Chronic Kidney Disease Guidelines Research Articles

Snacks for the Patient With Chronic Kidney Disease

Nutrition for the patient with chronic kidney disease (CKD) can be complex. Research has shown that nutritional intake can play a significant role in disease progression and includes consideration of dietary sodium, protein, potassium, phosphorus, and calcium. Depending on the phase of CKD, individuals will have different nutrient needs and therefore medical nutrition therapy intervention should be individualized.1 In the 2020 Kidney Disease Quality Initiative Outcomes Clinical Nutrition Guidelines for CKD, the role of the registered dietitian nutritionist with diet individualization was specifically highlighted.

Итоговое резюме KDIGO 2018 по гепатиту С для рекомендаций по ХБП: достижения в оценке и менеджменте

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Serum fibroblast growth factor-23 concentrations in young and mature adult cats with chronic kidney disease.

The aim of this study was to investigate serum fibroblast growth factor (FGF)-23 concentrations in young and mature adult cats with chronic kidney disease (CKD). The present study retrospectively investigated the serum samples and medical records of 1-8-year-old clinically healthy cats (control group, n = 7) and cats with CKD (n = 54). Cats with CKD were divided into four stages based on serum creatinine concentrations, according to the International Renal Interest Society (IRIS) CKD guidelines. Serum FGF-23 concentrations were compared between cats in the control group, IRIS stages 1, 2 and 3-4 CKD. Continuous variables were analysed using correlations and multiple linear regression. Serum FGF-23 concentrations were significantly higher in cats with IRIS stages 1, 2 and 3-4 CKD, compared with those in the control group (P = 0.02, P = 0.002 and P = 0.002, respectively). Additionally, serum FGF-23 concentrations in cats with IRIS stages 3-4 CKD had higher serum FGF-23 concentrations than those with IRIS stages 1 and 2 CKD (P = 0.04 and P = 0.02, respectively). In the multiple linear regression analysis, serum urea nitrogen concentration, serum phosphorus concentration and blood ionised calcium concentration were independent variables predicting serum FGF-23 concentration. Serum FGF-23 concentrations in younger cats with CKD increased in early-stage CKD and were associated with mineral metabolic markers, as also occurs in geriatric cats.

EVALUATION OF THE EFFECTS OF BIOCHEMICAL MARKERS LIKE CALCIUM, PHOSPHORUS AND PARATHORMONE IN PREDICTING THE COMPLICATIONS & MORTALITY IN CHRONIC KIDNEY DISEASE

Introduction: Chronic kidney disease (CKD) is an international public health problem affecting about 5–10% of the population. As kidney function declines, there is a progressive deterioration in mineral homeostasis with disruption of normal serum concentrations of phosphorus, calcium and changes in circulating levels of hormones like parathyroid hormone (PTH) and Vitamin D3. Hyperparathyroidism plays a vital role in the excess morbidity and mortality in chronic kidney disease. As a result; patients are at increased risk of bone disease, extraosseous calcification, and death. Aims and Objectives: To estimate the serum Calcium, Phosphorus, Parathyroid Hormone levels in patients with CKD and to compare them with healthy individuals. To know the association between Calcium, phosphorus and PTH in CKD patients. Material & Methods: 50 cases of CKD and 50 controls were included in the study. Serum calcium, phosphorus and PTH were measured in both cases and controls. Statistically significant increases in levels of all parameters were seen in cases as compared to controls. Conclusion: The levels of PTH, calcium & phosphorus are used as surrogate markers of disease progression. Abnormalities can occur subtly, usually without any symptoms, and may progress to cause more complications if not detected early. The ultimate goals of treating secondary hyperparathyroidism are to normalize mineral metabolism, prevent bone disease, and prevent extra skeletal manifestations of the altered biochemical processes. Various CKD Guidelines recommend targets and early treatment strategies to correct serum levels of phosphorus, calcium, and PTH levels. Keywords: CKD – Chronic kidney disease, PTH – Parathyroid hormone, ESRD – End stage renal disease, Glomerular filtration rate -GFR

Nationwide questionnaire survey on the management of chronic kidney disease for general practitioners in Japan.

