acid may also be linked to cardiovascular disease and mortality in patients with CKD, this review will focus only on uric acid as a potential therapeutic target to prevent kidney disease onset and progression. PMID:23058478

  17. Type 2 translational research for CKD.

    PubMed

    Tuttle, Katherine R; Tuot, Delphine S; Corbett, Cynthia L; Setter, Stephen M; Powe, Neil R

    2013-10-01

    Strategies to effectively treat people with CKD have been identified by conventional clinical research. Despite this evidence, awareness, screening, detection, diagnosis, risk factor control, treatment, and outcomes remain substandard. Translating clinical evidence into actionable measures that reduce the burden of CKD is a pressing need. Expansion from a "bench-to-bedside" paradigm (conventional type 1 translation) to research that encompasses "clinic and community" is the core concept of type 2 translation. Specifically, this is the discipline of identifying factors and using strategies that lead to adoption, maintenance, and sustainability of science-based interventions in practice. This review identifies key elements of type 2 translational research and highlights the current scope of this type of research for CKD. For type 2 translation to achieve the goals of providing high-quality care and better health outcomes, key facilitators (e.g., theory-based frameworks, adaptable interventions, and inclusion of sustainability and evaluation metrics) and essential elements (e.g., multidisciplinary team care, health information technology, and stakeholder engagement) must be integrated. The National Institute of Diabetes and Digestive and Kidney Diseases recently funded five proposals that aim to improve outcomes for people with CKD, focusing on diverse components of the healthcare continuum: patient safety and transitions; delivery of high-quality, evidence-based CKD care; and elimination of disparities. The need for type 2 translational research in CKD is urgent because of preventable human suffering and unsustainable costs of providing care. Focus on the theory, framework, and approaches we have suggested may help us meet that challenge. PMID:23620444

  18. Type 2 Translational Research for CKD

    PubMed Central

    Tuot, Delphine S.; Corbett, Cynthia L.; Setter, Stephen M.; Powe, Neil R.

    2013-01-01

    Summary Strategies to effectively treat people with CKD have been identified by conventional clinical research. Despite this evidence, awareness, screening, detection, diagnosis, risk factor control, treatment, and outcomes remain substandard. Translating clinical evidence into actionable measures that reduce the burden of CKD is a pressing need. Expansion from a “bench-to-bedside” paradigm (conventional type 1 translation) to research that encompasses “clinic and community” is the core concept of type 2 translation. Specifically, this is the discipline of identifying factors and using strategies that lead to adoption, maintenance, and sustainability of science-based interventions in practice. This review identifies key elements of type 2 translational research and highlights the current scope of this type of research for CKD. For type 2 translation to achieve the goals of providing high-quality care and better health outcomes, key facilitators (e.g., theory-based frameworks, adaptable interventions, and inclusion of sustainability and evaluation metrics) and essential elements (e.g., multidisciplinary team care, health information technology, and stakeholder engagement) must be integrated. The National Institute of Diabetes and Digestive and Kidney Diseases recently funded five proposals that aim to improve outcomes for people with CKD, focusing on diverse components of the healthcare continuum: patient safety and transitions; delivery of high-quality, evidence-based CKD care; and elimination of disparities. The need for type 2 translational research in CKD is urgent because of preventable human suffering and unsustainable costs of providing care. Focus on the theory, framework, and approaches we have suggested may help us meet that challenge. PMID:23620444

  19. Prognosis and management of chronic kidney disease (CKD) at the end of life.

    PubMed

    Davison, Rachel; Sheerin, Neil S

    2014-02-01

    The prevalence of chronic kidney disease (CKD) increases with age. As people are living longer, nephrologists are responsible for a progressively older cohort of patients with substantial comorbidities. Patients with CKD have a significant symptom burden and can benefit from intervention and symptom control from an early stage in the illness. It is also increasingly recognised that renal replacement therapy may not always offer an improvement in symptoms or a survival advantage to older patients with high levels of comorbidity. For these reasons, non-dialytic (conservative) management and end-of-life care is becoming part of routine nephrology practice. Such patients will also frequently be encountered in other specialities, requiring generalists to have some renal-specific skills and knowledge. Although there have been significant advances in this field in recent years, the optimum model of care and some of the care preferences of patients remain challenges that need to be addressed. PMID:24319094

  20. The effects of colestilan versus placebo and sevelamer in patients with CKD 5D and hyperphosphataemia: a 1-year prospective randomized study

    PubMed Central

    Locatelli, Francesco; Spasovski, Goce; Dimkovic, Nada; Wanner, Christoph; Dellanna, Frank; Pontoriero, Giuseppe

    2014-01-01

    Background This study compared the effects of short-term titrated colestilan (a novel non-absorbable, non-calcium, phosphate binder) with placebo, and evaluated the safety and efficacy of colestilan over 1 year compared with sevelamer, in patients with chronic kidney disease (CKD) 5D. Methods This prospective multicentre study comprised a 4-week phosphate binder washout period, a 16-week short-term, flexible-dose, treatment period (including a 4-week placebo-controlled withdrawal period) and a 40-week extension treatment phase. Results At Week 16 (the end of the 4-week placebo-controlled withdrawal period), serum phosphorus level was 0.43 mmol/L (1.32 mg/dL) lower with colestilan than placebo (P < 0.001; primary end point). Serum LDL-C level was also lower with colestilan than with placebo (P < 0.001). Both colestilan and sevelamer produced significant reductions from baseline in serum phosphorus levels (P < 0.001), maintained for 1 year, and the proportion of patients achieving target levels of ≤1.78 mmol/L (5.5 mg/dL) or ≤1.95 mmol/L (6.0 mg/dL) at study end were similar (65.3 and 73.3%, respectively, for colestilan, and 66.9 and 77.4%, respectively, for sevelamer). Serum calcium level remained stable in the colestilan group but tended to increase slightly in the sevelamer group (end-of-study increase of 0.035 mmol/L over baseline). Both binders produced similar reductions from baseline in LDL-C level (P < 0.001), and responder rates after 1 year, using a target of <1.83 mmol/L (70 mg/dL) or <2.59 mmol/L (100 mg/dL) were similar in both groups (50.7 and 85.3% for colestilan and 54.0 and 80.6% for sevelamer). Colestilan was generally well tolerated. Conclusions Colestilan is effective and safe for the treatment of hyperphosphataemia in patients with CKD 5D, and affords similar long-term phosphorus and cholesterol reductions/responder rates to sevelamer. PMID:24302608

  1. Albuminuria as a Risk Factor for Anemia in Chronic Kidney Disease: Result from the KoreaN Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD)

    PubMed Central

    Han, Ji Suk; Lee, Mi Jung; Park, Kyoung Sook; Han, Seung Hyeok; Yoo, Tae-Hyun; Oh, Kook-Hwan; Park, Sue Kyung; Lee, Joongyub; Hyun, Young Youl; Chung, Wookyung; Kim, Yeong Hoon; Ahn, Curie; Choi, Kyu Hun

    2015-01-01

    Background Anemia is a common complication among patients with chronic kidney disease (CKD), and it is associated with unfavorable clinical outcomes in patients with CKD independent of the estimated glomerular filtration rate (eGFR). We assessed the association of the urinary albumin-to-creatinine ratio (ACR) and eGFR with anemia in CKD patients. Methods We conducted a cross-sectional study using baseline data from the KoreaN Cohort Study for Outcome in Patients With Chronic Kidney Disease (KNOW-CKD). Multiple regression analysis was performed to identify the independent association of albuminuria with anemia. Furthermore, odds ratios for anemia were calculated by cross-categorization of ACR and eGFR. Results Among 1,456 patients, the mean age was 53.5 ± 12.4 years, and the mean eGFR and ACR were 51.9 ± 30.5 mL/min per 1.73 m2 and 853.2 ± 1,330.3 mg/g, respectively. Anemia was present in 644 patients (40.5%). Multivariate analysis showed that the odds ratio of anemia increased according to ACR levels, after adjusting for age, sex, eGFR, body mass index, pulse pressure, cause of CKD, use of erythropoiesis stimulating agents, serum calcium and ferritin (ACR < 30 mg/g as a reference group; 30–299 mg/g, adjusted odds ratio (OR) = 1.43, 95% confidence interval (CI) = 0.88–2.33; ≥300 mg/g, adjusted OR = 1.86, 95% CI = 1.12–3.10). In addition, graded associations were observed in cross-categorized groups of a higher ACR and eGFR compared to the reference group with an ACR <30 mg/g and eGFR ≥60 mL/min per 1.73 m2. Conclusion The present study demonstrated that albuminuria was a significant risk factor for anemia in CKD patients independent of the eGFR. PMID:26430892

  2. Management of Hypertension in CKD: Beyond the Guidelines

    PubMed Central

    Judd, Eric; Calhoun, David A.

    2015-01-01

    Hypertension (HTN) and CKD are closely associated with an intermingled cause and effect relationship. Blood pressure (BP) typically rises with declines in kidney function, and sustained elevations in BP hasten progression of kidney disease. This review addresses current management issues in HTN in patients with CKD including altered circadian rhythm of BP, timing of antihypertensive medication dosing, BP targets, diagnostic challenges in evaluating secondary forms of HTN, and the role of salt restriction in CKD. HTN in patients with CKD is often accompanied by a decrease in the kidney’s ability to remove salt. Addressing this salt sensitivity is critical for the management of HTN in CKD. In addition to the well-established use of an ACEI or angiotensin receptor blocker, dietary salt restriction and appropriate diuretic therapy make up the mainstay of HTN treatment in patients with CKD. Bedtime dosing of antihypertensive medications can restore nocturnal dips in BP, and future clinical practice guidelines may recommend bedtime dosing of 1 or more antihypertensive medications in patients with CKD. PMID:25704348

  3. Renal Denervation in Moderate to Severe CKD

    PubMed Central

    Hering, Dagmara; Mahfoud, Felix; Walton, Antony S.; Krum, Henry; Lambert, Gavin W.; Lambert, Elisabeth A.; Sobotka, Paul A.; Böhm, Michael; Cremers, Bodo; Esler, Murray D.

    2012-01-01

    Sympathetic activation contributes to the progression of CKD and is associated with adverse cardiovascular outcomes. Ablation of renal sympathetic nerves reduces sympathetic nerve activity and BP in patients with resistant hypertension and preserved renal function, but whether this approach is safe and effective in patients with an estimated GFR (eGFR) < 45 ml/min per 1.73 m2 is unknown. We performed bilateral renal denervation in 15 patients with resistant hypertension and stage 3–4 CKD (mean eGFR, 31 ml/min per 1.73 m2). We used CO2 angiography in six patients to minimize exposure to contrast agents. Estimated GFR remained unchanged after the procedure, irrespective of the use of CO2 angiography. Mean baseline BP ± SD was 174±22/91±16 mmHg despite the use of 5.6±1.3 antihypertensive drugs. Mean changes in office systolic and diastolic BP at 1, 3, 6, and 12 months were −34/−14, −25/−11, −32/−15, and −33/−19 mmHg, respectively. Night-time ambulatory BP significantly decreased (P<0.05), restoring a more physiologic dipping pattern. In conclusion, this study suggests a favorable short-term safety profile and beneficial BP effects of catheter-based renal nerve ablation in patients with stage 3–4 CKD and resistant hypertension. PMID:22595301

  4. Attenuation of the side effect profile of regadenoson: a randomized double-blind placebo-controlled study with aminophylline in patients undergoing myocardial perfusion imaging and have severe chronic kidney disease--the ASSUAGE-CKD trial.

    PubMed

    Doukky, Rami; Rangel, Maria Octavia; Dick, Rizcallah; Wassouf, Marwan; Alqaid, Ammar; Margeta, Bosko

    2013-06-01

    A subgroup analysis of the ASSUAGE trial suggested that the standardized intravenous aminophylline administration following regadenoson-stress leads to substantial attenuation of regadenoson adverse-effects in patients with severe chronic kidney disease (CKD). In a randomized, double-blinded, placebo-controlled clinical trial of patients with stage 4 and 5 CKD, we compared the frequency and severity of regadenoson adverse-effects in those who received 75 mg of intravenous aminophylline versus a matching placebo administered 90 s post-radioisotope injection. Consecutive 300 patients with severe CKD (36% women; 86% end-stage renal disease; age 55 (±13) years) were randomized to receive aminophylline (n = 150) or placebo (n = 150). In the aminophylline arm, there was 65% reduction in the incidence of the primary endpoint of diarrhea (9 (6.0%) vs. 26 (17.3%), P = 0.002), 51% reduction in the secondary endpoint of any regadenoson adverse-effect (47 (31.3%) vs. 96 (64%), P < 0.001) and 70% reduction in headache (16 (10.7%) vs. 54 (36%), P < 0.001). The stress protocol was better tolerated in the aminophylline group (P = 0.008). The quantitative summed difference score, as a measure of stress-induced ischemic burden, was similar between the study groups (P = 0.51). In conclusion, the routine standardized administration of intravenous aminophylline in patients with severe CKD substantially reduces the frequency and severity of the adverse-effects associated with regadenoson-stress without changing the ischemic burden. [NCT01336140]. PMID:23224354

  5. CKD as a Model for Improving Chronic Disease Care through Electronic Health Records.

    PubMed

    Drawz, Paul E; Archdeacon, Patrick; McDonald, Clement J; Powe, Neil R; Smith, Kimberly A; Norton, Jenna; Williams, Desmond E; Patel, Uptal D; Narva, Andrew

    2015-08-01

    Electronic health records have the potential to improve the care of patients with chronic medical conditions. CKD provides a unique opportunity to show this potential: the disease is common in the United States, there is significant room to improve CKD detection and management, CKD and its related conditions are defined primarily by objective laboratory data, CKD care requires collaboration by a diverse team of health care professionals, and improved access to CKD-related data would enable identification of a group of patients at high risk for multiple adverse outcomes. However, to realize the potential for improvement in CKD-related care, electronic health records will need to provide optimal functionality for providers and patients and interoperability across multiple health care settings. The goal of the National Kidney Disease Education Program Health Information Technology Working Group is to enable and support the widespread interoperability of data related to kidney health among health care software applications to optimize CKD detection and management. Over the course of the last 2 years, group members met to identify general strategies for using electronic health records to improve care for patients with CKD. This paper discusses these strategies and provides general goals for appropriate incorporation of CKD-related data into electronic health records and corresponding design features that may facilitate (1) optimal care of individual patients with CKD through improved access to clinical information and decision support, (2) clinical quality improvement through enhanced population management capabilities, (3) CKD surveillance to improve public health through wider availability of population-level CKD data, and (4) research to improve CKD management practices through efficiencies in study recruitment and data collection. Although these strategies may be most effectively applied in the setting of CKD, because it is primarily defined by laboratory

  6. Reducing CKD risks among vulnerable populations in primary care.

    PubMed

    Greer, Raquel; Boulware, L Ebony

    2015-01-01

    Ethnic/racial and socioeconomic status disparities in the health-care and clinical outcomes of patients with chronic kidney disease (CKD) are pervasive. The vast majority of care to decrease incidence of CKD risk and progression occurs in primary care settings. High-quality primary care, therefore, represents a key strategy through which disparities in the incidence and progression of CKD may be eliminated. The Chronic Care Model provides a framework for the delivery of high-quality primary care for chronic diseases, and it is frequently used to guide health-care quality improvement initiatives. Evidence suggests that Chronic Care Model constructs, including provider and organizational quality improvement initiatives focused on team approaches to chronic care (eg, case management, community health workers), are effective in modifying patients' CKD risks among ethnic minority and low-income patients. Other Chronic Care Model constructs, including clinical information systems (eg, disease registries), decision support interventions, and the provision of patient-centered care have been shown to improve processes related to CKD care but with limited and/or mixed effects on patient outcomes. Few studies have examined the effect of these approaches on reducing disparities. Research is needed to examine the effectiveness of these strategies to eliminate CKD disparities among vulnerable populations. PMID:25573516

  7. Alternative Splicing in CKD.

    PubMed

    Stevens, Megan; Oltean, Sebastian

    2016-06-01

    Alternative splicing (AS) has emerged in the postgenomic era as one of the main drivers of proteome diversity, with ≥94% of multiexon genes alternatively spliced in humans. AS is therefore one of the main control mechanisms for cell phenotype, and is a process deregulated in disease. Numerous reports describe pathogenic mutations in splice factors, splice sites, or regulatory sequences. Additionally, compared with the physiologic state, disease often associates with an abnormal proportion of splice isoforms (or novel isoforms), without an apparent driver mutation. It is therefore essential to study how AS is regulated in physiology, how it contributes to pathogenesis, and whether we can manipulate faulty splicing for therapeutic advantage. Although the disease most commonly linked to deregulation of AS in several genes is cancer, many reports detail pathogenic splice variants in diseases ranging from neuromuscular disorders to diabetes or cardiomyopathies. A plethora of splice variants have been implicated in CKDs as well. In this review, we describe examples of these CKD-associated splice variants and ideas on how to manipulate them for therapeutic benefit. PMID:26763787

  8. Chronic kidney disease (CKD) in disadvantaged populations

    PubMed Central

    Garcia-Garcia, Guillermo; Jha, Vivekanand

    2015-01-01

    Twelve March 2015 will mark the 10th anniversary of World Kidney Day (WKD), an initiative of the International Society of Nephrology and the International Federation of Kidney Foundations. Since its inception in 2006, WKD has become the most successful effort ever mounted to raise awareness among decision-makers and the general public about the importance of kidney disease. Each year WKD reminds us that kidney disease is common, harmful and treatable. The focus of WKD 2015 is on chronic kidney disease (CKD) in disadvantaged populations. This article reviews the key links between poverty and CKD and the consequent implications for the prevention of kidney disease and the care of kidney patients in these populations. PMID:25713703

  9. [Treatment for CKD-MBD(Chronic Kidney Disease-Mineral and Bone Disorder)].

    PubMed

    Iwashita, Yuko; Iwashita, Yu; Ito, Takafumi; Shigematsu, Takashi

    2016-02-01

    CKD is a common disease that is estimated to develop one in eight persons in Japan. The CKD itself is highly risk factor on the cardiac/vascular mortality. In addition,a new concept has been proposed "CKD-MBD". CKD-MBD is composed of a combination of abnormal mineral metabolism, abnormal bone, and extra skeletal calcification with cardiovascular high mortality. Treatment for CKD-MBD is a wide-ranging. We aim to decline cardiovascular event, fracture, and mortality rate of patients with CKD. The main therapeutic target for CKD-MBD becomes the phosphate control. Today, we can use of the VRDA, Calcimimetics and muti-phosphate binders as a lot of pharmacological intervention. PMID:26813506

  10. Chronic kidney disease (CKD) in the elderly -- a geriatrician's perspective.

    PubMed

    Munikrishnappa, Devaraj

    2007-09-01

    Chronic kidney disease (CKD) is becoming increasingly prevalent among many different populations all over the world, including the US and Europe. Its multitude of complications with devastating outcomes leads to a significantly higher risk for cardio-vascular and all-cause mortality in an individual. However, it is clear now that early detection of CKD might not only delay some of the complications but also prevent them. Therefore, various important public health organizations all over the world have turned their focus and attention to CKD and its risk factors, early detection and early intervention. Nevertheless, the general goals in preventing the increase in CKD and its complications are far from being completely achieved. Why is this so? What is the magnitude and complexity of the problem? How is it affecting the population - are there differences in its affection by age, gender or frail elderly versus the robust? Are we modifying the risk factors appropriately and aggressively? Are there subtle differences in managing the risk factors in those on dialysis versus the non-dialysis CKD patients? Is it important to treat anaemia of CKD aggressively, will it make a difference in the disease progression, its complications or to quality of life? What do these unfortunate individuals commonly succumb to? What do we advise patients who refuse dialysis or those who desire dialysis or transplant? Are there useful non-dialytic treatment recommendations for those who refuse dialysis? What is the role of the physicians caring for the elderly with CKD? When should the primary care givers refer a CKD patient to a nephrologist? The key to eventually controlling incident and prevalent CKD and improve quality of life of affected individuals, lies in not only knowing these and many other vital aspects, but also in applying such knowledge compulsively in day-to-day practice by each and every one us. As CKD is increasingly a disease of the elderly with men being affected more, this

  11. Approach to the Treatment of Chronic Metabolic Acidosis in CKD.

    PubMed

    Raphael, Kalani L

    2016-04-01

    Chronic metabolic acidosis is not uncommon in patients with chronic kidney disease (CKD). Clinical practice guidelines suggest that clinicians administer alkali to maintain serum bicarbonate level at a minimum of 22 mEq/L to prevent the effects of acidosis on bone demineralization and protein catabolism. Small interventional studies support the notion that correcting acidosis slows CKD progression as well. Furthermore, alkaline therapy in persons with CKD and normal bicarbonate levels may also preserve kidney function. Observational studies suggest that targeting a serum bicarbonate level near 28 mEq/L may improve clinical outcomes above and beyond targeting a value ≥ 22 mEq/L, yet values > 26 mEq/L have been reported to be associated with incident heart failure and mortality in the CRIC (Chronic Renal Insufficiency Cohort) Study. Furthermore, correcting acidosis may provoke vascular calcification. This teaching case discusses several uncertainties regarding the management of acidosis in CKD, such as when to initiate alkali treatment, potential side effects of alkali, and the optimum serum bicarbonate level based on current evidence in CKD. Suggestions regarding the maximum sodium bicarbonate dose to administer to patients with CKD to achieve the target serum bicarbonate concentration are offered. PMID:26776539

  12. Automated Clinical Reminders for Primary Care Providers in the Care of CKD: A Small Cluster-Randomized Controlled Trial

    PubMed Central

    Abdel-Kader, Khaled; Fischer, Gary S; Li, Jie; Moore, Charity G; Hess, Rachel; Unruh, Mark L

    2011-01-01

    Background Primary care physicians (PCPs) care for the majority of non-dialysis-dependent chronic kidney disease (CKD) patients. Studies suggest that PCPs may deliver suboptimal CKD care. One means to improve PCP treatment of CKD is clinical decision support systems (CDSS). Study Design Cluster randomized controlled trial Setting & Participants Thirty PCPs in a university-based outpatient general internal medicine practice and their 248 moderate to advanced CKD patients who had not been referred to a nephrologist. Intervention Two CKD educational sessions were held for PCPs in both arms. The 15 intervention arm PCPs also received real-time automated electronic medical record alerts for patients with estimated glomerular filtration rates < 45 ml/min/1.73m2 recommending renal referral and urine albumin quantification if not done within the prior year. Outcomes Primary outcome was referral to a nephrologist; secondary outcomes were albuminuria/proteinuria assessment, CKD documentation, optimal blood pressure (i.e., < 130/80), and use of renoprotective medications. Results The intervention and control arms did not differ in renal referrals (9.7% vs. 16.5%, respectively; between group difference, −6.8% (95% CI, −15.5% to 1.8%; P=0.1)) or proteinuria assessments (39.3% vs. 30.1%, respectively; between group difference, 9.2% (95% CI, −2.7% to 21.1%; P=0.1)). Among intervention and control group patients without a baseline proteinuria assessment, 27.7% versus 16.3%, respectively had one at follow-up (P=0.06). After controlling for clustering, these findings were largely unchanged and no significant differences were apparent between the groups. Limitations Small single-center university based practice, use of a passive CDSS that required PCPs to trigger the electronic order set. Conclusions PCPs were willing to partake in a randomized trial of CDSS to improve outpatient CKD care. While CDSS may possess potential, larger studies are needed to further explore how best

  13. Management of atrial fibrillation in patients with chronic kidney disease in Europe Results of the European Heart Rhythm Association Survey.

    PubMed

    Potpara, Tatjana S; Lenarczyk, Radoslaw; Larsen, Torben B; Deharo, Jean-Claude; Chen, Jian; Dagres, Nikolaos

    2015-12-01

    The purpose of this European Heart Rhythm (EHRA) Scientific Initiatives Committee EP Wire Survey was to assess 'real-world' practice in the management of patients with atrial fibrillation (AF) and chronic kidney disease (CKD) in the European Eelectrophysiology centres. Of 41 responding centres, 39 (95.1%) and 37 (90.2%) routinely evaluated renal function in AF patients at first presentation and during follow-up, respectively, but 13 centres (31.7%) re-assessed advanced CKD only at ≥1-year intervals. While the use of oral anticoagulants (OACs) in mild-to-moderate CKD patients was mostly guided by individual patient stroke risk, 31% of the centres used no therapy, or aspirin or the left appendage occlusion in patients with advanced CKD and HAS-BLED ≥ 3. Vitamin K antagonists (VKAs) were preferred in patients with severe CKD or under renal replacement therapy (RRT), any non-VKA in patients with mild CKD, and apixaban in patients with moderate CKD. Rhythm control was preferred in patients with mild-to-moderate CKD (48.7% of centres), and rate control in patients with severe CKD (51.2% of centres). In 20 centres (48.8%), AF ablation was not performed in advanced CKD patients. Most centres performed AF ablation on OAC, but heparin bridging was still used in >10% of centres. Our survey has shown that the importance of renal function monitoring in AF patients is well recognized in clinical practice. In patients with mild-to-moderate CKD, AF is mostly managed according to the guideline recommendations, but more data are needed to guide the management of AF in patients with severe CKD or RRT. PMID:26733617

  14. Long-Term Mortality After Invasive Angiography and Endovascular Revascularization in Patients With PAD Having Chronic Kidney Disease.

    PubMed

    Gebauer, Katrin; Engelbertz, Christiane; Malyar, Nasser M; Meyborg, Matthias; Lüders, Florian; Freisinger, Eva; Reinecke, Holger

    2016-07-01

    Peripheral arterial disease (PAD) and chronic kidney disease (CKD) are associated with increased mortality rates. We assessed long-term outcomes of patients with PAD and CKD. Patients with PAD undergoing invasive angiography and/or endovascular revascularization between 2005 and 2010 were retrospectively classified into 5 CKD stages. A follow-up was performed and 572 patients were included, 116 patients (20%) had normal renal function, 245 were in CKD stage 2 (43%), 156 in CKD stage 3 (27%), and 55 in CKD stages 4 + 5 (10%). Diabetes mellitus, hypertension, and anemia were more frequent in higher CKD stages (P < .03). During follow-up (mean 1135 days; 95% confidence interval 1159-1259), cumulative mortality was 21% and increased with advanced CKD stages (9%, 16%, 29%, and 47%, respectively, P < .001). In multivariate Cox regression models, higher CKD stages were significantly associated with poor survival. Medication adherence for secondary prevention was significantly lower than recommended but irrespective of CKD stages. Kidney function is an independent predictor of worse long-term survival in patients with PAD. While standard medications were used less often than recommended, no differences between CKD stages were noted. PMID:26324203

  15. [Pathogenesis and treatment of vascular calcification in CKD].

    PubMed

    Brancaccio, D; Gallieni, M; Pasho, S; Fallabrino, G; Olivi, L; Volpi, E; Ciceri, P; Missaglia, E; Ronga, C; Brambilla, C; Butti, A; Rocca-Rey, L; Chiarelli, G; Cozzolino, M

    2009-01-01

    Increased vascular calcification is a major cause of cardiovascular events in patients with chronic kidney disease (CKD). It is the result of an active ossification process counteracted by ''bone'' proteins such as osteopontin, alkaline phosphatase, osteoprotegerin, and osteocalcin. Chronic kidney disease - mineral and bone disorder (CKD-MBD) is a systemic disorder of mineral and bone metabolism that occurs in CKD. In addition to abnormalities in the serum calcium and phosphate profile, CKD-MBD is characterized by abnormalities of bone turnover, mineralization, volume and growth as well as vascular calcification. Considering that the presence and extent of vascular calcification in CKD portend a poor prognosis, many efforts have been made to shed light on this complicated phenomenon to prevent vascular calcium deposition and its progression. Indeed, careful control of calcium load, serum phosphate and parathyroid hormone along with the use of calcium-free phosphate binders and vitamin D receptor activators represent a new therapeutic armamentarium to improve quality of life and reduce mortality in CKD. PMID:19382090

  16. CKD-Mineral Bone Disorder in Stage 4 and 5 CKD: What We Know Today?

    PubMed

    Melamed, Michal L; Buttar, Rupinder Singh; Coco, Maria

    2016-07-01

    Patients with CKD stages 4 and 5 experience biochemical derangements associated with CKD-mineral bone disorder. Some of the key abnormalities are hyperparathyroidism, hyperphosphatemia, hypocalcemia, and metabolic acidosis. We review the available treatments for these conditions and the evidence behind the treatments. We conclude that there is greater evidence for treating hyperphosphatemia than hyperparathyroidism. Treatment of metabolic acidosis in small clinical trials appears to be safe. We caution the reader about side effects associated with some of these treatments that differ in patients with CKD Stages 4 and 5 compared with patients on dialysis. The use of cinacalcet has been associated with hyperphosphatemia in patients with functioning kidneys. Activated vitamin D therapy has been associated with elevated creatinine levels, which may or may not be a reflection of true decrement in kidney function. Finally, the use of non-calcium-containing phosphate binders may be associated with improved clinical outcomes in patients; however, many more clinical trials are needed in this important area of medicine. PMID:27324680

  17. Risk Prediction in CKD: The Rational Alignment of Health Care Resources in CKD 4/5 Care.

    PubMed

    Wojciechowski, Peter; Tangri, Navdeep; Rigatto, Claudio; Komenda, Paul

    2016-07-01

    CKD is a well-recognized global epidemic with consequences on patient morbidity, mortality, and health care resources. In the United States and Canada, a financial premium is often paid to programs and providers for caring for patients with Stage 4 to 5 CKD (not on dialysis) and is justified by the intensive care required by these patients, particularly in preparation for dialysis. About half of all patients with CKD Stages 3 and 4 never progress to kidney failure, and more than a quarter of them have stable kidney function for years. Among patients with Stage 3 CKD, even fewer progresses to kidney failure but small subpopulations with certain characteristics (eg, younger age, higher levels of proteinuria) have a more predictable trajectory. Clearly, a more robust method of screening patients for nephrology referral and subsequent enrollment into multidisciplinary clinics is needed to provide better efficiency within the health care system. The Kidney Failure Risk Equation is a generalizable CKD risk prediction model that has been externally validated and allows for the efficient risk-based triaging of nephrology referrals with a significant benefit to decreasing wait times. It is also efficiently used in a multidisciplinary kidney disease clinic with aiding timing in modality planning and frequency of follow-ups. The overall potential benefit of this system should allow for appropriate allocation of human resources to those at highest risk to yield optimal care in the most cost-effective manner to the health care system. PMID:27324675

  18. Altered intestinal microbial flora and impaired epithelial barrier structure and function in CKD: the nature, mechanisms, consequences and potential treatment.

    PubMed

    Vaziri, Nosratola D; Zhao, Ying-Yong; Pahl, Madeleine V

    2016-05-01

    Chronic kidney disease (CKD) results in systemic inflammation and oxidative stress which play a central role in CKD progression and its adverse consequences. Although many of the causes and consequences of oxidative stress and inflammation in CKD have been extensively explored, little attention had been paid to the intestine and its microbial flora as a potential source of these problems. Our recent studies have revealed significant disruption of the colonic, ileal, jejunal and gastric epithelial tight junction in different models of CKD in rats. Moreover, the disruption of the epithelial barrier structure and function found in uremic animals was replicated in cultured human colonocytes exposed to uremic human plasma in vitro We have further found significant changes in the composition and function of colonic bacterial flora in humans and animals with advanced CKD. Together, uremia-induced impairment of the intestinal epithelial barrier structure and function and changes in composition of the gut microbiome contribute to the systemic inflammation and uremic toxicity by accommodating the translocation of endotoxin, microbial fragments and other noxious luminal products in the circulation. In addition, colonic bacteria are the main source of several well-known pro-inflammatory uremic toxins such as indoxyl sulfate, p-cresol sulfate, trimethylamine-N-oxide and many as-yet unidentified retained compounds in end-stage renal disease patients. This review is intended to provide an overview of the effects of CKD on the gut microbiome and intestinal epithelial barrier structure and their role in the pathogenesis of systemic inflammation and uremic toxicity. In addition, potential interventions aimed at mitigating these abnormalities are briefly discussed. PMID:25883197

  19. Reducing CKD risks among vulnerable populations in primary care

    PubMed Central

    Greer, Raquel; Boulware, Ebony

    2014-01-01

    Ethnic/racial and socioeconomic status disparities in the health care and clinical outcomes of patients with chronic kidney disease are pervasive. The vast majority of care to decrease incidence of CKD risk and progression occurs in primary care settings. High quality primary care therefore represents a key strategy through which disparities in the incidence and progression of CKD may be eliminated. The Chronic Care Model provides a framework for the delivery of high quality primary care for chronic diseases, and it is frequently used to guide health care quality improvement initiatives. Evidence suggests that Chronic Care Model constructs, including provider and organizational quality improvement initiatives focused on team approaches to chronic care (e.g., case management, community health workers), are effective in modifying patients’ CKD risks among ethnic minority and low income and patients. Other Chronic Care Model constructs, including clinical information systems (e.g., disease registries), decision support interventions, and the provision of patient centered care have been shown to improve processes related to CKD care but with limited and/or mixed effects on patient outcomes. Few studies have examined the effect of these approaches on reducing disparities. Research is needed to examine the effectiveness of these strategies to eliminate CKD disparities among vulnerable populations. PMID:25573516

  20. CKD in an Electronic Health Record Problem List: Quality of Care, ESRD, and Mortality

    PubMed Central

    Jolly, Stacey E.; Navaneethan, Sankar D.; Schold, Jesse D.; Arrigain, Susana; Sharp, John W; Jain, Anil K; Schreiber, Martin J.; Simon, James F.; Nally, Joseph V

    2014-01-01

    Background Whether CKD recognition in an electronic health record (EHR) problem list improves processes of care or clinical outcomes of ESRD and death is unclear. Methods We identified patients who had at least 1 year of follow up (2005–2009) in our EHR based CKD registry (n=25,742). CKD recognition was defined by having ICD-9 codes for CKD, diabetic kidney disease, or hypertensive kidney disease in the problem list. We calculated proportions of patients with and without CKD recognition and examined differences by demographics, clinical factors, and development of ESRD or mortality. We evaluated differences in the proportion of patients with CKD specific labs checked before and after recognition among cases and propensity-matched controls. Results Only 11% (n=2735) had CKD recognition in the problem list and they were younger (68 vs. 71 yrs), a higher proportion were male (61% vs. 37%) and African-American (21% vs. 10%) compared to those unrecognized. CKD-specific labs for patients with eGFR 30–59 including iPTH (23% vs. 6%), Vitamin D (22% vs. 18%), phosphorus (29% vs. 7%), and a urine check for proteinuria (55% vs. 36%) were significantly more likely to be done among those with CKD recognition. (all p<0.05) Similar results were found for eGFR<30 except for proteinuria and in our propensity score matched control analysis. There was no independent association of CKD recognition with ESRD or mortality. Conclusions CKD recognition in the EHR problem list was low, but translated into more CKD specific processes of care; however ESRD or mortality were not affected. PMID:24714513

  1. Peripheral artery disease and CKD: a focus on peripheral artery disease as a critical component of CKD care.

    PubMed

    Garimella, Pranav S; Hart, Peter D; O'Hare, Ann; DeLoach, Stephanie; Herzog, Charles A; Hirsch, Alan T

    2012-10-01

    The incidence of peripheral artery disease (PAD) is higher in patients with chronic kidney disease (CKD) than in the general population. PAD is a strong independent risk factor for increased cardiovascular disease mortality and morbidity, including limb amputation, in persons with CKD. Diagnosis of PAD in patients with CKD may be challenging in the absence of classic intermittent claudication or the presence of atypical leg symptoms. In addition, pedal artery incompressibility may decrease the accuracy of ankle-brachial index measurement, the most common PAD diagnostic tool. Alternative methods such as toe-brachial index should be used if clinical suspicion persists despite a normal ankle-brachial index value. Aggressive risk-factor modification, including treatment of diabetes, hyperlipidemia, and hypertension and smoking cessation, should be mandatory in all patients. Treatment of all individuals with PAD should include antiplatelet medications and prescribed supervised exercise programs and/or cilostazol for individuals with claudication symptoms. Preventive foot care measures and a multidisciplinary approach involving podiatrists and vascular and wound care specialists should be used to reduce amputations. Revascularization for critical limb ischemia is associated with poor outcomes in patients with CKD with PAD. Future investigation is recommended to evaluate the benefit of earlier treatment strategies in this high cardiovascular disease risk population with CKD. PMID:22560831

  2. A retrospective analysis of kidney function and risk factors by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation in elderly Chinese patients.

    PubMed

    Liu, Wei; Yu, Feng; Wu, Yanhua; Fang, Xiaowu; Hu, Wenxue; Chen, Jian; Zhou, Ruili; Lin, Xinge; Hao, Wenke

    2015-01-01

    Chronic kidney disease accounts for much of the increased mortality, especially in the elder population. The prevalence of this disease is expected to increase significantly as the society ages. Our aim was to evaluate the kidney function and risk factors of reduced renal function among elderly Chinese patients. This study retrospectively collected clinical data from a total of 1062 inpatients aged 65 years or over. Estimated glomerular filtration rate (eGFR) was calculated with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Renal function and risk factors were also analyzed. For all 1062 subjects, the mean eGFR was 71.0 ± 24.8 mL/min/1.73 m(2), and the incidence rates of reduced renal function, proteinuria, hematuria and leukocyturia were 31.1%, 11.8%, 6.6% and 8.7%, respectively. The eGFR values were 83.4 ± 28.4, 72.2 ± 22.9, 67.8 ± 24.3 and 58.8 ± 29.1 mL/min/1.73 m(2) in the groups of 60-69, 70-79, 80-89 and ≥90 years age group (F = 15.101, p = 0.000), respectively; while the incidences of reduced renal function were 12.8%, 27.0%, 37.8% and 51.7% (χ(2) = 36.143, p = 0.000). Binary logistic regression analysis showed that hyperuricemia (OR = 4.62, p = 0.000), proteinuria (OR = 3.96, p = 0.000), urinary tumor (OR = 2.92, p = 0.015), anemia (OR = 2.45, p = 0.000), stroke (OR = 1.96, p = 0.000), hypertension (OR = 1.83, p = 0.006), renal cyst (OR = 1.64, p = 0.018), female (OR = 1.54, p = 0.015), coronary artery disease (OR = 1.53, p = 0.008) and age (OR = 1.05, p = 0.000) were the risk factors of reduced renal function. In conclusion, eGFR values decreased by age, while the incidence of reduced renal function, proteinuria, hematuria and leukocyturia increased with age. Treatment and control of comorbidities may slow the decline of renal function in elderly patients. PMID:26211499

  3. Hypertension Management in Transition: From CKD to ESRD.

    PubMed

    Valika, Aziz; Peixoto, Aldo J

    2016-07-01

    Hypertension is present in ∼90% of patients in late-stage CKD. There are scarce data focusing on the transition period between CKD Stages 4 and 5 (end-stage kidney disease) as it relates to hypertension evaluation and management. Here, we propose that a combination of the principles used in the management of patients with CKD Stages 4 and 5 be applied to patients in this transition. These include the use of out-of-office blood pressure (BP) monitoring (eg, home BP), avoidance of excessively tight BP goals, emphasis of sodium restriction, preferential use of blockers of the renin-angiotensin system and diuretics, and consideration of the use of beta blockers. PMID:27324679

  4. Effects of dietary interventions on incidence and progression of CKD.

    PubMed

    Jain, Nishank; Reilly, Robert F

    2014-12-01

    Traditional strategies for management of patients with chronic kidney disease (CKD) have not resulted in any change in the growing prevalence of CKD worldwide. A historic belief that eating healthily might ameliorate kidney disease still holds credibility in the 21(st) century. Dietary sodium restriction to <2.3 g daily, a diet rich in fruits and vegetables and increased water consumption corresponding to a urine output of 3-4 l daily might slow the progression of early CKD, polycystic kidney disease or recurrent kidney stones. Current evidence suggests that a reduction in dietary net acid load could be beneficial in patients with CKD, but the supremacy of any particular diet has yet to be established. More trials of dietary interventions are needed, especially in diabetic nephropathy, before evidence-based recommendations can be made. In the meantime, nephrologists should discuss healthy dietary habits with their patients and provide individualized care aimed at maximizing the potential benefits of dietary intervention, reducing the incidence of CKD and delaying its progression to end-stage renal disease. Keeping in mind the lack of data on hard outcomes, dietary recommendations should take into account barriers to adherence and be tailored to different cultures, ethnicities and geographical locations. PMID:25331786

  5. CKD and Infectious Diseases in Asia Pacific: Challenges and Opportunities.

    PubMed

    Jha, Vivekanand; Prasad, Narayan

    2016-07-01

    The exact number of patients with chronic kidney disease (CKD) in Asia Pacific is uncertain. In numeric terms, the region is home to the largest population of patients with untreated chronic kidney failure. The climatic, geographic, social, cultural, economic, and environmental diversity within this region is higher than in any other part of the world. Large parts of the region face a climate-related burden of infectious diseases. Infections contribute to the development and progression of CKD and complicate the course of patients with pre-existing CKD (especially those on dialysis therapy or who are immunosuppressed), increase the cost of CKD care, and contribute to mortality and morbidity. Kidney involvement is a feature of several infectious diseases prevalent in Asia Pacific. Examples include malaria, leptospirosis, scrub typhus, tuberculosis, hepatitis B and C virus, dengue hemorrhagic fever, and Hantaan virus infections. The contribution of infection-associated acute kidney injury to the overall burden of CKD has not been evaluated systematically. Research is needed to quantify the impact of infections on kidney health by undertaking prospective studies. Nephrologists need to work with infectious disease research groups and government infection surveillance and control programs. PMID:26943982

  6. Chronic Kidney Disease (CKD)

    MedlinePlus

    ... patients Join our Advocacy Network Join our Advocacy Network There is strength in numbers. Make your voice heard—join our nationwide Advocacy Network. Take action on current issues Take action on ...

  7. The Soluble VEGF Receptor sFlt1 Contributes to Endothelial Dysfunction in CKD

    PubMed Central

    Marco, Giovana S. Di; Reuter, Stefan; Hillebrand, Uta; Amler, Susanne; König, Maximilian; Larger, Etienne; Oberleithner, Hans; Brand, Eva; Pavenstädt, Hermann

    2009-01-01

    Endothelial dysfunction contributes to the increased cardiovascular risk that accompanies CKD. We hypothesized that the soluble VEGF receptor 1 (sFlt-1), a VEGF antagonist, plays a role in endothelial dysfunction and decreased angiogenesis in CKD. We enrolled 130 patients with CKD stages 3 to 5 and 56 age- and gender-matched control patients. Plasma sFlt-1 levels were higher in patients with CKD and, after multivariate regression analyses, exclusively associated with renal function and levels of vWF, a marker of endothelial dysfunction. Compared with serum from control patients, both recombinant sFlt-1 and serum from patients with CKD had antiangiogenic activity in the chick chorioallantoic membrane (CAM) assay, induced endothelial cell apoptosis in vitro, and decreased nitric oxide generation in two different endothelial cell lines. Pretreating the sera with an antibody against sFlt-1 abrogated all of these effects. Furthermore, we observed increased sFlt1 levels in 5/6-nephrectomized rats compared with sham-operated animals. Finally, using real-time PCR and ELISA, we identified monocytes as a possible source of increased sFlt-1 in patients with CKD. Our findings show that excess sFlt-1 associates with endothelial dysfunction in CKD and suggest that increased sFlt-1 may predict cardiovascular risk in CKD. PMID:19608702

  8. CKD screening and management in the Veterans Health Administration: the impact of system organization and an innovative electronic record.

    PubMed

    Patel, Thakor G; Pogach, Leonard M; Barth, Robert H

    2009-03-01

    At the beginning of this decade, Healthy People 2010 issued a series of objectives to "reduce the incidence, morbidity, mortality and health care costs of chronic kidney disease." A necessary feature of any program to reduce the burden of kidney disease in the US population must include mechanisms to screen populations at risk and institute early the aspects of management, such as control of blood pressure, management of diabetes, and, in patients with advanced chronic kidney disease (CKD), preparation for dialysis therapy and proper vascular access management, that can retard CKD progression and improve long-term outcome. The Department of Veterans Affairs and the Veterans Health Administration is a broad-based national health care system that is almost uniquely situated to address these issues and has developed a number of effective approaches using evidence-based clinical practice guidelines, performance measures, innovative use of a robust electronic medical record system, and system oversight during the past decade. In this report, we describe the application of this systems approach to the prevention of CKD in veterans through the treatment of risk factors, identification of CKD in veterans, and oversight of predialysis and dialysis care. The lessons learned and applicability to the private sector are discussed. PMID:19231765

  9. Diagnosis and Prediction of CKD Progression by Assessment of Urinary Peptides

    PubMed Central

    Schanstra, Joost P.; Alkhalaf, Alaa; Argiles, Angel; Bakker, Stephan J.L.; Beige, Joachim; Bilo, Henk J.G.; Chatzikyrkou, Christos; Dakna, Mohammed; Dawson, Jesse; Delles, Christian; Haller, Hermann; Haubitz, Marion; Husi, Holger; Jankowski, Joachim; Jerums, George; Kleefstra, Nanne; Kuznetsova, Tatiana; Maahs, David M.; Menne, Jan; Mullen, William; Ortiz, Alberto; Persson, Frederik; Rossing, Peter; Ruggenenti, Piero; Rychlik, Ivan; Serra, Andreas L.; Siwy, Justyna; Snell-Bergeon, Janet; Spasovski, Goce; Staessen, Jan A.; Vlahou, Antonia; Mischak, Harald; Vanholder, Raymond

    2015-01-01

    Progressive CKD is generally detected at a late stage by a sustained decline in eGFR and/or the presence of significant albuminuria. With the aim of early and improved risk stratification of patients with CKD, we studied urinary peptides in a large cross-sectional multicenter cohort of 1990 individuals, including 522 with follow-up data, using proteome analysis. We validated that a previously established multipeptide urinary biomarker classifier performed significantly better in detecting and predicting progression of CKD than the current clinical standard, urinary albumin. The classifier was also more sensitive for identifying patients with rapidly progressing CKD. Compared with the combination of baseline eGFR and albuminuria (area under the curve [AUC]=0.758), the addition of the multipeptide biomarker classifier significantly improved CKD risk prediction (AUC=0.831) as assessed by the net reclassification index (0.303±−0.065; P<0.001) and integrated discrimination improvement (0.058±0.014; P<0.001). Correlation of individual urinary peptides with CKD stage and progression showed that the peptides that associated with CKD, irrespective of CKD stage or CKD progression, were either fragments of the major circulating proteins, suggesting failure of the glomerular filtration barrier sieving properties, or different collagen fragments, suggesting accumulation of intrarenal extracellular matrix. Furthermore, protein fragments associated with progression of CKD originated mostly from proteins related to inflammation and tissue repair. Results of this study suggest that urinary proteome analysis might significantly improve the current state of the art of CKD detection and outcome prediction and that identification of the urinary peptides allows insight into various ongoing pathophysiologic processes in CKD. PMID:25589610

  10. Diagnosis and Prediction of CKD Progression by Assessment of Urinary Peptides.

    PubMed

    Schanstra, Joost P; Zürbig, Petra; Alkhalaf, Alaa; Argiles, Angel; Bakker, Stephan J L; Beige, Joachim; Bilo, Henk J G; Chatzikyrkou, Christos; Dakna, Mohammed; Dawson, Jesse; Delles, Christian; Haller, Hermann; Haubitz, Marion; Husi, Holger; Jankowski, Joachim; Jerums, George; Kleefstra, Nanne; Kuznetsova, Tatiana; Maahs, David M; Menne, Jan; Mullen, William; Ortiz, Alberto; Persson, Frederik; Rossing, Peter; Ruggenenti, Piero; Rychlik, Ivan; Serra, Andreas L; Siwy, Justyna; Snell-Bergeon, Janet; Spasovski, Goce; Staessen, Jan A; Vlahou, Antonia; Mischak, Harald; Vanholder, Raymond

    2015-08-01

    Progressive CKD is generally detected at a late stage by a sustained decline in eGFR and/or the presence of significant albuminuria. With the aim of early and improved risk stratification of patients with CKD, we studied urinary peptides in a large cross-sectional multicenter cohort of 1990 individuals, including 522 with follow-up data, using proteome analysis. We validated that a previously established multipeptide urinary biomarker classifier performed significantly better in detecting and predicting progression of CKD than the current clinical standard, urinary albumin. The classifier was also more sensitive for identifying patients with rapidly progressing CKD. Compared with the combination of baseline eGFR and albuminuria (area under the curve [AUC]=0.758), the addition of the multipeptide biomarker classifier significantly improved CKD risk prediction (AUC=0.831) as assessed by the net reclassification index (0.303±-0.065; P<0.001) and integrated discrimination improvement (0.058±0.014; P<0.001). Correlation of individual urinary peptides with CKD stage and progression showed that the peptides that associated with CKD, irrespective of CKD stage or CKD progression, were either fragments of the major circulating proteins, suggesting failure of the glomerular filtration barrier sieving properties, or different collagen fragments, suggesting accumulation of intrarenal extracellular matrix. Furthermore, protein fragments associated with progression of CKD originated mostly from proteins related to inflammation and tissue repair. Results of this study suggest that urinary proteome analysis might significantly improve the current state of the art of CKD detection and outcome prediction and that identification of the urinary peptides allows insight into various ongoing pathophysiologic processes in CKD. PMID:25589610

  11. Advanced chronic kidney disease: a strong risk factor for Clostridium difficile infection

    PubMed Central

    Kim, Sun Chul; Seo, Min Young; Lee, Jun Yong; Kim, Ki Tae; Cho, Eunjung; Kim, Myung-Gyu; Jo, Sang-Kyung; Cho, Won-Yong; Kim, Hyoung-Kyu

    2016-01-01

    Background/Aims: It has been suggested that chronic kidney disease (CKD) is a risk factor for Clostridium difficile infection (CDI) and is associated with increased mortality among patients infected with C. difficile. However, recent studies of the clinical impact of CKD on CDI in Asians are still insufficient. We sought to determine the relationship between CKD and CDI in a Korean population. Methods: This was a single-center, retrospective case-control study. In total, 171 patients with CDI were included as cases and 342 age- and gender-matched patients without CDI were used as controls. We compared the prevalence of CKD in the study sample and identified independent risk factors that could predict the development or prognosis of CDI. Results: Independent risk factors for CDI included stage IV to V CKD not requiring dialysis (odds ratio [OR], 2.90) and end-stage renal disease requiring dialysis (OR, 3.34). Patients with more advanced CKD (estimated glomerular filtration rate < 30) and CDI showed higher in-hospital mortality and poorer responses to the initial metronidazole therapy. Conclusions: More advanced CKD is an independent risk factor for CDI and is associated with higher in-hospital mortality and poor treatment responses in CDI patients. Thus, in CKD patients, careful attention should be paid to the occurrence of CDI and its management to improve the outcome of CDI. PMID:26767866

  12. A pharmacoepidemiological study of the multi-level determinants, predictors, and clinical outcomes of biosimilar epoetin alfa for renal anaemia in haemodialysis patients: background and methodology of the MONITOR-CKD5 study.

    PubMed

    Gesualdo, Loreto; London, Gérard; Turner, Matthew; Lee, Christopher; Macdonald, Karen; Goldsmith, David; Covic, Adrian; Zaoui, Philippe; Combe, Christian; Mann, Johannes; Dellanna, Frank; Muenzberg, Michael; Abraham, Ivo

    2013-08-01

    Prior longitudinal observational studies have examined the practice patterns and outcomes of anaemia management, including the use of erythropoiesis-stimulating agents (ESAs). Several dimensions of effectiveness remain unaddressed; especially considering the revised ESA label (target Hb levels between 10 and 12 g/dL), the recently published TREAT study, and the European approval of the first ESA biosimilar (HX575). Anecdotal evidence suggests that patient outcomes are influenced by physician-related variables and whether anaemia management is congruent with practice guidelines, but this has not been studied systematically. MONITOR-CKD5 is an international, prospective, observational, pharmacoepidemiological study evaluating the multi-level factors and outcomes of treatment with HX575 for renal anaemia in haemodialysis patients. Driven by a novel, integrated, multi-focal framework for post-approval observational studies, it examines determinants of response at both the patient and the physician level; integrates an advocated statistical methodology here to fore used mainly in the social and behavioural sciences; assesses factors potentially predictive of a poor treatment response; and evaluates the extent to which treatment is congruent with evidence-based guidelines, good practice evidence, and the revised ESA label. This pan-European study will recruit at least 1,000 patients from a minimum of 75 centres, and follow them for up to 24 months following initiation of anaemia management with biosimilar epoetin alfa. MONITOR-CKD5 will not only study the core issues addressed by prior observational studies but also aims to take knowledge discovery a step further by assessing outcomes across varying cohorts of patients, and examining the impact of evidence-based practice on clinical outcomes, differentiating, in the process, between physician-level and patient-level determinants. PMID:21590439

  13. Urinary Stone Disease: Advancing Knowledge, Patient Care, and Population Health.

    PubMed

    Scales, Charles D; Tasian, Gregory E; Schwaderer, Andrew L; Goldfarb, David S; Star, Robert A; Kirkali, Ziya

    2016-07-01

    Expanding epidemiologic and physiologic data suggest that urinary stone disease is best conceptualized as a chronic metabolic condition punctuated by symptomatic, preventable stone events. These acute events herald substantial future chronic morbidity, including decreased bone mineral density, cardiovascular disease, and CKD. Urinary stone disease imposes a large and growing public health burden. In the United States, 1 in 11 individuals will experience a urinary stone in their lifetime. Given this high incidence and prevalence, urinary stone disease is one of the most expensive urologic conditions, with health care charges exceeding $10 billion annually. Patient care focuses on management of symptomatic stones rather than prevention; after three decades of innovation, procedural interventions are almost exclusively minimally invasive or noninvasive, and mortality is rare. Despite these advances, the prevalence of stone disease has nearly doubled over the past 15 years, likely secondary to dietary and health trends. The NIDDK recently convened a symposium to assess knowledge and treatment gaps to inform future urinary stone disease research. Reducing the public health burden of urinary stone disease will require key advances in understanding environmental, genetic, and other individual disease determinants; improving secondary prevention; and optimal population health strategies in an increasingly cost-conscious care environment. PMID:26964844

  14. Drug induced pseudoporphyria in CKD: A case report

    PubMed Central

    Quaiser, S.; Khan, R.; Khan, A. S.

    2015-01-01

    Pseudoporphyria (PP) is used to describe a photodistributed bullous disorder with clinical and histologic features of porphyria cutanea tarda (PCT) but without accompanying biochemical porphyrin abnormalities. Medications, excessive sun and ultraviolet radiation exposure, have all been reported to develop PP. We report a case of PP in a 49-year-old man with CKD stage 3a, caused due to torsemide intake. This is probably the first reported case of PP developing in a dialysis naive patient CKD due to torsemide intake from India. PMID:26628799

  15. Drug induced pseudoporphyria in CKD: A case report.

    PubMed

    Quaiser, S; Khan, R; Khan, A S

    2015-01-01

    Pseudoporphyria (PP) is used to describe a photodistributed bullous disorder with clinical and histologic features of porphyria cutanea tarda (PCT) but without accompanying biochemical porphyrin abnormalities. Medications, excessive sun and ultraviolet radiation exposure, have all been reported to develop PP. We report a case of PP in a 49-year-old man with CKD stage 3a, caused due to torsemide intake. This is probably the first reported case of PP developing in a dialysis naive patient CKD due to torsemide intake from India. PMID:26628799

  16. Systematic Review of Structural and Functional Neuroimaging Findings in Children and Adults with CKD

    PubMed Central

    Reiser, Kathryn A.; Detre, John A.; Schultz, Robert T.; Herrington, John D.; Davatzikos, Christos; Doshi, Jimit J.; Erus, Guray; Liu, Hua-Shan; Radcliffe, Jerilynn; Furth, Susan L.; Hooper, Stephen R.

    2013-01-01

    Summary CKD has been linked with cognitive deficits and affective disorders in multiple studies. Analysis of structural and functional neuroimaging in adults and children with kidney disease may provide additional important insights into the pathobiology of this relationship. This paper comprehensively reviews neuroimaging studies in both children and adults. Major databases (PsychLit, MEDLINE, WorldCat, ArticleFirst, PubMed, Ovid MEDLINE) were searched using consistent search terms, and studies published between 1975 and 2012 were included if their samples focused on CKD as the primary disease process. Exclusion criteria included case reports, chapters, and review articles. This systematic process yielded 43 studies for inclusion (30 in adults, 13 in children). Findings from this review identified several clear trends: (1) presence of cerebral atrophy and cerebral density changes in patients with CKD; (2) cerebral vascular disease, including deep white matter hyperintensities, white matter lesions, cerebral microbleeds, silent cerebral infarction, and cortical infarction, in patients with CKD; and (3) similarities in regional cerebral blood flow between patients with CKD and those with affective disorders. These findings document the importance of neuroimaging procedures in understanding the effect of CKD on brain structure, function, and associated behaviors. Results provide a developmental linkage between childhood and adulthood, with respect to the effect of CKD on brain functioning across the lifespan, with strong implications for a cerebrovascular mechanism contributing to this developmental linkage. Use of neuroimaging methods to corroborate manifest neuropsychological deficits or perhaps to indicate preventive actions may prove useful to individuals with CKD. PMID:23723341

  17. Systematic review of structural and functional neuroimaging findings in children and adults with CKD.

    PubMed

    Moodalbail, Divya G; Reiser, Kathryn A; Detre, John A; Schultz, Robert T; Herrington, John D; Davatzikos, Christos; Doshi, Jimit J; Erus, Guray; Liu, Hua-Shan; Radcliffe, Jerilynn; Furth, Susan L; Hooper, Stephen R

    2013-08-01

    CKD has been linked with cognitive deficits and affective disorders in multiple studies. Analysis of structural and functional neuroimaging in adults and children with kidney disease may provide additional important insights into the pathobiology of this relationship. This paper comprehensively reviews neuroimaging studies in both children and adults. Major databases (PsychLit, MEDLINE, WorldCat, ArticleFirst, PubMed, Ovid MEDLINE) were searched using consistent search terms, and studies published between 1975 and 2012 were included if their samples focused on CKD as the primary disease process. Exclusion criteria included case reports, chapters, and review articles. This systematic process yielded 43 studies for inclusion (30 in adults, 13 in children). Findings from this review identified several clear trends: (1) presence of cerebral atrophy and cerebral density changes in patients with CKD; (2) cerebral vascular disease, including deep white matter hyperintensities, white matter lesions, cerebral microbleeds, silent cerebral infarction, and cortical infarction, in patients with CKD; and (3) similarities in regional cerebral blood flow between patients with CKD and those with affective disorders. These findings document the importance of neuroimaging procedures in understanding the effect of CKD on brain structure, function, and associated behaviors. Results provide a developmental linkage between childhood and adulthood, with respect to the effect of CKD on brain functioning across the lifespan, with strong implications for a cerebrovascular mechanism contributing to this developmental linkage. Use of neuroimaging methods to corroborate manifest neuropsychological deficits or perhaps to indicate preventive actions may prove useful to individuals with CKD. PMID:23723341

  18. HDL in children with CKD promotes endothelial dysfunction and an abnormal vascular phenotype.

    PubMed

    Shroff, Rukshana; Speer, Thimoteus; Colin, Sophie; Charakida, Marietta; Zewinger, Stephen; Staels, Bart; Chinetti-Gbaguidi, Giulia; Hettrich, Inga; Rohrer, Lucia; O'Neill, Francis; McLoughlin, Eve; Long, David; Shanahan, Catherine M; Landmesser, Ulf; Fliser, Danilo; Deanfield, John E

    2014-11-01

    Endothelial dysfunction begins in early CKD and contributes to cardiovascular mortality. HDL is considered antiatherogenic, but may have adverse vascular effects in cardiovascular disease, diabetes, and inflammatory conditions. The effect of renal failure on HDL properties is unknown. We studied the endothelial effects of HDL isolated from 82 children with CKD stages 2-5 (HDL(CKD)), who were free of underlying inflammatory diseases, diabetes, or active infections. Compared with HDL from healthy children, HDL(CKD) strongly inhibited nitric oxide production, promoted superoxide production, and increased vascular cell adhesion molecule-1 expression in human aortic endothelial cells, and reduced cholesterol efflux from macrophages. The effects on endothelial cells correlated with CKD grade, with the most profound changes induced by HDL from patients on dialysis, and partial recovery observed with HDL isolated after kidney transplantation. Furthermore, the in vitro effects on endothelial cells associated with increased aortic pulse wave velocity, carotid intima-media thickness, and circulating markers of endothelial dysfunction in patients. Symmetric dimethylarginine levels were increased in serum and fractions of HDL from children with CKD. In a longitudinal follow-up of eight children undergoing kidney transplantation, HDL-induced production of endothelial nitric oxide, superoxide, and vascular cell adhesion molecule-1 in vitro improved significantly at 3 months after transplantation, but did not reach normal levels. These results suggest that in children with CKD without concomitant disease affecting HDL function, HDL dysfunction begins in early CKD, progressing as renal function declines, and is partially reversed after kidney transplantation. PMID:24854267

  19. Chronic kidney disease guideline implementation in primary care: a qualitative report from the TRANSLATE CKD study

    PubMed Central

    Vest, Bonnie M.; York, Trevor R.M.; Sand, Jessica; Fox, Chester H.; Kahn, Linda S.

