Modified MDRD Equation Research Articles

Correlations of serum magnesium with dyslipidemia in patients on maintenance hemodialysis

Correlations of serum magnesium with dyslipidemia in patients on maintenance hemodialysis

Association of E/E′ and NT-proBNP with Renal Function in Patients with Essential Hypertension

ObjectivesTo evaluate the association of left ventricular (LV) diastolic function and N-terminal pro-brain natriuretic peptide (NT-proBNP) with renal function in essential hypertension.MethodsLV diastolic function was estimated by the ratio of early diastolic velocities (E) from transmitral inflow to early diastolic velocities (E′) of tissue Doppler at mitral annulus (septal corner); NT-proBNP was measured in 207 hypertensive patients (mean age 56±14 years). The subjects were classified into 3 groups: E/E′≤10 group (n = 48), 10<E/E′≤15 group (n = 109) and E/E′>15 group (n = 50). The renal function was estimated by glomerular filtration rate (GFR) with 99mTc-DTPA. GFR from 30 to 59 ml/min/1.73 m2 was defined as Stage 3 chronic kidney disease (CKD). GFR was also estimated using the modified MDRD equation. Albuminuria was defined by urinary albumin/creatinine ratio (UACR).ResultsGFR was lower and UACR was higher in E/E′ >15 group than in 10< E/E′ ≤15 group or E/E′ ≤10 group (p<0.0001), GFR was significantly negative and UACR was positive correlated with E/E′ and NT-proBNP (p<0.0001). In multivariate stepwise linear analysis, GFR had significant correlation with age (p = 0.001), gender (p = 0.003), E/E′ (p = 0.03), lgNT-proBNP (p = 0.001) and lgUACR (p = 0.01), while eGFR had no significant correlation with E/E′ or lgNT-proBNP. Multivariate logistic regression analysis, adjusted for potential confounding factors, showed that participants in E/E′>15 group were more likely to have Stage 3 CKD compared with those in E/E′≤10 group with an adjusted odds ratio of 8.31 (p = 0.0036).ConclusionsLV diastolic function, assessed with E/E′ and NT-proBNP is associated with renal function in essential hypertension.

Effects of atorvastatin on renal function in patients with dyslipidemia and chronic kidney disease: Rationale and design of the ASsessment of clinical Usefulness in CKD patients with Atorvastatin (ASUCA) trial

Since dyslipidemia has been shown to be an independent risk factor for the progression of chronic kidney disease (CKD), low-density lipoprotein cholesterol (LDL-C)-lowering therapy can be potentially associated with inhibition of CKD progression. The ASsessment of clinical Usefulness in CKD patients with Atorvastatin (ASUCA) trial was designed to determine whether atorvastatin has protective effects on renal function in patients with dyslipidemia and CKD. We decided to carry out a prospective multi-center, open-labeled, randomized trial to compare the reno-protective effects between diet therapy alone and atorvastatin plus diet therapy in patients with dyslipidemia (LDL-C ≥ 140 mg/dL if not treated or LDL-C ≥ 100 mg/dL if treated with lipid-lowering drugs in subjects taking dyslipidemia-treating agents other than statins) and CKD [estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m(2)]. The primary endpoint is the change in eGFR (mL/min/1.73 m(2)) as calculated by the modified MDRD equation for Japanese after 2 years of treatment. Enrollment began in April 2009 and was completed in March 2011. A total of 334 patients (213 male and 121 female) were randomly assigned to either diet therapy alone or atorvastatin plus diet therapy and included in an intent-to-treat population. In the atorvastatin and control groups, the mean ages were 63.2 and 63.1 years, mean eGFRs were 55.9 and 54.0 mL/min/1.73 m(2), and median urinary albumin/creatinine ratios were 24.9 and 29.1 mg/g, respectively. This study distinguishes itself from similar studies by increasing statistical accuracy derived from its significantly larger sample size and longitudinal magnitude. The results of this study will help to determine whether atorvastatin has reno-protective effects in patients with dyslipidemia and CKD.

