Late-stage Chronic Kidney Disease Research Articles

Annual all-cause mortality rate for patients with diabetic kidney disease in Singapore

BackgroundThe prognosis of diabetic kidney disease is poor because epidemiological data have shown that all-cause mortality increases with declining renal function. This study aims to estimate the annual mortality rate of diabetic kidney disease stratified by chronic kidney disease (CKD) stages and to identify the predictors of mortality. MethodsPatients with Stage 3–5 CKD (estimated glomerular filtration rate [eGFR] less than 60 mL/min per 1.73 m2) with diabetic kidney disease from the National Healthcare Group CKD Registry from 1 January 2007 to 31 December 2007 were included in this study. The patients were followed up till 30 November 2013. Cox's proportional hazards regression modelling was used to assess the factors associated with all-cause mortality. ResultsOver a median follow up period of 6.0 years, 985 out of 3008 patients (32.8%) died. Of those who died, 363 (36.9%) died from cardiovascular causes. The annual mortality rate was 64.1 per 1000 individuals (95% confidence interval [CI] 60.2–68.3) and the mortality rate increased with severity of CKD [Stage 3A (37.0), Stage 3B (57.5), Stage 4 (98.3) and Stage 5 (198.5)]. Predictors of mortality were age, male gender, CKD stages, albuminuria, comorbid conditions such as peripheral vascular disease, neuropathy, retinopathy and the use of antiplatelet agents. ConclusionOur study estimated the annual all-cause mortality rate for Singaporean patients with diabetic kidney disease by CKD stages and identified predictors of all-cause mortality. This study has affirmed the poor prognosis of these patients and an urgency to intervene early so as to retard the progression to later stages of CKD.

Salivary creatinine and urea analysis in patients with chronic kidney disease: a case control study.

BackgroundMany metabolic changes develop in patients with chronic kidney disease which often necessitate frequent biochemical analysis of blood. Saliva analysis as an alternative to blood has many advantages. The aims of this study were to evaluate levels of salivary creatinine and urea in patients with chronic kidney disease in comparison to healthy individuals; to determine correlation between salivary creatinine/urea and blood creatinine/urea and to evaluate the diagnostic potential of saliva.MethodsA case control study, involving 50 patients with late stage chronic kidney disease and 49 healthy individuals as control. Blood and saliva samples were analyzed for urea and creatinine levels. Data are presented as median with interquartile range and compared using Independent Samples Mann Whitney U test. Correlation between plasma and salivary creatinine as well as urea was determined using Spearman’s correlation test. Receiver operating characteristics (ROC) analysis was done to determine the diagnostic ability of salivary creatinine and urea and cut-off values were established.ResultsMedian salivary creatinine levels were 2.60 mg/dl and 0.20 mg/dl while median salivary urea levels were 92.00 mg/dl and 20.50 mg/dl in patients with chronic kidney disease and controls respectively. Salivary levels of creatinine and urea were significantly elevated in chronic kidney disease patients (p < 0.001). In addition, there was positive correlation between blood and salivary creatinine as well as urea levels. Total areas under the curve for salivary creatinine and urea were 0.97 and 0.89 respectively. Cut-off values for salivary creatinine and urea were 0.55 mg/dl and 27.50 mg/dl respectively which gave sensitivity and specificity of 94 % and 85 % for creatinine; as well as 86 % and 93 % for urea.ConclusionsFindings of this study suggest that analysis of salivary creatinine and urea in patients with chronic kidney disease reflects their levels in blood. Hence, salivary creatinine and urea could be used as diagnostic biomarkers of chronic kidney disease.

Incidence and mortality of postoperative acute kidney injury in non-dialysis patients: comparison between the AKIN and KDIGO criteria

