Health Of Chronic Kidney Disease Patients Research Articles

Dietary Omega-3 PUFA Intake in Patients with Chronic Kidney Disease: The Association with Vitamin D Deficiency, Intima-Media Thickness and Blood Pressure.

Background/Objectives: Numerous risk factors associated with development of cardiovascular disease (CVD) have been unfavorably altered in patients with chronic kidney disease (CKD). Low omega-3 polyunsaturated fatty acid (PUFA) intake and vitamin D deficiency are potential cardiometabolic risk factors in patients with CKD. The aim of this study was to evaluate dietary intake and status of omega-3 PUFA and vitamin D in pre-dialysis and hemodialysis patients and to examine the association of dietary α-linolenic acid (ALA) and fish consumption with blood pressure and carotid intima-media thickness (C-IMT), representing a non-invasive marker of atherosclerosis in CKD patients. Methods: All 77 selected patients (36 pre-dialysis, 41 on hemodialysis) underwent standardized clinical, nutritional, and laboratory assessments. Repeated 24 h recalls were performed to assess dietary intake. The fatty acid profile was determined by gas-liquid chromatography. Results: Inadequate vitamin D intake and vitamin D status were found in 95% of patients. PUFA profiles did not differ between hemodialysis and pre-dialysis participants. Dietary intake of ALA was negatively correlated with systolic blood pressure (SBP) (p = 0.013), C-IMT (p = 0.002), serum CRP (p = 0.044), iPTH (p = 0.01), and 25(OH)D3 (p = 0.006). ALA intake of more than 0.23 g daily was linked with lower SBP (p = 0.001), serum 25(OH)D3 (p = 0.004), and C-IMT (p = 0.002). Conclusions: This study contributes to a better understanding of the relationship between dietary ALA intake and C-IMT in CKD. The results of this study could emphasize the significant role of the high prevalence of vitamin D deficiency and inadequate omega-3 PUFA intake and status regarding CVD health in CKD patients.

Efficacy and Safety of Anti-Osteoporotic Agents across CKD Stages: A Meta-Analysis of Randomized Clinical Trials.

Osteoporosis poses a significant health concern, especially for individuals with chronic kidney disease (CKD). CKD disrupts mineral and bone metabolism, heightening the risk of fractures and complicating the management of osteoporosis. While anti-osteoporotic interventions aim to address bone health in CKD patients, ongoing research is essential to understand the comparative efficacy and safety of these medications, particularly in different CKD stages, notably in stages 4 and 5. We searched PubMed/MEDLINE, EMBASE, and the Cochrane CENTRAL for randomized controlled trials assessing the efficacy and safety of osteoporosis interventions in CKD up to June 15, 2024. The analysis utilized the pooled odds ratio (OR) along with the corresponding 95% confidence interval (CI), employing Comprehensive Meta-Analysis software, version 3.0. To assess heterogeneity in the results of individual studies, we used Cochran's Q statistic and the I2 statistic. We analyzed 12 randomized controlled trials involving 31,027 participants, revealing a significantly lower risk of vertebral fractures with anti-osteoporotic agents (teriparatide, denosumab, romosozumab, raloxifene) compared to placebo (pooled OR, 0.28 [95% CI, 0.22-0.36]). Stratification by CKD stages showed a lower risk in Stages 1-3 but no significant reduction in stages 4 and 5. Teriparatide, denosumab, and romosozumab were effective in lowering fracture risk, whereas Raloxifene showed no significant effect. The lumbar spine, femoral neck, and total hip BMD showed no significant differences between anti-osteoporotic agents (denosumab, raloxifene, risedronate, alendronate, teriparatide) and placebo. However, romosozumab demonstrated a significantly greater BMD change in all kidney function categories. No reported side effects were observed in CKD stages 1-5 across the trials. Our meta-analysis highlights the effectiveness of anti-osteoporotic agents in lowering vertebral fracture risk in CKD patients, particularly in stages 1-3. However, this benefit is not apparent in stages 4 and 5, necessitating further research. Despite the absence of reported side effects in CKD patients, clinicians should carefully assess the suitability of these medications, considering individual risks and benefits.

