Disease Outcomes Quality Initiative Guidelines Research Articles

When Should Commence Dialysis: Focusing on the Predialysis Condition

The prevalence of chronic kidney disease (CKD), as defined by the NFK-KDOQI (the national kidney foundation kidney disease outcomes quality initiative) guidelines, is a glomerular filtration rate less than 60 mL/min/1.73 m2 or the presence of microalbuminuria. CKD is increasing worldwide, leading to an increased risk of cardiovascular disease. There is general agreement on the importance of an early referral to a nephrologist and predialysis educational programs. Establishing the protocol for an early approach may assist in preventing the progression, and the most common complications of renal disease.Predialysis education helps patients in order to choose a renal replacement therapy (hemodialysis, peritoneal dialysis, transplantation) and improve their quality of life. Furthermore, adequate predialysis care allows the nephrologist to promptly prepare for vascular or peritoneal treatment. Regrettably, patients are often referred to the nephrologist when renal failure is already fall in the advanced stage. This is caused primarily by non-nephrologists failing to identify patients at risk for imminent renal failure. Furthermore, they may be defining the patient’s degree of renal failure according to the KDOQI classification. To further complicate matters, the serum creatinine alone does not provide an adequate estimate of renal function; however, both the MDRD (the modification of diet in renal disease) equation and the Cockcroft-Gault formula permit the more reliable and accurate estimation of the all-important glomerular filtration rate (GFR). Using the MDRD equation, the KDOQI guidelines recommend referral when GFR is less than 30 mL/min/1.73 m2. Late nephrology referral is an independent risk factor for early death while on dialysis; it is also associated with a more frequent use of temporary catheters, particularly in the elderly individuals. This subject underlines the importance of a multidisciplinary predialysis approach that may bring additional benefits – beyond referral to a nephrologist – including a reduced hospitalization period and a lower mortality rate.The KDOQI guidelines recommend evaluating the benefits and risks of starting renal replacement therapy when patients reach stage 5 (estimated GFR less than 15 mL/min/1.73 m2), although the ideal period for initiation of the replacement therapy remained a source of debate.

Intravenous Alfacalcidol Once Versus Twice or Thrice Weekly in Hemodialysis Patients

Secondary hyperparathyroidism remains a serious problem in hemodialysis patients. The use of vitamin D analogs still constitutes a basis for its treatment. This study was carried out to evaluate the efficacy of intravenous administration of alfacalcidol once versus twice or thrice weekly in hemodialysis patients with secondary hyperparathyroidism. Twenty-nine end-stage renal disease patients maintained on hemodialysis for more than one year were included in this prospective study after signing the consent. These patients with secondary hyperparathyroidism had been on intravenous alfacalcidol twice or thrice per week and were followed up to 4 months (stage 1). Then they were shifted to intravenous alfacalcidol once weekly starting with the last total weekly intravenous dose for another 4 months (stage 2). The dose of alfacalcidol was adjusted according to intact parathyroid hormone, serum calcium and phosphorus levels, and calcium-phosphorus product. Intact parathyroid hormone, calcium, phosphorus, calcium-phosphorus product were measured monthly. Parathyroid ultrasound was done as a baseline and then repeated at the end of stage 1 and stage 2. The intact parathyroid hormone was reduced from 49.72 ± 2.72 pmol/L (mean ± standard error of the mean [SEM] during stage 1 to 42.13 ± 2.15 pmol/L during stage 2 (P = 0.005). Dose of alfacalcidol was reduced from 18.80 ± 1.15 µg/month (mean ± SEM) in stage 1 to 15.18 ± 1.27 µg/month in stage 2 (P = 0.008), and consequently the cost of alfacalcidol was reduced from 21.05 ± 1.25 US$/month (mean ± SEM) during stage 1 to 16.87 ± 1.40 US$/month during stage 2 (P = 0.008). Although the phosphorus level increased from 1.56 ± 0.36 mmol/L (mean ± SD) in stage 1 to 1.70 ± 0.46 mmol/ L in stage 2 (P = 0.003), and calcium-phosphorus product increased from 3.48 ± 0.82 mmol(2)/L(2) (mean ± SD) in stage 1 to 3.76 ± 1.00 mmol(2) /L(2) in stage 2 (P = 0.017), they remained in the target levels recommended by the Kidney Disease Outcomes Quality Initiative guidelines. No serious effects were observed during stage 1 and stage 2, respectively. Intravenous alfacalcidol once weekly is effective, safe and less costly in suppressing intact parathyroid hormone compared to twice or thrice weekly administration in chronic hemodialysis patients.

