Occurrence Of End-stage Renal Disease Research Articles

The Efficacy of Mycophenolate Mofetil in Remission Maintenance Therapy for Microscopic Polyangiitis and Granulomatosis with Polyangiitis.

PurposeThe present study compared the efficacy of mycophenolate mofetil (MMF) with that of azathioprine (AZA) in Korean patients with microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA).Materials and MethodsThe medical records of 69 patients with MPA and GPA who received cyclophosphamide and subsequently received AZA or MMF for remission maintenance therapy were reviewed. All-cause mortality, relapse, end-stage renal disease (ESRD), cerebrovascular accident, and cardiovascular disease were evaluated as poor outcomes. Having a lower Birmingham Vasculitis Activity Score (BVAS) was defined as the lowest tertile of BVAS (BVAS ≤11 in this study).ResultsIn comparative analysis of the occurrence of poor outcomes among patients taking AZA only, MMF only, and MMF after AZA, patients taking MMF only exhibited a significantly lower cumulative ESRD-free survival rate than patients taking AZA only (p=0.028). In terms of ESRD occurrence between the groups based on BVAS at diagnosis, among patients with MPA and GPA with higher BVAS at diagnosis, patients taking MMF only exhibited a significantly lower cumulative ESRD-free survival rate than those taking AZA only (p=0.047). Among patients with MPA and GPA with the lowest tertile of BVAS at diagnosis, cumulative ESRD-free survival rates did not differ.ConclusionWith regard to ESRD occurrence, the efficacy of MMF in remission maintenance therapy was less effective than AZA in patients with MPA and GPA. However, among patients with lower BVAS, there was no difference in the occurrence of poor outcomes between patients taking MMF and those taking AZA.

The Treatment Effectiveness Evaluation for Slowing the Progression of Diabetic Nephropathy During Stage 4 Chronic Kidney Disease.

IntroductionPeople with advanced diabetic nephropathy (DN) are at high risk for development of end-stage renal disease (ESRD) or death. Whether renin-angiotensin system inhibitors and some concomitant drugs could still continue to delay the onset of ESRD in the later stage of DN needs to be clarified. This study aimed to evaluate the relationship of the therapeutic methods as well as clinicopathologic variables with prognosis of patients with biopsy-proven DN during stage 4 of chronic kidney disease (CKD).MethodsForty-six DN patients who underwent renal biopsy in stage 4 CKD were enrolled from January 1, 2002, to December 31, 2019. Clinical data were abstracted retrospectively from the time of renal biopsy. Follow-up data were collected until April 1, 2020, or from the day of renal biopsy to either the occurrence of ESRD or death. The primary outcome was the composite of ESRD or death. Treatment effectiveness and the prognostic ability of clinicopathologic data were evaluated using multivariate Cox regression analyses.ResultsThe median renal survival duration was 17.3 (95% confidence interval, 7.4–27.3 months). Primary endpoint events occurred in 29 individuals (63.0%) during follow-up, including 24 who reached ESRD and 5 who died before progression to ESRD. None of the clinicopathologic data, including pathologic cass of DN, were statistically independent prognostic factors for renal survival. Conventional therapies, such as use of renin-angiotensin system (RAS) inhibitors, a level of glycated hemoglobin (HbA1c) < 7%, and blood pressure < 130/80 mmHg, were also not statistically different between the stable and progressive groups.ConclusionSpecific therapies including targeting blood pressure < 130/80 mmHg, HbA1c concentration < 7%, and use of RAS inhibitors could not effectively delay the onset of ESRD in the later stage of DN. Therefore, efforts to slow the progression of DN should focus on early diagnosis and treatment.

Analgesic Nephropathy due to Diclofenac in a 24-year-old Indian Male Patient: A Case Report

Analgesics are commonly prescribed first line agent for the treatment of rheumatological disorders like rheumatoid arthritis and ankylosing spondylitis. Renal toxicities are known adverse reactions of analgesics, however, acute onset renal injury due to analgesics in rheumatological disorders is not currently known. Here we describe a case of a 24-yearold Indian male patient who was diagnosed with ankylosing spondylitis three years back and was prescribed tablet Diclofenac 150 mg in three divided doses per day. The patient presented with breathlessness, pedal edema and decreased urine output on 24th February 2019. The patient was diagnosed to have bilateral End Stage Renal Disease (ESRD) with small kidneys, pulmonary edema and left ventricular dysfunction using echocardiography. The patient was symptomatically treated and later transferred for renal transplant. Renal toxicity of analgesics is known but is usually reported after years of exposure. This case is first of the kind of occurrence of ESRD within three years of exposure. This case highlights the need for monitoring in patients who are prescribed analgesics for a long duration especially in patients of rheumatological disorders. Key words: Diclofenac, Nephropathy, Analgesic, Ankylosing spondylitis, Young.

