KDOQI Guidelines Research Articles

KDOQI US Commentary on the 2013 KDIGO Clinical Practice Guideline for Lipid Management in CKD

The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guideline for management of dyslipidemia in chronic kidney disease (CKD) was published in 2003. Since then, considerable evidence, including randomized controlled trials of statin therapy in adults with CKD, has helped better define medical treatments for dyslipidemia. In light of the new evidence, KDIGO (Kidney Disease: Improving Global Outcomes) formed a work group for the management of dyslipidemia in patients with CKD. This work group developed a new guideline that contains substantial changes from the prior KDOQI guideline. KDIGO recommends treatment of dyslipidemia in patients with CKD primarily based on risk for coronary heart disease, which is driven in large part by age. The KDIGO guideline does not recommend using low-density lipoprotein cholesterol level as a guide for identifying individuals with CKD to be treated or as treatment targets. Initiation of statin treatment is no longer recommended in dialysis patients. To assist US practitioners in interpreting and applying the KDIGO guideline, NKF-KDOQI convened a work group to write a commentary on this guideline. For the most part, our work group agreed with the recommendations of the KDIGO guideline, although we describe several areas in which we believe the guideline statements are either too strong or need to be more nuanced, areas of uncertainty and inconsistency, as well as additional research recommendations. The target audience for the KDIGO guideline includes nephrologists, primary care practitioners, and non-nephrology specialists such as cardiologists and endocrinologists. As such, we also put the current recommendations into the context of other clinical practice recommendations for cholesterol treatment.

Treatment of metabolic acidosis in patients with stage 3 chronic kidney disease with fruits and vegetables or oral bicarbonate reduces urine angiotensinogen and preserves glomerular filtration rate

Alkali therapy of metabolic acidosis in patients with chronic kidney disease (CKD) with plasma total CO2 (TCO2) below 22 mmol/l per KDOQI guidelines appears to preserve estimated glomerular filtration rate (eGFR). Since angiotensin II mediates GFR decline in partial nephrectomy models of CKD and even mild metabolic acidosis increases kidney angiotensin II in animals, alkali treatment of CKD-related metabolic acidosis in patients with plasma TCO2 over 22 mmol/l might preserve GFR through reduced kidney angiotensin II. To test this, we randomized 108 patients with stage 3 CKD and plasma TCO2 22-24 mmol/l to Usual Care or interventions designed to reduce dietary acid by 50% using sodium bicarbonate or base-producing fruits and vegetables. All were treated to achieve a systolic blood pressure below 130 mm Hg with regimens including angiotensin converting enzyme inhibition and followed for 3 years. Plasma TCO2 decreased in Usual Care but increased with bicarbonate or fruits and vegetables. By contrast, urine excretion of angiotensinogen, an index of kidney angiotensin II, increased in Usual Care but decreased with bicarbonate or fruits and vegetables. Creatinine-calculated and cystatin C-calculated eGFR decreased in all groups, but loss was less at 3 years with bicarbonate or fruits and vegetables than Usual Care. Thus, dietary alkali treatment of metabolic acidosis in CKD that is less severe than that for which KDOQI recommends therapy reduces kidney angiotensin II activity and preserves eGFR.

Abstract 321: Impact Of Chronic Kidney Disease On Heart Failure Outcomes In A Minority Cohort