Prescriptions for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and monitoring of serum creatinine and potassium in patients with chronic kidney disease

Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) are commonly used in patients with chronic kidney disease (CKD). We studied the status of ACEI/ARB prescriptions and serum creatinine (Scr) and potassium monitoring in CKD patients. A retrospective observational study was conducted on patients who had at least two sets of Scr data at outpatient visit. Estimated glomerular filtration rate (eGFR) based on the second Scr value was calculated using the Modification of Diet in Renal Disease four-variable equation. CKD was defined and staged according to the National Kidney Foundation Disease Outcomes Quality Initiative Guideline. Patients with diabetes and/or hypertension with an eGFR over 60 mL/min/1.73 m2 and without proteinuria were defined as the CKD-at-risk group. The percentages and factors associated with ACEI/ARB prescription and Scr and potassium monitoring were calculated and analyzed by logistic regression. Among the 5714 subjects included, ACEIs/ARBs were prescribed to over 50% of patients in the CKD-at-risk group and in CKD stages 1–5. After adjusting for age, sex, potassium level, eGFR, and co-morbidities, the odds ratios for prescriptions of ACEIs/ARBs were 1.66 [95% confidence interval (CI) 1.44–1.91, p < 0.001) and 2.80 (95% CI 2.12–3.70, p < 0.001) in CKD stage 3, and stages 4 and 5, respectively, compared with the reference group (eGFR≥60 mL/min/1.73 m2). During the year of ACEI/ARB treatment, Scr was monitored in 91.6% of ACEI/ARB-treated patients, while potassium was monitored in only 38.1%. Renal function status was the independent factor for monitoring of Scr and potassium. In conclusion, prescription of ACEIs/ARBs was common in all stages of CKD. Most patients underwent Scr monitoring, but potassium monitoring was less frequent, and this should be improved in clinical practice.

Central venous catheters as access for chronic hemodialysis

Although discouraged in previous Kidney Disease Outcomes Quality Initiative (K-DOQI) and European best practice guidelines (EPBG), central venous catheters as access for chronic hemodialysis are being increasingly used in hemodialysis units. Tunnelled, cuffed, double-lumen catheters are currently preferred for dialysis patients. The advantage of central venous catheters is that these devices can be quickly and easily inserted and provide immediate access for hemodialysis The most common complications are delayed complications, consisting of catheter dysfunction secondary to thrombotic events and catheter migration, catheter-related bacteraemia (CRB) and central venous stenosis. Intrinsic catheter-related thrombosis is the principal complication associated with hemodialysis catheters and is the main cause of catheter loss. Intraluminal lytic enzyme therapy must be tried. If this therapy is unsuccessful in restoring blood flow, the catheter must be changed after previously obliterating the fibrin sheath. Central venous stenosis is usually asymptomatic. In symptomatic lesions, the treatment of choice is percutaneous angioplasty. There are few data on the benefits of stents in hemodialysis.CRB is a complication that carries high morbidity and mortality. Various preventive measures have been advocated to diminish the infection rate. The adoption of a strict aseptic protocol alone significantly reduces the incidence of CRB. Early treatment is the most effective measure to prevent the fatal outcome that sometimes occurs.

The efficacy of cinacalcet combined with conventional therapy on bone and mineral metabolism in dialysis patients with secondary hyperparathyroidism: a meta-analysis