310 CLINICAL CHARCTERISTICS OF RESISTANT HYPERTENSION EVALUATED BY AMBULATORY BLOOD PRESSURE MONITORING

Objectives: It has been shown that strict control of blood pressure is important to prevent cardiovascular disease, although it is sometimes difficult to decrease blood pressure to target blood pressure levels. The aim of the present study was to investigate the clinical characteristics of resistant hypertension using ambulatory blood pressure monitoring. Methods: One hundred in hospital patients, whose 24-hour average blood pressure was higher than 130/80 mmHg even after treatment with more than three antihypertensive drugs, were included in the present analysis. Circadian variation of blood pressure was evaluated by the nighttime decrease in systolic blood pressure (ΔSBP); i.e. dipper (10%≤ΔSBP<20%), non-dipper (0%≤ΔSBP<10%), riser (ΔSBP<0%), and extreme-dipper (ΔSBP≥20%). An estimated glomerular filtration rate (eGFR) was calculated by using modified MDRD equation for Japanese. Results: Average blood pressures were both high in daytime and nighttime, 150.0/82.3 and 143.8/78.2 mmHg, respectively. Twenty patients had been treated with hemodialysis or peritoneal dialysis. In 63 patients out of the other 80 patients (79%), eGFR was also decreased (< 60 ml/min/1.73m2). The patients classified into dipper, non-dipper, riser and extreme-dipper were 20%, 43%, 34% and 3%, respectively. In addition, in 17 patients whose eGFR was preserved, 12 patients were non-dipper or riser, suggesting that it seemed difficult to account for this altered circadian blood pressure variation only by renal dysfunction. Conclusions: A large number of the patients with resistant hypertension suffered from renal dysfunction, although altered circadian blood pressure variation was difficult to be explained only by renal dysfunction.

Association of clofarabine (Clo)-associated GFR decline (GFRd) with dose and AUC.

e13120^ Background: Clo, a nucleoside analog, is approved for pediatric ALL, but also has activity in AML. We conducted a ph I-II trial of clo-melphalan-alemtuzumab for allo transplant and found grade 3-5 renal toxicity in 16 of 74 patients, despite prolonging infusion time to reduce Cmax (BBMT 2011, Epub). Methods: Clo pharmacokinetics were analyzed in 65 pts (Clo doses 10-40 mg/m2, infusion time 1 or 3 hrs) of 74 pts; baseline GFR estimated by modified MDRD equation. Clo levels were drawn at 1, 1.5, 2, 3, 5, 7, 9 and 24 hrs following the 1st and 3rd (or 4th) dose. GFRd (in ml/min/m2) between start of Clo (d-7) and day of transplant constituted the outcome of interest. Results: Median age 53 (21-73), median baseline GFR 94 ml/min/m2 (46-120). Mean (range) Cmax, clearance (CL) and AUC were 531 ng/ml (119-1010), 42002 ml/min (13979-88020) and 2052 ng*hr/ml (471-5835), respectively. Mean AUC per dose was 32.0 ng*hr/ml/mg (14-32). Systemic exposure was similar between d1 and d3. Further analyses used the highest AUC and Cmax. Decreases in GFR ranging from 10-100 ml/min/m2 (average 44 ml/min/m2) occurred in 30 of 65 patients. There was no correlation between Clo dose and GFRd (r=-0.02,p=0.87). There was a significant correlation between Clo AUC and GFRd (r=0.53, p &lt;0.0001), Clo AUC per dose and GFRd (r=0.62, p&lt;0.001) and between Clo CL and GRFd (r=-0.38, p=0.0001). There was a weaker correlation between Clo Cmax and GFRd (r=0.22, p=0.07). Clo CL was highly correlated with baseline GFR (r=0.4, p=0.0009). Of interest baseline GFR was inversely correlated with pt age (r=-0.46, p=0.0001) and age was significantly correlated with AUC (r=0.4, p=0.001), AUC per dose (r=0.36, p=0.003) and with GFRd (r=0.34, p=0.005). Conclusions: Decline in GFR is associated with inter-patient variability in exposure to Clo. Baseline GFR affects Clo CL and thus AUC, and potentially increases risk for renal toxicity. Older age is associated with decreased baseline GFR and risk for toxicity. Clo may require dose adjustment based upon renal function and/or age. These data require confirmation in further studies.

