Chronic Kidney Disease End-stage Renal Disease Research Articles

Assessment of Left Ventricular Functional Impairment in Patients With Chronic Kidney Disease Using Three-Dimensional Speckle Tracking Imaging.

Chronic kidney disease (CKD) is strongly linked to the incidence and mortality of cardiovascular diseases (CVDs), with left ventricular myocardial damage being the most prevalent. This study aimed to assess left ventricle (LV) dysfunction using three-dimensional speckle tracking imaging (3D-STI) in CKD patients. A total of 110 CKD patients and 55 healthy volunteers underwent echocardiography. CKD patients were divided into CKD1 group and CKD2 group based on the estimated glomerular filtration rate (eGFR). Assessing cardiac function via two-dimensional speckle tracking echocardiography (2D-STE) and three-dimensional speckle tracking echocardiography (3D-STE) parameters, with strain presented in absolute terms. Collecting and comparing clinical and echocardiographic parameters from three groups, assessing 3D-STI's value in evaluating LV functional impairment in CKD patients via correlation and receiver operating characteristic (ROC) curve analyses, and identifying risk factors for CKD progression to end-stage renal disease (ESRD) through univariate and multivariate analyses. In CKD2 group, 2D-left ventricular ejection fraction (LVEF), 3D-LVEF, 2D left ventricular global longitudinal strain (2D-LVGLS), 3D-LVGLS, and 3D-left ventricular global circumferential peak strain (LVGCS) significantly worsen compared to the control and CKD1 groups, with statistically significant distinctions between the latter two (all p < 0.05). The absolute value of 3D-LVGLS shows a robust correlation with N-terminal pro-B-type natriuretic peptide (NT-proBNP) and serum creatinine (Scr) (r = -0.598, -0.649, both p < 0.001). ROC curve analysis indicates higher diagnostic efficacy of 3D-LVGLS and 3D-LVGCS for LV systolic function than 2D-LVGLS. Univariate and multivariate analyses reveal an independent association of 3D-LVGLS with the progression to ESRD in CKD. 3D-LVGLS and 3D-LVGCS effectively detect LV dysfunction in CKD patients. Specifically, 3D-LVGLS demonstrates a robust correlation with NT-proBNP and Scr and is independently linked to CKD progressing to ESRD.

P0670DIFFUSIONAL KURTOSIS IMAGING PREDICTS THE PROGNOSIS OF CHRONIC KIDNEY DISEASE

Abstract Background and Aims Renal fibrosis is the strongest prognosis predictor of ESRD in chronic kidney disease (CKD), but non-invasive and repeatable imaging markers are missing. Magnetic resonance imaging (MRI) has wide range of applications in renal parenchymal diseases, and diffusional kurtosis imaging (DKI) is a new promising noninvasive method of MRI which can provide more information about non-Gaussian diffusion using a polynomial model. We had successfully used DKI to assess renal fibrosis in IgA nephropathy in our previous work. This study aimed to evaluate the prognostic value of DKI in CKD. Method We prospectively enrolled forty-two CKD patients in our study in Jan. 2017. On recruitment, the basic clinical data were documented, and DKI was performed on a clinical 3T MR scanner. Region-of-interest (ROI) measurements were performed to determine apparent diffusion coefficient (ADC), kurtosis (K) and diffusivity (D) of the cortex of the kidneys. We had followed up these patients for 3 years, and collected all the clinical data and outcomes. The prognostic value of DKI metrics and clinical parameters were investigated. Results Forty-two patients consisted of 26 males and 16 females with mean age of 41.3±15.4 years. The most common etiology was IgA nephropathy (25/42, 59.5%). At baseline, the mean value of serum creatinine (SCr) was 224.4±156.2μmol/L. Among them, 18 patients had eGFR≥45ml/min and 24 patients had eGFR&amp;lt;45ml/min. According to the etiology and CKD classification, all the patients had received appropriate treatment. Besides supportive treatment and management of CKD complications, 21 patients (50%) had received corticosteroid and/or immunosuppressants treatment. After 36 months follow up, 12 patients had progressed to end stage renal disease (ESRD), and the mean value of SCr of the remaining 30 patients was 153.0±78.8umol/L. The Kaplan-Meyer survival regression showed that the patients with eGFR&amp;lt;45ml/min had worse clinical outcomes (p=0.0006). ROC analysis and Kaplan-Meyer survival regression showed that DKI metrics (K≥0.66 or ADC&amp;lt;1.35) not only predicted severe renal fibrosis, but also had worse clinical outcomes (p=0.01 and p&amp;lt;0.0001) (Figure 1). According to the COX regression analysis, both K (K≥0.66, HR 4.676, 95%CI 1.262-17.325) and ADC (ADC&amp;lt;1.35, HR 13.118, 95%CI 3.499-49.178) values, but not age, gender and eGFR group (cut-off value: 45ml/min), were the independent risk factors for the progression to ESRD. Conclusion Renal ADC and K values obtained from DKI showed significant predictive value for the prognosis of CKD, could be a promising non-invasive technique in patients follow-up.