Cinacalcet, the first calcimimetic to be approved for the treatment of secondary hyperparathyroidism (SHPT) in the chronic kidney disease patients, offers a novel therapeutic approach to SHPT. The aim of this meta-analysis is to access the efficacy and safety of cinacalcet on bone and mineral metabolism disorders in the dialysis patients with SHPT. Randomized controlled trials on cinacalcet combined with vitamin D and/or phosphate binders in the dialysis patients with SHPT were identified in Pubmed, Sciencedirect, and the Cochrane library. Data were analyzed with RevMan software. We compared the proportion of patients achieving the biochemical targets recommended by the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines and the incidence of adverse events between the cinacalcet and control groups. Six trials involving 2,548 patients were included. A greater proportion of patients in the cinacalcet group compared with the conventional group achieved the KDOQI targets. The relative risks (RRs) were parathyroid hormone (PTH) (RR = 3.51, 95 % CI: 2.38-5.17), calcium (RR = 2.04, 95 % CI: 1.76-2.37), phosphorus (RR = 1.15, 95 % CI: 0.83-1.60), and calcium-phosphorus product (Ca × P) (RR = 1.41, 95 % CI: 1.18-1.69), the number of patients simultaneously achieving the KDOQI targets for PTH + Ca × P was also greater (RR = 3.89, 95 % CI: 2.36-6.41), with p < 0.001 for each. The most common adverse events were nausea, vomiting, diarrhea, and hypocalcemia, which had a higher incidence in the cinacalcet group, but were usually mild to moderate in severity and transient. Compared with conventional therapy, treatment with cinacalcet results in more patients achieving KDOQI targets and offers an effective and safety therapeutic option for controlling mineral and bone disorders in the dialysis patients with SHPT.

Reporting of the estimated glomerular filtration rate decreased creatinine clearance testing

The Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines suggest that clinicians use the estimated glomerular filtration rate (eGFR) measurements and minimize the use of timed urine creatinine clearance collection. The intent of this change was to improve recognition of chronic kidney disease. Here we used time-series modeling and intervention analyses to determine the effect of publication of the K/DOQI guidelines and the introduction of widespread eGFR reporting with prompts on physician ordering of 24-h urine collection for creatinine clearance. In this setting, clinical practice guidelines did not influence creatinine clearance testing; however, the direct introduction of eGFR reporting with prompts into physician workflow resulted in a sudden and significant 23.5% decrease in creatinine clearance collection over the 43 months analyzed. Thus, eGFR reporting with prompts may have produced a clinical practice change because it is integrated directly into physician workflow. Changing physician practice patterns may require more than publishing guidelines; rather it is more likely to occur through educational and structural changes to practice.

Specialist physician knowledge of chronic kidney disease: A comparison of internists and family physicians in West Africa

BackgroundPostgraduate training is aimed at equipping the trainee with the necessary skills to practise as an expert. Non-nephrology specialist physicians render the bulk of pre-end-stage renal disease care for patients with chronic kidney disease (CKD). We sought to ascertain the knowledge of CKD amongst non-nephrology specialist physicians who serve as trainers and examiners for a training, accrediting and certifying body in postgraduate medicine in West Africa. We also compared the knowledge of family physicians and non-nephrology internists.MethodsSelf-administered questionnaires were distributed to non-nephrology specialist physicians who serve as examiners for the West African College of Physicians.ResultsOnly 19 (27.5%) of the respondents were aware of the Kidney Disease Outcomes Quality Initiatives guidelines for CKD management. Twenty five (36.2%) of the respondents had adequate knowledge of CKD. There was no significant difference in the proportion of family physicians and non-nephrology internists who had adequate knowledge of CKD (27.3% vs. 40.4% respectively; p = 0.28). Hypertension and diabetes mellitus were identified by all of the physicians as risk factors for CKD. Non-nephrology internists more frequently identified systemic lupus erythematosus as a risk factor for CKD, urinalysis with microscopy as a laboratory test for CKD evaluation, and bone disease as a complication of CKD than family physicians.ConclusionThere is a lack of adequate CKD knowledge amongst non-nephrology specialist physicians, since many of them are unaware of the CKD management guidelines. Educational efforts are needed to improve the knowledge of CKD amongst non-nephrology specialist physicians. Guidelines on CKD need to be widely disseminated amongst these physicians.