Objectives This retrospective study determines whether the kidney disease: improving global outcomes (KDIGO) criteria are superior to acute kidney injury network (AKIN) criteria in detecting non-dialysis AKI events and predicting mortality in chronic kidney disease (CKD) patients after surgery. Methods Surgical patients who were admitted to the intensive care unit were enrolled. Non-dialysis AKI cases were defined using either KDIGO or AKIN creatinine criteria and stratified by CKD stages. The adjusted hazard ratios (AHRs) for in-hospital mortality are compared to those without AKI. The cumulative survival curves and the predictability for mortality are accessed by Kaplan–Meier method and calculating the area under the curve (AUC) for the receiver operating characteristic (ROC) curve, respectively. Results From a total of 826 postoperative patients, the overall in-hospital mortality rate was 11.6% (96 cases) and that for AKI according to KDIGO and AKIN criteria was 30.0% (248 cases) and 31.0% (256 cases). The cumulative survival curve stratified by CKD and AKI stages were comparable between KDIGO and AKIN criteria. The discriminative power for mortality stratified by CKD stages for KDIGO and AKIN criteria are as followed: all subjects: 0.678 versus 0.670 (both ps <0.001); non-CKD: 0.800 versus 0.809 (both ps <0.001); early-stage CKD: 0.676 versus 0.676 (both ps <0.001); late-stage CKD: 0.674 versus 0.660 (ps were <0.001 and 0.003). Conclusion The KDIGO criteria are superior to AKIN criteria in predicting mortality after surgery, especially in those with advanced CKD.

Nutritional assessment in children with chronic kidney disease.

Growth failure is a major problem in pediatric patients with chronic kidney disease (CKD), and the onset of the condition in infancy is more likely to have an adverse impact on growth than its development in later childhood. This study was aimed to assess nutritional intake and anthropometry of children presenting with CKD in a developing country. In this cross-sectional observational study, children (1-18 years) with CKD visiting the outpatient services were enrolled. The age of onset, cause of CKD, and anthropometry were recorded. Dietary intakes from three 24 h dietary recall (2 mid-week and 1 weekend day) were recorded. A blood sample was taken from all subjects for biochemical parameters. A total of 45 children (forty males and five females) with CKD underwent nutritional assessment. The median age at assessment was 108 months (13-167). Twenty-seven (60%) subjects had CKD stage 1, 2, or 3 while the remaining 40% had CKD stage 4 or 5. Of the 45 children, 27 (60%) had moderate to severe malnutrition at assessment. The mean weight and height (standard deviation scores) were -2.77 ± 2.07 and -2.30 ± 1.38, respectively. The prevalence of growth retardation was much higher in late stages of CKD; the difference was statistically significant (P <0.01). The mean caloric deficit from recommended daily allowance was -40.33% for calories, +6.2% for proteins, and -10.51% for fats. The diet was highly deficient in iron (mean 48.9% deficit); deficient in calcium (mean -22.2%) and had excess phosphates (mean 18.3%). There was a progressive decrease in intake of nutrients in advanced stages of CKD. There was a high prevalence of malnutrition (60%) in children with CKD, especially in higher stages of CKD. An appropriate dietary assessment and nutritional counseling should be planned for all patients with CKD to prevent complications associated with malnutrition and anemia.

Soy-based renoprotection.

Chronic kidney disease (CKD) is a significant public health problem as risk factors such as advanced age, obesity, hypertension and diabetes rise in the global population. Currently there are no effective pharmacologic treatments for this disease. The role of diet is important for slowing the progression of CKD and managing symptoms in later stages of renal insufficiency. While low protein diets are generally recommended, maintaining adequate levels of intake is critical for health. There is an increasing appreciation that the source of protein may also be important. Soybean protein has been the most extensively studied plant-based protein in subjects with kidney disease and has demonstrated renal protective properties in a number of clinical studies. Soy protein consumption has been shown to slow the decline in estimated glomerular filtration rate and significantly improve proteinuria in diabetic and non-diabetic patients with nephropathy. Soy's beneficial effects on renal function may also result from its impact on certain physiological risk factors for CKD such as dyslipidemia, hypertension and hyperglycemia. Soy intake is also associated with improvements in antioxidant status and systemic inflammation in early and late stage CKD patients. Studies conducted in animal models have helped to identify the underlying molecular mechanisms that may play a role in the positive effects of soy protein on renal parameters in polycystic kidney disease, metabolically-induced kidney dysfunction and age-associated progressive nephropathy. Despite the established relationship between soy and renoprotection, further studies are needed for a clear understanding of the role of the cellular and molecular target(s) of soy protein in maintaining renal function.

A Comparative Study of Neurological Complications in Chronic Kidney Disease with Special Reference to its Stages and Haemodialysis Status.

