3b Chronic Kidney Disease Research Articles

Evolution of Technique from Minimally Ischemic to Pure Off-Clamp Partial Nephrectomy: 15-Year Learning Curve and Outcomes of 1083 Patients

Introduction and Objective: There is a growing interest in surgical techniques aimed at minimizing ischemia during partial nephrectomy (PN). The aim of this video is to report surgical tips, perioperative, functional, and oncologic outcomes of first 1083 patients treated with laparoscopic or robotic minimally ischemic1,2 or pure off-clamp (Off-C) PN treated between 2002 and 2015 in a high-volume center. Materials and Methods: Patients were placed in an extended flank position and a four-port or five-port access was performed for laparoscopic or robotic approach, respectively. Hilar vessels were not clamped in any case; pure or hybrid tumor enucleation was the resection technique used. The first case shows a robotic PN with the “sutureless technique” for more exophytic masses, which can also be performed with a laparoscopic approach.3 The second video shows a 4 cm left mesorenal tumor treated with laparoscopic PN after superselective transarterial embolization.4–6 This original technique, first used in 2003, at the beginning of the learning curve, has been no longer used since 2010. The third video shows a robotic PN in a right solitary kidney, affected by a 4.3 cm tumor involving the medial aspect of the upper pole. Small arterial feeders identified or transected during the enucleation of the tumor were selectively coagulated. Two suction devices were used simultaneously to maintain a bloodless surgical field. A point-specific hemostasis was performed before starting a sliding clip renorrhaphy. Results: Overall complication rate was 15.7% with a transfusion rate of 7.8%. Only 4.25% of complications were severe with a Clavien grade equal to or greater than 3. Five-year local recurrence-free survival and cancer-specific survival rates were 98.1% and 98%, respectively. The 5-year risk of severe renal function (RF) deterioration (chronic kidney disease (CKD) stage 4) was 0%, 0.9%, 7.5%, and 10.7% for patients with stages 1, 2, 3A, and 3B CKD, respectively. At multivariable analysis, baseline RF (p = 0.001) and postoperative RF decrease ≥10% (p = 0.048) independently predicted a new onset stage 4 or 5 CKD. Conclusions: Off-C PN is a challenging surgical procedure. At the beginning of learning curve, a stepwise adoption of pure Off-C approach is mandatory and preparing hilar vessels for intermediate and high nephrometry score renal tumors is recommended. Oncologic outcomes were comparable with on-clamp PN series and excellent functional outcomes of our series support Off-C as a first line treatment option in high-volume tertiary referral centers. No competing financial interests exist. Runtime of video: 5 mins 5 secs Presented at the World Congress of Endourology in Cape Town, South Africa, November 2016.

Case Report Ramsay Hunt Syndrome presenting as “a window’’ to HIV diagnosis in 48 year old African female: A case report

Background: Ramsay Hunt Syndrome in adults is reported in a number of case reports as an uncommon presentation of Varicella zoster Virus infection. Ramsay Hunt Syndrome occurs when there is reactivation of the latent Varicella zoster virus present in the ganglia due to previous varicella infection. Following a breakdown of the immune system, latent Varicella zoster infection can be activated. HIV (Human Immunodeficiency Virus infection), causes immunosuppression and hence reactivation of Varicella zoster. The diagnosis of Ramsay Hunt Syndrome, gives a window of opportunity to investigate for HIV. Here we report our first case of Ramsay Hunt syndrome as a presenting feature of HIV disease in an apparently healthy looking 48 year old black African female who was unaware of her HIV status at the time of presentation.
 This case is reported in order to highlight the need to use Ramsay Hunt Syndrome as a window of opportunity to screen for underlying HIV.
 Case presentation: A 48 year old black African female who was unaware of her HIV status, presented to our outpatients department with a two day history of painful right ear pain, vesicles on the right pinna and inability to completely close her right eye, her mouth was deviated to the left, with a wrinkle free frown. She denied any alteration in taste sensation and hyperacusis. She had a grade IV House-Brackmann facial paralysis.A diagnosis of Ramsay Hunt Syndrome was made and an HIV test was offered, the test was positive for HIV.A subsequent HAART (Highly Active Antiretroviral Therapy) work up, revealed CKD 3B (Chronic Kidney Disease stage 3B) and a CD4 (cluster of differentiation 4) count of 217 cells/µl .She was started on antiretroviral therapy 2 weeks after completing a 10 day regimen of acyclovir. In addition to her drug treatment she received ocular care and physiotherapy. Four months on her facial nerve function has improved modestly.
 Conclusion: An HIV test should be an indispensable part of the Ramsay Hunt syndrome workup, as its diagnosis gives a window of opportunity to diagnose HIV and offer life- saving HAART.

