Chronic Kidney Disease Clinic Research Articles

Urinary CYP eicosanoid excretion correlates with glomerular filtration in African-Americans with chronic kidney disease

Previous studies have indicated that cytochrome P450 (CYP) metabolites of arachidonic acid (AA), i.e., 20-hydroxyeicosatetraenoic acid (20-HETE) and epoxyeicosatrienoic acids (EETs), play an important role in the regulation of renal tubular and vascular function. The present study for the first time profiled HETEs and epoxygenase derived dihydroxyeicosatetraenoic acid diHETEs levels in spot urines and plasma in 262 African American patients from the University of Mississippi Chronic Kidney Disease Clinic and 31 African American controls. Significant correlations in eGFR and urinary 20-HETE/creatinine and 19-HETE/creatinine levels were observed. The eGFR increased by 17.47 [p=0.001] and 60.68 [(p=0.005]ml/min/for each ng/mg increase in 20-HETE and 19-HETE levels, respectively. Similar significant positive associations were found between the other urinary eicosanoids and eGFR and also with 19-HETE/urine creatinine concentration and proteinuria. We found that approximately 80% of plasma HETEs and 30% diHETEs were glucuronidated and the fractional excretion of 20-HETE was less than 1%. These results suggest that there is a significant hepatic source of urinary 20-HETE glucuronide and EETs with extensive renal biotransformation to metabolites which may play a role in the pathogenesis of CKD.

Characteristics of South African patients presenting with kidney disease in rural KwaZulu-Natal: a cross sectional study.

BackgroundDiabetes mellitus is the leading cause of end-stage renal disease (ESRD) globally. Diabetes and human immunodeficiency virus (HIV), both prevalent in South Africa, have not been reported as significant causes of ESRD.MethodsWe evaluated chronic kidney disease (CKD) and cardiovascular disease risk factors in a cross-sectional study of 302 patients (165 females/ 137 males) at a CKD clinic in rural northern KwaZulu-Natal. We included all CKD outpatient clinic attendees and excluded acute renal failure patients. Demographic, clinical and laboratory data collected were analyzed with Stata11 software. Logistic regression analysis was used to determine factors associated with advanced CKD and results expressed as the odds ratio with the 95% confidence interval [OR (95% CI)].ResultsOf 302 patients analyzed, 290 (96%) were black African. Mean age ± SD was 47.1 ± 17.0 years. Approximately 86.4% of females and 54.5% of males were overweight/ obese. Dyslipidaemia was observed in 47.9% females and 29.2% males (P < 0.001). Estimated glomerular filtration rate (eGFR) was <30 ml/min/1.73 m2 in 50.6% patients. CKD risk factors observed were: hypertension (77.8%), diabetes (29.8%), HIV (28.5%), glomerulonephritis (7.0%) and tubulointerstitial diseases (5.6%). Independent factors associated with eGFR <30 ml/min/1.73 m2 at presentation were: HIV [OR = 2.4 (1.3-4.2), P = 0.004] and hypertension [OR = 2.3 (1.3-4.2), P = 0.007].ConclusionDiabetes and HIV are prevalent in CKD patients at primary/regional level healthcare in South Africa. With registry data lacking, dedicated CKD clinics at lower healthcare levels may provide valuable data on CKD epidemiology including changes in aetiology. Primary healthcare practitioners are faced with advanced CKD patients in resource-poor settings, with limited opportunity for upward referral hence the need for nephrology outreach programs.

Dialysis modality decision‐making for older adults with chronic kidney disease

To examine the personal and structural facilitators and barriers for home-dialysis decision-making for older adults with chronic kidney disease. Chronic illness is a global problem. Older adults with chronic kidney disease form a large and growing segment of the dialysis population in many high-income countries but are less likely to uptake home-dialysis despite its benefits. This qualitative ethnography framed in social theory took place in Canada and included adults with chronic kidney disease not on dialysis, older than 65 years of age. Thirteen people (seven men and six women, aged 65-83 years of age) who received care in a team chronic kidney disease clinic took part. Persons with chronic kidney disease were interviewed and group interviews were conducted with four of their chronic kidney disease clinic healthcare professionals. Content analysis was used for data analysis. The factors influencing older adults' chronic kidney disease modality decisions are similar to younger adults. However, older adults with chronic kidney disease are in a precarious state with persistent uncertainty. Age imposes some limitations on modality options and transplantation. Modality decisions were influenced by health status, gender, knowledge, values, beliefs, past experience, preferences, lifestyle and resources. Support from family and healthcare professionals was the largest determinant to home-dialysis selection. The social and contextual factors associated with age influenced home-dialysis decision-making. Adequate social support, functional status and resources enabled home-dialysis selection. Understanding more about the decision-making processes for older adults with chronic kidney disease is important for quality interventions and the economic sustainability of dialysis services.

