[Diagnostic ability of Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease-4 equations to estimate glomerular filtration rate in with multimorbidity patients].

PubMed

Cabrerizo-García, José Luis; Díez-Manglano, Jesús; García-Arilla, Ernesto; Revillo-Pinilla, Paz; Ramón-Puertas, José; Sebastián-Royo, Mariano

2015-01-06

The Modification of Diet in Renal Disease (MDRD) equation is recommended by most scientific societies to calculate the estimated glomerular filtration rate (GFR). Recently the group Chronic Kidney Disease Epidemiology Collaboration (CKP-EPI) has published a new, more precise and accurate equation. We have analyzed its behavior in a group of polypathological patients (PP) and compared it with the classic MDRD-4.version Multicenter, observational, descriptive and transversal study. We calculated GFR by MDRD-4 and CKD-EPI in 425 PP. Each stage was assigned according to the GFR: 1:>90; 2: 60-89; 3: 30-59; 4: 15-29; and 5 < 15 ml/min/1.73m(2). We analyzed the correlation between both and the patients reclassified by CKD-EPI. Mean age was (mean [SD]) 81.7 (7.9) years. 55.3% were women. The mean estimated GFR was 58.6 (26.3) ml/min/1,73m(2) by MDRD-4 and 52.7 (23.0) ml/min/1.73m(2) by CKD-EPI (P<.001; Spearman's Rho correlation and Lin concordance coefficients: 0.993 and 0.948). The Bland-Altman plots reflected lower values for GFR for CKD-EPI equation. In the stage 2, 21.2% were reclassified by CKD-EPI to the stage 3, with women older than 83 years being the more disadvantaged subgroup with 27.3% or reclassification. CKD-EPI equation applied to PP worsens the results of MDRD-4. In general, it originates low values of GFR and increases the degree of renal insufficiency, especially in older women. Copyright © 2013 Elsevier España, S.L.U. All rights reserved.

Comparison of the Chronic Kidney Disease Epidemiology Collaboration, the Modification of Diet in Renal Disease study and the Cockcroft-Gault equation in patients with heart failure.

PubMed

Szummer, Karolina; Evans, Marie; Carrero, Juan Jesus; Alehagen, Urban; Dahlström, Ulf; Benson, Lina; Lund, Lars H

2017-01-01

It is unknown how the creatinine-based renal function estimations differ for dose adjustment cut-offs and risk prediction in patients with heart failure. The renal function was similar with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) (median 59 mL/min/1.73 m 2 , IQR 42 to 77) and Modification of Diet in Renal Disease Study (MDRD) (59 mL/min/1.73 m 2 , IQR 43 to 75) and slightly lower with the Cockcroft-Gault (CG) equation (57 mL/min, IQR 39 to 82). Across the commonly used renal function stages, the CKD-EPI and the MDRD classified patients into the same stage in 87.2% (kappa coefficient 0.83, p<0.001); the CKD-EPI and the CG equation agreed in 52.3% (kappa coefficient 0.39, p<0.001). Hence, a differing number of patients will receive dose adjustment depending on which formula is used as cut-off. The CG equation predicted worse prognosis better (c-statistics 0.740, 95% CI 0.734 to 0.746) than CKD-EPI (0.697, 95% CI 0.690 to 0.703, p<0.001) and MDRD (0.680, 95% CI 0.734 to 0.746). Using net reclassification improvement (NRI), the CG identified 12.8% more patients at higher risk of death as compared with the CKD-EPI equation. Patients registered in the Swedish Heart Failure Registry (n= 40 736) with standardised creatinine values between 2000 and 2012 had their renal function estimated with the CKD-EPI, the MDRD and the CG. Agreement between the formulas was compared for categories. Prediction of death was assessed with c-statistics and with NRI. The choice of renal function estimation formula has clinical implications and differing results at various cut-off levels. For prognosis, the CG predicts mortality better than the CKD-EPI and MDRD.

Comparing the association of GFR estimated by the CKD-EPI and MDRD study equations and mortality: the third national health and nutrition examination survey (NHANES III)

PubMed Central

2012-01-01

Background The Chronic Kidney Disease Epidemiology Collaboration equation for estimation of glomerular filtration rate (eGFRCKD-EPI) improves GFR estimation compared with the Modification of Diet in Renal Disease Study equation (eGFRMDRD) but its association with mortality in a nationally representative population sample in the US has not been studied. Methods We examined the association between eGFR and mortality among 16,010 participants of the Third National Health and Nutrition Examination Survey (NHANES III). Primary predictors were eGFRCKD-EPI and eGFRMDRD. Outcomes of interest were all-cause and cardiovascular disease (CVD) mortality. Improvement in risk categorization with eGFRCKD-EPI was evaluated using adjusted relative hazard (HR) and Net Reclassification Improvement (NRI). Results Overall, 26.9% of the population was reclassified to higher eGFR categories and 2.2% to lower eGFR categories by eGFRCKD-EPI, reducing the proportion of prevalent CKD classified as stage 3–5 from 45.6% to 28.8%. There were 3,620 deaths (1,540 from CVD) during 215,082 person-years of follow-up (median, 14.3 years). Among those with eGFRMDRD 30–59 ml/min/1.73 m2, 19.4% were reclassified to eGFRCKD-EPI 60–89 ml/min/1.73 m2 and these individuals had a lower risk of all-cause mortality (adjusted HR, 0.53; 95% CI, 0.34-0.84) and CVD mortality (adjusted HR, 0.51; 95% CI, 0.27-0.96) compared with those not reclassified. Among those with eGFRMDRD >60 ml/min/1.73 m2, 0.5% were reclassified to lower eGFRCKD-EPI and these individuals had a higher risk of all-cause (adjusted HR, 1.31; 95% CI, 1.01-1.69) and CVD (adjusted HR, 1.42; 95% CI, 1.01-1.99) mortality compared with those not reclassified. Risk prediction improved with eGFRCKD-EPI; NRI was 0.21 for all-cause mortality (p < 0.001) and 0.22 for CVD mortality (p < 0.001). Conclusions eGFRCKD-EPI categories improve mortality risk stratification of individuals in the US population. If eGFRCKD-EPI replaces e

Comparison of the Chronic Kidney Disease Epidemiology Collaboration, the Modification of Diet in Renal Disease study and the Cockcroft-Gault equation in patients with heart failure

PubMed Central

Szummer, Karolina; Evans, Marie; Carrero, Juan Jesus; Alehagen, Urban; Dahlström, Ulf; Benson, Lina; Lund, Lars H

2017-01-01

Background It is unknown how the creatinine-based renal function estimations differ for dose adjustment cut-offs and risk prediction in patients with heart failure. Method and results The renal function was similar with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) (median 59 mL/min/1.73 m2, IQR 42 to 77) and Modification of Diet in Renal Disease Study (MDRD) (59 mL/min/1.73 m2, IQR 43 to 75) and slightly lower with the Cockcroft-Gault (CG) equation (57 mL/min, IQR 39 to 82). Across the commonly used renal function stages, the CKD-EPI and the MDRD classified patients into the same stage in 87.2% (kappa coefficient 0.83, p<0.001); the CKD-EPI and the CG equation agreed in 52.3% (kappa coefficient 0.39, p<0.001). Hence, a differing number of patients will receive dose adjustment depending on which formula is used as cut-off. The CG equation predicted worse prognosis better (c-statistics 0.740, 95% CI 0.734 to 0.746) than CKD-EPI (0.697, 95% CI 0.690 to 0.703, p<0.001) and MDRD (0.680, 95% CI 0.734 to 0.746). Using net reclassification improvement (NRI), the CG identified 12.8% more patients at higher risk of death as compared with the CKD-EPI equation. Patients registered in the Swedish Heart Failure Registry (n= 40 736) with standardised creatinine values between 2000 and 2012 had their renal function estimated with the CKD-EPI, the MDRD and the CG. Agreement between the formulas was compared for categories. Prediction of death was assessed with c-statistics and with NRI. Conclusion The choice of renal function estimation formula has clinical implications and differing results at various cut-off levels. For prognosis, the CG predicts mortality better than the CKD-EPI and MDRD. PMID:28761677

Prevalence of chronic kidney disease defined by using CKD-EPI equation and albumin-to-creatinine ratio in the Korean adult population.

PubMed

Ji, Eunhee; Kim, Yon Su

2016-11-01

An updated chronic kidney disease (CKD) definition and classification were proposed by Kidney Disease: Improving Global Outcomes (KDIGO), with adoption of a new equation to estimate glomerular filtration rate (GFR) and albuminuria to evaluate kidney structural damage. This study was performed to estimate the prevalence of CKD in the Korean adult population as defined and classified by the KDIGO guidelines. Cross-sectional samples of the fifth Korean National Health and Nutrition Examination Survey for 2011 to 2012 were examined for adults aged ≥ 19 years. CKD prevalence was determined based on decreased GFR and albuminuria. The GFR was estimated using the CKD Epidemiology Collaboration creatinine equation, and albuminuria was evaluated using the albumin-to-creatinine ratio (ACR) in spot urine. Of the 16,576 subjects participating in the survey, 10,636 (4,758 men, 5,878 women) were included in the present study. The prevalence of CKD was estimated as 7.9% (7.8% in 2011 and 8.0% in 2012, p = 0.770). The prevalence of low, moderately increased, high, and very high CKD risk prognosis was 92.0%, 6.3%, 1.1%, and 0.6%, respectively. The prevalence of albuminuria (ACR ≥ 30 mg/g) in individuals with GFR ≥ 60 mL/min/1.73 m 2 has reached 5.7%. The odds ratios of hypertension and diabetes to CKD were 3.4 and 3.1 in men, and 2.9 and 2.0 in women (all p < 0.001), respectively. A large percentage of CKD patients had albuminuria prior to a decrease in GFR. Regular laboratory tests for albuminuria for the high-risk group, and especially for hypertensive or diabetic patients, might improve detection of CKD at an early stage.

Discrepancies between the use of MDRD-4 IDMS and CKD-EPI equations, instead of the Cockcroft-Gault equation, in the determination of the dosage of direct oral anticoagulants in patients with non-valvular atrial fibrillation.

PubMed

Pérez Cabeza, Alejandro Isidoro; Chinchurreta Capote, Pedro Antonio; González Correa, Jose Antonio; Ruiz Mateas, Francisco; Rosas Cervantes, Gabriel; Rivas Ruiz, Francisco; Valle Alberca, Almudena; Bravo Marqués, Rafael

2018-02-09

Direct oral anticoagulants (DOACs) require dose adjustment according to estimated clearance creatinine (eClCr) using the Cockcroft-Gault (CG) equation. There are discrepancies with the equations that estimate glomerular filtration rate (eGFR). We analyse how the use of the CKD-EPI and MDRD-4 IDMS equations affect the recommended dosage for ACODs. Retrospective study of patients with non-valvular atrial fibrillation seen at a cardiology clinic between November 2012 and August 2014. Patients were reclassified according to the recommended dosage for dabigatran, rivaroxaban, apixaban and edoxaban, based on the eGFR equation used. Other clinical factors are taken into account, according to the product label. We analysed the percentage of discordance. Four hundred and fifty-four patients, 53.3% men, with a mean age of 68.7±13.8 years were studied. The mean intra-individual differences recorded for the CG equation were 3.9ml/min/1.73m 2 with MDRD-4 IDMS (95% CI 1.4-6.4, P=.003) and 11.3ml/min/1.73m 2 with CKD-EPI (95% CI 8.9-13.7, P<.001). A gradient is observed in the discordance of the posology (apixaban 1.1%, dabigatran 3.5%, edoxaban 5.7%, rivaroxaban 8.4% with MDRD-4 IDMS). Differences were limited to patients with eClCr<60ml/min and were more evident in≥75 years in which the eGFR equations overestimate renal function. In patients with non-valvular atrial fibrillation, especially with renal failure and in the elderly, eGFR equations tend to overestimate renal function relative to CG and therefore suggest an overdose of DOACs. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

Comparative evaluation of technetium-99m-diethylenetriaminepentaacetic acid renal dynamic imaging versus the Modification of Diet in Renal Disease equation and the Chronic Kidney Disease Epidemiology Collaboration equation for the estimation of GFR.

PubMed

Huang, Qi; Chen, Yunshuang; Zhang, Min; Wang, Sihe; Zhang, Weiguang; Cai, Guangyan; Chen, Xiangmei; Sun, Xuefeng

2018-04-01

We compared the performance of technetium-99m-diethylenetriaminepentaacetic acid ( 99m Tc-DTPA) renal dynamic imaging (RDI), the MDRD equation, and the CKD EPI equation to estimate glomerular filtration rate (GFR). A total of 551 subjects, including CKD patients and healthy individuals, were enrolled in this study. Dual plasma sample clearance method of 99m Tc-DTPA was used as the true value for GFR (tGFR). RDI and the MDRD and CKD EPI equations for estimating GFR were compared and evaluated. Data indicate that RDI and the MDRD equation underestimated GFR and CKD EPI overestimated GFR. RDI was associated with significantly higher bias than the MDRD and CKD EPI equations. The regression coefficient, diagnostic precision, and consistency of RDI were significantly lower than either equation. RDI and the MDRD equation underestimated GFR to a greater degree in subjects with tGFR ≥ 90 ml/min/1.73 m 2 compared with the results obtained from all subjects. In the tGFR60-89 ml/min/1.73 m 2 group, the precision of RDI was significantly lower than that of both equations. In the tGFR30-59 ml/min/1.73 m 2 group, RDI had the least bias, the most precision, and significantly higher accuracy compared with either equation. In tGFR < 30 ml/min/1.73 m 2 , the three methods had similar performance and were not significantly different. RDI significantly underestimates GFR and performs no better than MDRD and CKD EPI equations for GFR estimation; thus, it should not be recommended as a reference standard against which other GFR measurement methods are assessed. However, RDI better estimates GFR than either equation for individuals in the tGFR30-59 ml/min/1.73 m 2 group and thus may be helpful to distinguish stage 3a and 3b CKD.

Evaluation of various equations for estimating renal function in elderly Chinese patients with type 2 diabetes mellitus

PubMed Central

Guo, Mei; Niu, Jian-Ying; Ye, Xian-Wu; Han, Xiao-Jie; Zha, Ying; Hong, Yang; Fang, Hong; Gu, Yong

2017-01-01

Background The clinical assessment of kidney function based on the estimated glomerular filtration rate (GFR) in older patients remains controversial. This study evaluated the concordance and feasibility of using various creatinine-based equations for estimating GFR in elderly Chinese patients with type 2 diabetes mellitus (T2DM). Methods A cross-sectional analytical study was conducted in 21,723 older diabetic patients (≥60 years) based on electronic health records (EHR) for Minhang District, Shanghai, China. The concordance of chronic kidney disease (CKD) classification among different creatinine-based equations was assessed based on Kappa values, intraclass correlation coefficient (ICC) statistics, and the eGFR agreement between the equations was tested using Bland–Altman plots. The GFR was estimated using the Cockcroft–Gault (CG), Berlin Initiative Study 1 (BIS1), simplified Modification of Diet in Renal Disease (MDRD), MDRD modified for Chinese populations (mMDRD), chronic kidney disease epidemiology collaboration (CKD-EPI), CKD-EPI in Asians (CKD-EPI-Asia), and Ruijin equations. Results Overall, the proportion of CKD stages 3–5 (eGFR <60 mL/min/1.73 m2) was calculated as 28.9%, 39.1%, 11.8%, 8.4%, 14.3%, 11.5%, and 12.7% by the eGFRCG, eGFRBIS1, eGFRMDRD, eGFRmMDRD, eGFRCKD-EPI, eGFRCKD-EPI-Asia, and eGFRRuijin equations, respectively. The concordance of albuminuria and decreased eGFR based on the different equations was poor by both the Kappa (<0.2) and ICC (<0.4) statistics. The CKD-EPI-Asia equation resulted in excellent concordance with the CKD-EPI (ICC =0.931), MDRD (ICC =0.963), mMDRD (ICC =0.892), and Ruijin (ICC =0.956) equations for the classification of CKD stages, whereas the BIS1 equation exhibited good concordance with the CG equation (ICC =0.809). In addition, significant differences were observed for CKD stage 1 among all these equations. Conclusion Accurate GFR values are difficult to estimate using creatinine-based equations in older

Cystatin C enhances GFR estimating Equations in Kidney Transplant Recipients

PubMed Central

Kukla, Aleksandra; Issa, Naim; Jackson, Scott; Spong, Richard; Foster, Meredith C.; Matas, Arthur J.; Mauer, Michael S.; Eckfeldt, John H.; Ibrahim, Hassan N.

2014-01-01

Background The glomerular filtration rate (GFR) estimating equation incorporating both cystatin C and creatinine perform better than those using creatinine or cystatin C alone in patients with reduced GFR. Whether this equation performs well in kidney transplant recipients cross-sectionally, and more importantly, over time has not been addressed. Methods We analyzed four GFR estimating equations in participants of the Angiotensin II Blockade for Chronic Allograft Nephropathy Trial (NCT 00067990): Chronic Kidney Disease Epidemiology Collaboration equations based on serum cystatin C and creatinine (eGFR (CKD-EPI-Creat+CysC)), cystatin C alone (eGFR (CKD-EPI-CysC)), creatinine alone (eGFR (CKD-EPI-Creat)) and the Modification of Diet in Renal Disease study equation (eGFR(MDRD)). Iothalamate GFR served as a standard (mGFR). Results mGFR, serum creatinine, and cystatin C shortly after transplant were 56.1 ± 17.0 mL/min/1.73 m2, 1.2 ± 0.4 mg/dL, and 1.2 ± 0.3 mg/L respectively. eGFR (CKD-EPI-Creat+CysC) was most precise (R2=0.50) but slightly more biased than eGFR (MDRD); 9.0 ± 12.7 ml/min/1.73m2 vs. 6.4 ± 15.8 ml/min/1.73m2, respectively. This improved precision was most evident in recipients with mGFR >60 ml/min/1.73m2. For relative accuracy, eGFR (MDRD) and eGFR (CKD-EPI-Creat+CysC) had the highest percentage of estimates falling within 30% of mGFR; 75.8% and 68.9%, respectively. Longitudinally, equations incorporating cystatin C most closely paralleled the change in mGFR. Conclusion eGFR (CKD-EPI-Creat+CysC) is more precise and reflects GFR change over time reasonably well. eGFR (MDRD) had superior performance in recipients with mGFR between 30–60 ml/min/1.73m2. PMID:24457184

Renal dysfunction in patients with heart failure with preserved versus reduced ejection fraction: impact of the new Chronic Kidney Disease-Epidemiology Collaboration Group formula.

PubMed

McAlister, Finlay A; Ezekowitz, Justin; Tarantini, Luigi; Squire, Iain; Komajda, Michel; Bayes-Genis, Antoni; Gotsman, Israel; Whalley, Gillian; Earle, Nikki; Poppe, Katrina K; Doughty, Robert N

2012-05-01

Prior studies in heart failure (HF) have used the Modification of Diet in Renal Disease (MDRD) equation to calculate estimated glomerular filtration rate (eGFR). The Chronic Kidney Disease-Epidemiology Collaboration Group (CKD-EPI) equation provides a more-accurate eGFR than the MDRD when compared against the radionuclide gold standard. The prevalence and prognostic import of renal dysfunction in HF if the CKD-EPI equation is used rather than the MDRD is uncertain. We used individual patient data from 25 prospective studies to stratify patients with HF by eGFR using the CKD-EPI and the MDRD equations and examined survival across eGFR strata. In 20 754 patients (15 962 with HF with reduced ejection fraction [HF-REF] and 4792 with HF with preserved ejection fraction [HF-PEF]; mean age, 68 years; deaths per 1000 patient-years, 151; 95% CI, 146-155), 10 589 (51%) and 11 422 (55%) had an eGFR <60 mL/min using the MDRD and CKD-EPI equations, respectively. Use of the CKD-EPI equation resulted in 3760 (18%) patients being reclassified into different eGFR risk strata; 3089 (82%) were placed in a lower eGFR category and exhibited higher all-cause mortality rates (net reclassification improvement with CKD-EPI, 3.7%; 95% CI, 1.5%-5.9%). Reduced eGFR was a stronger predictor of all-cause mortality in HF-REF than in HF-PEF. Use of the CKD-EPI rather than the MDRD equation to calculate eGFR leads to higher estimates of renal dysfunction in HF and a more-accurate categorization of mortality risk. Renal function is more closely related to outcomes in HF-REF than in HF-PEF.

Evaluation of equations that estimate glomerular filtration rate in renal transplant recipients.

PubMed

De Alencastro, M G; Veronese, F V; Vicari, A R; Gonçalves, L F; Manfro, R C

2014-03-01

The accuracy of equations that estimate the glomerular filtration rate (GFR) in renal transplant patients has not been established; thus their performance was assessed in stable renal transplant patients. Renal transplant patients (N.=213) with stable graft function were enrolled. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation was used as the reference method and compared with the Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), Mayo Clinic (MC) and Nankivell equations. Bias, accuracy and concordance rates were determined for all equation relative to CKD-EPI. Mean estimated GFR values of the equations differed significantly from the CKD-EPI values, though the correlations with the reference method were significant. Values of MDRD differed from the CG, MC and Nankivell estimations. The best agreement to classify the chronic kidney disease (CKD) stages was for the MDRD (Kappa=0.649, P<0.001), and for the other equations the agreement was moderate. The MDRD had less bias and narrower agreement limits but underestimated the GFR at levels above 60 mL/min/1.73 m2. Conversely, the CG, MC and Nankivell equations overestimated the GFR, and the Nankivell equation had the worst performance. The MDRD equation P15 and P30 values were higher than those of the other equations (P<0.001). Despite their correlations, equations estimated the GFR and CKD stage differently. The MDRD equation was the most accurate, but the sub-optimal performance of all the equations precludes their accurate use in clinical practice.

Performance of Creatinine and Cystatin C GFR Estimating Equations in an HIV-positive population on Antiretrovirals

PubMed Central

INKER, Lesley A; WYATT, Christina; CREAMER, Rebecca; HELLINGER, James; HOTTA, Matthew; LEPPO, Maia; LEVEY, Andrew S; OKPARAVERO, Aghogho; GRAHAM, Hiba; SAVAGE, Karen; SCHMID, Christopher H; TIGHIOUART, Hocine; WALLACH, Fran; KRISHNASAMI, Zipporah

2013-01-01

Objective To evaluate the performance of CKD-EPI creatinine, cystatin C and creatinine-cystatin C estimating equations in HIV-positive patients. Methods We evaluated the performance of the MDRD Study and CKD-EPI creatinine 2009, CKD-EPI cystatin C 2012 and CKD-EPI creatinine-cystatin C 2012 glomerular filtration rate (GFR) estimating equations compared to GFR measured using plasma clearance of iohexol in 200 HIV-positive patients on stable antiretroviral therapy. Creatinine and cystatin C assays were standardized to certified reference materials. Results Of the 200 participants, median (IQR) CD4 count was 536 (421) and 61% had an undetectable HIV-viral load. Mean (SD) measured GFR (mGFR) was 87 (26) ml/min/1.73m2. All CKD-EPI equations performed better than the MDRD Study equation. All three CKD-EPI equations had similar bias and precision. The cystatin C equation was not more accurate than the creatinine equation. The creatinine-cystatin C equation was significantly more accurate than the cystatin C equation and there was a trend toward greater accuracy than the creatinine equation. Accuracy was equal or better in most subgroups with the combined equation compared to either alone. Conclusions The CKD-EPI cystatin C equation does not appear to be more accurate than the CKD-EPI creatinine equation in patients who are HIV-positive, supporting the use of the CKD-EPI creatinine equation for routine clinical care for use in North American populations with HIV. The use of both filtration markers together as a confirmatory test for decreased estimated GFR based on creatinine in individuals who are HIV-positive requires further study. PMID:22842844

Estimating equations for glomerular filtration rate in the era of creatinine standardization: a systematic review.

PubMed

Earley, Amy; Miskulin, Dana; Lamb, Edmund J; Levey, Andrew S; Uhlig, Katrin

2012-06-05

Clinical laboratories are increasingly reporting estimated glomerular filtration rate (GFR) by using serum creatinine assays traceable to a standard reference material. To review the performance of GFR estimating equations to inform the selection of a single equation by laboratories and the interpretation of estimated GFR by clinicians. A systematic search of MEDLINE, without language restriction, between 1999 and 21 October 2011. Cross-sectional studies in adults that compared the performance of 2 or more creatinine-based GFR estimating equations with a reference GFR measurement. Eligible equations were derived or reexpressed and validated by using creatinine measurements traceable to the standard reference material. Reviewers extracted data on study population characteristics, measured GFR, creatinine assay, and equation performance. Eligible studies compared the MDRD (Modification of Diet in Renal Disease) Study and CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equations or modifications thereof. In 12 studies in North America, Europe, and Australia, the CKD-EPI equation performed better at higher GFRs (approximately >60 mL/min per 1.73 m(2)) and the MDRD Study equation performed better at lower GFRs. In 5 of 8 studies in Asia and Africa, the equations were modified to improve their performance by adding a coefficient derived in the local population or removing a coefficient. Methods of GFR measurement and study populations were heterogeneous. Neither the CKD-EPI nor the MDRD Study equation is optimal for all populations and GFR ranges. Using a single equation for reporting requires a tradeoff to optimize performance at either higher or lower GFR ranges. A general practice and public health perspective favors the CKD-EPI equation. Kidney Disease: Improving Global Outcomes.

Performance of three glomerular filtration rate estimation equations in a population of sub-Saharan Africans with Type 2 diabetes.

PubMed

Agoons, D D; Balti, E V; Kaze, F F; Azabji-Kenfack, M; Ashuntantang, G; Kengne, A P; Sobngwi, E; Mbanya, J C

2016-09-01

We evaluated the performance of the Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Cockcroft-Gault (CG) equations against creatinine clearance (CrCl) to estimate glomerular filtration rate (GFR) in 51 patients with Type 2 diabetes. The CrCl value was obtained from the average of two consecutive 24-h urine samples. Results were adjusted for body surface area using the Dubois formula. Serum creatinine was measured using the kinetic Jaffe method and was calibrated to standardized levels. Bland-Altman analysis and kappa statistic were used to examine agreement between measured and estimated GFR. Estimates of GFR from the CrCl, MDRD, CKD-EPI and CG equations were similar (overall P = 0.298), and MDRD (r = 0.58; 95% CI: 0.36-0.74), CKD-EPI (r = 0.55; 95% CI: 0.33-0.72) and CG (r = 0.61; 95% CI: 0.39-0.75) showed modest correlation with CrCl (all P < 0.001). Bias was -0.3 for MDRD, 1.7 for CKD-EPI and -5.4 for CG. All three equations showed fair-to-moderate agreement with CrCl (kappa: 0.38-0.51). The c-statistic for all three equations ranged between 0.75 and 0.77 with no significant difference (P = 0.639 for c-statistic comparison). The MDRD equation seems to have a modest advantage over CKD-EPI and CG in estimating GFR and detecting impaired renal function in sub-Saharan African patients with Type 2 diabetes. The overall relatively modest correlation with CrCl, however, suggests the need for context-specific estimators of GFR or context adaptation of existing estimators. © 2015 Diabetes UK.

Optimal equation for estimation of glomerular filtration rate in autosomal dominant polycystic kidney disease: influence of tolvaptan.

PubMed

Yamaguchi, Tsuyoshi; Higashihara, Eiji; Okegawa, Takatsugu; Miyazaki, Isao; Nutahara, Kikuo

2018-05-22

The reliability of various equations for estimating the GFR in ADPKD patients and the influence of tolvaptan on the resulting estimates have not been examined when GFR is calculated on the basis of inulin clearance. We obtained baseline and on-tolvaptan measured GFRs (mGFRs), calculated on the basis of inulin clearance, in 114 ADPKD, and these mGFRs were compared with eGFRs calculated according to four basic equations: the MDRD, CKD-EPI, and JSN-CKDI equations and the Cockcroft-Gault formula, as well as the influence of tolvaptan and of inclusion of cystatin C on accuracy of the results. Accuracy of each of the seven total equations was evaluated on the basis of the percentage of eGFR values within mGFR ± 30% (P 30 ). mGFRs were distributed throughout CKD stages 1-5. Regardless of the CKD stage, P 30 s of the MDRD, CKD-EPI, and JSN-CKDI equations did not differ significantly between baseline values and on-tolvaptan values. In CKD 1-2 patients, P 30 of the CKD-EPI equation was 100.0%, whether or not the patient was on-tolvaptan. In CKD 3-5 patients, P 30 s of the MDRD, CKD-EPI, and JSN-CKDI equations were similar. For all four equations, regression coefficients and intercepts did not differ significantly between baseline and on-tolvaptan values, but accuracy of the Cockcroft-Gault formula was inferior to that of the other three equations. Incorporation of serum cystatin C reduced accuracy. The CKD-EPI equation is most reliable, regardless of the severity of CKD. Tolvaptain intake has minimal influence and cystatin C incorporation does not improve accuracy.

Creatinine-based equations for the adjustment of drug dosage in an obese population.

PubMed

Bouquegneau, Antoine; Vidal-Petiot, Emmanuelle; Moranne, Olivier; Mariat, Christophe; Boffa, Jean-Jacques; Vrtovsnik, François; Scheen, André-Jean; Krzesinski, Jean-Marie; Flamant, Martin; Delanaye, Pierre

2016-02-01

For drug dosing adaptation, the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend using estimated glomerular filtration rate (eGFR) by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, after 'de-indexation' by body surface area (BSA). In pharmacology, the Cockcroft-Gault (CG) equation is still recommended to adapt drug dosage. In the context of obesity, adjusted ideal body weight (AIBW) is sometimes preferred to actual body weight (ABW) for the CG equation. The aim of the present study was to compare the performance of the different GFR-estimating equations, non-indexed or de-indexed by BSA for the purpose of drug-dosage adaptation in obese patients. We analysed data from patients with a body mass index (BMI) higher than 30 kg m(-2) who underwent a GFR measurement. eGFR was calculated using the CKD-EPI and Modification of Diet in Renal Disease (MDRD) equations, de-indexed by BSA, and the CG equation, using either ABW, AIBW or lean body weight (LBW) for the weight variable and compared with measured GFR, expressed in ml min(-1). In our population of obese patients, use of the AIBW instead of the ABW in the CG equation, markedly improved the overall accuracy of this equation [57% for CGABW and 79% for CGAIBW (P < 0.05)]. For high BMI (over 40 kg m(-2)), the accuracy of the CG equations is no different when using LBW than when using AIBW. The MDRD and CKD-EPI equations de-indexed by the BSA also performed well, with an overall higher accuracy for the MDRD de-indexed equation [(80% and 76%, respectively (P < 0.05)]. The de-indexed MDRD equation appeared to be the most suitable for estimating the non-indexed GFR for the purpose of drug dosage adaptation in obese patients. © 2015 The British Pharmacological Society.

Using Mathematical Algorithms to Modify Glomerular Filtration Rate Estimation Equations

PubMed Central

Zhu, Bei; Wu, Jianqing; Zhu, Jin; Zhao, Weihong

2013-01-01

Background The equations provide a rapid and low-cost method of evaluating glomerular filtration rate (GFR). Previous studies indicated that the Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease-Epidemiology (CKD-EPI) and MacIsaac equations need further modification for application in Chinese population. Thus, this study was designed to modify the three equations, and compare the diagnostic accuracy of the equations modified before and after. Methodology With the use of 99 mTc-DTPA renal dynamic imaging as the reference GFR (rGFR), the MDRD, CKD-EPI and MacIsaac equations were modified by two mathematical algorithms: the hill-climbing and the simulated-annealing algorithms. Results A total of 703 Chinese subjects were recruited, with the average rGFR 77.14±25.93 ml/min. The entire modification process was based on a random sample of 80% of subjects in each GFR level as a training sample set, the rest of 20% of subjects as a validation sample set. After modification, the three equations performed significant improvement in slop, intercept, correlated coefficient, root mean square error (RMSE), total deviation index (TDI), and the proportion of estimated GFR (eGFR) within 10% and 30% deviation of rGFR (P10 and P30). Of the three modified equations, the modified CKD-EPI equation showed the best accuracy. Conclusions Mathematical algorithms could be a considerable tool to modify the GFR equations. Accuracy of all the three modified equations was significantly improved in which the modified CKD-EPI equation could be the optimal one. PMID:23472113

GFR Estimation: From Physiology to Public Health

PubMed Central

Levey, Andrew S.; Inker, Lesley A.; Coresh, Josef

2014-01-01

Estimating glomerular filtration rate (GFR) is essential for clinical practice, research, and public health. Appropriate interpretation of estimated GFR (eGFR) requires understanding the principles of physiology, laboratory medicine, epidemiology and biostatistics used in the development and validation of GFR estimating equations. Equations developed in diverse populations are less biased at higher GFR than equations developed in CKD populations and are more appropriate for general use. Equations that include multiple endogenous filtration markers are more precise than equations including a single filtration marker. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations are the most accurate GFR estimating equations that have been evaluated in large, diverse populations and are applicable for general clinical use. The 2009 CKD-EPI creatinine equation is more accurate in estimating GFR and prognosis than the 2006 Modification of Diet in Renal Disease (MDRD) Study equation and provides lower estimates of prevalence of decreased eGFR. It is useful as a “first” test for decreased eGFR and should replace the MDRD Study equation for routine reporting of serum creatinine–based eGFR by clinical laboratories. The 2012 CKD-EPI cystatin C equation is as accurate as the 2009 CKD-EPI creatinine equation in estimating eGFR, does not require specification of race, and may be more accurate in patients with decreased muscle mass. The 2012 CKD-EPI creatinine–cystatin C equation is more accurate than the 2009 CKD-EPI creatinine and 2012 CKD-EPI cystatin C equations and is useful as a confirmatory test for decreased eGFR as determined by an equation based on serum creatinine. Further improvement in GFR estimating equations will require development in more broadly representative populations, including diverse racial and ethnic groups, use of multiple filtration markers, and evaluation using statistical techniques to compare eGFR to “true GFR”. PMID

Estimating Renal Function in the Elderly Malaysian Patients Attending Medical Outpatient Clinic: A Comparison between Creatinine Based and Cystatin-C Based Equations.

PubMed

Jalalonmuhali, Maisarah; Elagel, Salma Mohamed Abouzriba; Tan, Maw Pin; Lim, Soo Kun; Ng, Kok Peng

2018-01-01

To assess the performance of different GFR estimating equations, test the diagnostic value of serum cystatin-C, and compare the applicability of cystatin-C based equation with serum creatinine based equation for estimating GFR (eGFR) in comparison with measured GFR in the elderly Malaysian patients. A cross-sectional study recruiting volunteered patients 65 years and older attending medical outpatient clinic. 51 chromium EDTA ( 51 Cr-EDTA) was used as measured GFR. The predictive capabilities of Cockcroft-Gault equation corrected for body surface area (CGBSA), four-variable Modification of Diet in Renal Disease (4-MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations using serum creatinine (CKD-EPIcr) as well as serum cystatin-C (CKD-EPIcys) were calculated. A total of 40 patients, 77.5% male, with mean measured GFR 41.2 ± 18.9 ml/min/1.73 m 2 were enrolled. Mean bias was the smallest for 4-MDRD; meanwhile, CKD-EPIcr had the highest precision and accuracy with lower limit of agreement among other equations. CKD-EPIcys equation did not show any improvement in GFR estimation in comparison to CKD-EPIcr and MDRD. The CKD-EPIcr formula appears to be more accurate and correlates better with measured GFR in this cohort of elderly patients.

The applicability of eGFR equations to different populations.

PubMed

Delanaye, Pierre; Mariat, Christophe

2013-09-01

The Cockcroft-Gault equation for estimating glomerular filtration rate has been learnt by every generation of medical students over the decades. Since the publication of the Modification of Diet in Renal Disease (MDRD) study equation in 1999, however, the supremacy of the Cockcroft-Gault equation has been relentlessly disputed. More recently, the Chronic Kidney Disease Epidemiology (CKD-EPI) consortium has proposed a group of novel equations for estimating glomerular filtration rate (GFR). The MDRD and CKD-EPI equations were developed following a rigorous process, are expressed in a way in which they can be used with standardized biomarkers of GFR (serum creatinine and/or serum cystatin C) and have been evaluated in different populations of patients. Today, the MDRD Study equation and the CKD-EPI equation based on serum creatinine level have supplanted the Cockcroft-Gault equation. In many regards, these equations are superior to the Cockcroft-Gault equation and are now specifically recommended by international guidelines. With their generalized use, however, it has become apparent that those equations are not infallible and that they fail to provide an accurate estimate of GFR in certain situations frequently encountered in clinical practice. After describing the processes that led to the development of the new GFR-estimating equations, this Review discusses the clinical situations in which the applicability of these equations is questioned.

Are cystatin C-based equations superior to creatinine-based equations for estimating GFR in Chinese elderly population?

PubMed

Pei, Xiaohua; Liu, Qiao; He, Juan; Bao, Lihua; Yan, Chengjing; Wu, Jianqing; Zhao, Weihong

2012-12-01

Cystatin C has been proposed as a surrogate marker of kidney function. The elderly population accounts for the largest proportion of chronic kidney disease (CKD) patients. The aim of this study was to assess the diagnostic value of serum cystatin C and compare the applicability of cystatin C-based equations with serum creatinine (Scr)-based equations for estimating glomerular filtration rate (GFR). The estimated GFR (eGFR) values from six cystatin C-based equations (Tan, MacIsaac, Ma, Stevens1-3) and three Scr-based equations (CG, MDRD, CKD-EPI) were compared with the reference GFR (rGFR) values from 99mTc-DTPA renal dynamic imaging method. A total of 110 elderly Chinese (60-92 year, 71.05±7.62 year) were enrolled. Cystatin C had better diagnostic value than Scr (relationship coefficient with rGFR: cystatin C -0.847 vs. Scr -0.729, P<0.01; sensitivity: cystatin C 0.90 vs. Scr 0.55, P<0.01; AUCROC: cystatin C 0.857 vs. Scr 0.757, P<0.01). All the equations predicted GFR more accurately for rGFR≥60 ml/min/1.73 m2 than for rGFR<60 ml/min/1.73 m2. Most equations had acceptable accuracy. The cystatin C-based equations deviated from rGFR by -12.78 ml/min/1.73 m2 to -2.12 ml/min/1.73 m2, with accuracy varying from 64.6 to 82.7%. The Scr-based equations deviated from rGFR by -5.37 ml/min/1.73 m2 to -0.68 ml/min/1.73 m2, with accuracy varying from 77.3 to 79.1%. The CKD-EPI, MacIsaac and Ma equations predicted no bias with rGFR (P>0.05), with higher accuracy and lower deviation in the total group. The MacIsaac, CKD-EPI and Stevens3 equations could be optimal for those with normal and mildly impaired kidney function, whereas the Ma equation for those with CKD. Cystatin C is a promising kidney function marker. However, not all cystatin C-based equations could be superior to the Scr-equations.

Estimated GFR and incident cardiovascular disease events in American Indians: the Strong Heart Study.

PubMed

Shara, Nawar M; Wang, Hong; Mete, Mihriye; Al-Balha, Yaman Rai; Azalddin, Nameer; Lee, Elisa T; Franceschini, Nora; Jolly, Stacey E; Howard, Barbara V; Umans, Jason G

2012-11-01

In populations with high prevalences of diabetes and obesity, estimating glomerular filtration rate (GFR) by using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation may predict cardiovascular disease (CVD) risk better than by using the Modification of Diet in Renal Disease (MDRD) Study equation. Longitudinal cohort study comparing the association of GFR estimated using either the CKD-EPI or MDRD Study equation with incident CVD outcomes. American Indians participating in the Strong Heart Study, a longitudinal population-based cohort with high prevalences of diabetes, CVD, and CKD. Estimated GFR (eGFR) predicted using the CKD-EPI and MDRD Study equations. Fatal and nonfatal cardiovascular events, consisting of coronary heart disease, stroke, and heart failure. The association between eGFR and outcomes was explored in Cox proportional hazards models adjusted for traditional risk factors and albuminuria; the net reclassification index and integrated discrimination improvement were determined for the CKD-EPI versus MDRD Study equations. In 4,549 participants, diabetes was present in 45%; CVD, in 7%; and stages 3-5 CKD, in 10%. During a median of 15 years, there were 1,280 cases of incident CVD, 929 cases of incident coronary heart disease, 305 cases of incident stroke, and 381 cases of incident heart failure. Reduced eGFR (<90 mL/min/1.73 m2) was associated with adverse events in most models. Compared with the MDRD Study equation, the CKD-EPI equation correctly reclassified 17.0% of 2,151 participants without incident CVD to a lower risk (higher eGFR) category and 1.3% (n=28) were reclassified incorrectly to a higher risk (lower eGFR) category. Single measurements of eGFR and albuminuria at study visits. Although eGFR based on either equation had similar associations with incident CVD, coronary heart disease, stroke, and heart failure events, in those not having events, reclassification of participants to eGFR categories was superior using the

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

KDIGO 2012 Clinical Practice Guideline CKD classification rules out creatinine clearance 24 hour urine collection?

PubMed

Ognibene, A; Grandi, G; Lorubbio, M; Rapi, S; Salvadori, B; Terreni, A; Veroni, F

2016-01-01

The recent guideline for the evaluation and management of Chronic Kidney Disease recommends assessing GFR employing equations based on serum creatinine; despite this, creatinine clearance 24-hour urine collection is used routinely in many settings. In this study we compared the classification assessed from CrCl (creatinine clearance 24h urine collection) and e-GFR calculated with CKD-EPI or MDRD formulas. In this retrospective study we analyze consecutive laboratory data: creatinine clearance 24h urine collection, serum creatinine and demographic data such as sex and age from 15,777 patients >18 years of age collected from 2011 to 2013 in our laboratory at Careggi Hospital. The results were then compared to the estimated GFR calculated with the equations according to the recent treatment guidelines. Consecutive and retrospective laboratory data (creatinine clearance 24h urine collection, serum creatinine and, demographic data such as sex and age) from 15,777 patients >18 years of age seen at Careggi Hospital were collected. Comparison between e-GFR calculated with CKD-EPI or MDRD formulas and GFR according CrCl determinations and bias [95% CI] were 11.34 [-47,4/70.1] and 11.4 [-50.2/73] respectively. The concordance for 18/65 years aged group when compared with e-GFR classification between MDRD vs CKDEPI, MDRD vs CrCl and CKD-EPI vs CrCl were 0.78, 0.34, and 0.41 respectively, while in the 65/110years aged group the concordance Kappas were 0.84, 0.38, and 0.36 respectively. The use of CrCl provides a different classification than the estimation of GFR using a prediction equation. The CrCl is unreliable when it is necessary to identify CKD subjects with decrease of GFR of 5ml/min/1.73m(2)/year. Copyright © 2015 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Cystatin C is Better than Serum Creatinine for Estimating Glomerular Filtration Rate to Detect Osteopenia in Chronic Kidney Disease Patients.

PubMed

Kwon, Young Eun; Lee, Mi Jung; Park, Kyoung Sook; Han, Seung Hyeok; Yoo, Tae Hyun; Oh, Kook Hwan; Lee, Joongyub; Lee, Kyu Beck; Chung, Wookyung; Kim, Yeong Hoon; Ahn, Curie; Choi, Kyu Hun

2017-03-01

Recent studies have reported that loss of bone mass is associated with renal function decline and increased fracture risks in chronic kidney disease (CKD) patients. The aim of this study was to investigate the best estimated glomerular filtration rate (eGFR) equation to detect osteopenia in CKD patients. This was a cross-sectional study, and 780 patients aged 50 years or above were classified into normal bone mass or osteopenia groups according to the -1.0 of T-scores at total hip and femur neck. Comparisons of area under the receiver operating characteristic (ROC) curves (AUC) were performed to investigate significant differences among three eGFR formulas: Modification of Diet in Renal Disease, CKD-Epidemiology Collaboration (EPI) creatinine, and CKD-EPI cystatin C (CKD-EPI-Cys). The mean age was 61 years old and the proportion of females was 37.3%. The total hip osteopenia group showed lower CKD-EPI-Cys eGFR levels (osteopenia group, 33.3±19.0 mL/min/1.73 m²; normal group, 48.1±26.2 mL/min/1.73 m², p<0.001). In multiple logistic regression analysis, CKD-EPI-Cys eGFR was independently associated with osteopenia at the total hip (per 1 mL/min/1.73 m² increase, odds ratio 0.98, 95% confidence interval 0.97-0.99, p=0.004) after adjusting for confounding variables. ROC curve analyses indicated that CKD-EPI-Cys shows the largest AUC for osteopenia at the total hip (AUC=0.678, all p<0.01) and the femur neck (AUC=0.665, all p<0.05). Decreased renal function assessed by CKD-EPI-Cys equation correlates with osteopenia better than creatinine-based methods in CKD patients, and the CKD-EPI-Cys formula might be a useful tool to assess skeletal-related event risks.

Correlation of Glomerular Filtration Rate Between Renal Scan and Estimation Equation for Patients With Scleroderma.

PubMed

Suebmee, Patcharawan; Foocharoen, Chingching; Mahakkanukrauh, Ajanee; Suwannaroj, Siraphop; Theerakulpisut, Daris; Nanagara, Ratanavadee

2016-08-01

Renal involvement in scleroderma is life-threatening. Early detection of a deterioration of the glomerular filtration rate (GFR) is needed to preserve kidney function. To (A) determine the correlation between (1) estimated GFR (eGFR) using 4 different formulae and (2) measured GFR (mGFR) using isotopic renal scan in Thai patients with scleroderma with normal serum creatinine and (B) to define the factors influencing eGFR. A cross-sectional study was performed in adult Thai patients with scleroderma at Srinagarind Hospital, Khon Kaen University, between December 2013 and April 2015. GFR was measured using the gold standard Tc-99m DTPA (Tc-99m diethylenetriaminepentaacetic acid) renal scan. We compared the latter with the eGFR, calculated using the Cockroft-Gault formula, Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and creatinine clearance equation. A total of 76 patients with scleroderma (50 women and 26 men) with median age 54.8 years (interquartile range: 47.4 to 58.9) were enrolled. Mean disease duration was 5.6 ± 4.5 years. Median value of mGFR was 100.1 ± 27.6mL/minute/1.73m². There was a correlation between mGFR from the Tc-99m DTPA renal scan and the eGFR using the Cockroft-Gault formula, MDRD and CKD-EPI equation (P = 0.01, <0.001 and <0.001, respectively), but no correlation with eGFR using the creatinine clearance equation (P = 0.27). Body weight, prednisolone use and systolic blood pressure (SBP) had a negative association with mGFR (P = 0.01, 0.01 and 0.007, respectively). After multivariate analysis, SBP was the only clinical parameter that influenced mGFR (P = 0.03). The Cockroft-Gault formula, MDRD study equation and CKD-EPI were useful formulae for assessing GFR in Thai patients with scleroderma. Higher SBP was associated with a lower GFR. Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.

Low dose aspirin increases 15-epi-lipoxin A4 levels in diabetic chronic kidney disease patients.

PubMed

Goicoechea, Marian; Sanchez-Niño, Maria Dolores; Ortiz, Alberto; García de Vinuesa, Soledad; Quiroga, Borja; Bernis, Carmen; Morales, Enrique; Fernández-Juarez, Gema; de Sequera, Patricia; Verdalles, Ursula; Verde, Eduardo; Luño, José

2017-10-01

Resolution of inflammation is regulated by endogenous lipid mediators, such as lipoxins and their epimers, including 15-epi-lipoxin A4 (15-epi-LXA4). However, there is no information on 15-epi-LXA4 and its in vivo regulation in chronic kidney disease (CKD) patients. Open label randomized clinical trial. 50 participants with chronic kidney disease (CKD) stage 3 and 4 without prior cardiovascular disease (25 in the aspirin group and 25 in the standard group) followed for 46 months. Aspirin (100mg/day) or standard treatment. To analyze the effect of aspirin on plasma 15-epi-LXA4 levels and inflammatory markers in CKD patients. Baseline plasma15-epi-LXA4 levels were lower in diabetic (1.22 ± 0.99ng/ml) than in non-diabetic CKD patients (2.05 ± 1.06ng/ml, p < 0.001) and inversely correlated with glycosylated hemoglobin levels (r = -0.303, p = 0.006). In multivariate analysis, diabetes was associated with lower 15-epi-LXA4 levels, adjusted for age, inflammatory markers and renal function (p = 0.005). In the whole study population, 15-epi-LXA4 levels tended to increase, but not significantly (p = 0.45), after twelve months on aspirin (from mean ± SD 1.84 ± 1.06 to 2.04 ± 0.75ng/ml) and decreased in the standard care group (1.60 ± 1.15 to 1.52 ± 0.68ng/ml, p = 0.04). The aspirin effect on 15-epi-LXA4 levels was more striking in diabetic patients, increasing from 0.94 ± 0.70 to 1.93 ± 0.74ng/ml, p = 0.017. Diabetic patients with CKD have lower circulating 15-epi-LXA4 levels than non-diabetic CKD patients. Low dose aspirin for 12 months increased 15-epi-LXA4 levels in diabetic patients. Given its anti-inflammatory properties, this increase in 15-epi-LXA4 levels may contribute to the beneficial effects of low dose aspirin. Copyright © 2017 Elsevier Ltd. All rights reserved.

Comparison of Various Equations for Estimating GFR in Malawi: How to Determine Renal Function in Resource Limited Settings?

PubMed Central

Phiri, Sam; Rothenbacher, Dietrich; Neuhann, Florian

2015-01-01

Background Chronic kidney disease (CKD) is a probably underrated public health problem in Sub-Saharan-Africa, in particular in combination with HIV-infection. Knowledge about the CKD prevalence is scarce and in the available literature different methods to classify CKD are used impeding comparison and general prevalence estimates. Methods This study assessed different serum-creatinine based equations for glomerular filtration rates (eGFR) and compared them to a cystatin C based equation. The study was conducted in Lilongwe, Malawi enrolling a population of 363 adults of which 32% were HIV-positive. Results Comparison of formulae based on Bland-Altman-plots and accuracy revealed best performance for the CKD-EPI equation without the correction factor for black Americans. Analyzing the differences between HIV-positive and –negative individuals CKD-EPI systematically overestimated eGFR in comparison to cystatin C and therefore lead to underestimation of CKD in HIV-positives. Conclusions Our findings underline the importance for standardization of eGFR calculation in a Sub-Saharan African setting, to further investigate the differences with regard to HIV status and to develop potential correction factors as established for age and sex. PMID:26083345

Estimation of GFR in South Asians: A Study From the General Population in Pakistan

PubMed Central

Jessani, Saleem; Levey, Andrew S.; Bux, Rasool; Inker, Lesley A.; Islam, Muhammad; Chaturvedi, Nish; Mariat, Christophe; Schmid, Christopher H.; Jafar, Tazeen H.

2015-01-01

Background South Asians are at high risk for chronic kidney disease. However, unlike those in the United States and United Kingdom, laboratories in South Asian countries do not routinely report estimated glomerular filtration rate (eGFR) when serum creatinine is measured. The objectives of the study were to: (1) evaluate the performance of existing GFR estimating equations in South Asians, and (2) modify the existing equations or develop a new equation for use in this population. Study Design Cross-sectional population-based study. Setting & Participants 581 participants 40 years or older were enrolled from 10 randomly selected communities and renal clinics in Karachi. Predictors eGFR, age, sex, serum creatinine level. Outcomes Bias (the median difference between measured GFR [mGFR] and eGFR), precision (the IQR of the difference), accuracy (P30; percentage of participants with eGFR within 30% of mGFR), and the root mean squared error reported as cross-validated estimates along with bootstrapped 95% CIs based on 1,000 replications. Results The CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) creatinine equation performed better than the MDRD (Modification of Diet in Renal Disease) Study equation in terms of greater accuracy at P30 (76.1% [95% CI, 72.7%–79.5%] vs 68.0% [95% CI, 64.3%–71.7%]; P <0.001) and improved precision (IQR, 22.6 [95% CI, 19.9–25.3] vs 28.6 [95% CI, 25.8–31.5] mL/min/1.73 m2; P < 0.001). However, both equations overestimated mGFR. Applying modification factors for slope and intercept to the CKD-EPI equation to create a CKD-EPI Pakistan equation (such that eGFRCKD-EPI(PK) = 0.686 × eGFRCKD-EPI1.059) in order to eliminate bias improved accuracy (P30, 81.6% [95% CI, 78.4%–84.8%]; P < 0.001) comparably to new estimating equations developed using creatinine level and additional variables. Limitations Lack of external validation data set and few participants with low GFR. Conclusions The CKD-EPI creatinine equation is more

Kidney function estimating equations in patients with chronic kidney disease.

PubMed

Hojs, R; Bevc, S; Ekart, R; Gorenjak, M; Puklavec, L

2011-04-01

The current guidelines emphasise the need to assess kidney function using predictive equations rather than just serum creatinine. The present study compares serum cystatin C-based equations and serum creatinine-based equations in patients with chronic kidney disease (CKD). Seven hundred and sixty-four adult patients with CKD were enrolled. In each patient serum creatinine and serum cystatin C were determined. Their glomerular filtration rate (GFR) was estimated using three serum creatinine-based equations [Cockcroft-Gault (C&G), modification of diet in renal disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI)] and two serum cystatin C-based equations [our own cystatin C formula (GFR=90.63 × cystatin C(-1.192) ) and simple cystatin C formula (GFR=100/cystatin C)]. The GFR was measured using (51) CrEDTA clearance. Statistically significant correlation between (51) CrEDTA clearance with serum creatinine, serum cystatin C and all observed formulas was found. The receiver operating characteristic curve analysis (cut-off for GFR 60 ml/min/1.73m(2)) showed that serum cystatin C and both cystatin C formulas had a higher diagnostic accuracy than C&G formula. Bland and Altman analysis for the same cut-off value showed that all formulas except simple cystatin C formula underestimated measured GFR. The accuracy within 30% of estimated (51) CrEDTA clearance values differs according to stages of CKD. Analysis of ability to correctly predict patient's GFR below or above 60 ml/min/1.73m(2) showed statistically significant higher ability for both cystatin C formulas compared to MDRD formula. Our results indicate that serum cystatin C-based equations are reliable markers of GFR comparable with creatinine-based formulas. © 2011 Blackwell Publishing Ltd.

Mortality Prediction in the Oldest Old with Five Different Equations to Estimate Glomerular Filtration Rate: The Health and Anemia Population-based Study

PubMed Central

Mandelli, Sara; Riva, Emma; Tettamanti, Mauro; Detoma, Paolo; Giacomin, Adriano; Lucca, Ugo

2015-01-01

Background Kidney function declines considerably with age, but little is known about its clinical significance in the oldest-old. Objectives To study the association between reduced glomerular filtration rate (GFR) estimated according to five equations with mortality in the oldest-old. Design Prospective population-based study. Setting Municipality of Biella, Piedmont, Italy. Participants 700 subjects aged 85 and older participating in the “Health and Anemia” Study in 2007–2008. Measurements GFR was estimated using five creatinine-based equations: the Cockcroft-Gault (C-G), Modification of Diet in Renal Disease (MDRD), MAYO Clinic, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Berlin Initiative Study-1 (BIS-1). Survival analysis was used to study mortality in subjects with reduced eGFR (<60 mL/min/1.73m2) compared to subjects with eGFR ≥60 mL/min/1.73m2. Results Prevalence of reduced GFR was 90.7% with the C-G, 48.1% with MDRD, 23.3% with MAYO, 53.6% with CKD-EPI and 84.4% with BIS-1. After adjustment for confounders, two-year mortality was significantly increased in subjects with reduced eGFR using BIS-1 and C-G equations (adjusted HRs: 2.88 and 3.30, respectively). Five-year mortality was significantly increased in subjects with eGFR <60 mL/min/1.73m2 using MAYO, CKD-EPI and, in a graduated fashion in reduced eGFR categories, MDRD. After 5 years, oldest old with an eGFR <30 mL/min/1.73m2 showed a significantly higher risk of death whichever equation was used (adjusted HRs between 2.04 and 2.70). Conclusion In the oldest old, prevalence of reduced eGFR varies noticeably depending on the equation used. In this population, risk of mortality was significantly higher for reduced GFR estimated with the BIS-1 and C-G equations over the short term. Though after five years the MDRD appeared on the whole a more consistent predictor, differences in mortality prediction among equations over the long term were less apparent. Noteworthy, subjects with

Mortality Prediction in the Oldest Old with Five Different Equations to Estimate Glomerular Filtration Rate: The Health and Anemia Population-based Study.

PubMed

Mandelli, Sara; Riva, Emma; Tettamanti, Mauro; Detoma, Paolo; Giacomin, Adriano; Lucca, Ugo

2015-01-01

Kidney function declines considerably with age, but little is known about its clinical significance in the oldest-old. To study the association between reduced glomerular filtration rate (GFR) estimated according to five equations with mortality in the oldest-old. Prospective population-based study. Municipality of Biella, Piedmont, Italy. 700 subjects aged 85 and older participating in the "Health and Anemia" Study in 2007-2008. GFR was estimated using five creatinine-based equations: the Cockcroft-Gault (C-G), Modification of Diet in Renal Disease (MDRD), MAYO Clinic, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Berlin Initiative Study-1 (BIS-1). Survival analysis was used to study mortality in subjects with reduced eGFR (<60 mL/min/1.73 m(2)) compared to subjects with eGFR ≥ 60 mL/min/1.73 m(2). Prevalence of reduced GFR was 90.7% with the C-G, 48.1% with MDRD, 23.3% with MAYO, 53.6% with CKD-EPI and 84.4% with BIS-1. After adjustment for confounders, two-year mortality was significantly increased in subjects with reduced eGFR using BIS-1 and C-G equations (adjusted HRs: 2.88 and 3.30, respectively). Five-year mortality was significantly increased in subjects with eGFR <60 mL/min/1.73 m(2) using MAYO, CKD-EPI and, in a graduated fashion in reduced eGFR categories, MDRD. After 5 years, oldest old with an eGFR <30 mL/min/1.73 m(2) showed a significantly higher risk of death whichever equation was used (adjusted HRs between 2.04 and 2.70). In the oldest old, prevalence of reduced eGFR varies noticeably depending on the equation used. In this population, risk of mortality was significantly higher for reduced GFR estimated with the BIS-1 and C-G equations over the short term. Though after five years the MDRD appeared on the whole a more consistent predictor, differences in mortality prediction among equations over the long term were less apparent. Noteworthy, subjects with a severely reduced GFR were consistently at higher risk of death

Serum metabolomic profiling and incident CKD among African Americans.

PubMed

Yu, Bing; Zheng, Yan; Nettleton, Jennifer A; Alexander, Danny; Coresh, Josef; Boerwinkle, Eric

2014-08-07

Novel biomarkers that more accurately reflect kidney function and predict future CKD are needed. The human metabolome is the product of multiple physiologic or pathophysiologic processes and may provide novel insight into disease etiology and progression. This study investigated whether estimated kidney function would be associated with multiple metabolites and whether selected metabolomic factors would be independent risk factors for incident CKD. In total, 1921 African Americans free of CKD with a median of 19.6 years follow-up among the Atherosclerosis Risk in Communities Study were included. A total of 204 serum metabolites quantified by untargeted gas chromatography-mass spectrometry and liquid chromatography-mass spectrometry was analyzed by both linear regression for the cross-sectional associations with eGFR (specified by the Chronic Kidney Disease Epidemiology Collaboration equation) and Cox proportional hazards model for the longitudinal associations with incident CKD. Forty named and 34 unnamed metabolites were found to be associated with eGFR specified by the Chronic Kidney Disease Epidemiology Collaboration equation with creatine and 3-indoxyl sulfate showing the strongest positive (2.8 ml/min per 1.73 m(2) per +1 SD; 95% confidence interval, 2.1 to 3.5) and negative association (-14.2 ml/min per 1.73 m(2) per +1 SD; 95% confidence interval, -17.0 to -11.3), respectively. Two hundred four incident CKD events with a median follow-up time of 19.6 years were included in the survival analyses. Higher levels of 5-oxoproline (hazard ratio, 0.70; 95% confidence interval, 0.60 to 0.82) and 1,5-anhydroglucitol (hazard ratio, 0.68; 95% confidence interval, 0.58 to 0.80) were significantly related to lower risk of incident CKD, and the associations did not appreciably change when mutually adjusted. These data identify a large number of metabolites associated with kidney function as well as two metabolites that are candidate risk factors for CKD and may provide

Serum Metabolomic Profiling and Incident CKD among African Americans

PubMed Central

Yu, Bing; Zheng, Yan; Nettleton, Jennifer A.; Alexander, Danny; Coresh, Josef

2014-01-01

Background and objectives Novel biomarkers that more accurately reflect kidney function and predict future CKD are needed. The human metabolome is the product of multiple physiologic or pathophysiologic processes and may provide novel insight into disease etiology and progression. This study investigated whether estimated kidney function would be associated with multiple metabolites and whether selected metabolomic factors would be independent risk factors for incident CKD. Design, setting, participants, & measurements In total, 1921 African Americans free of CKD with a median of 19.6 years follow-up among the Atherosclerosis Risk in Communities Study were included. A total of 204 serum metabolites quantified by untargeted gas chromatography–mass spectrometry and liquid chromatography–mass spectrometry was analyzed by both linear regression for the cross-sectional associations with eGFR (specified by the Chronic Kidney Disease Epidemiology Collaboration equation) and Cox proportional hazards model for the longitudinal associations with incident CKD. Results Forty named and 34 unnamed metabolites were found to be associated with eGFR specified by the Chronic Kidney Disease Epidemiology Collaboration equation with creatine and 3-indoxyl sulfate showing the strongest positive (2.8 ml/min per 1.73 m2 per +1 SD; 95% confidence interval, 2.1 to 3.5) and negative association (−14.2 ml/min per 1.73 m2 per +1 SD; 95% confidence interval, −17.0 to −11.3), respectively. Two hundred four incident CKD events with a median follow-up time of 19.6 years were included in the survival analyses. Higher levels of 5-oxoproline (hazard ratio, 0.70; 95% confidence interval, 0.60 to 0.82) and 1,5-anhydroglucitol (hazard ratio, 0.68; 95% confidence interval, 0.58 to 0.80) were significantly related to lower risk of incident CKD, and the associations did not appreciably change when mutually adjusted. Conclusions These data identify a large number of metabolites associated with

Creatinine Clearance and Estimated Glomerular Filtration Rate--When are they Interchangeable.

PubMed

Simetić, Lucija; Zibar, Lada; Drmić, Sandra; Begić, Ivana; Serić, Vatroslav

2015-09-01

Study goal was to examine which of glomerular rate equations is most suitable for prediction of creatinine clearance (CrCl). Using a retrospective review of data from 500 hospital patients we calculated glomerular filtration rate according to Cockcroft-Gault equation (C-G), Modification of Diet in Renal Disease Study equation (MDRD) and Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI). We determined if results of these equations were compatible with CrCl, and does stage of kidney disease, body-mass index (BMI), diabetes or old age have an impact on their ability to predict creatinine clearance. All of the equations showed high correlations with CrCl, regardless of diabetes, overweight or old age. There was no significant difference (p<0.05) between diagnostic accuracy when comparing ROC plots for MDRD and CKD-EPIat CrCl cut offs of 60 ml/min/1.73 m2 and 90 ml/min/1.73 m2 when analyzing data for all patients, older patients (>65 years) and diabetics. The percentage of overweight patients (BMI > or = 25) in patients with normal CrCl and decreased GFR was 64.81% for C-G, 92.04% for MDRD and 91.36% for CKD-EPI. Large number of overweight patients with normal CrCl and decreased GFR would indicate that CrCl overestimates GFR in overweight patients. The simple correction in CrCl for obese subjects is purposed. Passing-Bablok regression showed agreement between CrCl and MDRD and CrCl and CKD-EPI only in cases of severely decreased GFR (G4 and G5 stage of chronic kidney disease). Only in these stages of chronic kidney disease can CrCl and MDRD or CrCl and CKD-EPI be used simultaneously.

CKD Prevalence Varies across the European General Population

PubMed Central

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.

2016-01-01

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 m2, 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 m2. 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

Low Ankle Brachial Index and the Development of Rapid Estimated GFR Decline and CKD

PubMed Central

Foster, Meredith C.; Ghuman, Nimrta; Hwang, Shih-Jen; Murabito, Joanne M.; Fox, Caroline S.

2012-01-01

Background Low ankle brachial index (ABI) is associated with increases in serum creatinine. Whether low ABI is associated with the development of rapid estimated glomerular filtration rate (eGFR) decline, stage 3 chronic kidney disease (CKD), or microalbuminuria is uncertain. Study Design Prospective cohort study. Setting & Participants Framingham Offspring cohort participants who attended the sixth (1995-98) and eighth (2005-08) exams. Predictor ABI, categorized as normal (>1.1 to <1.4), low-normal (>0.9 to 1.1), and low (≤0.9). Outcomes Rapid eGFR decline (eGFR decline ≥3mL/min/1.73m2 per year), incident stage 3 CKD (eGFR<60mL/min/1.73m2), incident microalbuminuria. Measurements GFR was estimated using the serum creatinine-based CKD-EPI (CKD Epidemiology Collaboration) equation. Urinary albumin-creatinine ratio (UACR) was determined based on spot urine samples. Results Over 9.5 years, 9.0% (232 of 2592) experienced rapid eGFR decline and 11.1% (270 of 2426) developed stage 3 CKD. Compared to a normal ABI, low ABI was associated with a 5.73-fold increased odds of rapid eGFR decline (95% CI, 2.77-11.85; p<0.001) after age, sex, and baseline eGFR adjustment; this persisted after multivariable adjustment for standard CKD risk factors (OR, 3.60; 95% CI, 1.65-7.87; p=0.001). After adjustment for age, sex, and baseline eGFR, low ABI was associated with a 2.51-fold increased odds of stage 3 CKD (OR, 2.51; 95% CI, 1.16-5.44; p=0.02), although this was attenuated after multivariable adjustment (OR, 1.68; 95% CI, 0.75-3.76; p=0.2). Among 1902 free of baseline microalbuminuria, low ABI was associated with an increased odds of microalbuminuria after adjustment for age, sex, and baseline UACR (OR, 2.81; 95% CI, 1.07-7.37; p=0.04), with attenuation upon further adjustment (OR, 1.88; p=0.1). Limitations Limited number of events with a low ABI. Outcomes based on single serum creatinine and UACR measurements at each exam. Conclusions Low ABI is associated with an increased

Novel Filtration Markers for GFR Estimation

PubMed Central

Inker, Lesley A.; Coresh, Josef; Levey, Andrew S.; Eckfeldt, John H.

2017-01-01

Creatinine-based glomerular filtration rate estimation (eGFRcr) has been improved and refined since the 1970s through both the Modification of Diet in Renal Disease (MDRD) Study equation in 1999 and the CKD Epidemiology Collaboration (CKD-EPI) equation in 2009, with current clinical practice dependent primarily on eGFR for accurate assessment of GFR. However, researchers and clinicians have recognized limitations of relying on creatinine as the only filtration marker, which can lead to inaccurate GFR estimates in certain populations due to the influence of non-GFR determinants of serum or plasma creatinine. Therefore, recent literature has proposed incorporation of multiple serum or plasma filtration markers into GFR estimation to improve precision and accuracy and decrease the impact of non-GFR determinants for any individual biomarker. To this end, the CKD-EPI combined creatinine-cystatin C equation (eGFRcr-cys) was developed in 2012 and demonstrated superior accuracy to equations relying on creatinine or cystatin C alone (eGFRcr or eGFRcys). Now, the focus has broadened to include additional novel filtration markers to further refine and improve GFR estimation. Beta-2-microglobulin (B2M) and beta-trace-protein (BTP) are two filtration markers with established assays that have been proposed as candidates for improving both GFR estimation and risk prediction. GFR estimating equations based on B2M and BTP have been developed and validated, with the CKD-EPI combined BTP-B2M equation (eGFRBTP-B2M) demonstrating similar performance to eGFR and eGFR. Additionally, several studies have demonstrated that both B2M and BTP are associated with outcomes in CKD patients, including cardiovascular events, ESRD and mortality. This review will primarily focus on these two biomarkers, and will highlight efforts to identify additional candidate biomarkers through metabolomics-based approaches. PMID:29333147

[New topics regarding equations for GFR estimation based on serum creatinine and cystatin C].

PubMed

Horio, Masaru

2014-02-01

Japanese GFR equations and CKD-EPI equations based on standardized serum creatinine and standardized cystatin C are recommended in recent Japanese CKD guides and KDIGO guidelines for CKD management, respectively. CKD-EPIcreat overestimates GFR in Japanese subjects, probably due to the difference in muscle mass between Japanese and Caucasians. Unlike CKD-EPIcreat, CKD-EPIcys performs well in Japanese subjects, indicating the advantages of using cystatin C as a GFR marker. KDIGO guidelines suggest measuring eGFRcys in adults with eGFRcreat of 45-59 ml/min/1.73 m2 who do not have markers of kidney damage if confirmation of CKD is required. Creatinine is excreted by glomerular filtration, but also secreted by the tubules. Alteration of the tubular secretion of creatinine may influence the performance of GFR equations based on serum creatinine. Multivariate analysis showed that GFR and serum albumin levels were independent parameters affecting the fractional excretion of creatinine (FE-Cr). Alteration of FE-Cr according to the serum albumin levels may be one of the reasons for the bias of GFR equations based on serum creatinine. Low GFR is a risk factor for all-cause and cardiovascular mortality in a general population. However, the relationship between eGFR and the hazard risk of events is different depending on whether cystatin C or creatinine is used to calculate eGFR. The association between eGFRcys and the hazard risk is much stronger compared with eGFRcreat. Cystatin C may be a useful alternative to creatinine for detecting a high risk of complications in a general population and subjects with CKD.

Correlation of the Glomerular Filtration Rate Measured With the Use of DTPA-Tc99m in Live Kidney Donors With Equations Based on Creatinine and Cystatin C.

PubMed

Garcia-Covarrubias, L; Barragan, J; Castro, I; Hernandez, K; Reding, A; Hinojosa, H; Prieto, P; Garcia, A; Alejandra, C; Ortuño, D; Carmona, M; Fernández, D; Diliz, H

2018-03-01

Renal donation leads to a risk of developing chronic kidney disease, with an incidence of 0.47%. To evaluate for its presence, formulas based on serum creatinine are used, but up to 80% of these formulas underestimate the glomerular filtration rate (GFR) in donors. The aim of this work was to confirm the highest correlation of the GFR as measured with the use of DTPA-Tc99m with the GFR as estimated by means of the formula based on serum cystatin C (CKD-EPI creatinine-cystatin C) in healthy kidney donors. In this observational, analytic, cross-sectional study, the GFR of kidney donors was determined ≥1 year after donation by means of DTPA gammagram and estimation with the use of conventional formulations and with cystatin C. Of 112 donors, 38 (34%) were included, 20 (60%) were female, with an overall average age of 40 years, 36.5 months after donation, and body mass index of 25.5 kg/m 2 . Correlation with the GFR as measured by means of DTPA gammagram was better with the use of CKD-EPI cystatin C (0.402; P = .020) and CKD-EPI creatinine-cystatin (0.549; P < .001) than the conventional formulas. Linear correlation with serum cystatin C was 0.825 (P < .001; 95% confidence interval, -105.3 to -63.2) for the CKD-EPI cystatin C formula, 0.77 (P < .001; -89.9 to -48.1) for the CKD-EPI creatinine-cystatin formula, and 0.525 (P = .002; -91.1 to -23.2) for DTPA-Tc99m scintigraphy. There is a strong correlation between estimate the GFR by equations based on cystatin C and the measurement of the GFR by DTPA-Tc99m gammagram. Copyright © 2017 Elsevier Inc. All rights reserved.

Estimating the glomerular filtration rate in the Spanish working population: chronic kidney disease prevalence and its association with risk factors.

PubMed

Sánchez-Chaparro, Miguel-Angel; Calvo-Bonacho, Eva; González-Quintela, Arturo; Cabrera, Martha; Quevedo-Aguado, Luis; Fernández-Labandera, Carlos; Ruiz-Moraga, Montserrat; Sainz-Gutiérrez, Juan Carlos; Gómez-Martínez, Pablo; Román-García, Javier; Felices, Pedro Valdivielso; Ruilope, Luis-Miguel; Zanchetti, Alberto

2014-10-01

This study aims to investigate the influence of estimated glomerular filtration rate (eGFR) with two equations (and by one or two separate measurements), on the prevalence of chronic kidney disease (CKD) and its association with blood pressure, and cardiovascular and metabolic risk factors. Between January 2010 and October 2011, the Ibermutuamur CArdiovascular RIsk Assessment project included 128 588 workers (77.2% men, mean age 39.3 years, range 16-75), who underwent two consecutive yearly medical check-ups and had information for eGFR according to the MDRD-IDMS and CKD-EPI equations (serum creatinine was measured by a isotope-dilution mass spectrometry traceable method in a single central laboratory). CKD was defined by an eGFR less than 60 ml/min per 1.73 m. Subclinical (occult) renal disease was defined as an eGFR less than 60 ml/min per 1.73 m in patients with serum creatinine below 1.3 mg/dl and below 1.2 mg/dl in men and women, respectively. In this working population, prevalence of CKD was very low, but two to six times lower when two separate eGFRs below 60 ml/min per 1.73 m were used. The prevalence of CKD was significantly lower with the CKD-EPI compared to the MDRD-IDMS equation. The same applies to occult CKD. In male workers, occult CKD was practically nonexistent.Multivariate analyses show that blood pressure, total serum cholesterol, and serum glucose (positively), and high-density lipoprotein and low-density lipoprotein (negatively) were associated with CKD, with both equations. Another metabolic factor (waist circumference) was only associated (positively) with CKD defined by the CKD-EPI equation, which appears to be associated with most components of the metabolic syndrome. The CKD-EPI formula, calculated on the basis of two reported blood samples, may provide the most specific definition of CKD.

Association of the TG/HDL-C and Non-HDL-C/HDL-C Ratios with Chronic Kidney Disease in an Adult Chinese Population.

PubMed

Wen, Jia; Chen, Yiyin; Huang, Yun; Lu, Yao; Liu, Xing; Zhou, Honghao; Yuan, Hong

2017-01-01

Evidence indicates a role for dyslipidemia in the development of chronic kidney disease (CKD). However, the association of lipid abnormalities and their ratios with kidney disease using the new CKD Epidemiology Collaboration (CKD-EPI) equation is not well understood. This cross-sectional study included 48,054 adult subjects. CKD was defined as an estimated glomerular filtration rate <60 ml/min/1.73 m2 or dipstick-positive proteinuria. Logistic regression models were used to examine the relationship between lipid variables and CKD. The prevalence of CKD in this study was 3.7%. When the participants exhibited higher serum triglyceride (TG), a higher TG/high-density lipoprotein cholesterol (TG/HDL-c) ratio or a higher non-HDL-c/HDL-c ratio or HDL-c in a lower quartile, the prevalence of CKD tended to be higher. The multivariate adjusted odds ratios for CKD per 1 standard deviation increase in lipid level were 1.17 (1.10-1.23) for TG, 0.86 (0.79-0.93) for HDL-c, 1.21 (1.13-1.31) for the TG/HDL-c ratio, and 1.14 (1.06-1.22) for the non-HDL-c/HDL-c ratio. No significant association was detected between CKD and total cholesterol (TC), non-HDL-c or the low-density lipoprotein cholesterol/HDL-c (LDL-c/HDL-c) ratio. In this relatively healthy adult Chinese population, the CKD-EPI equation determined that the TG/HDL-c and non-HDL-c/HDL-c ratios as well as TG and HDL-c correlate with the prevalence of CKD. © 2017 The Author(s). Published by S. Karger AG, Basel.

Existing creatinine-based equations overestimate glomerular filtration rate in Indians.