Chronic kidney disease and the risk of stent thrombosis after percutaneous coronary intervention with drug‐eluting stents

Chronic kidney disease (CKD) has been demonstrated to be associated with adverse clinical outcomes for patients with coronary artery disease (CAD). However, data on relation of CKD and stent thrombosis (ST) after drug-eluting stent (DES) implantation are limited. This study was designed to examine whether CKD is associated with higher incidence of ST after elective coronary DES implantation compared with patients with normal renal function. We consecutively enrolled 2,862 patients undergoing elective percutaneous coronary intervention (PCI) with DES. Demographic and clinical data were collected preoperatively. CKD was defined as estimated glomerular filtration rate (eGFR) < 60 ml/min, calculated using the modified MDRD equation. The primary outcome was 1-year definite or probable ST. Four hundred and forty-five participants (15.5%) had CKD before procedure. The incidence of 1-year definite or probable ST was significantly higher in CKD patients compared with patients with normal renal function (1.8% vs. 0.6%, P = 0.014). After adjustment for multiple clinical and biochemical covariates, CKD was an independent predictor of 1-year definite or probable ST (hazard rate [HR] 0.396, 95% CI 0.165-0.951, P = 0.038). CKD is significantly associated with increased incidence of 1-year definite or probable ST in patients undergoing PCI with DES.

Gender Difference in the Association of Hyperuricemia with Chronic Kidney Disease in Southern China

Background: The effect of hyperuricemia on chronic kidney disease (CKD) is controversial, and little is known about gender as it relates to hyperuricemia and CKD. Methods: This was a cross-sectional study of 7,053 adults in the general Chinese population in Southern China using a multi-stage stratified sampling method. In which associations between hyperuricemia and indicators of CKD (defined by albuminuria (urinary albumin-to -creatinine ratio ≥ 30mg/g) or decreased modified MDRD equation estimated GFR (<60ml/min per 1.73m²) were tested using multivariate logistic regression. Results: After adjustment for potential confounders, hyperuricemia was associated with increased risk of reduced renal function and CKD but not albuminuria, with odds ratios (ORs) (95% CI) of 4.39 (3.38-5.70, P <0.001), 1.54 (1.31-1.82, P <0.001) and 0.96 (0.78-1.17, P =0.671), respectively. The interaction between gender and hyperuricemia with CKD was significant (P =0.010); and stratified analysis showed a stronger association of hyperuricemia with CKD in males (OR (95% CI): 2.04 (1.56-2.67), P <0.001) than in females (1.45 (1.17-1.80), P =0.001). Conclusions: We observed an independent association of hyperuricemia with CKD that was stronger in males, and this independent association in male might imply some gender specific mechanisms. These results should be confirmed in future prospective studies.

Distribution of reference GFR in a development population – a critical factor for the establishment of a GFR estimation equation