Is denosumab an efficient and safe drug for osteoporosis in dialysis patients? Considerations and state of the art about its use in this setting.

In patients with chronic kidney disease (CKD), renal osteodystrophy may be associated with a progressive bone mass loss that increases fracture risk. Denosumab, a monoclonal antibody inhibiting osteoclast activity, is an antiresorptive medication used for the treatment osteoporosis. Its efficacy and safety were initially established in the FREEDOM study, showing a significant reduction in incident fractures in osteoporotic women treated with denosumab. Subsequent post hoc analyses showed its efficacy in patients stratified by kidney function, but these analyses did not include patients with advanced stages of CKD. The capability of denosumab in improving bone mineral density in uremic patients was evaluated in 12 studies including 461 dialysis patients with low bone mineral density. The improvement of bone mineral density was the final end point in these studies assessed during a follow-up of 6-60months. Nine of these studies did not have hyperparathyroidism among criteria for patient inclusion and their participants may have low-turnover bone disease. Despite current recommendations, no patients underwent bone biopsy before denosumab therapy. Overall, findings in these studies suggest that denosumab is a viable option for promoting bone mass recovery in patients with advanced stages of CKD having either high or low serum levels of PTH. However, the increase of bone mineral density was lower in patients with low serum markers of bone turnover at baseline. These studies also highlighted the need for calcium and vitamin D supplementation to prevent hypocalcemia that remains a serious concern. Denosumab emerges as a potentially safe and effective option for enhancing bone health in CKD patients.

The expected changes with different periods of home-based resistance exercise in patients with chronic kidney disease.

The comprehensive impact of prolonged home-based resistance training on individuals grappling with chronic kidney disease (CKD) have yet to be fully elucidated. This study aimed to explore the outcomes of varying exercise durations on physical performance, nutritional status, and kidney function within this specific population, encompassing patients undergoing dialysis and those affected by severe sarcopenia. This was a 1-year observational double cohort study following a 52-week longitudinal design, we enrolled 101 adult CKD outpatients. These participants were divided into two groups: the continuous group, comprising individuals who consistently exercised for over 6 months, and the interrupted group, which included those who did not sustain regular exercise for the same duration. The exercise regimen involved resistance exercises conducted at least 3 to 5 days per week, involving activities like lifting dumbbells and executing weighted wall squats. Physical activity assessments and biochemical blood tests were conducted at weeks 0, 4, 16, 28, 40, and 52 for all participants. The continuous exercise group exhibited better handgrip strength and sit-to-stand movement compared to the interrupted group. Their estimated glomerular filtration rate stayed steady while the interrupted group was declined. Additionally, those who exercised consistently had better metabolism: higher carbon dioxide levels, increased albumin, better nutritional scores, and lower levels of blood urea nitrogen, creatinine, fasting blood glucose, and body weight. Subsequent adjustments for potential confounding factors continued to show improved physical performance and kidney function over time. Our findings indicate the advantageous impact of extended resistance exercise training on overall health of CKD patients, even those on dialysis or with severe sarcopenia. Dedication to this exercise routine could improve kidney function, metabolism, and physical abilities in these patients.

Crosstalk between bone and muscle in chronic kidney disease.

With increasing life expectancy, the related disorders of bone loss, metabolic dysregulation and sarcopenia have become major health threats to the elderly. Each of these conditions is prevalent in patients with chronic kidney disease (CKD), particularly in more advanced stages. Our current understanding of the bone-muscle interaction is beyond mechanical coupling, where bone and muscle have been identified as interrelated secretory organs, and regulation of both bone and muscle metabolism occurs through osteokines and myokines via autocrine, paracrine and endocrine systems. This review appraises the current knowledge regarding biochemical crosstalk between bone and muscle, and considers recent progress related to the role of osteokines and myokines in CKD, including modulatory effects of physical exercise and potential therapeutic targets to improve musculoskeletal health in CKD patients.