Developing Guidelines for Chronic Kidney Disease: We Should Include All of the Outcomes

Editorials17 April 2012Developing Guidelines for Chronic Kidney Disease: We Should Include All of the OutcomesKatrin Uhlig, MD, MS and Andrew S. Levey, MDKatrin Uhlig, MD, MSFrom Tufts Medical Center, Boston, MA 02111.Search for more papers by this author and Andrew S. Levey, MDFrom Tufts Medical Center, Boston, MA 02111.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-156-8-201204170-00012 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail This year marks the 10-year anniversary of the publication of the initial Kidney Disease Outcomes Quality Initiative guidelines for chronic kidney disease (CKD) (1). These guidelines have been accepted internationally with minor modification (2) and have led to worldwide recognition of CKD as a public health problem (3). The guidelines define and stage CKD on the basis of glomerular filtration rate (GFR) estimated from serum creatinine as a measure of kidney function and albuminuria as a marker of kidney damage, regardless of the underlying cause. This simple definition and staging system enabled detection of CKD by nonnephrologists and identification of ...

Abstract 49: The Effect of Gender, Obesity, and Chronic Kidney Disease on Cardiovascular Events

Background: Obesity and chronic kidney disease (CKD) are well known risk factors for cardiovascular (CV) events. Studies have shown that in patients with end-stage renal disease, the rate of CV events decreases as body mass index (BMI) increases. These studies, however, used only one measurement of BMI to predict CV events. The objective of this study was to assess whether rates of CV events changed according to variations in BMI and glomerular filtration rate (GFR) over time. Methods: A retrospective cohort of patients followed in outpatient practices from 1995 to 2010 was evaluated. Adult patients with at least 2 records of serum creatinine were included. The practices’ electronic health records (EHRs) were linked to the hospital EHR to assess CV events. GFR (mL/min/1.73m 2 ) was calculated using the Modification of Diet in Renal Disease equation and stratified according to the Kidney Disease Outcomes Quality Initiative guidelines as Normal (≥ 60), CKD stage 3 (30-59) and stage 4-5 (&lt; 30) at each patient’s encounter. Outcomes were identified using ICD9 codes for myocardial infarction, congestive heart failure, coronary heart disease, dysrhythmia, stroke and peripheral vascular disease. The data spanned up to 10 years from a patient’s index to last visit. CV events were modeled as a function of age, gender, race, BMI and CKD status by negative binomial regression for count data. The model included interactions of age, gender, race, BMI and CKD. Results: Over the 10-year period, there were a total of 1,024,891 observations from 39,605 patients with 8,901 CV events. There was a significant age by gender by race by BMI interaction as well as a significant CKD main effect (p &lt; 0.01). Increasing age, being male, black, overweight and having CKD, were associated with higher event rates. However, this association between BMI and event rates was not present for black females over 70, thus the 4-way sex by race by age by BMI interaction (Figure). Conclusion: These results support the hypothesis that overweight / obesity is not protective of CV events in CKD patients.

Ongoing gaps in CKD and CVD care: re-evaluating strategies for knowledge dissemination

Over the last decade, the nephrology community has come to recognize the importance of chronic kidney disease (CKD) as an important modifier of outcomes and of cardiovascular risk. We have attempted to categorize and quantify the risks of dying, having a cardiovascular event and going on to dialysis, and we have published extensively in both nephrology and non-nephrology journals about the importance of CKD in general populations [1–7]. Some jurisdictions have embarked on formal and well-organized education campaigns for general practitioners (GPs) and patients (UK, Canada, Australia, USA) with professional messaging and public campaigns. Guidelines have been written and disseminated [8, 9]. Despite these efforts and the quantity of publications regarding CKD, we have not systematically evaluated the impact of these efforts on quality of care for those persons with CKD. The paper in the current edition of Nephrology Dialysis Transplantation (27/4) by Razavian et al. describes GP awareness of CKD, gaps in treatment and gaps in prescribing in Australia in 2008, after the implementation of estimated glomerular filtration rate (eGFR) reporting by laboratories and 6 years after the publication of the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines for CKD definition, evaluation and classification. The study leveraged the infrastructure of the Australian Hypertension and Absolute Risk Study (AusHEART) and describes cardiovascular risk management in CKD in Australian primary care using a nationally representative, cluster stratified, cross-sectional survey among 322 GPs. Each GP was asked to provide data for 15–20 patients over the age of 55 who presented between April and June 2008. Within the study framework, records on 4966 patients were collected, in whom 37% had abnormal kidney function. The study describes the under-recognition of CKD by GPs (only 18% of the overall CKD cohort were correctly identified, with 67% of those being in Stages 4 and 5 and 28% being Stage 3), under-estimation of cardiovascular disease (CVD) risk in CKD patients and, paradoxically, the overestimation of CVD risk in non-CKD patients. Furthermore, the study identified gaps in achievement of targets for hypertension, use of renin-angiotensin system (RAS) blockade and lipid-lowering agents in CKD patients. The study is meritorious on a number of levels. Firstly, the robust methodology for random sampling of GP practices participating in the AusHEART study, stratified by state and urban/rural locations to reflect the distribution of the Australian adult population, ensures a representative sample of practices. While one may argue that those who volunteered to participate might be the ‘best’ practices, this would only lead to a conservative estimate of the ‘gap’ in knowledge and practice identified in the study. Within that sample, the ability to determine ‘prevalence’ of CKD (albeit using single time point values for eGFR and uACR measurements) adds another important quantitative dimension to the study. Simple one-page questionnaires were given to GPs, which included estimates of CVD risk in each of the patients without specifying how to determine this risk. The authors then compared these GP-generated risks to risk scores generated centrally from Framingham risk equa

