Chronic Kidney Disease Comorbidities Research Articles

Clinical outcomes and treatment patterns among Medicare patients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease.

BackgroundPatients with nonvalvular atrial fibrillation (NVAF) and chronic kidney disease (CKD) have increased risk of adverse outcomes. This study evaluated treatment with oral anticoagulants and outcomes in elderly NVAF patients with CKD.MethodsRetrospective observational cohort study of US Medicare fee-for-service patients aged ≥66 years with comorbid CKD (advanced: Stage 4 and higher; less advanced: Stages 1–3) and a new NVAF diagnoses from 2011–2013. All-cause mortality, stroke, major bleeding, and myocardial infarction rates were estimated for 1 year post-NVAF diagnosis. Associations between CKD stage and outcomes were evaluated with multivariate-adjusted Cox regression. We assessed oral anticoagulant (OAC) receipt within 90 days post-NVAF diagnosis and associations between OAC receipt and outcomes.ResultsThere were 198,380 eligible patients (79,681 with advanced CKD). After adjustment for age, gender, and comorbidities, advanced CKD was associated with increased mortality (Stage 5 HR 1.47; 95% CI 1.42–1.52), MI (HR 1.48; 95% CI 1.33–1.64), stroke (HR 1.23; 95% CI 1.11–1.37) and major bleed (HR 1.44; 95% CI 1.36–1.53) risks. Among Medicare Part D enrollees who survived ≥90 days post-NVAF diagnosis, 65–71% received no OACs in the first 90 days. Those receiving warfarin (HR 0.73; 95% CI 0.71–0.75) or DOACs (HR 0.52; 95% CI 0.49–0.56) within the first 90 days had reduced mortality in the period 90 days to 1 year following NVAF diagnosis compared to those without.ConclusionElderly NVAF patients with advanced CKD (Stage 4 or higher) had higher mortality risks and serious clinical outcomes than those with less advanced CKD (Stage 1–3). OAC use was low across all CKD stages, but was associated with a lower mortality risk than no OAC use in the first year post-NVAF diagnosis.

A multi-source data integration approach reveals novel associations between metabolites and renal outcomes in the German Chronic Kidney Disease study

Omics data facilitate the gain of novel insights into the pathophysiology of diseases and, consequently, their diagnosis, treatment, and prevention. To this end, omics data are integrated with other data types, e.g., clinical, phenotypic, and demographic parameters of categorical or continuous nature. We exemplify this data integration issue for a chronic kidney disease (CKD) study, comprising complex clinical, demographic, and one-dimensional 1H nuclear magnetic resonance metabolic variables. Routine analysis screens for associations of single metabolic features with clinical parameters while accounting for confounders typically chosen by expert knowledge. This knowledge can be incomplete or unavailable. We introduce a framework for data integration that intrinsically adjusts for confounding variables. We give its mathematical and algorithmic foundation, provide a state-of-the-art implementation, and evaluate its performance by sanity checks and predictive performance assessment on independent test data. Particularly, we show that discovered associations remain significant after variable adjustment based on expert knowledge. In contrast, we illustrate that associations discovered in routine univariate screening approaches can be biased by incorrect or incomplete expert knowledge. Our data integration approach reveals important associations between CKD comorbidities and metabolites, including novel associations of the plasma metabolite trimethylamine-N-oxide with cardiac arrhythmia and infarction in CKD stage 3 patients.

Modifying Phosphate Toxicity in Chronic Kidney Disease

Phosphate toxicity is a well-established phenomenon, especially in chronic kidney disease (CKD), where hyperphosphatemia is a frequent occurrence when CKD is advanced. Many therapeutic efforts are targeted at phosphate, and comprise dietary intervention, modifying dialysis schemes, treating uncontrolled hyperparathyroidism and importantly, phosphate binder therapy. Despite all these interventions, hyperphosphatemia persists in many, and its pathological influence is ongoing. In nephrological care, a somewhat neglected aspect of treatment—when attempts fail to lower exposure to a toxin like phosphate—is to explore the possibility of “anti-dotes”. Indeed, quite a long list of factors modify, or are mediators of phosphate toxicity. Addressing these, especially when phosphate itself cannot be sufficiently controlled, may provide additional protection. In this narrative overview, several factors are discussed that may qualify as either such a modifier or mediator, that can be influenced by other means than simply lowering phosphate exposure. A wider scope when targeting phosphate-induced comorbidity in CKD, in particular cardiovascular disease, may alleviate the burden of disease that is the consequence of this potentially toxic mineral in CKD.

Prognostic Impact of Chronic Kidney Disease in Patients with Heart Failure.