PubMed

Kumar, Vivek; Yadav, Ashok Kumar; Yasuda, Yoshinari; Horio, Masaru; Kumar, Vinod; Sahni, Nancy; Gupta, Krishan L; Matsuo, Seiichi; Kohli, Harbir Singh; Jha, Vivekanand

2018-02-01

Accurate estimation of glomerular filtration rate (GFR) is important for diagnosis and risk stratification in chronic kidney disease and for selection of living donors. Ethnic differences have required correction factors in the originally developed creatinine-based GFR estimation equations for populations around the world. Existing equations have not been validated in the vegetarian Indian population. We examined the performance of creatinine and cystatin-based GFR estimating equations in Indians. GFR was measured by urinary clearance of inulin. Serum creatinine was measured using IDMS-traceable Jaffe's and enzymatic assays, and cystatin C by colloidal gold immunoassay. Dietary protein intake was calculated by measuring urinary nitrogen appearance. Bias, precision and accuracy were calculated for the eGFR equations. A total of 130 participants (63 healthy kidney donors and 67 with CKD) were studied. About 50% were vegetarians, and the remainder ate meat 3.8 times every month. The average creatinine excretion were 14.7 mg/kg/day (95% CI: 13.5 to 15.9 mg/kg/day) and 12.4 mg/kg/day (95% CI: 11.2 to 13.6 mg/kg/day) in males and females, respectively. The average daily protein intake was 46.1 g/day (95% CI: 43.2 to 48.8 g/day). The mean mGFR in the study population was 51.66 ± 31.68 ml/min/1.73m 2 . All creatinine-based eGFR equations overestimated GFR (p < 0.01 for each creatinine based eGFR equation). However, eGFR by CKD-EPI Cys was not significantly different from mGFR (p = 0.38). The CKD-EPI Cys exhibited lowest bias [mean bias: -3.53 ± 14.70 ml/min/1.73m 2 (95% CI: -0.608 to -0.98)] and highest accuracy (P 30 : 74.6%). The GFR in the healthy population was 79.44 ± 20.19 (range: 41.90-134.50) ml/min/1.73m 2 . Existing creatinine-based GFR estimating equations overestimate GFR in Indians. An appropriately powered study is needed to develop either a correction factor or a new equation for accurate assessment of kidney function in the

The shrunken pore syndrome is associated with declined right ventricular systolic function in a heart failure population - the HARVEST study.

PubMed

Christensson, Anders; Grubb, Anders; Molvin, John; Holm, Hannes; Gransbo, Klas; Tasevska-Dinevska, Gordana; Bachus, Erasmus; Jujic, Amra; Magnusson, Martin

2016-11-01

The close relationship between heart and kidney diseases was studied with respect to the 'Shrunken pore syndrome' that is characterized by a difference in renal filtration between cystatin C and creatinine. Patients were retrieved from the HeARt and brain failure inVESTigation trail (HARVEST) which is an ongoing study undertaken in individuals hospitalized for the diagnosis of heart failure. Ninety-five of 116 patients who underwent transthoracic echocardiograms (TTE) were eligible for this study. We used four different formulas for estimated glomerular filtration rate (eGFR); CKD-EPI creatinine , CKD-EPI cystatin C , LMrev and CAPA. Presence of the syndrome was defined as eGFR cystatin C  ≤ 60% of eGFR creatinine and absence of the syndrome as eGFR cystatin C  >90% and <110% of eGFR creatinine . In a linear regression model, adjusted for age and sex, and the 'Shrunken pore syndrome' defined by the equation pair CAPA and LMrev and the equation pair CKD-EPI cystatin C and CKD-EPI creatinine, echocardiographic parameters were studied. The 'Shrunken pore syndrome' showed statistically significant associations with measurements of right ventricular (RV) systolic function; (TAPSE and RV S') (according to the equation pair CKD-EPI cystatin C and CKD-EPI creatinine ). In conclusion, heart failure patients with the 'Shrunken pore syndrome' are at increased risk of having RV systolic dysfunction whilst heart failure patients without 'Shrunken pore syndrome' seem protected. These findings may indicate common pathophysiological events in the kidneys and the heart explaining the observed increased risk of mortality in subjects with the 'Shrunken pore syndrome'.

Proenkephalin, Neutrophil Gelatinase-Associated Lipocalin, and Estimated Glomerular Filtration Rates in Patients With Sepsis.

PubMed

Kim, Hanah; Hur, Mina; Lee, Seungho; Marino, Rossella; Magrini, Laura; Cardelli, Patrizia; Struck, Joachim; Bergmann, Andreas; Hartmann, Oliver; Di Somma, Salvatore

2017-09-01

Proenkephalin (PENK) has been suggested as a novel biomarker for kidney function. We investigated the diagnostic and prognostic utility of plasma PENK in comparison with neutrophil gelatinase-associated lipocalin (NGAL) and estimated glomerular filtration rates (eGFR) in septic patients. A total of 167 septic patients were enrolled: 99 with sepsis, 37 with septic shock, and 31 with suspected sepsis. PENK and NGAL concentrations were measured and GFR was estimated by using the isotope dilution mass spectrometry traceable-Modification of Diet in Renal Disease (MDRD) Study and three Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations: CKD-EPI(Cr), CDK-EPI(CysC), and CKD-EPI(Cr-CysC). The PENK, NGAL, and eGFR results were compared according to sepsis severity, presence or absence of acute kidney injury (AKI), and clinical outcomes. The PENK, NGAL, and eGFR results were significantly associated with sepsis severity and differed significantly between patients with and without AKI only in the sepsis group (all P<0.05). PENK was superior to NGAL in predicting AKI (P=0.022) and renal replacement therapy (RRT) (P=0.0085). Regardless of the variable GFR category by the different eGFR equations, PENK showed constant and significant associations with all eGFR equations. Unlike NGAL, PENK was not influenced by inflammation and predicted the 30-day mortality. PENK is a highly sensitive and objective biomarker of AKI and RRT and is useful for prognosis prediction in septic patients. With its diagnostic robustness and predictive power for survival, PENK constitutes a promising biomarker in critical care settings including sepsis. © The Korean Society for Laboratory Medicine

Renal function assessment in patients with systemic lupus erythematosus.

PubMed

Martínez-Martínez, Marco Ulises; Borjas-García, Jaime Antonio; Magaña-Aquino, Martín; Cuevas-Orta, Enrique; Llamazares-Azuara, Lilia; Abud-Mendoza, Carlos

2012-08-01

Few studies have evaluated the glomerular filtration rate (GFR) in patients with systemic lupus erythematosus (SLE). Even though the National Kidney Foundation (NKF) suggests using the equations to estimate GFR, rheumatologists continue using creatinine clearance (CCl). The main objective of our study was the assessment of different equations to estimate GFR in patients with SLE: Simplified MDRD study equation (sMDRD), CCl, Cockcroft Gault (CG), CG calculated with ideal weight (CGi), Mayo Clinic Quadratic (MCQ), and Chronic Kidney Disease Epidemiology Collaboration Equation (CKD-EPI). CKD-EPI was considered as the reference standard, and it was compared with the other equations to evaluate bias, correlation (r), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), percentage of measurement of GFR between 70-130% of GFR measured through CKD-EPI (P30) and to compute the ROC curves. Adequacy of the 24-h urine collection was evaluated. To classify patients into GFR < 60 ml/min/1.73 m(2), the best sensitivity and NVP were obtained with sMDRD: the best PPV and specificity with MCQ. P30 was 99.3% with sMDRD, 77.5% CCl, 91.7% CG, 96.7% CGi, and 77.2% with MCQ. The lowest bias was for sMDRD and the highest for CCl. Only 159 (52.6%) urine collections were considered adequate, and when these patients were re-evaluated, the statistical results improved for CCl. CGi was better in general than CG. CCl should not be considered as an adequate GFR estimation. Ideal weight is better than real weight to calculate GFR through CG in patients with SLE.

Effects of Serum Creatinine Calibration on Estimated Renal Function in African Americans: the Jackson Heart Study

PubMed Central

Wang, Wei; Young, Bessie A.; Fülöp, Tibor; de Boer, Ian H.; Boulware, L. Ebony; Katz, Ronit; Correa, Adolfo; Griswold, Michael E.

2015-01-01

Background The calibration to Isotope Dilution Mass Spectroscopy (IDMS) traceable creatinine is essential for valid use of the new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation to estimate the glomerular filtration rate (GFR). Methods For 5,210 participants in the Jackson Heart Study (JHS), serum creatinine was measured with a multipoint enzymatic spectrophotometric assay at the baseline visit (2000–2004) and re-measured using the Roche enzymatic method, traceable to IDMS in a subset of 206 subjects. The 200 eligible samples (6 were excluded, 1 for failure of the re-measurement and 5 for outliers) were divided into three disjoint sets - training, validation, and test - to select a calibration model, estimate true errors, and assess performance of the final calibration equation. The calibration equation was applied to serum creatinine measurements of 5,210 participants to estimate GFR and the prevalence of CKD. Results The selected Deming regression model provided a slope of 0.968 (95% Confidence Interval (CI), 0.904 to 1.053) and intercept of −0.0248 (95% CI, −0.0862 to 0.0366) with R squared 0.9527. Calibrated serum creatinine showed high agreement with actual measurements when applying to the unused test set (concordance correlation coefficient 0.934, 95% CI, 0.894 to 0.960). The baseline prevalence of CKD in the JHS (2000–2004) was 6.30% using calibrated values, compared with 8.29% using non-calibrated serum creatinine with the CKD-EPI equation (P < 0.001). Conclusions A Deming regression model was chosen to optimally calibrate baseline serum creatinine measurements in the JHS and the calibrated values provide a lower CKD prevalence estimate. PMID:25806862

Clinical Relevance of Differences in Glomerular Filtration Rate Estimations in Frail Older People by Creatinine- vs. Cystatin C-Based Formulae.

PubMed

Jacobs, Anne; Benraad, Carolien; Wetzels, Jack; Rikkert, Marcel Olde; Kramers, Cornelis

2017-06-01

The risk of incorrect medication dosing is high in frail older people. Therefore, accurate assessment of the glomerular filtration rate is important. The objective of this study was to compare the estimated glomerular filtration rate using creatinine- and cystatin C-based formulae, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, in frail older people. We hypothesized that frailty determines the difference between the creatinine- and cystatin C-based formulae. The mean difference between CKD-EPI creatinine and cystatin C was determined using (cross-sectional) data of 55 patients (mean age 73 years) admitted to a psychiatric ward for older adults. The level of agreement of these estimations was assessed by a Bland-Altman analysis. In all patients, the Rockwood's Frailty Index was derived and correlated with the mean difference between CKD-EPI creatinine and cystatin C. The mean difference between CKD-EPI creatinine (mean 71.2 mL/min/1.73 m 2 ) and CKD-EPI cystatin C (mean 57.6 mL/min/1.73 m 2 ) was 13.6 mL/min/1.73 m 2 (p < 0.0001). The two standard deviation limit in the Bland-Altman plot was large (43.2 mL/min/1.73 m 2 ), which represents a low level of agreement. The Frailty Index did not correlate with the mean difference between the creatinine- and cystatin C-based glomerular filtration rate (Pearson correlation coefficient 0.182, p = 0.184). There was a significant gap between a creatinine- and cystatin C-based estimation of glomerular filtration rate, irrespective of frailty. The range of differences between the commonly used estimated glomerular filtration rate formulae might result in clinically relevant differences in drug prescription and differences in chronic kidney disease staging.

Concurrent use of methotrexate and celecoxib increases risk of silent liver fibrosis in rheumatoid arthritis patients with subclinical reduced kidney function.

PubMed

Park, Jin Su; Park, Min-Chan; Park, Yong-Beom; Lee, Soo-Kon; Lee, Sang-Won

2014-01-01

We evaluated the effects of concurrent use of methotrexate and celecoxib on silent liver and kidney damages in rheumatoid arthritis (RA) patients. We enrolled 92 RA patients with normal laboratory results related to liver and kidney functions, who had received methotrexate and celecoxib concurrently over 6 months. Liver stiffness measurement (LSM) using transient elastography and ultrasonography were performed along with blood and urine tests. Estimated glomerular filtration rate (eGFR) was calculated by both the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and the Modification of Diet in Renal Disease (MDRD) equations. Initial eGFR represented kidney function at the time of the initiation of celecoxib. The cutoff for abnormal LSM values was adopted as 5.3 kPa. The optimal cutoff of each eGFR for abnormal LSM values was also calculated. The median age of patients was 55 years old (74 women). The median LSM was 4.4 kPa and the median eGFRs and median initial eGFRs ranged from 89 to 99 mL/min/1.73 m(2). The cumulative doses of methotrexate and celecoxib and their concurrent administration duration did not affect LSM values and eGFRs. Both eGFRs were significantly associated with LSM values. Patients with initial eGFR(CKD-EPI), initial eGFR(MDRD), and eGFR(CKD-EPI) below each optimal cutoff had significantly high risks for silent liver fibrosis (RR 9.4, 10.3, and 4.4, p < 0.001, respectively). Both initial eGFRs (CKD-EPI and MDRD) and eGFR (CKD-EPI) were significant predictors for the development of silent liver fibrosis in RA patients who had received methotrexate and celecoxib concurrently for at least 6 months.

PubMed

Medina Arnaudo, Gisel Ivana

2017-09-08

Resumen: La valoración del Índice de Filtrado Glomerular (IFG) es fundamental para la selección de potenciales donantes renales. Para su medición existen métodos poco prácticos y complejos, por lo cual se han desarrollado ecuaciones de estimación del IFG. Objetivo: Evaluar el rendimiento diagnóstico de ecuaciones de estimación del IFG a partir de Creatinina y Cistatina C en una población de adultos sanos candidatos a donantes renales. Materiales y métodos: Se llevó a cabo un estudio transversal en 72 pacientes de ambos sexos de entre 18 y 75 años de edad, candidatos a donantes renales. Se les midió el IFG a través del clearance de Iotalamato no marcado (IFGm). Se evaluaron cuatro ecuaciones de estimación del FG (IFGe): MDRD, del estudio "Modification of Diet in Renal Disease"; CKD-EPI-Creatinina (CKD-EPI-CREAT) y CKD-EPI-Creatinina y Cistatina C (CKD-EPI-CREAT+CIS), desarrolladas por el grupo "Chronic Kidney Disease Epidemiology Collaboration"; y la que incluye Creatinina y Cistatina C propuesta por Stevens y col. (STEVENS-CREAT+CIS). Se analizó el desempeño de cada ecuación con respecto al IFGm. Resultados: Las ecuaciones CKD-EPI-CREAT+CIS, STEVENS-CREAT+CIS y CKD-EPI-CREAT mostraron ser más exactas (bias= 1,93; -0,71; -1,53 mL/min/1,73m2 respectivamente) que MDRD (bias= -10,36 mL/min/1,73m2). El mejor rendimiento diagnóstico lo mostró  el IFGe CKD-EPI-CREAT+CIS (LR(+)=9,8; "Positive Likelihood Ratios"), seguido por IFGe STEVENS-CREAT+CIS (LR(+)=4,7) y luego por IFGe CKD-EPI-CREAT (LR(+)=3,7). Discusión: Las ecuaciones CKD-EPI-CREAT+CIS, STEVENS-CREAT+CIS y CKD-EPI-CREAT demostraron tener un desempeño claramente superior a MDRD para estimar el IFG en la población estudiada.

Risk of Febuxostat-Associated Myopathy in Patients with CKD

PubMed Central

Liu, Chung-te; Chen, Chun-You; Hsu, Chien-Yi; Lin, Feng-Yen; Chen, Jaw-Wen; Lin, Shing-Jong

2017-01-01

Background and objectives Febuxostat, a nonpurine xanthine oxidase inhibitor, is widely used to treat hyperuricemia. Although febuxostat-associated rhabdomyolysis was reported in some patients with CKD, the association between CKD and febuxostat-associated myopathy remains uncertain. Design, setting, participants, & measurements Our retrospective cohort study included 1332 patients using febuxostat in Taipei Medical University–Wanfang Hospital from February of 2014 to January of 2016. The primary predictor was time-averaged eGFR as calculated by the equation proposed by the 2009 Chronic Kidney Disease Epidemiology Collaboration. The outcome was febuxostat-associated myopathy defined as elevated creatine kinase levels during febuxostat use that were not attributed to other muscular injuries. Results The median duration of febuxostat use was 224 days (25th, 75th percentiles: 86, 441.5 days). Of 1332 study participants, 1222 (91.7%) had CKD; the median eGFR was 20.8 ml/min per 1.73 m2 (25th, 75th percentiles: 9.0, 35.4 ml/min per 1.73 m2). Forty-one of the participants had febuxostat-associated myopathy (3.2%). All patients with myopathy had CKD, and the incident rate was 0.013 (95% confidence interval, 0.01 to 0.02) events per 100 patient-days in patients with CKD. Of 41 patients with myopathy, 37 had myositis, and four had rhabdomyolysis. Myopathy resolved in 17 patients who withdrew from treatment and eight patients who continued febuxostat treatment. Among the evaluated predictors, multivariate analysis showed that only the lowest eGFR tertile was significantly associated with myopathy in febuxostat users. The odds ratio of the lowest eGFR tertile to the highest tertile was 4.21 (95% confidence interval, 1.7 to 10.43). This finding remained consistent among subgroups stratified by age, sex, diabetes status, coronary artery disease, and statin or fibrate use. Conclusions Patients with severely reduced eGFR had higher risk of myopathy with treatment of febuxostat

Risk of Febuxostat-Associated Myopathy in Patients with CKD.

PubMed

Liu, Chung-Te; Chen, Chun-You; Hsu, Chien-Yi; Huang, Po-Hsun; Lin, Feng-Yen; Chen, Jaw-Wen; Lin, Shing-Jong

2017-05-08

Febuxostat, a nonpurine xanthine oxidase inhibitor, is widely used to treat hyperuricemia. Although febuxostat-associated rhabdomyolysis was reported in some patients with CKD, the association between CKD and febuxostat-associated myopathy remains uncertain. Our retrospective cohort study included 1332 patients using febuxostat in Taipei Medical University-Wanfang Hospital from February of 2014 to January of 2016. The primary predictor was time-averaged eGFR as calculated by the equation proposed by the 2009 Chronic Kidney Disease Epidemiology Collaboration. The outcome was febuxostat-associated myopathy defined as elevated creatine kinase levels during febuxostat use that were not attributed to other muscular injuries. The median duration of febuxostat use was 224 days (25th, 75th percentiles: 86, 441.5 days). Of 1332 study participants, 1222 (91.7%) had CKD; the median eGFR was 20.8 ml/min per 1.73 m 2 (25th, 75th percentiles: 9.0, 35.4 ml/min per 1.73 m 2 ). Forty-one of the participants had febuxostat-associated myopathy (3.2%). All patients with myopathy had CKD, and the incident rate was 0.013 (95% confidence interval, 0.01 to 0.02) events per 100 patient-days in patients with CKD. Of 41 patients with myopathy, 37 had myositis, and four had rhabdomyolysis. Myopathy resolved in 17 patients who withdrew from treatment and eight patients who continued febuxostat treatment. Among the evaluated predictors, multivariate analysis showed that only the lowest eGFR tertile was significantly associated with myopathy in febuxostat users. The odds ratio of the lowest eGFR tertile to the highest tertile was 4.21 (95% confidence interval, 1.7 to 10.43). This finding remained consistent among subgroups stratified by age, sex, diabetes status, coronary artery disease, and statin or fibrate use. Patients with severely reduced eGFR had higher risk of myopathy with treatment of febuxostat. Regular monitoring of creatine kinase level is suggested for early detection of febuxostat

Comparison of creatinine and cystatin C based eGFR in the estimation of glomerular filtration rate in Indigenous Australians: The eGFR Study.

PubMed

Barr, Elizabeth Lm; Maple-Brown, Louise J; Barzi, Federica; Hughes, Jaquelyne T; Jerums, George; Ekinci, Elif I; Ellis, Andrew G; Jones, Graham Rd; Lawton, Paul D; Sajiv, Cherian; Majoni, Sandawana W; Brown, Alex Dh; Hoy, Wendy E; O'Dea, Kerin; Cass, Alan; MacIsaac, Richard J

2017-04-01

The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation that combines creatinine and cystatin C is superior to equations that include either measure alone in estimating glomerular filtration rate (GFR). However, whether cystatin C can provide any additional benefits in estimating GFR for Indigenous Australians, a population at high risk of end-stage kidney disease (ESKD) is unknown. Using a cross-sectional analysis from the eGFR Study of 654 Indigenous Australians at high risk of ESKD, eGFR was calculated using the CKD-EPI equations for serum creatinine (eGFRcr), cystatin C (eGFRcysC) and combined creatinine and cystatin C (eGFRcysC+cr). Reference GFR (mGFR) was determined using a non-isotopic iohexol plasma disappearance technique over 4h. Performance of each equation to mGFR was assessed by calculating bias, % bias, precision and accuracy for the total population, and according to age, sex, kidney disease, diabetes, obesity and c-reactive protein. Data were available for 542 participants (38% men, mean [sd] age 45 [14] years). Bias was significantly greater for eGFRcysC (15.0mL/min/1.73m 2 ; 95% CI 13.3-16.4, p<0.001) and eGFRcysC+cr (10.3; 8.8-11.5, p<0.001) compared to eGFRcr (5.4; 3.0-7.2). Accuracy was lower for eGFRcysC (80.3%; 76.7-83.5, p<0.001) but not for eGFRcysC+cr (91.9; 89.3-94.0, p=0.29) compared to eGFRcr (90.0; 87.2-92.4). Precision was comparable for all equations. The performance of eGFRcysC deteriorated across increasing levels of c-reactive protein. Cystatin C based eGFR equations may not perform well in populations with high levels of chronic inflammation. CKD-EPI eGFR based on serum creatinine remains the preferred equation in Indigenous Australians. Copyright © 2016 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

Cystatin C-based glomerular filtration rate associates more closely with mortality than creatinine-based or combined glomerular filtration rate equations in unselected patients.

PubMed

Helmersson-Karlqvist, Johanna; Ärnlöv, Johan; Larsson, Anders

2016-10-01

Decreased glomerular filtration rate (GFR) is an important cardiovascular risk factor, but estimated GFR (eGFR) may differ depending on whether it is based on creatinine or cystatin C. A combined creatinine/cystatin C equation has recently been shown to best estimate GFR; however, the benefits of using the combined equation for risk prediction in routine clinical care have been less studied. This study compares mortality risk prediction by eGFR using the combined creatinine/cystatin C equation (CKD-EPI), a sole creatinine equation (CKD-EPI) and a sole cystatin C equation (CAPA), respectively, using assays that are traceable to international calibrators. All patients analysed for both creatinine and cystatin C from the same blood sample tube (n = 13,054) during 2005-2007 in Uppsala University Hospital Laboratory were divided into eGFR risk categories>60, 30-60 and <30 mL/min/1.73 m(2) by each eGFR equation. During follow-up (median 4.6 years), 4398 participants died, of which 1396 deaths were due to cardiovascular causes. Reduced eGFR was significantly associated with death as assessed by all eGFR equations. The net reclassification improvement (NRI) for the combination equation compared with the sole creatinine equation was 0.10 (p < 0.001) for all-cause mortality and 0.08 (p < 0.001) for cardiovascular mortality, indicating improved reclassification. In contrast, NRI for the combination equation, compared with the sole cystatin C equation, was -0.06 (p < 0.001) for all-cause mortality and -0.02 (p = 0.032) for cardiovascular mortality, indicating a worsened reclassification. In routine clinical care, cystatin C-based eGFR was more closely associated with mortality compared with both creatinine-based eGFR and creatinine/cystatin C-based eGFR. © The European Society of Cardiology 2016.

Cystatin C as a predictor of mortality in elderly patients with chronic kidney disease.

PubMed

Bevc, Sebastjan; Hojs, Nina; Knehtl, Maša; Ekart, Robert; Hojs, Radovan

2018-06-18

The prevalence of chronic kidney disease (CKD) in the elderly is high. Serum cystatin C is an accurate marker of kidney function and it also has prognostic utility in CKD patients. The aim of our study was to determine the prediction of serum cystatin C and other markers of kidney function on long-term survival in elderly CKD patients. Fifty eight adult Caucasian patients, older than 65 years, without known malignancy, thyroid disease and/or not on steroid therapy were enrolled in the study. In each patient, 51 CrEDTA clearance, serum creatinine, serum cystatin C, and estimated glomerular filtration rate using different equations were determined on the same day and patients were then followed for 11 years or until their death. The means are as follows: 51 CrEDTA clearance 53.3 ± 17.4 ml/min/1.73 m 2 , serum creatinine 1.62 ± 0.5 mg/dl, serum cystatin C 1.79 ± 0.5 mg/l, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation 40.1 ± 14 ml/min/1.73 m 2 , Berlin Initiative Study 2 (BIS2) equation 38.9 ± 10.7 ml/min/1.73 m 2 , full age spectrum (FAS) creatinine equation 43.8 ± 13.8 ml/min/1.73 m 2 , FAS cystatin C equation 40.1 ± 11.7 ml/min/1.73 m 2 . In the follow up period, 47 (81%) patients died. Cox regression analysis showed different hazard ratios (HRs) for death: for 51 CrEDTA clearance HR 1.022 (95% CI 1.004-1.042; p = .015), serum creatinine HR 1.013 (95% CI 1.006-1.019; p = .001), serum cystatin C HR 2.028 (95% CI 1.267-3.241; p = .003), CKD-EPI creatinine equation HR 1.048 (95% CI 1.019-1.076; p = .001), BIS2 equation HR 1.055 (95% CI 1.021-1.088; p = .001), FAS creatinine equation HR 1.046 (95% CI 1.017-1.074; p = .001), FAS cystatin C equation HR 1.039 (95% CI 1.010-1.071; p = .009). Our results showed the highest HR for serum cystatin C among kidney function markers for prediction of outcome in elderly CKD patients.

Shrunken Pore Syndrome is associated with a sharp rise in mortality in patients undergoing elective coronary artery bypass grafting.

PubMed

Dardashti, Alain; Nozohoor, Shahab; Grubb, Anders; Bjursten, Henrik

2016-01-01

Shrunken Pore Syndrome was recently suggested for the pathophysiologic state in patients characterized by an estimation of their glomerular filtration rate (GFR) based upon cystatin  C, which is lower or equal to 60% of their estimated GFR based upon creatinine, i.e. when eGFR cystatin  C ≤ 60% of eGFR creatinine. Not only the cystatin C level, but also the levels of other low molecular mass proteins are increased in this condition. The preoperative plasma levels of cystatin C and creatinine were measured in 1638 patients undergoing elective coronary artery bypass grafting. eGFR cystatin C and eGFR creatinine were calculated using two pairs of estimating equations, CAPA and LMrev, and CKD-EPI cystatin  C and CKD-EPI creatinine, respectively. The Shrunken Pore Syndrome was present in 2.1% of the patients as defined by the CAPA and LMrev equations and in 5.7% of the patients as defined by the CKD-EPI cystatin C and CKD-EPI creatinine equations. The patients were studied over a median follow-up time of 3.5 years (2.0-5.0 years) and the mortality determined. Shrunken Pore Syndrome defined by both pairs of equations was a strong, independent, predictor of long-term mortality as evaluated by Cox analysis and as illustrated by Kaplan-Meier curves. Increased mortality was observed also for the subgroups of patients with GFR above or below 60 mL/min/1.73 m(2). Changing the cut-off level from 60 to 70% for the CAPA and LMrev equations increased the number of patients with Shrunken Pore Syndrome to 6.5%, still displaying increased mortality.

Tubular secretion of creatinine in autosomal dominant polycystic kidney disease: consequences for cross-sectional and longitudinal performance of kidney function estimating equations.

PubMed

Spithoven, Edwin M; Meijer, Esther; Boertien, Wendy E; Sinkeler, Steef J; Tent, Hilde; de Jong, Paul E; Navis, Gerjan; Gansevoort, Ron T

2013-09-01

Autosomal dominant polycystic kidney disease (ADPKD) is characterized by renal tubular cell proliferation and dedifferentiation, which may influence tubular secretion of creatinine (CCr[TS]). Diagnostic test study. We therefore investigated CCr(TS) in patients with ADPKD and controls and studied consequences for the performance of glomerular filtration rate (GFR) estimating equations. In patients with ADPKD and healthy controls, we measured GFR as (125)I-iothalamate clearance while simultaneously determining creatinine clearance. 24-hour urinary albumin excretion. In 121 patients with ADPKD (56% men; mean age, 40 ± 11 [SD] years) and 215 controls (48% men; mean age, 53 ± 10 years), measured GFR (mGFR) was 78 ± 30 and 98 ± 17 mL/min/1.73 m(2), respectively, and CCr(TS) was 15.9 ± 10.8 and 10.9 ± 10.6 mL/min/1.73 m(2), respectively (P < 0.001). The higher CCr(TS) in patients with ADPKD remained significant after adjustment for covariates and appeared to be dependent on mGFR. Correlation and accuracy between mGFR and CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) estimated GFR (eGFR) were 0.95 and 99%, respectively; between mGFR and MDRD (Modification of Diet in Renal Disease) Study eGFR, they were 0.93 and 97%, respectively. Values for bias, precision, and accuracy were similar or slightly better than in controls. In addition, change in mGFR during 3 years of follow-up in 45 patients with ADPKD correlated well with change in eGFR. Cross-sectional, single center. CCr(TS) in patients with ADPKD is higher than that in controls, but this effect is limited and observed at only high-normal mGFR. Consequently, the CKD-EPI and MDRD Study equations perform relatively well in estimating GFR and change in GFR in patients with ADPKD. Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

A comparison of the performances of an artificial neural network and a regression model for GFR estimation.

PubMed

Liu, Xun; Li, Ning-shan; Lv, Lin-sheng; Huang, Jian-hua; Tang, Hua; Chen, Jin-xia; Ma, Hui-juan; Wu, Xiao-ming; Lou, Tan-qi

2013-12-01

Accurate estimation of glomerular filtration rate (GFR) is important in clinical practice. Current models derived from regression are limited by the imprecision of GFR estimates. We hypothesized that an artificial neural network (ANN) might improve the precision of GFR estimates. A study of diagnostic test accuracy. 1,230 patients with chronic kidney disease were enrolled, including the development cohort (n=581), internal validation cohort (n=278), and external validation cohort (n=371). Estimated GFR (eGFR) using a new ANN model and a new regression model using age, sex, and standardized serum creatinine level derived in the development and internal validation cohort, and the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) 2009 creatinine equation. Measured GFR (mGFR). GFR was measured using a diethylenetriaminepentaacetic acid renal dynamic imaging method. Serum creatinine was measured with an enzymatic method traceable to isotope-dilution mass spectrometry. In the external validation cohort, mean mGFR was 49±27 (SD) mL/min/1.73 m2 and biases (median difference between mGFR and eGFR) for the CKD-EPI, new regression, and new ANN models were 0.4, 1.5, and -0.5 mL/min/1.73 m2, respectively (P<0.001 and P=0.02 compared to CKD-EPI and P<0.001 comparing the new regression and ANN models). Precisions (IQRs for the difference) were 22.6, 14.9, and 15.6 mL/min/1.73 m2, respectively (P<0.001 for both compared to CKD-EPI and P<0.001 comparing the new ANN and new regression models). Accuracies (proportions of eGFRs not deviating >30% from mGFR) were 50.9%, 77.4%, and 78.7%, respectively (P<0.001 for both compared to CKD-EPI and P=0.5 comparing the new ANN and new regression models). Different methods for measuring GFR were a source of systematic bias in comparisons of new models to CKD-EPI, and both the derivation and validation cohorts consisted of a group of patients who were referred to the same institution. An ANN model using 3 variables did not perform

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

2015-05-07

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. Copyright © 2015 by the American Society of Nephrology.

Combining Cystatin C and Creatinine Yields a Reliable Glomerular Filtration Rate Estimation in Older Adults in Contrast to β-Trace Protein and β2-Microglobulin.

PubMed

Werner, Karin; Pihlsgård, Mats; Elmståhl, Sölve; Legrand, Helen; Nyman, Ulf; Christensson, Anders

2017-01-01

The glomerular filtration rate (GFR) is the most important measure of kidney function and chronic kidney disease (CKD). This study aims to validate commonly used equations for estimated GFR (eGFR) based on creatinine (cr), cystatin C (cys), β-trace protein (BTP), and β2-microglobulin (B2M) in older adults. We conducted a validation study with 126 participants aged between 72 and 98 with a mean measured GFR (mGFR) by iohexol clearance of 54 mL/min/1.73 m2. The eGFR equations (CKD-Epidemiology collaboration [CKD-EPI], Berlin Initiative Study [BIS], Full Age Spectrum [FAS], Modification of Diet in Renal Disease [MDRD]cr, Caucasian-Asian-Pediatric-Adult [CAPA]cys, Lund-Malmö Revised [LM-REV]cr, and MEAN-LM-CAPAcr-cys), were assessed in terms of bias (median difference: eGFR-mGFR), precision (interquartile range of the differences), and accuracy (P30: percentage of estimates ±30% of mGFR). The equations were compared to a benchmark equation: CKD-EPIcr-cys. All cystatin C-based equations underestimated the GFR compared to mGFR, whereas bias was mixed for the equations based only on creatinine. Accuracy was the highest for CKD-EPIcr-cys (98%) and lowest for MDRD (82%). Below mGFR 45 mL/min/1.73 m2 only equations incorporating cystatin C reached P30 accuracy >90%. CKD-EPIcr-cys was not significantly more accurate than the other cystatin C-based equations. In contrast, CKD-EPIcr-cys was significantly more accurate than all creatinine-based equations except LM-REVcr. This study confirms that it is reasonable to use equations incorporating cystatin C and creatinine in older patients across a wide spectrum of GFR. However, the results call into question the use of creatinine alone below mGFR 45 mL/min/1.73 m2. B2M and BTP do not demonstrate additional value in eGFR determination in older adults. © 2017 S. Karger AG, Basel.

The Prevalence of CKD in Rural Canadian Indigenous Peoples: Results From the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) Screen, Triage, and Treat Program.

PubMed

Komenda, Paul; Lavallee, Barry; Ferguson, Thomas W; Tangri, Navdeep; Chartrand, Caroline; McLeod, Lorraine; Gordon, Audrey; Dart, Allison; Rigatto, Claudio

2016-10-01

Indigenous Canadians have high rates of risk factors for chronic kidney disease (CKD), in particular diabetes. Furthermore, they have increased rates of complications associated with CKD, such as kidney failure and vascular disease. Our objective was to describe the prevalence of CKD in this population. Cross-sectional cohort. Indigenous (First Nations) Canadians 18 years or older screened as part of the First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED) project, an initiative completed in 2015 that accomplished community-wide screening in 11 rural communities in Manitoba, Canada. Indigenous ethnicity and geographic location (communities accessible by road compared with those accessible only by air). Prevalence of CKD, presumed based on a single ascertainment of urine albumin-creatinine ratio (UACR) ≥ 30mg/g and/or estimated glomerular filtration rate (eGFR)<60mL/min/1.73m(2). Kidney function measured by eGFR (CKD-EPI creatinine equation) and UACR. 1,346 adults were screened; 25.5% had CKD, defined as UACR≥30mg/g or eGFR<60mL/min/1.73m(2). Communities accessible by road had a lower prevalence of CKD (17.6%) than more remote communities accessible only by air (34.4%). Of those screened, 3.3% had reduced kidney function (defined as eGFR<60mL/min/1.73m(2)). Severely increased albuminuria was present in 5.0% of those screened. Presumption of chronicity based on a single ascertainment. There is a possibility of sampling bias, the net direction of which is uncertain. We found a 2-fold higher prevalence of CKD in indigenous Canadians in comparison to the general population and a prevalence of severely increased albuminuria that was 5-fold higher. This is comparable to patients with diabetes and/or hypertension. Public health strategies to screen, triage, and treat all Canadian indigenous peoples with CKD should be considered. Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Comparative study of three methods of estimation of creatinine clearance in critically ill patients.

PubMed

Blasco, V; Antonini, F; Zieleskiewicz, L; Hammad, E; Albanèse, J; Martin, C; Leone, M

2014-05-01

At the bedside, the reference method for creatinine clearance determination is based on the measurement of creatinine concentrations in urine and serum (mCrCl). Several models are available to calculate the creatinine clearance from the serum creatinine concentration. This observational survey aimed at testing the hypothesis that the proposed equations are unreliable to determine accurate creatinine clearance in patients admitted to intensive care unit (ICU). Creatinine clearance was determined by the use of mCrCl. Then, we compared three equations: Cockcroft-Gault (CG), Simplified Modification of Diet in Renal Disease (MDRDs), and Chronic Kidney Disease Epidemiology (CKD-EPI) in 156 consecutive patients within the first 24hours after ICU admission. We tested the hypothesis that the three equations were equivalent. The agreement between the three equations was evaluated by linear regression and Bland and Altman analysis. Bland and Altman analysis showed similar agreement between the three equations. The biases and precisions were -4.8±51, -1.3±50, and 8.2±44 for CG, MDRDs, and CKD-EPI equations, respectively (P>0.05). The precisions were similar for the three equations (P>0.05). The percentages of outliers at ±30% were 44%, 45%, and 49% for CG, MDRDs, and CKD-EPI, respectively (P>0.05). Regarding the high percentage of outliers, the use of these equations cannot be recommended in ICU patients. Copyright © 2014 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

[EpiData: the natural heir to EpiInfo 6?].

PubMed

Bohigas, Pedro Arias; Lauritsen, Jens L

2007-01-01

EpiData is an epidemiological software developed by the EpiData Association (www.epidata.dk). Following the EpiInfo 6 philosophy, Epidata, offers all the advantages of EpiInfo 6: simplicity, applicability, few operation and communication system requirements, widening them with a clear focus on data quality and documentation plus the advantages that, for many users, has the Windows operating system. The aim of this Note is to introduce to potential users the strengths and limitations of EpiData, a software that can become in a short time the equivalent to what EpiInfo 6 was a few years ago.

Chronic Kidney Disease (CKD)

MedlinePlus

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Determination of the best method to estimate glomerular filtration rate from serum creatinine in adult patients with sickle cell disease: a prospective observational cohort study.

PubMed

Arlet, Jean-Benoît; Ribeil, Jean-Antoine; Chatellier, Gilles; Eladari, Dominique; De Seigneux, Sophie; Souberbielle, Jean-Claude; Friedlander, Gérard; de Montalembert, Marianne; Pouchot, Jacques; Prié, Dominique; Courbebaisse, Marie

2012-08-06

Sickle cell disease (SCD) leads to tissue hypoxia resulting in chronic organ dysfunction including SCD associated nephropathy. The goal of our study was to determine the best equation to estimate glomerular filtration rate (GFR) in SCD adult patients. We conducted a prospective observational cohort study. Since 2007, all adult SCD patients in steady state, followed in two medical departments, have had their GFR measured using iohexol plasma clearance (gold standard). The Cockcroft-Gault, MDRD-v4, CKP-EPI and finally, MDRD and CKD-EPI equations without adjustment for ethnicity were tested to estimate GFR from serum creatinine. Estimated GFRs were compared to measured GFRs according to the graphical Bland and Altman method. Sixty-four SCD patients (16 men, median age 27.5 years [range 18.0-67.5], 41 with SS-genotype were studied. They were Sub-Saharan Africa and French West Indies natives and predominantly lean (median body mass index: 22 kg/m2 [16-33]). Hyperfiltration (defined as measured GFR >110 mL/min/1.73 m2) was detected in 53.1% of patients. Urinary albumin/creatinine ratio was higher in patients with hyperfiltration than in patients with normal GFR (4.05 mg/mmol [0.14-60] versus 0.4 mg/mmol [0.7-81], p = 0.01). The CKD-EPI equation without adjustment for ethnicity had both the lowest bias and the greatest precision. Differences between estimated GFRs using the CKP-EPI equation and measured GFRs decreased with increasing GFR values, whereas it increased with the Cockcroft-Gault and MDRD-v4 equations. We confirm that SCD patients have a high rate of glomerular hyperfiltration, which is frequently associated with microalbuminuria or macroalbuminuria. In non-Afro-American SCD patients, the best method for estimating GFR from serum creatinine is the CKD-EPI equation without adjustment for ethnicity. This equation is particularly accurate to estimate high GFR values, including glomerular hyperfiltration, and thus should be recommended to screen SCD adult patients

CKD.QLD: establishment of a chronic kidney disease [CKD] registry in Queensland, Australia.

PubMed

Venuthurupalli, Sree K; Hoy, Wendy E; Healy, Helen G; Cameron, Anne; Fassett, Robert G

2017-06-07

Chronic kidney disease [CKD] is recognised as a global public health problem. Until recently, the majority of information informing on CKD has been generated from renal registries reporting on patients with end-stage kidney disease [ESKD] and on renal replacement therapy [RRT]. There has been a paucity of information on pre-dialysis CKD cohorts, and many issues related to these poorly described populations are unresolved. To this end, international organizations have called for CKD surveillance systems across all countries. In Australia, we have responded by developing the Chronic Kidney Disease in Queensland [CKD.QLD] with three main platforms consisting of CKD Registry, clinical trials and development of biobank. This registry which is the core component of CKD surveillance was conceptualized specifically for the pre-dialysis population in the public health system in Queensland, Australia. Recruitment started in May 2011, and to date the Registry has evolved as one of the largest CKD cohorts in the world with recruitment close to 7000 patients. The Registry has had many outcomes, including being the nidus for Australia's first National Health and Medical Research Council [NHMRC] CKD Centre of Research Excellence [CKD.CRE]. The Registry, with its linkage to Queensland Health datasets, is reporting, and is expected to continue generating, significant information on multiple aspects of CKD, its trajectory, management and patient outcomes. Intent of the CKD.CRE is to facilitate an expanded Registry network that has representation from health services, both public and private, across Australia.

Creatinine Versus Cystatin C: Differing Estimates of Renal Function in Hospitalized Veterans Receiving Anticoagulants.

PubMed

Wang, Christina Hao; Rubinsky, Anna D; Minichiello, Tracy; Shlipak, Michael G; Price, Erika Leemann

2018-05-31

Current practice in anticoagulation dosing relies on kidney function estimated by serum creatinine using the Cockcroft-Gault equation. However, creatinine can be unreliable in patients with low or high muscle mass. Cystatin C provides an alternative estimation of glomerular filtration rate (eGFR) that is independent of muscle. We compared cystatin C-based eGFR (eGFR cys ) with multiple creatinine-based estimates of kidney function in hospitalized patients receiving anticoagulants, to assess for discordant results that could impact medication dosing. Retrospective chart review of hospitalized patients over 1 year who received non-vitamin K antagonist anticoagulation, and who had same-day measurements of cystatin C and creatinine. Seventy-five inpatient veterans (median age 68) at the San Francisco VA Medical Center (SFVAMC). We compared the median difference between eGFR by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) study equation using cystatin C (eGFR cys ) and eGFRs using three creatinine-based equations: CKD-EPI (eGFR EPI ), Modified Diet in Renal Disease (eGFR MDRD ), and Cockcroft-Gault (eGFR CG ). We categorized patients into standard KDIGO kidney stages and into drug-dosing categories based on each creatinine equation and calculated proportions of patients reclassified across these categories based on cystatin C. Cystatin C predicted overall lower eGFR compared to creatinine-based equations, with a median difference of - 7.1 (IQR - 17.2, 2.6) mL/min/1.73 m 2 versus eGFR EPI , - 21.2 (IQR - 43.7, - 8.1) mL/min/1.73 m 2 versus eGFR MDRD , and - 25.9 (IQR - 46.8, - 8.7) mL/min/1.73 m 2 versus eGFR CG . Thirty-one to 52% of patients were reclassified into lower drug-dosing categories using cystatin C compared to creatinine-based estimates. We found substantial discordance in eGFR comparing cystatin C with creatinine in this group of anticoagulated inpatients. Our sample size was limited and included few women. Further

The role of laboratory testing in detection and classification of chronic kidney disease: national recommendations

PubMed Central

Biljak, Vanja Radišić; Honović, Lorena; Matica, Jasminka; Krešić, Branka; Vojak, Sanela Šimić

2017-01-01

Chronic kidney disease (CKD) is a common clinical condition with significant adverse consequences for the patient and it is recognized as a significant public health problem. The role of laboratory medicine in diagnosis and management of CKD is of great importance: the diagnosis and staging are based on estimation of glomerular filtration rate (eGFR) and assessment of albuminuria (or proteinuria). Therefore, the joint working group of the Croatian society of medical biochemistry and laboratory medicine and Croatian chamber of medical biochemists for laboratory diagnostics in CKD issued this national recommendation regarding laboratory diagnostics of CKD.
Key factors for laboratories implementing the national guidelines for the diagnosis and management of CKD are:
1. Ensure good communication between laboratory professionals and clinicians, such as nephrologists or specialists in general/family medicine,
2. Ensure all patients are provided with the same availability of laboratory diagnostics,
3. Ensure creatinine assays are traceable to isotope dilution mass spectrometry (IDMS) method and have minimal bias and acceptable imprecision,
4. Select the appropriate GFR estimating formula. Recommended equation is the 2009 Chronic Kidney Disease Epidemiology Collaboration (CKD – EPI) equation,
5. In reporting the key laboratory tests (creatinine, eGFR, urine albumin-to-creatinine ratio, urine protein-to-creatinine ratio) use the appropriate reporting units,
6. Provide adequate information on limitations of creatinine measurement.
The manuscript has been organized to identify critical points in laboratory tests used in basic laboratory diagnostics of CKD and is based on the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. PMID:28392738

Cholesterol Metabolism in CKD

PubMed Central

Reiss, Allison B.; Voloshyna, Iryna; DeLeon, Joshua; Miyawaki, Nobuyuki; Mattana, Joseph

2015-01-01

Patients with chronic kidney disease (CKD) have a substantial risk of developing coronary artery disease. Traditional cardiovascular disease (CVD) risk factors such as hypertension and hyperlipidemia do not adequately explain the high prevalence of CVD in CKD. Both CVD and CKD are inflammatory states and inflammation adversely impacts lipid balance. Dyslipidemia in CKD is characterized by elevated triglycerides and high density lipoprotein that is both decreased and dysfunctional. This dysfunctional high density lipoprotein becomes pro-inflammatory and loses its atheroprotective ability to promote cholesterol efflux from cells, including lipid-overloaded macrophages in the arterial wall. Elevated triglycerides result primarily from defective clearance. The weak association between low density lipoprotein cholesterol level and coronary risk in CKD has led to controversy over the usefulness of statin therapy. This review examines disrupted cholesterol transport in CKD, presenting both clinical and pre-clinical evidence of the impact of the uremic environment on vascular lipid accumulation. Preventative and treatment strategies are explored. PMID:26337134

Palliative Care Disincentives in CKD: Changing Policy to Improve CKD Care.

PubMed

Tamura, Manjula Kurella; O'Hare, Ann M; Lin, Eugene; Holdsworth, Laura M; Malcolm, Elizabeth; Moss, Alvin H

2018-06-01

The dominant health delivery model for advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States, which focuses on provision of dialysis, is ill-equipped to address many of the needs of seriously ill patients. Although palliative care may address some of these gaps in care, its integration into advanced CKD care has been suboptimal due to several health system barriers. These barriers include uneven access to specialty palliative care services, underdeveloped models of care for seriously ill patients with advanced CKD, and misaligned policy incentives. This article reviews policies that affect the delivery of palliative care for this population, discusses reforms that could address disincentives to palliative care, identifies quality measurement issues for palliative care for individuals with advanced CKD and ESRD, and considers potential pitfalls in the implementation of new models of integrated palliative care. Reforming health care delivery in ways that remove policy disincentives to palliative care for patients with advanced CKD and ESRD will fill a critical gap in care. Copyright © 2018 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

NT-ProBNP and Troponin T and Risk of Rapid Kidney Function Decline and Incident CKD in Elderly Adults

PubMed Central

Katz, Ronit; Dalrymple, Lorien; de Boer, Ian; DeFilippi, Christopher; Kestenbaum, Bryan; Park, Meyeon; Sarnak, Mark; Seliger, Stephen; Shlipak, Michael

2015-01-01

Background and objectives Elevations in N-terminal pro–B-type natriuretic peptide and high-sensitivity troponin T are associated with poor cardiovascular outcomes. Whether elevations in these cardiac biomarkers are associated with decline in kidney function was evaluated. Design, setting, participants, & measurements N-terminal pro–B-type natriuretic peptide and troponin T were measured at baseline in 3752 participants free of heart failure in the Cardiovascular Health Study. eGFR was determined from the Chronic Kidney Disease Epidemiology Collaboration equation using serum cystatin C. Rapid decline in kidney function was defined as decline in serum cystatin C eGFR≥30%, and incident CKD was defined as the onset of serum cystatin C eGFR<60 among those without CKD at baseline (n=2786). Cox regression models were used to examine the associations of each biomarker with kidney function decline adjusting for demographics, baseline serum cystatin C eGFR, diabetes, and other CKD risk factors. Results In total, 503 participants had rapid decline in serum cystatin C eGFR over a mean follow-up time of 6.41 (1.81) years, and 685 participants developed incident CKD over a mean follow-up time of 6.41 (1.74) years. Participants in the highest quartile of N-terminal pro–B-type natriuretic peptide (>237 pg/ml) had an 67% higher risk of rapid decline and 38% higher adjusted risk of incident CKD compared with participants in the lowest quartile (adjusted hazard ratio for serum cystatin C eGFR rapid decline, 1.67; 95% confidence interval, 1.25 to 2.23; hazard ratio for incident CKD, 1.38; 95% confidence interval, 1.08 to 1.76). Participants in the highest category of troponin T (>10.58 pg/ml) had 80% greater risk of rapid decline compared with participants in the lowest category (adjusted hazard ratio, 1.80; 95% confidence interval, 1.35 to 2.40). The association of troponin T with incident CKD was not statistically significant (hazard ratio, 1.17; 95% confidence interval, 0

Chronic kidney disease in Asia: Protocol for a collaborative overview.

PubMed

Liyanage, Thaminda; Ninomiya, Toshiharu; Perkovic, Vlado; Woodward, Mark; Stirnadel-Farrant, Heide; Matsushita, Kunihiro; Iseki, Kunitoshi; Seong, Hooi Lai; Monaghan, Helen; Jha, Vivekanand

2017-06-01

The burden of chronic kidney disease (CKD) is growing rapidly around the world. However, there is limited information on the overall regional prevalence of CKD, as well as the prognostic implications and treatment patterns in Asian region. We have established the Asian Renal Collaboration (ARC) with the goal of consolidating region-wide data regarding CKD. This collaborative project will synthesize data and perform meta-analyses of observational studies conducted in Asia. Studies will be identified through a systematic literature search including abstracts, proceedings of meetings, electronic databases such as MEDLINE and EMBASE. Personal enquiry among collaborators and experts in the region will identify additional studies, or other data sources such as registries. Both cross-sectional and longitudinal studies that describe the prevalence of CKD and its complications will be included, as will longitudinal studies that describe important clinical outcomes for people with CKD. Individual participant data will be sought, where possible, from each of the studies included in the collaboration for baseline parameters and subsequent outcomes, in order to maximize flexibility and consistency of data analyses. This study is an initiative offering a unique opportunity to obtain information about the prevalence and manifestations of CKD in Asia, as well as its risk factors. The ARC will also provide insights into important outcomes including progression of CKD, CKD complications, cardiovascular disease and death. These findings will improve our understanding of kidney disease in Asia, and thus help inform service provision, preventive care and further research across the region. © 2016 Asian Pacific Society of Nephrology.

Parathyroidectomy Halts the Deterioration of Renal Function in Primary Hyperparathyroidism.

PubMed

Tassone, Francesco; Guarnieri, Andrea; Castellano, Elena; Baffoni, Claudia; Attanasio, Roberto; Borretta, Giorgio

2015-08-01

Decreased renal function has been consistently included among factors prompting recommendation for surgery in primary hyperparathyroidism (PHPT). However, most retrospective studies addressing this issue did not show an improvement in renal function after parathyroidectomy (PTX). The aim of this study was to investigate changes in renal function after PTX in PHPT patients subdivided according to renal function at diagnosis. This was a retrospective cross-sectional study. We studied 109 consecutive PHPT patients before and after PTX. Biochemical evaluation included fasting total and ionized serum calcium, phosphate, creatinine, immunoreactive intact PTH, and 25-hydroxyvitamin D3 levels. Glomerular filtration rate (GFR) was assessed with the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Mean (± SD) CKD-EPI estimated GFR (eGFR) at diagnosis was 82.4 ± 19.3 mL/min/1.73 m(2) (median, 84.8 mL/min/1.73 m(2); interquartile range, 68.5-94.2 mL/min/1.73 m(2)). Patients with eGFR equal to or higher than 60 mL/min/1.73 m(2) (group 1, n = 95) were significantly younger than patients with eGFR lower than 60 mL/min/1.73 m(2) (group 2, n = 14; P < .0003). After PTX, eGFR did not change in patients of group 2 (P = .509), whereas it was significantly reduced in patients of group 1 (P < .0002). The difference in eGFR between baseline and post-PTX values was correlated negatively with baseline serum creatinine (R = -0.27; P = .0052) and positively with baseline CKD-EPI eGFR (R = 0.32; P = .00062). At multiple regression analysis, only systolic blood pressure and baseline CKD-EPI eGFR were independent predictors of GFR variation. Surgical cure of PHPT halts renal function deterioration in patients with coexisting renal disease. Our study thus supports the indication for surgery in patients with eGFR less than 60 mL/min/1.73 m(2), as recommended by current guidelines. Moreover, our data show that presurgical renal function is a relevant predictor of renal

Community-based study on CKD subjects and the associated risk factors.

PubMed

Chen, Nan; Wang, Weiming; Huang, Yanping; Shen, Pingyan; Pei, Daoling; Yu, Haijin; Shi, Hao; Zhang, Qianying; Xu, Jing; Lv, Yilun; Fan, Qishi

2009-07-01

The study was performed to investigate the prevalence, awareness and the risk factors of chronic kidney disease (CKD) in the community population in Shanghai, China. A total of 2596 residents were randomly recruited from the community population in Shanghai, China. All were screened for albuminuria, haematuria, morning spot urine albumin-to-creatinine ratio and renal function. Serum creatinine, uric acid, cholesterol, triglyceride and haemoglobin were assessed. A simplified MDRD equation was used to estimate the glomerular filtration rate (eGFR). All studied subjects were screened by kidney ultrasound. Haematuria, if present in the morning spot urine dipstick test, was confirmed by microscopy. The associations among the demographic characteristics, health characteristics and indicators of kidney damage were examined. Two thousand five hundred and fifty-four residents (n = 2554), after giving informed consent and with complete data, were entered into this study. Albuminuria and haematuria were detected in 6.3% and 1.2% of all the studied subjects, respectively, whereas decreased kidney function was found in 5.8% of all studied subjects. Approximately 11.8% of subjects had at least one indicator of kidney damage. The rate of awareness of CKD was 8.2%. The logistic regression model showed that age, central obesity, hypertension, diabetes, anaemia, hyperuricaemia and nephrolithiasis each contributed to the development of CKD. This is the first Shanghai community-based epidemiological study data on Chinese CKD patients. The prevalence of CKD in the community population in Shanghai is 11.8%, and the rate of awareness of CKD is 8.2%. All the factors including age, central obesity, hypertension, diabetes, anaemia, hyperuricaemia and nephrolithiasis are positively correlated with the development of CKD in our studied subjects.

Prognostic value of chronic kidney disease in patients with coronary heart disease: role of estimating equations.

PubMed

Zhang, Qiu-Li; Brenner, Hermann; Koenig, Wolfgang; Rothenbacher, Dietrich

2010-07-01

Chronic kidney disease (CKD) increases risk of coronary heart disease (CHD), but the impact of using different equations for estimating kidney function on CHD is not clear yet. This study described the prognostic value of CKD as defined by various creatinine- (Cr-eGFR) and cystatin C-based estimating (Cys-eGFR) equations and their combinations on subsequent cardiovascular disease (CVD) events in patients with CHD. Cohort study. Patients with coronary heart disease in in-patient rehabilitation and long-term follow-up (mean 63.4 months). 1050 patients with coronary heart disease aged 30-70 years at baseline. CKD was defined as eGFR<60 mL/min/1.73 m2 (CKD stages 3-5) estimated by three Cr-eGFR equations (Cockroft-Gault equation adjusted for body surface area (CG/BSA), Modification of Diet in Renal Disease Study (MDRD) equation, CKD-EPIcrea) and by two Cys-eGFR equations (Arnal-Dade equation, CKD-EPIcys) and a combination. The primary endpoint of our study was subsequent CVD events. During follow-up 118 patients (11.2%) experienced the outcome of our study. CKD assessed by the CG/BSA, MDRD, and CKD-EPIcrea equations showed no statistically significant association with subsequent CVD events after adjustment for multiple covariates (hazard ratio (HR) 1.45 [95% CI, 0.81-2.59], HR 1.47 [95% CI, 0.84-2.60], and HR 1.31 [95% CI, 0.72-2.83], respectively). By contrast, the Cys-eGFR equations were much stronger associated with subsequent CVD endpoints (Arnal-Dade: HR, 2.01 [95% CI, 1.34-3.04]; CKD-EPIcys HR, 2.22 [95% CI, 1.46-3.37]). The CKD-EPIcys also provided the highest area under the curve value. Our study shows that prevalent CKD is an independent risk factor for subsequent CVD in patients with prevalent CHD and implies that Cys-eGFR equations show a better clinical utility compared to the Cr-eGFR equations. Copyright (c) 2010 Elsevier Ireland Ltd. All rights reserved.

Using an electronic self-management tool to support patients with chronic kidney disease (CKD): a CKD clinic self-care model.

PubMed

Ong, Stephanie W; Jassal, Sarbjit V; Porter, Eveline; Logan, Alexander G; Miller, Judith A

2013-01-01

New healthcare delivery models are needed to enhance the patient experience and improve quality of care for individuals with chronic conditions such as kidney disease. One potential avenue is to implement self-management strategies. There is growing evidence that self-management interventions help optimize various aspects of chronic disease management. With the increasing use of information technology (IT) in health care, chronic disease management programs are incorporating IT solutions to support patient self-management practices. IT solutions have the ability to promote key principles of self-management, namely education, empowerment, and collaboration. Positive clinical outcomes have been demonstrated for a number of chronic conditions when IT solutions were incorporated into self-management programs. There is a paucity of evidence for self-management in chronic kidney disease (CKD) patients. Furthermore, IT strategies have not been tested in this patient population to the same extent as other chronic conditions (e.g., diabetes, hypertension). Therefore, it is currently unknown if IT strategies will promote self-management behaviors and lead to improvements in overall patient care. We designed and developed an IT solution called My KidneyCare Centre to support self-management strategies for patients with CKD. In this review, we discuss the rationale and vision of incorporating an electronic self-management tool to support the care of patients with CKD. © 2013 Wiley Periodicals, Inc.

Assessing glomerular filtration rate (GFR) in critically ill patients with acute kidney injury - true GFR versus urinary creatinine clearance and estimating equations

PubMed Central

2013-01-01

Introduction Estimation of kidney function in critically ill patients with acute kidney injury (AKI), is important for appropriate dosing of drugs and adjustment of therapeutic strategies, but challenging due to fluctuations in kidney function, creatinine metabolism and fluid balance. Data on the agreement between estimating and gold standard methods to assess glomerular filtration rate (GFR) in early AKI are lacking. We evaluated the agreement of urinary creatinine clearance (CrCl) and three commonly used estimating equations, the Cockcroft Gault (CG), the Modification of Diet in Renal Disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, in comparison to GFR measured by the infusion clearance of chromium-ethylenediaminetetraacetic acid (51Cr-EDTA), in critically ill patients with early AKI after complicated cardiac surgery. Methods Thirty patients with early AKI were studied in the intensive care unit, 2 to 12 days after complicated cardiac surgery. The infusion clearance for 51Cr-EDTA obtained as a measure of GFR (GFR51Cr-EDTA) was calculated from the formula: GFR (mL/min/1.73m2) = (51Cr-EDTA infusion rate × 1.73)/(arterial 51Cr-EDTA × body surface area) and compared with the urinary CrCl and the estimated GFR (eGFR) from the three estimating equations. Urine was collected in two 30-minute periods to measure urine flow and urine creatinine. Urinary CrCl was calculated from the formula: CrCl (mL/min/1.73m2) = (urine volume × urine creatinine × 1.73)/(serum creatinine × 30 min × body surface area). Results The within-group error was lower for GFR51Cr-EDTA than the urinary CrCl method, 7.2% versus 55.0%. The between-method bias was 2.6, 11.6, 11.1 and 7.39 ml/min for eGFRCrCl, eGFRMDRD, eGFRCKD-EPI and eGFRCG, respectively, when compared to GFR51Cr-EDTA. The error was 103%, 68.7%, 67.7% and 68.0% for eGFRCrCl, eGFRMDRD, eGFRCKD-EPI and eGFRCG, respectively, when compared to GFR51Cr-EDTA. Conclusions The study

Glomerular filtration rate estimated using creatinine, cystatin C or both markers and the risk of clinical events in HIV-infected individuals.

PubMed

Lucas, G M; Cozzi-Lepri, A; Wyatt, C M; Post, F A; Bormann, A M; Crum-Cianflone, N F; Ross, M J

2014-02-01

The accuracy and precision of glomerular filtration rate (GFR) estimating equations based on plasma creatinine (GFR(cr)), cystatin C (GFR(cys)) and the combination of these markers (GFR(cr-cys)) have recently been assessed in HIV-infected individuals. We assessed the associations of GFR, estimated by these three equations, with clinical events in HIV-infected individuals. We compared the associations of baseline GFR(cr), GFR(cys) and GFR(cr-cys) [using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations] with mortality, cardiovascular events (CVEs) and opportunistic diseases (ODs) in the Strategies for the Management of Antiretroviral Therapy (SMART) study. We used Cox proportional hazards models to estimate unadjusted and adjusted hazard ratios per standard deviation (SD) change in GFR. A total of 4614 subjects from the SMART trial with available baseline creatinine and cystatin C data were included in this analysis. Of these, 99 died, 111 had a CVE and 121 had an OD. GFR(cys) was weakly to moderately correlated with HIV RNA, CD4 cell count, high-sensitivity C-reactive protein, interleukin-6, and D-dimer, while GFR(cr) had little or no correlation with these factors. GFR(cys) had the strongest associations with the three clinical outcomes, followed closely by GFR(cr-cys), with GFR(cr) having the weakest associations with clinical outcomes. In a model adjusting for demographics, cardiovascular risk factors, HIV-related factors and inflammation markers, a 1-SD lower GFR(cys) was associated with a 55% [95% confidence interval (CI) 27-90%] increased risk of mortality, a 21% (95% CI 0-47%) increased risk of CVE, and a 22% (95% CI 0-48%) increased risk of OD. Of the three CKD-EPI GFR equations, GFR(cys) had the strongest associations with mortality, CVE and OD. © 2013 British HIV Association.

Renal Function, Bisphenol A, and Alkylphenols: Results from the National Health and Nutrition Examination Survey (NHANES 2003–2006)

PubMed Central

You, Li; Zhu, Xiangzhu; Shrubsole, Martha J.; Fan, Hong; Chen, Jing; Dong, Jie; Hao, Chuan-Ming; Dai, Qi

2011-01-01

Background Urinary excretion of bisphenol A (BPA) and alkylphenols (APs) was used as a biomarker in most previous studies, but no study has investigated whether urinary excretion of these environmental phenols differed by renal function. Objective We estimated the association between renal function and urinary excretion of BPA and APs. Methods Analyses were conducted using data from the National Health and Nutrition Examination Survey (NHANES) 2003–2006. Renal function was measured as estimated glomerular filtration rate (eGFR) calculated by the Modification of Diet in Renal Disease (MDRD) Study equation and by the newly developed Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Regression models were used to calculate geometric means of urinary BPA and APs excretion by eGFR category (≥ 90, 60–90, < 60 mL/min/m2) after adjusting for potential confounding factors. Results When we used the MDRD Study equation, participants without known renal disease (n = 2,573), 58.2% (n = 1,499) had mildly decreased renal function or undiagnosed chronic kidney disease. The adjusted geometric means for urinary BPA excretion decreased with decreasing levels of eGFR (p for trend = 0.04). The associations appeared primarily in females (p for trend = 0.03). Urinary triclosan excretion decreased with decreasing levels of eGFR (p for trend < 0.01) for both males and females, and the association primarily appeared in participants < 65 years of age. The association between BPA and eGFR was nonsignificant when we used the CKD-EPI equation. Conclusions Urinary excretion of triclosan, and possibly BPA, decreased with decreasing renal function. The associations might differ by age or sex. Further studies are necessary to replicate our results and understand the mechanism. PMID:21147601

Epi info - present and future.

PubMed

Su, Y; Yoon, S S

2003-01-01

Epi Info is a suite of public domain computer programs for public health professionals developed by the Centers for Disease Control and Prevention (CDC). Epi Info is used for rapid questionnaire design, data entry and validation, data analysis including mapping and graphing, and creation of reports. Epi Info was originally created in 1985 using Turbo Pascal. In 1998, the last version of Epi Info for DOS, version 6, was released. Epi Info for DOS is currently supported by CDC but is no longer updated. The current version, Epi Info 2002, is Windows-based software developed using Microsoft Visual Basic. Approximately 300,000 downloads of Epi Info software occurred in 2002 from approximately 130 countries. These numbers make Epi Info probably one of the most widely distributed and used public domain programs in the world. The DOS version of Epi Info was translated into 13 languages, and efforts are underway to translate the Windows version into other major languages. Versions already exist for Spanish, French, Portuguese, Chinese, Japanese, and Arabic.

Lipoprotein(a) predicts a new onset of chronic kidney disease in people with Type 2 diabetes mellitus.

PubMed

Yun, J-S; Ahn, Y-B; Song, K-H; Yoo, K-D; Park, Y-M; Kim, H-W; Ko, S-H

2016-05-01

We investigated the association between lipoprotein(a) [Lp(a)] level and new-onset chronic kidney disease (CKD) in patients with Type 2 diabetes. We conducted a prospective cohort study from March 2003 to December 2004 with a median follow-up time of 10.1 years. Patients aged 25-75 years with Type 2 diabetes and without CKD [estimated glomerular filtration rate (eGFR) ≥ 90 ml/min/1.73 m(2) ) were consecutively enrolled. The eGFR was measured at least twice every year , and new-onset CKD was defined as a decreased eGFR status of < 60 ml/min/1.73 m(2) using a Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Of the 862 patients who were enrolled, 560 (65.0%) completed the follow-up and 125 (22.3%) progressed to CKD. The mean age and duration of diabetes were 53.3 ± 9.6 and 7.5 ± 6.0 years, respectively. The baseline eGFR was 101.8 ± 11.3 ml/min/1.73 m(2) . After adjusting for multiple confounding factors, a Cox hazard regression analysis revealed that the third tertile of Lp(a) was significantly associated with the development of CKD during the observation period when compared with the first tertile [hazard ratio 2.12 (95% confidence interval 1.33-3.36); P = 0.001). In this prospective, longitudinal, observational cohort study, we demonstrated that the Lp(a) level was an independent prognostic factor for the future development of CKD in patients with Type 2 diabetes. © 2015 Diabetes UK.

Undergraduate Students' Perceptions of Collaborative Learning in a Differential Equations Mathematics Course

ERIC Educational Resources Information Center

Hajra, Sayonita Ghosh; Das, Ujjaini

2015-01-01

This paper uses collaborative learning strategies to examine students' perceptions in a differential equations mathematics course. Students' perceptions were analyzed using three collaborative learning strategies including collaborative activity, group-quiz and online discussion. The study results show that students identified both strengths and…

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

PubMed

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

2014-08-01

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. 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. 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 the performances of the

Risk profile, quality of life and care of patients with moderate and advanced CKD : The French CKD-REIN Cohort Study.

PubMed

Stengel, Bénédicte; Metzger, Marie; Combe, Christian; Jacquelinet, Christian; Briançon, Serge; Ayav, Carole; Fouque, Denis; Laville, Maurice; Frimat, Luc; Pascal, Christophe; Herpe, Yves-Edouard; Morel, Pascal; Deleuze, Jean-François; Schanstra, Joost P; Lange, Céline; Legrand, Karine; Speyer, Elodie; Liabeuf, Sophie; Robinson, Bruce M; Massy, Ziad A

2018-04-09

The French Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort study was designed to investigate the determinants of prognosis and care of patients referred to nephrologists with moderate and advanced chronic kidney disease (CKD). We examined their baseline risk profile and experience. We collected bioclinical and patient-reported information from 3033 outpatients with CKD and estimated glomerular filtration rates (eGFRs) of 15-60 mL/min/1.73 m2 treated at 40 nationally representative public and private facilities. The patients' median age was 69 (60-76) years, 65% were men, their mean eGFR was 33 mL/min/1.73 m2, 43% had diabetes, 24% had a history of acute kidney injury (AKI) and 57% had uncontrolled blood pressure (BP; >140/90 mmHg). Men had worse risk profiles than women and were more likely to be past or current smokers (73% versus 34%) and have cardiovascular disease (59% versus 42%), albuminuria >30 mg/mmol (or proteinuria > 50) (40% versus 30%) (all P < 0.001) and a higher median risk of end-stage renal disease within 5 years, predicted by the kidney failure risk equation {12% [interquartile range (IQR) 3-37%] versus 9% [3-31%], P = 0.008}. During the previous year, 60% of patients reported one-to-two nephrologist visits and four or more general practitioner visits; only 25% saw a dietician and 75% were prescribed five or more medications daily. Physical and mental quality of life (QoL) were poor, with scores <50/100. The CKD-REIN study highlights high-risk profiles of cohort members and identifies several priorities, including improving BP control and dietary counselling and increasing doctors' awareness of AKI, polypharmacy and QoL. ClinicalTrials.gov identifier: NCT03381950.

Novel alpha-glucosidase inhibitors, CKD-711 and CKD-711a produced by Streptomyces sp. CK-4416. I. Taxonomy, fermentation and isolation.

PubMed

Kim, Jong-Gwan; Chang, Hung-Bae; Kwon, Young-In; Moon, Seung-Kee; Chun, Hyoung-Sik; Ahn, Soon Kil; Hong, Chung Il

2002-05-01

New alpha-glucosidase inhibitors, CKD-711 and CKD-711a were produced from the fermentation broth of Streptomyces sp. CK-4416 which was isolated from a forest soil of Jeju Island, South Korea. CKD-711 and CKD-711a were purified by Dowex 50W-2X and Sephadex G-10 column chromatography. In in vitro studies, CKD-711 showed a potent inhibitory activity against a-glucosidase from mammalian, but less inhibition against a-amylase from microorganism and mammalian. CKD-711a showed a lower inhibitory activity than CKD-711.

Augmented renal clearance is not a risk factor for mortality in Enterobacteriaceae bloodstream infections treated with appropriate empiric antimicrobials.

PubMed

Burnham, Jason P; Micek, Scott T; Kollef, Marin H

2017-01-01

The main objective of the study was to assess whether augmented renal clearance was a risk factor for mortality in a cohort of patients with Enterobacteriaceae sepsis, severe sepsis, or septic shock that all received appropriate antimicrobial therapy within 12 hours. Using a retrospective cohort from Barnes-Jewish Hospital, a 1,250-bed teaching hospital, we collected data on individuals with Enterobacteriaceae sepsis, severe sepsis, and septic shock who received appropriate initial antimicrobial therapy between June 2009 and December 2013. Clinical outcomes were compared according to renal clearance, as assessed by Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas, sepsis classification, demographics, severity of illness, and comorbidities. We identified 510 patients with Enterobacteriaceae bacteremia and sepsis, severe sepsis, or septic shock. Sixty-seven patients (13.1%) were nonsurvivors. Augmented renal clearance was uncommon (5.1% of patients by MDRD and 3.0% by CKD-EPI) and was not associated with increased mortality. Our results are limited by the absence of prospective determination of augmented renal clearance. However, in this small cohort, augmented renal clearance as assessed by MDRD and CKD-EPI does not seem to be a risk factor for mortality in patients with Enterobacteriaceae sepsis. Future studies should assess this finding prospectively.

High prevalence of chronic kidney disease in a community survey of urban Bangladeshis: a cross-sectional study

PubMed Central

2014-01-01

Background The burden of chronic kidney disease (CKD) will rise in parallel with the growing prevalence of type two diabetes mellitus in South Asia but is understudied. Using a cross-sectional survey of adults living in a middle-income neighborhood of Dhaka, Bangladesh, we tested the hypothesis that the prevalence of CKD in this group would approach that of the U.S. and would be strongly associated with insulin resistance. Methods We enrolled 402 eligible adults (>30 years old) after performing a multi-stage random selection procedure. We administered a questionnaire, and collected fasting serum samples and urine samples. We used the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation to estimate glomerular filtration rate, and sex-specific cut offs for albuminuria: > 1.9 mg/mmol (17 mg/g) for men, and >2.8 mg/mmol (25 mg/g) for women. We assessed health-related quality of life using the Medical Outcomes Study Short Form-12 (SF-12). Results A total of 357 (89%) participants with serum samples comprised the analytic cohort. Mean age of was 49.5 (± 12.7) years. Chronic kidney disease was evident in 94 (26%). Of the participants with CKD, 58 (62%) had albuminuria only. A participant with insulin resistance had a 3.6-fold increase in odds of CKD (95% confidence interval 2.1 to 6.4). Participants with stage three or more advanced CKD reported a decrement in the Physical Health Composite score of the SF-12, compared with participants without CKD. Conclusion We found an alarmingly high prevalence of CKD—particularly CKD associated with insulin resistance—in middle-income, urban Bangladeshis. PMID:24555767

Novel Equations for Estimating Lean Body Mass in Patients With Chronic Kidney Disease.

PubMed

Tian, Xue; Chen, Yuan; Yang, Zhi-Kai; Qu, Zhen; Dong, Jie

2018-05-01

Simplified methods to estimate lean body mass (LBM), an important nutritional measure representing muscle mass and somatic protein, are lacking in nondialyzed patients with chronic kidney disease (CKD). We developed and tested 2 reliable equations for estimation of LBM in daily clinical practice. The development and validation groups both included 150 nondialyzed patients with CKD Stages 3 to 5. Two equations for estimating LBM based on mid-arm muscle circumference (MAMC) or handgrip strength (HGS) were developed and validated in CKD patients with dual-energy x-ray absorptiometry as referenced gold method. We developed and validated 2 equations for estimating LBM based on HGS and MAMC. These equations, which also incorporated sex, height, and weight, were developed and validated in CKD patients. The new equations were found to exhibit only small biases when compared with dual-energy x-ray absorptiometry, with median differences of 0.94 and 0.46 kg observed in the HGS and MAMC equations, respectively. Good precision and accuracy were achieved for both equations, as reflected by small interquartile ranges in the differences and in the percentages of estimates that were 20% of measured LBM. The bias, precision, and accuracy of each equation were found to be similar when it was applied to groups of patients divided by the median measured LBM, the median ratio of extracellular to total body water, and the stages of CKD. LBM estimated from MAMC or HGS were found to provide accurate estimates of LBM in nondialyzed patients with CKD. Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Chronic Kidney Disease, Fluid Overload and Diuretics: A Complicated Triangle.

PubMed

Khan, Yusra Habib; Sarriff, Azmi; Adnan, Azreen Syazril; Khan, Amer Hayat; Mallhi, Tauqeer Hussain

2016-01-01

Despite promising role of diuretics to manage fluid overload among chronic kidney disease (CKD) patients, their use is associated with adverse renal outcomes. Current study aimed to determine the extent of renal deterioration with diuretic therapy. A total 312 non-dialysis dependent CKD (NDD-CKD) patients were prospectively followed-up for one year. Fluid overload was assessed via bioimpedance spectroscopy. Estimated GFR (eGFR) was calculated from serum creatinine values by using Chronic Kidney Disease- Epidemiology Collaboration (CKD-EPI) equation. Out of 312 patients, 64 (20.5%) were hypovolemic while euvolemia and hypervolemia were observed in 113 (36.1%) and 135 (43.4%) patients. Overall 144 patients were using diuretics among which 98 (72.6%) were hypervolemic, 35 (30.9%) euvolemic and 11 (17.2%) were hypovolemic. The mean decline in estimated GFR of entire cohort was -2.5 ± 1.4 ml/min/1.73m2 at the end of follow up. The use of diuretics was significantly associated with decline in eGFR. A total of 36 (11.5%) patients initiated renal replacement therapy (RRT) and need of RRT was more profound among diuretic users. The use of diuretics was associated with adverse renal outcomes indicated by decline in eGFR and increasing risk of RRT initiation in our cohort of NDD-CKD patients. Therefore, it is cautiously suggested to carefully prescribe diuretics by keeping in view benefit versus harm for each patient.