    2016-01-01

    Background Primary care physicians (PCPs) are optimally situated to identify and manage early-stage chronic kidney disease (CKD). Nonetheless, studies have documented suboptimal PCP understanding, awareness, and management of early CKD. The TRANSLATE CKD study is an ongoing national mixed-methods cluster randomized control trial that examines the implementation of evidence-based guidelines for CKD into primary care practice. Methods As part of mixed-methods process evaluation, semi-structured interviews were conducted by phone with 27 providers participating in the study. Interviews were audio-taped and transcribed. Thematic content analysis was used to identify themes. Themes were categorized according to the four domains of Normalization Process Theory (NPT). Results Identified themes illuminated the complex work undertaken in primary care practices to manage CKD. Barriers to guideline implementation were identified in each of the four NPT domains, including: 1) lack of knowledge and understanding around CKD (coherence), 2) difficulties engaging providers and patients in CKD management (cognitive participation), 3) limited time and competing demands (collective action), and 4) challenges obtaining and utilizing data to monitor progress (reflexive monitoring). Conclusions Addressing the barriers to implementation with concrete interventions at the levels at which they occur, informed by NPT, will ultimately improve the quality of CKD patient care. PMID:26355134

  20. Back to the future: restricted protein intake for conservative management of CKD, triple goals of renoprotection, uremia mitigation, and nutritional health.

    PubMed

    Kovesdy, Csaba P; Kalantar-Zadeh, Kamyar

    2016-05-01

    Lowering dietary protein intake (DPI) to approximately 0.6-0.8 g/kgBW/day may be renoprotective through various mechanisms, and it has been recommended in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) as a means to also control various metabolic consequences of advanced CKD, such as uremic symptoms, hyperparathyroidism, hypertension, hyperkalemia, and hyperphosphatemia. A meta-analysis in this issue of the Journal suggests that low-protein diet is effective and safe when used to retard progression of CKD and alleviate uremic complications. A potential deleterious consequence of lowering DPI in this population is the development or worsening of protein-energy wasting (PEW), which can contribute to poor clinical outcomes such as higher mortality and morbidity. There is currently insufficient high-level evidence to determine the ideal level of DPI in patients with NDD-CKD with high risk of PEW. For the time being we recommend a DPI of 0.6-0.8 g/kgBW/day, and increasing this as needed on an individual basis in patients with PEW. Further examination of this dilemma in randomized controlled clinical trials will be necessary. PMID:26886110

  1. A Pegylated Leptin Antagonist Ameliorates CKD-Associated Cachexia in Mice

    PubMed Central

    Cheung, Wai W.; Ding, Wei; Gunta, Sujana S.; Gu, Yong; Tabakman, Rinat; Klapper, Leah N.; Gertler, Arieh

    2014-01-01

    Elevated serum leptin levels correlate with inflammation and predict changes in lean body mass in patients with CKD, and activation of the melanocortin system by leptin signaling mediates the pathophysiology of CKD-associated cachexia. We tested whether treatment with a pegylated leptin receptor antagonist (PLA) attenuates cachexia in mice with CKD. CKD and Sham mice received vehicle or PLA (2 or 7 mg/kg per day). At these doses, PLA did not influence serum leptin levels in mice. Treatment with 7 mg/kg per day PLA stimulated appetite and weight gain, improved lean mass and muscle function, reduced energy expenditure, and normalized the levels of hepatic TNF-α and IL-6 mRNA in mice with CKD. Furthermore, treatment with 7 mg/kg per day PLA attenuated the CKD-associated increase in the transcriptional and protein abundance of uncoupling proteins that mediates thermogenesis, and it normalized the molecular signatures of processes associated with muscle wasting in CKD, including proteolysis, myogenesis and muscle regeneration, and expression of proinflammatory muscle cytokines, such as IL-1α, -1β, and -6 and TNF-α. Our results suggest that leptin antagonism may represent a viable therapeutic strategy for cachexia in CKD. PMID:24115476

  2. [The efficacy and safety of activated vitamin D for CKD-MBD].

    PubMed

    Hayakawa, Nobuki; Suzuki, Atsushi

    2016-09-01

    Metabolic bone disorders that are represented by secondary hyperparathyroidism occur with the progression of chronic kidney disease(CKD). The administration of activated vitamin D is expected to improve high-turnover bone disorders and is widely used for the management of bone mineral diseases in patients with CKD and end-stage renal disease. CKD is an underlying disease of secondary osteoporosis and coexists with primary osteoporosis at a high rate. With regard to osteoporosis patients with renal insufficiency, the administration of activated vitamin D is also thought to reduce the fracture incidence by both increasing bone mass and reducing falls. PMID:27561349

  3. Going Upstream: Coordination to Improve CKD Care.

    PubMed

    Johnson, Douglas S; Kapoian, Toros; Taylor, Robert; Meyer, Klemens B

    2016-01-01

    Care coordination for patients with chronic kidney disease has been shown to be effective in improving outcomes and reducing costs. However, few patients with CKD benefit from this systematic management of their kidney disease and other medical conditions. As a result, outcomes for patients with kidney disease are not optimal, and their cost of care is increased. For those patients who transition to kidney failure treatment in the United States, the transition does not go as well as it could. The effectiveness of treatments to delay progression of kidney disease in contemporary clinical practice does not match the efficacy of these treatments in clinical trials. Conservative care for kidney disease, which should be an option for patients who are very old and very sick, is not considered often enough or seriously enough. Opportunities for early and even pre-emptive transplantation are missed, as are opportunities for home dialysis. The process of dialysis access creation is rarely optimal. The consequence is care which is not as good as it could be, and much more expensive than it should be. We describe our initial efforts to implement care coordination for chronic kidney disease in routine clinical care and attempt to project some of the benefits to patients and the cost savings. PMID:26765792

  4. Tipping the balance from angiogenesis to fibrosis in CKD

    PubMed Central

    Ballermann, Barbara J; Obeidat, Marya

    2014-01-01

    Chronic progressive renal fibrosis leads to end-stage renal failure many patients with chronic kidney disease (CKD). Loss of the rich peritubular capillary network is a prominent feature, and seems independent of the specific underlying disease. The mechanisms that contribute to peritubular capillary regression include the loss of glomerular perfusion, as flow-dependent shear forces are required to provide the survival signal for endothelial cells. Also, reduced endothelial cell survival signals from sclerotic glomeruli and atrophic or injured tubule epithelial cells contribute to peritubular capillary regression. In response to direct tubular epithelial cell injury, and the inflammatory reaction that ensues, capillary pericytes dissociate from their blood vessels, also reducing endothelial cell survival. In addition, direct inflammatory injury of capillary endothelial cells, for instance in chronic allograft nephropathy, also contributes to capillary dropout. Chronic tissue hypoxia, which ensues from the rarefaction of the peritubular capillary network, can generate both an angiogenic and a fibrogenic response. However, in CKD, the balance is strongly tipped toward fibrogenesis. Understanding the underlying mechanisms for failed angiogenesis in CKD and harnessing endothelial-specific survival and pro-angiogenic mechanisms for therapy should be our goal if we are to reduce the disease burden from CKD. PMID:26312149

  5. Americans’ Use of Dietary Supplements That Are Potentially Harmful in CKD

    PubMed Central

    Grubbs, Vanessa; Plantinga, Laura C.; Tuot, Delphine S.; Hedgeman, Elizabeth; Saran, Rajiv; Saydah, Sharon; Rolka, Deborah; Powe, Neil R.

    2013-01-01

    patients with and at risk for CKD. PMID:23415417

  6. Is there a role for ketoacid supplements in the management of CKD?

    PubMed

    Shah, Anuja P; Kalantar-Zadeh, Kamyar; Kopple, Joel D

    2015-05-01

    Ketoacid (KA) analogues of essential amino acids (EAAs) provide several potential advantages for people with advanced chronic kidney disease (CKD). Because KAs lack the amino group bound to the α carbon of an amino acid, they can be converted to their respective amino acids without providing additional nitrogen. It has been well established that a diet with 0.3 to 0.4 g of protein per kilogram per day that is supplemented with KAs and EAAs reduces the generation of potentially toxic metabolic products, as well as the burden of potassium, phosphorus, and possibly sodium, while still providing calcium. These KA/EAA-supplemented very-low-protein diets (VLPDs) can maintain good nutrition, but the appropriate dose of the KA/EAA supplement has not been established. Thus, a KA/EAA dose-response study for good nutrition clearly is needed. Similarly, the composition of the KA/EAA supplement needs to be reexamined; for example, some KA/EAA preparations contain neither the EAA phenylalanine nor its analogue. Indications concerning when to inaugurate a KA/EAA-supplemented VLPD therapy also are unclear. Evidence strongly suggests that these diets can delay the need for maintenance dialysis therapy, but whether they slow the loss of glomerular filtration rate in patients with CKD is less clear, particularly in this era of more vigorous blood pressure control and use of angiotensin/aldosterone blockade. Some clinicians prescribe KA/EAA supplements for patients with CKD or treated with maintenance dialysis, but with diets that have much higher protein levels than the VLPDs in which these supplements have been studied. More research is needed to examine the effectiveness of KA/EAA supplements with higher protein intakes. PMID:25682182

  7. Changing European CKD trends: a call to action.

    PubMed

    Bennett, Lesley

    2007-01-01

    Increasing numbers of patients with chronic kidney disease (CKD) who require renal replacement therapy threaten to overwhelm nephrologists, nephrology nurses, and haemodialysis units in many European countries. Health care costs are increasing more rapidly than corresponding budgets. These changing trends mandate new policies to provide continued quality care for more patients at international, national, and local levels. Although individual countries have different requirements regarding health care systems, approaches must be taken that improve structure, process, and outcome. Common issues include improving professional education, increasing collaboration among health care providers and specialists, and the acquisition and allocation of funds. Solutions identified by some countries provide examples of model programs that could be adapted for others. The impending crisis that more and older patients with serious comorbidities and CKD will impose on health care delivery must be addressed now in a proactive manner by the nephrology health care community. PMID:18298031

  8. Vascular Effects of Exercise Training in CKD: Current Evidence and Pathophysiological Mechanisms

    PubMed Central

    Van Craenenbroeck, Emeline M.; Kouidi, Evangelia; Vrints, Christiaan J.; Couttenye, Marie M.; Conraads, Viviane M.

    2014-01-01

    Cardiovascular disease remains the main cause of morbidity and mortality in patients with CKD, an observation that cannot be explained by the coexistence of traditional risk factors alone. Recently, other mechanisms, such as alterations in nitric oxide bioavailability, impaired endothelial repair mechanisms, inflammation, and oxidative stress (all characteristic in CKD), have gained much attention as mediators for the increased cardiovascular risk. Regular physical training is a valuable nonpharmacological intervention for primary and secondary prevention of cardiovascular disease. Likewise, the benefits of exercise training on exercise capacity and quality of life are increasingly recognized in patients with CKD. Furthermore, exercise training could also influence potential reversible mechanisms involved in atherosclerosis and arteriosclerosis. After discussing briefly the general concepts of vascular disease in CKD, this review provides an overview of the current evidence for the effects of exercise training at both clinical and preclinical levels. It concludes with some practical considerations on exercise training in this specific patient group. PMID:24832091

  9. Vascular effects of exercise training in CKD: current evidence and pathophysiological mechanisms.

    PubMed

    Van Craenenbroeck, Amaryllis H; Van Craenenbroeck, Emeline M; Kouidi, Evangelia; Vrints, Christiaan J; Couttenye, Marie M; Conraads, Viviane M

    2014-07-01

    Cardiovascular disease remains the main cause of morbidity and mortality in patients with CKD, an observation that cannot be explained by the coexistence of traditional risk factors alone. Recently, other mechanisms, such as alterations in nitric oxide bioavailability, impaired endothelial repair mechanisms, inflammation, and oxidative stress (all characteristic in CKD), have gained much attention as mediators for the increased cardiovascular risk. Regular physical training is a valuable nonpharmacological intervention for primary and secondary prevention of cardiovascular disease. Likewise, the benefits of exercise training on exercise capacity and quality of life are increasingly recognized in patients with CKD. Furthermore, exercise training could also influence potential reversible mechanisms involved in atherosclerosis and arteriosclerosis. After discussing briefly the general concepts of vascular disease in CKD, this review provides an overview of the current evidence for the effects of exercise training at both clinical and preclinical levels. It concludes with some practical considerations on exercise training in this specific patient group. PMID:24832091

  10. Morbidity and treatment in patients with atrial fibrillation and chronic kidney disease.

    PubMed

    Reinecke, Holger; Nabauer, Michael; Gerth, Andrea; Limbourg, Tobias; Treszl, Andras; Engelbertz, Christiane; Eckardt, Lars; Kirchhof, Paulus; Wegscheider, Karl; Ravens, Ursula; Meinertz, Thomas; Steinbeck, Gerhard; Breithardt, Günter

    2015-01-01

    Chronic kidney disease (CKD) is associated with increased cardiovascular morbidity and mortality but there are few studies available about atrial fibrillation, the most frequent arrhythmia in CKD, and the applied treatment. Based on the prospective German Competence NETwork on Atrial Fibrillation, data of 3138 patients with atrial fibrillation were analyzed and categorized by their estimated glomerular filtration rate (stages 1-3 and 4 plus 5). With advanced CKD, significantly more patients suffered from a more severe form of atrial fibrillation. Despite significantly higher CHADS2 scores in advanced CKD, oral anticoagulation was not prescribed more frequently while antiarrhythmic drugs and catheter ablations were used significantly less often, in contrast to more pacemaker implantations. However, in multivariate hierarchical logistic regression analyses of in-hospital treatments and complications, only hemorrhages and pacemaker implantations turned out to be independently and significantly associated with higher CKD stages. This nationwide study shows that patients with CKD and atrial fibrillation suffer from a markedly higher comorbidity. Thus, while CKD patients have received cardioversions, ablations, antiarrhythmic, or anticoagulation drugs significantly less often in their history, current treatments were not different if adjusted for multiple comorbidities. This might indicate an improvement in the often reported therapeutic nihilism in CKD. PMID:24897032

  11. [Vascular diseases in CKD-MBD].

    PubMed

    Shioi, Atsushi

    2016-06-01

    Vascular calcification is an important component of CKD-MBD and occurs in association with vascular lesions of CKD-MBD such as atherosclerosis and arteriosclerosis. Atherosclerotic intimal calcification and medial calcification contribute to the development and progression of cardiovascular disease. Epidemiological data suggest that it is not atherothrombotic disease but myocardal disease including left ventricular hypertrophy with fibrosis and diastolic dysfunction which is the principal cause of cardiovascular death in CKD. Arteriosclerosis is characterized by thickening and calcification of the medial arterial layer. Medial calcification results in increased arterial stiffness and contributes to the development of myocardial disease. Therefore, it is important to develop novel therapeutics for medial calcification. PMID:27230844

  12. The intact nephron hypothesis: the concept and its implications for phosphate management in CKD-related mineral and bone disorder

    PubMed Central

    Slatopolsky, Eduardo

    2011-01-01

    Mechanistic understanding of secondary hyperparathyroidism, vascular calcification, and regulation of phosphate metabolism in chronic kidney disease (CKD) has advanced significantly in the past five decades. In 1960, Bricker developed the ‘intact nephron hypothesis', opening the door for hundreds of investigations. He emphasized that ‘as the number of functioning nephrons decreases, each remaining nephron must perform a greater fraction of total renal excretion'. Phosphate per se, independent of Ca2+ and calcitriol, directly affects the development of parathyroid gland hyperplasia and secondary hyperparathyroidism. Vitamin D receptor, Ca2+ sensing receptor, and Klotho–fibroblast growth factor (FGF) receptor-1 complex are all significantly decreased in the parathyroid glands of patients with CKD. Duodenal instillation of phosphate rapidly decreases parathyroid hormone release without changes in calcium or calcitriol. The same procedure also rapidly increases renal phosphate excretion independently of FGF-23, suggesting the possibility of an ‘intestinal phosphatonin'. These observations suggest a possible ‘phosphate sensor' in the parathyroid glands and gastrointestinal tract, although as yet there is no proof for the existence of such a sensor. Evidence shows that phosphate has a key role in parathyroid hyperplasia by activating the transforming growth factor-α–epidermal growth factor receptor complex. Thus, control of serum phosphorus early in the course of CKD will significantly ameliorate the pathological manifestations observed during progressive deterioration of renal function. PMID:21346721

  13. Effectiveness of the fixed-dose combination of olmesartan/amlodipine/hydrochlorothiazide for the treatment of hypertension in patients stratified by age, race and diabetes, CKD and chronic CVD.

    PubMed

    Chrysant, Steven G

    2013-09-01

    The prevalence of hypertension is high in patients with diabetes mellitus (DM), chronic kidney disease (CKD) and chronic cardiovascular disease (CVD), as well as in black and elderly subjects. In addition, these subjects have the lowest control of blood pressure (BP) among the hypertensive population, and also the risk of having a morbid or fatal cardiovascular event >20% in 10 years. For these reasons, aggressive control of BP to <130/80 mm Hg for these subjects is strongly recommended by National and International guidelines. To accomplish this goal, combination therapy with two or more antihypertensive drugs with a complementary mechanism of action is necessary. Drugs that block the renin-angiotensin system (RAS) in combination with a calcium channel blocker (CCB) and a diuretic have been shown to be the most effective combinations to accomplish this goal. However, this will require the administration of multiple drugs given separately, which will decrease the patient compliance and adherence to treatment. Poor patient compliance and adherence to treatment is a major factor for poor BP control. Several studies have shown that patient compliance is inversely related to the number of drugs being administered. To overcome this problem, several dual and triple-drug, fixed-dose combinations with a RAS blocker, a CCB and a diuretic have been developed and marketed, which are easier to administer, and have been shown to increase patient compliance and adherence to treatment. In this concise review, the effectiveness and safety of the fixed-dose, triple-combination of the RAS blocker olmesartan medoxomil, the CCB amlodipine besylate and the diuretic hydrochlorothiazide, as well as other similar combinations for the treatment of hypertension, will be discussed. These drug combinations have been shown to be effective, safe and well tolerated by most patients. PMID:24073676

  14. Contemporary Management of Coronary Artery Disease and Acute Coronary Syndrome in Patients with Chronic Kidney Disease and End-Stage Renal Disease

    PubMed Central

    Huang, Chin-Chou; Chen, Jaw-Wen

    2013-01-01

    Chronic kidney disease (CKD) and end-stage renal disease (ESRD) have emerged as a worldwide public health problem. Due to the remarkably higher incidence and prevalence of this chronic disease in Taiwan than in other countries, CKD/ESRD has contributed to a significant health burden in Taiwan. Patients with CKD/ESRD have an increased risk of coronary artery disease (CAD) and acute coronary syndrome (ACS) compared to the normal population. Patients with ACS alone can present differently than patients with ACS and CKD/ESRD. Also, due to the lower prevalence of chest pain and ST-segment elevation, CKD/ESRD patients were more difficult to diagnose than other patients. Furthermore, whether advances in ACS management with medical therapy and an early invasive approach could improve patient outcomes with CKD/ESRD is not known. The use of antiplatelets such as aspirin and other antithrombotic agents might reduce the incidence of ACS or stroke in CKD patients. However, such use could also increase bleeding risk and even increase the likelihood of mortality, especially in dialysis patients. While recent clinical data suggest the potential benefit of aggressive management with coronary intervention for CAD and ACS in this category of patients, further clinical studies are still indicated for the proper medical strategy and revascularization therapy to improve the outcomes of CAD and ACS in CKD/ESRD patients, both in Taiwan and worldwide. PMID:27122697

  15. Risk profiles of referred chronic kidney disease patients in a tertiary nephrology centre

    PubMed Central

    Lim, Christopher Thiam Seong; R, Raihan; A.S., Mohd Zharif Fikri

    2016-01-01

    Objective: To determine the risk profile of chronic kidney disease (CKD) patients. Methods: This is an observational cross sectional study involving 130 patients for which data was collected prospectively.. Sixty five subjects with an estimated glomerular filtration rate (eGFR) below 120 ml/min/1.73 m2 were recruited via random sampling technique from nephrology clinic in a tertiary nephrology referral center. Medical history, demographic data, urinary and serum biochemistry tests were obtained. Results: Most of the CKD patients who were referred to the nephrology clinic were asymptomatic. The most common laboratory abnormalities noted among CKD patients were proteinuria, anaemia and hyperkalaemia. Advancing age, pre-existing morbidities such as diabetes mellitus, hypertension and overweight are characteristics that are strongly associated with the referred CKD patients. Conclusions: Most of the referred CKD patients are in advanced age with diabetes, hypertension and overweight. Majority of the CKD remained asymptomatic despite in the advance stage of CKD. This strongly calls for cost effective screening for population at risk. PMID:27022339

  16. Association of Nocturnal Hypoxemia with Progression of CKD

    PubMed Central

    Hatta, Tsuguru; Hayashi, Terumasa; Shoji, Tatsuya; Suzuki, Akira; Tomida, Kodo; Okada, Noriyuki; Rakugi, Hiromi; Isaka, Yoshitaka; Tsubakihara, Yoshiharu

    2013-01-01

    Summary Background and objectives Nocturnal hypoxemia is highly prevalent among patients with CKD. Nocturnal hypoxemia contributes to systemic inflammation, oxidative stress, endothelial cell dysfunction, and activation of the renin-angiotensin system, which are common pathologic mechanisms of CKD progression. This study investigated whether nocturnal hypoxemia is independently associated with CKD progression. Design, setting, participants, & measurements This two-center retrospective cohort study included 161 patients with stages 3–4 CKD enrolled from January of 2009 to July of 2011 with a body mass index less than 25.0 kg/m2. The 4% oxygen desaturation index, the number of events per hour in which oxygen saturation decreases by >4% during sleep, was measured, and the declining rate of the estimated GFR was followed over 1 year. The severity of nocturnal hypoxemia was categorized as none (oxygen desaturation index<5.0), mild (5.0≤oxygen desaturation index<15.0), or moderate to severe (15.0≤oxygen desaturation index). Results The mean estimated GFR of the total cohort at baseline was 31 ml/min per 1.73 m2. Eighty patients (49.7%) were diagnosed with nocturnal hypoxemia; 64 patients were diagnosed with mild nocturnal hypoxemia, and 16 patients were diagnosed with moderate-to-severe nocturnal hypoxemia. The estimated GFR declined three- to fourfold faster in patients with moderate-to-severe nocturnal hypoxemia than patients with no or mild nocturnal hypoxemia (the mean values [95% confidence intervals] were −2.14 [−1.06 to −3.21], −3.02 [−1.31 to −4.74], and −8.59 [−2.00 to −15.2] ml/min per 1.73 m2 per year in the no, mild, and moderate-to-severe nocturnal hypoxemia groups, respectively; P=0.003). Nocturnal hypoxemia remained a significant predictor of decline in estimated GFR after adjustment for various baseline clinical factors. Conclusions In nonobese patients with CKD, nocturnal hypoxemia is an independent risk factor of a rapid decline

  17. Cross-Disciplinary Biomarkers Research: Lessons Learned by the CKD Biomarkers Consortium

    PubMed Central

    Hsu, Chi-yuan; Ballard, Shawn; Batlle, Daniel; Bonventre, Joseph V.; Böttinger, Erwin P.; Feldman, Harold I.; Klein, Jon B.; Coresh, Josef; Eckfeldt, John H.; Inker, Lesley A.; Kimmel, Paul L.; Kusek, John W.; Liu, Kathleen D.; Mauer, Michael; Mifflin, Theodore E.; Molitch, Mark E.; Nelsestuen, Gary L.; Rebholz, Casey M.; Rovin, Brad H.; Sabbisetti, Venkata S.; Van Eyk, Jennifer E.; Vasan, Ramachandran S.; Waikar, Sushrut S.; Whitehead, Krista M.

    2015-01-01

    Significant advances are needed to improve the diagnosis, prognosis, and management of persons with CKD. Discovery of new biomarkers and improvements in currently available biomarkers for CKD hold great promise to achieve these necessary advances. Interest in identification and evaluation of biomarkers for CKD has increased substantially over the past decade. In 2009, the National Institute of Diabetes and Digestive and Kidney Diseases established the CKD Biomarkers Consortium (http://www.ckdbiomarkersconsortium.org/), a multidisciplinary, collaborative study group located at over a dozen academic medical centers. The main objective of the consortium was to evaluate new biomarkers for purposes related to CKD in established prospective cohorts, including those enriched for CKD. During the first 5 years of the consortium, many insights into collaborative biomarker research were gained that may be useful to other investigators involved in biomarkers research. These lessons learned are outlined in this Special Feature and include a wide range of issues related to biospecimen collection, storage, and retrieval, and the internal and external quality assessment of laboratories that performed the assays. The authors propose that investigations involving biomarker discovery and validation are greatly enhanced by establishing and following explicit quality control metrics, including the use of blind replicate and proficiency samples, by carefully considering the conditions under which specimens are collected, handled, and stored, and by conducting pilot and feasibility studies when there are concerns about the condition of the specimens or the accuracy or reproducibility of the assays. PMID:25739849

  18. Cross-Disciplinary Biomarkers Research: Lessons Learned by the CKD Biomarkers Consortium.

    PubMed

    Hsu, Chi-Yuan; Ballard, Shawn; Batlle, Daniel; Bonventre, Joseph V; Böttinger, Erwin P; Feldman, Harold I; Klein, Jon B; Coresh, Josef; Eckfeldt, John H; Inker, Lesley A; Kimmel, Paul L; Kusek, John W; Liu, Kathleen D; Mauer, Michael; Mifflin, Theodore E; Molitch, Mark E; Nelsestuen, Gary L; Rebholz, Casey M; Rovin, Brad H; Sabbisetti, Venkata S; Van Eyk, Jennifer E; Vasan, Ramachandran S; Waikar, Sushrut S; Whitehead, Krista M; Nelson, Robert G

    2015-05-01

    Significant advances are needed to improve the diagnosis, prognosis, and management of persons with CKD. Discovery of new biomarkers and improvements in currently available biomarkers for CKD hold great promise to achieve these necessary advances. Interest in identification and evaluation of biomarkers for CKD has increased substantially over the past decade. In 2009, the National Institute of Diabetes and Digestive and Kidney Diseases established the CKD Biomarkers Consortium (http://www.ckdbiomarkersconsortium.org/), a multidisciplinary, collaborative study group located at over a dozen academic medical centers. The main objective of the consortium was to evaluate new biomarkers for purposes related to CKD in established prospective cohorts, including those enriched for CKD. During the first 5 years of the consortium, many insights into collaborative biomarker research were gained that may be useful to other investigators involved in biomarkers research. These lessons learned are outlined in this Special Feature and include a wide range of issues related to biospecimen collection, storage, and retrieval, and the internal and external quality assessment of laboratories that performed the assays. The authors propose that investigations involving biomarker discovery and validation are greatly enhanced by establishing and following explicit quality control metrics, including the use of blind replicate and proficiency samples, by carefully considering the conditions under which specimens are collected, handled, and stored, and by conducting pilot and feasibility studies when there are concerns about the condition of the specimens or the accuracy or reproducibility of the assays. PMID:25739849

  19. Effect of an Educational Program on Adherence to Therapeutic Regimen among Chronic Kidney Disease Stage5 (CKD5) Patients under Maintenance Hemodialysis

    ERIC Educational Resources Information Center

    Deif, Hala I. Abo; Elsawi, Khiria; Selim, Mohga; NasrAllah, Mohamed M.

    2015-01-01

    The burden of chronic disease on health care services worldwide is growing and the increased development of educational interventions which help patients to better manage their conditions is evident internationally. It has been recognized that poor adherence can be a serious risk to the health and wellbeing of patients. Adherence to fluid…

  20. Prevalence, Predictors, and Outcomes of Pulmonary Hypertension in CKD.

    PubMed

    Navaneethan, Sankar D; Roy, Jason; Tao, Kelvin; Brecklin, Carolyn S; Chen, Jing; Deo, Rajat; Flack, John M; Ojo, Akinlolu O; Plappert, Theodore J; Raj, Dominic S; Saydain, Ghulam; Sondheimer, James H; Sood, Ruchi; Steigerwalt, Susan P; Townsend, Raymond R; Dweik, Raed A; Rahman, Mahboob

    2016-03-01

    Pulmonary hypertension (PH) is associated with poor outcomes in the dialysis and general populations, but its effect in CKD is unclear. We evaluated the prevalence and predictors of PH measures and their associations with long-term clinical outcomes in patients with nondialysis-dependent CKD. Chronic Renal Insufficiency Cohort (CRIC) Study participants who had Doppler echocardiography performed were considered for inclusion. PH was defined as the presence of estimated pulmonary artery systolic pressure (PASP) >35 mmHg and/or tricuspid regurgitant velocity (TRV) >2.5 m/s. Associations between PH, PASP, and TRV and cardiovascular events, renal events, and all-cause mortality were examined using Cox proportional hazards models. Of 2959 eligible participants, 21% (n=625) had PH, with higher rates among those with lower levels of kidney function. In the multivariate model, older age, anemia, lower left ventricular ejection fraction, and presence of left ventricular hypertrophy were associated with greater odds of having PH. After adjusting for relevant confounding variables, PH was independently associated with higher risk for death (hazard ratio, 1.38; 95% confidence interval, 1.10 to 1.72) and cardiovascular events (hazard ratio, 1.23; 95% confidence interval, 1.00 to 1.52) but not renal events. Similarly, TRV and PASP were associated with death and cardiovascular events but not renal events. In this study of patients with CKD and preserved left ventricular systolic function, we report a high prevalence of PH. PH and higher TRV and PASP (echocardiographic measures of PH) are associated with adverse outcomes in CKD. Future studies may explain the mechanisms that underlie these findings. PMID:26386072

  1. Atrial fibrillation in CKD: balancing the risks and benefits of anticoagulation.

    PubMed

    Ng, Khai P; Edwards, Nicola C; Lip, Gregory Y H; Townend, Jonathan N; Ferro, Charles J

    2013-09-01

    Chronic kidney disease (CKD) and atrial fibrillation are common conditions that often coexist and are associated with increased risk of stroke. Despite the wealth of evidence for optimal management of atrial fibrillation in the general population, the role of anticoagulation with warfarin in individuals with CKD with atrial fibrillation is far less well defined. Current recommendations for anticoagulation in patients treated with dialysis and those with an earlier stage of CKD are based on clinical trials in the general atrial fibrillation population that have largely excluded individuals with CKD. Observational studies of anticoagulation in dialysis patients have produced conflicting results, mainly because of increased risk of bleeding. This, together with warfarin's potential adverse effects on ectopic/vascular calcification and progression of CKD, may result in negating the benefits associated with anticoagulation in the general population. With the recent emergence of novel oral anticoagulants, there is an urgent need for a better understanding of the complex inter-relationship among CKD, atrial fibrillation, stroke, and bleeding risk. This knowledge is paramount to optimize the potential benefits of treatment and minimize the potential harms in this very high-risk and growing population. PMID:23746378

  2. Statins and Cardiovascular Primary Prevention in CKD: A Meta-Analysis

    PubMed Central

    Cheung, Chee Kay; Gray, Laura J.; Brunskill, Nigel J.

    2015-01-01

    Background and objectives Multiple meta-analyses of lipid-lowering therapies for cardiovascular primary prevention in the general population have been performed. Other meta-analyses of lipid-lowering therapies in CKD have also been performed, but not for primary prevention. This meta-analysis assesses lipid-lowering therapies for cardiovascular primary prevention in CKD. Design, setting, participants, & measurements A systematic review and meta-analysis using a random-effects model was performed. MEDLINE was searched between January 2012 and September 2013 for new studies using predefined search criteria without language restrictions. A number of other sources including previously published meta-analyses were also reviewed. Inclusion criteria were randomized control trials of primary prevention with lipid-lowering therapy in non–end stage CKD. Results Six trials were identified, five including patients with stage 3 CKD only. These studies included 8834 participants and 32,846 person-years of follow-up. All trials were post hoc subgroup analyses of statins in the general population. Statins reduced the risk of cardiovascular disease (the prespecified primary outcome) by 41% in stages 1–3 CKD compared with placebo (pooled risk ratio, 0.59; 95% confidence interval [95% CI], 0.48 to 0.72). For the secondary outcomes, the risk ratios were 0.66 (95% CI, 0.49 to 0.88) for total mortality, 0.55 (95% CI, 0.42 to 0.72) for coronary heart disease events, and 0.56 (95% CI, 0.28 to 1.13) for stroke. In study participants with stage 3 CKD specifically, the results were similar. Conclusions This meta-analysis suggests that the use of statins in CKD for primary prevention of cardiovascular disease is effective. These findings are consistent with recent guidance for the use of statins in all patients with CKD. PMID:25833405

  3. Ferumoxytol for Treating Iron Deficiency Anemia in CKD

    PubMed Central

    Spinowitz, Bruce S.; Kausz, Annamaria T.; Baptista, Jovanna; Noble, Sylvia D.; Sothinathan, Renuka; Bernardo, Marializa V.; Brenner, Louis; Pereira, Brian J. G.

    2008-01-01

    Iron deficiency is an important cause of anemia in patients with chronic kidney disease (CKD), but intravenous iron is infrequently used among patients who are not on dialysis. Ferumoxytol is a novel intravenous iron product that can be administered as a rapid injection. This Phase III trial randomly assigned 304 patients with CKD in a 3:1 ratio to two 510-mg doses of intravenous ferumoxytol within 5 ± 3 d or 200 mg of elemental oral iron daily for 21 d. The increase in hemoglobin at day 35, the primary efficacy end point, was 0.82 ± 1.24 g/dl with ferumoxytol and 0.16 ± 1.02 g/dl with oral iron (P < 0.0001). Among patients who were not receiving erythropoiesis-stimulating agents, hemoglobin increased 0.62 ± 1.02 g/dl with ferumoxytol and 0.13 ± 0.93 g/dl with oral iron. Among patients who were receiving erythropoiesis-stimulating agents, hemoglobin increased 1.16 ± 1.49 g/dl with ferumoxytol and 0.19 ± 1.14 g/dl with oral iron. Treatment-related adverse events occurred in 10.6% of patients who were treated with ferumoxytol and 24.0% of those who were treated with oral iron; none was serious. In summary, a regimen of two doses of 510 mg of intravenous ferumoxytol administered rapidly within 5 ± 3 d was well tolerated and had the intended therapeutic effect. This regimen may offer a new, efficient option to treat iron deficiency anemia in patients with CKD. PMID:18525001

  4. Metabolic Acidosis of CKD: An Update.

    PubMed

    Kraut, Jeffrey A; Madias, Nicolaos E

    2016-02-01

    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. PMID:26477665

  5. Episodic pain in patients with advanced cancer.

    PubMed

    Zeppetella, Giovambattista; Ribeiro, Maria D C

    2002-01-01

    Episodic pain is a common problem for patients with advanced cancer and is often difficult to manage successfully. In this article, the daily variations in cancer-related episodic pain in a patient with metastatic lung cancer are described. The definition, etiology, prevalence, and pharmacological management of episodic pain are also reviewed PMID:12141792

  6. Recent advance in patient monitoring

    PubMed Central

    2010-01-01

    Recent advance in technology has developed a lot of new aspects of clinical monitoring. We can monitor sedation levels during anesthesia using various electroencephalographic (EEG) indices, while it is still not useful for anesthesia depth monitoring. Some attempts are made to monitor the changes in sympathetic nerve activity as one of the indicators of stress, pain/analgesia, or anesthesia. To know the balance of sympathetic and parasympathetic activity, heart rate or blood pressure variability is investigated. For trend of cardiac output, low invasive monitors have been investigated. Improvement of ultrasound enables us to see cardiac structure and function continuously and clearer, increases success rate and decreases complication of central venous puncture and various kinds of nerve blocks. Without inserting an arterial catheter, trends of arterial oxygen tension or carbon dioxide tension can be monitored. Indirect visualization of the airway decreases difficult intubation and makes it easier to teach tracheal intubation. The changes in blood volume can be speculated non-invasively. Cerebral perfusion and metabolism are not ordinary monitored yet, but some studies show their usefulness in management of critically ill. This review introduces recent advances in various monitors used in anesthesia and critical care including some studies of the author, especially focused on EEG and cardiac output. However, the most important is that these new monitors are not almighty but should be used adequately in a limited situation where their meaning is confirmed. PMID:20877698

  7. [Is denosmab really effective and safe in the care of CKD-MBD?].

    PubMed

    Hamano, Takayuki; Nakano, Chikako

    2016-09-01

    The authors of Freedom study enrolling primary osteoporosis patients argued that the anti-fracture effect of denosmab is not dependent on baseline estimated glomerular filtration rate(eGFR)by showing the non-significant interaction term between treatment and CKD stage. However, given disproportionate numbers of patients in each subgroup(4069, 2817, and only 73 patients, in CKD stage 2, 3, and, 4, respectively), this study seems to lack the statistical power to reach a definite conclusion on the effect modification by CKD stage. Truly, the serum concentration of infused denosmab in patients with CKD stage 4 is equivalent to that in patients without CKD, the risk of developing life-threatening or prolonged hypocalcemia is huge even under active vitamin D therapy in this population. In hemodialysis patients, this drug is relatively safer because each dialysis session delivers calcium into the circulation 3 times a week. However, even with concomitant administration of massive active vitamin D, the increase of intact PTH levels greater than 1000 pg/mL by this agent is not rare. In other words, this drug worsens secondary hyperparathyroidism. Moreover, reportedly, calcium and active vitamin D administered to avoid hypocalcemia can lead to ectopic calcification especially under the low bone turnover induced by this agent. In fact, transient hypercalcemia often follows hypocalcemia by the inevitable calcium supplementation. PMID:27561346

  8. Pregnancy and Chronic Kidney Disease: A Challenge in All CKD Stages

    PubMed Central

    Attini, Rossella; Vasario, Elena; Conijn, Anne; Biolcati, Marilisa; D'Amico, Federica; Consiglio, Valentina; Bontempo, Salvatore; Todros, Tullia

    2010-01-01

    Background and objectives: Chronic kidney disease (CKD) is a challenge for pregnancy. Its recent classification underlines the importance of its early phases. This study's aim was to evaluate outcomes of pregnancy according to CKD stage versus low-risk pregnancies followed in the same center. Design, setting, participants, & measurements: The prospective analysis was conducted from January 2000 to May 2009 with the start of observation at referral and end of observation 1 month after delivery. Ninety-one singleton deliveries were studied; 267 “low-risk” singleton pregnancies served as controls. Because of the lack of hard end points (death, start of dialysis), surrogate end points were analyzed (cesarean section, prematurity, neonatal intensive care). Results: CKD outcome was worse than physiologic pregnancies: preterm delivery (44% versus 5%); cesarean section (44% versus 25%); and need for neonatal intensive care (26% versus 1%). The differences were highly significant in stage 1 CKD (61 cases) versus controls (CKD stage 1: cesarean sections = 57%, preterm delivery = 33%, intensive care = 18%). In CKD, proteinuria and hypertension were correlated with outcomes [proteinuria dichotomized at 1 g/24 h at referral: need for intensive care, relative risk (RR) = 4.16 (1.05 to 16.46); hypertension: preterm delivery, RR = 7.24 (2.30 to 22.79); cesarean section, RR = 5.70 (1.69 to 19.24)]. Statistical significance across stages was reached for preterm delivery [RR = 3.32 (1.09 to 10.13)]. Conclusions: CKD is a challenge for pregnancy from early stages. Strict follow-up is needed for CKD patients, even when there is normal renal function. PMID:20413442

  9. Analgesia for patients with advanced disease: 2

    PubMed Central

    Hall, E; Sykes, N

    2004-01-01

    The first article in this series explored epidemiology and patterns of pain in advanced disease, non-pharmacological treatments, and the use of opioids to manage pain. This second article examines the use of non-opioid drugs and anaesthetic interventions for pain relief in advanced disease. It also discusses an approach to managing analgesia in dying patients and finally looks at future developments. PMID:15082837

  10. Blood Pressure Targets in CKD: Lessons Learned from SPRINT and Previous Observational Studies.

    PubMed

    Gosmanova, Elvira O; Kovesdy, Csaba P

    2016-09-01

    Hypertension management is one of the most common clinical tasks in the care of patients with chronic kidney disease (CKD). Elevated blood pressure (BP) is associated with greater risk of all-cause mortality, cardiovascular (CV) disease, and CKD progression in this population. However, it is still debated, to what target(s) BP should be lowered in patients with signs of kidney damage. The Systolic Blood Pressure Intervention Trial (SPRINT) provided new and important information about the effects of lowering systolic BP to a target of <120 mmHg, which is lower than the levels currently recommended by the most guidelines (<140/90 mmHg). The SPRINT results were not only exciting but also surprising for many clinicians because evidence from well-conducted observational studies in CKD patient showed increased mortality in patients with CKD whose office systolic BP levels were <120 mmHg, as compared with systolic BP in 120-139 mmHg range. In the present review, we will discuss whether a systolic BP goal of <120 mmHg that was found to be beneficial for CV and all-cause mortality outcomes in the SPRINT can be generalized to the entire CKD population. PMID:27448402

  11. Research Priorities in CKD: Report of a National Workshop Conducted in Australia.

    PubMed

    Tong, Allison; Crowe, Sally; Chando, Shingisai; Cass, Alan; Chadban, Steve J; Chapman, Jeremy R; Gallagher, Martin; Hawley, Carmel M; Hill, Sophie; Howard, Kirsten; Johnson, David W; Kerr, Peter G; McKenzie, Anne; Parker, David; Perkovic, Vlado; Polkinghorne, Kevan R; Pollock, Carol; Strippoli, Giovanni F M; Tugwell, Peter; Walker, Rowan G; Webster, Angela C; Wong, Germaine; Craig, Jonathan C

    2015-08-01

    Research aims to improve health outcomes for patients. However, the setting of research priorities is usually performed by clinicians, academics, and funders, with little involvement of patients or caregivers and using processes that lack transparency. A national workshop was convened in Australia to generate and prioritize research questions in chronic kidney disease (CKD) among diverse stakeholder groups. Patients with CKD (n=23), nephrologists/surgeons (n=16), nurses (n=8), caregivers (n=7), and allied health professionals and researchers (n=4) generated and voted on intervention questions across 4 treatment categories: CKD stages 1 to 5 (non-dialysis dependent), peritoneal dialysis, hemodialysis, and kidney transplantation. The 5 highest ranking questions (in descending order) were as follows: How effective are lifestyle programs for preventing deteriorating kidney function in early CKD? What strategies will improve family consent for deceased donor kidney donation, taking different cultural groups into account? What interventions can improve long-term post-transplant outcomes? What are effective interventions for post hemodialysis fatigue? How can we improve and individualize drug therapy to control post-transplant side effects? Priority questions were focused on prevention, lifestyle, quality of life, and long-term impact. These prioritized research questions can inform funding agencies, patient/consumer organizations, policy makers, and researchers in developing a CKD research agenda that is relevant to key stakeholders. PMID:25943716

  12. Advanced Diabetic Nephropathy with Nephrotic Range Proteinuria: A Pilot Study of the Long-Term Efficacy of Subcutaneous ACTH Gel on Proteinuria, Progression of CKD, and Urinary Levels of VEGF and MCP-1

    PubMed Central

    Tumlin, J. A.; Galphin, C. M.; Rovin, B. H.

    2013-01-01

    Background and Objective. Adrenocorticotropic hormone (ACTH) is able to reduce proteinuria in nondiabetic glomerulopathies through activation of melanocortin receptors (MCR) expressed in the podocyte. To determine the efficacy of ACTH, we conducted a randomized, open-label pilot trial of ACTH gel in patients with advanced diabetic nephropathy. Study Design. Twenty-three (23) patients with diabetic nephropathy were randomized to daily subcutaneous (SQ) injections of 16 or 32 units of ACTH gel for six months. Outcome. The primary endpoint was the percentage of patients achieving a complete remission (<300 mg/24 hours) within 6 months. Exploratory endpoints included the percentage of partial (50% reduction) remissions, changes in Cr, and urinary cytokine markers. Results. After 6 months of ACTH gel therapy, 8 of 14 (57%) patients achieved a complete (n = 1) or partial (n = 7) remission. In the low-dose ACTH gel group (16 units), urinary protein fell from 6709 + 953 to 2224 + 489 mg/24 hrs (P < 0.001). In contrast, 2 of 6 patients in the 32-unit group achieved partial remission, but aggregate proteinuria (5324 + 751 to 5154 + 853 mg/24 hours) did not change. Urinary VEGF increased from 388 to 1346 pg/mg urinary creatinine (P < 0.02) in the low-dose group but remained unchanged in the high-dose group. Conclusion. ACTH gel stabilizes renal function and reduces urinary protein for up to 6 months after treatment. The ClinTrials.gov identifier is NCT01028287. PMID:24159603

  13. A comparison of calcium to zoledronic acid for improvement of cortical bone in an animal model of CKD

    PubMed Central

    Moe, Sharon M.; Chen, Neal X.; Newman, Christopher L.; Gattone, Vincent H.; Organ, Jason M.; Chen, Xianming; Allen, Matthew R.

    2013-01-01

    Patients with chronic kidney disease (CKD) have increased risk of fractures, yet the optimal treatment is unknown. In secondary analyses of large randomized trials, bisphosphonates have been shown to improve bone mineral density and reduce fractures. However, bisphosphonates are currently not recommended in patients with advanced kidney disease due to concern about over-suppressing bone remodeling, which may increase the risk of developing arterial calcification. In the present study we used a naturally occurring rat model of CKD with secondary hyperparathyroidism, the Cy/+ rat, and compared the efficacy of treatment with zoledronic acid, calcium given in water to simulate a phosphate binder, and the combination of calcium and zoledronic acid. Animals were treated beginning at 25 weeks of age (approximately 30% of normal renal function) and followed for ten weeks. The results demonstrate that both zoledronic acid and calcium improved bone volume by microCT and both equally suppressed mineral apposition rate, bone formation rate, and mineralizing surface of trabecular bone. In contrast, only calcium treatment with or without zoledronic acid improved cortical porosity and cortical biomechanical properties (ultimate load and stiffness) and lowered parathyroid hormone (PTH). However, only calcium treatment led to the adverse effects of increased arterial calcification and fibroblast growth factor 23 (FGF23). These results suggest zoledronic acid may improve trabecular bone volume in CKD in the presence of secondary hyperparathyroidism, but does not benefit extraskeletal calcification or cortical biomechanical properties. Calcium effectively reduces PTH and benefits both cortical and trabecular bone yet increases the degree of extra skeletal calcification. PMID:24038306

  14. Decreased MicroRNA Is Involved in the Vascular Remodeling Abnormalities in Chronic Kidney Disease (CKD)

    PubMed Central

    O'Neill, Kalisha D.; Chen, Xianming; Moorthi, Ranjani N.; Gattone, Vincent H.; Allen, Matthew R.; Moe, Sharon M.

    2013-01-01

    Patients with CKD have abnormal vascular remodeling that is a risk factor for cardiovascular disease. MicroRNAs (miRNAs) control mRNA expression intracellularly and are secreted into the circulation; three miRNAs (miR-125b, miR-145 and miR-155) are known to alter vascular smooth muscle cell (VSMC) proliferation and differentiation. We measured these vascular miRNAs in blood from 90 patients with CKD and found decreased circulating levels with progressive loss of eGFR by multivariate analyses. Expression of these vascular miRNAs miR-125b, miR-145, and miR-155 was decreased in the thoracic aorta in CKD rats compared to normal rats, with concordant changes in target genes of RUNX2, angiotensin II type I receptor (AT1R), and myocardin. Furthermore, the expression of miR-155 was negatively correlated with the quantity of calcification in the aorta, a process known to be preceded by vascular de-differentiation in these animals. We then examined the mechanisms of miRNA regulation in primary VSMC and found decreased expression of miR-125b, 145, and 155 in VSMC from rats with CKD compared to normal littermates but no alteration in DROSHA or DICER, indicating that the low levels of expression is not due to altered intracellular processing. Finally, overexpression of miR-155 in VSMC from CKD rats inhibited AT1R expression and decreased cellular proliferation supporting a direct effect of miR-155 on VSMC. In conclusion, we have found ex vivo and in vitro evidence for decreased expression of these vascular miRNA in CKD, suggesting that alterations in miRNAs may lead to the synthetic state of VSMC found in CKD. The decreased levels in the circulation may reflect decreased vascular release but more studies are needed to confirm this relationship. PMID:23717629

  15. Remote Usability Testing and Satisfaction with a Mobile Health Medication Inquiry System in CKD

    PubMed Central

    Ginsberg, Jennifer S.; Yoffe, Marni; Lucas, Lisa; Prakash, Divya; Aggarwal, Saurabh; Fink, Wanda; Becker, Stefan; Fink, Jeffrey C.

    2015-01-01

    Background and objectives Inappropriate medication use is common in the care of patients with CKD. The feasibility of a simple mobile health tool designed to advise patients on safe medication usage in CKD was examined. Design, setting, participants, & measurements Participants with predialysis CKD (defined as eGFR<60 ml/min per 1.73 m2) in the Safe Kidney Care Cohort Study were recruited for home usability testing of a novel medication inquiry system between January and September of 2013. Testing was through two mobile platforms: (1) short messaging service text or (2) personal digital assistant (e.g., iPod Touch). Twenty participants (one half assigned to one device and one half assigned to the other device) were enrolled and received an in-center tutorial on device usage before the end of the study visit. Participants were subsequently mailed three sample pill bottles with the name of randomly selected medications and asked to input these medications into the medication inquiry system. The medication inquiry system response options were as follows: (1) safe in CKD, (2) not safe in CKD, (3) use with caution/speak with your health care provider, or (4) error message (for an incorrectly inputted medication). Participants were asked to record the response issued by the medication inquiry system for each medication sent for usability testing. A user satisfaction survey was administered after completion of the protocol. Results All participants owned a mobile telephone, but few owned a smartphone. Of 60 total medication queries, there were only three recorded errors, two of which occurred in the short messaging service texting group. Overall satisfaction with the application was high, with slightly higher satisfaction noted in the personal digital assistant group compared with the short messaging service group. Conclusions The mobile health medication inquiry system application had general ease of use and high acceptance across two platforms among individuals

  16. Worldwide growing epidemic of CKD: fact or fiction?

    PubMed

    De Nicola, Luca; Minutolo, Roberto

    2016-09-01

    Chronic kidney disease (CKD) is recognized as a major noncommunicable disease of growing epidemic dimension worldwide. However, recent surveys have shown a marked heterogeneity of CKD prevalence in the general population, from ∼5% to 13% across countries. Methodological issues, genetic diversity, and dietary factors may all play a role. An important, currently emerging aspect of CKD epidemiology is the variability of CKD trends over time, with some countries showing a stable or even a decreased prevalence. PMID:27521111

  17. Kidney bone disease and mortality in CKD: revisiting the role of vitamin D, calcimimetics, alkaline phosphatase, and minerals.

    PubMed

    Kalantar-Zadeh, Kamyar; Shah, Anuja; Duong, Uyen; Hechter, Rulin C; Dukkipati, Ramanath; Kovesdy, Csaba P

    2010-08-01

    Recent evidence suggests that the traditional syndromes known as renal osteodystrophy, secondary hyperparathyroidism, and vitamin D deficiency are related to mortality in persons with moderate to advanced chronic kidney disease (CKD). The so-called 'kidney bone disease', also known as 'mineral and bone disorders', is defined to include bone disorders, mineral disarrays, and vascular calcification. We have identified 14 common and clinically relevant conditions of contemporary nature that are related to the kidney bone disease, including calcitriol (active vitamin D) deficiency, 25(OH)-vitamin D deficiency, biochemical hyperparathyroidism, relatively low parathyroid hormone (PTH) level, increased serum alkaline phosphatase (hyperphosphatasemia), elevated fibroblast growth factor (FGF)-23, high turnover bone disease, adynamic bone disease, uremic osteoporosis, vascular calcification, hyper- and hypophosphatemia, and hyper- and hypocalcemia. We present a critical review of these 14 conditions with emphasis on patient survival and other pertinent clinical outcomes. We also review unresolved controversies surrounding the management of these conditions by administration of nutritional vitamin D (ergocalciferol and cholecalciferol), vitamin D receptor activators (calcitriol, alphacalcidiol, doxercalciferol), D-mimetics (paricalcitol, maxacalcitol), calcimimetics (cinacalcet), recombinant PTH (teriparatide), and receptor activator of nuclear factor-kappaB ligand modulators (denosumab); compare mortality predictability of PTH and alkaline phosphatase; and examine potential risks of bone disorders and mineral disarrays in CKD patients. PMID:20671739

  18. CKD Prevalence Varies across the European General Population.

    PubMed

    Brück, Katharina; Stel, Vianda S; Gambaro, Giovanni; Hallan, Stein; Völzke, Henry; Ärnlöv, Johan; Kastarinen, Mika; Guessous, Idris; Vinhas, José; Stengel, Bénédicte; Brenner, Hermann; Chudek, Jerzy; Romundstad, Solfrid; Tomson, Charles; Gonzalez, Alfonso Otero; Bello, Aminu K; Ferrieres, Jean; Palmieri, Luigi; Browne, Gemma; Capuano, Vincenzo; Van Biesen, Wim; Zoccali, Carmine; Gansevoort, Ron; Navis, Gerjan; Rothenbacher, Dietrich; Ferraro, Pietro Manuel; Nitsch, Dorothea; Wanner, Christoph; Jager, Kitty J

    2016-07-01

    CKD prevalence estimation is central to CKD management and prevention planning at the population level. This study estimated CKD prevalence in the European adult general population and investigated international variation in CKD prevalence by age, sex, and presence of diabetes, hypertension, and obesity. We collected data from 19 general-population studies from 13 European countries. CKD stages 1-5 was defined as eGFR<60 ml/min per 1.73 m(2), as calculated by the CKD-Epidemiology Collaboration equation, or albuminuria >30 mg/g, and CKD stages 3-5 was defined as eGFR<60 ml/min per 1.73 m(2) CKD prevalence was age- and sex-standardized to the population of the 27 Member States of the European Union (EU27). We found considerable differences in both CKD stages 1-5 and CKD stages 3-5 prevalence across European study populations. The adjusted CKD stages 1-5 prevalence varied between 3.31% (95% confidence interval [95% CI], 3.30% to 3.33%) in Norway and 17.3% (95% CI, 16.5% to 18.1%) in northeast Germany. The adjusted CKD stages 3-5 prevalence varied between 1.0% (95% CI, 0.7% to 1.3%) in central Italy and 5.9% (95% CI, 5.2% to 6.6%) in northeast Germany. The variation in CKD prevalence stratified by diabetes, hypertension, and obesity status followed the same pattern as the overall prevalence. In conclusion, this large-scale attempt to carefully characterize CKD prevalence in Europe identified substantial variation in CKD prevalence that appears to be due to factors other than the prevalence of diabetes, hypertension, and obesity. PMID:26701975

  19. Strategies for preserving residual renal function in peritoneal dialysis patients

    PubMed Central

    Nongnuch, Arkom; Assanatham, Montira; Panorchan, Kwanpeemai; Davenport, Andrew

    2015-01-01

    Although there have been many advancements in the treatment of patients with chronic kidney disease (CKD) over the last 50 years, in terms of reducing cardiovascular risk, mortality remains unacceptably high, particularly for those patients who progress to stage 5 CKD and initiate dialysis (CKD5d). As mortality risk increases exponentially with progressive CKD stage, the question arises as to whether preservation of residual renal function once dialysis has been initiated can reduce mortality risk. Observational studies to date have reported an association between even small amounts of residual renal function and improved patient survival and quality of life. Dialysis therapies predominantly provide clearance for small water-soluble solutes, volume and acid-base control, but cannot reproduce the metabolic functions of the kidney. As such, protein-bound solutes, advanced glycosylation end-products, middle molecules and other azotaemic toxins accumulate over time in the anuric CKD5d patient. Apart from avoiding potential nephrotoxic insults, observational and interventional trials have suggested that a number of interventions and treatments may potentially reduce the progression of earlier stages of CKD, including targeted blood pressure control, reducing proteinuria and dietary intervention using combinations of protein restriction with keto acid supplementation. However, many interventions which have been proven to be effective in the general population have not been equally effective in the CKD5d patient, and so the question arises as to whether these treatment options are equally applicable to CKD5d patients. As strategies to help preserve residual renal function in CKD5d patients are not well established, we have reviewed the evidence for preserving or losing residual renal function in peritoneal dialysis patients, as urine collections are routinely collected, whereas few centres regularly collect urine from haemodialysis patients, and haemodialysis dialysis

  20. Serum Anion Gap Predicts All-Cause Mortality in Patients with Advanced Chronic Kidney Disease: A Retrospective Analysis of a Randomized Controlled Study

    PubMed Central

    Lee, Sung Woo; Kim, Sejoong; Na, Ki Young; Cha, Ran-hui; Kang, Shin Wook; Park, Cheol Whee; Cha, Dae Ryong; Kim, Sung Gyun; Yoon, Sun Ae; Han, Sang Youb; Park, Jung Hwan; Chang, Jae Hyun; Lim, Chun Soo; Kim, Yon Su

    2016-01-01

    Background and Objectives Cardiovascular outcomes and mortality rates are poor in advanced chronic kidney disease (CKD) patients. Novel risk factors related to clinical outcomes should be identified. Methods A retrospective analysis of data from a randomized controlled study was performed in 440 CKD patients aged > 18 years, with estimated glomerular filtration rate 15–60 mL/min/1.73m2. Clinical data were available, and the albumin-adjusted serum anion gap (A-SAG) could be calculated. The outcome analyzed was all-cause mortality. Results Of 440 participants, the median (interquartile range, IQR) follow-up duration was 5.1 (3.0–5.5) years. During the follow-up duration, 29 participants died (all-cause mortality 6.6%). The area under the receiver operating characteristic curve of A-SAG for all-cause mortality was 0.616 (95% CI 0.520–0.712, P = 0.037). The best threshold of A-SAG for all-cause mortality was 9.48 mmol/L, with sensitivity 0.793 and specificity 0.431. After adjusting for confounders, A-SAG above 9.48 mmol/L was independently associated with increased risk of all-cause mortality, with hazard ratio 2.968 (95% CI 1.143–7.708, P = 0.025). In our study, serum levels of beta-2 microglobulin and blood urea nitrogen (BUN) were positively associated with A-SAG. Conclusions A-SAG is an independent risk factor for all-cause mortality in advanced CKD patients. The positive correlation between A-SAG and serum beta-2 microglobulin or BUN might be a potential reason. Future study is needed. Trial Registration Clinicaltrials.gov NCT 00860431 PMID:27249416

  1. FGF23 signaling impairs neutrophil recruitment and host defense during CKD

    PubMed Central

    Rossaint, Jan; Oehmichen, Jessica; Van Aken, Hugo; Reuter, Stefan; Pavenstädt, Hermann J.; Meersch, Melanie; Unruh, Mark

    2016-01-01

    Chronic kidney disease (CKD) has been associated with impaired host response and increased susceptibility to infections. Leukocyte recruitment during inflammation must be tightly regulated to protect the host against pathogens. FGF23 levels are increased in blood during CKD, and levels of this hormone have been associated with a variety of adverse effects in CKD patients. Here, we have shown that CKD impairs leukocyte recruitment into inflamed tissue and host defense in mice and humans. FGF23 neutralization during CKD in murine models restored leukocyte recruitment and host defense. Intravital microscopy of animals with chronic kidney failure showed that FGF23 inhibits chemokine-activated leukocyte arrest on the endothelium, and downregulation of FGF receptor 2 (FGFR2) on PMNs rescued host defense in these mice. In vitro, FGF23 inhibited PMN adhesion, arrest under flow, and transendothelial migration. Mechanistically, FGF23 binding to FGFR2 counteracted selectin- and chemokine-triggered β2 integrin activation on PMNs by activating protein kinase A (PKA) and inhibiting activation of the small GTPase Rap1. Moreover, knockdown of PKA abolished the inhibitory effect of FGF23 on integrin activation. Together, our data reveal that FGF23 acts directly on PMNs and dampens host defense by direct interference with chemokine signaling and integrin activation. PMID:26878171

  2. Cardiovascular risk assessment: addition of CKD and race to the Framingham equation

    PubMed Central

    Drawz, Paul E.; Baraniuk, Sarah; Davis, Barry R.; Brown, Clinton D.; Colon, Pedro J.; Cujyet, Aloysius B.; Dart, Richard A.; Graumlich, James F.; Henriquez, Mario A.; Moloo, Jamaluddin; Sakalayen, Mohammed G.; Simmons, Debra L.; Stanford, Carol; Sweeney, Mary Ellen; Wong, Nathan D.; Rahman, Mahboob

    2012-01-01

    Background/Aims The value of the Framingham equation in predicting cardiovascular risk in African Americans and patients with chronic kidney disease (CKD) is unclear. The purpose of the study was to evaluate whether the addition of CKD and race to the Framingham equation improves risk stratification in hypertensive patients. Methods Participants in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) were studied. Those randomized to doxazosin, age greater than 74 years, and those with a history of coronary heart disease (CHD) were excluded. Two risk stratification models were developed using Cox proportional hazards models in a two-thirds developmental sample. The first model included the traditional Framingham risk factors. The second model included the traditional risk factors plus CKD, defined by eGFR categories, and stratification by race (Black vs. Non-Black). The primary outcome was a composite of fatal CHD, nonfatal MI, coronary revascularization, and hospitalized angina. Results There were a total of 19,811 eligible subjects. In the validation cohort, there was no difference in C-statistics between the Framingham equation and the ALLHAT model including CKD and race. This was consistent across subgroups by race and gender and among those with CKD. One exception was among Non-Black women where the C-statistic was higher for the Framingham equation (0.68 vs 0.65, P=0.02). Additionally, net reclassification improvement was not significant for any subgroup based on race and gender, ranging from −5.5% to 4.4%. Conclusion The addition of CKD status and stratification by race does not improve risk prediction in high-risk hypertensive patients. PMID:23194494

  3. Growth hormone therapy in children with CKD after more than two decades of practice.

    PubMed

    Rees, Lesley

    2016-09-01

    This review focuses on the evidence for the efficacy and safety of recombinant human growth hormone (rhGH) therapy in children with all stages of chronic kidney disease (CKD) and at all ages. It describes the improving height prognosis for our patients both with and without rhGH; explains the underlying hormonal abnormalities that provide the rationale for rhGH use in CKD and the endocrine changes that accompany treatment; and views on who warrants treatment, with what dose, and how long for. PMID:26369925

  4. Drug Seems to Extend Survival for Advanced Melanoma Patients

    MedlinePlus

    ... html Drug Seems to Extend Survival for Advanced Melanoma Patients One-third of study participants lived 5 ... HealthDay News) -- More than one-third of advanced melanoma patients were still alive five years after starting ...

