Diet In Renal Disease Study Research Articles

Urinary Phosphate Excretion and Microvascular Function in a Population-Based Cohort

Urinary Phosphate Excretion and Microvascular Function in a Population-Based Cohort

Correlation between renal parenchymal thickness and EGFR in chronic kidney disease

Objective: A prospective study developed to determine the relationship between renal parenchymal thickness and glomerular filtration rate in patients with chronic kidney disease.Materials and Methods: From June 2019 to June 2020, 50 patients were clinically diagnosed with chronic kidney disease. The lowest serum creatinine was used for calculation of the glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease Study (MDRD) equations. The ultrasounds were done by a single radiologist and reviewed by 2 consultants. The renal parenchymal thickness was measured in the longitudinal from the renal sinus to the outer renal cortical margin at upper, mid and lower levels of each kidney and the mean value was estimated for each kidney. Statistical Package for Social Science (SPSS 20.0) version used for data analysis and an unpaired test was applied to find the statistical significance. Pearson correlation test applied to find the correlation between the variables. A P value less than 0.05 (p

Comparative Performance of Creatinine-Based GFR Estimation Equations in Exceptional Longevity: The Rugao Longevity and Ageing Study.

PurposeReduced kidney function has been associated with an increased risk for adverse outcomes. Accurate assessment of glomerular filtration rate (GFR) is key to diagnosis and management of kidney disfunction. Debate exists on the best GFR estimation equation for elderly people. This study aimed to compare the predictive validity and discriminative ability of four GFR equations in relation to 2-year and 6-year mortality in exceptional longevity (EL) (those over 95 years old with intact health) individuals and is an ideal model to address factors relating to life span and age-related diseases.Patients and MethodsThis study used 6 years’ data of 278 EL from the Rugao longevity cohort. Baseline GFR was estimated using four equations: Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, Modification of Diet in Renal Disease Study (MDRD) equation, Berlin Initiative Study-1 (BIS) equation, and modified MDRD equation. Predictive validity was tested using Cox proportional hazards analysis. Overall improvement in reclassification based on estimated GFR (eGFR) was assessed applying net reclassification improvement (NRI).ResultsMean age of participants was 97±2 years with median follow-up of 2.6 years. Median (IQR) eGFR by CKD-EPI, MDRD, BIS, and modified MDRD equations were 73.9 (62.2–77.6), 82.3 (67.4–98.6), 56.4 (47.9–63.9), and 101.5 (83.1–121.6) mL/min per 1.73 m2, respectively. Higher eGFREPI was associated with lower mortality after multivariate adjustment (for continuous eGFREPI, HRtwo-year 1.018, 95% CI 1.002–1.033, P=0.023; HRsix-year 1.013, 95% CI 1.002–1.025, P=0.022), while eGFR from other equations did not show any associations with mortality. NRI for two-year mortality was 0.14 and approximately significant, which may favor the CKD-EPI when compared to BIS equation (P=0.052).ConclusionThe CKD-EPI equation showed more accurate estimation of kidney function in the elderly with respect to GFR distribution and predictability of mortality risk.

Quadritherapy vs standard tritherapy immunosuppressant regimen after heart transplantation: A propensity score-matched cohort analysis.

After heart transplant, adding everolimus (EVL) to standard immunosuppressive regimen mostly relies on converting calcineurin inhibitors (CNIs) into EVL. The aim of this study was to describe the effects of combining low-dose EVL and CNIs in maintenance immunosuppression regimen (quadritherapy) and compare it with standard tritherapy associating standard-dose CNIs, mycophenolate mofetil, and corticosteroids. In the 3-year registry cohort of heart transplanted patients, those who received quadritherapy were compared with those who received tritherapy. EVL was added after 3months posttransplant. Three analyses were performed to control for confounders: propensity score matching, multivariable survival, and inverse probability score weighting analyses. Among 213 patients who were included (75 with quadritherapy), propensity score matching selected 64 unique pairs of patients with similar characteristics. In the matched cohort (n=128), quadritherapy was associated with fewer deaths (3 [4.7%] vs 17 [21.9%], P=.007) and biopsy-proven acute rejections (15 [23.4%] vs 31 [48.4%], P=.002). These results were confirmed in the overall cohort (n=213), after multivariable and inverse probability score weighting analyses. Renal function and donor-specific HLA-antibodies remained similar in both groups. Low-dose combination quadritherapy was associated with fewer deaths and rejections, compared with standard immunosuppression tritherapy.

