Chronic Kidney Disease Participants Research Articles

Subgroup analysis of the ASPirin in Reducing Events in the Elderly randomized clinical trial suggests aspirin did not improve outcomes in older adults with chronic kidney disease

The role of aspirin for primary prevention in older adults with chronic kidney disease (CKD) is unclear. Therefore, post hoc analysis of the randomized controlled trial ASPirin in Reducing Events in the Elderly (ASPREE) was undertaken comparing 100 mg of enteric-coated aspirin daily against matching placebo. Participants were community dwelling adults aged 70 years and older in Australia, 65 years and older in the United States, all free of a history of dementia or cardiovascular disease and of any disease expected to lead to death within five years. CKD was defined as present at baseline if either eGFR under 60mL/min/1.73m2 or urine albumin to creatinine ratio 3 mg/mmol or more. In 4758 participants with and 13004 without CKD, the rates of a composite endpoint (dementia, persistent physical disability or death), major adverse cardiovascular events and clinically significant bleeding in the CKD participants were almost double those without CKD. Aspirin's effects as estimated by hazard ratios were generally similar between CKD and non-CKD groups for dementia, persistent physical disability or death, major adverse cardiovascular events and clinically significant bleeding. Thus, in our analysis aspirin did not improve outcomes in older people while increasing the risk of bleeding, with mostly consistent effects in participants with and without CKD.

Cardiac Biomarkers and Risk of Mortality in CKD (the CRIC Study)

IntroductionCardiovascular disease (CVD) is the leading cause of mortality among individuals with chronic kidney disease (CKD). Cardiac biomarkers of myocardial distention, injury, and inflammation may signal unique pathways underlying CVD in CKD. In this analysis, we studied the association of baseline levels and changes in 4 traditional and novel cardiac biomarkers with risk of all-cause, CV, and non-CV mortality in a large cohort of patients with CKD.MethodsAmong 3664 adults with CKD enrolled in the Chronic Renal Insufficiency Cohort Study, we conducted a cohort study to examine the associations of baseline levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), cardiac high-sensitivity troponin T (hsTnT), growth differentiation factor−15 (GDF-15), and soluble ST-2 (sST-2) with risks of all-cause and cardiovascular (CV) mortality. Among a subcohort of 842 participants, we further examined the associations between change in biomarker levels over 2 years with risk of all-cause mortality. We used Cox proportional hazards regression models and adjusted for demographics, kidney function measures, cardiovascular risk factors, and medication use.ResultsAfter adjustment, elevated baseline levels of each cardiac biomarker were associated with increased risk of all-cause mortality: NT-proBNP (hazard ratio [HR] = 1.92, 95% confidence interval [CI] = 1.73−2.12); hsTnT (HR = 1.62, 95% CI = 1.48, 1.78]); GDF-15 (HR = 1.61, 95% CI = 1.46−1.78]); and sST-2 (HR = 1.26, CI = 1.16−1.37). Higher baseline levels of all 4 cardiac biomarkers were also associated with increased risk of CV. Declines in NT-proBNP (adjusted HR = 0.55, 95% CI = 0.36−0.86) and sST2 (HR = 0.55, 95% CI = 0.36−0.86]) over 2 years were associated with lower risk of all-cause mortality.ConclusionIn a large cohort of CKD participants, elevations of NT-proBNP, hsTnT, GDF-15, and sST-2 were independently associated with greater risks of all-cause and CV mortality.

Additional prognostic value of electrocardiographic left ventricular hypertrophy in traditional cardiovascular risk assessments in chronic kidney disease.

Left ventricular hypertrophy (LVH) is a common predictor of the cardiovascular prognosis in chronic kidney disease (CKD). However, whether or not electrocardiography-derived LVH (ECG-LVH) has prognostic value in patients with various degrees of CKD and improves the cardiovascular risk stratification based on traditional risk factors remains unclear. A total of 7206 participants at least 40 years of age who were free from cardiovascular events in a general population were followed for the incidence of cardiovascular events. CKD was confirmed by either the presence of a reduced estimated glomerular filtration rate (eGFR) (<60 ml/min per 1.73 m) or albuminuria, defined as a urinary albumin-to-creatinine ratio (UACR) of at least 30 mg/g Cr. A total of 1886 (26.2%) had CKD, of which 1471 (78.0%) had a preserved eGFR (CKD stage 1-2). After an average 11.3 years of follow-up, the adjusted hazard ratio for the incidence of cardiovascular events significantly increased for ECG-LVH according to the Sokolow--Lyon voltage, Cornell voltage, or Cornell voltage product among participants with CKD (hazard ratio 1.47, P = 0.002), in contrast to those without CKD (hazard ratio 1.15, P = 0.210). The inclusion of any ECG-LVH parameters improved the accuracy of reclassification in any risk prediction model based on the eGFR, UACR, or Framingham 10-year risk score in the CKD participants (net reclassification improvement = 0.13-0.32, all P values <0.040). In patients with CKD stage 1-5, ECG-LVH is useful for predicting the risk of future cardiovascular events and adds prognostic information to traditional cardiovascular risk assessments.