Chronic Kidney Disease in Children With Unilateral Renal Tumor

In patients who have undergone nephrectomy lower stage chronic kidney disease may develop, which is an independent risk factor for cardiovascular disease and overall mortality. We investigated whether the prevalence of lower stage chronic kidney disease is related to the amount of renal parenchyma excised in children with unilateral renal tumor. A total of 15 patients treated with nephrectomy and 10 treated with nephron sparing surgery were enrolled at a single academic center. The Kidney Disease Outcomes Quality Initiative guidelines were used to classify patients by chronic kidney disease stage based on estimated glomerular filtration rate values. The Modification of Diet in Renal Disease study equation and Schwartz equation were used in patients older and younger than 17 years, respectively. At a mean followup of more than 12 years 8 patients who had undergone nephrectomy and 1 treated with bilateral nephron sparing surgery presented with stage II chronic kidney disease (estimated glomerular filtration rate 60 to 89 ml/min/1.73 m(2)). Sequential measurements from diagnosis to 12 to 17 years postoperatively showed that stage II chronic kidney disease in patients who had undergone nephrectomy manifested as a negligible postoperative increase in mean ± SD estimated glomerular filtration rate (75.7 ± 25.5 vs 79.4 ± 3.9 ml/min/1.73 m(2), p = 0.6). Five of the 8 patients presented with stage II chronic kidney disease even before nephrectomy. The other 7 patients who had undergone nephrectomy and those treated with nephron sparing surgery presented with a significant postoperative increase in mean ± SD estimated glomerular filtration rate (81.1 ± 24 vs 102.3 ± 3 ml/min/1.73 m(2), p = 0.02, and 88.7 ± 2 vs 107.4 ± 14 ml/min/1.73 m(2), p = 0.005, respectively). A subset of children with unilateral renal tumor presents before and/or after nephrectomy, and not after nephron sparing surgery, with stage II chronic kidney disease, probably due to a reduced renal reserve capacity. Whether patients with preoperative renal dysfunction may benefit from nephron sparing surgery should be studied in a cooperative clinical trial setting.

Ergocalciferol Supplementation in Children with CKD Delays the Onset of Secondary Hyperparathyroidism

Vitamin D deficiency is an important contributor to the development of hyperparathyroidism and is independently associated with cardiovascular and bone disease. The hypothesis was that nutritional vitamin D (ergocalciferol) supplementation in children with CKD stages 2-4 delays the onset of secondary hyperparathyroidism. A randomized, double-blinded, placebo-controlled study in children with CKD2-4 who had 25-hydroxyvitamin D [25(OH)D] deficiency was conducted. Ergocalciferol (or a matched placebo) was given daily as per Kidney Disease Outcomes Quality Initiative guidelines. The primary endpoint was the time to development of hyperparathyroidism. Seventy-two children were screened. Forty-seven children were 25(OH)D-deficient and randomly assigned to receive ergocalciferol or placebo. Twenty children in each arm completed the study; median follow-up was 12 months. Groups were well matched for age, race, estimated GFR, and season when recruited. Nine of 20 children on placebo and 3 of 20 children on ergocalciferol developed hyperparathyroidism (odds ratio, 4.64; 95% confidence interval, 1.02-21.00). The time to development of hyperparathyroidism was significantly longer with ergocalciferol treatment compared with placebo (hazard ratio, 0.30; 95% confidence interval, 0.09-0.93, P=0.05). With ergocalciferol treatment, normal 25(OH)D levels were achieved in all 8 children with CKD2, 8 of 11 children with CKD3, but not in the single patient with CKD4. There were no ergocalciferol-related adverse events. 25(OH)D levels >100 nmol/L were required to achieve normal levels of 1,25-dihydroxyvitamin D. Ergocalciferol is an effective treatment that delays the development of secondary hyperparathyroidism in children with CKD2-3.