Tubular secretion of creatinine and kidney function: an observational study

BackgroundPrior papers have been inconsistent regarding how much creatinine clearance (CrCl) overestimates glomerular filtration rate (GFR). A recent cross-sectional study suggested that measurement error alone could entirely account for the longstanding observation that CrCl/GFR ratio is larger when GFR is lower among patients with chronic kidney disease (CKD); but there have been no validation of this in other cohorts.MethodsTo fill these gaps in knowledge regarding the relation between CrCl and GFR, we conducted cross-sectional and longitudinal analysis of the Modification of Diet in Renal Disease study (MDRD) and African American Study of Kidney Disease and Hypertension (AASK); and cross-sectional analysis of a clinical dataset from the Mayo Clinic of four different patient populations (CKD patients, kidney transplant recipients, post kidney donation subgroup and potential kidney donors). In the cross-sectional analyses (MDRD, AASK and Mayo Clinic cohort), we examined the relation between the CrCl/iothalamate GFR (iGFR) ratio at different categories of iGFR or different levels of CrCl. In the MDRD and AASK longitudinal analyses, we studied how the CrCl/iGFR ratio changed with those who had improvement in iGFR (CrCl) over time versus those who had worsening of iGFR (CrCl) over time.ResultsObserved CrCl/iGFR ratios were generally on the lower end of the range reported in the literature for CKD (median 1.24 in MDRD, 1.13 in AASK and 1.25 in Mayo Clinic cohort). Among CKD patients in whom CrCl and iGFR were measured using different timed urine collections, CrCl/iGFR ratio were higher with lower iGFR categories but lower with lower CrCl categories. However, among CKD patients in whom CrCl and iGFR were measured using the same timed urine collections (which reduces dis-concordant measurement error), CrCl/iGFR ratio were higher with both lower iGFR categories and lower CrCl categories.ConclusionsThese data refute the recent suggestion that measurement error alone could entirely account for the longstanding observation that CrCl/GFR ratio increases as GFR decreases in CKD patients. They also highlight the lack of certainty in our knowledge with regard to how much CrCl actually overestimates GFR.

Comparison of creatinine-based methods for estimating glomerular filtration rate in patients with heart failure.

AimsGlomerular filtration rate is an important factor in management of heart failure (HF). Our objective was to validate eight creatinine‐based equations for estimating glomerular filtration rate (eGFR) in an HF population against measured glomerular filtration rate.Methods and resultsOne hundred forty‐six HF patients (mean age 68 ± 13 years, mean left ventricular ejection fraction 45% ± 15) within a single‐centre hospital that underwent 51Cr‐EDTA clearance between 2010 and 2018 were included in this retrospective study. eGFR was estimated by means of Cockcroft–Gault ideal and actual weight, the Modification of Diet in Renal Disease Study (MDRD), simplified MDRD with isotope dilution mass spectroscopy traceable calibration, the Chronic Kidney Disease Epidemiology Collaboration, revised Lund–Malmö, full age spectrum, and the Berlin Initiative Study 1. Mean measured glomerular filtration rate was 42 mL/min/1.73 m2. Pearson's correlation coefficient (r) had the highest precision for MDRD (r = 0.9), followed by revised Lund–Malmö (r = 0.88). All equations except MDRD (mean difference −4.8%) resulted in an overestimation of the renal function. The accuracy was below 75% for all equations except MDRD.ConclusionsNone of the exclusively creatinine‐based methods was accurate in predicting eGFR in HF patients. Our findings suggest that more accurate methods are needed for determining eGFR in patients with HF.