P0813FRAILTY MODIFIES THE ASSOCIATION BETWEEN OPIOID USE AND MORTALITY IN CHRONIC KIDNEY DISEASE PATIENTS: A POPULATION-BASED COHORT STUDY

Abstract Background and Aims The prevalence of chronic pain in patients with chronic kidney disease (CKD) is high and is associated with higher frailty risk, but satisfactory pain control frequently fails to be achieved. Opioid remains instrumental regarding optimal pain management, but its influence on outcomes can be of concern in CKD patients. We examined whether opioid use affected patient outcome and whether such relationship was modified by frailty. Method From the longitudinal cohort of diabetic patients (n = 840,000), a well-maintained population-based cohort, we identified those with CKD who were opioid user (at least 7 days within any month; n = 26,029), followed by propensity score-matched to opioid never-users from the same cohort in a 1:1 ratio, based on demographic features, comorbidities, and other medications. We analysed the associations between opioid use and survival in these patients according to their baseline frailty status, defined by the modified FRAIL (Fatigue, Resistance, Ambulation, Illness, and Loss of weight) scale. Results Among the enrolled CKD participants (mean age 62.9 ± 13.5 years, 48.2% female), 20.3% did not have any FRAIL item satisfied, while 57.2%, 20.6%, and 1.9% had 1, 2, and at least 3 positive FRAIL items at baseline, respectively. After a median of 4.2 years, 16.4% participants died. Univariate analysis showed that opioid users had an elevated risk of morality compared to non-users (hazard ratio [HR] 1.124, 95% confidence interval [CI] 1.08 – 1.17) (Figure). Cox proportional hazard regression showed that opioid users exhibited an 18.3% higher risk of mortality compared to non-users (HR 1.183, 95% CI 1.13-1.24) among patients with CKD; furthermore, the mortality risk associated with opioid use was observed in CKD participants without frailty only (HR 1.18, 95% CI 1.13-1.24) but not in those with frailty (HR 1.08, 95% CI 0.83 – 1.4). Conclusion Opioid use might lead to a higher risk of mortality among CKD patients, but this relationship was observed among those without frailty only. Interestingly, frail CKD patients who were opioid users were not at an elevated risk of mortality compared to non-users.

Using Spot Urine Samples to Estimate Sodium and Potassium intake in Healthy vs CKD Patients: Results from a Controlled Feeding Study

Abstract Objectives Evaluating sodium (Na) and potassium (K) intake is important as both have implications for blood pressure and cardiovascular health, especially in individuals with chronic kidney disease (CKD). Spot urine samples may be used to estimate Na and K intake with several published equations, but the accuracy has not been thoroughly explored. Our objective was to compare estimated 24-hour urinary Na and K excretion (e24hUNa and e24hUK), calculated from a spot urine sample using published equations, to measured 24hUNa and 24hUK and Na and K intake, and to determine if there are differences between healthy and CKD participants. Methods This is a secondary analysis of a controlled feeding study in participants with moderate CKD matched to healthy adults (n = 16). Participants consumed a controlled diet for 9 days, providing ∼2400 mg Na/d and ∼3000 mg K/d. On days 7 and 8, participants collected all urine in an inpatient setting. Urine Na and K were analyzed by ICP and urine creatinine by the Jaffe reaction. The day 7 fasting urine sample was used to calculate e24hUNa using 2 equations and e24huK using 1 equation. Log-transformed Na intake, measured 24hUNa, and e24hUNa were compared using a general linear mixed model and partial correlations, and agreement between Na intake and e24hUNa was assessed using Bland-Altman plots. Similar analyses were run for K. Results Participants were aged 54.6 ± 13.0 y, n = 8 were female, n = 6 were black, and n = 10 were white. In CKD participants, eGFR was 40.7 ± 7.9 mL/min. Average Na intake on day 7 was 2138 ± 302 mg and K intake was 2528 ± 254 mg. Na intake, measured 24hUNa, and e24hUNa were not significantly different (P = 0.17) or correlated with each other (all P &amp;gt; 0.20) and there was no significant interaction with CKD status (P = 0.51). However, both e24hUNa were ∼500 mg higher than Na intake. For K, e24hUK was significantly different from K intake (P &amp;lt; 0.001) and measured 24hUK (P = 0.02), with no interaction with CKD (P = 0.53). K intake, measured 24hUK, and e24hUK were not correlated (all P &amp;gt; 0.05). Bland-Altman plots show poor agreement between both e24hUNa and Na intake and e24hUK and K intake. Conclusions Estimated 24hUNa and estimated 24hUK are poor predictors of Na and K intake, respectively, in both healthy and CKD participants. Results should be confirmed in a larger sample. Funding Sources Indiana CTSI (funded by NCATS CTSA program), NIDDK.