Association of 1,25-Dihydroxyvitamin D Levels With Physical Performance and Thigh Muscle Cross-sectional Area in Chronic Kidney Disease Stage 3 and 4

Declines in 1,25-dihydroxyvitamin D (1,25(OH)₂D) levels and physical functioning follow the course of chronic kidney disease (CKD). Although the molecular actions of vitamin D in skeletal muscle are well known, and muscle weakness and atrophy are observed in vitamin D-deficient states, there is little information regarding vitamin D and muscle function and size in CKD. To examine associations of vitamin D with physical performance (PF) and muscle size. Cross-sectional. CKD clinic. Twenty-six patients (61 ± 13 years, 92% men) with CKD stage 3 or 4. Gait speed, 6-minute walk, sit-to-stand time, 1-legged balance, and thigh muscle cross-sectional area (MCSA), measured by magnetic resonance imaging (MRI). Overall, 73% were 25-hydroxyvitamin D (25(OH)D) deficient (n = 10) or insufficient (n = 9) (Kidney Disease Outcomes Quality Initiative guidelines). 25(OH)D level was associated with normal gait speed only (r = 0.41, P = .04). Normal and fast gait speed, the distance walked in 6 minutes, and sit-to-stand time were best explained by 1,25(OH)₂D and body mass index (P < .05 for all) and 1-legged stand by 1,25(OH)₂D (r = 0.40, P < .05) only. There were no associations of age, estimated glomerular filtration rate (eGFR), intact parathyroid hormone (iPTH), or albumin with any PF measures. MCSA was associated with eGFR (r = 0.54, P < .01) only. Variance in MCSA was best explained by a model containing 1,25(OH)₂D, plasma Ca²⁺, and daily physical activity (by accelerometry) (P < .05 for all). Once these variables were in the model, there was no contribution of eGFR. These results suggest that 1,25(OH)₂D is a determinant of PF and muscle size in patients with stage 3 and 4 CKD.

Editorial What should the optimal blood pressure goal be in patients with diabetes mellitus or chronic kidney disease?

Editorial What should the optimal blood pressure goal be in patients with diabetes mellitus or chronic kidney disease?

Renal Function Assessment in Adults with Recurrent Calcium Kidney Stone Disease

The prevalence of nephrolihiasis and chronic kidney disease has risen over the past three decades, we sought to determine if person with a history of kidney stones have lower renal function relative to non stone formers. Methods: We conducted a case-control study utilizing 138 recurrent calcium kidney stone formers and 127 age and gender matched controls with no history of renal disease, all subjects were aged 30-55 years old, with no history of hypertension, diabetes mellitus, congestive heart failure and liver disease and also no urinary tract obstruction and medications can affect Glomerular Filtration Rate (GFR). We estimated GFR by Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EP I) equations and categorized using cut points suggested by Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines. Results: Mean GFR in case group and control group was: 80.17(18.45) ml/min/1.73m2 and 83.80(15.75) ml/ min/1.73m2 respectively (P value: 0.09). Distribution of subjects among stone formers in stage I, II, III was 59(42.8%), 71(51.4%) and 8(5.8%) and in control group was 67(52.8%), 59(46.4%) and 1(0.8%) respectively, (p: 0.03). There was an inverse correlation between GFR and number of passed stone but there was no significant correlation between history of extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL) and estimated GFR. Conclusion: Recurrent calcium stone disease may be associated with nephron damage and an increased risk of chronic kidney disease.