Povezanost između indeksa telesne mase i jačine glomerulske filtracije

INTRODUCTION: The increasing prevalence of chronic kidney disease (CKD) is a major health problem. The prevalence of obesity has also been rapidly increasing worldwide. Few studies have examined the relationship between excess body weight and CKD risk. Aim: To evaluate the possible contribution of increased body mass index (BMI) to impaired renal function in the general population sample. METHODS: The study involved 500 participants older than 30 years (228 men, 272 women, age 57.58±13.68) who visited their general practitioner in Health Center "Dr Simo Milošević". Blood samples, blood pressure anthropometric measures were performed on each participant. Estimated glomerular filtration rate was calculated using the abbreviated equation from MDRD study ("the Modification of Diet in Renal Disease Study") and CKD was defined as eGFR less than 60 ml/min/1.73m². Statistical analysis was performed using SPSS 19.0 software (IBM, Somers, New York, USA). RESULTS: The mean BMI was 25.09±3.54 kg/m² with 0.6% in underweight (BMI<18.5 kg/m²), 17.6% in lower normal (BMI 18.5 to 21.9 kg/m²), 33.2% in upper normal (BMI 22.0 to 24.9 kg/m²) and 48.6% in overweight or obese (BMI>25.0 kg/m²) body mass category. The mean eGFR was 100.33±30.78 ml/min/1.73m² with 112±8.62 in underweight, 116.94±3.8 in lower normal, 102.37±2.39 in upper normal and 92.78±1.72 in overweight or obese category. Estimated GFR values decreased significantly with increasing BMI specially in those in upper normal compared to lower normal (p<0.001) and overweight and obese compared to lower normal body mass category (p<0.001). Compared with participants with lower normal body mass, the non-adjusted odds ratio (OR) for mildly or moderately reduced renal function (eGFR<90 ml/min/1.73m²) was 2.54 (95% CI 1.41-4.56) for upper normal and 3.26 (95% CI 1.88-5.70) for overweight and obese participants. After adjusting for potential confounding variables (age, sex, diabetes mellitus, hypertension, hypercholesterolemia, hypertriglyceridemia and smoking status) or for mildly or moderately reduced renal function was 2.23 (95% CI 1.21-4.10) for upper normal 2.65 (95% CI 1.44-4.87) for overweight or obese participants compared to those in lower normal body mass category. CONCLUSION: Estimated GFR values decreased significantly with increasing BMI specially in those in upper normal compared to lower normal (p<0.001) and overweight and obese compared to lower normal body mass category (p<0.001). This study showed that increasing BMI is strongly associated with decreasing eGFR in the general population. The underlying mechanism behind this association remains to be investigated through prospective population-based studies.

Ketoacid Analogues Supplementation in Chronic Kidney Disease and Future Perspectives

Diet is a key component of care during chronic kidney disease (CKD). Nutritional interventions, and, specifically, a restricted protein diet has been under debate for decades. In order to reduce the risk of nutritional disorders in very-low protein diets (VLDP), supplementation by nitrogen-free ketoacid analogues (KAs) have been proposed. The aim of this review is to summarize the potential effects of this dietary therapy on renal function, uremic toxins levels, and nutritional and metabolic parameters and propose future directions. The purpose of this paper is also to select all experimental and randomized clinical studies (RCTs) that have compared VLDP + KA to normal diet or/and low protein diet (LPD). We reviewed the SCOPUS, WEB of SCIENCES, CENTRAL, and PUBMED databases from their inception to 1 January, 2019. Following duplicate removal and application of exclusion criteria, 23 RCTs and 12 experimental studies were included. LPD/VLPD + KAs appear nutritionally safe even if how muscle protein metabolism adapts to an LPD/VLPD + KAs is still largely unknown. VLPD + KAs seem to reduce uremic toxins production but the impact on intestinal microbiota remains unexplored. All studies observed a reduction of acidosis, phosphorus, and possibly sodium intake, while still providing adequate calcium intake. The impact of this diet on carbohydrate and bone parameters are only preliminary and need to be confirmed with RCTs. The Modification of Diet in Renal Disease study, the largest RCTs, failed to demonstrate a benefit in the primary outcome of the decline rate for the glomerular filtration rate. However, the design of this study was challenged and data were subsequently reanalyzed. However, when adherent patients were selected, with a rapid rate of progression and a long-term follow up, more recent meta-analysis and RCTs suggest that these diets can reduce the loss of the glomerular filtration rate in addition to the beneficial effects of renin-angiotensin-aldosterone system (RAAS) inhibitors. The current evidence suggests that KAs supplemented LPD diets should be included as part of the clinical recommendations for both the nutritional prevention and metabolic management of CKD. More research is needed to examine the effectiveness of KAs especially on uremic toxins. A reflection about the dose and composition of the KAs supplement, the cost-effective features, and their indication to reduce the frequency of dialysis needs to be completed.