Heart failure (HF) and chronic kidney disease (CKD) share many risk factors, and cardiac and renal dysfunction often coexist. The close association between HF and CKD worsens patient prognosis. To examine the association between progressing CKD with rates of hospitalization, 30-day readmission, and mortality in patients with HF. A retrospective analysis was conducted from January 1, 2012, to December 31, 2016, in the Kaiser Permanente Southern California Region. All patients age 18 years or older with a diagnosis of comorbid CKD and HF were included. Patients were excluded if they were noncontinuous members of Kaiser Permanente. Those included in the study were stratified into 2 cohorts: Early-stage CKD (stages 1, 2, and 3) and late-stage CKD (stages 4 and 5) on the basis of their estimated glomerular filtration rate in accordance with the National Kidney Foundation. A total of 27,366 patients were identified with comorbid HF and CKD. At the first year of follow-up, patients with HF and late-stage CKD had higher all-cause hospitalization (rate ratio [RR] = 1.56, 95% confidence interval [CI] = 1.48-1.65, p < 0.001), HF-related hospitalization (RR = 1.25, 95% CI = 1.20-1.41, p = 0.001), and 30-day readmission rates (RR = 1.46, 95% CI = 1.31-1.63, p < 0.001) compared with patients with HF and early-stage CKD. In subsequent follow-up years, patients continued to have higher all-cause and HF-related hospitalization rates in late-stage CKD. The late-stage CKD cohort had a significantly higher risk of 5-year mortality (hazard ratio = 1.40, 95% CI = 1.35-1.45, p < 0.001). Stage 4 and 5 CKD is a significant contributor to poor prognosis in patients with HF, leading to significantly higher rates of hospitalization, 30-day readmission, and mortality.

The ultrasonographic and pathomorphological markers of liver steatosis in patients with non-alcoholic fatty liver disease depending on the presence of comorbid chronic kidney disease (chronic pyelonephritis) and obesity

Objective — to establish the peculiarities of ultrasonographic and pathomorphological changes of liver parenchyma in patients with non-alcoholic liver steatosis (NAS) and non-alcoholic steatohepatitis (NASH) depending on the presence of comorbid chronic kidney disease (CKD) and obesity Materials and methods. The examinations involved 384 patients with non-alcoholic fatty liver disease (NAFLD), from them 84 subjects with I degree obesity (1 group) were divided into 2 subgroups: 32 patients with NAS and 52 patients with NASH. The second group consisted of 270 patients with NAFLD with comorbid I degree obesity and CKD І—ІІІ stage and included 110 patients with NAS and 160 patients with NASH. The control group consisted of 90 patients with CKD of the І—ІІІ stage with normal body weight (group 3). The mean age of patients was (45.8 ± 3.81) years. Results and discussion. The study demonstrated that the comorbidity of obesity and NASH with CKD increases the degree of steatosis (the area of hepatocytes affected by fatty liver dystrophy), the degree of ballooning degeneration, hyaline-drop dystrophy; the dystrophic changes in the centrilobular zone (3) deepen in the middle of the lobe with the development of panacinar injury and the involvement of zone 1. The course of NASH with CKD is characterized by a significantly higher incidence and intensity of clinical syndromes and the degree of biochemical and histological activity, which leads to the progression of fibrotic changes in the liver F2—F3. Conclusions. The NASH and CKD comorbidity is characterized by a higher degree of liver steatosis (LSD) (hepatorenal index 1.3 times higher than in the group of patients with NASH, p < 0.05) and the higher diagnostic threshold of values of the hepatotoxic index, which in strong interdependence correlates with the degree of steatosis of the liver, determined by Steato-test (r = 0.87; p < 0.001). In patients with NAS and NASH without comorbid pathology, a significant degree of LSD was found, with NASH it exceeds the reference values by 3.3 times (p < 0.05) and with NAS — by 1.8 times (p < 0.05). In comorbidity with CKD in patients with NAS, LSD was 3.5 times higher (p < 0.05) and in patients with NASH — 4.6 times higher (p < 0.05) than the reference values (p < 0.05).

Hip fractures in patients with chronic kidney disease admitted to Victorian hospitals.

There is a paucity of epidemiological data in Australia on fracture rates in patients with chronic kidney disease (CKD). Using data from the Victorian Admitted Episodes Dataset, we assessed the incidence of hip fractures requiring hospitalisation between 2006 and 2015, comparing those coded with and without the co-morbidity CKD. ICD-9 and ICD-10 codes were used to determine hip fractures and comorbidities. Overall, 7.4% of 77 076 Victorian hospital admissions for hip fractures had CKD as a co-morbidity, with an increasing proportion over the study period. Mortality was significantly higher in the CKD cohort compared to no CKD, perhaps in part due to increased associated comorbidities of diabetes and ischaemic heart disease.