In 2019, a nationwide questionnaire survey on the management of chronic kidney disease (CKD) was circulated to general practitioners (GPs) throughout Japan by The Japan Physicians Association. The aim was to assess the current state of CKD medical care in the country and evaluate the utilization of CKD-specific guidelines in the treatment by GPs. The voluntary survey targeted all members of Japan Physicians Association, a nationwide organization consisting primarily of 15,000 GPs in clinics throughout the country. GPs were divided into groups: 171 GPs using and 414 GPs not using the guidelines. Comparisons between the groups' responses were made using propensity score matching and component cluster analysis. Overall responses revealed that the estimated glomerular filtration rate's utilization rate was high (95.1%). However, evidence-practice gaps in urine protein quantification and anemia remedy were prominent. There were significantly favorable answers in terms of CKD management in the user group compared with those in the non-user group, except for the questions about a urine check at the first visit, stopping the use of renin-angiotensin system inhibitors, and the target blood pressure for elderly CKD patients. The differences suggest that utilization of the CKD guidelines has improved CKD management practices by GPs. Further promotion of CKD guidelines utilization (28% in this survey) is considered valid for CKD medical education.

Applying Logistic Regression to Predict Diabetic Nephropathy Based on Some Clinical and Paraclinical Characteristics of Type 2 Diabetic Patients

Applying Logistic Regression to Predict Diabetic Nephropathy Based on Some Clinical and Paraclinical Characteristics of Type 2 Diabetic Patients

Misclassification of calcium status in end-stage kidney disease using albumin-adjusted calcium levels.

Albumin-adjusted calcium remains widely used in clinical practice with guidelines for chronic kidney disease (CKD) mineral bone disorder recommending the use of serum calcium for monitoring. This is despite ionized calcium being the biologically active fraction. This study aimed to investigate the ability of total calcium and albumin-adjusted calcium to correctly assign calcium status in stage 5/5D CKD across non-dialysis, haemodialysis and peritoneal dialysis patients. Over a 6-months, 352 paired serum and ionized calcium samples were collected from stage 5 (n= 58) and 5D (n= 294, 196 haemodialysis, 98 peritoneal dialysis) CKD patients in a tertiary-hospital setting. Albumin-adjusted calcium was calculated using the modified-Payne formula. Ionized calcium was the reference standard. The agreement between the two methods in assigning calcium status was assessed using Cohen's weighted kappa (κ) statistic. Albumin-adjusted calcium was a poor predictor of calcium status compared to ionized calcium in stage 5/5D CKD (observed agreement 0.42, weighted κ 0.20, 95% CI 0.15-0.26). Dialysis dependence was associated with worse agreement (observed agreement 0.38, weighted κ 0.14, 95% CI 0.09-0.19). Total calcium was more reliable, however, remained inaccurate. Calcium status was not more accurately classified in those with higher albumin levels ≥30 g/L (observed agreement 0.47, weighted κ 0.23, 95% CI 0.10-0.36). Total calcium provides better approximation of calcium status than albumin-adjusted calcium in stage 5/5D CKD. Albumin-adjusted calcium tends to 'overcorrect' serum calcium upward. Clinicians should use ionized calcium where accurate measure of calcium is indicated, with total calcium used as the next best option where resources are limited.

Impact of Using Risk-Based Stratification on Referral of Patients With Chronic Kidney Disease From Primary Care to Specialist Care in the United Kingdom

IntroductionThe externally validated Kidney Failure Risk Equation (KFRE) for predicting risk of end-stage renal disease (ESRD) has been developed, but its potential impact in a population on referrals for patients with chronic kidney disease (CKD) from primary to specialty nephrology care is not known.MethodsA cross-sectional population-based study of individuals in United Kingdom primary care registered in The Health Improvement Network database was conducted. National Institute of Health and Care Excellence (NICE) 2014 CKD guidelines versus the 4-variable KFRE set at a >3% risk of ESRD at 5 years were applied to patients identified with CKD stage 3-5 between January 1, 2016, and March 31, 2017.ResultsIn all, 39,476 (36.6%) of 107,962 adults with CKD stage 3-5 had a urine albumin:creatinine ratio (ACR) available and entered into the primary analysis. Of that, 7566 (19.2%) patients fulfilled NICE criteria for referral, 2386 (31.5%) of whom had a ≤3% 5-year risk of ESRD. Also 8663 (21.9%) patients had a >3% 5-year risk of ESRD, 3483 (40.2%) of whom did not fulfill NICE criteria; this represents 8.8% of the primary population. By using the KFRE threshold rather than NICE criteria for referral, 5869 patients (14.9% of the primary analysis population) would have been reallocated between primary and specialist care. Imputational analysis was used for missing ACR measurements and showed similar results.ConclusionsA risk-based referral approach would lead to a substantial reallocation of patients between primary care and specialist nephrology care with only a small increase in numbers eligible, ensuring those at higher risk of progression are identified.