BACKGROUND: Heart failure (HF) and Chronic kidney disease (CKD) are major public health problems that often co-exist with a resultant high mortality and morbidity. Most of the studies evaluating their reciprocal prognostic impact have focused on mortality in majority populations. There is limited literature on the impact of CKD on HF morbidities in ethnic minorities. AIMS: Our study seeks to compare HF outcomes in patients with or without CKD in an African-American predominant cohort. METHODS: We obtained data from the NGH at Meharry Heart Failure Cohort; a comprehensive retrospective HF database comprised of patient care data (HF admissions, non-HF admissions, and emergency room visits) were assessed from January 2006 to December 2008. The study group consist of 306 subjects with a mean age of 65±15 years. 81% were African-American (AA), 19% Caucasian and 48.5% are females. Following the NKF KDOQI guidelines, 5 stages of CKD were outlined based on GFR. RESULTS: The overall prevalence of CKD in this population is 54.2%. CKD stage 1 was most prevalent with 45.8%, prevalence for stages 2-5 are 21.6%, 18.3%, 9.5% and 4.9% respectively. The comparison of the mean of ER visits, non HF hospitalizations and HF hospitalizations between normal and CKD patients was done using independent t-test and showed no significant difference in the mean number of ER visits (p=0.564), or HF hospitalizations(p=0.235). However, there is a statistically significant difference in the mean number of non -HF hospitalizations between normal and CKD patients (p=0.031). CONCLUSION: This study shows that the prevalence of CKD in this minority -predominant HF cohort is similar to prior studies in majority populations. However, only the non-HF hospitalizations were significantly increased in the CKD group. Future prospective studies will be needed to define the implications of this in the management of HF patients with CKD.

Why vascular access trials on flow surveillance failed.

Since the introduction of access flow surveillance technology for routine patient screening in 1995, more than 30 clinical trials have been presented in peer reviewed journals. Despite overall positive outcomes, some trials, including randomized control trials (RCTs), failed to produce positive outcomes for access surveillance. The purpose of this study is to analyze published data related to the main component of access surveillance--adequate increase of access flow after percutaneous transluminal angioplasty (PTA). A total of nine studies for arteriovenous grafts (AVGs) that include 350 accesses and nine studies for arteriovenous fistula (AVF) that included 503 accesses were considered for analysis from 14 publications. Practically, all reference data find high sensitivity (>90%) of access flow measurement to predict 50% stenosis. Mean access flow increase after PTA in AVGs was 319 ml/min (from 238 to 524 ml/min). Mean access flow increase in AVFs was 331 ml/min (from 195 to 402 ml/min). Relative flow increase in AVFs was 1.6 times greater than in AVGs. The authors of failed RCT for AVGs either did not select patients for PTA based on KDOQI guidelines and did not provide/analyze PTA flow results data, or reveal data that obviously show failure of PTA to adequately improve access flow. Access flow surveillance successfully identifies patients with hemodynamically significant stenosis. PTA performed on AVFs produce better hemodynamic results than in AVGs. Inadequate flow increases during PTA and not following KDOQI guidelines are major contributing factors for failed AVG randomized tails. Radiologists should use objective means for flow evaluation during PTA.

Determinants of hemoglobin variability in stable peritoneal dialysis patients

Significant within-patient hemoglobin (Hb) level variability is well recognized in particularly hemodialysis patients. Several factors such as hospitalizations, intercurrent diseases and IV iron therapy are found to be related to Hb variability (Hb-var). In this observational study, we aimed to identify predictors and outcome of Hb-var in peritoneal dialysis (PD) patients without hospitalization, intercurrent disease and IV iron therapy during the study period. All patients were in the maintenance phase of short-acting erythropoiesis-stimulating agents (ESAs) therapy. The target range of Hb was 11-12 g/dL according to KDOQI Guidelines in 2007. The desired range of Hb was 11-12.5 g/dL. Patients' demographic and laboratory data were collected at baseline. Atherosclerotic disease was assessed using carotid intima-media thickness (CIMT). We assessed Hb variability with various methods using SD Hbmean, SD Hbrange and the velocity of Hb change. Hb deflectpositive, Hb deflectnegative, Hb values and ESA dosing were recorded monthly for 6 months. This study included 50 prevalent PD patients (mean age 46.9 ± 13.7 years, 25 women). The mean velocity of Hb change was negatively correlated with age and positively correlated with frequent ESA dose changes. Higher albumin and residual renal function (RRF) were also positively correlated with Hb deflectpositive. Patients with CIMT ≥0.7 cm had lower SD Hb range compared to CIMT <0.7 cm. Cumulative survival was better in patients with Hb levels consistently ≥10 g/dL compared to patients who had Hb <10 g/dL for at least 1 month. However, Hb-var was not associated with mortality. In PD patients without hospitalization, intercurrent disease(s) or IV iron therapy, young age, higher albumin or RRF and lower CIMT were associated with greater oscillations in response to ESA therapy. Careful and appropriate ESA dose changes considering these parameters could minimize Hb variability in these patients.