ROLE OF FIBRINOLYTIC ACTIVITY OF BLOOD IN PATHOGENESIS OF NON-ALCOHOLIC FATTY LIVER DISEASE AND CHRONIC KIDNEY DISEASE (ORIGINAL RESEARCH)

The aim of the research − to find out of changes fibrinolytic activity of blood in patients with non-alcoholic fatty liver on the background of obesity, depending on the presence of comorbid chronic kidney disease. Material and methods of research: 444 patients were examined: 84 of them were with NAFLD and class I obesity (group 1), which contained 2 subgroups: 32 patients with non-alcoholic steatosis (NAS) and 52 patients with non-alcoholic steatohepatitis (NASH); 270 patients with NAFLD with comorbid class I obesity and CKD І–ІІІ stage (group 2), including 110 patients with NAS and 160 patients with NASH. The control group consisted of 90 patients with CKD of І–ІІІ stage with normal body weight (group 3). To determine the dependence of the NAFLD course on the form and stage of the CKD, the group of patients was randomized according to age, sex, degree of obesity, and activity of NASH. Research results. The study of fibrinolytic activity of blood showed that total fibrinolytic activity (TFA) of blood plasma in patients of all groups was significantly lower than the control indexes: in patients with NAS – by 7.1%, patients with NAS with CKD – by 14.9%, patients with NASH – by 17.2%, patients with NASH with CKD – by 18.9%, patients with CKD – by 10.6% (p &lt;0.05) with the presence of a probable intergroup difference between groups with comorbidity and isolated course of CKD (p &lt;0.05). The suppression of TFA occurred through the decrease of EF: in patients with NAS the index is significantly lower than that in the controls by 1.2 times, in patients with NAS with CKD – by 1.4 times, in patients with NASH – by 1.7 times, in the group of patients with NASH and CKD – by 1.9 times, while in the group of patients with CKD, the suppression of EF was registered – 1.3 times (p &lt;0.05). At the same time, the NEF in patients of all groups increased in comparison with the AHP group: in patients with NAS – by 1.2 times, in patients with NAS with CKD – by 1.3 times, in patients with NASH – by 1.4 times, in the group of patients with NASH with CKD – 1.5 times, while in the group of patients with CKD the activation of NEF was registered 1.2 times (p &lt;0.05), with the presence of a probable difference between the groups with comorbidity and isolated course of CKD (p &lt;0.05). Conclusion. Analysis of hemostasis and fibrinolysis indices in examined patients with NASH, depending on the stage of CKD showed that with the growth of the CKD stage, the activity of the cohort increases, with the exception of the fibrinogen content (most likely due to coagulopathy consumption), the activity of the anti-coagulants decreases, the total and enzymatic activity of fibrinolysis is reduced, and non-enzymatic compensator increases. Thus, metabolic intoxication, oxidative stress, which accompany the flow of NAFLD with obesity and CKD, promote the activation of the kallikrein-kinin system, the formation of plasma and thrombin, with subsequent disturbance of equilibrium between them, the development of stasis, slag phenomenon, the formation of platelet and erythrocyte aggregates in blood circulation system. The consequence of significant activation of hemocoagulation against the suppression of total fibrinolytic activity (TFA) is the local clotting of blood in the arteries.

FEATURES OF THE COLON MICROBIOCENOSIS IN PATIENTS WITH NONALCOHOLIC STEATOHEPATITIS DEPENDING ON THE PRESENCE OF CHRONIC KIDNEY DISEASE

The purpose of the study: to establish the features of the of colon cavity (CC) microbial state in patients with non-alcoholic steatohepatitis (NASH) with obesity, depending on the presence of comorbid chronic kidney disease (CKD) and its stages. Material and methods of research. 168 patients with NASH from 42 to 55 years of age were examined. All patients were distributed as follows. Group 1 consisted of 68 patients with NASH and obesity of 1st degree. Group 2 consisted of 100 patients with NASH and obesity of 1st degree with a comorbid CKD I-III stages (chronic pyelonephritis). We examined 30 practically healthy persons (PHPs), which by age and sex were not statistically significantly different from the main group and the comparison group. Microbiocenosis of CC was studied by microbiological method by sowing ten-fold dilutions of feces on differential-diagnostic nutrient media in accordance with the methodological recommendations Microbiological diagnosis of of the Ministry of Health of the USSR (1986).Results of the research and their discussion. The study revealed changes in the microbial cavity content of the colon (CC) during the comorbid flow of NASH with obesity and the CKD I-III stages, characterized by the development of deep dysbiosis (II-III degree) With the appearance and prevalence of pathogenic microflora, an increase in the number of opportunistic bacteria and yeast fungi of the genus Candida, a probable deficiency of representatives of normal microbiota: lactobacilli, bifidobacteria, bacteroids.Conclusion. It is established that one of the components of the pathogenesis of non-alcoholic steatohepatitis in patients with obesity and chronic kidney disease is metabolic intoxication, which arises as a result of a significant violation of the quantitative and qualitative composition of the microflora of the microbial cavity of the colon with the development of deep dysbiosis.