Tasa de filtración glomerular estimada y mortalidad posterior al alta en una unidad geriátrica de agudos

ObjectiveTo determine the relationship between estimated glomerular filtration rate (eGFR) and mortality in a retrospective cohort of older adults admitted to an acute care for the elderly (ACE) unit. Materials and methodsThe study included 1,678 patients aged 60 years and over admitted to an AEC, in Cali, Colombia, from 2012 to 2015, and followed- up until 2016. The primary outcome was mortality. Renal function (eGFR) was estimated using Modification of Diet in Renal Disease Study (MDRD-4) equation. The renal function was grouped according to the eGFR (ml/min/1.73m2) as follows: slightly decreased (≥60), moderately decreased (30-59), and severely decreased (<30). Bivariate survival and multivariate Cox regression analyses were performed. ResultsIn the univariate analysis, patients with severely decreased eGFR had higher mortality than those with a higher eGFR (P=.046). In the group with severely decreased eGFR, survival was lower in the functionally dependent group (Barthel index [IB]<60) than in the independent group (IB≥60) (log rank test; P=.001). In the multivariate analysis, there was a significant increase in the risk of death in the elderly with severely decreased eGFR (<30) compared with slightly decreased eGFR (≥60) (hazard ratio [HR], 1.44; 95% confidence interval [CI]; 1.02-2.05, P=.039). There was also a significant increase in the risk of death in the dependent elderly compared to the independent ones [HR 1.72; 95% CI; 1.26-2.34, P=.000], those who had the high morbidity (≥4) with low albumin (<3.2g/dL) compared with those with low morbidity (0-3) and high albumin (≥3.2) [HR 1.77; 95% CI; 1.18-2.65, P=.005], and in those with a high (16-102mg/dL) C-reactive protein (CRP) compared with those with low CRP (0-15) [HR 1.42; 95% CI; 1.01-2.01, P=.043]. ConclusionsThe risk of mortality after hospital admission to an AEC unit is greater in patients with eGFR<30. Poor functional status performance, high comorbidity, low plasma albumin, and increased inflammation markers are additional prognostic factors to be taken into account. The improvement in the functional status could improve the survival after hospitalisation.

Increased Glomerular Filtration Rate in Early Stage of Balkan Endemic Nephropathy.

Background: A previous study indicated that Balkan endemic nephropathy (BEN) patients in the early stage of the disease had significantly higher creatinine clearance (Ccr) than healthy persons. The aim of the study was to assess whether tubular creatinine secretion affects Ccr in early stages of BEN and to check the applicability of serum creatinine-based glomerular filtration rate (GFR) equations in these patients. Methods: The study involved 21 BEN patients with estimated GFR (eGFR) above 60 mL/min/1.73 m2, excluding any conditions that could affect GFR or tubular creatinine secretion, and 15 healthy controls. In all participants Ccr with and without cimetidine and iohexol clearance (mGFR) were measured and eGFR calculated using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Modification of Diet in Renal Disease Study (MDRD) equations. Glomerular hyperfiltration cutoff (GFR-HF) was calculated. Results: There was no significant difference between the groups in Ccr before and after cimetidine or for eGFR, but mGFR was significantly higher in BEN patients than in controls (122.02 ± 28.03 mL/min/1.73 m2 vs. 101.15 ± 27.32 mL/min/1.73 m2; p = 0.032). Cimetidine administration reduced Ccr by 10% in both groups. The ratio of Ccr to mGFR was significantly above one in seven BEN patients and five controls and their mGFR values were similar. Seven other patients and eight controls had this ratio equal to one, while values below one were recorded for seven more patients and two controls. mGFR of all these 14 patients was significantly higher than that of healthy controls (129.88 ± 27.52 mL/min/1.73 m2 vs. 107.43 ± 19.51 mL/min/1.73 m2; p = 0.009). Mean GFR-HF was significantly higher than mGFR in controls, but these two values were similar in BEN patients. eGFR underestimated mGFR in both BEN patients and controls. Conclusion: The ratio of Ccr to mGFR and mGFR to GFR-HF indicated that elevated mGFR in early stages of BEN could be explained by increased glomerular filtration, but tubular creatinine secretion augmented Ccr in a smaller proportion of patients, who did not differ from healthy subjects.