P0912THE SERUM CREATININE TO CYSTATIN C RATIO AND CLINICAL OUTCOMES IN PATIENTS WITH NON-DIALYSIS CHRONIC KIDNEY DISEASE: THE KNOW-CKD COHORT

Abstract Background and Aims Muscle wasting leads to poor outcomes in patient with chronic kidney disease (CKD). The serum creatinine to cystatin C (Cr/CysC) ratio has been reported as marker for muscle mass and may predict outcomes in chronic diseases. We hypothesized that the Cr/CysC ratio would be a predictor of outcomes in CKD. Method We investigated a total of 2142 patients (male 61%, aged 54±12 year) with CKD followed for a median of 3.74 years. We assessed the factors associated with Cr/CysC ratio and the relationship between Cr/CysC ratio and outcomes of end-stage renal disease (ESRD), cardiovascular event (CVE), and mortality. Results The Cr/CysC ratio significantly correlated with age (r=-0.18), estimated glomerular filtration rate (eGFR) (r=-0.21), serum albumin (r=0.11), 24-hour urine creatinine (r=0.38), and moderate to vigorous physical activity time (r=0.07). After adjusting for age, sex, eGFR, and log urine albumin creatinine ratio (model 1), the hazard ratios for ESRD, CVE, and mortality were 0.96 (95% CI, 0.86-1.07), 0.78 (95% CI, 0.61-0.99), and 0.72 (95% CI, 0.53-0.97) per 1 standard deviation Cr/CysC increase (0.21), respectively. After full adjustment for model 1 variables plus lifestyle factors, laboratory factors, and comorbidities (model 2), the hazard ratios for ESRD, CVE, and mortality were 0.99 (95% CI, 0.88-1.10), 0.84 (95% CI, 0.65-1.07), and 0.75 (95% CI, 0.55-0.99) per 1 standard deviation Cr/CysC increase (0.24), respectively. In subgroup of the elderly (age&amp;gt;65 year) and early stage CKD (eGFR&amp;gt;60 ml/min/1.73m2), the hazard ratios for CVE were significantly lower in patients with high Cr/CysC ratio. Conclusion Cr/CysC ratio correlates with muscle biomarkers and physical activity. A higher Cr/CysC ratio is associated with low CVE and mortality, but not ESRD in CKD.

Management of hyperkalemia in Nephrology and Cardiology clinics: reality and perspectives

Chronic kidney disease (CKD) and chronic heart failure (CHF) are two entities that share several aspects: (i) these are two chronic conditions associated with poor prognosis; (ii) they involve frailty patients who need strict monitoring in terms of visits and treatment; (iii) both CKD and CHF patients benefit from renin-angiotensin-aldosterone system inhibitors (RAASI). RAASI proved effective in significantly reducing the risk for cardiovascular events, mortality and end-stage renal disease in CKD and CHF patients. Notwithstanding, RAASI use may induce hyperkalemia. High serum potassium (≥5.0 mEq/l) is, per se, responsible for higher risk for end-stage renal disease, arrhythmias and mortality. This risk is even reinforced when patients who develop hyperkalemia withdraw or reduce RAASI treatment, thus losing nephro- and cardioprotective effects. Current available strategies aimed at reducing hyperkalemia include dietary restriction, loop diuretics, potassium binders, namely sodium/calcium polystyrene sulfonate (SPS/CPS), patiromer, and sodium zirconium cyclosilicate (SZC). SPS and CPS have shown low safety/efficacy and several drug-drug interactions, these being major limitations to their use. Patiromer and SZC were found to reduce potassium with less side effects. These findings combined provide strong support that management of hyperkalemia is crucial for cardiologists and nephrologists to improve prognosis among CKD and CHF patients.