Vitamin D resistance in chronic kidney disease (CKD)

BackgroundPrevious studies have shown that treatment with ergocalciferol in patients with CKD stage 3 + 4 is not effective with less than 33% of patients achieving a 25-OH vitamin D target of >30 ng/ml. The aim of this study was to test the response to cholecalciferol in CKD. We attempted to replete 25-OH vitamin D to a target level of 40–60 ng/ml using the response to treatment and PTH suppression as an outcome measure.MethodsThis retrospective cohort study identified patients (Stages 2–5 and Transplant) from 2001–2010 who registered at the Chronic Kidney Disease Clinic. Patients received cholecalciferol 10,000 IU capsules weekly as initial therapy. When levels above 40 ng/ml were not achieved, doses were titrated up to a maximum of 50,000 IU weekly. Active vitamin D analogs were also used in some Stage 4–5 CKD patients per practice guidelines. Patients reaching at least one level of 40 ng/mL were designated RESPONDER, and if no level above 40 ng/mL they were designated NON-RESPONDER. Patients were followed for at least 6 months and up to 5 years.Results352 patients were included with a mean follow up of 2.4 years. Of the CKD patients, the initial 25-OH vitamin D in the NON-RESPONDER group was lower than the RESPONDER group (18 vs. 23 ng/ml) (p = 0.03). Among all patients, the initial eGFR in the RESPONDER group was significantly higher than the NON-RESPONDER group (36 vs. 30 ml/min/1.73 m2) (p < 0.001). Over time, the eGFR of the RESPONDER group stabilized or increased (p < 0.001). Over time, the eGFR in the NON-RESPONDER group decreased toward a trajectory of ESRD. Proteinuria did not impact the response to 25-OH vitamin D replacement therapy. There were no identifiable variables associated with the response or lack of response to cholecalciferol treatment.ConclusionsCKD patients treated with cholecalciferol experience treatment resistance in raising vitamin D levels to a pre-selected target level. The mechanism of vitamin D resistance remains unknown and is associated with progressive loss of eGFR. Proteinuria modifies but does not account for the vitamin D resistance.

During the pre-dialysis stage of chronic kidney disease, which treatment is associated with better survival in dialysis?

Specialised care of patients in advanced stages of chronic kidney disease (CKD) is associated with better survival in dialysis, but it is not known which treatments specifically favour this outcome. To analyse normal treatment in advanced stages of CKD and establish which treatments are associated with better survival in dialysis as well as their relationship with causes of death. Cohort, prospective observational study of 591 patients who started dialysis (491 haemodialysis and 100 peritoneal dialysis), who had previously been monitored in the CKD clinic. The treatments analysed were: antihypertensive treatments, statins, antiplatelet drugs, xanthine oxidase inhibitors, correction of metabolic acidosis, treatment with (calcium or non-calcium) phosphate binders, vitamin D (calcitriol or paricalcitol), erythropoietin and the availability of an internal arteriovenous fistula (IAVF). The independent association of each of these treatments with mortality in dialysis was analysed using Cox regression models adjusted for age, sex, pre-dialysis monitoring time, renal function at the start of dialysis, comorbidity, serum albumin and C-reactive protein, and with stratification of the type of dialysis. With a median follow-up period of 28 months, the total number of patients who died was 191 (32%). In the multivariate models, we observed that, in addition to age, the comorbidity index, serum albumin, pre-dialysis treatment with angiotensin-converting-enzyme inhibitors and/or angiotensin receptor blockers, correction of acidosis with sodium bicarbonate and IAVF at the start of haemodialysis were significantly associated with better survival in dialysis. We did not observe differences in causes of death between the different treatments analysed. These results suggest a potential delayed benefit of some treatments in pre-dialysis stages on the outcome of dialysis. Furthermore, beginning dialysis without an IAVF, resulting in the need for intravenous catheters, worsens prognosis in these patients.

Canadian chronic kidney disease clinics: a national survey of structure, function and models of care.