Efficacy and safety of cinacalcet for the treatment of secondary hyperparathyroidism in patients with advanced chronic kidney disease before initiation of regular dialysis

To evaluate the compassionate use of cinacalcet for the management of secondary hyperparathyroidism in patients who are not on dialysis. Patients with stage 4-5 chronic kidney disease (CKD) who were not on dialysis, had an intact parathyroid hormone (iPTH) level greater than 300 pg/mL, and had not responded satisfactorily to treatment with phosphate binders and vitamin D were prospectively studied. Patients received 6 months of compassionate treatment with cinacalcet, which was initiated at a dose of 30 mg/day orally and flexibly dosed thereafter based on iPTH levels. Twenty-six patients with a mean age±standard deviation (SD) of 58.8±16.1 years were enrolled in the study and included in the statistical analysis. The mean percentage change in iPTH levels from baseline after 6 months of treatment was -67.9±17.0%, with 92.3% (95% confidence interval (CI), 75.9-97.9) of patients showing an iPTH level within the limits recommended by Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines. The mean serum calcium concentrations had decreased significantly at the end of the study (-8.0±6.9%), while the mean serum phosphorus concentration had significantly increased (+8.3±17.0%). Our results suggest that cinacalcet may be a useful alternative for the treatment of secondary hyperparathyroidism in pre-dialysis patients who are unresponsive to other treatments. The hypocalcemia and hyperphosphatemia reported in previous studies may not occur if a moderate dose of calcimimetics is used in patients with marginal glomerular filtration rates, especially if combined with vitamin D analogues and calcium-based phosphate binders.

Hypertension after kidney transplantation

Hypertension after kidney transplantation

Estimating Glomerular Filtration Rate in Kidney Transplant Recipients: Performance Over Time of Four Creatinine-Based Formulas

The management of kidney transplant recipients requires accurate estimate of glomerular filtration rate (GFR). This study aims at evaluating the performance of four creatinine-based formulas for estimating the GFR (estimated GFR) in this population. Performances of Cockcroft and Gault formula, Modification of Diet in Renal Disease (MDRD) simplified formula, Chronic Kidney Disease Epidemiology Collaboration formula, and Nankivell formula were assessed compared with inulin clearance taken as the gold standard for measuring GFR (measured GFR). Performances were assessed using the first measurements of GFR obtained in 1249 subjects. How estimated GFR tracks changes in measured GFR over time since transplantation in those patients with repeated measures was also assessed. The MDRD formula provided the best estimate of GFR with a mean bias of -0.5 mL/min/1.73 m, a standard deviation of bias of 12 mL/min/1.73 m, and a 30% accuracy at 85%. The MDRD formula also seemed to provide the best performance for estimating GFR, irrespective of age, stage of renal failure, and in people whose body mass index was more than 18.5 kg/m. This robustness is important in clinical practice. The performance of the four formulas was not modified by the posttransplant period. Even if 30% accuracy was suboptimal in the Kidney Disease Outcomes Quality Initiative guidelines, our results, obtained in a large number of patients, lead us to recommend using the MDRD formula to monitor GFR in kidney transplant recipients.

Exercise training for adults with chronic kidney disease.