Cystatin C as a novel predictor of preterm labor in severe preeclampsia.

BackgroundThe most common cause of acute kidney injury (AKI) in pregnancy is preeclampsia. Serum cystatin C (CysC) is a potential biomarker of early kidney damage as its levels are not disturbed by volume status changes in pregnancy, and serum CysC levels could serve as a replacement for conventionally used creatinine. In this study, we investigated the serum levels of CysC in severe preeclampsia cases and the associations between CysC levels and poor obstetric outcomes.MethodsOur cohort included severe preeclampsia patients with a normal serum creatinine level. Creatinine was measured to calculate estimated glomerular filtration rate (eGFR) based on the Cockcroft and Gault, Modification of Diet in Renal Disease Study (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, while CysC was measured to calculated eGFR based on a CysC-based equation. We then evaluated the correlations between serum CysC level, eGFR, and obstetric outcomes.ResultsTwenty-six patients were evaluated of which 38.5% delivered preterm and 30.8% had low-birth weight babies. Unlike creatinine-based eGFR and CysC-based eGFR, serum CysC demonstrate significant negative correlation with gestational age. Receiver operating characteristic curve analysis indicated that serum CysC is a potential biomarker of preterm delivery with a cut-off serum level of 1.48 mg/L with 80% sensitivity and 75% specificity.ConclusionGFR estimation using CysC is likely to be inaccurate in pregnancy. However, we found a significant correlation between preterm delivery and serum CysC level. Our results suggest that serum CysC level has the potential to predict preterm delivery in severe preeclampsia patients.

Renal Response in Carfilzomib (K)- Versus Bortezomib (V)-Treated Patients (Pts) with Relapsed or Refractory Multiple Myeloma (RRMM) in the Real-World Practice Setting

Introduction: Renal impairment (RI) is a classic clinicopathological feature of MM, is associated with poor prognosis and shorter survival (Eleutherakis-Papaiakovou Leuk Lymphoma 2007), and can complicate drug dosing and limit treatment options. In clinical trials, the proteasome inhibitors K and V have demonstrated efficacy in RRMM pts with RI, with superior efficacy observed in K-treated pts (Dimopoulos Blood 2017). K and V have also been observed to improve renal function in RRMM pts (Dimopoulos Clin Lymphoma Myeloma 2009; Dimopoulos Blood Advances 2017). However, few studies have investigated the real-world effectiveness of K- and V-based regimens in renal rescue. This study aimed to describe and compare renal response rates in RRMM pts treated with K + dexamethasone (Kd) and V + dexamethasone (Vd) in oncology clinics. Methods: The Oncology Services Comprehensive Electronic Records (OSCER) database (Lau Clin Epidemiol 2011) contains electronic medical records (EMR) from community- and hospital-affiliated oncology clinics in the United States. MM pts aged ≥18 who entered an OSCER clinic Jan 2012‒Feb 2018; initiated Kd or Vd treatment as line 2 (2L), 3L, or 4L; and had baseline renal impairment (Modification of Diet in Renal Disease Study estimated glomerular filtration rate [eGFR] Results: 543 Kd-treated and 1005 Vd-treated pts were included. Baseline characteristics were similar between cohorts, with no difference in baseline eGFR stages. More Kd pts were Conclusions: Using one of the most complete oncology EMR databases available, we found that RRMM pts with baseline RI treated with Kd had higher rates of overall and complete renal response, and were more likely to have a renal response, compared with pts treated with Vd. A limitation of the study is that we could not account for all concomitant medications or comorbidities that affect renal function, as some may not be captured in OSCER. Disclosures Kumar:AbbVie: Membership on an entity9s Board of Directors or advisory committees, Research Funding; Celgene: Membership on an entity9s Board of Directors or advisory committees, Research Funding; Janssen: Membership on an entity9s Board of Directors or advisory committees, Research Funding; KITE: Membership on an entity9s Board of Directors or advisory committees, Research Funding. Fu:Amgen: Employment, Equity Ownership. Mezzi:Amgen: Employment, Equity Ownership. Braunlin:Amgen: Employment. Kim:Amgen: Employment, Equity Ownership. Iskander:Amgen: Employment, Equity Ownership. Niesvizky:Amgen Inc.: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Celgene: Consultancy, Research Funding; Takeda: Consultancy, Research Funding. Jagannath:Celgene: Consultancy; Novartis: Consultancy; Merck: Consultancy; Medicom: Speakers Bureau; Multiple Myeloma Research Foundation: Speakers Bureau; Bristol-Myers Squibb: Consultancy. Boccia:Sandoz: Consultancy; Celgene: Speakers Bureau; Abbvie: Speakers Bureau; Genentech: Research Funding, Speakers Bureau; Amgen: Research Funding, Speakers Bureau; BMS: Research Funding; Pfizer: Consultancy; AstraZeneca: Research Funding, Speakers Bureau. Raje:Celgene: Consultancy; Janssen: Consultancy; Merck: Consultancy; Takeda: Consultancy; AstraZeneca: Research Funding; Research to Practice: Honoraria; Medscape: Honoraria; BMS: Consultancy; Amgen Inc.: Consultancy.