BackgroundThe goals of care for patients with chronic kidney disease (CKD) are to delay progression to end stage renal disease, reduce complications, and to ensure timely transition to dialysis or transplantation, while optimizing independence. Recent guidelines recommend that multidisciplinary team based care should be available to patients with CKD. While most provinces fund CKD care, the specific models by which these outcomes are achieved are not known. Funding for clinics is hospital or program based.ObjectivesTo describe the structure and function of clinics in order to understand the current models of care, inform best practice and potentially standardize models of care.DesignProspective cross sectional observational survey study.Setting, Patients/ParticipantsCanadian nephrology programs in all provinces.Methods and MeasurementsUsing an open-ended semi-structured questionnaire, we surveyed 71 of 84 multidisciplinary adult CKD clinics across Canada, by telephone and with written semi-structured questionnaires; (June 2012 to November 2013). Standardized introductory scripts were used, in both English and French.ResultsCKD clinic structure and models of care vary significantly across Canada. Large variation exists in staffing ratios (Nephrologist, dieticians, pharmacists and nurses to patients), and in referral criteria. Dialysis initiation decisions were usually made by MDs. The majority of clinics (57%) had a consistent model of care (the same Nephrologist and nurse per patient), while others had patients seeing a different nephrologist and nurses at each clinic visit. Targets for various modality choices varied, as did access to those modalities. No patient or provider educational tools describing the optimal time to start dialysis exist in any of the clinics.LimitationsThe surveys rely on self reporting without validation from independent sources, and there was limited involvement of Quebec clinics. These are relative limitations and do not affect the main results.ConclusionsThe variability in clinic structure and function offers an opportunity to explore the relationship of these elements to patient outcomes, and to determine optimal models of care. This list of contacts generated through this study, serves as a basis for establishing a CKD clinic network. This network is anticipated to facilitate the conduct of clinical trials to test novel interventions or strategies within the context of well characterized models of care.Electronic supplementary materialThe online version of this article (doi:10.1186/s40697-014-0029-2) contains supplementary material, which is available to authorized users.

Longitudinal association of body mass index and waist circumference with left ventricular mass in hypertensive predialysis chronic kidney disease patients

BackgroundThis study aimed to investigate the association of both body mass index (BMI) and waist circumference (WC) with left ventricular mass (LVM) in hypertensive predialysis chronic kidney disease (CKD) patients.MethodsFrom 2004 to 2005, 206 consecutive incident adult patients from the outpatient CKD clinics of two hospitals in Greece were included. Inclusion criteria were the presence of CKD and hypertension. BMI (kg/m2), WC (cm) and LVM (g) were assessed annually for 3 years.ResultsThe mean age was 68.1 years, mean BMI 29.1 kg/m2 and mean WC was 103.7 cm. The median LVM was 245.7 g (n = 179). In the cross-sectional data, linear regression models showed that WC {β = 1.2 [95% confidence interval (CI) 0.15; 2.3]}, and not BMI [β = 2.1 (95% CI: −0.70; 4.8)], was significantly associated with LVM. After adjustment for age, sex, primary renal disease, smoking and history of cardiovascular disease, both BMI [β = 4.7 (95% CI: 2.0; 7.4] and WC [β = 1.2 (95% CI: 0.14; 2.3)] were significantly associated with LVM. These associations were pronounced in CKD stage 1–3, but not in CKD stage 4–5. In the longitudinal analysis, linear mixed models adjusting for confounders showed that both an increase in BMI [β = 2.9 (95% CI: 0.74; 5.1)] and an increase in WC [β = 1.1 (95% CI: 0.28; 1.8)] were significantly associated with an increase in LVM.ConclusionsIn hypertensive predialysis CKD patients, both BMI and WC were associated with LVM in CKD stage 1–3, but not in CKD stage 4–5. In the longitudinal analysis, both an increase in BMI and WC were associated with an increase in LVM. Future studies should focus on mechanisms responsible for the associations between anthropometric variables and LVM.

Prevalence of true therapeutic inertia in blood pressure control in an academic chronic kidney disease clinic.

Therapeutic inertia (TI) in blood pressure (BP) control has been traditionally defined as failure to initiate or intensify therapy when treatment goals are not met. The fallacy with this definition is that TI may be overestimated because it includes hypertensive patients deliberately uncontrolled. This is a retrospective chart review study that evaluated physicians' response to an uncontrolled clinic BP reading in a population of patients with stage 3 to 5 chronic kidney disease (CKD) and hypertension. Of 429 patients screened, 166 had controlled BP and 263 did not. Of these 263 patients, 115 patients had no clear reason documented for the absence of changes in medication regimen. This population was defined as cases with true TI. In the remaining 148 patients, the medication regimen was changed in 81 patients. In the rest of the patients, there was a reason documented for not changing the medication regimen. The prevalence of true TI rate (defined as percentage of uncontrolled hypertension as a result of physician inaccountability) in our study was 44% as compared with 69% if the traditional TI definition is applied. Thus, we conclude that the prevalence of TI in the literature overestimates the rate of true TI as it does not account for physician decision making. The current definition of TI in BP control needs to be revised, as it underestimates a provider's care to improve BP control and is misleading. The TI definition should include some mechanism to account for interventions beyond medication titration.