Physical Function and Physical Activity Assessment and Promotion in the Hemodialysis Clinic: A Qualitative Study

Despite practice guidelines (KDOQI [Kidney Disease Outcomes Quality Initiative]) recommending regular assessment of physical function and encouragement of physical activity, few clinics in the United States objectively assess physical function/physical activity or provide recommendations for physical activity in their patient care. Qualitative methods were used to develop an understanding of practice patterns related tophysical function assessment and physical activity encouragement by dialysis staff. Data were collected in one outpatient university-based hemodialysis clinic. 15patient care staff were interviewed and 6 patients were observed. Semistructured interviews of patient care staff were conducted, along with nonparticipant observations of the clinic environment and operations and review of archival materials. Coding of the interviews was descriptive, followed by interpretive coding by the research team. On-site field notes were transcribed for analysis. There was universal unawareness of the KDOQI guideline related to physical function/physical activity; however, all staff thought their patients would benefit from physical activity. There were no objective assessments of physical function and no resources or training to facilitate physical activity encouragement. Staff described deteriorating physical function in their patients, which was frustrating and disappointing. Barriers to physical activity included clinical/disease factors, staff "overaccommodation," and a system of dialysis care that facilitates sedentary behavior and does not require or incentivize clinics to promote physical activity. The patient care technicians were interested and thought that they had time to promote physical activity, but thought that they were unprepared to do so, indicating a need for education and training and a need to develop protocols to address the issue as routine practice. This was a single university-based center; however, because hemodialysis procedures are prescribed by Centers for Medicare & Medicaid Services regulations, it is likely that practice in this clinic is representative of nationwide practice. Development of strategies to implement practice change that addresses low physical function and physical activity is warranted.

KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for the Evaluation and Management of CKD

The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guideline for evaluation, classification, and stratification of chronic kidney disease (CKD) was published in 2002. The KDOQI guideline was well accepted by the medical and public health communities, but concerns and criticisms arose as new evidence became available since the publication of the original guidelines. KDIGO (Kidney Disease: Improving Global Outcomes) recently published an updated guideline to clarify the definition and classification of CKD and to update recommendations for the evaluation and management of individuals with CKD based on new evidence published since 2002. The primary recommendations were to retain the current definition of CKD based on decreased glomerular filtration rate or markers of kidney damage for 3 months or more and to include the cause of kidney disease and level of albuminuria, as well as level of glomerular filtration rate, for CKD classification. NKF-KDOQI convened a work group to write a commentary on the KDIGO guideline in order to assist US practitioners in interpreting the KDIGO guideline and determining its applicability within their own practices. Overall, the commentary work group agreed with most of the recommendations contained in the KDIGO guidelines, particularly the recommendations regarding the definition and classification of CKD. However, there were some concerns about incorporating the cause of disease into CKD classification, in addition to certain recommendations for evaluation and management.

CP-122 Medicine costs analysis in haemodialysis

BackgroundThe management of anaemia and secondary hyperparathyroidism (SHPT) in haemodialysis patients with chronic kidney disease means a significant consumption of drugs with high economic and health consequences.PurposeTo evaluate the potential...