Quality of life and physical activity level in patients with chronic kidney disease during COVID-19 pandemic

ABSTRACT The COVID-19 pandemic process may affect the physical and psychosocial health in patients with chronic kidney disease (CKD). The aim of this study was to compare the quality of life, physical activity, fear of COVID-19 and mental health in CKD patients and healthy individualsand compare the aforementioned parameters in end-stage renal disease (ESRD) and renal transplantation (RTx) patients during the pandemic. Eighty-two patients (33 ESRD, 49 RTx) and age-gender matched 108 healthy individuals were included. Quality of life (Short Form 36 Health Survey Questionnaire-SF-36), physical activity (short form of the International Physical Activity Questionnaire -IPAQ-SF), fear of COVID-19 (Fear of COVID-19 Scale-FCV-19S) and mental health (Hospital Anxiety and Depression Scale-HADS) were evaluated. Physical activity levels and all SF-36 scores except mental health in CKD patients were significantly lower than healthy individuals (p < 0.05). FCV-19S and HADS scores were similar between the groups (p > 0.05). ESRD patients’ pain and general health perceptions scores of SF-36 were lower than RTx patients’ (p < 0.05). Quality of life and physical activity levels were worse in CKD patients compared to healthy individuals during the pandemic. The participants had fear of COVID-19, poor mental health and low physical activity. For these reasons, psychosocial and physical activity interventions for the both groups may be beneficial for the affected outcomes during COVID-19 pandemic.

Clinical utility of bone turnover markers in patients with chronic kidney disease.

The burden of fractures is very high in patients with chronic kidney disease (CKD). It is increasingly recognized that knowledge of bone turnover is of paramount importance in guiding mineral metabolism and osteoporosis therapy in CKD. Bone histomorphometry is the gold standard to assess bone turnover, but is seldomly performed in clinical practice. Bone turnover markers (BTMs) may be the long awaited noninvasive diagnostic that may help to close the therapeutic gap in patients with advanced CKD presenting with bone fragility. Mounting evidence indicates that BTMs may be useful in skeletal and nonskeletal risk stratification, in guiding mineral metabolism and osteoporosis therapy, and in monitoring the therapeutic response. BTMs provide information that is complementary to other clinical tests. It may be envisioned that in the near future, the assessment of nonkidney cleared BTMs may become part of routine clinical evaluation and monitoring of bone health in CKD patients, integrated with clinical risk factors, imaging data and, eventually, bone histomorphometry. Panels of BTMs will likely be more informative than single markers, and the same might hold true for trends as opposed to single time point data.

Topical Application of Glycerine – Paraffin Combination in CKD-associated Pruritus and Uremic Xerosis: Study Protocol for a Randomized Control Trial

Background: Chronic kidney disease associated pruritus (CKD-ap) and xerosis is intensely annoying and unpleasant manifestations associated with maintenance renal dialysis (MRD) among chronic kidney disease (CKD) patients. It severely compromises the quality of life by disturbing normal sleep pattern and also adversely affect the mental health in CKD patients. Many proposed treatment plan for CKD –ap is tested but none of the treatment plan provide complete relief from itch associated with MRD. Glycerine accelerate barrier repair and also has rapid hydrating and smoothing effect while Paraffin preserve the barrier function against irritant. As a comparator Mustard oil is used as it is commonly used home remedy by people in Indian sub-continent for dry skin.&#x0D; Objectives: The primary objective of the study is to compare the efficacy of Glycerine –paraffin combination with mustered oil on skin related quality of life among CKD patients with CKD-ap and xerosis.&#x0D; Methodology: A randomised, single blind, controlled, clinical trial intending to investigate and compare the efficacy of Glycerine – Paraffin combination with mustard oil in CKD –ap and xerosis and overall SRQOL among CKD patients. The study aims to enrol 140 CKD patients having moderate to severe CKD-ap and xerosis by using GI gammal score (standardized tool for assessment of xerosis). They will be randomly distributed among 2 parallel group, experimental &amp; control group. Allocation concealment will be maintained by using SNOSE technique. Experimental group will be instructed to apply glycerine paraffin combination and mustard oil to control group twice a day for 4 weeks. participant will be evaluated for xerosis and pruritus score at baseline, day 7, day 28 and day 56. Scores of SRQOL will be assessed at baseline and on 56 days. &#x0D; Conclusion: The RCT aims to identify &amp; compare the efficacy of Glycerine –paraffin combination with mustard oil on skin related quality of life among CKD patients with CKD-ap and xerosis.