PDB47 - THE ASSOCIATION BETWEEN RENAL FUNCTION AND HEALTHCARE COSTS IN US PATIENTS WITH TYPE 2 DIABETES

Examine healthcare costs for US patients with type 2 diabetes (T2D) and comorbid chronic kidney disease (CKD) IQVIA linked claims and medical records from January 1, 2012 through March 31, 2017 were used for this retrospective study. Patients age 18 and older, diagnosed with T2D, and identified with CKD were included. Patients with type 1 diabetes, pregnancy, or without continuous insurance coverage from the date first identified with CKD (the index date) through the 1-year post-period were excluded from the study. General linear models incorporating splines were constructed and information from these regressions were used to inform whether the relationship between costs and CKD would best be captured by incorporating non-linearities. These models also controlled for patient characteristics, vital signs, general health, prior medication use, prior visit to specialists, index A1c, and year of index date. There were 6,645 individuals who fit the study inclusion and exclusion criteria – 3,189 with Stage 1 or 2 CKD, 1,441 in Stage 3a, 1,184 in Stage 3b, 449 in Stage 4 and 382 in Stage 5. Results generally indicate sharp increases in total medical costs and non-drug medical costs for patients with Stage 4 or 5 CKD (estimated glomerular filtration rate [eGFR] ≤ 30 mL/min/1.73m2) with each 1 point reduction in eGFR from 30 associated with an increase of $1,870 in all-cause total medical costs (P<0.0001) and $1,805 of all-cause non-drug costs (P<0.0001). Similarly, each point decline below 30 mL/min was associated annual costs increases of $1,701 for CKD-related total medical costs, $1,695 for CKD-related non-drug costs, $174 for diabetes-related medical costs, and $187 for diabetes-related non-drug costs (all P<0.0001). Results indicate there are sharp and significant increases in medical costs among T2D patients with Stage 4 and 5 CKD compared to those with earlier stages of CKD.

The pathogenetic role of large intestine dysbiosis in the pathogenesis of the mutually burdened non-alcoholic fatty liver disease and chronic kidney disease

Objective — to establish the probable influence of the microbial state of the colon cavity (MSCC) content on the degree of steatosis and liver fibrosis in patients with non-alcoholic steatohepatitis (NASH) with obesity, depending on the presence of comorbid chronic kidney disease (CKD) and its stages.Materials and methods. The study involved 168 patients with NASH, aged 42 to 55 years examined. All patients were allocated to the following groups: Group 1 consisted of 68 patients with NASH with concomitant obesity of 1st degree, Group 2 consisted of 100 patients with NASH with obesity of 1st degree and a comorbid CKD I—III stages (chronic pyelonephritis). The control groups consisted of 30 practically healthy persons (PHPs), which by age and sex were not statistically significantly different from the main group and the comparison group. Microbiocenosis of MSCC was investigated with microbiological method by sowing ten-fold dilutions of feces on differential-diagnostic nutrient media in accordance with the methodological recommendations «Microbiological diagnosis of dysbiosis» of the Ministry of Health of the USSR (1986). The main markers allowed to make conclusions about dysbiotic changes were: the type of belonging of aerobes and anaerobes, quantitative characteristic (concentration) and the frequency of growth of sown colonies. Verification of the severity of dysbiosis was carried out on the basis of the classification of I.B. Kuvaevo, K.S. Ladodo (1991).Results and discussion. The study revealed changes in the microbial state of the colon cavity (MSCC) content during the comorbid course of NASH with obesity and CKD I—III stages, characterized by the development of deep dysbiosis (II—III stages). With the appearance and prevalence of pathogenic microflora, an increase in the number of opportunistic bacteria and yeast fungi of the genus Candida, a probable deficiency of representatives of normal microbiota: lactobacilli, bifidobacteria, bacteroids. The degree of dysbiosis of MSCC correlates with the content of increases with the growth of the CKD stage, the activity of cytolysis of hepatocytes, endotoxicosis, oxidative and nitrosative stress, degree of hepatocyte steatosis and hepatic tissue fibrosis.Conclusions. An important component of the pathogenesis of non-alcoholic steatohepatitis in obese patients and CKD is metabolic intoxication, which arises as a result of a significant violation of the quantitative and qualitative composition of the microflora of MSCC with the development of deep dysbiosis (II—III stages). The degree of dysbiosis of the colon in patients with a combined course of NASH, obesity and CKD increases with the growth of the CKD stage, the degree of obesity, the activity of cytolysis of hepatocytes, endotoxicosis, oxidative and nitrosative stress, interconnected with the degree of hepatocyte steatosis and hepatic tissue fibrosis.