Time to Revisit the Role of Renal Dietitian in the Dialysis Unit

THENOVEMBER 2013 issue of the journal published a very important and interesting study by Hand, Steiber, and Burrowes titled ‘‘Renal Dietitians Lack Time and Resources to Follow the NKF KDOQI Guidelines for Frequency and Method of Diet Assessment: Results of a Survey’’. The authors should be commended for executing an outstanding study on a very important but significantly overlooked subject—the roles and responsibilities of a renal dietitian in an outpatient dialysis unit. Although the dietitians cover a crucial aspect of care of chronic kidney disease (CKD) and end-stage renal disease (ESRD), there are only limited data regarding these issues. This well-conceived study provides very relevant data for the care of the ESRD patients in the outpatient dialysis setting, including but not limited to the characteristics of the dietitians and their workload, frequency and barriers to dietary intake data collection, and methods of dietary intake collection and analyses. Of those data, it is remarkable that the finding by Hand and colleagues suggests that over 25% of the practicing dietitians in the United States are assigned more than 150 ESRD patients at a given time. Accordingly, we are equally impressed, albeit not completely surprised, with the results showing that only 6.5% of dietitians follow the Kidney Disease Outcomes Quality Initiative recommendations for biannual dietary

Compliance with Mineral Metabolism Targets in Haemodialysis Patients: Moving Backwards?

Background: To standardize therapy and improve the clinical outcome for chronic haemodialysis (HD) patients, guidelines have been developed for mineral metabolism management. We evaluated compliance with different mineral metabolism guidelines. Methods: 2,951 chronic HD patients from 61 dialysis centres in Spain were studied. Mineral metabolism management data from a 1-year period were analysed according to KDOQI, KDIGO, and Spanish guidelines. Results: Only 1% (KDOQI), 6% (KDIGO) and 11% (Spanish guidelines) of patients continuously achieved total calcium (Ca), phosphate (P) and parathyroid hormone (PTH) target-range values during the year with higher percentages if we considered the 1-year average. The yearly Ca, P and iPTH average accomplished Spanish guidelines with different percentage among centres: CA 62-100%, P 59-91%, PTH 61-89%, and 28-77% considering all three targets together. The KDIGO guidelines recommend similar percentages except for P (33-77%). No differences were found related to eKt/V, online haemodiafiltration/HD, weight, body mass index, or dialysis vintage. They were only related to age, blood flow, effective treatment time, and dialysate calcium but without relevant clinical differences. Patients outside the target ranges generated significantly higher treatment costs. Conclusions: Compliance with mineral metabolism targets in HD patients was poor and showed a wide variation between treatment centres.

Retraction: Summary of KDIGO guideline: behind the scenes, need for guidance, and a framework for moving forward

The 2102 KDIGO Guidelines for CKD evaluation, classification, and management have updated the original 2002 KDOQI Guidelines, using newer data and addressing issues raised over the last decade concerning definitions and assessment. This commentary highlights the key aspects of the CKD guidelines, and describes the rationale for specific wording and the scope of the document. A precis of key concepts in each of the five sections of the guideline is presented. The guideline document is intended for general practioners and nephrologists, and covers both adult and pediatric CKD evaluation, classification, and management. Throughout the guideline, we have attempted to overtly address areas of controversy or non-consensus, international relevance, and impact on practice and public policy.

Prevalence of 25-OH Vitamin D Deficiency in a Population of Hemodialysis Patients and Efficacy of an Oral Ergocalciferol Supplementation Regimen

