Management Of Kidney Disease Research Articles

A Case of Ayurvedic management of chronic kidney disease with use of varunaadi kadha

Chronic renal failure, a consequence of chronic kidney disease, trauma, immune disorder, and certain other conditions, is a growing public health concern worldwide. Often causing high health care costs but yielding poor outcomes, kidney disease is the ninth leading cause of death in the United States, and is growing in incidence in other industrialized nations. All individuals with GFR <60 ml/min/1.73 m2 for 3 months are classified as having chronic kidney disease, irrespective of the presence or absence of kidney damage. Ayurvedic text have also described various categories of mutraroga like mutraghata, mutrakricchr, ashmari and wide range of herbo mineral drugs as therapeutic measures. This clinical observation was undertaken to notice the action of Ayurvedic drugs in the management of CRF on a 69 years old patient. Patient was advised Gomutra, Gokshur seed decoction and Gokshuradi Guggula with Varunadi kwath anupan for regularly two months. Significant improvement in all subjective as well as objective parameters was noted.

A Post Hoc Analysis of Statin Use in Tolvaptan Autosomal Dominant Polycystic Kidney Disease Pivotal Trials.

Tolvaptan is approved to slow kidney function decline in adults with autosomal dominant polycystic kidney disease (ADPKD) at risk of rapid progression. Because in vitro studies indicated that the tolvaptan oxobutyric acid metabolite inhibits organic anion-transporting polypeptide (OATP)1B1 and OATP1B3, United States prescribing information advises avoiding concurrent use with OATP1B1/1B3 substrates, including hepatic hydroxymethyl glutaryl-CoA reductase inhibitors (statins). This post hoc analysis of the pivotal phase 3 tolvaptan trials (Tolvaptan Efficacy and Safety in Management of Autosomal Dominant Polycystic Kidney Disease and Its Outcomes [TEMPO] 3:4 trial [NCT00428948] and Replicating Evidence of Preserved Renal Function: an Investigation of Tolvaptan Safety and Efficacy in ADPKD [REPRISE] trial [NCT02160145]) examined the safety of concurrent tolvaptan/statin use. The trials randomized a combined total of 2815 subjects with early- to late-stage ADPKD to tolvaptan (n=1644) or placebo (n=1171) for 3 years (TEMPO 3:4) and 1 year (REPRISE). Statin use was unrestricted, and 597 subjects (21.2% overall; 332 [20.2%] tolvaptan, 265 [22.6%] placebo) received statins. Statin use (duration, dose change, statin change, permanent discontinuation), incidences of statin-related adverse events, and hepatic transaminase elevations were determined for subjects who received tolvaptan+statin, placebo+statin, tolvaptan alone, and placebo alone. No differences in statin use parameters between tolvaptan- and placebo-treated subjects were observed. No statistically significant increases in commonly reported statin-related adverse events (e.g., musculoskeletal disorders, gastrointestinal symptoms) were seen between subjects receiving tolvaptan+statin and placebo+statin. For example, in TEMPO 3:4, frequencies were 5.4% and 7.8%, respectively, for myalgia (difference -2.4%; 95% confidence interval, -11.2% to 6.4%) and 9.3% and 7.8%, respectively, for abdominal pain (difference 1.5%; -7.9% to 10.9%). In an analysis that excluded participants concurrently using allopurinol, the frequency of alanine transaminase or aspartate transaminase >3× upper limit of normal in the pooled study populations was 3.6% for the tolvaptan+statin group and 2.3% for the placebo+statin group (difference 1.4%; -2.0% to 4.7%). Tolvaptan has been used safely in combination with statins in clinical trials. This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_04_06_CJN.08170719.mp3.

2019 Update of the Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA–EDTA) recommendations for the management of lupus nephritis

ObjectiveTo update the 2012 EULAR/ERA–EDTA recommendations for the management of lupus nephritis (LN).MethodsFollowing the EULAR standardised operating procedures, a systematic literature review was performed. Members of a multidisciplinary Task Force...

The future of diabetic kidney disease management: what to expect from the experimental studies?