MP49-08 ON-CLAMP VERSUS OFF-CLAMP PARTIAL NEPHECTOMY: PROPENSITY SCORE MATCHED COMPARISON OF LONG TERM FUNCTIONAL OUTCOMES

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy II1 Apr 2017MP49-08 ON-CLAMP VERSUS OFF-CLAMP PARTIAL NEPHECTOMY: PROPENSITY SCORE MATCHED COMPARISON OF LONG TERM FUNCTIONAL OUTCOMES Giuseppe Simone, Umberto Capitanio, Alessandro Larcher, Mariaconsiglia Ferriero, Leonardo Misuraca, Gabriele Tuderti, Giuseppe Romeo, Francesco Minisola, Salvatore Guaglianone, Fabio Muttin, Alessandro Nini, Francesco Trevisani, Francesco Montorsi, Roberto Bertini, and Michele Gallucci Giuseppe SimoneGiuseppe Simone More articles by this author , Umberto CapitanioUmberto Capitanio More articles by this author , Alessandro LarcherAlessandro Larcher More articles by this author , Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Leonardo MisuracaLeonardo Misuraca More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Giuseppe RomeoGiuseppe Romeo More articles by this author , Francesco MinisolaFrancesco Minisola More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Fabio MuttinFabio Muttin More articles by this author , Alessandro NiniAlessandro Nini More articles by this author , Francesco TrevisaniFrancesco Trevisani More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , Roberto BertiniRoberto Bertini More articles by this author , and Michele GallucciMichele Gallucci More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1510AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The elective indication for off-clamp (Off-C) partial nephrectomy (PN) in patients with good baseline renal function remains controversial. The aim of this study is to compare the risks of developing a severe (stage ≥3b) chronic kidney disease (CKD) in patients with cT1-2/N0/M0 renal tumors and baseline estimated glomerular filtration rate (eGFR) >60 ml/min after either Off-C or on-clamp (On-C) PN. METHODS A prospective ″renal cancer″ database of two high volume centers was queried for ″cT1-2/N0/M0″ tumors, ″PN″ and ″baseline eGFR>60 mL/min″. Overall 1073 patients met the inclusion criteria (483 Off-C and 588 On-C). A 1:2 propensity score-matched (PSM) analysis was employed to minimize the selection bias of non-random treatment assignment of patients. Kaplan-Meier method was used to compare the PSM cohorts specific risks of developing a CKD stage ≥ 3b during follow-up in the PSM cohorts, and the log-rank test was applied to assess statistical significance between groups. Univariable and multivariable Cox regression analyses were performed to identify independent predictors of developing a CKD stage ≥3b. RESULTS On-C patients were significantly younger (p=.001), less frequently smokers (.01), with a lower incidence of diabetes (.001) and hypertension (.001), lower ASA scores (<.001), higher baseline eGFR values (.003), smaller tumor sizes (<.001), and higher incidence of positive surgical margins (.021). After applying the PSM analysis, the two cohorts of 221 On-C and 485 Off-C PN cases did not differ for all clinical and pathologic covariates (Table 1; all p ≥ .06). The probability of developing a CKD stage ≥3b was significantly higher (log rank p=.006, Figure 1) in the On-C cohort (2, 5 and 8yr risk 0.9, 5.1 and 12.8% vs 0.6, 1.2 and 1.2% in the Off-C cohort, respectively). On-C technique was associated with a 5.2 fold increased risk of developing CKD stages ≥3b compared with the Off-C approach (HR 5.2 [95% CIs 1.4-18.9]; p=.012). At multivariable regression analysis, eGFR at discharge and Off-C PN were independent predictors of outcomes. For each increasing mL/min of eGFR at the discharge the risk of developing a CKD stage ≥3b was reduced by 5% (HR 0.95 [95‰ CIs 0.93-0.97]), while On-C approach was associated with a 5.8 fold increased risk of developing a CKD stage ≥3b (HR 5.8 [95% CIs 1.6-20.8]). CONCLUSIONS Conclusions: This study highlights the beneficial role of an Off-C approach in patients with cT1-2/N0/MO renal tumors and good baseline renal function candidate to elective PN. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e649 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Giuseppe Simone More articles by this author Umberto Capitanio More articles by this author Alessandro Larcher More articles by this author Mariaconsiglia Ferriero More articles by this author Leonardo Misuraca More articles by this author Gabriele Tuderti More articles by this author Giuseppe Romeo More articles by this author Francesco Minisola More articles by this author Salvatore Guaglianone More articles by this author Fabio Muttin More articles by this author Alessandro Nini More articles by this author Francesco Trevisani More articles by this author Francesco Montorsi More articles by this author Roberto Bertini More articles by this author Michele Gallucci More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Managing Chronic Kidney Disease and Chemotherapy-Induced Peripheral Neuropathy with Acupuncture and Herbal Medicine: A Case Study