Clinical features of Korean elderly patients with antineutrophil cytoplasmic antibody-associated vasculitis.

Background/AimsWe compared the clinical and laboratory data between elderly and non-elderly patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) at diagnosis; further, we investigated the predictors at diagnosis for all-cause mortality and end-stage renal disease (ESRD) occurrence during follow-up in Korean elderly patients with AAV.MethodsWe reviewed the medical records of 191 AAV patients regarding clinical manifestations and laboratory results at diagnosis and during follow-up. The follow-up duration was defined as the period from diagnosis to death for deceased patients or to the time of dialysis for ESRD patients, or to the last visit. Elderly (n = 67) and non-elderly (n = 124) patients were grouped based on an age threshold of 65 years.ResultsAt diagnosis, elderly patients exhibited higher median Birmingham Vasculitis Activity Score (BVAS) and higher frequencies of ANCA positivity and pulmonary manifestations than non-elderly patients. Furthermore, elderly patients exhibited increased median white blood cell count, blood urea nitrogen (BUN), alkaline phosphatase, erythrocyte sedimentation rate, and C-reactive protein and decreased median hemoglobin. However, there were no significant differences in all-cause mortality and ESRD occurrence between elderly and non-elderly patients. Meanwhile, elderly patients exhibited lower cumulative patients’ and ESRD-free survival rates than non-elderly patients. In the multivariable Cox hazards model, BUN, creatinine and serum albumin at diagnosis were independent predictors for ESRD occurrence, whereas there were no independent predictors at diagnosis for all-cause mortality.ConclusionsElderly AAV patients exhibited substantially higher rates of all-cause mortality and ESRD occurrence during follow-up compared than non-elderly AAV patients.

Hyperuricemia is associated with decreased renal function and occurrence of end-stage renal disease in patients with microscopic polyangiitis and granulomatosis with polyangiitis: a retrospective study.

Current evidence suggests that high uric acid levels are associated with accelerated renal damage. However, the clinical impact of serum uric acid level on patients with microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) is unknown. We aimed to evaluate the impact of hyperuricemia on such patients. A retrospective study was performed to obtain patients' demographic, clinical, and laboratory data from when they were diagnosed with MPA and GPA. Multivariable logistic regression and Cox hazard model analyses were performed to evaluate factors associated with hyperuricemia at diagnosis and predictive factors of end-stage renal disease (ESRD) development. Among 156 patients, 35 (22.4%) had hyperuricemia at baseline. Hyperuricemic patients had renal manifestation and impaired renal function more frequently than non-hyperuricemic patients. Logistic regression analysis revealed that serum creatinine was significantly associated with hyperuricemia at diagnosis [odds ratio 1.995; 95% confidence interval (CI), 1.503-2.648; P < 0.001]. Cox hazard model analysis revealed that body mass index and serum creatinine were significantly associated with ESRD when all variables were included, but hyperuricemia was independently associated with ESRD [hazard ratio (HR), 3.799; 95% CI 1.719-8.222; P < 0.001) when serum creatinine was excluded. Additionally, in a subgroup analysis of patients with decreased glomerular filtration rates (GFRs), serum uric acid was the sole predictor of ESRD (HR, 1.243; 95% CI 1.048-1.475; P = 0.013). Hyperuricemia is associated with renal damage and ESRD occurrence in MPA and GPA patients. Serum uric acid level is associated with ESRD occurrence in patients with decreased GFRs.

Comparison of Renal Effects of Ezetimibe-Statin Combination versus Statin Monotherapy: A Propensity-Score-Matched Analysis.