Diabetic kidney disease (DKD) is a major cause of end-stage renal disease. Intensive blood glucose and blood pressure control, particularly using inhibitors of the renin-angiotensin system, have long been mainstays of therapy in patients with DKD. Moreover, new anti-hyperglycemic drugs have recently shown renoprotective effects and this represents a major progress in the management of DKD. However, the risk of progression is still substantial and additional drugs are required. Recent preclinical studies have identified novel therapeutic targets that may optimize renoprotection in the near future. Besides strategies aimed to reduce oxidative stress and inflammation in the kidney, novel extra-renal approaches targeting stem cells, extracellular vesicles, and the microbiota are on the horizon with promising preclinical data. Herein, we will review these lines of research and discuss potential clinical applications. Given the poor yield of experimental studies in DKD in the past years, we will also discuss strategies to improve translation of preclinical research to humans.

Evaluation of the Usage of Erythropoietin in Patients with End-Stage Chronic Kidney Disease Dialysis Cycle in Hanoi Nephrology Hospital

Treatment and control of anemia plays an important role in improving the quality and effectiveness of artificial kidney. The study was conducted on 61 patients who met the selection and were not included in the excluded criteria group. Collecting data from medical records using retrospective, descriptive, vertical follow-up method for 6 months. Data were processed using Microsoft Excel Office 2010 and R. The results showed that patients used both EPO alpha and EPO beta simultaneously. Rate of usage’s EPO beta accounted for 23%, alpha EPO was 77%. Lyophilized form (EPO alpha) is most commonly used. Starting from T3, Hb. averages treat. There were no abnormalities in blood pressure, white blood cell, platelets, and electrolytes.
 Keywords
 Hanoi Kidney Hospital, EPO (erythropoietin), Hb, efficacy and safety.
 References
 [1] L.A. Szczech, W. Harmon, T.H. Hostetter et al, World Kidney Day 2009: Problem and Challenges in the Emering Epidemic of Kidney Disease, J Am Soc Nephrol 20 (2009) 453-455. https://doi.org/10.1681/ASN.2009010041.[2] D.T. Gilbertson, J. Liu et al, Projecting the Number of Patient with End Stage Renal Disease in the United States to the Year 2015, J Am Soc Nephrol 16 (2005) 3736-3741. https://doi.org/10.1681/ASN.2005010112.[3] A.E. Gaweda, G.R. Aronoff et al, Individualized anemia management reduces hemoglobin variability in hemodialysis patients, J Am Soc Nephrol 25(1) (2014) 159-66. https://doi.org/10.1681/ASN.2013010089.[4] Do Thi Thu Hien, Evaluation of the usage of erythropoietin in the treatment of anemia in patients with chronic renal failure on dialysis at Thai Binh Provincial General Hospital, Master of Pharmacy thesis, Hanoi University of Pharmacy, 2015 (in Vietnamese).[5] Trieu Thi Tuyet Van, Evaluation of the usage of erythropoietin in the treatment of anemia in patients with chronic renal failure on dialysis at the artificial kidney department - Bach Mai Hospital, Master of Pharmacy thesis, Hanoi University of Pharmacy, 2009 (in Vietnamese).[6] Nguyen Thi Uyen, Investigating the effectiveness and safety of Erythropoietin use in dialysis patients at artificial kidney monotherapy Sanit Paul Hospital, Graduation thesis of Pharmacist, Hanoi University of Pharmacy, 2016 (in Vietnamese).[7] Bui Thi Tam, Evaluation the effectiveness of anemia treatment with Erythropoietin in patients with chronic renal failure receiving dialysis at Dien Bien Provincial General Hospital, Graduation thesis of Pharmacist Specialist 2, Hanoi University of Pharmacy, 2011 (in Vietnamese).[8] Drug Administration of Vietnam - Ministry of health, Official dispatch number 4764/QLD-ĐK, 2014 (in Vietnamese).[9] The Vietnam Urology & Nephrology Association, Guidelines for treatment of anemia in chronic kidney disease, The Vietnam Urology & Nephrology Association, 2013 (in Vietnamese).[10] KDIGO, KDIGO 2012 Clinical practice guideline for the evaluation and management of chronic kidney disease, Kidney International Supplement, 2013, pp.1-150.[11] Lam Thanh Vung, Study on the characteristics of anemia and the effectiveness of Erythropoietin β combination with intravenous iron in patients with chronic renal dialysis by dialysis, Thesis Specialized level 2 Medical and Pharmaceutical University, Hue University, 2013.