  5. Impaired Myocardial Oxygenation Response to Stress in Patients With Chronic Kidney Disease

    PubMed Central

    Parnham, Susie; Gleadle, Jonathan M; Bangalore, Sripal; Grover, Suchi; Perry, Rebecca; Woodman, Richard J; De Pasquale, Carmine G; Selvanayagam, Joseph B

    2015-01-01

    Background Coronary artery disease and left ventricular hypertrophy are prevalent in the chronic kidney disease (CKD) and renal transplant (RT) population. Advances in cardiovascular magnetic resonance (CMR) with blood oxygen level–dependent (BOLD) technique provides capability to assess myocardial oxygenation as a measure of ischemia. We hypothesized that the myocardial oxygenation response to stress would be impaired in CKD and RT patients. Methods and Results Fifty-three subjects (23 subjects with CKD, 10 RT recipients, 10 hypertensive (HT) controls, and 10 normal controls without known coronary artery disease) underwent CMR scanning. All groups had cine and BOLD CMR at 3 T. The RT and HT groups also had late gadolinium CMR to assess infarction/replacement fibrosis. The CKD group underwent 2-dimensional echocardiography strain to assess fibrosis. Myocardial oxygenation was measured at rest and under stress with adenosine (140 μg/kg per minute) using BOLD signal intensity. A total of 2898 myocardial segments (1200 segments in CKD patients, 552 segments in RT, 480 segments in HT, and 666 segments in normal controls) were compared using linear mixed modeling. Diabetes mellitus (P=0.47) and hypertension (P=0.57) were similar between CKD, RT, and HT groups. The mean BOLD signal intensity change was significantly lower in the CKD and RT groups compared to HT controls and normal controls (−0.89±10.63% in CKD versus 5.66±7.87% in RT versus 15.54±9.58% in HT controls versus 16.19±11.11% in normal controls, P<0.0001). BOLD signal intensity change was associated with estimated glomerular filtration rate (β=0.16, 95% CI=0.10 to 0.22, P<0.0001). Left ventricular mass index and left ventricular septal wall diameter were similar between the CKD predialysis, RT, and HT groups. None of the CKD patients had impaired global longitudinal strain and none of the RT group had late gadolinium hyperenhancement. Conclusions Myocardial oxygenation response to stress is

  6. The AGE-RAGE pathway and its relation to cardiovascular disease in patients with chronic kidney disease.

    PubMed

    Leurs, Paul; Lindholm, Bengt

    2013-11-01

    Chronic kidney disease (CKD) carries an unequivocal high risk for cardiovascular disease (CVD) contributing to high morbimortality; however, the underlying reasons are not fully known. Among mechanisms involved in the pathophysiology of CVD, chronic overstimulation of the advanced glycation end-products (AGE)-receptor for AGE (RAGE) pathway is likely a major contributor in patients with CKD. This review describes briefly some of the components of this pathway, highlighting especially differences between circulating AGE and tissue AGE and how activation of the AGE-RAGE pathway may promote CVD in CKD. PMID:24231387

  7. Sialadenosis in Patients with Advanced Liver Disease

    PubMed Central

    Close, John M.; Eghtesad, Bijan

    2009-01-01

    Sialadenosis (sialosis) has been associated most often with alcoholic liver disease and alcoholic cirrhosis, but a number of nutritional deficiencies, diabetes, and bulimia have also been reported to result in sialadenosis. The aim of this study was to determine the prevalence of sialadenosis in patients with advanced liver disease. Patients in the study group consisted of 300 candidates for liver transplantation. Types of liver disease in subjects with clinical evidence of sialadenosis were compared with diagnoses in cases who had no manifestations of sialadenosis. The data were analyzed for significant association. Sialadenosis was found in 28 of the 300 subjects (9.3%). Among these 28 cases, 11 (39.3%) had alcoholic cirrhosis. The remaining 17 (60.7%) had eight other types of liver disease. There was no significant association between sialadenosis and alcoholic cirrhosis (P = 0.389). These findings suggest that both alcoholic and non-alcoholic cirrhosis may lead to the development of sialadenosis. Advanced liver disease is accompanied by multiple nutritional deficiencies which may be exacerbated by alcohol. Similar metabolic abnormalities may occur in patients with diabetes or bulimia. Malnutrition has been associated with autonomic neuropathy, the pathogenic mechanism that has been proposed for sialadenosis. PMID:19644542

  8. Comparison of multipotency and molecular profile of MSCs between CKD and healthy rats.

    PubMed

    Yamada, Akifumi; Yokoo, Takashi; Yokote, Shinya; Yamanaka, Shuichiro; Izuhara, Luna; Katsuoka, Yuichi; Shimada, Yohta; Shukuya, Akinori; Okano, Hirotaka James; Ohashi, Toya; Ida, Hiroyuki

    2014-04-01

    We previously showed that mesenchymal stem cells (MSCs) can differentiate into a functional miniature kidney, suggesting that MSCs may be a cell source for kidney regeneration. However, MSCs from long-term dialysis patients, which have been exposed to uremic toxin, can exhibit reduced viability. Therefore, the aim of this study was to examine the gene expression profiles and differentiation capabilities of bone marrow- and adipose-derived MSCs from chronic kidney disease (CKD) model rats. CKD was induced in rats by adenine feeding, and then MSCs were isolated from bone marrow (BMSCs) and adipose tissue (ASCs). After confirming MSC surface marker expression, comprehensive gene expression profiles were obtained by RT-PCR array. MSCs were differentiated into adipocytes, osteoblasts, and chondrocytes, and histological and/or functional assays were performed. Tgfb3 expression was up-regulated, while Bmp6, Gdf15, Mmp2, and Vegfa were down-regulated in CKD-ASCs compared with Control-ASCs. There were no significant differences in the gene expression of stemness markers, and the morphology of cells that underwent adipogenesis, osteogenesis, and chondrogenesis, or GPDH activity between CKD and control groups. Comparing BMSCs with ASCs, gene expression of Bglap, Bmp4, Igf1, Itgax, Pparg, Ptprc, and Tnf were up-regulated, while Col1a1, Mmp2, Sox9, and Vegfa were down-regulated in both CKD and control groups. Uremic toxin in CKD rats had a small effect on the gene expression and differentiation of MSCs. However, long-term exposure to uremic toxin and the differences in gene expression of MSCs derived from bone marrow or adipose tissue may affect renal regeneration. PMID:24496821

  9. Cysteamine Modulates Oxidative Stress and Blocks Myofibroblast Activity in CKD

    PubMed Central

    Bahrami, Nadia M.; Ren, Shuyu; Pasichnyk, Katie; Williams, Juliana M.; Gangoiti, Jon A.; Lopez-Guisa, Jesus M.; Yamaguchi, Ikuyo; Barshop, Bruce A.; Duffield, Jeremy S.; Eddy, Allison A.

    2014-01-01

    Therapy to slow the relentless expansion of interstitial extracellular matrix that leads to renal functional decline in patients with CKD is currently lacking. Because chronic kidney injury increases tissue oxidative stress, we evaluated the antifibrotic efficacy of cysteamine bitartrate, an antioxidant therapy for patients with nephropathic cystinosis, in a mouse model of unilateral ureteral obstruction. Fresh cysteamine (600 mg/kg) was added to drinking water daily beginning on the day of surgery, and outcomes were assessed on days 7, 14, and 21 after surgery. Plasma cysteamine levels showed diurnal variation, with peak levels similar to those observed in patients with cystinosis. In cysteamine-treated mice, fibrosis severity decreased significantly at 14 and 21 days after unilateral ureteral obstruction, and renal oxidized protein levels decreased at each time point, suggesting reduced oxidative stress. Consistent with these results, treatment of cultured macrophages with cysteamine reduced cellular generation of reactive oxygen species. Furthermore, treatment with cysteamine reduced α-smooth muscle actin–positive interstitial myofibroblast proliferation and mRNA levels of extracellular matrix proteins in mice and attenuated myofibroblast differentiation and proliferation in vitro, but did not augment TGF-β signaling. In a study of renal ischemia reperfusion, cysteamine therapy initiated 10 days after injury and continued for 14 days decreased renal fibrosis by 40%. Taken together, these data suggest previously unrecognized antifibrotic actions of cysteamine via TGF-β–independent mechanisms that include oxidative stress reduction and attenuation of the myofibroblast response to kidney injury and support further investigation into the potential benefit of cysteamine therapy in the treatment of CKD. PMID:24009239

  10. Baseline Characteristics and Prescription Patterns of Standard Drugs in Patients with Angiographically Determined Coronary Artery Disease and Renal Failure (CAD-REF Registry)

    PubMed Central

    Reinecke, Holger; Breithardt, Günter; Engelbertz, Christiane; Schmieder, Roland E.; Fobker, Manfred; Pinnschmidt, Hans O.; Schmitz, Boris; Bruland, Philipp; Wegscheider, Karl; Pavenstädt, Hermann; Brand, Eva

    2016-01-01

    Background Chronic kidney disease (CKD) is strongly associated with coronary artery disease (CAD). We established a prospective observational nationwide multicenter registry to evaluate current treatment and outcomes in patients with both CKD and angiographically documented CAD. Methods In 32 cardiological centers 3,352 CAD patients with ≥50% stenosis in at least one coronary artery were enrolled and classified according to their estimated glomerular filtration rate and proteinuria into one of five stages of CKD or as a control group. Results 2,723 (81.2%) consecutively enrolled patients suffered from CKD. Compared to controls, CKD patients had a higher prevalence of diabetes, hypertension, peripheral artery diseases, heart failure, and valvular heart disease (each p<0.001). Myocardial infarctions (p = 0.02), coronary bypass grafting, valve replacements and pacemaker implantations had been recorded more frequently (each p<0.001). With advanced CKD, the number of diseased coronary vessels and the proportion of patients with reduced left ventricular ejection fraction (LVEF) increased significantly (both p<0.001). Percutaneous coronary interventions were performed less frequently (p<0.001) while coronary bypass grafting was recommended more often (p = 0.04) with advanced CKD. With regard to standard drugs in CAD treatment, prescriptions were higher in our registry than in previous reports, but beta-blockers (p = 0.008), and angiotensin-converting-enzyme inhibitors and/or angiotensin-receptor blockers (p<0.001) were given less often in higher CKD stages. In contrast, in the subgroup of patients with moderately to severely reduced LVEF the prescription rates did not differ between CKD stages. In-hospital mortality increased stepwise with each CKD stage (p = 0.02). Conclusions In line with other studies comprising CKD cohorts, patients’ morbidity and in-hospital mortality increased with the degree of renal impairment. Although cardiologists’ drug prescription rates

  11. Light-Intensity Physical Activities and Mortality in the United States General Population and CKD Subpopulation

    PubMed Central

    Wei, Guo; Marcus, Robin L.; Chonchol, Michel; Greene, Tom

    2015-01-01

    Background and objectives Sedentary behavior is associated with increased mortality in the general population. Whether replacing sedentary behavior with low- or light-intensity activities confers a survival benefit in the general or CKD populations is unknown. Design, setting, participants, & measurements This observational analysis of the 2003–2004 National Health and Nutrition Examination Survey examined the associations of low- and light-intensity activities with mortality. On the basis of the number of counts/min recorded by an accelerometer, durations of sedentary (<100/min), low (100–499/min), light (500–2019/min), and moderate/vigorous (≥2020/min) activity were defined and normalized to 60 minutes. The mortality associations of 2 min/hr less sedentary duration in conjunction with 2 min/hr more (tradeoff) spent in one of the low, light, or moderate/vigorous activity durations while controlling for the other two activity durations were examined in multivariable Cox regression models in the entire cohort and in the CKD subgroup. Results Of the 3626 participants included, 383 had CKD. The mean sedentary duration was 34.4±7.9 min/hr in the entire cohort and 40.8±6.8 in the CKD subgroup. Tradeoff of sedentary duration with low activity duration was not associated with mortality in the entire cohort or the CKD subgroup. Tradeoff of sedentary duration with light activity duration was associated with a lower hazard of death in the entire cohort (hazard ratio, 0.67; 95% confidence interval, 0.48 to 0.93) and CKD subgroup (hazard ratio, 0.59; 95% confidence interval, 0.35 to 0.98). Tradeoff of sedentary duration with moderate/vigorous activity duration had a nonsignificant lower hazard in the entire cohort and CKD subgroup. Conclusions Patients with CKD are sedentary nearly two thirds of the time. Interventions that replace sedentary duration with an increase in light activity duration might confer a survival benefit. PMID:25931456

  12. Recent Advances in Traditional Chinese Medicine for Kidney Disease.

    PubMed

    Zhong, Yifei; Menon, Madhav C; Deng, Yueyi; Chen, Yiping; He, John Cijiang

    2015-09-01

    Because current treatment options for chronic kidney disease (CKD) are limited, many patients seek out alternative therapies such as traditional Chinese medicine. However, there is a lack of evidence from large clinical trials to support the use of traditional medicines in patients with CKD. Many active components of traditional medicine formulas are undetermined and their toxicities are unknown. Therefore, there is a need for research to identify active compounds from traditional medicines and understand the mechanisms of action of these compounds, as well as their potential toxicity, and subsequently perform well-designed, randomized, controlled, clinical trials to study the efficacy and safety of their use in patients with CKD. Significant progress has been made in this field within the last several years. Many active compounds have been identified by applying sophisticated techniques such as mass spectrometry, and more mechanistic studies of these compounds have been performed using both in vitro and in vivo models. In addition, several well-designed, large, randomized, clinical trials have recently been published. We summarize these recent advances in the field of traditional medicines as they apply to CKD. In addition, current barriers for further research are also discussed. Due to the ongoing research in this field, we believe that stronger evidence to support the use of traditional medicines for CKD will emerge in the near future. PMID:26015275

  13. Dietary intake of advanced cancer patients.

    PubMed

    Walsh, T D; Bowman, K B; Jackson, G P

    1983-02-01

    A state registered dietitian assessed the voluntary dietary intake of 13 advanced cancer inpatients on one ward of St. Christopher's Hospice for five consecutive days. There were 11 females, two males; median age 74 years (range 56 to 83). Two patients died on the fourth day of the study. A partially individualised weighed technique was used. Standard sized scoops and spoons were used to serve the food in small, medium or large standard portions (depending on appetite) and were weighed as served. Individual plate waste (by weight) was subtracted to give estimated individual intake. Foods provided by visitors was not included. The median and range of individual mean daily intakes (estimated) were: energy 5760 (938-8945) kJ, 1376 (224-2137) kcal; protein 44 (11-86) g; fat 52 (9-93) g; carbohydrate 169 (21-194) g; calcium 748 (268-1457) mg; iron 4.8 (0.5-21.0) mg; dietary fibre 5.0 (0.5-21.0) g. Compared to recommended amounts, energy, iron and dietary fibre intakes were low; calcium intake was high. Nutritional status may affect prognosis and/or subjective well-being in advanced cancer. The value of nutritional supplementation and the role of appetite stimulants in improving nutritional status needs investigation. PMID:6841131

  14. Diabetes mellitus increases the prevalence of anemia in patients with chronic kidney disease: A nested case-control study

    PubMed Central

    Loutradis, Charalampos; Skodra, Alexandra; Georgianos, Panagiotis; Tolika, Panagiota; Alexandrou, Dimitris; Avdelidou, Afroditi; Sarafidis, Pantelis A

    2016-01-01

    AIM: To compare anemia prevalence between matched chronic kidney disease (CKD) patients with and without diabetes mellitus (DM) and to assess factors associated with anemia development. METHODS: This is a nested case-control study of 184 type-2 diabetic and 184 non-diabetic CKD patients from a prospectively assembled database of a Nephrology outpatient clinic, matched for gender, age and estimated glomerular filtration rate (eGFR). Prevalence of anemia (hemoglobin: Men: < 13 g/dL, women: < 12 g/dL and/or use of recombinant erythropoietin) was examined in comparison, in the total population and by CKD Stage. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with anemia. RESULTS: The total prevalence of anemia was higher in diabetics (47.8% vs 33.2%, P = 0.004). Accordingly, prevalence was higher in diabetics in CKD Stage 3 (53.5% vs 33.1%, P < 0.001) and particularly in Stage 3a (60.4% vs 26.4%, P < 0.001), whereas it was non-significantly higher in Stage 4 (61.3% vs 48.4%; P = 0.307). Serum ferritin was higher in diabetics in total and in CKD stages, while serum iron was similar between groups. In multivariate analyses, DM (OR = 2.206, 95%CI: 1.196-4.069), CKD Stages 3a, 3b, 4 (Stage 4: OR = 12.169, 95%CI: 3.783-39.147) and serum iron (OR = 0.976, 95%CI: 0.968-0.985 per mg/dL increase) were independently associated with anemia. CONCLUSION: Prevalence of anemia progressively increases with advancing stages of CKD and is higher in diabetic than matched non-diabetic CKD patients and diabetes is independently associated with anemia occurrence. Detection and treatment of anemia in diabetic CKD patients should be performed earlier than non-diabetic counterparts. PMID:27458564

  15. Lower Superoxide Dismutase 2 (SOD2) Protein Content in Mononuclear Cells Is Associated with Better Survival in Patients with Hemodialysis Therapy

    PubMed Central

    Shen, Jianlin

    2016-01-01

    Mitochondrial superoxide dismutase 2 (SOD2) converts superoxide anions to hydrogen peroxide and oxygen. Human data on SOD2 protein content in chronic kidney disease (CKD) are sparse and mortality data are lacking. We investigated SOD2 protein content in monocytes from patients with hemodialysis therapy (n = 81), CKD stage 1–5 (n = 120), and healthy controls (n = 13) using in-cell Western assays. SOD2 protein decreased from CKD stage 1 until stage 4 whereas it increased again in stage 5 with and without hemodialysis. SOD2 gene expression, analyzed by quantitative real-time PCR, was not significantly different between the groups. Elevating cellular superoxide production reduced SOD2 protein content. This effect was abolished by the superoxide dismutase mimetic Tempol. Using gelelectrophoresis and Western blot we did not detect nitrotyrosine modifications of SOD2 in CKD. Finally, in patients with CKD stage 5 with hemodialysis therapy higher than median SOD2 protein content was associated with higher all-cause mortality. In conclusion, SOD2 protein content declined in CKD until stage 4 while SOD2 gene expression did not. Increased cellular superoxide anion production might affect SOD2 protein content. In advanced CKD (stage 5) SOD2 protein content increased again, but higher than median SOD2 protein content in these patients did not confer a survival benefit.

  16. Dietary Fructose Inhibits Intestinal Calcium Absorption and Induces Vitamin D Insufficiency in CKD

    PubMed Central

    Douard, Veronique; Asgerally, Abbas; Sabbagh, Yves; Sugiura, Shozo; Shapses, Sue A.; Casirola, Donatella

    2010-01-01

    Renal disease leads to perturbations in calcium and phosphate homeostasis and vitamin D metabolism. Dietary fructose aggravates chronic kidney disease (CKD), but whether it also worsens CKD-induced derangements in calcium and phosphate homeostasis is unknown. Here, we fed rats diets containing 60% glucose or fructose for 1 mo beginning 6 wk after 5/6 nephrectomy or sham operation. Nephrectomized rats had markedly greater kidney weight, blood urea nitrogen, and serum levels of creatinine, phosphate, and calcium-phosphate product; dietary fructose significantly exacerbated all of these outcomes. Expression and activity of intestinal phosphate transporter, which did not change after nephrectomy or dietary fructose, did not correlate with hyperphosphatemia in 5/6-nephrectomized rats. Intestinal transport of calcium, however, decreased with dietary fructose, probably because of fructose-mediated downregulation of calbindin 9k. Serum calcium levels, however, were unaffected by nephrectomy and diet. Finally, only 5/6-nephrectomized rats that received dietary fructose demonstrated marked reductions in 25-hydroxyvitamin D3 and 1,25-dihydroxyvitamin D3 levels, despite upregulation of 1α-hydroxylase. In summary, excess dietary fructose inhibits intestinal calcium absorption, induces marked vitamin D insufficiency in CKD, and exacerbates other classical symptoms of the disease. Future studies should evaluate the relevance of monitoring fructose consumption in patients with CKD. PMID:19959720

  17. Associations between Kidney Function and Subclinical Cardiac Abnormalities in CKD

    PubMed Central

    Hsu, Chi-yuan; Li, Yongmei; Mishra, Rakesh K.; Keane, Martin; Rosas, Sylvia E.; Dries, Daniel; Xie, Dawei; Chen, Jing; He, Jiang; Anderson, Amanda; Go, Alan S.; Shlipak, Michael G.

    2012-01-01

    Heart failure is a common consequence of CKD, and it portends high risk for mortality. However, among patients without known heart failure, the associations of different stages of estimated GFR (eGFR) with changes in cardiac structure and function are not well described. Here, we performed a cross-sectional analysis to study these associations among 3487 participants of the Chronic Renal Insufficiency Cohort Study. We estimated GFR using cystatin C. The prevalence of left ventricular hypertrophy (LVH) assessed by echocardiography was 32%, 48%, 57%, and 75% for eGFR categories ≥60, 45–59, 30–44, and <30 ml/min per 1.73 m2, respectively. In fully adjusted multivariable analyses, subjects with eGFR levels of <30 ml/min per 1.73 m2 had twofold higher odds of LVH (OR=2.20, 95% CI=1.40–3.40; P<0.001) relative to subjects with eGFR≥60 ml/min per 1.73 m2. This reduction in kidney function also significantly associated with abnormal LV geometry but not diastolic or systolic dysfunction. An eGFR of 30–44 ml/min per 1.73 m2 also significantly associated with LVH and abnormal LV geometry compared with eGFR≥60 ml/min per 1.73 m2. In summary, in this large CKD cohort, reduced kidney function associated with abnormal cardiac structure. We did not detect significant associations between kidney function and systolic or diastolic function after adjusting for potential confounding variables. PMID:22935481

  18. Quality of life and outcomes in African Americans with CKD.

    PubMed

    Porter, Anna; Fischer, Michael J; Wang, Xuelei; Brooks, Deborah; Bruce, Marino; Charleston, Jeanne; Cleveland, William H; Dowie, Donna; Faulkner, Marquetta; Gassman, Jennifer; Hiremath, Leena; Kendrick, Cindy; Kusek, John W; Norris, Keith C; Thornley-Brown, Denyse; Greene, Tom; Lash, James P

    2014-08-01

    Low health-related quality of life (HRQOL) has been associated with increased risk for hospitalization and death in ESRD. However, the relationship of HRQOL with outcomes in predialysis CKD is not well understood. We evaluated the association between HRQOL and renal and cardiovascular (CV) outcomes in 1091 African Americans with hypertensive CKD enrolled in the African American Study of Kidney Disease and Hypertension (AASK) trial and cohort studies. Outcomes included CKD progression (doubling of serum creatinine/ESRD), CV events/CV death, and a composite of CKD progression or death from any cause (CKD progression/death). We assessed HRQOL, including mental health composite (MHC) and physical health composite (PHC), using the Short Form-36 survey. Cox regression analyses were used to assess the relationship between outcomes and five-point decrements in MHC and PHC scores using measurements at baseline, at the most recent annual visit (time-varying), or averaged from baseline to the most recent visit (cumulative). During approximately 10 years of follow-up, lower mean PHC score was associated with increased risk of CV events/CV death and CKD progression/death across all analytic approaches, but only time-varying and cumulative decrements were associated with CKD progression. Similarly, lower mean MHC score was associated with increased risk of CV events/CV death regardless of analytic approach, while only time-varying and cumulative decrements in mean MHC score was associated with CKD progression and CKD progression or death. In conclusion, lower HRQOL is associated with a range of adverse outcomes in African Americans with hypertensive CKD. PMID:24700865

  19. Prevalence, awareness, and treatment of anemia in Chinese patients with nondialysis chronic kidney disease

    PubMed Central

    Li, Ya; Shi, Hao; Wang, Wei-Ming; Peng, Ai; Jiang, Geng-Ru; Zhang, Jin-Yuan; Ni, Zhao-Hui; He, Li-Qun; Niu, Jian-Ying; Wang, Nian-Song; Mei, Chang-Lin; Xu, Xu-Dong; Guo, Zhi-Yong; Yuan, Wei-Jie; Yan, Hai-Dong; Deng, Yue-Yi; Yu, Chen; Cen, Jun; Zhang, Yun; Chen, Nan

    2016-01-01

    Abstract This was the first multicenter, cross-sectional survey to assess the prevalence of anemia, patient awareness, and treatment status in China. Data of patients with chronic kidney disease (CKD; age, 18–75 years; both out- and inpatients) from 25 hospitals in Shanghai, seeking medical treatment at the nephrology department, were collected between July 1, 2012 and August 31, 2012. The prevalence, awareness, and treatment of anemia in patients with nondialysis CKD (ND-CKD) were assessed. Anemia was defined as serum hemoglobin (Hb) levels ≤12 g/dL in women and ≤13 g/dL in men. A total of 2420 patients with ND-CKD were included. Anemia was established in 1246 (51.5%) patients: 639 (51.3%) men and 607 (48.7%) women. The prevalence of anemia increased with advancing CKD stage (χ2trend = 675.14, P < 0.001). Anemia was more prevalent in patients with diabetic nephropathy (68.0%) than in patients with hypertensive renal damage (56.6%) or chronic glomerulonephritis (46.1%, both P < 0.001). Only 39.8% of the anemic patients received treatment with erythropoietin and 27.1% patients received iron products; furthermore, 22.7% of the patients started receiving treatment when their Hb level reached 7 g/dL. The target-achieving rate (Hb at 11–12 g/dL) was only 8.2%. Of the 1246 anemia patients, only 7.5% received more effective and recommended intravenous supplementation. Anemia is highly prevalent in patients with ND-CKD in China, with a low target-achieving rate and poor treatment patterns. The study highlights the need to improve multiple aspects of CKD management to delay the progression of renal failure. PMID:27310973

  20. Bevacizumab improves survival for patients with advanced cervical cancer

    Cancer.gov

    Patients with advanced, recurrent, or persistent cervical cancer that was not curable with standard treatment who received the drug bevacizumab (Avastin) lived 3.7 months longer than patients who did not receive the drug, according to an interim analysis

  1. Improving patient-centered care through advance care planning.

    PubMed

    Motley, Molly

    2013-06-01

    Advance care planning is crucial for patients confronting incurable, debilitating, or terminal disease. Discussing end-of-life issues can reduce overtreatment and undertreatment as defined by the patient, and improve satisfaction with care. PMID:23805592

  2. Autosomal dominant mutation in the signal peptide of renin in a kindred with anemia, hyperuricemia, and CKD.

    PubMed

    Beck, Bodo B; Trachtman, Howard; Gitman, Michael; Miller, Ilene; Sayer, John A; Pannes, Andrea; Baasner, Anne; Hildebrandt, Friedhelm; Wolf, Matthias T F

    2011-11-01

    Homozygous or compound heterozygous mutations in renin (REN) cause renal tubular dysgenesis, which is characterized by death in utero due to kidney failure and pulmonary hypoplasia. The phenotype resembles the fetopathy caused by angiotensin-converting enzyme inhibitor or angiotensin receptor blocker intake during pregnancy. Recently, heterozygous REN mutations were shown to result in early-onset hyperuricemia, anemia, and chronic kidney disease (CKD). To date, only 3 different heterozygous REN mutations have been published. We report mutation analysis of the REN gene in 39 kindreds with hyperuricemia and CKD who previously tested negative for mutations in the UMOD (uromodulin) and HNF1B (hepatocyte nuclear factor 1β) genes. We identified one kindred with a novel thymidine to cytosine mutation at position 28 in the REN complementary DNA, corresponding to a tryptophan to arginine substitution at amino acid 10, which is found within the signal sequence (c.28T>C; p.W10R). On this basis, we conclude that REN mutations are rare events in patients with CKD. Within the kindred, we found affected individuals over 4 generations who carried the novel REN mutation and were characterized by significant anemia, hyperuricemia, and CKD. Anemia was severe and disproportional to the degree of decreased kidney function. Because all heterozygous REN mutations that have been described are localized in the signal sequence, screening of the REN gene for patients with CKD with hyperuricemia and anemia may best be focused on sequencing of exon 1, which encodes the signal peptide. PMID:21903317

  3. Prevalence, awareness, and treatment of anemia in Chinese patients with nondialysis chronic kidney disease: First multicenter, cross-sectional study.

    PubMed

    Li, Ya; Shi, Hao; Wang, Wei-Ming; Peng, Ai; Jiang, Geng-Ru; Zhang, Jin-Yuan; Ni, Zhao-Hui; He, Li-Qun; Niu, Jian-Ying; Wang, Nian-Song; Mei, Chang-Lin; Xu, Xu-Dong; Guo, Zhi-Yong; Yuan, Wei-Jie; Yan, Hai-Dong; Deng, Yue-Yi; Yu, Chen; Cen, Jun; Zhang, Yun; Chen, Nan

    2016-06-01

    This was the first multicenter, cross-sectional survey to assess the prevalence of anemia, patient awareness, and treatment status in China. Data of patients with chronic kidney disease (CKD; age, 18-75 years; both out- and inpatients) from 25 hospitals in Shanghai, seeking medical treatment at the nephrology department, were collected between July 1, 2012 and August 31, 2012. The prevalence, awareness, and treatment of anemia in patients with nondialysis CKD (ND-CKD) were assessed. Anemia was defined as serum hemoglobin (Hb) levels ≤12 g/dL in women and ≤13 g/dL in men. A total of 2420 patients with ND-CKD were included. Anemia was established in 1246 (51.5%) patients: 639 (51.3%) men and 607 (48.7%) women. The prevalence of anemia increased with advancing CKD stage (χtrend = 675.14, P < 0.001). Anemia was more prevalent in patients with diabetic nephropathy (68.0%) than in patients with hypertensive renal damage (56.6%) or chronic glomerulonephritis (46.1%, both P < 0.001). Only 39.8% of the anemic patients received treatment with erythropoietin and 27.1% patients received iron products; furthermore, 22.7% of the patients started receiving treatment when their Hb level reached 7 g/dL. The target-achieving rate (Hb at 11-12 g/dL) was only 8.2%. Of the 1246 anemia patients, only 7.5% received more effective and recommended intravenous supplementation. Anemia is highly prevalent in patients with ND-CKD in China, with a low target-achieving rate and poor treatment patterns. The study highlights the need to improve multiple aspects of CKD management to delay the progression of renal failure. PMID:27310973

  4. Phosphorus: Tips for People with Chronic Kidney Disease (CKD)

    MedlinePlus

    Phosphorus Tips for People with Chronic Kidney Disease (CKD) National Kidney Disease Education Program What Is Phosphorus? Phosphorus is a mineral that helps keep your bones healthy. It also helps ...

  5. Randomized Placebo-Controlled EPPIC Trials of AST-120 in CKD.

    PubMed

    Schulman, Gerald; Berl, Tomas; Beck, Gerald J; Remuzzi, Giuseppe; Ritz, Eberhard; Arita, Kiyoshi; Kato, Akira; Shimizu, Miho

    2015-07-01

    Reduced GFR in patients with CKD causes systemic accumulation of uremic toxins, which has been correlated with disease progression and increased morbidity. The orally administered spherical carbon adsorbent AST-120 reduces systemic toxin absorption through gastrointestinal sequestration, which may slow disease progression in these patients. The multinational, randomized, double-blind, placebo-controlled Evaluating Prevention of Progression in CKD (EPPIC)-1 and EPPIC-2 trials evaluated the effects of AST-120 on the progression of CKD when added to standard therapy. We randomly assigned 2035 adults with moderate to severe disease (serum creatinine at screening, 2.0-5.0 mg/dl for men and 1.5-5.0 mg/dl for women) to receive either placebo or AST-120 (9 g/d). The primary end point was a composite of dialysis initiation, kidney transplantation, and serum creatinine doubling. Each trial continued until accrual of 291 primary end points. The time to primary end point was similar between the AST-120 and the placebo groups in both trials (EPPIC-1: hazard ratio, 1.03; 95% confidence interval, 0.84 to 1.27; P=0.78) (EPPIC-2: hazard ratio, 0.91; 95% confidence interval, 0.74 to 1.12; P=0.37); a pooled analysis of both trials showed similar results. The estimated median time to primary end points for the placebo groups was 124 weeks for power calculations, but actual times were 189.0 and 170.3 weeks for EPPIC-1 and EPPIC-2, respectively. Thus, disease progression was more gradual than expected in the trial populations. In conclusion, the benefit of adding AST-120 to standard therapy in patients with moderate to severe CKD is not supported by these data. PMID:25349205

  6. Fewer Advanced Alzheimer's Patients on Feeding Tubes

    MedlinePlus

    ... at someone in the advanced stages of a terminal illness, a feeding tube doesn't make a ... of palliative care (keeping a person with a terminal illness as comfortable as possible), Mitchell said. As ...

  7. Individuals with a family history of ESRD are a high-risk population for CKD: implications for targeted surveillance and intervention activities.

    PubMed

    McClellan, William M; Satko, Scott G; Gladstone, Elisa; Krisher, Jenna O; Narva, Andrew S; Freedman, Barry I

    2009-03-01

    Activities intended to improve the detection, treatment, and control of chronic kidney disease (CKD) should be incorporated into existing health care systems and targeted to high-risk populations to avoid redundancy and waste of resources. One high-risk population consists of first- or second-degree family members of patients with end-stage renal disease (ESRD), who are 2 to 3 times as likely to have incident ESRD, have high rates of impaired kidney function and undetected and uncontrolled high blood pressure, and are more likely to be obese. These individuals usually are unaware of their underlying CKD and may discount their own risk of ESRD. The ESRD Network 6 Family History Project shows that the ESRD Networks, which constitute a national CKD surveillance system for patients with stage 5 CKD, may be an existing resource that can be used to identify relatives of incident patients with ESRD and provide these families with information about CKD. Nationally available resources have been developed by the National Kidney Disease Education Program for use with these at-risk families. Individuals interested in population-based CKD control activities should be aware of and use these resources. PMID:19231753

  8. Safety, efficacy and renal effect of febuxostat in patients with moderate-to-severe kidney dysfunction.

    PubMed

    Shibagaki, Yugo; Ohno, Iwao; Hosoya, Tatsuo; Kimura, Kenjiro

    2014-10-01

    Hyperuricemia (HU) is common in patients with chronic kidney disease (CKD), and accumulating evidence suggests it has a pathogenic role in the progression of the disease. However, a major challenge in treating patients with HU is the adverse effects caused by urate-lowering drugs used to treat CKD. Because of these untoward effects, doses need to be reduced, which leads to suboptimal efficacy. Febuxostat has been shown to be highly efficacious in reducing serum uric acid (sUA) and is well tolerated in patients with mild kidney dysfunction. However, its safety and efficacy have not been well studied in more advanced cases of CKD. We studied the safety and efficacy of escalating doses of febuxostat over a 24-week period in 70 patients with CKD stages 3b, 4 and 5, and we also observed the changes in blood pressure, estimated glomerular filtration rate (eGFR) and proteinuria following the reduction of sUA. Drug-related adverse events (AEs) occurred in only 5 out of 70 patients. All but one of the events were mild, and all five patients fully recovered. By 24 weeks, the reduction of sUA levels was >40% in CKD stage 3b and >50% in CKD stages 4 and 5. More than 70% of patients achieved target sUA levels of 6 mg dl(-1) or less. Multivariate analysis showed that a greater reduction in sUA with febuxostat was associated with an increase in eGFR and a tendency toward decreased proteinuria. Febuxostat was safe and efficacious in the treatment of CKD stages 3b-5. PMID:24942770

  9. Association of Low-Protein Supplemented Diets with Fetal Growth in Pregnant Women with CKD

    PubMed Central

    Leone, Filomena; Attini, Rossella; Parisi, Silvia; Fassio, Federica; Deagostini, Maria Chiara; Ferraresi, Martina; Clari, Roberta; Ghiotto, Sara; Biolcati, Marilisa; Giuffrida, Domenica; Rolfo, Alessandro; Todros, Tullia

    2014-01-01

    Background and objectives Women affected by CKD increasingly choose to get pregnant. Experience with low-protein diets is limited. The aim of this study was to review results obtained from pregnant women with CKD on supplemented vegan–vegetarian low-protein diets. Design, setting, participants, & measurements This was a single-arm, open intervention study between 2000–2012 of a low-protein diet in pregnant patients with stages 3–5 CKD or severe proteinuria (>1 g/d in the first trimester or nephrotic at any time). Stages 3–5 CKD patients who were not on low-protein diets for clinical, psychologic, or logistic reasons served as controls. The setting was the Obstetrics-Nephrology Unit dedicated to kidney diseases in pregnancy. The treated group included 24 pregnancies—21 singleton deliveries, 1 twin pregnancy, 1 abortion, and 1 miscarriage. Additionally, there were 21 controls (16 singleton deliveries, 5 miscarriages). The diet was a vegan–vegetarian low-protein diet (0.6–0.8 g/kg per day) with keto-acid supplementation and 1–3 protein-unrestricted meals allowed per week. Results Treated patients and controls were comparable at baseline for median age (35 versus 34 years), referral week (7 versus 8), eGFR (59 versus 54 ml/min), and hypertension (43.5% versus 33.3%); median proteinuria was higher in patients on the low-protein diet (1.96 [0.1–6.3] versus 0.3 [0.1–2.0] g/d; P<0.001). No significant differences were observed in singletons with regard to gestational week (34 versus 36) or Caesarean sections (76.2% versus 50%). Kidney function at delivery was not different, but proteinuria was higher in the diet group. Incidence of small for gestational age babies was significantly lower in the diet group (3/21) versus controls (7/16; chi-squared test; P=0.05). Throughout follow-up (6 months to 10 years), hospitalization rates and prevalence of children below the third percentile were similar in both groups. Conclusion Vegan–vegetarian supplemented

  10. Interdisciplinary Management of Patient with Advanced Periodontal Disease.

    PubMed

    Kochar, Gagan Deep; Jayan, B; Chopra, S S; Mechery, Reenesh; Goel, Manish; Verma, Munish

    2016-01-01

    This case report describes the interdisciplinary management of an adult patient with advanced periodontal disease. Treatment involved orthodontic and periodontal management. Good esthetic results and dental relationships were achieved by the treatment. PMID:27319043

  11. Sorafenib in advanced, heavily pretreated patients with soft tissue sarcomas.

    PubMed

    Brämswig, Kira; Ploner, Ferdinand; Martel, Alexandra; Bauernhofer, Thomas; Hilbe, Wolfgang; Kühr, Thomas; Leitgeb, Clemens; Mlineritsch, Brigitte; Petzer, Andreas; Seebacher, Veronika; Stöger, Herbert; Girschikofsky, Michael; Hochreiner, Gerhard; Ressler, Sigrun; Romeder, Franz; Wöll, Ewald; Brodowicz, Thomas

    2014-08-01

    Therapeutic options for patients with advanced pretreated soft tissue sarcomas are limited. However, in this setting, sorafenib has shown promising results. We reviewed the data of 33 patients with soft tissue sarcoma treated with sorafenib within a named patient program in Austria. Twelve physicians from eight different hospitals provided records for the analysis of data. Among the 33 patients, the predominant histological subtype of sarcoma was leiomyosarcoma (n=18, 55%). Other subtypes were represented by only one or two cases. Fifteen patients presented with metastases at the time of diagnosis. Another 17 patients developed metastases later in the course of the disease (data on one patient are missing). Most of the 33 patients had undergone resection of the primary (n=29, 88%) and half of the patients had received radiotherapy (n=17, 52%). Chemotherapy for metastatic disease had been administered to 30 patients (91%). The majority had received two or more regimens of chemotherapy (n=25, 76%) before sorafenib treatment. The use of sorafenib resulted in a median time to treatment failure of 92 days in patients with leiomyosarcoma and 45 days in patients with other histological subtypes. One-third of the patients derived benefits from treatment: four patients were documented with partial response and six with stabilized disease. In terms of treatment-related toxicity, skin problems of various degrees and gastrointestinal disturbances were frequently reported. In this retrospective analysis of heavily pretreated patients with advanced soft tissue sarcomas, sorafenib was associated with some antitumor activity and an acceptable toxicity profile. PMID:24667659

  12. Phosphate Toxicity in CKD: The Killer among Us.

    PubMed

    Ritter, Cynthia S; Slatopolsky, Eduardo

    2016-06-01

    Maintenance of a normal serum phosphate level depends on absorption in the gut, reabsorption and excretion by the kidney, and the flux between the extracellular and skeletal pools. Phosphate homeostasis is a coordinated, complex system of crosstalk between the bone, intestine, kidney, and parathyroid gland. Dysfunction of this system has serious clinical consequences in healthy individuals and those with conditions, such as CKD, in which hyperphosphatemia is associated with increased risks of cardiovascular morbidity and mortality. The last half-century of renal research has helped define the contribution of the parathyroid hormone, calcitriol, fibroblast growth factor 23, and Klotho in the regulation of phosphate. However, despite new discoveries and insights gained during this time, what remains unchanged is the recognition that phosphate retention is the initiating factor for the development of many of the complications observed in CKD, namely secondary hyperparathyroidism and bone and cardiovascular diseases. Controlling phosphate load remains the primary goal in the treatment of CKD. This review discusses the clinical effects of dysregulated phosphate metabolism, particularly in CKD, and its association with cardiovascular disease. The importance of early control of phosphate load in the treatment of CKD is emphasized, and the latest research in the treatment of phosphate retention is discussed. PMID:26912542

  13. p-Cresyl sulfate promotes insulin resistance associated with CKD.

    PubMed

    Koppe, Laetitia; Pillon, Nicolas J; Vella, Roxane E; Croze, Marine L; Pelletier, Caroline C; Chambert, Stéphane; Massy, Ziad; Glorieux, Griet; Vanholder, Raymond; Dugenet, Yann; Soula, Hédi A; Fouque, Denis; Soulage, Christophe O

    2013-01-01

    The mechanisms underlying the insulin resistance that frequently accompanies CKD are poorly understood, but the retention of renally excreted compounds may play a role. One such compound is p-cresyl sulfate (PCS), a protein-bound uremic toxin that originates from tyrosine metabolism by intestinal microbes. Here, we sought to determine whether PCS contributes to CKD-associated insulin resistance. Administering PCS to mice with normal kidney function for 4 weeks triggered insulin resistance, loss of fat mass, and ectopic redistribution of lipid in muscle and liver, mimicking features associated with CKD. Mice treated with PCS exhibited altered insulin signaling in skeletal muscle through ERK1/2 activation. In addition, exposing C2C12 myotubes to concentrations of PCS observed in CKD caused insulin resistance through direct activation of ERK1/2. Subtotal nephrectomy led to insulin resistance and dyslipidemia in mice, and treatment with the prebiotic arabino-xylo-oligosaccharide, which reduced serum PCS by decreasing intestinal production of p-cresol, prevented these metabolic derangements. Taken together, these data suggest that PCS contributes to insulin resistance and that targeting PCS may be a therapeutic strategy in CKD. PMID:23274953

  14. CKD impairs barrier function and alters microbial flora of the intestine: a major link to inflammation and uremic toxicity

    PubMed Central

    Vaziri, Nosratola D.

    2013-01-01

    Purpose of review Chronic kidney disease (CKD) is associated with oxidative stress and inflammation which contribute to progression of kidney disease and its numerous complications. Until recently, little attention had been paid to the role of the intestine and its microbial flora in the pathogenesis of CKD-associated inflammation. This article is intended to provide an over view of the impact of uremia on the structure and function of the gut and its microbial flora and their potential link to the associated systemic inflammation. Recent findings Recent studies conducted in the author’s laboratories have demonstrated marked disintegration of the colonic epithelial barrier structure and significant alteration of the colonic bacterial flora in humans and animals with advanced CKD. The observed disruption of the intestinal epithelial barrier complex can play an important part in the development of systemic inflammation by enabling influx of endotoxin and other noxious luminal contents into the systemic circulation. Similarly via disruption of the normal symbiotic relationship and production, absorption and retention of noxious products, alteration of the microbial flora can contribute to systemic inflammation and uremic toxicity. In fact recent studies have documented the role of colonic bacteria as the primary source of several well known pro-inflammatory/pro-oxidant uremic toxins as well as many as-yet unidentified retained compounds. Summary CKD results in disruption of the intestinal barrier structure and marked alteration of its microbial flora –events that play a major role in the pathogenesis of inflammation and uremic toxicity. PMID:23010760

  15. Autosomal Dominant Mutation in the Signal Peptide of Renin in a Kindred with Anemia, Hyperuricemia, and CKD

    PubMed Central

    Beck, Bodo B.; Trachtman, Howard; Gitman, Michael; Miller, Ilene; Sayer, John A.; Pannes, Andrea; Baasner, Anne; Hildebrandt, Friedhelm; Wolf, Matthias T.F.

    2012-01-01

    Homozygous or compound heterozygous Renin (REN) mutations cause renal tubular dysgenesis (RTD), which is characterized by death in utero due to renal failure and pulmonary hypoplasia. The phenotype resembles the fetopathy caused by angiotensin-converting enzyme inhibitor or angiotensin receptor blocker intake during pregnancy. Recently, heterozygous REN mutations were shown to result in early-onset hyperuricemia, anemia and chronic renal failure. So far, only three different heterozygous REN mutations were reported. We performed mutation analysis of the REN gene in 39 kindreds with hyperuricemia and chronic kidney disease (CKD) previously tested negative for mutations in the UMOD and HNF1β genes. We identified one kindred with a novel c.28T>C (p.W10R) REN mutation in the signal sequence, concluding that REN mutations are rare events in CKD patients. Affected individuals over four generations were identified carrying the novel REN mutation and were characterized by significant anemia, hyperuricemia and CKD. Anemia was severe and disproportional to the degree of renal impairment. Moreover all heterozygous REN mutations are localized in the signal sequence. Therefore, screening of the REN gene for CKD patients with hyperuricemia and anemia may be focusing on exon 1 sequencing, which encodes the signal peptide. PMID:21903317

  16. Serum Glucocorticoid-Regulated Kinase 1 Blocks CKD-Induced Muscle Wasting Via Inactivation of FoxO3a and Smad2/3.

    PubMed

    Luo, Jinlong; Liang, Anlin; Liang, Ming; Xia, Ruohan; Rizvi, Yasmeen; Wang, Yun; Cheng, Jizhong

    2016-09-01

    Muscle proteolysis in CKD is stimulated when the ubiquitin-proteasome system is activated. Serum glucocorticoid-regulated kinase 1 (SGK-1) is involved in skeletal muscle homeostasis, but the role of this protein in CKD-induced muscle wasting is unknown. We found that, compared with muscles from healthy controls, muscles from patients and mice with CKD express low levels of SGK-1. In mice, SGK-1-knockout (SGK-1-KO) induced muscle loss that correlated with increased expression of ubiquitin E3 ligases known to facilitate protein degradation by the ubiquitin-proteasome, and CKD substantially aggravated this response. SGK-1-KO also altered the phosphorylation levels of transcription factors FoxO3a and Smad2/3. In C2C12 muscle cells, expression of dominant negative FoxO3a or knockdown of Smad2/3 suppressed the upregulation of E3 ligases induced by loss of SGK-1. Additionally, SGK-1 overexpression increased the level of phosphorylated N-myc downstream-regulated gene 1 protein, which directly interacted with and suppressed the phosphorylation of Smad2/3. Overexpression of SGK-1 in wild-type mice with CKD had similar effects on the phosphorylation of FoxO3a and Smad2/3 and prevented CKD-induced muscle atrophy. Finally, mechanical stretch of C2C12 muscle cells or treadmill running of wild-type mice with CKD stimulated SGK-1 production, and treadmill running inhibited proteolysis in muscle. These protective responses were absent in SGK-1-KO mice. Thus, SGK-1 could be a mechanical sensor that mediates exercise-induced improvement in muscle wasting stimulated by CKD. PMID:26880799

  17. Myofacial Trigger Points in Advanced Cancer Patients

    PubMed Central

    Hasuo, Hideaki; Ishihara, Tatsuhiko; Kanbara, Kenji; Fukunaga, Mikihiko

    2016-01-01

    Myofascial pain syndrome is started to be recognized as one of important factors of pain in cancer patients. However, no reports on features of myofascial trigger points were found in terminally-ill cancer populations. This time, we encountered 5 patients with myofascial pain syndrome and terminal cancer in whom delirium developed due to increased doses of opioid without a diagnosis of myofascial pain syndrome on initial presentation. The delirium subsided with dose reductions of opioid and treatment of myofascial pain syndrome. The common reason for a delayed diagnosis among the patients included an incomplete palpation of the painful sites, which led to unsuccessful myofascial trigger points identification. The features of myofascial trigger points included single onset in the cancer pain management site with opioid and the contralateral abdominal side muscles of the non-common sites. Withdrawal reflexes associated with cancer pain in the supine position, which are increasingly seen in the terminal cancer patients, were considered to have contributed to this siuation. We consider that careful palpation of the painful site is important, in order to obtain greater knowledge and understanding of the features of myofascial trigger points. PMID:26962285

  18. Subclinical Atherosclerosis Measures for Cardiovascular Prediction in CKD

    PubMed Central

    Sang, Yingying; Ballew, Shoshana H.; Shlipak, Michael; Katz, Ronit; Rosas, Sylvia E.; Peralta, Carmen A.; Woodward, Mark; Kramer, Holly J.; Jacobs, David R.; Sarnak, Mark J.; Coresh, Josef

    2015-01-01

    Whether inclusion of the coronary artery calcium score improves cardiovascular risk prediction in individuals with CKD, a population with unique calcium-phosphate homeostasis, is unknown. Among 6553 participants ages 45–84 years without prior cardiovascular disease in the Multi-Ethnic Study of Atherosclerosis, coronary artery calcium score was assessed for cardiovascular risk prediction beyond the Framingham predictors in those with (n=1284) and without CKD and contrasted with carotid intima-media thickness and ankle-brachial index (two other measures of subclinical atherosclerosis). During a median follow-up of 8.4 years, 650 cardiovascular events (coronary heart disease, stroke, heart failure, and peripheral artery disease) occurred (236 events in subjects with CKD). In Cox proportional hazards models adjusted for Framingham predictors, each subclinical measure was independently associated with cardiovascular outcomes, with larger adjusted hazard ratios (HRs; per 1 SD) for coronary artery calcium score than carotid intima-media thickness or ankle-brachial index in subjects without and with CKD (HR, 1.69; 95% confidence interval [95% CI], 1.45 to 1.97 versus HR, 1.12; 95% CI, 1.00 to 1.25 and HR, 1.20; 95% CI, 1.08 to 1.32, respectively). Compared with inclusion of carotid intima-media thickness or ankle-brachial index, inclusion of the coronary artery calcium score led to greater increases in C statistic for predicting cardiovascular disease and net reclassification improvement. Coronary artery calcium score performed best for the prediction of coronary heart disease and heart failure, regardless of CKD status. In conclusion, each measure improved cardiovascular risk prediction in subjects with CKD, with the greatest improvement observed with coronary artery calcium score. PMID:25145930

  19. Preparation of the Dialysis Access in Stages 4 and 5 CKD.

    PubMed

    Moist, Louise M; Al-Jaishi, Ahmed A

    2016-07-01

    Patients with Stages 4 and 5 CKD are optimally managed within a multidisciplinary care setting. This provides an opportunity to create a "patient centered" approach to renal replacement modality options and conservative care. The care team engages with the patient and caregivers to assist with the understanding of their health status, modality and vascular access selection, and overall living with the comorbidity of chronic illness. A systematic approach to provision of education, modality, and access selection, are in part, driven by the patient's expected survival and need for dialysis, the risks and benefits with different modalities, and access and adaptation to their preferences and home situations. Dialysis access education should be included in all education programs so that patients can consider risks and benefits of all modalities. Decision support interventions have been effective in reducing decisional conflict and informed values-based decision-making. For both hemodialysis and peritoneal dialysis, timing of the surgical referral and access creation should be individualized based on the rate of CKD progression, risk of complications, and ease of access to surgical services. The health care team should support the patients' decision balancing risks and benefits, as well as their lifestyle, values, beliefs, and preferences. PMID:27324681

  20. Medication Adherence Behavior and Priorities Among Older Adults With CKD: A Semistructured Interview Study

    PubMed Central

    Rifkin, Dena E.; Laws, M. Barton; Rao, Madhumathi; Balakrishnan, V. S.; Sarnak, Mark J.; Wilson, Ira B.

    2010-01-01

    Background Older adults with chronic kidney disease (CKD) typically take more than five medications and have multiple prescribing physicians. Little however is known about how they prioritize their medical conditions or decide which medications to take. Methods Semistructured interviews (average length 40 minutes) with twenty community-dwelling adults with CKD stages 3-5D, receiving nephrology care at a tertiary referral center. Respondents were asked about medications, prescribing physicians, and medication-taking behaviors. We performed thematic analysis to explain patients’ decisions regarding medication prioritization, understanding, and adherence decisions. Results Participants (age range, 55–84 years; mean, 72) took 5–14 prescribed medications, had 2–9 physicians, and 5–11 comorbid conditions. All had assigned implicit priorities to their medications. While the majority expressed the intention to be adherent, many regularly skipped medications they considered less important. Most identified the prescribing physician and indication for each medication, but there was often substantial discordance between beliefs about medications and conventional medical opinion. Respondents prioritized medications based on the salience of the particular condition, perceived effects of the treatment, and on the barriers (physical, logistic, or financial) to taking the prescribed drug. Side effects of medications were common and anxiety-provoking, but discussions with the prescribing physician were often delayed or unfulfilling for the patient. Conclusions Polypharmacy in CKD patients leads to complex medication choices and adherence behaviors in this population. Most of the patients we interviewed had beliefs or priorities that were non-concordant with conventional medical opinion, but patients rarely discussed these beliefs and priorities, or the resultant poor medication adherence, with their physicians. Further study is needed to provide quantitative data on the

  1. Physician orders to supplement advance directives: rescuing patient autonomy.

    PubMed

    Miller, Ronald B

    2009-01-01

    To adapt Churchill's comment on democracy, "No one pretends that [POLSTs are] perfect..." but physicians' orders about life-sustaining treatments are a very important supplement to advance directives, especially for patients who are extremely or terminally ill, and most particularly for patients who require emergency treatment by first responders or by physicians who do not know them as persons. The standardized orders of limited options, however, are no substitute for a detailed treatment directive of a patient with a known illness, with predictable trajectories and complications. And, in this latter circumstance, a thoroughly informed proxy may also assist physicians in selecting appropriate treatment for patients who have lost decisional capacity and/or the ability to express it. I believe all patients should have an advance directive, preferably a combined proxy-treatment directive, and preferably one that has been thoroughly discussed with the attending physician and with the proxy, successor proxies, and preferably relatives and friends. Nurses, social workers, and chaplains may be very helpful to the patient in thinking through his or her preferences, especially if the severity of illness and the limited efficacy of interventions are such that the patient would wish to omit life-sustaining treatment or to discontinue it after a time-limited trial. Finally, because POLST is new or yet to be initiated in many areas of the country, it behooves all physicians to become knowledgeable of POLST and to initiate discussion of it with colleagues, patients, patients' proxies, and with relatives of patients. Even more recent is the combined advance directive/physician's orders to permit natural dying, actionable immediately for patients suffering severely and irremediably, but actionable at a future time if the patient progresses to advanced stages of dementia or other devastating brain disorders. In order to encourage physicians to initiate advance care planning with

  2. Protein-bound uremic toxins: new culprits of cardiovascular events in chronic kidney disease patients.

    PubMed

    Ito, Shunsuke; Yoshida, Masayuki

    2014-02-01

    Chronic kidney disease (CKD) has been considered a major risk factor for cardiovascular diseases. Although great advances have recently been made in the pathophysiology and treatment of cardiovascular diseases, CKD remains a major global health problem. Moreover, the occurrence rates of cardiovascular events among CKD patients increase even in cases in which patients undergo hemodialysis, and the mechanisms underlying the so-called "cardiorenal syndrome" are not clearly understood. Recently, small-molecule uremic toxins have been associated with cardiovascular mortality in CKD and/or dialysis patients. These toxins range from small uncharged solutes to large protein-bound structures. In this review, we focused on protein-bound uremic toxins, such as indoxyl sulfate and p-cresyl sulfate, which are poorly removed by current dialysis techniques. Several studies have demonstrated that protein-bound uremic toxins, especially indoxyl sulfate, induce vascular inflammation, endothelial dysfunction, and vascular calcification, which may explain the relatively poor prognosis of CKD and dialysis patients. The aim of this review is to provide novel insights into the effects of indoxyl sulfate and p-cresyl sulfate on the pathogenesis of atherosclerosis. PMID:24561478

  3. Palliative care for patients with advance chronic kidney disease.

    PubMed

    Douglas, C A

    2014-01-01

    Over the past three decades there has been a dramatic rise in the number of patients with advanced chronic kidney disease. The fastest expanding group receiving dialysis has been the elderly. However, for those patients who are very elderly with co-morbidity, dialysis may not offer a survival advantage. Therefore, active conservative management is a growing service offered by many renal units in the UK and focuses on non-dialytic correction of fluid and electrolyes, management of renal anaemia, and assessment and management of symptoms. The five-year survival of a patient over 75 years of age starting dialysis is 20% and if a patient is over 75 years, has co-morbidity, or a poor performance status, dialysis may not offer any survival advantage. Whether a patient is managed by dialysis or by conservative management the symptom burden suffered is high. These symptoms are under-recognised and often managed poorly because of increased drug toxicity in renal failure. This complex group of patients require close working between renal, palliative care, medicine for the elderly, and community teams, to allow best quality of life and end of life care. This review describes some of the challenges in providing Advanced Care Planning for dialysis and conservatively managed patients, highlights the symptom burden of patients with advanced chronic kidney disease, and offers guidance in how to manage the symptoms effectively. PMID:25318401

  4. Predictors of CKD and rate of decline in eGFR in the elderly: A case-cohort study.

    PubMed

    Ghaffar, Umbar; Maharjan, Najindra; Moore, Page C

    2016-04-01

    We wanted to examine the predictors of annual estimated glomerular filtration rate (eGFR) decline during a five-year follow-up in elderly individuals with pre-existing chronic kidney disease (CKD) stage 3 or greater (defined as baseline eGFR of less than 60 ml/min per 1.73 m2 or a urinary albumin-to-creatinine ratio > 30 mg/g), and to examine the difference in risk factors when compared to a co-hort without CKD. Our research team identified 599 patients who were 65 years of age or older with and without CKD stage 3 or greater at baseline. Data regarding various predictors such as age, sex, race, proteinuria, medication use, contrast exposure, acute kidney injury episodes, coronary artery disease, congestive heart failure, dyslipidemia, gout etc. were obtained. Semi-partial correlations were used to determine the fac-tors providing the largest unique contribution to the overall variability in eGFR. Semi-partial correlations identified age, proteinuria, and intravenous contrast ex-posure as the most significant predictors of eGFR decline in this population. Overall, patients in the pre-existing CKD cohort were more likely to be older, Af-rican American and with co-morbidities like diabetes, hypertension, etc. In this group, the unadjusted rate of decline in eGFR varied from 0.5% to 8.3% per year. This study identifies important risk factors for eGFR decline in the population aged > 65 years. It also concludes that each episode of acute kidney injury, wheth-er related to contrast or other nephrotoxins, increases the risk for CKD progression and eGFR decline in the elderly. PMID:27257659

  5. Body Mass Index and Mortality in CKD

    Technology Transfer Automated Retrieval System (TEKTRAN)

    BACKGROUND: Greater body mass index (BMI) is associated with worse survival in the general population, but appears to confer a survival advantage in patients with kidney failure treated by hemodialysis. Data are limited on the relationship of BMI with mortality in patients in the earlier stages of c...