In- Hospital Outcome of Acute St Elevation Myocardial Infarction With Impaired Renal Function

Background: Ischemic Heart disease (IHD) is a common cardiac disorder and is the no.1 cause of mortality and morbidity worldwide. Associated Chronic Kidney Disease (CKD) may further affect the outcome of acute ST elevation myocardial infarction adversely. So, Effective risk stratification is integral to the management of patients with acute coronary syndromes with a co-morbidity of CKD. This observational study was conducted to evaluate the clinical outcome of patients with acute ST Segment Elevation Myocardial Infarction (STEMI) with impaired renal function. Materials and methods: The study was done in the Department of Cardiology, Chittagong Medical College from January 2015 to December 2015. 100 STEMI patients diagnosed by clinical, biochemical and ECG criteria were included in the study. Biochemical and clinical parameters were obtained from eligible subjects. Data was analyzed by computer based software SPSS- 17. Results: Mean ages of patients were 51. 4 years ± SD- 9.54 years. Male to female ratio was 3.34:01. 97% patients were presented with chest pain and breathlessness was found in 65% of patients. Among 100 patients 73 had arrhythmias, 21 were found to develop heart failure, 14 were having cardiogenic shock and death occurred in case of 4 patients. Conclusion: Early detection and appropriate management of renal impairment is necessary to avoid increased mortality and morbidity in STEMI patients.&#x0D; JCMCTA 2018 ; 29 (1) : 5-10

Caracterización de la disfunción tiroidea en adultos con enfermedad renal crónica en diálisis

Introducción: existe una clara relación entre la disfunción tiroidea y la enfermedad renal crónica (ERC) que se evidencia por el aumento de la prevalencia de hipotiroidismo primario a medida que disminuye la tasa de filtración glomerular.Objetivo: caracterizar los pacientes adultos con disfunción tiroidea y enfermedad renal crónica en terapia dialítica.Métodos: se realizó un estudio observacional de tipo descriptivo, transversal, que caracterizó y recolectó datos de laboratorio en pacientes mayores de 18 años con ERC. Estos pacientes se encontraban en terapia dialítica en una unidad renal de la ciudad de Cartagena (Colombia) y se les practicó un control de TSH en el año 2016.Resultados: se incluyeron 350 pacientes con registro de TSH. La mediana de edad fue de 59 años y el 49.1% eran mujeres. La principal causa de la ERC fue la hipertensión (36.3%) y la principal comorbilidad fue el hiperpatioidismo (56%). En relación con la disfunción tiroidea, se evidenció que el 25.4% de la población presentó niveles de TSH mayores a 4.5 μIU/mL. Dentro de este segmento, un 5.7% se encontraba en rango de hipotiroidismo (TSH&gt;10 μIU/mL).Conclusiones: la prevalencia de la disfunción tiroidea fue mayor en la muestra, en comparación con la población general. No obstante, se requieren estudios adicionales con medición de T4L para realizar una adecuada categorización.

ІНТЕНСИВНІСТЬ ФІБРОЗОУТВОРЕННЯ В ПЕЧІНЦІ ХВОРИХ НА НЕАЛКОГОЛЬНИЙ СТЕАТОГЕПАТИТ НА ТЛІ ОЖИРІННЯ І–ІІ СТУПЕНІВ ТА ХРОНІЧНУ ХВОРОБУ НИРОК