Early Diagnosis for Chronic Kidney Disease and its Associated Risk Factors among Adults in a Rural Population of Delhi: A Cross-Sectional Study

Background: Chronic kidney disease (CKD) is emerging public health problem worldwide including India. It’s diagnosis at 5th stage complicates treatment leading to end-stage renal disease (ESRD). The early interventions, life style modification and management may help to slow its progress. Methods: A total of 859 participants were screened in OPD of Rural Health Training Center Najafgarh rural area of Delhi in 2018 after getting written informed consent from the participants. The data was recorded through a pre-structured questionnaire containing their personal and medical history. Blood sugar, urea, serum creatinine and serum albumin were examined. Other anthropometric parameters like blood pressure (BP) and height weight were also measured for the body mass index (BMI). Data was analyzed with the help of SPSS ver 16. CKD versus Non-CKD participants were compared for any significant difference and chi square test was. Result: The mean age of participants was 39.72±SD 16.85 (range 18-90 years). More participants were males (61%), literate (81.8%) and unemployed (68.8%). 21.9%, 24.8% and 5.7% had previous history of BP, diabetes and any kidney problems. The overall prevalence of CKD was 8.7%; mean eGFR was 91.67 ± 24.20 in CKD versus 96.44±19.95 in non-CKD group. Prevalence of CKD stages 1, 2, 3a, 3b, 4 and 5 were 56%, 35%, 6.05%, 1.08%, 0.93% and 0.46% respectively. Hypertensive and diabetic were significantly associated with CKD. Conclusion: The prevalence of CKD was 8.7% and 6.0% had stage 3a or worse. Diabetic and hypertensive patients should be screened for kidney diseases as early intervention may retard the progression of kidney disease. How to cite this article:Tripathi N, Kishore J, Kumar N, Bhatnagar A, Kumar R, Verm H. Early Diagnosis for Chronic Kidney Disease and its Associated Risk Factors among Adults in a Rural Population of Delhi: A Cross-Sectional Study. J Adv Res Med 2019; 6(4): 20-26. DOI: https://doi.org/10.24321/2349.7181.201921

SUN-200 Pulmonary Function Tests in Hemodialysis Patients and their First-Degree Rlatives as Kidney Donors

End-stage kidney disease-ESKD-patients not infrequently develop pulmonary complications such as oedema, infection or pleurisy and eventually need renal replacement therapy(RRT) via dialysis (either hemodialysis or peritoneal dialysis) or kidney transplantation to survive. This prospective study evaluated the pulmonary function tests of patients with chronic kidney disease (CKD) and healthy donors who attended the kidney donor clinic at the Royal Hospital. The study was carried on during the period from Jan ’2010 till Jan “2015. All patients have undergone Pulmonary Functions Test (PFT) at the next day post their hemodialysis session. For statistical analysis, the STATA 12.0 software was used. FVC was 3.67(0.78) and 3.12 (0.82) for control and CKD participants, respectively, p=0.019. FEV1 was 2.97(0.63) 2.57 (0.74) for control and CKD participants, respectively, p=0.043. On the other hand, the FEV1/FVC ratio was 80.5(6.9) and 81.8(0.74) for control and CKD participants, respectively p=0.56. Similarly, there was no significant statistical difference regarding PEF and TLC between CKD and control participants. The VC was 3.78(0 .73) vs 3.38 (0.55), p=0.04 for control and CKD participants, respectively. The ERV values were 1.41 (0.34) and 1.78 (0.48), p=0.01 for control and CKD participants, respectively. But RV and RV/TLC showed no statistically significant difference between control and CKD participants, as shown in table 1. The DLCO was 23.29 (4.77) and 18.16 (4.57), p<0.001, for control and CKD participants, respectively. The VA for control and CKD participants was 4.62 (0.99) and 4.12 (0.84), p=0.06, respectively. DLCO/VA was 5.13 (0.88) and 4.47 (1.0), p=0.01, for control and CKD participants, respectively. The DL/VA adjusted was 5.13(0.17) and 4.46 (1.0), p=0.02, for control and CKD participants, respectively. But, IVC values showed no statistically significant difference between control and CKD participants.Tabled 1ItemPotential Kidney donorCKD -Recipient for KTXP. ValueFVC3.67 SD 0.783.12 SD 0.820.0185FEV12.97 SD 0.632.57 SD 0 .740.0434FEV1/FVC80.48 SD 6.9281.79 SD 9.000.5605PEF416.89 SD 102.89386.92 SD 105.480.3099TLC5.39 SD 2.135.23 SD 2.990.8347VC3.78 SD 0 .733.38 SD 0.550.0424ERV1.41 SD 0.341.78 SD 0.480.0122RV1.61 SD 2.081.95 SD 3.000.6464RV/TLC24.85 SD14.8529.55 SD 16.600.3172DLCO23.29 SD 4.7718.16 SD 4.570.0005DLCO/VA5.13 SD 0.884.47 SD 1.000.0192DL/VA adjusted5.13 SD 0.174.46 SD 1.000.0192VA4.62 SD 0 .994.12 SD 0.840.0695IVC2.14 SD 0.461.98 SD 0.610.3704 Open table in a new tab To the best of our knowledge, this is the first paper to compare pulmonary function tests in hemodialysis patients that being worked up for kidney transplant with their first-degree relatives who were worked up as their kidney donors. The findings of the present study demonstrated that volume overload is closely associated with restrictive and obstructive respiratory abnormalities where respiratory function tests in patients with CKD undergoing dialysis show lower values than those of the general population, and that patients undergoing dialysis have greater impairment of DLCO and FVC than do their first relatives’ kidney transplant donor patients. Uremic pulmonary toxicity is likely to be multifactorial and may differ with different patterns of CKD disease.