Dietary patterns associated with renal impairment in the Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA)

BackgroundDietary-based primary prevention guidelines for chronic kidney disease (CKD) treatment are lacking due to limited evidence. Single nutrient intake studies do not account for complex dietary interactions. We assessed associations between dietary patterns and renal function in the Northern Ireland Cohort for the Longitudinal Study of Ageing (NICOLA).DesignA cross-sectional observational study used NICOLA baseline dietary data collected between February 2014 and March 2016 via a food frequency questionnaire for 2590 participants aged ≥ 50 years. Principal component analysis identified a posteriori dietary patterns. Renal function was characterised by estimated glomerular filtration rate (eGFR) using serum creatinine and cystatin-C. Associations were assessed according to quintiles of dietary pattern adherence and multivariable regression analysis examined associations with eGFR.ResultsVariation in three dietary patterns was significantly associated with eGFR. After adjustment for potential confounders, participants with least adherence to the ‘healthy’ dietary pattern 1 had a mean eGFR 3.4 ml/min/1.73m2 (95% confidence interval, [CI] − 5.0, − 1.7, p < 0.001) lower than the most adherent. Those with lowest adherence to the ‘unhealthy’ dietary pattern 2 had a mean eGFR 1.9 ml/min/1.73m2 (CI 0.2, 3.5, p = 0.03) higher than those with highest adherence. Participants with lowest adherence to dietary pattern 3, characterised by a high consumption of alcohol and coffee, had a mean eGFR 1.8 ml/min/1.73m2 (− 3.5, − 0.01, p = 0.05) lower than those with greatest adherence.ConclusionsOur findings identify independent associations between dietary patterns and eGFR. These findings can inform the development of diet-related primary prevention advice for CKD.

Neighborhood Socioeconomic Status and Quality of Kidney Care: Data From Electronic Health Records

Rational & ObjectiveElectronic health records can be leveraged to assess quality-of-care measures in patients with chronic kidney disease (CKD). Neighborhood socioeconomic status could be a potential barrier to receiving appropriate evidence-based therapy and follow-up. We examined whether neighborhood socioeconomic status is independently associated with quality of care received by patients with CKD.Study DesignObservational study using electronic health record data.Setting & ParticipantsRetrospective study of patients seen at a health care system in the 7-county Minneapolis/St Paul area.ExposuresCensus tract socioeconomic status measures (wealth, income, and education).OutcomesIndicators of CKD quality of care: (1) prescription for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in patients with stage ≥ 3 CKD or stage 1 or 2 CKD with urinary albumin-creatinine ratio (UACR) > 300 mg/d, (2) UACR measurement among patients with laboratory-based CKD (estimated glomerular filtration rate < 60 mL/min/1.72 m2), and (3) CKD identified on the problem list or coded for at an encounter among patients with laboratory-based CKD.Analytic ApproachMultilevel Poisson regression with robust error variance with a random intercept at the census tract level.ResultsOf the 16,776 patients who should be receiving an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 65% were prescribed these medications. Among patients with laboratory-based CKD (n = 25,097), UACR was measured in 27% and CKD was identified in the electronic health record in 55%. We found no independent association between any neighborhood socioeconomic status measures and CKD quality-of-care indicators.Limitations1 health care system and selection bias.ConclusionsWe found no association of neighborhood socioeconomic status with quality of CKD care in our cohort. However, adherence to CKD guidelines is low, indicating an opportunity to improve care for all patients regardless of neighborhood socioeconomic status.