Our previous work showed that the performance of MDRD equations could be improved by modifying the original MDRD equation. However, during the modification we recognized that reference GFR (rGFR) distribution was not similar between the MDRD study and the Chinese Estimating GFR (eGFR) Investigation Study. This present study was designed to illustrate that the GFR estimating equation might be influenced by the difference of rGFR distribution in the development population. Racial factors might not be as important as once thought. The Chinese eGFR Investigation Study dataset containing 684 CKD patients was defined as Dataset I, the modified MDRD equation for Chinese was defined as Equation 1. Datasets II and III were generated respectively by deleting 125 cases of CKD Stage 1 from Dataset I and by adding 297 cases of apparently healthy Chinese adults into Dataset I. eGFR was estimated using Equation 1. Using rGFR as dependent and eGFR as independent, linear regression models were constructed using Dataset II and Dataset III, respectively, and generated Equation 2 and Equation 3. The prevalence of eGFR less than 60 ml/min/1.73 m2 in the adult Beijing population was calculated using Equation 1, 2 and 3. The previous reported prevalence of decreased GFR using Equation 1 in the Beijing adult population was 1.3% (0.8 - 1.8). By using Equation 2 and Equation 3, the prevalence increased to 3.2% (2.49 - 4.13) and decreased to 0.8% (0.57 - 1.28), respectively. GFR estimating equation was influenced by rGFR distribution of the development dataset.

Serum C-Reactive Protein Levels and Death and Cardiovascular Events in Mild to Moderate Chronic Kidney Disease

Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular (CV) disease. Elevated circulating levels of high sensitivity C-reactive protein (hsCRP) have been suggested to be associated with high risk of CV disease. It is uncertain whether the CV risk in CKD can be stratified by hsCRP levels in the Japanese population. Baseline data including serum hsCRP and creatinine levels were determined in the general population. Estimated glomerular filtration rate (eGFR) was calculated using a modified MDRD equation, and CKD was defined as eGFR below 60 mL/minute/1.73m(2). We analyzed 1,074 male subjects with mild to moderate CKD (mean age, 70.4 years). CV events (stroke and myocardial infarction) and all-cause death were surveyed prospectively. The CKD subjects were followed for 5.1 years, and 72 CV events and 115 all-cause deaths were found (composite endpoint). After adjustment for established CV risk factors, hazard ratios (HRs) for the endpoint were significantly increased according to the hsCRP quintile (P < 0.001), and HR for the highest (versus the lowest) quintile was 2.77 (95% CI; 1.61-4.77). These results suggest that serum hsCRP measurement is a useful tool for the risk stratification of CV events and death in CKD male subjects selected from the general population.

E0503 Impact of renal function on outcomes of patients undergoing complete revascularisation for the treatment of multivessel coronary artery disease

BackgroundChronic kidney disease (CKD) is a strong predictor of adverse cardiac events after revascularisation for patients with multiple coronary artery disease. However, the comparison of the two strategies of revascularisation,...

E0504 Chronic kidney disease and the risk of stent thrombosis after percutaneous coronary intervention with drug-eluting stents

BackgroundChronic kidney disease (CKD) has been demonstrated to be associated with adverse clinical outcomes for patients with coronary heart disease. However, data on relation of CKD and stent thrombosis after...

Metabolic syndrome and chronic kidney disease in a rural adult population of Hunan province, China

To explore the relationship between metabolic syndrome and chronic kidney disease (CKD) in a rural adult population of Hunan province. 1953 residents (older than 18 years) from the same village were randomly selected, using a stratified, multistage sampling method. All residents were interviewed and tested for albuminuria with morning spot urine albumin to creatinine ratio (abnormal: >/= 30 mg/g), reduced renal function with estimated glomerular filtration rate by modified MDRD equation [abnormal: < 60 ml/min (1.73 m(2))]. The associations of kidney damage indicators with demographic characteristics (age, gender, smoking status), indicators on health (diabetes, hypertension) and metabolic syndrome traits were examined. Eligible data of 1709 subjects were enrolled in the study. After the adjustment of age, gender and other metabolic syndrome traits, participants with metabolic syndrome had a higher prevalence of CKD (19.3% vs. 13.2%, P < 0.001) than those without the syndrome. As the number of metabolic syndrome traits increased, so did the prevalence of CKD. There seemed to be a strong and independent association between metabolic syndrome and chronic kidney disease. For participants without hypertension and diabetes, metabolic syndrome was also associated with CKD (OR value 1.733, 95%CI: 1.20 - 2.41, P = 0.004). In these 1709 adults under this study from a village of southern China, metabolic syndrome seemed to be associated with CKD.