SUN-119 COMPARING SURVIVAL IN PATIENTS WITH CHRONIC KIDNEY DISEASE ACROSS THREE COUNTRIES - RESULTS FROM THE STUDY OF HEART AND RENAL PROTECTION-EXTENDED REVIEW (SHARP-ER)

Chronic kidney disease (CKD) is a key determinant of health outcomes and an important driver of mortality. International comparison is important to better understand how inter-regional differences affect clinical outcomes. We examined whether survival differed between participants from Australia (AUS), Malaysia (MYL) and New Zealand (NZ) in the SHARP-ER study. SHARP-ER did not involve allocation to further study treatment, but was a 5-year post-trial extended follow-up of participants from AUS, MYL and NZ in the SHARP trial, a randomized double-blind trial of simvastatin and ezetimibe vs. placebo in CKD participants in 18 countries with median follow up of 4.9 years. Baseline demographic and laboratory variables were recorded at SHARP commencement. Initiation of renal replacement therapy and death were identified through adverse event records (SHARP) and linkage to national registries (SHARP-ER). All study participants from AUS, MYL and NZ who entered SHARP were included in this analyses. For those not eligible for inclusion in SHARP-ER, study completion date was recorded as the date of last SHARP follow up. For participants eligible for SHARP-ER, study completion date was 5 years after the last SHARP follow up visit. Multi-variable Cox regression models were constructed with and without censoring for transplantation. Of 2029 participants randomized in the SHARP trial from AUS, MYL and NZ, 1533 were alive at the end of SHARP, of whom 1136 participants (74.1% of those alive) entered the SHARP-ER follow up study. 803 participants (70.7 % of those entering SHARP-ER) were alive at completion of SHARP-ER. Baseline characteristics varied between countries; Malaysian participants were younger than those from AUS and NZ and diabetes was more prevalent in participants from MYL. The requirement for maintenance dialysis at study commencement was also more prevalent in MYL. Median duration of follow up from randomization was 5.6 (IQR 4.2-9.7) years in AUS, 9.4 (IQR 5.8-10.6) years in MYL and 5.5 (IQR 4.3-9.5) years in NZ. There was a significantly greater risk of mortality for participants from MYL (HR 4.24, 95% CI 1.66-10.82, p<0.01) and NZ (HR 4.82, 95% CI 1.31-17.70, p=0.02) compared with participants from AUS. Other predictors of mortality included worsening CKD stage, with highest risk associated with maintenance dialysis requirement at study commencement (HR 3.91, 95%CI 3.06-5.00, p<0.01) compared with participants with stage III CKD. Diabetes (HR 1.83, 95% CI 1.58-2.13, p<0.01) and cerebrovascular disease (1.39, 95% CI 0.99-1.95, p=0.05)) at study commencement were also associated with a greater risk of mortality. Rates of kidney transplantation were higher in AUS (20.5%) and NZ (17.9%) than MYL (1.9%). When analyses were censored at transplantation the effect of country on risk of mortality was reduced for participants in MYL (HR 1.20, 95% CI 1.01-1.43, p=0.04) and NZ (HR 1.26, 95 CI 1.02-1.56, p=0.04). Analysis of international post-trial cohorts are useful in exploring differing clinical outcomes between countries in comparable patients. When doing such analyses it is important to consider differences in practice patterns, such as transplantation rates, which may materially influence the findings.

High-sensitivity Troponin I Predicts Galectin-3 in Chronic Kidney Disease Patients

Plasma galectin-3 (pG3) regulates inflammation. B-type natriuretic peptide (BNP), high-sensitivity Troponin I (hsTnI), and pG3 concentrations are elevated in chronic kidney disease (CKD) patients. The associations of pG3 with hsTnI/BNP are unclear. We explored the relationship of hsTnI and BNP with pG3 in Asian CKD patients and healthy controls. We retrieved prospectively collected frozen plasma samples from 163 stable CKD patients and 105 healthy controls. BNP, hsTnI and pG3 were assayed. pG3 was assessed for associations with age, gender, ethnicity, blood pressures; height, weight, body mass index (BMI), previously diagnosed CKD, diabetes, hypertension, coronary artery disease, estimated glomerular filtration rate (eGFR); C-reactive protein, beta-trace protein, 24h urine protein, serum albumin, uric acid and cystatin C. We created two models predicting pG3 using multiple linear regression. Akaike Information Criterion (AIC) was used for comparison. Significance was taken at P < 0.05. CKD versus healthy participants: mean BMI (28.2 vs. 24.9kg/m2), median serum creatinine (159 vs. 69µmol/L; 1.8 vs. 0.78mg/dL), median eGFR (49 vs. 104mL/min/1.73m2), median pG3 (29.4 vs. 15.4ng/mL), median BNP (136 vs. 23pg/mL), and median hsTnI (12.5 vs. 2.6pg/mL). By univariate analysis, all variables are associated with pG3 except weight, gender and diagnosis of cerebrovascular or peripheral vascular diseases. A parsimonious model selected for hsTnI, BMI, serum albumin, cystatin C and eGFR (AIC = 77.6). BNP and hsTnI are associated with pG3 in Asian CKD patients. hsTnI is a better predictor of pG3.