Adherence to the Kidney Disease: Improving Global Outcomes CKD Guideline in Nephrology Practice Across Countries

IntroductionThe uptake of the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 chronic kidney disease (CKD) Guideline is not fully described in real-world nephrology practice across the world.MethodsWe used baseline data from the CKD Outcomes and Practice Patterns Study (2013–2017), a 4-country cohort of patients with estimated glomerular filtration rate <60 ml/min per 1.73 m2 recruited from national samples of nephrology clinics, to describe adherence to measures for monitoring and delaying CKD progression. Data were collected as in clinical practice, except laboratory measures per protocol in France.ResultsThe mean age ranged from 65 years in Brazil to 72 years in Germany. Albuminuria (mostly proteinuria) was measured routinely in 36% to 43% of patients in Brazil, Germany, and the United States. Blood pressure control (≤140/90 mm Hg) ranged from 49% in France to 76% in Brazil; <40% of patients had blood pressure ≤130/80 mm Hg everywhere but Brazil (52%). More than 40% of nephrologists in Brazil reported a systolic blood pressure target ≤130 mm Hg for nondiabetic patients without proteinuria, but only 19% to 24% elsewhere. Prescription of renin-angiotensin aldosterone system inhibitors ranged from 52% in the United States to 81% in Germany. Dietary advice was more frequent for salt than protein intake; dietitian visits were uncommon. In nondiabetic patients, achievement of all 3 targets including blood pressure ≤130/80 mm Hg, renin-angiotensin aldosterone system inhibition, and dietary advice, ranged from 10% in the United States to 32% in Brazil; in treated diabetic patients, this ranged from 6% to 11% after including hemoglobin A1c target.ConclusionAdherence to recommendations to slow CKD progression is low in typical practice settings, and substantial variation among countries for some indicates opportunities for improvement.

Editorial introductions

Current Opinion in Nephrology and Hypertension was launched in 1992. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of nephrology and hypertension is divided into 12 sections that are each reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Maarten W. TaalMaarten W. TaalDr Maarten W. Taal graduated from the University of Cape Town Medical School, South Africa, in 1987. After completing his post-graduate training in internal medicine and nephrology at Groote Schuur Hospital, Cape Town, South Africa he joined the Laboratory of Kidney and Electrolyte Physiology at Brigham and Women's Hospital, Boston, USA under the directorship of Barry M. Brenner, MD. His research focused on mechanisms underlying the progression of chronic kidney disease and earned him a Doctor of Medicine degree. He subsequently moved to the United Kingdom where he was appointed a Consultant Renal Physician at Royal Derby Hospital, UK, in 2002 and Honorary Associate Professor at the University of Nottingham, UK in 2011. He was appointed Professor of Medicine in the Division of Medical Sciences and Graduate Entry Medicine at the University of Nottingham in April 2014, where he leads the Centre for Kidney Research and Innovation. His current research interests include chronic kidney disease progression, diabetic nephropathy, renal osteodystrophy and cardiovascular disease in patients with chronic kidney disease (CKD). He has a career-long interest in CKD and co-authored the Renal Association's Clinical Practice Guidelines for CKD. He serves as an Editor for Brenner and Rector's The Kidney, Section Editor for Current Opinion in Nephrology and Hypertension and Academic Editor for PLOS Medicine. He is Chair of the UK Kidney Research Consortium CKD Clinical Study Group and Immediate Past President of the British Renal Society. David J. CohenDavid J. CohenDavid J. Cohen, MD, MA is the Daniel Midler-John A Catsimatidis Professor of Nephrology (in Medicine) and the Medical Director of Kidney and Pancreas Transplantation at Columbia University Irving Medical Center, USA/New York Presbyterian Hospital, New York, USA. He completed his nephrology training at Columbia University, followed by a research fellowship in the transplantation and immunogenetics laboratory of Dr Bernard Carpenter at the Brigham and Women's Hospital, Boston, Massachusetts, USA. He has been on the full-time faculty at Columbia University since 1983. He is a former member of the Board of Directors of the American Society of Transplantation, and served as the head of the Public Policy Committee for many years. He was the co-Editor of NephSAP Transplantation in 2019, 2013 and 2011. His research interests include the clinical application of new immunosuppressive medications, live donor advocacy and improving access to kidney transplantation through reducing the number of kidney discards.

The Kidney Score Platform for Patient and Clinician Awareness, Communication, and Management of Kidney Disease: Protocol for a Mixed Methods Study.