Perceptions of Patient With Chronic Kidney Disease (CKD) About Kidney Transplantation: A Study of an Inner City CKD Clinic

Perceptions of Patient With Chronic Kidney Disease (CKD) About Kidney Transplantation: A Study of an Inner City CKD Clinic

Using an Electronic Self‐Management Tool to Support Patients with Chronic Kidney Disease (CKD): A CKD Clinic Self‐Care Model

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.

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

BackgroundChronic 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.MethodsWe 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.ResultsWe 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.ConclusionsThrough 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.

Abstract 348: Urinary CYP Eicosanoid Excretion Correlates with Glomerular Filtration in African-Americans with Chronic Kidney Disease

Previous studies have indicated that cytochrome P450 (CYP) metabolites of arachidonic acid, ie, 20-hydroxyeicosatetraenoic acid (20-HETE) and epoxyeicosatrienoic acids (EETs) play an important role in the regulation of renal tubular function and vascular tone. More recent studies suggest that variants in the CYP4A11 and CYP4F2 genes are linked to the development of hypertension in a variety of human population studies. However, little is known about the role of 20-HETE or EETs in the pathogenesis of hypertension or diabetic induced renal disease because CYP eicosanoids have not been measured in patients with CKD. The present study profiled HETEs and the dihydroxy metabolites of EETs (DHETs) levels, from spot urines at the time of their clinic visit using LC/MS/MS in 106 African-American patients from the University of Mississippi (UMC) Chronic Kidney Disease (CKD) Clinic with various etiologies of renal disease. Informed consent was obtained for this UMMC IRB approved protocol. Significant positive correlations were found between urinary 5,6- DHETE, 8,9-DHETE, 11,12-DIHETE, 14,15-DHETE, 20-HETE and 19-, 15- and 8-HETE levels and estimated GFR (eGFR) as derived from the MDRD. The magnitude of the influence of urinary eicosanoid levels on eGFR was relatively profound since the slopes of these relationships indicated that there is a 5-10% decrement eGFR associated with each ng/ml fall in urinary eicosanoid levels. These results suggest that a decline in the renal formation of 20-HETE and/or EETs may contribute to the pathogenesis of CKD. At very least, urinary CYP eicosanoids may serve as a useful biomarker for progressive disease.

The effect of a multidisciplinary care clinic on the outcomes in pediatric chronic kidney disease

Current best evidence-based practice for children with chronic kidney disease (CKD) attempts to achieve good clinical outcomes through careful management of comorbidities and is likely best achieved with a multidisciplinary care (MDC) CKD clinic. In this retrospective study of children with CKD in British Columbia, Canada, we analyzed clinical outcomes in a cohort of 73 CKD patients from 2003 under a standard care model and a second cohort of 125 CKD patients from 2009 under a MDC clinic model. Patient demographics were similar, but there was a decrease in the percentage of patients with CKD stage 3-5 in 2009 (59 vs. 75 %; p = 0.002), although the absolute number increased. After adjustment for severity of CKD, hemoglobin was significantly higher (13.0 g/dl vs. 12.2 g/dl, p < 0.03), calcium was significantly higher (9.6 mg/dl vs. 9.1 mg/dl, p < 0.001), and albumin was significantly higher (4.4 g/dl vs. 3.8 g/dl, p < 0.001) in the 2009 MDC cohort. The rate of disease progression, assessed by annualized estimated glomerular filtration rate (eGFR) slope, improved from -4.0 ml/min/1.73 m(2) in the 2003 cohort to 0.5 ml/min/1.73 m(2) in the 2009 cohort (p < 0.01). Blood pressure control was better in 2009 although not statistically significant. Multidisciplinary care improved the outcomes of children with CKD especially in anemia management, bone mineral metabolism, nutrition, and renal disease progression.