Chronic Kidney Disease, Fluid Overload and Diuretics: A Complicated Triangle

PubMed Central

Khan, Yusra Habib; Sarriff, Azmi; Adnan, Azreen Syazril; Khan, Amer Hayat; Mallhi, Tauqeer Hussain

2016-01-01

Background Despite promising role of diuretics to manage fluid overload among chronic kidney disease (CKD) patients, their use is associated with adverse renal outcomes. Current study aimed to determine the extent of renal deterioration with diuretic therapy. Methods A total 312 non-dialysis dependent CKD (NDD-CKD) patients were prospectively followed-up for one year. Fluid overload was assessed via bioimpedance spectroscopy. Estimated GFR (eGFR) was calculated from serum creatinine values by using Chronic Kidney Disease- Epidemiology Collaboration (CKD-EPI) equation. Results Out of 312 patients, 64 (20.5%) were hypovolemic while euvolemia and hypervolemia were observed in 113 (36.1%) and 135 (43.4%) patients. Overall 144 patients were using diuretics among which 98 (72.6%) were hypervolemic, 35 (30.9%) euvolemic and 11 (17.2%) were hypovolemic. The mean decline in estimated GFR of entire cohort was -2.5 ± 1.4 ml/min/1.73m2 at the end of follow up. The use of diuretics was significantly associated with decline in eGFR. A total of 36 (11.5%) patients initiated renal replacement therapy (RRT) and need of RRT was more profound among diuretic users. Conclusions The use of diuretics was associated with adverse renal outcomes indicated by decline in eGFR and increasing risk of RRT initiation in our cohort of NDD-CKD patients. Therefore, it is cautiously suggested to carefully prescribe diuretics by keeping in view benefit versus harm for each patient. PMID:27442587

Medication Therapy Management after Hospitalization in CKD: A Randomized Clinical Trial.

PubMed

Tuttle, Katherine R; Alicic, Radica Z; Short, Robert A; Neumiller, Joshua J; Gates, Brian J; Daratha, Kenn B; Barbosa-Leiker, Celestina; McPherson, Sterling M; Chaytor, Naomi S; Dieter, Brad P; Setter, Stephen M; Corbett, Cynthia F

2018-02-07

CKD is characterized by remarkably high hospitalization and readmission rates. Our study aim was to test a medication therapy management intervention to reduce subsequent acute care utilization. The CKD Medication Intervention Trial was a single-blind (investigators), randomized clinical trial conducted at Providence Health Care in Spokane, Washington. Patients with CKD stages 3-5 not treated by dialysis who were hospitalized for acute illness were recruited. The intervention was designed to improve posthospitalization care by medication therapy management. A pharmacist delivered the intervention as a single home visit within 7 days of discharge. The intervention included these fundamental elements: comprehensive medication review, medication action plan, and a personal medication list. The primary outcome was a composite of acute care utilization (hospital readmissions and emergency department and urgent care visits) for 90 days after hospitalization. Baseline characteristics of participants ( n =141) included the following: age, 69±11 (mean±SD) years old; women, 48% (67 of 141); diabetes, 56% (79 of 141); hypertension, 83% (117 of 141); eGFR, 41±14 ml/min per 1.73 m 2 (serum creatinine-based Chronic Kidney Disease Epidemiology Collaboration equation); and urine albumin-to-creatinine ratio median, 43 mg/g (interquartile range, 8-528) creatinine. The most common primary diagnoses for hospitalization were the following: cardiovascular events, 36% (51 of 141); infections, 18% (26 of 141); and kidney diseases, 12% (17 of 141). The primary outcome occurred in 32 of 72 (44%) of the medication intervention group and 28 of 69 (41%) of those in usual care (log rank P =0.72). For only hospital readmission, the rate was 19 of 72 (26%) in the medication intervention group and 18 of 69 (26%) in the usual care group (log rank P =0.95). There was no between-group difference in achievement of guideline-based goals for use of renin-angiotensin system inhibition or for BP

Glomerular Filtration Rate in Patients with Multiple Sclerosis Undergoing Stem Cell Transplantation and Treated With Cyclophosphamide.

PubMed

Ruiz-Argüelles, Alejandro; Gastélum-Cano, Jose M; Méndez-Huerta, Mariana A; Rodríguez-Gallegos, Alma B; Ruiz-Argüelles, Guillermo J

2018-06-15

Glomerular filtration rate (GFR) is partially impaired in patients with multiple sclerosis (MS). When given chemotherapy before receiving hematopoietic stem-cell transplantation, GFR might be further deteriorated. To measure the effect of cyclophosphamide on GFR in patients with MS who undergo chemotherapy. We estimated GFR based on creatinine and cystatin C plasma concentrations in patients undergoing autologous hematopoietic stem-cell transplantation to treat their MS. Baseline GFR values were lower in the 28 patients with MS than in the 20 healthy individuals. Also, according to the Chronic Kidney Disease-Epidemiology Collaborative Group (CKD-EPI) 2012 Creat-CysC equation criteria, 4 of 28 patients were classified as having chronic kidney disease (CKD) before receiving the chemotherapy drugs. After receiving 4 × 50 mg per kg body weight cyclophosphamide, abnormal GFR results were recorded in 12 of 28 patients. Renal function must be monitored in patients with MS undergoing autologous stem-cell transplantation. Also, chemotherapy should be constrained as much as possible to prevent further deterioration of renal function.

New perspectives on CKD-induced dyslipidemia.

PubMed

Bermúdez-López, Marcelino; Arroyo, David; Betriu, Àngels; Masana, Luis; Fernández, Elvira; Valdivielso, Jose M

2017-10-01

Chronic kidney disease (CKD) is a world-wide health concern associated with a significantly higher cardiovascular morbidity and mortality. One of the principal cardiovascular risk factors is the lipid profile. CKD patients have a more frequent and progressive atheromatous disease that cannot be explained by the classical lipid parameters used in the daily clinical practice. Areas covered: The current review summarizes prevailing knowledge on the role of lipids in atheromathosis in CKD patients, including an overview of lipoprotein metabolism highlighting the CKD-induced alterations. Moreover, to obtain information beyond traditional lipid parameters, new state-of-the-art technologies such as lipoprotein subfraction profiling and lipidomics are also reviewed. Finally, we analyse the potential of new lipoprotein subclasses as therapeutic targets in CKD. Expert opinion: The CKD-induced lipid profile has specific features distinct from the general population. Besides quantitative alterations, renal patients have a plethora of qualitative lipid alterations that cannot be detected by routine determinations and are responsible for the excess of cardiovascular risk. New parameters, such as lipoprotein particle number and size, together with new biomarkers obtained by lipidomics will personalize the management of these patients. Therefore, nephrologists need to be aware of new insights into lipoprotein metabolism to improve cardiovascular risk assessment.

Telomere attrition, kidney function, and prevalent chronic kidney disease in the United States.

PubMed

Mazidi, Moshen; Rezaie, Peyman; Covic, Adriac; Malyszko, Jolanta; Rysz, Jacek; Kengne, Andre Pascal; Banach, Maciej

2017-10-06

Telomere length is an emerging novel biomarker of biologic age, cardiovascular risk and chronic medical conditions. Few studies have focused on the association between telomere length (TL) and kidney function. We investigated the association between TL and kidney function/prevalent chronic kidney disease (CKD) in US adults. The National Health and Nutrition Examination Survey (NHANES) participants with measured data on kidney function and TL from 1999 to 2002 were included. Estimated glomerular filtration rate (eGFR) was based on CKD Epidemiology Collaboration (CKD-EPI) equation. Urinary albumin excretion was assessed using urinary albumin-creatinine ratio (ACR). We used multivariable adjusted linear and logistic regression models, accounting for the survey design and sample weights. Of the 10568 eligible participants, 48.0% ( n =5020) were men. Their mean age was 44.1 years. eGFR significantly decreased and ACR significantly increased across increasing quarters of TL (all p <0.001). The association between TL and kidney function remained robust even after adjusting for potential confounding factors, but the association between TL and ACR was only borderline significant (β-coefficient= -0.012, p =0.056). The association of kidney function with a marker of cellular senescence suggests an underlying mechanism influencing the progression of nephropathy.

Upper gastrointestinal bleeding in patients with CKD.

PubMed

Liang, Chih-Chia; Wang, Su-Ming; Kuo, Huey-Liang; Chang, Chiz-Tzung; Liu, Jiung-Hsiun; Lin, Hsin-Hung; Wang, I-Kuan; Yang, Ya-Fei; Lu, Yueh-Ju; Chou, Che-Yi; Huang, Chiu-Ching

2014-08-07

Patients with CKD receiving maintenance dialysis are at risk for upper gastrointestinal bleeding. However, the risk of upper gastrointestinal bleeding in patients with early CKD who are not receiving dialysis is unknown. The hypothesis was that their risk of upper gastrointestinal bleeding is negatively linked to renal function. To test this hypothesis, the association between eGFR and risk of upper gastrointestinal bleeding in patients with stages 3-5 CKD who were not receiving dialysis was analyzed. Patients with stages 3-5 CKD in the CKD program from 2003 to 2009 were enrolled and prospectively followed until December of 2012 to monitor the development of upper gastrointestinal bleeding. The risk of upper gastrointestinal bleeding was analyzed using competing-risks regression with time-varying covariates. In total, 2968 patients with stages 3-5 CKD who were not receiving dialysis were followed for a median of 1.9 years. The incidence of upper gastrointestinal bleeding per 100 patient-years was 3.7 (95% confidence interval, 3.5 to 3.9) in patients with stage 3 CKD, 5.0 (95% confidence interval, 4.8 to 5.3) in patients with stage 4 CKD, and 13.9 (95% confidence interval, 13.1 to 14.8) in patients with stage 5 CKD. Higher eGFR was associated with a lower risk of upper gastrointestinal bleeding (P=0.03), with a subdistribution hazard ratio of 0.93 (95% confidence interval, 0.87 to 0.99) for every 5 ml/min per 1.73 m(2) higher eGFR. A history of upper gastrointestinal bleeding (P<0.001) and lower serum albumin (P=0.004) were independently associated with higher upper gastrointestinal bleeding risk. In patients with CKD who are not receiving dialysis, lower renal function is associated with higher risk for upper gastrointestinal bleeding. The risk is higher in patients with previous upper gastrointestinal bleeding history and low serum albumin. Copyright © 2014 by the American Society of Nephrology.

Improving the identification and management of chronic kidney disease in primary care: lessons from a staged improvement collaborative.

PubMed

Harvey, Gill; Oliver, Kathryn; Humphreys, John; Rothwell, Katy; Hegarty, Janet

2015-02-01

Undiagnosed chronic kidney disease (CKD) contributes to a high cost and care burden in secondary care. Uptake of evidence-based guidelines in primary care is inconsistent, resulting in variation in the detection and management of CKD. Routinely collected general practice data in one UK region suggested a CKD prevalence of 4.1%, compared with an estimated national prevalence of 8.5%. Of patients on CKD registers, ∼ 30% were estimated to have suboptimal management according to Public Health Observatory analyses. An evidence-based framework for implementation was developed. This informed the design of an improvement collaborative to work with a sample of 30 general practices. A two-phase collaborative was implemented between September 2009 and March 2012. Key elements of the intervention included learning events, improvement targets, Plan-Do-Study-Act cycles, benchmarking of audit data, facilitator support and staff time reimbursement. Outcomes were evaluated against two indicators: number of patients with CKD on practice registers; percentage of patients achieving evidence-based blood pressure (BP) targets, as a marker for CKD care. In Phase 1, recorded prevalence of CKD in collaborative practices increased ∼ 2-fold more than that in comparator local practices; in Phase 2, this increased to 4-fold, indicating improved case identification. Management of BP according to guideline recommendations also improved. An improvement collaborative with tailored facilitation support appears to promote the uptake of evidence-based guidance on the identification and management of CKD in primary care. A controlled evaluation study is needed to rigorously evaluate the impact of this promising improvement intervention. © The Author 2014. Published by Oxford University Press in association with the International Society for Quality in Health Care.

Improving the identification and management of chronic kidney disease in primary care: lessons from a staged improvement collaborative

PubMed Central

Harvey, Gill; Oliver, Kathryn; Humphreys, John; Rothwell, Katy; Hegarty, Janet

2015-01-01

Quality problem Undiagnosed chronic kidney disease (CKD) contributes to a high cost and care burden in secondary care. Uptake of evidence-based guidelines in primary care is inconsistent, resulting in variation in the detection and management of CKD. Initial assessment Routinely collected general practice data in one UK region suggested a CKD prevalence of 4.1%, compared with an estimated national prevalence of 8.5%. Of patients on CKD registers, ∼30% were estimated to have suboptimal management according to Public Health Observatory analyses. Choice of solution An evidence-based framework for implementation was developed. This informed the design of an improvement collaborative to work with a sample of 30 general practices. Implementation A two-phase collaborative was implemented between September 2009 and March 2012. Key elements of the intervention included learning events, improvement targets, Plan-Do-Study-Act cycles, benchmarking of audit data, facilitator support and staff time reimbursement. Evaluation Outcomes were evaluated against two indicators: number of patients with CKD on practice registers; percentage of patients achieving evidence-based blood pressure (BP) targets, as a marker for CKD care. In Phase 1, recorded prevalence of CKD in collaborative practices increased ∼2-fold more than that in comparator local practices; in Phase 2, this increased to 4-fold, indicating improved case identification. Management of BP according to guideline recommendations also improved. Lessons learned An improvement collaborative with tailored facilitation support appears to promote the uptake of evidence-based guidance on the identification and management of CKD in primary care. A controlled evaluation study is needed to rigorously evaluate the impact of this promising improvement intervention. PMID:25525148

Diabetes mellitus and CKD awareness: the Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES).

PubMed

Whaley-Connell, Adam; Sowers, James R; McCullough, Peter A; Roberts, Tricia; McFarlane, Samy I; Chen, Shu-Cheng; Li, Suying; Wang, Changchun; Collins, Allan J; Bakris, George L

2009-04-01

Diabetes contributes to increased morbidity and mortality in patients with chronic kidney disease (CKD). We sought to describe CKD awareness and identify factors associated with optimal glycemic control in diabetic and nondiabetic individuals both aware and unaware of CKD. This cross-sectional analysis compared Kidney Early Evaluation Program (KEEP) and National Health and Nutrition and Examination Survey (NHANES) 1999 to 2006 participants with diabetes and CKD. CKD was defined and staged using glomerular filtration rate (estimated by using the 4-variable Modification of Diet in Renal Disease Study equation) and urine albumin-creatinine ratio. NHANES defined diabetes as self-reported diabetes or fasting plasma blood glucose level of 126 mg/dL or greater, and KEEP as self-reported diabetes or diabetic retinopathy, use of diabetes medications, fasting blood glucose level of 126 mg/dL or greater, or nonfasting glucose level of 200 mg/dL or greater. Of 77,077 KEEP participants, 20,200 (26.2%) were identified with CKD and 23,082 (29.9%) were identified with diabetes. Of 9,536 NHANES participants, 1,743 (18.3%) were identified with CKD and 1,127 (11.8%) were identified with diabetes. Of KEEP participants with diabetes and CKD (n = 7,853), 736 (9.4%) were aware of CKD. Trends in lack of CKD awareness were similar for KEEP participants with and without diabetes. Unaware participants with and without diabetes identified with stages 1 and 2 CKD were less likely to reach target glucose levels, defined as fasting glucose level less than 126 mg/dL or nonfasting glucose level less than 140 mg/dL, than those with stages 3 to 5 (odds ratio, 0.69; 95% confidence interval, 0.62 to 0.78; odds ratio, 0.69; 95% confidence interval, 0.58 to 0.81; P < 0.001, respectively). Our data support that KEEP, as a targeted screening program, is a more enriched population with CKD and comorbid diabetes than NHANES. In addition, our findings highlight the relationship between dysglycemia and early

Relationship between occult hepatitis B virus infection and chronic kidney disease in a Chinese population-based cohort.

PubMed

Kong, Xiang-Lei; Ma, Xiao-Jing; Su, Hong; Xu, Dong-Mei

2016-03-01

Previous studies have revealed inconsistent results regarding the association between occult hepatitis B virus (HBV) infection and chronic kidney disease (CKD). Therefore, we conducted a prospective cohort study to evaluate the association between occult HBV infection and CKD. A total of 4329 adults, aged 46.2 ± 13.7 years, without CKD at baseline were enrolled while undergoing physical examinations. Occult HBV infection was defined as seropositivity for antibody to HBV core antigen. CKD was defined as decreased estimated glomerular filtration rate (eGFR < 60 ml·min -1 ·1.73 m -2 ) or presence of proteinuria ≥1+, assessed using a repeated dipstick method. eGFR was computed using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. The prevalence of occult HBV infection was 8.1% (352/4329). During 5 years of follow-up, 165 patients (3.8%) developed CKD. Univariate Logistic regression analysis showed that occult HBV infection was positively associated with decreased eGFR, with an odds ratio ( OR ) of 2.15 (95% confidence interval ( CI ): 1.05-4.11). In contrast, occult HBV infection was not associated with either proteinuria or CKD ( P  > 0.05). After adjustment for potential confounders in the multivariate Logistic regression analysis, age, hypertension, diabetes, and the highest quartile of uric acid were associated with CKD, with OR s of 1.04 (95% CI : 1.02-1.05), 2.1 (95% CI : 1.46-3.01), 2.02 (95% CI : 1.36-2.99), and 1.86 (95% CI : 1.17-2.95), respectively. However, occult HBV infection was not associated with CKD, with an OR of 1.12 (95% CI : 0.65-1.95). This study did not find an association between occult HBV infection and CKD. However, high-risk patients infected with HBV should still be targeted for monitoring for the development of CKD.

Dietary and fluid restrictions in CKD: a thematic synthesis of patient views from qualitative studies.

PubMed

Palmer, Suetonia C; Hanson, Camilla S; Craig, Jonathan C; Strippoli, Giovanni F M; Ruospo, Marinella; Campbell, Katrina; Johnson, David W; Tong, Allison

2015-04-01

Managing the complex fluid and diet requirements of chronic kidney disease (CKD) is challenging for patients. We aimed to summarize patients' perspectives of dietary and fluid management in CKD to inform clinical practice and research. Systematic review of qualitative studies. Adults with CKD who express opinions about dietary and fluid management. MEDLINE, EMBASE, PsycINFO, CINAHL, Google Scholar, reference lists, and PhD dissertations were searched to May 2013. Thematic synthesis. We included 46 studies involving 816 patients living in middle- to high-income countries. Studies involved patients treated with facility-based and home hemodialysis (33 studies; 462 patients), peritoneal dialysis (10 studies; 112 patients), either hemodialysis or peritoneal dialysis (3 studies; 73 patients), kidney transplant recipients (9 studies; 89 patients), and patients with non-dialysis-dependent CKD stages 1 to 5 (5 studies; 80 patients). Five major themes were identified: preserving relationships (interference with roles, social limitations, and being a burden), navigating change (feeling deprived, disrupting held truths, breaking habits and norms, being overwhelmed by information, questioning efficacy, and negotiating priorities), fighting temptation (resisting impositions, experiencing mental invasion, and withstanding physiologic needs), optimizing health (accepting responsibility, valuing self-management, preventing disease progression, and preparing for and protecting a transplant), and becoming empowered (comprehending paradoxes, finding solutions, and mastering change and demands). Limited data in non-English languages and low-income settings and for adults with CKD not treated with hemodialysis. Dietary and fluid restrictions are disorienting and an intense burden for patients with CKD. Patient-prioritized education strategies, harnessing patients' motivation to stay well for a transplant or to avoid dialysis, and viewing adaptation to restrictions as a collaborative

Metabolomic Alterations Associated with Cause of CKD.

PubMed

Grams, Morgan E; Tin, Adrienne; Rebholz, Casey M; Shafi, Tariq; Köttgen, Anna; Perrone, Ronald D; Sarnak, Mark J; Inker, Lesley A; Levey, Andrew S; Coresh, Josef

2017-11-07

Causes of CKD differ in prognosis and treatment. Metabolomic indicators of CKD cause may provide clues regarding the different physiologic processes underlying CKD development and progression. Metabolites were quantified from serum samples of participants in the Modification of Diet in Renal Disease (MDRD) Study, a randomized controlled trial of dietary protein restriction and BP control, using untargeted reverse phase ultraperformance liquid chromatography tandem mass spectrometry quantification. Known, nondrug metabolites ( n =687) were log-transformed and analyzed to discover associations with CKD cause (polycystic kidney disease, glomerular disease, and other cause). Discovery was performed in Study B, a substudy of MDRD with low GFR ( n =166), and replication was performed in Study A, a substudy of MDRD with higher GFR ( n =423). Overall in MDRD, average participant age was 51 years and 61% were men. In the discovery study (Study B), 29% of participants had polycystic kidney disease, 28% had glomerular disease, and 43% had CKD of another cause; in the replication study (Study A), the percentages were 28%, 24%, and 48%, respectively. In the discovery analysis, adjusted for demographics, randomization group, body mass index, hypertensive medications, measured GFR, log-transformed proteinuria, and estimated protein intake, seven metabolites (16-hydroxypalmitate, kynurenate, homovanillate sulfate, N2,N2-dimethylguanosine, hippurate, homocitrulline, and 1,5-anhydroglucitol) were associated with CKD cause after correction for multiple comparisons ( P <0.0008). Five of these metabolite associations (16-hydroxypalmitate, kynurenate, homovanillate sulfate, N2,N2-dimethylguanosine, and hippurate) were replicated in Study A ( P <0.007), with all replicated metabolites exhibiting higher levels in polycystic kidney disease and lower levels in glomerular disease compared with CKD of other causes. Metabolomic profiling identified several metabolites strongly associated with

The iron cycle in chronic kidney disease (CKD): from genetics and experimental models to CKD patients

PubMed Central

Zumbrennen-Bullough, Kimberly; Babitt, Jodie L.

2014-01-01

Iron is essential for most living organisms but iron excess can be toxic. Cellular and systemic iron balance is therefore tightly controlled. Iron homeostasis is dysregulated in chronic kidney disease (CKD) and contributes to the anemia that is prevalent in this patient population. Iron supplementation is one cornerstone of anemia management in CKD patients, but has not been rigorously studied in large prospective randomized controlled trials. This review highlights important advances from genetic studies and animal models that have provided key insights into the molecular mechanisms governing iron homeostasis and its disturbance in CKD, and summarizes how these findings may yield advances in the care of this patient population. PMID:24235084

The systemic nature of CKD.

PubMed

Zoccali, Carmine; Vanholder, Raymond; Massy, Ziad A; Ortiz, Alberto; Sarafidis, Pantelis; Dekker, Friedo W; Fliser, Danilo; Fouque, Denis; Heine, Gunnar H; Jager, Kitty J; Kanbay, Mehmet; Mallamaci, Francesca; Parati, Gianfranco; Rossignol, Patrick; Wiecek, Andrzej; London, Gerard

2017-06-01

The accurate definition and staging of chronic kidney disease (CKD) is one of the major achievements of modern nephrology. Intensive research is now being undertaken to unravel the risk factors and pathophysiologic underpinnings of this disease. In particular, the relationships between the kidney and other organs have been comprehensively investigated in experimental and clinical studies in the last two decades. Owing to technological and analytical limitations, these links have been studied with a reductionist approach focusing on two organs at a time, such as the heart and the kidney or the bone and the kidney. Here, we discuss studies that highlight the complex and systemic nature of CKD. Energy balance, innate immunity and neuroendocrine signalling are highly integrated biological phenomena. The diseased kidney disrupts such integration and generates a high-risk phenotype with a clinical profile encompassing inflammation, protein-energy wasting, altered function of the autonomic and central nervous systems and cardiopulmonary, vascular and bone diseases. A systems biology approach to CKD using omics techniques will hopefully enable in-depth study of the pathophysiology of this systemic disease, and has the potential to unravel critical pathways that can be targeted for CKD prevention and therapy.

[Consensus document: recommendations for the use of equations to estimate glomerular filtration rate in children].

PubMed

Montañés Bermúdez, R; Gràcia Garcia, S; Fraga Rodríguez, G M; Escribano Subias, J; Diez de Los Ríos Carrasco, M J; Alonso Melgar, A; García Nieto, V

2014-05-01

The appearance of the K/DOQI guidelines in 2002 on the definition, evaluation and staging of chronic kidney disease (CKD) have led to a major change in how to assess renal function in adults and children. These guidelines, recently updated, recommended that the study of renal function is based, not only on measuring the serum creatinine concentration, but this must be accompanied by the estimation of glomerular filtration rate (GFR) obtained by an equation. However, the implementation of this recommendation in the clinical laboratory reports in the paediatric population has been negligible. Numerous studies have appeared in recent years on the importance of screening and monitoring of patients with CKD, the emergence of new equations for estimating GFR, and advances in clinical laboratories regarding the methods for measuring plasma creatinine and cystatin C, determined by the collaboration between the departments of paediatrics and clinical laboratories to establish recommendations based on the best scientific evidence on the use of equations to estimate GFR in this population. The purpose of this document is to provide recommendations on the evaluation of renal function and the use of equations to estimate GFR in children from birth to 18 years of age. The recipients of these recommendations are paediatricians, nephrologists, clinical biochemistry, clinical analysts, and all health professionals involved in the study and evaluation of renal function in this group of patients. Copyright © 2013 Asociación Española de Pediatría. Published by Elsevier Espana. All rights reserved.

Epi-Fluorescence Microscopy

PubMed Central

Webb, Donna J.; Brown, Claire M.

2012-01-01

Epi-fluorescence microscopy is available in most life sciences research laboratories, and when optimized can be a central laboratory tool. In this chapter, the epi-fluorescence light path is introduced and the various components are discussed in detail. Recommendations are made for incident lamp light sources, excitation and emission filters, dichroic mirrors, objective lenses, and charge-coupled device (CCD) cameras in order to obtain the most sensitive epi-fluorescence microscope. The even illumination of metal-halide lamps combined with new “hard” coated filters and mirrors, a high resolution monochrome CCD camera, and a high NA objective lens are all recommended for high resolution and high sensitivity fluorescence imaging. Recommendations are also made for multicolor imaging with the use of monochrome cameras, motorized filter turrets, individual filter cubes, and corresponding dyes that are the best choice for sensitive, high resolution multicolor imaging. Images should be collected using Nyquist sampling and should be corrected for background intensity contributions and nonuniform illumination across the field of view. Photostable fluorescent probes and proteins that absorb a lot of light (i.e., high extinction co-efficients) and generate a lot of fluorescence signal (i.e., high quantum yields) are optimal. A neuronal immune-fluorescence labeling protocol is also presented. Finally, in order to maximize the utility of sensitive wide-field microscopes and generate the highest resolution images with high signal-to-noise, advice for combining wide-field epi-fluorescence imaging with restorative image deconvolution is presented. PMID:23026996

CKD.QLD: chronic kidney disease surveillance and research in Queensland, Australia

PubMed Central

Venuthurupalli, Sree K.; Hoy, Wendy E.; Healy, Helen G.; Salisbury, Anne; Fassett, Robert G.

2012-01-01

Background Chronic kidney disease (CKD) is recognized as a major public health problem in Australia with significant mortality, morbidity and economic burden. However, there is no comprehensive surveillance programme to collect, collate and analyse data on CKD in a systematic way. Methods We describe an initiative called CKD Queensland (CKD.QLD), which was established in 2009 to address this deficiency, and outline the processes and progress made to date. The foundation is a CKD Registry of all CKD patients attending public health renal services in Queensland, and patient recruitment and data capture have started. Results We have established through early work of CKD.QLD that there are over 11 500 CKD patients attending public renal services in Queensland, and these are the target population for our registry. Progress so far includes conducting two CKD clinic site surveys, consenting over 3000 patients into the registry and initiation of baseline data analysis of the first 600 patients enrolled at the Royal Brisbane and Women's Hospital (RBWH) site. In addition, research studies in dietary intake and CKD outcomes and in models of care in CKD patient management are underway. Conclusions Through the CKD Registry, we will define the distribution of CKD patients referred to renal practices in the public system in Queensland by region, remoteness, age, gender, ethnicity and socioeconomic status. We will define the clinical characteristics of those patients, and the CKD associations, stages, co-morbidities and current management. We will follow the course and outcomes in individuals over time, as well as group trends over time. Through our activities and outcomes, we are aiming to provide a nidus for other states in Australia to join in a national CKD registry and network. PMID:23115138

CKD Self-management: Phenotypes and Associations With Clinical Outcomes.

PubMed

Schrauben, Sarah J; Hsu, Jesse Y; Rosas, Sylvia E; Jaar, Bernard G; Zhang, Xiaoming; Deo, Rajat; Saab, Georges; Chen, Jing; Lederer, Swati; Kanthety, Radhika; Hamm, L Lee; Ricardo, Ana C; Lash, James P; Feldman, Harold I; Anderson, Amanda H

2018-03-24

To slow chronic kidney disease (CKD) progression and its complications, patients need to engage in self-management behaviors. The objective of this study was to classify CKD self-management behaviors into phenotypes and assess the association of these phenotypes with clinical outcomes. Prospective cohort study. Adults with mild to moderate CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study. 3,939 participants in the CRIC Study recruited between 2003 and 2008 served as the derivation cohort and 1,560 participants recruited between 2013 and 2015 served as the validation cohort. CKD self-management behavior phenotypes. CKD progression, atherosclerotic events, heart failure events, death from any cause. Latent class analysis stratified by diabetes was used to identify CKD self-management phenotypes based on measures of body mass index, diet, physical activity, blood pressure, smoking status, and hemoglobin A 1c concentration (if diabetic); Cox proportional hazards models. 3 identified phenotypes varied according to the extent of implementation of recommended CKD self-management behaviors: phenotype I characterized study participants with the most recommended behaviors; phenotype II, participants with a mixture of recommended and not recommended behaviors; and phenotype III, participants with minimal recommended behaviors. In multivariable-adjusted models for those with and without diabetes, phenotype III was strongly associated with CKD progression (HRs of 1.82 and 1.49), death (HRs of 1.95 and 4.14), and atherosclerotic events (HRs of 2.54 and 1.90; each P < 0.05). Phenotype II was associated with atherosclerotic events and death among those with and without diabetes. No consensus definition of CKD self-management; limited to baseline behavior data. There are potentially 3 CKD self-management behavior phenotypes that distinguish risk for clinical outcomes. These phenotypes may inform the development of studies and guidelines regarding optimal self

A model for rigorously applying the Exploration, Preparation, Implementation, Sustainment (EPIS) framework in the design and measurement of a large scale collaborative multi-site study.

PubMed

Becan, Jennifer E; Bartkowski, John P; Knight, Danica K; Wiley, Tisha R A; DiClemente, Ralph; Ducharme, Lori; Welsh, Wayne N; Bowser, Diana; McCollister, Kathryn; Hiller, Matthew; Spaulding, Anne C; Flynn, Patrick M; Swartzendruber, Andrea; Dickson, Megan F; Fisher, Jacqueline Horan; Aarons, Gregory A

2018-04-13

This paper describes the means by which a United States National Institute on Drug Abuse (NIDA)-funded cooperative, Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS), utilized an established implementation science framework in conducting a multi-site, multi-research center implementation intervention initiative. The initiative aimed to bolster the ability of juvenile justice agencies to address unmet client needs related to substance use while enhancing inter-organizational relationships between juvenile justice and local behavioral health partners. The EPIS (Exploration, Preparation, Implementation, Sustainment) framework was selected and utilized as the guiding model from inception through project completion; including the mapping of implementation strategies to EPIS stages, articulation of research questions, and selection, content, and timing of measurement protocols. Among other key developments, the project led to a reconceptualization of its governing implementation science framework into cyclical form as the EPIS Wheel. The EPIS Wheel is more consistent with rapid-cycle testing principles and permits researchers to track both progressive and recursive movement through EPIS. Moreover, because this randomized controlled trial was predicated on a bundled strategy method, JJ-TRIALS was designed to rigorously test progress through the EPIS stages as promoted by facilitation of data-driven decision making principles. The project extended EPIS by (1) elucidating the role and nature of recursive activity in promoting change (yielding the circular EPIS Wheel), (2) by expanding the applicability of the EPIS framework beyond a single evidence-based practice (EBP) to address varying process improvement efforts (representing varying EBPs), and (3) by disentangling outcome measures of progression through EPIS stages from the a priori established study timeline. The utilization of EPIS in JJ-TRIALS provides a model

Management of Gout and Hyperuricemia in CKD.

PubMed

Vargas-Santos, Ana Beatriz; Neogi, Tuhina

2017-09-01

Hyperuricemia and gout, the clinical manifestation of monosodium urate crystal deposition, are common in patients with chronic kidney disease (CKD). Although the presence of CKD poses additional challenges in gout management, effective urate lowering is possible for most patients with CKD. Initial doses of urate-lowering therapy are lower than in the non-CKD population, whereas incremental dose escalation is guided by regular monitoring of serum urate levels to reach the target level of <6mg/dL (or <5mg/dL for patients with tophi). Management of gout flares with presently available agents can be more challenging due to potential nephrotoxicity and/or contraindications in the setting of other common comorbid conditions. At present, asymptomatic hyperuricemia is not an indication for urate-lowering therapy, though emerging data may support a potential renoprotective effect. Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Performance of the Cockcroft-Gault and MDRD equations in adult Nigerians with chronic kidney disease.

PubMed

Agaba, Emmanuel I; Wigwe, Chinyere M; Agaba, Patricia A; Tzamaloukas, Antonios H

2009-01-01

Estimation of the glomerular filtration rate (GFR) is required in the assessment of patients with chronic kidney disease (CKD) in order to provide information regarding the functional status of the kidneys. Current guidelines advocate the use of prediction equations, such as the Cockcroft-Gault (CG) formula and the Modification of Diet in Renal Disease (MDRD) study-derived equations, over clearance of endogenous creatinine (Ccr) in achieving this aim. We were interested in knowing the accuracy of these equations in predicting the GFR in adult Nigerians with CKD. We conducted a review of records of patients who were evaluated for CKD at the Nephrology Clinic of the Jos University Teaching Hospital between 2001 and 2003. We compared the CG and MDRD equations against the Ccr in predicting the GFR in 130 patients (88 males and 42 females) with CKD. The means +/- standard deviation (SD) for the measured and predicted GFR by the CG and MDRD equations were similar (17.6 +/- 25.8 ml/min, 19.9 +/- 24.0 ml/min and 21.5 +/- 28.2 ml/min, respectively; analysis of variance [ANOVA], F = 0.68, P = 0.5). The mean difference between CG and Ccr was -2.2 +/- 14.8 ml/min, with discordance at Ccr values >25 ml/min. The mean difference between MDRD and Ccr was -3.9 +/- 18.1 ml/min, with discordance at Ccr values >40 ml/min. The CG and MDRD equations provide reliable alternatives to measured Ccr in the estimation of the GFR in Nigerian patients with CKD.

Relating illness complexity to reimbursement in CKD patients.

PubMed

Bessette, Russell W; Carter, Randy L

2011-01-01

Despite significant investments of federal and state dollars to transition patient medical records to an all-electronic system, a chasm still exists between health care quality and payment for it. A major reason for this gap is the difficulty in evaluating health care outcomes based on claims data. Since both payers and patients may not appreciate how illness complexity impacts treatment outcomes, it is difficult to determine fair provider compensation. Chronic kidney disease (CKD) typifies these problems and is often associated with comorbidities that impact cost, health, and work productivity. Thus, the objective of this study was to evaluate an illness complexity score (ICS) based on a linear regression of select blood values that might assist in predicting average monthly reimbursements in CKD patients. A second objective was to compare the results of this ICS prediction to results obtained by prediction of average monthly reimbursement using CKD stage. A third objective was to analyze the relationship between the change in ICS, estimated glomerular filtration rate (eGFR), and CKD stage over time to average monthly reimbursement. We calculated parsimonious values for select variables associated with CKD patients and compared the ICS to ordinal staging of renal disease. Data from 177 de-identified patients over 13 months was collected, which included 15 blood chemistry observations along with complete claims data for all medical expenses. To test for the relationship between average blood chemistry values, stages of CKD, age, and average monthly reimbursement, we modeled an association through a linear regression function of age, eGFR, and the Z-scores calculated from average monthly values of phosphorus, parathyroid hormone, glucose, hemoglobin, bicarbonate, albumin, creatinine, blood urea nitrogen, potassium, calcium, sodium, alkaline phosphatase, alanine aminotransferase, and white blood cells. The results of our study demonstrated that the association

Comparison of estimates of resting energy expenditure equations in haemodialysis patients.

PubMed

Hung, Rachel; Sridharan, Sivakumar; Farrington, Ken; Davenport, Andrew

2017-04-21

Waste products of metabolism accumulate in patients with chronic kidney disease, and require clearance by haemodialysis (HD). We wished to determine whether there was an association between resting energy expenditure (REE) and total energy expenditure (TEE) in HD patients and body composition. We determined REE by recently validated equations (CKD equation) and compared REE with that estimated by standard equations for REE, and TEE calculated from patient reported physical activity, in HD patients with corresponding body composition measured by dual energy X-ray absorptiometry (DEXA) scanning. We studied 107 patients, 69 male (64.5%), mean age 62.7 ± 15.1 years. The CKD equation REE was 72.5 ± 13.3 watts (W) and TEE 83.2 ± 9.7 W. There was a strong association between REE with body surface area (BSA) (r2 = 0.80), total soft lean and fat lean tissue mass (r2 = 0.69), body mass index (BMI) (r2 = 0.34), all p<0.001. REE estimated using the modified Harris Benedict, Mifflin St. Jeor, Katch McArdle, Bernstein and Robertson equations underestimated REE compared to the CKD equation. TEE was more strongly associated with BSA (r2 = 0.51), appendicular muscle mass (r2 = 0.42), than BMI (r2 = 0.15) all p<0.001.TEE was greater for those employed (104.9 ± 10.7 vs. 83.1 ± 12.3 W, p<0.001), and with no co-morbidity (88.7 ± 14.8 vs. 82.7 ± 12.3 W, p<0.05). Standard equations underestimate REE in HD patients compared to the CKD equation. TEE was greater in those with more skeletal muscle mass, in those who were employed and in those with the least co-morbidity. More metabolically active patients may well require greater dialytic clearances.

Quality of Life and Outcomes in African Americans with CKD

PubMed Central

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.

2014-01-01

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

Older Patients’ Perspectives on Managing Complexity in CKD Self-Management

PubMed Central

Vandenberg, Ann E.; Phillips, Lawrence S.; McClellan, William M.; Johnson, Theodore M.; Echt, Katharina V.

2017-01-01

Background and objectives Patients with CKD are asked to perform self-management tasks including dietary changes, adhering to medications, avoiding nephrotoxic drugs, and self-monitoring hypertension and diabetes. Given the effect of aging on functional capacity, self-management may be especially challenging for older patients. However, little is known about the specific challenges older adults face maintaining CKD self-management regimens. Design, setting, participants, & measurements We conducted an exploratory qualitative study designed to understand the relationship among factors facilitating or impeding CKD self-management in older adults. Six focus groups (n=30) were held in August and September of 2014 with veterans≥70 years old with moderate-to-severe CKD receiving nephrology care at the Atlanta Veterans Affairs Medical Center. Grounded theory with a constant comparative method was used to collect, code, and analyze data. Results Participants had a mean age (range) of 75.1 (70.1–90.7) years, 60% were black, and 96.7% were men. The central organizing concept that emerged from these data were managing complexity. Participants typically did not have just one chronic condition, CKD, but a number of commonly co-occurring conditions. Recommendations for CKD self-management therefore occurred within a complex regimen of recommendations for managing other diseases. Participants identified overtly discordant treatment recommendations across chronic conditions (e.g., arthritis and CKD). Prioritization emerged as one effective strategy for managing complexity (e.g., focusing on BP control). Some patients arrived at the conclusion that they could group concordant recommendations to simplify their regimens (e.g., protein restriction for both gout and CKD). Conclusions Among older veterans with moderate-to-severe CKD, multimorbidity presents a major challenge for CKD self-management. Because virtually all older adults with CKD have multimorbidity, an integrated

Factors Associated with CKD in the Elderly and Nonelderly Population

PubMed Central

Lin, Ming-Yen; Chiu, Yi-Wen; Lee, Chien-Hung; Yu, Hui-Yen; Chen, Hung-Chun; Wu, Ming-Tsang

2013-01-01

Summary Background and objectives The risk factors for CKD in different age groups remain unknown. This community-based study aimed to identify the risk factors for CKD in elderly and nonelderly patients. Design, setting, participants, & measurements A multistage sampling survey for CKD was conducted in 2007 in Kaohsiung County, an area with the highest prevalence of dialysis in the world. CKD was defined as proteinuria in at least the microalbuminuric stage or an estimated GFR (eGFR) of <60 ml/min per 1.73 m2. The factors for CKD in elderly and nonelderly patient groups were identified (with age 60 years as a cutoff value). Results The analyses included 3352 participants, of whom 687 had CKD. The weighted prevalence of CKD was 19.4% (95% confidence interval [CI], 18.0%–20.7%). Elderly patients typically presented with low eGFR and nonelderly patients, with proteinuria. Age, annual income, use of oral analgesics, metabolic syndrome, hyperuricemia, and hemoglobin were risk factors for CKD in both age groups. In elderly patients, risk factors were medical history of diabetes mellitus, CKD, stroke, and not using analgesic injection (odds ratios [95% CIs], 3.58 [2.06–6.22], 3.66 [1.58–8.43], 3.89 [1.09–13.87], 2.27 [1.21–4.17], respectively). In nonelderly patients, associated risk factors for CKD were gout, hepatitis B virus infection, and use of the Chinese herbal medicine Long Dan Xie Gan Tang (odds ratios [95% CIs], 3.15 [1.96–5.07], 1.66 [1.09–2.53], and 8.86 [1.73–45.45], respectively). Conclusions The risk factors for CKD vary by age. PMID:23085726

Older Patients' Perspectives on Managing Complexity in CKD Self-Management.

PubMed

Bowling, C Barrett; Vandenberg, Ann E; Phillips, Lawrence S; McClellan, William M; Johnson, Theodore M; Echt, Katharina V

2017-04-03

Patients with CKD are asked to perform self-management tasks including dietary changes, adhering to medications, avoiding nephrotoxic drugs, and self-monitoring hypertension and diabetes. Given the effect of aging on functional capacity, self-management may be especially challenging for older patients. However, little is known about the specific challenges older adults face maintaining CKD self-management regimens. We conducted an exploratory qualitative study designed to understand the relationship among factors facilitating or impeding CKD self-management in older adults. Six focus groups ( n =30) were held in August and September of 2014 with veterans≥70 years old with moderate-to-severe CKD receiving nephrology care at the Atlanta Veterans Affairs Medical Center. Grounded theory with a constant comparative method was used to collect, code, and analyze data. Participants had a mean age (range) of 75.1 (70.1-90.7) years, 60% were black, and 96.7% were men. The central organizing concept that emerged from these data were managing complexity. Participants typically did not have just one chronic condition, CKD, but a number of commonly co-occurring conditions. Recommendations for CKD self-management therefore occurred within a complex regimen of recommendations for managing other diseases. Participants identified overtly discordant treatment recommendations across chronic conditions ( e.g., arthritis and CKD). Prioritization emerged as one effective strategy for managing complexity ( e.g. , focusing on BP control). Some patients arrived at the conclusion that they could group concordant recommendations to simplify their regimens ( e.g. , protein restriction for both gout and CKD). Among older veterans with moderate-to-severe CKD, multimorbidity presents a major challenge for CKD self-management. Because virtually all older adults with CKD have multimorbidity, an integrated treatment approach that supports self-management across commonly occurring conditions may be

Constipation and Incident CKD

PubMed Central

Sumida, Keiichi; Molnar, Miklos Z.; Potukuchi, Praveen K.; Thomas, Fridtjof; Lu, Jun Ling; Matsushita, Kunihiro; Yamagata, Kunihiro; Kalantar-Zadeh, Kamyar

2017-01-01

Constipation is one of the most prevalent conditions in primary care settings and increases the risk of cardiovascular disease, potentially through processes mediated by altered gut microbiota. However, little is known about the association of constipation with CKD. In a nationwide cohort of 3,504,732 United States veterans with an eGFR ≥60 ml/min per 1.73 m2, we examined the association of constipation status and severity (absent, mild, or moderate/severe), defined using diagnostic codes and laxative use, with incident CKD, incident ESRD, and change in eGFR in Cox models (for time-to-event analyses) and multinomial logistic regression models (for change in eGFR). Among patients, the mean (SD) age was 60.0 (14.1) years old; 93.2% of patients were men, and 24.7% were diabetic. After multivariable adjustments, compared with patients without constipation, patients with constipation had higher incidence rates of CKD (hazard ratio, 1.13; 95% confidence interval [95% CI], 1.11 to 1.14) and ESRD (hazard ratio, 1.09; 95% CI, 1.01 to 1.18) and faster eGFR decline (multinomial odds ratios for eGFR slope <−10, −10 to <−5, and −5 to <−1 versus −1 to <0 ml/min per 1.73 m2 per year, 1.17; 95% CI, 1.14 to 1.20; 1.07; 95% CI, 1.04 to 1.09; and 1.01; 95% CI, 1.00 to 1.03, respectively). More severe constipation associated with an incrementally higher risk for each renal outcome. In conclusion, constipation status and severity associate with higher risk of incident CKD and ESRD and with progressive eGFR decline, independent of known risk factors. Further studies should elucidate the underlying mechanisms. PMID:28122944

Regulation of Potassium Homeostasis in CKD.

PubMed

DuBose, Thomas D

2017-09-01

Disturbances of potassium homeostasis can cause either hyperkalemia or hypokalemia and result in serious consequences. Although the consequences of acute and chronic hyperkalemia and treatment of these conditions in CKD have been widely appreciated by nephrologists, more recent information has focused attention on the consequences of chronic hypokalemia. Several recent studies have documented a "U-shaped" relationship between the serum [K + ] and higher mortality in several clinical studies. The causes of dyskalemias are placed into the unique perspective of patients with CKD and its evolution with progression of CKD to later stages and focuses on the pathophysiology of these disorders. Emphasis is placed on the high mortality associated with both low and high levels of potassium that are unique to patients with CKD. Recent information regarding sensors of changes in the serum [K + ] that evoke changes in NaCl transport in the DCT1 and subsequent efferent responses by aldosterone-responsive cells in the DCT2 and cortical collecting duct to adjust K + secretion by the renal outer medullary potassium channel is reviewed in detail. These sensing mechanisms can be interrupted by drugs, such as the calcineurin inhibitors to cause both hypertension and hyperkalemia in kidney transplant patients, or can be inherited as familial hypertensive hyperkalemia. The role and pathogenesis of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in causing hyperkalemia is a common stop point for cessation of these important drugs, but, and newer agents to lower the serum [K + ] that might allow continuation of angiotensin-converting enzyme or angiotensin receptor blocker therapy are examined. Finally, the importance of emphasis on potassium-containing foods, such as fresh produce and fruit in the diets of patients with early-stage CKD, is examined as an under-appreciated area requiring more emphasis by nephrologists caring for these patients and may be unique

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

Background The prevalence in the United States of dietary supplement use that may be harmful to those with chronic kidney disease (CKD) is unknown. We sought to characterize potentially harmful supplement use by individual CKD status. Study Design Cross-sectional national survey (National Health and Nutrition Examination Survey, 1999-2008) Setting & Participants Community-based survey of 21,169 non-pregnant, non-institutionalized U.S. civilian adults (≥20 years) Predictor CKD status (no CKD, at risk for CKD [presence of diabetes, hypertension and/or cardiovascular disease], stage 1/2 [albuminuria only (albumin-creatinine ratio ≥30 mg/g)], or stage 3/4 [estimated glomerular filtration rate of 15-59 ml/min/1.73 m2]). Outcome Self-reported use of dietary supplements containing any of 37 herbs the National Kidney Foundation identified as potentially harmful in the setting of CKD. Measurements Albuminuria and estimated glomerular filtration rate assessed from urine and blood samples; demographics and comorbid conditions assessed by standardized questionnaire. Results An estimated 8.0% of U.S. adults reported potentially harmful supplement use within the last 30 days. Lower crude estimated prevalence of potentially harmful supplement use was associated with higher CKD severity (no CKD, 8.5%; at risk, 8.0%; stage 1/2, 6.1%; and stage 3/4, 6.2%; p<0.001). However, after adjustment for confounders, those with or at risk for CKD were as likely to use a potentially harmful supplement as those without CKD: at-risk OR, 0.93 (95% CI, 0.79 -1.09); stage 1/2 OR, 0.83 (95% CI, 0.64 -1.08); stage 3/4 OR, 0.87 (95% CI, 0.63 -1.18); all vs. no CKD. Limitations Herb content was not available and the list of potentially harmful supplements examined is unlikely to be exhaustive. Conclusions The use of dietary supplements potentially harmful to people with CKD is common, regardless of CKD status. Healthcare providers should discuss the use and potential risks of supplements with

Americans' use of dietary supplements that are potentially harmful in CKD.

PubMed

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

2013-05-01

The prevalence in the United States of dietary supplement use that may be harmful to those with chronic kidney disease (CKD) is unknown. We sought to characterize potentially harmful supplement use by individual CKD status. Cross-sectional national survey (National Health and Nutrition Examination Survey, 1999-2008). Community-based survey of 21,169 nonpregnant noninstitutionalized US civilian adults (aged ≥20 years). CKD status (no CKD, at risk of CKD [presence of diabetes, hypertension, and/or cardiovascular disease], stages 1/2 [albuminuria only (albumin-creatinine ratio ≥30 mg/g)], or stages 3/4 [estimated glomerular filtration rate of 15-59 mL/min/1.73 m(2)]). Self-reported use of dietary supplements containing any of 37 herbs the National Kidney Foundation identified as potentially harmful in the setting of CKD. Albuminuria and estimated glomerular filtration rate assessed from urine and blood samples; demographics and comorbid conditions assessed by standardized questionnaire. An estimated 8.0% of US adults reported potentially harmful supplement use within the last 30 days. A lower crude estimated prevalence of potentially harmful supplement use was associated with higher CKD severity (no CKD, 8.5%; at risk, 8.0%; stages 1/2, 6.1%; and stages 3/4, 6.2%; P < 0.001). However, after adjustment for confounders, those with or at risk of CKD were as likely to use a potentially harmful supplement as those without CKD: at-risk OR, 0.93 (95% CI, 0.79-1.09); stages 1/2 OR, 0.83 (95% CI, 0.64-1.08); and stages 3/4 OR, 0.87 (95% CI, 0.63-1.18); all versus no CKD. Herb content was not available and the list of potentially harmful supplements examined is unlikely to be exhaustive. The use of dietary supplements potentially harmful to people with CKD is common regardless of CKD status. Health care providers should discuss the use and potential risks of supplements with patients with and at risk of CKD. Copyright © 2013 National Kidney Foundation, Inc. All rights

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. Copyright © 2014 by the American Society of Nephrology.

Estimating GFR using Serum Cystatin C Alone and in Combination with Serum Creatinine: A Pooled Analysis of 3418 Individuals with CKD

PubMed Central

Stevens, Lesley A; Coresh, Josef; Schmid, Christopher H; Feldman, Harold I.; Froissart, Marc; Kusek, John; Rossert, Jerome; Van Lente, Frederick; Bruce, Robert D.; Zhang, Yaping (Lucy); Greene, Tom; Levey, Andrew S

2008-01-01

Background Serum cystatin C (Scys) has been proposed as a potential replacement for serum creatinine (Scr) in glomerular filtration rate (GFR) estimation. We report development and evaluation of GFR estimating equations using Scys alone and Scys, Scr or both with demographic variables. Study Design Test of diagnostic accuracy. Setting and Participants Participants screened for three chronic kidney disease (CKD) studies in the US (n=2980) and a clinical population in Paris, France (n=438) Reference Test Measured GFR (mGFR). Index Test Estimated GFR using the four new equations based on Scys alone, Scys, Scr or both with age, sex and race. New equations were developed using regression with log GFR as the outcome in 2/3 data from US studies. Internal validation was performed in remaining 1/3 of data from US CKD studies; external validation was performed in the Paris study. Measurements GFR was measured using urinary clearance of 125I-iothalamate in the US studies and chromium-ethylenediaminetetraacetate (51Cr-EDTA) in the Paris study. Scys was measured by Dade Behring assay, standardized Scr. Results Mean mGFR, Scr and Scys were 48 (5th–95th percentile 15–95) ml/min/1.73m2 2.1 mg/dL and 1.8 mg/L respectively. For the new equations, the coefficients for age, sex and race were significant in the equation with Scys but 2 to 4 fold smaller than in the equation with Scr. Measures of performance among new equations were consistent across development, internal and external validation datasets. Percent of eGFR within 30% of mGFR for equations based on Scys alone, Scys, Scr or both with age, sex and race were 81, 83, 85, and 89%, respectively. The equation using Scys alone yields estimates with small biases in age, sex and race subgroups, which are improved in equations including these variables. Limitations Study population composed mainly of patients with CKD. Conclusions Scys alone provides GFR estimates that are nearly as accurate as Scr adjusted for age, sex and race

Improving the prognosis of patients with severely decreased glomerular filtration rate (CKD G4+): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

PubMed Central

Eckardt, Kai-Uwe; Bansal, Nisha; Coresh, Josef; Evans, Marie; Grams, Morgan E.; Herzog, Charles A.; James, Matthew T.; Heerspink, Hiddo J.L.; Pollock, Carol A.; Stevens, Paul E.; Tamura, Manjula Kurella; Tonelli, Marcello A.; Wheeler, David C.; Winkelmayer, Wolfgang C.; Cheung, Michael; Hemmelgarn, Brenda R.

2018-01-01

Patients with severely decreased glomerular filtration rate (GFR) (i.e., chronic kidney disease [CKD] G4+) are at increased risk for kidney failure, cardiovascular disease (CVD) events (including heart failure), and death. However, little is known about the variability of outcomes and optimal therapeutic strategies, including initiation of kidney replacement therapy (KRT). Kidney Disease: Improving Global Outcomes (KDIGO) organized a Controversies Conference with an international expert group in December 2016 to address this gap in knowledge. In collaboration with the CKD Prognosis Consortium (CKD-PC) a global meta-analysis of cohort studies (n = 264,515 individuals with CKD G4+) was conducted to better understand the timing of clinical outcomes in patients with CKD G4+ and risk factors for different outcomes. The results confirmed the prognostic value of traditional CVD risk factors in individuals with severely decreased GFR, although the risk estimates vary for kidney and CVD outcomes. A 2- and 4-year model of the probability and timing of kidney failure requiring KRT was also developed. The implications of these findings for patient management were discussed in the context of published evidence under 4 key themes: management of CKD G4+, diagnostic and therapeutic challenges of heart failure, shared decision-making, and optimization of clinical trials in CKD G4+ patients. Participants concluded that variable prognosis of patients with advanced CKD mandates individualized, risk-based management, factoring in competing risks and patient preferences. PMID:29656903

Nondepressive Psychosocial Factors and CKD Outcomes in Black Americans.

PubMed

Lunyera, Joseph; Davenport, Clemontina A; Bhavsar, Nrupen A; Sims, Mario; Scialla, Julia; Pendergast, Jane; Hall, Rasheeda; Tyson, Crystal C; Russell, Jennifer St Clair; Wang, Wei; Correa, Adolfo; Boulware, L Ebony; Diamantidis, Clarissa J

2018-02-07

Established risk factors for CKD do not fully account for risk of CKD in black Americans. We studied the association of nondepressive psychosocial factors with risk of CKD in the Jackson Heart Study. We used principal component analysis to identify underlying constructs from 12 psychosocial baseline variables (perceived daily, lifetime, and burden of lifetime discrimination; stress; anger in; anger out; hostility; pessimism; John Henryism; spirituality; perceived social status; and social support). Using multivariable models adjusted for demographics and comorbidity, we examined the association of psychosocial variables with baseline CKD prevalence, eGFR decline, and incident CKD during follow-up. Of 3390 (64%) Jackson Heart Study participants with the required data, 656 (19%) had prevalent CKD. Those with CKD (versus no CKD) had lower perceived daily (mean [SD] score =7.6 [8.5] versus 9.7 [9.0]) and lifetime discrimination (2.5 [2.0] versus 3.1 [2.2]), lower perceived stress (4.2 [4.0] versus 5.2 [4.4]), higher hostility (12.1 [5.2] versus 11.5 [4.8]), higher John Henryism (30.0 [4.8] versus 29.7 [4.4]), and higher pessimism (2.3 [2.2] versus 2.0 [2.1]; all P <0.05). Principal component analysis identified three factors from the 12 psychosocial variables: factor 1, life stressors (perceived discrimination, stress); factor 2, moods (anger, hostility); and, factor 3, coping strategies (John Henryism, spirituality, social status, social support). After adjustments, factor 1 (life stressors) was negatively associated with prevalent CKD at baseline among women only: odds ratio, 0.76 (95% confidence interval, 0.65 to 0.89). After a median follow-up of 8 years, identified psychosocial factors were not significantly associated with eGFR decline (life stressors: β =0.08; 95% confidence interval, -0.02 to 0.17; moods: β =0.03; 95% confidence interval, -0.06 to 0.13; coping: β =-0.02; 95% confidence interval, -0.12 to 0.08) or incident CKD (life stressors: odds ratio, 1

Single-shot EPI with Nyquist ghost compensation: Interleaved Dual-Echo with Acceleration (IDEA) EPI

PubMed Central

Poser, Benedikt A; Barth, Markus; Goa, Pål-Erik; Deng, Weiran; Stenger, V Andrew

2012-01-01

Echo planar imaging is most commonly used for BOLD fMRI, owing to its sensitivity and acquisition speed. A major problem with EPI is Nyquist (N/2) ghosting, most notably at high field. EPI data are acquired under an oscillating readout gradient and hence vulnerable to gradient imperfections such as eddy current delays and off-resonance effects, as these cause inconsistencies between odd and even k-space lines after time reversal. We propose a straightforward and pragmatic method herein termed Interleaved Dual Echo with Acceleration (IDEA) EPI: Two k-spaces (echoes) are acquired under the positive and negative readout lobes, respectively, by performing phase blips only before alternate readout gradients. From these two k-spaces, two almost entirely ghost free images per shot can be constructed, without need for phase correction. The doubled echo train length can be compensated by parallel imaging and/or partial Fourier acquisition. The two k-spaces can either be complex-averaged during reconstruction, which results in near-perfect cancellation of residual phase errors, or reconstructed into separate images. We demonstrate the efficacy of IDEA EPI and show phantom and in vivo images at both 3 and 7 Tesla. PMID:22411762

Male sex and vascular risk factors affect cystatin C-derived renal function in older people without diabetes or overt vascular disease.

PubMed

Werner, Karin Birgitta; Elmståhl, Sölve; Christensson, Anders; Pihlsgård, Mats

2014-05-01

to explore the effect of ageing on renal function with cystatin C as the marker of glomerular filtration rate (GFR) in the general population without vascular disease or diabetes. a cross-sectional analysis of a healthy subset from the Good Aging in Skåne-cohort study representative of the Swedish general population. 1252 participants without vascular disease and diabetes (43.9% men) of whom 203 were over 80 years old were included from the original cohort of 2931. plasma cystatin C and plasma creatinine were used as markers for GFR. Estimated GFR (eGFR) was calculated with three chronic kidney disease epidemiology collaboration (CKD-EPI) formulas involving cystatin C, creatinine or both. the median for plasma cystatin C was 0.93 mg/l (60-69 years old), 1.04 (70-79 years old) and 1.24 (80+ years old). The difference in mg/l between the 5th and 95th percentile was 0.46, 0.62 and 0.90 for these age groups. Male sex increased the age effect on plasma cystatin C levels with 0.004 mg/l/year (P = 0.03), adjusted for vascular risk factors. Smoking, lower HDL and higher diastolic blood pressure were associated with higher cystatin C levels. 54.7% (CKD-EPI creatinine) to 73.9% (CKD-EPI cystatin C) of the 80+ had an eGFR < 60 ml/min/1.73 m2. non-diabetics without overt vascular disease exhibit an age related but heterogeneous decline in renal function. The ageing effect is more pronounced in men. At least half of healthy 80+ years old could be expected to have at least CKD Stage 3 with eGFR < 60 ml/min/1.73 m2.

Effect of Contrast Media on Single Shot EPI: Implications for Abdominal Diffusion Imaging

PubMed Central

Gulani, Vikas; Willatt, Jonathan M.; Blaimer, Martin; Hussain, Hero K.; Duerk, Jeffrey L.; Griswold, Mark A.

2010-01-01

Purpose The goal of this study was to determine the effect of contrast media on the signal behavior of single shot echo planar imaging (ssEPI) used for abdominal diffusion imaging. Materials and Methods The signal of a ssEPI spin echo sequence in a water phantom with varying concentrations of gadolinium was modeled with Bloch equations and the predicted behavior validated on a phantom at 1.5 T. Six volunteers were given gadolinium contrast, and signal intensity (SI) time courses for regions of interest (ROIs) in the liver, pancreas, spleen, renal cortex and medulla were analyzed. The Student's t-test was used to compare pre-contrast SI to 0, 1, 4, 5, 10, and 13 minutes following contrast. Results The results show that following contrast, ssEPI SI goes through a nadir, recovering differently for each organ. Maximal contrast related signal losses relative to pre-contrast signal are 20%, 20%, 53%, and 67%, for the liver, pancreas, renal cortex and medulla respectively. The SIs remain statistically below the pre-contrast values for 5, 4, and 1 minutes for the pancreas, liver, and spleen, and for all times measured for the renal cortex and medulla. Conclusion Abdominal diffusion imaging should be performed prior to contrast due to adverse effects on the signal in ssEPI. PMID:19856456

Disease management programs for CKD patients: the potential and pitfalls.

PubMed

Rocco, Michael V

2009-03-01

Disease management describes the use of a number of approaches to identify and treat patients with chronic health conditions, especially those that are expensive to treat. Disease management programs have grown rapidly in the United States in the past several years. These programs have been established for patients with chronic kidney disease (CKD), but some have been discontinued because of the high cost of the program. Disease management programs for CKD face unique challenges. Identification of patients with CKD is hampered by incomplete use of the International Classification of Diseases, Ninth Revision (ICD-9) codes for CKD by physicians and the less than universal use of estimated glomerular filtration rate from serum creatinine measurements to identify patients with an estimated glomerular filtration rate less than 60 mL/min/1.73 m(2). CKD affects multiple organ systems. Thus, a comprehensive disease management program will need to manage each of these aspects of CKD. These multiple interventions likely will make a CKD disease management program more costly than similar disease management programs designed for patients with diabetes mellitus, congestive heart failure, or other chronic diseases. The lack of data that can be used to develop effective disease management programs in CKD makes it difficult to determine goals for the management of each organ system affected by CKD. Finally, long periods of observation will be needed to determine whether a particular disease management program is effective in not only improving patient outcomes, but also decreasing both resource use and health care dollars. This long-term observation period is contrary to how most disease management contracts are written, which usually are based on meeting goals during a 1- to 3-year period. Until these challenges are resolved, it likely will be difficult to maintain effective disease management programs for CKD.

Identification of Incident CKD Stage 3 in Research Studies

PubMed Central

Grams, Morgan E.; Rebholz, Casey; MacMahon, Blaithin; Whelton, Seamus; Ballew, Shoshana H.; Selvin, Elizabeth; Wruck, Lisa; Coresh, Josef

2014-01-01

Background In epidemiologic research, incident chronic kidney disease (CKD) is commonly determined by laboratory tests performed at planned study visits. Given the morbidity and mortality associated with CKD, persons with incident disease may be less likely to attend scheduled visits, affecting observed associations. The objective of this study was to quantify loss-to-follow-up by CKD status, and to determine whether supplementation with diagnostic code data improves capture of incident CKD. Study Design Prospective cohort study. Setting & Participants 11,560 participants in the Atherosclerosis Risk in Communities (ARIC) Study underwent continuous surveillance for hospitalizations and death from baseline visit (1996-1999) to follow-up visit (2011-2013). A subset of hospitalizations in Washington County, MD, was used in diagnostic code validation (n=2,540). Predictor Baseline demographics and comorbid conditions. Outcomes Incident CKD stage 3 ascertained by follow-up visit (visit-based definition), or by hospitalization surveillance (hospitalization-based definition). Measurements Visit-based definition: ≥25% decline from baseline estimated glomerular filtration rate to <60 ml/min/1.73 m2 at follow-up visit; hospitalization-based definition: hospitalization CKD diagnostic code. Results Among 11,560 participants, 5,951 attended the follow-up visit, and 9,264 were hospitalized. Never-hospitalized participants were younger, more often female, and had fewer comorbid conditions; 73.5% attended the follow-up visit. Incident CKD stage 3 occurred in 1,172 participants by the visit-based definition (251 were never-hospitalized) and 1,078 participants by the hospitalization-based definition (237 attended the follow-up study visit). The sensitivity of the hospitalization-based CKD definition was 35.5% (95% CI, 31.6%-39.7%); specificity was 95.7% (95% CI, 94.2%-96.8%). Sensitivity was higher with later time period, older participant age, and baseline prevalent diabetes and

Patients' Experiences After CKD Diagnosis: A Meta-ethnographic Study and Systematic Review.

PubMed

Teasdale, Emma J; Leydon, Geraldine; Fraser, Simon; Roderick, Paul; Taal, Maarten W; Tonkin-Crine, Sarah

2017-11-01

Chronic kidney disease (CKD) is often asymptomatic at first diagnosis, and awareness of CKD is low in the general population. Thus, individuals who are unexpectedly identified as having CKD may struggle to adjust to living with this diagnosis. This study aims to synthesize qualitative research exploring patients' views and experiences of a CKD diagnosis and how they adjust to it. Systematic review and meta-ethnography. Adult patients with CKD stages 1 to 5. MEDLINE, PsycINFO, CINAHL, Embase, and Web of Science were searched from the earliest date available to November 2015. Qualitative studies were selected that explored patients' views and experiences of a CKD diagnosis and their adjustment. Meta-ethnography was adopted to synthesize the findings. 10 studies involving 596 patients with CKD from secondary-care settings were included. 7 key themes were identified: a challenging diagnosis, diverse beliefs about causation, anticipated concerns about progression, delaying disease progression, unmet informational needs, psychosocial impact of CKD, and adjustment to life with CKD. Limited to views and experiences of participants in included studies, which were mostly conducted in high-income countries. Studies not written in English were excluded. Transferability of findings to other populations may be limited. This review highlights variation in patients' understanding of CKD, an overall lack of information on the trajectory of CKD, and a need for psychosocial support, especially in later stages, to help patients adjust to living with CKD. Future research that acknowledges CKD as a condition with diverse complicating morbidities and explores how patients' information and psychosocial needs vary according to severity and comorbid conditions would be beneficial. This will support delivery of easily understandable, timely, and targeted information about CKD, as well as practical advice about recommended lifestyle changes. Copyright © 2017 National Kidney Foundation, Inc

Comparison of Associations of Urine Protein-Creatinine Ratio Versus Albumin-Creatinine Ratio With Complications of CKD: A Cross-sectional Analysis

PubMed Central

Fisher, Herrick; Hsu, Chi-yuan; Vittinghoff, Eric; Lin, Feng; Bansal, Nisha

2013-01-01

Background Urine albumin-creatinine ratio (ACR) and protein-creatinine ratio (PCR) are important markers of kidney damage and are utilized for prognosis in persons with chronic kidney disease (CKD). Despite how commonly these measurements are done in clinical practice, relatively few studies have directly compared the performance of these two measures with regard to associations with clinical outcomes, which may inform clinicians about which measure of urinary protein excretion is best. We studied the association of ACR and PCR with common complications of CKD. Study Design Cross-sectional study. Setting & Participants 3,481 participants with CKD in the Chronic Renal Insufficiency Cohort (CRIC) study. Predictors ACR and PCR. Outcomes We examined the association between ACR and PCR with measures of common CKD complications: serum hemoglobin, bicarbonate, parathyroid hormone, phosphorus, potassium and albumin. Measurements Restricted cubic spline analyses adjusted for estimated glomerular filtration rate (eGFR; calculated by the MDRD [Modification of Diet in Renal Disease] Study Equation) were performed to study the continuous association with our predictors with each outcome. Results Mean eGFR was 43 ± 13 (SD) ml/min/1.73 m2 and median levels of PCR and ACR were 140 and 46 mg/g, respectively. In continuous analyses adjusted for eGFR, higher ACR and PCR were comparable and both were associated with lower levels of serum hemoglobin, bicarbonate, and albumin and higher levels of parathyroid hormone, phosphorus, and potassium. Across all outcomes, the associations of ACR and PCR were comparable with only small, absolute differences in the outcome measure. Similar associations were seen in patients with diabetes mellitus. Limitations Participants largely had moderate CKD with low levels of ACR and PCR, so results may not be generalizable to all CKD populations. Conclusions In persons with CKD, ACR and PCR are relatively comparable in their associations with common

Hyperkalemia and Hypokalemia in CKD: Prevalence, Risk Factors, and Clinical Outcomes.

PubMed

Gilligan, Sarah; Raphael, Kalani L

2017-09-01

Abnormalities of serum potassium are common in patients with CKD. Although hyperkalemia is a well-recognized complication of CKD, the prevalence rates of hyperkalemia (14%-20%) and hypokalemia (12%-18%) are similar. CKD severity, use of medications such as renin-angiotensin-aldosterone system inhibitors and diuretics, and dietary potassium intake are major determinants of serum potassium concentration in CKD. Demographic factors, acid-base status, blood glucose, and other comorbidities contribute as well. Both hyperkalemia and hypokalemia are associated with similarly increased risks of death, cardiovascular disease, and hospitalization. On the other hand, limited evidence suggests a link between hypokalemia, but not hyperkalemia, and progression of CKD. This article reviews the prevalence rates and risk factors for hyperkalemia and hypokalemia, and their associations with adverse outcomes in CKD. Published by Elsevier Inc.

Going national with EPI in Nigeria.

PubMed

Reid, R S; Smith, E A

1984-01-01

The basic purposes set out for the Owo Local Government Area (LGA) Expanded Program on Immunization (EPI) model project in Ondo State, Nigeria, were: to demonstrate in 1 LGA that 80% EPI coverage can be achieved within the resources that the government normally provides to EPI; to dispel the unquestioning acquiescence that 10-15% coverage is all that can be done; to demonstrate that the health establishment at large can be convinced of these approaches and processes and can be expected to adopt them for a much wider dissemination; to show that a substantial number of health officers and workers are willing to work toward a higher EPI achievement; and to prove that resources from various origins can be integrated given the proper operational environment and a tight organization. The problems associated with EPI are basically similar in all Nigeria, leading to the decision to undertake a model project in a selected area. The EPI project was designed to break ground in Owo for further elements of primary health care. The project's objective was to capitalize upon the success and experience in EPI to introduce other health-related and self-help activities to communities. The project was organized with an overall project director exercising broad control and supervision over a management group at the project level. The management group is made up of a project manager, an assistant project manager, and heads of functional areas such as field operation, vaccine management system, transport system, mobile operation, health education, and administration and finance. The simple organization was designed to grow gradually to meet heavier volumes of work, altering and modifying approaches as required. The 2 key technical elements in the Owo approach were greatly increased use of cold packs and a decreased reliance on refrigerators; and increased use of simple static centers to reach remote catchment areas, instead of relying heavily on the mobile units. In both elements, the

Outcomes of In-Hospital Cardiopulmonary Resuscitation in Patients with CKD.

PubMed

Saeed, Fahad; Adil, Malik M; Kaleem, Umar M; Zafar, Taqi T; Khan, Abdus Salam; Holley, Jean L; Nally, Joseph V

2016-10-07

Advance care planning, including code/resuscitation status discussion, is an essential part of the medical care of patients with CKD. There is little information on the outcomes of cardiopulmonary resuscitation in these patients. We aimed to measure cardiopulmonary resuscitation outcomes in these patients. Our study is observational in nature. We compared the following cardiopulmonary resuscitation-related outcomes in patients with CKD with those in the general population by using the Nationwide Inpatient Sample (2005-2011): ( 1 ) survival to hospital discharge, ( 2 ) discharge destination, and ( 3 ) length of hospital stay. All of the patients were 18 years old or older. During the study period, 71,961 patients with CKD underwent in-hospital cardiopulmonary resuscitation compared with 323,620 patients from the general population. Unadjusted in-hospital mortality rates were higher in patients with CKD (75% versus 72%; P <0.001) on univariate analysis. After adjusting for age, sex, and potential confounders, patients with CKD had higher odds of mortality (odds ratio, 1.24; 95% confidence interval, 1.11 to 1.34; P ≤0.001) and length of stay (odds ratio, 1.11; 95% confidence interval, 1.07 to 1.15; P =0.001). Hospitalization charges were also greater in patients with CKD. There was no overall difference in postcardiopulmonary resuscitation nursing home placement between the two groups. In a separate subanalysis of patients ≥75 years old with CKD, higher odds of in-hospital mortality were also seen in the patients with CKD (odds ratio, 1.10; 95% confidence interval, 1.02 to 1.17; P =0.01). In conclusion, we observed slightly higher in-hospital mortality in patients with CKD undergoing in-hospital cardiopulmonary resuscitation. Copyright © 2016 by the American Society of Nephrology.

Lifetime Incidence of CKD Stages 3–5 in the United States

PubMed Central

Grams, Morgan E.; Chow, Eric K.H.; Segev, Dorry L.; Coresh, Josef

2013-01-01

Background Lifetime risk estimates of chronic kidney disease (CKD) can motivate preventative behaviors at the individual level and forecast disease burden and health care utilization at the population level. Study Design Markov Monte Carlo model simulation study. Setting & Population Current U.S. black and white population. Model, Perspective, & Timeframe Markov models simulating kidney disease development, using an individual perspective and lifetime horizon. Outcomes Age-, sex- and race-specific residual lifetime risks of CKD stages 3a+ (eGFR<60 ml/min/1.73m2), 3b+ (eGFR<45 ml/min/1.73 m2), and 4+ (eGFR<30 ml/min/1.73m2), and end stage renal disease (ESRD). Measurements State transition probabilities of developing CKD and of dying prior to its development were modeled using: 1) mortality rates from National Vital Statistics Report, 2) mortality risk estimates from a 2-million person meta-analysis, and 3) CKD prevalence from National Health and Nutrition Examination Surveys. Incidence, prevalence, and mortality related to ESRD were supplied by the US Renal Disease System. Results At birth, the overall lifetime risks of CKD stages 3a+, 3b+, 4+, and ESRD were 59.1%, 33.6%, 11.5%, and 3.6%, respectively. Women experienced greater CKD risk yet lower ESRD risk than men; blacks of both sexes had markedly higher CKD stage 4+ and ESRD risk (lifetime risks for white men, white women, black men, and black women, respectively: 53.6%, 64.9%, 51.8%, and 63.6% [CKD stage 3a+]; 29.0%, 36.7%, 33.7%, and 40.2% [CKD stage 3b+]; 9.3%, 11.4%, 15.8%, and 18.5% [CKD stage 4+]; and 3.3%, 2.2%, 8.5%, and 7.8% [ESRD]). Risk of CKD increased with age, with approximately one-half of CKD stage 3a+ cases developing after 70 years of age. Limitations CKD incidence estimates were modeled from prevalence in the U.S. population. Conclusions In the U.S., the lifetime risk of developing CKD stage 3a+ is high, underscoring the importance of primary prevention and effective therapy to reduce CKD

Integration of Care in Management of CKD in Resource-Limited Settings.