Emotional Freedom Technique (EFT) Therapy on Chronic Kidney Disease (CKD) Patients to Reduce Fatigue

Introduction: Fatigue is one of the most common symptoms felt by patients who experience Chronic Kidney Disease, the level of fatigue experienced from low to severe. Some management to deal with fatigue has been done a lot, but the results have not been maximized. Emotional Freedom Technique (EFT) is a psychological therapy that can treat many diseases, both physical illness and psychological illness. Objectives: This study aims to determine the effect of EFT therapy on fatigue in CKD patients. Methods: This type of research is a quasi experimental design with a control group pre-post-test Sample divided into twogroups, consisted of 19 people, selected through purposive sampling. Results: The results showed that the p-value in the treatment group = 0,000 means that there is an effect of therapy EFT on health in CKD patients, whereas, in the control group, there is no difference with the p-value = 1,000. Discussion: The change in CKD patients' fatigue level after EFT therapy is due to a combination of techniques that support the effectiveness of EFT therapy. Conclusion: With this study, it is expected that hospitals can carry out EFT therapy to reduce fatigue in CKD patients to help cure patients.

Division of an Iliac Crest Bone Biopsy Specimen to Allow Histomorphometry, Immunohistochemical, Molecular Analysis, and Tissue Banking: Technical Aspect and Applications.

ABSTRACTThe evaluation of bone complications in chronic kidney disease (CKD) often requires a bone biopsy, the analysis of which can refine the diagnosis of bone defects. Bone histomorphometry performed on sections of the iliac crest biopsy remains the reference procedure for the quantitative assessment of bone health in CKD patients, whereas immunohistochemistry and other molecular biology analyses are indispensable tools for studying the disrupted signaling pathways. Traditionally, the whole iliac crest biopsy was included in methyl‐methacrylate (MMA) and was exclusively used for bone histomorphometry to describe static, dynamic, and structural parameters. Therefore, further molecular analysis of the bone tissue or the need for tissue banking would require a second biopsy to be made, because inclusion in MMA prevents the extraction of good‐quality nucleic acids. In this work, we describe a simple approach to divide a single iliac crest bone biopsy into multiple parts. This allows for simultaneous assessments of histology, immunohistochemistry, biomolecular analysis, and tissue banking while preserving the same bone surface area for histomorphometry. © 2020 American Society for Bone and Mineral Research © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Indoxyl Sulfate, a Uremic Endotheliotoxin.

Chronic kidney disease (CKD) is associated with a high prevalence of cardiovascular diseases. During CKD, the uremic toxin indoxyl sulfate (IS)—derived from tryptophan metabolism—accumulates. IS is involved in the pathophysiology of cardiovascular complications. IS can be described as an endotheliotoxin: IS induces endothelial dysfunction implicated in cardiovascular morbidity and mortality during CKD. In this review, we describe clinical and experimental evidence for IS endothelial toxicity and focus on the various molecular pathways implicated. In patients with CKD, plasma concentrations of IS correlate with cardiovascular events and mortality, with vascular calcification and atherosclerotic markers. Moreover, IS induces a prothrombotic state and impaired neovascularization. IS reduction by AST-120 reverse these abnormalities. In vitro, IS induces endothelial aryl hydrocarbon receptor (AhR) activation and proinflammatory transcription factors as NF-κB or AP-1. IS has a prooxidant effect with reduction of nitric oxide (NO) bioavailability. Finally, IS alters endothelial cell and endothelial progenitor cell migration, regeneration and control vascular smooth muscle cells proliferation. Reducing IS endothelial toxicity appears to be necessary to improve cardiovascular health in CKD patients.