BackgroundPatient awareness, clinician detection, and management of chronic kidney disease remain suboptimal, despite clinical practice guidelines and diverse education programs.ObjectiveThis protocol describes a study to develop and investigate the impact of the National Kidney Foundation Kidney Score Platform on chronic kidney disease awareness, communication, and management, by leveraging the Behavior Change Wheel, an implementation science framework that helps identify behavioral intervention targets and functions that address barriers to behavior change.MethodsWe interviewed 20 patients with chronic kidney disease and 11 clinicians to identify patient and clinician behaviors suitable for intervention and barriers to behavior change (eg, limited awareness of chronic kidney disease clinical practice guidelines within primary care settings, limited data analytics to highlight chronic kidney disease care gaps, asymptomatic nature of chronic kidney disease in conjunction with patient reliance on primary care clinicians to determine risk and order kidney testing). Leveraging the Behavior Change Wheel, the Kidney Score Platform was developed with a patient-facing online Risk Calculator and a clinician-facing Clinical Practice Toolkit. The Risk Calculator utilizes risk predictive analytics to provide interactive health information tailored to an individual’s chronic kidney disease risk and health status. The Clinical Practice Toolkit assists clinicians in discussing chronic kidney disease with individuals at risk for and with kidney disease and in managing their patient population with chronic kidney disease. The Kidney Score Platform will be tested in 2 Veterans Affairs primary health care settings using a pre–post study design. Outcomes will include changes in patient self-efficacy for chronic kidney disease management (primary outcome), quality of communication with clinicians about chronic kidney disease, and practitioners’ knowledge of chronic kidney disease guidelines. Process outcomes will identify usability and adoption of different elements of the Kidney Score Platform using qualitative and quantitative methods.ResultsAs of September 2020, usability studies are underway with veterans and clinicians to refine the patient-facing components of the Kidney Score Platform before study initiation. Results and subsequent changes to the Kidney Score Platform will be published at a later date. The study is expected to be completed by December 2021.ConclusionsResults of this study will be used to inform integration of the Kidney Score Platform within primary care settings so that it can serve as a central component of the National Kidney Foundation public awareness campaign to educate, engage, and empower individuals at risk for and living with chronic kidney disease.International Registered Report Identifier (IRRID)PRR1-10.2196/22024

ASIAN PACIFIC SOCIETY OF NEPHROLOGY CLINICAL PRACTICE GUIDELINE ON DIABETIC KIDNEY DISEASE.

ASIAN PACIFIC SOCIETY OF NEPHROLOGY CLINICAL PRACTICE GUIDELINE ON DIABETIC KIDNEY DISEASE.

CKDNET, a quality improvement project for prevention and reduction of chronic kidney disease in the Northeast Thailand

BackgroundThe incidence of chronic kidney disease (CKD) is high in the Northeast Thailand compared to other parts of the country. Therefore, a broad program applying all levels of care is inevitable. This paper describes the results of the first year trial of the Chronic Kidney Disease Prevention in the Northeast Thailand (CKDNET), a quality improvement project collaboratively established to curb CKD.MethodsWe have covered general population, high risk persons and all stages of CKD patients with expansive strategies such as early screening, effective CKD registry, prevention and CKD comprehensive care models including cost effectiveness analysis.ResultsThe preliminary results from CKD screening in general population of two rural sub-districts show that 26.8% of the screened population has CKD and 28.9% of CKD patients are of unknown etiology. We have established the CKD registry that has enlisted a total of 10.4 million individuals till date, of which 0.13 million are confirmed to have CKD. Pamphlets, posters, brochures and other media of 94 different types in the total number of 478,450 has been distributed for CKD education and awareness at the community level. A CKD guideline that suits for local situation has been formulated to deal the problem effectively and improve care. Moreover, our multidisciplinary intervention and self-management supports were effective in improving glomerular filtration rate (49.57 versus 46.23 ml/min/1.73 m2; p < 0.05), blood pressure (129.6/76.1 versus 135.8/83.6 mmHg) and quality of life of CKD patients included in the program compared to those of the patients under conventional care. The cost effectiveness analysis revealed that lifetime cost for the comprehensive health services under the CKDNET program was 486,898 Baht compared to that of the usual care of 479,386 Baht, resulting in an incremental-cost effectiveness ratio of 18,702 Baht per quality-adjusted life years gained.ConclusionCKDNET, a quality improvement project of the holistic approach is currently applying to the population in the Northeast Thailand which will facilitate curtailing of CKD burden in the region.