PubMed

Okpechi, Ikechi G; Bello, Aminu K; Ameh, Oluwatoyin I; Swanepoel, Charles R

2017-05-01

The prevalence of noncommunicable diseases, including chronic kidney disease (CKD), continues to increase worldwide, and mortality from noncommunicable diseases is projected to surpass communicable disease-related mortality in developing countries. Although the treatment of CKD is expensive, unaffordable, and unavailable in many developing countries, the current structure of the health care system in such countries is not set up to deliver comprehensive care for patients with chronic conditions, including CKD. The World Health Organization Innovative Care for Chronic Conditions framework could be leveraged to improve the care of CKD patients worldwide, especially in resource-limited countries where high cost, low infrastructure, limited workforce, and a dearth of effective health policies exist. Some developing countries already are using established health systems for communicable disease control to tackle noncommunicable diseases such as hypertension and diabetes, therefore existing systems could be leveraged to integrate CKD care. Decision makers in developing countries must realize that to improve outcomes for patients with CKD, important factors should be considered, including enhancing CKD prevention programs in their communities, managing the political environment through involvement of the political class, involving patients and their families in CKD care delivery, and effective use of health care personnel. Copyright © 2017 Elsevier Inc. All rights reserved.

Variability in CKD stage in outpatients followed in two large renal clinics.

PubMed

Sikaneta, Tabo; Abdolell, Mohamed; Taskapan, Hulya; Roscoe, Janet; Fung, Jason; Nagai, Gordon; Ting, Robert H; Ng, Paul; Wu, George; Oreopoulos, Dimitrios; Tam, Paul Y

2012-10-01

Chronic kidney disease (CKD) is staged by glomerular filtration rate (GFR). CKD stages sometimes vary between routine office visits, and it is unknown if this impacts renal and patient survival separately from a cross-sectional CKD stage value. We quantified and categorized CKD stage variability in a large group of outpatients and correlated this with clinical and demographic features and with renal and patient survival. All estimated GFRs were staged in the first observation period. CKD stages were then categorized as static, improving, worsening, or fluctuating. Logistic regression analysis was performed to identify clinical variables associated with CKD stage variability. Death and dialysis progression rates were then collected and analyzed using Cox proportional regression. During a 1.1-year observation period, 1,262 patients (mean age 71.25 years) had a mean 5 eGFR's. CKD stages were static in 60.4%, worsened in 14.4%, improved in 7.4%, and fluctuated in 17.2% of patients. Secondary analysis revealed heavy proteinuria and East Asian ethnicity to be negatively, and diabetes mellitus and previous acute kidney injury to be positively associated with improving CKD stages. Cox proportional regression of 902 patients analyzed 2.3 years later revealed a negative association with improving CKD stage and subsequent need for dialysis. CKD stage changed in 40% of 1,262 elderly patients when determined 5 times in just over 1 year. Improving CKD stage was the only variability pattern significantly associated with any of the clinical outcomes when assessed 2.3 years later, being unlikely to be linked with subsequent need for dialysis.

Changes in estimated glomerular filtration rate over time in South African HIV-1-infected patients receiving tenofovir: a retrospective cohort study

PubMed Central

De Waal, Reneé; Cohen, Karen; Fox, Matthew P; Stinson, Kathryn; Maartens, Gary; Boulle, Andrew; Igumbor, Ehimario U; Davies, Mary-Ann

2017-01-01

Abstract Introduction: Tenofovir has been associated with decline in kidney function, but in patients with low baseline kidney function, improvements over time have been reported. Additionally, the magnitude and trajectory of estimated glomerular filtration rate (eGFR) changes may differ according to how eGFR is calculated. We described changes in eGFR over time, and the incidence of, and risk factors for, kidney toxicity, in a South African cohort. Methods: We included antiretroviral-naïve patients ≥16 years old who started tenofovir-containing antiretroviral therapy (ART) between 2002 and 2013. We calculated eGFR using the Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), and Cockcroft-Gault equations. We described changes in eGFR from ART initiation using linear mixed effects regression. We described the incidence of eGFR <30 mL/min on treatment, and identified associations with low eGFR using Cox regression. Results: We included 15156 patients with median age of 35.4 years (IQR 29.9–42.0), median CD4 cell count of 168 cells/µL (IQR 83–243), and median eGFR (MDRD) of 98.6 mL/min (IQR 84.4–115.6). Median duration of follow up on tenofovir was 12.9 months (IQR 5.1–23.3). Amongst those with a baseline and subsequent eGFR  available, mean eGFR change from baseline at 12 months was −4.4 mL/min (95% CI −4.9 to −4.0), −2.3 (−2.5 to −2.1), and 0.6 (0.04 to 1.2) in those with baseline eGFR ≥90 mL/min; and 11.9 mL/min (11.0 to 12.7), 14.6 (13.5 to 15.7), and 11.0 (10.3 to 11.7) in those with baseline eGFR <90 mL/min, according to the MDRD, CKD-EPI (n = 11 112), and Cockcroft-Gault (n = 9 283) equations, respectively. Overall, 292 (1.9%) patients developed eGFR <30 mL/min. Significant associations with low eGFR included older age, baseline eGFR <60 mL/min, CD4 count <200 cells/µL, body weight <60 kg, and concomitant protease inhibitor use. Conclusions: Patients on

Improving the prognosis of patients with severely decreased glomerular filtration rate (CKD G4+): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.

PubMed

Eckardt, Kai-Uwe; Bansal, Nisha; Coresh, Josef; Evans, Marie; Grams, Morgan E; Herzog, Charles A; James, Matthew T; Heerspink, Hiddo J L; Pollock, Carol A; Stevens, Paul E; Tamura, Manjula Kurella; Tonelli, Marcello A; Wheeler, David C; Winkelmayer, Wolfgang C; Cheung, Michael; Hemmelgarn, Brenda R

2018-06-01

Patients with severely decreased glomerular filtration rate (GFR) (i.e., chronic kidney disease [CKD] G4+) are at increased risk for kidney failure, cardiovascular disease (CVD) events (including heart failure), and death. However, little is known about the variability of outcomes and optimal therapeutic strategies, including initiation of kidney replacement therapy (KRT). Kidney Disease: Improving Global Outcomes (KDIGO) organized a Controversies Conference with an international expert group in December 2016 to address this gap in knowledge. In collaboration with the CKD Prognosis Consortium (CKD-PC) a global meta-analysis of cohort studies (n = 264,515 individuals with CKD G4+) was conducted to better understand the timing of clinical outcomes in patients with CKD G4+ and risk factors for different outcomes. The results confirmed the prognostic value of traditional CVD risk factors in individuals with severely decreased GFR, although the risk estimates vary for kidney and CVD outcomes. A 2- and 4-year model of the probability and timing of kidney failure requiring KRT was also developed. The implications of these findings for patient management were discussed in the context of published evidence under 4 key themes: management of CKD G4+, diagnostic and therapeutic challenges of heart failure, shared decision-making, and optimization of clinical trials in CKD G4+ patients. Participants concluded that variable prognosis of patients with advanced CKD mandates individualized, risk-based management, factoring in competing risks and patient preferences. Copyright © 2018 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.

Social Determinants of Racial Disparities in CKD

PubMed Central

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

2016-01-01

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

Stirring the Pot: Can Dietary Modification Alleviate the Burden of CKD?

PubMed Central

Snelson, Matthew; Clarke, Rachel E.; Coughlan, Melinda T.

2017-01-01

Diet is one of the largest modifiable risk factors for chronic kidney disease (CKD)-related death and disability. CKD is largely a progressive disease; however, it is increasingly appreciated that hallmarks of chronic kidney disease such as albuminuria can regress over time. The factors driving albuminuria resolution remain elusive. Since albuminuria is a strong risk factor for GFR loss, modifiable lifestyle factors that lead to an improvement in albuminuria would likely reduce the burden of CKD in high-risk individuals, such as patients with diabetes. Dietary therapy such as protein and sodium restriction has historically been used in the management of CKD. Evidence is emerging to indicate that other nutrients may influence kidney health, either through metabolic or haemodynamic pathways or via the modification of gut homeostasis. This review focuses on the role of diet in the pathogenesis and progression of CKD and discusses the latest findings related to the mechanisms of diet-induced kidney disease. It is possible that optimizing diet quality or restricting dietary intake could be harnessed as an adjunct therapy for CKD prevention or progression in susceptible individuals, thereby reducing the burden of CKD. PMID:28287463

A collaborative project to improve identification and management of patients with chronic kidney disease in a primary care setting in Greater Manchester.

PubMed

Humphreys, John; Harvey, Gill; Coleiro, Michelle; Butler, Brook; Barclay, Anna; Gwozdziewicz, Maciek; O'Donoghue, Donal; Hegarty, Janet

2012-08-01

Research has demonstrated a knowledge and practice gap in the identification and management of chronic kidney disease (CKD). In 2009, published data showed that general practices in Greater Manchester had a low detection rate for CKD. A 12-month improvement collaborative, supported by an evidence-informed implementation framework and financial incentives. 19 general practices from four primary care trusts within Greater Manchester. Number of recorded patients with CKD on practice registers; percentage of patients on registers achieving nationally agreed blood pressure targets. The collaborative commenced in September 2009 and involved three joint learning sessions, interspersed with practice level rapid improvement cycles, and supported by an implementation team from the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Greater Manchester. At baseline, the 19 collaborative practices had 4185 patients on their CKD registers. At final data collection in September 2010, this figure had increased by 1324 to 5509. Blood pressure improved from 34% to 74% of patients on practice registers having a recorded blood pressure within recommended guidelines. Evidence-based improvement can be implemented in practice for chronic disease management. A collaborative approach has been successful in enabling teams to test and apply changes to identify patients and improve care. The model has proved to be more successful for some practices, suggesting a need to develop more context-sensitive approaches to implementation and actively manage the factors that influence the success of the collaborative.

Association of CKD with Disability in the United States

PubMed Central

Plantinga, Laura C.; Johansen, Kirsten; Crews, Deidra C.; Shahinian, Vahakn B.; Robinson, Bruce M.; Saran, Rajiv; Burrows, Nilka Rios; Williams, Desmond E.; Powe, Neil R.

2010-01-01

Background Little is known about disability in early-stage chronic kidney disease (CKD). Study Design Cross-sectional national survey (National Health and Nutrition Examination Survey 1999–2006). Setting and Participants Community-based survey of 16,011 non-institutionalized U.S. civilian adults (≥20 years). Predictor CKD, categorized as: no CKD, stages 1 and 2 [albuminuria and estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m2], and stages 3 and 4 (eGFR 15–59). Outcome Self-reported disability, defined by limitations in working, walking, and cognition; and difficulties in activities of daily living (ADL), instrumental ADL, leisure and social activities, lower extremity mobility, and general physical activity. Measurements Albuminuria and eGFR assessed from urine and blood samples; disability, demographics, access to care, and comorbid conditions assessed by standardized questionnaire. Results Age-adjusted prevalence of reported limitations was generally significantly greater with CKD: e.g., difficulty with ADLs was reported by 17.6%, 24.7%, and 23.9% of older (≥65 years) and 6.8%, 11.9%, and 11.0% of younger (20–64 years) adults with no CKD, stages 1 and 2, and stages 3 and 4, respectively. CKD was also associated with greater reported limitations and difficulty in other activities after age adjustment, including instrumental ADL, leisure and social activities, lower extremity mobility, and general physical activity. Other demographics, socioeconomic status, and access to care generally only slightly attenuated the observed associations, particularly among older individuals; adjustment for cardiovascular disease, arthritis, and cancer attenuated most associations such that statistical significance was no longer achieved. Limitations Inability to establish causality and possible unmeasured confounding. Conclusion CKD is associated with higher prevalence of disability in the United States. Age and other comorbid conditions account for most

Uremic Toxicity of Advanced Glycation End Products in CKD

PubMed Central

Stinghen, Andréa E.M.; Massy, Ziad A.; Vlassara, Helen; Striker, Gary E.

2016-01-01

Advanced glycation end products (AGEs), a heterogeneous group of compounds formed by nonenzymatic glycation reactions between reducing sugars and amino acids, lipids, or DNA, are formed not only in the presence of hyperglycemia, but also in diseases associated with high levels of oxidative stress, such as CKD. In chronic renal failure, higher circulating AGE levels result from increased formation and decreased renal clearance. Interactions between AGEs and their receptors, including advanced glycation end product–specific receptor (RAGE), trigger various intracellular events, such as oxidative stress and inflammation, leading to cardiovascular complications. Although patients with CKD have a higher burden of cardiovascular disease, the relationship between AGEs and cardiovascular disease in patients with CKD is not fully characterized. In this paper, we review the various deleterious effects of AGEs in CKD that lead to cardiovascular complications and the role of these AGEs in diabetic nephropathy. We also discuss potential pharmacologic approaches to circumvent these deleterious effects by reducing exogenous and endogenous sources of AGEs, increasing the breakdown of existing AGEs, or inhibiting AGE-induced inflammation. Finally, we speculate on preventive and therapeutic strategies that focus on the AGE-RAGE axis to prevent vascular complications in patients with CKD. PMID:26311460

Physical Activity and Change in Estimated GFR among Persons with CKD

PubMed Central

Littman, Alyson J.; Duncan, Glen E.; Weiss, Noel S.; Sachs, Michael C.; Ruzinski, John; Kundzins, John; Rock, Denise; de Boer, Ian H.; Ikizler, T. Alp; Himmelfarb, Jonathan; Kestenbaum, Bryan R.

2014-01-01

Physical activity may counteract metabolic disturbances that promote the progression of CKD. To address this concept, we performed a longitudinal cohort study of 256 participants in the Seattle Kidney Study, a clinic-based study of CKD. Participants with an estimated GFR (eGFR) of 15–59 ml/min per 1.73 m2 at baseline were eligible for the study. Physical activity was quantified using the Four-Week Physical Activity History Questionnaire. We used generalized estimating equations to test associations of physical activity with change in eGFR determined by longitudinal measurements of serum cystatin C. Mean baseline eGFR was 42 ml/min per 1.73 m2. During a median 3.7 years of follow-up, the mean change in eGFRcystatin C was −7.6% per year (interquartile range, −16.8%, 4.9% per year). Participants who reported >150 minutes of physical activity per week had the lowest rate of eGFRcystatin C loss (mean −6.2% per year compared with −9.6% per year among inactive participants). In adjusted analyses, each 60-minute increment in weekly physical activity duration associated with a 0.5% slower decline per year in eGFR (95% confidence interval, 0.02 to 0.98; P=0.04). Results were similar in sensitivity analyses restricted to participants without cardiovascular disease or diabetes, or to participants with moderate/high physical function. After adjustment for eGFR at the time of questionnaire completion, physical activity did not associate with the incidence of ESRD (n=34 events). In summary, higher physical activity levels associated with slower rates of eGFR loss in persons with established CKD. PMID:24335971

CKD in disadvantaged populations.

PubMed

Garcia-Garcia, Guillermo; Jha, Vivekanand

2015-02-01

The increased burden of CKD in disadvantaged populations is due to both global factors and population-specific issues. Low socioeconomic status and poor access to care contribute to health-care disparities and exacerbate the negative effects of genetic or biologic predisposition. Provision of appropriate renal care to these populations requires a two-pronged approach: expansion of the reach of dialysis through development of low-cost alternatives that can be practiced in remote locations, and implementation and evaluation of cost-effective prevention strategies. Kidney transplantation should be promoted by expansion of deceased-donor transplant programs and use of inexpensive, generic immunosuppressive drugs. The message of WKD 2015 is that a concerted attack against the diseases that lead to ESRD, by increased community outreach, better education, improved economic opportunity, and access to preventive medicine for those at highest risk, could end the unacceptable relationship between CKD and disadvantage in these communities.

Dosing of cytotoxic chemotherapy: impact of renal function estimates on dose.

PubMed

Dooley, M J; Poole, S G; Rischin, D

2013-11-01

Oncology clinicians are now routinely provided with an estimated glomerular filtration rate on pathology reports whenever serum creatinine is requested. The utility of using this for the dose determination of renally excreted drugs compared with other existing methods is needed to inform practice. Renal function was determined by [Tc(99m)]DTPA clearance in adult patients presenting for chemotherapy. Renal function was calculated using the 4-variable Modification of Diet in Renal Disease (4v-MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Cockcroft and Gault (CG), Wright and Martin formulae. Doses for renal excreted cytotoxic drugs, including carboplatin, were calculated. The concordance of the renal function estimates according to the CKD classification with measured Tc(99m)DPTA clearance in 455 adults (median age 64.0 years: range 17-87 years) for the 4v-MDRD, CKD-EPI, CG, Martin and Wright formulae was 47.7%, 56.3%, 46.2%, 56.5% and 60.2%, respectively. Concordance for chemotherapy dose for these formulae was 89.0%, 89.5%, 85.1%, 89.9% and 89.9%, respectively. Concordance for carboplatin dose specifically was 66.4%, 71.4%, 64.0%, 73.8% and 73.2%. All bedside formulae provide similar levels of concordance in dosage selection for the renal excreted chemotherapy drugs when compared with the use of a direct measure of renal function.

Rapid whole-brain resting-state fMRI at 3 T: Efficiency-optimized three-dimensional EPI versus repetition time-matched simultaneous-multi-slice EPI.

PubMed

Stirnberg, Rüdiger; Huijbers, Willem; Brenner, Daniel; Poser, Benedikt A; Breteler, Monique; Stöcker, Tony

2017-12-01

State-of-the-art simultaneous-multi-slice (SMS-)EPI and 3D-EPI share several properties that benefit functional MRI acquisition. Both sequences employ equivalent parallel imaging undersampling with controlled aliasing to achieve high temporal sampling rates. As a volumetric imaging sequence, 3D-EPI offers additional means of acceleration complementary to 2D-CAIPIRINHA sampling, such as fast water excitation and elliptical sampling. We performed an application-oriented comparison between a tailored, six-fold CAIPIRINHA-accelerated 3D-EPI protocol at 530 ms temporal and 2.4 mm isotropic spatial resolution and an SMS-EPI protocol with identical spatial and temporal resolution for whole-brain resting-state fMRI at 3 T. The latter required eight-fold slice acceleration to compensate for the lack of elliptical sampling and fast water excitation. Both sequences used vendor-supplied on-line image reconstruction. We acquired test/retest resting-state fMRI scans in ten volunteers, with simultaneous acquisition of cardiac and respiration data, subsequently used for optional physiological noise removal (nuisance regression). We found that the 3D-EPI protocol has significantly increased temporal signal-to-noise ratio throughout the brain as compared to the SMS-EPI protocol, especially when employing motion and nuisance regression. Both sequence types reliably identified known functional networks with stronger functional connectivity values for the 3D-EPI protocol. We conclude that the more time-efficient 3D-EPI primarily benefits from reduced parallel imaging noise due to a higher, actual k-space sampling density compared to SMS-EPI. The resultant BOLD sensitivity increase makes 3D-EPI a valuable alternative to SMS-EPI for whole-brain fMRI at 3 T, with voxel sizes well below 3 mm isotropic and sampling rates high enough to separate dominant cardiac signals from BOLD signals in the frequency domain. Copyright © 2017 Elsevier Inc. All rights reserved.

Comparison of Diffusion-Weighted Imaging in the Human Brain Using Readout-Segmented EPI and PROPELLER Turbo Spin Echo With Single-Shot EPI at 7 T MRI.

PubMed

Kida, Ikuhiro; Ueguchi, Takashi; Matsuoka, Yuichiro; Zhou, Kun; Stemmer, Alto; Porter, David

2016-07-01

The purpose of the present study was to compare periodically rotated overlapping parallel lines with enhanced reconstruction-type turbo spin echo diffusion-weighted imaging (pTSE-DWI) and readout-segmented echo planar imaging (rsEPI-DWI) with single-shot echo planar imaging (ssEPI-DWI) in a 7 T human MR system. We evaluated the signal-to-noise ratio (SNR), image distortion, and apparent diffusion coefficient values in the human brain. Six healthy volunteers were included in this study. The study protocol was approved by our institutional review board. All measurements were performed at 7 T using pTSE-DWI, rsEPI-DWI, and ssEPI-DWI sequences. The spatial resolution was 1.2 × 1.2 mm in-plane with a 3-mm slice thickness. Signal-to-noise ratio was measured using 2 scans. The ssEPI-DWI sequence showed significant image blurring, whereas pTSE-DWI and rsEPI-DWI sequences demonstrated high image quality with low geometrical distortion compared with reference T2-weighted, turbo spin echo images. Signal loss in ventral regions near the air-filled paranasal sinus/nasal cavity was found in ssEPI-DWI and rsEPI-DWI but not pTSE-DWI. The apparent diffusion coefficient values for ssEPI-DWI were 824 ± 17 × 10 and 749 ± 25 × 10 mm/s in the gray matter and white matter, respectively; the values obtained for pTSE-DWI were 798 ± 21 × 10 and 865 ± 40 × 10 mm/s; and the values obtained for rsEPI-DWI were 730 ± 12 × 10 and 722 ± 25 × 10 mm/s. The pTSE-DWI images showed no additional distortion comparison to the T2-weighted images, but had a lower SNR than ssEPI-DWI and rsEPI-DWI. The rsEPI-DWI sequence provided high-quality images with minor distortion and a similar SNR to ssEPI-DWI. Our results suggest that the benefits of the rsEPI-DWI and pTSE-DWI sequences, in terms of SNR, image quality, and image distortion, appear to outweigh those of ssEPI-DWI. Thus, pTSE-DWI and rsEPI-DWI at 7 T have great potential use for clinical diagnoses. However, it is noteworthy that both

Current Status of Bicarbonate in CKD

PubMed Central

Dobre, Mirela; Rahman, Mahboob

2015-01-01

Metabolic acidosis was one of the earliest complications to be recognized and explained pathologically in patients with CKD. Despite the accumulated evidence of deleterious effects of acidosis, treatment of acidosis has been tested very little, especially with respect to standard clinical outcomes. On the basis of fundamental research and small alkali supplementation trials, correcting metabolic acidosis has a strikingly broad array of potential benefits. This review summarizes the published evidence on the association between serum bicarbonate and clinical outcomes. We discuss the role of alkali supplementation in CKD as it relates to retarding kidney disease progression, improving metabolic and musculoskeletal complications. PMID:25150154

How does CKD affect HbA1c?

PubMed

Bloomgarden, Zachary; Handelsman, Yehuda

2018-04-01

HOW DOES CHRONIC KIDNEY DISEASE AFFECT HBA1C?: A number of factors determine HbA1c other than the level of glucose exposure alone. In an subset analysis of the Atherosclerosis Risk in Communities study of 941 diabetic people with varying degrees of chronic kidney disease (CKD), as well as 724 who did not have CKD, and mean age in the eighth decade, Jung et al. ask whether HbA1c is reliable as an indicator of glycemia in people with kidney disease (CKD) to the same degree as in those not having kidney disease, and, if not, whether measures of glycated serum proteins may be more useful. The only available measure of glycemia for comparison was a single fasting glucose level, and the authors acknowledge that this gives an incomplete measure, particularly in people with relatively mild diabetes, whose mean HbA1c was 6.4%, with most having levels of 7.5% or lower. In patients of this sort, postprandial glucose levels may better explain variations in mean HbA1c. Recognizing that the dataset may be limited, Jung et al. nevertheless give an intriguingly negative answer to the first question, of the reliability of HbA1c with kidney disease. Using Deming regression analysis, Jung et al. showed that the correlation between HbA1c and fasting glucose weakens as renal function worsens, and, moreover, that this appears particularly to be the case in people with anemia (hemoglobin <130 and <120 g/L for men and women, respectively), confirming earlier observations. Among those diabetic people with neither anemia nor CKD, the correlation coefficient between HbA1c and fasting glucose was r = 0.70, compared with r = 0.35 among those with both anemia and very severe CKD (estimated glomerular filtration rate [eGFR] <30 or <45 mL/min per 1.73 m 2 with at least microalbuminuria, or eGFR <60 mL/min per 1.73 m 2 with macroalbuminuria). As far as the second question, of whether the alternative measures, namely fructosamine and glycated albumin, may be more useful with CKD

Multishot EPI-SSFP in the heart.

PubMed

Herzka, Daniel A; Kellman, Peter; Aletras, Anthony H; Guttman, Michael A; McVeigh, Elliot R

2002-04-01

Refocused steady-state free precession (SSFP), or fast imaging with steady precession (FISP or TrueFISP), has recently proven valuable for cardiac imaging because of its high signal-to-noise ratio (SNR) and excellent blood-myocardium contrast. In this study, various implementations of multiecho SSFP or EPI-SSFP for imaging in the heart are presented. EPI-SSFP has higher scan-time efficiency than single-echo SSFP, as two or more phase-encode lines are acquired per repetition time (TR) at the cost of a modest increase in TR. To minimize TR, a noninterleaved phase-encode order in conjunction with a phased-array ghost elimination (PAGE) technique was employed, removing the need for echo time shifting (ETS). The multishot implementation of EPI-SSFP was used to decrease the breath-hold duration for cine acquisitions or to increase the temporal or spatial resolution for a fixed breath-hold duration. The greatest gain in efficiency was obtained with the use of a three-echo acquisition. Image quality for cardiac cine applications using multishot EPI-SSFP was comparable to that of single-echo SSFP in terms of blood-myocardium contrast and contrast-to-noise ratio (CNR). The PAGE method considerably reduced flow artifacts due to both the inherent ghost suppression and the concomitant reduction in phase-encode blip size. The increased TR of multishot EPI-SSFP led to a reduced specific absorption rate (SAR) for a fixed RF flip angle, and allowed the use of a larger flip angle without increasing the SAR above the FDA-approved limits. Copyright 2002 Wiley-Liss, Inc.

Multishot EPI-SSFP in the Heart

PubMed Central

Herzka, Daniel A.; Kellman, Peter; Aletras, Anthony H.; Guttman, Michael A.; McVeigh, Elliot R.

2007-01-01

Refocused steady-state free precession (SSFP), or fast imaging with steady precession (FISP or TrueFISP), has recently proven valuable for cardiac imaging because of its high signal-to-noise ratio (SNR) and excellent blood-myocardium contrast. In this study, various implementations of multiecho SSFP or EPI-SSFP for imaging in the heart are presented. EPI-SSFP has higher scan-time efficiency than single-echo SSFP, as two or more phase-encode lines are acquired per repetition time (TR) at the cost of a modest increase in TR. To minimize TR, a noninterleaved phase-encode order in conjunction with a phased-array ghost elimination (PAGE) technique was employed, removing the need for echo time shifting (ETS). The multishot implementation of EPI-SSFP was used to decrease the breath-hold duration for cine acquisitions or to increase the temporal or spatial resolution for a fixed breath-hold duration. The greatest gain in efficiency was obtained with the use of a three-echo acquisition. Image quality for cardiac cine applications using multishot EPI-SSFP was comparable to that of single-echo SSFP in terms of blood-myocardium contrast and contrast-to-noise ratio (CNR). The PAGE method considerably reduced flow artifacts due to both the inherent ghost suppression and the concomitant reduction in phase-encode blip size. The increased TR of multishot EPI-SSFP led to a reduced specific absorption rate (SAR) for a fixed RF flip angle, and allowed the use of a larger flip angle without increasing the SAR above the FDA-approved limits. PMID:11948726

Association of CKD with Outcomes Among Patients Undergoing Transcatheter Aortic Valve Implantation

PubMed Central

Kaier, Klaus; Kaleschke, Gerrit; Gebauer, Katrin; Meyborg, Matthias; Malyar, Nasser M.; Freisinger, Eva; Baumgartner, Helmut; Reinecke, Holger; Reinöhl, Jochen

2017-01-01

Background and objectives Despitethe multiple depicted associations of CKD with reduced cardiovascular and overall prognoses, the association of CKD with outcome of patients undergoing transcatheter aortic valve implantation has still not been well described. Design, setting, participants, & measurements Data from all hospitalized patients who underwent transcatheter aortic valve implantation procedures between January 1, 2010 and December 31, 2013 in Germany were evaluated regarding influence of CKD, even in the earlier stages, on morbidity, in-hospital outcomes, and costs. Results A total of 28,716 patients were treated with transcatheter aortic valve implantation. A total of 11,189 (39.0%) suffered from CKD. Patients with CKD were predominantly women; had higher rates of comorbidities, such as coronary artery disease, heart failure at New York Heart Association 3/4, peripheral artery disease, and diabetes; and had a 1.3-fold higher estimated logistic European System for Cardiac Operative Risk Evaluation value. In-hospital mortality was independently associated with CKD stage ≥3 (up to odds ratio, 1.71; 95% confidence interval, 1.35 to 2.17; P<0.05), bleeding was independently associated with CKD stage ≥4 (up to odds ratio, 1.82; 95% confidence interval, 1.47 to 2.24; P<0.001), and AKI was independently associated with CKD stages 3 (odds ratio, 1.83; 95% confidence interval, 1.62 to 2.06) and 4 (odds ratio, 2.33; 95% confidence interval, 1.92 to 2.83 both P<0.001). The stroke risk, in contrast, was lower for patients with CKD stages 4 (odds ratio, 0.23; 95% confidence interval, 0.16 to 0.33) and 5 (odds ratio, 0.24; 95% confidence interval, 0.15 to 0.39; both P<0.001). Lengths of hospital stay were, on average, 1.2-fold longer, whereas reimbursements were, on average, only 1.03-fold higher in patients who suffered from CKD. Conclusions This analysis illustrates for the first time on a nationwide basis the association of CKD with adverse outcomes in patients

Association of CKD with Outcomes Among Patients Undergoing Transcatheter Aortic Valve Implantation.

PubMed

Lüders, Florian; Kaier, Klaus; Kaleschke, Gerrit; Gebauer, Katrin; Meyborg, Matthias; Malyar, Nasser M; Freisinger, Eva; Baumgartner, Helmut; Reinecke, Holger; Reinöhl, Jochen

2017-05-08

Despitethe multiple depicted associations of CKD with reduced cardiovascular and overall prognoses, the association of CKD with outcome of patients undergoing transcatheter aortic valve implantation has still not been well described. Data from all hospitalized patients who underwent transcatheter aortic valve implantation procedures between January 1, 2010 and December 31, 2013 in Germany were evaluated regarding influence of CKD, even in the earlier stages, on morbidity, in-hospital outcomes, and costs. A total of 28,716 patients were treated with transcatheter aortic valve implantation. A total of 11,189 (39.0%) suffered from CKD. Patients with CKD were predominantly women; had higher rates of comorbidities, such as coronary artery disease, heart failure at New York Heart Association 3/4, peripheral artery disease, and diabetes; and had a 1.3-fold higher estimated logistic European System for Cardiac Operative Risk Evaluation value. In-hospital mortality was independently associated with CKD stage ≥3 (up to odds ratio, 1.71; 95% confidence interval, 1.35 to 2.17; P <0.05), bleeding was independently associated with CKD stage ≥4 (up to odds ratio, 1.82; 95% confidence interval, 1.47 to 2.24; P <0.001), and AKI was independently associated with CKD stages 3 (odds ratio, 1.83; 95% confidence interval, 1.62 to 2.06) and 4 (odds ratio, 2.33; 95% confidence interval, 1.92 to 2.83 both P <0.001). The stroke risk, in contrast, was lower for patients with CKD stages 4 (odds ratio, 0.23; 95% confidence interval, 0.16 to 0.33) and 5 (odds ratio, 0.24; 95% confidence interval, 0.15 to 0.39; both P <0.001). Lengths of hospital stay were, on average, 1.2-fold longer, whereas reimbursements were, on average, only 1.03-fold higher in patients who suffered from CKD. This analysis illustrates for the first time on a nationwide basis the association of CKD with adverse outcomes in patients who underwent transcatheter aortic valve implantation. Thus, classification of CKD stages

Poverty, Race, and CKD in a Racially and Socioeconomically Diverse Urban Population

PubMed Central

Crews, Deidra C.; Charles, Raquel F.; Evans, Michele K.; Zonderman, Alan B.; Powe, Neil R.

2010-01-01

Background Low socioeconomic status (SES) and African American race are both independently associated with end-stage renal disease and progressive chronic kidney disease (CKD), however, despite their frequent co-occurrence, the effect of low SES independent of race has not been well-studied in CKD. Study Design Cross-sectional study. Setting & Participants 2,375 community-dwelling adults age 30-64 years residing within 12 neighborhoods selected for both socioeconomic and racial diversity in Baltimore City, Maryland. Predictors Low SES [self-reported household income <125% of 2004 Department of Health and Human Services guideline], higher SES (≥125% of guideline); white and African American race. Outcomes & Measurements CKD defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Logistic regression used to calculate odds ratios (OR) for relationship between poverty and CKD, stratified by race. Results Of 2,375 participants; 955 were white (347 low SES and 608 higher SES); 1,420 were African American (713 low SES and 707 higher SES). A total of 146 (6.2%) participants had CKD. Overall, race was not associated with CKD [OR, 1.05; 95% confidence interval (CI), 0.57-1.96]; however, African Americans had a much greater odds of advanced CKD (eGFR <30 mL/min/1.73 m2). Low SES was independently associated with 59% greater odds of CKD after adjustment for demographics, insurance status and comorbid disease (OR, 1.59; 95% CI, 1.27-1.99). However, when stratified by race, low SES was associated with CKD in African Americans (OR, 1.91; 95% CI, 1.54-2.38), but not in whites (OR, 0.95; 95% CI, 0.58-1.55; P for interaction, 0.003). Limitations Cross-sectional design; findings may not be generalizable to non-urban populations. Conclusions Low SES has a profound relationship with CKD in African Americans but not in whites in an urban population of adults, and its role in the racial disparities seen in CKD is worthy of further investigation. PMID:20207457

Poverty, race, and CKD in a racially and socioeconomically diverse urban population.

PubMed

Crews, Deidra C; Charles, Raquel F; Evans, Michele K; Zonderman, Alan B; Powe, Neil R

2010-06-01

Low socioeconomic status (SES) and African American race are both independently associated with end-stage renal disease and progressive chronic kidney disease (CKD). However, despite their frequent co-occurrence, the effect of low SES independent of race has not been well studied in CKD. Cross-sectional study. 2,375 community-dwelling adults aged 30-64 years residing within 12 neighborhoods selected for both socioeconomic and racial diversity in Baltimore City, MD. Low SES (self-reported household income <125% of 2004 Department of Health and Human Services guideline), higher SES (> or =125% of guideline); white and African American race. CKD defined as estimated glomerular filtration rate <60 mL/min/1.73 m(2). Logistic regression used to calculate ORs for relationship between poverty and CKD, stratified by race. Of 2,375 participants, 955 were white (347 low SES and 608 higher SES) and 1,420 were African American (713 low SES and 707 higher SES). 146 (6.2%) participants had CKD. Overall, race was not associated with CKD (OR, 1.05; 95% CI, 0.57-1.96); however, African Americans had a much greater odds of advanced CKD (estimated glomerular filtration rate <30 mL/min/1.73 m(2)). Low SES was independently associated with 59% greater odds of CKD after adjustment for demographics, insurance status, and comorbid disease (OR, 1.59; 95% CI, 1.27-1.99). However, stratified by race, low SES was associated with CKD in African Americans (OR, 1.91; 95% CI, 1.54-2.38), but not whites (OR, 0.95; 95% CI, 0.58-1.55; P for interaction = 0.003). Cross-sectional design; findings may not be generalizable to non-urban populations. Low SES has a profound relationship with CKD in African Americans, but not whites, in an urban population of adults, and its role in the racial disparities seen in CKD is worthy of further investigation. Copyright 2010 National Kidney Foundation, Inc. All rights reserved.

Nutritional Status in Adults with Predialysis Chronic Kidney Disease: KNOW-CKD Study.

PubMed

Hyun, Young Youl; Lee, Kyu Beck; Han, Seung Hyeok; Kim, Yeong Hoon; Kim, Yong Soo; Lee, Sung Woo; Oh, Yun Kyu; Chae, Dong Wan; Ahn, Curie

2017-02-01

Adverse changes in nutrition are prevalent and are strong indicators of adverse outcomes in patients with chronic kidney disease (CKD). The International Society of Renal Nutrition and Metabolism (ISRNM) proposed a common nomenclature and diagnostic criteria to identify protein-energy wasting (PEW) in CKD patients. We examined the nutritional status in 1,834 adults with predialysis CKD enrolled in the KoreaN cohort study for Outcome in patients With Chronic Kidney Disease (KNOW-CKD) study. As there was a need for further understanding of nutritional status and associated factors in CKD, we evaluated the prevalence and associated factors of PEW in adults with predialysis CKD. The prevalence of PEW was about 9.0% according to ISRNM criteria and tended to increase with advanced stage in predialysis CKD. Those who concurrently had PEW, inflammation, and CVD were a small proportion (0.4%). In multivariate logistic regression model, PEW was independently associated with estimated glomerular filtration rate (eGFR) (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96-0.99), total CO₂ (OR, 0.93; 95% CI, 0.87-0.99), physical activity (OR, 0.43; 95% CI, 0.26-0.69), comorbid diabetes (OR, 1.68; 95% CI, 1.09-2.59), and high sensitivity C-reactive protein (hs-CRP) (OR, 1.03; 95% CI, 1.01-1.06). Our study suggests that PEW increases with advanced CKD stage. PEW is independently associated with renal function, low total CO₂, low physical activity, comorbid diabetes, and increased hs-CRP in adults with predialysis CKD.

Osteoporosis, bone mineral density and CKD-MBD complex (I): Diagnostic considerations.

PubMed

Bover, Jordi; Ureña-Torres, Pablo; Torregrosa, Josep-Vicent; Rodríguez-García, Minerva; Castro-Alonso, Cristina; Górriz, José Luis; Laiz Alonso, Ana María; Cigarrán, Secundino; Benito, Silvia; López-Báez, Víctor; Lloret Cora, María Jesús; daSilva, Iara; Cannata-Andía, Jorge

2018-04-24

Osteoporosis (OP) and chronic kidney disease (CKD) independently influence bone and cardiovascular health. A considerable number of patients with CKD, especially those with stages 3a to 5D, have a significantly reduced bone mineral density leading to a high risk of fracture and a significant increase in associated morbidity and mortality. Independently of classic OP related to age and/or gender, the mechanical properties of bone are also affected by inherent risk factors for CKD ("uraemic OP"). In the first part of this review, we will analyse the general concepts regarding bone mineral density, OP and fractures, which have been largely undervalued until now by nephrologists due to the lack of evidence and diagnostic difficulties in the context of CKD. It has now been proven that a reduced bone mineral density is highly predictive of fracture risk in CKD patients, although it does not allow a distinction to be made between the causes which generate it (hyperparathyroidism, adynamic bone disease and/or senile osteoporosis, etc.). Therefore, in the second part, we will analyse the therapeutic indications in different CKD stages. In any case, the individual assessment of factors which represent a higher or lower risk of fracture, the quantification of this risk (i.e. using tools such as FRAX ® ) and the potential indications for densitometry in patients with CKD could represent an important first step pending new clinical guidelines based on randomised studies which do not exclude CKD patients, all the while avoiding therapeutic nihilism in an area of growing importance. Copyright © 2018 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.

New frontiers for health information systems using Epi Info in developing countries: structured application framework for Epi Info (SAFE).

PubMed

Ma, J; Otten, M; Kamadjeu, R; Mir, R; Rosencrans, L; McLaughlin, S; Yoon, S

2008-04-01

For more than two decades, Epi Info software has been used to meet the data management, analysis, and mapping needs of public health professionals in more than 181 countries and 13 languages. Until now, most Epi Info systems have been relatively simple, mainly because of a lack of detailed and structured guidance for developing complex systems. We created the structured application framework for Epi Info (SAFE), which is a set of guidelines that allows developers to create both simple and complex information systems using accepted good programming practices. This has resulted in application code blocks that are re-useable and easy to maintain, modify, and enhance. The flexibility of SAFE allows various aggregate and case-based application modules to be rapidly created, combined, and updated to create health information systems or sub-systems enabling continuous, incremental enhancement as national and local capacity increases. SAFE and Epi Info are both cost-free and have low system requirements--characteristics that render this framework and software beneficial for developing countries.

Food Insecurity, CKD, and Subsequent ESRD in US Adults.

PubMed

Banerjee, Tanushree; Crews, Deidra C; Wesson, Donald E; Dharmarajan, Sai; Saran, Rajiv; Ríos Burrows, Nilka; Saydah, Sharon; Powe, Neil R

2017-07-01

Poor access to food among low-income adults has been recognized as a risk factor for chronic kidney disease (CKD), but there are no data for the impact of food insecurity on progression to end-stage renal disease (ESRD). We hypothesized that food insecurity would be independently associated with risk for ESRD among persons with and without earlier stages of CKD. Longitudinal cohort study. 2,320 adults (aged ≥ 20 years) with CKD and 10,448 adults with no CKD enrolled in NHANES III (1988-1994) with household income ≤ 400% of the federal poverty level linked to the Medicare ESRD Registry for a median follow-up of 12 years. Food insecurity, defined as an affirmative response to the food-insecurity screening question. Development of ESRD. Demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. Dietary acid load was estimated from 24-hour dietary recall. We used a Fine-Gray competing-risk model to estimate the relative hazard (RH) for ESRD associated with food insecurity after adjusting for covariates. 4.5% of adults with CKD were food insecure. Food-insecure individuals were more likely to be younger and have diabetes (29.9%), hypertension (73.9%), or albuminuria (90.4%) as compared with their counterparts (P<0.05). Median dietary acid load in the food-secure versus food-insecure group was 51.2 mEq/d versus 55.6 mEq/d, respectively (P=0.05). Food-insecure adults were more likely to develop ESRD (RH, 1.38; 95% CI, 1.08-3.10) compared with food-secure adults after adjustment for demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. In the non-CKD group, 5.7% were food insecure. We did not find a significant association between food insecurity and ESRD (RH, 0.77; 95% CI, 0.40-1.49). Use of single 24-hour diet recall; lack of laboratory follow-up data and measure of changes in food insecurity over time; follow-up of cohort ended 10 years ago. Among adults with CKD, food

Multinational Assessment of Accuracy of Equations for Predicting Risk of Kidney Failure: A Meta-analysis.

PubMed

Tangri, Navdeep; Grams, Morgan E; Levey, Andrew S; Coresh, Josef; Appel, Lawrence J; Astor, Brad C; Chodick, Gabriel; Collins, Allan J; Djurdjev, Ognjenka; Elley, C Raina; Evans, Marie; Garg, Amit X; Hallan, Stein I; Inker, Lesley A; Ito, Sadayoshi; Jee, Sun Ha; Kovesdy, Csaba P; Kronenberg, Florian; Heerspink, Hiddo J Lambers; Marks, Angharad; Nadkarni, Girish N; Navaneethan, Sankar D; Nelson, Robert G; Titze, Stephanie; Sarnak, Mark J; Stengel, Benedicte; Woodward, Mark; Iseki, Kunitoshi

2016-01-12

Identifying patients at risk of chronic kidney disease (CKD) progression may facilitate more optimal nephrology care. Kidney failure risk equations, including such factors as age, sex, estimated glomerular filtration rate, and calcium and phosphate concentrations, were previously developed and validated in 2 Canadian cohorts. Validation in other regions and in CKD populations not under the care of a nephrologist is needed. To evaluate the accuracy of the risk equations across different geographic regions and patient populations through individual participant data meta-analysis. Thirty-one cohorts, including 721,357 participants with CKD stages 3 to 5 in more than 30 countries spanning 4 continents, were studied. These cohorts collected data from 1982 through 2014. Cohorts participating in the CKD Prognosis Consortium with data on end-stage renal disease. Data were obtained and statistical analyses were performed between July 2012 and June 2015. Using the risk factors from the original risk equations, cohort-specific hazard ratios were estimated and combined using random-effects meta-analysis to form new pooled kidney failure risk equations. Original and pooled kidney failure risk equation performance was compared, and the need for regional calibration factors was assessed. Kidney failure (treatment by dialysis or kidney transplant). During a median follow-up of 4 years of 721,357 participants with CKD, 23,829 cases kidney failure were observed. The original risk equations achieved excellent discrimination (ability to differentiate those who developed kidney failure from those who did not) across all cohorts (overall C statistic, 0.90; 95% CI, 0.89-0.92 at 2 years; C statistic at 5 years, 0.88; 95% CI, 0.86-0.90); discrimination in subgroups by age, race, and diabetes status was similar. There was no improvement with the pooled equations. Calibration (the difference between observed and predicted risk) was adequate in North American cohorts, but the original risk

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.

Injury survey in Choi Kwang Do (CKD) martial art practitioners around the world: CKD is a safe form of training for adults.

PubMed

Jee, Yong-Seok; Eun, Denny

2018-02-01

Among the many sports and activities to choose from, martial arts are becoming increasingly popular for health and fitness. Due to the different nature of the various styles of martial arts, injuries are not uncommon. Though there have been studies on the injury rates of several martial art styles, there have been none regarding Choi Kwang Do (CKD), a noncompetitive martial art with relaxed and fluid movements designed to promote health and fitness for people of all ages. The purpose of this study was to examine the rate of injury for adults training in CKD to find out whether this is a safe style of martial art for adults. This study found the prevalence, causes, severity, and types of injuries from CKD practitioners around the world through an online survey targeting adults (n=122), aged 18 or older, with varying years of training experience. The annual rate of injury was 11.73 for every 100 CKD practitioners. There was no correlation between the length of training experience and injury. Training frequency and duration had no significant relationship with injury rates. A significant positive relationship between training intensity and injury existed ( P =0.009). The results of the study found that CKD can be an attractive option for adults of any age who are looking to learn a martial art or choose a physical activity with a low risk of injury, however the training intensity should be kept at a level that is not excessively high.

Injury survey in Choi Kwang Do (CKD) martial art practitioners around the world: CKD is a safe form of training for adults

PubMed Central

Jee, Yong-Seok; Eun, Denny

2018-01-01

Among the many sports and activities to choose from, martial arts are becoming increasingly popular for health and fitness. Due to the different nature of the various styles of martial arts, injuries are not uncommon. Though there have been studies on the injury rates of several martial art styles, there have been none regarding Choi Kwang Do (CKD), a noncompetitive martial art with relaxed and fluid movements designed to promote health and fitness for people of all ages. The purpose of this study was to examine the rate of injury for adults training in CKD to find out whether this is a safe style of martial art for adults. This study found the prevalence, causes, severity, and types of injuries from CKD practitioners around the world through an online survey targeting adults (n=122), aged 18 or older, with varying years of training experience. The annual rate of injury was 11.73 for every 100 CKD practitioners. There was no correlation between the length of training experience and injury. Training frequency and duration had no significant relationship with injury rates. A significant positive relationship between training intensity and injury existed (P=0.009). The results of the study found that CKD can be an attractive option for adults of any age who are looking to learn a martial art or choose a physical activity with a low risk of injury, however the training intensity should be kept at a level that is not excessively high. PMID:29511654

Readability of Written Materials for CKD Patients: A Systematic Review.

PubMed

Morony, Suzanne; Flynn, Michaela; McCaffery, Kirsten J; Jansen, Jesse; Webster, Angela C

2015-06-01

The "average" patient has a literacy level of US grade 8 (age 13-14 years), but this may be lower for people with chronic kidney disease (CKD). Current guidelines suggest that patient education materials should be pitched at a literacy level of around 5th grade (age 10-11 years). This study aims to evaluate the readability of written materials targeted at patients with CKD. Systematic review. Patient information materials aimed at adults with CKD and written in English. Patient education materials designed to be printed and read, sourced from practices in Australia and online at all known websites run by relevant international CKD organizations during March 2014. Quantitative analysis of readability using Lexile Analyzer and Flesch-Kincaid tools. We analyzed 80 materials. Both Lexile Analyzer and Flesch-Kincaid analyses suggested that most materials required a minimum of grade 9 (age 14-15 years) schooling to read them. Only 5% of materials were pitched at the recommended level (grade 5). Readability formulas have inherent limitations and do not account for visual information. We did not consider other media through which patients with CKD may access information. Although the study covered materials from the United States, United Kingdom, and Australia, all non-Internet materials were sourced locally, and it is possible that some international paper-based materials were missed. Generalizability may be limited due to exclusion of non-English materials. These findings suggest that patient information materials aimed at patients with CKD are pitched above the average patient's literacy level. This issue is compounded by cognitive decline in patients with CKD, who may have lower literacy than the average patient. It suggests that information providers need to consider their audience more carefully when preparing patient information materials, including user testing with a low-literacy patient population. Copyright © 2015 National Kidney Foundation, Inc. Published by

Revisiting RAAS blockade in CKD with newer potassium-binding drugs.

PubMed

Georgianos, Panagiotis I; Agarwal, Rajiv

2018-02-01

Among patients with proteinuric chronic kidney disease (CKD), current guideline recommendations mandate the use of agents blocking the renin angiotensin aldosterone system (RAAS) as first-line antihypertensive therapy based on randomized trials demonstrating that RAAS inhibitors are superior to other antihypertensive drug classes in slowing nephropathy progression to end-stage renal disease. However, the opportunities for adequate RAAS blockade in CKD are often limited, and an important impediment is the risk of hyperkalemia, especially when RAAS inhibitors are used in maximal doses or are combined. Accordingly, a large proportion of patients with proteinuric CKD may not have the anticipated renoprotective benefits since RAAS blockers are often discontinued due to incident hyperkalemia or are administered at suboptimal doses for fear of the development of hyperkalemia. Two newer potassium binders, patiromer and sodium zirconium cyclosilicate (ZS-9), have been shown to effectively and safely reduce serum potassium levels and maintain long-term normokalemia in CKD patients receiving background therapy with RAAS inhibitors. Whether these novel potassium-lowering therapies can overcome the barrier of hyperkalemia and enhance the tolerability of RAAS inhibitor use in proteinuric CKD awaits randomized trials. Published by Elsevier Inc.

Soluble Flt-1 links microvascular disease with heart failure in CKD.

PubMed

Di Marco, Giovana S; Kentrup, Dominik; Reuter, Stefan; Mayer, Anna B; Golle, Lina; Tiemann, Klaus; Fobker, Manfred; Engelbertz, Christiane; Breithardt, Günter; Brand, Eva; Reinecke, Holger; Pavenstädt, Hermann; Brand, Marcus

2015-05-01

Chronic kidney disease (CKD) is associated with an increased risk of heart failure (HF). Elevated plasma concentrations of soluble Flt-1 (sFlt-1) have been linked to cardiovascular disease in CKD patients, but whether sFlt-1 contributes to HF in CKD is still unknown. To provide evidence that concludes a pathophysiological role of sFlt-1 in CKD-associated HF, we measured plasma sFlt-1 concentrations in 586 patients with angiographically documented coronary artery disease and renal function classified according to estimated glomerular filtration rate (eGFR). sFlt-1 concentrations correlated negatively with eGFR and were associated with signs of heart failure, based on New York Heart Association functional class and reduced left ventricular ejection fraction (LVEF), and early mortality. Additionally, rats treated with recombinant sFlt-1 showed a 15 % reduction in LVEF and a 29 % reduction in cardiac output compared with control rats. High sFlt-1 concentrations were associated with a 15 % reduction in heart capillary density (number of vessels/cardiomyocyte) and a 24 % reduction in myocardial blood volume. Electron microscopy and histological analysis revealed mitochondrial damage and interstitial fibrosis in the hearts of sFlt-1-treated, but not control rats. In 5/6-nephrectomised rats, an animal model of CKD, sFlt-1 antagonism with recombinant VEGF121 preserved heart microvasculature and significantly improved heart function. Overall, these findings suggest that a component of cardiovascular risk in CKD patients could be directly attributed to sFlt-1. Assessment of patients with CKD confirmed that sFlt-1 concentrations were inversely correlated with renal function, while studies in rats suggested that sFlt-1 may link microvascular disease with HF in CKD.

Association of frailty and physical function in patients with non-dialysis CKD: a systematic review

PubMed Central

2013-01-01

Background Frailty is a condition characterized by a decline in physical function and functional capacity. Common symptoms of frailty, such as weakness and exhaustion, are prevalent in patients with chronic kidney disease (CKD). The increased vulnerability of frail patients with coexisting CKD may place them at a heightened risk of encountering additional health complications. The purpose of this systematic review was to explore the link between frailty, CKD and clinical outcomes. Methods We searched for cross sectional and prospective studies in the general population and in the CKD population indexed in EMBASE, Pubmed, Web of Science, CINAHL, Cochrane and Ageline examining the association between frailty and CKD and those relating frailty in patients with CKD to clinical outcomes. Results We screened 5,066 abstracts and retrieved 108 studies for full text review. We identified 7 studies associating frailty or physical function to CKD. From the 7 studies, we identified only two studies that related frailty in patients with CKD to a clinical outcome. CKD was consistently associated with increasing frailty or reduced physical function [odds ratios (OR) 1.30 to 3.12]. In patients with CKD, frailty was associated with a greater than two-fold higher risk of dialysis and/or death [OR from 2.0 to 5.88]. Conclusions CKD is associated with a higher risk of frailty or diminished physical function. Furthermore, the presence of frailty in patients with CKD may lead to a higher risk of mortality. Further research must be conducted to understand the mechanisms of frailty in CKD and to confirm its association with clinical outcomes. PMID:24148266

Electronegative LDL-mediated cardiac electrical remodeling in a rat model of chronic kidney disease

PubMed Central

Lee, An-Sheng; Chen, Wei-Yu; Chan, Hua-Chen; Chung, Ching-Hu; Peng, Hsien-Yu; Chang, Chia-Ming; Su, Ming-Jai; Chen, Chu-Huang; Chang, Kuan-Cheng

2017-01-01

The mechanisms underlying chronic kidney disease (CKD)–associated higher risks for life-threatening ventricular tachyarrhythmias remain poorly understood. In rats subjected to unilateral nephrectomy (UNx), we examined cardiac electrophysiological remodeling and relevant mechanisms predisposing to ventricular arrhythmias. Adult male Sprague-Dawley rats underwent UNx (n = 6) or sham (n = 6) operations. Eight weeks later, the UNx group had higher serum blood urea nitrogen and creatinine levels and a longer electrocardiographic QTc interval than did the sham group. Patch-clamp studies revealed epicardial (EPI)-predominant prolongation of the action potential duration (APD) at 50% and 90% repolarization in UNx EPI cardiomyocytes compared to sham EPI cardiomyocytes. A significant reduction of the transient outward potassium current (Ito) in EPI but not in endocardial (ENDO) cardiomyocytes of UNx rats led to a decreased transmural gradient of Ito. The reduction of Ito currents in UNx EPI cardiomyocytes was secondary to downregulation of KChIP2 but not Kv4.2, Kv4.3, and Kv1.4 protein expression. Incubation of plasma electronegative low-density lipoprotein (LDL) from UNx rats with normal EPI and ENDO cardiomyocytes recapitulated the electrophysiological phenotype of UNx rats. In conclusion, CKD disrupts the physiological transmural gradient of Ito via downregulation of KChIP2 proteins in the EPI region, which may promote susceptibility to ventricular tachyarrhythmias. Electronegative LDL may underlie downregulation of KChIP2 in CKD. PMID:28094801

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. Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Cystatin C– and Creatinine-Based Estimated Glomerular Filtration Rate, Vascular Disease, and Mortality in Persons With Diabetes in the U.S.

PubMed Central

Tsai, Ching-Wei; Grams, Morgan E.; Inker, Lesley A.; Coresh, Josef; Selvin, Elizabeth

2014-01-01

OBJECTIVE Serum cystatin C is an alternative to serum creatinine for estimating glomerular filtration rate (GFR), since cystatin C is less influenced by age and muscle mass. Among persons with diabetes, we compared the performance of GFR estimated using cystatin C (eGFRcys) with that using creatinine (eGFRcr) for the identification of reduced kidney function and its association with diabetes complications. RESEARCH DESIGN AND METHODS We analyzed data from adult participants from the 1999–2002 National Health and Nutrition Examination Survey with available cystatin C (N = 4,457). Kidney function was dichotomized as preserved (eGFR ≥60 mL/min/1.73 m2) or reduced (eGFR <60 mL/min/1.73 m2) using the 2012 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) cystatin C and the 2009 CKD-EPI creatinine equations. RESULTS Among 778 persons with diabetes, the prevalence of reduced kidney function was 16.5% using eGFRcr and 22.0% using eGFRcys. More persons with diabetes were reclassified from preserved kidney function by eGFRcr to reduced kidney function by eGFRcys than persons without diabetes (odds ratio 3.1 [95% CI 1.9–4.9], P < 0.001). The associations between lower eGFR and higher prevalence of albuminuria, retinopathy, peripheral arterial disease, and coronary artery disease were robust regardless of filtration marker. Similarly, the risk of all-cause mortality increased with lower eGFRcr and eGFRcys. Only lower eGFRcys was significantly associated with cardiovascular mortality. CONCLUSIONS More persons with diabetes had reduced kidney function by eGFRcys than by eGFRcr, and lower eGFRcys was strongly associated with diabetes complications. Whether eGFRcys is superior to eGFRcr in approximating true kidney function in a diabetic population requires additional study. PMID:24271191

Is Kidney Transplantation a Better State of CKD? Impact on Diagnosis and Management.

PubMed

Parajuli, Sandesh; Clark, Dana F; Djamali, Arjang

2016-09-01

Patients with CKD are at increased risk for cardiovascular events, hospitalizations, and mortality. Kidney transplantation (KTx) is the preferred treatment for end-stage kidney disease. Although comorbidities including anemia and bone and mineral disease improve or are even halted after KTx, kidney transplant recipients carry higher cardiovascular mortality risk than the general population, as well as an increased risk of infections, malignancies, fractures, and obesity. When comparing CKD with CKD after transplantation (CKD-T), the rate of decline of estimated glomerular filtration rate (eGFR) is significantly lower in CKD-T. Higher rate of decline of eGFR has been associated with increased risk of mortality. However, due to the significant increased risk of mortality due to cardiovascular events, infections, and malignancies, many kidney transplant recipients may not benefit of decline in the rate of eGFR. Patients with CKD-T are a unique subset of patients with multiple traditional and transplant-specific risk factors. Proper management and appropriate preventive health measures may improve long-term patient and allograft survival in patients with CKD-T. Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Homocysteine and C-reactive protein as useful surrogate markers for evaluating CKD risk in adults.

PubMed

Chuang, Chung-Hsun; Lee, Yi-Yen; Sheu, Bor-Fuh; Hsiao, Cheng-Ting; Loke, Song-Seng; Chen, Jih-Chang; Li, Wen-Cheng

2013-01-01

This study aimed to evaluate the effectiveness of homocysteine and C-reactive protein (CRP) as potential markers for chronic kidney disease (CKD) in adults in Taiwan, and to identify associations between these factors and CKD, stratifying by gender. This cross-sectional study analyzed multi-center data retrospectively. Data were collected from 22,043 adult Taiwanese at Chang-Gung Memorial Hospital from 2005 to 2011. Smoking/drinking history, personal medical/medication history, pregnancy, fasting times as well as laboratory parameters, including homocysteine and CRP were measured and analyzed. Significant differences were observed between four homocysteine and CRP quartiles in eGFR and CKD. For males, only one model showed significant associations between plasma homocysteine and CKD, while in females, all three models showed significant associations with CKD. On the contrary, the gender difference in the case of CRP was opposite. Combined homocysteine and CRP were associated with CKD in males but not in females. Among Taiwanese adults, plasma homocysteine is associated with CKD in females and plasma hsCRP is associated with CKD in males. High hsCRP/high homocysteine is associated with elevated CKD risk in male. Our results suggest that homocysteine and hsCRP may be useful surrogate markers for evaluating CKD risk in adults. © 2013 S. Karger AG, Basel.

Variation in Patients’ Awareness of CKD according to How They Are Asked

PubMed Central

Zhu, Yunnuo; Velasquez, Alexandra; Espinoza, Juan; Mendez, C. Damaris; Banerjee, Tanushree; Hsu, Chi-yuan; Powe, Neil R.

2016-01-01

Background and objectives Awareness of CKD is necessary for patient engagement and adherence to medical regimens. Having an accurate tool to assess awareness is important. Use of the National Health and Nutrition Examination Survey (NHANES) CKD awareness question “Have you ever been told by a doctor or other health professional that you had weak or failing kidneys (excluding kidney stones, bladder infections, or incontinence)?” produces surprisingly low measures of CKD awareness. We sought to compare the sensitivity and specificity of different questions ascertaining awareness of CKD and other health conditions. Design, setting, participants, & measurements Between August of 2011 and August of 2014, an in-person questionnaire was administered to 220 adults with CKD, diabetes, hypertension, or hyperlipidemia who received primary care in a public health care delivery system to ascertain awareness of each condition. CKD awareness was measured using the NHANES question, and other questions, asking if patients knew about their “kidney disease”, “protein in the urine”, “kidney problem”, or “kidney damage.” Demographic data were self-reported; health literacy was measured. The sensitivity and specificity of each question was calculated using the medical record as the gold standard. Results In this diverse population (9.6% white, 40.6% black, 36.5% Hispanic, 12.3% Asian), the mean age was 58 years, 30% had a non-English language preference, and 45% had low health literacy. Eighty percent of participants had CKD, with a mean eGFR of 47.2 ml/min per 1.73 m2. The sensitivities of each CKD awareness question were: 26.4% for “kidney damage”, 27.7% for “kidney disease”, 33.2% for “weak or failing kidneys”, 39.8% for “protein in the urine”, and 40.1% for “kidney problem.” Specificities ranged from 82.2% to 97.6%. The best two-question combination yielded a sensitivity of 53.1% and a specificity of 83.3%. This was lower than awareness of

Targeting inflammation: new therapeutic approaches in chronic kidney disease (CKD).

PubMed

Impellizzeri, Daniela; Esposito, Emanuela; Attley, James; Cuzzocrea, Salvatore

2014-03-01

Chronic inflammation and oxidative stress, features that are closely associated with nuclear factor (NF-κB) activation, play a key role in the development and progression of chronic kidney disease (CKD). Several animal models and clinical trials have clearly demonstrated the effectiveness of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy to improve glomerular/tubulointerstitial damage, reduce proteinuria, and decrease CKD progression, but CKD treatment still represents a clinical challenge. Bardoxolone methyl, a first-in-class oral Nrf-2 (nuclear factor erythroid 2-related factor 2) agonist that until recently showed considerable potential for the management of a range of chronic diseases, had been shown to improve kidney function in patients with advanced diabetic nephropathy (DN) with few adverse events in a phase 2 trial, but a large phase 3 study in patients with diabetes and CKD was halted due to emerging toxicity and death in a number of patients. Instead, palmitoylethanolamide (PEA) a member of the fatty acid ethanolamine family, is a novel non-steroidal, kidney friendly anti-inflammatory and anti-fibrotic agent with a well-documented safety profile, that may represent a potential candidate in treating CKD probably by a combination of pharmacological properties, including some activity at the peroxisome proliferator activated receptor alpha (PPAR-α). The aim of this review is to discuss new therapeutic approaches for the treatment of CKD, with particular reference to the outcome of two therapies, bardoxolone methyl and PEA, to improve our understanding of which pharmacological properties are responsible for the anti-inflammatory effects necessary for the effective treatment of renal disease. Copyright © 2014 Elsevier Ltd. All rights reserved.

Telehealth Applications to Enhance CKD Knowledge and Awareness Among Patients and Providers.

PubMed

Tuot, Delphine S; Boulware, L Ebony

2017-01-01

CKD affects 13% of the US adult population, causes excess mortality, and is associated with significant sociodemographic disparities. Optimal CKD management slows progression of disease and reduces cardiovascular-related outcomes. Resources for patients and primary care providers, major stakeholders in preventive CKD care, are critically needed to enhance understanding of the disease and to optimize CKD health, particularly because of the asymptomatic nature of kidney disease. Telehealth is defined as the use of electronic communication and telecommunications technology to support long-distance clinical health care, patient and professional health-related education, and public health and health administration. It provides new opportunities to enhance awareness and understanding among these important stakeholders. This review will examine the role of telehealth within existing educational theories, identify telehealth applications that can enhance CKD knowledge and behavior change among patients and primary care providers, and examine the advantages and disadvantages of telehealth vs usual modalities for education. Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Effects of phosphate binders in moderate CKD.

PubMed

Block, Geoffrey A; Wheeler, David C; Persky, Martha S; Kestenbaum, Bryan; Ketteler, Markus; Spiegel, David M; Allison, Matthew A; Asplin, John; Smits, Gerard; Hoofnagle, Andrew N; Kooienga, Laura; Thadhani, Ravi; Mannstadt, Michael; Wolf, Myles; Chertow, Glenn M

2012-08-01

Some propose using phosphate binders in the CKD population given the association between higher levels of phosphorus and mortality, but their safety and efficacy in this population are not well understood. Here, we aimed to determine the effects of phosphate binders on parameters of mineral metabolism and vascular calcification among patients with moderate to advanced CKD. We randomly assigned 148 patients with estimated GFR=20-45 ml/min per 1.73 m(2) to calcium acetate, lanthanum carbonate, sevelamer carbonate, or placebo. The primary endpoint was change in mean serum phosphorus from baseline to the average of months 3, 6, and 9. Serum phosphorus decreased from a baseline mean of 4.2 mg/dl in both active and placebo arms to 3.9 mg/dl with active therapy and 4.1 mg/dl with placebo (P=0.03). Phosphate binders, but not placebo, decreased mean 24-hour urine phosphorus by 22%. Median serum intact parathyroid hormone remained stable with active therapy and increased with placebo (P=0.002). Active therapy did not significantly affect plasma C-terminal fibroblast growth factor 23 levels. Active therapy did, however, significantly increase calcification of the coronary arteries and abdominal aorta (coronary: median increases of 18.1% versus 0.6%, P=0.05; abdominal aorta: median increases of 15.4% versus 3.4%, P=0.03). In conclusion, phosphate binders significantly lower serum and urinary phosphorus and attenuate progression of secondary hyperparathyroidism among patients with CKD who have normal or near-normal levels of serum phosphorus; however, they also promote the progression of vascular calcification. The safety and efficacy of phosphate binders in CKD remain uncertain.

Hypervitaminosis A is prevalent in children with CKD and contributes to hypercalcemia.

PubMed

Manickavasagar, Baheerathi; McArdle, Andrew J; Yadav, Pallavi; Shaw, Vanessa; Dixon, Marjorie; Blomhoff, Rune; Connor, Graeme O'; Rees, Lesley; Ledermann, Sarah; Van't Hoff, William; Shroff, Rukshana

2015-02-01

Vitamin A accumulates in renal failure, but the prevalence of hypervitaminosis A in children with predialysis chronic kidney disease (CKD) is not known. Hypervitaminosis A has been associated with hypercalcemia. In this study we compared dietary vitamin A intake with serum retinoid levels and their associations with hypercalcemia. We studied the relationship between vitamin A intake, serum retinoid levels, and serum calcium in 105 children with CKD stages 2-5 on dialysis and posttransplant. Serum retinoid measures included retinol (ROH), its active retinoic acid (RA) metabolites [all-trans RA (at-RA) and 13-cis RA] and carrier proteins [retinol-binding protein-4 (RBP4) and transthyretin (TTR)]. Dietary vitamin A intake was assessed using a food diary. Twenty-five children were in CKD 2-3, 35 in CKD 4-5, 23 on dialysis and 22 posttransplant; 53 % had vitamin A intake above the Reference Nutrient Intake (RNI) value. Children receiving supplemental feeds compared with diet alone had higher vitamin A intake (p = 0.02) and higher serum ROH (p < 0.001). Notably, increased ROH was seen as early as CKD stage 2. For every 10 ml/min/1.73 m(2) fall in estimated glomerular filtration rate (eGFR), there was a 13 % increase in ROH. RBP4 levels were increased in CKD 3-5 and dialysis patients. The lowest ratios of ROH:RBP4 were seen in dialysis compared with CKD 2-3 (p = 0.03), suggesting a relative increase in circulating RBP4. Serum ROH, RBP4 and at-RA were associated with serum calcium. On multivariable analysis RBP4 levels and alfacalcidol dose were significant predictors of serum calcium (model R (2) 32 %) in dialysis patients. Hypervitaminosis A is seen in early CKD, with highest levels in children on supplemental feeds compared with diet alone. Serum retinoid levels significantly predict hypercalcemia.

Serum α1-proteinase inhibitor concentrations in dogs with exocrine pancreatic disease, chronic hepatitis or proteinuric chronic kidney disease.

PubMed

Heilmann, R M; Grützner, N; Hokamp, J A; Lidbury, J A; Xenoulis, P G; Suchodolski, J S; Nabity, M B; Cianciolo, R; Steiner, J M

2018-06-01

Serum canine α 1 -proteinase inhibitor (cα 1 -PI) concentrations were evaluated in dogs with pancreatitis (n=24), exocrine pancreatic insufficiency (EPI; n=29), chronic hepatitis (CH; n=11) or proteinuric chronic kidney disease (CKD-P; n=61) to determine whether systemic proteinase/proteinase-inhibitor balance is altered in these conditions. Dogs with CKD-P had significantly lower cα 1 -PI concentrations than dogs with pancreatitis, EPI or CH; 16% of dogs with CKD-P had serum cα 1 -PI concentrations below the reference interval. Serum and urine cα 1 -PI concentrations were inversely correlated in dogs with CKD-P, but not in dogs with CH. This suggests that renal loss of cα 1 -PI contributes to decreased serum concentrations in dogs with CKD-P, while hepatic cα 1 -PI synthesis with CH either is not compromised or is counterbalanced by extrahepatic production. Copyright © 2018 Elsevier Ltd. All rights reserved.

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

PubMed

Martín-Cleary, Catalina; Ortiz, Alberto

2014-12-01

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.

Knowledge deficit of patients with stage 1-4 CKD: a focus group study.

PubMed

Lopez-Vargas, Pamela A; Tong, Allison; Phoon, Richard K S; Chadban, Steven J; Shen, Yvonne; Craig, Jonathan C

2014-04-01

Patients with early-stage chronic kidney disease (CKD) must make lifestyle modifications and adhere to treatment regimens to prevent their progression to end-stage kidney disease. The aim of this study was to elicit the perspectives of patients with stage 1-4 CKD about their disease, with a specific focus on their information needs in managing and living with CKD and its sequelae. Patients with CKD stages 1-4 were purposively sampled from three major hospitals in Sydney, Australia to participate in focus groups. Transcripts were thematically analysed. From nine focus groups including 38 participants, six major themes were identified: medical attentiveness (shared decision-making, rapport, indifference and insensitivity); learning self-management (diet and nutrition, barriers to physical activity, medication safety); contextualizing comorbidities (prominence of CKD, contradictory treatment); prognostic uncertainty (hopelessness, fear of disease progression, disbelief regarding diagnosis); motivation and coping mechanisms (engage in research, pro-active management, optimism, feeling normal); and knowledge gaps (practical advice, access to information, comprehension of pathology results and CKD diagnosis, education for general practitioners). Patients capacity to slow the progression of CKD may be limited by their lack of knowledge about the disease, its comorbidities, psychosocial influences and their ability to interact and communicate effectively with their health-care provider. Support from a multidisciplinary care team, combined with provision of comprehensive, accessible and practical educational resources may enhance patients' ability and motivation to access and adhere to therapeutic and lifestyle interventions to retard progression of CKD. © 2014 Asian Pacific Society of Nephrology.

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

Zoomed EPI-DWI of the pancreas using two-dimensional spatially-selective radiofrequency excitation pulses.

PubMed

Riffel, Philipp; Michaely, Henrik J; Morelli, John N; Pfeuffer, Josef; Attenberger, Ulrike I; Schoenberg, Stefan O; Haneder, Stefan

2014-01-01

Implementation of DWI in the abdomen is challenging due to artifacts, particularly those arising from differences in tissue susceptibility. Two-dimensional, spatially-selective radiofrequency (RF) excitation pulses for single-shot echo-planar imaging (EPI) combined with a reduction in the FOV in the phase-encoding direction (i.e. zooming) leads to a decreased number of k-space acquisition lines, significantly shortening the EPI echo train and potentially susceptibility artifacts. To assess the feasibility and image quality of a zoomed diffusion-weighted EPI (z-EPI) sequence in MR imaging of the pancreas. The approach is compared to conventional single-shot EPI (c-EPI). 23 patients who had undergone an MRI study of the abdomen were included in this retrospective study. Examinations were performed on a 3T whole-body MR system (Magnetom Skyra, Siemens) equipped with a two-channel fully dynamic parallel transmit array (TimTX TrueShape, Siemens). The acquired sequences consisted of a conventional EPI DWI of the abdomen and a zoomed EPI DWI of the pancreas. For z-EPI, the standard sinc excitation was replaced with a two-dimensional spatially-selective RF pulse using an echo-planar transmit trajectory. Images were evaluated with regard to image blur, respiratory motion artifacts, diagnostic confidence, delineation of the pancreas, and overall scan preference. Additionally ADC values of the pancreatic head, body, and tail were calculated and compared between sequences. The pancreas was better delineated in every case (23/23) with z-EPI versus c-EPI. In every case (23/23), both readers preferred z-EPI overall to c-EPI. With z-EPI there was statistically significantly less image blur (p<0.0001) and respiratory motion artifact compared to c-EPI (p<0.0001). Diagnostic confidence was statistically significantly better with z-EPI (p<0.0001). No statistically significant differences in calculated ADC values were observed between the two sequences. Zoomed diffusion-weighted EPI

Iron Therapy Challenges for the Treatment of Nondialysis CKD Patients

PubMed Central

Mazzaferro, Sandro; Yee, Jerry

2016-01-01

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

A patient with CKD and poor nutritional status.

PubMed

Ikizler, T Alp

2013-12-01

Protein energy wasting is common in patients with CKD and ESRD and is associated with adverse clinical outcomes, such as increased rates of hospitalization and death, in these patients. A multitude of factors can affect the nutritional and metabolic status of patients with CKD, including decreased dietary nutrient intake, catabolic effects of renal replacement therapy, systemic inflammation, metabolic and hormonal derangements, and comorbid conditions (such as diabetes and depression). Unique aspects of CKD also confound reliable assessment of nutritional status, further complicating management of this comorbid condition. In patients in whom preventive measures and oral dietary intake from regular meals cannot help them maintain adequate nutritional status, nutritional supplementation, administered orally, enterally, or parenterally, is effective in replenishing protein and energy stores. The advantages of oral nutritional supplements include proven efficacy, safety, and compliance. Anabolic steroids and exercise, with nutritional supplementation or alone, improve protein stores and represent potential additional approaches for the treatment of PEW. There are several emerging novel therapies, such as appetite stimulants, anti-inflammatory interventions, and anabolic agents.

Accelerating EPI distortion correction by utilizing a modern GPU-based parallel computation.

PubMed

Yang, Yao-Hao; Huang, Teng-Yi; Wang, Fu-Nien; Chuang, Tzu-Chao; Chen, Nan-Kuei

2013-04-01

The combination of phase demodulation and field mapping is a practical method to correct echo planar imaging (EPI) geometric distortion. However, since phase dispersion accumulates in each phase-encoding step, the calculation complexity of phase modulation is Ny-fold higher than conventional image reconstructions. Thus, correcting EPI images via phase demodulation is generally a time-consuming task. Parallel computing by employing general-purpose calculations on graphics processing units (GPU) can accelerate scientific computing if the algorithm is parallelized. This study proposes a method that incorporates the GPU-based technique into phase demodulation calculations to reduce computation time. The proposed parallel algorithm was applied to a PROPELLER-EPI diffusion tensor data set. The GPU-based phase demodulation method reduced the EPI distortion correctly, and accelerated the computation. The total reconstruction time of the 16-slice PROPELLER-EPI diffusion tensor images with matrix size of 128 × 128 was reduced from 1,754 seconds to 101 seconds by utilizing the parallelized 4-GPU program. GPU computing is a promising method to accelerate EPI geometric correction. The resulting reduction in computation time of phase demodulation should accelerate postprocessing for studies performed with EPI, and should effectuate the PROPELLER-EPI technique for clinical practice. Copyright © 2011 by the American Society of Neuroimaging.