  6. Chemotherapy and prognosis in advanced thymic carcinoma patients

    PubMed Central

    Song, Zhengbo; Yu, Xinmin; Zhang, Yiping

    2015-01-01

    OBJECTIVE: The role of chemotherapy in treating advanced thymic carcinoma is unclear. The purpose of the current study was to investigate the efficacy of chemotherapy and the prognostic factors for patients with advanced thymic carcinoma. METHODS: A retrospective review of the medical records of 86 patients treated with chemotherapy for advanced thymic carcinoma was conducted between 2000 and 2012 at our institution. The clinical characteristics, chemotherapy regimens and prognostic factors were analyzed. Survival curves were plotted using the Kaplan–Meier method and the Cox proportional hazard model was used for multivariate analysis. RESULTS: Of the 86 patients, 56 were male and 30 were female. The median survival time was 24.5 months. For the first-line chemotherapy treatment, the objective response rate was 47.7% and the disease control rate was 80.2%. The median progression-free survival for all patients was 6.5 months for first-line chemotherapy. No significant differences in progression-free survival were observed among the different chemotherapy regimens. Multivariate analyses revealed that the prognostic factors for overall survival included performance status (p=0.043), histology grade (p=0.048), and liver metastasis (p=0.047). CONCLUSION: Our results suggest that there is no difference in efficacy between multiagent and doublet regimens. The prognosis of patients with advanced thymic carcinoma can be predicted based on histological grade, liver metastasis and performance status. PMID:26735216

  7. [Ethics and palliative care in patients with advanced cancer].

    PubMed

    Tenorio-González, Francisco

    2005-01-01

    Recent research in both the biology of cancer and the treatment of patients has increased the life expectancy of cancer patients with recurrence and who have a longer survival rate. Cancer is no longer considered a lethal but a chronic disease. More patients survive, but above all there are more patients with recurrences thus increasing the need for physical or psychological treatment of patients with longer lives. The American Cancer Society reported in 1992 that in the U.S. more than 8 million people survived between 4 and 5 years. This produces both an ethical and medical challenge for treatment of cancer patients. This paper reviews the actual criteria for palliative care: treatment for pain and the ethical and psychological treatment of advanced cancer patients and their families. PMID:16454965

  8. Genetic damage in patients with chronic kidney disease, peritoneal dialysis and haemodialysis: a comparative study.

    PubMed

    Rangel-López, Angélica; Paniagua-Medina, Maria Eugenia; Urbán-Reyes, Marcia; Cortes-Arredondo, Martha; Alvarez-Aguilar, Cleto; López-Meza, Joel; Ochoa-Zarzosa, Alejandra; Lindholm, Bengt; García-López, Elvia; Paniagua, José Ramón

    2013-03-01

    Patients with chronic kidney disease (CKD) have signs of genomic instability and, as a consequence, extensive genetic damage, possibly due to accumulation of uraemic toxins, oxidative stress mediators and other endogenous substances with genotoxic properties. We explored factors associated with the presence and background levels of genetic damage in CKD. A cross-sectional study was performed in 91 CKD patients including pre-dialysis (CKD patients; n = 23) and patients undergoing peritoneal dialysis (PD; n = 33) or haemodialysis (HD; n = 35) and with 61 healthy subjects, divided into two subgroups with the older group being in the age range of the patients, serving as controls. Alkaline comet assay and cytokinesis-block micronucleus assay in peripheral blood lymphocytes were used to determine DNA and chromosome damage, respectively, present in CKD. Markers of oxidative stress [malondialdehyde (MDA), advanced glycation end products (AGEs), thiols, advanced oxidation protein products and 8-hydroxy-2'-deoxyguanosine] and markers of inflammation (C-reactive protein, interleukin-6 and tumour necrosis factor alpha) were also measured. Micronucleus (MN) frequency was significantly higher (P < 0.05) in the CKD group (46±4‰) when compared with the older control (oC) group (27.7±14). A significant increase in MN frequency (P < 0.05) was also seen in PD patients (41.9±14‰) versus the oC group. There was no statistically significant difference for the HD group (29.7±15.6‰; P = NS) versus the oC group. Comet assay data showed a significant increase (P < 0.001) of tail DNA intensity in cells of patients with CKD (15.6±7%) with respect to the total control (TC) group (11±1%). PD patients (14.8±7%) also have a significant increase (P < 0.001) versus the TC group. Again, there was no statistically significant difference for the HD group (12.5±3%) compared with the TC group. Patients with MN values in the upper quartile had increased cholesterol, triglycerides, AGEs and

  9. Genetic damage in patients with chronic kidney disease, peritoneal dialysis and haemodialysis: a comparative study

    PubMed Central

    Rangel-López, Angélica

    2013-01-01

    Patients with chronic kidney disease (CKD) have signs of genomic instability and, as a consequence, extensive genetic damage, possibly due to accumulation of uraemic toxins, oxidative stress mediators and other endogenous substances with genotoxic properties. We explored factors associated with the presence and background levels of genetic damage in CKD. A cross-sectional study was performed in 91 CKD patients including pre-dialysis (CKD patients; n = 23) and patients undergoing peritoneal dialysis (PD; n = 33) or haemodialysis (HD; n = 35) and with 61 healthy subjects, divided into two subgroups with the older group being in the age range of the patients, serving as controls. Alkaline comet assay and cytokinesis-block micronucleus assay in peripheral blood lymphocytes were used to determine DNA and chromosome damage, respectively, present in CKD. Markers of oxidative stress [malondialdehyde (MDA), advanced glycation end products (AGEs), thiols, advanced oxidation protein products and 8-hydroxy-2′-deoxyguanosine] and markers of inflammation (C-reactive protein, interleukin-6 and tumour necrosis factor alpha) were also measured. Micronucleus (MN) frequency was significantly higher (P < 0.05) in the CKD group (46±4‰) when compared with the older control (oC) group (27.7±14). A significant increase in MN frequency (P < 0.05) was also seen in PD patients (41.9±14‰) versus the oC group. There was no statistically significant difference for the HD group (29.7±15.6‰; P = NS) versus the oC group. Comet assay data showed a significant increase (P < 0.001) of tail DNA intensity in cells of patients with CKD (15.6±7%) with respect to the total control (TC) group (11±1%). PD patients (14.8±7%) also have a significant increase (P < 0.001) versus the TC group. Again, there was no statistically significant difference for the HD group (12.5±3%) compared with the TC group. Patients with MN values in the upper quartile had increased cholesterol, triglycerides, AGEs

  10. Contrasting Cholesterol Management Guidelines for Adults with CKD

    PubMed Central

    Colantonio, Lisandro D.; Baber, Usman; Banach, Maciej; Tanner, Rikki M.; Warnock, David G.; Gutiérrez, Orlando M.; Safford, Monika M.; Wanner, Christoph; Howard, George

    2015-01-01

    The Kidney Disease Improving Global Outcomes Lipid Work Group recommends statins for adults ≥50 years old with CKD. The American College of Cardiology/American Heart Association endorses statins for adults with atherosclerotic cardiovascular disease, adults with LDL cholesterol≥190 mg/dl, and adults 40–79 years old with LDL cholesterol=70–189 mg/dl and diabetes or a 10-year predicted risk for atherosclerotic cardiovascular disease ≥7.5% estimated using the Pooled Cohort risk equations. Using data from the Reasons for Geographic and Racial Differences in Stroke Study, we calculated the agreement for statin treatment between these two guidelines for adults 50–79 years old with CKD (eGFR<60 ml/min per 1.73 m2 or albuminuria≥30 mg/g) not on dialysis. We assessed the validity of the Pooled Cohort risk equations in individuals with CKD. Study participants were enrolled between 2003 and 2007, and we report incident cardiovascular disease events (stroke and coronary heart disease) through December of 2010. Among 4726 participants with CKD, 2366 (50%) were taking statins, and 1984 (42%) were recommended statins by the American College of Cardiology/American Heart Association guideline but not taking them. Overall, 376 (8%) participants did not meet the American College of Cardiology/American Heart Association criteria for initiating statin treatment. Cardiovascular disease incidence was low (3.0/1000 person-years; 95% confidence interval, 0.1 to 5.9) among these participants. The Pooled Cohort risk equations were well calibrated (Hosmer–Lemeshow chi-squared=2.7, P=0.45) with moderately good discrimination (C index, 0.71; 95% confidence interval, 0.65 to 0.77). In conclusion, these guidelines show high concordance for statin treatment for adults with CKD. PMID:25395432

  11. Motolimod effectively drives immune activation in advanced cancer patients

    PubMed Central

    Dietsch, Gregory N.

    2016-01-01

    ABSTRACT A novel approach to immunotherapy is the activation of toll-like receptor 8 (TLR8). Motolimod, a selective TLR8 agonist can act in concert with approved immunotherapies to sensitize T cells and augment natural killer (NK) cell function. Despite treatment with chemotherapeutic agents and advance disease, cancer patients remain sensitive to motolimod.

  12. A Review of Recent Advances in Perioperative Patient Safety

    PubMed Central

    Fowler, Alexander J.

    2013-01-01

    Major complications in surgery affect up to 16% of surgical procedures. Over the past 50 years, many patient safety initiatives have attempted to reduce such complications. Since the formation of the National Patient Safety Agency in 2001, there have been major advances in patient safety. Most recently, the production and implementation of the Surgical Safety Checklist by the World Health Organisation (WHO), a checklist ensuring that certain ‘never events’ (wrong-site surgery, wrong operation etc.) do not occur, irrespective of healthcare allowance. In this review, a summary of recent advances in patient safety are considered – including improvements in communication, understanding of human factors that cause mistakes, and strategies developed to minimise these. Additionally, the synthesis of best medical practice and harm minimisation is examined, with particular emphasis on communication and appreciation of human factors in the operating theatre. This is based on the resource management systems developed in other high risk industries (e.g. nuclear), and has also been adopted for other high risk medical areas. The WHO global movement to reduce surgical mortality has been highly successful, especially in the healthcare systems of developing nations where mortality reductions of up to 50% have been observed, and reductions in patient complications of 4%. Incident reporting has long been a key component of patient safety and continues to be so; allowing reflection and improved guideline formation. All patients are placed at risk in the surgical environment. It is crucial that this risk is minimised, whilst optimising the patient's outcome. In this review, recent advances in perioperative patient safety are examined and placed in context. PMID:26977290

  13. Orphan symptoms in advanced cancer patients followed at home.

    PubMed

    Mercadante, Sebastiano; Porzio, Giampiero; Valle, Alessandro; Fusco, Flavio; Aielli, Federica; Adile, Claudio; Casuccio, Alessandra

    2013-12-01

    Orphan symptoms are rarely assessed, particularly at home. The aim of this multicenter prospective study was to assess the prevalence of these symptoms and eventual factors possibly associated in advanced cancer patients at admission of a home care program. A prospective study was performed at three home care programs in Italy. Patients' data were collected, including age, sex, diagnosis, and Karnofsky status. Possible contributing factors were analyzed; preexisting neurological diseases, cerebral metastases, hyperthermia, diabetes, a state of dehydration clinically evident and/or oliguria, possible biochemical parameters when available, data regarding recent chemotherapy, opioids and doses, use of neuroleptics, benzodiazepine or anticonvulsants, corticosteroids, anti-inflammatory, and antibiotics were collected. Myoclonus, hiccup, sweating, pruritus, and tenesmus, either rectal or vesical, were assessed, according to a preliminary definition, at time of home care program admission. Three hundred sixty-two patients were surveyed at the three home care programs. Globally, 48 patients presented one or more orphan symptoms in the period taken into consideration, and 7 patients presented more than 1 symptom. One patient presented occasional and diffuse myoclonus. Nineteen patients presented sweating, 13 patients presented pruritus, and 14 patients presented hiccup. Finally, nine patients presented rectal or vesical tenesmus. There was a significant correlation between sweating and transdermal fentanyl use (P = 0.044), fever (P = 0.001), hiccup (P < 0.0005), and vesical tenesmus (P = 0.028). Pruritus was not associated to any factor. Hiccup was associated with gender (males, P = 0.006) and sweating (P < 0.0005). Vesical tenesmus was associated with fever (P = 0.019) and sweating (P = 0.028). Although the symptoms examined have a low prevalence in advanced cancer patients admitted to home care, the distress for patients may be high and

  14. New Targeted Treatment May Slow Disease in Patients with Advanced GIST

    MedlinePlus

    ... Patients with Advanced GIST A new oral drug, regorafenib (Stivarga®), may delay the progression of advanced gastrointestinal ... in The Lancet demonstrated that patients treated with regorafenib lived longer without their disease progressing than patients ...

  15. The adverse effects of sorafenib in patients with advanced cancers.

    PubMed

    Li, Ye; Gao, Zu-Hua; Qu, Xian-Jun

    2015-03-01

    Sorafenib is the first multi-kinase inhibitor (TKI) approved for the treatment of advanced hepatocellular cancer (HCC) and metastatic renal cell cancer (RCC) and is increasingly being used to treat patients with well-differentiated radioiodine-resistant thyroid cancer (DTC). Sorafenib demonstrates targeted activity on several families of receptor and non-receptor tyrosine kinases that are involved in angiogenesis, tumour growth and metastatic progression of cancer. Sorafenib treatment results in long-term efficacy and low incidence of life-threatening toxicities. Although sorafenib has demonstrated many benefits in patients, the adverse effects cannot be ignored. The most common treatment-related toxicities include diarrhoea, fatigue, hand-foot skin reaction and hypertension. Most of these toxicities are considered mild to moderate and manageable to varying degrees; however, cardiovascular events might lead to death. In this MiniReview, we summarize the adverse effects of sorafenib that commonly occur in patients with advanced cancers. PMID:25495944

  16. Advanced glycation end-products and skin autofluorescence in end-stage renal disease: a review.

    PubMed

    Arsov, Stefan; Graaff, Reindert; van Oeveren, Wim; Stegmayr, Bernd; Sikole, Aleksandar; Rakhorst, Gerhard; Smit, Andries J

    2014-01-01

    Chronic kidney disease (CKD), especially in its end stage, is marked by extremely high cardiovascular rates of morbidity and mortality; hemodialysis patients have a five-fold shorter life expectancy than healthy subjects of the same age. In CKD the metabolic products that accumulate in the body are so-called uremic toxins. These include advanced glycation end-products (AGE). AGE levels are markedly increased in CKD patients not only because of impaired excretion but also because of increased production. AGE formation has initially been described as a non-enzymatic reaction between proteins and glucose in the so-called Maillard reaction, but they are also more rapidly formed during oxidative stress and subsequent formation of reactive carbonyl compounds like (methyl)glyoxal. AGE accumulate in tissue where they cross-link with proteins, e.g., collagen, inducing tissue stiffening of blood vessels and skin. They may also interact with receptor of AGE (RAGE) and other receptors, which lead to activation of intracellular transduction mechanisms resulting in cytokine release and further tissue damage in CKD. The accumulation of AGE in the skin can be measured non-invasively using autofluorescence. The skin autofluorescence is a strong marker of cardiovascular mortality in CKD. The focus of this review is on the role of tissue and plasma AGE, and of skin autofluorescence as a proxy of tissue AGE accumulation, in the increase in cardiovascular disease in end stage renal disease (ESRD). This review will also present the possibility of reducing the AGE accumulation in ESRD patients using the following five methods: 1) use of low AGE peritoneal dialysis solutions; 2) use of advanced hemodialysis techniques; 3) use of AGE reducing drugs; 4) optimizing the nutrition of hemodialysis patients; and 5) renal transplantation. PMID:23612551

  17. [Study of 4 patients implemented to Advance Care Planning].

    PubMed

    Kawabata, Megumi; Fujiwara, Yoko; Kawabata, Hidenobu

    2015-11-01

    This is a study of 4 patients implemented to Advance Care Planning (ACP) reflecting on the health care professionals' role and the outcomes. ACP has been defined as a process of formal decision making that aims to help patients establish their decision about future care that take effect when they lose capacity. For about two years, we tried to engage all patients who were referred to our palliative care team and their families to ACP since their first consultation. We informed their conditions at that time, how their health might change and how treatment might impact on their life goals. We also attempted to help patients' decision making and then fulfill their wishes in cooperation with patients' families and healthcare professionals. We learned three important elements: understanding patients' values and wishes, explaining prediction of the clinical course of the patients and establishing a collaborative healthcare team in order to fulfill the patients' hopes. ACP improved quality of life (QOL) not only for the patients involved, but also for the family members. ACP can play a crucial role in ensuring that patients receive the care they want throughout various stages of their lives. PMID:26742180

  18. The effect of ONCE Renal on minerals and electrolytes in predialysis patients with chronic kidney disease

    PubMed Central

    Satirapoj, Bancha; Prapakorn, Janjira; Punpanich, Dollapas; Pongsuparbchon, Chantima; Supasyndh, Ouppatham

    2016-01-01

    Background Malnutrition is one common adverse consequence in patients with advanced chronic kidney disease (CKD), and most patients have a lower-than-normal dietary energy intake. The present study was undertaken to examine whether orally administered ONCE Renal formula (ORF) supplement would improve energy intake without minerals and electrolytes disturbances in predialysis patients with CKD. Methods All eligible nondiabetic patients with CKD received ORF supplement for 1 week. Nutrition markers, renal function, and minerals and electrolytes were evaluated before and after supplementing. All patients kept a 3-day food record and were interviewed by a registered dietitian. Results A total of 29 patients with mean age 64.9±13.3 years were included. Mean estimated glomerular filtration rate was 37.7±12.1 mL/min/1.73 m2. A significant increase was observed in amount of energy, fat, fiber, calcium, and magnesium intake after 1 week of ORF supplement. Moreover, in comparison with baseline values, the patients displayed decreased dietary protein intake and blood urea nitrogen and increased serum magnesium. However, no significant change was found in renal function, nutritional markers (body weight, prealbumin, albumin, and protein equivalence of total nitrogen appearance), serum calcium, phosphorus, sodium, potassium, and bicarbonate. Conclusion In patients with CKD, ingestion of ORF was well tolerated and had a positive effect with an increase in dietary energy, fat, and fiber intake, as well as a decreased dietary protein intake. No mineral or electrolyte abnormalities were observed during the study. PMID:27103839

  19. Ketoanalogue-Supplemented Vegetarian Very Low-Protein Diet and CKD Progression.

    PubMed

    Garneata, Liliana; Stancu, Alexandra; Dragomir, Diana; Stefan, Gabriel; Mircescu, Gabriel

    2016-07-01

    Dietary protein restriction may improve determinants of CKD progression. However, the extent of improvement and effect of ketoanalogue supplementation are unclear. We conducted a prospective, randomized, controlled trial of safety and efficacy of ketoanalogue-supplemented vegetarian very low-protein diet (KD) compared with conventional low-protein diet (LPD). Primary end point was RRT initiation or >50% reduction in initial eGFR. Nondiabetic adults with stable eGFR<30 ml/min per 1.73 m(2), proteinuria <1 g/g urinary creatinine, good nutritional status, and good diet compliance entered a run-in phase on LPD. After 3 months, compliant patients were randomized to KD (0.3 g/kg vegetable proteins and 1 cps/5 kg ketoanalogues per day) or continue LPD (0.6 g/kg per day) for 15 months. Only 14% of screened patients patients were randomized, with no differences between groups. Adjusted numbers needed to treat (NNTs; 95% confidence interval) to avoid composite primary end point in intention to treat and per-protocol analyses in one patient were 4.4 (4.2 to 5.1) and 4.0 (3.9 to 4.4), respectively, for patients with eGFR<30 ml/min per 1.73 m(2) Adjusted NNT (95% confidence interval) to avoid dialysis was 22.4 (21.5 to 25.1) for patients with eGFR<30 ml/min per 1.73 m(2) but decreased to 2.7 (2.6 to 3.1) for patients with eGFR<20 ml/min per 1.73 m(2) in intention to treat analysis. Correction of metabolic abnormalities occurred only with KD. Compliance to diet was good, with no changes in nutritional parameters and no adverse reactions. Thus, this KD seems nutritionally safe and could defer dialysis initiation in some patients with CKD. PMID:26823552

  20. Npt2b Deletion Attenuates Hyperphosphatemia Associated with CKD

    PubMed Central

    Tang, Wen; Bracken, Christina; O’Brien, Stephen P.; Song, Wenping; Boulanger, Joseph; Ryan, Susan; Phillips, Lucy; Liu, Shiguang; Arbeeny, Cynthia; Ledbetter, Steven; Sabbagh, Yves

    2012-01-01

    The incidence of cardiovascular events and mortality strongly correlates with serum phosphate in individuals with CKD. The Npt2b transporter contributes to maintaining phosphate homeostasis in the setting of normal renal function, but its role in CKD-associated hyperphosphatemia is not well understood. Here, we used adenine to induce uremia in both Npt2b-deficient and wild-type mice. Compared with wild-type uremic mice, Npt2b-deficient uremic mice had significantly lower levels of serum phosphate and attenuation of FGF23. Treating Npt2b-deficient mice with the phosphate binder sevelamer carbonate further reduced serum phosphate levels. Uremic mice exhibited high turnover renal osteodystrophy; treatment with sevelamer significantly decreased the number of osteoclasts and the rate of mineral apposition in Npt2b-deficient mice, but sevelamer did not affect bone formation and rate of mineral apposition in wild-type mice. Taken together, these data suggest that targeting Npt2b in addition to using dietary phosphorus binders may be a therapeutic approach to modulate serum phosphate in CKD. PMID:22859851

  1. Spinal analgesia for advanced cancer patients: an update.

    PubMed

    Mercadante, Sebastiano; Porzio, Giampiero; Gebbia, Vittorio

    2012-05-01

    In the nineties, spinal analgesia has been described as an useful means to control pain in advanced cancer patients. The aim of this review was to update this information with a systematic analysis of studies performed in the last 10 years. 27 papers pertinent with the topic selected for review were collected according to selection criteria. Few studies added further information on spinal analgesia in last decade. Despite a lack of a clinical evidence, spinal analgesia with a combination of opioids, principally morphine, and local anesthetics may allow to achieve analgesia in patients who had been intensively treated unsuccessfully with different trials of opioids. Some adjuvant drugs such as clonidine, ketamine, betamethasone, meperidine, and ziconotide may be promising agents, but several problems have to be solved before they can be used in the daily practice. In complex pain situations, spinal analgesia should not be negated to cancer patients, and oncologists should address this group of patients to other specialists. PMID:21684173

  2. Working with advanced dementia patients in a day care setting.

    PubMed

    Abramowitz, Leah

    2008-01-01

    Alzheimer's disease and most other causes of dementia are regressive by nature. As such one can expect patients with such types of mental impairment to gradually decline in function and ability to participate in day care activities. This paper attempts to show that with the right kind of orientation, staff can "tune into" the more advanced dementia patients, find the key to their personal needs, desires and remaining abilities and design a program that allows them not only to continue to participate in a social and therapeutic framework, but also to gain some meaningful human contact and quality of life despite their cognitive deterioration. PMID:18510188

  3. Aggressive chemosurgical debulking in patients with advanced ovarian cancer.

    PubMed

    Ng, L W; Rubin, S C; Hoskins, W J; Jones, W B; Hakes, T B; Markman, M; Reichman, B; Almadrones, L; Lewis, J L

    1990-09-01

    From July 1986 to June 1989, 43 evaluable patients with advanced ovarian cancer were treated on protocol with initial cytoreductive surgery, two courses of high-intensity intravenous Cytoxan (1000 mg/m2) and cisplatin (120-200 mg/m2) chemotherapy, and repeat debulking laparotomy in an effort to maximize response to a subsequent four cycles of intraperitoneal platinum-based chemotherapy. Two patients were stage IIIA, 2 stage IIIB, 28 stage IIIC, and 11 stage IV. Five tumors were grade 1, 9 grade 2, and 29 grade 3. Thirty-eight (88%) patients had bulky tumor (5-25 cm) found at first laparotomy; 25 of these had greater than 1-cm residual after initial debulking. Following two cycles of intensive intravenous chemotherapy 18 of these 25 had greater than 1-cm disease found at second laparotomy; 12 of 18 underwent secondary cytoreduction to less than 1 cm. Thus, 30 of these 38 (79%) patients entered the intraperitoneal phase of the protocol with less than 1-cm disease. Four patients had 2- to 5-cm tumor at initial laparotomy; two of four were debulked to less than 1-cm residual. All four were found to have less than 1-cm disease at second laparotomy. This combination regimen was well tolerated. There was one treatment-related death. In sum, 42 of 43 patients had tumor greater than 2 cm at staging laparotomy and 38 (88%) had large, bulky disease (5-25 cm); 34 of 43 (79%) entered the intraperitoneal phase of the protocol with optimal (less than 1-cm) disease. Aggressive chemosurgical cytoreduction in patients with bulky advanced ovarian cancer can leave a large proportion of patients with minimal residual disease and maximize their chances of responding to subsequent intraperitoneal chemotherapy. PMID:2227548

  4. The Problem of Atrial Fibrillation in Patients with Chronic Kidney Disease.

    PubMed

    Franczyk, Beata; Gluba-Brzózka, Anna; Ciałkowska-Rysz, Aleksandra; Banach, Maciej; Rysz, Jacek

    2016-01-01

    Chronic kidney disease (CKD) is associated with the risk of multiple life-threatening complications such as: progression to chronic renal failure and cardiovascular disease including coronary heart disease, heart failure and peripheral arterial disease. Also, atrial fibrillation (AF) is common in this group of patients. Factors contributing to the occurrence of AF in patients undergoing dialysis include: age, presence of coronary heart disease, echocardiographic abnormalities (low ejection fraction, atrial enlargement, valvular calcification, left ventricular hypertrophy), heart failure, chronic obstructive pulmonary disease, hypertension, stroke, malnutrition (low levels of albumin, total cholesterol and high-density lipoprotein (HDL), secondary hyperparathyroidism, low predialysis systolic blood pressure, duration of renal replacement therapy as well as the method of renal replacement therapy (more frequent in haemodialysis patients). The optimal management of thromboprophylaxis in patients with CKD and AF is complex due to the fact that in patients with CKD many physiologic mechanisms are altered which lead to substantial changes in haemostasis and thus this group of patients is characterized by an increased risk of thrombotic and haemorrhagic complications. Recommendations concerning the treatment of patients with AF do not include guidelines on how to manage patients with advanced CKD, due to the lack of large randomized trials assessing the efficacy and benefits of drugs in these patients. Patients with CKD and permanent, persistent, and paroxysmal AF ought to be treated as a group with high risk of bleeding and ischaemic stroke. In case of patients with no or only one moderate risk factors, it seems that anticoagulation with antiplatelet drugs can be considered as efficient therapy, while in patients with ≥2 risk factors an oral anticoagulation therapy may be used. During long-term treatment, the international normalized ratio (INR) must be controlled at

  5. Ageing Renal Patients: We Need More Collaboration between Geriatric Services and Nephrology Departments

    PubMed Central

    Alston, Helen; Burns, Aine

    2015-01-01

    There has been a significant increase in the number of frail older patients diagnosed with advanced chronic kidney disease (CKD) over the past thirty years. These elderly patients have high levels of comorbidity, and as a consequence the face of renal medicine is changing—There is an increasing need to focus on traditionally geriatric areas of expertise such as falls prevention and rehabilitation, and to shift our emphasis onto improving patient well-being rather than longevity. Over the past decade, many nephrologists have found that they are already acting as de facto “amateur geriatricians”. This denies patients both the benefits of specialist geriatric assessment, and equally importantly denies them access to the wider geriatric multidisciplinary team. This article describes the prevalence and underlying causes of the so-called “Geriatric Giants” in patients with advanced CKD, and discusses possible improvements in care that closer working with geriatricians could bring.

  6. Managing addiction in advanced cancer patients: why bother?

    PubMed

    Passik, S D; Theobald, D E

    2000-03-01

    The management of addiction in patients with advanced cancer can be time-consuming, labor-intensive, and difficult. Some clinicians believe that it is not worth the effort, due in part to a failure to appreciate the deleterious impact of addiction on palliative care efforts and a view of addiction as intractable in any case. Indeed, it is possible that some clinicians perceive addiction not only fatalistically but, because of common misconceptions, believe that managing or attempting to decrease the patient's use of alcohol or illicit substances would be tantamount to depriving a dying patient of a source of pleasure. In this paper, we argue that managing addiction is an essential aspect of palliative care for chemically-dependent and alcoholic patients. The goal of such efforts is not complete abstinence, but exerting enough control over illicit drug and alcohol use to allow palliative care interventions to decrease suffering. To illustrate this view, we describe two patients with chemical-dependency. We highlight the impact of unchecked substance abuse on patients' perpetuation of their own suffering, the complication of symptom management, the diagnosis and treatment of mood/anxiety disorders, and the effect on the patients' family and caregivers. PMID:10760628

  7. CKD hotspots around the world: where, why and what the lessons are. A CKJ review series

    PubMed Central

    Martín-Cleary, Catalina; Ortiz, Alberto

    2014-01-01

    Chronic kidney disease (CKD) is one of the three causes of death that has had the highest increase in the last 20 years. The increasing CKD burden occurs in the context of lack of access of most of the world population to adequate healthcare and an incomplete understanding of the pathogenesis of CKD. However, CKD is not homogeneously distributed. CKD hotspots are defined as countries, region, communities or ethnicities with higher than average incidence of CKD. Analysis of CKD hotspots has the potential to provide valuable insights into the pathogenesis of kidney disease and to improve the life expectancy of the affected communities. Examples include ethnicities such as African Americans in the USA or Aboriginals in Australia, regions such as certain Balkan valleys or Central America and even groups of people sharing common activities or interests such as young women trying to lose weight in Belgium. The study of these CKD hotspots has identified underlying genetic factors, such as ApoL1 gene variants, environmental toxins, such as aristolochic acid and socioeconomic factors leading to nutritional deprivation and inflammation/infection. The CKD hotspots series of CKJ reviews will explore the epidemiology and causes in CKD hotspots, beginning with Australian Aboriginals in this issue. An online map of CKD hotspots around the world will feature the reviewed hotspots, highlighting known or suspected causes as well as ongoing projects to unravel the cause and providing a directory of public health officials, physicians and basic scientists involved in these efforts. Since the high prevalence of CKD in a particular region or population may only be known to local physicians, we encourage readers to propose further CKD hotspots to be reviewed. PMID:25859368

  8. Advances in the care of patients with mucinous colorectal cancer.

    PubMed

    Hugen, Niek; Brown, Gina; Glynne-Jones, Robert; de Wilt, Johannes H W; Nagtegaal, Iris D

    2016-06-01

    The majority of colorectal cancers (CRCs) are classified as adenocarcinoma not otherwise specified (AC). Mucinous carcinoma (MC) is a distinct form of CRC and is found in 10-15% of patients with CRC. MC differs from AC in terms of both clinical and histopathological characteristics, and has long been associated with an inferior response to treatment compared with AC. The debate concerning the prognostic implications of MC in patients with CRC is ongoing and MC is still considered an unfavourable and unfamiliar subtype of the disease. Nevertheless, in the past few years epidemiological and clinical studies have shed new light on the treatment and management of patients with MC. Use of a multidisciplinary approach, including input from surgeons, pathologists, oncologists and radiologists, is beginning to lead to more-tailored approaches to patient management, on an individualized basis. In this Review, the authors provide insight into advances that have been made in the care of patients with MC. The prognostic implications for patients with colon or rectal MC are described separately; moreover, the predictive implications of MC regarding responses to commonly used therapies for CRC, such as chemotherapy, radiotherapy and chemoradiotherapy, and the potential for, and severity of, metastasis are also described. PMID:26323388

  9. Differential patient-caregiver opinions of treatment and care for advanced lung cancer patients.

    PubMed

    Zhang, Amy Y; Zyzanski, Stephen J; Siminoff, Laura A

    2010-04-01

    This study examined the differences of opinion between cancer patients and caregivers with regard to treatment and care decisions. 184 advanced lung cancer patients and 171 primary caregivers were recruited as a convenience sample from hospitals in Cleveland, Ohio. A telephone interview was conducted to collect data using a semi-structured questionnaire. Nonparametric tests and regression analysis were performed. The findings showed that patients and caregivers reported significant disagreement on three main issues: trade-off between treatment side effects and benefits; reporting treatment side effects to physicians, and hospice care. Caregivers were more concerned about patient's quality of life and more willing to discuss hospice issues than were patients (p < or = 01). Perceived family disagreement is associated with depression in both patients and caregivers (p < or = 01; R(2)=8%). The study provided empirical evidence for patient-caregiver disagreement about treatment and care decisions and its significant adverse impact on both patients and caregivers. PMID:20137849

  10. Microbiota and the nitrogen cycle: Implications in the development and progression of CVD and CKD.

    PubMed

    Briskey, David; Tucker, Patrick S; Johnson, David W; Coombes, Jeff S

    2016-07-01

    Chronic kidney disease (CKD) is associated with an increased risk of death from cardiovascular disease (CVD). One factor involved in CVD development is nitric oxide (NO), which acts as a powerful vasodilator. NO is produced via the nitrogen cycle, through the reduction of nitrate to nitrite with the process mainly occurring in the mouth by commensal microbiota. People with CKD have compromised microbiota (dysbiosis) with an increased abundance of potentially pathogenic and pro-inflammatory bacteria capable of producing uremic toxins that contribute to CKD development and reduce enzymatic NO production. However, to date, few studies have comprehensively documented the gut or saliva microbiota in the CKD population or investigated the role of NO in people with CKD. This review will discuss NO pathways that are linked to the progression of CKD and CVD and therapeutic options for targeting these pathways. PMID:27164294

  11. Patient Simulation Software to Augment an Advanced Pharmaceutics Course

    PubMed Central

    Schonder, Kristine

    2011-01-01

    Objective To implement and assess the effectiveness of adding a pharmaceutical care simulation program to an advanced therapeutics course. Design PharmaCAL (University of Pittsburgh), a software program that uses a branched-outcome decision making model, was used to create patient simulations to augment lectures given in the course. In each simulation, students were presented with a challenge, given choices, and then provided with consequences specific to their choices. Assessments A survey was administered at the end of the course and students indicated the simulations were enjoyable (92%), easy to use (90%), stimulated interest in critically ill patients (82%), and allowed for application of lecture material (91%). A 5-item presimulation and postsimulation test on the anemia simulation was administered to assess learning. Students answered significantly more questions correctly on the postsimulation test than on the presimulation test (p < 0.001). Seventy-eight percent of students answered the same 5 questions correctly on the final examination. Conclusion Patient simulation software that used a branched-outcome decision model was an effective supplement to class lectures in an advanced pharmaceutics course and was well-received by pharmacy students. PMID:21519411

  12. Integrative Biology Identifies Shared Transcriptional Networks in CKD

    PubMed Central

    Martini, Sebastian; Nair, Viji; Keller, Benjamin J.; Eichinger, Felix; Hawkins, Jennifer J.; Randolph, Ann; Böger, Carsten A.; Gadegbeku, Crystal A.; Fox, Caroline S.; Cohen, Clemens D.

    2014-01-01

    A previous meta-analysis of genome-wide association data by the Cohorts for Heart and Aging Research in Genomic Epidemiology and CKDGen consortia identified 16 loci associated with eGFR. To define how each of these single-nucleotide polymorphisms (SNPs) could affect renal function, we integrated GFR-associated loci with regulatory pathways, producing a molecular map of CKD. In kidney biopsy specimens from 157 European subjects representing nine different CKDs, renal transcript levels for 18 genes in proximity to the SNPs significantly correlated with GFR. These 18 genes were mapped into their biologic context by testing coregulated transcripts for enriched pathways. A network of 97 pathways linked by shared genes was constructed and characterized. Of these pathways, 56 pathways were reported previously to be associated with CKD; 41 pathways without prior association with CKD were ranked on the basis of the number of candidate genes connected to the respective pathways. All pathways aggregated into a network of two main clusters comprising inflammation- and metabolism-related pathways, with the NRF2-mediated oxidative stress response pathway serving as the hub between the two clusters. In all, 78 pathways and 95% of the connections among those pathways were verified in an independent North American biopsy cohort. Disease-specific analyses showed that most pathways are shared between sets of three diseases, with closest interconnection between lupus nephritis, IgA nephritis, and diabetic nephropathy. Taken together, the network integrates candidate genes from genome-wide association studies into their functional context, revealing interactions and defining established and novel biologic mechanisms of renal impairment in renal diseases. PMID:24925724

  13. High Dietary Acid Load Predicts ESRD among Adults with CKD.

    PubMed

    Banerjee, Tanushree; Crews, Deidra C; Wesson, Donald E; Tilea, Anca M; Saran, Rajiv; Ríos-Burrows, Nilka; Williams, Desmond E; Powe, Neil R

    2015-07-01

    Small clinical trials have shown that a reduction in dietary acid load (DAL) improves kidney injury and slows kidney function decline; however, the relationship between DAL and risk of ESRD in a population-based cohort with CKD remains unexamined. We examined the association between DAL, quantified by net acid excretion (NAEes), and progression to ESRD in a nationally representative sample of adults in the United States. Among 1486 adults with CKD age≥20 years enrolled in the National Health and Nutrition Examination Survey III, DAL was determined by 24-h dietary recall questionnaire. The development of ESRD was ascertained over a median 14.2 years of follow-up through linkage with the Medicare ESRD Registry. We used the Fine-Gray competing risks method to estimate the association of high, medium, and low DAL with ESRD after adjusting for demographics, nutritional factors, clinical factors, and kidney function/damage markers and accounting for intervening mortality events. In total, 311 (20.9%) participants developed ESRD. Higher levels of DAL were associated with increased risk of ESRD; relative hazards (95% confidence interval) were 3.04 (1.58 to 5.86) for the highest tertile and 1.81 (0.89 to 3.68) for the middle tertile compared with the lowest tertile in the fully adjusted model. The risk of ESRD associated with DAL tertiles increased as eGFR decreased (P trend=0.001). Among participants with albuminuria, high DAL was strongly associated with ESRD risk (P trend=0.03). In conclusion, high DAL in persons with CKD is independently associated with increased risk of ESRD in a nationally representative population. PMID:25677388

  14. Cost-effectiveness of Simvastatin plus Ezetimibe for Cardiovascular Prevention in CKD: Results of the Study of Heart and Renal Protection (SHARP)

    PubMed Central

    Mihaylova, Borislava; Schlackow, Iryna; Herrington, William; Lozano-Kühne, Jingky; Kent, Seamus; Emberson, Jonathan; Reith, Christina; Haynes, Richard; Cass, Alan; Craig, Jonathan; Gray, Alastair; Collins, Rory; Landray, Martin J.; Baigent, Colin; Collins, R.; Baigent, C.; Landray, M.J.; Bray, C.; Chen, Y.; Baxter, A.; Young, A.; Hill, M.; Knott, C.; Cass, A.; Feldt-Rasmussen, B.; Fellström, B.; Grobbee, D.E.; Grönhagen-Riska, C.; Haas, M.; Holdaas, H.; Hooi, L.S.; Jiang, L.; Kasiske, B.; Krairittichai, U.; Levin, A.; Massy, Z.A.; Tesar, V.; Walker, R.; Wanner, C.; Wheeler, D.C.; Wiecek, A.; Dasgupta, T.; Herrington, W.; Lewis, D.; Mafham, M.; Majoni, W.; Reith, C.; Emberson, J.; Parish, S.; Simpson, D.; Strony, J.; Musliner, T.; Agodoa, L.; Armitage, J.; Chen, Z.; Craig, J.; de Zeeuw, D.; Gaziano, J.M.; Grimm, R.; Krane, V.; Neal, B.; Ophascharoensuk, V.; Pedersen, T.; Sleight, P.; Tobert, J.; Tomson, C.

    2016-01-01

    Background Simvastatin, 20 mg, plus ezetimibe, 10 mg, daily (simvastatin plus ezetimibe) reduced major atherosclerotic events in patients with moderate to severe chronic kidney disease (CKD) in the Study of Heart and Renal Protection (SHARP), but its cost-effectiveness is unknown. Study Design Cost-effectiveness of simvastatin plus ezetimibe in SHARP, a randomized controlled trial. Setting & Population 9,270 patients with CKD randomly assigned to simvastatin plus ezetimibe versus placebo; participants in categories by 5-year cardiovascular risk (low, <10%; medium, 10%-<20%; or high, ≥20%) and CKD stage (3, 4, 5 not on dialysis, or on dialysis therapy). Model, Perspective, & Timeline Assessment during SHARP follow-up from the UK perspective; long-term projections. Intervention Simvastatin plus ezetimibe (2015 UK £1.19 per day) during 4.9 years’ median follow-up in SHARP; scenario analyses with high-intensity statin regimens (2015 UK £0.05-£1.06 per day). Outcomes Additional health care costs per major atherosclerotic event avoided and per quality-adjusted life-year (QALY) gained. Results In SHARP, the proportional reductions per 1 mmol/L of low-density lipoprotein (LDL) cholesterol reduction with simvastatin plus ezetimibe in all major atherosclerotic events of 20% (95% CI, 6%-32%) and in the costs of vascular hospital episodes of 17% (95% CI, 4%-28%) were similar across participant categories by cardiovascular risk and CKD stage. The 5-year reduction in major atherosclerotic events per 1,000 participants ranged from 10 in low-risk to 58 in high-risk patients and from 28 in CKD stage 3 to 36 in patients on dialysis therapy. The net cost per major atherosclerotic event avoided with simvastatin plus ezetimibe compared to no LDL-lowering regimen ranged from £157,060 in patients at low risk to £15,230 in those at high risk (£30,500-£39,600 per QALY); and from £47,280 in CKD stage 3 to £28,180 in patients on dialysis therapy (£13,000-£43,300 per QALY

  15. Prognostic Importance of Serum Alkaline Phosphatase in CKD Stages 3–4 in a Clinical Population

    PubMed Central

    Taliercio, Jonathan J.; Schold, Jesse D.; Simon, James F.; Arrigain, Susana; Tang, Anne; Saab, Georges; Nally, Joseph V.; Navaneethan, Sankar D.

    2013-01-01

    Background Elevated total serum alkaline phosphatase (ALP) levels have been associated with mortality in the general population and in dialysis patients. Study Design Retrospective cohort study. Setting & Participants 28,678 patients with chronic kidney disease (CKD) stages 3 and 4 (estimated glomerular filtration rate [eGFR], 15–59 ml/min/1.73 m2) were identified using the Cleveland Clinic Chronic Kidney Disease Registry. CKD was defined as two eGFR values <60 ml/min/1.73 m2 drawn >90 days apart using the Chronic Kidney Disease Epidemiology Collaboration creatinine equation. Predictor ALP levels measured using the calorimetric assay was examined as quartiles (quartile 1, <66 U/L; Q2, 66–81 U/L; Q3, 82–101 U/L; and Q4, ≥102 U/L) and as a continuous measure. Outcomes & Measurements All-cause mortality and ESRD were ascertained using the Social Security Death Index and US Renal Data System. Results After a median follow up of 2.2 years, 588 patients progressed to ESRD and 4,755 died. There was a graded increase in the risk for mortality with higher ALP quartiles (Q2, Q3, Q4) when compared to the reference quartile (Q1) after adjusting for demographics, comorbid conditions, use of relevant medications and liver function tests. The highest quartile of ALP was associated with a hazard ratio for ESRD of 1.38 (95% CI, 1.09–1.76). Each 1-standard deviation (42.7 U/L) higher ALP level was associated with 15% (95% CI, 1.09–1.22) and 16% (95% CI, 1.14–1.18) increased risk of ESRD and mortality respectively. Limitations Single center observational study, lack complete data including PTH for all study participants and attrition bias. Conclusions Higher serum ALP levels in CKD stages 3–4 were independently associated with all-cause mortality and ESRD. PMID:23769134

  16. Renoprotection and the Bardoxolone Methyl Story - Is This the Right Way Forward? A Novel View of Renoprotection in CKD Trials: A New Classification Scheme for Renoprotective Agents.

    PubMed

    Onuigbo, Macaulay

    2013-01-01

    In the June 2011 issue of the New England Journal of Medicine, the BEAM (Bardoxolone Methyl Treatment: Renal Function in CKD/Type 2 Diabetes) trial investigators rekindled new interest and also some controversy regarding the concept of renoprotection and the role of renoprotective agents, when they reported significant increases in the mean estimated glomerular filtration rate (eGFR) in diabetic chronic kidney disease (CKD) patients with an eGFR of 20-45 ml/min/1.73 m(2) of body surface area at enrollment who received the trial drug bardoxolone methyl versus placebo. Unfortunately, subsequent phase IIIb trials failed to show that the drug is a safe alternative renoprotective agent. Current renoprotection paradigms depend wholly and entirely on angiotensin blockade; however, these agents [angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs)] have proved to be imperfect renoprotective agents. In this review, we examine the mechanistic limitations of the various previous randomized controlled trials on CKD renoprotection, including the paucity of veritable, elaborate and systematic assessment methods for the documentation and reporting of individual patient-level, drug-related adverse events. We review the evidence base for the presence of putative, multiple independent and unrelated pathogenetic mechanisms that drive (diabetic and non-diabetic) CKD progression. Furthermore, we examine the validity, or lack thereof, of the hyped notion that the blockade of a single molecule (angiotensin II), which can only antagonize the angiotensin cascade, would veritably successfully, consistently and unfailingly deliver adequate and qualitative renoprotection results in (diabetic and non-diabetic) CKD patients. We clearly posit that there is this overarching impetus to arrive at the inference that multiple, disparately diverse and independent pathways, including any veritable combination of the mechanisms that we examine in this review, and many

  17. Renoprotection and the Bardoxolone Methyl Story – Is This the Right Way Forward? A Novel View of Renoprotection in CKD Trials: A New Classification Scheme for Renoprotective Agents

    PubMed Central

    Onuigbo, Macaulay

    2013-01-01

    In the June 2011 issue of the New England Journal of Medicine, the BEAM (Bardoxolone Methyl Treatment: Renal Function in CKD/Type 2 Diabetes) trial investigators rekindled new interest and also some controversy regarding the concept of renoprotection and the role of renoprotective agents, when they reported significant increases in the mean estimated glomerular filtration rate (eGFR) in diabetic chronic kidney disease (CKD) patients with an eGFR of 20-45 ml/min/1.73 m2 of body surface area at enrollment who received the trial drug bardoxolone methyl versus placebo. Unfortunately, subsequent phase IIIb trials failed to show that the drug is a safe alternative renoprotective agent. Current renoprotection paradigms depend wholly and entirely on angiotensin blockade; however, these agents [angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs)] have proved to be imperfect renoprotective agents. In this review, we examine the mechanistic limitations of the various previous randomized controlled trials on CKD renoprotection, including the paucity of veritable, elaborate and systematic assessment methods for the documentation and reporting of individual patient-level, drug-related adverse events. We review the evidence base for the presence of putative, multiple independent and unrelated pathogenetic mechanisms that drive (diabetic and non-diabetic) CKD progression. Furthermore, we examine the validity, or lack thereof, of the hyped notion that the blockade of a single molecule (angiotensin II), which can only antagonize the angiotensin cascade, would veritably successfully, consistently and unfailingly deliver adequate and qualitative renoprotection results in (diabetic and non-diabetic) CKD patients. We clearly posit that there is this overarching impetus to arrive at the inference that multiple, disparately diverse and independent pathways, including any veritable combination of the mechanisms that we examine in this review, and many

  18. Audit-based education lowers systolic blood pressure in chronic kidney disease: the Quality Improvement in CKD (QICKD) trial results

    PubMed Central

    de Lusignana, Simon; Gallagher, Hugh; Jones, Simon; Chan, Tom; van Vlymen, Jeremy; Tahir, Aumran; Thomas, Nicola; Jain, Neerja; Dmitrieva, Olga; Rafi, Imran; McGovern, Andrew; Harris, Kevin

    2013-01-01

    Strict control of systolic blood pressure is known to slow progression of chronic kidney disease (CKD). Here we compared audit-based education (ABE) to guidelines and prompts or usual practice in lowering systolic blood pressure in people with CKD. This 2-year cluster randomized trial included 93 volunteer general practices randomized into three arms with 30 ABE practices, 32 with guidelines and prompts, and 31 usual practices. An intervention effect on the primary outcome, systolic blood pressure, was calculated using a multilevel model to predict changes after the intervention. The prevalence of CKD was 7.29% (41,183 of 565,016 patients) with all cardiovascular comorbidities more common in those with CKD. Our models showed that the systolic blood pressure was significantly lowered by 2.41 mm Hg (CI 0.59–4.29 mm Hg), in the ABE practices with an odds ratio of achieving at least a 5 mm Hg reduction in systolic blood pressure of 1.24 (CI 1.05–1.45). Practices exposed to guidelines and prompts produced no significant change compared to usual practice. Male gender, ABE, ischemic heart disease, and congestive heart failure were independently associated with a greater lowering of systolic blood pressure but the converse applied to hypertension and age over 75 years. There were no reports of harm. Thus, individuals receiving ABE are more likely to achieve a lower blood pressure than those receiving only usual practice. The findings should be interpreted with caution due to the wide confidence intervals. PMID:23536132

  19. Maximizing cochlear implant patients' performance with advanced speech training procedures.

    PubMed

    Fu, Qian-Jie; Galvin, John J

    2008-08-01

    Advances in implant technology and speech processing have provided great benefit to many cochlear implant patients. However, some patients receive little benefit from the latest technology, even after many years' experience with the device. Moreover, even the best cochlear implant performers have great difficulty understanding speech in background noise, and music perception and appreciation remain major challenges. Recent studies have shown that targeted auditory training can significantly improve cochlear implant patients' speech recognition performance. Such benefits are not only observed in poorly performing patients, but also in good performers under difficult listening conditions (e.g., speech noise, telephone speech, music, etc.). Targeted auditory training has also been shown to enhance performance gains provided by new implant devices and/or speech processing strategies. These studies suggest that cochlear implantation alone may not fully meet the needs of many patients, and that additional auditory rehabilitation may be needed to maximize the benefits of the implant device. Continuing research will aid in the development of efficient and effective training protocols and materials, thereby minimizing the costs (in terms of time, effort and resources) associated with auditory rehabilitation while maximizing the benefits of cochlear implantation for all recipients. PMID:18295992

  20. Dose equivalence between continuous erythropoietin receptor activator (CERA), Darbepoetin and Epoetin in patients with advanced chronic kidney disease

    PubMed Central

    Vega, A; Abad, S; Verdalles, U; Aragoncillo, I; Velazquez, K; Quiroga, B; Escudero, V; López-Gómez, JM

    2014-01-01

    Background: Anemia is a prevalent situation in patients with chronic kidney disease (CKD) and can be well managed with erythropoiesis-stimulating agents (ESAs). Continuous erythropoietin receptor activator (CERA) has a long half-life that allows to be administered once monthly. The lowest recommended dose for patients with non dialysis CKD is 120 μg per month. The objectives were to assess the efficacy of subcutaneous monthly dosing of CERA in CKD stages 4 and 5 not on dialysis, and to determine the equivalent dose to epoetin β and darbepoetin α. Methods: This is a cohort study. A 30-patient group that ESAs was changed to CERA (μg/month) was used as treatment group. We used the following clinically-based equivalent dosing: epoetin β (IU/week) and darbepoetin α (μg/week): 3000/15= 50; 4000/20=75; 6000/30=100; 8000/40=150. Another group of 30 patients with similar characteristics was used as control group and received the same epoetin β and darbepoetin α doses. Results: The mean CERA initial dose and at 6 months was 81.9 ± 35.2 and 82.0 ± 37.82 μg/month (p=0.37). The mean erythropoietin resistance index (ERI) and hemoglobin at baseline and at 6 months in the CERA group and in the control group were not statistically significant. Conclusion: Monthly dosing treatment with CERA is safe and effective. A dose of 75-100 μg/month is enough to maintain stable levels of hemoglobin. Hippokratia 2014; 18 (4): 315-318. PMID:26052197

  1. Advance Care Planning Beyond Advance Directives: Perspectives from Patients and Surrogates

    PubMed Central

    McMahan, Ryan; Knight, Sara J.; Fried, Terri R.; Sudore, Rebecca L.

    2014-01-01

    Context Advance care planning (ACP) has focused on documenting life-sustaining treatment preferences in advance directives (ADs). ADs alone may be insufficient to prepare diverse patients and surrogates for complex medical decisions. Objectives To understand what steps best prepare patients and surrogates for decision making. Methods We conducted 13 English/Spanish focus groups with participants from a Veterans Affairs and county hospital and the community. Seven groups included patients (n=38) aged ≥65 years, who reported making serious medical decisions. Six separate groups included surrogates (n=31), aged ≥18 years, who made decisions for others. Semi-structured focus groups asked what activities best prepared participants for decision making. Two investigators independently coded data and performed thematic content analysis. Disputes were resolved by consensus. Results Mean±SD patient age was 78±8 years and 61% were non-white. Mean±SD surrogate age was 57±10 years and 91% were non-white. Qualitative analysis identified four overarching themes about how to best prepare for decision making: 1) identify values based on past experiences and quality of life, 2) choose surrogates wisely and verify they understand their role, 3) decide whether to grant leeway in surrogate decision making, and 4) inform other family and friends of one's wishes to prevent conflict. Conclusion Beyond ADs, patients and surrogates recommend several additional steps to prepare for medical decision making including using past experiences to identify values, verifying the surrogate understands their role, deciding whether to grant surrogates leeway, and informing other family and friends of one's wishes. Future ACP interventions should consider incorporating these additional ACP activities. PMID:23200188

  2. [Advanced directives document and neurologist-patient relationship].

    PubMed

    Boada Rovira, M

    2004-12-01

    Perception of health and disease, pain and suffering, quality of life, personal relationships, privacy and intimacy, culture and social values, can now be stated in a written document, by way of a living will, giving legal legitimacy to each patient's way of being and understanding life, to be used when the subject cannot express it by him/herself. In this way, the patients will participate in the therapeutic process and will incorporate their desires and decisions through the Informed Consent and the Advanced Directives Document (ADD). Both documents translate and indicate how to treat and care for a patient who will progressively lose his/her cognitive faculties and others will decided for him/her, in the case of dementias. The basis of ADD is respect and promotion of the patient's autonomy, prolonging his/her right to decide in the stages in which he/she cannot do it. It consists in some instructions or orientations for the patient to be cared for in a certain way, according to his/her will. To this effect, a representative will be named who will act in the subject's name and who will help to interpret and make decisions when the patient cannot. Specifically, in Alzheimer's disease, ADD allows the patient to decide, in full lucidity, freedom and autonomy, how to live a progressive and irreversible disease. Explicit mention can be made to the will of making his/her disease known publically or not, the care of its aspect, privacy, type of care, whether institutionalized or home care, limitation of visits, treatment intensity and prolongation, palliative cares, donation of biological samples, participation in drug clinical trials. PMID:15719290

  3. Preoperative Imatinib Treatment in Patients With Advanced Gastrointestinal Stromal Tumors: Patient Experiences and Systematic Review of 563 Patients

    PubMed Central

    Xu, Jia; Ling, Tian-Long; Wang, Ming; Zhao, Wen-Yi; Cao, Hui

    2015-01-01

    Preoperative IM therapy for GIST is now a research focus. Due to the low incidence of the disease, there are few RCTs on the preoperative treatment for advanced GIST, let alone relevant meta-analysis. Efficacy of this therapy and targeting population are still undetermined. Therefore, the first part of this article is composed of a controlled retrospective study and demonstrates that preoperative therapy with IM can significantly improve the outcome of advanced GIST. In the second part of the paper, we further investigated what portion of advanced GIST patients benefit more from the therapy, based on a meta-analysis. As the disease is relatively rare, we involved 563 cases in the meta-analysis, much higher than in the controlled clinical studies (51 cases). The objective of this paper is to investigate effects of surgical resection on imatinib-treated advanced GIST. Twenty-two consecutive advanced GIST patients (Group A) with preoperative IM treatment were compared to 29 patients (Group B) who underwent initial tumor resection during the same period. Subsequently, a systematic review of 563 patients was applied to identify the benefit of the advanced GIST patients receiving imatinib before surgery. Compared with Group B, less patients in Group A underwent multivisceral resection (18.2% versus 48.3%, P = 0.026) or suffered tumor rupture at time of surgery (0% versus 17.2%, P = 0.04). The 3-year estimated progression-free survival of Group A (94.4%) was also superior to that of Group B (61.4%; P = 0.045). Subsequent meta-analysis indicated that primarily unresectable patients had higher complete resection and 2-year PFS rates than recurrent/metastasis patients (P = 0.005 and 0.20, respectively); (b) stable disease (SD) patients had better outcome in resection including resectability rate (P < 0.0001), PFS (P < 0.00001) and OS (P = 0.0008) than progressive disease (PD) patients; (c) in recurrent/metastatic PD patients, surgery played a minor role, because they had a

  4. Designing a web-application to support home-based care of childhood CKD stages 3-5: Qualitative study of family and professional preferences

    PubMed Central

    2014-01-01

    Background There is a lack of online, evidence-based information and resources to support home-based care of childhood CKD stages 3-5. Methods Qualitative interviews were undertaken with parents, patients and professionals to explore their views on content of the proposed online parent information and support (OPIS) web-application. Data were analysed using Framework Analysis, guided by the concept of Self-efficacy. Results 32 parents, 26 patients and 12 professionals were interviewed. All groups wanted an application that explains, demonstrates, and enables parental clinical care-giving, with condition-specific, continously available, reliable, accessible material and a closed communication system to enable contact between families living with CKD. Professionals advocated a regularly updated application to empower parents to make informed health-care decisions. To address these requirements, key web-application components were defined as: (i) Clinical care-giving support (information on treatment regimens, video-learning tools, condition-specific cartoons/puzzles, and a question and answer area) and (ii) Psychosocial support for care-giving (social-networking, case studies, managing stress, and enhancing families’ health-care experiences). Conclusions Developing a web-application that meets parents’ information and support needs will maximise its utility, thereby augmenting parents’ self-efficacy for CKD caregiving, and optimising outcomes. Self-efficacy theory provides a schema for how parents’ self-efficacy beliefs about management of their child’s CKD could potentially be promoted by OPIS. PMID:24548640

  5. Clinical and Practical Use of Calcimimetics in Dialysis Patients With Secondary Hyperparathyroidism.

    PubMed

    Bover, Jordi; Ureña, Pablo; Ruiz-García, César; daSilva, Iara; Lescano, Patricia; del Carpio, Jacqueline; Ballarín, José; Cozzolino, Mario

    2016-01-01

    CKD and CKD-related mineral and bone disorders (CKD-MBDs) are associated with high cardiovascular and mortality risks. In randomized clinical trials (RCTs), no single drug intervention has been shown to reduce the high mortality risk in dialysis patients, but several robust secondary analyses point toward important potential beneficial effects of controlling CKD-MBD-related factors and secondary hyperparathyroidism. The advent of cinacalcet, which has a unique mode of action at the calcium-sensing receptor, represented an important step forward in controlling CKD-MBD. In addition, new RCTs have conclusively shown that cinacalcet improves achievement of target levels for all of the metabolic abnormalities associated with CKD-MBD and may also attenuate the progression of vascular and valvular calcifications in dialysis patients. However, a final conclusion on the effect of cinacalcet on hard outcomes remains elusive. Tolerance of cinacalcet is limited by frequent secondary side effects such as nausea, vomiting, hypocalcemia and oversuppression of parathyroid hormone, which may cause some management difficulties, especially for those lacking experience with the drug. Against this background, this review aims to summarize the results of studies on cinacalcet, up to and including the publication of the recent ADVANCE and EVOLVE RCTs, as well as recent post hoc analyses, and to offer practical guidance on how to improve the clinical management of the most frequent adverse events associated with cinacalcet, based on both currently available information and personal experience. In addition, attention is drawn to less common secondary effects of cinacalcet treatment and advisable precautions. PMID:26224878

  6. How to Read a Food Label: Tips for People with Chronic Kidney Disease (CKD)

    MedlinePlus

    ... to Read a Tips for People with Chronic Kidney Disease (CKD) National Kidney Disease Education Program If you have CKD, you may ... 4 KIDNEY (1-866-454-3639). The National Kidney Disease Education Program (NKDEP) encourages people to get tested ...