This case study details the treatment of a 59-year-old male with Stage 3B chronic kidney disease (CKD) and chemotherapy-induced peripheral neuropathy of the left limbs using acupuncture and bulk herbs. After 6 weeks of combined acupuncture and herbal treatments, glomerular filtration rate increased significantly from 37 mL/min to 51 mL/min and serum creatinine level decreased from 1.85 mg/dL to 1.41 mg/dL. After a course of 15 acupuncture treatments over 4 months with some appointments in closer proximity, the patient additionally reported increased sensation of his left limbs. Since there are limited treatments for CKD, others with CKD may benefit from acupuncture and herbal treatments. This study offers an approach to managing CKD and chemotherapy-induced peripheral neuropathy more effectively using herbs and acupuncture supported by biomedical verification results.

Australian general practitioners’ current practice for chronic kidney disease (CKD) detection and management

Background Guidelines for early detection of chronic kidney disease (CKD) emphasise regular testing of kidney health in high-risk individuals. However, evidence suggests that CKD is not being adequately detected or appropriately managed in primary care. Aims Assess Australian general practitioners’ (GP) current practice in relation to CKD detection and management. Methods This was a cross-sectional study utilising a random sample of GPs identified by interrogation of the national online telephone directory, and stratified by geographical location. Data collection occurred between October 2014 and January 2015. Of 2,815 eligible contacts, the final response rate was 23 per cent. Results Of the 656 respondents, over 90 per cent assessed kidney health at least annually in people with diabetes or high blood pressure, and 71 per cent correctly assessed kidney health every 3–6 months in a patient with Stage 3b CKD. The tests most commonly used to assess kidney health were serum creatinine (with eGFR), blood pressure and urine albumin creatinine ratio. The most commonly reported CKD management strategies were ‘blood pressure reduction using pharmacological agents’ (81 per cent) and ‘glycaemic control if diabetes present’ (64 per cent). Knowledge testing highlighted that 32 per cent of respondents were not able to correctly identify how to properly assess absolute cardiovascular risk, and this was significantly more common in more experienced GPs (p=0.003). Conclusion The results indicate that Australian GPs are mainly practising in accordance with current guidelines for detection and management of patients with CKD, but with room for improvement in some areas.

Tumor Anatomy Scoring and Renal Function for Nephron-Sparing Treatment Selection in Patients With Small Renal Masses: A Microsimulation-Based Decision Analysis.

The purpose of this article is to compare the effectiveness of a treatment algorithm for small renal tumors incorporating the nephrometry score, a renal tumor anatomy scoring system developed by urologists, with the current standard of uniformly recommended partial nephrectomy in patients with mild-to-moderate chronic kidney disease (CKD). We developed a state-transition microsimulation model to project life expectancy (LE) in hypothetic patients with baseline mild or moderate CKD undergoing treatment of small renal masses. Our model incorporated the nephrometry score, which is predictive of postsurgical renal function loss. The two tested strategies were uniform treatment with partial nephrectomy and selective treatment based on nephrometry score and CKD stage, including percutaneous ablation for CKD stages 2 or 3a and intermediate-to-high nephrometry score or stage 3b CKD and any nephrometry score; otherwise, partial nephrectomy was assumed for other CKD stages and nephrometry scores. The model accounted for benign and malignant lesions, renal function decline, recurrence, and metastatic disease rates specific to each treatment, mortality by CKD stage, and comorbidities. Sensitivity analysis tested the stability of results when varying key parameters. Selective treatment with partial nephrectomy resulted in an average LE benefit of 0.48 year (95% interpercentile range, 0.42-0.54 year) in 65-year-old men and 0.37 year (95% interpercentile range, 0.30-0.43 year) in 65-year-old women relative to nondiscriminatory surgery, due to worsening CKD and cardiovascular mortality associated with partial nephrectomy. Model results were most sensitive to the rate of renal function decline and CKD-related mortality. Nephron-sparing treatment selection for small renal masses based on nephrometry score may improve LE in patients with mild or moderate CKD.