122 Impact of a Kidney Disease Management Program on ER Utilization, In-Patient Utilization and Total Cost of Care

122 Impact of a Kidney Disease Management Program on ER Utilization, In-Patient Utilization and Total Cost of Care

Innovative education for people with chronic kidney disease: an evaluation study.

An innovative Community Kidney Service has been running since 2016 in four health regions in East London, United Kingdom. This paper focuses on the patient education (self-management) programme within the service. To understand the experiences of people with stage 1-3b chronic kidney disease invited to individual or group education sessions. To assess the usefulness of the programme's educational resources to primary care nurses. A mixed-method project. A steering group involving patients shaped both survey and interview questions. Paper surveys (n = 266) were sent to patients 7-19 months after they had attended. Semi-structured interviews were undertaken with patients who returned the survey and indicated they were willing to be interviewed (n = 9). Survey links were sent electronically to primary care nurses. Fifty-four surveys were returned from patients. The education session increased self-reported knowledge about kidney disease and two-thirds of patients reported making lifestyle changes. Analysis of interview data identified recognition of kidney disease, motivation to change and reliance on "experts" as key themes. Surveys were returned from 21 nurses. Most were aware of the community kidney service but only one-third had used the education resources with their patients. Secondary care nursing involvement in primary care-based education for people with kidney disease is rare in the United Kingdom and internationally. This educational intervention, developed with patients, supports people to make changes that have the potential to reduce progression of kidney disease and our findings have significance for other teams working in chronic kidney disease management.

Barriers and enablers to detection and management of chronic kidney disease in primary healthcare: a systematic review

BackgroundChronic kidney disease (CKD) is growing population health concern worldwide, and with early identification and effective management, kidney disease progression can be slowed or prevented. Most patients with risk factors for chronic kidney disease are treated within primary healthcare. Therefore, it is important to understand how best to support primary care providers (PC-P) to detect and manage chronic kidney disease. The aim of this systematic review was to evaluate barriers and enablers to the diagnosis and management of CKD in primary care.MethodsA systematic review of qualitative research on the barriers and/or enablers to detection and/or management of CKD in adults within primary healthcare was conducted. The databases Medline (EBSCO), PubMed, Cochrane CENTRAL, CINAHL (EBSCO) and Joanna Briggs Institute Evidence Based Practice (Ovid) were searched until 27th August 2019. Barriers and/or enablers reported in each study were identified, classified into themes, and categorised according to the Theoretical Domains Framework.ResultsA total of 20 studies were included in this review. The most commonly reported barriers related to detection and management of CKD in primary care were categorised into the ‘Environmental context and resources’ domain (n = 16 studies). Overall, the most common barrier identified was a lack of time (n = 13 studies), followed by a fear of delivering a diagnosis of CKD, and dissatisfaction with CKD guidelines (both n = 10 studies). Overall, the most common enabler identified was the presence of supportive technology to identify and manage CKD (n = 7 studies), followed by the presence of a collaborative relationship between members of the healthcare team (n = 5 studies).ConclusionThis systematic review identified a number of barriers and enablers which PC-P face when identifying and managing CKD. The findings of this review suggest a need for time-efficient strategies that promote collaboration between members of the healthcare team, and practice guidelines which consider the frequently co-morbid nature of CKD. Enhanced collaboration between PC-P and nephrology services may also support PC-Ps when diagnosing CKD in primary care, and facilitate improved patient self-management.

Neighborhood Food Outlet Access and Dietary Intake among Adults with Chronic Kidney Disease: Results from the Chronic Renal Insufficiency Cohort Study