  7. Hepatocellular carcinoma in patients with chronic kidney disease

    PubMed Central

    Lee, Chern-Horng; Hsieh, Sen-Yung; Lin, Ja-Liang; Liu, Maw-Sen; Yen, Tzung-Hai

    2013-01-01

    AIM: To investigate outcomes of hepatocellular carcinomas (HCCs) in patients with chronic kidney disease (CKD). METHODS: Four hundred and forty patients referred between 2000 and 2002 for management of HCCs were categorized according to their CKD stage, i.e., estimated glomerular filtration rate (eGFR) > 90 (stage 1), 60-90 (stage 2), 30-60 (stage 3), 15-30 (stage 4), and < 15 (stage 5) mL/min per 1.73 m2, respectively. Demographic, clinical and laboratory data were collected and mortality rates and cause of mortality were analyzed. The mortality data were examined with Kaplan-meier method and the significance was tested using a log-rank test. An initial univariate Cox regression analysis was performed to compare the frequency of possible risk factors associated with mortality. To control for possible confounding factors, a multivariate Cox regression analysis (stepwise backward approach) was performed to analyze those factors that were significant in univariate models (P < 0.05) and met the assumptions of a proportional hazard model. RESULTS: Most HCC patients with CKD were elderly, with mean age of diagnosis of 60.6 ± 11.9 years, and mostly male (74.8%). Hepatitis B, C and B and C co-infection virus were positive in 61.6%, 45.7% and 14.1% of the patients, respectively. It was found that patients with stages 4 and 5 CKD were not only older (P = 0.001), but also had higher hepatitis C virus carrier rate (P = 0.001), lower serum albumin level (P = 0.001), lower platelet count (P = 0.037), longer prothrombin time (P = 0.001) as well as higher proportions of advanced cirrhosis (P = 0.002) and HCCs (P = 0.001) than patients with stages 1 and 2 CKD. At the end of analysis, 162 (36.9%) patients had died. Kaplan-Meier analysis revealed that patients with stages 4 and 5 CKD suffered lower cumulative survival than stages 1 and 2 CKD (log-rank test, χ2 = 11.764, P = 0.003). In a multivariate Cox-regression model, it was confirmed that CKD stage [odds ratio (OR) = 1.988, 95

  8. Integrative and complementary therapies for patients with advanced cancer.

    PubMed

    Marchand, Lucille

    2014-07-01

    In integrative medicine, well-being is emphasized, and in palliative care, quality of life (QOL) is a similar concept or goal. Both can occur despite advanced cancer. Integrative medicine serves to combine the best of alternative, complementary and conventional therapies to optimize well-being and QOL, whether or not a person is at the end of their life. When integrative medicine is combined with palliative care modalities, the toolbox to provide symptom control and well-being or QOL is increased or broadened. Palliative care and integrative medicine are best provided early in the trajectory of illness such as cancer, and increase in amount as the illness progresses toward end of life. In cancer care, symptoms of the cancer, as well as symptoms produced by cancer therapies, are addressed with conventional and integrative therapies. Goals of care change as the disease progresses, and a patient's unique situation creates a different balance of integrative and conventional therapies. Integrative therapies such as music, aromatherapy, and massage might appeal to more patients than more specific, less common integrative therapies that might be more expensive, or seem more unusual such as Ayurvedic medicine and energy modalities. Each person may be drawn to different integrative modalities depending on factors such as cultural traditions, beliefs, lifestyle, internet information, advice from family and friends, books, etc. This review focuses on how integrative and complementary modalities can be included in comprehensive palliative care for patients with advanced malignancies. Nutrition and movement, often neglected in conventional treatment strategies, will also be included in the larger context of integrative and palliative modalities. Both conventional and integrative modalities in palliative care help patients live with empowerment, hope, and well-being no matter how long their lives last. A comprehensive review of all integrative and complementary therapies is

  9. Advances in the management of patients with thyroid disease.

    PubMed

    Dworkin, H J; Meier, D A; Kaplan, M

    1995-07-01

    Discoveries related to thyroid immunology, especially concerning the thyroid-stimulating hormone (TSH) receptor, may facilitate new immunologic approaches to the therapy of Graves' disease and the thyroiditis syndromes. Advances in genetics are being applied to the thyroid hormone resistance syndromes and papillary and medullary carcinomas. The development of ever more sensitive TSH assays has led to the detection of subclinical thyroid disease, which has special implications for the sick and elderly patients. Sensitive TSH assays also allow more precise titration of levothyroxine (T4) dosages, especially for patients with a past history of thyroid cancer. Evidence continues to accumulate suggesting that postmenopausal women on T4 doses that suppress the TSH level below 0.1 ulU/mL have lower bone mineral density than matched patients with healthy TSH levels. Also, pregnant hypothyroid women need higher T4 doses to normalize the TSH levels. In the evaluation of thyroid nodules, fine-needle aspiration biopsy is the single most definitive modality in selecting the patients for surgery. Scintigraphy provides a complimentary role, especially in defining autonomously functioning thyroid adenomas (AFTA), because these should not be treated with T4 suppression. Ultrasound-guided needle biopsy is occasionally helpful with nodules that are difficult to palpate. Concern for possible tracheal compression after treatment of toxic multinodular goiter with large doses of radioactive iodine (I-131) in the range of 50 to 150 mCi (1.85 to 5.5 GBq) does not seem warranted. Work, primarily out of Italy, suggests AFTA can be ablated with repeat ethanol injections. Residual tissues after thyroidectomy for differentiated carcinoma can be "stunned" by tracer doses of 131I greater than 3.0 mCi (111 MBq), which diminishes the uptake and effectiveness of a subsequent therapy dose. Positron emission tomograph, imaging with thallium-201, and Technetium 99m Sestamibi can identify a small number

  10. Patient education for phosphorus management in chronic kidney disease

    PubMed Central

    Kalantar-Zadeh, Kamyar

    2013-01-01

    Objectives: This review explores the challenges and solutions in educating patients with chronic kidney disease (CKD) to lower serum phosphorus while avoiding protein insufficiency and hypercalcemia. Methods: A literature search including terms “hyperphosphatemia,” “patient education,” “food fatigue,” “hypercalcemia,” and “phosphorus–protein ratio” was undertaken using PubMed. Results: Hyperphosphatemia is a strong predictor of mortality in advanced CKD and is remediated via diet, phosphorus binders, and dialysis. Dietary counseling should encourage the consumption of foods with the least amount of inorganic or absorbable phosphorus, low phosphorus-to-protein ratios, and adequate protein content, and discourage excessive calcium intake in high-risk patients. Emerging educational initiatives include food labeling using a “traffic light” scheme, motivational interviewing techniques, and the Phosphate Education Program – whereby patients no longer have to memorize the phosphorus content of each individual food component, but only a “phosphorus unit” value for a limited number of food groups. Phosphorus binders are associated with a clear survival advantage in CKD patients, overcome the limitations associated with dietary phosphorus restriction, and permit a more flexible approach to achieving normalization of phosphorus levels. Conclusion: Patient education on phosphorus and calcium management can improve concordance and adherence and empower patients to collaborate actively for optimal control of mineral metabolism. PMID:23667310

  11. Recent Clinical Trials of Pharmacologic Cardiovascular Interventions in Patients with Chronic Kidney Disease: An Update.

    PubMed

    Nataatmadja, Melissa; Cho, Yeoungjee; Fahim, Magid; Johnson, David W

    2016-01-01

    As a consequence of both traditional and non-traditional risk factors, cardiovascular disease is over-represented, and the leading cause of mortality, among patients with Chronic Kidney Disease (CKD). Whilst recommendations for reducing cardiovascular risk in the general population exist, their applicability to the CKD population is questionable due to the exclusion of CKD patients from the majority of contemporary cardiovascular interventional studies. The aim of this review is to critically evaluate the literature regarding pharmacologic cardiovascular interventions in patients with CKD, with an emphasis on studies published since our 2008 review. Interventions discussed include erythropoiesis-stimulating agents (TREAT, U.S. Normal Hematocrit, CHOIR, CREATE, Palmer meta-analysis); statins (SHARP, AURORA, PPP, 4D, ALERT); Fibrates (VA-HIT); Folic Acid (ASFAST, US FOLIC acid trial, HOST); Antihypertensive Agents, Including Angiotensin-Converting Enzyme Inhibitors, angiotensin-receptor blockers, Beta-blockers and Combination therapy (Cice et al, FOSDIAL, Agarwal et al, ONTARGET); sevelamer (DCOR); Cinacalcet (ADVANCE, EVOLVE, Cunningham meta-analysis); Anti-oxidants (SPACE, HOPE, ATIC); Aspirin (HOT study re-analysis); vitamin D analogues (PRIMO); and multidisciplinary intervention (LANDMARK). Unfortunately, there remains a paucity of evidence in this area and a large number of methodologically poor quality studies with negative results. It is possible that these interventions do not have the same positive effect in CKD patients due to differences in the pathogenesis driving cardiovascular disease burden, such as altered bone metabolism and calcific vascular disease. Further well-designed studies with appropriately selected study populations and patient level outcomes are required. Until such time, physicians must consider on an individual patient basis the appropriateness of these interventions. PMID:26497837

  12. Advancing chronic kidney disease care: new imperatives for recognition and intervention.

    PubMed

    Szromba, Charlotte; Thies, Mary Ann; Ossman, Sherry Smith

    2002-12-01

    Chronic kidney disease (CKD) affects over 6.2 million people in the U.S. and most commonly results from diabetes and/or hypertension. Patients with CKD have an increased risk of anemia and hypertension. Anemia occurs early in CKD and can be effectively treated with epoetin alfa. Hypertension can be managed with lifestyle modifications and medications. Nurses play a vital role in managing these patients by providing early CKD/anemia screening and intervention, education, patient monitoring, and support for patients and caregivers. PMID:12596604

  13. Erythropoiesis-stimulating Agents and Anemia in Patients with Non-dialytic Chronic Kidney Disease

    PubMed Central

    2016-01-01

    Anemia is common in patients with advanced chronic kidney disease (CKD). Though erythropoiesis-stimulating agents (ESAs) have been strongly endorsed in guidelines, it is of particular financial interest. Recently, the reimbursement of ESAs in non-dialytic patients was started by the Korean National Health Insurance System. Thus, we investigated the impact of the reimbursement of ESAs on the anemia care in non-dialytic CKD patients. Medical records of patients with advanced CKD (estimated GFR <30 mL/min/1.73 m2) were reviewed. Use of ESAs, blood transfusion, and hemoglobin concentrations were analyzed from one year prior to reimbursement to three years following. We used multivariable modified Poisson regression to estimate the utilization prevalence ratio (PRs). A total of 1,791 medical records were analyzed. The proportion of patients receiving ESAs increased from 14.8% before reimbursement to a peak 33.6% in 1 yr after reimbursement; thereafter, ESA use decreased to 22.4% in 3 yr after reimbursement (compared with baseline; PR, 2.19 [95% CI, 1.40-3.42]). In patients with Hb <10 g/dL, the proportion of receiving ESAs increased from 32.1% before reimbursement to 66.7% in 3 yr after reimbursement (compared with baseline; PR, 2.04 [95% CI, 1.25-3.32]). Mean hemoglobin concentrations were 10.06±1.54 g/dL before reimbursement and increased to 10.78±1.51 g/dL in 3 yr after the reimbursement change (P=0.001). However, the requirement of blood transfusion was not changed over time. With the reimbursement of ESAs, the advanced CKD patients were more likely to be treated with ESAs, and the hemoglobin concentrations increased. PMID:26770038

  14. Report on the Workshop and Regular Meeting of the Imode-CKD and Bcmolmed Marie Curie Training and Research Programs.

    PubMed

    Krochmal, Magdalena; Cisek, Katryna; Markoska, Katerina; Spasovski, Goce; Vlahou, Antonia

    2015-01-01

    A Workshop and Regular Meeting of the Marie Curie Training and Research Programs iMODECKD (Identification of the Molecular Determinants of established Chronic Kidney Disease) and BCMolMed (Molecular Medicine for Bladder Cancer) was held from 20-22 March at the Macedonian Academy of Science and Arts (MASA). The meeting was hosted by the participating center University of Skopje (SKO) - Goce Spasovski and MASA - Momir Polenakovic (R. Macedonia). The representative from MASA proteomic research center - Katerina Davalieva (R. Macedonia) had presentation on proteomic research in prostate cancer (PCa). 40 researchers from 13 different countries participated at the meeting. The Workshop was devoted on "Chronic Kidney Disease: Clinical Management issues", and consisted of 15 oral presentations given by nephrologists and experts in the field of CKD. Raymond Vanholder (Belgium) - past president of ERA-EDTA had a keynote lecture on "CKD: Questions that need to be answered and are not (or at least not entirely)". The workshop continued in four sessions with lectures from Alberto Ortiz (Spain), Olivera Stojceva-Taneva (R. Macedonia), Dimitrios Goumenos (Greece), Joachim Beige (Germany), Marian Klinger (Poland), Goce Spasovski (R. Macedonia), Joachim Jankowski (Germany), Adalbert Schiller (Romania), Robert Johnson (USA), Franco Ferrario (Italy), Ivan Rychlik (Czech Republic), Fulvio Magni (Italy) and Giovambattista Capasso (Italy), all covering a training theme. Within the meeting there were two lectures on complimentary skills for ethics in science and career advancement from two principal investigators - Goce Spasovski (R. Macedonia) and Joost Schanstra (France). During the Regular Meeting, 13 PhD students i.e. Early Stage Researchers and one Experienced Researcher from both Programs presented their work and progress within iMODE-CKD and BCMolMed projects. This meeting was a great opportunity to exchange experience and ideas in the field of systems biology approaches and

  15. Association of eGFR-Related Loci Identified by GWAS with Incident CKD and ESRD

    PubMed Central

    Böger, Carsten A.; Gorski, Mathias; Li, Man; Hoffmann, Michael M.; Huang, Chunmei; Yang, Qiong; Teumer, Alexander; Krane, Vera; O'Seaghdha, Conall M.; Kutalik, Zoltán; Wichmann, H.-Erich; Haak, Thomas; Boes, Eva; Coassin, Stefan; Coresh, Josef; Kollerits, Barbara; Haun, Margot; Paulweber, Bernhard; Köttgen, Anna; Li, Guo; Shlipak, Michael G.; Powe, Neil; Hwang, Shih-Jen; Dehghan, Abbas; Rivadeneira, Fernando; Uitterlinden, André; Hofman, Albert; Beckmann, Jacques S.; Krämer, Bernhard K.; Witteman, Jacqueline; Bochud, Murielle; Siscovick, David; Rettig, Rainer; Kronenberg, Florian; Wanner, Christoph; Thadhani, Ravi I.; Heid, Iris M.

    2011-01-01

    Family studies suggest a genetic component to the etiology of chronic kidney disease (CKD) and end stage renal disease (ESRD). Previously, we identified 16 loci for eGFR in genome-wide association studies, but the associations of these single nucleotide polymorphisms (SNPs) for incident CKD or ESRD are unknown. We thus investigated the association of these loci with incident CKD in 26,308 individuals of European ancestry free of CKD at baseline drawn from eight population-based cohorts followed for a median of 7.2 years (including 2,122 incident CKD cases defined as eGFR <60ml/min/1.73m2 at follow-up) and with ESRD in four case-control studies in subjects of European ancestry (3,775 cases, 4,577 controls). SNPs at 11 of the 16 loci (UMOD, PRKAG2, ANXA9, DAB2, SHROOM3, DACH1, STC1, SLC34A1, ALMS1/NAT8, UBE2Q2, and GCKR) were associated with incident CKD; p-values ranged from p = 4.1e-9 in UMOD to p = 0.03 in GCKR. After adjusting for baseline eGFR, six of these loci remained significantly associated with incident CKD (UMOD, PRKAG2, ANXA9, DAB2, DACH1, and STC1). SNPs in UMOD (OR = 0.92, p = 0.04) and GCKR (OR = 0.93, p = 0.03) were nominally associated with ESRD. In summary, the majority of eGFR-related loci are either associated or show a strong trend towards association with incident CKD, but have modest associations with ESRD in individuals of European descent. Additional work is required to characterize the association of genetic determinants of CKD and ESRD at different stages of disease progression. PMID:21980298

  16. Using Adult Learning Concepts To Assist Patients in Completing Advance Directives.

    ERIC Educational Resources Information Center

    Meyer, Rose Mary

    2000-01-01

    Advance directives that enable individuals to control their health care are underused due to lack of patient knowledge. Nurses can teach patients about them using adult learning principles, transformation theory, and skills for learning how to learn. (SK)

  17. Association of Chronic Kidney Disease and Cerebral Small Vessel Disease with Cognitive Impairment in Elderly Patients with Type 2 Diabetes

    PubMed Central

    Umemura, Toshitaka; Kawamura, Takahiko; Umegaki, Hiroyuki; Kawano, Naoko; Mashita, Shinichi; Sakakibara, Toshimasa; Hotta, Nigishi; Sobue, Gen

    2013-01-01

    Background/Aims In recent years, the relationship between chronic kidney disease (CKD) and cognitive impairment has been attracting attention. Cerebral small vessel disease (SVD) is also associated with an increased risk of cognitive impairment. However, it is still unknown whether CKD markers are associated with cognitive impairment independently of SVD in elderly diabetic patients. Methods Seventy-nine type 2 diabetic patients (mean age, 76.0 years) were enrolled in the present study. CKD was defined as the presence of albuminuria and/or a low estimated glomerular filtration rate (eGFR <60 ml/min/1.73 m2). SVD was evaluated by the presence and severity of silent brain infarcts (SBIs) and white matter lesions (WMLs) on brain magnetic resonance imaging. Neuropsychological tests were assessed using four validated cognitive instruments. Results In multiple linear regression analyses, albuminuria was associated with worse modified Stroop Color Word scores (β = 0.284, p = 0.017) and low eGFR was associated with reduced Digit Symbol Substitution scores (β = −0.224, p = 0.026) after adjustment for age, sex, education years, diabetes duration, hypertension, multiple SBIs, and advanced WMLs. In contrast, there were no significant associations between CKD markers and Mini-Mental State Examination or Word Recall scores. Conclusion Our findings suggest that albuminuria and low eGFR are associated with frontal lobe dysfunction independently of SVD in elderly type 2 diabetic patients. PMID:23888167

  18. Deep vein thrombosis in patients with chronic kidney disease.

    PubMed

    Daneschvar, H Leon; Seddighzadeh, Ali; Piazza, Gregory; Goldhaber, Samuel Z

    2008-06-01

    Deep vein thrombosis (DVT) is a poorly understood complication of chronic kidney disease (CKD). The objective of our analysis was to profile DVT patients with and without CKD. We defined CKD as patients requiring dialysis or patients having nephrotic syndrome. We compared 268 patients with CKD (184 patients with dialysis-dependent renal disease and 84 with nephrotic syndrome) to 4,307 patients with preserved renal function from a prospective United States multicenter deep venous thrombosis (DVT) registry. Compared with non-CKD patients, CKD patients with DVT were younger (median age 62 vs. 69 years, p < 0.0001), more often African-American (p < 0.0001), and more often Hispanic (p = 0.0003). CKD patients underwent surgery more frequently in the three months prior to developing DVT (48.9% vs. 39.0%, p = 0.001) and more often had concomitant congestive heart failure (20.9% vs. 14.6%, p = 0.005). CKD patients suffered upper extremity DVT more frequently (30.0% vs. 10.8%, p < 0.0001). Patients with CKD presented less often with typical DVT symptoms of extremity discomfort (42.9% vs. 52.4%, p = 0.003) and difficulty ambulating (5.4% vs. 10.1%, p = 0.01). Prophylaxis rates prior to DVT were similarly low in CKD and non-CKD patients (44.2% vs. 38.0%, p = 0.06). Future studies of DVT in CKD patients should explore novel strategies for improving prophylaxis utilization and the detection of DVT in this special population. PMID:18521505

  19. Hepatitis B Vaccination in Chronic Kidney Disease: Review of Evidence in Non-Dialyzed Patients

    PubMed Central

    Grzegorzewska, Alicja E.

    2012-01-01

    Context Hepatitis B vaccination of hemodialysis patients is performed all over the world. There are also recommendations from world health organizations to vaccinate patients with chronic kidney disease (CKD) prior dialysis commencement, but the implementation of a hepatitis B vaccination program is less common and not well organized. Evidence Acquisition This review article summarizes data indicating why, when and how to vaccinate CKD patients before they start renal replacement therapy. Publication for this review was bringing into being from PubMed. Results There is an agreement in the nephrological societies and among clinicians and scientists that CKD patients should be vaccinated in early stages of their disease, because a higher glomerular filtration rate is more likely to be associated with the responsiveness to vaccination. Schedules of vaccination and optimal vaccine doses are still being investigated. Differences in data with respect to these problems may result from comparisons of various vaccine doses and vaccination schedules without reference to one gold standard, variations in patients` clinical status and glomerular filtration rate, and also the small groups of the affected patients make statistical analysis non-conclusive. A titer of antibodies to surface antigen of hepatitis B virus (anti-HBs) > 10 IU/L or ≥ 10 IU/L is commonly considered as a marker of seroconversion to anti-HBs positivity after vaccination in both non-dialyzed and dialyzed patients. In advanced CKD, vaccine–induced serconversion rate is seldom observed in more than 90% of vaccinees. Various strategies have been utilized in order to increase vaccine-induced seroconversion rate in patients with advanced CKD. Changing the injection mode, the use of adjuvants and immunostimulants to improve the immunogenicity of existing recombinant hepatitis B vaccines, introduction of mammalian-cell derived pre-S/S HBV vaccines (third-generation vaccines) were tried in order to improve the

  20. Normal 25-Hydroxyvitamin D Levels Are Associated with Less Proteinuria and Attenuate Renal Failure Progression in Children with CKD.

    PubMed

    Shroff, Rukshana; Aitkenhead, Helen; Costa, Nikola; Trivelli, Antonella; Litwin, Mieczyslaw; Picca, Stefano; Anarat, Ali; Sallay, Peter; Ozaltin, Fatih; Zurowska, Aleksandra; Jankauskiene, Augustina; Montini, Giovanni; Charbit, Marina; Schaefer, Franz; Wühl, Elke

    2016-01-01

    Angiotensin-converting enzyme inhibitors (ACEi) for renin-angiotensin-aldosterone system (RAAS) blockade are routinely used to slow CKD progression. However, vitamin D may also promote renoprotection by suppressing renin transcription through cross-talk between RAAS and vitamin D-fibroblast growth factor-23 (FGF-23)-Klotho pathways. To determine whether vitamin D levels influence proteinuria and CKD progression in children, we performed a post hoc analysis of the Effect of Strict Blood Pressure Control and ACE Inhibition on Progression of CKD in Pediatric Patients (ESCAPE) cohort. In 167 children (median eGFR 51 ml/min per 1.73 m(2)), serum 25-hydroxyvitamin D (25(OH)D), FGF-23, and Klotho levels were measured at baseline and after a median 8 months on ACEi. Children with lower 25(OH)D levels had higher urinary protein/creatinine ratios at baseline (P=0.03) and at follow-up (P=0.006). Levels of 25(OH)D and serum vitamin D-binding protein were not associated, but 25(OH)D ≤50 nmol/L associated with higher diastolic BP (P=0.004). ACEi therapy also associated with increased Klotho levels (P<0.001). The annualized loss of eGFR was inversely associated with baseline 25(OH)D level (P<0.001, r=0.32). Five-year renal survival was 75% in patients with baseline 25(OH)D ≥50 nmol/L and 50% in those with lower 25(OH)D levels (P<0.001). This renoprotective effect remained significant but attenuated with ACEi therapy (P=0.05). Renal survival increased 8.2% per 10 nmol/L increase in 25(OH)D (P=0.03), independent of eGFR; proteinuria, BP, and FGF-23 levels; and underlying renal diagnosis. In children with CKD, 25(OH)D ≥50 nmol/L was associated with greater preservation of renal function. This effect was present but attenuated with concomitant ACEi therapy. PMID:26069294

  1. Chronic increase of urea leads to carbamylated proteins accumulation in tissues in a mouse model of CKD.

    PubMed

    Pietrement, Christine; Gorisse, Laëtitia; Jaisson, Stéphane; Gillery, Philippe

    2013-01-01

    Carbamylation is a general process involved in protein molecular ageing due to the nonenzymatic binding of isocyanic acid, mainly generated by urea dissociation, to free amino groups. In vitro experiments and clinical studies have suggested the potential involvement of carbamylated proteins (CPs) in chronic kidney disease (CKD) complications like atherosclerosis, but their metabolic fate in vivo is still unknown. To address this issue, we evaluated protein carbamylation in the plasma and tissues of control and 75% nephrectomised C57BL/6J mice by LC-MS/MS assay of homocitrulline, the major carbamylation-derived product (CDP). A basal level of carbamylation was evidenced under all conditions, showing that carbamylation is a physiological process of protein modification in vivo. CP plasma concentrations increased in nephrectomized vs. control mice over the 20 weeks of the experiment (e.g. 335 ± 43 vs. 167 ± 19 μmol homocitrulline/mol lysine (p<0.001) 20 weeks after nephrectomy). Simultaneously, CP content increased roughly by two-fold in all tissues throughout the experiment. The progressive accumulation of CPs was specifically noted in long-lived extracellular matrix proteins, especially collagen (e.g. 1264 ± 123 vs. 726 ± 99 μmol homocitrulline/mol lysine (p<0.01) in the skin of nephrectomized vs. control mice after 20 weeks of evolution). These results show that chronic increase of urea, as seen in CKD, increases the carbamylation rate of plasma and tissue proteins. These results may be considered in the perspective of the deleterious effects of CPs demonstrated in vitro and of the correlation evidenced recently between plasma CPs and cardiovascular risk or mortality in CKD patients. PMID:24324801

  2. Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life.

    PubMed

    Wordingham, Sara E; McIlvennan, Colleen K; Dionne-Odom, J Nicholas; Swetz, Keith M

    2016-02-01

    Care for patients with advanced cardiac disease continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and efforts at improving patient-centered care and shared decision-making. Despite improvements in quality of life and survival with these interventions, optimal supportive care across the advanced illness trajectory remains diverse and heterogeneous. Herein, we outline challenges in prognostication, communication, and caregiving in advanced heart failure and review the unique needs of patients who experience frequent hospitalizations, require chronic home inotropic support, and who have implantable cardioverter-defibrillators and mechanical circulatory support in situ, to name a few. PMID:26829929

  3. A Genetic Biomarker of Oxidative Stress, the Paraoxonase-1 Q192R Gene Variant, Associates with Cardiomyopathy in CKD: A Longitudinal Study

    PubMed Central

    Bouba, I.; Spoto, B.; Pappas, K.; Tripepi, G.; Georgiou, I.; Tselepis, A.; Elisaf, M.; Tsakiris, D.; Zoccali, C.; Siamopoulos, K.

    2016-01-01

    Background. Oxidative stress is a hallmark of CKD and this alteration is strongly implicated in LV hypertrophy and in LV dysfunction. Methods and Patients. We resorted to the strongest genetic biomarker of paraoxonase-1 (PON1) activity, the Q192R variant in the PON1 gene, to unbiasedly assess (Mendelian randomization) the cross-sectional and longitudinal association of this gene-variant with LV mass and function in 206 CKD patients with a 3-year follow-up. Results. The R allele of Q192R polymorphism associated with oxidative stress as assessed by plasma 8-isoPGF2α (P = 0.03) and was dose-dependently related in a direct fashion to LVMI (QQ: 131.4 ± 42.6 g/m2; RQ: 147.7 ± 51.1 g/m2; RR: 167.3 ± 41.9 g/m2; P = 0.001) and in an inverse fashion to systolic function (LV Ejection Fraction) (QQ: 79 ± 12%; RQ: 69 ± 9%; RR: 65 ± 10% P = 0.002). On longitudinal observation, this gene variant associated with the evolution of the same echocardiographic indicators [LVMI: 13.40 g/m2 per risk allele, P = 0.005; LVEF: −2.96% per risk allele, P = 0.001]. Multivariate analyses did not modify these associations. Conclusion. In CKD patients, the R allele of the Q192R variant in the PON1 gene is dose-dependently related to the severity of LVH and LV dysfunction and associates with the longitudinal evolution of these cardiac alterations. These results are compatible with the hypothesis that oxidative stress is implicated in cardiomyopathy in CKD patients. PMID:27313824

  4. Distinguishing Symptoms of Grief and Depression in a Cohort of Advanced Cancer Patients

    ERIC Educational Resources Information Center

    Jacobsen, Juliet C.; Zhang, Baohui; Block, Susan D.; Maciejewski, Paul K.; Prigerson, Holly G.

    2010-01-01

    Several studies have shown that the symptoms of grief are different from symptoms of depression among bereaved family members. This study is an attempt to replicate this finding among advanced cancer patients and examine clinical correlates of patient grief and depression. Analyses were conducted on data from interviews with 123 advanced cancer…

  5. Evaluation of Instrumental Activities of Daily Living in Greek Patients with Advanced Cancer

    ERIC Educational Resources Information Center

    Mystakidou, Kyriaki; Parpa, Efi; Tsilika, Eleni; Panagiotoua, Irene; Roumeliotou, Anna; Symeonidi, Matina; Galanos, Antonis; Kouvaris, Ioannis

    2013-01-01

    Translation of the instrumental activities of daily living (IADL) was carried out and its psychometric properties were assessed in a Greek sample of patients with advanced cancer. The scale was translated with the forward-backward procedure into the Greek language. It was initially administered to 136 advanced cancer patients. To assess…

  6. Improving the Advance Directive Request and Retrieval Process in Critical Access Hospitals: Honoring the Patient's Wishes.

    PubMed

    Jones, Faith M; Sabin, Tawnie L; Torma, Linda M

    2016-01-01

    The Patient Self-Determination Act was created to enhance awareness and use of advance directives. Several states also have created registries where the advance directives can be easily retrieved when needed. Quick retrieval is especially important in critical access hospitals where patients are often transferred to other facilities. This article describes an innovative project designed to improve the advance directives request and retrieval process on admission to a critical access hospital. PMID:26681498

  7. Honey in the Prevention and Treatment of Infection in the CKD Population: A Narrative Review

    PubMed Central

    Francis, Anna; Cho, Yeoungjee; Johnson, David W.

    2015-01-01

    Infection is a major cause of morbidity and mortality at all stages of chronic kidney disease (CKD). Multiresistant organisms are becoming increasingly common, particularly in the CKD population. Unfortunately, the rapid evolution of antibiotic resistance has not been mirrored by innovation in new antibiotic agents. Novel treatments are therefore urgently needed. Honey has garnered much interest due to its broad-spectrum antibacterial properties based on extensive experimental data. Unlike conventional antibiotics, honey has an added advantage as it appears to avoid inducing antimicrobial resistance in bacteria. This review discusses the potential mechanisms of action and role of honey in infection management in the general population, epidemiology and special challenges of infections in CKD populations, and the clinical trial evidence pertaining to the safety and efficacy of honey for the prevention and treatment of infections in CKD population. PMID:26167189

  8. Honey in the Prevention and Treatment of Infection in the CKD Population: A Narrative Review.

    PubMed

    Francis, Anna; Cho, Yeoungjee; Johnson, David W

    2015-01-01

    Infection is a major cause of morbidity and mortality at all stages of chronic kidney disease (CKD). Multiresistant organisms are becoming increasingly common, particularly in the CKD population. Unfortunately, the rapid evolution of antibiotic resistance has not been mirrored by innovation in new antibiotic agents. Novel treatments are therefore urgently needed. Honey has garnered much interest due to its broad-spectrum antibacterial properties based on extensive experimental data. Unlike conventional antibiotics, honey has an added advantage as it appears to avoid inducing antimicrobial resistance in bacteria. This review discusses the potential mechanisms of action and role of honey in infection management in the general population, epidemiology and special challenges of infections in CKD populations, and the clinical trial evidence pertaining to the safety and efficacy of honey for the prevention and treatment of infections in CKD population. PMID:26167189

  9. Mitochondrial dysfunction and oxidative stress in patients with chronic kidney disease.

    PubMed

    Gamboa, Jorge L; Billings, Frederic T; Bojanowski, Matthew T; Gilliam, Laura A; Yu, Chang; Roshanravan, Baback; Roberts, L Jackson; Himmelfarb, Jonathan; Ikizler, T Alp; Brown, Nancy J

    2016-05-01

    Mitochondria abnormalities in skeletal muscle may contribute to frailty and sarcopenia, commonly present in patients with chronic kidney disease (CKD). Dysfunctional mitochondria are also a major source of oxidative stress and may contribute to cardiovascular disease in CKD We tested the hypothesis that mitochondrial structure and function worsens with the severity of CKD Mitochondrial volume density, mitochondrial DNA (mtDNA) copy number, BNIP3, and PGC1α protein expression were evaluated in skeletal muscle biopsies obtained from 27 subjects (17 controls and 10 with CKD stage 5 on hemodialysis). We also measured mtDNA copy number in peripheral blood mononuclear cells (PBMCs), plasma isofurans, and plasma F2-isoprostanes in 208 subjects divided into three groups: non-CKD (eGFR>60 mL/min), CKD stage 3-4 (eGFR 60-15 mL/min), and CKD stage 5 (on hemodialysis). Muscle biopsies from patients with CKD stage 5 revealed lower mitochondrial volume density, lower mtDNA copy number, and higher BNIP3 content than controls. mtDNA copy number in PBMCs was decreased with increasing severity of CKD: non-CKD (6.48, 95% CI 4.49-8.46), CKD stage 3-4 (3.30, 95% CI 0.85-5.75, P = 0.048 vs. non-CKD), and CKD stage 5 (1.93, 95% CI 0.27-3.59, P = 0.001 vs. non-CKD). Isofurans were higher in patients with CKD stage 5 (median 59.21 pg/mL, IQR 41.76-95.36) compared to patients with non-CKD (median 49.95 pg/mL, IQR 27.88-83.46, P = 0.001), whereas F2-isoprostanes did not differ among groups. Severity of CKD is associated with mitochondrial dysfunction and markers of oxidative stress. Mitochondrial abnormalities, which are common in skeletal muscle from patients with CKD stage 5, may explain the muscle dysfunction associated with frailty and sarcopenia in CKD Further studies are required to evaluate mitochondrial function in vivo in patients with different CKD stages. PMID:27162261

  10. Quality Nursing Care for Hospitalized Patients with Advanced Illness: Concept Development

    PubMed Central

    Izumi, Shigeko; Baggs, Judith G.; Knafl, Kathleen A.

    2011-01-01

    The quality of nursing care as perceived by hospitalized patients with advanced illness has not been examined. A concept of quality nursing care for this population was developed by integrating the literature on constructs defining quality nursing care with empirical findings from interviews of 16 patients with advanced illness. Quality nursing care was characterized as competence and personal caring supported by professionalism and delivered with an appropriate demeanor. Although the attributes of competence, caring, professionalism, and demeanor were identified as common components of quality care across various patient populations, the caring domain increased in importance when patients with advanced illness perceived themselves as vulnerable. Assessment of quality nursing care for patients with advanced illness needs to include measures of patient perceptions of vulnerability. PMID:20572095

  11. The roles of the skeleton and phosphorus in the CKD mineral bone disorder.

    PubMed

    Hruska, Keith A; Mathew, Suresh

    2011-03-01

    The CKD mineral bone disorder is a new term coined to describe the multiorgan system failure that is a major component of the excess cardiovascular mortality and morbidity complicating decreased kidney function. This syndrome embodies new discoveries of organ-to-organ communication including the skeletal hormone fibroblast growth factor-23 (FGF-23), which signals the status of skeletal mineral deposition to the kidney. The CKD mineral bone disorder begins with mild decreases in kidney function (stage 2 CKD) affecting the skeleton, as marked by increased FGF-23 secretion. At this stage, the stimulation of cardiovascular risk has begun and the increases in FGF-23 levels are strongly predictive of cardiovascular events. Later in CKD, hyperphosphatemia ensues when FGF-23 and hyperparathyroidism are no longer sufficient to maintain phosphate excretion. Hyperphosphatemia has been shown to be a direct stimulus to several cell types including vascular smooth muscle cells migrating to the neointima of atherosclerotic plaques. Phosphorus stimulates FGF-23 secretion by osteocytes and expression of the osteoblastic transcriptome, thereby increasing extracellular matrix mineralization in atherosclerotic plaques, hypertrophic cartilage, and skeletal osteoblast surfaces. In CKD, the skeleton positively contributes to hyperphosphatemia through excess bone resorption and inhibition of matrix mineralization. Thus, through the action of phosphorus, FGF-23, and other newly discovered skeletal hormones, such as osteocalcin, the skeleton plays an important role in the occurrence of cardiovascular morbidity in CKD. PMID:21406294

  12. Estrogen Deficiency Leads to Further Bone Loss in the Mandible of CKD Mice

    PubMed Central

    Guo, Yuchen; Sun, Ningyuan; Duan, Xiaobo; Xu, Xin; Zheng, Liwei; Seriwatanachai, Dutmanee; Wang, Yongyue; Yuan, Quan

    2016-01-01

    Background Chronic kidney disease (CKD) has been regarded as a grave public health problem. Estrogen is a critical factor for both renal protection and bone remodeling. Our previous study demonstrated that CKD impairs the healing of titanium implants. The aim of this study was to investigate the effects of estrogen deficiency on the mandibular bone in CKD mice. Methods Forty eleven-week-old female C57BL mice were used in this study. Uremia and estrogen deficiency were induced by 5/6 nephrectomy and ovariectomy (OVX), respectively. After 8 weeks, the mice were sacrificed, and their mandibles were collected for micro-CT analysis and histological examination. Results All the mice survived the experimental period. Serum measurements confirmed a significant increase in BUN in the CKD group that was further increased by OVX. OVX led to significant decreases in both the BV/TV and cortical thickness of the mandibular bone in CKD mice. Conclusion In summary, our findings indicate that estrogen deficiency leads to further mandibular bone loss in CKD mice. PMID:26886008

  13. αKlotho Mitigates Progression of AKI to CKD through Activation of Autophagy.

    PubMed

    Shi, Mingjun; Flores, Brianna; Gillings, Nancy; Bian, Ao; Cho, Han Jun; Yan, Shirley; Liu, Yang; Levine, Beth; Moe, Orson W; Hu, Ming Chang

    2016-08-01

    AKI confers increased risk of progression to CKD. αKlotho is a cytoprotective protein, the expression of which is reduced in AKI, but the relationship of αKlotho expression level to AKI progression to CKD has not been studied. We altered systemic αKlotho levels by genetic manipulation, phosphate loading, or aging and examined the effect on long-term outcome after AKI in two models: bilateral ischemia-reperfusion injury and unilateral nephrectomy plus contralateral ischemia-reperfusion injury. Despite apparent initial complete recovery of renal function, both types of AKI eventually progressed to CKD, with decreased creatinine clearance, hyperphosphatemia, and renal fibrosis. Compared with wild-type mice, heterozygous αKlotho-hypomorphic mice (αKlotho haploinsufficiency) progressed to CKD much faster, whereas αKlotho-overexpressing mice had better preserved renal function after AKI. High phosphate diet exacerbated αKlotho deficiency after AKI, dramatically increased renal fibrosis, and accelerated CKD progression. Recombinant αKlotho administration after AKI accelerated renal recovery and reduced renal fibrosis. Compared with wild-type conditions, αKlotho deficiency and overexpression are associated with lower and higher autophagic flux in the kidney, respectively. Upregulation of autophagy protected kidney cells in culture from oxidative stress and reduced collagen 1 accumulation. We propose that αKlotho upregulates autophagy, attenuates ischemic injury, mitigates renal fibrosis, and retards AKI progression to CKD. PMID:26701976

  14. Some Advanced Kidney Cancer Patients May Postpone Treatment

    MedlinePlus

    ... advanced kidney cancer that has spread require immediate, aggressive treatment, a small new study suggests. "A subset ... them the inconvenience and debilitating side effects of aggressive treatments for about a year, and in some ...

  15. Caring for patients with chronic kidney disease: a joint opinion of the ambulatory care and the nephrology practice and research networks of the American College of Clinical Pharmacy.

    PubMed

    Zillich, Alan J; Saseen, Joseph J; Dehart, Renee M; Dumo, Peter; Grabe, Darren W; Gilmartin, Cheryl; Hachey, David M; Hudson, Joanna Q; Pruchnicki, Maria C; Joy, Melanie S

    2005-01-01

    An increasing number of patients are developing chronic kidney disease (CKD). Appropriate care for patients with CKD must occur in the earliest stages, preferably before CKD progresses to more severe stages. Therefore, recognition and treatment of CKD and its associated complications must occur in primary care settings. Patients with CKD often have comorbid conditions such as diabetes mellitus, hypertension, and dyslipidemia, creating specific considerations when treating these diseases. Also, these patients have CKD-related conditions, including anemia and renal osteodystrophy, that are not traditionally evaluated and monitored by the primary care practitioner. Collectively, many opportunities exist for pharmacists who practice in the primary care setting to improve the care of patients with CKD. PMID:15767229

  16. [Electrolyte and acid-base balance disorders in advanced chronic kidney disease].

    PubMed

    Alcázar Arroyo, R

    2008-01-01

    1. The kidneys are the key organs to maintain the balance of the different electrolytes in the body and the acid-base balance. Progressive loss of kidney function results in a number of adaptive and compensatory renal and extrarenal changes that allow homeostasis to be maintained with glomerular filtration rates in the range of 10-25 ml/min. With glomerular filtration rates below 10 ml/min, there are almost always abnormalites in the body's internal environment with clinical repercussions. 2. Water Balance Disorders: In advanced chronic kidney disease (CKD), the range of urine osmolality progressively approaches plasma osmolality and becomes isostenuric. This manifests clinically as symptoms of nocturia and polyuria, especially in tubulointerstitial kidney diseases. Water overload will result in hyponatremia and a decrease in water intake will lead to hypernatremia. Routine analyses of serum Na levels should be performed in all patients with advanced CKD (Strength of Recommendation C). Except in edematous states, a daily fluid intake of 1.5-2 liters should be recommended (Strength of Recommendation C). Hyponatremia does not usually occur with glomerular filtration rates above 10 ml/min (Strength of Recommendation B). If it occurs, an excessive intake of free water should be considered or nonosmotic release of vasopressin by stimuli such as pain, anesthetics, hypoxemia or hypovolemia, or the use of diuretics. Hypernatremia is less frequent than hyponatremia in CKD. It can occur because of the provision of hypertonic parenteral solutions, or more frequently as a consequence of osmotic diuresis due to inadequate water intake during intercurrent disease, or in some circumstance that limits access to water (obtundation, immobility). 3. Sodium Balance Disorders: In CKD, fractional excretion of sodium increases so that absolute sodium excretion is not modified until glomerular filtration rates below 15 ml/min (Strength of Recommendation B). Total body content of sodium is

  17. High burden and unmet patient needs in chronic kidney disease

    PubMed Central

    Braun, LeeAnn; Sood, Vipan; Hogue, Susan; Lieberman, Bonnie; Copley-Merriman, Catherine

    2012-01-01

    Chronic kidney disease (CKD) is a complex debilitating condition affecting more than 70 million people worldwide. With the increased prevalence in risk factors such as diabetes, hypertension, and cardiovascular disease in an aging population, CKD prevalence is also expected to increase. Increased awareness and understanding of the overall CKD burden by health care teams (patients, clinicians, and payers) is warranted so that overall care and treatment management may improve. This review of the burden of CKD summarizes available evidence of the clinical, humanistic, and economic burden of CKD and the current unmet need for new treatments and serves as a resource on the overall burden. Across countries, CKD prevalence varies considerably and is dependent upon patient characteristics. The prevalence of risk factors including diabetes, hypertension, cardiovascular disease, and congestive heart failure is noticeably higher in patients with lower estimated glomerular filtration rates (eGFRs) and results in highly complex CKD patient populations. As CKD severity worsens, there is a subsequent decline in patient health-related quality of life and an increased use of health care resources as well as burgeoning costs. With current treatment, nearly half of patients progress to unfavorable renal and cardiovascular outcomes. Although curative treatment that will arrest kidney deterioration is desired, innovative agents under investigation for CKD to slow kidney deterioration, such as atrasentan, bardoxolone methyl, and spherical carbon adsorbent, may offer patients healthier and more productive lives. PMID:23293534

  18. Comparison of the Schwartz and CKD-EPI Equations for Estimating Glomerular Filtration Rate in Children, Adolescents, and Adults: A Retrospective Cross-Sectional Study

    PubMed Central

    Selistre, Luciano; Rabilloud, Muriel; Cochat, Pierre; de Souza, Vandréa; Iwaz, Jean; Lemoine, Sandrine; Beyerle, Françoise; Poli-de-Figueiredo, Carlos E.; Dubourg, Laurence

    2016-01-01

    Background Estimating kidney glomerular filtration rate (GFR) is of utmost importance in many clinical conditions. However, very few studies have evaluated the performance of GFR estimating equations over all ages and degrees of kidney impairment. We evaluated the reliability of two major equations for GFR estimation, the CKD-EPI and Schwartz equations, with urinary clearance of inulin as gold standard. Methods and Findings The study included 10,610 participants referred to the Renal and Metabolic Function Exploration Unit of Edouard Herriot Hospital (Lyon, France). GFR was measured by urinary inulin clearance (only first measurement kept for analysis) then estimated with isotope dilution mass spectrometry (IDMS)–traceable CKD-EPI and Schwartz equations. The participants’ ages ranged from 3 to 90 y, and the measured GFRs from 3 to 160 ml/min/1.73 m2. A linear mixed-effects model was used to model the bias (mean ratio of estimated GFR to measured GFR). Equation reliability was also assessed using precision (interquartile range [IQR] of the ratio) and accuracy (percentage of estimated GFRs within the 10% [P10] and 30% [P30] limits above and below the measured GFR). In the whole sample, the mean ratio with the CKD-EPI equation was significantly higher than that with the Schwartz equation (1.17 [95% CI 1.16; 1.18] versus 1.08 [95% CI 1.07; 1.09], p < 0.001, t-test). At GFR values of 60–89 ml/min/1.73 m2, the mean ratios with the Schwartz equation were closer to 1 than the mean ratios with the CKD-EPI equation whatever the age class (1.02 [95% CI 1.01; 1.03] versus 1.15 [95% CI 1.13; 1.16], p < 0.001, t-test). In young adults (18–40 y), the Schwartz equation had a better precision and was also more accurate than the CKD-EPI equation at GFR values under 60 ml/min/1.73 m2 (IQR: 0.32 [95% CI 0.28; 0.33] versus 0.40 [95% CI 0.36; 0.44]; P30: 81.4 [95% CI 78.1; 84.7] versus 63.8 [95% CI 59.7; 68.0]) and also at GFR values of 60–89 ml/min/1.73 m2. In all patients

  19. Intraperitoneal radiolabeled OC 125 in patients with advanced ovarian cancer

    SciTech Connect

    Finkler, N.J.; Muto, M.G.; Kassis, A.I.; Weadock, K.; Tumeh, S.S.; Zurawski, V.R. Jr.; Knapp, R.C. )

    1989-09-01

    Twenty patients with recurrent or persistent epithelial ovarian cancer failing conventional therapies were treated with a single intraperitoneal injection of iodine-131-labeled OC 125 monoclonal antibody. Rare acute side effects were nausea and mild diarrhea. At doses up to 120 mCi of iodine-131, median white blood cell and platelet count nadirs were 3.6k/microliters and 187k/microliters, respectively. Two patients acquired thyroid toxicities despite thyroid blockage with cold iodine. One patient had transient TSH elevation while remaining clinically euthyroid, and 1 patient developed activation of a thyroid nodule and clinical hyperthyroidism. Dose-limiting toxicity has not yet been observed. Twelve of 20 patients are alive 3 to 17 months following therapy. Tumor progression was noted in the majority of patients, although 3 patients had documented decreases in tumor burden of short duration. We conclude that, at the doses examined, iodine-131 OC 125 can be safely administered intraperitoneally.

  20. Special Issues Involving Periprosthetic Infection in Immunodeficiency Patients

    PubMed Central

    Tornero, Eduard; Riba, Josep; Garcia-Ramiro, Sebastian

    2013-01-01

    Chronic systemic illnesses such as diabetes mellitus, chronic kidney disease (CKD), liver cirrhosis, neoplasia, etc. have been clearly associated with high rates of SWI. However, the exact mechanisms underlying these observations are still under investigation. Chronic kidney disease (CKD) is a growing problem in our society. Many of these patients will require an arthroplasty and it appears that the prosthetic infection risk for these types of patients is much higher than in the normal population. The risk of complications due to infection seems to be lower in patients with kidney transplants than in patients undergoing haemodialysis. Both prophylaxis and treatment of infection in patients with CKD should be carried out with a strict monitoring of potentially nephrotoxic antibiotics. The literature on the prognosis and risk of infection in patients with haematopoietic stem cell transplant is scarce and occasionally contradictory. The optimal time for the surgery should be determined by taking into account the immunological state of the patient and should be avoided, as much as possible, during the first year after the HSCT. Child’s classification system is the most widely used method of stratifying the surgical risk for patients with cirrhosis; the infection appeared to be associated in a statistically significant way with advanced age and a Child B pre-operative classification. The prevention of prosthetic joint infections in HIV-infected patients should not be significantly different from the prevention for any other patient. Those patients that receive adequate antiretroviral treatment and periodic laboratory control show infection rates and periprosthetic complications that are similar to those for patients not affected by HIV. Therefore, the patient’s level of immunodeficiency is the most important prognostic factor for prosthetic infection. The particular immunological condition of these patients can lead to infections due to particular microorganisms

  1. Integrating Palliative Care Into the Care of Patients With Advanced Lung Cancer.

    PubMed

    Kapo, Jennifer M; Akgün, Kathleen M

    2015-01-01

    Lung cancer is the leading cause of death due to malignancy. Although lung cancer mortality has been decreasing in recent years, it remains substantially higher than other causes of cancer death. Median survival for patients with locally advanced non-small cell lung cancer, defined as lung cancer involving regional lymph nodes, is estimated to be approximately 10 to 17 months, and median survival for patients with metastatic disease is only 6 to 9 months. In addition, patients with advanced lung cancer often experience debilitating symptoms and poor quality of life. Pain, dyspnea, and fatigue are most frequently reported and affect at least 65% of patients with advanced lung cancer. Given this burden of symptoms and high mortality, patients and their families facing a diagnosis of advanced lung cancer are in need of support. Palliative care, with its focus on addressing the emotional, physical, and spiritual sources of suffering utilizing the expertise of an interdisciplinary team, can provide this comprehensive support. This review describes the role of supportive and palliative care integrated into the treatment of patients with a diagnosis of advanced lung cancer with sections focused on the evaluation and treatment of pain and dyspnea, approaches to challenging communication tasks, and the support of caregivers who care for patients with advanced lung cancer. PMID:26389769

  2. Future care planning: a first step to palliative care for all patients with advanced heart disease.

    PubMed

    Denvir, M A; Murray, S A; Boyd, K J

    2015-07-01

    Palliative care is recommended for patients with end-stage heart failure with several recent, randomised trials showing improvements in symptoms and quality of life and more studies underway. Future care planning provides a framework for discussing a range of palliative care problems with patients and their families. This approach can be introduced at any time during the patient's journey of care and ideally well in advance of end-of-life care. Future care planning is applicable to a wide range of patients with advanced heart disease and could be delivered systematically by cardiology teams at the time of an unplanned hospital admission, akin to cardiac rehabilitation for myocardial infarction. Integrating cardiology care and palliative care can benefit many patients with advanced heart disease at increased risk of death or hospitalisation. Larger, randomised trials are needed to assess the impact on patient outcomes and experiences. PMID:25900977

  3. Crizotinib Improves Progression-Free Survival in Some Patients with Advanced Lung Cancer

    MedlinePlus

    ... Prevention Lung Cancer Screening Research Crizotinib Improves Progression-Free Survival in Some Patients with Advanced Lung Cancer ( ... starting treatment without their disease getting worse (progression-free survival), as assessed by radiologic review. Results Progression- ...

  4. CKD-Induced Wingless/Integration1 Inhibitors and Phosphorus Cause the CKD–Mineral and Bone Disorder

    PubMed Central

    Fang, Yifu; Ginsberg, Charles; Seifert, Michael; Agapova, Olga; Sugatani, Toshifumi; Register, Thomas C.; Freedman, Barry I.; Monier-Faugere, Marie-Claude; Malluche, Hartmut

    2014-01-01

    In chronic kidney disease, vascular calcification, renal osteodystrophy, and phosphate contribute substantially to cardiovascular risk and are components of CKD–mineral and bone disorder (CKD-MBD). The cause of this syndrome is unknown. Additionally, no therapy addresses cardiovascular risk in CKD. In its inception, CKD-MBD is characterized by osteodystrophy, vascular calcification, and stimulation of osteocyte secretion. We tested the hypothesis that increased production of circulating factors by diseased kidneys causes the CKD-MBD in diabetic mice subjected to renal injury to induce stage 2 CKD (CKD-2 mice). Compared with non-CKD diabetic controls, CKD-2 mice showed increased renal production of Wnt inhibitor family members and higher levels of circulating Dickkopf-1 (Dkk1), sclerostin, and secreted klotho. Neutralization of Dkk1 in CKD-2 mice by administration of a monoclonal antibody after renal injury stimulated bone formation rates, corrected the osteodystrophy, and prevented CKD-stimulated vascular calcification. Mechanistically, neutralization of Dkk1 suppressed aortic expression of the osteoblastic transcription factor Runx2, increased expression of vascular smooth muscle protein 22-α, and restored aortic expression of klotho. Neutralization of Dkk1 did not affect the elevated plasma levels of osteocytic fibroblast growth factor 23 but decreased the elevated levels of sclerostin. Phosphate binder therapy restored plasma fibroblast growth factor 23 levels but had no effect on vascular calcification or osteodystrophy. The combination of the Dkk1 antibody and phosphate binder therapy completely treated the CKD-MBD. These results show that circulating Wnt inhibitors are involved in the pathogenesis of CKD-MBD and that the combination of Dkk1 neutralization and phosphate binding may have therapeutic potential for this disorder. PMID:24578135

  5. Morbid obesity in a young woman affected by advanced chronic kidney disease: an exceptional case report. Does a high dose of essential amino acids play a key role in therapeutic success?

    PubMed Central

    Caria, S; Murtas, S; Loria, G; Dioguardi, F S; Secci, R; Bolasco, P

    2016-01-01

    A 38-year-old woman, obese (219 kg), diabetic, hypertensive, chronic kidney disease (CKD) stage 4, with low plasma albumin level (2.9 g dl−1) and marked proteinuria (22 g per day) was studied. Given the advanced-stage CKD with nephrotic proteinuria, we supplemented low-protein diet with high doses of a tailored essential amino acid mixture (AAs: 44 g per day) to improve weight reduction in the patient. After 20 months of conservative therapy, the patient lost 43 kg; despite two episodes of infection, albumin plasma levels increased up to 3.7 g per day. After a further 20 months of dialysis, the patient maintained a diet of 1800 kcal supplemented with 32 g of AAs and lost 47 kg, whereas both albumin (3.89±0.12 g dl−1) and C reactive protein returned to normal. During the follow-up period, anemia improved, erythropoietin was thus discontinued and insulin requirement decreased to 105 IU. This therapeutic option may be beneficial in advanced CKD patients with obesity and diabetes resulting from malnutrition. PMID:26926587

  6. Survival advantages of obesity in dialysis patients.

    PubMed

    Kalantar-Zadeh, Kamyar; Abbott, Kevin C; Salahudeen, Abdulla K; Kilpatrick, Ryan D; Horwich, Tamara B

    2005-03-01

    In the general population, a high body mass index (BMI; in kg/m(2)) is associated with increased cardiovascular disease and all-cause mortality. However, the effect of overweight (BMI: 25-30) or obesity (BMI: >30) in patients with chronic kidney disease (CKD) undergoing maintenance hemodialysis (MHD) is paradoxically in the opposite direction; ie, a high BMI is associated with improved survival. Although this "reverse epidemiology" of obesity or dialysis-risk-paradox is relatively consistent in MHD patients, studies in CKD patients undergoing peritoneal dialysis have yielded mixed results. Growing confusion has developed among physicians, some of whom are no longer confident about whether to treat obesity in CKD patients. A similar reverse epidemiology of obesity has been described in geriatric populations and in patients with chronic heart failure (CHF). Possible causes of the reverse epidemiology of obesity include a more stable hemodynamic status, alterations in circulating cytokines, unique neurohormonal constellations, endotoxin-lipoprotein interaction, reverse causation, survival bias, time discrepancies among competitive risk factors, and malnutrition-inflammation complex syndrome. Reverse epidemiology may have significant clinical implications in the management of dialysis, CHF, and geriatric patients, ie, populations with extraordinarily high mortality. Exploring the causes and consequences of the reverse epidemiology of obesity in dialysis patients can enhance our insights into similar paradoxes observed for other conventional risk factors, such as blood pressure and serum cholesterol and homocysteine concentrations, and in other populations such as those with CHF, advanced age, cancer, or AIDS. Weight-gaining interventional studies in dialysis patients are urgently needed to ascertain whether they can improve survival and quality of life. PMID:15755821

  7. What drives quality improvement in chronic kidney disease (CKD) in primary care: process evaluation of the Quality Improvement in Chronic Kidney Disease (QICKD) trial

    PubMed Central

    Nihat, Akin; de Lusignan, Simon; Thomas, Nicola; Tahir, Mohammad Aumran; Gallagher, Hugh

    2016-01-01

    Objectives This study is a process evaluation of the Quality Improvement in Chronic Kidney Disease (QICKD) study, comparing audit-based education (ABE) and sending clinical guidelines and prompts (G&P) with usual practice, in improving systolic blood pressure control in primary care. This evaluation aimed to explore how far clinical staff in participating practices were aware of the intervention, and why change in practice might have taken place. Setting 4 primary care practices in England: 2 received ABE, and 2 G&P. We purposively selected 1 northern/southern/city and rural practice from each study arm (from a larger pool of 132 practices as part of the QICKD trial). Participants The 4 study practices were purposively sampled, and focus groups conducted with staff from each. All staff members were invited to attend. Interventions Focus groups in each of 4 practices, at the mid-study point and at the end. 4 additional trial practices not originally selected for in-depth process evaluation took part in end of trial focus groups, to a total of 12 focus groups. These were recorded, transcribed and analysed using the framework approach. Results 5 themes emerged: (1) involvement in the study made participants more positive about the CKD register; (2) clinicians did not always explain to patients that they had CKD; (3) while practitioners improved their monitoring of CKD, many were sceptical that it improved care and were more motivated by pay-for-performance measures; (4) the impact of study interventions on practice was generally positive, particularly the interaction with specialists, included in ABE; (5) the study stimulated ideas for future clinical practice. Conclusions Improving quality in CKD is complex. Lack of awareness of clinical guidelines and scepticism about their validity are barriers to change. While pay-for-performance incentives are the main driver for change, quality improvement interventions can have a complementary influence. PMID:27053264

  8. Survival among patients with advanced renal cell carcinoma in the pretargeted versus targeted therapy eras.

    PubMed

    Li, Pengxiang; Wong, Yu-Ning; Armstrong, Katrina; Haas, Naomi; Subedi, Prasun; Davis-Cerone, Margaret; Doshi, Jalpa A

    2016-02-01

    Between December 2005 and October 2009, FDA approved six targeted therapies shown to significantly extend survival for advanced renal cell carcinoma (RCC) patients in clinical trials. This study aimed to examine changes in survival between the pretargeted and targeted therapy periods in advanced RCC patients in a real-world setting. Utilizing the 2000-2010 SEER Research files, a pre-post study design with a contemporaneous comparison group was employed to examine differences in survival outcomes for patients diagnosed with advanced RCC (study group) or advanced prostate cancer (comparison group, for whom no significant treatment innovations happened during this period) across the pretargeted therapy era (2000-2005) and the targeted therapy era (2006-2010). RCC patients diagnosed in the targeted therapy era (N = 6439) showed improved survival compared to those diagnosed in the pretargeted therapy era (N = 7231, hazard ratio (HR) for all-cause death: 0.86, P < 0.01), while the change between the pre-post periods was not significant for advanced prostate cancer patients (HR: 0.97, P = 0.08). Advanced RCC patients had significantly larger improvements in overall survival compared to advanced prostate cancer patients (z = 4.31; P < 0.01). More detailed year-to-year analysis revealed greater survival improvements for RCC in the later years of the posttargeted period. Similar results were seen for cause-specific survival. Subgroup analyses by nephrectomy status, age, and gender showed consistent findings. Patients diagnosed with advanced RCC during the targeted therapy era had better survival outcomes than those diagnosed during the pretargeted therapy era. Future studies should examine the real-world survival improvements directly associated with targeted therapies. PMID:26645975

  9. Care of Patients at the End of Life: Advance Care Planning.

    PubMed

    Ackermann, Richard J

    2016-08-01

    Advance directives are legal documents that give instructions about how to provide care when patients develop life-threatening illnesses and can no longer communicate their wishes. Two types of documents are widely used-a living will and a durable power of attorney for health care. Most states also authorize physician orders for life-sustaining treatment. Physicians should encourage patients, particularly those with severe chronic or terminal conditions, to prepare advance directives. Medicare now reimburses billing codes for advance care consultations. Directions regarding cardiopulmonary resuscitation and artificial ventilation often are included in advance care plans, and use of artificial nutrition and hydration (ANH) also should be addressed, particularly for patients with advanced dementia. Evidence shows that in such patients, ANH does not prolong survival, increase comfort, or improve quality of life. Given the lack of benefit, physicians should recommend against use of ANH for patients with dementia. Finally, physicians should encourage use of hospice services by patients whose life expectancy is 6 months or less. Although Medicare and most other health care insurers cover hospice care, and despite evidence that patient and family satisfaction increase when hospice services are used, many patients do not use these services. PMID:27490070

  10. Association of KRAS and EGFR Mutations with Survival in Patients with Advanced Lung Adenocarcinomas

    PubMed Central

    Johnson, Melissa L.; Sima, Camelia S.; Chaft, Jamie; Paik, Paul K.; Pao, William; Kris, Mark G.; Ladanyi, Marc; Riely, Gregory J.