Advanced chronic kidney disease populations have elevated trimethylamine N-oxide levels associated with increased cardiovascular events

Cardiovascular disease is more common in patients with chronic kidney disease (CKD), and traditional risk factors do not adequately predict those at risk for cardiovascular (CV) events. Recent evidence suggests elevated trimethylamine N-oxide (TMAO), created by gut microflora from dietary L-carnitine and choline, is associated with CV events. We investigated the relationship of TMAO levels in patients with stages 3b and 4 CKD to ischemic CV events using the CanPREDDICT cohort, a Canada-wide observational study with prospective 3-year follow-up of adjudicated CV events. Baseline samples were obtained for 2529 CKD patients. TMAO, choline, and L-carnitine levels were measured using tandem mass spectrometry. Baseline median TMAO level was high for the whole cohort (20.41 μM; interquartile range [IQR]: 12.82-32.70 μM). TMAO was independently associated with CV events (hazard ratio 1.23; 95% confidence interval: 1.06-1.42 / 1 SD lnTMAO) after adjusting for all potential CV risk factors. Those in the highest TMAO quartile had significantly higher risk of CV events (adjusted hazard ratio 1.59; 95% confidence interval: 1.04-2.43; P = 0.0351) in the analysis of recurring ischemic events. Among those with stage 3b CKD (hazard ratio 1.45; 95% confidence interval: 1.12-1.87 / 1 SD lnTMAO), independent of kidney function, TMAO levels identified those at highest risk for events. Our results suggest that TMAO may represent a new potentially modifiable CV risk factor for CKD patients. Further studies are needed to determine sources of variability and if lowering of TMAO reduces CV risk in CKD.

Renal Function Outcomes and Risk Factors for Stage 3B Chronic Kidney Disease after Urinary Diversion in Patients with Muscle Invasive Bladder Cancer [corrected

ObjectivesTo assess the effects of urinary diversion on renal function, we retrospectively investigated renal function over 5 years after urinary diversion using a propensity score matching strategy.MethodsBetween May 1996 and November 2013, 345 consecutive adult patients underwent radical cystectomy and urinary diversion in our hospital; one hundred and fifteen patients with more than a 5-year follow-up were enrolled. Propensity scores were calculated using logistic analysis, and the data used in the analyses included age, gender, Eastern Cooperative Oncology Group Performance Status (ECOG-PS), clinical tumor stage, presence of cardiovascular disease; hypertension; and type 2 diabetes and preoperative eGFR at the initial visit. Multivariate logistic regression analysis was used to assess the risk factors for stage 3B chronic kidney disease (CKD) after the different types of urinary diversion.ResultsContinent and incontinent diversion were performed in 68 and 47 patients, respectively. The mean preoperative eGFR was significantly lower in the incontinent than in the continent group (P < 0.001). In propensity score-matched patients (n = 34 each), no significant differences were observed in pre- and postoperative eGFR and 5-year eGFR decrease rates between the groups. In the incontinent group, the number of postoperative stage 3B CKD patients was significantly increased than the continent group. Using multivariate analysis, independent risk factors significantly associated with stage 3B CKD at 5 years after surgery were older age, eGFR before surgery, incontinent diversion (cutaneous ureterostomy), and postoperative hydronephrosis.ConclusionsThe types of urinary diversion had no significant impact on renal function decline, whereas older age, preexisting impaired renal function, postoperative hydronephrosis, and cutaneous ureterostomy were independent risk factors for stage 3B CKD at 5 years after radical cystectomy.

Abstract WP312: The Association of Chronic Kidney Disease (CKD) With 30-day and 1-year Post Ischemic Stroke Mortality and Rehospitalization: Get With the Guidelines (GWTG) Stroke