Neither lowering of blood lipid levels nor treatment with statins definitively improves renal outcomes. Ezetimibe, a non-statin antilipidemic agent, is known to not only decrease blood lipid levels but also reduce inflammatory response and activate autophagy. We evaluated the effect of adding ezetimibe to a statin on renal outcome compared with statin monotherapy by analyzing longitudinal data of 4537 patients treated with simvastatin 20 mg plus ezetimibe 10 mg (S + E) or simvastatin 20 mg alone (S) for more than 180 days. A propensity-score-based process was used to match baseline characteristics, medical history, and estimated glomerular filtration rate (eGFR) between S + E and S groups. Changes in serum creatinine and incidence of renal events, defined as doubling of serum creatinine to ≥1.5 mg/dL or occurrence of end-stage renal disease after the first day of treatment initiation, were compared between the groups. Among 3104 well-matched patients with a median follow-up of 4.2 years, the S + E group showed a significantly lower risk of renal events than the S group (hazard ratio 0.58; 95% CI 0.35-0.95, P = 0.032). In addition, the S + E group tended to preserve renal function compared with the S group throughout follow-up, as assessed by serum creatinine changes (P-values for time–group interactions <0.001). These data support the beneficial effects on renal function when combining ezetimibe with a statin.

Glomerular C4 deposition and glomerulosclerosis predict worse renal outcomes in Chinese patients with IgA nephropathy

Background Immunoglobulin A nephropathy (IgAN) is a clinical and pathological syndrome with heterogenous manifestation and progression. Complement activation is involved in the disease. However, the clinical significance of C4 deposition in IgAN is obscure. Methods A multicenter retrospective study was conducted in biopsy-proven IgAN patients. Based on mesangial C4 deposition, patients were divided into two groups. The baseline clinical data and immunopathological phenotypes were compared. The composite endpoint was defined as eGFR decline greater than 50%, doubling of baseline serum creatinine, the occurrence of end-stage renal disease (ESRD). Results A total of 642 IgAN patients were recruited, with 41 patients showing mesangial C4 deposition. The mesangial C4 positive group showed lower serum albumin, higher proteinuria, and a higher rate of IgG, IgM, and C1q mesangial deposition. After a median follow-up of 43.18 months, 81 (12.62%) patients achieved the composite endpoint. The multivariate Cox regression models identified glomerular C4 deposition (hazard ratios [HR] = 3.22, 95% confidence intervals [CI] = 1.51–6.87, p < 0.01), global sclerosis (G1 vs. G0, HR = 1.90, 95%CI = 1.02–3.52, p = 0.04; G2 vs. G0, HR = 3.72, 95%CI = 1.98–7.00, p < 0.01), male (HR = 1.80, 95%CI = 1.10–2.97, p = 0.02), serum creatinine (HR = 1.01, 95%CI = 1.00–1.01, p < 0.01), triglyceride (HR = 1.17, 95%CI = 1.01–1.35, p = 0.04), proteinuria (HR = 1.07, 95%CI = 1.01–1.13, p = 0.02), serum C3 level (HR = 0.05, 95%CI = 0.01–0.25, p < 0.01), and serum C4 level (HR = 99.59, 95%CI = 8.69–1140.89, p < 0.01) as independent risk factors for poor renal outcomes. Conclusions Glomerular mesangial C4 deposition and global sclerosis are independent predictors for poor prognosis in IgAN patients.

The Value of Renal Biopsy in Non-Insulin-Dependent Diabetes Mellitus in Singapore over the Past Two Decades

Objective: This study on the prevalence of diabetic nephropathy (DN) and coexistence of non-diabetic renal disease (NDRD) in a cohort of 255 non-insulin-dependent diabetes mellitus (NIDDM) patients aims to determine the value of performing renal biopsies in these patients and elucidate the factors which could affect their progression to end-stage renal disease (ESRD). Methods: Among 255 NIDDM patients, 93 had DN alone, 69 had NDRD alone, and the remaining 93 had DN plus NDRD (mixed group). The indications for renal biopsy were based on clinical suspicion of superimposed NDRD, including heavy or rapidly increasing proteinuria, renal impairment even though diabetes is of relatively short duration, rapidly declining renal function, and presence of hematuria with dysmorphic red blood cells suggesting presence of glomerulonephritis. Results: The following were predictors of ESRD: high systolic BP at biopsy, longer duration of diabetes, heavy proteinuria, and presence of diabetic retinopathy. Comparing patients in the NDRD group with the DN group and the mixed group, the NDRD group had lower serum creatinine and higher eGFR with lower urinary proteinuria and higher serum albumin at presentation and on follow-up. Kimmelstiel-Wilson nodules were associated with a poorer prognosis leading to a higher occurrence of ESRD among patients with DN. Conclusion: Renal biopsy is of value in indicating the prognosis of NIDDM patients with DN based on the diabetic lesions. For NIDDM patients with atypical course and suspicion of associated NDRD, a renal biopsy would enable us to diagnose the underlying NDRD and offer appropriate therapy. Most nephrologists would consider renal biopsy for an NIDDM patient based on clinical indications like atypical clinical course and suspicion of an associated NDRD, but they would not perform a routine renal biopsy like for a CKD patient, unless it is for a research indication.