Renal Dysfunction in Heart Failure With Preserved Ejection Fraction: Insights From the RELAX Trial

Patients with heart failure with preserved ejection fraction (HFpEF) and chronic kidney disease (CKD) represent a high-risk phenotype. The Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in Heart Failure with Preserved Ejection Fraction (RELAX) trial enrolled a high proportion of CKD participants, allowing investigation into differences in HFpEF by CKD status. Among 212 participants, we investigated the associations of CKD with biomarkers, cardiac structure, and exercise capacity, and identified predictors of change in estimated glomerular filtration rate (eGFR) over trial follow-up. CKD participants (eGFR ≤60 mL/min/1.73m2) were older, had more comorbidities, and had worse diastolic function. Lower eGFR was associated with higher levels of endothelin-1, N-terminal pro-B-type natriuretic peptide, aldosterone, uric acid, and biomarkers of fibrosis (P < .05 for all). Whereas lower eGFR was associated with worse peak oxygen consumption (VO2) after adjustment for demographics, clinical comorbidities, exercise modality, ejection fraction, and chronotropic index (β coefficient per 1 SD decrease in eGFR: -0.61, 95% CI: -1.01, -0.22, P = .002), this association was attenuated after further adjustment for hemoglobin (β coefficient: -0.26, 95% CI: -0.68, 0.16, P = .22). Hemoglobin mediated 35% of the association between eGFR and peak VO2. Sildenafil therapy was independently associated with worsening eGFR over the trial (β coefficient: -2.79, 95% CI: -5.34, -0.24, P = .03). Renal dysfunction in HFpEF is characterized by echocardiographic and biomarker profiles indicative of more advanced disease, and reduced hemoglobin is a strong mediator of the association between renal dysfunction and low exercise capacity. Sildenafil therapy was associated with worsening of renal function in RELAX.

Subclinical atherosclerosis burden predicts cardiovascular events in individuals with diabetes and chronic kidney disease

BackgroundIndividuals with diabetes have remarkably high rates of cardiovascular morbidity and mortality. However, the incremental cardiovascular risk in diabetes is heterogeneous and has often been related to renal involvement. The purpose of this study was to analyse the prognostic value of subclinical atherosclerosis in determining the incidence of first cardiovascular events (CVEs) in individuals with diabetes and chronic kidney disease (CKD) compared to CKD individuals without diabetes.MethodsWe included data from individuals with CKD with and without diabetes, free from pre-existing cardiovascular disease, from the NEFRONA cohort. Participants underwent baseline carotid and femoral ultrasound and were followed up for 4 years. All CVEs during follow-up were registered. Bivariate analysis and Fine–Gray competing risk models were used to perform the statistical analysis.ResultsDuring the mean follow-up time of 48 months, a total of 203 CVE was registered. 107 CVE occurred among participants without diabetes (19.58 per 1000 person-years) and 96 CVE occurred among participants with diabetes (44.44 per 1000 person-years). Following the competing risk analysis, the variables predicting CVEs in CKD individuals without diabetes were the number of territories with plaque at baseline (HR 1.862, 95% CI [1.432;2.240]), age (HR 1.026, 95% CI [1.003;1.049]) and serum concentrations of 25-OH vitamin D (HR 0.963, 95% CI [0.933;0.094]). The only variable predicting CVEs among CKD participants with diabetes was the number of territories with plaque at baseline (HR 1.782, 95% CI [1.393, 2.278]). For both models, concordance (C) index yielded was over 0.7.ConclusionsThe burden of subclinical atherosclerosis is the strongest predictor of future CVEs in diabetic individuals with CKD. Early detection of subclinical atherosclerotic burden by multiterritorial vascular ultrasound could improve CVE prediction in this population.

Metabolic acidosis augments exercise pressor responses in chronic kidney disease.

Chronic kidney disease (CKD) patients experience augmented blood pressure (BP) reactivity during exercise that is associated with an increased risk of cardiovascular mortality. Exaggerated exercise pressor responses in CKD are in part mediated by augmented sympathetic nerve activation due to heightened muscle mechanoreflex. One mechanism that may lead to sensitization of the muscle mechanoreflex in CKD is metabolic acidosis. We hypothesized that CKD patients with low serum [bicarbonate] would exhibit exaggerated increases in arterial BP, greater reductions in muscle interstitial pH, and fatigue earlier during exercise compared with CKD patients with normal serum bicarbonate concentration ([bicarbonate]). Eighteen CKD participants with normal serum [bicarbonate] (≥24 mmol/l, normal-bicarb) and 9 CKD participants with mild metabolic acidosis ([bicarbonate] range 20-22 mmol/l, low-bicarb) performed rhythmic handgrip (RHG) exercise to volitional fatigue at 40% of maximal voluntary contraction. BP, heart rate, and muscle interstitial pH using near infrared spectroscopy were measured continuously. While mean arterial pressure (MAP) increased with exercise in both groups (P ≤ 0.002), CKD with low-bicarb had an exaggerated MAP response compared with CKD with normal-bicarb (+5.9 ± 1.3 mmHg/30 s vs. +2.6 ± 0.5 mmHg/30 s, P = 0.01). The low-bicarb group reached exhaustion earlier than the normal-bicarb group (179 ± 21 vs. 279 ± 19 s, P = 0.003). There were no differences in the change in muscle interstitial pH during exercise between groups (P = 0.31). CKD patients with metabolic acidosis have augmented exercise-induced increases in BP and poorer exercise tolerance. There was no difference in change in muscle interstitial pH between groups, however, suggesting that augmented exercise BP responses in metabolic acidosis are not due to impaired muscle-buffering capacity.