Background: The extent to which CKD is associated with 30-day and 1-year post ischemic stroke mortality and rehospitalization rates has not been well studied. Methods: Data from 232,236 fee for service Medicare patients admitted with ischemic stroke to 1581 AHA GWTG-Stroke participating hospitals between January 2009 and December 2012 were analyzed. Estimated GFR in mL/min/1.73 m2 was determined based on the MDRD study equation categorized as: no CKD (GFR ≥60); stage 3a CKD (GFR 45-59); stage 3b CKD (GFR 30-44); stage 4 CKD, (GFR 15-29); stage 5 CKD (GFR &lt;15 excluding those on dialysis). Dialysis was identified by ICD-9 codes. Multivariable Cox proportional hazards models adjusted for demographics, medical history, NIHSS, arrival hour, and hospital characteristics were used to determine the independent associations of CKD (reference group those without CKD) with mortality and readmission at 30 days and 1 year. Results: After adjustment, 30-days poststroke mortality was highest among those with CKD stage 5 (HR 1.94, 95%CI 1.72-2.18), even after excluding in-hospital mortality and patients discharged to hospice (HR 2.09, 95%CI 1.66-2.63). Unadjusted 1-year mortality and readmission rates were highest among patients on dialysis (Figure). After adjustment, 1-year post-stroke mortality remained highest among patients on dialysis (HR 2.19, 95%CI 2.08-2.31), even after excluding in-hospital mortality and discharge to hospice (HR 2.65, 95%CI 2.49-2.81). For those discharged alive, 30-day and 1-year rehospitalization rates were also highest among patients on dialysis (HR 2.10, 95%CI 1.95-2.26; HR 2.55, 95%CI 2.44-2.66, respectively) as was the 30-day and 1-year composite of mortality and rehospitalization (HR 2.04, 95%CI 1.90-2.18; HR 2.46, 95% CI 2.36-2.56, respectively). Conclusion: Among Medicare beneficiaries with acute ischemic stroke, poststroke mortality and rehospitalization varied by CKD stage and were highest among those with advanced CKD.

The relationships between glucose variability and renal function in type 2 diabetes patients on basal-bolus insulin therapy

Aim. To assess the relationship of glucose variability (GV) and renal function in patients with type 2 diabetes on basal-bolus insulin therapy.Materials and methods. We observed 101 females with type 2 diabetes, aged 47–79 years, with a glomerular filtration rate (GFR) 30 mL/min/1.73 m2. Insulin was combined with metformin in 45 of these women. The mean glucose and standard deviation, continuous overlapping net glucose action, lability index, J-index, low blood glucose index (LBGI), high blood glucose index (HBGI), M-value and mean absolute glucose (MAG) were calculated based on the results of blinded continuous glucose monitoring. The prevalence of episodes of low interstitial glucose (3.9 and 2.8 mmol/L) of at least 20-min duration was estimated.Results. Patients with a GFR of 30–44 mL/min/1.73 m2 had significantly lower HBGI, J-index, MAG and M-value compared with those with better filtration (all p 0.05); LBGI was not dependent on GFR. The GFR values were weakly and positively correlated with HBGI, J-index, M-value and MAG. Multiple regression analysis showed that GFR is an independent predictor of MAG (p = 0.04). No significant differences were found in the prevalence of episodes of low interstitial glucose between patients with different GFR ranges.Conclusions. GV parameters are related to renal function in type 2 diabetic women on basal-bolus insulin therapy. Patients with stage 3b chronic kidney disease have reduced GV, predominantly in the hyperglycaemic band, compared with those with better filtration.

Regarding mini-review on bicarbonate therapy for prevention of chronic kidney disease progression

To the Editor: The mini-review on bicarbonate therapy for prevention of chronic kidney disease progression1 was a much-needed, well-written, and informative review. It has long been known that chronic acidosis seen in chronic kidney disease (CKD) 4 and 5 has a deleterious effect on digestion and general nutrition. The recommendation of rigorous treatment to prevent progression of CKD was well explained by various recently reported pathophysiological mechanisms that support the urgency of treatment. However, there was a recommendation in the management that is a cause of concern. Because of the probability of poor compliance and intolerance with administration of NaHCO3 compounds, the authors recommend other alkali products—e.g., Shohl’s solution (sodium citrate and citric acid) or polycitra (citric acid, potassium citrate, and sodium citrate)—as alternatives. They do issue a warning of the dangers of increased aluminum (Al) absorption in patients taking Al-containing phosphate binders but did not elaborate on this point. We showed that ingestion of a low dose of citrate contained in a well-known effervescent calcium supplement taken by normal volunteers as well as subjects with stable chronic renal failure resulted in an increase in the excretion of urinary Al in normal individuals and an increase in both serum and urine Al in those with CKD.2 The experiments showing this were accompanied by a low dose of Al hydroxide supplementation. The point of the research, however, was to alert medical practitioners that, even without Al supplementation, patients with CKD 3b, 4, and 5 may experience an increase in serum and urine Al if receiving compounds containing citrate. This is because all foodstuffs in a powdery form contain Al to prevent them from congealing, as AL has hydrophobic properties. For this reason we believe that all citrate-containing preparations are totally contraindicated because of the Al contained in, e.g., flour, custard powder, salt, sugar, etc. Although the bicarbonate powder may occasionally be unpleasant to take, it is safe and inexpensive, and the unpleasant taste can be disguised.

Hemoglobin discriminates stages of chronic kidney disease in elderly patients.