Vitamin D receptor activation raises soluble thrombomodulin levels in chronic kidney disease patients: a double blind, randomized trial.

Thrombomodulin (TM) is a proteoglycan highly represented in the endothelial glycocalix that regulates the haemostasis and the endothelial response to inflammation. High soluble TM levels underlie a lower risk for coronary heart disease in population studies. Activation of vitamin D receptor (VDR) upregulates TM, but the effect of this intervention on soluble TM has never been tested in chronic kidney disease (CKD) patients. We performed a post hoc analysis of a 12 weeks double blind, randomized, placebo-controlled trial testing the effect of VDR activation by paricalcitol (PCT) on endothelium-dependent flow-mediated vasodilatation (FMD) in the forearm (ClinicalTrials.gov identifier: NCT01680198). Circulating TM was measured in the whole CKD population [88 patients: PCT n = 44; placebo n = 44] that took part into this trial. Soluble TM at baseline was inversely related to the glomerular filtration rate (r = -0.65, P < 0.001) and to FMD (Spearman's ρ = -0.29, P = 0.01). Alongside the expected effects on bone mineral biomarkers, PCT produced a consistent rise (P = 0.005) in TM levels, from a median value of 8446.0 pg/mL [interquartile range (IQR): 6227.8-10 910.8 pg/mL] to 9127.5 pg/mL (6393.0-11 287.3 pg/mL) while placebo had no effect (between-groups difference P = 0.008). TM levels re-approached baseline values 2 weeks after stopping PCT. TM changes across the trial paralleled simultaneous changes in FMD. VDR activation by PCT raises TM levels and FMD and such effects are rapidly reversible after stopping the treatment. The TM rise induced by PCT is a possible mechanism whereby improvement in endothelial function by VDR activation may favourably impact upon vascular health in CKD patients.

The Effect of Diet on the Survival of Patients with Chronic Kidney Disease.

The prevalence of chronic kidney disease (CKD) is high and it is gradually increasing. Individuals with CKD should introduce appropriate measures to hamper the progression of kidney function deterioration as well as prevent the development or progression of CKD-related diseases. A kidney-friendly diet may help to protect kidneys from further damage. Patients with kidney damage should limit the intake of certain foods to reduce the accumulation of unexcreted metabolic products and also to protect against hypertension, proteinuria and other heart and bone health problems. Despite the fact that the influence of certain types of nutrients has been widely studied in relation to kidney function and overall health in CKD patients, there are few studies on the impact of a specific diet on their survival. Animal studies demonstrated prolonged survival of rats with CKD fed with protein-restricted diets. In humans, the results of studies are conflicting. Some of them indicate slowing down of the progression of kidney disease and reduction in proteinuria, but other underline significant worsening of patients’ nutritional state, which can be dangerous. A recent systemic study revealed that a healthy diet comprising many fruits and vegetables, fish, legumes, whole grains, and fibers and also the cutting down on red meat, sodium, and refined sugar intake was associated with lower mortality in people with kidney disease. The aim of this paper is to review the results of studies concerning the impact of diet on the survival of CKD patients.

Effects of exercise in the whole spectrum of chronic kidney disease: a systematic review.