BackgroundHealthy diet is essential in the management of chronic kidney disease (CKD) and preventing related comorbidities. Food outlet access has been studied in the general population; however, the influence of the local food environment on dietary intake among people with CKD has not been evaluated. ObjectivesThis study examined the associations of food outlet density and type of outlets with dietary intake in a multicenter cohort of racially and ethnically diverse patients with CKD. MethodsThe Chronic Renal Insufficiency Cohort Study is a multicenter prospective study of patients with CKD that used a validated food frequency questionnaire to capture dietary intake at the baseline visit. This is a cross-sectional analysis of 2,484 participants recruited in 2003-2006 from seven Chronic Renal Insufficiency Cohort Study centers. Food outlet data were used to construct a count of the number of fast-food restaurants, convenience stores, and grocery stores per 10,000 population for each geocoded census block group. Multivariable linear and logistic regression models were used to evaluate the associations between measures of food outlet availability and dietary factors. ResultsThe proportion of participants living in zero–, low–, and high–food outlet density areas differed by gender, race or ethnicity, and income level. Among male subjects, living in areas with zero or the highest number of outlets was associated with having the highest caloric intakes in multivariable models. Male subjects living in areas with zero outlets consumed the highest levels of sodium and phosphorous. Female subjects living in areas with zero outlets had the lowest average intake of calories, sodium, and phosphorous. Among low-income female subjects, close proximity to more outlets was associated with higher calorie consumption. Among all participants, access to fast-food restaurants was not associated with an unhealthy diet score, and access to grocery stores was not associated with a healthy diet score. ConclusionsAverage caloric and nutrient intakes differed by outlet availability; however, there were no strong associations with type of food outlet. This should be considered when developing food-focused public health policies.

SUN-467 CLINICOPATHOLOGICAL SPECTRUM OF RENAL BIOPSIES IN UNIVERSITY CHILDREN’S HOSPITAL IN DAMASCUS

Renal biopsy is an important tool for establishing the histological diagnosis and prognosis, as well as guiding therapy of renal disease in children and adults. There is great variation in epidemiology of renal histopathology all over the world, due to differences in race, socioeconomical difference and policy of performing kidney biopsy in children. There are very few renal pathology studies available in the literature from developing world, so we performed this study to identify the distribution of histopathological types of renal diseases in patients in Children’s Hospital in Damascus, and describe the clinicopathological correlation, and its effect on the choice of treatment, for establishing the important indications for renal biopsy. A Descriptive retrospective study carried out in Children’s Hospital in Damascus, included all patients admitted and had percutaneous kidney biopsy, in a period of 6 years, from January 2011 to December 2016. A sample was considered adequate if more than ten glomeruli were present. The specimen was examined only under light microscopy and immunofluorescence, as electron microscopy is not available at our center. We collected the data, which were discussed and compared with similar studies in the literature. The study includes 105 patients had kidney biopsy, with slight male dominance (52%) and median age 6 years, ranged from 40 days to 14 years. All patients tolerated the biopsy well, without important complications. Nephrotic Syndrome was the most common indication for kidney biopsy (62%), followed by Persistent Isolated Glomerular Hematuria (13%) and Systemic Lupus Erythematosus (12.5%) and Acute Nephritic Syndrome (8.5%). Steroid-resistant Nephrotic Syndrome was the commonest indication for biopsy in Nephrotic Syndrome patients (51%). Focal Segmental Glomerulosclerosis was the commonest histopathological diagnosis in Nephrotic Syndrome patients (45%), then Minimal Change Disease (32%). In Persistent Isolated Glomerular Hematuria patients (14 cases), the biopsy was normal in (50%), and revealed IgA Nephropathy in (29%). In Systemic Lupus Erythematosus patients (13 cases), the most common histopathological type was Lupus Nephritis type IV (38%). Renal biopsy is a safe procedure in children and occupies a fundamental position in the management of kidney diseases. The most common indication for the renal biopsy in children remains Nephrotic Syndrome, mainly Steroid-resistant Nephrotic Syndrome, and the commonest histopathological diagnosis in Nephrotic Syndrome patients who had kidney biopsy is Focal Segmental Glomerulosclerosis. Biopsy had no therapeutic effect in Persistent Isolated Glomerular Hematuria, so it is not urgent procedure in these cases. It is important to do renal biopsy in Systemic Lupus Erythematosus cases in children, which help in guiding therapy and follow it.