Background/Aims: Optimal dosing regimens for 25-OH vitamin D (VitD) deficiency are unknown in hemodialysis (HD) patients. Our aim was to evaluate the efficacy of prescribing ergocalciferol supplementation based on KDOQI guidelines for chronic kidney disease (CKD) stages III-IV in HD patients. Methods: We conducted a retrospective study of 96 urban, predominately African-American HD patients at a single-center dialysis unit with VitD insufficiency or deficiency treated with ergocalciferol. Patients were classified as either compliant or non-compliant with supplementation as determined by review of pharmacy records. The primary outcome was VitD levels 6 months after initiation of treatment and secondary outcomes were VitD levels at 11 months, bone/mineral and anemia parameters. Results: The population was predominately African-American (69%) and Hispanic (28%). There were 61 individuals in the compliant group and 35 individuals in the non-compliant group. The compliant group was older but otherwise similar in demographics and co-morbid conditions to the non-compliant group. After 6 months of treatment, the compliant group had a significant increase in VitD level (14.7 ± 6.0 to 28.7 ± 10.0 ng/ml, p < 0.0001) compared to the non-compliant group (14.7 ± 5.5 to 14.8 ± 7.1 ng/ml, p = 0.95). There were no differences in the incidence of hypercalcemia between the two groups. Except for a decrease in phosphorus in the compliant group (5.6 ± 1.6 to 4.9 ± 1.7 mg/dl, p = 0.004), there were no significant difference in bone/mineral or anemia parameters including dosing of darbepoetin. Conclusion: An ergocalciferol-prescribing strategy using the KDOQI guidelines for stage III-IV kidney disease in HD patients with VitD deficiency or insufficiency is inadequate to achieve repletion or maintenance of normal VitD levels.

Summary of KDIGO guideline: behind the scenes, need for guidance, and a framework for moving forward

The 2102 KDIGO Guidelines for CKD evaluation, classification, and management have updated the original 2002 KDOQI Guidelines, using newer data and addressing issues raised over the last decade concerning definitions and assessment. This commentary highlights the key aspects of the CKD guidelines, and describes the rationale for specific wording and the scope of the document. A precis of key concepts in each of the five sections of the guideline is presented. The guideline document is intended for general practioners and nephrologists, and covers both adult and pediatric CKD evaluation, classification, and management. Throughout the guideline, we have attempted to overtly address areas of controversy or non-consensus, international relevance, and impact on practice and public policy.

Influence of Four Different PTH Methods on the Classification of Chronic Kidney Disease PatientS According to the New KDIGO Guideline

Secondary hyperparathyroidism develops frequently with chronic kidney disease (CKD) and is associated with poor outcome. The new CKD-MBD guideline, Kidney Disease: Improving Global Outcomes (KDIGO), recommends a target range for PTH which is based on the locally used, upper reference range limit (URL). We examined the impact of the KDIGO guideline on the classification of dialysis patients in two different hospitals using 4 different intact-PTH assays. Blood samples from 76 consecutive hemodialysis CKD patients were measured for PTH concentration. Classification of the patients was performed according to the previous KDOQI and the KDIGO guideline using the manufacturers' and laboratory determined URLs. Classification of patients based on 3 different PTH methods (Siemens ADVIA Centaur, Siemens Immulite 2000, and Beckman Coulter Unicel DxI) was compared with the classification found in another hospital using the Roche Modular E170 PTH assay. Depending on the PTH assay used, between 9 (12%) to 14 (18%) of the patients were classified differently in the two hospitals if the KDOQI guideline was followed. Application of the KDIGO-PTH target range resulted in a similar or decreased number of differently classified patients if the PTH concentration was measured using the Advia Centaur and Immulite assays. With the Beckman Coulter PTH assay, however, the number of differently KDIGO-classified patients increased if the manufacturers' URL (9.3 pmol/L) was used to calculate the PTH-target range. Application of the laboratory determined URL (7.0 pmol/L) improved concordance in classification, although the number of differently classified patients was still higher than with the other PTH assays. The best concordance in classification for the Beckman Coulter assay was found at a PTH value of 6.0 pmol/L. Regarding the Roche and Siemens assays, no significant difference was found in the classification using the URL either determined by the laboratory or the manufacturers. Compared with the KDOQI guideline, the new KDIGO guideline may increase the number of discrepancies in the classification of CKD patients if the Access Beckman Coulter PTH assay is used in conjunction with the calculated target range based on the manufacturers' URL. The best concordance in the classification for the Beckman Coulter assay was found at a PTH value below the manufacturers' and laboratory determined URL.