    2014-01-01

    Background Lung adenocarcinomas can be distinguished by identifying mutated driver oncogenes including EGFR and KRAS. Mutations in EGFR are associated with both an improved survival as well as response to treatment with erlotinib and gefitinib. However, the prognostic significance of KRAS has not been evaluated in large numbers of patients and remains controversial. We examined the association of EGFR and KRAS mutations with survival among patients with advanced lung adenocarcinomas. Methods We analyzed data from patients with advanced lung adenocarcinomas and known EGFR and KRAS mutation status evaluated between 2002 and 2009. We collected clinical variables including age, gender, Karnofsky Performance Status, smoking history, and treatment history. Overall survival from diagnosis of advanced disease was analyzed using Kaplan-Meier and Cox proportional hazard methods. Results We evaluated 1036 patients, including 610 women (59%) and 344 never-smokers (33%). Patients had a median age of 65 (range, 25–92) and the majority (81%) had a KPS ≥80%. In multivariate analysis, EGFR mutations were associated with a longer overall survival (HR= 0.6, p<0.001) and KRAS mutations with a shorter survival (HR=1.21, p=0.048). Conclusions KRAS mutations predict shorter survival for patients with advanced lung adenocarcinomas. The presence of EGFR and KRAS mutations define distinct subsets of patients with lung adenocarcinomas, and should be determined in patients upon diagnosis of advanced disease. Clinical trial reports should include EGFR and KRAS mutation status along with other prognostic factors. PMID:22810899

  11. Does the quality of advanced prosthetic dentistry determine patient satisfaction?

    PubMed

    Hakestam, U; Karlsson, T; Söderfeldt, B; Rydén, O; Glantz, P O

    1997-12-01

    In a clinical follow-up study 42 patients were selected from an original sample of 335 individuals who had undergone extensive prosthetic treatment. The selection was done in accordance with a treatment satisfaction measure. The selected patients' appliances were classified in accordance with the California Dental Association (CDA) quality assessment system. Altogether, most of the new reconstructions were rated as satisfactory. The removable partial dentures had a somewhat higher share of non-acceptable appliances according to the CDA criteria. There was an association between the CDA categories and patient satisfaction. Using logistic regression analysis and knowing the CDA rating, we could correctly classify 67% of the patients with regard to the satisfaction measure. The satisfaction measure was modified on the basis of an interview, improving the model to 83% correctly classified. It was concluded that the technical quality of the prosthodontic treatment was associated with patient satisfaction. PMID:9477029

  12. Transplant options for patients with type 2 diabetes and chronic kidney disease

    PubMed Central

    Fourtounas, Costas

    2014-01-01

    Chronic kidney disease (CKD) has become a real epidemic around the world, mainly due to ageing and diabetic nephropathy. Although diabetic nephropathy due to type 1 diabetes mellitus (T1DM) has been studied more extensively, the vast majority of the diabetic CKD patients suffer from type 2 diabetes mellitus (T2DM). Renal transplantation has been established as a first line treatment for diabetic nephropathy unless there are major contraindications and provides not only a better quality of life, but also a significant survival advantage over dialysis. However, T2DM patients are less likely to be referred for renal transplantation as they are usually older, obese and present significant comorbidities. As pre-emptive renal transplantation presents a clear survival advantage over dialysis, all T2DM patients with CKD should be referred for early evaluation by a transplant center. The transplant center should have enough time in order to examine their eligibility focusing on special issues related with diabetic nephropathy and explore the best options for each patient. Living donor kidney transplantation should always be considered as the first line treatment. Otherwise, the patient should be listed for deceased donor kidney transplantation. Recent progress in transplantation medicine has improved the “transplant menu” for T2DM patients with diabetic nephropathy and there is an ongoing discussion about the place of simultaneous pancreas kidney (SPK) transplantation in well selected patients. The initial hesitations about the different pathophysiology of T2DM have been forgotten due to the almost similar short- and long-term results with T1DM patients. However, there is still a long way and a lot of ethical and logistical issues before establishing SPK transplantation as an ordinary treatment for T2DM patients. In addition recent advances in bariatric surgery may offer new options for severely obese T2DM patients with CKD. Nevertheless, the existing data for T2DM

  13. Diets for patients with chronic kidney disease, should we reconsider?

    PubMed

    Mitch, William E; Remuzzi, Giuseppe

    2016-01-01

    Here we revisit how dietary factors could affect the treatment of patients with complications of chronic kidney disease (CKD), bringing to the attention of the reader the most recent developments in the field. We will briefly discuss five CKD-induced complications that are substantially improved by dietary manipulation: 1) metabolic acidosis and the progression of CKD; 2) improving the diet to take advantage of the benefits of angiotensin converting enzyme inhibitors (ACEi) on slowing the progression of CKD; 3) the diet and mineral bone disorders in CKD; 4) the safety of nutritional methods utilizing dietary protein restriction; and 5) evidence that new strategies can treat the loss of lean body mass that is commonly present in patients with CKD. PMID:27401192

  14. Chemotherapy Regimen Extends Survival in Advanced Pancreatic Cancer Patients

    Cancer.gov

    A four-drug chemotherapy regimen has produced the longest improvement in survival ever seen in a phase III clinical trial of patients with metastatic pancreatic cancer, one of the deadliest types of cancer.

  15. [Transarterial infusion chemotherapy using fine-powder cisplatin in patients with advanced hepatocellular carcinoma].

    PubMed

    Hatanaka, Takeshi; Kakizaki, Satoru; Ueno, Takashi; Takeuchi, Suguru; Takizawa, Daichi; Katakai, Kenji

    2014-02-01

    We investigated the therapeutic effects and safety of fine powder cisplatin for patients with advanced hepatocellular carcinoma( HCC). From January 2006 to March 2012, 123 patients with advanced HCC were treated by transarterial infusion chemotherapy(TAI)with fine-powder cisplatin(IA-call®, Nippon Kayaku Co. Ltd., Tokyo, Japan). The drug was infused into the liver through the feeding artery at a dose of 65 mg/m2. The treatment was repeated every 4 to 8 weeks until evidence of either tumor progression or unacceptable toxicity appeared. Treatment responses were classified as complete response(CR), partial response(PR), stable disease(SD), and progressive disease(PD)in 3.2%, 12.0%, 32.2%, and 52.4% of patients, respectively. The median survival durations were as follows: overall, 12.2 months; CR/PR patients, 23.8 months; and SD/PD patients, 10.6 months. The cumulative survival rates of CR/PR patients were significantly higher than those of SD/PD patients (p<0.05). Multivariate analyses revealed that treatment response, etiology, Child-Pugh grading, and level of protein induced by the vitamin K antagonist- II (PIVKA- II )were predictive factors of survival duration. Problematic adverse events were not observed in any of the patients. Our results suggest that TAI using fine-powder cisplatin can be safely administered for advanced HCC and can improve the prognosis of patients with advanced disease. PMID:24743198

  16. The effect of locoregional therapies in patients with advanced hepatocellular carcinoma treated with sorafenib

    PubMed Central

    Sarpel, Umut; Spivack, John H.; Berger, Yaniv; Heskel, Marina; Aycart, Samantha N.; Sweeney, Robert; Edwards, Martin P.; Labow, Daniel M.; Kim, Edward

    2016-01-01

    Background & aims It is unknown whether the addition of locoregional therapies (LRTx) to sorafenib improves prognosis over sorafenib alone in patients with advanced hepatocellular carcinoma (HCC). The aim of this study was to assess the effect of LRTx in this population. Methods A retrospective analysis was performed of patients with advanced HCC as defined by extrahepatic metastasis, lymphadenopathy >2 cm, or gross vascular invasion. Sorafenib therapy was required for inclusion. Survival of patients who received LRTx after progression to advanced stage was compared to those who did not receive LRTx. Results Using an intention to treat analysis of 312 eligible patients, a propensity weighted proportional hazards model demonstrated LRTx as a predictor of survival (HR = 0.505, 95% CI: 0.407–0.628; P < 0.001). The greatest benefit was seen in patients with the largest tumor burden (HR = 0.305, 95% CI: 0.236–0.393; P < 0.01). Median survival in the sorafenib arm was 143 days (95% CI: 118–161) vs. 247 days (95% CI: 220–289) in the sorafenib plus LRTx arm (P < 0.001). Conclusions These results demonstrate a survival benefit with the addition of LRTx to sorafenib for patients with advanced HCC. These findings should prompt a prospective clinical trial to further assess the role of LRTx in patients with advanced HCC. PMID:27154804

  17. Heading perception in patients with advanced retinitis pigmentosa

    NASA Technical Reports Server (NTRS)

    Li, Li; Peli, Eli; Warren, William H.

    2002-01-01

    PURPOSE: We investigated whether retinis pigmentosa (RP) patients with residual visual field of < 100 degrees could perceive heading from optic flow. METHODS: Four RP patients and four age-matched normally sighted control subjects viewed displays simulating an observer walking over a ground. In experiment 1, subjects viewed either the entire display with free fixation (full-field condition) or through an aperture with a fixation point at the center (aperture condition). In experiment 2, patients viewed displays of different durations. RESULTS: RP patients' performance was comparable to that of the age-matched control subjects: heading judgment was better in the full-field condition than in the aperture condition. Increasing display duration from 0.5 s to 1 s improved patients' heading performance, but giving them more time (3 s) to gather more visual information did not consistently further improve their performance. CONCLUSIONS: RP patients use active scanning eye movements to compensate for their visual field loss in heading perception; they might be able to gather sufficient optic flow information for heading perception in about 1 s.

  18. Technology advances in hospital practices: robotics in treatment of patients.

    PubMed

    Rosiek, Anna; Leksowski, Krzysztof

    2015-06-01

    Laparoscopic cholecystectomy is widely considered as the treatment of choice for acute cholecystitis. The safety of the procedure and its minimal invasiveness made it a valid treatment option for a patient not responding to antibiotic therapy. Our research shows that patients positively assess this treatment method, but the world's tendency is to turn to a more sophisticated method utilizing robot-assisted surgery as a gold standard. Providing patient with minimally invasive surgical procedures that utilize the state-of-the-art equipment like the da Vinci Robotic Surgical System underscores the commitment to high-quality patient care while enhancing patient safety. The advantages include minimal invasive scarring, less pain and bleeding, faster recovery time, and shorter hospital stay. The move toward less invasive and less morbid procedures and a need to re-create the true open surgical experience have paved the way for the development and application of robotic and computer-assisted systems in surgery in Poland as well as the rest of the world. PMID:25782187

  19. Fostering Innovation, Advancing Patient Safety: The Kidney Health Initiative

    PubMed Central

    Archdeacon, Patrick; Winkelmayer, Wolfgang C.; Falk, Ronald J.; Roy-Chaudhury, Prabir

    2013-01-01

    Summary To respond to the serious and underrecognized epidemic of kidney disease in the United States, the US Food and Drug Administration and the American Society of Nephrology have founded the Kidney Health Initiative—a public–private partnership designed to create a collaborative environment in which the US Food and Drug Administration and the greater kidney community can interact to optimize the evaluation of drugs, devices, biologics, and food products. The Kidney Health Initiative will bring together all the necessary stakeholders, including patients, regulators, industry, health care providers, academics, and other governmental agencies, to improve patient safety and foster innovation. This initiative is intended to enable the kidney community as a whole to provide the right drug, device, or biologic for administration to the right patient at the right time by fostering partnerships that will facilitate development and delivery of those products and addressing challenges that currently impede these goals. PMID:23744001

  20. Fostering innovation, advancing patient safety: the kidney health initiative.

    PubMed

    Archdeacon, Patrick; Shaffer, Rachel N; Winkelmayer, Wolfgang C; Falk, Ronald J; Roy-Chaudhury, Prabir

    2013-09-01

    To respond to the serious and underrecognized epidemic of kidney disease in the United States, the US Food and Drug Administration and the American Society of Nephrology have founded the Kidney Health Initiative-a public-private partnership designed to create a collaborative environment in which the US Food and Drug Administration and the greater kidney community can interact to optimize the evaluation of drugs, devices, biologics, and food products. The Kidney Health Initiative will bring together all the necessary stakeholders, including patients, regulators, industry, health care providers, academics, and other governmental agencies, to improve patient safety and foster innovation. This initiative is intended to enable the kidney community as a whole to provide the right drug, device, or biologic for administration to the right patient at the right time by fostering partnerships that will facilitate development and delivery of those products and addressing challenges that currently impede these goals. PMID:23744001

  1. Allergen immunotherapy for birch pollen-allergic patients: recent advances.

    PubMed

    Moingeon, Philippe; Floch, Véronique Bordas-Le; Airouche, Sabi; Baron-Bodo, Véronique; Nony, Emmanuel; Mascarell, Laurent

    2016-05-01

    As of today, allergen immunotherapy is performed with aqueous natural allergen extracts. Recombinant allergen vaccines are not yet commercially available, although they could provide patients with well-defined and highly consistent drug substances. As Bet v 1 is the major allergen involved in birch pollen allergy, with more than 95% of patients sensitized to this allergen, pharmaceutical-grade recombinant Bet v 1-based vaccines were produced and clinically tested. Herein, we compare the clinical results and modes of action of treatments based on either a birch pollen extract or recombinant Bet v 1 expressed as hypoallergenic or natural-like molecules. We also discuss the future of allergen immunotherapy with improved drugs intended for birch pollen-allergic patients suffering from rhinoconjunctivitis. PMID:27140409

  2. [Prognostic value of apolipoproteins A and B in the clinical course of patients with chronic kidney disease previous to dialysis].

    PubMed

    Cerezo, I; Fernández, N; Romero, B; Fernández-Carbonero, E; Hernández-Gallego, R; Caravaca, F

    2009-01-01

    Dyslipidemia is a well-established risk factor for cardiovascular diseases in the general population. However, this association is not observed in chronic kidney disease (CKD) patients. This study examines the association between lipid levels, including apolipoproteins A-I and B concentrations, and all-cause mortality or the development of new cardiovascular events in advanced CKD patients not yet on dialysis. This observational prospective historical study included 331 patients with CKD stage 4 or 5 not yet on dialysis. In addition to conventional clinical and biochemical data, total cholesterol, triglycerides, HDL, LDL, apolipoprotein A-I (apo A) and B (apo B) plasma concentrations were measured. Cox proportional hazard models were adjusted for age, sex, comorbidity index, residual renal function, serum albumin, C-reactive protein levels, and treatment with statins. The median follow-up time was 985 days, and during this period 105 patients died and 54 patients had a new cardiovascular event. In fully-adjusted fixed-covariate Cox models, the hazard ratio for each 10 mg/dl increase of apo A concentration was 0.915 (C.I. 95% 0.844 to 0.992; p=0,031). Patients with an apo A /apo B ratio in the upper tertile (i.e. > 1.42) had a better survival than that of the rest of study patients (hazard ratio = 0.592, C.I. 95% 0.368 to 0.953, p<0.05). None of the study lipid parameters was associated with new cardiovascular events in the adjusted models. In conclusion, apo A concentrations and high apo A / apo B ratios added independent predictive information about survival of CKD patients not yet on dialysis. PMID:19935998

  3. Moderator's view: Vitamin D deficiency treatment in advanced chronic kidney disease: a close look at the emperor's clothes.

    PubMed

    Zoccali, Carmine; Mallamaci, Francesca

    2016-05-01

    Two recent vitamin D supplementation (ergocalciferol) trials in stage G5D CKD patients with vitamin D insufficiency showed that this sterol effectively increases serum 25-hydroxyvitamin D [25(OH)D] but fails to modify serum PTH and other clinical outcomes. The Pro side of this polar view emphasizes that the duration of these studies was too short to allow sensible analyses based on a clinical endpoint. Furthermore, he notes that in the second study, the use of active forms of vitamin D, phosphate binders and cinacalcet could have hindered appreciation of the effect of ergocalciferol supplementation per se The Con side produces an updated meta-analysis showing that inactive vitamin D forms largely fail to reduce serum PTH and affect various relevant endpoints, including muscle strength, functional capacity, quality of life and hospitalization. Studies suggesting an effect of inactive vitamin D forms in advanced CKD are either very small and mainly based on sequential, uncontrolled observations or inherently weak, simple pre/post studies. No biological or clinical evidence exists that 25(OH)D may exert meaningful effects in CKD patients who are being treated with active forms of vitamin D. Careful a etiologic studies based on the omics sciences, i.e. precise pathophysiological profiling of individual CKD patients followed by consequential, well-targeted intervention(s) in the precision medicine scenario, will likely provide a definitive answer to the lingering question of whether inactive vitamin D forms may have biological effects beyond those produced by their proximate metabolite 1,25-dihydroxyvitamin D3. PMID:27190394

  4. Effectiveness of the Mindfulness Art Therapy Short Version for Japanese Patients with Advanced Cancer

    ERIC Educational Resources Information Center

    Ando, Michiyo; Kira, Haruko; Hayashida, Shigeru; Ito, Sayoko

    2016-01-01

    The aim of this study was to investigate the feasibility of the Mindfulness Art Therapy Short Version for Japanese patients with advanced cancer. Patients learned mindfulness practices and then made art to express their feelings in the first session. After receiving instruction on practicing mindfulness 2 weeks later, they participated in a second…

  5. Homotopic Approximate Solutions for the Perturbed CKdV Equation with Variable Coefficients

    PubMed Central

    Lu, Dianchen; Chen, Tingting

    2014-01-01

    This work concerns how to find the double periodic form of approximate solutions of the perturbed combined KdV (CKdV) equation with variable coefficients by using the homotopic mapping method. The obtained solutions may degenerate into the approximate solutions of hyperbolic function form and the approximate solutions of trigonometric function form in the limit cases. Moreover, the first order approximate solutions and the second order approximate solutions of the variable coefficients CKdV equation in perturbation εun are also induced. PMID:24737983

  6. Homotopic approximate solutions for the perturbed CKdV equation with variable coefficients.

    PubMed

    Lu, Dianchen; Chen, Tingting; Hong, Baojian

    2014-01-01

    This work concerns how to find the double periodic form of approximate solutions of the perturbed combined KdV (CKdV) equation with variable coefficients by using the homotopic mapping method. The obtained solutions may degenerate into the approximate solutions of hyperbolic function form and the approximate solutions of trigonometric function form in the limit cases. Moreover, the first order approximate solutions and the second order approximate solutions of the variable coefficients CKdV equation in perturbation εu (n) are also induced. PMID:24737983

  7. Hospitalists caring for patients with advanced cancer: An experience-based guide.

    PubMed

    Koo, Douglas J; Tonorezos, Emily S; Kumar, Chhavi B; Goring, Tabitha N; Salvit, Cori; Egan, Barbara C

    2016-04-01

    Every year, nearly 5 million adults with cancer are hospitalized. Limited evidence suggests that hospitalization of the cancer patient is associated with adverse morbidity and mortality. Hospitalization of the patient with advanced cancer allows for an intense examination of health status in the face of terminal illness and an opportunity for defining goals of care. This experience-based guide reports what is currently known about the topic and outlines a systematic approach to maximizing opportunities, improving quality, and enhancing the well-being of the hospitalized patient with advanced cancer. Journal of Hospital Medicine 2016;11:292-296. © 2015 Society of Hospital Medicine. PMID:26588430

  8. Polypharmacy in patients with advanced cancer and the role of medication discontinuation.

    PubMed

    LeBlanc, Thomas W; McNeil, Michael J; Kamal, Arif H; Currow, David C; Abernethy, Amy P

    2015-07-01

    Polypharmacy is a well known problem in elderly patients in general, but its prevalence and effects in patients with cancer are less clear, particularly in end-of-life settings. This Review examines the existing literature on polypharmacy in advanced cancer and end-of-life settings by reviewing evidence-based approaches to reduce polypharmacy, and outlining the potential benefits of decreasing the number of drugs that patients with cancer can take, with emphasis on the need for thoughtful discontinuation initiatives in the context of life-limiting malignant disease. In view of the apparent burden of polypharmacy in patients with advanced cancer, we expect that greater attention to polypharmacy could lead to improvements in adverse drug events, cost, and possibly quality of life. However, few data for specific interventions in the advanced cancer population are available, and thus more research is warranted. PMID:26149885

  9. Alteration of circulatory platelet microparticles and endothelial microparticles in patients with chronic kidney disease

    PubMed Central

    Lu, Guo-Yuan; Xu, Rui-Jun; Zhang, Shu-Hua; Qiao, Qing; Shen, Lei; Li, Ming; Xu, De-Yu; Wang, Zhao-Yue

    2015-01-01

    Objective: To compare plasma platelet microparticles (PMPs), P-selectin, endothelial microparticles (EMPs), and von Willebrand factor (vWF) between a normal control group and patients with chronic kidney disease (CKD) and to explore the significance of PMPs and EMPs in CKD. Methods: Levels of plasma PMPs, P-selectin, EMPs and vWF in 122 CKD patients and 20 normal controls were detected by flow cytometry and enzyme-linked immunosorbent assay (ELISA). Relationships between PMPs, EMPs and blood pressure, creatinine clearance rate, 24-hour urine protein, hemoglobin, and cholesterol were analyzed. Results: (1) Plasma PMPs, P-selectin, EMPs and vWF levels in CKD patients were significantly higher than those of the control group. Plasma PMPs and P-selectin levels for nephrotic syndrome (NS) were significantly higher than for other CKD groups. No significant difference was found between other CKD groups. Plasma EMPs and vWF in NS, lupus nephritis (LN) and hypertensive nephropathy groups were significantly higher than that of diabetic nephropathy (DN) and chronic glomerulonephritis (CGN) groups. (2) Plasma PMPs, P-selectin, EMPs and vWF in stage I-II CKD patients were significantly higher than those of stage III-V CKD patients, no significant difference was found within stage I-II CKD patients or stage III-V CKD patients. (3) PMPs and EMPs were positively correlated with blood pressure and 24-hour urinary protein, but no significant correlation was found with the creatinine clearance rate, hemoglobin or cholesterol. P-selectin and vWF were positively correlated with PMPs and EMPs respectively. Conclusion: CKD patients have significant platelet activation and endothelial dysfunction, which was involved in CKD’s occurrence and development; high blood pressure and proteinuria are important reasons for platelet activation and endothelial dysfunction in patients with CKD; PMPs and EMPs can be used as new markers for dysfunctional platelet activation and endothelium. PMID

  10. Use of Virtual Patients in an Advanced Therapeutics Pharmacy Course to Promote Active, Patient-Centered Learning

    PubMed Central

    Mohammad, Rima A.; Benedict, Neal

    2014-01-01

    Objective. To assess student satisfaction and learning of course objectives following the integration of virtual patient cases designed to promote active, patient-centered learning in an advanced therapeutics pharmacy course. Design. A dynamic virtual patient platform that incorporated a branched-narrative, decision-making teaching model was used in an advanced therapeutics course to supplement lecture content. Assessment. Presimulation and postsimulation tests were used to assess student learning. The use of virtual patients significantly enhanced student learning for both higher- and lower-level test questions (p<0.001 and p=0.01, respectively). Students agreed or strongly agreed that the virtual patient cases provided an effective way to learn (72%), were enjoyable (69%), and were appropriate in content (80%), and that more should be incorporated (59%). Conclusion. The use of virtual patients in an advanced therapeutics practicum effectively promoted active, patient-centered learning; engaged students in an interactive and dynamic educational technology; encouraged teamwork; enhanced higher-level student learning; and improved student satisfaction in the course. PMID:25147397

  11. Dying tax free: the modern advance directive and patients' financial values.

    PubMed

    Kirk, Timothy W; Luck, George R

    2010-03-01

    Advance directives are often used to help patients articulate their end-of-life treatment preferences and guide proxy decision makers in making health care decisions when patients cannot. This case study and commentary puts forth a situation in which a palliative care consultation team encountered a patient with an advance directive that instructed her proxy decision maker to consider estate tax implications when making end-of-life decisions. Following presentation of the case, the authors focus on two ethical issues: 1) the appropriateness of considering patients' financial goals and values in medical decision making and 2) whether certain kinds of patient values should be considered more or less relevant than others as reasons for expressed treatment preferences. Clinicians are encouraged to accept a wide range of patient values as relevant to the clinical decision-making process and to balance the influence of those values with more traditional notions of clinical harm and benefit. PMID:20303033

  12. Anxiety and depression in patients with advanced macular degeneration: current perspectives

    PubMed Central

    Cimarolli, Verena R; Casten, Robin J; Rovner, Barry W; Heyl, Vera; Sörensen, Silvia; Horowitz, Amy

    2016-01-01

    Age-related macular degeneration (AMD) – despite advances in prevention and medical treatment options – remains prevalent among older adults, often resulting in functional losses that negatively affect the mental health of older adults. In particular, the prevalence of both anxiety and depression in patients with AMD is high. Along with medical treatment options, low vision rehabilitation and AMD-specific behavioral and self-management programs have been developed and have demonstrated effectiveness in improving the mental health of AMD patients. This article reviews the prevalence of anxiety and depression in patients with advanced AMD, discusses potential mechanisms accounting for the development of depression and anxiety in AMD patients, presents the state-of the-art of available interventions for addressing anxiety and depression in AMD patients, and delineates recommendations for eye care professionals regarding how to screen for these two prevalent mental health problems and how to facilitate appropriate treatment for patients with AMD. PMID:26766899

  13. Sarcopenia and Physical Inactivity in Patients With Chronic Kidney Disease.

    PubMed

    Hirai, Keiji; Ookawara, Susumu; Morishita, Yoshiyuki

    2016-05-01

    Sarcopenia and physical inactivity synergistically progress in patients with chronic kidney disease (CKD) and are strong predictors of mortality in this population. Exercise training and essential amino acids and vitamin D supplements may contribute to improving sarcopenia and physical inactivity in CKD patients. PMID:27570755

  14. Hepcidin and Risk for Anemia in CKD: A Cross-sectional and Longitudinal Analysis in the CKiD Cohort

    PubMed Central

    Atkinson, Meredith A.; Kim, Ji Young; Roy, Cindy N.; Warady, Bradley A.; White, Colin T.; Furth, Susan L.

    2014-01-01

    Background Hepcidin, a key iron regulatory protein, is elevated in patients with chronic kidney disease (CKD). Its role in the development and progression of the anemia of CKD in children remains poorly defined. Methods Cross-sectional and longitudinal study in children aged 1–16 years with stage 2–4 CKD in the Chronic Kidney Disease in Children (CKiD) cohort (n=133) with hepcidin measured at baseline and hemoglobin (HGB) measured annually in follow-up. Anemia was defined as HGB < 5th percentile for age/sex OR treatment with an erythropoiesis stimulating agent (ESA). Results Hepcidin levels correlated negatively with glomerular filtration rate (GFR) (r=−0.22, p=0.01) and positively with ferritin (r=0.67, p<0.001). At the lower end of the GFR spectrum at baseline (10th percentile, 27.5 ml/min/1.73m2), higher hepcidin was associated with a 0.87 g/dL decrease in HGB during follow-up (95% CI −1.69, −0.05 g/dL, p=0.038). At higher GFR percentiles there was no significant association between baseline hepcidin and HGB during follow-up. Among 90 non-anemic subjects at baseline, 23.3% developed incident anemia. In subjects with GFR ≤ the median, a higher hepcidin level was associated with an increased risk for incident anemia (at 10th %ile GFR, HR 3.471, 95% CI 1.228, 9.810, p=0.019; at 25th %ile GFR HR 2.641, 95% CI 1.213, 5.750, p=0.014; at 50th %ile GFR, HR 1.953, 95% CI 1.011, 3.772, p=0.046). Among subjects with GFR in the 75th percentile or above, incrementally higher baseline hepcidin was not associated with increased anemia risk. Conclusions Higher hepcidin levels are associated with a decreased HGB and an increased risk for incident anemia, and this association is most significant among subjects with lower GFR. PMID:25380788

  15. Metronomic Capecitabine in Advanced Hepatocellular Carcinoma Patients: A Phase II Study

    PubMed Central

    de Rosa, Francesco; Agostini, Valentina; di Girolamo, Stefania; Andreone, Pietro; Bolondi, Luigi; Serra, Carla; Sama, Claudia; Golfieri, Rita; Gramenzi, Annagiulia; Cucchetti, Alessandro; Pinna, Antonio Daniele; Trevisani, Franco; Biasco, Guido

    2013-01-01

    Background. Anti-angiogenic treatment with targeted agents is effective in advanced hepatocellular carcinoma (HCC). This trial evaluated the safety and efficacy of metronomic capecitabine in patients with HCC. Methods. This single-institution phase II trial included 59 previously untreated patients with advanced HCC and 31 patients resistant to or intolerant of sorafenib. The treatment schedule was capecitabine 500 mg twice daily until progression of disease, unacceptable toxicity level, or withdrawal of informed consent. Progression-free survival (PFS) was chosen as the primary endpoint. Results. A total of 59 previously untreated and 31 previously treated patients with HCC were enrolled. The first cohort achieved a median PFS of 6.03 months and an overall survival (OS) of 14.47 months. Two patients achieved a complete response, 1 patient achieved partial response, and in 30 patients, stable disease was the best outcome. The second cohort achieved a median PFS of 3.27 months and a median OS of 9.77 months. No complete or partial responses were observed, but 10 patients had stable disease. An unscheduled comparison of the first cohort of patients with 3,027 untreated patients with HCC from the Italian Liver Cancer (ITA.LI.CA) database was performed. One-to-one matching according to demographic/etiologic/oncologic features was possible for 50 patients. The median OS for these 50 capecitabine-treated patients was 15.6 months, compared with a median OS of 8.0 months for the matched untreated patients (p = .043). Conclusion. Metronomic capecitabine is well tolerated by patients with advanced HCC and appears to have activity both in treatment-naive patients and in those previously treated with sorafenib. PMID:24232581

  16. Recent advances in MRI technology: Implications for image quality and patient safety

    PubMed Central

    Sobol, Wlad T.

    2012-01-01

    Recent advances in MRI technology are presented, with emphasis on how this new technology impacts clinical operations (better image quality, faster exam times, and improved throughput). In addition, implications for patient safety are discussed with emphasis on the risk of patient injury due to either high local specific absorption rate (SAR) or large cumulative energy doses delivered during long exam times. Patient comfort issues are examined as well. PMID:23961024

  17. Advances in Patient-Reported Outcomes: The NIH PROMIS® Measures

    PubMed Central

    Broderick, Joan E.; DeWitt, Esi Morgan; Rothrock, Nan; Crane, Paul K.; Forrest, Christopher B.

    2013-01-01

    Patient-reported outcomes (PRO) are questionnaire measures of patients’ symptoms, functioning, and health-related quality of life. They are designed to provide important clinical information that generally cannot be captured with objective medical testing. In 2004, the National Institutes of Health launched a research initiative to improve the clinical research enterprise by developing state-of-the-art PROs. The NIH Patient-Reported Outcomes Measurement System (PROMIS) and Assessment Center are the products of that initiative. Adult, pediatric, and parent-proxy item banks have been developed by using contemporary psychometric methods, yielding rapid, accurate measurements. PROMIS currently provides tools for assessing physical, mental, and social health using short-form and computer-adaptive testing methods. The PROMIS tools are being adopted for use in clinical trials and translational research. They are also being introduced in clinical medicine to assess a broad range of disease outcomes. Recent legislative developments in the United States support greater efforts to include patients’ reports of health experience in order to evaluate treatment outcomes, engage in shared decision-making, and prioritize the focus of treatment. PROs have garnered increased attention by the Food and Drug Administration (FDA) for evaluating drugs and medical devices. Recent calls for comparative effectiveness research favor inclusion of PROs. PROs could also potentially improve quality of care and disease outcomes, provide patient-centered assessment for comparative effectiveness research, and enable a common metric for tracking outcomes across providers and medical systems. PMID:25848562

  18. Advances in cancer therapeutics and patient access to new drugs.

    PubMed

    Dranitsaris, George; Truter, Ilse; Lubbe, Martie S; Amir, Eitan; Evans, William

    2011-03-01

    Globally, there are approximately 7.4 million cancer deaths annually, approximately 13% of deaths from all causes. Cancer is a disease of older people and, as the population ages over the next 10-20 years, we can expect an increase in the cancer incidence. Encouragingly, cancer mortality has stabilized in many countries. Part of this success may be attributed to the development of new cancer agents, collectively called 'targeted therapies', that are more specific to key components of tumour growth. Worldwide, however, one of the main factors that limit patient access to these important new drugs is their cost, which is higher than traditional chemotherapy. In this review, the clinical and pharmacoeconomic data of selected targeted agents are discussed. In the second part of this article, the challenges faced by healthcare systems in making such drugs available to patients is reviewed. Current strategies used by many countries around the world to manage cancer drug budgets are presented, along with a proposed approach using pharmacoeconomic methodology that may increase patient access. PMID:21184619

  19. Neutrophil CD64 expression: a reliable diagnostic marker of infection in advanced cancer patients?

    PubMed

    Comolli, Giuditta; Torchio, Martina; Lenta, Elisa; Franceschetti, Benvenuto; Chiesa, Antonella; Calarota, Sandra A; Baldanti, Fausto; Scudeller, Luigia; Marone, Piero; Danova, Marco; Marco, Danova

    2015-07-01

    Infection and sepsis are major health problems in cancer patients. There is a need for the identification and validation of biomarkers to improve their early diagnosis and treatment. Emerging evidence showed that neutrophil CD64 is a highly sensitive and specific marker for systemic infection and sepsis in critically ill patients with various diseases but data on patients bearing solid tumors are still lacking. Using a dedicated flow cytometric assay we evaluated neutrophil CD64 expression in patients with advanced cancer without active infections to verify if it could be utilized as a reliable biomarker of early infections also in oncologic patients. PMID:26147145

  20. Management of locally advanced and metastatic colon cancer in elderly patients

    PubMed Central

    Kurniali, Peter C; Hrinczenko, Borys; Al-Janadi, Anas

    2014-01-01

    Colon cancer is the second leading cause of cancer mortality in the United States with a median age at diagnosis of 69 years. Sixty percent are diagnosed over the age of 65 years and 36% are 75 years or older. At diagnosis, approximately 58% of patients will have locally advanced and metastatic disease, for which systemic chemotherapy has been shown to improve survival. Treatment of cancer in elderly patients is more challenging due to multiple factors, including disabling co-morbidities as well as a decline in organ function. Cancer treatment of elderly patients is often associated with more toxicities that may lead to frequent hospitalizations. In locally advanced disease, fewer older patients receive adjuvant chemotherapy despite survival benefit and similar toxicity when compared to their younger counterparts. A survival benefit is also observed in the palliative chemotherapy setting for elderly patients with metastatic disease. When treating elderly patients with colon cancer, one has to consider drug pharmacokinetics and pharmacodynamics. Since chronological age is a poor marker of a patient’s functional status, several methods of functional assessment including performance status and activities of daily living (ADL) or instrumental ADL, or even a comprehensive geriatric assessment, may be used. There is no ideal chemotherapy regimen that fits all elderly patients and so a regimen needs to be tailored for each individual. Important considerations when treating elderly patients include convenience and tolerability. This review will discuss approaches to the management of elderly patients with locally advanced and metastatic colon cancer. PMID:24616568

  1. [Effect of Jinshuibao capsule on the immunological function of 36 patients with advanced cancer].

    PubMed

    Zhou, D H; Lin, L Z

    1995-08-01

    Jinshuibao Capsule (JSBC), produced by Jiangxi Jinshuibao pharmaceutical Company Limited, possesses the similar active principles and pharmacological activity with those of Cordyceps sinensis. The effect of JSBC on the immunological function of 36 patients with advanced cancer showed that it could restore cellular immunological function, improve quality of life, but had no significant effect on humoral immunological function. The results suggested that JSBC could be used as adjuvant drug in advanced cancer. PMID:8580695

  2. Life-threatening coagulopathy and hypofibrinogenaemia induced by tigecycline in a patient with advanced liver cirrhosis.

    PubMed

    Rossitto, Giacomo; Piano, Salvatore; Rosi, Silvia; Simioni, Paolo; Angeli, Paolo

    2014-06-01

    Bacterial infections because of multidrug-resistant (MDR) bacteria are spreading worldwide. In patients with advanced liver cirrhosis, healthcare-acquired and hospital-acquired infections are common and are frequently sustained by MDR bacteria. In these settings, tigecycline, a new antibiotic, has been shown to be useful in the treatment of MDR bacteria, and it has been proposed for the treatment of hospital-acquired infections in patients with cirrhosis. Nevertheless, poor data exist on the safety profile of tigecycline in patients with cirrhosis. Here, an experience is reported in a female patient with advanced liver cirrhosis, who developed sepsis by an MDR Stenotrophomonas maltophilia and was treated with tigecycline. She experienced life-threatening side effects consisting of severe coagulopathy with hypofibrinogenaemia and subsequent gastrointestinal haemorrhage. The side effect disappeared after the withdrawal of tigecycline. Therefore, a strict monitoring of coagulation parameters in patients with cirrhosis treated with tigecycline is recommended. PMID:24667348

  3. The desire to die: making treatment decisions for suicidal patients who have an advance directive.

    PubMed

    Salter, Erica K

    2014-01-01

    This article enumerates and critically examines the potential grounds on which we might treat the case of a patient with an advance directive who attempted suicide, differently from one whose injuries were the result of an accident. Grounds for differentiation are distilled into two potential justifications. The first addresses the concern that withholding or withdrawing care from a patient with self-inflicted injuries would be aiding and abetting suicide.The second examines concerns about the patient's decisionmaking capacity. Ultimately, it is argued that while there might be legitimate reasons to hold the advance directive of a suicidal patient to a different standard of scrutiny, the fact that the patient's medical state was self-inflicted should not, in and of itself, necessarily invalidate the guidance of the directive. Finally, four practical recommendations are offered for negotiating similar cases. PMID:24779318

  4. Negative religious coping as a correlate of suicidal ideation in patients with advanced cancer

    PubMed Central

    Trevino, K. M.; Balboni, M.; Zollfrank, A.; Balboni, T.; Prigerson, H. G.

    2016-01-01

    Objective The purpose of this study is to examine the relationship between negative religious coping (NRC) and suicidal ideation in patients with advanced cancer, controlling for demographic and disease characteristics and risk and protective factors for suicidal ideation. Methods Adult patients with advanced cancer (life expectancy ≤6 months) were recruited from seven medical centers in the northeastern and southwestern USA (n = 603). Trained raters verbally administered the examined measures to patients upon study entry. Multivariable logistic regression analyses regressed suicidal ideation on NRC controlling for significant demographic, disease, risk, and protective factors. Results Negative religious coping was associated with an increased risk for suicidal ideation (OR, 2.65 [95% CI, 1.22, 5.74], p = 0.01) after controlling for demographic and disease characteristics, mental and physical health, self-efficacy, secular coping, social support, spiritual care received, global religiousness and spirituality, and positive religious coping. Conclusions Negative religious coping is a robust correlate of suicidal ideation. Assessment of NRC in patients with advanced cancer may identify patients experiencing spiritual distress and those at risk for suicidal ideation. Confirmation of these results in future studies would suggest the need for interventions targeting the reduction of NRC to reduce suicidal ideation among advanced cancer patients. PMID:24577802

  5. A resistant starch fiber diet ameliorates oxidative stress, inflammation, and progression of chronic kidney disease (CKD)

    Technology Transfer Automated Retrieval System (TEKTRAN)

    Inflammation is a constant feature and a major mediator of CKD progression. It is, in part, driven by altered gut microbiome and disruption of intestinal epithelial barrier, events which are primarily caused by: 1- urea influx in the intestine resulting in dominance of urease-possessing bacteria; 2-...

  6. Serum neuron specific enolase levels correlate with patient prognosis for advanced lung cancer

    PubMed Central

    Xue, Feng; Zhu, Lin; Wang, Liyan; Wang, Quan

    2015-01-01

    To analyze the clinical and prognostic value of neuron specific enolase (NSE) levels in serum of advanced lung cancer patients, we analyzed serum NSE level of 110 advanced lung cancer patients (case group), 100 benign lung disease patients (benign disease group), and 100 healthy persons (control group). Case group patients were divided by NSE level into ≥25 ng/mL (52 cases) and <25 ng/mL (58 cases) groups to analyze overall survival (OS) and progression-free survival (PFS). The results showed the serum NSE levels of case group patients were significantly higher than those of control or benign disease group patients (P<0.05). Serum NSE levels of small cell lung cancer patients were significantly higher than those of patients with other tumor pathologies (all P<0.05). Median OS significantly differed between patients with NSE levels ≥25 ng/mL (23.7 months) and <25 ng/mL (31.4 months) (P<0.05). Median PFS also significantly differed between patients with NSE levels ≥25 ng/mL (13.5 months) and <25 ng/mL (17.6 months) (χ 2=9.992; P<0.05). Tumor pathology (RR=4.136), patient performance status score (RR=2.903), and serum NSE level (RR=2.338) were factors influencing OS (P<0.05). Patient performance status score (RR=2.903), number of chemotherapy lines (RR=1.776), and serum NSE level (RR=2.075) were influencing factors in patients’ PFS (P<0.05). In brief, serum NSE level significantly correlates with advanced lung cancer patient prognosis and may be useful as an auxiliary index to predict prognosis. PMID:26309614

  7. Beneficial effects through aggressive coronary screening for type 2 diabetes patients with advanced vascular complications.

    PubMed

    Tsujimoto, Tetsuro; Sugiyama, Takehiro; Yamamoto-Honda, Ritsuko; Kishimoto, Miyako; Noto, Hiroshi; Morooka, Miyako; Kubota, Kazuo; Kamimura, Munehiro; Hara, Hisao; Kajio, Hiroshi; Kakei, Masafumi; Noda, Mitsuhiko

    2016-08-01

    Glycemic control alone does not reduce cardiovascular events in patients with type 2 diabetes (T2D), and routine screening of all T2D patients for asymptomatic coronary artery disease (CAD) is not effective for preventing acute cardiac events. We examined the effectiveness of an aggressive screening protocol for asymptomatic CAD in T2D patients with advanced vascular complications.We designed a 3-year cohort study investigating the effectiveness of the aggressive coronary screening for T2D patients with advanced vascular complications and no known coronary events using propensity score adjusted analysis at a national center in Japan. Eligibility criteria included T2D without known coronary events and with any 1 of the following 4 complications: advanced diabetic retinopathy, advanced chronic kidney disease, peripheral artery disease, or cerebrovascular disease. In the aggressive screening group (n = 122), all patients received stress single photon emission computed tomography and those exhibiting myocardial perfusion abnormalities underwent coronary angiography. In the conventional screening group (n = 108), patients were examined for CAD at the discretion of their medical providers. Primary endpoint was composite outcome of cardiovascular death and nonfatal cardiovascular events.Asymptomatic CAD with ≥70% stenosis was detected in 39.3% of patients completing aggressive screening. The proportions achieving revascularization and receiving intensive medical therapy within 90 days after the screening were significantly higher in the aggressive screening group than in the conventional screening group [19.7% vs 0% (P < 0.001) and 48.4% vs 9.3% (P < 0.001), respectively]. The cumulative rate of primary composite outcome was significantly lower in the aggressive screening group according to a propensity score adjusted Cox proportional hazards model (hazard ratio, 0.35; 95% confidence interval, 0.12-0.96; P = 0.04).Aggressive coronary screening for T2D patients

  8. Patient and Caregiver Incongruence in Advanced Heart Failure

    PubMed Central

    Kitko, Lisa A.; Hupcey, Judith E.; Pinto, Casey; Palese, Maureen

    2014-01-01

    The important role of caregivers in heart failure (HF) management is well documented, but few studies have explored HF patient–caregiver dyads when dyadic incongruence is evident. The purpose of this study was to determine the prevalence of incongruence between HF patient–caregiver dyads, areas of incongruence, and the impact on individuals in the dyadic relationship. Data were collected as part of a longitudinal qualitative study examining the palliative care needs of HF dyads. Interviews with dyads determined to be incongruent were further analyzed. Of the 100 dyads, 47 were identified as being incongruent. Dyads were found to be incongruent in illness management, health care issues, and end-of-life decisions. Dyads that were incongruent reported more psychosocial issues and distress within the dyad and individually. Further research is needed to determine the impact of incongruence and whether interventions to modify incongruence will lead to improved HF patient and caregiver outcomes and experiences. PMID:24599063

  9. Early-Life Overweight Trajectory and CKD in the 1946 British Birth Cohort Study

    PubMed Central

    Silverwood, Richard J.; Pierce, Mary; Hardy, Rebecca; Thomas, Claudia; Ferro, Charles; Savage, Caroline; Sattar, Naveed; Kuh, Diana; Nitsch, Dorothea

    2013-01-01

    Background Few studies have examined the impact of childhood obesity on later kidney disease, and consequently, our understanding is very limited. Study Design Longitudinal population-based cohort. Setting & Participants The Medical Research Council National Survey of Health and Development, a socially stratified sample of 5,362 singletons born in 1 week in March 1946 in England, Scotland, and Wales, of which 4,340 were analyzed. Predictor Early-life overweight latent classes (never, prepubertal only, pubertal onset, or always), derived from repeated measurements of body mass index between ages 2 and 20 years. Outcomes & Measurements The primary outcome was chronic kidney disease (CKD), defined as creatinine- or cystatin C–based estimated glomerular filtration rate (eGFRcr and eGFRcys, respectively) <60 mL/min/1.73 m2 or urine albumin-creatinine ratio (UACR) ≥3.5 mg/mmol measured at age 60-64 years. Associations were explored through regression analysis, with adjustment for socioeconomic position, smoking, physical activity level, diabetes, hypertension, and overweight at ages 36 and 53 years. Results 2.3% of study participants had eGFRcr <60 mL/min/1.73 m2, 1.7% had eGFRcys <60 mL/min/1.73 m2, and 2.9% had UACR ≥3.5 mg/mmol. Relative to being in the never-overweight latent class, being in the pubertal-onset– or always-overweight latent classes was associated with eGFRcys-defined CKD (OR, 2.04; 95% CI, 1.09-3.82). Associations with CKD defined by eGFRcr (OR, 1.27; 95% CI, 0.71-2.29) and UACR (OR, 1.33; 95% CI, 0.70-2.54) were less marked, but in the same direction. Adjustment for lifestyle and health factors had little impact on effect estimates. Limitations A low prevalence of CKD resulted in low statistical power. No documentation of chronicity for outcomes. All-white study population restricts generalizability. Conclusions Being overweight in early life was found to be associated with eGFRcys-defined CKD in later life. The associations with CKD defined

  10. Ozone therapy ameliorates tubulointerstitial inflammation by regulating TLR4 in adenine-induced CKD rats.

    PubMed

    Chen, Zhiyuan; Liu, Xiuheng; Yu, Gang; Chen, Hui; Wang, Lei; Wang, Zhishun; Qiu, Tao; Weng, Xiaodong

    2016-06-01

    Tubulointerstitium inflammation is a common pathway aggravating chronic kidney disease (CKD) progression and the mechanism is partly associated with excessive activation of toll-like receptor 4 (TLR4) in tubulointerstitium. Ozone therapy is demonstrated to alleviate inflammation in some experiments. The aim of this study is to examine whether ozone therapy could ameliorate chronic tubulointerstitium inflammation by suppressing TLR4 in adenine-induced CKD rats. Sprague-Dawley rats were fed with 0.75% adenine-containing diet to induce CKD and tubulointerstitium inflammation injury. Ozone therapy (1.1 mg/kg) was simultaneously administrated by rectal insufflations (i.r.). After 4 weeks, serum and kidney samples were collected for detection. Renal function and systemic electrolyte were detected. Renal pathological changes were assessed by hematoxylin-eosin (H&E) staining and Masson trichrome (MT) staining. Immunohistochemistry, Western blot and Real-time PCR were applied to evaluate tubulointerstitium inflammation as well as the expression of TLR4 and phosphorylated nuclear factor kappa B P65 (p-NF-κB P65) in rats. The results showed ozone therapy improved serious renal insufficiency, systemic electrolyte disorder and tubulointerstitium morphology damages in adenine-induced CKD rats. In addition, ozone therapy suppressed excessive activation of TLR4 and p-NF-κB P65 in the tubulointerstitium of adenine-induced CKD rats, accompanied by the reduction of inflammation-related cytokines including monocyte chemoattractant protein-1 (MCP-1), tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β) and interleukin-6 (IL-6). The protein expression of TLR4 was positively correlated with the protein expression levels of MCP-1 (r = 0.7863, p < 0.01) and TNF-α (r = 0.7547, p < 0.01) in CKD rats. These findings indicated ozone therapy could attenuate tubulointerstitium inflammation injury in adenine-induced CKD rats and the mechanism might associate with the

  11. Evaluation of Salivary Leptin Levels in Healthy Subjects and Patients with Advanced Periodontitis

    PubMed Central

    Khorsand, Afshin; Bayani, Mojtaba; Torabi, Sepehr; Kharrazifard, Mohammad Javad; Mohammadnejhad, Fatemeh

    2016-01-01

    Objectives: Leptin is a hormone-like protein produced by the adipose tissue. It plays an important role in protection of host against inflammation and infection. Some studies have reported changes in leptin levels in the gingival crevicular fluid (GCF), saliva and blood serum of patients with periodontal disease compared to healthy individuals. The aim of the present study was to compare the salivary leptin levels in patients with advanced periodontitis and healthy individuals. Materials and Methods: In this case-control study, the salivary samples of healthy individuals and patients with advanced periodontitis with clinical attachment loss >5mm were obtained using a standardized method and the leptin levels were measured in the salivary samples by means of ELISA. The effects of the periodontal status and sex on the salivary leptin levels of both groups were statistically analyzed by two-way ANOVA. Results: The means ± standard deviation (SD) of salivary leptin levels in healthy subjects and patients with advanced periodontitis were 34.27±6.88 and 17.87±5.89 pg/mL, respectively. Statistical analysis showed that the effect of sex on the salivary leptin levels was not significant (P=0.91), while the effect of advanced periodontitis on the salivary leptin levels was significant compared to healthy individuals (P<0.0001). Conclusions: In patients with advanced periodontitis, the salivary leptin levels were significantly lower compared to healthy individuals. Thus, assessment of salivary leptin can be done as a non-invasive and simple method to determine the susceptibility of patients to advanced periodontitis. PMID:27536322

  12. Identifying Advanced Glycation End Products as a Major Source of Oxidants in Aging: Implications for the Management and/or Prevention of Reduced Renal Function in Elderly Persons

    PubMed Central

    Vlassara, Helen; Uribarri, Jaime; Ferrucci, Luigi; Cai, Weijing; Torreggiani, Massimo; Post, James B.; Zheng, Feng; Striker, Gary E.

    2016-01-01

    Summary Aging is characterized by increasing inflammation and oxidant stress (OS). Reduced renal function was present in more than 20% of normal-aged individuals sampled in the National Health and Nutrition Examination Survey (NHANES) cross-sectional study of the US population. Longitudinal studies in the United States and Italy showed that renal function does not decline in some individuals, suggesting that a search for causes of the loss of renal function in some persons might be indicated and interventions to reduce this outcome should be sought. Because advanced glycation end products (AGEs) induce both inflammation and OS, accumulate with age, and primarily are excreted by the kidney, one outcome of reduced renal function in aging could be decreased AGE disposal. The build-up of AGEs with reduced renal function could contribute to inflammation, increased oxidant stress, and accumulation of AGEs in aging. In fact, results from a longitudinal study of normal aging adults in Italy showed that the most significant correlation with mortality was the level of renal function. A clear link between inflammation, OS, AGEs, and chronic disease was shown in studies of mice that showed that reduction of AGE levels by drugs or decreased intake of AGEs reduces chronic kidney disease (CKD) and cardiovascular disease of aging. The data support a role for AGEs in the development of renal lesions in aging mice and reveal that AGEs in the diet are very important contributors to renal and cardiovascular lesions. AGEs signal through two receptors, one of which is anti-inflammatory (AGER1) and the other is proinflammatory (RAGE). Overexpression of AGER1 protects against OS and acute vascular injury. The reduction of AGEs in the diet is as efficient in preventing aging-related cardiovascular and renal lesions in mice as that seen with calorie restriction. Studies in normal adults of all ages and those with CKD suggest that the findings in mice may be directly applicable to both aging

  13. Low-frequency electrical stimulation attenuates muscle atrophy in CKD--a potential treatment strategy.

    PubMed

    Hu, Li; Klein, Janet D; Hassounah, Faten; Cai, Hui; Zhang, Cong; Xu, Ping; Wang, Xiaonan H

    2015-03-01

    Effective therapeutic strategies to treat CKD-induced muscle atrophy are urgently needed. Low-frequency electrical stimulation (LFES) may be effective in preventing muscle atrophy, because LFES is an acupuncture technique that mimics resistance exercise by inducing muscle contraction. To test this hypothesis, we treated 5/6-nephrectomized mice (CKD mice) and control mice with LFES for 15 days. LFES prevented soleus and extensor digitorum longus muscle weight loss and loss of hind-limb muscle grip in CKD mice. LFES countered the CKD-induced decline in the IGF-1 signaling pathway and led to increases in markers of protein synthesis and myogenesis and improvement in muscle protein metabolism. In control mice, we observed an acute response phase immediately after LFES, during which the expression of inflammatory cytokines (IFN-γ and IL-6) increased. Expression of the M1 macrophage marker IL-1β also increased acutely, but expression of the M2 marker arginase-1 increased 2 days after initiation of LFES, paralleling the change in IGF-1. In muscle cross-sections of LFES-treated mice, arginase-1 colocalized with IGF-1. Additionally, expression of microRNA-1 and -206, which inhibits IGF-1 translation, decreased in the acute response phase after LFES and increased at a later phase. We conclude that LFES ameliorates CKD-induced skeletal muscle atrophy by upregulation of the IGF-1 signaling pathway, which improves protein metabolism and promotes myogenesis. The upregulation of IGF-1 may be mediated by decreased expression of microRNA-1 and -206 and/or activation of M2 macrophages. PMID:25228359

  14. Left Ventricular Mass Progression Despite Stable Blood Pressure and Kidney Function in Stage 3 CKD

    PubMed Central

    Seifert, Michael E.; Fuentes, Lisa de las; Ginsberg, Charles; Rothstein, Marcos; Dietzen, Dennis J.; Cheng, Steven C.; Ross, Will; Windus, David; Dávila-Román, Victor G.; Hruska, Keith A.

    2014-01-01

    Background/Aims Progressive chronic kidney disease (CKD) is associated with worsening cardiovascular risk not explained by traditional risk factors. Left ventricular hypertrophy (LVH) is an important cardiovascular risk factor, but its progression has not been documented in early CKD. We explored whether progression of LVH in early CKD would occur despite stable kidney function. Methods We conducted a post hoc analysis of a 12-m nth study of lanthanum carbonate in stage 3 CKD, which included longitudinal assessments of cardiovascular biomarkers. Primary outcome for the analysis was the change in LV mass indexed to height in meters2.7 (LVM/Ht2.7). Secondary outcomes were changes in blood pressure (BP), pulse-wave velocity, LV systolic/diastolic function, fibroblast growth factor-23 (FGF23), klotho, and eGFR. Results 31 of 38 original subjects had sufficient data for analysis. LVM/Ht2.7 increased (47 ± 13 vs. 53 ± 13 g/m2.7, P=0.006) over 12 months despite stable BP, stable eGFR and normal LV systolic function. Vascular stiffness and LV diastolic dysfunction persisted throughout the study. Klotho levels decreased (748 ± 289 to 536 ± 410 pg/ml, P=0.03) but were unrelated to changes in LVM/Ht2.7. The change in FGF23/klotho ratio was strongly correlated with changes in LVM/Ht2.7 (r2 0.582, P=0.03). Conclusion Subjects with stage 3 CKD exhibited increasing LV mass, persistent LV diastolic dysfunction and vascular stiffness despite stable kidney function, BP and LV systolic function. Abnormal FGF23 signaling due to reduced klotho expression may be associated with increasing LV mass. These findings deserve further evaluation in a larger population, given the adverse prognostic value of these cardiovascular biomarkers. PMID:24818573

  15. Current advances in targeted therapies for metastatic gastric cancer: improving patient care.

    PubMed

    Aguiar, Pedro Nazareth; Muniz, Thiago Pimentel; Miranda, Raelson Rodrigues; Tadokoro, Hakaru; Forones, Nora Manoukian; Monteiro, Ines-de-Paula; Castelo-Branco, Pedro; Janjigian, Yelena Y; de Mello, Ramon Andrade

    2016-03-01

    In this article, we review the literature on the current advances in targeted therapies for metastatic gastric cancer aimed at improving patient care. We conclude that the key to guiding targeted therapy is individual biomarkers, which are not completely elucidated. HER2 overexpression is the only predictive biomarker currently in use. Furthermore, it is necessary to understand that gastric tumors are heterogeneous; therefore, is impossible to evaluate a novel biological compound without evaluating personal biomarkers. The selection of patients who are able to receive each treatment is paramount for improving advanced gastric cancer survival and reducing unnecessary costs. PMID:26838766

  16. The Meaning of Parenteral Hydration to Family Caregivers and Patients with Advanced Cancer Receiving Hospice Care

    PubMed Central

    Cohen, Marlene Z; Torres-Vigil, Isabel; Burbach, Beth E.; de Rosa, Allison; Bruera, Eduardo

    2012-01-01

    Context In the U.S., patients with advanced cancer who are dehydrated or have decreased oral intake virtually always receive parenteral hydration in acute care facilities but rarely in the hospice setting. Objectives To describe the meaning of hydration for terminally ill cancer patients in home hospice care and for their primary caregivers. Methods Phenomenological interviews were conducted at two time points with 85 patients and 84 caregivers enrolled in a randomized, double-blind, controlled trial examining the efficacy of parenteral hydration in patients with advanced cancer receiving hospice care in the southern U.S. Transcripts were analyzed hermeneutically by the interdisciplinary research team until consensus on the theme labels was reached. Results Patients and their family caregivers both saw hydration as meaning hope and comfort. Hope was the view that hydration might prolong a life of dignity and enhance quality of life by reducing symptoms such as fatigue and increasing patients’ alertness. Patients and caregivers also described hydration as improving patients’ comfort by reducing pain, enhancing the effectiveness of pain medication, and nourishing the body, mind and spirit. Conclusion These findings differ from traditional hospice beliefs that dehydration enhances patient comfort given that patients and their families in the study viewed fluids as enhancing comfort, dignity and quality of life. Discussion with patients and families about their preferences for hydration may help tailor care plans to meet specific patient needs. PMID:22459230

  17. Pain sensitivity profiles in patients with advanced knee osteoarthritis.

    PubMed

    Frey-Law, Laura A; Bohr, Nicole L; Sluka, Kathleen A; Herr, Keela; Clark, Charles R; Noiseux, Nicolas O; Callaghan, John J; Zimmerman, M Bridget; Rakel, Barbara A

    2016-09-01

    The development of patient profiles to subgroup individuals on a variety of variables has gained attention as a potential means to better inform clinical decision making. Patterns of pain sensitivity response specific to quantitative sensory testing (QST) modality have been demonstrated in healthy subjects. It has not been determined whether these patterns persist in a knee osteoarthritis population. In a sample of 218 participants, 19 QST measures along with pain, psychological factors, self-reported function, and quality of life were assessed before total knee arthroplasty. Component analysis was used to identify commonalities across the 19 QST assessments to produce standardized pain sensitivity factors. Cluster analysis then grouped individuals who exhibited similar patterns of standardized pain sensitivity component scores. The QST resulted in 4 pain sensitivity components: heat, punctate, temporal summation, and pressure. Cluster analysis resulted in 5 pain sensitivity profiles: a "low pressure pain" group, an "average pain" group, and 3 "high pain" sensitivity groups who were sensitive to different modalities (punctate, heat, and temporal summation). Pain and function differed between pain sensitivity profiles, along with sex distribution; however, no differences in osteoarthritis grade, medication use, or psychological traits were found. Residualizing QST data by age and sex resulted in similar components and pain sensitivity profiles. Furthermore, these profiles are surprisingly similar to those reported in healthy populations, which suggests that individual differences in pain sensitivity are a robust finding even in an older population with significant disease. PMID:27152688

  18. Use of advanced imaging techniques during visits to emergency departments-implications, costs, patient benefits/risks.