Novel glomerular filtration markers.

Chronic kidney disease is currently assessed by estimated glomerular filtration rate, a mathematical construct based on creatinine or creatinine and cystatin concentration. Creatinine-based equations have improved with standardization efforts and the Modification of Diet in Renal Disease Study (MDRD) and CKD-Epidemiology Collaboration Study (CKD-EPI). Because the measurement of creatinine is subject to interference from non-GFR determinants, alternative markers have long been sought. These have included cystatin C and low molecular weight proteins like β2-microglobulin and beta trace protein. Tubular disease often occurs before glomerular filtration is impaired and investigators have investigated the excretion of other low molecular weight proteins such as Neutrophil Gelatinase-Associated Lipocalin (NGAL) and Kidney Injury Molecule-1 and N-acetyl-β-d-glucosaminidase. While preliminary, there is some evidence linking these analytes with GFR, disease stage and mortality. Although asymmetrical dimethyl arginine, an inhibitor of nitric oxide, has been shown to be associated with progression of renal disease, symmetric dimethyl arginine may be a better marker. Recent work has also explored the potential of microRNA (miRNA) analysis and metabolomics studies to further elucidate this complex pathophysiologic disease process. Investigators hope to improve our ability to detect CKD by the use of test panels, i.e., various marker combinations thereof. Unfortunately, most of these markers lack standardization unlike traditional measures that rely on creatinine and cystatin C measurement.

Measured Glomerular Filtration Rate After Kidney Donation: No Evidence of Accelerated Decay.

The rate of measured glomerular filtration rate (GFR) change in kidney donor years after donation has not been adequately addressed. Whether this change is accelerated in the setting of 1 kidney is also understudied. Two hundred fourteen randomly selected donors underwent serial GFR measurements of nonradioactive iohexol. Estimated GFR at each visit was calculated using the Chronic Kidney Disease Epidemiology Collaboration and Modification of Diet in Renal Disease study equations. Glomerular filtration rate visits were 4.8 ± 1.3 years apart and the second occurring 16.9 ± 9.1 years after donation. Most (97.7%) were white, 60.8% female, and 78.5% were related to their recipient. Most, 84.6%, had a GFR of 60 mL/min per 1.73 m or higher, 14.0% had a GFR between 45 and 60 mL/min per 1.73 m, and 1.4% had a GFR less than 45 mL/min per 1.73 m. Between visits 1 and 2, 56.5% had a GFR decline, 36.0% increase, and in 7.5%, there was no change. Overall, GFR declined at a rate of -0.42 mL/min per 1.73 m per year. Of GFR estimating models, only Chronic Kidney Disease Epidemiology Collaboration-Creatinine equation produced a slope that was steeper than measured GFR. Nearly 2 decades postdonation GFR declined at a rate similar to that seen in the general population, and in one third, GFR continues to increase.