Depression and neurocognitive dysfunction in pediatric and young adult chronic kidney disease

Depression affects 7-35% of children with chronic kidney disease (CKD), and in adults with CKD, the presence of depression links to poorer medical outcomes, social functioning difficulties, and neurocognitive impairments. The relationship between depression and neurocognitive function in youth with CKD is unclear. We sought to identify factors associated with depression in youth with CKD and to determine whether depression affects neurocognitive performance. We conducted cross-sectional analyses in 71 CKD and 64 control participants aged 8 to 25years who completed depression inventories and neurocognitive assessments as part of the Neurocognitive Assessment and Magnetic Resonance Imaging Analysis of Children and Young Adults with CKD Study. In the CKD group, multivariable logistic regression analysis determined associations between clinical and demographic factors and depression. In the full study cohort, multivariable linear regression analyses, including an interaction term between CKD status and depression evaluated the effect of depression on 11 neurocognitive outcome domains. Obesity significantly associated with depression in the CKD group (OR 10.25, P = 0.01). In adjusted analyses, depressed youth with CKD scored worse than non-depressed CKD participants by 0.6-1.0 standard deviations in 5 neurocognitive domains: attention, visual memory, visual-spatial, visual working memory, and problem solving. CKD youth with obesity are more likely to be depressed, and those who are depressed exhibit worse neurocognitive performance. Depression may represent a therapeutic target to improve neurocognitive performance in youth with CKD.

Parenteral versus oral iron therapy for adults and children with chronic kidney disease.

Background The anaemia seen in chronic kidney disease (CKD) may be exacerbated by iron deficiency. Iron can be provided through different routes, with advantages and drawbacks of each route. It remains unclear whether the potential harms and additional costs of intravenous (IV) compared with oral iron are justified. Objectives To determine the benefits and harms of IV iron supplementation compared with oral iron for anaemia in adults and children with CKD. Search methods In March 2010 we searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE and EMBASE without language restriction. Selection criteria We included randomised controlled trials (RCTs) and quasi-RCTs in which oral and IV routes of iron administration were compared in adults and children with CKD. Data collection and analysis Two authors independently assessed study eligibility, risk of bias, and extracted data. Results were reported as risk ratios (RR) or risk differences (RD) with 95% confidence intervals (CI) for dichotomous outcomes and for continuous outcomes the mean difference (MD) was used or standardised mean difference (SMD) if different scales had been used. Statistical analyses were performed using the random-effects model. Subgroup analysis and univariate meta-regression were performed to investigate between study differences. Main results Twenty eight studies (2098 participants) were included. Risk of bias attributes were poorly performed and/or reported with low risk of bias reported in 12 (43%) studies for sequence generation, incomplete outcome reporting and selective outcome reporting and in 6 (16%) studies for allocation concealment. No study was blinded for participants, investigators and outcome assessors but all were considered at low risk of bias because the primary outcome of haemoglobin was a laboratory outcome and unlikely to be influenced by lack of blinding. Haemoglobin (22 studies, 1862 patients: MD 0.90 g/dL, 95% CI 0.44 to 1.37); ferritin (24 studies, 1751 patients: MD 243.25 μg/L, 95% CI 188.74 to 297.75); and transferrin saturation (18 studies, 1457 patients: MD 10.20%, 95% CI 5.56 to 14.83) were significantly increased by IV iron compared with oral iron. There was a significant reduction in erythropoiesis-stimulating agent (ESA) dose in patients receiving dialysis who were treated with IV iron (9 studies, 487 patients: SMD -0.76, 95% CI -1.22 to -0.30). There was a high level of heterogeneity in all analyses. Mortality and cardiovascular morbidity did not differ significantly, but were reported in few studies. Gastrointestinal side effects were more common with oral iron, but hypotensive and allergic reactions were more common with IV iron. Authors' conclusions The included studies provide strong evidence for increased ferritin and transferrin saturation levels, together with a small increase in haemoglobin, in patients with CKD who were treated with IV iron compared with oral iron. From a limited body of evidence, we identified a significant reduction in ESA requirements in patients treated with IV iron, and found no significant difference in mortality. Adverse effects were reported in only 50% of included studies. We therefore suggest that further studies that focus on patient-centred outcomes are needed to determine if the use of IV iron is justified on the basis of reductions in ESA dose and cost, improvements in patient quality of life, and with few serious adverse effects.