Мета роботи – дослідити біохімічні маркери фіброзу печінки при НАСГ, що розвинувся на тлі ожиріння І–ІІ ступенів та ХХН І–ІІІ стадій.Матеріал і методи. Обстежено 98 хворих на НАСГ на тлі ожиріння І–ІІ ступенів, у тому числі 52 хворих на НАСГ на тлі ожиріння І–ІІ ступенів (1 група) без супровідної ХХН, 46 хворих на НАСГ на тлі ожиріння І–ІІ ступенів із коморбідною ХХН І–ІІІ ст. (2 група). Контрольну групу склали 20 практично здорових осіб (ПЗО) відповідного віку та статі.Визначення структурних змін паренхіми печінки та нирок здійснювали шляхом проведення ультрасонографічного (УСГ) дослідження. З метою кількісної оцінки змін ехогенності печінки використали метод еходенситомет­рії із обчисленням гепаторенального індексу (ГРІ). Біопсія печінки виконана 32 хворим на НАСГ із супровідною ХХН І–ІІІ ст., 28 хворим на НАСГ без ХХН. Біоптати печінки отримували шляхом черезшкірної чи лапароскопічної прицільної біопсії.Результати. Встановлено, що коморбідний перебіг НАСГ із ХХН характеризується вищим ступенем стеатозу печінки (ГРІ у 1,3 раза вищий, порівняно з групою хворих на НАСГ (p&lt;0,05)), та вищим діагностичним порогом значень гепаторенального індексу, який у сильній взаємозалежності корелює зі ступенем стеатозу печінки, визначеним за Steato-test (r=0,87; p&lt;0,001).При неалкогольному стеатогепатиті, що розвивається на тлі ожиріння та ХХН І–ІІІ стадії, встановлено наявність у печінковій тканині фібротичних змін, які за біохімічним індексом фіброзу перевищують такі у хворих на НАСГ без коморбідності з патологією нирок. При НАСГ встановлено прояви переважно F0–F1 cтадій фіброзу печінки, при НАСГ із супровідною ХХН І–ІІІ стадії переважали F1–F2 стадії фіброзу печінкової тканини.Висновки. У хворих на НАСГ на тлі ожиріння найчастіше спостерігали перицелюлярний фіброз (у 100 % випадків), дещо рідше зустрічали фіброз перисинусоїдально типу (39,3 %) та центролобулярний (35,7 %) і у 10,7 % спостерігали перипортальний та портальний фіброз печінки. У хворих на НАСГ на тлі ожиріння та ХХН І–ІІІ ст. перицелюлярний фіброз також виявляли у 100 % випадків, значний відсоток займали перисинусоїдальний (78,1 %) та перивенулярний (68,8 %) фіброз 3-ї зони, а також фіброз портального та/або перипортального типу з поодинокими септами (25,0 %).

Kidney disease incidence in patients with diabetes mellitus in China

Diabetic kidney diseases (DKDs) are the primary diabetic microvascular complications and the main causes of end-stage renal disease (ESRD) worldwide. In China, the prevalence of diabetes has increased alongside the fast economic development. DKD has gradually become the chief cause of ESRD, and the prevalence of patients with type 2 diabetes mellitus and chronic kidney disease (CKD) is high. Patients with DKD have worse survival than those with comorbid diabetes on chronic hemodialysis. Hyperuricemia is an independent risk factor for DKD. The treatments of DKD and diabetes with comorbid CKD include the usual blood glucose and pressure controls, urinary albumin reduction, and treatment of complications. Currently, lowering uric acid is gradually gaining focus as a treatment. How is the rapid rise in the prevalence of diabetes affecting that of CKD in China? The problems of how to ensure early diagnosis, prevention, and delay of the development of DKD and diabetes with comorbid CKD require solutions. In this study, we summarize the epidemiology, diagnosis, and treatment of DKD and those of diabetes with comorbid CKD in China.

The case of toxic epidermal necrolysis in the patient with the chronic kidney disease of V stage on replacement therapy by the programme hemodialysis method

High comorbidity of chronic kidney disease dictates special, multidiscipline approach to the patients with terminal chronic renal failure. Toxic epidermal necrolysis, or Lyell’s syndrome refers to the severe, rarely encountered diseases, diagnosis and treatment of which against the background of the terminal stage of chronic kidney disease causes significant difficulties. The article describes own clinical observation of toxic epidermal necrolysis in a patient with chronic kidney disease stage V on renal replacement therapy by hemodialysis. The patient, who received hemodialysis for 6 years, was directed to correction of the arteriovenous shunt with his thrombosis and suppuration. The formation of a new permanent vascular access in the middle third of the thigh in the postoperative period was complicated by a purulent-septic process with the development of generalized sepsis and Lyell’s syndrome. The occurrence of Lyell’s syndrome in a patient with CKD stage V on hemodialysis demonstrates immunological features and high comorbidity in patients with terminal chronic renal failure and confirms the difficulty of maintaining this patient category.