[Sodium Glucose Co-transporter Type 2 (SGLT2) Inhibitors in CKD].

PubMed

Insalaco, Monica; Zanoli, Luca; Rastelli, Stefania; Lentini, Paolo; Rapisarda, Francesco; Fatuzzo, Pasquale; Castellino, Pietro; Granata, Antonio

2015-01-01

Among the new drugs used for the treatment of Diabetes Mellitus type 2, sodium-glucose cotransporter 2 (SGLT2) inhibitors represent a promising therapeutic option. Since their ability to lower glucose is proportional to GFR, their effect is reduced in patients with chronic kidney disease (CKD). The antidiabetic mechanism of these drugs is insulin-independent and, therefore, complimentary to that of others antihyperglicaemic agents. Moreover, SGLT2 inhibitors are able to reduce glomerular hyperfiltration, systemic and intraglomerular pressure and uric acid levels, with consequent beneficial effects on the progression of kidney disease in non diabetic patients as well. Only few studies have been performed to evaluate the effects of SGLT2 inhibitors in patients with CKD. Therefore, safety and efficacy of SGLT2 inhibitors should be better clarified in the setting of CKD. In this paper, we will review the use of SGLT2 inhibitors in diabetic patients, including those with CKD.

A Summary of Worldwide National Activities in Chronic Kidney Disease (CKD) Testing

PubMed Central

Ruiz-Arenas, Roberto; Sierra-Amor, Rosa; Seccombe, David; Raymondo, Stella; Graziani, Maria Stella; Panteghini, Mauro; Adedeji, Tewogbade A.; Kamatham, Shanthi Naidu

2017-01-01

Chronic kidney disease (CKD) is a major public health issue worldwide and is associated with adverse health outcomes, especially in low- and middle-income countries. In a cash limited healthcare system, guidelines that improve the efficiency of health care free up resources needed for other healthcare services. This short review presents some examples from national acitivities in CKD testing, including countries throughout the globe: Mexico in North America, Uruguay in South America, Italy in Europe, Nigeria in Africa and India in Asia. Considering the fact that treatment of CKD is cost-effective and improves outcomes, this observation argue in favor of including CKD in national guidelines and noncommunicable chronic disease (NCD) programs. This diverse example of national activities fullfil the very first step in achieving this goal. PMID:29333149

Chronic Kidney Disease Epidemiology Collaboration versus Modification of Diet in Renal Disease equations for renal function evaluation in patients undergoing partial nephrectomy.

PubMed

Shikanov, Sergey; Clark, Melanie A; Raman, Jay D; Smith, Benjamin; Kaag, Matthew; Russo, Paul; Wheat, Jeffrey C; Wolf, J Stuart; Huang, William C; Shalhav, Arieh L; Eggener, Scott E

2010-11-01

A novel equation, the Chronic Kidney Disease Epidemiology Collaboration, has been proposed to replace the Modification of Diet in Renal Disease for estimated glomerular filtration rate due to higher accuracy, particularly in the setting of normal renal function. We compared these equations in patients with 2 functioning kidneys undergoing partial nephrectomy. We assembled a cohort of 1,158 patients from 5 institutions who underwent partial nephrectomy between 1991 and 2009. Only subjects with 2 functioning kidneys were included in the study. The end points were baseline estimated glomerular filtration rate, last followup estimated glomerular filtration rate (3 to 18 months), absolute and percent change estimated glomerular filtration rate ([absolute change/baseline] × 100%), and proportion of newly developed chronic kidney disease stage III. The agreement between the equations was evaluated using Bland-Altman plots and the McNemar test for paired observations. Mean baseline estimated glomerular filtration rate derived from the Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration equations were 73 and 77 ml/minute/1.73 m(2), respectively, and following surgery were 63 and 67 ml/minute/1.73 m(2), respectively. Mean percent change estimated glomerular filtration rate was -12% for both equations (p = 0.2). The proportion of patients with newly developed chronic kidney disease stage III following surgery was 32% and 25%, according to the Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration equations, respectively (p = 0.001). For patients with 2 functioning kidneys undergoing partial nephrectomy the Chronic Kidney Disease Epidemiology Collaboration equation provides slightly higher glomerular filtration rate estimates compared to the Modification of Diet in Renal Disease equation, with 7% fewer patients categorized as having chronic kidney disease stage III or worse. Copyright © 2010

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. Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Creatinine measurement on dry blood spot sample for chronic kidney disease screening.

PubMed

Silva, Alan Castro Azevedo E; Gómez, Juan Fidel Bencomo; Lugon, Jocemir Ronaldo; Graciano, Miguel Luis

2016-03-01

Chronic kidney disease (CKD) screening is advisable due to its high morbidity and mortality and is usually performed by sampling blood and urine. Here we present an innovative and simpler method, by measuring creatinine on a dry blood spot on filter paper. One-hundred and six individuals at high risk for CKD were enrolled. The creatinine values obtained using both tests and the demographic data of each participant allowed us to determinate the eGFR. The adopted cutoff for CKD was an eGFR < 60 ml/min. Mean age was 57 ± 12 years, 74% were female, 40% white, and 60% non-white. Seventy-six percent were hypertensive, 30% diabetic, 37% had family history of CKD, and 22% of smoking. The BMI was 29.5 ± 6.9 kg/m2, median systolic blood pressure was 125 mmHg (IQR 120-140 mmHg) and median diastolic blood pressure was 80 mmHg (IQR 70-80 mmHg). According to MDRD equation, sensitivity was 96%, specificity 55%, predictive positive value 96%, predictive negative value 55% and accuracy 92%. By the CKD-EPI equation the sensitivity was 94%, specificity 55%, predictive positive value 94%, predictive negative value 55% and accuracy 90%. A Bland and Altman analysis showed a relatively narrow range of creatinine values differences (+ 0.68mg/dl to -0.55mg/dl) inside the ± 1.96 SD, without systematic differences. Measurement of creatinine on dry blood sample is an easily feasible non-invasive diagnostic test with good accuracy that may be useful to screen chronic kidney disease.

Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD): Form and Function

PubMed Central

Levin, Adeera; Adams, Evan; Barrett, Brendan J.; Beanlands, Heather; Burns, Kevin D.; Chiu, Helen Hoi-Lun; Chong, Kate; Dart, Allison; Ferera, Jack; Fernandez, Nicolas; Fowler, Elisabeth; Garg, Amit X.; Gilbert, Richard; Harris, Heather; Harvey, Rebecca; Hemmelgarn, Brenda; James, Matthew; Johnson, Jeffrey; Kappel, Joanne; Komenda, Paul; McCormick, Michael; McIntyre, Christopher; Mahmud, Farid; Pei, York; Pollock, Graham; Reich, Heather; Rosenblum, Norman D.; Scholey, James; Sochett, Etienne; Tang, Mila; Tangri, Navdeep; Tonelli, Marcello; Turner, Catherine; Walsh, Michael; Woods, Cathy; Manns, Braden

2018-01-01

Purpose of review This article serves to describe the Can-SOLVE CKD network, a program of research projects and infrastructure that has excited patients and given them hope that we can truly transform the care they receive. Issue Chronic kidney disease (CKD) is a complex disorder that affects more than 4 million Canadians and costs the Canadian health care system more than $40 billion per year. The evidence base for guiding care in CKD is small, and even in areas where evidence exists, uptake of evidence into clinical practice has been slow. Compounding these complexities are the variations in outcomes for patients with CKD and difficulties predicting who is most likely to develop complications over time. Clearly these gaps in our knowledge and understanding of CKD need to be filled, but the current state of CKD research is not where it needs to be. A culture of clinical trials and inquiry into the disease is lacking, and much of the existing evidence base addresses the concerns of the researchers but not necessarily those of the patients. Program overview The Canadian Institutes of Health Research (CIHR) has launched the national Strategy for Patient-Oriented Research (SPOR), a coalition of federal, provincial, and territorial partners dedicated to integrating research into care. Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) is one of five pan-Canadian chronic kidney disease networks supported through the SPOR. The vision of Can-SOLVE CKD is that by 2020 every Canadian with or at high risk for CKD will receive the best recommended care, experience optimal outcomes, and have the opportunity to participate in studies with novel therapies, regardless of age, sex, gender, location, or ethnicity. Program objective The overarching objective of Can-SOLVE CKD is to accelerate the translation of knowledge about CKD into clinical research and practice. By focusing on the patient’s voice and implementing relevant findings in

Japanese Leigh syndrome case treated with EPI-743.

PubMed

Kouga, Takeshi; Takagi, Mariko; Miyauchi, Akihiko; Shimbo, Hiroko; Iai, Mizue; Yamashita, Sumimasa; Murayama, Kei; Klein, Matthew B; Miller, Guy; Goto, Tomohide; Osaka, Hitoshi

2018-02-01

Leigh syndrome is a mitochondrial disease caused by respiratory chain deficiency, and there are no proven effective therapies. EPI-743 is a potent cellular oxidative stress protectant and results of clinical trials for mitochondrial diseases are accumulating. At 5months, a girl presented with the scarce eye movement and diminished muscle tone. She was diagnosed with Leigh encephalopathy from blood and cerebrospinal fluid lactate elevation and MRI findings. Sequence analysis for mitochondrial DNA revealed a T10158C mutation in the mitochondrial encoded ND3 gene in complex I. At 8months, succinate was prescribed expected to restore the electron transport chain system. After that her condition got worse and succinate was discontinued. Subsequent administration of EPI-743 improved her eye movement, fine motor movements of the extremities, and bowel movement. She is now 5years old. Although brain atrophy has progressed, she has still respiratory free time. Our patient showed visible improvement with EPI-743 treatment and the only patient surviving after 4years. There is a possibility that EPI-743 is modifying the natural course of the syndrome. Copyright © 2017 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.

Dialysis Patient Perspectives on CKD Advocacy: A Semistructured Interview Study.

PubMed

Schober, Gregory S; Wenger, Julia B; Lee, Celeste C; Oberlander, Jonathan; Flythe, Jennifer E

2017-01-01

Health advocacy groups provide education, raise public awareness, and engage in legislative, scientific, and regulatory processes to advance funding and treatments for many diseases. Despite a high burden of chronic kidney disease (CKD) in the United States, public awareness and research funding lag behind those for other disease states. We undertook this study of patients receiving maintenance dialysis to describe knowledge and beliefs about CKD advocacy, understand perceptions regarding advocacy participation, and elicit ideas for generating more advocacy in the dialysis community. Qualitative study. 48 patients (89% response rate) receiving in-center hemodialysis (n=39), home hemodialysis (n=4), and peritoneal dialysis (n=5) from 14 US states. Semistructured interviews. Transcripts were thematically analyzed. 5 themes describing patient perspectives on CKD advocacy were identified: (1) advocacy awareness (advocacy vs engagement knowledge, concrete knowledge, CKD publicity), (2) willingness to participate (personal qualities, internal efficacy, external efficacy), (3) motivations (altruism, providing a purpose, advancement of personal health, self-education), (4) resource availability (time, financial and transportation, health status), and (5) mobilization experience (key figure, mobilization network). Participants displayed operational understanding of advocacy but generally lacked knowledge about specific opportunities for participation. Personal qualities and external efficacy were perceived as important for advocacy participation, as were motivating factors such as altruism and self-education. Resources factored heavily into perceived participation ability. Most participants identified a key figure who invited them to participate in advocacy. In-person patient-delivered communication about advocacy opportunities was identified as critical to enhancing CKD advocacy among patients living on dialysis therapy. Potential selection bias and inclusion of only

Higher Serum Direct Bilirubin Levels Were Associated with a Lower Risk of Incident Chronic Kidney Disease in Middle Aged Korean Men

PubMed Central

Ryu, Seungho; Chang, Yoosoo; Zhang, Yiyi; Woo, Hee-Yeon; Kwon, Min-Jung; Park, Hyosoon; Lee, Kyu-Beck; Son, Hee Jung; Cho, Juhee; Guallar, Eliseo

2014-01-01

Background The association between serum bilirubin levels and incident chronic kidney disease (CKD) in the general population is unknown. We aimed to examine the association between serum bilirubin concentration (total, direct, and indirect) and the risk of incident CKD. Methods and Findings Longitudinal cohort study of 12,823 Korean male workers 30 to 59 years old without CKD or proteinuria at baseline participating in medical health checkup program in a large worksite. Study participants were followed for incident CKD from 2002 through 2011. Estimated glomerular filtration rate (eGFR) was estimated by using the CKD-EPI equation. CKD was defined as eGFR <60 mL/min per 1.73 m2. Parametric Cox models and pooled logistic regression models were used to estimate adjusted hazard ratios for incident CKD. We observed 238 incident cases of CKD during 70,515.8 person-years of follow-up. In age-adjusted models, the hazard ratios for CKD comparing quartiles 2–4 vs. quartile 1 of serum direct bilirubin were 0.93 (95% CI 0.67–1.28), 0.88 (0.60–1.27) and 0.60 (0.42–0.88), respectively. In multivariable models, the adjusted hazard ratio for CKD comparing the highest to the lowest quartile of serum direct bilirubin levels was 0.60 (95% CI 0.41–0.87; P trend = 0.01). Neither serum total nor indirect bilirubin levels were significantly associated with the incidence of CKD. Conclusions Higher serum direct bilirubin levels were significantly associated with a lower risk of developing CKD, even adjusting for a variety of cardiometabolic parameters. Further research is needed to elucidate the mechanisms underlying this association and to establish the role of serum direct bilirubin as a marker for CKD risk. PMID:24586219

Parturient perineal distensibility tolerance assessed by EPI-NO: an observational study.

PubMed

Nakamura, Mary Uchiyama; Sass, Nelson; Elito Júnior, Julio; Petricelli, Carla Dellabarba; Alexandre, Sandra Maria; Araujo Júnior, Edward; Zanetti, Miriam Raquel Diniz

2014-01-01

To determine how parturient women tolerate the use of a perineal distensibility assessment technique using the EPI-NO device. An observational study with a total of 227 full-term parturient women was performed. During the evaluation with EPI-NO, parturient patients were asked about their sensation of discomfort. The degree of discomfort was measured using the Visual Analogue Scale, with a score from zero to 10. The Mann-Whitney test was applied to assess perineal distensibility measured by EPI-NO and the degree of discomfort caused by the test according to parity. The relation between perineal distensibility and discomfort was analyzed by using the Spearman correlation test (r). The test with EPI-NO caused only slight discomfort (mean Visual Analogue Scale of 3.8), and primiparous women reported significantly greater discomfort (mean Visual Analogue Scale of 4.5) than did multiparous (mean Visual Analogue Scale=3.1), with p<0.001 women. A negative correlation was observed, in other words, the greater the perineal distensibility on the EPI-NO, the lower the pain reported by the patients (r=-0.424; p<0.001). The assessment of perineal distensibility with EPI-NO was well tolerated by the parturient women.

Marker of lipid peroxidation related to diabetic nephropathy in Indonesian type 2 diabetes mellitus patients.

PubMed

Sauriasari, R; Andrajati, R; Azizahwati; Dharmeizar; Saputri, D A; Muris, R U; Manfaatun, A; Amanda, O F; Setiawan, H; Sakano, N; Wang, D H; Ogino, K

2015-04-01

Even though diabetes patients exhibit an increased oxidative stress, its correlation with diabetic nephropathy is not fully understood. The purpose of this study was to determine whether lipid peroxidation marker correlates well with eGFR and UACR in type 2 diabetes mellitus patients. We collected urine and serum samples of Indonesian type 2 diabetes mellitus outpatients with normo- and microalbuminuria at a Local Government Clinic (from ages: 39-74 years). Urinary 8-iso-PGF2α was measured by ELISA, the serum malondialdehyde by TBARS assay, and urinary albumin by BCG albumin assay. eGFR was calculated using the corrected-Cockcroft-Gault (CG), MDRD, and CKD-EPI equation. Other necessary data were obtained through questionnaires. The results showed that the increasing level of malondialdehyde was mildly correlated with the decline in eGFR (MDRD). In contrary, there was a significant positive correlation between 8-iso-PGF2α concentration and eGFR based on the corrected-CG, MDRD study, and CKD-EPI equation (r=0.457, p<0.001; r=0.424, p<0.001; r=0.443, p<0.001). This relationship still persisted in the normoalbuminuric subjects (n=43) (r=0.491, p=0.001; r=0.461, p=0.002; r=0.455, p=0.002). The multivariate analysis showed that 8-iso-PGF2α together with fasting plasma glucose was the most predictive factor for the high 2-quantile eGFR (adjusted OR 1.001, (95% CI, 1.000-1.001)). However, there was no significant correlation between UACR with malondialdehyde (r=0.268, p=0.050) and 8-iso-PGF2α(r=-0.030, p=0.808). UACR itself was inversely correlated with eGFR based on the corrected-CG, the MDRD, and CKD-EPI (r=-0.232, p<0.05; r=-0.228, p<0.05; r=-0.232, p<0.05). Increased 8-iso-PGF2α and malondialdehyde in type 2 diabetes mellitus patients may play a role in the pathophysiologic significance of diabetic nephropathy, even while considering the effect of potential confounders. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Physics of epi-thermal boron neutron capture therapy (epi-thermal BNCT).

PubMed

Seki, Ryoichi; Wakisaka, Yushi; Morimoto, Nami; Takashina, Masaaki; Koizumi, Masahiko; Toki, Hiroshi; Fukuda, Mitsuhiro

2017-12-01

The physics of epi-thermal neutrons in the human body is discussed in the effort to clarify the nature of the unique radiologic properties of boron neutron capture therapy (BNCT). This discussion leads to the computational method of Monte Carlo simulation in BNCT. The method is discussed through two examples based on model phantoms. The physics is kept at an introductory level in the discussion in this tutorial review.

The community health promotion plan: a CKD prevention and management strategy.

PubMed

Sinasac, Lisa

2012-01-01

Chronic kidney disease (CKD) is one of the top 10 causes of death. CKD is often caused by diabetes mellitus (DM) and hypertension (HTN). Both DM Type 2 and HTN are treatable and preventable and, yet, the population of individuals diagnosed with these two diseases is increasing. Millions of dollars are spent every year providing dialysis treatments for patients with CKD. This money only accounts for dialysis and does not include the millions spent on complications such as infections, medications, tests and procedures. The burden to society is tremendous and the quality of life for these people is often poor. Health promotion and early detection is a key factor in reducing the risk for and incidence of DM and HTN, thus reducing the incidence of CKD. Three-quarters of health problems are preventable. Educating and providing the community with resources about diet, exercise, regular physical examinations, medication, and smoking cessation can empower the population with the necessary knowledge to help prevent these diseases. Health promotion and access to health promotion activities can, therefore, provide an active and healthier life.

DisEpi: Compact Visualization as a Tool for Applied Epidemiological Research.

PubMed

Benis, Arriel; Hoshen, Moshe

2017-01-01

Outcomes research and evidence-based medical practice is being positively impacted by proliferation of healthcare databases. Modern epidemiologic studies require complex data comprehension. A new tool, DisEpi, facilitates visual exploration of epidemiological data supporting Public Health Knowledge Discovery. It provides domain-experts a compact visualization of information at the population level. In this study, DisEpi is applied to Attention-Deficit/Hyperactivity Disorder (ADHD) patients within Clalit Health Services, analyzing the socio-demographic and ADHD filled prescription data between 2006 and 2016 of 1,605,800 children aged 6 to 17 years. DisEpi's goals facilitate the identification of (1) Links between attributes and/or events, (2) Changes in these relationships over time, and (3) Clusters of population attributes for similar trends. DisEpi combines hierarchical clustering graphics and a heatmap where color shades reflect disease time-trends. In the ADHD context, DisEpi allowed the domain-expert to visually analyze a snapshot summary of data mining results. Accordingly, the domain-expert was able to efficiently identify that: (1) Relatively younger children and particularly youngest children in class are treated more often, (2) Medication incidence increased between 2006 and 2011 but then stabilized, and (3) Progression rates of medication incidence is different for each of the 3 main discovered clusters (aka: profiles) of treated children. DisEpi delivered results similar to those previously published which used classical statistical approaches. DisEpi requires minimal preparation and fewer iterations, generating results in a user-friendly format for the domain-expert. DisEpi will be wrapped as a package containing the end-to-end discovery process. Optionally, it may provide automated annotation using calendar events (such as policy changes or media interests), which can improve discovery efficiency, interpretation, and policy implementation.

EpiAssist: Service-learning in public health education.

PubMed

Horney, Jennifer A; Bamrara, Sanjana; Macik, Maria Lazo; Shehane, Melissa

2016-01-01

Although public health degree programs typically require practica and other field experiences, service-learning courses, with a focus on civic engagement and the application of classroom learning in real world settings, can go beyond these requirements and provide benefits to students and community-based practice partners. The goal of this paper is to assess potential benefits of service-learning programs for both graduate-level public health students and state and local public health agency partners. EpiAssist is a new service-learning program developed at the School of Public Health of the Texas A and M University Health Science Center, USA, in January 2015. EpiAssist was integrated into a new course, Methods in Field Epidemiology. The integration of service-learning was guided by a partnership with the Texas A and M Center for Teaching Excellence. State, regional, and local public health partners requested EpiAssist via email or telephone. A listserv was used to recruit student volunteers to meet requests. 54 of 86 registered EpiAssist students (63%) participated in at least one of ten service-learning and three training activities between January and June, 2015. Service-learning activities included questionnaire development, in-person and telephone data collection, and data analysis. Training topics for students included the Epi Info™ software, community assessment and communicable disease reporting. Students and partner organizations provided generally positive assessments of this service learning program through an online evaluation. Service-learning provides students with enhanced classroom learning through applied public health experience in state, regional and local health departments. These experiences provide both needed surge capacity to public health departments and valuable hands-on field experience to students.

Divergent Synthesis of Solanidine and 22-epi-Solanidine.

PubMed

Hou, Ling-Li; Shi, Yong; Zhang, Zhi-Dan; Wu, Jing-Jing; Yang, Qing-Xiong; Tian, Wei-Sheng

2017-07-21

A divergent synthesis of solanidine and 22-epi-solanidine, two 25S natural steroidal alkaloids, from 25R-configured diosgenin acetate, is described. Initially, solanidine was synthesized through a series of transformations including a cascade ring-switching process of furostan-26-acid, an epimerization of C25 controlled by the conformation of six-membered lactone ring, an intramolecular Schmidt reaction, and an imine reduction/intramolecular aminolysis process. To address the epimerization issue during Schmidt reaction, an improved synthesis was developed, which also led to a synthesis of 22-epi-solanidine. In this synthesis, selective transformation of azido lactone to azido diol and amino diol was realized through a reduction relay tactic. The azido diol was transformed to solanidine via an intramolecular Schmidt reaction/N-alkylation/reduction process and to 22-epi-solanidine via an intramolecular double N-alkylation process.

Parturient perineal distensibility tolerance assessed by EPI-NO: an observational study

PubMed Central

Nakamura, Mary Uchiyama; Sass, Nelson; Elito, Julio; Petricelli, Carla Dellabarba; Alexandre, Sandra Maria; Araujo, Edward; Zanetti, Miriam Raquel Diniz

2014-01-01

ABSTRACT Objective: To determine how parturient women tolerate the use of a perineal distensibility assessment technique using the EPI-NO device. Methods: An observational study with a total of 227 full-term parturient women was performed. During the evaluation with EPI-NO, parturient patients were asked about their sensation of discomfort. The degree of discomfort was measured using the Visual Analogue Scale, with a score from zero to 10. The Mann-Whitney test was applied to assess perineal distensibility measured by EPI-NO and the degree of discomfort caused by the test according to parity. The relation between perineal distensibility and discomfort was analyzed by using the Spearman correlation test (r). Results: The test with EPI-NO caused only slight discomfort (mean Visual Analogue Scale of 3.8), and primiparous women reported significantly greater discomfort (mean Visual Analogue Scale of 4.5) than did multiparous (mean Visual Analogue Scale=3.1), with p<0.001 women. A negative correlation was observed, in other words, the greater the perineal distensibility on the EPI-NO, the lower the pain reported by the patients (r=-0.424; p<0.001). Conclusion: The assessment of perineal distensibility with EPI-NO was well tolerated by the parturient women. PMID:24728241

External validation of the Revised Cardiac Risk Index and update of its renal variable to predict 30-day risk of major cardiac complications after non-cardiac surgery: rationale and plan for analyses of the VISION study.

PubMed

Roshanov, Pavel S; Walsh, Michael; Devereaux, P J; MacNeil, S Danielle; Lam, Ngan N; Hildebrand, Ainslie M; Acedillo, Rey R; Mrkobrada, Marko; Chow, Clara K; Lee, Vincent W; Thabane, Lehana; Garg, Amit X

2017-01-09

The Revised Cardiac Risk Index (RCRI) is a popular classification system to estimate patients' risk of postoperative cardiac complications based on preoperative risk factors. Renal impairment, defined as serum creatinine >2.0 mg/dL (177 µmol/L), is a component of the RCRI. The estimated glomerular filtration rate has become accepted as a more accurate indicator of renal function. We will externally validate the RCRI in a modern cohort of patients undergoing non-cardiac surgery and update its renal component. The Vascular Events in Non-cardiac Surgery Patients Cohort Evaluation (VISION) study is an international prospective cohort study. In this prespecified secondary analysis of VISION, we will test the risk estimation performance of the RCRI in ∼34 000 participants who underwent elective non-cardiac surgery between 2007 and 2013 from 29 hospitals in 15 countries. Using data from the first 20 000 eligible participants (the derivation set), we will derive an optimal threshold for dichotomising preoperative renal function quantified using the Chronic Kidney Disease Epidemiology Collaboration (CKD-Epi) glomerular filtration rate estimating equation in a manner that preserves the original structure of the RCRI. We will also develop a continuous risk estimating equation integrating age and CKD-Epi with existing RCRI risk factors. In the remaining (approximately) 14 000 participants, we will compare the risk estimation for cardiac complications of the original RCRI to this modified version. Cardiac complications will include 30-day non-fatal myocardial infarction, non-fatal cardiac arrest and death due to cardiac causes. We have examined an early sample to estimate the number of events and the distribution of predictors and missing data, but have not seen the validation data at the time of writing. The research ethics board at each site approved the VISION protocol prior to recruitment. We will publish our results and make our models available online at http

Renal sympathetic denervation guided by renal nerve stimulation to treat ventricular arrhythmia in CKD patients with ICD

PubMed Central

Kiuchi, Márcio Galindo; Chen, Shaojie; Rodrigues Paz, Luis Marcelo; Pürerfellner, Helmut

2017-01-01

Chronic kidney disease (CKD) patients on stage 4 present greater risk rates for malignant ventricular arrhythmia events. This study examined patients with CKD in stages 1, 2, 3 and 4, left ventricular dysfunction and automatic implantable cardioverter-defibrillator (ICD). Our goal was to record the appropriate therapies, “Anti-tachycardia Therapy Pacing” (ATP) and shock events during the 18 months of follow-up and compare the incidence and severity of these at different stages of CKD, mainly in patients with CKD stage 4 underwent renal sympathetic denervation (RSD) guided by renal nerve stimulation (RNS). One hundred and fifteen patients were evaluated once every three months till 18 months of follow-up. The arrhythmic events were assessed at each follow-up visit. Comparing the groups, we can see the number of ATP and shock events recorded by ICD during 18 months of follow-up, and differences in the number of therapeutic events between the various stages of CKD. The hazard ratio (HR), 95% confidence interval (CI) and P value for ATP and shock events between all the CKD stages were evaluated by the log-rank/Mantel-Haenszel test. At the 18th month of follow-up, 75% of patients with CKD stage 4 received ATP, and 70% were treated with shock while only 20% of the subjects with CKD stage 4 that were submitted to RSD received ATP and 20% were treated with shock, P<0.0001 and P=0.0002, respectively. In our study, a decline occurred in the incidence of arrhythmias, and therefore, appropriate ICD therapies in advanced stages of CKD, reducing the risk rates for these events in patients with CKD on stage 4 after RSD guided by RNS in comparison to the other CKD stages. Our results suggest that RSD can control the higher incidence of malignant arrhythmias in advanced CKD stages. PMID:28415795

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

Chronic Kidney Disease Guideline Implementation in Primary Care: A Qualitative Report from the TRANSLATE CKD Study.

PubMed

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

2015-01-01

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. As part of the mixed-methods process evaluation, semistructured 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 4 domains of Normalization Process Theory (NPT). Identified themes illuminated the complex work undertaken to manage CKD in primary care practices. Barriers to guideline implementation were identified in each of the 4 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 using data to monitor progress (reflexive monitoring). 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. © Copyright 2015 by the American Board of Family Medicine.

Awareness and knowledge of clinical practice guidelines for CKD among internal medicine residents: a national online survey.

PubMed

Agrawal, Varun; Ghosh, Amit K; Barnes, Michael A; McCullough, Peter A

2008-12-01

The National Kidney Foundation published Kidney Disease Outcomes Quality Initiative guidelines that recommend early detection and management of chronic kidney disease (CKD) and timely referral to a nephrologist. Many patients with CKD are seen by primary care physicians who are less experienced than nephrologists to offer optimal pre-end-stage renal disease care. It is not known whether current postgraduate training adequately prepares a future internist in CKD management. Cross-sectional study using an online questionnaire survey. Internal medicine residents in the United States (n = 479) with postgraduate year (PGY) distribution of 166 PGY1, 187 PGY2, and 126 PGY3. Awareness and knowledge of CKD clinical practice guidelines measured by using the questionnaire instrument. Total performance score (maximum = 30). Half the residents did not know that the presence of kidney damage (proteinuria) for 3 or more months defines CKD. One-third of the residents did not know the staging of CKD. All residents (99%) knew the traditional risk factors for CKD of diabetes and hypertension, but were less aware of other risk factors of obesity (38%), elderly age (71%), and African American race (68%). Most residents (87%) were aware of estimated glomerular filtration rate in the evaluation of patients with CKD. Most residents (90%) knew goal blood pressure (<130/80 mm Hg) for patients with CKD. Most residents identified anemia (91%) and bone disorder (82%) as complications of CKD, but only half recognized CKD as a risk factor for cardiovascular disease. Most residents (90%) chose to refer a patient with a glomerular filtration rate less than 30 mL/min/1.73 m(2) to a nephrologist. A small improvement in mean performance score was observed with increasing PGY (PGY1, 68.8% +/- 15.4%; PGY2, 72.9% +/- 14.7%; and PGY3, 74.0% +/- 12.0%; P = 0.004). Self-selection, lack of nonrespondent data. Our survey identified specific gaps in knowledge of CKD guidelines in internal medicine residents

Use of Radiocontrast Agents in CKD and ESRD.

PubMed

Bahrainwala, Jehan Z; Leonberg-Yoo, Amanda K; Rudnick, Michael R

2017-07-01

Contrast exposure in a population with chronic kidney disease (CKD) requires additional consideration given the risk of contrast-induced nephropathy (CIN) after exposure to iodinated contrast as well as systemic injury with exposure to gadolinium-based contrast agents (GBCA). Strategies to avoid CIN, and manage patients after exposure, including extracorporeal removal of contrast media, may differ among an advanced CKD population as compared to a general population. There is strong evidence to support the use of isotonic volume expansion and the lowest dose of low-osmolar or iso-osmolar contrast media possible to decrease CIN. The current literature on other newer prophylactic strategies such as statins, remote ischemic preconditioning, discontinuation of renin angiotensin aldosterone system (RAAS) blockade, and RenalGuard is limited thus these strategies cannot currently be recommended as routine prophylaxis for CIN. The use of extracorporeal removal of contrast agents as prophylaxis to reduce CIN has been the subject of multiple studies; however, data do not support a beneficial effect in reduction in CIN. Immediate removal of contrast by dialysis in a maintenance dialysis population is also not recommended, unless an individual's cardiopulmonary status is dependent on strict volume management. In patients with reduced renal function, GCBA exposure increases the risk of NSF. In patients with AKI, CKD stage 3 or greater (eGFR <30 ml/minute/1.73 m 2 ), or patients on dialysis, we do not recommend the use of GBCA and alternative imaging modalities should be considered. If patients absolutely need magnetic resonance imaging with GBCA, we recommend the use of the lowest dose possible of the newer macrocylic, ionic agents (gadoterate meglumine) as well as immediate postprocedural HD in patients already on HD or peritoneal dialysis or with stage 5 CKD and with a functioning dialysis access already in place. © 2017 Wiley Periodicals, Inc.

Prevalence and correlates of self-reported sexual dysfunction in CKD: a meta-analysis of observational studies.

PubMed

Navaneethan, Sankar D; Vecchio, Mariacristina; Johnson, David W; Saglimbene, Valeria; Graziano, Giusi; Pellegrini, Fabio; Lucisano, Giuseppe; Craig, Jonathan C; Ruospo, Marinella; Gentile, Giorgio; Manfreda, Valeria Maria; Querques, Marialuisa; Stroumza, Paul; Torok, Marietta; Celia, Eduardo; Gelfman, Ruben; Ferrari, Juan Nin; Bednarek-Skublewska, Anna; Dulawa, Jan; Bonifati, Carmen; Hegbrant, Jörgen; Wollheim, Charlotta; Jannini, Emmanuele A; Strippoli, Giovanni F M

2010-10-01

Sexual dysfunction is an under-recognized problem in men and women with chronic kidney disease (CKD). The prevalence, correlates, and predictors of this condition in patients with CKD have not been evaluated comprehensively. Systematic review and meta-analysis. Patients treated using dialysis (dialysis patients), patients treated using transplant (transplant recipients), and patients with CKD not treated using dialysis or transplant (nondialysis nontransplant patients with CKD). Observational studies conducted in patients with CKD only or including a control group without CKD. Type of study population. Sexual dysfunction in men and women with CKD using validated tools, such as the International Index of Erectile Function, the Female Sexual Function Index (FSFI), or other measures as reported by study investigators. 50 studies (8,343 patients) of variable size (range, 16-1,023 patients) were included in this review. Almost all studies explored sexual dysfunction in men and specifically erectile dysfunction. The summary estimate of erectile dysfunction in men with CKD was 70% (95% CI, 62%-77%; 21 studies, 4,389 patients). Differences in reported prevalence rates of erectile dysfunction between different studies were attributable primarily to age, study populations, and type of study tool used to assess the presence of erectile dysfunction. In women, the reported prevalence of sexual dysfunction was assessed in only 306 patients from 2 studies and ranged from 30%-80%. Compared with the general population, women with CKD had a significantly lower overall FSFI score (8 studies or subgroups, 407 patients; mean difference, -9.28; 95% CI, -12.92 to -5.64). Increasing age, diabetes mellitus, and depression consistently were found to correlate with sexual dysfunction in 20 individual studies of patients with CKD using different methods. Suboptimal and lack of uniform assessment of outcome measures. Sexual dysfunction is highly prevalent in both men and women with CKD

Prevalence and cardiovascular risk profile of chronic kidney disease in Italy: results of the 2008-12 National Health Examination Survey.

PubMed

De Nicola, Luca; Donfrancesco, Chiara; Minutolo, Roberto; Lo Noce, Cinzia; Palmieri, Luigi; De Curtis, Amalia; Iacoviello, Licia; Zoccali, Carmine; Gesualdo, Loreto; Conte, Giuseppe; Vanuzzo, Diego; Giampaoli, Simona

2015-05-01

National surveys in countries outside Europe have reported a high prevalence (11-13%) of chronic kidney disease (CKD). Studies in Europe have provided a variable prevalence likely due to differences in study design, including age and extent of geographic areas, equation used to evaluate estimated glomerular filtration rate (eGFR) and CKD stages examined. The 2008-12 National Health Examination Survey in Italy randomly extracted samples from the general population aged 35-79 years, stratified by age and gender, from the resident list of each Italian region (440 persons/1.5 million of residents). We estimated the prevalence of CKD by means of urinary albumin : creatinine ratio and eGFR (CKD-EPI equation-enzymatic assay of serum creatinine). Cardiovascular (CV) risk profile was also evaluated. Three thousand eight hundred and forty-eight men and 3704 women were examined. In the whole population, mean age was 57 ± 12 and 56 ± 12 years in men and women, respectively; hypertension was prevalent in men and women, respectively (56 and 43%) and the same held true for overweight (48 and 33%), obesity (26 and 27%), diabetes (14 and 9%) and smoking (21 and 18%), whereas CV disease was less frequent (9 and 6%). Overall, the prevalence of CKD (95% confidence interval) was 7.05% (6.48-7.65). Early stages constituted 59% of the CKD population [Stage G1-2 A2-3: 4.16% (3.71-4.61) and Stage G3-5: 2.89% (2.51-3.26)]. At multivariate regression analysis, age, obesity, hypertension, diabetes, CV disease and smoking were all independent correlates of CKD. CKD has a relatively lower prevalence in Italy, in particular for advanced stages, when compared with similar national surveys outside Europe. This occurs despite older age and unfavourable CV risk profile of the whole population. © The Author 2014. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Miniaturized video-rate epi-third-harmonic-generation fiber-microscope.

PubMed

Chia, Shih-Hsuan; Yu, Che-Hang; Lin, Chih-Han; Cheng, Nai-Chia; Liu, Tzu-Ming; Chan, Ming-Che; Chen, I-Hsiu; Sun, Chi-Kuang

2010-08-02

With a micro-electro-mechanical system (MEMS) mirror, we successfully developed a miniaturized epi-third-harmonic-generation (epi-THG) fiber-microscope with a video frame rate (31 Hz), which was designed for in vivo optical biopsy of human skin. With a large-mode-area (LMA) photonic crystal fiber (PCF) and a regular microscopic objective, the nonlinear distortion of the ultrafast pulses delivery could be much reduced while still achieving a 0.4 microm lateral resolution for epi-THG signals. In vivo real time virtual biopsy of the Asian skin with a video rate (31 Hz) and a sub-micron resolution was obtained. The result indicates that this miniaturized system was compact enough for the least invasive hand-held clinical use.

Association of anthropometric measures of obesity and chronic kidney disease in elderly women.

PubMed

Jaroszynski, Andrzej; Dereziński, Tadeusz; Jaroszyńska, Anna; Zapolski, Tomasz; Wąsikowska, Beata; Wysokiński, Andrzej; Jawień, Arkadiusz; Załuska, Wojciech; Horoch, Andrzej

2016-12-23

Growing evidence suggests that obesity is an important contributor to the development of chronic kidney disease (CKD). The relationship between obesity and CKD is complex and not completely understood, and the best anthropometric index of obesity in predicting CKD is controversial. This study aimed to determine the best anthropometric index of obesity in predicting CKD in a population of elderly women. Anthropometric indexes of obesity including body mass index (BMI), waist circumference (WC), waist-to-height ratio (WheiR) and waist-to-hip-ratio (WHR), were obtained in 730 selected females. Biochemical measurements including blood glucose, lipid profile, and 2-h postprandial blood glucose were performed. GFR was estimated by using CKD-EPI equation. The prevalence of CKD stage ≥ 3 was 12.2%. Overweight and obesity was found in 50% and 36% of participants, respectively. Increased central fat distribution, as defined by WheiR, WC and WHR, was found in 89.6%, 91.7% and 89.4% individuals, respectively. Univariate linear regression analysis showed positive correlations between CKD and age (p<0.001), BMI (p<0.001), WC (p<0.001), WHR (p=0.007), WheiR (p<0.001), diabetes (p=0.002), as well as triglicerydes (p=0.031), and negative correlation between CKD and HDL level (p=0.017). Multivariable analysis demonstrated that hypertension, diabetes, WC and WheiR were independent predictors of CKD. The area under the receiver operating characteristics curve was best for WheiR (0.647), followed by WC (0.620), BMI (0.616), and WHR (0.532). Abdominal obesity is an important predictor of CKD. Of commonly used anthropometric parameters of obesity WheiR ≥ 0.6 is particularly associated with CKD in elderly females.

Association of chronic kidney disease with abnormal cardiac mechanics and adverse outcomes in patients with heart failure and preserved ejection fraction.

PubMed

Unger, Erin D; Dubin, Ruth F; Deo, Rajat; Daruwalla, Vistasp; Friedman, Julie L; Medina, Crystal; Beussink, Lauren; Freed, Benjamin H; Shah, Sanjiv J

2016-01-01

Chronic kidney disease (CKD) is associated with worse outcomes in heart failure with preserved ejection fraction (HFpEF). Whether this association is due the effect of CKD on intrinsic abnormalities in cardiac function is unknown. We hypothesized that CKD is independently associated with worse cardiac mechanics in HFpEF. We prospectively studied 299 patients enrolled in the Northwestern University HFpEF Program. Using the creatinine-based CKD-Epi equation to calculate estimated glomerular filtration rate (eGFR), study participants were analysed by CKD status (using eGFR <60 mL/min/1.73 m(2) to denote CKD). Indices of cardiac mechanics (longitudinal strain parameters) were measured using speckle-tracking echocardiography. Using multivariable-adjusted linear and Cox regression analyses, we determined the association between CKD and echocardiographic parameters and clinical outcomes (cardiovascular hospitalization or death). Of 299 study participants, 48% had CKD. CKD (dichotomous variable) and reduced eGFR (continuous variable) were both associated with worse cardiac mechanics indices including left atrial (LA) reservoir strain, LV longitudinal strain, and right ventricular free wall strain even after adjusting for potential confounders, including co-morbidities, EF, and volume status. For example, for each 1-SD decrease in eGFR, LA reservoir strain was 3.52% units lower (P < 0.0001) after multivariable adjustment. Reduced eGFR was also associated with worse outcomes [adjusted hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.01-1.61 per 1-SD decrease in eGFR; P = 0.039]. The association was attenuated after adjustment for indices of cardiac mechanics (P = 0.064). In HFpEF, CKD is independently associated with worse cardiac mechanics, which may explain why HFpEF patients with CKD have worse outcomes. NCT01030991. © 2015 The Authors European Journal of Heart Failure © 2015 European Society of Cardiology.

Examination of Potential Modifiers of the Association of APOL1 Alleles with CKD Progression

PubMed Central

Choi, Michael J.; Kao, W.H. Linda; Astor, Brad C.; Scialla, Julia J.; Appel, Lawrence J.; Li, Liang; Lipkowitz, Michael S.; Wolf, Myles; Parekh, Rulan S.; Winkler, Cheryl A.; Estrella, Michelle M.; Crews, Deidra C.

2015-01-01

Background and objectives Common apolipoprotein L1 (APOL1) variants are associated with increased risk of progressive CKD; however, not all individuals with high–risk APOL1 variants experience CKD progression. Identification of factors contributing to heterogeneity has important scientific and clinical implications. Design, setting, participants, & measurements Using multivariable Cox models, we analyzed data from 693 participants in the African American Study of Kidney Disease and Hypertension to identify factors that modify the association between APOL1 genotypes and CKD progression (doubling of serum creatinine or incident ESRD). Results Participant mean age was 54 years old, median GFR was 49 ml/min per 1.73 m2, and 23% had the APOL1 high–risk genotype (two copies of the high-risk allele). Over a mean follow-up of 7.8 years, 288 (42%) participants experienced CKD progression. As previously reported, the high-risk genotype was associated with higher risk of CKD progression compared with the low-risk genotype (hazard ratio [HR], 1.88; 95% confidence interval [95% CI], 1.46 to 2.41). Although we found some suggestion that obesity (HR, 1.48; 95% CI, 1.05 to 2.08 and HR, 2.44; 95% CI, 1.66 to 3.57 for body mass index ≥30 versus <30 kg/m2; P interaction =0.04) and increased urinary excretion of urea nitrogen (HR, 1.43; 95% CI, 0.98 to 2.09 versus HR, 2.33; 95% CI, 1.65 to 3.30 for urine urea nitrogen ≥8 versus <8 g/d; P interaction =0.04) were associated with lower APOL1–associated risk for CKD progression, these findings were not robust in sensitivity analyses with alternative cut points. No other sociodemographic (e.g., education and income), clinical (e.g., systolic BP and smoking), or laboratory (e.g., net endogenous acid production, urinary sodium and potassium excretions, 25-hydroxy vitamin D, intact parathyroid hormone, or fibroblast growth factor 23) variables modified the association between APOL1 and CKD progression (P interaction >0.05 for each

CKD in diabetes: diabetic kidney disease versus nondiabetic kidney disease.

PubMed

Anders, Hans-Joachim; Huber, Tobias B; Isermann, Berend; Schiffer, Mario

2018-06-01

The increasing global prevalence of type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) has prompted research efforts to tackle the growing epidemic of diabetic kidney disease (DKD; also known as diabetic nephropathy). The limited success of much of this research might in part be due to the fact that not all patients diagnosed with DKD have renal dysfunction as a consequence of their diabetes mellitus. Patients who present with CKD and diabetes mellitus (type 1 or type 2) can have true DKD (wherein CKD is a direct consequence of their diabetes status), nondiabetic kidney disease (NDKD) coincident with diabetes mellitus, or a combination of both DKD and NDKD. Preclinical studies using models that more accurately mimic these three entities might improve the ability of animal models to predict clinical trial outcomes. Moreover, improved insights into the pathomechanisms that are shared by these entities - including sodium-glucose cotransporter 2 (SGLT2) and renin-angiotensin system-driven glomerular hyperfiltration and tubular hyper-reabsorption - as well as those that are unique to individual entities might lead to the identification of new treatment targets. Acknowledging that the clinical entity of CKD plus diabetes mellitus encompasses NDKD as well as DKD could help solve some of the urgent unmet medical needs of patients affected by these conditions.

[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.

Dietary fiber intake is associated with chronic kidney disease (CKD) progression and cardiovascular risk, but not protein nutritional status, in adults with CKD.

PubMed

Lu, Lu; Huang, Yan-Feng; Wang, Ming-Qing; Chen, De-Xiu; Wan, Heng; Wei, Lian-Bo; Xiao, Wei

Evidence suggests that dietary fiber benefits patients with chronic kidney disease (CKD); however, this conclusion requires further validation. In this study, we examined the effects of dietary fiber on kidney function, inflammation, indoxyl sulfate, nutritional status, and cardiovascular risk in patients with advanced CKD. We performed linear regressions to assess the association between dietary fiber intake and CKD parameters. The aforementioned parameters were compared over an 18-month follow- up period. Kaplan-Meier analysis was used to investigate the association between fiber intake and Cardiac vascular disease (CVD). In total, 157 patients were included in this study. Dietary fiber and inflammatory indices were associated (interleukin [IL]-6: β=-0.024, p=0.035). The differential estimated glomerular filtration rate (ΔeGFR) as well as levels of C-reactive protein, IL-6, indoxyl sulfate, and serum cholesterol in the higher fiber intake (>=25 g/day) group were lower than those in the lower fiber intake (<25 g/day) group (p<0.05). Differences in IL-6 and indoxyl sulfate levels were more significant in patients in the higher protein intake group (p<0.05). Dietary fiber intake may be a protective factor associated with CVD (hazard ratio=0.537 and 0.305- 0.947). The protein nutritional status was not different between the two groups (p>0.05). Our results suggest that increasing fiber intake can retard the decrease in the eGFR; can reduce the levels of proinflammatory factors, indoxyl sulfate, and serum cholesterol; and is negatively associated with cardiovascular risk, but does not disrupt the nutritional status of patients with CKD.

Serum 6-Bromotryptophan Levels Identified as a Risk Factor for CKD Progression.

PubMed

Tin, Adrienne; Nadkarni, Girish; Evans, Anne M; Winkler, Cheryl A; Bottinger, Erwin; Rebholz, Casey M; Sarnak, Mark J; Inker, Lesley A; Levey, Andrew S; Lipkowitz, Michael S; Appel, Lawrence J; Arking, Dan E; Coresh, Josef; Grams, Morgan E

2018-05-18

Background Metabolite levels reflect physiologic homeostasis and may serve as biomarkers of disease progression. Identifying metabolites associated with APOL1 risk alleles-genetic variants associated with CKD risk commonly present in persons of African descent-may reveal novel markers of CKD progression relevant to other populations. Methods We evaluated associations between the number of APOL1 risk alleles and 760 serum metabolites identified via untargeted profiling in participants of the African American Study of Kidney Disease and Hypertension (AASK) ( n =588; Bonferroni significance threshold P <6.5×10 -5 ) and replicated findings in 678 black participants with CKD in Bio Me , an electronic medical record-linked biobank. We tested the metabolite association with CKD progression in AASK, Bio Me , and the Modification of Diet in Renal Disease (MDRD) Study. Results One metabolite, 6-bromotryptophan, was significant in AASK ( P =4.7×10 -5 ) and replicated in Bio Me ( P =5.7×10 -3 ) participants, with lower levels associated with more APOL1 risk alleles. Lower levels of 6-bromotryptophan were associated with CKD progression in AASK and Bio Me participants and in white participants in the MDRD Study, independent of demographics and clinical characteristics, including baseline GFR (adjusted hazard ratio per two-fold higher 6-bromotryptophan level, AASK, 0.76; 95% confidence interval [95% CI], 0.64 to 0.91; Bio Me , 0.61; 95% CI, 0.43 to 0.85; MDRD, 0.52; 95% CI, 0.34 to 0.79). The interaction between the APOL1 risk alleles and 6-bromotryptophan was not significant. The identity of 6-bromotryptophan was confirmed in experiments comparing its molecular signature with that of authentic standards of other bromotryptophan isomers. Conclusions Serum 6-bromotryptophan is a consistent and novel risk factor for CKD progression. Copyright © 2018 by the American Society of Nephrology.

Genome-Wide Association of CKD Progression: The Chronic Renal Insufficiency Cohort Study.

PubMed

Parsa, Afshin; Kanetsky, Peter A; Xiao, Rui; Gupta, Jayanta; Mitra, Nandita; Limou, Sophie; Xie, Dawei; Xu, Huichun; Anderson, Amanda Hyre; Ojo, Akinlolu; Kusek, John W; Lora, Claudia M; Hamm, L Lee; He, Jiang; Sandholm, Niina; Jeff, Janina; Raj, Dominic E; Böger, Carsten A; Bottinger, Erwin; Salimi, Shabnam; Parekh, Rulan S; Adler, Sharon G; Langefeld, Carl D; Bowden, Donald W; Groop, Per-Henrik; Forsblom, Carol; Freedman, Barry I; Lipkowitz, Michael; Fox, Caroline S; Winkler, Cheryl A; Feldman, Harold I

2017-03-01

The rate of decline of renal function varies significantly among individuals with CKD. To understand better the contribution of genetics to CKD progression, we performed a genome-wide association study among participants in the Chronic Renal Insufficiency Cohort Study. Our outcome of interest was CKD progression measured as change in eGFR over time among 1331 blacks and 1476 whites with CKD. We stratified all analyses by race and subsequently, diabetes status. Single-nucleotide polymorphisms (SNPs) that surpassed a significance threshold of P <1×10 -6 for association with eGFR slope were selected as candidates for follow-up and secondarily tested for association with proteinuria and time to ESRD. We identified 12 such SNPs among black patients and six such SNPs among white patients. We were able to conduct follow-up analyses of three candidate SNPs in similar (replication) cohorts and eight candidate SNPs in phenotype-related (validation) cohorts. Among blacks without diabetes, rs653747 in LINC00923 replicated in the African American Study of Kidney Disease and Hypertension cohort (discovery P =5.42×10 -7 ; replication P =0.039; combined P =7.42×10 -9 ). This SNP also associated with ESRD (hazard ratio, 2.0 (95% confidence interval, 1.5 to 2.7); P =4.90×10 -6 ). Similarly, rs931891 in LINC00923 associated with eGFR decline ( P =1.44×10 -4 ) in white patients without diabetes. In summary, SNPs in LINC00923 , an RNA gene expressed in the kidney, significantly associated with CKD progression in individuals with nondiabetic CKD. However, the lack of equivalent cohorts hampered replication for most discovery loci. Further replication of our findings in comparable study populations is warranted. Copyright © 2017 by the American Society of Nephrology.

The association of alcohol and smoking with CKD in a Japanese nationwide cross-sectional survey.

PubMed

Matsumoto, Ayako; Nagasawa, Yasuyuki; Yamamoto, Ryohei; Shinzawa, Maki; Hasuike, Yukiko; Kuragano, Takahiro; Isaka, Yoshitaka; Nakanishi, Takeshi; Iseki, Kunitoshi; Yamagata, Kunihiro; Tsuruya, Kazuhiko; Yoshida, Hideaki; Fujimoto, Shouichi; Asahi, Koichi; Moriyama, Toshiki; Watanabe, Tsuyoshi

2017-08-01

Chronic kidney disease (CKD) is characterized by a reduced glomerular filtration rate (GFR) and proteinuria. Modifiable lifestyle factors such as smoking and alcohol contribute to CKD. Recent cohort studies have shown that moderate alcohol consumption attenuates the decline of the GFR and smoking has been previously shown to be associated with CKD. However, the association of smoking and alcohol consumption on CKD is not entirely clear. To examine whether there is evidence to assume that smoking is an effective modifier of the association between CKD and alcohol consumption, we conducted a cross-sectional study of a population of people who presented for a health checkup under a program that targets the insured population aged ≧40 years using data from the Specific Health Check and Guidance in Japan between April 2008 and March 2009. Of the 506 807 participants aged ⩾40 years, 292 013 (57.6%) were included in the present analysis. Outcomes were kidney dysfunction, as an eGFR of <60 ml/min/1.73 m 2 , and proteinuria. In nonsmokers, drinking a small amount was associated with a lower prevalence of proteinuria, but in smokers, the association between alcohol and proteinuria was not observed. The analysis regarding eGFR <60 ml/min/1.73 m 2 revealed that in both smokers and nonsmokers, alcohol consumption was inversely associated with the risk of CKD. Mild to moderate alcohol consumption might be associated with a lower risk of CKD (proteinuria and eGFR), especially among nonsmokers, because smoking might have modified the potential benefits of alcohol to prevent CKD.

What do we know about chronic kidney disease in India: first report of the Indian CKD registry.

PubMed

Rajapurkar, Mohan M; John, George T; Kirpalani, Ashok L; Abraham, Georgi; Agarwal, Sanjay K; Almeida, Alan F; Gang, Sishir; Gupta, Amit; Modi, Gopesh; Pahari, Dilip; Pisharody, Ramdas; Prakash, Jai; Raman, Anuradha; Rana, Devinder S; Sharma, Raj K; Sahoo, R N; Sakhuja, Vinay; Tatapudi, Ravi Raju; Jha, Vivekanand

2012-03-06

There are no national data on the magnitude and pattern of chronic kidney disease (CKD) in India. The Indian CKD Registry documents the demographics, etiological spectrum, practice patterns, variations and special characteristics. Data was collected for this cross-sectional study in a standardized format according to predetermined criteria. Of the 52,273 adult patients, 35.5%, 27.9%, 25.6% and 11% patients came from South, North, West and East zones respectively. The mean age was 50.1 ± 14.6 years, with M:F ratio of 70:30. Patients from North Zone were younger and those from the East Zone older. Diabetic nephropathy was the commonest cause (31%), followed by CKD of undetermined etiology (16%), chronic glomerulonephritis (14%) and hypertensive nephrosclerosis (13%). About 48% cases presented in Stage V; they were younger than those in Stages III-IV. Diabetic nephropathy patients were older, more likely to present in earlier stages of CKD and had a higher frequency of males; whereas those with CKD of unexplained etiology were younger, had more females and more frequently presented in Stage V. Patients in lower income groups had more advanced CKD at presentation. Patients presenting to public sector hospitals were poorer, younger, and more frequently had CKD of unknown etiology. This report confirms the emergence of diabetic nephropathy as the pre-eminent cause in India. Patients with CKD of unknown etiology are younger, poorer and more likely to present with advanced CKD. There were some geographic variations.

EpiCollect+: linking smartphones to web applications for complex data collection projects

PubMed Central

Aanensen, David M.; Huntley, Derek M.; Menegazzo, Mirko; Powell, Chris I.; Spratt, Brian G.

2014-01-01

Previously, we have described the development of the generic mobile phone data gathering tool, EpiCollect, and an associated web application, providing two-way communication between multiple data gatherers and a project database. This software only allows data collection on the phone using a single questionnaire form that is tailored to the needs of the user (including a single GPS point and photo per entry), whereas many applications require a more complex structure, allowing users to link a series of forms in a linear or branching hierarchy, along with the addition of any number of media types accessible from smartphones and/or tablet devices (e.g., GPS, photos, videos, sound clips and barcode scanning). A much enhanced version of EpiCollect has been developed (EpiCollect+). The individual data collection forms in EpiCollect+ provide more design complexity than the single form used in EpiCollect, and the software allows the generation of complex data collection projects through the ability to link many forms together in a linear (or branching) hierarchy. Furthermore, EpiCollect+ allows the collection of multiple media types as well as standard text fields, increased data validation and form logic. The entire process of setting up a complex mobile phone data collection project to the specification of a user (project and form definitions) can be undertaken at the EpiCollect+ website using a simple ‘drag and drop’ procedure, with visualisation of the data gathered using Google Maps and charts at the project website. EpiCollect+ is suitable for situations where multiple users transmit complex data by mobile phone (or other Android devices) to a single project web database and is already being used for a range of field projects, particularly public health projects in sub-Saharan Africa. However, many uses can be envisaged from education, ecology and epidemiology to citizen science. PMID:25485096

EpiCollect+: linking smartphones to web applications for complex data collection projects.

PubMed

Aanensen, David M; Huntley, Derek M; Menegazzo, Mirko; Powell, Chris I; Spratt, Brian G

2014-01-01

Previously, we have described the development of the generic mobile phone data gathering tool, EpiCollect, and an associated web application, providing two-way communication between multiple data gatherers and a project database. This software only allows data collection on the phone using a single questionnaire form that is tailored to the needs of the user (including a single GPS point and photo per entry), whereas many applications require a more complex structure, allowing users to link a series of forms in a linear or branching hierarchy, along with the addition of any number of media types accessible from smartphones and/or tablet devices (e.g., GPS, photos, videos, sound clips and barcode scanning). A much enhanced version of EpiCollect has been developed (EpiCollect+). The individual data collection forms in EpiCollect+ provide more design complexity than the single form used in EpiCollect, and the software allows the generation of complex data collection projects through the ability to link many forms together in a linear (or branching) hierarchy. Furthermore, EpiCollect+ allows the collection of multiple media types as well as standard text fields, increased data validation and form logic. The entire process of setting up a complex mobile phone data collection project to the specification of a user (project and form definitions) can be undertaken at the EpiCollect+ website using a simple 'drag and drop' procedure, with visualisation of the data gathered using Google Maps and charts at the project website. EpiCollect+ is suitable for situations where multiple users transmit complex data by mobile phone (or other Android devices) to a single project web database and is already being used for a range of field projects, particularly public health projects in sub-Saharan Africa. However, many uses can be envisaged from education, ecology and epidemiology to citizen science.

Pragmatic Randomized, Controlled Trial of Patient Navigators and Enhanced Personal Health Records in CKD.

PubMed

Navaneethan, Sankar D; Jolly, Stacey E; Schold, Jesse D; Arrigain, Susana; Nakhoul, Georges; Konig, Victoria; Hyland, Jennifer; Burrucker, Yvette K; Dann, Priscilla Davis; Tucky, Barbara H; Sharp, John; Nally, Joseph V

2017-09-07

Patient navigators and enhanced personal health records improve the quality of health care delivered in other disease states. We aimed to develop a navigator program for patients with CKD and an electronic health record-based enhanced personal health record to disseminate CKD stage-specific goals of care and education. We also conducted a pragmatic randomized clinical trial to compare the effect of a navigator program for patients with CKD with enhanced personal health record and compare their combination compared with usual care among patients with CKD stage 3b/4. Two hundred and nine patients from six outpatient clinics (in both primary care and nephrology settings) were randomized in a 2×2 factorial design into four-study groups: ( 1 ) enhanced personal health record only, ( 2 ) patient navigator only, ( 3 ) both, and ( 4 ) usual care (control) group. Primary outcome measure was the change in eGFR over a 2-year follow-up period. Secondary outcome measures included acquisition of appropriate CKD-related laboratory measures, specialty referrals, and hospitalization rates. Median age of the study population was 68 years old, and 75% were white. At study entry, 54% of patients were followed by nephrologists, and 88% were on renin-angiotensin system blockers. After a 2-year follow-up, rate of decline in eGFR was similar across the four groups ( P =0.19). Measurements of CKD-related laboratory parameters were not significantly different among the groups. Furthermore, referral for dialysis education and vascular access placement, emergency room visits, and hospitalization rates were not statistically significant different between the groups. We successfully developed a patient navigator program and an enhanced personal health record for the CKD population. However, there were no differences in eGFR decline and other outcomes among the study groups. Larger and long-term studies along with cost-effectiveness analyses are needed to evaluate the role of patient navigators

Evidence for Anti-Inflammatory Effects of Exercise in CKD

PubMed Central

Kosmadakis, George C.; Watson, Emma L.; Bevington, Alan; Feehally, John; Bishop, Nicolette C.; Smith, Alice C.

2014-01-01

CKD is associated with a complex state of immune dysfunction characterized by immune depression, predisposing patients to infections, and immune activation, resulting in inflammation that associates with higher risk of cardiovascular disease. Physical exercise may enhance immune function and exert anti-inflammatory effects, but such effects are unclear in CKD. We investigated the separate effects of acute and regular moderate-intensity aerobic exercise on neutrophil degranulation (elastase release), activation of T lymphocytes (CD69 expression) and monocytes (CD86 and HLA-DR expression), and plasma inflammatory markers (IL-6, IL-10, soluble TNF-receptors, and C-reactive protein) in patients with predialysis CKD. A single 30-minute (acute) bout of walking induced a normal pattern of leukocyte mobilization and had no effect on T-lymphocyte and monocyte activation but improved neutrophil responsiveness to a bacterial challenge in the postexercise period. Furthermore, acute exercise induced a systemic anti-inflammatory environment, evidenced by a marked increase in plasma IL-10 levels (peaked at 1 hour postexercise), that was most likely mediated by increased plasma IL-6 levels (peaked immediately postexercise). Six months of regular walking exercise (30 min/d for 5 times/wk) exerted anti-inflammatory effects (reduction in the ratio of plasma IL-6 to IL-10 levels) and a downregulation of T-lymphocyte and monocyte activation, but it had no effect on circulating immune cell numbers or neutrophil degranulation responses. Renal function, proteinuria, and BP were also unaffected. These findings provide compelling evidence that walking exercise is safe with regard to immune and inflammatory responses and has the potential to be an effective anti-inflammatory therapy in predialysis CKD. PMID:24700875

Nighttime BP in Elderly Individuals with Prediabetes/Diabetes with and without CKD: The HEIJO-KYO Study.

PubMed

Obayashi, Kenji; Saeki, Keigo; Kurumatani, Norio

2016-05-06

and objectives Although previous studies suggested that nighttime BP is elevated in diabetes mellitus, the association between prediabetes and nighttime BP remains unclear. In addition, the relationship between diabetic status, renal function, and nighttime BP has not been evaluated in large populations. In this cross-sectional study, we assessed diabetic status, renal function, and ambulatory BP parameters among 1081 community-dwelling elderly individuals (mean age, 71.8±7.0 years). Participants were classified into six categories based on diabetic status (normoglycemia, prediabetes, or diabetes mellitus) and renal function (normal function or CKD). BP was measured at 30-minute intervals for 48 hours using a validated ambulatory recorder. The mean nighttime systolic BP (SBP) was 115.7±16.1 mmHg. The multivariable analysis, adjusted for age, sex, smoking status, and daytime SBP, revealed that, compared with participants with normoglycemia but without CKD (n=378), mean nighttime SBP was significantly higher in participants with both prediabetes and CKD (n=93) by 2.9 mmHg (95% confidence interval [95% CI], 0.2 to 5.6; P=0.03) and in patients with both diabetes mellitus and CKD (n=30) by 7.8 mmHg (95% CI, 3.5 to 12.2; P<0.001) but not in participants with both normoglycemia and CKD (n=75), participants with prediabetes without CKD (n=374), or patients with diabetes mellitus without CKD (n=131). Notably, the multivariable analysis indicated that the interaction terms of diabetic status and renal function were significantly associated with nighttime SBP (P=0.03). Nighttime SBP was significantly higher in participants with prediabetes and CKD but not in participants with prediabetes without CKD, compared with participants with normoglycemia and without CKD. In addition, a significant interaction effect of diabetic status and renal function on nighttime SBP was detected in a general elderly population. Copyright © 2016 by the American Society of Nephrology.

Nighttime BP in Elderly Individuals with Prediabetes/Diabetes with and without CKD: The HEIJO-KYO Study

PubMed Central

Saeki, Keigo; Kurumatani, Norio

2016-01-01

Background and objectives Although previous studies suggested that nighttime BP is elevated in diabetes mellitus, the association between prediabetes and nighttime BP remains unclear. In addition, the relationship between diabetic status, renal function, and nighttime BP has not been evaluated in large populations. Design, setting, participants, & measurements In this cross-sectional study, we assessed diabetic status, renal function, and ambulatory BP parameters among 1081 community-dwelling elderly individuals (mean age, 71.8±7.0 years). Participants were classified into six categories based on diabetic status (normoglycemia, prediabetes, or diabetes mellitus) and renal function (normal function or CKD). BP was measured at 30-minute intervals for 48 hours using a validated ambulatory recorder. Results The mean nighttime systolic BP (SBP) was 115.7±16.1 mmHg. The multivariable analysis, adjusted for age, sex, smoking status, and daytime SBP, revealed that, compared with participants with normoglycemia but without CKD (n=378), mean nighttime SBP was significantly higher in participants with both prediabetes and CKD (n=93) by 2.9 mmHg (95% confidence interval [95% CI], 0.2 to 5.6; P=0.03) and in patients with both diabetes mellitus and CKD (n=30) by 7.8 mmHg (95% CI, 3.5 to 12.2; P<0.001) but not in participants with both normoglycemia and CKD (n=75), participants with prediabetes without CKD (n=374), or patients with diabetes mellitus without CKD (n=131). Notably, the multivariable analysis indicated that the interaction terms of diabetic status and renal function were significantly associated with nighttime SBP (P=0.03). Conclusions Nighttime SBP was significantly higher in participants with prediabetes and CKD but not in participants with prediabetes without CKD, compared with participants with normoglycemia and without CKD. In addition, a significant interaction effect of diabetic status and renal function on nighttime SBP was detected in a general elderly

HIF Activation Against CVD in CKD: Novel Treatment Opportunities.

PubMed

Tanaka, Tetsuhiro; Eckardt, Kai-Uwe

2018-05-01

Cardiovascular disease is a common and serious complication in patients with chronic kidney disease (CKD). One of the fundamental functions of the cardiovascular system is oxygen delivery, therefore cardiovascular disease inherently is linked to insufficient tissue oxygenation. Advances in our knowledge of cellular oxygen sensing by a family of prolyl hydroxylases (PHDs) and their role in regulating hypoxia-inducible factors (HIFs) have led to the discovery of PHD inhibitors as HIF stabilizers. Several small-molecule PHD inhibitors are currently in clinical trials for the treatment of anemia in CKD. An additional advantage of PHD inhibition may be found in the potential impact on cardiovascular consequences associated with CKD. Several preclinical studies have suggested a potential benefit of HIF activation in myocardial infarction, cardiac remodeling, atherosclerosis, and peripheral artery disease. Ameliorating glucose and lipid metabolism and lowering blood pressure may also contribute to cardiovascular protection. On the other hand, the broad spectrum of HIF-dependent functions also may include unwanted side effects. Clinical application of PHD inhibitors therefore necessitates careful evaluation of the net systemic effect of HIF activation. Copyright © 2018 Elsevier Inc. All rights reserved.

Measuring and Estimating GFR and Treatment Effect in ADPKD Patients: Results and Implications of a Longitudinal Cohort Study

PubMed Central

Cannata, Antonio; Carrara, Fabiola; Cella, Claudia; Ferrari, Silvia; Stucchi, Nadia; Prandini, Silvia; Ene-Iordache, Bogdan; Diadei, Olimpia; Perico, Norberto; Ondei, Patrizia; Pisani, Antonio; Buongiorno, Erasmo; Messa, Piergiorgio; Dugo, Mauro; Remuzzi, Giuseppe

2012-01-01

Trials failed to demonstrate protective effects of investigational treatments on glomerular filtration rate (GFR) reduction in Autosomal Dominant Polycystic Kidney Disease (ADPKD). To assess whether above findings were explained by unreliable GFR estimates, in this academic study we compared GFR values centrally measured by iohexol plasma clearance with corresponding values estimated by Chronic Kidney Disease Epidemiology Collaboration (CKD-Epi) and abbreviated Modification of Diet in Renal Disease (aMDRD) formulas in ADPKD patients retrieved from four clinical trials run by a Clinical Research Center and five Nephrology Units in Italy. Measured baseline GFRs and one-year GFR changes averaged 78.6±26.7 and 8.4±10.3 mL/min/1.73 m2 in 111 and 71 ADPKD patients, respectively. CKD-Epi significantly overestimated and aMDRD underestimated baseline GFRs. Less than half estimates deviated by <10% from measured values. One-year estimated GFR changes did not detect measured changes. Both formulas underestimated GFR changes by 50%. Less than 9% of estimates deviated <10% from measured changes. Extent of deviations even exceeded that of measured one-year GFR changes. In ADPKD, prediction formulas unreliably estimate actual GFR values and fail to detect their changes over time. Direct kidney function measurements by appropriate techniques are needed to adequately evaluate treatment effects in clinics and research. PMID:22393413

Predictors and Outcomes of Health–Related Quality of Life in Adults with CKD

PubMed Central

Lash, James P.; Xie, Dawei; Pan, Qiang; DeLuca, Jennifer; Kanthety, Radhika; Kusek, John W.; Lora, Claudia M.; Nessel, Lisa; Ricardo, Ana C.; Wright Nunes, Julie; Fischer, Michael J.

2016-01-01

Background and objectives Low health–related quality of life is associated with increased mortality in patients with ESRD. However, little is known about demographic and clinical factors associated with health–related quality of life or its effect on outcomes in adults with CKD. Design, settings, participants, & measurements Data from 3837 adult participants with mild to severe CKD enrolled in the prospective observational Chronic Renal Insufficiency Cohort and Hispanic Chronic Renal Insufficiency Cohort Studies were analyzed. Health–related quality of life was assessed at baseline with the Kidney Disease Quality of Life-36 and its five subscales: mental component summary, physical component summary, burden of kidney disease (burden), effects of kidney disease (effects), and symptoms and problems of kidney disease (symptoms). Low health–related quality of life was defined as baseline score >1 SD below the mean. Using Cox proportional hazards analysis, the relationships between low health–related quality of life and the following outcomes were examined: (1) CKD progression (50% eGFR loss or incident ESRD), (2) incident cardiovascular events, and (3) all-cause death. Results Younger age, women, low education, diabetes, vascular disease, congestive heart failure, obesity, and lower eGFR were associated with low baseline health–related quality of life (P<0.05). During a median follow-up of 6.2 years, there were 1055 CKD progression events, 841 cardiovascular events, and 694 deaths. Significantly higher crude rates of CKD progression, incident cardiovascular events, and all-cause death were observed among participants with low health–related quality of life in all subscales (P<0.05). In fully adjusted models, low physical component summary, effects, and symptoms subscales were independently associated with a higher risk of incident cardiovascular events and death, whereas low mental component summary was independently associated with a higher risk of death

[Bibliometric analysis of IBERPOC and EPI-SCAN studies. Contribution of the smoking variable on the iberpoc study].

PubMed

de Granda-Orive, J I; Alonso-Arroyo, A; López-Padilla, D; Segrelles-Calvo, G; Jiménez-Ruiz, C A; Solano-Reina, S

2018-03-01

The aim of this study was to perform a bibliometric analysis of EPI-SCAN and IBERPOC studies using the Science Citation Index and Scopus databases, and to determine the overall impact with the impact of smoking on IBERPOC as a secondary objective. A general searching was conducted in Science Citation Index-Expanded through the Web of Science (WoS) (Thomson Reuters) platform and Scopus on 23 March 2015. The search strategy included the terms "iberpoc" OR "episcan" was performed on 15 October 2015. A total of 24 publications were obtained; 13 from IBERPOC study (9 on "COPD" and 4 for "tobacco"), with 11 from the EPI-SCAN (All COPD) study. A total of 841 WoS citations were obtained (445 IBERPOC [99 of tobacco]), and 1,442 from Scopus (963 IBERPOC [144 tobacco]). The theme "tobacco" contributed with 22.24% and 14.95% of total citations in WoS and Scopus, respectively to the IBERPOC study. It was found that Scopus citations were newer, and a similar impact from both WoS studies was detected, although the IBERPOC impact was greater in Scopus. Collaborative networks of institutions and authors of both studies were identified. There is an important productivity and impact of both studies. Scopus citations are newer than those in WoS. The "tobacco" variable added IBERPOC impact and visibility. There was high density, accessibility, and cohesion in collaborative networks of both studies. Copyright © 2017 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.

Retinopathy and Cognitive Impairment in Adults With CKD

PubMed Central

Yaffe, Kristine; Ackerson, Lynn; Hoang, Tina D.; Go, Alan S.; Maguire, Maureen G.; Ying, Gui-Shuang; Daniel, Ebenezer; Bazzano, Lydia A.; Coleman, Martha; Cohen, Debbie L.; Kusek, John W.; Ojo, Akinlolu; Seliger, Stephen; Xie, Dawei; Grunwald, Juan E.

2014-01-01

Background Retinal microvascular abnormalities have been associated with cognitive impairment, possibly serving as a marker of cerebral small vessel disease. This relationship has not been evaluated among persons with chronic kidney disease (CKD), a condition associated with increased risk of both retinal pathology and cognitive impairment. Study Design Cross-sectional study Setting & Participants 588 participants ≥ 52 years old with CKD in the Chronic Renal Insufficiency Cohort (CRIC) Study Predictor Retinopathy graded using the Early Treatment Diabetic Retinopathy Study severity scale and diameters of retinal vessels. Outcomes Neuropsychological battery of six cognitive tests Measurements Logistic regression models were used to evaluate the association of retinopathy, individual retinopathy features, and retinal vessel diameters with cognitive impairment (≤1 SD from the mean), and linear regression models were used to compare cognitive test scores across levels of retinopathy adjusting for age, race, sex, education, and medical comorbidities. Results The mean age of the cohort was 65.3 +/− 5.6 (SD) years; 51.9% were non-White, and 52.6% were male. The prevalence of retinopathy was 30.1% and 14.3% for cognitive impairment. Compared to those without retinopathy, participants with retinopathy had increased likelihood of cognitive impairment on executive function (35.1% vs. 11.5%; OR, 3.4; 95% CI, 2.0-6.0), attention (26.7% vs. 7.3%; OR, 3.0; 95% CI, 1.8-4.9), and naming (26.0% vs. 10.0%; OR, 2.1; 95% CI, 1.2-3.4) after multivariable adjustment. Increased level of retinopathy was also associated with lower cognitive performance on executive function and attention. Microaneurysms were associated with cognitive impairment on some domains, but there were no significant associations with other retinal measures after multivariable adjustment. Limitations Unknown temporal relationship between retinopathy and impairment. Conclusions In adults with CKD, retinopathy is

Chronic hyperkalemia in non-dialysis CKD: controversial issues in nephrology practice.

PubMed

De Nicola, Luca; Di Lullo, Luca; Paoletti, Ernesto; Cupisti, Adamasco; Bianchi, Stefano

2018-06-07

Chronic hyperkalemia is a major complication of chronic kidney disease (CKD) that occurs frequently, heralds poor prognosis, and necessitates careful management by the nephrologist. Current strategies aimed at prevention and treatment of hyperkalemia are still suboptimal, as evidenced by the relatively high prevalence of hyperkalemia in patients under stable nephrology care, and even in the ideal setting of randomized trials where best treatment and monitoring are mandatory. The aim of this review was to identify and discuss a range of unresolved issues related to the management of chronic hyperkalemia in non-dialysis CKD. The following topics of clinical interest were addressed: diagnosis, relationship with main comorbidities of CKD, therapy with inhibitors of the renin-angiotensin-aldosterone system, efficacy of current dietary and pharmacological treatment, and the potential role of the new generation of potassium binders. Opinion-based answers are provided for each of these controversial issues.