    PubMed

    Dick, Elizabeth A; Varma, Dinesh; Kashef, Elika; Curtis, John

    2016-05-01

    25 years ago, on a Friday evening at 9 pm, the emergency department (ED) was full of patients with a wide range of clinical problems. Their investigations included plain radiographs, but no other imaging was included until the next working day. At present, many patients are receiving advanced imaging such as ultrasound, CT and MRI, often delivered out of hours-an obvious advance for patients or sometimes an unnecessary development? In this article, we will consider how to assess patient benefits and whether increased use of advanced imaging is an overall advance for patients. We will address the general implications for healthcare services which come with greater use of advanced imaging. We will then address the effect of advanced imaging on individual fictional ED patients with a variety of complaints. PMID:26693970

  19. Advances in targeted therapy for the treatment of patients with relapsed/refractory multiple myeloma.

    PubMed

    Le Ray, Emmanuelle; Jagannath, Sundar; Palumbo, Antonio

    2016-01-01

    The development of proteasome inhibitors (PIs) and immunomodulatory drugs has significantly improved outcomes for patients with relapsed/refractory multiple myeloma (RRMM); however, not all patients benefit from treatment with these agents and some patients can become drug refractory over time. Due to the largely incurable nature of multiple myeloma, the development of newer agents is ongoing and includes new oral PIs (ixazomib), immunotherapies (e.g., CD38- or SLAMF7-targeted antibodies), and small molecules. This review provides an overview of the advances in targeted therapy for patients with RRMM, including recently approved agents, with a focus on monotherapy and combined targeted therapies. PMID:26558304

  20. [Briefly summarized nursing card for patients with advanced cancer receiving out hospital management].

    PubMed

    Hayashi, Y; Andoh, M; Hioki, M; Sugitoh, Y; Hyoudoh, C

    1994-12-01

    Briefly summarized nursing card to perform adequate nursing for readmission patients with advanced cancer receiving outhospital management was developed and its clinical usefulness for nursing is discussed. The card is 18 cm x 13 cm, differential colored for diseases, and written only necessary summarized informations for adequate nursing at the patient's emergent readmission. By using this card for 24 patients, it was very useful because of its very selected, brief and summarized information. This card has much usefulness for nursing of such patients. PMID:7802460

  1. Optimal pharmacotherapeutic strategies for elderly patients with advanced non-small cell lung cancer.

    PubMed

    Quoix, Elisabeth

    2011-11-01

    Increases in both life expectancy and cancer incidence with age result in a significant rise in lung cancer rates among elderly patients, with a median age at diagnosis of between 63 and 70 years. However, elderly patients are under-represented in clinical trials and generally receive suboptimal treatment, mainly because of fears about increased toxicity of chemotherapy. Indeed, physiological modification of renal and haematopoietic functions with age together with co-morbidity and associated polypharmacy may alter the metabolism of chemotherapy drugs, resulting in greater toxicity. Moreover, performance status (PS), the main prognostic factor in younger patients, does not correlate well with geriatric indexes such as activities of daily living, cognition and physical performance, and comprehensive geriatric assessment is important in elderly patients. Until 2010, based on the small number of clinical trials designed for elderly patients, monotherapy was the recommended treatment for those with advanced non-small cell lung cancer (NSCLC), whereas for fit younger patients, a platinum-based doublet was and continues to be the recommended first-line therapy. However, at the plenary session of the 2010 Annual Meeting of the American Society of Clinical Oncology, results were presented from a randomized controlled trial conducted by the French Intergroup of Thoracic Oncology that demonstrated that in PS 0-2 patients aged≥70 years with advanced NSCLC, monthly carboplatin with weekly paclitaxel resulted in significantly longer survival than single-agent therapy (vinorelbine or gemcitabine). It should be noted that even in a priori unfavourable prognostic subgroups (patients with a PS score of 2, those aged>80 years or those with an activities of daily living scale score of <6), doublet therapy was associated with a survival advantage over monotherapy. Thus, the new paradigm of treatment of elderly patients with advanced NSCLC and a PS score of 0-2 should now be monthly

  2. Advanced Renal Failure in Patients with Sickle Cell Anemia: Clinical Course and Prognosis

    PubMed Central

    Cruz, Iluminado A.; Hosten, Adrian O.; Dillard, Martin G.; Castro, Oswaldo L.

    1982-01-01

    Advanced renal failure occurred in nine adult sickle cell disease patients. There were six men and three women with a mean age of 38.6 years. Eight patients had homozygous SS disease, one had sickle cell thalassemia. Three patients had acute renal failure from which they partially recovered. Six developed endstage kidney disease requiring dialysis. Two of these received a kidney transplant, and there was one death in the immediate postoperative period. Angina pectoris, hyperkalemia, and severe anemia complicated chronic dialysis, suggesting that early transplantation should be considered for sickle cell anemia patients with renal failure. PMID:6757451

  3. Frequency of Elevated Hepatocellular Carcinoma (HCC) Biomarkers in Patients with Advanced Hepatitis C

    PubMed Central

    Sterling, Richard K.; Wright, Elizabeth C.; Morgan, Timothy R.; Seeff, Leonard B.; Hoefs, John C.; Di Bisceglie, Adrian M.; Dienstag, Jules L.; Lok, Anna S.

    2013-01-01

    Background Prospective studies of serum HCC biomarkers in patients with advanced hepatitis C are lacking. Aims To determine frequencies and performance of elevated alpha-fetoprotein (AFP), AFP-L3, and des-gamma-carboxy prothrombin (DCP) levels as HCC biomarkers in advanced hepatitis C. Methods Patients in the HALT-C Trial were tested every 3 months for 42 months. Screening ultrasound was performed every 12 months. Levels of biomarkers were compared in patients in whom HCC did or did not develop. Results 855 patients were evaluated; HCC developed in 46. Among patients without HCC, 73.2% had AFP consistently <20, 24.5% had at least one AFP between 20-199, while 2.3% had at least one AFP value ≥200 ng/mL; 73.7% had DCP consistently <90, 11.6% had at least one DCP between 90-149, and 14.7% had at least one DCP value ≥150 mAU/mL. AFP-L3 ≥10% was present at least once in 9.0% and in 17.1% of those with AFP >20 ng/mL. Among all patients with elevated biomarkers, a diagnosis of HCC was made in 0-31.6% (depending on the biomarker and cutoff) during the subsequent 24 months. AFP ≥200 ng/mL had the highest specificity (99%), but sensitivity was ≤20%. DCP ≥40 mAU/mL had the highest sensitivity (76%), but specificity was ≤58%. Independent predictors of elevated AFP were gender (female), race (Black), more advanced disease, and HCC. Elevated DCP was associated with more advanced disease and HCC. Conclusions Mild-moderate elevations in total AFP and DCP but not AFP-L3 occur frequently in patients with chronic hepatitis C and advanced fibrosis, are related to factors other than HCC, and are poor predictors of HCC. PMID:21931376

  4. Symptoms and problems in a nationally representative sample of advanced cancer patients.

    PubMed

    Johnsen, A T; Petersen, M A; Pedersen, L; Groenvold, M

    2009-09-01

    Little is known about the need for palliative care among advanced cancer patients who are not in specialist palliative care. The purpose was to identify prevalence and predictors of symptoms and problems in a nationally representative sample of Danish advanced cancer patients. Patients with cancer stage 3 or 4 from 54 hospital departments (n = 1630) received the EORTC QLQ-C30 questionnaire. Mean scores were calculated according to the scoring manual and in addition a 'symptom/problem' and a 'severe symptom/problem' was defined and calculated. Multiple logistic regression was used to identify predictors. In total, 977 (60%) patients participated. The most frequent symptoms/problems were fatigue (57%; severe 22%) followed by reduced role function, insomnia and pain. Age, cancer stage, primary tumour, type of department, marital status and whether the patient had recently been hospitalized or not were associated with several symptoms and problems. This is probably the first nationally representative study of its kind. It shows that advanced cancer patients in Denmark have symptoms and problems that deserve attention and that some patient groups are especially at risk. PMID:19443525

  5. Management of patients with advanced prostate cancer: recommendations of the St Gallen Advanced Prostate Cancer Consensus Conference (APCCC) 2015.

    PubMed

    Gillessen, S; Omlin, A; Attard, G; de Bono, J S; Efstathiou, E; Fizazi, K; Halabi, S; Nelson, P S; Sartor, O; Smith, M R; Soule, H R; Akaza, H; Beer, T M; Beltran, H; Chinnaiyan, A M; Daugaard, G; Davis, I D; De Santis, M; Drake, C G; Eeles, R A; Fanti, S; Gleave, M E; Heidenreich, A; Hussain, M; James, N D; Lecouvet, F E; Logothetis, C J; Mastris, K; Nilsson, S; Oh, W K; Olmos, D; Padhani, A R; Parker, C; Rubin, M A; Schalken, J A; Scher, H I; Sella, A; Shore, N D; Small, E J; Sternberg, C N; Suzuki, H; Sweeney, C J; Tannock, I F; Tombal, B

    2015-08-01

    The first St Gallen Advanced Prostate Cancer Consensus Conference (APCCC) Expert Panel identified and reviewed the available evidence for the ten most important areas of controversy in advanced prostate cancer (APC) management. The successful registration of several drugs for castration-resistant prostate cancer and the recent studies of chemo-hormonal therapy in men with castration-naïve prostate cancer have led to considerable uncertainty as to the best treatment choices, sequence of treatment options and appropriate patient selection. Management recommendations based on expert opinion, and not based on a critical review of the available evidence, are presented. The various recommendations carried differing degrees of support, as reflected in the wording of the article text and in the detailed voting results recorded in supplementary Material, available at Annals of Oncology online. Detailed decisions on treatment as always will involve consideration of disease extent and location, prior treatments, host factors, patient preferences as well as logistical and economic constraints. Inclusion of men with APC in clinical trials should be encouraged. PMID:26041764

  6. Management of patients with advanced prostate cancer: recommendations of the St Gallen Advanced Prostate Cancer Consensus Conference (APCCC) 2015

    PubMed Central

    Gillessen, S.; Omlin, A.; Attard, G.; de Bono, J. S.; Efstathiou, E.; Fizazi, K.; Halabi, S.; Nelson, P. S.; Sartor, O.; Smith, M. R.; Soule, H. R.; Akaza, H.; Beer, T. M.; Beltran, H.; Chinnaiyan, A. M.; Daugaard, G.; Davis, I. D.; De Santis, M.; Drake, C. G.; Eeles, R. A.; Fanti, S.; Gleave, M. E.; Heidenreich, A.; Hussain, M.; James, N. D.; Lecouvet, F. E.; Logothetis, C. J.; Mastris, K.; Nilsson, S.; Oh, W. K.; Olmos, D.; Padhani, A. R.; Parker, C.; Rubin, M. A.; Schalken, J. A.; Scher, H. I.; Sella, A.; Shore, N. D.; Small, E. J.; Sternberg, C. N.; Suzuki, H.; Sweeney, C. J.; Tannock, I. F.; Tombal, B.

    2015-01-01

    The first St Gallen Advanced Prostate Cancer Consensus Conference (APCCC) Expert Panel identified and reviewed the available evidence for the ten most important areas of controversy in advanced prostate cancer (APC) management. The successful registration of several drugs for castration-resistant prostate cancer and the recent studies of chemo-hormonal therapy in men with castration-naïve prostate cancer have led to considerable uncertainty as to the best treatment choices, sequence of treatment options and appropriate patient selection. Management recommendations based on expert opinion, and not based on a critical review of the available evidence, are presented. The various recommendations carried differing degrees of support, as reflected in the wording of the article text and in the detailed voting results recorded in supplementary Material, available at Annals of Oncology online. Detailed decisions on treatment as always will involve consideration of disease extent and location, prior treatments, host factors, patient preferences as well as logistical and economic constraints. Inclusion of men with APC in clinical trials should be encouraged. PMID:26041764

  7. Considerations in Starting a Patient with Advanced Frailty on Dialysis: Complex Biology Meets Challenging Ethics

    PubMed Central

    2013-01-01

    Summary Nephrologists have focused on the uremic syndrome as an indication for dialysis. The elderly frail renal patient approaching ESRD represents a complex biologic system that is already failing. This patient phenotype exhibits progressive geriatric disabilities and dependence interspersed with shrinking periods of stability regardless of whether dialysis is started. Consequently, the frail renal patient faces challenging treatment choices underpinned by ethical tensions. Identifying the advanced frail renal patient and optimizing the shared decision-making process will enable him or her to make well informed choices based on an understanding of his or her overall condition and personal values and preferences. This approach will also permit nephrologists to fulfill their ethical obligations to respect patient autonomy, promote patient benefit, and minimize patient harm. PMID:23788617

  8. Clinically Apparent Internal Mammary Nodal Metastasis in Patients With Advanced Breast Cancer: Incidence and Local Control

    SciTech Connect

    Zhang Yujing; Oh, Julia L.; Whitman, Gary J.

    2010-07-15

    Purpose: To investigate the incidence and local control of internal mammary lymph node metastases (IMN+) in patients with clinical N2 or N3 locally advanced breast cancer. Methods and Materials: We retrospectively reviewed the records of 809 breast cancer patients diagnosed with advanced nodal disease (clinical N2-3) who received radiation treatment at our institution from January 2000 December 2006. Patients were considered IMN+ on the basis of imaging studies. Results: We identified 112 of 809 patients who presented with IMN+ disease (13.8%) detected on ultrasound, computed tomography (CT), positron emission tomography/CT (PET/CT), and/or magnetic resonance imaging (MRI) studies. All 112 patients with IMN+ disease received anthracycline and taxane-based chemotherapy. Neoadjuvant chemotherapy (NCT) resulted in a complete response (CR) on imaging studies of IMN disease in 72.1% of patients. Excluding 16 patients with progressive disease, 96 patients received adjuvant radiation to the breast or the chest wall and the regional lymphatics including the IMN chain with a median dose of 60 Gy if the internal mammary lymph nodes normalized after chemotherapy and 66 Gy if they did not. The median follow-up of surviving patients was 41 months (8-118 months). For the 96 patients able to complete curative therapy, the actuarial 5-year IMN control rate, locoregional control, overall survival, and disease-free survival were 89%, 80%, 76%, and 56%. Conclusion: Over ten percent of patients with advanced nodal disease will have IMN metastases on imaging studies. Multimodality therapy including IMN irradiation achieves excellent rates of control in the IMN region and a DFS of more than 50% after curative treatment.

  9. Dietary Advanced Glycation End Products and Risk Factors for Chronic Disease: A Systematic Review of Randomised Controlled Trials

    PubMed Central

    Clarke, Rachel E.; Dordevic, Aimee L.; Tan, Sih Min; Ryan, Lisa; Coughlan, Melinda T.

    2016-01-01

    Dietary advanced glycation end-products (AGEs) form during heating and processing of food products and are widely prevalent in the modern Western diet. Recent systematic reviews indicate that consumption of dietary AGEs may promote inflammation, oxidative stress and insulin resistance. Experimental evidence indicates that dietary AGEs may also induce renal damage, however, this outcome has not been considered in previous systematic reviews. The purpose of this review was to examine the effect of consumption of a high AGE diet on biomarkers of chronic disease, including chronic kidney disease (CKD), in human randomized controlled trials (RCTs). Six databases (SCOPUS, CINHAL, EMBASE, Medline, Biological abstracts and Web of Science) were searched for randomised controlled dietary trials that compared high AGE intake to low AGE intake in adults with and without obesity, diabetes or CKD. Twelve dietary AGE interventions were identified with a total of 293 participants. A high AGE diet increased circulating tumour necrosis factor-alpha and AGEs in all populations. A high AGE diet increased 8-isoprostanes in healthy adults, and vascular cell adhesion molecule-1 (VCAM-1) in patients with diabetes. Markers of CKD were not widely assessed. The evidence presented indicates that a high AGE diet may contribute to risk factors associated with chronic disease, such as inflammation and oxidative stress, however, due to a lack of high quality randomised trials, more research is required. PMID:26938557

  10. Patient, Carer and Professional Perspectives on Barriers and Facilitators to Quality Care in Advanced Heart Failure

    PubMed Central

    Browne, Susan; Macdonald, Sara; May, Carl R.; Macleod, Una; Mair, Frances S.

    2014-01-01

    Background Those with advanced heart failure (HF) experience high levels of morbidity and mortality, similar to common cancers. However, there remains evidence of inequity of access to palliative care services compared to people with cancer. This study examines patient, carer, and professional perspectives on current management of advanced HF and barriers and facilitators to improved care. Methods Qualitative study involving semi-structured interviews and focus groups with advanced HF patients (n = 30), carers (n = 20), and professionals (n = 65). Data analysed using Normalisation Process Theory (NPT) as the underpinning conceptual framework. Findings Uncertainty is ubiquitous in accounts from advanced HF patients and their caregivers. This uncertainty relates to understanding of the implications of their diagnosis, appropriate treatments, and when and how to seek effective help. Health professionals agree this is a major problem but feel they lack knowledge, opportunities, or adequate support to improve the situation. Fragmented care with lack of coordination and poor communication makes life difficult. Poor understanding of the condition extends to the wider circle of carers and means that requests for help may not be perceived as legitimate, and those with advanced HF are not prioritised for social and financial supports. Patient and caregiver accounts of emergency care are uniformly poor. Managing polypharmacy and enduring concomitant side effects is a major burden, and the potential for rationalisation exists. This study has potential limitations because it was undertaken within a single geographical location within the United Kingdom. Conclusions Little progress is being made to improve care experiences for those with advanced HF. Even in the terminal stages, patients and caregivers are heavily and unnecessarily burdened by health care services that are poorly coordinated and offer fragmented care. There is evidence that these poor experiences

  11. [Triple therapy in cirrhotic patients and those with advanced fibrosis: relevant aspects in clinical practice].

    PubMed

    Albillos, Agustín; Luis Calleja, José; Molina, Esther; Planas, Ramon; Romero-Gómez, Manuel; Turnes, Juan; Hernández-Guerra, Manuel

    2014-07-01

    The first-line option in the treatment of patients with advanced fibrosis and cirrhosis due to genotype 1 hepatitis C virus is currently triple therapy with boceprevir/telaprevir and pegylated interferon-ribavirin. However, certain limitations could constitute a barrier to starting treatment or achieving sustained viral response in these patients. These limitations include the patient's or physician's perception of treatment effectiveness in routine clinical practice-which can weight against the decision to start treatment-, the advanced stage of the disease with portal hypertension and comorbidity, treatment interruption due to poor adherence, and adverse effects, mainly anemia. In addition, it is now possible to identify patients who could benefit from a shorter therapeutic regimen with a similar cure rate. This review discusses these issues and their possible effect on the use of triple therapy. PMID:25907434

  12. Precision oncology for patients with advanced cancer: the challenges of malignant snowflakes

    PubMed Central

    Kurzrock, Razelle; Giles, Francis J

    2015-01-01

    Precision oncology implies customizing treatment to the unique molecular and biologic characteristics of each individual and their cancer. Its implementation is being facilitated by remarkable technological advances in genomic sequencing, as well as the increasing availability of targeted and immunotherapeutic drugs. Yet, next generation sequencing may be a disruptive technology in that its results suggest that classic paradigms for clinical research and practice are a poor fit with the complex reality encountered in metastatic malignancies. Indeed, it is evident that advanced tumors have heterogeneous molecular landscapes that mostly differ between patients. Traditional modes of clinical research/practice are drug centered, with a strategy of finding commonalities between patients so that they can be grouped together and treated similarly. However, if each patient with metastatic cancer has a unique molecular portfolio, a new patient-centered, N-of-one approach that utilizes individually tailored treatment is needed. PMID:26030337

  13. Advanced Basal cell carcinoma in a patient with schizoaffective disorder: constraints and management.

    PubMed

    Taylor, Elise J; Golas, Liliya; Martel, Joseph R; Martel, James B

    2013-01-01

    The approach used by the authors for managing a patient with a schizoaffective disorder and advanced basal cell carcinoma involving the eyelids, orbit, and face is presented. Complexities included the advanced nature of the disease, neglect of the patient's condition due to schizoaffective disorder, the difficulty of obtaining informed consent, the required aggressive surgical intervention, reconstruction, and the necessary management during the postsurgical period. A multidisciplinary team approach with psychiatry, ophthalmology, ear, nose, and throat, plastic surgery, radiation oncology, oncology, legal, and bioethics specialties is required in patients with cognitive disabilities. Curative treatment requires complete excision, reconstruction, and proper postoperative care, which can be prohibitive in a schizophrenic patient from a surgical and ethical perspective. Staging of this condition after proper informed consent with biopsy, computed tomography, and magnetic resonance imaging is presented. The options for management are discussed, including surgical intervention and palliative care. PMID:23235512

  14. [Respect for autonomy of "incompetent" patients?--the ethical problem of advanced directives].

    PubMed

    Rehbock, Theda

    2005-12-01

    In addressing the ethical and legal problems of advanced directives, the article discusses whether respect for the autonomy of the so-called "incompetent" patients is possible and morally required. Starting with a critique of how modern medicine threatens patient autonomy and care (2.), the author goes on to highlight the mutual interdependence between respect for autonomy and patient care as two moral requirements arising from respect for human dignity (3.). Finally; the article elucidates the practical consequences as they relate to a treatment approach for each patient that is simultaneously caring and respectful of their autonomy, commenting on the ramifications for a sensitive and conscientious approach to advanced medical directives and for the special -role of nursing in this context. PMID:16398303

  15. KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Management of Blood Pressure in CKD

    PubMed Central

    Taler, Sandra J.; Agarwal, Rajiv; Bakris, George L.; Flynn, Joseph T.; Nilsson, Peter M.; Rahman, Mahboob; Sanders, Paul W.; Textor, Stephen C.; Weir, Matthew R.; Townsend, Raymond R.

    2014-01-01

    In response to the 2012 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for blood pressure management in patients with chronic kidney disease not on dialysis, the National Kidney Foundation organized a group of US experts in hypertension and transplant nephrology to review the recommendations and comment on their relevancy in the context of current US clinical practice and concerns. The overriding message was the dearth of clinical trial evidence to provide strong evidence-based recommendations. For patients with CKD with normal to mildly increased albuminuria, goal blood pressure has been relaxed to ≤140/90 mm Hg for both diabetic and nondiabetic patients. In contrast, KDIGO continues to recommend goal blood pressure ≤130/80 mm Hg for patients with chronic kidney disease with moderately or severely increased albuminuria and for all renal transplant recipients regardless of the presence of proteinuria, without supporting data. The expert panel thought the KDIGO recommendations were generally reasonable but lacking in sufficient evidence support and that additional studies are greatly needed. PMID:23684145

  16. A prospective evaluation of an interdisciplinary nutrition–rehabilitation program for patients with advanced cancer

    PubMed Central

    Gagnon, B.; Murphy, J.; Eades, M.; Lemoignan, J.; Jelowicki, M.; Carney, S.; Amdouni, S.; Di Dio, P.; Chasen, M.; MacDonald, N.

    2013-01-01

    Background Cancer can affect many dimensions of a patient’s life, and in turn, it should be targeted using a multimodal approach. We tested the extent to which an interdisciplinary nutrition–rehabilitation program can improve the well-being of patients with advanced cancer. Methods Between January 10, 2007, and September 29, 2010, 188 patients with advanced cancer enrolled in the 10–12-week program. Body weight, physical function, symptom severity, fatigue dimensions, distress level, coping ability, and overall quality of life were assessed at the start and end of the program. Results Of the enrolled patients, 70% completed the program. Patients experienced strong improvements in the physical and activity dimensions of fatigue (effect sizes: 0.8–1.1). They also experienced moderate reductions in the severity of weakness, depression, nervousness, shortness of breath, and distress (effect sizes: 0.5–0.7), and moderate improvements in Six Minute Walk Test distance, maximal gait speed, coping ability, and quality of life (effect sizes: 0.5–0.7) Furthermore, 77% of patients either maintained or increased their body weight. Conclusions Interdisciplinary nutrition–rehabilitation can be advantageous for patients with advanced cancer and should be considered an integrated part of standard palliative care. PMID:24311946

  17. Chemotherapy for patients with advanced lung cancer receiving long-term oxygen therapy

    PubMed Central

    Suzuki, Hidekazu; Shiroyama, Takayuki; Tamiya, Motohiro; Okamoto, Norio; Tanaka, Ayako; Morishita, Naoko; Nishida, Takuji; Nishihara, Takashi; Hirashima, Tomonori

    2016-01-01

    Background Long-term oxygen therapy (LTOT) is sometimes prescribed for patients with advanced lung cancer who are potential candidates for chemotherapy. The aim of this study was to assess the usefulness of chemotherapy for patients with this disease who require LTOT. Methods The medical records of 40 patients with advanced lung cancer who received LTOT while undergoing systemic chemotherapy at our institution between January 2009 and December 2014 were retrospectively reviewed. Chemotherapy consisted of cytotoxic or molecular-targeted agents. Results Twenty-four patients had adenocarcinoma, 6 had squamous cell carcinoma, and 10 had small cell lung cancer (SCLC). The median survival time from the date of the first chemotherapy cycle performed in conjunction with LTOT was 194 days. In a multivariate analysis, the only factor significantly associated with better prognosis was the line (first or second) of the first chemotherapy with LTOT (hazard ratio =0.42; 95% confidence interval, 0.18 to 0.94). Among the 40 patients, 10 (25%) received chemotherapy during the last 30 days of their lives, 2 of whom died of chemotherapy-related adverse events. Conclusions Chemotherapy for patients with advanced lung cancer who receive LTOT may be acceptable if it is the first- or second-line treatment. However, we should be mindful of the potential overuse of chemotherapy and its negative impact on quality of life. PMID:26904219

  18. Hepatic intra-arterial chemotherapy in patients with advanced primary liver tumours

    PubMed Central

    Spada, Francesca; Fazio, Nicola; Bonomo, Guido; Monfardini, Lorenzo; Vigna, Paolo Della; Radice, Davide; Boselli, Sabrina; Orsi, Franco

    2012-01-01

    Background: Primary liver tumours (PLTs) are currently a major health problem worldwide. The study’s aim was to investigate the feasibility, toxicity, and activity of hepatic intra-arterial chemotherapy (HIAC) in patients with advanced PLTs. Methods: We retrospectively analysed 43 patients with advanced unresectable PLT, who were consecutively treated. HIAC with 5-fluorouracil, cisplatin, and mitomycin-C was administered through a radiologically positioned temporary percutaneous catheter every six weeks until tumour progression or unacceptable toxicity was reached. Results: Partial response was observed in 26% and stable disease in 41% of patients. The median overall survival was 12.3 months. Manageable catheter-related complications occurred in 23% of patients. The grade 3–4 toxicities included neutropenia, thrombocytopenia, and transaminitis. There were no toxic deaths. Conclusion: The results of this retrospective study show that HIAC is feasible, active, and manageable in patients with PLTs. The treatment could be studied in selected patients with advanced progressive HCC/BTC being treated with or ineligible for sorafenib/cisplatin plus gemcitabine. PMID:23226162

  19. Phase 1 Study of Erlotinib Plus Radiation Therapy in Patients With Advanced Cutaneous Squamous Cell Carcinoma

    SciTech Connect

    Heath, C. Hope; Deep, Nicholas L.; Nabell, Lisle; Carroll, William R.; Desmond, Renee; Clemons, Lisa; Spencer, Sharon; Magnuson, J. Scott; Rosenthal, Eben L.

    2013-04-01

    Purpose: To assess the toxicity profile of erlotinib therapy combined with postoperative adjuvant radiation therapy in patients with advanced cutaneous squamous cell carcinoma. Methods and Materials: This was a single-arm, prospective, phase 1 open-label study of erlotinib with radiation therapy to treat 15 patients with advanced cutaneous head-and-neck squamous cell carcinoma. Toxicity data were summarized, and survival was analyzed with the Kaplan-Meier method. Results: The majority of patients were male (87%) and presented with T4 disease (93%). The most common toxicity attributed to erlotinib was a grade 2-3 dermatologic reaction occurring in 100% of the patients, followed by mucositis (87%). Diarrhea occurred in 20% of the patients. The 2-year recurrence rate was 26.7%, and mean time to cancer recurrence was 10.5 months. Two-year overall survival was 65%, and disease-free survival was 60%. Conclusions: Erlotinib and radiation therapy had an acceptable toxicity profile in patients with advanced cutaneous squamous cell carcinoma. The disease-free survival in this cohort was comparable to that in historical controls.

  20. Proteinuria as a Therapeutic Target in Advanced Chronic Kidney Disease: a Retrospective Multicenter Cohort Study.

    PubMed

    Chen, Chang-Hsu; Wu, Hon-Yen; Wang, Chieh-Li; Yang, Feng-Jung; Wu, Pei-Chen; Hung, Szu-Chun; Kan, Wei-Chih; Yang, Chung-Wei; Chiang, Chih-Kang; Huang, Jenq-Wen; Hung, Kuan-Yu

    2016-01-01

    Current evidence of proteinuria reduction as a surrogate target in advanced chronic kidney disease (CKD) is incomplete due to lack of patient-pooled database. We retrospectively studied a multicenter cohort of 1891 patients who were enrolled in the nationwide multidisciplinary pre-end stage renal disease care program with a baseline glomerular filtration rate (GFR) <45 mL/min/1.73 m(2) and followed longitudinally to investigate the effect of the change in proteinuria on renal death (defined as composite of dialysis and death occurring before initiation of dialysis). The group with a change in proteinuria ≤0.30 g/g (n = 1261) had lower cumulative probabilities of renal death (p < 0.001). In a linear regression model, a higher baseline proteinuria and a greater increase in proteinuria were associated with faster annual GFR decline. Cox's analysis showed that every 1 unit increase in natural log(baseline proteinuria, 10 g/g) and every 0.1 g/g increase in the change in proteinuria resulted in 67% (HR = 1.67, 95% CI: 1.46-1.91) and 1% (HR = 1.01, 95% CI: 1.01-1.01) greater risk of renal death respectively after adjusting for the effects of the other covariates. Our study provided a patient-based evidence to support proteinuria as a therapeutic target in advanced CKD. PMID:27198863

  1. Proteinuria as a Therapeutic Target in Advanced Chronic Kidney Disease: a Retrospective Multicenter Cohort Study

    PubMed Central

    Chen, Chang-Hsu; Wu, Hon-Yen; Wang, Chieh-Li; Yang, Feng-Jung; Wu, Pei-Chen; Hung, Szu-Chun; Kan, Wei-Chih; Yang, Chung-Wei; Chiang, Chih-Kang; Huang, Jenq-Wen; Hung, Kuan-Yu

    2016-01-01

    Current evidence of proteinuria reduction as a surrogate target in advanced chronic kidney disease (CKD) is incomplete due to lack of patient-pooled database. We retrospectively studied a multicenter cohort of 1891 patients who were enrolled in the nationwide multidisciplinary pre-end stage renal disease care program with a baseline glomerular filtration rate (GFR) <45 mL/min/1.73 m2 and followed longitudinally to investigate the effect of the change in proteinuria on renal death (defined as composite of dialysis and death occurring before initiation of dialysis). The group with a change in proteinuria ≤0.30 g/g (n = 1261) had lower cumulative probabilities of renal death (p < 0.001). In a linear regression model, a higher baseline proteinuria and a greater increase in proteinuria were associated with faster annual GFR decline. Cox’s analysis showed that every 1 unit increase in natural log(baseline proteinuria, 10 g/g) and every 0.1 g/g increase in the change in proteinuria resulted in 67% (HR = 1.67, 95% CI: 1.46–1.91) and 1% (HR = 1.01, 95% CI: 1.01–1.01) greater risk of renal death respectively after adjusting for the effects of the other covariates. Our study provided a patient-based evidence to support proteinuria as a therapeutic target in advanced CKD. PMID:27198863

  2. Involved-field radiotherapy for patients in partial remission after chemotherapy for advanced Hodgkin's lymphoma

    SciTech Connect

    Aleman, Berthe M.P. . E-mail: b.aleman@nki.nl; Raemaekers, John M.M.; Tomisic, Radka; Baaijens, Margreet H.A.; Bortolus, Roberto; Lybeert, Marnix L.M.; Maazen, Richard W.M. van der; Girinsky, Theodore; Demeestere, Geertrui; Lugtenburg, Pieternella; Lievens, Yolande; Jong, Daphne de; Pinna, Antonella; Henry-Amar, Michel

    2007-01-01

    Purpose: The use of radiotherapy in patients with advanced Hodgkin's lymphoma (HL) is controversial. The purpose of this study was to describe the role of radiotherapy in patients with advanced HL who were in partial remission (PR) after chemotherapy. Methods: In a prospective randomized trial, patients <70 years old with previously untreated Stage III-IV HL were treated with six to eight cycles of mechlorethamine, vincristine, procarbazine, prednisone/doxorubicin, bleomycine, vinblastine hybrid chemotherapy. Patients in complete remission (CR) after chemotherapy were randomized between no further treatment and involved-field radiotherapy (IF-RT). Those in PR after six cycles received IF-RT (30 Gy to originally involved nodal areas and 18-24 Gy to extranodal sites with or without a boost). Results: Of 739 enrolled patients, 57% were in CR and 33% in PR after chemotherapy. The median follow-up was 7.8 years. Patients in PR had bulky mediastinal involvement significantly more often than did those in CR after chemotherapy. The 8-year event-free survival and overall survival rate for the 227 patients in PR who received IF-RT was 76% and 84%, respectively. These rates were not significantly different from those for CR patients who received IF-RT (73% and 78%) or for those in CR who did not receive IF-RT (77% and 85%). The incidence of second malignancies in patients in PR who were treated with IF-RT was similar to that in nonirradiated patients. Conclusion: Patients in PR after six cycles of mechlorethamine, vincristine, procarbazine, prednisone/doxorubicine, bleomycine, vinblastine treated with IF-RT had 8-year event-free survival and overall survival rates similar to those of patients in CR, suggesting a definite role for RT in these patients.

  3. Ethical issues in the geriatric patient with advanced cancer 'living to the end'.

    PubMed

    Daher, M

    2013-10-01

    Cancer incidence will increase as the population ages; there will be a 50% increase in new cancer cases over the next 20 years, and the biggest rates of increase will occur in the developing world. Owing to technical advances in the care of critical illness, as it is the case in elderly people with advanced cancer, physicians, patients and families are often confronted with ambiguous circumstances in which medical advances may inadvertently prolong suffering and the dying process rather than bring healing and recovery. In this review of the ethical issues confronting physicians who care for patients with advanced life-limiting illnesses like cancer, a philosophical debate continues in the medical community regarding the rightness or wrongness of certain actions (e.g. physician-assisted death, euthanasia), while at the same time there is a strong desire to find a common ground for moral discourse that could guide medical decision-making in this difficult period in the lives of our patients. We will discuss how a good palliative care can be an alternative to these ethical dilemmas. Although some issues (e.g. the role of physician-assisted death in addressing suffering) remain very controversial, there is much common ground based on the application of the four major principles of medical ethics, no malfeasance, beneficence, autonomy and justice. Thus, the physician's primary commitment must always be the patient's welfare and best interests, whether the physician is treating illness or helping patients to cope with illness, disability and death. A key skill here is the communication of bad news and to negotiate a treatment plan that is acceptable to the patient, the family and the healthcare team. Attention to psychosocial issues demands involvement of the patients and their families as partners. Physicians should be sensitive to the range of psychosocial distress and social disruption common to dying patients and their families. Spiritual issues often come to the

  4. Effect of pravastatin on the survival of patients with advanced gastric cancer

    PubMed Central

    Bujanda, Luis; Rodríguez-González, Araceli; Sarasqueta, Cristina; Eizaguirre, Emma; Hijona, Elizabeth; Marín, José J.G.; Perugorria, María J.; Banales, Jesús M.; Cosme, Angel

    2016-01-01

    Objectives A fluoropyrimidine plus cisplatin combined with surgery is standard first-line treatment for advanced gastric cancer. We evaluated the effect of pravastatin on overall survival in patients with advanced gastric cancer in a prospective cohort study. Methods At the time of surgery, we assigned 60 patients with advanced gastric cancer (stage III or IV) to receive standard first-line treatment (control group) or standard first-line treatment plus pravastatin at a dose of 40 mg once daily (pravastatin group). The minimum follow-up period was 4 years and the maximum of 6 years. Results The mean of age was 66 years and the TNM stage was III and IV in 65% and 35% of patients, respectively. There was no significant difference between the two groups (control vs pravastatin) in median overall survival (15 vs 14 months; P = 0.8). Predictors of survival were the stage (hazard ratio of death stage IV (III stage as reference): 4.4; 95% CI: 2–9.7; p < 0.05) and older age (hazard ratio of death ≥ 65 years (< 65 years as reference): 2.8; 95% CI: 1.3–6; p < 0.05). Conclusions Pravastatin did not improve outcome in patients with advanced gastric cancer. PMID:26735890

  5. Long-Term Progression-Free Survival in a Patient with Locally Advanced, Unresectable Pancreatic Adenocarcinoma

    PubMed Central

    Kahn, Leonel A; Matin, Mahan; Bold, Richard J; Tanaka, Michael I; Monjazeb, Arta M

    2015-01-01

    Pancreatic adenocarcinoma is amongst the most lethal malignancies with dismal five-year survival rates. Surgical excision is the mainstay of therapy and unresectable disease is considered incurable. Herein, we describe a patient with unresectable, advanced stage pancreatic adenocarcinoma with a remarkable clinical course following definitive chemoradiotherapy. PMID:26824007

  6. Effect of pravastatin on survival in patients with advanced hepatocellular carcinoma. A randomized controlled trial

    PubMed Central

    Kawata, S; Yamasaki, E; Nagase, T; Inui, Y; Ito, N; Matsuda, Y; Inada, M; Tamura, S; Noda, S; Imai, Y; Matsuzawa, Y

    2001-01-01

    Chemotherapy is not effective for hepatocellular carcinoma (HCC). HMG-CoA redutase inhibitors have cytostatic activity for cancer cells, but their clinical usefulness is unknown. To investigate whether pravastatin, a potent HMG-CoA reductase inhibitor, prolongs survival in patients with advanced HCC, this randomized controlled trial was conducted between February 1990 and February 1998 at Osaka University Hospital. 91 consecutive patients <71 years old (mean age 62) with unresectable HCC were enroled in this study. 8 patients were withdrawn because of progressive liver dysfunction; 83 patients were randomized to standard treatment with or without pravastatin. All patients underwent transcatheter arterial embolization (TAE) followed by oral 5-FU 200 mg−1d for 2 months. Patients were then randomly assigned to control (n = 42) and pravastatin (n = 41) groups. Pravastatin was administered at a daily dose of 40 mg. The effect of pravastatin on tumour growth was assessed by ultrasonography. Primary endpoint was death due to progression of HCC. The duration of pravastatin administration was 16.5 ± 9.8 months (mean ± SD). No patients in either group were lost to follow-up. Median survival was 18 months in the pravastatin group versus 9 months in controls (P = 0.006). The Cox proportional hazards model showed that pravastatin was a significant factor contributing to survival. Pravastatin prolonged the survival of patients with advanced HCC, suggesting its value for adjuvant treatment. © 2001 Cancer Research Campaign http://www.bjcancer.com PMID:11286466

  7. Surgery is an essential component of multimodality therapy for patients with locally advanced esophageal adenocarcinoma

    PubMed Central

    Murphy, Caitlin C.; Correa, Arlene M.; Ajani, Jaffer A.; Komaki, Ritsuko U.; Welsh, James W.; Swisher, Stephen G.; Hofstetter, Wayne L.

    2016-01-01

    Background Experience with neoadjuvant chemoradiation (CXRT) has raised questions regarding the additional benefit of surgery after locally advanced esophageal adenocarcinoma patients achieve a clinical response to CXRT. We sought to quantify the value of surgery by comparing the overall (OS) and disease-free survival (DFS) of trimodality eligible patients treated with definitive CXRT versus CXRT followed by esophagectomy. Methods We identified 143 clinical stage III esophageal adenocarcinoma patients that were eligible for trimodality therapy. All patients successfully completed neoadjuvant CXRT and were considered appropriate candidates for resection. Patients that were medically inoperable were excluded. Cox regression models were used to identify significant predictors of survival. Results Among the 143 patients eligible for surgery after completing CXRT, 114 underwent resection and 29 did not. Poorly differentiated tumors (HR=2.041, 95% CI 1.235–3.373) and surgical resection (HR=0.504, 95% CI 0.283–0.899) were the only independent predictors of OS. Patients treated with surgery had a 50% and 54% risk reduction in overall and cancer-specific mortality, respectively. Median OS (41.2 months vs. 20.3 months, p=0.012) and DFS (21.5 months vs. 11.4 months, p=0.007) were significantly improved with the addition of surgery compared to definitive CXRT. Conclusions Surgery provides a significant survival benefit to trimodality-eligible esophageal adenocarcinoma patients with locally advanced disease. PMID:23715646

  8. Deciding what information is necessary: do patients with advanced cancer want to know all the details?

    PubMed Central

    Russell, Bethany J; Ward, Alicia M

    2011-01-01

    Communicating effectively with patients who have advanced cancer is one of the greatest challenges facing physicians today. Whilst guiding the patient through complex diagnostic and staging techniques, treatment regimens and trials, the physician must translate often imprecise or conflicting data into meaningful personalized information that empowers the patient to make decisions about their life and body. This requires understanding, compassion, patience, and skill. This narrative literature review explores current communication practices, information preferences of oncology patients and their families, and communication strategies that may assist in these delicate interactions. Overwhelmingly, the literature suggests that whilst the majority of patients with advanced cancer do want to know their diagnosis and receive detailed prognostic information, this varies not only between individuals but also for a given individual over time. Barriers to the delivery and understanding of information exist on both sides of the physician–patient relationship, and family dynamics are also influential. Despite identifiable trends, the information preferences of a particular patient cannot be reliably predicted by demographic, cultural, or cancer-specific factors. Therefore, our primary recommendation is that the physician regularly asks the patient what information they would like to know, who else should be given the information and be involved in decision making, and how that information should be presented. PMID:21792328

  9. [Bone disease in the field of CKD-MBD].

    PubMed

    Yajima, Aiji; Tsuchiya, Ken; Yokota, Hiroki; Nitta, Kosaku

    2016-06-01

    The pathophysiology and treatment for renal bone disease have made remakable progress. Moreover, osteocyte reseach has made tremendous progress. In the clinical aspect, (1) hyperphosphatemia, (2) hyperparathyroid and hypoparathyroid bone disease in patients with chronic kidney disease, (3) increased serum level of fibroblast growth factor 23 (FGF-23) and(4) reduced level of Klotho should be taken into consideration when analyzing these conditions. On the other hand, hyperphosphatemia must be successfully treated. Hyperparathyroid bone disease has been successfully treated with vitamin D sterol, cinacalcet hydrochloride and parathyroidectomy, however, the treatment of hypoparathyroidism inpatient with diabetes or non-diabetes met with high hurdles. We must treat these patients in thinking about osteocytic perilacunar/canalicular system. PMID:27230843

  10. Assessing patients' needs and preferences in the management of advanced colorectal cancer.

    PubMed Central

    Redmond, K.

    1998-01-01

    Clinical decision-making in advanced cancer is a highly complex process. Many factors are thought to influence this process arguably the most important of these is the patient's own preference. Studies show that most patients want to be fully informed as to their diagnosis and involved in clinical decision-making. However, the attitudes of healthcare workers often preclude patient involvement. Studies have also shown that acceptability of chemotherapy for minimal therapeutic gain differs markedly between patients depending on factors such as age, gender and family status. It is clearly impossible to make decisions about what is best for patients without involving them in the decision-making process. Indeed, it could be argued that active patient participation actually simplifies this process. PMID:9579849

  11. Determinants of esophageal varices bleeding in patients with advanced hepatocellular carcinoma treated with sorafenib

    PubMed Central

    Iavarone, Massimo; Primignani, Massimo; Vavassori, Sara; Sangiovanni, Angelo; La Mura, Vincenzo; Romeo, Raffaella

    2015-01-01

    Background and aims Sorafenib is the standard of care for patients with advanced hepatocellular carcinoma (HCC), yet treatment safety may be challenged by portal hypertension. We therefore assessed the prevalence, risk factors and clinical consequences of esophageal varices (EVs) in sorafenib-treated patients with HCC. Methods Starting in 2008, all compensated patients with advanced or intermediate HCC not eligible for other therapies were consecutively enrolled in a prospective evaluation of sorafenib therapy, all with pretreatment by upper-gastrointestinal endoscopy (UGE). Results A total of 150 patients received sorafenib for 4.6 (95% CI, 3.3–5.6) months. At baseline, 61 (41%) patients were EV free (group A), 78 (52%) had EVs (61 small EVs (group B), 17 medium/large EVs (group C)) and 11 (7%) previously endoscopically treated EVs (group D). Propranolol was given to all patients with medium/large EVs and those with previous bleeding. Twelve patients (8%) bled from EVs after 36 (18–260) days of sorafenib. During sorafenib, bleeding occurred in six of 26 group B patients with neoplastic portal vein thrombosis (nPVT), three of nine group C patients with nPVT, two of five group D patients with nPVT and one of six without nPVT (p < 0.0001), nPVT being the strongest independent predictor of bleeding by multivariate analysis (HR = 15.4, 95% CI 1.84–129.6). Conclusion UGE screening is worthwhile in HCC patients allocated to sorafenib since it identifies patients with EVs at risk of bleeding during therapy, particularly those with nPVT.

  12. The patient perspective: Quality of life in advanced heart failure with frequent hospitalisations.

    PubMed

    Nieminen, Markku S; Dickstein, Kenneth; Fonseca, Cândida; Serrano, Jose Magaña; Parissis, John; Fedele, Francesco; Wikström, Gerhard; Agostoni, Piergiuseppe; Atar, Shaul; Baholli, Loant; Brito, Dulce; Colet, Josep Comín; Édes, István; Gómez Mesa, Juan E; Gorjup, Vojka; Garza, Eduardo Herrera; González Juanatey, José R; Karanovic, Nenad; Karavidas, Apostolos; Katsytadze, Igor; Kivikko, Matti; Matskeplishvili, Simon; Merkely, Béla; Morandi, Fabrizio; Novoa, Angel; Oliva, Fabrizio; Ostadal, Petr; Pereira-Barretto, Antonio; Pollesello, Piero; Rudiger, Alain; Schwinger, Robert H G; Wieser, Manfred; Yavelov, Igor; Zymliński, Robert

    2015-07-15

    End of life is an unfortunate but inevitable phase of the heart failure patients' journey. It is often preceded by a stage in the progression of heart failure defined as advanced heart failure, and characterised by poor quality of life and frequent hospitalisations. In clinical practice, the efficacy of treatments for advanced heart failure is often assessed by parameters such as clinical status, haemodynamics, neurohormonal status, and echo/MRI indices. From the patients' perspective, however, quality-of-life-related parameters, such as functional capacity, exercise performance, psychological status, and frequency of re-hospitalisations, are more significant. The effects of therapies and interventions on these parameters are, however, underrepresented in clinical trials targeted to assess advanced heart failure treatment efficacy, and data are overall scarce. This is possibly due to a non-universal definition of the quality-of-life-related endpoints, and to the difficult standardisation of the data collection. These uncertainties also lead to difficulties in handling trade-off decisions between quality of life and survival by patients, families and healthcare providers. A panel of 34 experts in the field of cardiology and intensive cardiac care from 21 countries around the world convened for reviewing the existing data on quality-of-life in patients with advanced heart failure, discussing and reaching a consensus on the validity and significance of quality-of-life assessment methods. Gaps in routine care and research, which should be addressed, were identified. Finally, published data on the effects of current i.v. vasoactive therapies such as inotropes, inodilators, and vasodilators on quality-of-life in advanced heart failure patients were analysed. PMID:25981363

  13. Restless Legs Syndrome in Non-Dialysis Renal Patients: Is It Really That Common?

    PubMed Central

    Calviño, Jesús; Cigarrán, Secundino; Lopez, Luis M.; Martinez, Agustin; Sobrido, Maria-Jesús

    2015-01-01

    Background: Sleep disorders are frequent in chronic kidney disease (CKD). Among them, restless legs syndrome (RLS) may affect up to 60% of patients on dialysis, and it has been related to a poor quality of life and higher cardiovascular risk. Despite its high prevalence in advanced stages of renal disease, RLS frequency in non-dialysis CKD has not been clearly established. The aim of this study was to assess the frequency of RLS in non-dialysis CKD patients (stages 2 to 4) followed in a reference nephrology outpatient clinic. Methods: A standardized questionnaire following the international RLS study group diagnostic criteria was self-administered by 110 patients regularly followed in the nephrology clinic. The series comprised 69 men and 41 women, aged 68 ± 13.2 years, with mean serum creatinine of 1.7 ± 0.8 mg/dL. Subsequently, patients classified as probable RLS according to the questionnaire underwent a systematic neurological examination. The presence of peripheral artery disease was evaluated by the ankle-brachial index (ABI). Results: The frequency of probable RLS according to the questionnaire results was 21% (17% for men and 27% for women). However, after thorough neurological examination, the diagnosis of RLS was confirmed in only 5 patients. Therefore, the overall definitive RLS frequency was 4.5% (within the prevalence reported for the general population) and was higher among women (9.7% vs 0.2%). In the remaining cases symptoms were due to leg discomfort related with other disorders. Patients with probable and improbable RLS were not significantly different in age, ABI, diabetes, and other comorbid circumstances, except for tricyclic antidepressant prescription, which was more frequent in the probable RLS group (17% vs 2%). Renal function was better in definitive RLS patients than cases classified as probable RLS by the questionnaire but not confirmed after neurological exam. Conclusions: Although RLS can represent an early manifestation of CKD, its

  14. The Burden of Nephrotoxic Drug Prescriptions in Patients with Chronic Kidney Disease: A Retrospective Population-Based Study in Southern Italy

    PubMed Central

    Ingrasciotta, Ylenia; Sultana, Janet; Giorgianni, Francesco; Caputi, Achille Patrizio; Arcoraci, Vincenzo; Tari, Daniele Ugo; Linguiti, Claudio; Perrotta, Margherita; Nucita, Andrea; Pellegrini, Fabio; Fontana, Andrea; Cavagna, Lorenzo; Santoro, Domenico; Trifirò, Gianluca

    2014-01-01

    Background The use of nephrotoxic drugs can further worsening renal function in chronic kidney disease (CKD) patients. It is therefore imperative to explore prescribing practices that can negatively affect CKD patients. Aim To analyze the use of nephrotoxic drugs in CKD patients in a general population of Southern Italy during the years 2006–2011. Methods The general practice “Arianna” database contains data from 158,510 persons, registered with 123 general practitioners (GPs) of Caserta. CKD patients were identified searching: CKD-related ICD-9 CM codes among causes of hospitalization; CKD-relevant procedures undergone in hospital (e.g. dialysis); drug prescriptions issued for a CKD-related indication. A list of nephrotoxic drugs was compiled and validated by pharmacologists and nephrologists. The summary of product characteristics was used to classify drugs as ‘contraindicated’ or ‘to be used with caution’ in renal diseases. Frequency of nephrotoxic drug use, overall, by drug class and single compounds, by GPs within one year prior or after first CKD diagnosis and within one year after dialysis entry was calculated. Results Overall, 1,989 CKD patients and 112 dialysed patients were identified. Among CKD patients, 49.8% and 45.2% received at least one prescription for a contraindicated nephrotoxic drug within one year prior or after first CKD diagnosis, respectively. In detail, 1,119 CKD patients (56.3%) had at least one nonsteroidal anti-inflammatory drugs (NSAIDs) prescription between CKD diagnosis and end of follow-up. A large proportion of CKD patients (35.6%) were treated with NSAIDs for periods exceeding 90 days. Contraindicated nephrotoxic drugs were used commonly in CKD, with nimesulide (16.6%) and diclofenac (11.0%) being most frequently used. Conclusions Contraindicated nephrotoxic drugs were highly prescribed in CKD patients from a general population of Southern Italy. CKD diagnosis did not seem to reduce significantly the prescription of

  15. Sneddon-Wilkinson disease induced by sorafenib in a patient with advanced hepatocellular carcinoma.

    PubMed

    Tajiri, Kazuto; Nakajima, Takahiko; Kawai, Kengo; Minemura, Masami; Sugiyama, Toshiro

    2015-01-01

    Sorafenib is the standard treatment for patients with advanced hepatocellular carcinoma (HCC), although it is known to cause a variety of dermatologic adverse events. Subcorneal pustular dermatosis (SCPD), also known as Sneddon-Wilkinson disease, is a rare skin eruption that accompanies various systemic disorders and may become chronically progressive. We herein describe the case of a patient who developed SCPD after sorafenib administration. The dermatologic reaction was improved by the cessation of sorafenib and worsened by its readministration. Clinicians treating HCC patients with sorafenib should be aware of the possibility of SCPD. PMID:25786448

  16. Gastrostomy tube placement in patients with advanced dementia or near end of life.

    PubMed

    Schwartz, Denise Baird; Barrocas, Albert; Wesley, John R; Kliger, Gustavo; Pontes-Arruda, Alessandro; Márquez, Humberto Arenas; James, Rosemarie Lembo; Monturo, Cheryl; Lysen, Lucinda K; DiTucci, Angela

    2014-12-01

    Based on current scientific literature, gastrostomy tube (G-tube) placement or other long-term enteral access devices should be withheld in patients with advanced dementia or other near end-of-life conditions. In many instances healthcare providers are not optimally equipped to implement this recommendation at the bedside. Autonomy of the patient or surrogate decision maker should be respected, as should the patient's cultural, religious, social, and emotional value system. Clinical practice needs to address risks, burdens, benefits, and expected short-term and long-term outcomes in order to clarify practice changes. This paper recommends a change in clinical practice and care strategy based on the results of a thorough literature review and provides tools for healthcare clinicians, particularly in the hospital setting, including an algorithm for decision making and a checklist to use prior to the placement of G-tubes or other long-term enteral access devices. Integrating concepts of patient-centered care, shared decision making, health literacy, and the teach-back method of education enhances the desired outcome of ethical dilemma prevention. The goal is advance care planning and a timely consensus among health team members, family members, and significant others regarding end-of-life care for patients who do not have an advance directive and lack the capacity to advocate for themselves. Achieving this goal requires interdisciplinary collaboration and proactive planning within a supportive healthcare institution environment. PMID:25293595

  17. Patients with Advanced Ovarian Cancer Administered Oral Etoposide following Taxane as Maintenance Chemotherapy

    PubMed Central

    Nagano, Hiroaki; Tachibana, Yasunari; Kawakami, Megumi; Ueno, Mariko; Morita, Yoshihiro; Muraoka, Mitsue; Takagi, Koichiro

    2016-01-01

    Introduction The concept of maintenance therapy is one of the highly relevant approaches in the management of advanced ovarian cancer. The fundamental goal of maintenance therapy is to improve survival outcomes. We attempted to reinforce maintenance chemotherapy by adding oral etoposide following taxane administration. Cases We retrospectively evaluated 14 patients with advanced ovarian cancer who had achieved clinically defined complete response to a primary platinum/taxane chemotherapy regimen and who were administered oral etoposide (50 mg/day × 21 days per cycle monthly for 3–5 cycles) following paclitaxel or docetaxel administration as maintenance chemotherapy. With regard to oral etoposide toxicity, grade 2 oral mucositis and grade 3 anemia were observed in 1 patient each. Three to five cycles of etoposide were administered to all patients, though daily dosage was reduced to 25 mg in 2 patients due to toxicity. The median progression-free survival was 43.5 months, the median overall survival was 86 months, and 5-year overall survival was 77.1%. Conclusion The results from this ovarian cancer treatment evaluation suggest that oral etoposide may be administered safely following paclitaxel or docetaxel as maintenance chemotherapy. We expect this regimen to contribute to the improvement in the survival outcomes of patients with advanced ovarian cancer. PMID:27099605

  18. Predictors of psychological distress in advanced cancer patients under palliative treatments.

    PubMed

    Diaz-Frutos, D; Baca-Garcia, E; García-Foncillas, J; López-Castroman, J

    2016-07-01

    This work aims to investigate the factors associated with psychological distress in advanced cancer patients under palliative treatment. We comprehensively assessed the demographic, psychosocial and health factors of 158 advanced cancer patients. Patients with high and low distress, according to the Hospital Anxiety and Depression Scale, were compared. A regression analysis was built to identify the best predictors of distress. Patients with high psychological distress (81%) were more likely to have lung cancer, suicidal ideation, hopelessness, low quality of life and poor body image than those without. In the multivariate model, only poor emotional functioning (OR = .89; 95% CI = .83-.95; p ≤ .001), hopelessness (OR = .86; 95% CI = .78-.94; p ≤ .001) and body image distortions (OR = .77; 95% CI = .68-.85; p = .005) were retained. High levels of hopelessness, impaired emotional functioning and body image distortions are the main factors associated with psychological distress in patients with advanced cancer. Potential interventions to modify these factors in palliative units are discussed. PMID:27271213

  19. Communicating with patients who have advanced dementia: training nurse aide students.

    PubMed

    Beer, Laura E; Hutchinson, Susan R; Skala-Cordes, Kristine K

    2012-01-01

    The increase of dementia in older adults is changing how medical care is delivered. Recognizing symptoms of pain, managing behaviors, and providing quality of life for people who have advanced dementia requires a new skill set for caregivers. Researchers in this study targeted nurse aide students to test an educational module's effect on students' perceptions of dementia and their ability to care for patients with dementia. The results indicated the training was effective regarding nurse aides' understanding of residual cognitive abilities and need for meaningful contact among patients with advanced dementia; however, the training was not successful in terms of nurse aides' comfort level or perceived skills in working with this population of patients. The findings suggest a need to transform how caregivers are trained in communication techniques. Incorporating this training into nurse aide education has the potential to increase quality of life for people with dementia. PMID:23095223

  20. Nitric oxide status in patients with chronic kidney disease.

    PubMed

    Reddy, Y S; Kiranmayi, V S; Bitla, A R; Krishna, G S; Rao, P V L N Srinivasa; Sivakumar, V

    2015-01-01

    Patients with chronic kidney disease (CKD) are at an increased risk of cardiovascular (CVD) morbidity and mortality, mainly due to atherosclerosis. Decreased production or reduced bioavailability of nitric oxide (NO) can result in endothelial dysfunction (ED). Multiple mechanisms are known to cause a state of NO deficiency in patients with CKD. Patients in various stages of CKD grouped as group-1 (CKD stage 1 and 2), group-2 (CKD stage 3 and 4), group-3 (CKD stage 5) and healthy controls were included in the study. Each group of patients and controls comprised 25 subjects. Plasma nitrites, L-arginine, asymmetric dimethyl arginine (ADMA) and citrulline were measured in all the subjects. Patients in all stages of CKD had lower NO and higher ADMA levels compared to controls. Further, group-2 and group-3 patients had lower levels of NO and higher levels of ADMA than group-1 patients. L-arginine levels showed no difference between patients and controls. However, group-3 patients had lower L-arginine levels compared to group-1 patients. Citrulline levels were decreased in group-3 patients. NO production was decreased in patients in all stages of CKD. The decrease could be due to decreased availability of the substrate, L-arginine or due to an increased ADMA, a potent inhibitor of endothelial NO synthase. Therapeutic interventions directed towards improvement of NO production in addition to management of other CVD risk factors may prevent development of ED and facilitate proper management of CKD patients who are at increased risk for CVD. PMID:26628794

  1. Assessment of printed patient-educational materials for chronic kidney disease

    PubMed Central

    Tuot, Delphine S; Davis, Elizabeth; Velasquez, Alexandra; Banerjee, Tanushree; Powe, Neil R

    2013-01-01

    Background Awareness of chronic kidney disease (CKD) is suboptimal among patients with CKD, perhaps due to poor readability of patient education materials (PEMs). We reviewed the suitability and readability of common PEMs that focused on 5 content areas: basics of CKD, risk factors for CKD development, risk factors for CKD progression, complications of CKD and self-management strategies to improve kidney health. Methods Three reviewers (nephrologist, primary care physician, patient) used the Suitability Assessment of Materials to rate PEMs on message content/stimulation of learning, typography, visuals and layout and determined literacy level. Mean ratings were calculated for each PEM by content area and overall (Superior=70–100; Adequate=40–69; Inadequate=<40). Linear regression was used to determine the impact of literacy level on mean rating. Results We reviewed 69 PEMs from 19 organizations, divided into 113 content area sections. Most (79%) PEM sections were “Adequate” (mean rating, 58.3%). Inclusion of patient-centered content and opportunities for patient interaction were associated with “Superior” ratings. Mean ratings (SD) were similar across content areas: basics of CKD, 58.9% [9.1]; risk factors for CKD development, 57.0% [12.3]; risk factors for CKD progression, 58.5% [12.0]; CKD complications, 62.3% [15.7] and self-management strategies, 62.2% [12.3]. ≤ 6th grade literacy level (vs >6th grade) was associated with an 11.7 point higher mean rating. Conclusion Most PEMs for kidney disease were adequate. Outstanding PEMs shared characteristics of patient centeredness, a low literacy level, and patient interaction. Providers should be aware of strengths and limitations of PEMs when educating their patients about CKD. PMID:23970127

  2. GFR decline as an end point for clinical trials in CKD: a scientific workshop sponsored by the National Kidney Foundation and the US Food and Drug Administration.