Correlation of cardiovascular risk factors versus glomerular filtration rate in healthy population

To evaluate the relationship between cardiovascular risk factors and glomerular filtration rate in healthy population. A community-based cross-sectional study was conducted in Shenyang. The Framingham sex-specific risk equation was employed to evaluate the cardiovascular risk factors of 501 healthy study objects, calculate Framingham risk score and estimate the risk of 10-year coronary heart disease (CHD). A total of 501 study subjects were then divided into 3 groups according to 10-year CHD risk: low risk group (< 10%), moderate risk group (10% -20%) and high risk group ( > 20%). Study subjects were also divided into 5 groups according to age: < or = 44 years old; 45 - 54 years old; 55 - 64 years old; 65 - 74 years old and > or = 75 years old. The Cockcroft-Gault equation (GFR(CG)), abbreviated MDRD equation (GFR(MDRD1)) and modified MDRD equation (GFR(MDRD2)) were used to estimate glomerular filtration rate (GFR). Glomerular filtration rate (GFR) were compared among different risk groups and correlation coefficients between Framingham risk score and glomerular filtration rate calculated. GFR(CC), GFR(MDRD1) and GFR(MDRD2) in the low risk group was [(103 +/- 27) ml x min(-1) GFR(MDRD2) in moderate risk group all decreased [(84 +/- 24) ml x min(-1) x (1.73 m2) (-1), (101 +/- 27) ml x min(-1) x (1.73 m2) (-1), (124 +/- 33)ml x min(-1) (1.73 m2) (-1), all P < 0.01]. GFR(CG), GFR(MDRD1) and GFR(MR(MDRD2) in the high risk group all decreased [(71 +/- 15) ml x min(-1) (1.73 m2) (-1), (88 +/- 15) ml x min(-1) x (1.73 m2)(-1), (109 +/-18)ml x min(-1) x (1.73 m2) (-1), all P < 0.01]. The GFR(CG), GFR(MDRD1) and GFR(MDRD2) in the high risk group all decreased compared with the moderate risk group (P < 0.05). There was a significantly inverse correlation between Framingham risk score and GFR with the Pearson correlation coefficient -0.586 (GFR(CG), P < 0.01) and -0.449 (GFR(MDRD1) and GFR(MDRD2), P < 0.01). There is an inverse correlation between cardiovascular risk factors and GFR in healthy population. With the increasing of risk factors and their severity, Framingham risk score increases and GFR decreases.

Modified MDRD equation in predicting glomerular filtration rate in patients with chronic kidney disease: an assessment of applicability

Objective:To evaluate the applicability of modified MDRD equation in predicting Glomerular filtration rate in patients with chronic kidney disease(CKD).Methods: Totally 481 CKD patients,who were diagnosed based on K/DOQI guideline from Jan.2005 to Jan.2007 in our hospital,were enrolled in this study.The sex,age,body weight and height of patients were recorded;the plasma creatinine,serum albumin and 99mTc-GFR(standardized by body surface area) were measured.GFRs were estimated by abbreviated MDRD equation and the modified MDRD equation separately.The bias,accuracy and precision of both equations were compared.Results: The estimated GFRs(eGFRs) by both equations were significantly correlated with the rGFR(P0.01).Except for the slightly decreased precision,the modified MDRD equation showed great improvements in the 5%,30%,and 50% accuracy and bias when compared with the original abbreviated MDRD equation(P0.05).Compared with the original equation,the modified MDRD equation showed smaller bias in all stages of CKD except for stage 5(P0.05).The modified MDRD equation also decreased the absolute bias and improved the 30% accuracy in stage 2 CKD(P0.01).Conclusion: Compared with original equation,the modified MDRD equation has great advantages in predicting the total GFR and GFRs at different CKD stages.Currently it can be used in predicting the GFR of Chinese CKD patients.