SAT-151 A DILEMMA OF CALCITRIOL IN PRE-DIALYTIC CHRONIC KIDNEY DISEASE: A 1-YEAR STUDY FOR COMBINATION THERAPY OF CALCITRIOL AND RENIN-ANGIOTENSIN ALDOSTERONE BLOCKER IN CHRONIC KIDNEY DISEASE

Renin-angiotensin aldosterone system blockers (RASB) is main stream of management of chronic kidney disease (CKD). Vitamin D (vitD) is known as a potent negative regulator of renin-angiotensin aldosterone system via vitamin D receptor. VitD deficiency often presents, even in early CKD. However, there is no a definite guideline of use of vitD in CKD. In addition, the use of vitD should be given a careful attention due to development of hypercalcemia or vascular calcification in CKD. Now, we report results of a 1-year study for combination therapy of calcitriol and RASB in patients with pre-dialytic CKD and vitD deficiency. Forty five patients with pre-dialytic CKD and proteinuria >500 mg/day despites of RASB during at least 6 months were enrolled. We prescribed calcitriol of 0.5 μg, thrice weekly only in patients with serum calclium <10 mg/dL and 25(OH)vitD of <15 ng/mL. Only a total 27 patients received combination therapy of calcitriol and RASB, and laboratory data were retrospectively analyzed. Urine albumin-creatinine ratio (UACR) at baseline was measured. UACR and serum creatinine were followed with 6-month interval. We also divided the enrolled patients into two groups, early CKD and advanced CKD group, based on eGFR of 60 mL/min/1.73m2. We performed a comparative analysis for impacts of combination therapy on albuminuria and renal function in the groups based on eGFR. Total 27 patients used calcitriol and RASB. Eleven patients among the 27 patients were classified into early CKD group and sixteen patients were classified into advanced CKD group. Total 18 patients used only RASB. Twelve patients among the 18 patients were classified into early CKD group and six patients were classified into advanced CKD group. (Table 1,2: not shown in the abstract) In combination group, UACR were 3.15 g/g ± 3.82 at baseline and fell to 2.28 g/g ± 2.90 and 1.91 g/g ± 2.75 after 6 and 12 months. (p=0.031 and p=0.096, respectively) (Table 3) Moreover, in RASB only group, UACR were 1.05 g/d ± 1.71 at baseline and fell to 0.34 g/g ± 0.37 and 0.74 g/g ± 1.13 after 6 and 12 months. (p=0.039 and p=0.133, respectively) (Table 4) Change of UACR after 6 months from baseline did not show statistical significance in both groups. However, in combination group, when subgroup analyses were performed in early CKD and advanced CKD, UACR were 3.61 g/g ± 4.13 at baseline and significantly fell to 2.44 g/g ± 3.04 and 1.17 g/g ± 1.68 after 6 and 12 months (p=0.005 and p=0.022, respectively) in only early CKD. In addition, change of GFR in early CKD patients received combination therapy did not decrease significantly during 12 months. (p=0.099) (Table 3) Moreover, we performed a comparative analysis between combination and RASB only to identify effect of calcitriol on UACR according to time. The difference of decreasing UACR between combination and RASB only group was not statistically significant in both groups, however, in early CKD patients, the difference based on time between both groups seemed to be significant. (p=0.05) (Table 4 and Figure 1) View Large Image Figure ViewerDownload Hi-res image Download (PPT) Our study didnot show a significant impact on albuminuria of vitD combination therapy compared with only RASB therapy. However, if sample size and study-duration are expanded, combination therapy might show negative impact on albuminuria, particularly in early CKD patients with persistent proteinuria despites of use of RASB.

SUN-370 TOLVAPTAN USE IN YOUNG ADULTS WITH RAPIDLY PROGRESSING AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE

Regulatory approval of tolvaptan as a treatment for autosomal dominant polycystic kidney disease (ADPKD) in adults with evidence of rapidly progressing disease has changed the management of this condition. Given that young adults with ADPKD are likely to have early-stage disease and that questions on the screening, assessment, and treatment of these patients remain debated, a manuscript on tolvaptan use in the 18−24-year age group is needed. The phase 3 Tolvaptan Efficacy and Safety in Management of Autosomal Dominant Polycystic Kidney Disease and Its Outcomes (TEMPO 3:4) clinical trial evaluated tolvaptan in a large population (N=1,445) of subjects aged 18−50 years over a 3-year period. However, it did not specifically assess the use of tolvaptan in adolescents and young adults (AYAs) with ADPKD. A post hoc analysis of the TEMPO 3:4 trials was performed for patients 18-24 years old. The inclusion criteria were a diagnosis of ADPKD by Ravine criteria, and estimated creatinine clearance ≥60 mL/min (by Cockcroft-Gault) or rapidly progressive kidney growth (total volume ≥750 mL) by MRI at randomization. The primary outcome was the annual rate of change in total kidney volume (TKV). A total of 51 patients in the 18-24 group were analyzed. Out of the 51 patients, 29 were subjected to tolvaptan treatment while 22 were given placebo. The tolvaptan group had a lower mean % TKV growth per year compared to the placebo group (3.9% vs. 6.5%, p=0.0491). Tolvaptan, with appropriate patient selection and management, can provide effective and acceptably safe treatment in AYAs with ADPKD.