Double positivity for antineutrophil cytoplasmic antibody (ANCA) and anti-glomerular basement membrane antibody could predict end-stage renal disease in ANCA-associated vasculitis: a monocentric pilot study.

To investigate the detection rate of double positivity for antineutrophil cytoplasmic antibody (ANCA) and anti-glomerular basement membrane (GBM) antibody at diagnosis and its clinical implication during follow-up in Korean patients with ANCA-associated vasculitis (AAV). We retrospectively reviewed the medical records of 96 Korean AAV patients. We obtained data at diagnosis and assessed the poor outcomes of AAV such as all-cause mortality, relapse and end-stage renal disease (ESRD). Comparison of cumulative survivals were analysed by the Kaplan-Meier survival analysis, and hazard ratios (HRs) were obtained by the multivariable Cox hazard model. Seven of 96 AAV patients (7.3%) had double positivity for ANCA and anti-GBM. Among variables at diagnosis, there were no significant differences between patients with double positivity for ANCA and anti-GBM and those without. In the cumulative survival analysis, AAV patient with double positivity for ANCA and anti-GBM at diagnosis exhibited the lower cumulative ESRD-free survival rate than those without (P = 0.044) and furthermore, than those with positive for only ANCA and those with double negativity (P = 0.022). Myeloperoxidase (MPO)-ANCA, renal manifestation and five-factor score at diagnosis were also associated with ESRD occurrence in AAV patients. In the multivariable Cox hazards model using these 4 variables, only double positivity for ANCA and anti-GBM exhibited the significant association with ESRD occurrence during follow-up (HR 3.831). Double positivity for ANCA and anti-GBM at diagnosis were observed in 7.3% of AAV patients, and it could predict ESRD occurrence during follow-up in Korean patients with AAV.Key Points• 7.3% of AAV patients had double positivity for ANCA and anti-GBM at diagnosis (total n = 96)• Double positivity for ANCA and anti-GBM could predict ESRD occurrence during follow-up (HR 9.021, P = 0.004)• AAV patients with double positivity for ANCA and anti-GBM exhibited the lower cumulative ESRD-free survival rate compared with those without (P = 0.044).

Anti-hepatitis C virus therapy in chronic kidney disease patients improves long-term renal and patient survivals.

BACKGROUNDHepatitis C virus (HCV) infection is a documented risk factor for chronic kidney disease (CKD) and progression to end-stage renal disease (ESRD). However, to date there are no reports on the long-term hard endpoints (ESRD and death) of anti-HCV therapy [interferon-based therapy (IBT) or new direct-acting antivirals] in CKD patients. Direct-acting antivirals are not available in Taiwan’s single-payer national health insurance database currently released for research. Therefore, we hypothesized that a retrospective analysis of the long-term outcomes of IBT in CKD patients will serve as a proxy for direct-acting antivirals to increase our understanding of progression to ESRD following HCV infection.AIMTo evaluate the long-term outcomes (ESRD and death) of anti-HCV therapy, especially IBT, in HCV-infected patients with stage 1-5 CKD.METHODSWe analyzed 93894 Taiwanese adults diagnosed with CKD and without HBV infection. Of these, 4.9% were infected with HCV. Of the 4582 HCV-infected CKD patients, 482 (10.5%) received IBT (treated cohort). They were matched 1:4 with 1928 untreated HCV-infected CKD patients (untreated cohort) by propensity scores and year, which further matched 1:2 by propensity scores with 3856 CKD patients without HCV infection (uninfected cohort). All participants were followed until the occurrence of ESRD, death, or the end of 2012. The association between HCV infection, IBT use, and risks of ESRD and death was analyzed using competing risk analysis.RESULTSTaking the uninfected cohort as a reference, the adjusted hazard ratios for ESRD, after adjusting for competing mortality, were 0.34 (0.14-0.84, P = 0.019) and 1.28 (1.03-1.60, P = 0.029) in the treated and untreated cohorts, respectively. The treated cohort had a 29% (0.54-0.92, P = 0.011) decrease in mortality compared to the untreated cohort, in which the mortality was 31% (1.18-1.45, P < 0.001) higher than in the uninfected cohort. The reduced risks of ESRD (0.14, 0.03–0.58, P = 0.007) and death (0.57, 0.41-0.79, P = 0.001) were greatest in HCV-infected CKD patients who received at least 4 mo of IBT, which accounted for 74% of the treated cohort.CONCLUSIONAdequate anti-HCV therapy in CKD patients improves long-term renal and patient survival.