Insuficiencia renal oculta y prescripción de fármacos en atención primaria

Objective To study the prevalence of chronic kidney disease (CKD) [glomerular filtration rate (GFR) <60 ml/min/1.73 m 2] and occult kidney disease (OKD) (normal serum creatinine values with GFR <60) in elderly patients. Design Retrospective, observational study. Setting Four primary care centres in the province of Huesca, Spain. Participants About 4014 patients older than 65 years were randomly selected. Main measurements GFR was calculated for all subjects using the four-variable modified MDRD equation. We registered all drugs prescriptions to the patients during a period of twelve months focusing on the potential nephrotoxic drugs. Results After exclusions, GFR was estimated in 3286 patients (1424 men of 75.49±6.6 years and 1862 women of 76.29±7.04 years; P=.001). The prevalence of CKD was 21.2%. A total of 10.1% of patients (12.8% of women and 6.44% of men) had OKD. We recorded the complete drug prescription in 269 patientes. Mean of all different drugs that were prescribed by patient-year was 10.69±5.92 (men 9.55±5.57 and women 11.11±6; P=.05)]. A large number of patients were treated with potentially dangerous drugs, particularly the non-steroidal anti-inflammatory drugs with 165 cases (61.34%), and 72% were exposed to drugs that can lead to hyperkalaemia. Conclusions We conclude that GFR estimation by clinical laboratories in the setting of primary care can contribute to prevent the adverse effects of inappropriate drug prescriptions.

Abstract 3149: Is Plasma B-type Natriuretic Peptide Measurement Valid for Prediction of Cardiovascular Events in Chronic Kidney Disease? A Community-Based Longitudinal Study

Elevated plasma B-type natriuretic peptide (BNP) levels have been reported to be a marker for risk of cardiovascular events (CVE) including heart failure, coronary artery disease and stroke in the general population. However, plasma BNP is increased by renal dysfunction, and it is therefore not known whether plasma BNP might be a reliable biomarker for predicting onset of CVE in the cohort with impaired renal function as represented by chronic kidney disease (CKD). Baseline data including plasma BNP, serum creatinine, and urine protein were determined in 14265 participants from a community-based population. Estimated glomerular filtration rate (eGFR) was calculated using a modified MDRD equation, and CKD was defined by the following two methods (Def 1 = eGFR&lt;60 ml/min/1.73m 2 and/or proteinuria; Def 2 = eGFR&lt;60 ml/min/1.73m 2 ). Numbers of CKD subjects were 1927 according to Def 1 and 1604 according to Def 2. CVE endpoint was surveyed prospectively. The mean follow-up duration was 2.9 years. After adjustment for traditional cardiovascular risk factors and atrial fibrillation, relative risk (RR) for CVE was significantly higher in the highest BNP quartile compared to the lowest BNP quartile according to both definitions (Def 1, RR=3.51, p&lt;0.01: Def 2, RR=4.67, p&lt;0.01) (Figure ). Furthermore, the RR for a composite endpoint of CVE and death was also significantly higher in the highest BNP quartile, again by both definitions (Def1, RR=2.71, p&lt;0.01: Def 2, RR=3.09, p&lt;0.02). Measurement of plasma BNP levels provides strong predictive information about future onset of CVE and death, even in CKD subjects selected from the general population.