Chronic kidney disease (CKD) is a worldwide public health problem. In the National Kidney Foundation Disease Outcomes Quality Initiative guidelines it is stressed that lifestyle issues such as physical activity should be seen as cornerstones of the therapy. The physical fitness in adults with CKD is so reduced that it impinges on ability and capacity to perform activities in everyday life and occupational tasks. An increasing number of studies have been published regarding health effects of various regular exercise programmes in adults with CKD and in renal transplant patients. We aimed to: 1) assess the effects of regular exercise in adults with CKD and kidney transplant patients; and 2) determine how the exercise programme should be designed (e.g. type, duration, intensity, frequency of exercise) to be able to affect physical fitness and functioning, level of physical activity, cardiovascular dimensions, nutrition, lipids, glucose metabolism, systemic inflammation, muscle morphology and morphometrics, dropout rates, compliance, adverse events and mortality. We searched the Cochrane Renal Group's specialised register, CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science, Biosis, Pedro, Amed, AgeLine, PsycINFO and KoreaMed. We also handsearched reference lists of review articles and included studies, conference proceeding's abstracts. There were no language restrictions.Date of last search: May 2010. We included any randomised controlled trial (RCT) enrolling adults with CKD or kidney transplant recipients undergoing any type of physical exercise intervention undertaken for eight weeks or more. Studies using less than eight weeks exercise, those only recommending an increase in physical activity, and studies in which co-interventions are not applied or given to both groups were excluded. Data extraction and assessment of study and data quality were performed independently by the two authors. Continuous outcome data are presented as standardised mean difference (SMD) or mean difference (MD) with 95% confidence intervals (CI). Forty-five studies, randomising 1863 participants were included in this review. Thirty two studies presented data that could be meta-analysed. Types of exercise training included cardiovascular training, mixed cardiovascular and resistance training, resistance-only training and yoga. Some studies used supervised exercise interventions and others used unsupervised interventions. Exercise intensity was classed as 'high' or 'low', duration of individual exercise sessions ranged from 20 minutes/session to 110 minutes/session, and study duration was from two to 18 months. Seventeen per cent of studies were classed as having an overall low risk of bias, 33% as moderate, and 49% as having a high risk of bias.The results shows that regular exercise significantly improved: 1) physical fitness (aerobic capacity, 24 studies, 847 participants: SMD -0.56, 95% CI -0.70 to -0.42; walking capacity, 7 studies, 191 participants: SMD -0.36, 95% CI-0.65 to -0.06); 2) cardiovascular dimensions (resting diastolic blood pressure, 11 studies, 419 participants: MD 2.32 mm Hg, 95% CI 0.59 to 4.05; resting systolic blood pressure, 9 studies, 347 participants: MD 6.08 mm Hg, 95% CI 2.15 to 10.12; heart rate, 11 studies, 229 participants: MD 6 bpm, 95% CI 10 to 2); 3) some nutritional parameters (albumin, 3 studies, 111 participants: MD -2.28 g/L, 95% CI -4.25 to -0.32; pre-albumin, 3 studies, 111 participants: MD - 44.02 mg/L, 95% CI -71.52 to -16.53; energy intake, 4 studies, 97 participants: SMD -0.47, 95% CI -0.88 to -0.05); and 4) health-related quality of life. Results also showed how exercise should be designed in order to optimise the effect. Other outcomes had insufficient evidence. There is evidence for significant beneficial effects of regular exercise on physical fitness, walking capacity, cardiovascular dimensions (e.g. blood pressure and heart rate), health-related quality of life and some nutritional parameters in adults with CKD. Other outcomes had insufficient evidence due to the lack of data from RCTs. The design of the exercise intervention causes difference in effect size and should be considered when prescribing exercise with the aim of affecting a certain outcome. Future RCTs should focus more on the effects of resistance training interventions or mixed cardiovascular- and resistance training as these exercise types have not been studied as much as cardiovascular exercise.

Management of patients with chronic kidney disease

Chronic kidney disease (CKD) is a silent disease which worsens gradually to end-stage kidney disease (ESKD). US kidney disease outcomes quality initiative (KDOQI) guidelines indicate five stages of CKD based on the severity of kidney function which is assessed by estimating the glomerular filtration rate (GFR) by the modification of diet in renal disease (MDRD) formula. The management of CKD patients with mild renal damage (stage 1-2 KDOQI) is articulated on the reduction of proteinuria (<500mg/day), reduction of sitting systolic and diastolic blood pressure (<130/80mmHg), salt restriction diet, diuretics (furosemide, spironolactone), antihypertensive agents (ACE inhibitors or ARBs (angiotensin II receptor blockers) or both as first-line therapy), additional other antihypertensives (aliskiren, non-dihydropyridine calcium channel blockers, beta blockers), body weight reduction, cigarette smoking stopping, allopurinol therapy and non-use of some drugs (non-steroidal anti-inflammatory agents, acetaminophen, bisphosphonates, oral estrogens) and herbals. The management of CKD patients with moderate-severe renal damage (stage 3-5 KDOQI) is based on the above recommendations plus low protein diet, correction of hyperkalaemia, metabolic acidosis, and administration of vitamin D derivates and erythropoietin for the correction of mineral metabolism disorders and anemia, respectively. In conclusion, patients with CKD (stage 1-2 KDOQI) may be correctly managed by primary care physicians, individuals in stage 3-5 KDOQI need the supervision of nephrologists to assess those patients who progress to ESKD and require renal replacement therapy.