The burden of chronic kidney disease in systemic lupus erythematosus: A nationwide epidemiologic study.

To analyze the impact of chronic kidney disease (CKD) on major clinical outcome in SLE by using a nationwide database. Characteristics of all admitted SLE patients experiencing CKD (eGFR <60 mL/min/1.73 m2) in France from 2009 to 2015 were analyzed through the French medico- administrative database. Factors associated with CKD and major clinical outcomes such as end-stage renal disease (ESRD), cardiovascular event (CVE), septic shock and death were assessed. We used a multivariate Cox proportional hazard model and subdistribution hazard models to analyze survival without major clinical events according to the presence of CKD. From 2009 to 2015, 26,320 SLE patients were hospitalized in France. Among them, 6439 (86.5% women; mean age 45.7 [16.5] years old) had a baseline stay in 2009 during which CKD was reported in 428 (6.7%) cases. Multivariate analysis showed that lupus nephritis (OR 6.6 [5.2-8.4]), high blood pressure (OR 3.5 [2.8-4.5]), septic shock (OR 3.2 [1.7-6.0]) and past cardiovascular history (OR 1.4 [1.0-2.0]) were associated with CKD status. From 2009 to 2015, ESRD, CVE, septic shock, and death occurred in 4.0%, 14.4%, 6.3% and 9.6% of the 6439 SLE patients. CKD at baseline was independently and strongly associated with the occurrence of ESRD (sdHR 15.9 [11.6-21.9]), CVE (sdHR 1.7 [1.4-2.2]), septic shock (sdHR 2.1 [1.5-2.8]) and death (HR 1.7 [1.3-2.2]) during the follow up. CKD is a major risk factor for overall morbidity and mortality in SLE patients, highlighting the need for early pre-CKD lupus nephritis diagnosis and treatment.

Gut microbiota and probiotics intervention: A new therapeutic target for management of chronic kidney disease

Epidemiological investigation showed that the prevalence of chronic kidney disease (CKD) is 8%−16%. A multi-center survey in China also showed that the total prevalence of CKD in adults is 10.8%, which demonstrated that CKD has become a global public health problem. Failed timely and effective treatment of CKD leads to progressive deterioration, and eventual development of end-stage renal disease (ESRD), which requires long-term renal replacement therapy. ESRD is accompanied by several complications and poor long-term prognosis, imposing a heavy economic burden on individuals and society. Therefore, delaying the progression of CKD and reducing the occurrence of ESRD is an urgent issue and currently is a trending research topic for nephrologists. The intestinal tract can be compared to an invisible immune organ, capable of influencing nutrition, metabolism, physiology, and immune function in the host. Intestinal homeostasis refers to the dynamic balance between the hosts mucosal barrier and intestinal microecology (including the intestinal microflora, nutritive and metabolic products, etc). The intestinal microflora is influenced by a multitude of factors such as an individuals external environment, lifestyle, eating habits, medicine intake and surgeries, etc. In recent years, gut microbiota have been considered to be involved in the occurrence and development of chronic kidney diseases (CKD). CKD is associated with impaired intestinal barrier function. Preliminary evidence indicates that toxic products generated by a dysbiotic gut microbiome and bacterial translocation may contribute to CKD progression and cardiovascular and cerebrovascular complications. The interplay between the accumulation of uremic toxins, inflammatory responses and metabolic disorders produces a vicious circle, as all three factors influence intestinal homeostasis and are crucial risk factors in the development of CKD. Therefore, it is imperative to find effective intervention measures to effectively regulate these three factors and improve intestinal homeostasis to prevent CKD progression. Probiotics, as a main intervention measure to regulate intestinal flora, may alleviate CKD progression by regulating intestinal homeostasis and reducing enteral uremic toxin. As the regulatory capacity of physiological processes by probiotics is strain specific, it is essential to choose appropriate probiotic strains according to their functional properties. Probiotics present as a new therapeutic target for management of chronic kidney disease. This review mainly summarizes the role of intestinal flora in CKD and the effect and mechanism of action of probiotics in CKD.