Correlation of Pretransplant Glucose Metabolism and Nonalcoholic Fatty Liver Disease with the Development of Post Transplantation Diabetes Mellitus

Introduction Post transplant diabetes mellitus (PTDM) is a strong independent predictor of mortality. Metabolic syndrome is known risk factor for diabetes and non alcoholic fatty liver disease(NAFLD) is a liver manifestation of metabolic syndrome. The aim of study was to analyze influence of pretransplant glucose metabolism and NAFLD on PTDM and to see any change in pattern of fatty liver post transplant. Materials and Methods Fifty chronic kidney disease, end stage renal disease(CKD-ESRD) patients who underwent renal transplantation were enrolled in study. Demographic data were collected; anthropometric variables were measured. Measurements of plasma glucose in the fasting state and 2 hours after ingestion of 75 g glucose, fasting insulin, c-peptide, beta cell function and insulin resistance were done within1 week before transplant and followed in post transplant period at 1,3 and 6 months.HOMA model was used to define beta cell function and insulin resistance. Insulin resistance (IR) = (FI x G) /22.5 Beta cell function (B) = (20 x FI) / (G -3.5) Insulin sensitivity (IS) = 100/ IR; FI=fasting insulin (μIU/ml), and G=fasting glucose (mmol/l) HbA1c, UGS abdomen and fibroscan were done pretransplant and repeated at 3, 6 months post transplant. Diabetes was defined according to ADA criteria. Results PTDM developed in 17(34%) patients. Mean age was 32.26 + 9.51 years. 2 hr plasma glucose was found to be higher in group that developed PTDM (123.18±8.15vs 97.30±1.72, p=0.010). HbA1c, FBS, fasting insulin, c peptide, insulin resistance and beta cell function were found to be non significantly higher in the group that later developed PTDM. Anthropometric variables, gender, basic disease, dialysis duration, NAFLD had no bearing on development of PTDM. No significant change was seen in pattern of fatty liver post transplant. Discussion The incidence of PTDM in our study was 34%(17/50 patients) which is comparable to study by Vincenti et al, who reported 30% incidence of PTDM(1).The mean duration of development of PTDM in our study was 30 days post transplant. In our study,2hr plasma glucose predicted development of diabetes in post transplant period which is similar to findings of a study done by Rao M et al(2). Conclusion PPBS is more sensitive parameter then FBS in predicting PTDM. Anthropometric measures and NAFLD are not predictive of PTDM in our group of patients where malnutrition acts as a confounder.

Arteriosclerosis and vascular calcification: causes, clinical assessment and therapy.

Arteriosclerosis is a pathological, structural (media vascular calcification) and physiological (modified vascular smooth vessel cells; increased arterial stiffness) alteration of the vessel wall. Through improved assessment methods (functional and imaging), it has become a well-known phenomenon in recent decades. However, its clinical importance was underestimated until recently. Currently available English-speaking data about conditions/diseases associated with arteriosclerosis, its clinical sequels, available diagnostic procedures and therapeutic modalities were reviewed and summarized. In recent decades, emerging data have brought about a better understanding of causes and consequences of arteriosclerosis and highlight its growing clinical impact. Although arteriosclerosis showed an independent clinical impact on cardiovascular morbidity and mortality, especially in patients with chronic kidney disease/end-stage renal disease (CKD/ESRD) and diabetes mellitus, convincing clinical therapy concepts are not available until now. The establishment of novel therapeutic strategies derived from basic research is strongly needed.