Globally, Chronic Kidney Disease (CKD) is a critical and rapidly growing health problem and also a major cause of mortality and morbidity. Neurological complications occur in all levels of the nervous system. Central nervous system complications include cerebrovascular accidents, posterior reversible encephalopathy syndrome, osmotic demyelization syndrome, cerebral infection and sinus vein thrombosis. Peripheral nervous system complications include polyneuropathy, mononeuropathy and carpal tunnel syndrome. Haemodialysis (HD) related neurological complications include dialysis disequilibrium syndrome, dementia and cerebrovascular accidents. To assess the neurological complications of CKD and to compare the various neurological complications in patients on HD with those not on HD. Hundred patients with CKD were included in the study. They were categorized into two groups according to the stage of CKD and those with stage 3 or more were considered as cases and stage 2 or less as controls. The cases and controls were followed up during subsequent visits for neurological complications. This study comprised of 50 cases and 50 controls. Among 50 cases, males were 62% and females were 38% with male: female ratio was 1.6:1 and in controls, male: female ratio was 1.08:1. The maximum patients were in the age group of 51-60 years. The incidence of neurological complications was significantly higher in cases compared to controls and among people who underwent dialysis compared to those who were not. Headache was the most common complication both among cases and controls and as well as in people who were on HD. Stroke, seizures and altered sensorium were significantly associated with later stage of CKD. Cases underwent HD had significant association with headache, altered sensorium and stroke than those without HD but peripheral neuropathy and seizure did not show such association. The chances of development of neurological complications were significantly higher in late stages of CKD compared to early stages of CKD. Those neurological complications were more among people who underwent dialysis when compared to those not on maintenance HD.

Drug therapies to delay the progression of chronic kidney disease

Chronic kidney disease (CKD) is associated with significant morbidity and mortality, impacted not alone by progression to end-stage kidney disease, but also by the high associated incidence of cardiovascular events and related mortality. Despite our current understanding of the pathogenesis of CKD and the treatments available, the reported incidence of CKD continues to rise worldwide, and is often referred to as the silent public healthcare epidemic. The significant cost to patient wellbeing and to the economy of managing the later stages of CKD have prompted efforts to develop interventions to delay the development and progression of this syndrome. In this article, we review established and novel agents that may aid in delaying the progression of CKD and improve patient outcomes.

Influence of Nephrologist Care on Management and Outcomes in Adults with Chronic Kidney Disease.

Predialysis nephrology care for adults with late stage chronic kidney disease (CKD) is associated with improved outcomes. Less is known about the effects of nephrology care in earlier stages of CKD. We aimed to evaluate the effect of nephrology care on management of CKD risk factors and complications, CKD progression, incident cardiovascular disease (CVD), and death. This was a prospective cohort study. Participants included 3855 men and women aged 21 to 74 years enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study with a mean (SD) estimated glomerular filtration rate (eGFR) at entry of 45 (17) ml/min/1.73 m(2), followed for a median of 6.6 years. The main predictor was self-reported prior contact with a nephrologist at study enrollment. Outcomes evaluated included CKD progression (≥ 50 % eGFR loss or end-stage renal disease), incident CVD, and death. Two-thirds (67 %) of the participants reported prior contact with a nephrologist at study enrollment. They were younger, more likely to be male, non-Hispanic white, and had lower eGFR and higher urine protein (p < 0.05). A subgroup with eGFR 30- < 60 ml/min/1.73 m(2) and prior contact with a nephrologist were more likely to receive pharmacologic treatment for CKD-related complications and to report angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use. After propensity score matching (for reporting prior contact with a nephrologist vs. not) and adjusting for demographic and clinical variables, prior contact with a nephrologist was not significantly associated with CKD progression, incident CVD or death (p > 0.05). One-third of CRIC participants had not seen a nephrologist before enrollment, and this prior contact was subject to age, sex, and ethnic-related disparities. While prior nephrology care was associated with more frequent treatment of CKD complications and use of ACEi/ARB medications, there was neither an association between this care and achievement of guideline-recommended intermediate measures, nor long-term adverse outcomes.

Immunosuppression in the failing and failed transplant kidney: optimizing outcomes.

There is little data to guide clinicians on the optimal management of immunosuppression in patients whose kidney transplant has failed and who have returned to dialysis. Nor is there robust data on whether to perform a transplant nephrectomy. Finally, management of late stage chronic kidney disease, including deciding on dialysis initiation, modality and access planning, must occur simultaneously with efforts aimed at preserving the failing kidney and residual renal function for as long as possible. In this article, we will review the evidence on these topics and suggest areas for improvement.