Intensity of oxidative and nitrosative stress in patients with nonalcoholic steatohepatitis and comorbid chronic kindney disease

Objective — to establish intensity of the oxidative and nitrosative stress at the comorbid course of nonalcoholic steatohepatitis (NASH) and chronic kidney disease (CKD) of the 1st and 2nd stages. Materials and methods. Investigation involved 105 patients (48 men and 57 women) with NASH, form them 52 had 1st degree obesity (group 1), and in 53 patients NASH was combined with 1st degree obesity and І - ІІ stages CKD (group 2). The average age of patients was (45.8 ± 3.81) years. The control group consisted of 30 practically healthy age- and sex-matched subjects. The functional endothelium state was studied by the blood levels of stable nitrogen monoxide (NO) metabolites (nitrites, nitrates) by L. C. Green et al. The number of desquamated endothelial cells in blood was determined by the method of J. Hladovec in the modification of N.N Petrischev et al. The state of the antioxidant protection system (AOP) was studied based on the erythrocyte levels of the restored glutathione (GSH), glutathione peroxidase (GPx), glutathione-S-transferase (GSTs), catalase, superoxide dismutase (SOD), ceruloplasmin (CP). Results. It has been established that in case of comorbidity of NASH and І - ІІ stages CKD, the oxidative stress intensity increased with accompanying accumulation of not only intermediate, but also final products of free radical lipid oxidation in all observation groups, testifying presence of the decompensated oxidative stress in this category of patients. The latter fact is an undeniable evidence of the involvement of oxidative stress in the NASH pathogenesis, and its intensity increases with the CKD comorbidity. The obtained results showed the significant increase in blood NO levels of NASH patients vs indices of practically healthy people. The raised number of desquamated endothelial cells in 1.9 times (p < 0.05) evidenced about the expressed endothelial dysfunction in NASH patients. Conclusions. The investigation showed that in case of comorbid course of NASH and І - ІІ stages CKD, the oxidative stress intensity increased with accompanying accumulation of the intermediate and final products of free radical lipid oxidation, early development of the endothelial dysfunction (increased blood number of desquamated endothelial cells and blood levels of the stable NO metabolites) against the background of the activity of the factors of antiradical defense (the decreased erythrocytic levels of the restored glutathione, superoxide dismutase activity, glutathione-dependent enzymes).

Renal Function and Exercise Training in AmbulatoryHeart Failure Patients With a Reduced Ejection Fraction

Patients with chronic kidney disease (CKD) and/or end-stage renal disease are less active and experience significant functional limitations. The impact of a structured aerobic exercise intervention on outcomes in ambulatory heart failure (HF) patients with comorbid CKD is unknown. HF-ACTION enrolled 2,331 outpatients with HF and a reduced ejection fraction (i.e., ≤35%) from April 2003 to February 2007 and randomized them to aerobic exercise training versus usual care. Patients were grouped according to the presence of CKD, defined as an estimated glomerular filtration rate <60 ml/min/1.73 m2. A total of 2,091 patients (90%) had serum creatinine measured and were included in the final analytical cohort. The prevalence of CKD was 41% at baseline. In patients with and without CKD, respectively, the incidence of all-cause death and hospitalization was 75% and 63% over a median follow-up of 30 months. After adjusting for potential confounders, CKD was associated with increased risk of the composite of all-cause mortality and hospitalization (hazard ratio 1.18, 95% confidence interval 1.04 to 1.33; p value ≤0.01). With the exception of a marginally greater improvement in exercise duration in response to aerobic exercise training (estimate ± standard error: 0.9 ± 0.2 minutes vs 1.4 ± 0.1 minutes; p value = 0.01), there was no interaction between treatment arm and CKD on functional status, health-related quality of life, or clinical outcomes (p value ≥0.05 for all interactions). In conclusion, the prevalence of CKD was high in ambulatory reduced ejection fraction patients and was associated with a poorer overall prognosis but not a differential response to aerobic exercise training.

Features of the non-alcoholic steatohepatitis and chronic kidney disease courses, pathogenetic correction efficiency

The aim of the study. To establish the mechanisms of mutual burden and progression of non-alcoholic steatohepatitis (NASH) and chronic kidney disease (CKD) in patients with obesity.Material and methods. 114 patients with NASH were examined against the background of І-ІІ degree obesity, including: 52 patients with NASH (group 1) (without accompanying CKD), 62 patients with NASH with a comorbid CKD І-ІІ degree (group 2). The average age of patients was (45.8 ± 3.81) years. The control group consisted of 20 practically healthy persons (PHPs) of the corresponding age and sex. Results. The obtained data testify that under the conditions of the H2S deficit and hyperproduction of homocysteine for the comorbidity of NASH from CKD I-II degree the synthesis and resorption of collagen are activated, but the anabolism processes predominate as a result of the activation of the fibroblasts system, with a significant hyperproduction of acute phase proteins, fibronectin, a higher degree of hyperthyroidism and dyslipidemia with predominance of proatherogenic lipoprotein fractions, and a higher degree of endothelium dysfunction.Conclusions. A significant increase in the synthesis of collagen and glycoproteins (fibronectin) in patients with NASH, which was observed on the background of obesity, was established, which is accompanied by an ineffective resorption of newly formed collagen due to inhibition of collagenolysis against activation of proteinase inhibitors (α2-MG), accompanied by hyperproduction of the fibroblast growth factor, homocysteine, endothelin‑1, deficiency in the liberation of hydrogen sulfide and nitrogen monoxide.