    PubMed

    Levey, Andrew S; Inker, Lesley A; Matsushita, Kunihiro; Greene, Tom; Willis, Kerry; Lewis, Edmund; de Zeeuw, Dick; Cheung, Alfred K; Coresh, Josef

    2014-12-01

    The US Food and Drug Administration currently accepts halving of glomerular filtration rate (GFR), assessed as doubling of serum creatinine level, as a surrogate end point for the development of kidney failure in clinical trials of kidney disease progression. A doubling of serum creatinine level generally is a late event in chronic kidney disease (CKD); thus, there is great interest in considering alternative end points for clinical trials to shorten their duration, reduce sample size, and extend their conduct to patients with earlier stages of CKD. However, the relationship between lesser declines in GFR and the subsequent development of kidney failure has not been well characterized. The National Kidney Foundation and Food and Drug Administration sponsored a scientific workshop to critically examine available data to determine whether alternative GFR-based end points have sufficiently strong relationships with important clinical outcomes of CKD to be used in clinical trials. Based on a series of meta-analyses of cohorts and clinical trials and simulations of trial designs and analytic methods, the workshop concluded that a confirmed decline in estimated GFR of 30% over 2 to 3 years may be an acceptable surrogate end point in some circumstances, but the pattern of treatment effects on GFR must be examined, specifically acute effects on estimated GFR. An estimated GFR decline of 40% may be more broadly acceptable than a 30% decline across a wider range of baseline GFRs and patterns of treatment effects on GFR. However, there are other circumstances in which these end points could lead to a reduction in statistical power or erroneous conclusions regarding benefits or harms of interventions. We encourage careful consideration of these alternative end points in the design of future clinical trials. PMID:25441437

  3. Frailty and comorbidity are independent predictors of outcome in patients referred for pre-dialysis education

    PubMed Central

    Pugh, Julia; Aggett, Justine; Goodland, Annwen; Prichard, Alison; Thomas, Nerys; Donovan, Kieron; Roberts, Gareth

    2016-01-01

    Background The incidence of chronic kidney disease (CKD) is rising and is likely to continue to do so for the foreseeable future, with the fastest growth seen among adults ≥75 years of age. Elderly patients with advanced CKD are likely to have a higher burden of comorbidity and frailty, both of which may influence their disease outcome. For these patients, treatment decisions can be complex, with the current lack of robust prognostic tools hindering the shared decision-making process. The current study aims to assess the impact of comorbidity and frailty on the outcomes of patients referred for pre-dialysis education. Methods We performed a single-centre study of patients (n = 283) referred for pre-dialysis education between 2010 and 2012. The Charlson Comorbidity Index (CCI) and Clinical Frailty Scale (CFS) were used to assess comorbid disease burden and frailty, respectively. Follow-up data were collected until February 2015. Results The CCI and CFS scores at the time of referral to the pre-dialysis service were independent predictors of mortality. Within the study follow-up period, 76% of patients with a high CFS score at the time of pre-dialysis education had died, with 63% of these patients not commencing dialysis before death. Conclusion A relatively simple frailty scale and comorbidity score could be used to predict survival and better inform the shared decision-making process for patients with advanced kidney disease. PMID:26985387

  4. Management of gouty arthritis in patients with chronic kidney disease.

    PubMed

    Abdellatif, Abdul A; Elkhalili, Naser

    2014-01-01

    Chronic kidney disease (CKD) is a comorbid condition that affects, based on recent estimates, between 47% and 54% of patients with gouty arthritis. However, data from randomized controlled trials in patients with gouty arthritis and CKD are limited, and current gouty arthritis treatment guidelines do not address the challenges associated with managing this patient population. Nonsteroidal anti-inflammatory drugs and colchicine are recommended first-line treatments for acute gouty arthritis attacks. However, in patients with CKD, nonsteroidal anti-inflammatory drugs are not recommended because their use can exacerbate or cause acute kidney injury. Also, colchicine toxicity is increased in patients with CKD, and dosage reduction is required based on level of kidney function. Allopurinol, febuxostat, and pegloticase are all effective treatments for controlling elevated uric acid levels after the treatment of an acute attack. However, in patients with CKD, required allopurinol dosage reductions may limit efficacy; pegloticase requires further investigation in this population, and febuxostat has not been studied in patients with creatinine clearance<30 mL/min. This article reviews the risks and benefits associated with currently available pharmacologic agents for the management of acute and chronic gouty arthritis including urate-lowering therapy in patients with CKD. Challenges specific to primary care providers are addressed, including guidance to help them decide when to collaborate with, or refer patients to, rheumatology and nephrology specialists based on the severity of gout and CKD. PMID:22960848

  5. Exercise and relaxation intervention for patients with advanced lung cancer: a qualitative feasibility study.

    PubMed

    Adamsen, L; Stage, M; Laursen, J; Rørth, M; Quist, M

    2012-12-01

    Lung cancer patients experience loss of physical capacity, dyspnea, pain, reduced energy and psychological distress. The aim of this study was to explore feasibility, health benefits and barriers of exercise in former sedentary patients with advanced stage lung cancer, non-small cell lung cancer (NSCLC) (III-IV) and small cell lung cancer (SCLC) (ED), undergoing chemotherapy. The intervention consisted of a hospital-based, supervised, group exercise and relaxation program comprising resistance-, cardiovascular- and relaxation training 4 h weekly, 6 weeks, and a concurrent unsupervised home-based exercise program. An explorative study using individual semi-structured interviews (n=15) and one focus group interview (n=8) was conducted among the participants. Throughout the intervention the patients experienced increased muscle strength, improvement in wellbeing, breathlessness and energy. The group exercise and relaxation intervention showed an adherence rate of 76%, whereas the patients failed to comply with the home-based exercise. The hospital-based intervention initiated at time of diagnosis encouraged former sedentary lung cancer patients to participation and was undertaken safely by cancer patients with advanced stages of disease, during treatment. The patients experienced physical, functional and emotional benefits. This study confirmed that supervised training in peer-groups was beneficial, even in a cancer population with full-blown symptom burden and poor prognosis. PMID:21599754

  6. Long-term efficacy of intensive cycle ergometer exercise training program for advanced COPD patients

    PubMed Central

    Pothirat, Chaicharn; Chaiwong, Warawut; Phetsuk, Nittaya; Liwsrisakun, Chalerm; Bumroongkit, Chaiwat; Deesomchok, Athavudh; Theerakittikul, Theerakorn; Limsukon, Atikun

    2015-01-01

    Background Exercise training has been incorporated into the international guidelines for the treatment of chronic obstructive pulmonary disease (COPD). However, the long-term efficacy of the training program for patients with advanced COPD has never been evaluated in Thailand. Purpose To determine the long-term efficacy of intensive cycle ergometer exercise program on various clinical parameters of patients with advanced COPD. Materials and methods The patients with advanced COPD were separated into two groups: the intensive ergometer exercise program group and the control group. The clinical parameters of all the patients were assessed at baseline, every month for the first 3 months, and then every 3 months until they had completed the 24-month follow-up. Mann–Whitney U test was used to compare baseline mean differences between the groups. Repeated measure analysis was applied to determine the progress in all parameters during the entire follow-up period. Mean incase imputation method was applied to estimate the parameters of dropout cases. Results A total of 41 patients were enrolled: 27 in the intensive ergometer exercise program group and 14 in the control group. The intensive cycle ergometer exercise program group showed statistically significant improvements in muscle strength (from month 1 till the end of the study, month 24), endurance time (from month 1 till the end of measurement, month 12) and clinically significant improvements in 6-minute walk distance (from month 2 until month 9), dyspnea severity by transitional dyspnea index (from month 1 till the end of the study, month 24), and quality of life (from month 1 till the end of the study, month 24). There was no significant difference in survival rates between the groups. Conclusion The intensive ergometer exercise training program revealed meaningful long-term improvements in various clinical parameters for up to 2 years. These promising results should encourage health care professionals to promote

  7. Rethinking autonomy: decision making between patient and surgeon in advanced illnesses

    PubMed Central

    Hinshaw, Daniel B.

    2016-01-01

    Patients with advanced illness such as advanced stage cancer presenting with the need for possible surgical intervention can be some of the most challenging cases for a surgeon. Often there are multiple factors influencing the decisions made. For patients they are facing not just the effects of the disease on their body, but the stark realization that the disease will also limit their life. Not only are these factors a consideration when patients are making decisions, but also the desire to make the decision that is best for themselves, the autonomous decision. Also included in this process for the patient facing the possible need for an intervention is the surgeon. While patient autonomy remains one of the main principles within medicine, guiding treatment decisions, there is also the surgeon’s autonomy to be considered. Surgeons determine if there is even a possible intervention to be offered to patients, a decision making process that respects surgeons’ autonomous choices and includes elements of paternalism as surgeons utilize their expertise to make decisions. Included in the treatment decisions that are made and the care of the patient is the impact patients’ outcomes have on the surgeon, the inherent drive to be the best for the patient and desire for good outcomes for the patient. While both the patient’s and surgeon’s autonomy are a dynamic interface influencing decision making, the main goal for the patient facing a palliative procedure is that of making treatment decisions based on the concept of shared decision making, always giving primary consideration to the patient’s goals and values. Lastly, regardless of the decision made, it is the responsibility of surgeons to their patients to be a source of support through this challenging time. PMID:27004224

  8. Clinical and radiographic evaluation of maxillary central incisors exposure in patients undergoing maxillary advancement

    PubMed Central

    Trento, Guilherme dos Santos; Bernabé, Felipe Bueno Rosettti; da Costa, Delson João; Rebellato, Nelson Luis Barbosa; Klüppel, Leandro Eduardo; Scariot, Rafaela

    2015-01-01

    Abstract Introduction: Patients with dentofacial deformities may undergo orthodontic or orthodontic-surgical treatment. Both modalities can affect esthetics. Objective: This study aims to evaluate clinical and radiographic changes in exposure of maxillary central incisors occurring after orthognathic surgery for maxillary advancement. Methods: A total of 17 patients who underwent orthognathic surgery for maxillary advancement between September, 2010 and July, 2011 were selected. Exposure of maxillary central incisors was evaluated clinically and by lateral cephalograms. Measurements were taken one week before and three months after surgery. Data were paired in terms of sex, age, nasolabial angle, height and thickness of the upper lip, the amount of maxillary advancement, clinical exposure and inclination of maxillary central incisor by statistical tests (CI 95%). Results: After maxillary advancement, incisor clinical exposure had increased even with relaxed lips and under forced smile. Moreover, there was a mean increase of 23.33% revealed by lateral cephalograms. There was an inverse correlation between upper lip thickness and incisors postsurgical exposure revealed by radiographic images (p = 0.002). Conclusions: Significant changes in the exposure of maxillary central incisors occur after maxillary advancement, under the influence of some factors, especially lip thickness. PMID:26691970

  9. Effect of pentoxifylline on renal outcomes in chronic kidney disease patients: A systematic review and meta-analysis.

    PubMed

    Leporini, Christian; Pisano, Anna; Russo, Emilio; D'Arrigo, Graziella; de Sarro, Giovambattista; Coppolino, Giuseppe; Bolignano, Davide

    2016-05-01

    Chronic kidney disease (CKD) represents an important health problem worldwide and the search for new therapeutic approaches for retarding CKD progression is a timely issue. Recent evidence suggest that the anti-inflammatory and hemorrheologic drug Pentoxifylline (PTX), may produce favorable effects on kidney function. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to ascertain whether PTX derivatives, alone or in combination to other treatments, may be useful in slowing down disease progression in patients with diabetic or non-diabetic CKD. We found 26 studies (1518 subjects) matching our search criteria. Information on the effects of PTX on hard renal outcomes (doubling of serum creatinine or need for chronic dialysis) were lacking in all the reviewed trials. Conversely, PTX was effective in reducing proteinuria compared to control, a benefit that was more evident in patients with type-1 diabetes mellitus, higher proteinuria at baseline and early renal impairment. An improvement in renal function (eGFR/creatinine clearance) was observed particularly in patients with more advanced CKD stage and in studies with longer follow-up. Conversely, cumulative analyses did not reveal any evident reduction in urinary albumin excretion, even in diabetic patients. The use of PTX was relatively safe as most trials recorded only minor gastrointestinal adverse effects. Although these findings point at some reno-protective effects of PTX, there is no conclusive evidence proving the usefulness of this agent for improving renal outcomes in subjects with chronic kidney disease of various etiology. Future trials adequately powered and designed on hard clinical end-points are needed. PMID:26995301

  10. The effects of curcumin (diferuloylmethane) on body composition of patients with advanced pancreatic cancer

    PubMed Central

    Parsons, Henrique A.; Baracos, Vickie E.; Hong, David S.; Abbruzzese, James; Bruera, Eduardo; Kurzrock, Razelle

    2016-01-01

    Background Curcumin is a natural product that is often explored by patients with cancer. Weight loss due to fat and muscle depletion is a hallmark of pancreatic cancer and is associated with worse outcomes. Studies of curcumin's effects on muscularity show conflicting results in animal models. Methods and results Retrospective matched 1:2 case-control study to evaluate the effects of curcumin on body composition (determined by computerized tomography) of 66 patients with advanced pancreatic cancer (22 treated,44 controls). Average age (SEM) was 63(1.8) years, 30/66(45%) women, median number of prior therapies was 2, median (IQR) time from advanced pancreatic cancer diagnosis to baseline image was 7(2-13.5) months (p>0.2, all variables). All patients lost weight (3.3% and 1.3%, treated vs. control, p=0.13). Treated patients lost more muscle (median [IQR] percent change −4.8[−9.1,-0.1] vs. −0.05%[−4.2, 2.6] in controls,p<0.001) and fat (median [IQR] percent change −6.8%[−15,-0.6] vs. −4.0%[−7.6, 1.3] in controls,p=0.04). Subcutaneous fat was more affected in the treated patients. Sarcopenic patients treated with curcumin(n=15) had survival of 169(115-223) days vs. 299(229-369) sarcopenic controls(p=0.024). No survival difference was found amongst non-sarcopenic patients. Conclusions Patients with advanced pancreatic cancer treated with curcumin showed significantly greater loss of subcutaneous fat and muscle than matched untreated controls. PMID:26934122

  11. How Oncologists and Their Patients with Advanced Cancer Communicate about Health-Related Quality of Life

    PubMed Central

    Rodriguez, Keri L.; Bayliss, Nichole; Alexander, Stewart C.; Jeffreys, Amy S.; Olsen, Maren K.; Pollak, Kathryn I.; Kennifer, Sarah L.; Tulsky, James A.; Arnold, Robert M.

    2011-01-01

    Objective To describe the content and frequency of communication about health-related quality of life (HRQOL) during outpatient encounters between oncologists and their patients with advanced cancer. Methods We coded for HRQOL talk in a subset of audio recorded conversations (each previously found to contain prognostic talk by the oncologist) from the Study of Communication in Oncologist-Patient Encounters (SCOPE) Trial, a randomized controlled trial conducted from 2003 to 2008 in two large U.S. academic medical centers and one Veterans Affairs Medical Center. Results Seventy-three encounters that involved 70 patients and 37 oncologists. Patients were more likely to be female (53%), white (86%), married (78%), and possessing some college education (62%). Most oncologists were male (78%) and white (78%). Mean ages were 59 years for patients and 44 years for oncologists. Every encounter included some talk about HRQOL and HRQOL discussions made up, on average, 25% of the visit time. HRQOL segments described symptoms (50%); general HRQOL (27%); and the following concerns: physical (27%), functional (22%), psychological (9%), social (7%), spiritual (1%), and other (28%). Topics included treatment (56%), disease (14%), and testing (3%), and conversations focused on past (44%), present (68%), and future HRQOL (59%). Conclusions HRQOL discussions between oncologists and patients are common, but the emphasis is often on treatment (e.g., side effects) and symptoms (e.g., pain) even in patients with advanced disease. Given the often intense emotional experience of patients with advanced cancer, oncologists may need to pay more attention to psychological, social, and spiritual HRQOL concerns. PMID:19449348

  12. The association between malnutrition and psychological distress in patients with advanced head-and-neck cancer

    PubMed Central

    Ma, L.; Poulin, P.; Feldstain, A.; Chasen, M.R.

    2013-01-01

    Objective Malnutrition and psychological distress are often seen in patients with head-and-neck cancer, but little is known about the interrelationships between those two symptoms. The present study examined the relationship between malnutrition and psychological distress in patients with advanced head-and-neck cancer. Methods Using the Patient-Generated Subjective Global Assessment, 99 patients with advanced-stage head-and-neck cancer were screened for nutrition status. The patients were also screened for psychosocial distress (using the Distress Thermometer) and for psychosocial issues (using the Problem Checklist). Any relationship between malnutrition and psychosocial distress was determined by regression and correlation analysis. We also used t-tests to compare distress levels for patients with and without specific nutrition-related symptoms. Results The study group included 80 men and 19 women [mean age: 58.4 ± 10.9 years (range: 23–85 years)]. The correlation between poorer nutrition status and level of psychological distress was significant r = 0.37 (p < 0.001). Specifically, reduced food intake and symptoms were both positively associated with distress: r = 0.27 and r = 0.29 respectively, both significant at p < 0.01. After controlling for the effects of psychosocial problems and pain, nutrition status remained a significant predictor of distress, explaining 3.8% of the variance in the distress scores of the patients (p < 0.05). Conclusions Malnutrition and symptoms were strongly related to distress in patients with advanced head-and-neck cancer. Our results suggest the need for further research into the complex relationship between nutrition status and distress and into the management of both nutrition and distress in cancer care. PMID:24311956

  13. Alternative donor transplants for patients with advanced hematologic malignancies, conditioned with thiotepa, cyclophosphamide and antithymocyte globulin.

    PubMed

    Lamparelli, T; van Lint, M T; Gualandi, F; Raiola, A M; Barbanti, M; Sacchi, N; Ficai, G; Ghinatti, C; Bregante, S; Berisso, G; Dominietto, A; Di Grazia, C; Bruno, B; Sessarego, M; Casarino, L; Verdiani, S; Bacigalupo, A

    2000-12-01

    Preparative regimens without total body irradiation (TBI) have been reported for alternative donor hemopoietic stem cell transplants (HSCT). Between 7 September 1994 and 7 June 1999 48 patients with advanced hematologic malignancies were conditioned with thiotepa (THIO) 15 mg/kg, cyclophosphamide (CY) 150 mg/kg and antithymocyte globulin (ATG). Donors were HLA mismatched family members (1-2 antigens) (FAM) (n = 24, median age 31 years) or HLA matched unrelated donors (UD) (n = 24, median age 34 years). GVHD prophylaxis was cyclosporine and methotrexate. Stem cell source was peripheral blood (n = 8) or bone marrow (n = 40). Hematologic recovery was seen in 42/46 (91%) evaluable patients and complete chimerism in 31/37 patients (85%). Acute GVHD grades III-IV were seen in 10/46 patients surviving 10 days (21%) and extensive chronic GVHD in 2/36 patients surviving 100 days (5%). Twenty-six patients died (54%), eight of recurrent disease (17%) and 18 of transplant-related complications (37%): main causes of TRM were GVHD (15%), infections (15%) and graft failure (4%). Twenty-two patients (46%) survive with a median follow-up of 877 days (287-1840). The actuarial 3-year survival is 49% for FAM and 42% for UD transplants. Results obtained with this regimen in unrelated grafts for advanced CML (n = 15) were not significantly different when compared to 21 concurrent UD grafts for advanced CML prepared with CY-TBI. In conclusion, the combination of THIO-CY-ATG allows engraftment of alternative donor hemopoietic stem cells. Results are similar when using unrelated matched donors or partially mismatched family donors, and not significantly different when compared to patients conditioned with CY-TBI. PMID:11223970

  14. Assessment of some cardiovascular risk factors in predialysis chronic kidney disease patients in Southern Nigeria

    PubMed Central

    Adejumo, Oluseyi A.; Okaka, Enajite I.; Madumezia, George; Okwuonu, Chimezie G.; Ojogwu, Louis I.

    2015-01-01

    Background: Cardiovascular risk factors are responsible for cardiovascular disease and rapid progression of chronic kidney disease (CKD) to end-stage renal disease. Prompt evaluation, modification, and treatment of these factors in predialysis patients will reduce morbidity and mortality. This study assessed some cardiovascular risk factors in predialysis CKD patients in a tertiary hospital in Southern Nigeria. Patients and Methods: This was a case–control study that involved 76 consecutive predialysis CKD patients and 38 age-and sex-matched controls without CKD over 1 year period. Both groups were assessed for cardiovascular risk factors, and comparisons were made. A P value of <0.05 was taken as significant. Results: The mean ages of the CKD versus control group were 48.00 ± 15.28 versus 45.34 ± 15.35 years. The male:female ratio was 1.7:1 for both groups. The common etiologies of CKD in this study were hypertension 30 (39.5%), diabetes mellitus 23 (30.3%), and chronic glomerulonephritis 19 (25%). There were 38 (50%) in CKD stage 3, 31 (40.8%) in CKD stage 4, and 7 (9.2%) in CKD stage 5. The common cardiovascular risk factors found in the CKD versus control were hypertension (96.1% vs. 42.1%), anemia (96.1% vs. 23.7%), left ventricular hypertrophy (77.6% vs. 23.7%), dyslipidemia (67.1% vs. 39.5%), hypocalcemia (60.1% vs. 18.5%), hyperphosphatemia (63.2% vs. 0%), and hyperuricemia (57.9% vs. 15.8%). These risk factors were significantly higher in CKD group. Hyperphosphatemia and hypoalbuminemia significantly increased across CKD stages 3–5. Anemia was significantly more common in males whereas dyslipidemia was more common in female CKD patients. Conclusion: Cardiovascular risk factors were highly prevalent in predialysis CKD subjects even in early stages. Hypoalbuminemia and hyperphosphatemia significantly increased across the CKD stages 3–5 whereas anemia and dyslipidemia showed significant gender differences. Cardiovascular risk factors should be treated

  15. A Potential Role for Mechanical Forces in the Detachment of Podocytes and the Progression of CKD

    PubMed Central

    Lemley, Kevin V.

    2015-01-01

    Loss of podocytes underlies progression of CKD. Detachment of podocytes from the glomerular basement membrane (GBM) rather than apoptosis or necrosis seems to be the major mechanism of podocyte loss. Such detachment of viable podocytes may be caused by increased mechanical distending and shear forces and/or impaired adhesion to the GBM. This review considers the mechanical challenges that may lead to podocyte loss by detachment from the GBM under physiologic and pathophysiologic conditions, including glomerular hypertension, hyperfiltration, hypertrophy, and outflow of filtrate from subpodocyte spaces. Furthermore, we detail the cellular mechanisms by which podocytes respond to these challenges, discuss the protective effects of angiotensin blockade, and note the questions that must be addressed to better understand the relationship between podocyte detachment and progression of CKD. PMID:25060060

  16. Gemcitabine-Based Regional Intra-Arterial Infusion Chemotherapy in Patients With Advanced Pancreatic Adenocarcinoma

    PubMed Central

    Liu, Xiaoyu; Yang, Xuerong; Zhou, Guofeng; Chen, Yi; Li, Changyu; Wang, Xiaolin

    2016-01-01

    Abstract The present study was carried out to investigate the prognostic factors in patients who received intra-arterial infusion for advanced pancreatic cancer. In addition, the detailed procedure of intra-arterial infusion chemotherapy was described. A total of 354 patients with advanced unresectable pancreatic adenocarcinoma were recruited from January 2012, to April 2015, at Zhongshan Hospital Fudan University, Shanghai, China. Demographic and clinic characteristics of the patients were extracted from electronic medical records. Restricted cubic spline was used to assess the nonliner regression between baseline CA19-9 value and overall survival. Kaplan–Meier analysis and Cox proportional hazard models were used to estimate the association between overall survival and clinical characteristics. Of all 354 included patients, 230 (65%) were male (male/female ratio = 1.8), and 72 (20%) patients were diagnosed with detectable distant metastases. Pretreatment CA19-9 value of patients with metastases was significantly higher as compared to those with locally advanced cancer (median: 922.30 vs 357.00 U/mL, P = 0.0090). Totally 274 patients completed 1 cycle of intra-arterial infusion, whereas 80 patients received 2 or more cycles of the chemotherapy. For all the 354 patients, median OS was 7.0 months (95% CI: 6.0, 8.0 months) with a 6-, 12-, and 18-month survival rate of 0.48, 0.28, and 0.18, respectively. The median OS of patients, who received 1 cycle of intra-arterial infusion therapy, was 6.0 months (95% CI: 5.0, 8.0 months), which was similar to 7.0 months (95% CI: 6.0, 9.0 months) in patients who received 2 or more cycles. Restricted cubic spline revealed the nonline association between baseline CA19-9 and prognosis. The Cox proportional hazard model showed that age, CA19-9 baseline, CA19-9 value, and tumor location were significantly associated with the OS. In conclusion, the gemcitabine-based RIAC presented a potential treatment method for advanced

  17. Interleukin-6 and leptin as markers of energy metabolic changes in advanced ovarian cancer patients.

    PubMed

    Macciò, Antonio; Madeddu, Clelia; Massa, Daniela; Astara, Giorgio; Farci, Daniele; Melis, Gian Benedetto; Mantovani, Giovanni

    2009-09-01

    The progression of the neoplastic disease is characterized by specific alterations of energy metabolism and by symptoms like fatigue, anorexia, nausea, anaemia, immunodepression and poor performance status (PS). The main cause of these symptoms and metabolic abnormalities is the chronic action of proinflammatory cytokines released both by tumour and immune cells. The present study aimed to assess the relationship between markers of inflammation (C-Reactive Protein, Fibrinogen, proinflammatory cytokines) and energy metabolic status (BMI, leptin, oxidative stress) according to clinical parameters in 104 ovarian cancer patients at different stage and, moreover, to evaluate prospectively the changes of these parameters in accordance to tumour response in a subgroup of 70 advanced stage ovarian cancer patients. Advanced stage and poor PS were associated to high-grade inflammation and impaired energy metabolism. Among inflammatory mediators, interleukin (IL)-6 had a central role as predictive factor of leptin, reactive oxygen species and glutathione peroxidase. In turn, leptin considered the key marker of the nutritional status and energy metabolism, was independently determined from stage and IL-6, not only from BMI. Moreover, the evaluation of the changes of these parameters during the course of the neoplastic disease in the subgroup of advanced ovarian cancer patients clearly unveils the central role of IL-6 and leptin as early markers of the metabolic alterations and symptoms associated to disease progression in advanced stage ovarian cancer. Their assessment should be included in monitoring disease outcome, especially when cancer is no longer curable and quality of life becomes the primary endpoint. PMID:18624749

  18. Validation of CKD and Related Conditions in Existing Datasets: A Systematic Review

    PubMed Central

    Grams, Morgan E.; Plantinga, Laura C.; Hedgeman, Elizabeth; Saran, Rajiv; Myers, Gary L.; Williams, Desmond E.; Powe, Neil R.

    2010-01-01

    Background Accurate classification of individuals with kidney disease is vital to research and public health efforts aimed at improving health outcomes. Our objective was to identify and synthesize published literature evaluating the accuracy of existing data sources related to kidney disease. Study design A systematic review of studies seeking to validate the accuracy of the underlying data relevant to kidney disease. Setting & Population U.S.-based and international studies covering a wide range of both outpatient and inpatient study populations. Selection Criteria for Studies Any English-language study investigating the prevalence or etiology of kidney disease, the existence of co-morbid conditions, or the cause of death in those with CKD. All definitions and stages of CKD, including end-stage renal disease (ESRD), were accepted. Index Tests Presence of a kidney disease-related variable in existing datasets, including administrative datasets and disease registries. Reference Tests Presence of a kidney disease-related variable defined by laboratory criteria or medical record review. Results Thirty studies were identified. Most studies investigated the accuracy of kidney disease reporting, comparing coded renal disease to that defined by estimated glomerular filtration rate (eGFR). Sensitivity of coded renal disease varied widely (0.08–0.83). Specificity was higher, with all studies reporting values of ≥0.90. The studies evaluating the etiology of CKD, comorbidities, and the cause of death in CKD all used ESRD or transplant populations exclusively, and accuracy was highly variable when compared to ESRD registry data. Limitations Only English-language studies were evaluated. Conclusions Given the heterogeneous results of validation studies, a variety of attributes of existing data sources, including the accuracy of individual data items within these sources, should be carefully considered prior to use in research, quality improvement and public health efforts

  19. Association between physical performance and all-cause mortality in CKD.

    PubMed

    Roshanravan, Baback; Robinson-Cohen, Cassianne; Patel, Kushang V; Ayers, Ernest; Littman, Alyson J; de Boer, Ian H; Ikizler, T Alp; Himmelfarb, Jonathan; Katzel, Leslie I; Kestenbaum, Bryan; Seliger, Stephen

    2013-04-01

    In older adults, measurements of physical performance assess physical function and associate with mortality and disability. Muscle wasting and diminished physical performance often accompany CKD, resembling physiologic aging, but whether physical performance associates with clinical outcome in CKD is unknown. We evaluated 385 ambulatory, stroke-free participants with stage 2-4 CKD enrolled in clinic-based cohorts at the University of Washington and University of Maryland and Veterans Affairs Maryland Healthcare systems. We compared handgrip strength, usual gait speed, timed up and go (TUAG), and 6-minute walking distance with normative values and constructed Cox proportional hazards models and receiver operating characteristic curves to test associations with all-cause mortality. Mean age was 61 years and the mean estimated GFR was 41 ml/min per 1.73 m(2). Measures of lower extremity performance were at least 30% lower than predicted, but handgrip strength was relatively preserved. Fifty deaths occurred during the median 3-year follow-up period. After adjustment, each 0.1-m/s decrement in gait speed associated with a 26% higher risk for death, and each 1-second longer TUAG associated with an 8% higher risk for death. On the basis of the receiver operating characteristic analysis, gait speed and TUAG more strongly predicted 3-year mortality than kidney function or commonly measured serum biomarkers. Adding gait speed to a model that included estimated GFR significantly improved the prediction of 3-year mortality. In summary, impaired physical performance of the lower extremities is common in CKD and strongly associates with all-cause mortality. PMID:23599380

  20. Phytoextraction of chloride from a cement kiln dust (CKD) contaminated landfill with Phragmites australis.

    PubMed

    McSorley, Kaitlin; Rutter, Allison; Cumming, Robert; Zeeb, Barbara A

    2016-05-01

    Cement kiln dust (CKD) is a globally produced by-product from cement manufacturing that is stockpiled or landfilled. Elevated concentrations of chloride pose toxic threats to plants and aquatic communities, as the anion is highly mobile in water and can leach into surrounding water sources. Re-vegetation and in situ phytoextraction of chloride from a CKD landfill in Bath, ON, Canada, was investigated with the resident invasive species Phragmites australis (haplotype M). Existing stands of P. australis were transplanted from the perimeter of the site into the highest areas of contamination (5.9×10(3)μg/g). Accumulation in the shoots of P. australis was quantified over one growing season by collecting samples from the site on a bi-weekly basis and analyzing for chloride. Concentrations decreased significantly from early May (24±2.2×10(3)μg/g) until mid-June (15±2.5×10(3)μg/g), and then remained stable from June to August. Shoot chloride accumulation was not significantly affected by water level fluctuations at the site, however elevated potassium concentrations in the soil may have contributed to uptake. Based on shoot chloride accumulation and total biomass, it was determined that phytoextraction from the CKD landfill can remove 65±4kg/km(2) of chloride per season. Based on this extraction rate, removal of chloride present in the highly contaminated top 10cm of soil can be achieved in 3-9years. This is the first study to apply phytotechnologies at a CKD landfill, and to successfully demonstrate in situ phytoextraction of chloride. PMID:26597371

  1. Insomnia in Patients With Chronic Kidney Disease.

    PubMed

    Lindner, Anett V; Novak, Marta; Bohra, Miqdad; Mucsi, Istvan

    2015-07-01

    Insomnia and poor self-perceived sleep are very common in patients with chronic kidney disease (CKD). Poor sleep is associated with fatigue, sleepiness, impaired daytime functioning, impaired health-related quality of life, and increased morbidity and mortality. Many illness- and treatment-related factors (metabolic changes, inflammation, altered sleep regulatory mechanisms, symptoms and complications of CKD, comorbid conditions, medications, and renal replacement therapies) may disturb sleep and contribute to the high prevalence of insomnia in this patient population. Accordingly, the approach to both diagnosing and treating this condition is quite complex. Although sleep-related problems are very important for patients with CKD, they largely are under-recognized and undertreated. Very few intervention trials provide an evidence base to support treatment decisions in this particular patient population. With this review we hope to increase awareness of insomnia among professionals involved in the management of patients with CKD and to provide guidance in recognizing and treating this important condition. PMID:26355254

  2. Tracking Patient Encounters and Clinical Skills to Determine Competency in Ambulatory Care Advanced Pharmacy Practice Experiences

    PubMed Central

    Pereira, Chrystian R.; Harris, Ila M.; Moon, Jean Y.; Westberg, Sarah M.; Kolar, Claire

    2016-01-01

    Objective. To determine if the amount of exposure to patient encounters and clinical skills correlates to student clinical competency on ambulatory care advanced pharmacy practice experiences (APPEs). Design. Students in ambulatory care APPEs tracked the number of patients encountered by medical condition and the number of patient care skills performed. At the end of the APPE, preceptors evaluated students’ competency for each medical condition and skill, referencing the Dreyfus model for skill acquisition. Assessment. Data was collected from September 2012 through August 2014. Forty-six responses from a student tracking tool were matched to preceptor ratings. Students rated as competent saw more patients and performed more skills overall. Preceptors noted minimal impact on workload. Conclusions. Increased exposure to patient encounters and skills performed had a positive association with higher Dreyfus stage, which may represent a starting point in the conversation for more thoughtful design of ambulatory care APPEs. PMID:26941440

  3. [Timing of Advance Care Planning in frail elderly patients: when to start?].

    PubMed

    Ott, Brenda; van Thiel, Ghislaine J M W; de Ruiter, Corinne M; van Delden, Hans J J M

    2015-01-01

    Advance Care Planning (ACP) is the process of discussing and recording patient preferences concerning goals for end-of-life care and to facilitate decision-making. ACP is an essential element of care for frail elderly patients because frailty increases the risks of negative health outcomes and loss of function. In this article, we present three patient cases to illustrate how general practitioners (GPs) can perform ACP and to demonstrate the importance of early and iterative end-of-life discussions with frail elderly patients. Good timing is decisive for the success of the intervention. GPs are in a key position to identify and discuss ACP matters at an early stage, supported by the geriatrician if necessary. Posing the 'surprise question' has proved helpful to determine timing. Complex ACP interventions contribute to care which is better adapted to the needs of frail elderly patients. PMID:25650032

  4. Foreign travel for advanced cancer patients: a guide for healthcare professionals

    PubMed Central

    Perdue, Colin; Noble, Simon

    2007-01-01

    The opportunity for a patient with advanced cancer to travel abroad may, for some, be a life affirming event during a dark period in their life. For others, what they hoped to be a time of joy may become an unmitigated disaster if they become unwell while away from the safety net of local cancer services. The rise of low budget airlines and cheaper foreign travel has led to an increase in the number of people travelling by air. Health professionals are more likely to face requests by patients to advise them on travel plans. Although foreign travel is an unrealistic goal for some patients, appropriate forward planning and proactive management can allow some patients to make an important journey abroad. This paper looks at the practical issues facing cancer patients who intend to travel overseas and offers practical advice on considerations that need to be made. PMID:17621611

  5. Foreign travel for advanced cancer patients: a guide for healthcare professionals.

    PubMed

    Perdue, Colin; Noble, Simon

    2007-07-01

    The opportunity for a patient with advanced cancer to travel abroad may, for some, be a life affirming event during a dark period in their life. For others, what they hoped to be a time of joy may become an unmitigated disaster if they become unwell while away from the safety net of local cancer services. The rise of low budget airlines and cheaper foreign travel has led to an increase in the number of people travelling by air. Health professionals are more likely to face requests by patients to advise them on travel plans. Although foreign travel is an unrealistic goal for some patients, appropriate forward planning and proactive management can allow some patients to make an important journey abroad. This paper looks at the practical issues facing cancer patients who intend to travel overseas and offers practical advice on considerations that need to be made. PMID:17621611

  6. 'Hitting you over the head': oncologists' disclosure of prognosis to advanced cancer patients.

    PubMed

    Gordon, Elisa J; Daugherty, Christopher K

    2003-04-01

    The disclosure of prognosis to terminally ill patients has emerged as a recent concern given greater demands for patient involvement in medical decision-making in the United States. As part of the informed consent process, American physicians are legally and ethically obligated to provide information to such patients about risks, benefits, and alternatives of all available treatment options including the use of experimental therapies. Although not legally required, the disclosure of terminal prognosis is ethically justified because it upholds the principle of self-determination and enables patients to make treatment decisions consistent with their life goals. To understand oncologists' attitudes about disclosing prognostic information to cancer patients with advanced disease, we interviewed fourteen oncologists and conducted one focus group of medical fellows. Although oncologists reported to disclose prognosis in terms of cancer not being curable, they tend to avoid using percentages to convey prognosis. Oncologists' reported reluctance to disclosing prognosis was conveyed through the use of metaphors depicting the perceived violent impact of such information on patients. Oncologists' reluctance to disclose prognosis and preserve patient hope are held in check by their need to ensure that patients have 'realistic expectations' about therapy. We discuss these data in light of the cultural, ethical, and legal dimensions of prognosis disclosure, patient hope and the doctor-patient relationship, and recommend ways to enhance the communication process. PMID:12812182

  7. Masked Hypertension Associates with Left Ventricular Hypertrophy in Children with CKD

    PubMed Central

    Flynn, Joseph; Cohn, Silvia; Samuels, Joshua; Blydt-Hansen, Tom; Saland, Jeffrey; Kimball, Thomas; Furth, Susan; Warady, Bradley

    2010-01-01

    Left ventricular hypertrophy (LVH) associates with increased risk for cardiovascular disease. Hypertension leads to LVH in adults, but its role in the pathogenesis of LVH in children is not as well established. To examine left ventricular mass and evaluate factors associated with LVH in children with stages 2 through 4 chronic kidney disease (CKD), we analyzed cross-sectional data from children who had baseline echocardiography (n = 366) and underwent ambulatory BP monitoring (n = 226) as a part of the observational Chronic Kidney Disease in Children (CKiD) cohort study. At baseline, 17% of children had LVH (11% eccentric and 6% concentric) and 9% had concentric remodeling of the left ventricle. On the basis of a combination of ambulatory and casual BP assessment (n = 198), 38% of children had masked hypertension (normal casual but elevated ambulatory BP) and 18% had confirmed hypertension (both elevated casual and ambulatory BP). There was no significant association between LVH and kidney function. LVH was more common in children with either confirmed (34%) or masked (20%) hypertension compared with children with normal casual and ambulatory BP (8%). In multivariable analysis, masked (odds ratio 4.1) and confirmed (odds ratio 4.3) hypertension were the strongest independent predictors of LVH. In conclusion, casual BP measurements alone are insufficient to predict the presence of LVH in children with CKD. The high prevalence of masked hypertension and its association with LVH supports early echocardiography and ambulatory BP monitoring to evaluate cardiovascular risk in children with CKD. PMID:19917781

  8. Alteration of the Intestinal Environment by Lubiprostone Is Associated with Amelioration of Adenine-Induced CKD.

    PubMed

    Mishima, Eikan; Fukuda, Shinji; Shima, Hisato; Hirayama, Akiyoshi; Akiyama, Yasutoshi; Takeuchi, Yoichi; Fukuda, Noriko N; Suzuki, Takehiro; Suzuki, Chitose; Yuri, Akinori; Kikuchi, Koichi; Tomioka, Yoshihisa; Ito, Sadayoshi; Soga, Tomoyoshi; Abe, Takaaki

    2015-08-01

    The accumulation of uremic toxins is involved in the progression of CKD. Various uremic toxins are derived from gut microbiota, and an imbalance of gut microbiota or dysbiosis is related to renal failure. However, the pathophysiologic mechanisms underlying the relationship between the gut microbiota and renal failure are still obscure. Using an adenine-induced renal failure mouse model, we evaluated the effects of the ClC-2 chloride channel activator lubiprostone (commonly used for the treatment of constipation) on CKD. Oral administration of lubiprostone (500 µg/kg per day) changed the fecal and intestinal properties in mice with renal failure. Additionally, lubiprostone treatment reduced the elevated BUN and protected against tubulointerstitial damage, renal fibrosis, and inflammation. Gut microbiome analysis of 16S rRNA genes in the renal failure mice showed that lubiprostone treatment altered their microbial composition, especially the recovery of the levels of the Lactobacillaceae family and Prevotella genus, which were significantly reduced in the renal failure mice. Furthermore, capillary electrophoresis-mass spectrometry-based metabolome analysis showed that lubiprostone treatment decreased the plasma level of uremic toxins, such as indoxyl sulfate and hippurate, which are derived from gut microbiota, and a more recently discovered uremic toxin, trans-aconitate. These results suggest that lubiprostone ameliorates the progression of CKD and the accumulation of uremic toxins by improving the gut microbiota and intestinal environment. PMID:25525179

  9. The Perspectives of Patients on Health-Care for Co-Morbid Diabetes and Chronic Kidney Disease: A Qualitative Study

    PubMed Central

    Lo, Clement; Ilic, Dragan; Teede, Helena; Cass, Alan; Fulcher, Greg; Gallagher, Martin; Johnson, Greg; Kerr, Peter G.; Mathew, Tim; Murphy, Kerry; Polkinghorne, Kevan; Walker, Rowan; Zoungas, Sophia

    2016-01-01

    Background Multi-morbidity due to diabetes and chronic kidney disease (CKD) remains challenging for current health-systems, which focus on single diseases. As a first step toward health-care improvement, we explored the perspectives of patients and their carers on factors influencing the health-care of those with co-morbid diabetes and CKD. Methods In this qualitative study participants with co-morbid diabetes and CKD were purposively recruited using maximal variation sampling from 4 major tertiary health-services from 2 of Australia’s largest cities. Separate focus groups were conducted for patients with CKD stages 3, 4 and 5. Findings were triangulated with semi-structured interviews of carers of patients. Discussions were transcribed verbatim and thematically analysed. Results Twelve focus groups with 58 participants and 8 semi-structured interviews of carers were conducted. Factors influencing health-care of co-morbid diabetes and CKD grouped into patient and health service level factors. Key patient level factors identified were patient self-management, socio-economic situation, and adverse experiences related to co-morbid diabetes and CKD and its treatment. Key health service level factors were prevention and awareness of co-morbid diabetes and CKD, poor continuity and coordination of care, patient and carer empowerment, access and poor recognition of psychological co-morbidity. Health-service level factors varied according to CKD stage with poor continuity and coordination of care and patient and carer empowerment emphasized by participants with CKD stage 4 and 5, and access and poor recognition of psychological co-morbidity emphasised by participants with CKD stage 5 and carers. Conclusions According to patients and their carers the health-care of co-morbid diabetes and CKD may be improved via a preventive, patient-centred health-care model which promotes self-management and that has good access, continuity and coordination of care and identifies and

  10. Laser immunotherapy for treatment of patients with advanced breast cancer and melanoma

    NASA Astrophysics Data System (ADS)

    Li, Xiaosong; Hode, Tomas; Guerra, Maria C.; Ferrel, Gabriela L.; Nordquist, Robert E.; Chen, Wei R.

    2011-02-01

    Laser immunotherapy (LIT) was developed for the treatment of metastatic tumors. It combines local selective photothermal interaction and active immunological stimulation to induce a long-term, systemic anti-tumor immunity. During the past sixteen years, LIT has been advanced from bench-top to bedside, with promising outcomes. In our pre-clinical and preliminary clinical studies, LIT has demonstrated the capability in inducing immunological responses, which not only can eradicate the treated primary tumors, but also can eliminate untreated metastases at distant sites. Specifically, LIT has been used to treat advanced melanoma and breast cancer patients during the past five years. LIT was shown to be effective in controlling both primary tumors and distant metastases in late-stage patients, who have failed conventional therapies such as surgery, chemotherapy, radiation, and other more advanced approaches. The methodology and the development of LIT are presented in this paper. The patients' responses to LIT are also reported in this paper. The preliminary results obtained in these studies indicated that LIT could be an effective modality for the treatment of patients with late-stage, metastatic cancers, who are facing severely limited options.

  11. Optimism, Social Support, and Mental Health Outcomes in Patients with Advanced Cancer

    PubMed Central

    Applebaum, Allison J.; Stein, Emma M.; Lord-Bessen, Jennifer; Pessin, Hayley; Rosenfeld, Barry; Breitbart, William

    2014-01-01

    Objective Optimism and social support serve as protective factors against distress in medically ill patients. Very few studies have specifically explored the ways in which these variables interact to impact quality of life (QOL), particularly among patients with advanced cancer. The present study examined the role of optimism as a moderator of the relationship between social support and anxiety, depression, hopelessness, and QOL among patients with advanced cancer. Methods Participants (N = 168) completed self-report assessments of psychosocial, spiritual, and physical well-being, including social support, optimism, hopelessness, depressive and anxious symptoms, and QOL. Hierarchical multiple regression analyses were conducted to determine the extent to which social support and optimism were associated with depressive and anxious symptomatology, hopelessness and QOL, and the potential role of optimism as a moderator of the relationship between social support and these variables. Results Higher levels of optimism were significantly associated with fewer anxious and depressive symptoms, less hopelessness and better QOL. Higher levels of perceived social support were also significantly associated with better QOL. Additionally, optimism moderated the relationship between social support and anxiety, such that there was a strong negative association between social support and anxiety for participants with low optimism. Conclusions This study highlights the importance of optimism and social support in the QOL of patients with advanced cancer. As such, interventions that attend to patients’ expectations for positive experiences and the expansion of social support should be the focus of future clinical and research endeavors. PMID:24123339

  12. Advanced stages of PD: interventional therapies and related patient-centered care.

    PubMed

    Krüger, Rejko; Hilker, Rüdiger; Winkler, Christian; Lorrain, Michael; Hahne, Matthias; Redecker, Christoph; Lingor, Paul; Jost, Wolfgang H

    2016-01-01

    During the last decades, symptomatic treatment of motor symptoms of Parkinson's disease (PD) improved continuously and is reflected by long-range independency of the patient during the disease course. However, advanced stages of PD still represent an important challenge to patients, caregivers and treating physicians. In patients with advanced PD, interventional therapy strategies are increasingly applied. These device-related treatment strategies using pump-based continuous dopaminergic stimulation (CDS) or deep brain stimulation (DBS) opened new treatment options especially if motor complications predominate. Well-designed clinical studies on these interventional therapeutic approaches provided class 1 evidence for the efficacy of DBS and CDS in advanced PD and opened new perspectives for their use in earlier disease stages also. Therefore, careful selection of patients amenable to the (semi)invasive therapy options becomes more and more important and requires an interdisciplinary setting that accounts for (i) optimal patient information and awareness, (ii) selection of best individual treatment modality, (iii) training of relatives and caregivers, (iv) management of complications, and (v) follow-up care. Here, we address these topics by summarizing current state-of-the-art in patient selection, providing specificities of treatment options and troubleshooting, and defining steps towards an optimized patient-centered care. Interventional therapies pioneer in the area of individualized treatment approaches for PD, and may be complemented in the future by biomarker-based improved stratification and by closed-loop systems for adaptive therapeutic strategies. In the present review, we summarize the proceedings of an Expert Workshop on Parkinson's disease held on November 22, 2014 in Frankfurt, Germany. PMID:26138439

  13. Disparities in the Use of Radiation Therapy in Patients With Local-Regionally Advanced Breast Cancer

    SciTech Connect

    Martinez, Steve R.; Beal, Shannon H.; Chen, Steven L.; Canter, Robert J.; Khatri, Vijay P.; Chen, Allen; Bold, Richard J.

    2010-11-01

    Background: Radiation therapy (RT) is indicated for the treatment of local-regionally advanced breast cancer (BCa). Hypothesis: We hypothesized that black and Hispanic patients with local-regionally advanced BCa would receive lower rates of RT than their white counterparts. Methods: The Surveillance Epidemiology and End Results database was used to identify white, black, Hispanic, and Asian patients with invasive BCa and {>=}10 metastatic lymph nodes diagnosed between 1988 and 2005. Univariate and multivariate logistic regression evaluated the relationship of race/ethnicity with use of RT. Multivariate models stratified for those undergoing mastectomy or lumpectomy. Results: Entry criteria were met by 12,653 patients. Approximately half of the patients did not receive RT. Most patients were white (72%); the remainder were Hispanic (10.4%), black (10.3%), and Asian (7.3%). On univariate analysis, Hispanics (odd ratio [OR] 0.89; 95% confidence interval [CI], 0.79-1.00) and blacks (OR 0.79; 95% CI, 0.70-0.89) were less likely to receive RT than whites. On multivariate analysis, blacks (OR 0.76; 95% CI, 0.67-0.86) and Hispanics (OR 0.80; 95% CI, 0.70-0.90) were less likely than whites to receive RT. Disparities persisted for blacks (OR 0.74; 95% CI, 0.64-0.85) and Hispanics (OR 0.77; 95% CI, 0.67-0.89) who received mastectomy, but not for those who received lumpectomy. Conclusions: Many patients with local-regionally advanced BCa do not receive RT. Blacks and Hispanics were less likely than whites to receive RT. This disparity was noted predominately in patients who received mastectomy. Future efforts at improving rates of RT are warranted. Efforts at eliminating racial/ethnic disparities should focus on black and Hispanic candidates for postmastectomy RT.

  14. Symptom clusters and quality of life among patients with advanced heart failure

    PubMed Central

    Yu, Doris SF; Chan, Helen YL; Leung, Doris YP; Hui, Elsie; Sit, Janet WH

    2016-01-01

    Objectives To identify symptom clusters among patients with advanced heart failure (HF) and the independent relationships with their quality of life (QoL). Methods This is the secondary data analysis of a cross-sectional study which interviewed 119 patients with advanced HF in the geriatric unit of a regional hospital in Hong Kong. The symptom profile and QoL were assessed by using the Edmonton Symptom Assessment Scale (ESAS) and the McGill QoL Questionnaire. Exploratory factor analysis was used to identify the symptom clusters. Hierarchical regression analysis was used to examine the independent relationships with their QoL, after adjusting the effects of age, gender, and comorbidities. Results The patients were at an advanced age (82.9 ± 6.5 years). Three distinct symptom clusters were identified: they were the distress cluster (including shortness of breath, anxiety, and depression), the decondition cluster (fatigue, drowsiness, nausea, and reduced appetite), and the discomfort cluster (pain, and sense of generalized discomfort). These three symptom clusters accounted for 63.25% of variance of the patients' symptom experience. The small to moderate correlations between these symptom clusters indicated that they were rather independent of one another. After adjusting the age, gender and comorbidities, the distress (β = −0.635, P < 0.001), the decondition (β = −0.148, P = 0.01), and the discomfort (β = −0.258, P < 0.001) symptom clusters independently predicted their QoL. Conclusions This study identified the distinctive symptom clusters among patients with advanced HF. The results shed light on the need to develop palliative care interventions for optimizing the symptom control for this life-limiting disease. PMID:27403150

  15. Curative effect of the recent photofrin photodynamic adjuvant treatment on young patients with advanced colorectal cancer

    PubMed Central

    SUN, BO; LI, WEI; LIU, NING

    2016-01-01

    Advanced colorectal cancer has a high mortality rate and conventional treatments have poor therapeutic effects. The aim of the present study was to analyze the recent curative effect and adverse reaction of photofrin photodynamic adjuvant treatment on young patients with advanced colorectal cancer. A total of 23 patients with advanced colorectal cancer who had accepted semiconductor laser photodynamic adjuvant treatment were selected as the observation group. In addition, 30 patients who had accepted concurrent radiotherapy and chemotherapy during the same period served as the control group. The observation group received photofrin (2 mg/kg) intravenously in 100 ml of 5% glucose, followed by the introduction of the endoscopic optical fiber to deliver laser radiation with an intensity of 630 nm wavelength pulse power. After 2 days, necrotic tissues were removed and irradiation of the original or new tumor lesions was performed and necrotic tissues were removed. The total effective rate and survival time was higher and the length of hospital stay was shorter in the observation group in comparison with the control group. The differences were statistically significant (P<0.05). The number of patients in the control and observation groups with symptoms of hematochezia, change in bowel habit, intestinal stimulation and incomplete intestinal obstruction were reduced. Additionally, the reduced ratio of the observation group was significantly increased in comparison with the control group (P<0.05). The adverse reaction rate of the observation group was lower than that of the control group and this difference was also statistically significant (P<0.05). In conclusion, use of photodynamic treatment for young patients with advanced colorectal cancer can effectively improve the clinical symptoms and reduce complications. PMID:26998124

  16. Recent advances in managing chronic HCV infection: focus on therapy in patients with severe liver disease

    PubMed Central

    Maan, Raoel; van der Meer, Adriaan J.

    2016-01-01

    Chronic hepatitis C virus (HCV) infection still represents a major public health problem, as it is thought to be responsible for more than 350,000 deaths around the globe on a yearly basis. Fortunately, successful eradication of the virus has been associated with improved clinical outcome and reduced mortality rates. In the past few years, treatment has improved considerably by the implementation of direct-acting antivirals (DAAs). From 2014 onwards, sofosbuvir, simeprevir, daclatasvir, ledipasvir, paritaprevir, ombitasvir, and dasabuvir have been approved by the US Food and Drug Administration (FDA) and European Medicines Agency (EMA). Regimens with various combinations of these new drugs, without the use of interferon (IFN), proved to be very effective and well tolerated, even among patients with advanced liver disease. Moreover, treatment duration could be shortened to 12 weeks in the majority of patients. The high costs of these DAAs, however, limit the availability of IFN-free therapy worldwide. Even in wealthy countries, it is deemed necessary to prioritize DAA treatment in order to limit the immediate impact on the health budget. As patients with advanced liver disease are in most need of HCV clearance, many countries decided to treat those patients first. In the current review, we focus on the currently available IFN-free treatment options for patients with cirrhosis. We discuss the virological efficacy as well as the clinical relevance of these regimens among this specific patient population. PMID:27006761

  17. [Efficacy and safety of selective estrogen receptor modulators in patients with advanced chronic kidney disease].

    PubMed

    Nakai, Kentaro

    2016-09-01

    Selective estrogen receptor modulators(SERMs)have beneficial effects on the improvement of bone mineral density of the spine and hip, and decrease the vertebral fracture in postmenopausal women. Similar to patients with advanced chronic kidney disease, including dialysis patients, however, SERMs cannot decrease the risk of hip fracture, which is extremely high in Japanese dialysis patients. One of the most important disadvantages of SERMs is an increase in the risk of venous thromboembolic events and fatal stroke in high-risk groups of the Framingham Stroke Risk Score. On the other hand, SERMs may be used in unique osteoporosis drugs for reducing the incidence and progression of breast cancer. Moreover, SERMs attenuate oxidative stress and may lessen the deterioration of kidney function in patients with chronic kidney disease. The evidences for the efficacy and safety of SERMs in patients with advanced chronic kidney disease are insufficient, and knowledge concerning the selection and indication of osteoporosis drugs for those patients need to be developed. PMID:27561348

  18. The impact of delirium on the circadian distribution of breakthrough analgesia in advanced cancer patients.

    PubMed

    Gagnon, B; Lawlor, P G; Mancini, I L; Pereira, J L; Hanson, J; Bruera, E D

    2001-10-01

    Most cancer patients will experience pain requiring opioid therapy during their illness. Standard opioid therapy includes fixed scheduled doses and so-called "rescue" doses for breakthrough pain. Circadian rhythms seem to influence the expression of pain and the responsiveness to analgesic medication. Delirium is a common complication in advanced cancer patients and it also may modify the expression of pain and the use of analgesic medication. We reviewed the circadian distribution of breakthrough analgesia (BTA) doses in 104 advanced cancer patients who were part of a prospective study of the occurrence of delirium. We found that the circadian distribution of BTA is significantly different from a random distribution in the case of patients with and without delirium. Patients without delirium tended to use more BTA (P < 0.001) in the morning, whereas patients with delirium tended to use more BTA in the evening and at night (P = 0.02). We conclude that delirium is associated with changes in the circadian distribution of BTA, which is possibly related to reversal of the normal circadian rhythm. PMID:11576799

  19. Chemotherapy in elderly patients with advanced non-small cell lung cancer.

    PubMed

    Quoix, Elisabeth; Westeel, Virginie; Zalcman, Gérard; Milleron, Bernard

    2011-12-01

    Because of increasing life expectancy and of higher risk of cancer with ageing, lung cancer in elderly is a frequent disease. For a long time nihilism influenced treatment decisions in elderly patients with advanced non-small cell lung cancer. Since the beginning of the last decade single agent chemotherapy has been accepted as standard of care, vinorelbine and gemcitabine being the most frequently used drugs in Europe and US, docetaxel in Japan. Platinum-based doublets have been shown to be superior to monotherapy in young and fit patients with advanced non-small cell lung cancer. Although there were some indications from subgroup analyses of clinical trials not specifically dedicated to elderly patients that a platinum-based doublet might also benefit to older patients, there was no definitive proof of concept until ASCO meeting 2010. At this meeting results of a phase 3 trial showed that PS 0-2 patients, aged 70-89 years drove a significant benefit from a treatment with carboplatin associated to weekly paclitaxel compared to a monotherapy. Thus, the paradigm of treatment in elderly patients should perhaps be modified from a single agent to doublet chemotherapy. Whether other platinum-based doublets would provide the same benefit as the specific one studied remains to be evaluated. PMID:21893363

  20. Recent advances in managing chronic HCV infection: focus on therapy in patients with severe liver disease.

    PubMed

    Maan, Raoel; van der Meer, Adriaan J

    2016-01-01

    Chronic hepatitis C virus (HCV) infection still represents a major public health problem, as it is thought to be responsible for more than 350,000 deaths around the globe on a yearly basis. Fortunately, successful eradication of the virus has been associated with improved clinical outcome and reduced mortality rates. In the past few years, treatment has improved considerably by the implementation of direct-acting antivirals (DAAs). From 2014 onwards, sofosbuvir, simeprevir, daclatasvir, ledipasvir, paritaprevir, ombitasvir, and dasabuvir have been approved by the US Food and Drug Administration (FDA) and European Medicines Agency (EMA). Regimens with various combinations of these new drugs, without the use of interferon (IFN), proved to be very effective and well tolerated, even among patients with advanced liver disease. Moreover, treatment duration could be shortened to 12 weeks in the majority of patients. The high costs of these DAAs, however, limit the availability of IFN-free therapy worldwide. Even in wealthy countries, it is deemed necessary to prioritize DAA treatment in order to limit the immediate impact on the health budget. As patients with advanced liver disease are in most need of HCV clearance, many countries decided to treat those patients first. In the current review, we focus on the currently available IFN-free treatment options for pati