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.

When Should a Patient Receive an Arteriovenous Graft Rather Than a Fistula?

There has been a dramatic increase in the placement and use of arteriovenous fistulas (AVF) in US patients with chronic kidney disease over the past few years, in accordance with strong recommendations by Fistula First Initiative and KDOQI guidelines. However, AVF nonmaturation remains a substantial obstacle to achieving functional AVFs in a subset of patients, despite the widespread use of preoperative vascular mapping to assist surgeons in planning access surgery, and the growing use of interventions to salvage nonmaturing AVFs. In the right patient, aggressive efforts result in a functioning AVF, which provides adequate dialysis with relatively few interventions required to maintain its long-term patency for dialysis. In the wrong patient, aggressive efforts to achieve a mature AVF may result in numerous failed surgical and percutaneous procedures and prolonged catheter dependence, with all its associated complications. Thus, strict recommendations to place an AVF in all dialysis patients might not benefit every patient, and may actually harm some patients. There are no randomized clinical trials to address which patients are more suitable for placement of an arteriovenous graft (AVG), rather than an AVF. However, there is a wealth of observational studies, which taken cumulatively, may assist clinicians in identifying those patients who should receive an AVG. In this article, we review the relevant published literature regarding this topic and provide suggestions for stratifying patients who should receive each type of vascular access.

Should We Do Cardiac Stress Tests in Asymptomatic Renal Transplant Candidates?

Background: Although the high burden of coronary artery disease in the dialysis population, the expected benefit of screening tests in asymptomatic renal transplant candidates is a controversial topic. Recently, we found that the rates of noninvasive stress testing(stress echocardiogram, or nuclear stress test) range from 20 to 100% depending on which renal specific transplant guidelines(KDOQI, AST, and Lisbon) were applied. Interestingly the positive predictive value of ischemia on noninvasive stress test is about 5% -10% in KDOQI, AST, and Lisbon guidelines. Noninvasive stress tests are more expensive and able to trigger ischemia, and arrhythmia than conventional trans thoracic echocardiography(TTE). We compared episodes of patient death with heart disease, and ischemic heart disease Methods: Kidney transplant candidates who recommended stress test according to the guidelines (KDOQI and AST) were enrolled. Although they had multiple risk factors, they had a good ordinary activity and no symptoms. All of patients were performed TTE and selected that did not show any regional wall motion abnormality, severe valvular disease, and abnormal ejection fraction. 165 paitents were enrolled and divided into two groups. A group underwent only TTE (N=124) and B group underwent TTE with noninvasive stress test (n=41). We measured incidence of patient death with heart disease, and symptomatic ischemic heart disease within 3 years after kidney transplantation. Results: The mean age of group A was 39 ±7 years, and B group was 40 ±5 years. Diabetes patients of group A and B were consisted of 8.8%(11/124) and 9.7% (4/41), respectively. Only 4 patients of group B had a positive result on noninvasive stress test but they had no obstructive coronary disease on coronary angiograms. The total incidence of ischemic heart disease of group A and B were 6.4% (8/124) and 7.3% (3/41), respectively. There was no patient in both groups who death with primary heart problems within 3 years after kidney transplantation. Conclusion: Conventional TTE has a similar effect to predict ischemic heart disease in asymptomatic candidates who are relatively young, and have a good physical functional copacity. Renal transplant specific guidelines recommend widespread pretransplant cardiac test. Therefore we need prospective studies that compare screening tests and their associated clinical outcomes to find proper application of diagnostic strategies in kidney transplant candidates.