Concordancia de la filtración glomerular estimada según las fórmulas utilizadas en Colombia en pacientes con enfermedad renal crónica no en diálisis

Introducción: las guías colombianas de enfermedad renal crónica (ERC) recomiendan estimar la filtración glomerular (FG) con la fórmula de Epidemiología de la Enfermedad Renal Crónica (CKD-EPI). No se han realizado estudios que comparen en la población colombiana la exactitud de esta fórmula con otras utilizadas en la práctica clínica.&#x0D; Diseño y Métodos: En 757 pacientes adultos evaluamos el desempeño para estimar la FG por las fórmulas de la Modificación de la Dieta en la Enfermedad Renal (MDRD4), Cockroft-Gault (CG) y Cockroft-Gault corregida para la superficie corporal (CG-SC) comparada con la fórmula de CKD-EPI. El desempeño se evaluó con mediciones del sesgo, precisión y exactitud.&#x0D; Resultados: La media de la FG por CKD-EPI fue 37.32±12.71 ml/min/1.73m2, por MDRD4 de 39.8±13.2 ml/min/1.73m2, por CG fue 35±12.6 ml/min y por CG-SC de 34.52±11.34 ml/min/1.73m2. Todas las fórmulas tuvieron un sesgo con relación a la FG por CKD-EPI. La fórmula más precisa y más exacta fue la MDRD4 que sólo difirió una proporción&gt;15% y del 30% en el 2.9% y 0.26% de las mediciones respectivamente y la menos exacta fue la FG estimada por CG que difirió en el 40.3% y 18.23% de las mediciones. El coeficiente de correlación entre la FG por CKD-EPI y MDRD4 fue de 0.97, con CG y CG-SC de 0.78 y 0.85, respectivamente.&#x0D; Conclusiones: la fórmula alterna más exacta para estimar la filtración glomerular en esta población colombiana es la MDRD-4 que tiene una alta concordancia con la fórmula de CKD-EPI. Se sugiere no utilizar la estimación de la FG con la fórmula de CG.

Translation of Nutrient Level Recommendations to Control Serum Phosphate Into Food-Based Advice

The control of hyperphosphatemia is key to the management of chronic kidney disease mineral and bone disorder. Dietary restriction of phosphorus is essential to control hyperphosphatemia. Guidelines for chronic kidney disease and end-stage kidney disease generally provide high-level guidance on whether a nutrient should be restricted e.g, restrict dietary phosphorus. Dietitians translate such guidance into nutrient-based strategies and finally into food-based practical dietary advice for patients to follow. The practical aspects of dietary advice are not well described in the literature, neither are the challenges of concurrently altering 1 nutrient e.g., phosphorus while continuing to restrict others e.g., potassium, while maintaining overall nutritional adequacy and quality of life. In this article, we describe how we translated updated nutrient level recommendations into practical dietary advice to be delivered at the bedside.

Recent advances in the management of secondary hypertension: chronic kidney disease.

Hypertension in chronic kidney disease (CKD) is the most commonly observed comorbidity and is a risk factor for end-stage renal disease (ESRD) as well as cardiovascular disease (CVD) and mortality. Therefore, suitable blood pressure (BP) control in CKD patients is very important in preventing both CVD and ESRD. We herein describe the recommendations of target BP and the pharmacological drug options from the evidence-based clinical practice guidelines for CKD in 2018 by the Japanese Society of Nephrology (JSN CKD 2018) and recent advances in the management of hypertension in CKD, including sodium-glucose cotransporter (SGLT) 2 inhibitors, mineralocorticoid receptor blockers, and renal denervation. In particular, SGLT2 inhibitors are a new class of "antihypertensive drugs" that have a homeostatic mechanism that regulates body fluid volume in addition to diuretic action, which may be closely associated with their cardiorenal protective properties.