Chronic kidney disease (CKD) is a public health problem. Although physical activity is essential for the prevention and treatment of most chronic diseases, exercise is rarely prescribed for CKD patients. The objective of the study was to search for and appraise evidence on the effectiveness of exercise interventions on health endpoints in CKD patients. A systematic review was performed of randomized clinical trials (RCTs) designed to compare exercise with usual care regarding effects on the health of CKD patients. MEDLINE, EMBASE, Cochrane Central, Clinical Trials registry, and proceedings of major nephrology conference databases were searched, using terms defined according to the PICO (Patient, Intervention, Comparison and Outcome) methodology. RCTs were independently evaluated by two reviewers. A total of 5489 studies were assessed for eligibility, of which 59 fulfilled inclusion criteria. Most of them included small samples, lasted from 8 to 24 weeks and applied aerobic exercises. Three studies included only kidney transplant patients, and nine included pre-dialysis patients. The remaining RCTs allocated hemodialysis patients. The outcome measures included quality of life, physical fitness, muscular strength, heart rate variability, inflammatory and nutritional markers and progression of CKD. Most of the trials had high risk of bias. The strongest evidence is for the effects of aerobic exercise on improving physical fitness, muscular strength and quality of life in dialysis patients. The benefits of exercise in dialysis patients are well established, supporting the prescription of physical activity in their regular treatment. RCTs including patients in earlier stages of CKD and after kidney transplantation are urgently required, as well as studies assessing long-term outcomes. The best exercise protocol for CKD patients also remains to be established.

Bone Disorders in Chronic Kidney Disease: An Update in Diagnosis and Management.

Renal osteodystrophy (ROD) is a bone disorder that occurs in chronic kidney disease (CKD) patients and is associated with 2- to 14-fold increased fracture risk compared to the general population. Risk of fractures is also increased in kidney transplant recipients especially within the first 5 years after transplantation. Fractures in CKD patients are associated with increased morbidity and mortality; thus, proper screening and management of CKD bone complications is critical to improving clinical outcomes. Tetracycline double-labeled transiliac crest bone biopsy with histomorphometry is the gold standard for the diagnosis and classification of ROD. However, bone biopsy is not practical to obtain in all patients. Thus, there is great interest in noninvasive approaches that can be used in the clinic to assess ROD. Here, we discuss the role of surrogate measures of bone health in CKD patients, such as dual energy X-ray absorptiometry (DXA) and novel high-resolution imaging, in conjunction with biochemical biomarkers of bone turnover. Recommended guidelines for diagnosis and management of CKD-MBD are discussed.

Noninvasive assessment of bone health in Indian patients with chronic kidney disease.

Abnormalities in mineral and bone disease are common in chronic kidney disease (CKD). Evaluation of bone health requires measurement of parameters of bone turnover, mineralization, and volume. There are no data on bone health in CKD patients from India. In this cross-sectional study, we evaluated serum biomarkers of bone turnover: Bone-specific alkaline phosphatase (BAP) and total deoxypyridinoline (tDPD) along with parathyroid hormone, 25(OH) vitamin D, and bone mineral density (BMD) using dual absorption X-ray absorptiometry in a cohort of 74 treatment-naive patients with newly diagnosed stage 4 and 5 CKD (age 42 ± 14.5 years, 54 men) and 52 non-CKD volunteers (age 40.2 ± 9.3 years, 40 men). Compared to the controls, CKD subjects showed elevated intact PTH (iPTH), BAP, and tDPD and lower BMD. There was a strong correlation between iPTH and BAP (r = 0.88, P < 0.0001), iPTH and tDPD (r = 0.51, P < 0.0001), and BAP and tDPD (r = 0.46, P = 0.0004). The iPTH elevation was greater than twice the upper range of normal in 73% cases, and BAP was >40 U/L in 66% cases. The combination of these markers suggests high turnover bone disease in over 60% cases. The prevalence of osteopenia and osteoporosis was 37% and 12%, respectively. Osteoporotic subjects had higher iPTH, BAP, and tDPD, suggesting a role of high turnover in genesis of osteoporosis. Vitamin D deficiency was seen in 80%, and another 13% had insufficient levels. Vitamin D correlated inversely with BAP (r = −0.3, P = 0.009), and levels were lower in those with iPTH >300 pg/ml (P = 0.0.04). In conclusion, over 60% of newly diagnosed Indian stage 4–5 CKD patients show biochemical parameters consistent with high turnover bone disease. High turnover could contribute to the development of osteoporosis in CKD subjects. Deficiency of 25 (OH) vitamin D is widespread and seems to have a role in the genesis of renal bone disease. Studies on the effect of supplementation of native vitamin D are needed.