Monitoring of patients with type 2 diabetes and nephropathy in a specialized diabetic nephropathy clinic seems to be beneficial

BackgroundThe purpose of this study was to evaluate the outcome of DM2 patients with nephropathy when they are under surveillance of a joined clinic run by endocrinologists & nephrologists. Patients and methodsA cohort of 106 patients with DM2, 42–83 years of age, and eGFR < 60 ml/min/m2 were included. Age, sex, duration of diabetes, duration of attending our clinic, smoking habits, BMI, data regarding ischemic heart disease and induction of hemodialysis, urine albumin excretion (UAE) levels, eGFR (MDRD equation) and values of various biochemical parameters were recorded too. Follow-up period ranged from one to 25 years. Paired samples t-test and non-parametrical Kruskal–Wallis test were used for the analyses of the data. ResultsFifty percent of patients had no further progression, 25.9% improvement, while 24.1% had worsening of the UAE levels. During the follow-up in the joined clinic, there was a smaller than the expected from the medical literature decrease in median eGFR, i.e. 2,3 ml/min/m2 and a statistically significant improvement in glycosylated hemoglobin levels from 8.0% to 7.4% (p = 0.016). Time in years of follow-up in the joined clinic of our hospital appeared to be the most significant factor in the improvement or stabilization against deterioration of the UAE levels (p = 0.018). ConclusionsClose follow-up of DM2 patients with eGFR < 60 ml/min/m2 has resulted in a minor annual eGFR decrease. Monitoring of these patients in a specialized diabetic nephropathy clinic is beneficial for this group of patients for delaying the occurrence of end-stage renal disease.

Associations between arsenic in drinking water and occurrence of end-stage renal disease with modifications by comorbidities: A nationwide population-based study in Taiwan

Arsenic may affect the function of proximal convoluted tubules and glomeruli, but epidemiological data on the association between arsenic ingestion and end-stage renal disease (ESRD) are limited. Therefore, we conducted a nationwide population-based study in Taiwan, where the incidence of ESRD is the highest in the world, to study the potential association. Using the National Health Insurance Database in Taiwan, we constructed a cohort of 362,505 members with age≥40years in 1998. We identified patients of ESRD newly diagnosed between January 1, 1998 and December 31, 2010 and performed Cox proportional hazard regressions to identify risk factors for ESRD and evaluate their effects. Arsenic levels in drinking water were assessed on the basis of a nationwide census survey conducted by the government, of which measurement reports were available for 311 townships. We identified 5442 new patient of ESRD during the study period and found that residents of areas with arsenic levels≥50μg/L in the drinking water had a hazard ratio (HR) of 1.14 (95% confidence interval [CI]: 1.08–1.21) for ESRD. After adjusting for sex, age, income, and comorbidities, we found an adjusted HR of 1.12 (95% CI: 1.06–1.19), which was still statistically significant. Furthermore, the effect was modified by comorbidities, with more prominent effects on patients with less than three comorbidities (adjusted HR=1.51; 95% CI: 1.22–1.86 for low comorbidity score). In conclusion, a high arsenic level in drinking water was a risk factor for ESRD, independent of other documented risk factors. Reducing high-risk comorbidities in patients with early-stage renal dysfunction is important for slowing the progression of the disease to ESRD, even in the endemic area of arsenic exposure.