The prevalence of chronic kidney disease (CKD) increases with age, and anemia is known to affect the outcome of subjects with CKD. However, little is known with regard to the associations between metabolic complications and stages of CKD among elderly patients. Thus, the aim of the present study was to investigate the prevalence of CKD in elderly Chinese patients, as well as the associations between stages of CKD and clinically important complications of anemia. In total, 2,258 individuals with CKD, divided into younger (n=989) and elderly (n=1,269) groups, were enrolled in the study between June 2009 and December 2011. The glomerular filtration rate (GFR) was assessed using a 99mTc-DTPA renal dynamic imaging method (modified Gate's method). The levels of serum creatinine (SCr) and hemoglobin (Hb), and the hematocrit (HCT) were measured simultaneously per manufacturer's instructions. In the elderly group, the levels of SCr and proportional ratios were higher, while the GFR, Hb level, HCT and proportional ratios were lower when compared with the values in the younger group. Statistically significant differences were observed in the Hb concentrations when comparing individuals classified with different stages of CKD in the younger and elderly groups. In the younger group, there was no significant difference in the Hb concentrations between the stage 3a and 3b CKD patients. However, in the elderly group, the Hb concentrations were significantly higher in patients classified with stage 3a CKD when compared with those with stage 3b, whose GFR cutoff point was <60 ml/min/1.73 m2. In conclusion, the results indicated that Hb levels may be used to discriminate stages of CKD in elderly patients; thus, Hb may be used as a biomarker to assess the severity of CKD.

Drugs and the kidney.

This article on drug nephrotoxicity is detailed, as it is important to be fully aware of renal side-effects of drugs with regard to prevention andearly diagnosis in order to manage the condition correctly. Many therapeutic agents are nephrotoxic, particularly when the serum half-life isprolonged and blood levels are raised because of decreased renal excretion. Distal nephrotoxicity is markedly enhanced when the glomerularfiltration rate (GFR) is reduced and is a particular threat in elderly patients with so-called 'normal' creatinine levels. In patients of 45 - 55 years of age theGFR is reduced by about 1 mL/min/year, so that an otherwise healthy person of 80 may have an estimated GFR (eGFR) of &lt;60 mL/min or &lt;50 mL/min,i.e. stage 2, 3 or 3b chronic kidney disease (CKD). Furthermore, other effects related to kidney dysfunction may be seen, e.g. worsening of hypertensionwith the use of non-steroidal anti-inflammatory drugs, increased bruising or bleeding tendency with aspirin, and hyponatraemia hypertensionacidosis with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Digoxin is contraindicated in stage 3 CKD, even ina reduced dosage. Other drugs can cause the direct formation of kidney stones, e.g. topiramate (used in the prophylaxis of resistant migraine).Levofloxacin (Tavanic) can cause rupture of the Achilles tendon and other tendons.Radiocontrast media must be used with care. Occasionally, strategies to prevent acute kidney insufficiency cause irreversible CKD,especially in patients with diabetes and those with myeloma who have stage 4 - 5 CKD. Gadolinium in its many forms (even the newerproducts) used as contrast medium for magnetic resonance imaging is best avoided in patients with stages 4 and 5 CKD.

Impact of chronic kidney disease on the outcomes of transcatheter aortic valve implantation: results from the FRANCE 2 registry.

The aim of this study was to assess the influence of chronic kidney disease (CKD) classification on clinical outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). Data of 2,929 consecutive patients undergoing TAVI in the FRANCE 2 registry were analysed. Patients were divided into five groups: CKD 1+2, 3a, 3b, 4, and 5. Both 30-day and one-year mortality rates were significantly increased and positively correlated with CKD severity in all groups. After adjusting for significant influential confounders in a Cox regression multivariate model, CKD 4 and 5 were associated with increased risk of both 30-day mortality and one-year mortality when compared with CKD 1+2 as the reference. This higher mortality was predominantly driven by renal failure and infection in patients with CKD 4 and 5, respectively. Procedural success rate in CKD 5 was significantly lower than that in other groups. All CKD patients trended towards a higher incidence of acute kidney injury (AKI), in parallel with the degree of CKD severity. Classification of CKD stages before TAVI allows risk stratification for 30-day and one-year clinical outcomes. CKD 3b, 4 and 5 correlate with poor outcome and are considered a significant risk for TAVI.

Predictors of patient self-report of chronic kidney disease: baseline analysis of a randomised controlled trial.