Abstract 3381: Usefulness of Carperitide as an Adjunctive Therapy for Acute Myocardial Infarction in Patients with Chronic Kidney Disease -Subgroup Analysis of J-WIND-ANP trial

Background Chronic kidney disease (CKD) is highly prevalent in patients with cardiovascular disease. Recent investigation suggests that nesiritide (human brain natriuretic peptide) increases the risk of worsening renal function in patients with acute heart failure, whereas carperitide (human atrial natriuretic peptide) has beneficial effects on renal function. Methods We evaluated the usefulness of carperitide as an adjunctive therapy for acute myocardial infarction (AMI) in 158 patients with low eGRF (&lt;60ml/min) estimated by the modified MDRD equation in J-WIND-ANP trial. Of 158 patients, 78 received carperitide (67±9 years old, male 54 patients) and 80 received placebo (67±9 years old, male 54 patients). Other risk factors such as hypertension, diabetes mellitus, and smoking were comparable between two groups. There was no difference in elapsed time between carperitide group (3.6hr 95%CI 3.0hr–5.9hr) and placebo group (3.5hr 95%CI 2.5hr-5.5hr). We analyzed the effects of carperitide on AUC of CK, ejection fraction (EF) at 6 months, and cardiac events. Results Carperitide administration reduced AUC of CK compared with placebo (carperitide group 65,040 mg/dl vs placebo group 79,286 mg/dl, p&lt;0.05). Carperitide increased EF at 6 months after the onset of AMI compared with placebo (carperitide group 48.1±7.6% vs placebo group 44.0±10.0%, p&lt;0.05). We found no significant difference in total death, cardiac events and reperfusion injury between both groups. Conclusions Carperitide reduced infarct size and improved chronic left ventricular function in AMI patients with CKD. These results suggest that carperitide is useful as an adjunctive therapy for AMI in AMI patients with CKD.

Impact of Recipient Obesity on Living Donor Kidney Transplant Outcomes: A Single-Center Experience

The number of overweight and obese patients undergoing renal transplantation has drastically increased in the last two decades. Studies on graft survival and complication rates of these obese patients have had conflicting results, with some reporting a significant risk and others reporting relatively good outcomes. We examined 1-year outcomes in obese and nonobese patients who underwent living donor transplants at our transplant program, a slightly different approach than prior studies of deceased donor transplants into patients with high body mass index (BMI). The mean serum creatinine clearance by the modified MDRD equation at the end of 1 year in the nonobese group was 58.9 mL/min whereas the mean creatinine clearance in the obese group was 48.9 mL/min ( P = .09). The length of stay, incidence of delayed graft function, and 1-year graft survival did not differ between the obese and nonobese groups. The results of this single-center experience with living donor transplant into obese subjects suggest no differences in outcomes with regard to surgical or wound complications, delayed graft function, or serum creatinine at 1 year.

The Epidemic of Chronic Kidney Disease in Patients Referred to a Hematologist for Anemia.