Associations between Arsenic in Drinking Water and the Occurrence of End-Stage Renal Disease with Modifications by Comorbidities: A Nationwide Population-Based Cohort Study in Taiwan

Associations between Arsenic in Drinking Water and the Occurrence of End-Stage Renal Disease with Modifications by Comorbidities: A Nationwide Population-Based Cohort Study in Taiwan

Epidemiology of Acute Kidney Injury

The worldwide incidence of acute kidney injury (AKI) is increasing. Recent surveys demonstrated that AKI occurs in 21% of hospital admissions. In low-income countries, AKI has a bimodal presentation. In large urban centers, the pattern of AKI is very similar to that found in high and upper middle-income countries, with a predominance of hospital-acquired AKI, occurring mostly in older, critically ill, multiorgan failure patients with comorbidities. At the same time, in regional hospitals in small urban communities and rural areas, AKI is usually a community-acquired disease (related to diarrheal and infectious diseases, animal venom, and septic abortion). Although AKI mortality seems to be decreasing, it remains extremely high, varying from 23.9 to 60% in recent series. The most important risk factors for short-term mortality (in hospital or &lt; 90 days) in AKI are the primary diagnosis (sepsis) and the severity of the acute illness, expressed by the presence of nonrenal organ dysfunction. New biomarkers, such as urinary neutrophil gelatinase-associated lipocalin, cystatin C, and interleukin-18 measurements, have been able to identify patients with AKI who are at risk for a less favorable prognosis, such as the likelihood of the need for renal replacement therapy, nonrecovery of kidney function, and higher mortality. Several studies have demonstrated an association between hospital-associated AKI and postdischarge mortality in a variety of contexts, and the most important risk factors for this late lethality are older age, preexisting comorbid disease (chronic kidney disease [CKD], cardiovascular disease, or malignancy), and incomplete organ recovery with ongoing residual disease. AKI is associated with de novo end-stage renal disease (ESRD) (CKD, progression of preexisting CKD) and the occurrence of ESRD in the long term. Herein, it is suggested that high-risk patients recovering from an AKI episode, such as those with baseline CKD, diabetes mellitus, or heart failure and those dialyzed for AKI, should likely be followed by a nephrologist.

Prehypertension among 2.19 million adolescents and future risk for end-stage renal disease.

Persistent hypertension in adulthood is a leading cause of end-stage renal disease (ESRD). Whether lower blood pressure (BP) values, in the range of prehypertension, are also associated with future occurrence of ESRD is unclear. Even less clear is the potential risk of early prehypertension appearing in adolescence. To address this question, we examined whether BP measurements in the prehypertensive range at age 16-19 years predict adult ESRD. Medical data on 2194 635 16-19-year-old adolescents examined for medical fitness prior to military service from 1977 to 2013 were linked to the Israeli ESRD registry in this nationwide population-based cohort study. Incident cases of ESRD were recorded. Survival models were applied. During 35 007 506 person-years of follow-up (median follow-up 16.8 years), there were 690 ESRD cases, with an overall incidence rate of 1.97 cases per 100 000 person-years. Examinees with elevated BP readings in the prehypertensive range (BP between the 90th and 95th percentiles or between 120 and 139/80-89 mmHg) had increased incidence of ESRD with a hazard ratio of 1.32 (95% confidence interval, 1.11-1.58) adjusted for year of birth, age at examination, sex, BMI, education, socioeconomic status, and country of origin. Hypertension (BP above the 95th percentile or above 140/90 mmHg) was associated with a hazard ratio of 1.44 (95% confidence interval, 1.17-1.79). A spline model demonstrated a nadir of risk at SBP values as low as 94 mmHg. Asymptomatic, healthy adolescents with prehypertension have a 32% increased risk for subsequent ESRD, compared with adolescents with optimal BP.

Epidemiology of Acute Kidney Injury

The worldwide incidence of acute kidney injury (AKI) is increasing. Recent surveys demonstrated that AKI occurs in 21% of hospital admissions. In low-income countries, AKI has a bimodal presentation. In large urban centers, the pattern of AKI is very similar to that found in high and upper middle-income countries, with a predominance of hospital-acquired AKI, occurring mostly in older, critically ill, multiorgan failure patients with comorbidities. At the same time, in regional hospitals in small urban communities and rural areas, AKI is usually a community-acquired disease (related to diarrheal and infectious diseases, animal venom, and septic abortion). Although AKI mortality seems to be decreasing, it remains extremely high, varying from 23.9 to 60% in recent series. The most important risk factors for short-term mortality (in hospital or &lt; 90 days) in AKI are the primary diagnosis (sepsis) and the severity of the acute illness, expressed by the presence of nonrenal organ dysfunction. New biomarkers, such as urinary neutrophil gelatinase-associated lipocalin, cystatin C, and interleukin-18 measurements, have been able to identify patients with AKI who are at risk for a less favorable prognosis, such as the likelihood of the need for renal replacement therapy, nonrecovery of kidney function, and higher mortality. Several studies have demonstrated an association between hospital-associated AKI and postdischarge mortality in a variety of contexts, and the most important risk factors for this late lethality are older age, preexisting comorbid disease (chronic kidney disease [CKD], cardiovascular disease, or malignancy), and incomplete organ recovery with ongoing residual disease. AKI is associated with de novo end-stage renal disease (ESRD) (CKD, progression of preexisting CKD) and the occurrence of ESRD in the long term. Herein, it is suggested that high-risk patients recovering from an AKI episode, such as those with baseline CKD, diabetes mellitus, or heart failure and those dialyzed for AKI, should likely be followed by a nephrologist.