Pulmonary Hypertension in Predialysis Chronic Kidney Disease: Frequency and Potential Mechanisms

AbstractBackground: Pulmonary arterial hypertension (PH) and Chronic Kidney Disease (CKD) both profoundly affect patient outcomes, whether as primary disease states or as comorbid conditions. PH is a common comorbidity in CKD and vice versa. PH is an independent predictor of mortality in such patients. In a recent review, the prevalence of PHT in ESRD patients was reported to be around 40-50% however, the epidemiological data for this disorder in earlier stages of Chronic Kidney Disease (CKD) and the risk factors associated with its presence are scarce.Aim: To evaluate the frequency of pulmonary hypertension among chronic kidney disease nondialysis dependent patients and to compare clinical and metabolic variables among those patients with the control group to search for possible mecha-nisms.Subjects and Methods: 40 CKD patients (55% men, 45% women; mean age, 42.9±15.13 years) with. According to the magnitude of Glomerular Filtration Rate (GFR) decrease, the CKD patients have divided into 3 groups: (1) 2 patients with a GFR of 89-60ml/min; (2) 6 with a GFR of 59-45ml/min; (3) 32 with a GFR of 44-15ml/min. A control group consisted of 40 individuals with preserved kidney function (a GFR of >90 ml/min). Physical examination and echocardiography were performed in all the patients. The serum concentrations of homocysteine and serum PTH were determined.Results: PH was detected in 20 (50%) of the 40 patients with CKD. As CKD progressed, the frequency of pulmonary hypertension in Groups 1, 2, and 3 increased, amounting to 18.2%, 24.2%, and 35%, respectively.Conclusion: This study demonstrated a high frequency of pulmonary hypertension among patients with CKD without dialysis.The frequency was highest among patients especially those with older age higher, serum creatinine phosphorus c-reactive protein parathyroid hormone and homocysteine; lower hemoglobin, lower EF% which all positively correlated with PASP and may be involved in the pathogenesis of pulmonary hypertension. Early detection of pulmonary hypertension is important in order to avoid the serious consequences of the disease, also managing these potential mechanisms will result in areduction in the occurrence of pulmonary hypertension and thus reducing the incidence of the cardiovascular compli-cations which are considered as one of the most important causes of death in the group of patients.

Comorbidity of chronic kidney disease, diabetes and lower glycated hemoglobin predicts support/care-need certification in community-dwelling older adults.

Chronic kidney disease (CKD), diabetes and lower glycated hemoglobin (HbA1c ) range in diabetes patients are associated with higher mortality. We investigated whether these conditions were associated with the risk of loss of independence in community-dwelling older adults. We analyzed 1078 older adults with no history of support/care-need certification in Long-Term Care Insurance aged 65-94 years. Associations of baseline CKD, diabetes, and lower HbA1c range of <6.0% in the diabetes patients, at baseline health checkup with risk of later certification and/or death for 5 years were estimated using the Cox proportional hazards regression model. The prevalence of both CKD and diabetes in the total population increased with age, due to a net increase in the coexistence of CKD and diabetes. The prevalence of the lower HbA1c range also increased with age in participants with the coexistence. During 5 years, 135 certifications and 53 deaths occurred. After adjustment, patients with comorbidity of the triad of CKD, diabetes and the lower HbA1c range had significantly higher hazard ratios (HR) for certification (HR 3.52, 95% confidence interval [CI] 1.91-6.48, P < 0.001) and for death (HR 3.79, 95% CI 1.46-9.85, P = 0.006) compared with those without CKD and diabetes. The harmful impact of the lower HbA1c range on later certification compared with higher HbA1c range of ≥6.0% was maintained in diabetes patients with use of antidiabetic agents and CKD (HR 2.40, 95% CI 1.06-6.45, P = 0.036). Excessive HbA1c reduction might cause discontinuance of disability-free survival in community-dwelling older diabetes patients with CKD. Geriatr Gerontol Int 2018; 18: 521-529.