The effects of home exercise on insulin resistant in chronic kidney disease patients

Insulin resistance appears at an earlier stage of chronic kidney disease (CKD) and closely correlates with atherosclerosis and cardiovascular mortality. Exercise training may improve hyperinsulinemia in patients with chronic disease, but it has proven difficult to motivate many such patients to undergo exercise training chronically. We aimed to demonstrate the effect of regular home rubber band exercise on insulin resistant in patients with CKD stage 3-5.The randomized controlled trial was conducted in CKD clinic at Phramongkutklao hospital, Bangkok, Thailand, during June to December 2010. The eligible CKD stage 3-5 participants were asked to randomly assigned to do only home gentle exercise (control) or plus home resistance exercise by using rubber band (treatment) for 12 weeks. The exercise training was supervised and strictly monitored by sport scientist every four weeks. Fasting plasma glucose and insulin concentrations was performed to calculate homeostasis model assessment (HOMA). There were 21 patients in the control group (mean age 66.05±13.72 years) and 24 patients in the treatment group (mean age 66.05±13.72 years) . At the end of study, the fasting plasma glucose (-0.76±1.84 mmol/L) and HOMA-IR (-1.09±2.43) decreased significantly in the treatment group, whereas the fasting plasma glucose (0.49±1.65 mmol/L) and HOMA-IR (0.38±2.12) slightly increase significantly in the control group. In addition, there were significant different of HOMA-IR between the control group and the treatment group (1.9±1.85 vs 3.72±3.26, P= 0.031, respectively). Moreover, all patients in the treatment group did not have serious side effect from resistance exercise, but only five patients had muscle cramp. In conclusion, regular home exercise ameliorate insulin resistance without any serious adverse effects in the CKD population.

Day-to-Day Variability in Spot Urine Protein-Creatinine Ratio Measurements

Accurate measurement of proteinuria is important in the diagnosis and management of chronic kidney disease (CKD). The reference standard test, 24-hour urinary protein excretion, is inconvenient and vulnerable to collection errors. Spot urine protein-creatinine ratio (PCR) is a convenient alternative and is in widespread use. However, day-to-day variability in PCR measurements has not been evaluated. Prospective cohort study of day-to-day variability in spot urine PCR measurement. Clinically stable outpatients with CKD (n = 145) attending a university hospital CKD clinic in Australia between July 2007 and April 2010. Spot urine PCR. Spot PCR variability was assessed and repeatability limits were determined using fractional polynomials. Spot PCRs were measured from urine samples collected at 9:00 am on consecutive days and 24-hour urinary protein excretion was collected concurrently. Paired results were analyzed from 145 patients: median age, 56 years; 59% men; and median 24-hour urinary protein excretion, 0.7 (range, 0.06-35.7) g/d. Day-to-day variability was substantial and increased in absolute terms, but decreased in relative terms with increasing baseline PCR. For patients with a low baseline PCR (20 mg/mmol [177 mg/g]), a change greater than ±160% (repeatability limits, 0-52 mg/mmol [0-460 mg/g]) is required to indicate a real change in proteinuria status with 95% certainty, whereas for those with a high baseline PCR (200 mg/mmol [1,768 mg/g]), a change of ±50% (decrease to <100 mg/mmol [<884 mg/g] or increase to >300 mg/mmol [>2,652 mg/g]) represents significant change. These study results need to be replicated in other ethnic groups. Changes in PCR observed in patients with CKD, ranging from complete resolution to doubling of PCR values, could be due to inherent biological variation and may not indicate a change in disease status. This should be borne in mind when using PCR in the diagnosis and management of CKD.

Pharmaceutical cost distribution in childhood chronic kidney disease

Chronic kidney disease (CKD) is associated with significant economic burdens to both patients and the healthcare system, but pharmaceutical cost analyses are uncommon despite drug therapy being a cornerstone of CKD management. This observational, retrospective review of drug cost distribution at a single tertiary care pediatric nephrology program in Canada was conducted on prevalent patients with CKD aged 1 month to 20 years, between 1 January and 31 December 2009. The time-adjusted annual pharmaceutical cost of our cohort (n = 148) was just below US $250,000 with a cost per patient per year of $1,800. The highest costs were in the growth and nutrition category, followed by anemia, hypertension and bone metabolism. Total drug cost per patient increased as CKD stage advanced. Adherence was not demonstrated in any drug category, and the mean daily pill burden was nine (range 2-23). This study has shown that while the annual pharmaceutical costs on a per patient basis are similar between children and adults, the cost distribution is very different. An increase in awareness of the unique needs of the pediatric population should allow for more cost-effective financial planning in pediatric CKD clinics.