NHANES survey estimates the prevalence of CKD to be approximately 11% in the general population and 25% in the population over 65 years of age, and the prevalence of Chronic Kidney Disease (CKD) associated anemia approaches 75% in Stage 5 CKD. Despite the high prevalence of CKD, and its strong association with anemia, many patients diagnosed with anemia and referred to a hematologist for evaluation frequently have the diagnosis of CKD overlooked, especially if one is using a serum creatinine to assess renal function. A more accurate method of assessing renal function and to appropriately stage CKD is the use of an estimated glomerular filtration rate (eGFR) utilizing the modified MDRD equation. With the realization that CKD clearly has become known as a significant magnifier of cardiovascular risk (CVR), the importance of making the diagnosis of CKD has become quite apparent. Hypothesis: Patients referred to a hematologist for evaluation of anemia represent a population enriched with CKD. A retrospective chart audit was performed on patients being referred to a hematology practice from community physicians for the evaluation of anemia from January 2004 through December 31, 2005. All patients with a prior knowledge of CKD and a history of malignancy or myelodysplastic process were excluded from the study. The cohort consisted of 256 patients (37.5 % male and 62.5 % female) with a mean age of 67.56 ± 15.9 years. The mean serum creatinine was 1.16 ± .74 mg/dL with a mean calculated GFR by the modified MDRD (4 variable) equation of 69.9 ± 34.2 ml/min/1.73 m2.The mean ± SEM serum creatinine by stage of CKD in our patient population is: Stage 1: 0.67 ± 0.14 mg/dL, Stage 2: 0.92 ± 0.15 mg/dL, Stage 3: 1.40 ± 0.29 mg/dL, Stage 4: 2.23 ± 0.53 mg/dL, and Stage 5: 5.2 ± 2.89 mg/dL. Conservatively, we defined CKD as GFR <60 as urinalysis, imaging, or biopsy data were not available. In conclusion, an astounding 42.2 % of patients referred to a hematologist for the evaluation of anemia have CKD as compared to an estimated prevalence of 11 % in the general population reported by K/DOQI. Not only were these patients not aware of their diagnosis of CKD, but, of note also is the fact that 5.1 % were not aware of the presence of advanced CKD (GFR < 30) and 4 patients had Stage 5 CKD without awareness. 55.8 % of the patients over the age of 65 with anemia have CKD as compared to an estimated 25 % of the general population over the age of 65. This information stresses the need to assess all anemia patients for CKD and to appropriately stage them. Given the well accepted association between CKD and CVR, physicians caring for these patients can then stress the need for aggressive pursuit of both traditional and non traditional risk factor reduction to circumvent the significant CVR that is present in this population.Prevalence of Abnormal Renal Function by GFRFrequencyPercentGFR > 90 (Normal /K/DOQI* Stage 1)5119.9GFR 89 - 60 (K/DOQI Stage 2)9737.9GFR 59 - 30 (K/DOQI Stage 3)9537.1GFR 29 - 15 (K/DOQI Stage 4)93.5GFR < 15 (K/DOQI Stage 5)41.6*K/DOQI = National Kidney Foundation's Kidney Disease Outcome Quality Initiative

Renal function, concomitant medication use and outcomes following acute coronary syndromes

Chronic kidney disease (CKD) is highly prevalent in patients with cardiovascular disease. We explored the associations of CKD with outcomes using combined data from two large acute coronary syndrome (ACS) trials. We also explored the associations of CKD with prescription patterns for common cardiovascular medications and the association of these prescription patterns with clinical outcomes. Patients were stratified by CKD stage using creatinine clearance (CrCl, ml/min) estimated by the modified MDRD equation using baseline core laboratory creatinine measures. Serum creatinine > or =1.5 mg/dl was an exclusion criterion for the SYMPHONY trials. Baseline characteristics and outcomes across CKD categories were compared and Cox proportional hazards regression was used to assess the relationship of renal insufficiency with clinical outcomes after adjusting for previously identified outcome predictors. Interactions between the use of specific medications and calculated CrCl were tested in the final Cox proportional hazards model predicting time to mortality. Of 13 707 patients analysed, 6840 had CKD stage I (CrCl > or =90 ml/min), 5909 stage II (CrCl 60-89 ml/min), 955 stage III (CrCl 30-59 ml/min) and three stage IV (CrCl <30 ml/min). Patients with more advanced CKD (III) were older, more often female, non-smokers and more likely to have co-morbid diseases including diabetes mellitus, hypertension and congestive heart failure. Cardiovascular medications were used less frequently in patients with CKD. Unadjusted survival was poorer in patients with CKD stages > or =II. In adjusted analyses, for those with CrCl < or =91, each 10 ml/min increase in CrCl was associated with a significantly decreased risk of mortality (hazards ratio 0.897, 95% confidence interval 0.815-0.986) (P = 0.024). The interaction between use of angiotensin-converting enzyme (ACE) inhibitors and CrCl was significantly associated with outcomes; the benefit of drug therapy was greater among patients with CKD. CKD is an independent predictor of risk among ACS patients, and is associated with less frequent use of proven medical therapies. More aggressive use of conventional cardiovascular therapies in patients with CKD and ACS may be warranted.