Medical Nutrition Therapy for Patients with Non–Dialysis-Dependent Chronic Kidney Disease: Barriers and Solutions

Medical Nutrition Therapy for Patients with Non–Dialysis-Dependent Chronic Kidney Disease: Barriers and Solutions

Prevalence and risk factors for chronic kidney disease among patients with type 2 diabetes mellitus managed in community health centers in Shanghai

Objective To estimate the prevalence of chronic kidney disease and to identify influencing factors among patients enrolled in diabetes management by the community health centers in Shanghai. Methods A questionnaire survey and physical examination were conducted in patients with type 2 diabetes through a random sampling method. Eligible date of 1 618 subjects were enrolled in the study. Estimated glomerular filtration rate was calculated according to equation of the Modification of Diet in Renal Disease Study for serum creatinine. Logistic regression was performed to examine the association between risk factors and chronic kidney disease. Results The prevalence of chronic kidney disease was 43.4%, of which 16.1% were in Stage 1, 14.8% in Stage 2, 11.6% in Stage 3, and 1.0% in Stage 4/5 in the total of 1 618 patients, but only 3.6% of the patients as defined in this study were aware of their condition. A higher prevalence of chronic kidney disease in females than that in males(47.3% vs 37.8%). The prevalence of chronic kidney disease increased with age (χtend2=38.663, P<0.01). Female gender, older age, lower education, lower monthly income per capital, long duration of diabetes, uncontrolled glycosylated hemoglobin, uncontrolled systolic blood pressure, and uncontrolled triglycerides, were influencing factors of chronic kidney disease. Conclusion The patients under diabetes management in community health centers had higher prevalence of chronic kidney disease with lower awareness. Patients with type 2 diabetes should be encouraged to control blood glucose, blood pressure and blood lipids, to reduce the risk for chronic kidney disease. (Chin J Endocrinol Metab, 2018, 34: 485-489) Key words: Chronic kidney disease; Diabetes mellitus, type 2; Prevalence; Risk factors

Target blood pressure and kidney protection

For many years, low on-treatment blood pressure values were widely regarded as necessary to maximise renal protection in individuals with high blood pressure. This notion was generated by several lines of evidence. Findings suggested that low blood pressure values could diminish or eliminate glomerular protein excretion, 1 Mancia G Schumacher H Redon J et al. Blood pressure targets recommended by guidelines and incidence of cardiovascular and renal events in the Ongoing Telmisartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET). Circulation. 2011; 124: 1727-1736 Crossref PubMed Scopus (137) Google Scholar which might lead to renal damage. Furthermore, the kidney can autoregulate its blood flow effectively over a wide range of blood pressure values, lessening concerns that low blood pressure might trigger renal underfusion, renal ischaemia, and a J-shaped relation with cardiac events. 2 Mancia G Grassi G Aggressive blood pressure lowering is dangerous: the J-curve. Hypertension. 2014; 63: 29-36 Crossref PubMed Scopus (89) Google Scholar Finally, in clinical studies, a progressive reduction in the glomerular filtration rate was attenuated in patients with intense treatment-induced blood pressure reductions versus less intense lowering of blood pressure, 3 Jafar TH Stark PC Schmid CH et al. Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Intern Med. 2003; 139: 244-252 Crossref PubMed Scopus (957) Google Scholar which also seemed to occur in patients with pronounced proteinuria. In the Modification of Diet in Renal Disease study in patients with non-diabetic nephropathy, 4 Peterson JC Adler S Burkart JM et al. Blood pressure control, proteinuria, and the progression of renal disease: the Modification of Diet in Renal Disease Study. Ann Intern Med. 1995; 123: 754-762 Crossref PubMed Scopus (1228) Google Scholar cutting mean arterial pressure to 92 mm Hg rather than 107 mm Hg was associated with a lesser decline in renal function in the subgroup of individuals with urinary protein excretion greater than 3 g/day. Intensive systolic blood pressure control and incident chronic kidney disease in people with and without diabetes mellitus: secondary analyses of two randomised controlled trialsIntensive lowering of systolic blood pressure increased the risk of incident chronic kidney disease in people with and without type 2 diabetes. However, the absolute risk of incident chronic kidney disease was higher in people with type 2 diabetes. Our findings suggest the need for vigilance in monitoring kidney function during intensive antihypertensive drug treatment, particularly in adults with diabetes. Long-term studies are needed to understand the clinical implications of antihypertensive treatment-related reductions in eGFR. Full-Text PDF