End-Stage Renal Disease Outcomes among the Kaiser Permanente Southern California Creatinine Safety Program (Creatinine SureNet): Opportunities to Reflect and Improve

PubMed Central

Sim, John J; Batech, Michael; Danforth, Kim N; Rutkowski, Mark P; Jacobsen, Steven J; Kanter, Michael H

2017-01-01

Objectives: The Kaiser Permanente Southern California (KPSC) creatinine safety program (Creatinine SureNet) identifies and outreaches to thousands of people annually who may have had a missed diagnosis for chronic kidney disease (CKD). We sought to determine the value of this outpatient program and evaluate opportunities for improvement. Methods: Longitudinal cohort study (February 2010 through December 2015) of KPSC members captured into the creatinine safety program who were characterized using demographics, laboratory results, and different estimations of glomerular filtration rate. Age- and sex-adjusted rates of end-stage renal disease (ESRD) were compared with those in the overall KPSC population. Results: Among 12,394 individuals, 83 (0.7%) reached ESRD. The age- and sex-adjusted relative risk of ESRD was 2.7 times higher compared with the KPSC general population during the same period (94.7 vs 35.4 per 100,000 person-years; p < 0.001). Screening with the Chronic Kidney Disease Epidemiology Collaboration (vs Modification Diet in Renal Diseases) equation would capture 44% fewer individuals and have a higher predictive value for CKD. Of those who had repeated creatinine measurements, only 13% had a urine study performed (32% among patients with confirmed CKD). Conclusion: Our study found a higher incidence of ESRD among individuals captured into the KPSC creatinine safety program. If the Chronic Kidney Disease Epidemiology Collaboration equation were used, fewer people would have been captured while improving the accuracy for diagnosing CKD. Urine testing was low even among patients with confirmed CKD. Our findings demonstrate the importance of a creatinine safety net program in an integrated health system but also suggest opportunities to improve CKD care and screening. PMID:28241912

End-Stage Renal Disease Outcomes among the Kaiser Permanente Southern California Creatinine Safety Program (Creatinine SureNet): Opportunities to Reflect and Improve.

PubMed

Sim, John J; Batech, Michael; Danforth, Kim N; Rutkowski, Mark P; Jacobsen, Steven J; Kanter, Michael H

2017-01-01

The Kaiser Permanente Southern California (KPSC) creatinine safety program (Creatinine SureNet) identifies and outreaches to thousands of people annually who may have had a missed diagnosis for chronic kidney disease (CKD). We sought to determine the value of this outpatient program and evaluate opportunities for improvement. Longitudinal cohort study (February 2010 through December 2015) of KPSC members captured into the creatinine safety program who were characterized using demographics, laboratory results, and different estimations of glomerular filtration rate. Age- and sex-adjusted rates of end-stage renal disease (ESRD) were compared with those in the overall KPSC population. Among 12,394 individuals, 83 (0.7%) reached ESRD. The age- and sex-adjusted relative risk of ESRD was 2.7 times higher compared with the KPSC general population during the same period (94.7 vs 35.4 per 100,000 person-years; p < 0.001). Screening with the Chronic Kidney Disease Epidemiology Collaboration (vs Modification Diet in Renal Diseases) equation would capture 44% fewer individuals and have a higher predictive value for CKD. Of those who had repeated creatinine measurements, only 13% had a urine study performed (32% among patients with confirmed CKD). Our study found a higher incidence of ESRD among individuals captured into the KPSC creatinine safety program. If the Chronic Kidney Disease Epidemiology Collaboration equation were used, fewer people would have been captured while improving the accuracy for diagnosing CKD. Urine testing was low even among patients with confirmed CKD. Our findings demonstrate the importance of a creatinine safety net program in an integrated health system but also suggest opportunities to improve CKD care and screening.

Development of a Model of Chronic Kidney Disease in the C57BL/6 Mouse with Properties of Progressive Human CKD

PubMed Central

Cruz, Gaile L.; Lu, Chao; Carlisle, Rachel E.; Werner, Kaitlyn E.; Ask, Kjetil; Dickhout, Jeffrey G.

2015-01-01

Chronic kidney disease (CKD) is a major healthcare problem with increasing prevalence in the population. CKD leads to end stage renal disease and increases the risk of cardiovascular disease. As such, it is important to study the mechanisms underlying CKD progression. To this end, an animal model was developed to allow the testing of new treatment strategies or molecular targets for CKD prevention. Many underlying risk factors result in CKD but the disease itself has common features, including renal interstitial fibrosis, tubular epithelial cell loss through apoptosis, glomerular damage, and renal inflammation. Further, CKD shows differences in prevalence between the genders with premenopausal women being relatively resistant to CKD. We sought to develop and characterize an animal model with these common features of human CKD in the C57BL/6 mouse. Mice of this genetic background have been used to produce transgenic strains that are commercially available. Thus, a CKD model in this strain would allow the testing of the effects of numerous genes on the severity or progression of CKD with minimal cost. This paper describes such a mouse model of CKD utilizing angiotensin II and deoxycorticosterone acetate as inducers. PMID:26064882

Insignificant impact of VUR on the progression of CKD in children with CAKUT.

PubMed

Ishikura, Kenji; Uemura, Osamu; Hamasaki, Yuko; Nakai, Hideo; Ito, Shuichi; Harada, Ryoko; Hattori, Motoshi; Ohashi, Yasuo; Tanaka, Ryojiro; Nakanishi, Koichi; Kaneko, Tetsuji; Iijima, Kazumoto; Honda, Masataka

2016-01-01

Vesicoureteral reflux (VUR) is associated with an increased risk of kidney disorders. It is unclear whether VUR is associated with progression from chronic kidney disease (CKD) to end-stage kidney disease (ESKD) in children with congenital anomalies of the kidney and urinary tract (CAKUT). We conducted a 3-year follow-up survey of a cohort of 447 children with CKD (stage 3-5). Rates of and risk factors for progression to ESKD were determined using the Kaplan-Meier method and Cox regression respectively. Congenital anomaly of the kidney and urinary tract was the primary etiology in 278 out of 447 children; 118 (42.4 %) had a history of VUR at the start of the cohort study. There were significantly more boys than girls with VUR, whereas the proportions were similar in children without VUR. The types of urinary anomalies/complications of the two groups were significantly different. Three-year renal survival rates of the groups were not significantly different, irrespective of CKD stage. Age  < 2 years and age after puberty, stage 4 or 5 CKD, and heavy proteinuria, but not history of VUR, were significantly associated with progression to ESKD. History of VUR at the start of follow-up was not associated with the progression of stage 3-5 CKD in children with CAKUT.

COSMOS: the dialysis scenario of CKD-MBD in Europe.

PubMed

Fernández-Martín, José Luis; Carrero, Juan Jesus; Benedik, Miha; Bos, Willem-Jan; Covic, Adrian; Ferreira, Aníbal; Floege, Jürgen; Goldsmith, David; Gorriz, José Luis; Ketteler, Markus; Kramar, Reinhard; Locatelli, Francesco; London, Gérard; Martin, Pierre-Yves; Memmos, Dimitrios; Nagy, Judit; Naves-Díaz, Manuel; Pavlovic, Drasko; Rodríguez-García, Minerva; Rutkowski, Boleslaw; Teplan, Vladimir; Tielemans, Christian; Verbeelen, Dierik; Wüthrich, Rudolf P; Martínez-Camblor, Pablo; Cabezas-Rodriguez, Iván; Sánchez-Alvarez, José Emilio; Cannata-Andia, Jorge B

2013-07-01

Chronic kidney disease-mineral and bone disorders (CKD-MBD) are important complications of CKD5D patients that are associated with mortality. COSMOS is a multicentre, open cohort, prospective, observational 3-year study carried out in haemodialysis patients from 20 European countries during 2005-07. The present article describes the main characteristics of the European dialysis population, the current practice for the prevention, diagnosis and treatment of secondary hyperparathyroidism and the differences across different European regions. The haemodialysis population in Europe is an aged population (mean age 64.8±14.2 years) with a high prevalence of diabetes (29.5%) and cardiovascular disease (76.0%), and 28.7% of patients have been on haemodialysis more than 5 years. Patients from the former Eastern countries are younger (59.3±14.3 versus 66.0±13.9), having a lower proportion of diabetics (24.1 versus 30.7%). There were relevant differences in the frequency of measurement of the main CKD-MBD biochemical parameters [Ca, P and parathyroid hormone (PTH)] and the Eastern countries showed a poorer control of these biochemical parameters (K/DOQI and K/DIGO targets). Overall, 48.0% of the haemodialysis patients received active vitamin D treatment. Calcitriol use doubled that of alfacalcidiol in the Mediterranean countries, whereas the opposite was found in the non-Mediterranean countries. The criteria followed to perform parathyroidectomy were different across Europe. In the Mediterranean countries, the level of serum PTH considered to perform parathyroidectomy was higher than in non-Mediterranean countries; as a result, in the latter, more parathyroidectomies were performed in the year previous to inclusion to COSMOS. The COSMOS baseline results show important differences across Europe in the management of CKD-MBD.

Comparison of Intact PTH and Bio-Intact PTH Assays Among Non-Dialysis Dependent Chronic Kidney Disease Patients.

PubMed

Einbinder, Yael; Benchetrit, Sydney; Golan, Eliezer; Zitman-Gal, Tali

2017-09-01

The third-generation bio-intact parathyroid hormone (PTH) (1-84) assay was designed to overcome problems associated with the detection of C-terminal fragments by the second-generation intact PTH assay. The two assays have been compared primarily among dialysis populations. The present study evaluated the correlations and differences between these two PTH assays among patients with chronic kidney disease (CKD) stages 3 to 5 not yet on dialysis. Blood samples were collected from 98 patients with CKD stages 3 to 5. PTH concentrations were measured simultaneously by using the second-generation - PTH intact-STAT and third-generation bio-intact 1-84 PTH assays. Other serum biomarkers of bone mineral disorders were also assessed. CKD stage was calculated by using the CKD-Epidemiology Collaboration (EPI) formula. Serum bio-intact PTH concentrations were strongly correlated but significantly lower than the intact PTH concentrations (r=0.963, P<0.0001). This finding was consistent among CKD stages 3 to 5. PTH concentrations by both assays (intact and bio-intact PTH) positively correlated with urea (r=0.523, r=0.504; P=0.002, respectively), phosphorus (r=0.532, r=0.521; P<0.0001, respectively) and negatively correlated with blood calcium (r=-0.435, r=-0.476; P<0.0001, respectively), 25(OH) vitamin D, (r=-0.319, r=-0.353; respectively, P<0.0001) and the estimated glomerular filtration rate (r=-0.717, r=-0.688; P<0.0001, respectively). Among patients with CKD stages 3 to 5 not on dialysis, the bio-intact PTH assay detected significantly lower PTH concentrations compared with intact PTH assay. Additional studies that correlate the diagnosis and management of CKD mineral and bone disorders with bone histomorphometric findings are needed to determine whether bio-intact PTH assay results are better surrogate markers in these early stages of CKD. © The Korean Society for Laboratory Medicine

Potential influence of tubular dysfunction on the difference between estimated and measured glomerular filtration rate after kidney transplantation.

PubMed

Lezaic, V; Mirkovic, D; Ristic, S; Radivojevic, D; Dajak, M; Naumovic, R; Marinkovic, J; Djukanovic, L J

2013-05-01

Because no consensus exists regarding the most accurate calculation to estimate glomerular filtration rate (GFR) based on serum creatinine concentrations (sCr) after kidney transplantation, this study sought to assess the potential role of tubular dysfunction on GFR estimates using various equations as well as the effect of pharmacologic blockades on tubular secretion of creatinine on creatinine clearance (ClCr). Iohexol GFR (mGFR) was performed in 17 stable kidney transplant recipients(R) at >24 months post-transplantation. Their mean age was 48.3 ± 11.3 years. All R were treated with a calcineurin inhibitor (CNI). At the time of study we measured sCr, 24 hour-ClCr, cystatin C, 24-hour proteinuria, microalbuminuria, FE Na, alfa1-microglobulinuria (alfa1-MG), and CNI concentrations. To block tubular secretion of Cr, recipients were prescribed cimetidine (2400 mg) 2 days before the sCr measurement. Additionally, to exclude dietary influences on sCr, R did not eat meat for 2 days before testing. GFR was estimated using the Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Cockroft-Gault (C&G), and Cystatin C (Cyst C) GFR equations. Mean kidney graft function over the previous 6 months was used as the control. Pearson correlation was determined between the differences between mGFR and estimatedGFR: Iohexol minus MDRD, EPI, Cyst C or C&G GFR for paired estimates. The diagnostic accuracy of the eGFRs to detect an mGFR of 60 mL/min/1.73 m(2) was examined by receiver operating characteristic curves. Mean mGFR was 75.2 ± 35.8 mL/min/1.73 m(2). The sCr increased but the 24-hour ClCr, MDRD, EPI, and C&G decreased after vs before cimetidine. The difference was significant for sCr (F = 12.933; P = .002) and MDRD GFR (F = 15.750; P = .001). mGFR was not significantly higher than all pair values of eGFRs, and not significantly lower than 24-hour ClCr before and after cimetidine. However, in comparison to all eGFRs, Cl

Visual outcomes after Epi-LASIK and PRK for low and moderate myopia.

PubMed

Sia, Rose K; Coe, Charles D; Edwards, Jayson D; Ryan, Denise S; Bower, Kraig S

2012-01-01

To evaluate visual outcomes following epi-LASIK compared to photorefractive keratectomy (PRK). Of a total 294 patients aged ≥21 years, 145 (290 eyes) underwent epi-LASIK and 149 (298 eyes) underwent PRK for low to moderate myopia or myopic astigmatism. Epi-LASIK was performed with the Amadeus II epikeratome (Abbott Medical Optics) and PRK with the Amoils rotary epithelial brush (Innovative Excimer Solutions). All ablations were performed using the same excimer laser system. Outcome measures included intraoperative complications, corneal reepithelialization, postoperative pain, uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent (MRSE), corrected distance visual acuity (CDVA), corneal haze, and quality of vision. Mean preoperative MRSE was -2.97±1.19 diopters (D) for epi-LASIK versus -2.95±1.06 D for PRK. Complete reepithelialization was achieved by postoperative day 4 in 46.9% of epi-LASIK eyes versus 92.4% of PRK eyes, with superior UDVA at postoperative day 1 in the PRK group (P=.002). Using Fisher exact test, a significantly higher percentage of epi-LASIK eyes compared to PRK eyes achieved 20/15 or better at 1 month (25.8% vs 17.8%, P=.031), 3 months (62.3% vs 49.3%, P=.004), 6 months (77.1% vs 57.9%, P<.001), and 12 months (75.9% vs 61.9%, P=.002). A change in MRSE >0.50 D occurred in 8.4% of epi-LASIK eyes within the 3- and 12-month interval versus 17.7% of PRK eyes (P=.04). No differences were noted between the two procedures in CDVA or clinically significant haze. Epi-LASIK showed superior refractive efficacy and stability but required more time for wound healing, resulting in inferior early visual outcomes and a tendency to overcorrect higher refractive errors compared to PRK. Both treatments were safe and comparable in terms of pain and haze formation. Copyright 2012, SLACK Incorporated.

CKD and Acute and Long-Term Outcome of Patients with Peripheral Artery Disease and Critical Limb Ischemia.

PubMed

Lüders, Florian; Bunzemeier, Holger; Engelbertz, Christiane; Malyar, Nasser M; Meyborg, Matthias; Roeder, Norbert; Berger, Klaus; Reinecke, Holger

2016-02-05

Despite the many studies showing an association between CKD and a high risk of ischemic events and mortality, the association of CKD with peripheral arterial disease (PAD) still has not been well described. This large cohort study assessed the association of CKD, even in the earlier stages, with morbidity, short- and long-term outcome, and costs among patients with PAD. We identified 41,882 patients with PAD who had an index hospitalization between January 1, 2009, and December 31, 2011. Of these, 8470 (20.2%) also had CKD (CKD stage 2: n=2158 [26%]; stage 3: n=3941 [47%]; stage 4: n=935 [11%]; stage 5: n=1436 [17%]). The ratio of women to men was 1:1.2. Compared with patients without known CKD, those with CKD had higher frequencies of coronary artery disease (1.8-fold higher; P<0.001), chronic heart failure (3.3-fold higher; P<0.001), and Rutherford PAD categories 5 and 6 (1.8-fold higher; P<0.001); underwent significantly fewer revascularizations (0.9-fold fewer; P<0.001); had a nearly two-fold higher amputation rate (P<0.001); had higher frequencies of in-hospital infections (2.1-fold higher; P<0.001), acute renal failure (2.8-fold higher; P<0.001), and sepsis (1.9-fold higher; P<0.001); had a 2.5-fold higher frequency of myocardial infarction (P<0.001); and had a nearly three-fold higher in-hospital mortality rate (P<0.001). In an adjusted multivariable Cox regression model, CKD remained a significant predictor of long-term outcome of patients with PAD during follow-up for up to 4 years (until December 31, 2012; median, 775 days; 25th-75th percentiles, 469-1120 days); the hazard ratio was 2.59 (95% confidence interval, 2.21 to 2.78; P<0.001). The projected mortality rates after 4 years were 27% in patients without known CKD and 46%, 52%, 72%, and 78% in those with CKD stages 2, 3, 4, and 5, respectively. Lengths of hospital stay and reimbursement costs were on average nearly 1.4-fold higher (P<0.001) in patients who also had CKD. This analysis illustrates the

Applying the Growth Failure in CKD Consensus Conference: evaluation and treatment algorithm in children with chronic kidney disease.

PubMed

Mahan, John D

2006-07-01

Growth failure is a common and significant clinical problem for children with chronic kidney disease (CKD), particularly those with chronic renal insufficiency (CRI). Children with CRI (typically defined by a glomerular filtration rate [GFR] <75 mL/min/1.73 m2) who have growth impairment exhibit a variety of medical and psychological problems in addition to increased mortality. Growth failure in children with CKD is usually multifactorial in etiology, including abnormalities in the growth hormone (GH)-insulin-like growth factor (IGF)-I axis and a variety of nutritional and metabolic concerns characteristic of CKD. Proper management of these factors contributes to better growth in affected children. Although the safety and efficacy of recombinant human GH (rhGH) therapy in promoting growth in children with CKD are well established, recent data indicate that the use of rhGH administration in children with CKD and growth failure remains low. Recently, guidelines were developed by the Consensus Conference for Evaluation and Treatment of Growth Failure in Children with CKD. This paper focuses on the application of these guidelines to children with CKD.

Safety of intravenous ferric carboxymaltose versus oral iron in patients with nondialysis-dependent CKD: an analysis of the 1-year FIND-CKD trial.

PubMed

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

2017-09-01

The evidence base regarding the safety of intravenous (IV) iron therapy in patients with chronic kidney disease (CKD) is incomplete and largely based on small studies of relatively short duration. FIND-CKD (ClinicalTrials.gov number NCT00994318) was a 1-year, open-label, multicenter, prospective study of patients with nondialysis-dependent CKD, anemia and iron deficiency randomized (1:1:2) to IV ferric carboxymaltose (FCM), targeting higher (400-600 µg/L) or lower (100-200 µg/L) ferritin, or oral iron. A post hoc analysis of adverse event rates per 100 patient-years was performed to assess the safety of FCM versus oral iron over an extended period. The safety population included 616 patients. The incidence of one or more adverse events was 91.0, 100.0 and 105.0 per 100 patient-years in the high ferritin FCM, low ferritin FCM and oral iron groups, respectively. The incidence of adverse events with a suspected relation to study drug was 15.9, 17.8 and 36.7 per 100 patient-years in the three groups; for serious adverse events, the incidence was 28.2, 27.9 and 24.3 per 100 patient-years. The incidence of cardiac disorders and infections was similar between groups. At least one ferritin level ≥800 µg/L occurred in 26.6% of high ferritin FCM patients, with no associated increase in adverse events. No patient with ferritin ≥800 µg/L discontinued the study drug due to adverse events. Estimated glomerular filtration rate remained the stable in all groups. These results further support the conclusion that correction of iron deficiency anemia with IV FCM is safe in patients with nondialysis-dependent CKD. © The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA.

Nutritional status in stage V dialyzed patient versus CKD patient on conservative therapy across different economic status.

PubMed

Vijayan, Madhusudan; Abraham, Georgi; Alex, Merina E; Vijayshree, N; Reddy, Yuvaram; Fernando, Edwin; Mathew, Milly; Nair, Sanjeev; Yuvaraj, Anand

2014-04-01

This aim of this multi-centric cross-sectional study was to assess the nutritional status in Indian chronic kidney disease (CKD) patients and to compare the nutritional indicators between stage 5 dialyzed (CKD-D) patients below the poverty line (BPL), and stage 3-4 non-dialyzed (CKD-ND) patients above (APL) and below the poverty line. Patients were selected from a government medical college hospital, a charity-based outpatient dialysis unit, and a non-profit tertiary care center. The study groups included BPL CKD-ND (n = 100), BPL CKD-D (n = 98), and APL CKD-ND (n = 92) patients, based on a cut-off of per capita income US $1.25 a day. Patients were enquired by a qualified renal dietitian about their pattern of diet, and daily energy and protein intake by 24 h recall method. Anthropometric measurements and biochemical investigations were made and compared. Nutritional indicators were low in all three groups compared to those prescribed by European Best Practice Guidelines (EBPG). BPL CKD-D patients had low serum albumin levels (32.44444 ± 6.279961 g/L; p = 0.017) and 41.83% of them were underweight. The APL CKD-ND group registered the lowest mean daily energy (22.576 ± 6.289 kcal/kg/day) and protein intake (0.71 ± 0.06 g/kg/day), due to dietary restrictions imposed on them by themselves and unqualified renal dietitians. The APL group had better indicators of nutritional status in terms of mid-upper arm circumference (p = 0.001), triceps skin fold thickness (p < 0.001), and serum hemoglobin (p < 0.001). Several nutritional parameters were below the recommended international guidelines for all the three groups, though the high income group had better parameters from several indicators. There is an urgent need for nutritional counseling for CKD-D and CKD-ND patients.

Assessment of cement kiln dust (CKD) for stabilization/solidification (S/S) of arsenic contaminated soils.

PubMed

Moon, Deok Hyun; Wazne, Mahmoud; Yoon, In-Ho; Grubb, Dennis G

2008-11-30

A stabilization/solidification (S/S) process for arsenic (As) contaminated soils was evaluated using cement kiln dust (CKD). Laboratory-prepared slurries, made of either kaolinite or montmorillonite, and field soils spiked with either As(3+) or As(5+) were prepared and treated with CKD ranging from 10 to 25 wt%. Sodium arsenite and sodium arsenate at 0.1 wt% were used to simulate arsenite (As(3+)) and arsenate (As(5+)) source contamination in soils, respectively. The effectiveness of treatment was evaluated at curing periods of 1- and 7-days based on the toxicity characteristic leaching procedure (TCLP). As-CKD and As-clay-CKD slurries were also spiked at 10 wt% to evaluate As immobilization mechanism using X-ray powder diffraction (XRPD) analyses. Overall, the TCLP results showed that only the As(5+) concentrations in kaolinite amended with 25 wt% CKD after 1 day of curing were less than the TCLP regulatory limit of 5mg/L. Moreover, at 7 days of curing, all As(3+) and As(5+) concentrations obtained from kaolinite soils were less than the TCLP criteria. However, none of the CKD-amended montmorillonite samples satisfied the TCLP-As criteria at 7 days. Only field soil samples amended with 20 wt% CKD complied with the TCLP criteria within 1 day of curing, where the source contamination was As(5+). XRPD and scanning electron microscopy (SEM)-energy dispersive X-ray spectroscopy (EDX) results showed that Ca-As-O and NaCaAsO(4).7.5H(2)O were the primary phases responsible for As(3+) and As(5+) immobilization in the soils, respectively.

Usability of a CKD educational website targeted to patients and their family members.

PubMed

Diamantidis, Clarissa J; Zuckerman, Marni; Fink, Wanda; Hu, Peter; Yang, Shiming; Fink, Jeffrey C

2012-10-01

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. 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). 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. 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.

[Association of mineral and bone disorder with increasing PWV in CKD 1-5 patients].

PubMed

Shiota, Jun; Watanabe, Mitsuhiro

2007-01-01

The association between pulse wave velocity(PWV) and chronic kidney disease mineral and bone disorder(CKD-MBD) was investigated in CKD 1-5 patients without dialysis. Pulse pressure(PP), PWV, serum Cr, non-HDL-cholesterol, Alb, Ca, Pi, calcitriol, intact-PTH and BAP were measured in sixty patients not receiving a phosphate binder or vitamin D. Using the relationship between age and baPWV in healthy subjects, we determined delta baPWV(measured baPWV-calculated baPWV) as an index for the effect of CKD-related factors. delta baPWV was significantly higher in diabetic patients (p < 0.00001). Simple regression analysis revealed that delta baPWV was positively correlated with PP (p < 0.05) and Log(intact-PTH) (p < 0.01), but negatively correlated with Log(estimated GFR) and Log(calcitriol) (p < 0.01). Multiple regression analysis revealed that delta baPWV was significantly associated with PP and calcitriol, or PP and intact-PTH. These results suggest a relationship between PWV and CKD-MBD.

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

PubMed

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

2015-08-07

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. Participants with predialysis CKD (defined as eGFR<60 ml/min per 1.73 m(2)) 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. 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. The mobile health medication inquiry system application had general ease of use and high acceptance across two platforms among individuals representative of the CKD population. Tailored mobile health technology may improve medication

Uric Acid and the Risks of Kidney Failure and Death in Individuals With CKD.

PubMed

Srivastava, Anand; Kaze, Arnaud D; McMullan, Ciaran J; Isakova, Tamara; Waikar, Sushrut S

2018-03-01

Serum uric acid concentrations increase in chronic kidney disease (CKD) and may lead to tubular injury, endothelial dysfunction, oxidative stress, and intrarenal inflammation. Whether uric acid concentrations are associated with kidney failure and death in CKD is unknown. Prospective observational cohort study. 3,885 individuals with CKD stages 2 to 4 enrolled in the Chronic Renal Insufficiency Cohort (CRIC) between June 2003 and September 2008 and followed up through March 2013. Baseline uric acid concentrations. Kidney failure (initiation of dialysis therapy or transplantation) and all-cause mortality. During a median follow-up of 7.9 years, 885 participants progressed to kidney failure and 789 participants died. After adjustment for demographic, cardiovascular, and kidney-specific covariates, higher uric acid concentrations were independently associated with risk for kidney failure in participants with estimated glomerular filtration rates (eGFRs) ≥ 45mL/min/1.73m 2 (adjusted HR per 1-standard deviation greater baseline uric acid, 1.40; 95% CI, 1.12-1.75), but not in those with eGFRs<30mL/min/1.73m 2 . There was a nominally higher HR in participants with eGFRs of 30 to 44mL/min/1.73m 2 (adjusted HR, 1.13; 95% CI, 0.99-1.29), but this did not reach statistical significance. The relationship between uric acid concentration and all-cause mortality was J-shaped (P=0.007). Potential residual confounding through unavailable confounders; lack of follow-up measurements to adjust for changes in uric acid concentrations over time. Uric acid concentration is an independent risk factor for kidney failure in earlier stages of CKD and has a J-shaped relationship with all-cause mortality in CKD. Adequately powered randomized placebo-controlled trials in CKD are needed to test whether urate lowering may prove to be an effective approach to prevent complications and progression of CKD. Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All

Small Field-of-view single-shot EPI-DWI of the prostate: Evaluation of spatially-tailored two-dimensional radiofrequency excitation pulses.

PubMed

Attenberger, Ulrike I; Rathmann, Nils; Sertdemir, Metin; Riffel, Philipp; Weidner, Anja; Kannengiesser, Stefan; Morelli, John N; Schoenberg, Stefan O; Hausmann, Daniel

2016-06-01

Spatially-tailored (RF) excitation pulses in echo-planar imaging (EPI), combined with a decreased FOV in the phase-encoding direction, enable a reduction of k-space acquisition lines, which shortens the echo train length (ETL) and reduces susceptibility artifacts. The purpose of this study was to evaluate the image quality of a zoomed EPI (z-EPI) sequence in diffusion-weighted imaging (DWI) of the prostate in comparison to a conventional single-shot EPI using single-channel (c-EPI1) and multi-channel (c-EPI2) RF excitation, with and without use of an endorectal coil. 33 consecutive patients (mean age: 61 +/- 9 years; mean PSA: 8.67±6.23 ng/ml) with examinations between 10/2012 and 02/2014 were analyzed in this retrospective study. In 26 of 33 patients the initial multiparametric (mp)-MRI was performed on a whole-body 3T scanner (Magnetom Trio, Siemens, Erlangen, Germany) using an endorectal coil (c (conventional)-EPI1). Zoomed-EPI (Z-EPI) examinations of these patients and a complete mp-MRI protocol including c-EPI2 of 7 additional patients were carried out on another 3T wb MR scanner with two-channel dynamic parallel transmit capability (Magnetom Skyra with TimTX TrueShape, Siemens). For z-EPI, the one-dimensional spatially selective RF excitation pulse was replaced by a two-dimensional RF pulse. Degree of image blur and susceptibility artifacts (0=not present to 3= non-diagnostic), maximum image distortion (mm), apparent diffusion coefficient (ADC) values, as well as overall scan preference were evaluated. SNR maps were generated to compare c-EPI2 and z-EPI. Overall image quality of z-EPI was preferred by both readers in all examinations with a single exception. Susceptibility artifacts were rated significantly lower on z-EPI compared to both other methods (z-EPI vs c-EPI1: p<0.01; z-EPI vs c-EPI2: p<0.01) as well as image blur (z-EPI vs c-EPI1: p<0.01; z-EPI vs c-EPI2: p<0.01). Image distortion was not statistically significantly reduced with z-EPI (z-EPI vs c-EPI

CKD and Acute and Long-Term Outcome of Patients with Peripheral Artery Disease and Critical Limb Ischemia

PubMed Central

Bunzemeier, Holger; Engelbertz, Christiane; Malyar, Nasser M.; Meyborg, Matthias; Roeder, Norbert; Berger, Klaus; Reinecke, Holger

2016-01-01

Background and objectives Despite the many studies showing an association between CKD and a high risk of ischemic events and mortality, the association of CKD with peripheral arterial disease (PAD) still has not been well described. Design, setting, participants, & measurements This large cohort study assessed the association of CKD, even in the earlier stages, with morbidity, short- and long-term outcome, and costs among patients with PAD. Results We identified 41,882 patients with PAD who had an index hospitalization between January 1, 2009, and December 31, 2011. Of these, 8470 (20.2%) also had CKD (CKD stage 2: n=2158 [26%]; stage 3: n=3941 [47%]; stage 4: n=935 [11%]; stage 5: n=1436 [17%]). The ratio of women to men was 1:1.2. Compared with patients without known CKD, those with CKD had higher frequencies of coronary artery disease (1.8-fold higher; P<0.001), chronic heart failure (3.3-fold higher; P<0.001), and Rutherford PAD categories 5 and 6 (1.8-fold higher; P<0.001); underwent significantly fewer revascularizations (0.9-fold fewer; P<0.001); had a nearly two-fold higher amputation rate (P<0.001); had higher frequencies of in-hospital infections (2.1-fold higher; P<0.001), acute renal failure (2.8-fold higher; P<0.001), and sepsis (1.9-fold higher; P<0.001); had a 2.5-fold higher frequency of myocardial infarction (P<0.001); and had a nearly three-fold higher in-hospital mortality rate (P<0.001). In an adjusted multivariable Cox regression model, CKD remained a significant predictor of long-term outcome of patients with PAD during follow-up for up to 4 years (until December 31, 2012; median, 775 days; 25th–75th percentiles, 469–1120 days); the hazard ratio was 2.59 (95% confidence interval, 2.21 to 2.78; P<0.001). The projected mortality rates after 4 years were 27% in patients without known CKD and 46%, 52%, 72%, and 78% in those with CKD stages 2, 3, 4, and 5, respectively. Lengths of hospital stay and reimbursement costs were on average nearly 1

Stem Cell Technology for (Epi)genetic Brain Disorders.

PubMed

Riemens, Renzo J M; Soares, Edilene S; Esteller, Manel; Delgado-Morales, Raul

2017-01-01

Despite the enormous efforts of the scientific community over the years, effective therapeutics for many (epi)genetic brain disorders remain unidentified. The common and persistent failures to translate preclinical findings into clinical success are partially attributed to the limited efficiency of current disease models. Although animal and cellular models have substantially improved our knowledge of the pathological processes involved in these disorders, human brain research has generally been hampered by a lack of satisfactory humanized model systems. This, together with our incomplete knowledge of the multifactorial causes in the majority of these disorders, as well as a thorough understanding of associated (epi)genetic alterations, has been impeding progress in gaining more mechanistic insights from translational studies. Over the last years, however, stem cell technology has been offering an alternative approach to study and treat human brain disorders. Owing to this technology, we are now able to obtain a theoretically inexhaustible source of human neural cells and precursors in vitro that offer a platform for disease modeling and the establishment of therapeutic interventions. In addition to the potential to increase our general understanding of how (epi)genetic alterations contribute to the pathology of brain disorders, stem cells and derivatives allow for high-throughput drugs and toxicity testing, and provide a cell source for transplant therapies in regenerative medicine. In the current chapter, we will demonstrate the validity of human stem cell-based models and address the utility of other stem cell-based applications for several human brain disorders with multifactorial and (epi)genetic bases, including Parkinson's disease (PD), Alzheimer's disease (AD), fragile X syndrome (FXS), Angelman syndrome (AS), Prader-Willi syndrome (PWS), and Rett syndrome (RTT).

Nurse Practitioner Care Improves Renal Outcome in Patients with CKD

PubMed Central

van Zuilen, Arjan D.; van den Brand, Jan A.J.G.; Bots, Michiel L.; van Buren, Marjolijn; ten Dam, Marc A.G.J.; Kaasjager, Karin A.H.; Ligtenberg, Gerry; Sijpkens, Yvo W.J.; Sluiter, Henk E.; van de Ven, Peter J.G.; Vervoort, Gerald; Vleming, Louis-Jean; Blankestijn, Peter J.; Wetzels, Jack F.M.

2014-01-01

Treatment goals for patients with CKD are often unrealized for many reasons, but support by nurse practitioners may improve risk factor levels in these patients. Here, we analyzed renal endpoints of the Multifactorial Approach and Superior Treatment Efficacy in Renal Patients with the Aid of Nurse Practitioners (MASTERPLAN) study after extended follow-up to determine whether strict implementation of current CKD guidelines through the aid of nurse practitioners improves renal outcome. In total, 788 patients with moderate to severe CKD were randomized to receive nurse practitioner support added to physician care (intervention group) or physician care alone (control group). Median follow-up was 5.7 years. Renal outcome was a secondary endpoint of the MASTERPLAN study. We used a composite renal endpoint of death, ESRD, and 50% increase in serum creatinine. Event rates were compared with adjustment for baseline serum creatinine concentration and changes in estimated GFR were determined. During the randomized phase, there were small but significant differences between the groups in BP, proteinuria, LDL cholesterol, and use of aspirin, statins, active vitamin D, and antihypertensive medications, in favor of the intervention group. The intervention reduced the incidence of the composite renal endpoint by 20% (hazard ratio, 0.80; 95% confidence interval, 0.66 to 0.98; P=0.03). In the intervention group, the decrease in estimated GFR was 0.45 ml/min per 1.73 m2 per year less than in the control group (P=0.01). In conclusion, additional support by nurse practitioners attenuated the decline of kidney function and improved renal outcome in patients with CKD. PMID:24158983

Cross-sectional survey in CKD patients across Europe describing the association between quality of life and anaemia.

PubMed

Eriksson, Daniel; Goldsmith, David; Teitsson, Siguroli; Jackson, James; van Nooten, Floortje

2016-07-26

Deteriorating renal function in chronic kidney disease (CKD) patients is commonly associated with reduced haemoglobin levels, adding to the already considerable humanistic burden of CKD. This analysis evaluated the impact of anaemia on disease burden in patients with CKD stages 3-4, and in those on dialysis. This was a descriptive, cross-sectional analysis of European data from an Adelphi CKD Disease-Specific Programme. This programme collected data from patients and their treating nephrologists/endocrinologists; patient- and physician-reported data were matched for each patient. Health-related quality of life (HRQoL) data were obtained through patient completion of the EQ-5D, SF-12 and KDQOL-36. Additional information was obtained via physician reporting of patient symptoms, and patients' reports of impaired activity. Anaemia was defined by haemoglobin level and/or current use of erythropoiesis stimulating agents. Significant, but modest Spearman's rank correlations were observed between haemoglobin levels and extent of HRQoL impairment, regardless of instrument used (range 0.19-0.23; all P-values < 0.0001). When stratified by anaemia status, impairment was consistently lower for anaemic than non-anaemic CKD patients across measurement scales (e.g. EQ-5D index value [standard deviation {SD}] 0.72 [0.31] vs 0.83 [0.23], respectively; P < 0.0001). Physician-reported patient tiredness was associated with increased disease burden at all levels of CKD studied (total EQ-5D index value [SD] in patients reporting no tiredness vs tiredness 0.81 [0.26] vs 0.70 [0.30] respectively; P < 0.0001) with P < 0.0001 for no tiredness vs tiredness at all stages of CKD. The presence of anaemia was associated with impaired activity levels at CKD stages 3 (37.5 % vs 28.4 %, respectively; P = 0.0044) and 4 (48.1 % vs 39.9 %, respectively; P = 0.0292), and in patients on dialysis (52.0 % vs 45.0 %, respectively; P = 0.0732). The analysis found that CKD

An object simulation model for modeling hypothetical disease epidemics – EpiFlex

PubMed Central

Hanley, Brian

2006-01-01

Background EpiFlex is a flexible, easy to use computer model for a single computer, intended to be operated by one user who need not be an expert. Its purpose is to study in-silico the epidemic behavior of a wide variety of diseases, both known and theoretical, by simulating their spread at the level of individuals contracting and infecting others. To understand the system fully, this paper must be read together in conjunction with study of the software and its results. EpiFlex is evaluated using results from modeling influenza A epidemics and comparing them with a variety of field data sources and other types of modeling. EpiFlex is an object-oriented Monte Carlo system, allocating entities to correspond to individuals, disease vectors, diseases, and the locations that hosts may inhabit. EpiFlex defines eight different contact types available for a disease. Contacts occur inside locations within the model. Populations are composed of demographic groups, each of which has a cycle of movement between locations. Within locations, superspreading is defined by skewing of contact distributions. Results EpiFlex indicates three phenomena of interest for public health: (1) R0 is variable, and the smaller the population, the larger the infected fraction within that population will be; (2) significant compression/synchronization between cities by a factor of roughly 2 occurs between the early incubation phase of a multi-city epidemic and the major manifestation phase; (3) if better true morbidity data were available, more asymptomatic hosts would be seen to spread disease than we currently believe is the case for influenza. These results suggest that field research to study such phenomena, while expensive, should be worthwhile. Conclusion Since EpiFlex shows all stages of disease progression, detailed insight into the progress of epidemics is possible. EpiFlex shows the characteristic multimodality and apparently random variation characteristic of real world data, but does

A retrospective case-control analysis of the outpatient expenditures for western medicine and dental treatment modalities in CKD patients in Taiwan.

PubMed

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

2014-01-01

To determine if expenditures for dentistry (DENT) correlate with severity of chronic kidney disease (CKD). 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. 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. Patients with advanced CKD used DENT OPD service less frequently. However, the connection between CKD and DENT service utilization requires further study.

EpiModel: An R Package for Mathematical Modeling of Infectious Disease over Networks.

PubMed

Jenness, Samuel M; Goodreau, Steven M; Morris, Martina

2018-04-01

Package EpiModel provides tools for building, simulating, and analyzing mathematical models for the population dynamics of infectious disease transmission in R. Several classes of models are included, but the unique contribution of this software package is a general stochastic framework for modeling the spread of epidemics on networks. EpiModel integrates recent advances in statistical methods for network analysis (temporal exponential random graph models) that allow the epidemic modeling to be grounded in empirical data on contacts that can spread infection. This article provides an overview of both the modeling tools built into EpiModel , designed to facilitate learning for students new to modeling, and the application programming interface for extending package EpiModel , designed to facilitate the exploration of novel research questions for advanced modelers.

Medication Safety Principles and Practice in CKD.

PubMed

Whittaker, Chanel F; Miklich, Margaret A; Patel, Roshni S; Fink, Jeffrey C

2018-06-18

Ensuring patient safety is a priority of medical care because iatrogenic injury has been a primary concern. Medications are an important source of medical errors, and kidney disease is a thoroughfare of factors threatening safe administration of medicines. Principal among these is reduced kidney function because almost half of all medications used are eliminated via the kidney. Additionally, kidney patients often suffer from multimorbidity, including diabetes, hypertension, and heart failure, with a range of prescribers who often do not coordinate treatments. Patients with kidney disease are also susceptible to further kidney injury and metabolic derangements from medications, which can worsen the disease. In this review, we will present the key issues and threats to safe medication use in kidney disease, with a focus on predialysis CKD, as the scope of medication safety in ESKD and transplantation are unique and deserve their own consideration. We discuss drugs that need to be avoided or dose modified, and review the complications of a range of medications routinely administered in CKD, as these also call for cautious use. Copyright © 2018 by the American Society of Nephrology.

Incident Atrial Fibrillation and Risk of End-Stage Renal Disease in Adults with Chronic Kidney Disease

PubMed Central

Bansal, Nisha; Fan, Dongjie; Hsu, Chi-yuan; Ordonez, Juan D.; Marcus, Gregory M.; Go, Alan S.

2013-01-01

Background Atrial fibrillation (AF) frequently occurs in patients with chronic kidney disease (CKD). However, the long-term impact of development of AF on the risk of adverse renal outcomes in patients with CKD is unknown. In this study, we determined the association between incident AF and risk of end-stage renal disease (ESRD) among adults with CKD. Methods and Results We studied adults with CKD (defined as persistent glomerular filtration rate [eGFR] <60 ml/min/1.73 m2 by the CKD-EPI equation) enrolled in Kaiser Permanente Northern California who were identified between 2002–2010 and who did not have prior ESRD or previously documented AF. Incident AF was identified using primary hospital discharge diagnoses and/or two or more outpatient visits for AF. Incident ESRD was ascertained from a comprehensive health plan registry for dialysis and renal transplant. Among 206,229 adults with CKD, 16,463 developed incident AF. During a mean follow-up of 5.1± 2.5 years, there were 345 cases of ESRD that occurred after development of incident AF (74 per 1000 person-years) compared with 6505 cases of ESRD during periods without AF (64 per 1000 person-years, P<0.001). After adjustment for potential confounders, incident AF was associated with a 67% increase in rate of ESRD (hazard ratio 1.67, 95% confidence interval: 1.46–1.91). Conclusions Incident AF is independently associated with increased risk of developing ESRD in adults with CKD. Further study is needed to identify potentially modifiable pathways through which AF leads to a higher risk of progression to ESRD. PMID:23275377

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

Urine Potassium Excretion, Kidney Failure, and Mortality in CKD.

PubMed

Leonberg-Yoo, Amanda K; Tighiouart, Hocine; Levey, Andrew S; Beck, Gerald J; Sarnak, Mark J

2017-03-01

Low urine potassium excretion, as a surrogate for dietary potassium intake, is associated with higher risk for hypertension and cardiovascular disease in a general population. Few studies have investigated the relationship of urine potassium with clinical outcomes in chronic kidney disease (CKD). Longitudinal cohort study. The MDRD (Modification of Diet in Renal Disease) Study was a randomized controlled trial (N = 840) conducted in 1989 to 1993 to examine the effects of blood pressure control and dietary protein restriction on kidney disease progression in adults aged 18 to 70 years with CKD stages 2 to 4. This post hoc analysis included 812 participants. The primary predictor variable was 24-hour urine potassium excretion, measured at baseline and at multiple time points (presented as time-updated average urine potassium excretion). Kidney failure, defined as initiation of dialysis therapy or transplantation, was determined from US Renal Data System data. All-cause mortality was assessed using the National Death Index. Median follow-up for kidney failure was 6.1 (IQR, 3.5-11.7) years, with 9 events/100 patient-years. Median all-cause mortality follow-up was 19.2 (IQR, 10.8-20.6) years, with 3 deaths/100 patient-years. Baseline mean urine potassium excretion was 2.39±0.89 (SD) g/d. Each 1-SD higher baseline urine potassium level was associated with an adjusted HR of 0.95 (95% CI, 0.87-1.04) for kidney failure and 0.83 (95% CI, 0.74-0.94) for all-cause mortality. Results were consistent using time-updated average urine potassium measurements. Analyses were performed using urine potassium excretion as a surrogate for dietary potassium intake. Results are obtained from a primarily young, nondiabetic, and advanced CKD population and may not be generalizable to the general CKD population. Higher urine potassium excretion was associated with lower risk for all-cause mortality, but not kidney failure. Copyright © 2016 National Kidney Foundation, Inc. Published by

Parental perspectives on the financial impact of caring for a child with CKD.

PubMed

Medway, Meredith; Tong, Allison; Craig, Jonathan C; Kim, Siah; Mackie, Fiona; McTaggart, Steven; Walker, Amanda; Wong, Germaine

2015-03-01

The economic consequences of chronic kidney disease (CKD) are severe for adult patients and their households, but the out-of-pocket expenses and economic burden of CKD and how this affects the caregivers of children with kidney disease are unclear. This study aims to describe parental perspectives on the financial impact of caring for a child with CKD. Face-to-face semistructured interviews. Parents of children with CKD from 3 pediatric nephrology centers in Australia. Transcripts were analyzed thematically. 27 parents of 26 children participated. We identified 5 themes: loss of freedom and control (prioritizing care, limiting occupational opportunities, and appreciating socioeconomic advantage), burden of sole responsibility (inability to rely on others, lack of respite, increased separation of family roles, and self-reliance), adapting for survival (vigilant budgeting, redefining normality and expectations, rechanneling resources to basic needs, and negotiating work flexibility), instability of circumstances (depleted capacity to work, unpredictability of child's health, burden of travel-related costs, imposition of debt, and domestic upheaval), and struggle in seeking support ("falling through the cracks" and unmet information needs). Few participants were fathers (n=5), and results may not be transferable to non-English-speaking caregivers because these participants were excluded. Parents focused their resources and attention on meeting the complex needs of their child. Inability to sustain employment due to focus on their child's care and both medical and nonmedical expenses were major contributors to the financial impact, with financial stress compounded by difficulties accessing government support. As a result, parents experienced profound financial and social instability and physical and psychological fatigue and exercised extreme financial vigilance. Increased access to respite and domestic support and financial and psychosocial interventions are suggested

[The use of systematic review to develop a self-management program for CKD].

PubMed

Lee, Yu-Chin; Wu, Shu-Fang Vivienne; Lee, Mei-Chen; Chen, Fu-An; Yao, Yen-Hong; Wang, Chin-Ling

2014-12-01

Chronic kidney disease (CKD) has become a public health issue of international concern due to its high prevalence. The concept of self-management has been comprehensively applied in education programs that address chronic diseases. In recent years, many studies have used self-management programs in CKD interventions and have investigated the pre- and post-intervention physiological and psychological effectiveness of this approach. However, a complete clinical application program in the self-management model has yet to be developed for use in clinical renal care settings. A systematic review is used to develop a self-management program for CKD. Three implementation steps were used in this study. These steps include: (1) A systematic literature search and review using databases including CEPS (Chinese Electronic Periodical Services) of Airiti, National Digital Library of Theses and Dissertations in Taiwan, CINAHL, Pubmed, Medline, Cochrane Library, and Joanna Briggs Institute. A total of 22 studies were identified as valid and submitted to rigorous analysis. Of these, 4 were systematic literature reviews, 10 were randomized experimental studies, and 8 were non-randomized experimental studies. (2) Empirical evidence then was used to draft relevant guidelines on clinical application. (3) Finally, expert panels tested the validity of the draft to ensure the final version was valid for application in practice. This study designed a self-management program for CKD based on the findings of empirical studies. The content of this program included: design principles, categories, elements, and the intervention measures used in the self-management program. This program and then was assessed using the content validity index (CVI) and a four-point Liker's scale. The content validity score was .98. The guideline of self-management program to CKD was thus developed. This study developed a self-management program applicable to local care of CKD. It is hoped that the guidelines

EpiModel: An R Package for Mathematical Modeling of Infectious Disease over Networks

PubMed Central

Jenness, Samuel M.; Goodreau, Steven M.; Morris, Martina

2018-01-01

Package EpiModel provides tools for building, simulating, and analyzing mathematical models for the population dynamics of infectious disease transmission in R. Several classes of models are included, but the unique contribution of this software package is a general stochastic framework for modeling the spread of epidemics on networks. EpiModel integrates recent advances in statistical methods for network analysis (temporal exponential random graph models) that allow the epidemic modeling to be grounded in empirical data on contacts that can spread infection. This article provides an overview of both the modeling tools built into EpiModel, designed to facilitate learning for students new to modeling, and the application programming interface for extending package EpiModel, designed to facilitate the exploration of novel research questions for advanced modelers. PMID:29731699

Cystatin C and Cardiac Measures in Children and Adolescents With CKD.

PubMed

Brady, Tammy M; Townsend, Kelly; Schneider, Michael F; Cox, Christopher; Kimball, Thomas; Madueme, Peace; Warady, Bradley; Furth, Susan; Mitsnefes, Mark

2017-02-01

Cardiovascular disease (CVD) is highly prevalent among children with chronic kidney disease (CKD). Cystatin C is an established marker of kidney function and an emerging biomarker for CVD events. We quantified the relationship between cystatin C level and cardiac structure and function over time among children with CKD and assessed whether cystatin C level and diastolic function retained an association after accounting for kidney function. Prospective cohort study. 678 children and adolescents with mild to moderate CKD enrolled in the CKD in Children (CKiD) Study with 1,228 echocardiographically obtained cardiac structure and function measurements. Serum cystatin C (mg/L) measured annually. Cardiac structure (left ventricular mass index [g/m 2.7 ]) and cardiac function (shortening fraction; E/A, E'/A', E/E' ratios) measured every other year. Demographics and anthropometrics, measured glomerular filtration rate (mGFR), heart rate, blood pressure, hemoglobin z score, serum albumin level, and calcium-phosphorus product. Independent of time, each 1-mg/L increase in cystatin C level was independently associated with a concurrent 7.7% (95% CI, 5.3%-10.0%) increase in left ventricular mass index, a -4.7% (95% CI, -7.0% to -2.4%) change in E/A ratio, a -6.6% (95% CI, -9.0% to -4.2%) change in E'/A' ratio, and a 2.5% (95% CI, 0.3%-4.7%) increase in E/E' ratio. mGFR was also independently associated with E'/A' ratio. When cystatin C level and mGFR were included in the same model, cystatin C level remained independently associated with E'/A' ratio, whereas mGFR was not. 24% of the cohort was missing data for outcomes of interest or measurements; study population includes only children and adolescents with mild to moderate CKD. In this study of children and adolescents with mild to moderate CKD, cystatin C level was independently associated with cardiac structure and diastolic function. Cystatin C level remained able to predict diastolic function decline via E'/A' ratio

A Randomized Trial of Vitamin D Supplementation on Vascular Function in CKD.

PubMed

Kumar, Vivek; Yadav, Ashok Kumar; Lal, Anupam; Kumar, Vinod; Singhal, Manphool; Billot, Laurent; Gupta, Krishan Lal; Banerjee, Debasish; Jha, Vivekanand

2017-10-01

Vitamin D deficiency associates with mortality in patients with CKD, and vitamin D supplementation might mitigate cardiovascular disease risk in CKD. In this randomized, double-blind, placebo-controlled trial, we investigated the effect of cholecalciferol supplementation on vascular function in 120 patients of either sex, aged 18-70 years, with nondiabetic CKD stage 3-4 and vitamin D deficiency (serum 25-hydroxyvitamin D ≤20 ng/ml). We randomized patients using a 1:1 ratio to receive either two directly observed oral doses of cholecalciferol (300,000 IU) or matching placebo at baseline and 8 weeks. The primary outcome was change in endothelium-dependent brachial artery flow-mediated dilation at 16 weeks. Secondary outcome measures included changes in pulse wave velocity and circulating biomarkers. Cholecalciferol supplementation significantly increased endothelium-dependent brachial artery flow-mediated dilation at 16 weeks, whereas placebo did not (between-group difference in mean change: 5.49%; 95% confidence interval, 4.34% to 6.64%; P <0.001). Intervention also led to significant favorable changes in pulse wave velocity and circulating IL-6 levels. Thus, in nondiabetic patients with stage 3-4 CKD and vitamin D deficiency, vitamin D supplementation may improve vascular function. This study is registered with the Clinical Trials Registry of India (no.: CTRI/2013/05/003648). Copyright © 2017 by the American Society of Nephrology.

Potential effects of reclassifying CKD as a coronary heart disease risk equivalent in the US population.

PubMed

Foster, Meredith C; Rawlings, Andreea M; Marrett, Elizabeth; Neff, David; Grams, Morgan E; Kasiske, Bertram L; Willis, Kerry; Inker, Lesley A; Coresh, Josef; Selvin, Elizabeth

2014-05-01

Persons with chronic kidney disease (CKD) are at high risk for cardiovascular disease events, but are not classified as such in current US cholesterol treatment guidelines. We examined potential effects of modified guidelines in which CKD was considered a "coronary heart disease (CHD) risk equivalent" for risk stratification. Nationally representative cross-sectional study. 4,823 adults 20 years or older from the 2007-2010 National Health and Nutrition Examination Survey. Cardiovascular risk stratification based on current US cholesterol treatment guidelines and 2 simulated scenarios in which CKD stages 3-5 or CKD stages 1-5 were considered a CHD risk equivalent. Proportion of persons with low-density lipoprotein (LDL) cholesterol at levels above treatment targets and above the threshold for lipid-lowering therapy initiation, based on current guidelines and the 2 simulated scenarios. Under current guidelines, 55.1 million adults in 2010 did not achieve the target LDL cholesterol goal. Of these, 25.2 million had sufficiently elevated levels to meet recommendations for initiating lipid-lowering therapy; 12.1 million were receiving this therapy but remained above goal. When CKD stages 3-5 were considered a CHD risk equivalent, 59.2 million persons were above target LDL cholesterol goals, with 28.5 million and 13.3 million meriting therapy initiation and intensification, respectively. When CKD stages 1-5 were considered a CHD risk equivalent, 65.2 million adults were above goal, with 33.9 million and 14.4 million meriting therapy initiation and intensification, respectively. CKD and LDL cholesterol defined using a single laboratory value. Many adults in the United States currently do not meet recommended goals for LDL cholesterol levels. Modifying the current cholesterol guidelines to include CKD as a CHD risk equivalent would lead to a substantial increase in both the number of persons with levels above LDL cholesterol treatment targets and those recommended to

Skin autofluorescence and all-cause mortality in stage 3 CKD.

PubMed

Fraser, Simon D S; Roderick, Paul J; McIntyre, Natasha J; Harris, Scott; McIntyre, Christopher W; Fluck, Richard J; Taal, Maarten W

2014-08-07

Novel markers may help to improve risk prediction in CKD. One potential candidate is tissue advanced glycation end product accumulation, a marker of cumulative metabolic stress, which can be assessed by a simple noninvasive measurement of skin autofluorescence. Skin autofluorescence correlates with higher risk of cardiovascular events and mortality in people with diabetes or people requiring RRT, but its role in earlier CKD has not been studied. A prospective cohort of 1741 people with CKD stage 3 was recruited from primary care between August 2008 and March 2010. Participants underwent medical history, clinical assessment, blood and urine sampling for biochemistry, and measurement of skin autofluorescence. Kaplan-Meier plots and multivariate Cox proportional hazards models were used to investigate associations between skin autofluorescence (categorical in quartiles) and all-cause mortality. In total, 1707 participants had skin autofluorescence measured; 170 (10%) participants died after a median of 3.6 years of follow-up. The most common cause of death was cardiovascular disease (41%). Higher skin autofluorescence was associated significantly with poorer survival (all-cause mortality, P<0.001) on Kaplan-Meier analysis. Univariate and age/sex-adjusted Cox proportional hazards models showed that the highest quartile of skin autofluorescence was associated with all-cause mortality (hazard ratio, 2.64; 95% confidence interval, 1.71 to 4.08; P<0.001 and hazard ratio, 1.84; 95% confidence interval, 1.18 to 2.86; P=0.003, respectively, compared with the lowest quartile). This association was not maintained after additional adjustment to include cardiovascular disease, diabetes, smoking, body mass index, eGFR, albuminuria, and hemoglobin. Skin autofluorescence was not independently associated with all-cause mortality in this study. Additional research is needed to clarify whether it has a role in risk prediction in CKD. Copyright © 2014 by the American Society of

Genetic African Ancestry and Markers of Mineral Metabolism in CKD

PubMed Central

Parsa, Afshin; Isakova, Tamara; Scialla, Julia J.; Chen, Jing; Flack, John M.; Nessel, Lisa C.; Gupta, Jayanta; Bellovich, Keith A.; Steigerwalt, Susan; Sondheimer, James H.; Wright, Jackson T.; Feldman, Harold I.; Kusek, John W.; Lash, James P.; Wolf, Myles

2016-01-01

Background and objectives Disorders of mineral metabolism are more common in African Americans with CKD than in European Americans with CKD. Previous studies have focused on the differences in mineral metabolism by self-reported race, making it difficult to delineate the importance of environmental compared with biologic factors. Design, setting, participants, & measurements In a cross-sectional analysis of 3013 participants of the Chronic Renal Insufficiency Cohort study with complete data, we compared markers of mineral metabolism (phosphorus, calcium, alkaline phosphatase, parathyroid hormone, fibroblast growth factor 23, and urine calcium and phosphorus excretion) in European Americans versus African Americans and separately, across quartiles of genetic African ancestry in African Americans (n=1490). Results Compared with European Americans, African Americans had higher blood concentrations of phosphorus, alkaline phosphatase, fibroblast growth factor 23, and parathyroid hormone, lower 24-hour urinary excretion of calcium and phosphorus, and lower urinary fractional excretion of calcium and phosphorus at baseline (P<0.001 for all). Among African Americans, a higher percentage of African ancestry was associated with lower 24-hour urinary excretion of phosphorus (Ptrend<0.01) in unadjusted analyses. In linear regression models adjusted for socio-demographic characteristics, kidney function, serum phosphorus, and dietary phosphorus intake, higher percentage of African ancestry was significantly associated with lower 24-hour urinary phosphorus excretion (each 10% higher African ancestry was associated with 39.6 mg lower 24-hour urinary phosphorus, P<0.001) and fractional excretion of phosphorus (each 10% higher African ancestry was associated with an absolute 1.1% lower fractional excretion of phosphorus, P=0.01). Conclusions A higher percentage of African ancestry was independently associated with lower 24-hour urinary phosphorus excretion and lower fractional

Genetic African Ancestry and Markers of Mineral Metabolism in CKD.

PubMed

Gutiérrez, Orlando M; Parsa, Afshin; Isakova, Tamara; Scialla, Julia J; Chen, Jing; Flack, John M; Nessel, Lisa C; Gupta, Jayanta; Bellovich, Keith A; Steigerwalt, Susan; Sondheimer, James H; Wright, Jackson T; Feldman, Harold I; Kusek, John W; Lash, James P; Wolf, Myles

2016-04-07

Disorders of mineral metabolism are more common in African Americans with CKD than in European Americans with CKD. Previous studies have focused on the differences in mineral metabolism by self-reported race, making it difficult to delineate the importance of environmental compared with biologic factors. In a cross-sectional analysis of 3013 participants of the Chronic Renal Insufficiency Cohort study with complete data, we compared markers of mineral metabolism (phosphorus, calcium, alkaline phosphatase, parathyroid hormone, fibroblast growth factor 23, and urine calcium and phosphorus excretion) in European Americans versus African Americans and separately, across quartiles of genetic African ancestry in African Americans (n=1490). Compared with European Americans, African Americans had higher blood concentrations of phosphorus, alkaline phosphatase, fibroblast growth factor 23, and parathyroid hormone, lower 24-hour urinary excretion of calcium and phosphorus, and lower urinary fractional excretion of calcium and phosphorus at baseline (P<0.001 for all). Among African Americans, a higher percentage of African ancestry was associated with lower 24-hour urinary excretion of phosphorus (Ptrend<0.01) in unadjusted analyses. In linear regression models adjusted for socio-demographic characteristics, kidney function, serum phosphorus, and dietary phosphorus intake, higher percentage of African ancestry was significantly associated with lower 24-hour urinary phosphorus excretion (each 10% higher African ancestry was associated with 39.6 mg lower 24-hour urinary phosphorus, P<0.001) and fractional excretion of phosphorus (each 10% higher African ancestry was associated with an absolute 1.1% lower fractional excretion of phosphorus, P=0.01). A higher percentage of African ancestry was independently associated with lower 24-hour urinary phosphorus excretion and lower fractional excretion of phosphorus among African Americans with CKD. These findings suggest that genetic

Calcium as a cardiovascular toxin in CKD-MBD.

PubMed

Moe, Sharon M

2017-07-01

Disordered calcium balance and homeostasis are common in patients with chronic kidney disease. Such alterations are commonly associated with abnormal bone remodeling, directly and indirectly. Similarly, positive calcium balance may also be a factor in the pathogenesis of extra skeletal soft tissue and arterial calcification. Calcium may directly affect cardiac structure and function through direct effects to alter cell signaling due to abnormal intracellular calcium homeostasis 2) extra-skeletal deposition of calcium and phosphate in the myocardium and small cardiac arterioles, 3) inducing cardiomyocyte hypertrophy through calcium and hormone activation of NFAT signaling mechanisms, and 4) increased aorta calcification resulting in chronic increased afterload leading to hypertrophy. Similarly, calcium may alter vascular smooth muscle cell function and affect cell signaling which may predispose to a proliferative phenotype important in arteriosclerosis and arterial calcification. Thus, disorders of calcium balance and homeostasis due to CKD-MBD may play a role in the high cardiovascular burden observed in patients with CKD. Published by Elsevier Inc.

Epi-Two-Dimensional Fluid Flow: A New Topological Paradigm for Dimensionality

NASA Astrophysics Data System (ADS)

Yoshida, Z.; Morrison, P. J.

2017-12-01

While a variety of fundamental differences are known to separate two-dimensional (2D) and three-dimensional (3D) fluid flows, it is not well understood how they are related. Conventionally, dimensional reduction is justified by an a priori geometrical framework; i.e., 2D flows occur under some geometrical constraint such as shallowness. However, deeper inquiry into 3D flow often finds the presence of local 2D-like structures without such a constraint, where 2D-like behavior may be identified by the integrability of vortex lines or vanishing local helicity. Here we propose a new paradigm of flow structure by introducing an intermediate class, termed epi-two-dimensional flow, and thereby build a topological bridge between 2D and 3D flows. The epi-2D property is local and is preserved in fluid elements obeying ideal (inviscid and barotropic) mechanics; a local epi-2D flow may be regarded as a "particle" carrying a generalized enstrophy as its charge. A finite viscosity may cause "fusion" of two epi-2D particles, generating helicity from their charges giving rise to 3D flow.

Thyrotropin levels are associated with chronic kidney disease among healthy subjects in cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

PubMed

Peixoto de Miranda, Érique José F; Bittencourt, Márcio Sommer; Goulart, Alessandra C; Santos, Itamar S; de Oliveira Titan, Silvia Maria; Ladeira, Roberto Marini; Barreto, Sandhi Maria; Lotufo, Paulo A; Benseñor, Isabela Judith Martins

2017-12-01

Few studies have evaluated a possible relationship between thyrotropin levels and glomerular filtration rate (GFR) and albumin/creatinine ratio in euthyroid subjects. We aimed to analyze this association using baseline data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Cross-sectionally, we included subjects with normal thyroid function and with subclinical hypothyroidism (SCH). We excluded individuals using medications that affect thyroid function. Linear and logistic regression models evaluated GFR estimated by Chronic Kidney Disease Epidemiology Collaboration (CKD-Epi) and albuminuria/creatinine ratio as dependent variables and thyrotropin quartiles in individuals with euthyroidism and SCH as independent variables, adjusted for demographical characteristics and diseases related to CKD. We included 13,193 subjects with a median age of 51 years [interquartile range, (IQR): 45-58], 6840 (51.8%) women, 12,416 (94.1%) euthyroid, and 777 (5.9%) with SCH. SCH subjects were characterized by higher age, triglycerides, frequency of white race, cardiovascular disease, CKD, and former smokers. In adjusted models, log-transformed TSH in euthyroid subjects was inversely and strongly associated with CKD (β = -2.181, 95% CI -2.714 to -1.648), P < 0.0001 for glomerular filtration rate and 4.528 (1.190-7.865) for albuminuria/creatinine ratio. Multivariate logistic models for euthyroid subjects showed an OR of 1.45 (95% CI 1.15-1.83) for GFR and of 1.95 (95% CI 1.08-3.54) for albuminuria/creatinine ratio in the fourth quartile of TSH using the first as the reference. Thyrotropin levels are independently associated with CKD in euthyroid subjects.

Interleaved EPI based fMRI improved by multiplexed sensitivity encoding (MUSE) and simultaneous multi-band imaging.

PubMed

Chang, Hing-Chiu; Gaur, Pooja; Chou, Ying-hui; Chu, Mei-Lan; Chen, Nan-kuei

2014-01-01

Functional magnetic resonance imaging (fMRI) is a non-invasive and powerful imaging tool for detecting brain activities. The majority of fMRI studies are performed with single-shot echo-planar imaging (EPI) due to its high temporal resolution. Recent studies have demonstrated that, by increasing the spatial-resolution of fMRI, previously unidentified neuronal networks can be measured. However, it is challenging to improve the spatial resolution of conventional single-shot EPI based fMRI. Although multi-shot interleaved EPI is superior to single-shot EPI in terms of the improved spatial-resolution, reduced geometric distortions, and sharper point spread function (PSF), interleaved EPI based fMRI has two main limitations: 1) the imaging throughput is lower in interleaved EPI; 2) the magnitude and phase signal variations among EPI segments (due to physiological noise, subject motion, and B0 drift) are translated to significant in-plane aliasing artifact across the field of view (FOV). Here we report a method that integrates multiple approaches to address the technical limitations of interleaved EPI-based fMRI. Firstly, the multiplexed sensitivity-encoding (MUSE) post-processing algorithm is used to suppress in-plane aliasing artifacts resulting from time-domain signal instabilities during dynamic scans. Secondly, a simultaneous multi-band interleaved EPI pulse sequence, with a controlled aliasing scheme incorporated, is implemented to increase the imaging throughput. Thirdly, the MUSE algorithm is then generalized to accommodate fMRI data obtained with our multi-band interleaved EPI pulse sequence, suppressing both in-plane and through-plane aliasing artifacts. The blood-oxygenation-level-dependent (BOLD) signal detectability and the scan throughput can be significantly improved for interleaved EPI-based fMRI. Our human fMRI data obtained from 3 Tesla systems demonstrate the effectiveness of the developed methods. It is expected that future fMRI studies requiring high

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

Vegan-vegetarian low-protein supplemented diets in pregnant CKD patients: fifteen years of experience.

PubMed

Attini, Rossella; Leone, Filomena; Parisi, Silvia; Fassio, Federica; Capizzi, Irene; Loi, Valentina; Colla, Loredana; Rossetti, Maura; Gerbino, Martina; Maxia, Stefania; Alemanno, Maria Grazia; Minelli, Fosca; Piccoli, Ettore; Versino, Elisabetta; Biolcati, Marilisa; Avagnina, Paolo; Pani, Antonello; Cabiddu, Gianfranca; Todros, Tullia; Piccoli, Giorgina B

2016-09-20

Pregnancy in women with advanced CKD becoming increasingly common. However, experience with low-protein diets in CKD patients in pregnancy is still limited. Aim of this study is to review the results obtained over the last 15 years with moderately restricted low-protein diets in pregnant CKD women (combining: CKD stages 3-5, proteinuria: nephrotic at any time, or > =1 g/24 at start or referral; nephrotic in previous pregnancy). CKD patients on unrestricted diets were employed for comparison. January, 2000 to September, 2015: 36 on-diet pregnancies (31 singleton deliveries, 3 twin deliveries, 1 pregnancy termination, 1 miscarriage); 47 controls (42 singleton deliveries, 5 miscarriages). The diet is basically vegan; since occasional milk and yoghurt are allowed, we defined it vegan-vegetarian; protein intake (0.6-0.8 g/Kg/day), keto-acid supplementation, protein-unrestricted meals (1-3/week) are prescribed according to CKD stage and nutritional status. Statistical analysis was performed as implemented on SPSS. Patients and controls were similar (p: ns) at baseline with regard to age (33 vs 33.5), referral week (7 vs 9), kidney function (CKD 3-5: 48.4 % vs 64.3 %); prevalence of hypertension (51.6 % vs 40.5 %) and proteinuria >3 g/24 h (16.1 % vs 12.2 %). There were more diabetic nephropathies in on-diet patients (on diet: 31.0 % vs controls 5.3 %; p 0.007 (Fisher)) while lupus nephropathies were non-significantly higher in controls (on diet: 10.3 % vs controls 23.7 %; p 0.28 (Fisher)). The incidence of preterm delivery was similar (<37 weeks: on-diet singletons 77.4 %; controls: 71.4 %). The incidence of other adverse pregnancy related outcomes was non-significantly lower in on-diet patients (early preterm delivery: on diet: 32.3 % vs controls 35.7 %; birth-weight = <1.500 g: on diet: 9.7 % vs controls 23.8 %). None of the singletons in the on-diet series died, while two perinatal deaths occurred among the controls (p = 0.505). The

EpiCaster: An Integrated Web Application For Situation Assessment and Forecasting of Global Epidemics

PubMed Central

Deodhar, Suruchi; Bisset, Keith; Chen, Jiangzhuo; Barrett, Chris; Wilson, Mandy; Marathe, Madhav

2016-01-01

Public health decision makers need access to high resolution situation assessment tools for understanding the extent of various epidemics in different regions of the world. In addition, they need insights into the future course of epidemics by way of forecasts. Such forecasts are essential for planning the allocation of limited resources and for implementing several policy-level and behavioral intervention strategies. The need for such forecasting systems became evident in the wake of the recent Ebola outbreak in West Africa. We have developed EpiCaster, an integrated Web application for situation assessment and forecasting of various epidemics, such as Flu and Ebola, that are prevalent in different regions of the world. Using EpiCaster, users can assess the magnitude and severity of different epidemics at highly resolved spatio-temporal levels. EpiCaster provides time-varying heat maps and graphical plots to view trends in the disease dynamics. EpiCaster also allows users to visualize data gathered through surveillance mechanisms, such as Google Flu Trends (GFT) and the World Health Organization (WHO). The forecasts provided by EpiCaster are generated using different epidemiological models, and the users can select the models through the interface to filter the corresponding forecasts. EpiCaster also allows the users to study epidemic propagation in the presence of a number of intervention strategies specific to certain diseases. Here we describe the modeling techniques, methodologies and computational infrastructure that EpiCaster relies on to support large-scale predictive analytics for situation assessment and forecasting of global epidemics. PMID:27796009

Collaboration, Negotiation, and Coalescence for Interagency-Collaborative Teams to Scale-up Evidence-Based Practice

PubMed Central

Aarons, Gregory A.; Fettes, Danielle; Hurlburt, Michael; Palinkas, Lawrence; Gunderson, Lara; Willging, Cathleen; Chaffin, Mark

2014-01-01

Objective Implementation and scale-up of evidence-based practices (EBPs) is often portrayed as involving multiple stakeholders collaborating harmoniously in the service of a shared vision. In practice, however, collaboration is a more complex process that may involve shared and competing interests and agendas, and negotiation. The present study examined the scale-up of an EBP across an entire service system using the Interagency Collaborative Team (ICT) approach. Methods Participants were key stakeholders in a large-scale county-wide implementation of an EBP to reduce child neglect, SafeCare®. Semi-structured interviews and/or focus groups were conducted with 54 individuals representing diverse constituents in the service system, followed by an iterative approach to coding and analysis of transcripts. The study was conceptualized using the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Results Although community stakeholders eventually coalesced around implementation of SafeCare, several challenges affected the implementation process. These challenges included differing organizational cultures, strategies, and approaches to collaboration, competing priorities across levels of leadership, power struggles, and role ambiguity. Each of the factors identified influenced how stakeholders approached the EBP implementation process. Conclusions System wide scale-up of EBPs involves multiple stakeholders operating in a nexus of differing agendas, priorities, leadership styles, and negotiation strategies. The term collaboration may oversimplify the multifaceted nature of the scale-up process. Implementation efforts should openly acknowledge and consider this nexus when individual stakeholders and organizations enter into EBP implementation through collaborative processes. PMID:24611580

Association between periodontal disease and mortality in people with CKD: a meta-analysis of cohort studies.

PubMed

Zhang, Jian; Jiang, Hong; Sun, Min; Chen, Jianghua

2017-08-16

Periodontal disease occurs relatively prevalently in people with chronic kidney disease (CKD), but it remains indeterminate whether periodontal disease is an independent risk factor for premature death in this population. Interventions to reduce mortality in CKD population consistently yield to unsatisfactory results and new targets are necessitated. So this meta-analysis aimed to evaluate the association between periodontal disease and mortality in the CKD population. Pubmed, Embase, Web of Science, Scopus and abstracts from recent relevant meeting were searched by two authors independently. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated for overall and subgroup meta-analyses. Statistical heterogeneity was explored by chi-square test and quantified by the I 2 statistic. Eight cohort studies comprising 5477 individuals with CKD were incorporated. The overall pooled data demonstrated that periodontal disease was associated with all-cause death in CKD population (RR, 1.254; 95% CI 1.046-1.503; P = 0.005), with a moderate heterogeneity, I 2  = 52.2%. However, no evident association was observed between periodontal disease and cardiovascular mortality (RR, 1.30, 95% CI, 0.82-2.06; P = 0.259). Besides, statistical heterogeneity was substantial (I 2  = 72.5%; P = 0.012). Associations for mortality were similar between subgroups, such as the different stages of CKD, adjustment for confounding factors. Specific to all-cause death, sensitivity and cumulative analyses both suggested that our results were robust. As for cardiovascular mortality, the association with periodontal disease needs to be further strengthened. We demonstrated that periodontal disease was associated with an increased risk of all-cause death in CKD people. Yet no adequate evidence suggested periodontal disease was also at elevated risk for cardiovascular death.

Survival advantage in black versus white men with CKD: effect of estimated GFR and case mix.

PubMed

Kovesdy, Csaba P; Quarles, L Darryl; Lott, Evan H; Lu, Jun Ling; Ma, Jennie Z; Molnar, Miklos Z; Kalantar-Zadeh, Kamyar

2013-08-01

Black dialysis patients have significantly lower mortality compared with white patients, in contradistinction to the higher mortality seen in blacks in the general population. It is unclear whether a similar paradox exists in patients with non-dialysis-dependent chronic kidney disease (CKD), and if it does, what its underlying reasons are. Historical cohort. 518,406 white and 52,402 black male US veterans with non-dialysis-dependent CKD stages 3-5. Black race. We examined overall and CKD stage-specific all-cause mortality using parametric survival models. The effect of sociodemographic characteristics, comorbid conditions, and laboratory characteristics on the observed differences was explored in multivariable models. During a median follow-up of 4.7 years, 172,093 patients died (mortality rate, 71.0 [95% CI, 70.6-71.3] per 1,000 patient-years). Black race was associated with significantly lower crude mortality (HR, 0.95; 95% CI, 0.94-0.97; P < 0.001). The survival advantage was attenuated after adjustment for age (HR, 1.14; 95% CI, 1.12-1.16), but was magnified after full multivariable adjustment (HR, 0.72; 95% CI, 0.70-0.73; P < 0.001). The unadjusted survival advantage of blacks was more prominent in those with more advanced stages of CKD, but CKD stage-specific differences were attenuated by multivariable adjustment. Exclusively male patients. Black patients with CKD have lower mortality compared with white patients. The survival advantage seen in blacks is accentuated in patients with more advanced stages of CKD, which may be explained by changes in case-mix and laboratory characteristics occurring during the course of kidney disease. Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.