Effect of probiotic-prebiotic supplementation with diet counseling in chronic kidney disease

Chronic kidney disease (CKD) is a progressive disease leading to requirement of renal replacement therapy (RRT) over a period of time. Limited availability and high cost of RRT in many countries necessitates the researchers to focus on either prevention or slowing the progression of CKD. High dose probiotics have been hypothesized to metabolize the nitrogenous waste products, thus delaying the requirement of dialysis. The purpose of this short term intervention study was to study the effect of probiotic-prebiotic therapy and diet counseling on nutrition, renal progression, and overall health of CKD patients. Thirty predialysis CKD patients (21 males, 9 females) were included in the study. The diet charts were designed according to the underlying nutritional status and blood parameters. Calorie intake was 30-40 kcal/kg; proteins 0.6-0.8 g/kg (with at least 50% high biological value); potassium 1.5-2 gm./day; and phosphorus

Optimal vitamin D, calcitriol, and vitamin D analog replacement in chronic kidney disease: to D or not to D: that is the question

Patients with chronic kidney disease (CKD) are often insufficient in 25(OH) vitamin D and are almost uniformly deficient in 1,25(OH)2 vitamin D, because of decreased renal hydroxylation resulting from hyperphosphatemia and elevated fibroblast growth factor-23 (FGF-23) levels. These same abnormalities lead to secondary hyperparathyroidism for which the administration of calcitriol or vitamin D analogs has been the mainstay of therapy for decades. This review summarizes new trials of vitamin D, calcitriol, and its analogs over the last 2 years. In addition to the endocrine effects of the vitamin D axis on bone and mineral metabolism, studies have demonstrated there is also extrarenal conversion of 25(OH) vitamin D to 1,25(OH)2 vitamin D in multiple cells leading to autocrine effects. This advance has led to the speculation that CKD patients may also need to be supplemented with ergocalciferol or cholecalciferol. Unfortunately, to date, the majority of interventional studies have focused on biochemical end points. There are no randomized controlled trials demonstrating that therapy with any formulation of vitamin D results in improved patient level outcomes. Despite the physiologic importance of vitamin D in health and disease, more research is required to determine which vitamin D derivative is required for optimal health in CKD patients.

Systemic Consequences of Poor Oral Health in Chronic Kidney Disease Patients

Changes in the oral cavity, such as periodontitis and other manifestations of poor oral health, are common in patients with chronic kidney disease (CKD) and may contribute to increased morbidity and mortality because of systemic consequences such as inflammation, infections, protein-energy wasting, and atherosclerotic complications. Poor oral health in CKD patients may thus represent an important, but often overlooked, problem. Several studies show that uremic patients have higher rates of decayed, missing, and filled teeth, loss of attachment, and periapical and mucosal lesions than the general population. The consequences of poor oral health may be more severe in CKD patients because of advanced age, common comorbidities such as diabetes, concurrent medications, and a state of immune dysfunction that may increase the risk for systemic consequences of periodontitis and other oral and dental pathologic conditions. Poor dentition and other signs of poor oral health should be an alarm clock also at early stages of CKD. However, it remains to be determined whether more successful management of poor oral health and periodontitis will reduce the risk of inflammation, infection, protein-energy wasting, and atherosclerotic complications in CKD patients. This review explores etiological factors and potential systemic consequences of poor oral health in CKD patients as well as possible preventive and therapeutic strategies.