Long-Term Outcomes of Systemic Lupus Erythematous Patients after Pregnancy: A Nationwide Population-Based Cohort Study.

BackgroundData on long-term maternal outcomes in patients with systemic lupus erythematosus (SLE) are lacking. The study aimed to explore the relationships among SLE, pregnancy, outcomes of end-stage renal disease (ESRD), and overall mortality.MethodsWe established a retrospective cohort study consisting of four cohorts: pregnant (case cohort) and nonpregnant SLE patients, as well as pregnant and nonpregnant non-SLE patients. One case cohort and three comparison cohorts were matched by age at first pregnancy and index date of pregnancy by using the Taiwan National Health Insurance Research Dataset. All study subjects were selected based on the index date to the occurrence of ESRD or overall death. Cox proportional hazard regression models and Kaplan–Meier curves were used in the analysis.ResultsSLE pregnant patients exhibited significantly increased risk of ESRD after adjusting for other important confounders, including immunosuppressant and parity (HR = 3.19, 95% CI: 1.35–7.52 for pregnant non-SLE; and HR = 2.77, 95% CI: 1.24–6.15 for nonpregnant non-SLE patients). No significant differences in ESRD incidence were observed in pregnant and nonpregnant SLE patients. Pregnant SLE patients exhibited better clinical condition at the baseline and a significantly lower risk of overall mortality than nonpregnant SLE patients.ConclusionsOur data support current recommendations for SLE patients to avoid pregnancy until disease activity is quiescent. Multicenter recruitment and clinical information can be used to further examine the association of SLE and ESRD (or mortality) after pregnancy.

Analysis of the prognostic risk factors of idiopathic membranous nephropathy using a new surrogate end-point.

Idiopathic membranous nephropathy (IMN) is one of the most common causes of nephrotic syndrome (NS) in adults. The latest study of the chronic kidney disease-prognosis consortium showed that a 30% decrease in the estimated glomerular filtration rate (eGFR) within 2 years could cover more patients and showed a better correlation with end-stage renal disease (ESRD), as compared with serum creatinine (SCr). The aim of the present study was to analyze prognostic factors of ESRD using a 30% decrease in eGFR within 2 years as the end-point. The medical records of patients who were diagnosed as having IMN by clinical pathology between February 2011 and August 2012 and had been followed up for ≥24 months were analyzed retrospectively. A 30% decrease in eGFR or the occurrence of ESRD were the end-points. Factors affecting the prognosis were analyzed by the χ2 test and multivariate logistic regression analysis, and the cumulative risk of risk factors was analyzed by Kaplan-Meier curve. A total of 73 patients with IMN were confirmed by clinical pathology. Blood pressure, tubulointerstitial injury area (TIA), glomerular sclerosis ratio, SCr, blood urea nitrogen, cystatin C, serum albumin and 24-h urine protein. In total, 28 patients (38.4%) reached the observation end-point. Multivariate logistic regression analysis showed that only age ≥60 years, serum albumin <25 g/l and TIA >25% were independent risk factors for predicting the occurrence of end-point events in the two groups (P<0.05), which increased the risk of the occurrence of end-point events in IMN patients by 3.471-, 3.195- and 6.724-fold, respectively. Kaplan-Meier curve showed that the occurrence of end-point events within 2 years was significantly higher in IMN patients whose age was ≥60 years, serum albumin <25 g/l and TIA >25% (log-rank P=0.004, P=0.024 and P=0.001). The results of the present study revealed that age ≥60 years, low serum albumin concentrations and severe tubulointerstitial injury are independent risk factors for the occurrence of ESRD in IMN patients.