Cinacalcet for hemodialyzed patients with or without a high PTH level to control serum calcium and phosphorus: ECO (evaluation of cinacalcet HCl outcome) study

We investigated the influence of cinacalcet on serum Ca and P in hemodialyzed patients with or without a high PTH level, according to K/DOQI guideline, to control serum Ca and P levels. We recruited 130 patients in this prospective cohort study and classified them into Group A (iPTH > 300 pg/ml), Group B (iPTH = 181 - 300 pg/ml), and Group C (iPTH ≤ 180 pg/ml). After 24 weeks on cinacalcet, serum Ca, P and iPTH were measured. The achievement rate of the target iPTH level in JSDT guideline was significantly higher in Group B compared with Group A. The achievement rate of serum Ca and P target levels in the Japanese Society for Dialysis Therapy (JSDT) guideline was higher in Group C. In Group A and Group C, the simultaneous achievement rates (Ca, P, and iPTH) in KDOQI guideline increased after treatment with cinacalcet (p < 0.01). There was no difference in the reduction of Ca and P among the groups, while the iPTH reduction was significantly lower in groups B and C compared with that in A. Administration of cinacalcet to patients with or without high PTH levels, according to the K/DOQI guideline, facilitates the control of Ca and P levels.

Pregnancy in CKD: whom should we follow and why?

Chronic kidney disease (CKD) has a high prevalence in pregnancy. In a period of cost constraints, there is the need for identification of the risk pattern and for follow-up. Patients were staged according to K-DOQI guidelines. The analysis was prospective, January 2000-June 2011. Two hundred and forty-nine pregnancies were observed in 225 CKD patients; 176 singleton deliveries were recorded. The largest group encompasses stage 1 CKD patients, with normal renal function, in which 127 singleton deliveries were recorded. No hard outcomes occurred (death; dialysis); therefore, surrogate outcomes were analysed [caesarean section, prematurity, need for neonatal intensive care unit (NICU)]. Stage 1 patients were compared with normal controls (267 low-risk pregnancies followed in the same setting) and with patients with CKD stages 2-4 (49 singleton deliveries); two referral patterns were also analysed (known diagnoses; new diagnoses). The risk for adverse pregnancy rises significantly in stage 1 CKD, when compared with controls: odds ratios were caesarean section 2.73 (1.72-4.33); preterm delivery 8.50 (4.11-17.57); NICU 16.10 (4.42-58.66). The risks rise in later stages. There is a high prevalence of new CKD diagnosis (overall: 38.6%; stage 1: 43.3%); no significant outcome difference was found across the referral patterns. Hypertension and proteinuria are confirmed as independent risk factors. CKD is a risk factor in pregnancy; all patients should be followed within dedicated programmes from stage 1. There is need for dedicated interventions and educational programmes for maximizing the diagnostic and therapeutic potentials in early CKD stages.

Kidney biopsy in patients with glomerulonephritis: is the earlier the better?

BackgroundInterventional diagnostic procedures are established for several diseases in medicine. Despite the KDOQI guideline recommendation for histological diagnosis of kidney disease to enable risk stratification, its optimal time point has not been evaluated. We have therefore analyzed whether histological diagnosis of glomerulonephritis (GN) at an early stage of chronic kidney disease (CKD) is associated with different outcome compared to diagnosis at a more advanced stage.MethodsA cohort of 424 consecutive patients with histological diagnosis of GN were included in a retrospective data analysis. Kidney function was assessed by glomerular filtration rate (GFR) estimation at the time point of kidney biopsy and after consecutive immunosuppressive therapy. Censored events were death, initiation of dialysis or kidney transplantation, or progression of disease, defined as deterioration of CKD stage ≥1 from kidney biopsy to last available kidney function measurement.ResultsOccurrence of death, dialysis/transplantation or progression of disease were associated with GFR and CKD stage at the time of kidney biopsy (p < 0.001 for all). Patients with CKD stage 1 and 2 at kidney biopsy had fewer endpoints compared to patients with a GFR of <60 ml/min (p < 0.001).ConclusionKidney function at the time point of histological GN diagnosis is associated with clinical outcome, likely due to early initiation of specific drug treatment. This suggests that selection of therapy yields greatest benefit before renal function is impaired in GN.