Validation of equations to estimate glomerular filtration rate in South Africans of mixed ancestry.

The Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations are two commonly used formulae to estimate glomerular filtration rate (GFR) in adults. The CKD-EPI equation is recommended in current international and local guidelines for the diagnosis and management of chronic kidney disease (CKD), unless an alternative equation has been shown to have superior accuracy. Validation and comparison of the equations in local populations are therefore required. Previous studies have reported on the accuracy of these prediction equations in black South Africans and those of Indian ancestry. To evaluate the MDRD and CKD-EPI equations in South African (SA) adults of mixed ancestry. In all participants, GFR was measured (mGFR) from plasma clearance of 99mTc-diethylenetetraaminepenta-acetic acid (99mTc-DTPA), using a standardised technique. Serum creatinine assays were isotope dilution mass spectrometry traceable. GFR was estimated (eGFR) using the MDRD and CKD-EPI equations, with and without the black ethnicity factor. The agreement, bias, precision and accuracy of each equation was determined. Eighty adults were included (30 male, median age 39 years, median GFR 59 mL/min/1.73 m2). Sixty-eight had a diagnosis of CKD, 10 were potential kidney donors, and 2 were healthy volunteers. Both equations, without the black ethnicity factor, had good agreement with measured GFR. The equations tended to overestimate GFR, with bias of 1.6 and 7.9 mL/min/1.73 m2 for the MDRD and CKD-EPI equations, respectively. The interquartile ranges of the differences were 15.9 and 20.2 mL/min/1.73 m2, and as a measure of accuracy, the percentages of estimates that fell within 30% of the mGFR (P30) were 80% and 72.5% (p=0.18). For identification of individuals with a GFR &lt;60 mL/min/1.73 m2, the sensitivity of MDRD eGFR was 97.3% and that of CKD-EPI eGFR was 97.1%. The MDRD and CKD-EPI equations have shown satisfactory and comparable performance in this SA mixed-ancestry adult population, with the MDRD equation marginally less biased than the CKD-EPI.

Physicians’ Recognition and Management of Kidney Disease: A Randomized Vignette Study Evaluating the Impact of the KDIGO 2012 CKD Classification System

Rationale & ObjectiveThe Kidney Disease Outcome Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) chronic kidney disease (CKD) classification systems published in 2002 and 2012, respectively, are recommended worldwide and based on strong epidemiologic data. However, their impact on CKD recognition and management is not well evaluated in clinical practice, and we therefore investigated whether they help physicians recognize and appropriately care for patients with CKD.Study DesignRandomized vignette experiment with fractional factorial design based on 6 kidney-related scenarios and 3 laboratory presentation methods reflecting the CKD guidelines. Participants evaluated 1 of 3 subsets of the 18 vignettes (ie, 6 vignettes each with 4 answer alternatives).Setting & Participants249 interns, general practitioners, and residents/fellows attending postgraduate meetings and courses in Norway and the United States.InterventionKidney-related results (serum creatinine level and urinary albumin excretion) were presented as the “minimal data” (high/low levels), KDOQI-2002 (estimated glomerular filtration rate [eGFR] reported automatically), or KDIGO-2012 (eGFR + albuminuria categorization + risk for complications) laboratory report.OutcomeCKD management choice by physicians.ResultsWhen kidney laboratory data were presented as the KDOQI-2002 report (automatic eGFR calculation), there was a significantly higher odds for correct patient management decisions compared with the minimal data report (OR, 1.57; P < 0.001). Additional significant improvement was obtained with the KDIGO-2012 report (OR, 2.28 for correct answer vs minimal data report [P < 0.001]; OR, 1.45 compared to KDOQI-2002 report [P = 0.005]). The KDIGO classification system improved physician management in 4 of the 6 clinical scenarios covering a wide range of kidney-related topics. Interaction analysis showed that general practitioners and those with 1 to 3 years of internal medicine experience had the greatest improvements with the new presentation techniques.LimitationsPhysicians’ management was evaluated by theoretical scenarios rather than direct patient care.ConclusionsAutomatic GFR estimation, albuminuria categorization, and notification of the associated risk for complications improve most physicians` recognition and management of a wide range of CKD clinical scenarios.