BackgroundImproving the quality of care for patients with vascular disease is a priority. Clinical guidance has emphasised the importance of early identification and active management of chronic kidney disease (CKD) in primary care in order to maintain vascular health. However, awareness of stage 3 CKD amongst patients remains limited. We aimed to identify predictors of patient self-report of CKD to inform tailoring of conversations around CKD in primary care for diverse patient populations.MethodsWe conducted a cross-sectional analysis of baseline data from 436 patients with stage 3 CKD from 24 GP practices taking part in a randomised controlled trial (RCT) evaluating a complex self-management intervention, which aimed to support the maintenance of vascular health in patients with stage 3 CKD. Potential predictors of patient self-report of CKD included demographics, stage of CKD, cardiovascular risk, self-reported co-morbidities, health status, self-management ability, and health service utilisation.ResultsAround half (52%, n = 227) of patients did not self-report CKD. Self-report rates did not appreciably differ by practice. Multivariate analysis revealed that female patients (p = 0.004), and patients with stage 3b CKD (p < 0.001), and with higher anxiety levels (p < 0.001), were more likely to self-report CKD.ConclusionsSelf-report of kidney problems by patients on CKD registers was variable and patterned by sociodemographic factors. Although it cannot be assumed that failure to self-report indicates a lack of awareness of CKD, our data do suggest the need for greater consistency in discussions around kidney health, with meaningful and relevant clinical dialogue that is aligned with existing clinical encounters to enable shared decision making and minimise anxiety.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-014-0196-3) contains supplementary material, which is available to authorized users.

Mechanisms Contributing to Adverse Cardiovascular Events in Patients with Type 2 Diabetes Mellitus and Stage 4 Chronic Kidney Disease Treated with Bardoxolone Methyl

Background: Bardoxolone methyl, an Nrf2-activating and nuclear factor-κB-inhibiting semisynthetic oleanane triterpenoid compound, was evaluated in a phase 3 trial (BEACON) in patients with type 2 diabetes mellitus (T2DM) and stage 4 chronic kidney disease (CKD). The trial was terminated because of an increase in heart failure events in the bardoxolone methyl group, many of which appeared related to fluid retention. Thus, additional analyses were conducted to explain these serious adverse events. Methods: Patients (n = 2,185) were randomized to receive once-daily bardoxolone methyl (20 mg) or placebo. Twenty-four-hour urine collections were analyzed in a subset of the BEACON population and from a separate, open-label pharmacology study in patients with stage 3b/4 CKD and T2DM administered 20 mg bardoxolone methyl once daily for 56 consecutive days. Results: Bardoxolone-methyl-treated patients in the BEACON substudy had a clinically meaningful reduction in urine volume and sodium excretion at week 4 relative to baseline (p < 0.05), and a separate study revealed that decreased sodium excretion and urine output occurred in some patients with stage 4 CKD but not those with stage 3b CKD. The clinical phenotype of fluid overload and heart failure in BEACON was similar to that observed with endothelin receptor antagonists in advanced CKD patients, and preclinical data demonstrate that bardoxolone methyl modifies endothelin signaling. Conclusions: The totality of the evidence suggests that through modulation of the endothelin pathway, bardoxolone methyl may pharmacologically promote acute sodium and volume retention and increase blood pressure in patients with more advanced CKD.

Metabolic acidosis-induced hypercalcemia in an azotemic patient with primary hyperparathyroidism.

A 58-year-old man with Stage 3b chronic kidney disease and primary hyperparathyroidism treated with cinacalcet was admitted for acute cholecystitis. A cholecystostomy tube was placed, estimated glomerular filtration rate decreased, metabolic acidosis developed and ionized calcium increased from 1.33 to 1.76 mM despite cinacalcet administration. A sodium bicarbonate infusion corrected the metabolic acidosis restoring ionized calcium to normal despite no improvement in renal function. The correlation between the increase in serum bicarbonate and decrease in ionized calcium was r = −0.93, P < 0.001. In summary, severe hypercalcemia was attributable to metabolic acidosis increasing calcium efflux from bone while renal failure decreased the capacity to excrete calcium.

Benefits of Aldosterone Receptor Antagonism in Chronic Kidney Disease (BARACK D) trial-a multi-centre, prospective, randomised, open, blinded end-point, 36-month study of 2,616 patients within primary care with stage 3b chronic kidney disease to compare the efficacy of spironolactone 25mg once daily in addition to routine care on mortality and cardiovascular outcomes versus routine care alone: study protocol for a randomized