PUK9 - “Cost Of Illness” Analysis Of Chronic Kidney Disease In The Entire Population Of The Russian Federation

To conduct the “cost of illness” analysis of chronic kidney disease (CKD) based on the entire population of the Russian Federation. Information retrieval was in the public domain. Pharmacoeconomic analysis method “cost of illness” was used. Direct and indirect cost analysis was also performed. Analysis of found epidemiological data revealed that, in fact, in the Russian Federation the only available epidemiological information is on the later stages of CKD (accompanied by the appointment of renal replacement therapy). Based on that during “cost of illness” analysis at the population level we have extrapolated data on the distribution of patients by stage of CKD available in the article Lori A. et al. 2011. Then the cost of various stages of CKD (including direct and indirect costs) per patient was calculated. At the final stage the economic burden of CKD on the entire patient population in the Russian Federation was determined. The total cost for all patients with CKD who are in stages with I to V in the year were: CKD I – 1157758914 $, CKD II – 1348201542 $, CKD III – 2622796532 $, CKD IV – 218480559 $, CKD V (not receiving renal replacement therapy) – 890038600 $, CKD V (on hemodialysis) - 462938674 $, CKD V (on peritoneal dialysis) - 50407252 $, CKD V (exposed of the kidney transplant) - 79916759 $. Thus, the total economic burden of all stages of CKD in country scale was 6830521313 $ per year (1 $ = 66,0983). “Cost of illness” analysis showed the economic burden of CKD on the entire patient population of the Russian Federation and found that the major portion of the cost appears in the early stages of CKD.

Influence of late-stage chronic kidney disease on overall survival in patients with upper tract urothelial carcinoma following radical nephroureterectomy

ObjectivesThe prevalence of both chronic kidney disease (CKD) and upper tract urothelial carcinoma (UTUC) in Taiwan is unusually high, and we aimed to investigate the impact of preoperative renal function on UTUC after radical nephroureterectomy. Materials and methodsBetween 2000 and 2013, 248 UTUC patients were enrolled in this retrospective study after excluding patients who had concomitant muscle-invasive bladder cancer, whose tumor metastasized at initial presentation, and who received perioperative chemotherapy or radiotherapy. The significance of CKD on overall survival (OS), cancer-specific survival (CSS), and bladder recurrence-free survival (BRFS) was evaluated by Cox proportional hazard model. ResultsThe median follow-up time was 45.41 months. Overall 5-year OS, CSS, and BRFS rates were 78.27%, 87.81%, and 70.42%, respectively. Aging, late-stage CKD, and nonorgan-confined primary tumor stage were independent predictors for OS after adjustment. Nonorgan-confined primary tumor stage and lymph node involvement were two independent predictors for CSS after adjustment. Concomitant bladder tumor was the only significant predictor for BRFS after adjustment. ConclusionPatients with late-stage CKD had a higher risk of having poor OS. Patients with concomitant bladder tumor had a greater risk of having bladder cancer recurrence despite primary tumor stage. Concomitant bladder tumor, however, had no effect on OS and CSS in this study.

Consensus Conference on Best Practices in Live Kidney Donation: Recommendations to Optimize Education, Access, and Care

Live donor kidney transplantation is the best treatment option for most patients with late-stage chronic kidney disease; however, the rate of living kidney donation has declined in the United States. A consensus conference was held June 5-6, 2014 to identify best practices and knowledge gaps pertaining to live donor kidney transplantation and living kidney donation. Transplant professionals, patients, and other key stakeholders discussed processes for educating transplant candidates and potential living donors about living kidney donation; efficiencies in the living donor evaluation process; disparities in living donation; and financial and systemic barriers to living donation. We summarize the consensus recommendations for best practices in these educational and clinical domains, future research priorities, and possible public policy initiatives to remove barriers to living kidney donation.

Medical resource utilization and costs associated with autosomal dominant polycystic kidney disease in the USA: a retrospective matched cohort analysis of private insurer data.