A Virtual Multidisciplinary Care Program for Management of Advanced Chronic Kidney Disease: Matched Cohort Study.

BackgroundIt is not well established whether a virtual multidisciplinary care program for persons with advanced chronic kidney disease (CKD) can improve their knowledge about their disease, increase their interest in home dialysis therapies, and result in more planned outpatient (versus inpatient) dialysis starts.ObjectiveWe aimed to evaluate the feasibility and preliminary associations of program participation with disease knowledge, home dialysis modality preference, and outpatient dialysis initiation among persons with advanced CKD in a community-based nephrology practice.MethodsIn a matched prospective cohort, we enrolled adults aged 18 to 85 years with at least two estimated glomerular filtration rates (eGFRs) of less than 30 mL/min/1.73 m2 into the Cricket Health program and compared them with controls receiving care at the same clinic, matched on age, gender, eGFR, and presence of heart failure and diabetes. The intervention included online education materials, a virtual multidisciplinary team (nurse, pharmacist, social worker, dietician), and patient mentors. Prespecified follow-up time was nine months with extended follow-up to allow adequate time to determine the dialysis start setting. CKD knowledge and dialysis modality choice were evaluated in a pre-post survey among intervention participants.ResultsThirty-seven participants were matched to 61 controls by age (mean 67.2, SD 10.4 versus mean 68.8, SD 9.5), prevalence of diabetes (54%, 20/37 versus 57%, 35/61), congestive heart failure (22%, 8/37 versus 25%, 15/61), and baseline eGFR (mean 19, SD 6 versus mean 21, SD 5 mL/min/1.73 m2), respectively. At nine-month follow-up, five patients in each group started dialysis (P=.62). Among program participants, 80% (4/5) started dialysis as an outpatient compared with 20% (1/5) of controls (OR 6.28, 95% CI 0.69-57.22). In extended follow-up (median 15.7, range 11.7 to 18.1 months), 19 of 98 patients started dialysis; 80% (8/10) of the intervention group patients started dialysis in the outpatient setting versus 22% (2/9) of control patients (hazard ratio 6.89, 95% CI 1.46-32.66). Compared to before participation, patients who completed the program had higher disease knowledge levels (mean 52%, SD 29% versus mean 94%, SD 14% of questions correct on knowledge-based survey, P<.001) and were more likely to choose a home modality as their first dialysis choice (36%, 7/22 versus 68%, 15/22, P=.047) after program completion.ConclusionsThe Cricket Health program can improve patient knowledge about CKD and increase interest in home dialysis modalities, and may increase the proportion of dialysis starts in the outpatient setting.

The Efficacy of Paricalcitol Administration for Management of Pediatric Chronic Kidney Disease: A Systematic Review and Meta-analysis

Background There is still controversy about the efficacy of paricalcitol in children with chronic kidney disease (CKD). Therefore, the present study was designed to assess current evidence on the efficacy of paricalcitol in CKD children. Materials and Methods In this systematic review, an extensive search was performed on the databases of Medline, Embase, Scopus and Web of Science up to the end of October 2019. The keywords related to CKD and paricalcitol were combined and searched. Two independent researchers reviewed the papers; data were analyzed in STATA 14.0 statistical program and the effect of paricalcitol administration on serum levels of intact parathyroid hormone (iPTH), calcium (Ca), phosphorous (P), and Ca × P product ratio were reported as odds ratio (OR), and 95% confidence interval (95%CI). Results: Finally, data from three studies were included in the present study. Paricalcitol administration decreased iPTH levels in children with CKD (OR=0.12; 95%CI: 0.05 to 0.29; p<0.001). However, paricalcitol administration had no effect on serum calcium level (OR=1.16; 95%CI: 0.48 to 2.80; p=0.741), serum phosphorus level (OR=0.87; 95%CI: 0.38 to 1.99; p=0.735), and Ca × P ratio (OR=0.48; 95% CI: 0.15 to 1.50; p=0.208). No study has investigated the efficacy of paricalcitol on the control of proteinuria following CKD. Conclusion There is limited evidence on the efficacy and safety of paricalcitol in children with CKD. There are no studies in CKD children that have shown efficacy of Paricalcitol in controlling proteinuria.