Myocardial dysfunction occurs prior to changes in ventricular geometry in mice with chronic kidney disease (CKD).

PubMed

Winterberg, Pamela D; Jiang, Rong; Maxwell, Josh T; Wang, Bo; Wagner, Mary B

2016-03-01

Uremic cardiomyopathy is responsible for high morbidity and mortality rates among patients with chronic kidney disease (CKD), but the underlying mechanisms contributing to this complex phenotype are incompletely understood. Myocardial deformation analyses (ventricular strain) of patients with mild CKD have recently been reported to predict adverse clinical outcome. We aimed to determine if early myocardial dysfunction in a mouse model of CKD could be detected using ventricular strain analyses. CKD was induced in 5-week-old male 129X1/SvJ mice through partial nephrectomy (5/6Nx) with age-matched mice undergoing bilateral sham surgeries serving as controls. Serial transthoracic echocardiography was performed over 16 weeks following induction of CKD. Invasive hemodynamic measurements were performed at 8 weeks. Gene expression and histology was performed on hearts at 8 and 16 weeks. CKD mice developed decreased longitudinal strain (-25 ± 4.2% vs. -29 ± 2.3%; P = 0.01) and diastolic dysfunction (E/A ratio 1.2 ± 0.15 vs. 1.9 ± 0.18; P < 0.001) compared to controls as early as 2 weeks following 5/6Nx. In contrast, ventricular hypertrophy was not apparent until 4 weeks. Hearts from CKD mice developed progressive fibrosis at 8 and 16 weeks with gene signatures suggestive of evolving heart failure with elevated expression of natriuretic peptides. Uremic cardiomyopathy in this model is characterized by early myocardial dysfunction which preceded observable changes in ventricular geometry. The model ultimately resulted in myocardial fibrosis and increased expression of natriuretic peptides suggestive of progressive heart failure. © 2016 The Authors. Physiological Reports published by Wiley Periodicals, Inc. on behalf of the American Physiological Society and The Physiological Society.

Survival Advantage in Black Versus White Men With CKD: Effect of Estimated GFR and Case Mix

PubMed Central

Kovesdy, Csaba P.; Quarles, L. Darryl; Lott, Evan H.; Lu, Jun Ling; Ma, Jennie Z.; Molnar, Miklos Z.; Kalantar-Zadeh, Kamyar

2013-01-01

Background Black dialysis patients have significantly lower mortality compared to white patients, in contradistinction to the higher mortality seen in blacks in the general population. It is unclear if a similar paradox exists in non–dialysis-dependent CKD, and if it does, what its underlying reasons are. Study Design Historical cohort. Setting & Participants 518,406 white and 52,402 black male US veterans with non-dialysis dependent CKD stages 3–5. Predictor Black race. Outcomes & Measurements We examined overall and CKD stage-specific all-cause mortality using parametric survival models. The effect of sociodemographic characteristics, comorbidities and laboratory characteristics on the observed differences was explored in multivariable models. Results Over a median follow-up of 4.7 years 172,093 patients died (mortality rate, 71.0 [95% CI, 70.6–71.3] per 1000 patient-years). Black race was associated with significantly lower crude mortality (HR, 0.95; 95% CI, 0.94–0.97; p<0.001). The survival advantage was attenuated after adjustment for age (HR, 1.14; 95% CI, 1.12–1.16), but was even magnified after full multivariable adjustment (HR, 0.72; 95% CI, 0.70–0.73; p<0.001). The unadjusted survival advantage of blacks was more prominent in those with more advanced stages of CKD, but CKD stage-specific differences were attenuated by multivariable adjustment. Limitations Exclusively male patients. Conclusions Black patients with CKD have lower mortality compared to white patients. The survival advantage seen in blacks is accentuated in patients with more advanced stages of CKD, which may be explained by changes in case mix and laboratory characteristics occurring during the course of kidney disease. PMID:23369826

[Iron deficiency in ND-CKD: from diagnosis to treatment].

PubMed

Liberti, Maria Elena; Garofalo, Carlo; Sagliocca, Adelia; Borrelli, Silvio; Conte, Giuseppe; De Nicola, Luca; Minutolo, Roberto

2017-09-28

In non-dialysis-chronic kidney disease (CKD), iron deficiency is a frequent nutritional disorder due to either the greater tendency to occult gastrointestinal bleeding or to the chronic inflammatory state resulting in a reduced intestinal iron reabsorption through an increased synthesis of hepcidin. These phenomenon are responsible for a negative iron balance that compromises erythropoiesis and contributes to the pathogenesis of anemia in CKD. Several laboratory tests are now available to allow an adequate diagnosis of iron deficiency. Among the new parameters, the percentage of hypochromic red cells (% HYPO) and the reticulocyte hemoglobin content (CHr) are now considered as the most specific markers for diagnosing iron-deficiency erythropoiesis. Unfortunately, their implementation in clinical practice is limited by the scarce availability. In non-dialyzed CKD , subjects intolerant or non-responsive to oral iron therapy, can be effectively treated with novel intravenous iron preparations, such as iron carboxymaltose, that allow a complete and rapid correction of iron deficient anemia. Furthermore, this iron compound is associated with lower rate of adverse effects since the carbohydrate shell (carboxymaltose) is more stable than gluconate and saccarate thus reducing the release of free iron in the bloodstream. Of note, the possibility of administering this drug at high doses and reduced frequency decreases the risk of infusion reactions. Finally, a substantial economic saving mainly dependent on a reduction in indirect costs represents a further advantage in the use of iron carboxymaltose in this population. Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.

EPI64B Acts as a GTPase-activating Protein for Rab27B in Pancreatic Acinar Cells*

PubMed Central

Hou, Yanan; Chen, Xuequn; Tolmachova, Tatyana; Ernst, Stephen A.; Williams, John A.

2013-01-01

The small GTPase Rab27B localizes to the zymogen granule membranes and plays an important role in regulating protein secretion by pancreatic acinar cells, as does Rab3D. A common guanine nucleotide exchange factor (GEF) for Rab3 and Rab27 has been reported; however, the GTPase-activating protein (GAP) specific for Rab27B has not been identified. In this study, the expression in mouse pancreatic acini of two candidate Tre-2/Bub2/Cdc16 (TBC) domain-containing proteins, EPI64 (TBC1D10A) and EPI64B (TBC1D10B), was first demonstrated. Their GAP activity on digestive enzyme secretion was examined by adenovirus-mediated overexpression of EPI64 and EPI64B in isolated pancreatic acini. EPI64B almost completely abolished the GTP-bound form of Rab27B, without affecting GTP-Rab3D. Overexpression of EPI64B also enhanced amylase release. This enhanced release was independent of Rab27A, but dependent on Rab27B, as shown using acini from genetically modified mice. EPI64 had a mild effect on both GTP-Rab27B and amylase release. Co-overexpression of EPI64B with Rab27B can reverse the inhibitory effect of Rab27B on amylase release. Mutations that block the GAP activity decreased the inhibitory effect of EPI64B on the GTP-bound state of Rab27B and abolished the enhancing effect of EPI64B on the amylase release. These data suggest that EPI64B can serve as a potential physiological GAP for Rab27B and thereby participate in the regulation of exocytosis in pancreatic acinar cells. PMID:23671284

Combination therapy of 15-epi-lipoxin A4 with antibiotics protects mice from Escherichia coli-induced sepsis*.

PubMed

Ueda, Tomomi; Fukunaga, Koichi; Seki, Hiroyuki; Miyata, Jun; Arita, Makoto; Miyasho, Taku; Obata, Toru; Asano, Koichiro; Betsuyaku, Tomoko; Takeda, Junzo

2014-04-01

Inflammation occurs along with infection during sepsis. 15-Epi-lipoxin A4 has protective and resolving effects in experimental models of infection. In this study, we examined the effects of 15-epi-lipoxin A4 combined with antibiotics on Escherichia coli-induced peritonitis. Prospective experimental study. University research laboratory. Male C57BL/6 mice. Mice were injected with E. coli to induce peritonitis and were given either 15-epi-lipoxin A4 (1 μg/mouse) or placebo (saline) with antibiotics (ceftazidime). The effects of 15-epi-lipoxin A4 on peritoneal cell populations, bacterial burden, and cytokine production were assessed. Survival rates were observed for up to 7 days. In addition, we examined the effects of 15-epi-lipoxin A4 on peritoneal macrophages stimulated with lipopolysaccharide, CpG DNA, or live E. coli. Treatment with 15-epi-lipoxin A4 significantly reduced the number of neutrophils in the peritoneum, inhibited production of cytokines and chemokines, and decreased bacterial load in the serum. Combined treatment of 15-epi-lipoxin A4 with antibiotics significantly improved survival in E. coli-infected mice. 15-Epi-lipoxin A4 also attenuated the production of interleukin-6 and tumor necrosis factor-α by lipopolysaccharide- or CpG DNA-stimulated peritoneal macrophages. Furthermore, 15-epi-lipoxin A4 combined with antibiotics synergistically reduced the production of interleukin-6 and tumor necrosis factor-α by peritoneal macrophages stimulated with live E. coli. 15-Epi-lipoxin A4 combined with antibiotics attenuated systemic inflammation, inhibited bacteria dissemination, and improved survival in E. coli-infected mice. The reduced production of interleukin-6 and tumor necrosis factor-α by peritoneal macrophages suggested that 15-epi-lipoxin A4 blocked the initial proinflammatory response. Taken together, these data suggested that 15-epi-lipoxin A4 combined with antibiotics was beneficial in regulating the proinflammatory response in sepsis without

Beliefs and Attitudes to Bowel Cancer Screening in Patients with CKD: A Semistructured Interview Study.

PubMed

James, Laura J; Wong, Germaine; Craig, Jonathan C; Ju, Angela; Williams, Narelle; Lim, Wai H; Cross, Nicholas; Tong, Allison

2017-04-03

Bowel cancer is a leading cause of cancer-related death in people with CKD. Shared decision making regarding cancer screening is particularly complex in CKD and requires an understanding of patients' values and priorities, which remain largely unknown. Our study aimed to describe the beliefs and attitudes to bowel cancer screening in patients with CKD. Face to face, semistructured interviews were conducted from April of 2014 to December of 2015 with 38 participants ages 39-78 years old with CKD stages 3-5, on dialysis, or transplant recipients from four renal units in Australia and New Zealand. Thematic analysis was used to analyze the transcripts. Five themes were identified: invisibility of cancer (unspoken stigma, ambiguity of risk, and absence of symptomatic prompting); prioritizing kidney disease (preserving the chance of transplantation, over-riding attention to kidney disease, protecting graft survival, and showing loyalty to the donor); preventing the crisis of cancer (evading severe consequences and cognizant of susceptibility); cognitive resistance (reluctance to perform a repulsive procedure, intensifying disease burden threshold, anxiety of a positive test, and accepting the inevitable); and pragmatic accessibility (negligible financial effect, convenience, and protecting anonymity). Patients with CKD understand the potential health benefits of bowel cancer screening, but they are primarily committed to their kidney health. Their decisions regarding screening revolve around their present health needs, priorities, and concerns. Explicit consideration of the potential practical and psychosocial burdens that bowel cancer screening may impose on patients in addition to kidney disease and current treatment is suggested to minimize decisional conflict and improve patient satisfaction and health care outcomes in CKD. Copyright © 2017 by the American Society of Nephrology.

Beliefs and Attitudes to Bowel Cancer Screening in Patients with CKD: A Semistructured Interview Study

PubMed Central

Wong, Germaine; Craig, Jonathan C.; Ju, Angela; Williams, Narelle; Lim, Wai H.; Cross, Nicholas; Tong, Allison

2017-01-01

Background and objectives Bowel cancer is a leading cause of cancer-related death in people with CKD. Shared decision making regarding cancer screening is particularly complex in CKD and requires an understanding of patients’ values and priorities, which remain largely unknown. Our study aimed to describe the beliefs and attitudes to bowel cancer screening in patients with CKD. Design, setting, participants, & measurements Face to face, semistructured interviews were conducted from April of 2014 to December of 2015 with 38 participants ages 39–78 years old with CKD stages 3–5, on dialysis, or transplant recipients from four renal units in Australia and New Zealand. Thematic analysis was used to analyze the transcripts. Results Five themes were identified: invisibility of cancer (unspoken stigma, ambiguity of risk, and absence of symptomatic prompting); prioritizing kidney disease (preserving the chance of transplantation, over-riding attention to kidney disease, protecting graft survival, and showing loyalty to the donor); preventing the crisis of cancer (evading severe consequences and cognizant of susceptibility); cognitive resistance (reluctance to perform a repulsive procedure, intensifying disease burden threshold, anxiety of a positive test, and accepting the inevitable); and pragmatic accessibility (negligible financial effect, convenience, and protecting anonymity). Conclusions Patients with CKD understand the potential health benefits of bowel cancer screening, but they are primarily committed to their kidney health. Their decisions regarding screening revolve around their present health needs, priorities, and concerns. Explicit consideration of the potential practical and psychosocial burdens that bowel cancer screening may impose on patients in addition to kidney disease and current treatment is suggested to minimize decisional conflict and improve patient satisfaction and health care outcomes in CKD. PMID:28153937

Bardoxolone methyl and kidney function in CKD with type 2 diabetes.

PubMed

Pergola, Pablo E; Raskin, Philip; Toto, Robert D; Meyer, Colin J; Huff, J Warren; Grossman, Eric B; Krauth, Melissa; Ruiz, Stacey; Audhya, Paul; Christ-Schmidt, Heidi; Wittes, Janet; Warnock, David G

2011-07-28

Chronic kidney disease (CKD) associated with type 2 diabetes is the leading cause of kidney failure, with both inflammation and oxidative stress contributing to disease progression. Bardoxolone methyl, an oral antioxidant inflammation modulator, has shown efficacy in patients with CKD and type 2 diabetes in short-term studies, but longer-term effects and dose response have not been determined. In this phase 2, double-blind, randomized, placebo-controlled trial, we assigned 227 adults with CKD (defined as an estimated glomerular filtration rate [GFR] of 20 to 45 ml per minute per 1.73 m(2) of body-surface area) in a 1:1:1:1 ratio to receive placebo or bardoxolone methyl at a target dose of 25, 75, or 150 mg once daily. The primary outcome was the change from baseline in the estimated GFR with bardoxolone methyl, as compared with placebo, at 24 weeks; a secondary outcome was the change at 52 weeks. Patients receiving bardoxolone methyl had significant increases in the mean (±SD) estimated GFR, as compared with placebo, at 24 weeks (with between-group differences per minute per 1.73 m(2) of 8.2±1.5 ml in the 25-mg group, 11.4±1.5 ml in the 75-mg group, and 10.4±1.5 ml in the 150-mg group; P<0.001). The increases were maintained through week 52, with significant differences per minute per 1.73 m(2) of 5.8±1.8 ml, 10.5±1.8 ml, and 9.3±1.9 ml, respectively. Muscle spasms, the most frequent adverse event in the bardoxolone methyl groups, were generally mild and dose-related. Hypomagnesemia, mild increases in alanine aminotransferase levels, and gastrointestinal effects were more common among patients receiving bardoxolone methyl. Bardoxolone methyl was associated with improvement in the estimated GFR in patients with advanced CKD and type 2 diabetes at 24 weeks. The improvement persisted at 52 weeks, suggesting that bardoxolone methyl may have promise for the treatment of CKD. (Funded by Reata Pharmaceuticals; BEAM ClinicalTrials.gov number, NCT00811889.).

PROPELLER EPI: An MRI Technique Suitable for Diffusion Tensor Imaging at High Field Strength With Reduced Geometric Distortions

PubMed Central

Wang, Fu-Nien; Huang, Teng-Yi; Lin, Fa-Hsuan; Chuang, Tzu-Chao; Chen, Nan-Kuei; Chung, Hsiao-Wen; Chen, Cheng-Yu; Kwong, Kenneth K.

2013-01-01

A technique suitable for diffusion tensor imaging (DTI) at high field strengths is presented in this work. The method is based on a periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) k-space trajectory using EPI as the signal readout module, and hence is dubbed PROPELLER EPI. The implementation of PROPELLER EPI included a series of correction schemes to reduce possible errors associated with the intrinsically higher sensitivity of EPI to off-resonance effects. Experimental results on a 3.0 Tesla MR system showed that the PROPELLER EPI images exhibit substantially reduced geometric distortions compared with single-shot EPI, at a much lower RF specific absorption rate (SAR) than the original version of the PROPELLER fast spin-echo (FSE) technique. For DTI, the self-navigated phase-correction capability of the PROPELLER EPI sequence was shown to be effective for in vivo imaging. A higher signal-to-noise ratio (SNR) compared to single-shot EPI at an identical total scan time was achieved, which is advantageous for routine DTI applications in clinical practice. PMID:16206142

PROPELLER EPI: an MRI technique suitable for diffusion tensor imaging at high field strength with reduced geometric distortions.

PubMed

Wang, Fu-Nien; Huang, Teng-Yi; Lin, Fa-Hsuan; Chuang, Tzu-Chao; Chen, Nan-Kuei; Chung, Hsiao-Wen; Chen, Cheng-Yu; Kwong, Kenneth K

2005-11-01

A technique suitable for diffusion tensor imaging (DTI) at high field strengths is presented in this work. The method is based on a periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) k-space trajectory using EPI as the signal readout module, and hence is dubbed PROPELLER EPI. The implementation of PROPELLER EPI included a series of correction schemes to reduce possible errors associated with the intrinsically higher sensitivity of EPI to off-resonance effects. Experimental results on a 3.0 Tesla MR system showed that the PROPELLER EPI images exhibit substantially reduced geometric distortions compared with single-shot EPI, at a much lower RF specific absorption rate (SAR) than the original version of the PROPELLER fast spin-echo (FSE) technique. For DTI, the self-navigated phase-correction capability of the PROPELLER EPI sequence was shown to be effective for in vivo imaging. A higher signal-to-noise ratio (SNR) compared to single-shot EPI at an identical total scan time was achieved, which is advantageous for routine DTI applications in clinical practice. (c) 2005 Wiley-Liss, Inc.

Impact of a Primary Care CKD Registry in a US Public Safety-Net Health Care Delivery System: A Pragmatic Randomized Trial.

PubMed

Tuot, Delphine S; McCulloch, Charles E; Velasquez, Alexandra; Schillinger, Dean; Hsu, Chi-Yuan; Handley, Margaret; Powe, Neil R

2018-04-23

Many individuals with chronic kidney disease (CKD) do not receive guideline-concordant care. We examined the impact of a team-based primary care CKD registry on clinical measures and processes of care among patients with CKD cared for in a public safety-net health care delivery system. Pragmatic trial of a CKD registry versus a usual-care registry for 1 year. Primary care providers (PCPs) and their patients with CKD in a safety-net primary care setting in San Francisco. The CKD registry identified at point of care all patients with CKD, those with blood pressure (BP)>140/90mmHg, those without angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) prescription, and those without albuminuria quantification in the past year. It also provided quarterly feedback pertinent to these metrics to promote "outreach" to patients with CKD. The usual-care registry provided point-of-care cancer screening and immunization data. Changes in systolic BP at 12 months (primary outcome), proportion of patients with BP control, prescription of ACE inhibitors/ARBs, quantification of albuminuria, severity of albuminuria, and estimated glomerular filtration rate. The patient population (n=746) had a mean age of 56.7±12.1 (standard deviation) years, was 53% women, and was diverse (8% non-Hispanic white, 35.7% black, 24.5% Hispanic, and 24.4% Asian). Randomization to the CKD registry (30 PCPs, 285 patients) versus the usual-care registry (49 PCPs, 461 patients) was associated with 2-fold greater odds of ACE inhibitor/ARB prescription (adjusted OR, 2.25; 95% CI, 1.45-3.49) and albuminuria quantification (adjusted OR, 2.44; 95% CI, 1.38-4.29) during the 1-year study period. Randomization to the CKD registry was not associated with changes in systolic BP, proportion of patients with uncontrolled BP, or degree of albuminuria or estimated glomerular filtration rate. Potential misclassification of CKD; missing baseline medication data; limited to study of a public safety

Evaluation of Renal Blood Flow and Oxygenation in CKD Using Magnetic Resonance Imaging.

PubMed

Khatir, Dinah S; Pedersen, Michael; Jespersen, Bente; Buus, Niels H

2015-09-01

Animal studies suggest that progression of chronic kidney disease (CKD) is related to renal hypoxia. With renal blood supply determining oxygen delivery and sodium absorption being the main contributor to oxygen consumption, we describe the relationship between renal oxygenation, renal artery blood flow, and sodium absorption in patients with CKD and healthy controls. Cross-sectional study. 62 stable patients with CKD stages 3 to 4 (mean age, 61±13 [SD] years) and 24 age- and sex-matched controls. CKD versus control status. Renal artery blood flow, tissue oxygenation (relative changes in deoxyhemoglobin concentration of the renal medulla [MR2*] and cortex [CR2*]), and sodium absorption. Renal artery blood flow was determined by phase-contrast magnetic resonance imaging (MRI); MR2* and CR2* were determined by blood oxygen level-dependent MRI. Ultrafiltered and reabsorbed sodium were determined from measured glomerular filtration rate (mGFR) and 24-hour urine collections. mGFR in patients was 37% that of controls (36±15 vs 97±23 mL/min/1.73 m(2); P < 0.001), and reabsorbed sodium was 37% that of controls (6.9 vs 19.1 mol/24 h; P < 0.001). Single-kidney patient renal artery blood flow was 72% that of controls (319 vs 443 mL/min; P < 0.001). Glomerular filtration fraction was 9% in patients and 18% in controls (P < 0.001). Patients and controls had similar CR2* (13.4 vs 13.3 s(-1)) and medullary MR2* (26.4 vs 26.5 s(-1)) values. Linear regression analysis demonstrated no associations between R2* and renal artery blood flow or sodium absorption. Increasing arterial blood oxygen tension by breathing 100% oxygen had very small effects on CR2*, but reduced MR2* in both groups. Only renal artery blood flow was determined and thus regional perfusion could not be related to CR2* or MR2*. In CKD, reductions of mGFR and reabsorbed sodium are more than double that of renal artery blood flow, whereas cortical and medullary oxygenation are within the range of healthy persons

Estimated Glomerular Filtration Rate; Laboratory Implementation and Current Global Status.

PubMed

Miller, W Greg; Jones, Graham R D

2018-01-01

In 2002, the Kidney Disease Outcomes Quality Initiative guidelines for identifying and treating CKD recommended that clinical laboratories report estimated glomerular filtration rate (eGFR) with every creatinine result to assist clinical practitioners to identify people with early-stage CKD. At that time, the original Modification of Diet in Renal Disease (MDRD) Study equation based on serum creatinine measurements was recommended for calculating eGFR. Because the MDRD Study equation was developed using a nonstandardized creatinine method, a Laboratory Working Group of the National Kidney Disease Education program was formed and implemented standardized calibration traceability for all creatinine methods from global manufacturers by approximately 2010. A modified MDRD Study equation for use with standardized creatinine was developed. The Chronic Kidney Disease Epidemiology Collaboration developed a new equation in 2009 that was more accurate than the MDRD Study equation at values above 60 mL/min/1.73 m 2 . As of 2017, reporting eGFR with creatinine is almost universal in many countries. A reference system for cystatin C became available in 2010, and manufacturers are in the process to standardize cystatin C assays. Equations for eGFR based on standardized cystatin C alone and with creatinine are now available from the Chronic Kidney Disease Epidemiology Collaboration and other groups. Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Investigation of the C-3-epi-25(OH)D3 of 25-hydroxyvitamin D3 in urban schoolchildren.

PubMed

Berger, Samantha E; Van Rompay, Maria I; Gordon, Catherine M; Goodman, Elizabeth; Eliasziw, Misha; Holick, Michael F; Sacheck, Jennifer M

2018-03-01

The physiological relevance C-3 epimer of 25-hydroxyvitamin D (3-epi-25(OH)D) is not well understood among youth. The objective of this study was to assess whether demographic/physiologic characteristics were associated with 3-epi-25(OH)D 3 concentrations in youth. Associations between 3-epi-25(OH)D 3 and demographics and between 3-epi-25(OH)D 3 , total 25-hydroxyvitamin (25(OH)D) (25(OH)D 2 + 25(OH)D 3 ), total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides were examined in racially/ethnically diverse schoolchildren (n = 682; age, 8-15 years) at Boston-area urban schools. Approximately 50% of participants had detectable 3-epi-25(OH)D 3 (range 0.95-3.95 ng/mL). The percentage of 3-epi-25(OH)D 3 of total 25(OH)D ranged from 2.5% to 17.0% (median 5.5%). Males were 38% more likely than females to have detectable 3-epi-25(OH)D 3 concentrations. Both Asian and black race/ethnicity were associated with lower odds of having detectable 3-epi-25(OH)D 3 compared with non-Hispanic white children (Asian vs. white, odds ratio (OR) 0.28, 95% confidence interval (CI) 0.14-0.53; black vs. white, OR 0.38, 95%CI 0.23-0.63, p < 0.001). Having an adequate (20-29 ng/mL) or optimal (>30 ng/mL) 25(OH)D concentration was associated with higher odds of having detectable 3-epi-25(OH)D 3 than having an inadequate (<20 ng/mL) concentration (OR 4.78, 95%CI 3.23-6.94 or OR 14.10, 95%CI 7.10-28.0, respectively). There was no association between 3-epi-25(OH)D 3 and blood lipids. However, when considering 3-epi-25(OH)D 3 as a percentage of total 25(OH)D, total cholesterol was lower in children with percent 3-epi-25(OH)D 3 above the median (mean difference -7.1 mg/dL, p = 0.01). In conclusion, among schoolchildren, sex, race/ethnicity, and total serum 25(OH)D concentration is differentially associated with 3-epi-25(OH)D. The physiological relevance of 3-epi-25(OH)D 3 may be related to the 3-epi-25(OH)D 3 as a percentage of total 25(OH)D and should be considered in

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

Risk factors for CKD in persons with kidney stones: a case-control study in Olmsted County, Minnesota.

PubMed

Saucier, Nathan A; Sinha, Mukesh K; Liang, Kelly V; Krambeck, Amy E; Weaver, Amy L; Bergstralh, Eric J; Li, Xujian; Rule, Andrew D; Lieske, John C

2010-01-01

Kidney stones are associated with increased risk of chronic kidney disease (CKD); however, risk factors in the general community are poorly defined. A nested case-control study was performed in residents of Olmsted County, MN, who presented with a kidney stone at the Mayo Clinic in 1980-1994 to contrast patients with kidney stones who developed CKD with a group that did not. Participants were selected from the Rochester Epidemiology Project, an electronic linkage system among health care providers in Olmsted County, MN. Cases were identified by diagnostic code for CKD and confirmed to have an estimated glomerular filtration rate < 60 mL/min/1.73 m(2). Controls were matched 2:1 to cases for age, sex, date of first kidney stone, and length of medical record. Charts were abstracted to characterize stone disease, hypertension, diabetes, obesity, tobacco use, ileal conduit, symptomatic stones, type and number of stones, urinary tract infections, number and type of surgical procedures, and medical therapy. Kidney stone patients with CKD were compared with matched stone patients without CKD. There were 53 cases and 106 controls with a mean age of 57 years at first stone event and 59% men. In kidney stone patients, cases with CKD were significantly more likely (P < 0.05) than controls to have had a history of diabetes (41.5% vs 17.0%), hypertension (71.7% vs 49.1%), frequent urinary tract infections (22.6% vs 6.6%), struvite stones (7.5% vs 0%), and allopurinol use (32.1% vs 4.7%) based on univariate analysis. Potential limitations include limited statistical power to detect associations, incomplete data from 24-hour urine studies, and that stone composition was not always available. As in the general population, hypertension and diabetes are associated with increased risk of CKD in patients with kidney stones. However, other unique predictors were identified in patients with kidney stones that increased the possibility of CKD. Further studies are warranted to elucidate

Dietary Modeling of Foods for Advanced CKD Based on General Healthy Eating Guidelines: What Should Be on the Plate?

PubMed

Chan, Maria; Kelly, John; Tapsell, Linda

2017-03-01

Chronic kidney disease (CKD) is a major public health problem with significant clinical, societal, and psychosocial burdens. Nutrition therapy has been an integral part of the medical management of patients with CKD for more than a century, with the main goals of preserving kidney function and preventing complications. Nutrition abnormalities may emerge well before dialysis therapy is initiated and are associated with poor outcomes. It is therefore important to revisit nutrition management in the advanced stages of CKD to gain a broader insight into its role and effect on patient outcomes. Traditionally, nutrition recommendations have focused on the prescription of energy (calories) and macro- and micronutrients. Today, dietary modeling also focuses on the evidence for food consumption on health. This review argues that advanced non-dialysis-dependent CKD nutrition requirements to a large extent align with healthy eating guidelines for the general population and should not be based on deprivation or be unusually restrictive. The best currently available evidence for the CKD diet is likely to be derived from CKD nutrition prescriptions in conjunction with evidence underpinning national dietary guidelines and evidence of healthy dietary patterns, such as Mediterranean-style and Dietary Approaches to Stop Hypertension (DASH)-style eating. Positive messages from these dietary patterns should improve acceptance of CKD dietary interventions among patients. Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

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

PubMed Central

Norton, Jenna M.; Boulware, L. Ebony

2016-01-01

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

Evaluating the feasibility of the KDIGO CKD referral recommendations.

PubMed

Singh, Karandeep; Waikar, Sushrut S; Samal, Lipika

2017-07-07

In 2012, the international nephrology organization Kidney Disease Improving Global Outcomes (KDIGO) released recommendations for nephrology referral for chronic kidney disease (CKD) patients. The feasibility of adhering to these recommendations is unknown. We conducted a retrospective analysis of the primary care population at Brigham and Women's Hospital (BWH). We translated referral recommendations based upon serum creatinine, estimated glomerular filtration rate (eGFR), and albuminuria into a set of computable criteria in order to project referral volume if the KDIGO referral recommendations were to be implemented. Using electronic health record data, we evaluated each patient using the computable criteria at the times that the patient made clinic visits in 2013. We then compared the projected referral volume with baseline nephrology clinic volume. Out of 56,461 primary care patients at BWH, we identified 5593 (9.9%) who had CKD based on albuminuria or estimated GFR. Referring patients identified by the computable criteria would have resulted in 2240 additional referrals to nephrology. In 2013, this would represent a 38.0% (2240/5892) increase in total nephrology patient volume and 67.3% (2240/3326) increase in new referral volume. This is the first study to examine the projected impact of implementing the 2012 KDIGO referral recommendations. Given the large increase in the number of referrals, this study is suggestive that implementing the KDIGO referral guidelines may not be feasible under current practice models due to a supply-demand mismatch. We need to consider new strategies on how to deliver optimal care to CKD patients using the available workforce in the U.S. health care system.

Kidney Function Can Improve in Patients with Hypertensive CKD

PubMed Central

Gadegbeku, Crystal; Lipkowitz, Michael S.; Rostand, Stephen; Lewis, Julia; Wright, Jackson T.; Appel, Lawrence J.; Greene, Tom; Gassman, Jennifer; Astor, Brad C.

2012-01-01

The typical assumption is that patients with CKD will have progressive nephropathy. Methodological issues, such as measurement error and regression to the mean, have made it difficult to document whether kidney function might improve in some patients. Here, we used data from 12 years of follow-up in the African American Study of Kidney Disease and Hypertension to determine whether some patients with CKD can experience a sustained improvement in GFR. We calculated estimated GFR (eGFR) based on serum creatinine measurements during both the trial and cohort phases. We defined clearly improved patients as those with positive eGFR slopes that we could not explain by random measurement variation under Bayesian mixed-effects models. Of 949 patients with at least three follow-up eGFR measurements, 31 (3.3%) demonstrated clearly positive eGFR slopes. The mean slope among these patients was +1.06 (0.12) ml/min per 1.73 m2 per yr, compared with −2.45 (0.07) ml/min per 1.73 m2 per yr among the remaining patients. During the trial phase, 24 (77%) of these 31 patients also had clearly positive slopes of 125I-iothalamate–measured GFR during the trial phase. Low levels of proteinuria at baseline and randomization to the lower BP goal (mean arterial pressure ≤92 mmHg) associated with improved eGFR. In conclusion, the extended follow-up from this study provides strong evidence that kidney function can improve in some patients with hypertensive CKD. PMID:22402803

Health-related quality of life in patients with autosomal dominant polycystic kidney disease and CKD stages 1-4: a cross-sectional study.

PubMed

Miskulin, Dana C; Abebe, Kaleab Z; Chapman, Arlene B; Perrone, Ronald D; Steinman, Theodore I; Torres, Vicente E; Bae, K Ty; Braun, William; Winklhofer, Franz T; Hogan, Marie C; Rahbari-Oskoui, Fred; Moore, Charity G; Flessner, Michael F; Schrier, Robert W

2014-02-01

In people with early autosomal dominant polycystic kidney disease (ADPKD), average total kidney volume (TKV) is 3 times normal and increases by an average of 5% per year despite a seemingly normal glomerular filtration rate (GFR). We hypothesized that increased TKV would be a source of morbidity and diminished quality of life that would be worse in patients with more advanced disease. Cross-sectional. 1,043 patients with ADPKD, hypertension, and a baseline estimated GFR (eGFR)> 20mL/min/1.73m(2). (1) eGFR, (2) height-adjusted TKV (htTKV) in patients with eGFR> 60mL/min/1.73m(2). 36-Item Short Form Health Survey (SF-36) and the Wisconsin Brief Pain Survey. Questionnaires were self-administered. GFR was estimated from serum creatinine using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation. htTKV was measured by magnetic resonance imaging. Back pain was reported by 50% of patients, and 20% experienced it "often, usually, or always." In patients with early disease (eGFR> 60mL/min/1.73m(2)), there was no association between pain and htTKV, except in patients with large kidneys (htTKV> 1,000mL/m). Comparing across eGFR levels and including patients with eGFRs< 60mL/min/1.73m(2), patients with eGFRs of 20-44mL/min/1.73m(2) were significantly more likely to report that pain impacted on their daily lives and had lower SF-36 scores than patients with eGFRs of 45-60 and ≥60mL/min/1.73m(2). Symptoms relating to abdominal fullness were reported by 20% of patients and were related significantly to lower eGFRs in women, but not men. TKV and liver volume were not measured in patients with eGFR < 60mL/min/1.73m(2). The number of patients with eGFRs< 30mL/min/1.73m(2) is small. Causal inferences are limited by cross-sectional design. Pain is a common early symptom in the course of ADPKD, although it is not related to kidney size in early disease (eGFR> 60mL/min/1.73m(2)), except in individuals with large kidneys (htTKV> 1,000 m

Peer support for CKD patients and carers: overcoming barriers and facilitating access.

PubMed

Taylor, Francesca; Gutteridge, Robin; Willis, Carol

2016-06-01

Peer support is valued by its users. Nevertheless, there is initial low take-up of formal peer support programmes among patients with chronic kidney disease (CKD), with fewer patients participating than expressing an interest. There is little evidence on reasons for low participation levels. Few studies have examined the perspectives of carers. To explore with CKD patients and carers their needs, wants and expectations from formal peer support and examine how barriers to participation may be overcome. Qualitative interviews with a sample of 26 CKD stage five patients and carers. Principles of Grounded Theory were applied to data coding and analysis. Six NHS Hospital Trusts. Whilst informal peer support might occur naturally and is welcomed, a range of emotional and practical barriers inhibit take-up of more formalized support. Receptivity varies across time and the disease trajectory and is associated with emotional readiness; patients and carers needing to overcome complex psychological hurdles such as acknowledging support needs. Practical barriers include limited understanding of peer support. An attractive peer relationship is felt to involve reciprocity based on sharing experiences and both giving and receiving support. Establishing rapport is linked with development of reciprocity. There is potential to facilitate active uptake of formal peer support by addressing the identified barriers. Our study suggests several facilitation methods, brought together in a conceptual model, including clinician promotion of peer support as an intervention suitable for anyone with CKD and their carers, and opportunity for choice of peer supporter. © 2015 The Authors Health Expectations Published by John Wiley & Sons Ltd.

Mapping three-dimensional oil distribution with π-EPI MRI measurements at low magnetic field

NASA Astrophysics Data System (ADS)

Li, Ming; Xiao, Dan; Romero-Zerón, Laura; Marica, Florea; MacMillan, Bryce; Balcom, Bruce J.

2016-08-01

Magnetic resonance imaging (MRI) is a robust tool to image oil saturation distribution in rock cores during oil displacement processes. However, a lengthy measurement time for 3D measurements at low magnetic field can hinder monitoring the displacement. 1D and 2D MRI measurements are instead often undertaken to monitor the oil displacement since they are faster. However, 1D and 2D images may not completely reflect the oil distribution in heterogeneous rock cores. In this work, a high-speed 3D MRI technique, π Echo Planar Imaging (π-EPI), was employed at 0.2 T to monitor oil displacement. Centric scan interleaved sampling with view sharing in k-t space was employed to improve the temporal resolution of the π-EPI measurements. A D2O brine was employed to distinguish the hydrocarbon and water phases. A relatively homogenous glass bead pack and a heterogeneous Spynie core plug were employed to show different oil displacement behaviors. High quality 3D images were acquired with π-EPI MRI measurements. Fluid quantification with π-EPI compared favorably with FID, CPMG, 1D-DHK-SPRITE, 3D Fast Spin Echo (FSE) and 3D Conical SPRITE measurements. π-EPI greatly reduced the gradient duty cycle and improved sensitivity, compared to FSE and Conical SPRITE measurements, enabling dynamic monitoring of oil displacement processes. For core plug samples with sufficiently long lived T2, T2∗, π-EPI is an ideal method for rapid 3D saturation imaging.

High resolution T2(*)-weighted Magnetic Resonance Imaging at 3 Tesla using PROPELLER-EPI.

PubMed

Krämer, Martin; Reichenbach, Jürgen R

2014-05-01

We report the application of PROPELLER-EPI for high resolution T2(*)-weighted imaging with sub-millimeter in-plane resolution on a clinical 3 Tesla scanner. Periodically rotated blades of a long-axis PROPELLER-EPI sequence were acquired with fast gradient echo readout and acquisition matrix of 320 × 50 per blade. Images were reconstructed by using 2D-gridding, phase and geometric distortion correction and compensation of resonance frequency drifts that occurred during extended measurements. To characterize these resonance frequency offsets, short FID calibration measurements were added to the PROPELLER-EPI sequence. Functional PROPELLER-EPI was performed with volunteers using a simple block design of right handed finger tapping. Results indicate that PROPELLER-EPI can be employed for fast, high resolution T2(*)-weighted imaging provided geometric distortions and possible resonance frequency drifts are properly corrected. Even small resonance frequency drifts below 10 Hz as well as non-corrected geometric distortions degraded image quality substantially. In the initial fMRI experiment image quality and signal-to-noise ratio was sufficient for obtaining high resolution functional activation maps. Copyright © 2014. Published by Elsevier GmbH.

Characterization of nonpolar a-plane GaN epi-layers grown on high-density patterned r-plane sapphire substrates

NASA Astrophysics Data System (ADS)

Jinno, Daiki; Otsuki, Shunya; Sugimori, Shogo; Daicho, Hisayoshi; Iwaya, Motoaki; Takeuchi, Tetsuya; Kamiyama, Satoshi; Akasaki, Isamu

2018-02-01

To reduce the number of threading dislocations (TDs) in nonpolar a-plane GaN (a-GaN) epi-layers grown on flat r-plane sapphire substrates (r-FSS), we investigated the effects on the crystalline quality of the a-GaN epi-layers of high-density patterned r-plane sapphire substrates (r-HPSS), the patterns of which were placed at intervals of several hundred nanometers. Two types of r-HPSS, the patterns of which had diameters and heights on the order of several hundred nanometers (r-NHPSS) or several micrometers (r-MHPSS), were prepared with conventional r-FSS. The effect of these r-HPSS on the a-GaN epi-layers was demonstrated by evaluating the surface morphology and the crystalline quality of the epi-layers. The surfaces of the a-GaN epi-layer grown on r-FSS and r-NHPSS were pit-free and mirror-like, whereas the surface of the a-GaN epi-layer grown on r-MHPSS was very rough due to the large, irregular GaN islands that grew on the patterns, mainly at the initial growth stage. The crystalline quality of the a-GaN epi-layer grown on r-NHPSS was better than that of the a-GaN epi-layer grown on r-FSS. We confirmed that there were fewer TDs in the a-GaN epi-layer grown on r-NHPSS than there were in the a-GaN epi-layer grown on r-FSS. The TDs propagating to the surface in a-GaN epi-layer grown on r-NHPSS were mainly generated on the flat sapphire regions between the patterns. Interestingly, it was also found that the TDs that propagated to the surface concentrated with a periodic pitch along the c-axis direction. The TD densities of a-GaN epi-layers grown on r-FSS and r-NHPSS were estimated to be approximately 5.0 × 1010 and 1.5 × 109 cm-2, respectively. This knowledge will contribute to the further development of a-GaN epi-layers for high-performance devices.

Safety and effectiveness of rivaroxaban and warfarin in moderate-to-advanced CKD: real world data.

PubMed

Di Lullo, Luca; Tripepi, Giovanni; Ronco, Claudio; De Pascalis, Antonio; Barbera, Vincenzo; Granata, Antonio; Russo, Domenico; Di Iorio, Biagio Raffaele; Paoletti, Ernesto; Ravera, Maura; Fusaro, Maria; Bellasi, Antonio

2018-06-07

In recent years, novel anticoagulant drugs have been introduced in the clinical armamentarium and have progressively gained momentum. Although their use is increasing among CKD patients, some skepticism about their risk-benefit ratio still persists. We sought to investigate the safety and effectiveness of rivaroxaban in a cohort of moderate-to-advanced CKD patients. This observational, retrospective, longitudinal study involved 347 consecutive CKD stage 3b-4 (according to NKF-KDOQI guidelines) patients enrolled from 8 cardiac outpatient clinics between March 2015 and October 2017. All patients received anticoagulation (100 warfarin vs. 247 rivaroxaban) as part of their non-valvular atrial fibrillation management at the attending physician's discretion. Clinical effectiveness (defined as the occurrence of ischemic stroke, venous thromboembolism, or transient ischemic attack) and safety (intracranial hemorrhage, gastrointestinal or other bleeding) were assessed separately. Over a mean follow-up period of 16 ± 0.3 months, 25 stroke episodes (15 hemorrhagic, and 10 ischemic) occurred in 24 warfarin treated patients vs. none in the rivaroxaban arm. There were 5 vs. 0 episodes of deep venous thrombosis and 8 vs. 2 major episodes of bleeding in the warfarin and rivaroxaban groups, respectively. In contrast, the proportion of minor episodes of bleeding was similar between groups. Rivaroxaban seems a safe and effective therapeutic option in CKD stage 3b-4 patients. However, future randomized controlled trials are needed to definitively establish the role of rivaroxaban in CKD patients.

Construction and validation of a web-based epidemiological database for inflammatory bowel diseases in Europe An EpiCom study.

PubMed

Burisch, Johan; Cukovic-Cavka, Silvija; Kaimakliotis, Ioannis; Shonová, Olga; Andersen, Vibeke; Dahlerup, Jens F; Elkjaer, Margarita; Langholz, Ebbe; Pedersen, Natalia; Salupere, Riina; Kolho, Kaija-Leena; Manninen, Pia; Lakatos, Peter Laszlo; Shuhaibar, Mary; Odes, Selwyn; Martinato, Matteo; Mihu, Ion; Magro, Fernando; Belousova, Elena; Fernandez, Alberto; Almer, Sven; Halfvarson, Jonas; Hart, Ailsa; Munkholm, Pia

2011-08-01

The EpiCom-study investigates a possible East-West-gradient in Europe in the incidence of IBD and the association with environmental factors. A secured web-based database is used to facilitate and centralize data registration. To construct and validate a web-based inception cohort database available in both English and Russian language. The EpiCom database has been constructed in collaboration with all 34 participating centers. The database was translated into Russian using forward translation, patient questionnaires were translated by simplified forward-backward translation. Data insertion implies fulfillment of international diagnostic criteria, disease activity, medical therapy, quality of life, work productivity and activity impairment, outcome of pregnancy, surgery, cancer and death. Data is secured by the WinLog3 System, developed in cooperation with the Danish Data Protection Agency. Validation of the database has been performed in two consecutive rounds, each followed by corrections in accordance with comments. The EpiCom database fulfills the requirements of the participating countries' local data security agencies by being stored at a single location. The database was found overall to be "good" or "very good" by 81% of the participants after the second validation round and the general applicability of the database was evaluated as "good" or "very good" by 77%. In the inclusion period January 1st -December 31st 2010 1336 IBD patients have been included in the database. A user-friendly, tailor-made and secure web-based inception cohort database has been successfully constructed, facilitating remote data input. The incidence of IBD in 23 European countries can be found at www.epicom-ecco.eu. Copyright © 2011 European Crohn's and Colitis Organisation. All rights reserved.

Vegetarian low-protein diets supplemented with keto analogues: a niche for the few or an option for many?

PubMed

Piccoli, Giorgina B; Ferraresi, Martina; Deagostini, Maria C; Vigotti, Federica Neve; Consiglio, Valentina; Scognamiglio, Stefania; Moro, Irene; Clari, Roberta; Fassio, Federica; Biolcati, Marilisa; Porpiglia, Francesco

2013-09-01

Low-protein diets are often mentioned but seldom used to slow chronic kidney disease (CKD) progression. The aim of the study was to investigate the potential for implementation of a simplified low-protein diet supplemented with alpha-keto analogues (LPD-KA) as part of the routine work-up in CKD patients. In an implementation study (December 2007-November 2011), all patients with CKD Stages IV-V not on dialysis, rapidly progressive Stage III and/or refractory proteinuria, were offered either a simplified LPD-KA, or commercially available low-protein food. LPD-KA consisted of proteins 0.6 g/kg/day, supplementation with Ketosteril 1 pill/10 Kg, 1-3 free-choice meals/week and a simplified schema based on 'allowed' and 'forbidden' foods. 'Success' was defined as at least 6 months on LPD-KA. Progression was defined as reduction in glomerular filtration rate (GFR)[(Chronic Kidney Disease Epidemiology Collaboration) formula CKD-EPI] in patients with at least 6 months of follow-up. Of about 2500 patients referred (8% CKD Stages IV-V), 139 started LPD-KA; median age (70 years) and prevalence of comorbidity (79%) were in line with the dialysis population. Start of dialysis was the main reason for discontinuation (40 cases, unplanned in 7); clinical reasons were recorded in 7, personal preference in 14 and improvement and death in 8 each. The low gross mortality (4% per year) and the progression rate (from -8 to 0 mL/min/year at 6 months) are reassuring concerning safety. None of the baseline conditions, including age, educational level, comorbidity or kidney function, discriminated the patients who followed the diet for at least 6 months. Our data suggest a wider offer of LPD-KA to patients with severe and progressive CKD. The promising results in terms of mortality and progression need confirmation with different study designs.

Marijuana and Cannabinoids in ESRD and Earlier Stages of CKD.

PubMed

Rein, Joshua L; Wyatt, Christina M

2018-02-01

Marijuana is the most commonly used recreational drug in the United States, and legal recreational and medicinal use has gained public acceptance during the last decade. Twenty-nine US states have established medical marijuana programs, 8 of which have also legalized recreational marijuana, and Canada is expected to legalize recreational marijuana in 2018. Advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) are chronic conditions with significant associated morbidity and mortality. Patients experience substantial symptom burden that is frequently undertreated due to adverse medication side effects. This article reviews the available evidence for the use of medical marijuana to manage chronic pain, nausea/vomiting, anorexia/cachexia, and pruritus, all of which are frequently reported by patients with advanced CKD or ESRD. Potential adverse health effects of medical and recreational marijuana use are also discussed. Regardless of personal, social, and political beliefs, marijuana use is becoming mainstream, and nephrologists should be aware of the potential impact on our patient population. Further research is warranted to investigate the renal endocannabinoid system, the impact of marijuana use on kidney disease outcomes, and the risks and benefits of medical marijuana use on symptoms of advanced CKD and ESRD. Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Low Serum Bicarbonate and Kidney Function Decline: The Multi-Ethnic Study of Atherosclerosis (MESA)

PubMed Central

Driver, Todd H.; Shlipak, Michael G.; Katz, Ronit; Goldenstein, Leonard; Sarnak, Mark J.; Hoofnagle, Andrew N.; Siscovick, David S.; Kestenbaum, Bryan; de Boer, Ian H.; Ix, Joachim H.

2014-01-01

Background Among populations with established chronic kidney disease (CKD), metabolic acidosis is associated with more rapid progression of kidney disease. The association of serum bicarbonate concentrations with early declines in kidney function is less clear. Study Design Retrospective cohort study. Setting & Participants 6380 participants in the Multi-Ethnic Study of Atherosclerosis (MESA) with a baseline estimated glomerular filtration rate (eGFR) >60 mL/min/1.73m2 using the CKD-EPI (CKD Epidemiology Collaboration) creatinine–cystatin C equation. Predictors Serum bicarbonate concentrations. Outcomes Rapid kidney function decline (eGFR decline >5% per year) and incident reduced eGFR (eGFR<60 mL/min/1.73 m2 with minimum rate of eGFR loss of 1 mL/min/1.73 m2 per year). Results The average bicarbonate concentration was 23.2 ± 1.8 mEq/L. 1730 (33%) participants had rapid kidney function decline, and 487 had incident reduced eGFR during follow-up. Each 1-SD lower baseline bicarbonate concentration was associated with 12% higher adjusted odds of rapid kidney function decline (95% CI, 6%–20%) and higher risk of incident reduced eGFR (adjusted incidence rate ratio, 1.11; 95% CI, 1.03–1.20) in models adjusting for demographics, baseline eGFR, albuminuria, and CKD risk factors. The OR for the associations of bicarbonate <21mEq/L relative to 23–24 mEq/L was 1.35 (95% CI, 1.05–1.73) for rapid kidney function decline, and the incidence rate ratio was 1.16 (95% CI, 0.83–1.62) for incident reduced eGFR. Limitations Etiology of metabolic acidosis cannot be determined in this study. Conclusions Lower serum bicarbonate concentrations are independently associated with rapid kidney function decline independent of eGFR or albuminuria in community-living persons with a baseline eGFR >60 mL/min/1.73 m2. If confirmed, our findings suggest that metabolic acidosis may indicate either early kidney disease that is not captured by eGFR or albuminuria, or may have a causal role

Low serum bicarbonate and kidney function decline: the Multi-Ethnic Study of Atherosclerosis (MESA).

PubMed

Driver, Todd H; Shlipak, Michael G; Katz, Ronit; Goldenstein, Leonard; Sarnak, Mark J; Hoofnagle, Andrew N; Siscovick, David S; Kestenbaum, Bryan; de Boer, Ian H; Ix, Joachim H

2014-10-01

Among populations with established chronic kidney disease (CKD), metabolic acidosis is associated with more rapid progression of kidney disease. The association of serum bicarbonate concentrations with early declines in kidney function is less clear. Retrospective cohort study. 5,810 participants in the Multi-Ethnic Study of Atherosclerosis (MESA) with a baseline estimated glomerular filtration rate (eGFR) > 60mL/min/1.73 m(2) using the CKD-EPI (CKD Epidemiology Collaboration) creatinine-cystatin C equation. Serum bicarbonate concentrations. Rapid kidney function decline (eGFR decline > 5% per year) and incident reduced eGFR (eGFR < 60mL/min/1.73 m(2) with minimum rate of eGFR loss of 1 mL/min/1.73 m(2) per year). Average bicarbonate concentration was 23.2 ± 1.8mEq/L. 1,730 (33%) participants had rapid kidney function decline, and 487 had incident reduced eGFR during follow-up. Each 1-SD lower baseline bicarbonate concentration was associated with 12% higher adjusted odds of rapid kidney function decline (95% CI, 6%-20%) and higher risk of incident reduced eGFR (adjusted incidence rate ratio, 1.11; 95% CI, 1.03-1.20) in models adjusting for demographics, baseline eGFR, albuminuria, and CKD risk factors. The OR for the associations of bicarbonate level < 21 mEq/L relative to 23-24 mEq/L was 1.35 (95% CI, 1.05-1.73) for rapid kidney function decline, and the incidence rate ratio was 1.16 (95% CI, 0.83-1.62) for incident reduced eGFR. Cause of metabolic acidosis cannot be determined in this study. Lower serum bicarbonate concentrations are associated independently with rapid kidney function decline independent of eGFR or albuminuria in community-living persons with baseline eGFR > 60 mL/min/1.73 m(2). If confirmed, our findings suggest that metabolic acidosis may indicate either early kidney disease that is not captured by eGFR or albuminuria or may have a causal role in the development of eGFR < 60 mL/min/1.73 m(2). Copyright © 2014 National Kidney Foundation, Inc

[Cystatin C as a mortality predictor in a hypertensive population in Extremadura, Spain].

PubMed

Garcia Gallego, Francisco; Robles, Nicolás Roberto; Matias Orozco, Nicolás; Mena, Candido; Cidoncha, Antonio

2015-09-07

Cystatin C has proven to be a useful parameter to evaluate renal and cardiovascular risk. Nevertheless, there are scanty reports on the utility of this test in the Spanish population. We performed a survey in a group of patients followed up in Primary Care settings. Prospective follow up of Primary Care attended patients recruited in 2008 and the first half of 2009. The sample included 142 subjects (mean age 64.2±14.6 years, 59.2% men). In all cases, cystatin C was determined and glomerular filtration rate (GFR) was estimated through the Hoek formula. Serum creatinine was also quantified as it was GFR estimated using CKD-EPI equation. The primary objective was a combination of death and major cardiovascular events incidence. There were 29 events registered (4 of them were deaths) and 9 non cardiovascular deaths. The odds ratio for the primary objective was 5.74 for the last quartile of cystatin C distribution (>1mg/l) (P=.002), while it was 6.44 for cystatin C derived GFR (P=.008) and 5.59 for CKD-EPI estimated GFR (P=.002, Mantel-Haenszel test). Cystatin C showed a good association with general mortality and the incidence of cardiovascular events in the Spanish population. Nevertheless, it was not better than the observed relationship with GFR, estimated from creatinine. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.

Effects of Vitamin D Receptor Activation and Dietary Sodium Restriction on Residual Albuminuria in CKD: The ViRTUE-CKD Trial.

PubMed

Keyzer, Charlotte A; van Breda, G Fenna; Vervloet, Marc G; de Jong, Maarten A; Laverman, Gozewijn D; Hemmelder, Marc H; Janssen, Wilbert M T; Lambers Heerspink, Hiddo J; Kwakernaak, Arjan J; Bakker, Stephan J L; Navis, Gerjan; de Borst, Martin H

2017-04-01

Reduction of residual albuminuria during single-agent renin-angiotensin-aldosterone blockade is accompanied by improved cardiorenal outcomes in CKD. We studied the individual and combined effects of the vitamin D receptor activator paricalcitol (PARI) and dietary sodium restriction on residual albuminuria in CKD. In a multicenter, randomized, placebo (PLAC)-controlled, crossover trial, 45 patients with nondiabetic CKD stages 1-3 and albuminuria >300 mg/24 h despite ramipril at 10 mg/d and BP<140/90 mmHg were treated for four 8-week periods with PARI (2 μ g/d) or PLAC, each combined with a low-sodium (LS) or regular sodium (RS) diet. We analyzed the treatment effect by linear mixed effect models for repeated measurements. In the intention-to-treat analysis, albuminuria (geometric mean) was 1060 (95% confidence interval, 778 to 1443) mg/24 h during RS + PLAC and 990 (95% confidence interval, 755 to 1299) mg/24 h during RS + PARI ( P =0.20 versus RS + PLAC). LS + PLAC reduced albuminuria to 717 (95% confidence interval, 512 to 1005) mg/24 h ( P <0.001 versus RS + PLAC), and LS + PARI reduced albuminuria to 683 (95% confidence interval, 502 to 929) mg/24 h ( P <0.001 versus RS + PLAC). The reduction by PARI beyond the effect of LS was nonsignificant ( P =0.60). In the per-protocol analysis restricted to participants with ≥95% compliance with study medication, PARI did provide further albuminuria reduction ( P =0.04 LS + PARI versus LS + PLAC). Dietary adherence was good as reflected by urinary excretion of 174±64 mmol Na + per day in the combined RS groups and 108±61 mmol Na + per day in the LS groups ( P <0.001). In conclusion, moderate dietary sodium restriction substantially reduced residual albuminuria during fixed dose angiotensin-converting enzyme inhibition. The additional effect of PARI was small and nonsignificant. Copyright © 2017 by the American Society of Nephrology.

Effects of Vitamin D Receptor Activation and Dietary Sodium Restriction on Residual Albuminuria in CKD: The ViRTUE-CKD Trial

PubMed Central

Keyzer, Charlotte A.; van Breda, G. Fenna; Vervloet, Marc G.; de Jong, Maarten A.; Laverman, Gozewijn D.; Hemmelder, Marc H.; Janssen, Wilbert M.T.; Lambers Heerspink, Hiddo J.; Kwakernaak, Arjan J.; Bakker, Stephan J.L.; Navis, Gerjan

2017-01-01

Reduction of residual albuminuria during single–agent renin-angiotensin-aldosterone blockade is accompanied by improved cardiorenal outcomes in CKD. We studied the individual and combined effects of the vitamin D receptor activator paricalcitol (PARI) and dietary sodium restriction on residual albuminuria in CKD. In a multicenter, randomized, placebo (PLAC)–controlled, crossover trial, 45 patients with nondiabetic CKD stages 1–3 and albuminuria >300 mg/24 h despite ramipril at 10 mg/d and BP<140/90 mmHg were treated for four 8-week periods with PARI (2 μg/d) or PLAC, each combined with a low-sodium (LS) or regular sodium (RS) diet. We analyzed the treatment effect by linear mixed effect models for repeated measurements. In the intention-to-treat analysis, albuminuria (geometric mean) was 1060 (95% confidence interval, 778 to 1443) mg/24 h during RS + PLAC and 990 (95% confidence interval, 755 to 1299) mg/24 h during RS + PARI (P=0.20 versus RS + PLAC). LS + PLAC reduced albuminuria to 717 (95% confidence interval, 512 to 1005) mg/24 h (P<0.001 versus RS + PLAC), and LS + PARI reduced albuminuria to 683 (95% confidence interval, 502 to 929) mg/24 h (P<0.001 versus RS + PLAC). The reduction by PARI beyond the effect of LS was nonsignificant (P=0.60). In the per-protocol analysis restricted to participants with ≥95% compliance with study medication, PARI did provide further albuminuria reduction (P=0.04 LS + PARI versus LS + PLAC). Dietary adherence was good as reflected by urinary excretion of 174±64 mmol Na+ per day in the combined RS groups and 108±61 mmol Na+ per day in the LS groups (P<0.001). In conclusion, moderate dietary sodium restriction substantially reduced residual albuminuria during fixed dose angiotensin–converting enzyme inhibition. The additional effect of PARI was small and nonsignificant. PMID:27856633

Telemedicine to promote patient safety: Use of phone-based interactive voice response system (IVRS) to reduce adverse safety events in predialysis CKD

PubMed Central

Weiner, Shoshana; Fink, Jeffery C.

2017-01-01

Chronic kidney disease (CKD) patients have several features conferring upon them a high risk of adverse safety events, which are defined as incidents with unintended harm related to processes of care or medications. These characteristics include impaired renal function, polypharmacy, and frequent health system encounters. The consequences of such events in CKD can include new or prolonged hospitalization, accelerated renal function loss, acute kidney injury, end-stage renal disease and death. Health information technology administered via telemedicine presents opportunities for CKD patients to remotely communicate safety-related findings to providers for the purpose of improving their care. However, many CKD patients have limitations which hinder their use of telemedicine and access to the broad capabilities of health information technology. In this review we summarize previous assessments of the pre-dialysis CKD populations’ proficiency in using telemedicine modalities and describe the use of interactive voice-response system (IVRS) to gauge the safety phenotype of the CKD patient. We discuss the potential for expanded IVRS use in CKD to address the safety threats inherent to this population. PMID:28224940

Cohort profile: the chronic kidney disease prognosis consortium.

PubMed

Matsushita, Kunihiro; Ballew, Shoshana H; Astor, Brad C; Jong, Paul E de; Gansevoort, Ron T; Hemmelgarn, Brenda R; Levey, Andrew S; Levin, Adeera; Wen, Chi-Pang; Woodward, Mark; Coresh, Josef

2013-12-01

The Chronic Kidney Disease Prognosis Consortium (CKD-PC) was established in 2009 to provide comprehensive evidence about the prognostic impact of two key kidney measures that are used to define and stage CKD, estimated glomerular filtration rate (eGFR) and albuminuria, on mortality and kidney outcomes. CKD-PC currently consists of 46 cohorts with data on these kidney measures and outcomes from >2 million participants spanning across 40 countries/regions all over the world. CKD-PC published four meta-analysis articles in 2010-11, providing key evidence for an international consensus on the definition and staging of CKD and an update for CKD clinical practice guidelines. The consortium continues to work on more detailed analysis (subgroups, different eGFR equations, other exposures and outcomes, and risk prediction). CKD-PC preferably collects individual participant data but also applies a novel distributed analysis model, in which each cohort runs statistical analysis locally and shares only analysed outputs for meta-analyses. This distributed model allows inclusion of cohorts which cannot share individual participant level data. According to agreement with cohorts, CKD-PC will not share data with third parties, but is open to including further eligible cohorts. Each cohort can opt in/out for each topic. CKD-PC has established a productive and effective collaboration, allowing flexible participation and complex meta-analyses for studying CKD.

Serum levels of 3-epi-25-OH-D3 during hypervitaminosis D in clinical practice.

PubMed

Granado-Lorencio, F; Blanco-Navarro, I; Pérez-Sacristán, B; Donoso-Navarro, E; Silvestre-Mardomingo, R

2012-12-01

Intoxication from vitamin D supplements has been rarely reported, but nowadays, it occurs more frequently. The presence of the C-3 epimer of 25-hydroxyvitamin D(3) (3-epi-25-OH-D(3)) is highly prevalent in adults, although there is little information regarding its in vivo relevance, if any, especially under pathological conditions. Our aim was to assess the presence of the 3-epi-25-OH-D(3) in serum samples displaying 25-OH-D(3) concentrations indicative of hypervitaminosis D. A total of 58 samples displaying a wide range of concentrations of 25-OH-D(3) (>64-439 ng/ml) by ultrafast liquid chromatography were consecutively recruited and reassessed for the presence of 3-epi-25-OH-D(3) using a second chromatographic system. Data from additional biochemical tests performed as part of the patient evaluation were also recorded. Mean relative contribution of 3-epi-25-OH-D(3) was less than 4%, and concentrations ranged from 2-28.6 ng/ml. Serum levels of the C3 epimer, but not the relative contribution, correlate with serum 25-OH-D(3). Overall, in subjects with 25-OH-D(3) concentrations indicative of hypervitaminosis D, the presence of the C-3 epimer and its levels were apparently unrelated to age, serum markers of renal and liver function, acute-phase reactants, and the presence of hypercalcemia. 3-Epi-25-OH-D(3) did not correlate with PTH, but subjects displaying PTH suppression (<14 pg/ml) showed higher concentrations of 3-epi-25-OH-D(3). The relative contribution of 3-epi-25-D(3) was not significantly altered during hypervitaminosis D, although the absolute levels reached in serum may be biologically relevant. From a clinical viewpoint, although the small size of the group may affect the lack of relationships, the presence of 3-epi-25-OH-D(3) was apparently unrelated to serum markers of renal and liver function, acute-phase reactants, PTH, and the presence of hypercalcemia.

Perceived barriers and facilitators of using dietary modification for CKD prevention among African Americans of low socioeconomic status: a qualitative study.

PubMed

Johnson, Amber E; Boulware, L Ebony; Anderson, Cheryl A M; Chit-ua-aree, Tatpong; Kahan, Kimberly; Boyér, LaPricia Lewis; Liu, Yang; Crews, Deidra C

2014-12-06

Factors influencing the use of dietary interventions for modification of CKD risk among African Americans have not been well-explored. We assessed perceived barriers and facilitators of CKD prevention through dietary modifications among African Americans with low socioeconomic status (SES) and at high risk for CKD. We conducted a qualitative study involving three 90 minute focus groups of low SES (limited education, unemployed, uninsured, or income<$25,000/year) African American residents of Baltimore, Maryland (N=17), who were aged 18-60 years, with no known history of CKD and (1) a family history of end stage renal disease and (2) self-reported diabetes, hypertension, cardiovascular disease, HIV or obesity. A trained moderator asked a series of 21 closed and open-ended questions. Group sessions were recorded, transcribed, and two independent investigators reviewed transcripts to identify common themes. Participants' mean (SD) age was 39.8 (12.4) years. Most (59%) were female and earned <$5,000/year (71%). One quarter (24%) had self-reported diabetes and over half had hypertension (53%). Few (12%) perceived their CKD risk as high. Perceived barriers to CKD prevention through dietary change included the expense and unavailability of healthy foods, family member preferences, convenience of unhealthy foods, and inability to break lifelong habits. They identified vouchers for healthy foods, family-based interventions, nutritional counseling and group gatherings for persons interested in making dietary changes as acceptable facilitators of dietary CKD prevention efforts. Low SES African Americans at high risk for CKD had limited perception of their risk but they identified multiple barriers and potential facilitators of CKD prevention via dietary modifications which can inform future studies and public health interventions.

Impact of Educational Attainment on Health Outcomes in Moderate to Severe CKD.

PubMed

Morton, Rachael L; Schlackow, Iryna; Staplin, Natalie; Gray, Alastair; Cass, Alan; Haynes, Richard; Emberson, Jonathan; Herrington, William; Landray, Martin J; Baigent, Colin; Mihaylova, Borislava

2016-01-01

The inverse association between educational attainment and mortality is well established, but its relevance to vascular events and renal progression in a population with chronic kidney disease (CKD) is less clear. This study aims to determine the association between highest educational attainment and risk of vascular events, cause-specific mortality, and CKD progression. Prospective epidemiologic analysis among participants in the Study of Heart and Renal Protection (SHARP), a randomized controlled trial. 9,270 adults with moderate to severe CKD (6,245 not receiving dialysis at baseline) and no history of myocardial infarction or coronary revascularization recruited in Europe, North America, Asia, Australia, and New Zealand. Highest educational attainment measured at study entry using 6 levels that ranged from "no formal education" to "tertiary education." Any vascular event (any fatal or nonfatal cardiac, cerebrovascular, or peripheral vascular event), cause-specific mortality, and CKD progression during 4.9 years' median follow-up. There was a significant trend (P<0.001) toward increased vascular risk with decreasing levels of education. Participants with no formal education were at a 46% higher risk of vascular events (relative risk [RR], 1.46; 95% CI, 1.14-1.86) compared with participants with tertiary education. The trend for mortality across education levels was also significant (P<0.001): all-cause mortality was twice as high among those with no formal education compared with tertiary-educated individuals (RR, 2.05; 95% CI, 1.62-2.58), and significant increases were seen for both vascular (RR, 1.84; 95% CI, 1.21-2.81) and nonvascular (RR, 2.15; 95% CI, 1.60-2.89) deaths. Lifestyle factors and prior disease explain most of the excess mortality risk. Among 6,245 participants not receiving dialysis at baseline, education level was not significantly associated with progression to end-stage renal disease or doubling of creatinine level (P for trend = 0.4). No

Impact of Educational Attainment on Health Outcomes in Moderate to Severe CKD

PubMed Central

Morton, Rachael L.; Schlackow, Iryna; Staplin, Natalie; Gray, Alastair; Cass, Alan; Haynes, Richard; Emberson, Jonathan; Herrington, William; Landray, Martin J.; Baigent, Colin; Mihaylova, Borislava

2016-01-01

Background The inverse association between educational attainment and mortality is well established, but its relevance to vascular events and renal progression in a population with chronic kidney disease (CKD) is less clear. This study aims to determine the association between highest educational attainment and risk of vascular events, cause-specific mortality, and CKD progression. Study Design Prospective epidemiologic analysis among participants in the Study of Heart and Renal Protection (SHARP), a randomized controlled trial. Setting & Participants 9,270 adults with moderate to severe CKD (6,245 not receiving dialysis at baseline) and no history of myocardial infarction or coronary revascularization recruited in Europe, North America, Asia, Australia, and New Zealand. Predictor Highest educational attainment measured at study entry using 6 levels that ranged from “no formal education” to “tertiary education.” Outcomes Any vascular event (any fatal or nonfatal cardiac, cerebrovascular, or peripheral vascular event), cause-specific mortality, and CKD progression during 4.9 years’ median follow-up. Results There was a significant trend (P < 0.001) toward increased vascular risk with decreasing levels of education. Participants with no formal education were at a 46% higher risk of vascular events (relative risk [RR], 1.46; 95% CI, 1.14-1.86) compared with participants with tertiary education. The trend for mortality across education levels was also significant (P < 0.001): all-cause mortality was twice as high among those with no formal education compared with tertiary-educated individuals (RR, 2.05; 95% CI, 1.62-2.58), and significant increases were seen for both vascular (RR, 1.84; 95% CI, 1.21-2.81) and nonvascular (RR, 2.15; 95% CI, 1.60-2.89) deaths. Lifestyle factors and prior disease explain most of the excess mortality risk. Among 6,245 participants not receiving dialysis at baseline, education level was not significantly associated with

4C.05: PWV IS AN INDEPENDENT DETERMINANT OF COGNITIVE DYSFUNCTION IN CKD PATIENTS.

PubMed

Karasavvidou, D; Pappas, K; Stagikas, D; Makridis, D; Katsinas, C; Kalaitzidis, R

2015-06-01

Cognitive dysfunction has long been recognized as a complication of chronic kidney disease (CKD), through several putative mechanisms, including high BP, large and small artery damage. Our study tests the hypothesis that large artery stiffness and microvascular damage are related to brain microcirculation changes as reflected by impaired cognitive function in CKD patients.(Figure is included in full-text article.) : Two hundred seventeen patients (50 with CKD stage 1; 67 stage 2; 53 stage 3; 47 stage 4), with mean age 58.4 years (64.5% males), were enrolled in a cross-sectional study. Cognitive function was assessed using Mini Mental State Examination (MMSE). Full score on the MMSE is 30; cognitive impairment was defined as <26 and cognitive dysfunction as <19. Educational level was categorized as lower versus higher education. Using the Sphygmocor system and an oscillometric device, we directly measured brachial SBP (bSBP) and pulse pressure (bPP), carotid SBP (cSBP) and pulse pressure (cPP) and estimated aortic SBP (aSBP) and pulse pressure (aPP) from the radial pressure waveform. Pulse Pressure Amplification (PPA), augmentation index (AIx) and carotid-femoral pulse wave velocity (cfPWV) were calculated. The risk of cognitive dysfunction increased significantly from CKD stage 3 to 4 (p < 0.01). Table. In univariate analysis, age (p < 0.001), education level (p < 0.001) stages of CKD (p < 0.004), cfPWV (p < 0.029), AIx (p < 0.03), bSBP (p < 0.002), aSBP (p < 0.012), cSBP (p < 0.015) and cPP (p < 0.002) were significantly and negatively associated with MMSE. In multivariate regression analysis, adjusted for CKD stages, the remaining independent factor significantly (p < 0.02) associated with cognitive dysfunction was cfPWV. Carotid-femoral PWV may be a more sensitive marker of cognitive dysfunction than other parameters of central blood pressure. Since high cfPWV is associated with high pressure pulsatility at the

Comparison between Different Measures of Body Fat with Kidney Function Decline and Incident CKD.

PubMed

Madero, Magdalena; Katz, Ronit; Murphy, Rachel; Newman, Anne; Patel, Kushang; Ix, Joachim; Peralta, Carmen; Satterfield, Suzanne; Fried, Linda; Shlipak, Michael; Sarnak, Mark

2017-06-07

Although anthropometric measures of body fat are associated with development of CKD, they may not be able to distinguish between various forms of fat and therefore may be less accurate than computed tomography (CT) measures. We compared the association of CT and anthropometric measures of obesity with kidney outcomes in the Health Aging and Body Composition Study. Participants were recruited from March of 1997 through July of 1998. CT measures included visceral abdominal fat (VAT), subcutaneous adipose tissue (SAT), and intermuscular fat area (IMAT), whereas anthropometric measures included waist circumference (WC) and body mass index (BMI). Kidney outcomes included kidney function (KF) decline (30% decrease in eGFR cysC in follow-up at either year 3 or 10) or incident CKD (follow-up eGFR cysC ≤60 ml/min per 1.73 m 2 in individuals with baseline GFR>60 ml/min per 1.73 m 2 ). Multivariable logistic regression models and Poisson regression models were used to evaluate the association with decline in KF and incident kidney disease, respectively. We also assessed for the independent associations among the exposure measures by including them in the same model. Two-thousand four-hundred and eighty-nine individuals were included. Mean age was 74±3 years, 49% were men, 39% were black, 59% were hypertensive, and 15% were diabetic. KF decline occurred in 17% of the population, whereas incident CKD also occurred in 17% of those at risk. In continuous models, SAT, VAT, IMAT, BMI, and WC (per SD increase) were all significantly associated with KF decline. There was a significant interaction between VAT and CKD with regard to KF decline ( P =0.01). Only VAT, BMI, and WC were associated with incident CKD. Only VAT remained a significant risk factor for incident CKD when other exposure variables were included in the same model. There was no association between any measure of obesity and kidney outcomes when creatinine values at years 3 and 10 were used to estimate changes in e

Oral iron supplementation: Potential implications for the gut microbiome and metabolome in patients with CKD.

PubMed

Kortman, Guus A M; Reijnders, Dorien; Swinkels, Dorine W

2017-06-01

Patients with chronic kidney disease (CKD) and loss of kidney function are at increased risk for morbidity and mortality. The risks of CKD are attributed to "uremia," an increased concentration of uremic retention solutes (toxins) in the plasma. Recently, a colo-renal axis became clearly apparent and uremia has been associated with an altered gut microbiome composition and metabolism. There is a high prevalence of anemia in patients with CKD, for which patients are often treated with oral or intravenous iron. Recent in vivo and in vitro studies have reported adverse effects of oral iron supplementation on the gut microbiota composition, gut metabolome, and intestinal health, which in turn may result in an increased production of uremic toxins. It may also affect circulating levels of other microbe-derived molecules, that can act as mediators of immune regulation. Changes in body iron levels have also been reported to exert subtle effects on host immune function by modulating immune cell proliferation and differentiation, and by directly regulating cytokine formation and antimicrobial immune effector mechanisms. Based on the foregoing it is conceivable that oral iron supplementation in iron deficient predialysis CKD patients adversely changes gut microbiota composition, the gut and systemic metabolome, and host immunity and infection. Future studies are needed to confirm these hypotheses and to assess whether, compared to IV iron supplementation, oral iron supplementation negatively impacts on morbidity of CKD, and whether these adverse effects depend on the iron bioavailability of the iron formulation to the microbiota. © 2017 International Society for Hemodialysis.

Interaction between GFR and Risk Factors for Morbidity and Mortality in African Americans with CKD

PubMed Central

Lea, Janice; McClellan, William M.