Secondary Prevention of Hyperkalemia With Sodium Polystyrene Sulfonate in Cardiac and Kidney Patients on Renin‐Angiotensin‐Aldosterone System Inhibition Therapy

Hyperkalemia, induced by renin-angiotensin-aldosterone system inhibition (RAAS-I) in patients with chronic kidney disease (CKD), or cardiac disease often leads to withdrawal of RAAS-I therapy. Sodium polystyrene sulfonate (SPS) is a potassium-binding resin used for the treatment of hyperkalemia. Recently, concerns about the safety and efficacy of SPS were raised. We report here a follow-up of 14 patients with CKD and heart disease on RAAS-I treatment who were treated with low-dose daily SPS to prevent recurrence of hyperkalemia. Daily SPS is safe and effective for secondary prevention of hyperkalemia induced by RAAS-I therapy in CKD patients with heart disease. We reviewed the medical charts of the patients with CKD (nondialysis patients) and heart disease treated in our CKD clinic from 2005 to 2010 and identified all patients on RAAS-I therapy who were treated with daily SPS (sorbitol-free) after episodes of hyperkalemia. Data on hospitalizations, symptoms that may be attributed to SPS therapy, and electrolyte concentration levels were obtained. Fourteen patients were treated with low-dose SPS therapy for a total of 289 months (median length of follow-up, 14.5 months). None of the patients developed colonic necrosis or life-threatening events that could be attributed to SPS use. Mild hypokalemia was noted in 2 patients and responded to reducing the dose of SPS. No further episodes of hyperkalemia were recorded while patients were on the therapy. SPS was well-tolerated during the follow-up without need for withdrawal or reduction of the dose of RAAS-I therapy by any patients. Low-dose SPS was safe and effective as a secondary preventive measure for hyperkalemia induced by RAAS-I in CKD patients with heart disease.

Iron deficiency in children with early chronic kidney disease

Iron deficiency (ID) contributes to the development of anemia in patients with chronic kidney disease (CKD). The frequency of ID in children with early CKD has not previously been reported. This was a retrospective chart review of children with CKD stages 2 and 3 followed at the CKD clinic of Children's Hospital of Michigan. ID was defined as low ferritin and transferrin saturation <20%. Patients on iron supplements were considered as iron-deficient cases. There were 50 patients included in the study (72% male) with a mean age of 10.31 (±5.21). The mean glomerular filtration rate (GFR) was 55.4 ml/min/1.73 m(2) (±14.61). ID was present in 42% of patients, out of whom almost half (42.9%) presented with anemia. Females had a higher frequency of ID (64.3%). The frequency of ID with anemia increased from 4.3% to 29.6%, (p = 0.03) in stage 2 to stage 3 CKD, respectively. The frequency of ID without anemia also increased with progression of CKD from stage 2 to stage 3, however, the difference was not statistically significant. ID is frequent in patients with early CKD. Monitoring of iron tests and treatment of ID is important in this population of patients.

Quality of care and mortality are worse in chronic kidney disease patients living in remote areas

Many patients with non-dialysis dependent chronic kidney disease (CKD) live far from the closest nephrologist; although reversible, this might constitute a barrier to optimal care. In order to evaluate outcomes, we selected 31,452 outpatients older than 18 years with an estimated glomerular filtration rate (eGFR) less than 45 ml/min per 1.73 m² who had serum creatinine measured at least once during 2005 in Alberta, Canada. We then used logistic regression to examine the association between outcomes of 6545 patients who lived more than 50 km from the nearest nephrologist. Over a median follow-up of 27 months, 7684 participants died and 15,075 were hospitalized at least once. Compared with those living within 50 km, those further away were significantly less likely to visit a nephrologist or a multidisciplinary CKD clinic within 18 months of the index measurement of the eGFR. Similarly, remote dwellers with diabetes were significantly less likely to have hemoglobin A1c evaluated within 1 year of the index eGFR measurement, to have urinary albumin assessed biannually, or to receive an angiotensin converting enzyme inhibitor or receptor blocker in the setting of diabetes or proteinuria. Remote-dwelling participants were also significantly more likely to die or be hospitalized during follow-up than those living closer. Thus, among people with CKD, remote dwellers were less likely to receive specialist care, recommended laboratory testing, and appropriate medications, and were more likely to die or be hospitalized compared with those living closer to a nephrologist.

Practice Spotlight: Pharmacist in a Chronic Kidney Disease Clinic

Practice Spotlight: Pharmacist in a Chronic Kidney Disease Clinic