Onco-nephrology highlights: Chronic kidney disease, end-stage kidney disease, and cancer patients

With increasing prevalence of both kidney disease and cancer, patients who have both are common. Toxicity from treatment or direct kidney injury by the cancer itself can lead to acute kidney injury or progression of pre-existing chronic kidney disease. Management of advanced chronic kidney disease or end-stage kidney disease among those with concomitant cancer is challenging; however, better understanding of complications in this population will allow for optimization of treatments. Strategies for medication dosing, judicious use of erythropoiesis-stimulating agents in anemia, and treatment options for mineral bone disorders will be reviewed. Among those who require dialysis, special consideration should be made surrounding medication dosing, and end-of-life care should be addressed as early as possible in a patient-centered manner.

Treatment strategies in management of chronic kidney disease from perspective of biological regenerative medicine

Chronic kidney disease (CKD) is characterized by a gradual loss of kidney function that happens over time and from the point of view of modern conventional medicine is considered to be an incurable and irreversible disease. The main risk factors attributing to CKR are diabetes mellitus, hypertension, glomerulonephritis, renal artery stenosis and family history of kidney disease. Affecting approximately 1 in 10 people of a Global population CKD imposes a significant threat to individuals’ lives and carries a major financial burden to patients and healthcare systems. CKD is the cause of at least 1 million deaths per year globally and consume nearly 6% of all medical expenses. In this article we discuss possibilities of disease control and reversal from the perspective of Biological Regenerative Medicine.

The old becomes new: advances in imaging techniques to assess nephron mass in children.

Renal imaging is widely used in the assessment of surrogate markers of nephron mass correlated to renal function. Autopsy studies have tested the validity of various imaging modalities in accurately estimating "true" nephron mass. However, in vivo assessment of nephron mass has been largely limited to kidney volume determination by ultrasonography (US) in pediatric populations. Practical limitations and risks create challenges in incorporating more precise 3D volumetric imaging, like magnetic resonance imaging (MRI), and computed tomography (CT) technologies, compared to US for routine kidney volume assessment in children. Additionally, accounting for structural anomalies such as hydronephrosis when estimating renal parenchymal area in congenital anomalies of the kidney and urinary tract (CAKUT) is important, as it correlates with chronic kidney disease (CKD) progression. 3D imaging using CT and MRI has been shown to be superior to US, which has traditionally relied on 2D measurements to estimate kidney volume using the ellipsoid calculation. Recent innovations using 3D and contrast-enhanced US (CEUS) provide improved accuracy with low risk. Indexing kidney volume to body surface area in children is an important standard that may allow early detection of CKD progression in high-risk populations. This review highlights current understanding of various imaging modalities in assessing nephron mass, discusses applications and limitations, and describes recent advances in the field of imaging and kidney disease. Although renal imaging has been a long-standing, essential tool in assessing kidney disease, innovation and new applications of established technologies provide important tools in the study and management of kidney disease in children.

Distribution and management of the pediatric refugee population with renal replacement: A German pediatric cohort.

With migration rising, the pediatric nephrology community is faced with challenges concerning the management of end-stage kidney disease (ESKD) in the pediatric refugee population. Data on the care of the pediatric refugee cohort on renal replacement therapy (RRT) is not available. A survey conducted by us in 2018 showed that the group of refugee children arriving to Germany during the years 2015-2017 accounts for approximately 20% of the total pediatric dialysis population in Germany. Provision of (medical) care for these children and their families is often hampered by psychosocial problems, cultural differences, language barriers, and administrative issues. Treating centers need to provide additional human as well as financial and logistic resources. In this educational review, we raise awareness and discuss possible challenges occurring in the treatment of refugee children with ESKD.