The Glycemic Indices in Dialysis Evaluation (GIDE) study: Comparative measures of glycemic control in diabetic dialysis patients.

The validity of hemoglobin A1c (HgbA1c) is undergoing increasing scrutiny in the advanced CKD/ESRD (chronic kidney disease/end-stage renal disease) population, where it appears to be discordant from other glycemic indices. In the Glycemic Indices in Dialysis Evaluation (GIDE) Study, we sought to assess correlation of HgbA1c with casual glucose, glycated albumin, and serum fructosamine in a large group of diabetic patients on dialysis. From 26 dialysis facilities in the United States, 1758 diabetic patients (hemodialysis = 1476, peritoneal dialysis = 282) were enrolled in the first quarter of 2013. The distributions of HgbA1c and the other glycemic indices were analyzed. Intra-patient coefficients of variation and correlations among the four glycemic indices were determined. Patients with low HgbA1c values were both on higher erythropoietin (ESA) doses and more anemic. Serum glucose exhibited the highest intra-patient variability over a 3-month period; variability was modest among the other glycemic indices, and least with HgbA1c. Statistical analyses inclusive of all glycemic markers indicated modest to strong correlations. HgbA1c was more likely to be in the target range than glycated albumin or serum fructosamine, suggesting factors which may or may not be directly related to glycemic control, including anemia, ESA management, and iron administration, in interpreting HgbA1c values. These initial results from the GIDE Study clarify laboratory correlations among glycemic indices and add to concerns about reliance on HgbA1c in patients with diabetes and advanced kidney disease.

Dyslipoproteinemia and Impairment of Renal Function in Diabetic Kidney Disease: An Analysis of Animal Studies, Observational Studies, and Clinical Trials

Dyslipoproteinemia is highly prevalent in diabetes, chronic kidney disease, and diabetic kidney disease (DKD). Both diabetes and chronic kidney disease (CKD) are associated with hypertriglyceridemia, lower high-density lipoprotein, and higher small, dense low-density lipoprotein. A number of observational studies have reported that dyslipidemia may be associated with albuminuria, renal function impairment, and end-stage renal disease (ESRD) in the general population, and especially in CKD and DKD patients. Diabetic glomerulopathy and the related albuminuria are the main manifestations of DKD. Numerous animal studies support the finding that glomerular atherosclerosis is the main mechanism of glomerulosclerosis in CKD and DKD. Some randomized, controlled trials suggest the use of statins for the prevention of albuminuria and renal function impairment in CKD and DKD patients. However, a large clinical study, the Study of Heart and Renal Protection (SHARP), does not support that statins could reduce ESRD in CKD. In this article, we analyze the complex association of dyslipoproteinemia with DKD and deduce its relevance from animal studies, observational studies, and clinical trials. We show that special subgroups could benefit from the statin treatment.

Health-related quality of life functioning over a 2-year period in children with end-stage renal disease

Optimal care of the pediatric chronic kidney disease/end stage renal disease (CKD/ESRD) patient must now incorporate health-related quality of life (HRQOL) assessment and management. This study reports the first data on longitudinal change in global (PedsQL(TM)4.0) and disease-specific (PedsQL(TM)3.0 ESRD Module) HRQOL pediatric ESRD patient and proxy ratings over four assessment periods spanning approximately a 2-year period. General linear mixed modeling was used to analyze associations between patient demographics, medical variables, and patient and proxy HRQOL scores. Self-reported and/or proxy data were available for at least two time-points for 53 patients (age 2-18years; 60 % male), of whom 27 were receiving in-center hemodialysis. Patient ratings on global health and physical activity, emotional, and social and disease-specific worry and communication domains were higher (i.e., better) than parent-proxy ratings, confirming the importance of obtaining both sources of information. Patients on dialysis longer, particularly females, reported worse emotional functioning; females also reported more physical appearance concerns. Parents rated older children and those on dialysis longer as functioning worse on multiple global and disease-specific (e.g., fatigue, relationship) domains. Parents also rated children as functioning increasingly worse in school over time. Further, patient ESRD history (acute onset vs. medically managed) impacted how parents viewed the burden of ESRD on their child over time.