BackgroundAutosomal dominant polycystic kidney disease (ADPKD) results in kidney cyst development and enlargement, resulting in chronic kidney disease (CKD) leading to renal failure. This study sought to determine if ADPKD patients in the early stages of CKD contribute to a sizable economic burden for the US health care system.MethodsThis was a retrospective, matched cohort study, reviewing medical resource utilization (MRU) and costs for adults in a US private-payer claims database with a diagnosis code of ADPKD (ICD-9-CM 753.13). ADPKD patients were matched by age grouping (0–17, 18–34, 35–44, 45–54, 55–64, and 65+ years) and sex to controls to understand the burden of ADPKD. Descriptive statistics on 6-month MRU and costs were assessed by CKD stages, dialysis use, or previous renal transplant.ResultsThe analysis included ADPKD patients in CKD stages 1–5 (n=316 to n=860), dialysis (n=586), and post-transplant (n=615). Mean ages did not differ across CKD stages (range 43–56 years). Men were the majority in the later stages but the minority in the early stages. The proportion of patients with at least one hospitalization increased with CKD stage, (12% to >40% CKD stage 2 to stage 5, dialysis or post-transplant). The majority had at least one hospital outpatient visit and at least one pharmacy claim. Total 6-month per-patient costs were greater among ADPKD patients than in age-matched and sex-matched healthy non-ADPKD controls (P<0.001 for all comparisons).ConclusionADPKD patients with normal kidney function are associated with a significant economic burden to the health care system relative to the general population. Any treatments that delay progression to later stages of CKD may provide potential health care cost offsets.

Urinary Biomarkers for Detection of Early and Advanced Chronic Kidney Disease - A Pilot Study

Chronic kidney disease (CKD) is a significant and costly public health problem with increasing prevalence in most societies and the need for improved diagnosis. The aim of this study was to demonstrate how it is possible to decipher a combination of markers from a compendium of differentially-expressed proteins using available statistical tools when more than two study groups are involved. Screening for potential urinary biomarker profile stratifying early and later stages of CKD were performed. Sixteen patients with defined CKD staging were selected and compared with ten healthy individuals. Urinary proteins were quantified using theiTRAQ method and analysed with ProteinPilot, GenEx and Meta Core software. Four proteins (out of 194) (apolipoprotein D; protein AMBP; zinc-alpha-2-glycoprotein; and kininogen 1) were identified as critical for CKD stage separation. In conclusion, this preliminary work provides evidence that several unique urinary proteins are involved in early and later stages of CKD and suggests that a selected combination of biomarkers could be used to profile patients into different CKD stages. Further validation studies are now needed.

Etiological Spectrum of Chronic Kidney Disease in Young: A Single Center Study from South India

Background and objectives: Chronic kidney disease (CKD) is an important, chronic, noncommunicable disease epidemic that affects the world. Lack of registries precludes an accurate estimation of the number of patients with CKD. Only a few studies are done in our country to assess etiology of CKD in young patients. This study was aimed to assess the etiology of CKD in young patients. Materials and Methods: Data were collected from 50 patients of CKD between 15 and 40 years age who presented to Government General Hospital, Kurnool from July 2012 to June 2013. They were clinically evaluated and underwent relevant investigations including renal biopsy in indicated cases. Results: Of the 50 patients studied, there was an overall male preponderance over all age groups with a mean age of 27.6 ± 4.9 years. Small kidneys were seen in 70% of patients. 92% of patients had proteinuria. Most common symptoms of presentation were related to gastrointestinal disturbances, breathlessness, easy fatigability, and urinary disturbances. Pallor, pedal edema, and facial puffiness were major clinical features. Majority (62%) had CKD of unknown etiology. In this unknown etiology patients, majority were found to have glomerular disease (42%) based on clinical presentation and other supporting investigations. 92% presented in stage IV or stage V CKD. Histopathologically etiology was proven among 19 patients (38%) with renal biopsy. Conclusion: It is concluded that male patients in the third and fourth decades were in the majority requiring medical care. Chronic Glomerulonephritis of unknown causes constitutes a major etiology among the young presenting in late stages of CKD.