Ethnic prevalence of anemia and predictors of anemia among chronic kidney disease patients at a tertiary hospital in Johannesburg, South Africa.

IntroductionAnemia is a complication of chronic kidney disease (CKD) that can greatly impact on its prognosis. However, the risk factors for anemia, including the influence of ethnicity, are not well established among the CKD population in Johannesburg.MethodsThis was a cross-sectional study of 353 adult CKD patients attending the renal outpatient clinic of the Charlotte Maxeke Johannesburg Academic Hospital (Johannesburg, South Africa) from June 1, 2016 to December 30, 2016. Sociodemographic and clinical characteristics were obtained using a proforma. Blood samples were collected for serum electrolytes and hematological parameters. Predictors of low hemoglobin and iron deficiency anemia (IDA) were evaluated using multivariable binary logistic regression.ResultsThe mean age and prevalence of anemia among the CKD participants were 55.3±15.0 years and 43.18% (95% CI: 38.1%–48.4%), respectively. Blacks had the highest prevalence of anemia (46.9%), while Indians/Asians had the lowest (18.2%). Although the odds of anemia was 3.8-fold higher (odds ratio =3.8, P-value =0.059) among CKD stage V participants as compared to CKD stage I, the relationship between anemia and stages of CKD was non-linear. Diabetes mellitus (odds ratio =2.31, P-value =0.005) had a strong association with anemia among the CKD participants.ConclusionAlmost half of the CKD participants were anemic, and the odds of anemia did not increase linearly with increasing severity of CKD. There was a marked ethnic disparity in anemia prevalence. Our study highlights the need for risk-based management of anemia among CKD patients.

A comparison of normal kidneys to those with chronic kidney disease using ultrasound shearwave elastography

Background Chronic kidney disease (CKD) is based on estimated glomerular filtration rate (eGFR) results in blood analysis. Patients also undergo diagnostic ultrasound to confirm and supplement the eGFR findings. Renal fibrosis is the end stage of CKD and has been subjectively evaluated with renal ultrasound. This study was designed to determine if patients with CKD will have a stiffer renal cortex compared to a normal control group using ultrasound shearwave elastography (SWE) in a quantifiable manner. Objectives The aim of this study is to measure and compare the renal cortical stiffness Young Modulus values in kilopascals (kPa) using SWE for normal and CKD participants. Methods Outpatient volunteers were recruited for this study. All participants were greater than 18 years of age. The normal control group had an eGFR results of greater than 90, while the CKD group had an eGFR of less than 60, within three months of the SWE measurements. Both groups did not have any evidence of hydronephrosis, renal calculus or distinct renal malignancies. After gaining consent, both groups underwent SWE as an extension to their routine diagnostic ultrasound examination of the upper abdomen or renal system. A brief medical questionnaire was completed by each volunteer. The bipolar renal length was recorded. The renal cortex elasticity values were measured with circular regions of interest placed in the upper, mid and lower zones of both kidneys and their corresponding Young's modulus (YM) SWE values measured in kilopascals (kPa) were recorded. Two sample unpaired t-tests was used to compare the measured renal stiffness SWE values (in kPa) between the normal control and CKD group. Results 40 participants were recruited, of those 20 had CKD and 20 control. The bipolar renal length was significantly reduced in CKD participants to 104mm ( ± 21mm) from control group of 111mm ( ± 11mm) (p = 0.03). The SWE values (in kPa) measuring the renal stiffness was significantly higher in the CKD group than those of normal controls (p Conclusion Participants with CKD had significantly higher (p

Comparison of atrial fibrillation in CKD and non-CKD populations: A cross-sectional analysis from the Kailuan study

ObjectivesTo compare clinical epidemiological features of atrial fibrillation (AF) in chronic kidney disease (CKD) and non-CKD populations. MethodsThis study included 88,312 adults aged ≥45 years old from the KAILUAN study. AF was ascertained with a 12-lead electrocardiogram. CKD was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 and/or proteinuria. Participants were categorized into non-CKD (eGFR > 60 mL/min/1.73 m2 without proteinuria, n = 66,725) and CKD (n = 21,578) groups. We evaluated the prevalence of AF in both groups, evaluated risk factors for AF using multivariable-adjusted logistic regression analysis. ResultsThe prevalence of AF among non-CKD and CKD participants was 0.26% and 1.00%, respectively. Multivariable-adjusted analysis showed that older age (odds ratio [OR]: 1.08, 95% confidence interval [CI]: 1.07–1.10, P < 0.001), smoking (OR: 1.23, 95% CI: 1.07–1.57, P = 0.017), hypertension (OR: 2.14, 95% CI: 1.44–3.17, P < 0.001), diabetes (OR: 1.79, 95% CI: 1.10–2.89, P < 0.001), and larger waist circumference (OR: 1.03, 95% CI: 1.01–1.04, P < 0.001) were significantly associated with AF in the non-CKD group. In the CKD group, older age, smoking, larger waist circumference, reduced eGFR (OR: 0.97, 95% CI: 0.95–0.99, P < 0.001), proteinuria (OR: 2.01, 95% CI: 1.09–3.74, P < 0.001) and raised serum C-reactive protein (1.01, 1.00–1.03, P < 0.001) were significantly associated with AF. ConclusionsThe prevalence of AF in Chinese adults with CKD is higher than that among those without CKD. Risk factors for AF in non-CKD population were not the same compared with those in CKD population, kidney function and inflammatory markers were associated with the prevalence of AF.