P1156TWO YEAR FOLLOW UP QUALITY INDICATORS COMPLIANCE IN A LARGE INTERNATIONAL PERITONEAL DIALYSIS INSTITUTION

Abstract Background and Aims Peritoneal dialysis (PD) practice is not universally homogeneous, best clinical practices are not completely understood as reference values are often obtained from small sized populations and/or frequently based on chronic kidney disease (CKD) and/or hemodialysis data. To evaluate two years of follow up of compliance with PD-related quality indicators (QIs) following definition of new targets in an international PD network. Method All English and Spanish language CKD and PD guidelines were reviewed. Twelve Qis were considered being of significant relevance and targets for these QIs were defined (see table). Retrospective data analysis. Results Achievement of QI targets for years 2017-2018 is shown in table. Variability among countries not shown. Conclusion There was a significant increase in QIs achievement in 2018 vs. 2017. ≥75% of patients met the target for the following variables: total weekly Kt/Vurea, 24 h fluid removal, mean arterial blood pressure and serum albumin. Peritonitis rates are clearly over International objectives and were improving. Due to the lack of referral source data, these series may help to understand PD practice and outcomes in a global setting.

P0758THE CORRELATION BETWEEN THE MANAGEMENT OF COMORBIDITIES AND THE PROGRESSION OF THE RENAL DYSFUNCTION OR ADVERSE EVENTS OF CHRONIC KIDNEY DISEASE

Abstract Background and Aims Several factors, such as anemia, hypertension, hyperuricemia, metabolic acidosis, and chronic kidney disease (CKD)-mineral and bone disorder (MBD), are associated with the progression of CKD or adverse events in CKD patients. However, the significant factors associated with the progression of CKD or adverse events in patients under the condition of appropriate control according to guidelines have not been clarified. Method The study was a 3-year observational study conducted in a single center. In 88 patients with various stages of CKD (not on renal replacement therapy (RRT)) who were treated by nephrologists, blood levels of Hb, ferritin, iron, total iron-binding capacity, and albumin were measured every 3 months, and high-sensitivity C reactive protein (hCRP), β2-microglobulin (MG), HCO3-, and intact-parathyroid hormone (int-PTH), in addition to urinary sodium, potassium, calcium, phosphorus, protein, and β2-MG levels, were measured every 6 months. We also evaluated the doses of iron, erythropoiesis-stimulating agent (ESA), vitamin D, phosphate binder, anti-hypertensive agents, and anti-hyperuricemic agents. All patients were treated according to the clinical practice guidelines for CKD (Japanese Society of Nephrology 2013). A time-dependent Cox hazard model was applied to evaluate the associations between clinical parameters and adverse events (initiation of RRT and hospitalization resulting in cardiovascular disease or infection). Results Unexpectedly, under the condition of appropriate control by nephrologists, hypertension, hyperuricemia, metabolic acidosis, iron metabolism, and inflammation were not selected as significant predictors of the progression of renal dysfunction or adverse events. (Factors associated with the progression of renal dysfunction) In multiple regression analysis, lower baseline blood levels of Hb (β=0.497, P&amp;lt;0.001) and vitamin D 125 (β=0.258, P=0.006) and higher baseline blood levels of int-PTH (β=-0.334, P=0.001), urinary phosphorus (β=0.328, P=0.001), urinary β2-MG (β=-0.225, P=0.031) and urinary protein (β=0.280, P=0.02) were selected as significant predictors of reduced estimated glomerular filtration rate (eGFR) or 1/creatinine (Cr) at the end of the study. (Factors associated with the initiation of RRT and adverse events) In the Cox hazard model, low calcium (HR: 0.37, P=0.026), high phosphate (HR: 5.90, P&amp;lt;0.001), low 1,25-vitamin D (HR: 0.94, P=0.013), high int-PTH (HR: 1.02, P&amp;lt;0.001), use of a phosphate binder (HR: 4.95, P=0.012), and use of vitamin D analogs (HR: 3.75, P=0.014) were selected as risks for adverse events, including the initiation of RRT. Conclusion In this study, we found that among several factors, anemia and CKD-MBD-related factors (phosphate, calcium, vitamin D, int-PTH) were selected as significant predictors of the progression of renal dysfunction. Furthermore, although phosphate binders or vitamin D analogs were administered appropriately, CKD-MBD-related factors (phosphate, calcium, vitamin D, and int-PTH) were associated with RRT initiation or adverse events in these patients. From these results, we presumed that early intervention or strict control of CKD-MBD factors might attenuate the risk for adverse events in CKD patients.