BackgroundChronic kidney disease (CKD) is common and increasing in prevalence. Cardiovascular disease (CVD) is a major cause of morbidity and death in CKD, though of a different phenotype to the general CVD population. Few therapies have proved effective in modifying the increased CVD risk or rate of renal decline in CKD. There are accumulating data that aldosterone receptor antagonists (ARA) may offer cardio-protection and delay renal impairment in patients with the CV phenotype in CKD. The use of ARA in CKD has therefore been increasingly advocated. However, no large study of ARA with renal or CVD outcomes is underway.MethodsThe study is a prospective randomised open blinded endpoint (PROBE) trial set in primary care where patients will mainly be identified by their GPs or from existing CKD lists. They will be invited if they have been formally diagnosed with CKD stage 3b or there is evidence of stage 3b CKD from blood results (eGFR 30–44 mL/min/1.73 m2) and fulfil the other inclusion/exclusion criteria. Patients will be randomised to either spironolactone 25 mg once daily in addition to routine care or routine care alone and followed-up for 36 months.DiscussionBARACK D is a PROBE trial to determine the effect of ARA on mortality and cardiovascular outcomes (onset or progression of CVD) in patients with stage 3b CKD.Trial registrationEudraCT: 2012-002672-13ISRTN: ISRCTN44522369

Effect of a Cooked Meat Meal on Serum Creatinine and Estimated Glomerular Filtration Rate in Diabetes-Related Kidney Disease

Fasting is not routinely recommended for renal function tests, despite the known effects of cooked meat on creatinine. We therefore studied variation in creatinine and estimated glomerular filtration rate (eGFR) after a standardized cooked meat meal in 80 subjects: healthy volunteers and diabetic patients with chronic kidney disease (CKD) stages 1 and 2, 3a, 3b, and 4 (n = 16/group). The interventions were a standardized cooked meat and a nonmeat meal, each providing ∼54 g protein, together with 250 mL water, on separate days. Fasting and postprandial blood samples at 1, 2, and 4 h were drawn for creatinine measurement using a kinetic alkaline picrate assay on an Olympus AU640 analyzer. The modified four-variable Modification of Diet in Renal Disease equation traceable to isotope dilution mass spectrometry creatinine was used to calculate eGFR. Consumption of a standardized cooked meat meal significantly increased serum creatinine and resulted in significant fall in eGFR in all stages of CKD studied; 6 of 16 CKD 3a patients were misclassified as CKD 3b. This effect of cooked meat on serum creatinine disappears after 12 h of fasting in all study participants. Creatine in meat is converted to creatinine on cooking, which is absorbed, causing significant increases in serum creatinine. This could impact management, as threshold for commencing and withdrawing certain medications and expensive investigations is defined by eGFR. eGFR calculated using fasting serum creatinine would be a better reflection of kidney function in these patients.

Comments on “Progression of stages 3b–5 chronic kidney disease—Preliminary results of Taiwan national pre-ESRD disease management program in Southern Taiwan”

Background/Purpose The outcomes and their predictors, and rates of estimated glomerular filtration rate (eGFR) changes among Taiwanese, an ethnic Chinese population, with chronic kidney disease (CKD) stages 3b–5, enrolled in a nationwide pre-end-stage renal disease (pre-ESRD) management program that have not been previously reported. Methods This study focused on a cohort of patients enrolled in the Taiwan's pre-ESRD disease management program from Southern Taiwan, including 4061 CKD 3b–5 patients who received more than 12 weeks of follow-up from 2007 to 2010. The decline rates of eGFR, outcomes, and the predictors of initiating dialysis were analyzed. Results The study participants consisted of patients who were 70.1 ± 12.3 years old, of whom 56.4% were male, 46.3% were diabetic, and 72.1% were hypertensive. The mean annual eGFR changes were 0.47 ± 0.42 mL/min/1.73 m2/year, −1.27 ± 0.32 mL/min/1.73 m2/year, and −2.69 ± 0.39 mL/min/1.73 m2/year for stages 3b, 4, and 5, respectively; however, more rapid declines were noted in diabetic patients. The Kaplan–Meier analyses revealed that the probabilities of patients remaining alive and free of dialysis treatment for CKD stage 3b, 4, and 5 without or with diabetes were 89.46% versus 84.65%, 79.88% versus 55.68%, and 34.42% versus 9.64%, respectively, during 42 months of follow-up. Male gender, diabetes, lower baseline eGFR, higher systolic blood pressure, lower hematocrit, and albumin levels were the significant risk factors for initiating dialysis. Conclusion Even though we cannot conclude with certainty that the Taiwan pre-ESRD disease management program is beneficial in slowing the progression of CKD stages 3b–5, our preliminary results seem to suggest this trend. Furthermore, the program may be improved by integrating it with other programs, such as those on diabetes and hypertension, thus making it a more patient-centered, multidisciplinary program.