Haematological profile of chronic kidney disease in a mixed-ancestry South African population: a cross-sectional study

ObjectivesThe objectives were to characterise the haematological profile of screen-detected chronic kidney disease (CKD) participants and to correlate the complete blood count measures with the commonly advocated kidney function estimators.MethodsThe...

Applying the new intensive blood pressure categories to a nondialysis chronic kidney disease population: the Prevalence, Awareness and Treatment Rates in Chronic Kidney Disease Patients with Hypertension in China survey.

The 2017 high blood pressure (BP) clinical practice guideline reported by the American College of Cardiology/American Heart Association put forward new categories of BP. This study aimed to assess the applicability of the new guideline in a nondialysis chronic kidney disease (CKD) population. This is a nationwide, multicenter, cross-sectional study with a large sample. A total of 8927 nondialysis CKD patients in 61 tertiary hospitals in all 31 provinces, municipalities and autonomous regions of China (except Hong Kong, Macao and Taiwan) were analyzed. The categories of BP were defined as normal BP (<120/80 mmHg), elevated BP [systolic BP (SBP) 120-130 and diastolic BP (DBP) <80 mmHg], and Stage 1 (SBP 130-139 or DBP 80-89 mmHg) and Stage 2 (SBP ≥140 or DBP ≥90 mmHg) hypertension. The prevalence and control of hypertension were estimated using a new definition, and the association between the main target organs' injury and new categories of BP was analyzed. The prevalence, awareness and treatment of hypertension in nondialysis CKD patients were 79.8, 72.4 and 68.3%, respectively. Approximately 11.9% had BP <130/80 mmHg and 6.6% had BP <120/80 mmHg. Subgroups by categories of BP had significant differences in age, sex, body mass index category, primary cause and CKD stage (P < 0.001). After multivariable adjustment, only Stage 2 hypertension was associated with decreased renal function [odds ratio (OR) 2.4, 95% confidence interval (CI) 1.9-3.0, P < 0.001], cardiovascular disease (OR 2.0, 95% CI 1.3-3.1, P = 0.001) and cerebrovascular disease (OR 2.7, 95% CI 1.2-5.8, P = 0.015). Using the new definition of hypertension, the higher prevalence and lower control of hypertension were shown in nondialysis CKD participants. More studies are necessary to confirm the applicability of new categories of BP in CKD population because only Stage 2 hypertension showed statistical association with the main target organs' injury.

Utility of reticulocyte haemoglobin content and percentage hypochromic red cells as markers of iron deficiency anaemia among black CKD patients in South Africa.

IntroductionIron deficiency anaemia (IDA) worsens the prognosis and outcomes of chronic kidney disease (CKD). However, while the haemoglobin level is unreliable for early detection of IDA, reticulocyte haemoglobin content (CHr) and hypochromic red cells (%HYPO) are early markers of IDA.MethodsThis was a cross sectional study of black adult participants (n = 258) with CKD and apparently healthy members of staff and patients’ relatives (n = 141) at the Charlotte Maxeke Johannesburg Academic Hospital, South Africa, between 1 June 2016 and 31 December 2016. Serum iron, serum ferritin and transferrin were measured using standard laboratory methods, while the haematology analyser was employed to measure CHr and %HYPO. The validity of CHr and %HYPO as markers of IDA were evaluated. Multivariable binary logistic regression was conducted to determine predictors of the relationship between IDA, CHr and %HYPO. The area under the receiver operator characteristics (ROC) curve (AUC) of the final models were utilised to evaluate the discriminatory value of CHr and %HYPO respectively.ResultsAbout one-quarter (26.1%) of the participants had IDA which was more than three times more frequent among CKD patients, compared to controls (35.3% vs 9.2%); 32.3% (95%CI: 27.90%– 37.10%) of the study population had iron deficiency without anaemia and the prevalence of iron deficiency without anaemia was lower in CKD patients compared to controls (29.5% vs 37.6%). The mean age of CKD patients was higher than in controls (52.7 ±14.3 vs 40.4 ±12.6 years, P-value<0.001). The sensitivity and specificity for diagnosing IDA among CKD participants was 62.6% and 80.2% respectively for CHr (at a cut-off value of <28pg) and 63.3% and 79.8% respectively for %HYPO. CKD participants with CHr levels >28pg were 82% less likely to be diagnosed as having IDA as compared to those with CHr levels ≤ 28pg) (adj odds ratio = 0.18, 95% CI: 0.09–0.37). The AUC of CHr (0.81, 95% CI: 0.76–0.87) was higher than the AUC of %HYPO (0.76, 95%CI: 0.70–0.82).ConclusionThe diagnostic usefulness of CHr and the screening performance of %HYPO in predicting IDA among CKD patients are high. Their lower cost compared to conventional markers of ID recommend their use in clinical practice. Further cost effectiveness studies of these parameters are warranted.