Con: The role of diet for people with advanced Stage 5 CKD.

Restriction of dietary protein intake has been used in the management of chronic kidney disease (CKD) for many decades, yet remains controversial, with marked variations in its application in clinical practice. There is extensive literature on the subject, with some expert opinion advocating the use of protein restriction based on the balance of the available evidence. The largest randomized trial of low-protein diets is the Modification of Diet in Renal Disease study. Despite multiple secondary analyses, the essential intention-to-treat analysis failed to demonstrate a benefit in the primary outcome of rate of decline of glomerular filtration rate. There are criticisms of many published studies and meta-analyses, including the likelihood of publication bias and unsuitable biochemical endpoints that may be affected by dietary restriction in the absence of effects on kidney function, leading to false positive findings. It is also uncertain whether any benefits observed in these often older studies would be derived in patients undergoing modern standards of CKD management, including blood pressure control and renin-angiotensin blockade. Thus it is unclear whether, even in the strictly controlled environment of a clinical study, low-protein diets significantly slow CKD progression. Important questions exist regarding the applicability of these diets in routine clinical practice. Even in carefully selected study populations with intensive dietetic input, adherence to low-protein diets is poor. It is likely that only a small minority of CKD patients in routine practice could adhere to these diets, and although risks of malnutrition arising from protein restriction are uncertain, they will be greater in less supervised care outside of studies.

Assessment of nutritional status in a patient with chronic kidney disease: How Do I Do It?

Studies report a high prevalence of protein-energy malnutrition in patients with chronic kidney disease (CKD) and in dialysis-dependent end-stage kidney disease (ESKD) patients. The strongest evidence comes from the Modification of Diet in Renal Disease study, which showed that, in patients with CKD, as renal function decreases, dietary protein and energy intake, anthropometric parameters, and biochemical markers of nutrition progressively decline. Even we have observed that the calorie and protein intake of Indian patients with CKD and ESRD is poor. This article discusses the methods to assess dietary intake in CKD and ESKD on maintenance dialysis.

Assessment of Kidney Function in Patients With Cancer.

Cancer patients are living longer. The sequelae of cancer treatment and the role of comorbid conditions present before the diagnosis, such as CKD, have been increasingly recognized. The interface between CKD and cancer is multifaceted. CKD is frequently observed in patients with cancer, and cancer treatment contributes to CKD development and progression. In addition, CKD has been recognized as an important risk factor for cancer development and reduced specific cancer survival. In this context, an accurate evaluation of the glomerular filtration rate (GFR) during oncologic treatment is pivotal and is used to define surgery strategies, program prophylactic management of contrasted examinations, make decisions on cisplatin eligibility, and adjust drug prescriptions, particularly chemotherapy agents. Although the most commonly used equations to estimate GFR based on serum creatinine levels in clinical practice (Cockcroft-Gault, Modification of Diet in Renal Disease Study, and CKD Epidemiology Collaboration equations) have not been validated in patients with cancer in large prospective studies, there is increasingly evidence supporting the use of CKD Epidemiology Collaboration equation to assess the GFR in patients with cancer, including for the use of chemotherapy prescriptions. Many patients with cancer may have changes in nutrition status and clearance measurements such as exogenous filtration markers might be extremely useful when clinical decisions differ depending on the GFR level. Future perspectives include the advent of new serum GFR biomarkers such as cystatin C, beta-trace protein, and beta-2 microglobulin as well as the GFR assessment by measuring total kidney parenchymal volume through image examinations.