2013-01-01

Summary Background and objectives The African American Study of Kidney Disease Trial identified risk factors for CKD progression and suggested that GFR level may modify the association between these risk factors and CKD progression or death. Design, setting, participants, & measurements Enrollment in the African American Study of Kidney Disease Trial occurred between June of 1995 and September of 2001, with median follow-up of 48.6 months. Among 1094 patients with hypertensive kidney disease in the trial, this study tested whether the association between six previously identified risk factors for CKD progression (or death) and a composite clinical outcome (progression of CKD, ESRD, or death) depends on level of GFR. Multivariate Cox regression was used to control for other baseline risk factors. Results After controlling for baseline risk factors, only proteinuria was more closely associated with the composite clinical outcome at lower levels of GFR (P value for interaction term=0.002); increased hazards of the clinical composite outcome associated with a doubling of proteinuria ranged from 30% (95% confidence interval=21%–39%) with a GFR of 50 to 55% (95% confidence interval=40%–72%) with a GFR of 25. Conclusions The magnitude of the association between proteinuria and CKD progression, ESRD, or death in the African American Study of Kidney Disease Trial cohort depends on the level of GFR; proteinuria is a stronger independent predictor of the composite clinical outcome at lower levels of GFR. This finding reinforces that African Americans with proteinuria and lower GFR represent a population at particularly high risk for adverse outcomes. PMID:23085727

Waist-to-hip ratio and body mass index as risk factors for cardiovascular events in CKD.

PubMed

Elsayed, Essam F; Tighiouart, Hocine; Weiner, Daniel E; Griffith, John; Salem, Deeb; Levey, Andrew S; Sarnak, Mark J

2008-07-01

The role of obesity as a risk factor for cardiovascular disease in patients with chronic kidney disease (CKD) is poorly understood. Waist-to-hip ratio (WHR) is less influenced by muscle and bone mass than body mass index (BMI). We compared WHR and BMI as risk factors for cardiac events (myocardial infarction and fatal coronary disease) in persons with CKD. Cohort study. Persons with CKD, defined as baseline estimated glomerular filtration rate of 15 to 60 mL/min/1.73 m(2), drawn from 2 community studies: the Atherosclerosis Risk in Communities Study and the Cardiovascular Health Study. WHR, waist circumference, and BMI. Myocardial infarction and fatal coronary heart disease. Of 1,669 participants with CKD, mean age was 70.3 years and 56% were women. Mean (SD) WHRs were 0.97 +/- 0.08 in men and 0.90 +/- 0.07 in women; mean (SD) BMI was 27.2 +/- 4.6 kg/m(2). During a mean of 9.3 years of follow-up, there were 334 cardiac events. In multivariable-adjusted Cox models, the highest WHR group (n = 386) was associated with an increased risk of cardiac events compared with the lowest WHR group (hazard ratio, 1.36; 95% confidence interval, 1.01 to 1.83). Obesity, defined as BMI greater than 30 kg/m(2) (n = 381), was not associated with cardiac events (hazard ratio, 0.86; 95% confidence interval, 0.62 to 1.20) in comparison to participants with normal BMI (<25 kg/m(2)). Results with waist circumference were similar to those with BMI. Absence of a gold standard for measurement of visceral fat. WHR, but not BMI, is associated with cardiac events in persons with CKD. Relying exclusively on BMI may underestimate the importance of obesity as a cardiovascular disease risk factor in persons with CKD.

Effects of serum creatinine calibration on estimated renal function in african americans: the Jackson heart study.

PubMed

Wang, Wei; Young, Bessie A; Fülöp, Tibor; de Boer, Ian H; Boulware, L Ebony; Katz, Ronit; Correa, Adolfo; Griswold, Michael E

2015-05-01

The calibration to isotope dilution mass spectrometry-traceable creatinine is essential for valid use of the new Chronic Kidney Disease Epidemiology Collaboration equation to estimate the glomerular filtration rate. For 5,210 participants in the Jackson Heart Study (JHS), serum creatinine was measured with a multipoint enzymatic spectrophotometric assay at the baseline visit (2000-2004) and remeasured using the Roche enzymatic method, traceable to isotope dilution mass spectrometry in a subset of 206 subjects. The 200 eligible samples (6 were excluded, 1 for failure of the remeasurement and 5 for outliers) were divided into 3 disjoint sets-training, validation and test-to select a calibration model, estimate true errors and assess performance of the final calibration equation. The calibration equation was applied to serum creatinine measurements of 5,210 participants to estimate glomerular filtration rate and the prevalence of chronic kidney disease (CKD). The selected Deming regression model provided a slope of 0.968 (95% confidence interval [CI], 0.904-1.053) and intercept of -0.0248 (95% CI, -0.0862 to 0.0366) with R value of 0.9527. Calibrated serum creatinine showed high agreement with actual measurements when applying to the unused test set (concordance correlation coefficient 0.934, 95% CI, 0.894-0.960). The baseline prevalence of CKD in the JHS (2000-2004) was 6.30% using calibrated values compared with 8.29% using noncalibrated serum creatinine with the Chronic Kidney Disease Epidemiology Collaboration equation (P < 0.001). A Deming regression model was chosen to optimally calibrate baseline serum creatinine measurements in the JHS, and the calibrated values provide a lower CKD prevalence estimate.

The relative roles of ANC and EPI in the continuous distribution of LLINs: a qualitative study in four countries.

PubMed

Theiss-Nyland, Katherine; Koné, Diakalia; Karema, Corine; Ejersa, Waqo; Webster, Jayne; Lines, Jo

2017-05-01

The continuous distribution of long-lasting insecticidal nets (LLINs) for malaria prevention, through the antenatal care (ANC) and the Expanded Programme on Immunizations (EPI), is recommended by the WHO to improve and maintain LLIN coverage. Despite these recommendations, little is known about the relative strengths and weaknesses of the ANC and EPI-based LLIN distribution. This study aimed to explore and compare the roles of the ANC and EPI for LLIN distribution in four African countries. In a qualitative evaluation of continuous distribution through the ANC and EPI, semi-structured, individual and group interviews were conducted in Kenya, Malawi, Mali, and Rwanda. Respondents included national, sub-national, and facility-level health staff, and were selected to capture a range of roles related to malaria, ANC and EPI programmes. Policies, guidelines, and data collection tools were reviewed as a means of triangulation to assess the structure of LLIN distribution, and the methods of data collection and reporting for malaria, ANC and EPI programmes. In the four countries visited, distribution of LLINs was more effectively integrated through ANC than through EPI because of a) stronger linkages and involvement between malaria and reproductive health programmes, as compared to malaria and EPI, and b) more complete programme monitoring for ANC-based distribution, compared to EPI-based distribution. Opportunities for improving the distribution of LLINs through these channels exist, especially in the case of EPI. For both ANC and EPI, integrated distribution of LLINs has the potential to act as an incentive, improving the already strong coverage of both these essential services. The collection and reporting of data on LLINs distributed through the ANC and EPI can provide insight into the performance of LLIN distribution within these programmes. Greater attention to data collection and use, by both the global malaria community, and the integrated programmes, can improve

Impact of the Triglycerides to High-Density Lipoprotein Cholesterol Ratio on the Incidence and Progression of CKD: A Longitudinal Study in a Large Japanese Population.

PubMed

Tsuruya, Kazuhiko; Yoshida, Hisako; Nagata, Masaharu; Kitazono, Takanari; Iseki, Kunitoshi; Iseki, Chiho; Fujimoto, Shouichi; Konta, Tsuneo; Moriyama, Toshiki; Yamagata, Kunihiro; Narita, Ichiei; Kimura, Kenjiro; Kondo, Masahide; Asahi, Koichi; Kurahashi, Issei; Ohashi, Yasuo; Watanabe, Tsuyoshi

2015-12-01

The impact of the triglycerides to high-density lipoprotein cholesterol (TG:HDL-C) ratio on chronic kidney disease (CKD) is unclear. Longitudinal cohort study. 124,700 participants aged 39 to 74 years in the Japanese Specific Health Check and Guidance System, including 50,392 men, 74,308 women, 102,900 without CKD, and 21,800 with CKD. Quartiles of TG:HDL-C ratio. Changes in estimated glomerular filtration rate (eGFR) and urinary protein excretion during the 2-year study period. Incident CKD in participants without CKD, and progression of CKD in participants with CKD. In the entire study population, higher quartile of TG:HDL-C ratio at baseline was significantly associated with greater decline in eGFR and increase in urinary protein excretion during the 2-year study period, even after adjustment for confounding factors. A higher ratio was associated with higher risk of incident CKD in participants without CKD and higher risk of rapid decline in eGFR and increase in urinary protein excretion in participants with CKD. Higher TG:HDL-C ratio was more strongly associated with decline in eGFR (P for interaction = 0.002) and with incident CKD (P for interaction = 0.05) in participants with diabetes than without diabetes. Short observation period and single measurement of all variables. A higher TG:HDL-C ratio affects the decline in eGFR and incidence and progression of CKD in the Japanese population. Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Association between Urine Creatinine Excretion and Arterial Stiffness in Chronic Kidney Disease: Data from the KNOW-CKD Study.

PubMed

Hyun, Young Youl; Kim, Hyang; Sung, Su-Ah; Kim, Soo Wan; Chae, Dong Wan; Kim, Yong-Soo; Choi, Kyu Hun; Ahn, Curie; Lee, Kyu-Beck

2016-01-01

Previous studies have shown that low muscle mass is associated with arterial stiffness, as measured by pulse wave velocity (PWV), in a population without chronic kidney disease (CKD). This link between low muscle mass and arterial stiffness may explain why patients with CKD have poor cardiovascular outcomes. However, the association between muscle mass and arterial stiffness in CKD patients is not well known. Between 2011 and 2013, 1,529 CKD patients were enrolled in the prospective Korean Cohort Study for Outcome in Patients With Chronic Kidney Disease (KNOW-CKD). We analyzed 888 participants from this cohort who underwent measurements of 24-hr urinary creatinine excretion (UCr) and brachial-ankle PWV (baPWV) at baseline examination. The mean of the right and left baPWV (mPWV) was used as a marker of arterial stiffness. The baPWV values varied according to the UCr quartile (1,630±412, 1,544±387, 1,527±282 and 1,406±246 for the 1st to 4th quartiles of UCr, respectively, P<0.001). For each 100 mg/d increase in UCr, baPWV decreased by 6m/sec in a multivariable linear regression model fully adjusted for traditional and renal cardiovascular risk factors. The odds ratio of the 1st quartile for high baPWV (highest quintile of mPWV) compared with the 4th quartile was 2.62 (1.24-5.54, P=0.011) in a logistic model fully adjusted for traditional and renal cardiovascular risk factors. Low muscle mass estimated by low UCr was associated high baPWV in pre-dialysis CKD patients in Korea. Further studies are needed to confirm the causal relationship between UCR and baPWV, and the role of muscle mass in the development of cardiovascular disease in CKD. © 2016 The Author(s) Published by S. Karger AG, Basel.

Risk score for first-screening of prevalent undiagnosed chronic kidney disease in Peru: the CRONICAS-CKD risk score.

PubMed

Carrillo-Larco, Rodrigo M; Miranda, J Jaime; Gilman, Robert H; Medina-Lezama, Josefina; Chirinos-Pacheco, Julio A; Muñoz-Retamozo, Paola V; Smeeth, Liam; Checkley, William; Bernabe-Ortiz, Antonio

2017-11-29

Chronic Kidney Disease (CKD) represents a great burden for the patient and the health system, particularly if diagnosed at late stages. Consequently, tools to identify patients at high risk of having CKD are needed, particularly in limited-resources settings where laboratory facilities are scarce. This study aimed to develop a risk score for prevalent undiagnosed CKD using data from four settings in Peru: a complete risk score including all associated risk factors and another excluding laboratory-based variables. Cross-sectional study. We used two population-based studies: one for developing and internal validation (CRONICAS), and another (PREVENCION) for external validation. Risk factors included clinical- and laboratory-based variables, among others: sex, age, hypertension and obesity; and lipid profile, anemia and glucose metabolism. The outcome was undiagnosed CKD: eGFR < 60 ml/min/1.73m 2 . We tested the performance of the risk scores using the area under the receiver operating characteristic (ROC) curve, sensitivity, specificity, positive/negative predictive values and positive/negative likelihood ratios. Participants in both studies averaged 57.7 years old, and over 50% were females. Age, hypertension and anemia were strongly associated with undiagnosed CKD. In the external validation, at a cut-off point of 2, the complete and laboratory-free risk scores performed similarly well with a ROC area of 76.2% and 76.0%, respectively (P = 0.784). The best assessment parameter of these risk scores was their negative predictive value: 99.1% and 99.0% for the complete and laboratory-free, respectively. The developed risk scores showed a moderate performance as a screening test. People with a score of ≥ 2 points should undergo further testing to rule out CKD. Using the laboratory-free risk score is a practical approach in developing countries where laboratories are not readily available and undiagnosed CKD has significant morbidity and mortality.

Reduced Kidney Function Is Associated With Cardiometabolic Risk Factors, Prevalent and Predicted Risk of Cardiovascular Disease in Chinese Adults: Results From the REACTION Study.

PubMed

Lu, Jieli; Mu, Yiming; Su, Qing; Shi, Lixin; Liu, Chao; Zhao, Jiajun; Chen, Lulu; Li, Qiang; Yang, Tao; Yan, Li; Wan, Qin; Wu, Shengli; Liu, Yan; Wang, Guixia; Luo, Zuojie; Tang, Xulei; Chen, Gang; Huo, Yanan; Gao, Zhengnan; Ye, Zhen; Wang, Youmin; Qin, Guijun; Deng, Huacong; Yu, Xuefeng; Shen, Feixia; Chen, Li; Zhao, Liebin; Sun, Jichao; Sun, Wanwan; Wang, Tiange; Du, Rui; Lin, Lin; Dai, Meng; Xu, Yu; Xu, Min; Bi, Yufang; Lai, Shenghan; Li, Donghui; Wang, Weiqing; Ning, Guang

2016-07-22

Chronic kidney disease (CKD) increases cardiovascular disease (CVD) risk. However, the association of mildly reduced kidney function with CVD risk is unclear. This study investigated the association of estimated glomerular filtration rate (eGFR) with prevalent CVDs, 10-year Framingham risk for coronary heart disease (CHD), and 10-year risk of atherosclerotic cardiovascular diseases (ASCVD) in 239 832 participants from the baseline of the Risk Evaluation of cAncers in Chinese diabeTic Individuals: a lONgitudinal study. With an interviewer-assisted questionnaire, we collected information on CVD, including reported CHD, stroke, or myocardial infarction. Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation was used to calculate eGFR. Compared with individuals with normal eGFR (≥90 mL/min per 1.73 m(2)), those with decreased eGFR (75-89, 60-74, and <60 mL/min per 1.73 m(2)) had higher risk of prevalent obesity, diabetes mellitus, hypertension, and dyslipidemia in both men and women (P for trend all <0.001). Moreover, a significantly higher 10-year Framingham risk for CHD and 10-year risk for ASCVD was observed in both men and women with mildly decreased eGFR (60-89 mL/min per 1.73 m(2)). Even mildly reduced eGFR (under 90 mL/min per 1.73 m(2)) is associated with elevated 10-year Framingham risk for CHD and 10-year ASCVD risk among Chinese adults. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Activated Omentum Slows Progression of CKD

PubMed Central

Garcia-Gomez, Ignacio; Pancholi, Nishit; Patel, Jilpa; Gudehithlu, Krishnamurthy P.; Sethupathi, Periannan; Hart, Peter; Dunea, George; Arruda, Jose A.L.

2014-01-01

Stem cells show promise in the treatment of AKI but do not survive long term after injection. However, organ repair has been achieved by extending and attaching the omentum, a fatty tissue lying above the stomach containing stem cells, to various organs. To examine whether fusing the omentum to a subtotally nephrectomized kidney could slow the progression of CKD, we used two groups of rats: an experimental group undergoing 5/6 nephrectomy only and a control group undergoing 5/6 nephrectomy and complete omentectomy. Polydextran gel particles were administered intraperitoneally before suture only in the experimental group to facilitate the fusion of the omentum to the injured kidney. After 12 weeks, experimental rats exhibited omentum fused to the remnant kidney and had lower plasma creatinine and urea nitrogen levels; less glomerulosclerosis, tubulointerstitial injury, and extracellular matrix; and reduced thickening of basement membranes compared with controls. A fusion zone formed between the injured kidney and the omentum contained abundant stem cells expressing stem cell antigen-1, Wilms’ tumor 1 (WT-1), and CD34, suggesting active, healing tissue. Furthermore, kidney extracts from experimental rats showed increases in expression levels of growth factors involved in renal repair, the number of proliferating cells, especially at the injured edge, the number of WT-1–positive cells in the glomeruli, and WT-1 gene expression. These results suggest that contact between the omentum and injured kidney slows the progression of CKD in the remnant organ, and this effect appears to be mediated by the presence of omental stem cells and their secretory products. PMID:24627352

Relationship Between Renal Function and Physical Performance in Elderly Hospitalized Patients

PubMed Central

Lattanzio, Fabrizia; Abbatecola, Angela Marie; Volpato, Stefano; Pedone, Claudio; Pranno, Luigi; Laino, Irma; Garasto, Sabrina; Corica, Francesco; Passarino, Giuseppe; Antonelli Incalzi, Raffaele

2012-01-01

Abstract Chronic kidney disease (CKD) is increasingly recognized as a cause of worsening physical functioning in older patients. The Short Physical Performance Battery (SPPB) is highly reliable in older populations, but no data on older hospitalized patients with different degrees of kidney function are available. We aimed at testing the association between estimated glomerular filtration rate (eGFR) and SPPB, either global score (range 0–12) or its individual components (muscle strength, balance, and walking speed, each ranging from 0 to 4), in a sample of older hospitalized patients. Our series consisted of 486 patients aged 65 or more consecutively enrolled in 11 acute care medical wards participating to a multicenter observational study. eGFR was obtained by the Chronic Kidney Disease Epidemiological Collaboration (CKD-EPI) equation. Physical performance was objectively measured by the SPPB. The relationship between eGFR and SPPB was investigated by multiple linear regression analysis. Physically impaired patients (SPPB total score<5) were older, had lower serum albumin and Mini-Mental State Examination (MMSE) scores as well as higher overall co-morbidity, prevalence of stroke, cancer, and anemia compared to those with intermediate (SPPB=5–8) and good physical performance (SPPB=9–12). Fully adjusted multivariate models showed that eGFR (modeled as 10 mL/min per 1.73 m2 intervals) was independently associated with the SPPB total score (B=0.49; 95% confidence interval [CI]=0.18–0.66; p=0.003), balance (B=0.30; 95% CI=0.10–0.49; p=0.005), and muscle strength (B=0.06; 95% CI=0.01–0.10; p=0.043), but not with walking speed (B=−0.04; 95% CI=−0.09–0.11; p=0.107). In conclusion, reduced renal function is associated with poorer physical performance in older hospitalized patients. SPPB is worthy of testing to monitor changes in physical performance in elderly CKD patients. PMID:22950422

Sleep Duration and Health-Related Quality of Life in Predialysis CKD.

PubMed

Sung, Su-Ah; Hyun, Young Youl; Lee, Kyu Beck; Park, Hayne Cho; Chung, Wookyung; Kim, Yeong Hoon; Kim, Yong-Soo; Park, Sue Kyung; Oh, Kook-Hwan; Ahn, Curie

2018-06-07

Sleep duration has been associated with cardiometabolic risk and mortality. The health-related quality of life represents a patient's comprehensive perception of health and is accepted as a health outcome. We examined the relationship between sleep duration and health-related quality of life in predialysis CKD. In this cross-sectional study, data from 1910 adults with CKD enrolled in the Korean Cohort Study for Outcome in Patients with CKD were analyzed. Health-related quality of life was assessed with the physical component summary and mental component summary of the Short Form-36 Health Survey. Low health-related quality of life was defined as a Short Form-36 Health Survey score >1 SD below the mean. Using a generalized additive model and multivariable logistic regression analysis, the relationship between self-reported sleep duration and health-related quality of life was examined. Seven-hour sleepers showed the highest health-related quality of life. We found an inverted U-shaped relationship between sleep duration and health-related quality of life as analyzed by a generalized additive model. In multivariable logistic analysis, short sleepers (≤5 h/d) had lower health-related quality of life (odds ratio, 3.23; 95% confidence interval, 1.86 to 5.60 for the physical component summary; odds ratio, 2.37; 95% confidence interval, 1.43 to 3.94 for the mental component summary), and long sleepers (≥9 h/d) had lower health-related quality of life (odds ratio, 2.80; 95% confidence interval, 1.55 to 5.03 for the physical component summary; odds ratio, 2.08; 95% confidence interval, 1.20 to 3.60 for the mental component summary) compared with 7-hour sleepers. Sleep duration had a significant U-shaped association with low health-related quality of life. These findings suggest that short or long sleep duration is independently associated with low health-related quality of life in adults with CKD. Copyright © 2018 by the American Society of Nephrology.

Motion correction for functional MRI with three-dimensional hybrid radial-Cartesian EPI.

PubMed

Graedel, Nadine N; McNab, Jennifer A; Chiew, Mark; Miller, Karla L

2017-08-01

Subject motion is a major source of image degradation for functional MRI (fMRI), especially when using multishot sequences like three-dimensional (3D EPI). We present a hybrid radial-Cartesian 3D EPI trajectory enabling motion correction in k-space for functional MRI. The EPI "blades" of the 3D hybrid radial-Cartesian EPI sequence, called TURBINE, are rotated about the phase-encoding axis to fill out a cylinder in 3D k-space. Angular blades are acquired over time using a golden-angle rotation increment, allowing reconstruction at flexible temporal resolution. The self-navigating properties of the sequence are used to determine motion parameters from a high temporal-resolution navigator time series. The motion is corrected in k-space as part of the image reconstruction, and evaluated for experiments with both cued and natural motion. We demonstrate that the motion correction works robustly and that we can achieve substantial artifact reduction as well as improvement in temporal signal-to-noise ratio and fMRI activation in the presence of both severe and subtle motion. We show the potential for hybrid radial-Cartesian 3D EPI to substantially reduce artifacts for application in fMRI, especially for subject groups with significant head motion. The motion correction approach does not prolong the scan, and no extra hardware is required. Magn Reson Med 78:527-540, 2017. © 2016 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2016 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine.

Motion correction for functional MRI with three‐dimensional hybrid radial‐Cartesian EPI

PubMed Central

McNab, Jennifer A.; Chiew, Mark; Miller, Karla L.

2016-01-01

Purpose Subject motion is a major source of image degradation for functional MRI (fMRI), especially when using multishot sequences like three‐dimensional (3D EPI). We present a hybrid radial‐Cartesian 3D EPI trajectory enabling motion correction in k‐space for functional MRI. Methods The EPI “blades” of the 3D hybrid radial‐Cartesian EPI sequence, called TURBINE, are rotated about the phase‐encoding axis to fill out a cylinder in 3D k‐space. Angular blades are acquired over time using a golden‐angle rotation increment, allowing reconstruction at flexible temporal resolution. The self‐navigating properties of the sequence are used to determine motion parameters from a high temporal‐resolution navigator time series. The motion is corrected in k‐space as part of the image reconstruction, and evaluated for experiments with both cued and natural motion. Results We demonstrate that the motion correction works robustly and that we can achieve substantial artifact reduction as well as improvement in temporal signal‐to‐noise ratio and fMRI activation in the presence of both severe and subtle motion. Conclusion We show the potential for hybrid radial‐Cartesian 3D EPI to substantially reduce artifacts for application in fMRI, especially for subject groups with significant head motion. The motion correction approach does not prolong the scan, and no extra hardware is required. Magn Reson Med 78:527–540, 2017. © 2016 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. PMID:27604503

Effects of motion and b-matrix correction for high resolution DTI with short-axis PROPELLER-EPI

PubMed Central

Aksoy, Murat; Skare, Stefan; Holdsworth, Samantha; Bammer, Roland

2010-01-01

Short-axis PROPELLER-EPI (SAP-EPI) has been proven to be very effective in providing high-resolution diffusion-weighted and diffusion tensor data. The self-navigation capabilities of SAP-EPI allow one to correct for motion, phase errors, and geometric distortion. However, in the presence of patient motion, the change in the effective diffusion-encoding direction (i.e. the b-matrix) between successive PROPELLER ‘blades’ can decrease the accuracy of the estimated diffusion tensors, which might result in erroneous reconstruction of white matter tracts in the brain. In this study, we investigate the effects of alterations in the b-matrix as a result of patient motion on the example of SAP-EPI DTI and eliminate these effects by incorporating our novel single-step non-linear diffusion tensor estimation scheme into the SAP-EPI post-processing procedure. Our simulations and in-vivo studies showed that, in the presence of patient motion, correcting the b-matrix is necessary in order to get more accurate diffusion tensor and white matter pathway reconstructions. PMID:20222149

Relationship between Stage of Chronic Kidney Disease and Sarcopenia in Korean Aged 40 Years and Older Using the Korea National Health and Nutrition Examination Surveys (KNHANES IV-2, 3, and V-1, 2), 2008-2011.

PubMed

Moon, Sung Jin; Kim, Tae Ho; Yoon, Soo Young; Chung, Jae Ho; Hwang, Hee-Jin

2015-01-01

Protein-energy wasting is common in patients with end-stage kidney disease. However, few studies have examined the relationship between early stages of chronic kidney disease (CKD) and sarcopenia. We conducted a cross-sectional study based on data in the Korea National Health and Nutrition Examination Survey, 2008-2011. In total, 11,625 subjects aged 40 years or older who underwent dual-energy X-ray absorptiometry were analyzed. Sarcopenia was defined based on values of appendicular skeletal muscle mass as a percentage of body weight (ASM/Wt) two standard deviations below the gender-specific mean for young adults. Estimated glomerular filtration rates (eGFR) were calculated using the CKD-EPI equation. Mean age, body mass index (BMI), and HOMA-IR were higher and caloric intake, physical activity, and vitamin D level were lower in the sarcopenia groups in both men and women. As the stage of CKD increased, the prevalence of sarcopenia increased, even in the early stages of CKD (normal and CKD1, 2, and 3-5: 2.6%, 5.6%, and 18.1% in men and 5.3%, 7.1%, and 12.6% in women, respectively; p < 0.001). In addition, a correlation analysis showed that GFR and ASM/Wt had significant correlations in both men and women. Logistic regression analyses, after adjusting for age, BMI, caloric intake, log(physical activity), vitamin D level, and log(HOMA-IR), showed that the odds ratio for sarcopenia with respect to CKD 3-5 was 1.93 (95% CI = 1.02-3.68) in men but was not statistically significant in women. The prevalence of sarcopenia was higher in elderly Korean patients with even mildly reduced kidney function. Stage of CKD was associated with an increased prevalence of sarcopenia in men but not women. Thus, we should evaluate the risk of sarcopenia and work to prevent it, even in patients with early CKD.

Relationship between Stage of Chronic Kidney Disease and Sarcopenia in Korean Aged 40 Years and Older Using the Korea National Health and Nutrition Examination Surveys (KNHANES IV-2, 3, and V-1, 2), 2008–2011

PubMed Central

Moon, Sung Jin; Kim, Tae Ho; Yoon, Soo Young; Chung, Jae Ho; Hwang, Hee-Jin

2015-01-01

Background Protein-energy wasting is common in patients with end-stage kidney disease. However, few studies have examined the relationship between early stages of chronic kidney disease (CKD) and sarcopenia. Methods We conducted a cross-sectional study based on data in the Korea National Health and Nutrition Examination Survey, 2008–2011. In total, 11,625 subjects aged 40 years or older who underwent dual-energy X-ray absorptiometry were analyzed. Sarcopenia was defined based on values of appendicular skeletal muscle mass as a percentage of body weight (ASM/Wt) two standard deviations below the gender-specific mean for young adults. Estimated glomerular filtration rates (eGFR) were calculated using the CKD-EPI equation. Results Mean age, body mass index (BMI), and HOMA-IR were higher and caloric intake, physical activity, and vitamin D level were lower in the sarcopenia groups in both men and women. As the stage of CKD increased, the prevalence of sarcopenia increased, even in the early stages of CKD (normal and CKD1, 2, and 3-5: 2.6%, 5.6%, and 18.1% in men and 5.3%, 7.1%, and 12.6% in women, respectively; p < 0.001). In addition, a correlation analysis showed that GFR and ASM/Wt had significant correlations in both men and women. Logistic regression analyses, after adjusting for age, BMI, caloric intake, log(physical activity), vitamin D level, and log(HOMA-IR), showed that the odds ratio for sarcopenia with respect to CKD 3–5 was 1.93 (95% CI = 1.02–3.68) in men but was not statistically significant in women. Conclusions The prevalence of sarcopenia was higher in elderly Korean patients with even mildly reduced kidney function. Stage of CKD was associated with an increased prevalence of sarcopenia in men but not women. Thus, we should evaluate the risk of sarcopenia and work to prevent it, even in patients with early CKD. PMID:26083479

Effect of Genetic African Ancestry on eGFR and Kidney Disease

PubMed Central

Nadkarni, Girish N.; Belbin, Gillian; Lotay, Vaneet; Wyatt, Christina; Gottesman, Omri; Bottinger, Erwin P.; Kenny, Eimear E.; Peter, Inga

2015-01-01

Self-reported ancestry, genetically determined ancestry, and APOL1 polymorphisms are associated with variation in kidney function and related disease risk, but the relative importance of these factors remains unclear. We estimated the global proportion of African ancestry for 9048 individuals at Mount Sinai Medical Center in Manhattan (3189 African Americans, 1721 European Americans, and 4138 Hispanic/Latino Americans by self-report) using genome-wide genotype data. CKD-EPI eGFR and genotypes of three APOL1 coding variants were available. In admixed African Americans and Hispanic/Latino Americans, serum creatinine values increased as African ancestry increased (per 10% increase in African ancestry, creatinine values increased 1% in African Americans and 0.9% in Hispanic/Latino Americans; P≤1x10−7). eGFR was likewise significantly associated with African genetic ancestry in both populations. In contrast, APOL1 risk haplotypes were significantly associated with CKD, eGFR<45 ml/min per 1.73 m2, and ESRD, with effects increasing with worsening disease states and the contribution of genetic African ancestry decreasing in parallel. Using genetic ancestry in the eGFR equation to reclassify patients as black on the basis of ≥50% African ancestry resulted in higher eGFR for 14.7% of Hispanic/Latino Americans and lower eGFR for 4.1% of African Americans, affecting CKD staging in 4.3% and 1% of participants, respectively. Reclassified individuals had electrolyte values consistent with their newly assigned CKD stage. In summary, proportion of African ancestry was significantly associated with normal-range creatinine and eGFR, whereas APOL1 risk haplotypes drove the associations with CKD. Recalculation of eGFR on the basis of genetic ancestry affected CKD staging and warrants additional investigation. PMID:25349204

Epi proColon® 2.0 CE: A Blood-Based Screening Test for Colorectal Cancer.

PubMed

Lamb, Yvette N; Dhillon, Sohita

2017-04-01

Epi proColon ® 2.0 CE is a blood-based test designed to aid in the early detection of colorectal cancer. The test comprises a qualitative assay for the polymerase chain reaction (PCR) detection of methylated Septin9 DNA, the presence of which is associated with colorectal cancer: however, positive results should be verified by colonoscopy or sigmoidoscopy. Epi proColon ® 2.0 CE discriminated between patients with colorectal cancer and healthy controls with high clinical sensitivity and specificity in pivotal case-control studies. The sensitivity of the test did not appear to be affected by the tumour location or by patient age or gender. In addition, limited data suggest that Epi proColon ® 2.0 CE discriminated between patients with colorectal cancer and healthy controls with higher sensitivity and generally similar specificity to that of the faecal immunochemical test, and with higher sensitivity and specificity to that of the guaiac-based faecal occult blood test (statistical data not available). In an observational study, most patients who refused colonoscopy for screening accepted a non-invasive test option as an alternative, and preferred Epi proColon ® 2.0 CE over a stool-based test. Large prospective trials of Epi proColon ® 2.0 CE in a screening setting will be required to further elucidate the cost-effectiveness of the test. Nevertheless, currently available data suggests that Epi proColon ® 2.0 CE has the potential to be a sensitive and convenient screening option for patients refusing screening by colonoscopy.

Development of a single-frequency bioimpedance prediction equation for fat-free mass in an adult Indigenous Australian population.

PubMed

Hughes, J T; Maple-Brown, L J; Piers, L S; Meerkin, J; O'Dea, K; Ward, L C

2015-01-01

To describe the development of a single-frequency bioimpedance prediction equation for fat-free mass (FFM) suitable for adult Aboriginal and Torres Strait Islander peoples with and without diabetes or indicators of chronic kidney disease (CKD). FFM was measured by whole-body dual-energy X-ray absorptiometry in 147 adult Indigenous Australians. Height, weight, body circumference and resistance were also measured. Adults with and without diabetes and indicators of CKD were examined. A random split sample with internal cross-validation approach was used to predict and subsequently validate FFM using resistance, height, weight, age and gender against measured FFM. Among 147 adults with a median body mass index of 31 kg/m(2), the final model of FFM was FFM (kg)=0.432 (height, cm(2)/resistance, ohm)-0.086 (age, years)+0.269 (weight, kg)-6.422 (if female)+16.429. Adjusted R(2) was 0.94 and the root mean square error was 3.33 kg. The concordance was high (rc=0.97) between measured and predicted FFM across a wide range of FFM (31-85 kg). In the context of the high burden of diabetes and CKD among adult Indigenous Australians, this new equation for FFM was both accurate and precise and based on easily acquired variables (height, weight, age, gender and resistance) among a heterogeneous adult cohort.

Biomarkers of Cardiovascular Disease and Mortality Risk in Patients with Advanced CKD

PubMed Central

Sun, Jia; Axelsson, Jonas; Machowska, Anna; Heimbürger, Olof; Bárány, Peter; Lindholm, Bengt; Lindström, Karin; Stenvinkel, Peter

2016-01-01

Background and objectives The high risk of cardiovascular disease (CVD) and premature death in patients with CKD associates with a plethora of elevated circulating biomarkers that may reflect distinct signaling pathways or simply, are epiphenomena of CKD. We compared the predictive strength of 12 biomarkers analyzed concomitantly in patients with stage 5 CKD. Design, setting, participants, & measurements From 1994 to 2014, 543 patients with stage 5 CKD (median age =56 years old; 63% men; 199 patients had CVD) took part in our study on malnutrition, inflammation, and CVD in incident dialysis patients. Circulating levels of albumin, ferritin, high–sensitivity C–reactive protein (hsCRP), IGF-1, IL-6, orosomucoid, troponin T (TnT), TNF, soluble intracellular adhesion molecule, soluble vascular cellular adhesion molecule 1 (sVCAM-1), and platelet and white blood cell (WBC) counts were analyzed as predictors of the presence of clinically overt CVD at baseline, protein-energy wasting (PEW), and subsequent all–cause mortality. During follow-up for a median of 28 months, there were 149 deaths, 81 of which were caused by CVD. Results Most biomarkers were elevated compared with reference values and–—except for albumin, ferritin, and IGF-1—higher in patients with CVD. In receiver operating characteristic analysis, age, IL-6, TnT, hsCRP, and IGF-1 were classifiers of baseline CVD and predictors of all-cause mortality. In addition to age, diabetes mellitus, smoking (for CVD), and PEW, only IL-6, relative risk (RR) 1.10 and 95% confidence interval ([95% CI], 1.02 to 1.19), sVCAM-1 RR 1.09 (95% CI, 1.01 to 1.17), and serum albumin RR 0.89 (95% CI, 0.83 to 0.95) associated with baseline CVD, and only WBC, hazard ratio (HR) 1.94 (95% CI, 1.34 to 2.82), IL-6 HR 1.79 (95% CI, 1.20 to 2.67), and TNF HR 0.65 (95% CI, 0.44 to 0.97) predicted all-cause mortality. Conclusions In addition to age and comorbidities, only IL-6, sVCAM-1, and albumin could—independently of other

Prevalence and Correlates of Fatigue in CKD and ESRD: Are Sleep Disorders a Key to Understanding Fatigue?

PubMed Central

Jhamb, Manisha; Liang, Kelly; Yabes, Jonathan; Steel, Jennifer L; Dew, Mary Amanda; Shah, Nirav; Unruh, Mark

2014-01-01

Background Fatigue is an important symptom to patients with advanced CKD. The aim of this study is to examine the prevalence and severity of fatigue among non-dialysis dependent CKD and ESRD patients; examine association of fatigue with subjective and objective sleep quality; identify other modifiable factors associated with fatigue. Methods Cross-sectional survey of 87 non-dialysis dependent CKD (eGFR ≤45 ml/min/1.73 m2) and 86 ESRD patients was done using Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F) and SF-36 vitality scale. Higher FACIT-F score denoted less fatigue. Objective sleep was assessed using in-home polysomnography. Predictors of fatigue were determined using linear regression model. Results Mean FACIT-F score among all participants was 34.5±11.0. Mean scores were similar among CKD and ESRD groups (34.25±11.28 versus 34.73±10.86; p=0.73). On univariate analyses, patients with higher levels of fatigue were more likely to have cardiovascular disease, benzodiazepine use, depressive symptoms, slightly lower hemoglobin and serum albumin levels. There was no significant association between severity of sleep apnea and level of fatigue (Apnea Hypopnea Index 20.1±27.6 versus 20.3±22.0; p=0.69). Presence of cardiovascular disease, low serum albumin, depressive symptoms, poor subjective sleep quality, excessive daytime sleepiness and restless legs syndrome (RLS) were independently associated with greater fatigue in multivariable regression models. The FACIT-F score correlated closely with the SF-36 vitality score (r =0.81, p<0.0001). Conclusions Patients with advanced CKD and ESRD experience profound fatigue. Depressive symptoms, RLS, excessive daytime sleepiness, and low albumin levels may provide targets for interventions to improve fatigue in patients with advanced CKD. PMID:24335380

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

CKD of Uncertain Etiology: A Systematic Review

PubMed Central

Mohottige, Dinushika; Isenburg, Megan Von; Jeuland, Marc; Patel, Uptal D.; Stanifer, John W.

2016-01-01

Background and objectives Epidemics of CKD of uncertain etiology (CKDu) are emerging around the world. Highlighting common risk factors for CKD of uncertain etiology across various regions and populations may be important for health policy and public health responses. Design, setting, participants, & measurements We searched PubMed, Embase, Scopus and Web of Science databases to identify published studies on CKDu. The search was generated in January of 2015; no language or date limits were used. We used a vote-counting method to evaluate exposures across all studies. Results We identified 1607 articles, of which 26 met inclusion criteria. Eighteen (69%) were conducted in known CKDu–endemic countries: Sri Lanka (38%), Nicaragua (19%), and El Salvador (12%). The other studies were from India, Japan, Australia, Mexico, Sweden, Tunisia, Tanzania, and the United States. Heavy metals, heat stress, and dietary exposures were reported across all geographic regions. In south Asia, family history, agrochemical use, and heavy metal exposures were reported most frequently, whereas altitude and temperature were reported only in studies from Central America. Across all regions, CKDu was most frequently associated with a family history of CKDu, agricultural occupation, men, middle age, snake bite, and heavy metal exposure. Conclusions Studies examining etiologies of CKDu have reported many exposures that are heterogeneous and vary by region. To identify etiologies of CKDu, designing consistent and comparative multisite studies across high-risk populations may help elucidate the importance of region–specific versus global risk factors. PMID:26712810

CKD of Uncertain Etiology: A Systematic Review.

PubMed

Lunyera, Joseph; Mohottige, Dinushika; Von Isenburg, Megan; Jeuland, Marc; Patel, Uptal D; Stanifer, John W

2016-03-07

Epidemics of CKD of uncertain etiology (CKDu) are emerging around the world. Highlighting common risk factors for CKD of uncertain etiology across various regions and populations may be important for health policy and public health responses. We searched PubMed, Embase, Scopus and Web of Science databases to identify published studies on CKDu. The search was generated in January of 2015; no language or date limits were used. We used a vote-counting method to evaluate exposures across all studies. We identified 1607 articles, of which 26 met inclusion criteria. Eighteen (69%) were conducted in known CKDu-endemic countries: Sri Lanka (38%), Nicaragua (19%), and El Salvador (12%). The other studies were from India, Japan, Australia, Mexico, Sweden, Tunisia, Tanzania, and the United States. Heavy metals, heat stress, and dietary exposures were reported across all geographic regions. In south Asia, family history, agrochemical use, and heavy metal exposures were reported most frequently, whereas altitude and temperature were reported only in studies from Central America. Across all regions, CKDu was most frequently associated with a family history of CKDu, agricultural occupation, men, middle age, snake bite, and heavy metal exposure. Studies examining etiologies of CKDu have reported many exposures that are heterogeneous and vary by region. To identify etiologies of CKDu, designing consistent and comparative multisite studies across high-risk populations may help elucidate the importance of region-specific versus global risk factors. Copyright © 2016 by the American Society of Nephrology.

Making an IMPAKT; Improving care of Chronic Kidney Disease patients in the community through collaborative working and utilizing Information Technology.

PubMed

Xu, Gang; Major, Rupert; Shepherd, David; Brunskill, Nigel

2017-01-01

efficient working by targeting of high-risk groups, and improved communication between primary/secondary care. The project could be adapted for other chronic disease conditions. Despite the recorded improvements in blood pressure management, a large proportion of high-risk patients remained above ideal blood pressure, additional interventions in this area need to be explored. Through collaborative and multi-professional working and utilizing IT resources, we have shown it is possible to deliver measurable and sustainable improvements in blood pressure control for patients with CKD in a real life clinical setting.

Intralaboratory and interlaboratory evaluation of the EpiDerm 3D human reconstructed skin micronucleus (RSMN) assay.

PubMed

Hu, Ting; Kaluzhny, Yulia; Mun, Greg C; Barnett, Brenda; Karetsky, Viktor; Wilt, Nathan; Klausner, Mitchell; Curren, Rodger D; Aardema, Marilyn J

2009-03-17

A novel in vitro human reconstructed skin micronucleus (RSMN) assay has been developed using the EpiDerm 3D human skin model [R. D. Curren, G. C. Mun, D. P. Gibson, and M. J. Aardema, Development of a method for assessing micronucleus induction in a 3D human skin model EpiDerm, Mutat. Res. 607 (2006) 192-204]. The RSMN assay has potential use in genotoxicity assessments as a replacement for in vivo genotoxicity assays that will be banned starting in 2009 according to the EU 7th Amendment to the Cosmetics Directive. Utilizing EpiDerm tissues reconstructed with cells from four different donors, intralaboratory and interlaboratory reproducibility of the RSMN assay were examined. Seven chemicals were evaluated in three laboratories using a standard protocol. Each chemical was evaluated in at least two laboratories and in EpiDerm tissues from at least two different donors. Three model genotoxins, mitomycin C (MMC), vinblastine sulfate (VB) and methyl methanesulfonate (MMS) induced significant, dose-related increases in cytotoxicity and MN induction in EpiDerm tissues. Conversely, four dermal non-carcinogens, 4-nitrophenol (4-NP), trichloroethylene (TCE), 2-ethyl-1,3-hexanediol (EHD), and 1,2-epoxydodecane (EDD) were negative in the RSMN assay. Results between tissues reconstructed from different donors were comparable. These results indicate the RSMN assay using the EpiDerm 3D human skin model is a promising new in vitro genotoxicity assay that allows evaluation of chromosome damage following "in vivo-like" dermal exposures.

Montreal Cognitive Assessment (MoCA) screening mild cognitive impairment in patients with chronic kidney disease (CKD) pre-dialysis.

PubMed

Paraizo, Marilise de Andrade; Almeida, Ana Laura Maciel; Pires, Leopoldo Antônio; Abrita, Renata Silva Almeida; Crivellari, Mary Hellen Teixeira; Pereira, Beatriz Dos Santos; Fernandes, Natália Maria da Silva; Bastos, Marcus Gomes

2016-03-01

Individuals with chronic kidney disease (CKD) are at higher risk of developing cognitive impairment (CI), initially mild (MCI), potentially identifiable, but still poorly diagnosed and treated. The Montreal Cognitive Assessment (MoCA) has been indicated for MCI screening in CKD. To assess MCI in patients with CKD not yet on dialysis. Study conducted in 72 non-elderly subjects with pre-dialysis CKD. The neuropsychological assessment included: The global cognitive assessment test MoCA; the clock drawing (CD); the digit span forward (DSF) and reverse (DSR); phonemic verbal (VF) fluency (FAS) and semantics (animals); the fist-edge-palm (FEP); and the memory 10 pictures. The average age of the participants was 56.74 ± 7.63 years, with predominance of male sex (55.6%), mainly with ≥ 4 years of education (84.3%), with CKD cathegories 1, 2 and 3a and 3b (67.6%), hypertension (93.1%) and diabetes mellitus (52.1%). MCI (MoCA ≤ 24) was observed in 73.6% of the patients. We did not find association among MCI with demographic and clinical variables, but a tendency to association with age (p = 0.07), educational level (p= 0.06) and diabetes (0.06). The executive function tests CD, DS-reverse and FEP, individually were able to identify CI with good sensibility and negative predictive value compared to MoCA and together, showed the same capability to identify MCI when compared to MoCA. The MCI is common in non-elderly patients with CKD not yet on dialysis. Together, the CD, DSR and FEP showed similar performance in identify MCI in this population when compared to MoCA, suggesting impairment of executive functions.

High Dietary Acid Load Predicts ESRD among Adults with CKD

PubMed Central

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

2015-01-01

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

CKD-516 displays vascular disrupting properties and enhances anti-tumor activity in combination with chemotherapy in a murine tumor model.

PubMed

Moon, Chang Hoon; Lee, Seung Ju; Lee, Ho Yong; Dung, Le Thi Kim; Cho, Wha Ja; Cha, HeeJeong; Park, Jeong Woo; Min, Young Joo

2014-06-01

CKD-516 is a benzophenone analog in which the B ring is modified by replacement with a carbonyl group. The study assessed CKD-516 as a vascular disrupting agent or anti-cancer drug. To assess the effect of S516 on vascularization, we analyzed the effect on human umbilical vein endothelial cells (HUVECs). To determine the inhibition of cell proliferation of S516, we used H460 lung carcinoma cells. The alteration of microtubules was analyzed using immunoblot, RT-PCR and confocal imaging. To evaluate the anti-tumor effects of gemcitabine and/or CKD-516, H460 xenograft mice were treated with CKD-516 (2.5 mg/kg) and/or gemcitabine (40 mg/kg), and tumor growth was compared with vehicle-treated control. For histologic analysis, liver, spleen and tumor tissues from H460 xenograft mice were obtained 12 and 24 h after CKD-516 injection. Cytoskeletal changes of HUVECs treated with 10 nM S516 were assessed by immunoblot and confocal imaging. S516 disrupted tubulin assembly and resulted in microtubule dysfunction, which induced cell cycle arrest (G2/M). S516 markedly enhanced the depolymerization of microtubules, perhaps due to the vascular disrupting properties of S516. Interestingly, S516 decreased the amount of total tubulin protein in HUVECs. Especially, S516 decreased mRNA expression α-tubulin (HUVECs only) and β-tubulin (HUVECs and H460 cells) at an early time point (4 h). Immunocytochemical analysis showed that S516 changed the cellular microtubule network and inhibited the formation of polymerized microtubules. Extensive central necrosis of tumors was evident by 12 h after treatment with CKD-516 (2.5 mg/kg, i.p.). In H460 xenografts, CKD-516 combined with gemcitabine significantly delayed tumor growth up to 57 % and 36 % as compared to control and gemcitabine alone, respectively. CKD-516 is a novel agent with vascular disrupting properties and enhances anti-tumor activity in combination with chemotherapy.

Does Ramadan Fasting Affect Hydration Status and Kidney Function in CKD Patients?

PubMed

Hassan, Shadia; Hassan, Fadi; Abbas, Nur; Hassan, Kamal; Khatib, Nihal; Edgim, Rabia; Fadol, Rawia; Khazim, Khaled

2018-01-01

This study is the first of its kind to examine the impact of the Ramadan fasting on hydration status, plasma brain natriuretic peptide (BNP) levels, and kidney function in chronic kidney disease (CKD) patient. This prospective cohort study included 2 groups of patients with CKD grades 2-4: thirty-one Muslim patients who fasted the month of Ramadan (fasting group) and 26 Muslim patients who did not fast (control group). One week before the Ramadan fast, in the last week of the month of Ramadan (4 weeks), and 4 weeks after the end of the Ramadan month (8 weeks), hydration status and blood analysis of urea, creatinine and BNP levels were measured. Among fasting patients, serum urea levels increased significantly (p = 0.024) during the last week of fasting and returned to basal levels at 4 weeks after the end of the Ramadan month, the estimated glomerular filtration rate did not change significantly at the end of fasting (p = 0.411), the hydration status indices and plasma BNP levels were significantly decreased after fasting (p ≤ 0.021) but returned to basal values 4 weeks thereafter. Patients with CKD grades 2-4 can fast throughout the month of Ramadan with no significant deterioration of renal functions and with a reasonable degree of safety. © 2018 S. Karger AG, Basel.

Effect of picric acid and enzymatic creatinine on the efficiency of the glomerular filtration rate predicator formula.

PubMed

Qiu, Ling; Guo, Xiuzhi; Zhu, Yan; Shou, Weilin; Gong, Mengchun; Zhang, Lin; Han, Huijuan; Quan, Guoqiang; Xu, Tao; Li, Hang; Li, Xuewang

2013-01-01

To investigate the impact of serum creatinine measurement on the applicability of glomerular filtration rate (GFR) evaluation equations. 99mTc-DTPA plasma clearance rate was used as GFR reference (rGFR) in patients with chronic kidney disease (CKD). Serum creatinine was measureded using enzymatic or picric acid creatinine reagent. The GFR of the patients were estimated using the Cockcroft-Gault equation corrected for body surface area, simplified Modification of Diet in Renal Disease (MDRD) equation, simplified MDRD equation corrected to isotopes dilution mass spectrometry, the CKD epidemiology collaborative research equation, and two Chinese simplified MDRD equations. Significant differences in the eGFR results estimated through enzymatic and picric acid methods were observed for the same evaluation equation. The intraclass correlation coefficient (ICC) of eGFR when the creatinine was measured by the picric acid method was significantly lower than that of the enzymatic method. The assessment accuracy of every equation using the enzymatic method to measure creatinine was significantly higher than that measured by the picric acid method when rGFR was > or = 60 mL/min/1.73m2. A significant difference was demonstrated in the same GFR evaluation equation using the picric acid and enzymatic methods. The enzymatic creatinine method was better than the picric acid method.

Soluble Urokinase-Type Plasminogen Activator Receptor in Black Americans with CKD.

PubMed

Luo, Shengyuan; Coresh, Josef; Tin, Adrienne; Rebholz, Casey M; Chen, Teresa K; Hayek, Salim S; Tracy, Melissa; Lipkowitz, Michael S; Appel, Lawrence J; Levey, Andrew S; Inker, Lesley A; Reiser, Jochen; Grams, Morgan Erika

2018-06-14

Black Americans with and without APOL1 kidney disease risk variants face high risk of ESKD. Soluble urokinase-type plasminogen activator receptor (suPAR), a circulating signaling protein and marker of immune activation, constitutes a promising biomarker of CKD-associated risks. We aimed to quantify the associations between serum suPAR concentration and adverse outcomes in Black Americans with and without APOL1 kidney disease risk variants, over and above iodine-125 iothalamate measured GFR and proteinuria. Using data from the African-American Study of Kidney Disease and Hypertension, a multicenter clinical trial followed by a cohort phase with a median total follow-up of 9.7 years (interquartile range, 6.5-10.9 years), we examined the associations of suPAR with CKD progression (defined as doubling of serum creatinine or ESKD), ESKD, worsening proteinuria (defined as pre-ESKD doubling of 24-hour urine protein-to-creatinine ratio to ≥220 mg/g), and all-cause death. At baseline, the median suPAR was 4462 pg/ml, mean measured GFR was 46 ml/min per 1.73 m 2 , and median 24-hour urine protein-to-creatinine ratio was 80 mg/g. After controlling for baseline demographics, randomization arm, GFR, proteinuria, APOL1 risk status, and clinical risk factors, there was a 1.26-times higher risk for CKD progression per SD higher baseline log-transformed suPAR (hazard ratio [HR], 1.26; 95% confidence interval [95% CI], 1.11 to 1.43; P <0.001). Higher suPAR was also independently associated with risk of ESKD (HR, 1.36; 95% CI, 1.17 to 1.58; P <0.001) and death (HR, 1.25; 95% CI, 1.08 to 1.45; P =0.003). suPAR was only associated with worsening proteinuria in patients with two APOLI risk alleles (HR, 1.46; 95% CI, 1.08 to 1.99; P =0.02). Higher suPAR was associated with various adverse outcomes in Black Americans with CKD, with and without APOL1 kidney disease risk variants, independently of proteinuria and GFR. Copyright © 2018 by the American Society of Nephrology.

Prospective randomised multicentre trial with the birth trainer EPI-NO for the prevention of perineal trauma.

PubMed

Ruckhäberle, Eugen; Jundt, Katharina; Bäuerle, Martin; Brisch, Karl-Heinz; Ulm, Kurt; Dannecker, Christian; Schneider, Karl Theo Mario

2009-10-01

In several non-randomised trials training with EPI-NO increased the rate of intact perineum and decreased episiotomy rates, shortened the second stage of labour and lowered use of pain killers. To verify the preliminary results with EPI-NO in a prospective randomised trial. Randomised, single-blind multicentre trial in four university hospitals in Germany including 276 primigravidae. After training with EPI-NO we observed a significant increase in the incidence of intact perineum (37.4% vs 25.7%; P = 0.05) and a tendency towards lower episiotomy rates (41.9% vs 50.5%; P = 0.11). We found no significant differences between the two groups regarding incidence of perineal tears, duration of second stage of labour, use of pain relief and rate of vaginal infection. Training with EPI-NO increases significantly the likelihood of having an intact perineum and reduces the episiotomy rate.

Antepartum use of Epi-No birth trainer for preventing perineal trauma: systematic review.

PubMed

Brito, Luiz Gustavo Oliveira; Ferreira, Cristine Homsi Jorge; Duarte, Geraldo; Nogueira, Antonio Alberto; Marcolin, Alessandra Cristina

2015-10-01

In this systematic review we aimed to assess if the Epi-No birth trainer used during antepartum could prevent perineal trauma in nulliparous women. We searched CENTRAL, MEDLINE, EMBASE, Scielo, and Conference abstracts, looking for randomized controlled studies (RCT). High heterogeneity (i(2) > 50 %) was corrected with random models. All studies were analyzed according to their quality and risk of bias. Nulliparous women or women whose previous pregnancy ended before 21 weeks' gestation were included and the main outcome measures were: episiotomy rates, perineal tears, severe (3rd/4th) perineal tears, and intact perineum. Five studies were included (1,369 participants) for systematic review and two of them (932 participants) were eligible for meta-analysis. Epi-No did not reduce episiotomy rates (RR 0.92 [95%CI 0.75-1.13], n = 710, p =0.44; two studies; fixed model) and second stage of labor (MD -12.50 [95%CI -29.62, -4.62], n = 162, p = 0.54; one study; fixed model), and did not increase intact perineum (RR 1.15 [95 % CI 0.81-1.64], n = 705, p = 0.43; two studies; random model). No influence of Epi-No on reducing all perineal tears (RR 0.99 [95%CI 0.84-1.17], n = 705, p = 0.93, two studies; fixed model) or severe (3rd/4th) perineal tears (RR 1.31 [95%CI 0.72-2.37], n = 705, p = 0.38, two studies; fixed model). Mean birthweight of the Epi-No group was higher than that of the control group in both studies, with no statistical significance. Epi-No birth trainer is a device that did not reduce episiotomy rates and had no influence on reducing perineal tears.

The effect of some medications given to CKD patients on vitamin D levels.

PubMed

Yuste, Claudia; Quiroga, Borja; de Vinuesa, Soledad García; Goicoechea, Maria Angeles; Barraca, Daniel; Verdalles, Ursula; Luño, Jose

2015-01-01

Vitamin D deficiency and polypharmacy is a common problem over chronic kidney disease (CKD) population. To assess the clinical and analytical characteristics of CKD patients with 25-OH-D3 deficiency (<15 ng/mL), including the possible role of associated drugs. A single center observational review of 137 incident patients referred to our outpatient clinic with different stages of CKD and 25-OH-D3<15ng/mL (male gender 53.3%, mean age 70.8 [±16.1] years, mean GFR (MDRD-4) 43.6 [±25.5] ml/min/1.73 m²). 25-OH-D3 levels were collected in spring. Clinical and biochemical data and associated medications were recorded. Mean 25-OH-D3 levels were 8.23 [±4.03] ng/ml. Eighty-eight patients (64.7%) had 3 or more concomitant drugs. Only 7 patients (5.1%) were not receiving any medication. Patients were divided in three groups according the therapies into none (n=26), RAS inhibitors or allopurinol (n=81), and RAS inhibitors plus allopurinol (n=30); with the aim to study the influence of statin therapy. Patients under renin angiotensin (RAS) inhibitors or Allopurinol treatment presented significantly higher 25-OH-D3 levels (p=0.001 and p=0.01 respectively), however patients with Statins treatment had lower 25-OH-D3 level (p=0.039). Personal history of diabetes, cardiovascular events or other therapies did not modify 25-OH-D3 levels, adjusted by age and eGFR. CKD patients with vitamin D deficiency who received RAS inhibitors or Allopurinol treatment had higher 25-OH-D3 levels, however those with statins treatment had lower vitamin D levels. Randomized controlled trials are required to confirm these findings. Copyright © 2015. Published by Elsevier España, S.L.U.

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. Published by Elsevier Inc.

The EpiNo® Device: Efficacy, Tolerability, and Impact on Pelvic Floor—Implications for Future Research

PubMed Central

Kavvadias, Tilemachos; Hoesli, Irene

2016-01-01

Aims. The aim of this review is to provide a comprehensive overview of the available literature on preventing perineal trauma with the EpiNo. Methods. We perfomed a literature research in the MedLine and EMBASE databases for studies referring to EpiNo published between 1990 and 2014, without restrictions for language and study type. Results. Five published studies were identified, regarding the effect of EpiNo on the rate of episiotomy and perineal tears, pelvic floor muscle function, and fetal outcome. The device seems to reduce episiotomy and perineal tears' rate, as well as the risk for levator ani microtrauma and avulsion, though not always statistically significant. It does not seem to have an effect on duration of second stage of labour and fetal outcome. The device is well tolerated and the adverse events are rare and mild. However, design and reporting bias in the reviewed articles do not allow evidence based conclusions. Conclusions. The EpiNo device seems to be promising, with potential positive effects on natural birth, while being uncomplicated to use and without major complications. Well designed, randomized trials are needed in order to understand the effects of EpiNo on pelvic floor and make evidence based recommendations on its use. PMID:26981126

Multinational assessment of accuracy of equations for predicting risk of kidney failure: a meta-analysis

PubMed Central

Tangri, Navdeep; Grams, Morgan E.; Levey, Andrew S.; Coresh, Josef; Appel, Lawrence; Astor, Brad C.; Chodick, Gabriel; Collins, Allan J.; Djurdjev, Ognjenka; Elley, C. Raina; Evans, Marie; Garg, Amit X.; Hallan, Stein I.; Inker, Lesley; Ito, Sadayoshi; Jee, Sun Ha; Kovesdy, Csaba P.; Kronenberg, Florian; Lambers Heerspink, Hiddo J.; Marks, Angharad; Nadkarni, Girish N.; Navaneethan, Sankar D.; Nelson, Robert G.; Titze, Stephanie; Sarnak, Mark J.; Stengel, Benedicte; Woodward, Mark; Iseki, Kunitoshi

2016-01-01

Importance Identifying patients at risk of chronic kidney disease (CKD) progression may facilitate more optimal nephrology care. Kidney failure risk equations (KFREs) were previously developed and validated in two Canadian cohorts. Validation in other regions and in CKD populations not under the care of a nephrologist is needed. Objective To evaluate the accuracy of the KFREs across different geographic regions and patient populations through individual-participant data meta-analysis. Data Sources Thirty-one cohorts, including 721,357 participants with CKD Stages 3–5 in over 30 countries spanning 4 continents, were studied. These cohorts collected data from 1982 through 2014. Study Selection Cohorts participating in the CKD Prognosis Consortium with data on end-stage renal disease. Data Extraction and Synthesis Data were obtained and statistical analyses were performed between July 2012 and June 2015. Using the risk factors from the original KFREs, cohort-specific hazard ratios were estimated, and combined in meta-analysis to form new “pooled” KFREs. Original and pooled equation performance was compared, and the need for regional calibration factors was assessed. Main Outcome and Measure Kidney failure (treatment by dialysis or kidney transplantation). Results During a median follow-up of 4 years, 23,829 cases of kidney failure were observed. The original KFREs achieved excellent discrimination (ability to differentiate those who developed kidney failure from those who did not) across all cohorts (overall C statistic, 0.90 (95% CI 0.89–0.92) at 2 years and 0.88 (95% CI 0.86–0.90) at 5 years); discrimination in subgroups by age, race, and diabetes status was similar. There was no improvement with the pooled equations. Calibration (the difference between observed and predicted risk) was adequate in North American cohorts, but the original KFREs overestimated risk in some non-North American cohorts. Addition of a calibration factor that lowered the baseline

Assessing physical function and physical activity in patients with CKD.

PubMed

Painter, Patricia; Marcus, Robin L

2013-05-01

Patients with CKD are characterized by low levels of physical functioning, which, along with low physical activity, predict poor outcomes in those treated with dialysis. The hallmark of clinical care in geriatric practice and geriatric research is the orientation to and assessment of physical function and functional limitations. Although there is increasing interest in physical function and physical activity in patients with CKD, the nephrology field has not focused on this aspect of care. This paper provides an in-depth review of the measurement of physical function and physical activity. It focuses on physiologic impairments and physical performance limitations (impaired mobility and functional limitations). The review is based on established frameworks of physical impairment and functional limitations that have guided research in physical function in the aging population. Definitions and measures for physiologic impairments, physical performance limitations, self-reported function, and physical activity are presented. On the basis of the information presented, recommendations for incorporating routine assessment of physical function and encouragement for physical activity in clinical care are provided.

Roles of epi-anecic taxa of earthworms in the organic matter recycling

NASA Astrophysics Data System (ADS)

Hoeffner, Kevin; Monard, Cécile; Santonja, Mathieu; Pérès, Guénola; Cluzeau, Daniel

2017-04-01

Given their impact on soil functioning and their interactions with soil organisms, earthworms contribute to the recycling of organic matter and participate significantly in the numerous ecosystem services provided by soils. Most studies on the role of earthworms in organic matter recycling were conducted at the level of the four functional groups (epigeic, epi-anecic, anecic strict and endogeic), but their effects at taxa level remain largely unknown. Still, within a functional group, anatomic and physiologic earthworm taxa traits are different, which should impact organic matter recycling. This study aims at determining, under controlled conditions, epi-anecic taxa differences in (i) leaf litter mass loss, (ii) assimilation and (iii) impact on microorganisms communities implied in organic matter degradation. In seperate microcosms, we chose 4 epi anecic taxa (Lumbricus rubellus, Lumbricus festivus, Lumbricus centralis and Lumbricus terrestris). Each taxon was exposed separately to leaves of three different plants (Holcus lanatus, Lolium perenne and Corylus avellana). In the same microcosm, leaves of each plant was both placed on the surface and buried 10cm deep. The experiment lasted 10 days for half of the samples and 20 days for the second half. Microorganisms communities were analysed using TRFLP in each earthworm taxon burrow walls at 20 days. We observed differences between epi-anecic taxa depending on species of plant and the duration of the experiment. Results are discussed taking into account physical and chemical properties of these 3 trophic resources (e.g. C/N ratio, phenolic compounds, percentage of lignin and cellulose...).

Q-ball imaging with PROPELLER EPI acquisition.

PubMed

Chou, Ming-Chung; Huang, Teng-Yi; Chung, Hsiao-Wen; Hsieh, Tsyh-Jyi; Chang, Hing-Chiu; Chen, Cheng-Yu

2013-12-01

Q-ball imaging (QBI) is an imaging technique that is capable of resolving intravoxel fiber crossings; however, the signal readout based on echo-planar imaging (EPI) introduces geometric distortions in the presence of susceptibility gradients. This study proposes an imaging technique that reduces susceptibility distortions in QBI by short-axis PROPELLER EPI acquisition. Conventional QBI and PROPELLER QBI data were acquired from two 3T MR scans of the brains of five healthy subjects. Prior to the PROPELLER reconstruction, residual distortions in single-blade low-resolution b0 and diffusion-weighted images (DWIs) were minimized by linear affine and nonlinear diffeomorphic demon registrations. Subsequently, the PROPELLER keyhole reconstruction was applied to the corrected DWIs to obtain high-resolution PROPELLER DWIs. The generalized fractional anisotropy and orientation distribution function maps contained fewer distortions in PROPELLER QBI than in conventional QBI, and the fiber tracts more closely matched the brain anatomy depicted by turbo spin-echo (TSE) T2-weighted imaging (T2WI). Furthermore, for fixed T(E), PROPELLER QBI enabled a shorter scan time than conventional QBI. We conclude that PROPELLER QBI can reduce susceptibility distortions without lengthening the acquisition time and is suitable for tracing neuronal fiber tracts in the human brain. Copyright © 2013 John Wiley & Sons, Ltd.

Managing chronic inflammation in the aging diabetic patient with CKD by diet or sevelamer carbonate: a modern paradigm shift.

PubMed

Vlassara, H; Cai, W; Chen, X; Serrano, E J; Shobha, M S; Uribarri, J; Woodward, M; Striker, G E

2012-12-01

The maintenance of normal metabolism and body defenses depends on the balance between cellular antioxidant and anti-inflammatory factors. This balance can be disrupted by agents/mechanisms in the extracellular milieu that induce excess reactive oxygen species (ROS) and inflammation. Cytopathic advanced glycation endproducts, present in ever increasing amounts in the modern diet, are one of the major environmental factors that cause excess ROS and/or inflammation at all ages and induce complications in aging, such as chronic kidney disease (CKD) and type 2 diabetes. Increased ROS and/or inflammation are present in both aging and CKD, and are associated with reduced cellular defenses against ROS and/or inflammation. Affected individuals have reduced defenses against further stress and are predisposed to organ failure, now a well-known phenomenon in aging. Thus, new methods are urgently needed to safely reduce ROS and/or inflammation in the aging type 2 diabetes patient with CKD. Studies of both normal aging and diabetic patients with kidney disease underline the fact that increased ROS and/or inflammation can be managed in these conditions by economical, safe, and effective interventions that reduce the uptake of advanced glycation endproducts by either modifying preparation of food or an oral drug. This communication reviews these data and adds new information on the efficacy of a drug, sevelamer carbonate, required to reduce ROS and/or inflammation in the aging type 2 diabetes patient complicated by CKD. If larger and longer studies confirm the hypothesis that one or both of these interventions reduce progression of CKD, it could represent a new paradigm in the management of complications in the type 2 diabetes patient with CKD.

Mothers' knowledge about EPI and its relation with age-appropriate vaccination of infants in peri-urban Karachi.

PubMed

Siddiqi, Nazish; Siddiqi, Azfar-e-alam; Nisar, Nighat; Khan, Altaf

2010-11-01

To evaluate the relation between the knowledge of mothers about EPI vaccinations and their infant's coverage. Effect of other socio-demographic variables on mothers' knowledge and child's coverage was also assessed. A cross-sectional survey was conducted, utilizing World Health Organization's thirty-cluster sampling strategy. All households with at least one infant were considered eligible. After obtaining verbal consent, the mother was interviewed to assess her knowledge and attitudes towards EPI vaccination. Infant's coverage status was verified by checking EPI card or verbal inquiry. A knowledge score was developed by summing all correct answers. A total of 210 mothers (7 per cluster) were identified and interviewed. The number and proportion of mothers correctly identifying the seven EPI diseases were as follows; Tuberculosis 57 (27.1%), Diphtheria 53 (25.2%), Pertussis 71 (33.8%), Tetanus 70 (33.3%), Measles 85 (40.5%), Polio 91 (43.3%) and Hepatitis B 65 (31.0%). Only ninety four (44.8%) children were appropriately vaccinated for their age. In the multivariate model, mothers' knowledge was not significantly associated with appropriate vaccination of their children (p = 0.22), however, mothers' education was found to be significant (p < 0.001). Mothers' knowledge about EPI vaccination in peri-urban Karachi was quite low and not associated with their children's EPI coverage. Mothers' educational status, however, was significantly associated with Child's coverage. This finding depicts a better health seeking behaviour of a more educated mother.

Association of low-protein supplemented diets with fetal growth in pregnant women with CKD.

PubMed

Piccoli, Giorgina B; 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

2014-05-01

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. 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. 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. Vegan-vegetarian supplemented low-protein diets in pregnant women with stages 3-5 CKD may reduce the likelihood of small for gestational age

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

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. Copyright © 2015 Elsevier Ltd. All rights reserved.

EPI-743 reverses the progression of the pediatric mitochondrial disease--genetically defined Leigh Syndrome.

PubMed

Martinelli, Diego; Catteruccia, Michela; Piemonte, Fiorella; Pastore, Anna; Tozzi, Giulia; Dionisi-Vici, Carlo; Pontrelli, Giuseppe; Corsetti, Tiziana; Livadiotti, Susanna; Kheifets, Viktoria; Hinman, Andrew; Shrader, William D; Thoolen, Martin; Klein, Matthew B; Bertini, Enrico; Miller, Guy

2012-11-01

Genetically defined Leigh syndrome is a rare, fatal inherited neurodegenerative disorder that predominantly affects children. No treatment is available. EPI-743 is a novel small molecule developed for the treatment of Leigh syndrome and other inherited mitochondrial diseases. In compassionate use cases and in an FDA Expanded Access protocol, children with Leigh syndrome treated with EPI-743 demonstrated objective signs of neurologic and neuromuscular improvement. To confirm these initial findings, a phase 2A open label trial of EPI-743 for children with genetically-confirmed Leigh syndrome was conducted and herein we report the results. A single arm clinical trial was performed in children with genetically defined Leigh syndrome. Subjects were treated for 6 months with EPI-743 three times daily and all were eligible for a treatment extension phase. The primary objective of the trial was to arrest disease progression as assessed by neuromuscular and quality of life metrics. Results were compared to the reported natural history of the disease. Ten consecutive children, ages 1-13 years, were enrolled; they possessed seven different genetic defects. All children exhibited reversal of disease progression regardless of genetic determinant or disease severity. The primary endpoints--Newcastle Pediatric Mitochondrial Disease Scale, the Gross Motor Function Measure, and PedsQL Neuromuscular Module--demonstrated statistically significant improvement (p<0.05). In addition, all children had an improvement of one class on the Movement Disorder-Childhood Rating Scale. No significant drug-related adverse events were recorded. In comparison to the natural history of Leigh syndrome, EPI-743 improves clinical outcomes in children with genetically confirmed Leigh syndrome. Copyright © 2012 Elsevier Inc. All rights reserved.

Vascular function and cholecalciferol supplementation in CKD: A self-controlled case series.

PubMed

Kumar, Vivek; Yadav, Ashok Kumar; Singhal, Manphool; Kumar, Vinod; Lal, Anupam; Banerjee, Debasish; Gupta, Krishan Lal; Jha, Vivekanand

2018-06-01

Vitamin D deficiency is common and associated with mortality in chronic kidney disease (CKD) patients. Cardiovascular disease (CVD) is the commonest cause of mortality in CKD patients. In a randomized, double blind, placebo controlled trial, we have recently reported favorable effects of vitamin D supplementation on vascular & endothelial function and inflammatory biomarkers in vitamin D deficient patients with non-diabetic stage 3-4 CKD (J Am Soc Nephrol 28: 3100-3108, 2017). Subjects in the placebo group who had still not received vitamin D after completion of the trial received two oral doses 300,000 IU of oral cholecalciferol at 8 weeks interval followed by flow mediated dilatation (FMD), pulse wave velocity (PWV), circulating endothelial and inflammatory markers (E-Selectin, vWF, hsCRP and IL-6), 125 (OH) 2 D, iPTH and iFGF-23 assessment at 16 weeks. 31 subjects completed this phase of the study. Last values recorded in the preceding clinical trial were taken as baseline values. Serum 25(OH)D and 1,25(OH) 2 D increased and FMD significantly improved after cholecalciferol supplementation [mean change in FMD%: 5.8% (95% CI: 4.0-7.5%, p < 0.001]. Endothelium independent nitroglycerine mediated dilatation, PWV, iPTH, iFGF-23 and IL-6 also showed favorable changes. The data further cement the findings of beneficial effects of correction of vitamin D deficiency on vascular function. Copyright © 2018 Elsevier Ltd. All rights reserved.

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

Pregnancy as an early stress test for cardiovascular and kidney disease diagnosis.

PubMed

Facca, Thaís Alquezar; Mastroianni-Kirsztajn, Gianna; Sabino, Amélia Rodrigues Pereira; Passos, Michelle Tiveron; Dos Santos, Larissa Fátima; Famá, Eduardo Augusto Brosco; Nishida, Sonia Kiyomi; Sass, Nelson

2017-11-23

Pregnancy is a cardiometabolic and renal stress test for women, primarily when associated with hypertension syndrome, which can have deleterious effects in the long term. We undertook this study to make a long-term evaluation on these women. A retrospective cohort study was conducted to investigate voluntary women who had pregnancy-induced hypertension syndrome versus normal pregnancy. We evaluated a total of 85 women, divided in case (n = 25) and control (n = 60) groups, by clinical, anthropometric and epidemiological profiles, general, metabolic and renal tests, and risk stratification for cardiovascular disease (CVD) and chronic kidney disease (CKD). The case group showed a higher incidence of hypertension (P = .003), shorter period between its diagnosis and end of pregnancy (P < .001) and lower age at diagnosis (P = .033); higher weight (P < .001), body mass index (BMI) (P < .001), waist-to-height ratio (p = .001) and abdominal circumference (P < .001); higher fat percentage (P = .004) and weight to lose (P < .001) as measured by bioimpedance; lower estimate glomerular filtration rate (eGFR) by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation (P = .021), greater difference between estimated vascular age and real age (P = .008) according to Framingham Risk Score (2008) and higher frequency of metabolic syndrome (P < .001). Women who had pregnancy-induced hypertension syndrome were found with a higher incidence of obesity, metabolic syndrome and hypertension, earlier onset of hypertension, higher estimated vascular age and lower eGFR. These findings reinforce the importance of investigating the history of hypertension syndrome in pregnancy, which should be considered an indicator to be followed long term after childbirth. Copyright © 2017 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.

Compressed Sensing for fMRI: Feasibility Study on the Acceleration of Non-EPI fMRI at 9.4T

PubMed Central

Kim, Seong-Gi; Ye, Jong Chul

2015-01-01

Conventional functional magnetic resonance imaging (fMRI) technique known as gradient-recalled echo (GRE) echo-planar imaging (EPI) is sensitive to image distortion and degradation caused by local magnetic field inhomogeneity at high magnetic fields. Non-EPI sequences such as spoiled gradient echo and balanced steady-state free precession (bSSFP) have been proposed as an alternative high-resolution fMRI technique; however, the temporal resolution of these sequences is lower than the typically used GRE-EPI fMRI. One potential approach to improve the temporal resolution is to use compressed sensing (CS). In this study, we tested the feasibility of k-t FOCUSS—one of the high performance CS algorithms for dynamic MRI—for non-EPI fMRI at 9.4T using the model of rat somatosensory stimulation. To optimize the performance of CS reconstruction, different sampling patterns and k-t FOCUSS variations were investigated. Experimental results show that an optimized k-t FOCUSS algorithm with acceleration by a factor of 4 works well for non-EPI fMRI at high field under various statistical criteria, which confirms that a combination of CS and a non-EPI sequence may be a good solution for high-resolution fMRI at high fields. PMID:26413503