Clinical significance of saliva urea and creatinine levels in patients with chronic kidney disease

Objectives This study was carried out to explore the changes and clinical significance of urea and creatinine in saliva in patients with chronic kidney disease (CKD) and provide a noninvasive, quick, accurate, and reliable test for diagnosing kidney disease. Background Monitoring of markers in saliva instead of serum is advantageous because saliva collection is a noninvasive, simple, and inexpensive approach. Measurement of biomarkers in saliva may be an effective alternative method for monitoring the effectiveness of hemodialysis. Patients and methods Urea and Cr in the saliva and serum were collected from both healthy individuals and CKD patients and measured with a biochemical analyzer. Fifty individuals participated in this study, divided into 40 patients with CKD and 10 apparent healthy controls. Results The concentrations of urea and Cr in both saliva and serum were positively correlated in healthy individuals and CKD patients. The levels of saliva urea and Cr in CKD patients were significantly higher than those of healthy individuals (P Conclusion The levels of urea and Cr in saliva and serum are closely related. The concentration of saliva urea and Cr can reflect renal damage, monitor the kidney function of CKD patients, and help in the diagnosis of middle-stage and late-stage CKD. It is a simple, noninvasive, and quick method.

Utility of adenosine deaminase (ADA), PCR & thoracoscopy in differentiating tuberculous & non-tuberculous pleural effusion complicating chronic kidney disease.

Pleural effusion is a common occurrence in patients with late-stage chronic kidney disease (CKD). In developing countries, many effusions remain undiagnosed after pleural fluid analysis (PFA) and patients are empirically treated with antitubercular therapy. The aim of this study was to evaluate the role of adenosine deaminase (ADA), nucleic acid amplification tests (NAAT) and medical thoracoscopy in distinguishing tubercular and non-tubercular aetiologies in exudative pleural effusions complicating CKD. Consecutive stage 4 and 5 CKD patients with pleural effusions underwent PFA including ADA and PCR [65 kDa gene; multiplex (IS6110, protein antigen b, MPB64)]. Patients with exudative pleural effusion undiagnosed after PFA underwent medical thoracoscopy. All 107 patients underwent thoracocentesis with 45 and 62 patients diagnosed as transudative and exudative pleural effusions, respectively. Twenty six of the 62 patients underwent medical thoracoscopy. Tuberculous pleurisy was diagnosed in six while uraemic pleuritis was diagnosed in 20 subjects. The sensitivity and specificity of pleural fluid ADA, 65 kDa gene PCR, and multiplex PCR were 66.7 and 90 per cent, 100 and 50 per cent, and 100 and 100 per cent, respectively. Thoracoscopy was associated with five complications in three patients. Uraemia remains the most common cause of pleural effusion in CKD even in high TB prevalence country. Multiplex PCR and thoracoscopy are useful investigations in the diagnostic work-up of pleural effusions complicating CKD while the sensitivity and/or specificity of ADA and 65 kDa gene PCR is poor.

Challenges and opportunities in late-stage chronic kidney disease

There is increasing recognition that chronic diseases are a major challenge for health delivery systems and treasuries. These are highly prevalent and costly diseases and frequency is expected to increase greatly as the population of many countries ages. Chronic kidney disease (CKD) has not received the same attention as other chronic diseases such as congestive heart failure; yet, the prevalence and costs of CKD are substantial. Greater recognition and support for CKD may require that the disease no longer be viewed as one continuous disease state. Early CKD stages require less complex care and generate lower costs. In contrast, late-stage CKD is every bit as complex and costly as other major chronic diseases. Health authorities may not recognize and fund CKD care appropriately until late-stage CKD is defined clearly as separate and distinct from earlier stages of disease. In this review, we describe the burden of chronic diseases, consider the challenges and barriers and propose processes to improve late-stage CKD care. In particular, we recommend the need for improved continuity of care, enhanced use of information technology, multidisciplinary care, timely referral to nephrologists, protocol use and improved patient engagement.

The role of diabetes mellitus and hypertension in chronic kidney disease.

*Corresponding author: Seyed Seifollah Beladi-Mousavi, Chronic Renal Failure Research Center, Department of Internal Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. Email: beladimusavi@yahoo.com With interest, we read the article by Hernandez et al. about increasing awareness of chronic kidney disease and aging (1). We agree with the authors of the article that, the diabetes mellitus and hypertension are the leading causes of chronic kidney disease (CKD). Over the last decade, different kinds of glomerulonephritis (GN) were the leading causes of CKD in the world, too. However, possibly due to lifestyle changes and increasing prevalence of obesity, diabetes and hypertension and because of more available aggressive treatment of GN, it is well established that diabetes and hypertension are now the primary causes of CKD in developed countries (2-6). However, it seems that there is an important difference between causes of end-stage renal disease (ESRD) in developed and developing countries. In contrast to the United States and other developed countries, in developing countries, the cause of ESRD among significant percent of patients is the unknown etiology possibly due to late presentation and late referral of patients with CKD to the specialists (7-12). For example, in a report from Iran, Beladi-Mousavi et al. evaluated the cause of CKD among 1000 adult ESRD patients from January 1999 to March 2010. Although according to the result of this study, diabetic nephropathy and hypertensive nephrosclerosis were the most common causes of ESRD, however in the significant number of the patients (n=242, 24.2%), the causes of ESRD were unknown (8). The results of other studies which have done in Iran, for example Haghighi et al. in 2002 (7), Malekmakan et al. in 2009 (11) and Salahi et al. in 2004 (12) were also similar. In some developing countries like Iran, the significant percent of patients with CKD are presented to the nephrologist with the severe symptoms of uremia and late stage of the disease. Unfortunately at this time, determining the primary causes of CKD is not possible. Renal biopsy is also not helpful and it cannot determine the cause of CKD at the end-stage of the disease. Regardless of the causes of CKD, histologic findings of kidney biopsy at the late stage of CKD are glomerulosclerosis, tubular atrophy and interstitial fibrosis and therefore renal biopsy is not helpful. In addition, in most of the patients with CKD, the sizes of kidneys are gradually decreased and kidney biopsy is not possible at the end stage. It is associated with increment risk and therefore kidney biopsy not recommended (13,14). In conclusion, although the diabetic nephropathy and hypertensive nephrosclerosis are also the most common Seyed Bahman Ghaderian1, Seyed Seifollah Beladi-Mousavi2’*

Abstract 18256: Impact of Chronic Kidney Disease Staging on Coronary Atherosclerotic Plaque Change of Non-culprit Lesions after Culprit Percutaneous Coronary Intervention

Introduction: Renal dysfunction is associated with increased coronary plaque burden, which may cause future coronary events. However, little is known about the impact of chronic kidney disease (CKD) staging on coronary atherosclerotic plaque change of non-culprit lesions (NCL) under standard medical therapy after culprit percutaneous coronary intervention (PCI). We investigated serial coronary plaque change of NCL in patients with different stages of CKD using integrated backscatter intravascular ultrasound (IB-IVUS). Methods: We investigated 113 NCL in 113 patients undergoing both IVUS-guided PCI and follow-up IVUS examination. Patients were divided into 4 groups according to baseline CKD stage: CKD-1, n=18; CKD-2, n=43; CKD-3, n=29; and CKD 4-5, n=24. Volumetric IVUS analyses were performed at proximal NCL in de novo target vessels post PCI and at 8-month follow-up. We compared serial changes of plaque burden and composition among groups under standard medical therapy including statins. Results: Baseline patient characteristics showed age was significantly older, diabetic patients were more in CKD-3 than the other groups, but otherwise there was no significant difference among groups. Plaque volume at baseline was greater in CKD 4-5 than the other groups. (p =0.009). At follow-up, plaque volume increased in CKD-3 (+ 4.6 mm3, p &lt;0.001) and CKD 4-5 (+ 9.8 mm3, p &lt;0.001), but decreased in CKD-1 (- 5.4 mm3, p =0.002) and CKD-2 (- 3.2 mm3, p=0.001). Serial plaque volume change was correlated with eGFR. (Y= - 0.2X +11.4, p&lt;0.0001). IB-IVUS analysis showed that lipid plaque increased in CKD-3 (+ 4.6 mm3, p &lt;0.001) and CKD 4-5 (+ 5.4 mm3, p &lt;0.001), but significantly decreased in CKD-2 (- 2.7 mm3, p &lt;0.05) at follow-up. Fibrotic plaque also increased in CKD 4-5 (+ 3.4 mm3, p &lt;0.001), whereas it decreased in CKD-1 (- 3.3 mm3, p &lt;0.05). Multivariate models revealed CKD staging is an independent predictor of plaque progression. Conclusions: Despite standard medical therapy after culprit PCI, late stages of CKD were associated with coronary plaque progression characterized by greater lipid and fibrotic plaque volumes in NCL. Strict risk management should be required to prevent subsequent coronary events in those patients.