Predialysis Chronic Kidney Disease Population Research Articles

Depression and associated factors in chronic kidney disease patients in southern Nigeria: a cross-sectional study

Background The most common psychological problem encountered in patients with chronic kidney disease (CKD) is depression. However, it is often undiagnosed and undertreated in this group of patients. The prevalence of depression in pre-dialysis CKD patients and its associated factors were determined in this study Patients and methods This was a cross-sectional study that determined the prevalence of depression in pre-dialysis CKD patients using the Hamilton-Depression rating scale. Associated factors with depression were determined by logistic regression. P value less than 0.05 was taken as a significant Results A total of 250 CKD patients with a mean age of 52.3 ± 16.0 years were studied. They comprised of 116 (46.4%) males. Fifty-six (22.4%) of the study participants had depressive symptoms. Depression was significantly more common in those who were unmarried (38.3% vs. 18.7%; P= 0.002) and those whose duration of CKD was less than 6 months (26.6% vs. 15.2%; P= 0.026). Depression was significantly associated CKD stage (P=0.002). The significant factors associated with depression in the CKD patients were being unmarried (adjusted odds ratio: 2.54; confidence interval: 1.19–5.42; P= 0.02) and CKD stage (adjusted odds ratio:3.81; confidence interval: 1.50–9.83; P=0.01). Conclusion Depression is common in the pre-dialysis CKD population and its screening should be included in the evaluation and management of all pre-dialysis CKD patients.

Prevalence, risk factors and impact of proteinuria-associated hypomagnesemia in chronic kidney disease patients: cross-sectional study

BackgroundHypomagnesemia is a predictor of progression and mortality of chronic kidney disease (CKD) patients. However, limited data is available about the prevalence and kidney-related risk factors of hypomagnesemia in the CKD patients. We aimed to investigate the prevalence and risk factors of low serum magnesium level associated with proteinuria and its impact on CKD patients. This cross-sectional study enrolled 100 CKD patients with different stages according to estimated glomerular filtration rate (eGFR), divided into 2 groups (proteinuric and non-proteinuric) in the period from February 2020 to August 2020.ResultsThe number of participants in this study was 100 subjects, 50 patients were proteinuric and 50 patients had no proteinuria. The study participants’ serum magnesium levels ranged from 1.2 to 2.7 mg/dL. Fourteen (28%) of proteinuric individuals had a serum magnesium level of less than 1.8 mg/dL. Hypomagnesemic patients had significantly higher urine albumin creatinine ratio (UACR) (2071 mg/g vs. 812 mg/g, P<0.001), significantly higher CRP (48 mg/L vs. 12 mg/L, P<0.001), and lower mean hemoglobin levels as well (10.4 g/dL vs. 10.91 g/dL, P= 0.044). Serum magnesium level showed negative correlation with UACR (r=−0.504, P<0.001), parathyroid hormone (r=−0.276, P=0.005), and CRP (r=−0.505, P<0.001).ConclusionsHypomagnesemia is a frequent electrolyte disorder in patients with CKD. Hypomagnesemia is independently associated with proteinuria. Hypomagnesemia is a risk factor of inflammation, anemia and hyperparathyroidism in pre-dialysis CKD population.

Rapid Weight Change Over Time Is a Risk Factor for Adverse Outcomes in Patients With Predialysis Chronic Kidney Disease: A Prospective Cohort Study

Both obesity and being underweight are risk factors for adverse outcomes in chronic kidney disease (CKD) patients. However, the effects of longitudinal weight changes on patients with predialysis CKD have not yet been studied. In this study, we analyzed the effects of weight change over time on the adverse outcomes in predialysis CKD population. Longitudinal data from a multicenter prospective cohort study (KNOW-CKD) were analyzed. In a total of 2,022 patients, the percent weight change per year were calculated using regression analysis and the study subjects were classified into five categories: group 1, ≤ -5%/year; group 2, -5< to≤ -2.5%/year; group 3, -2.5< to <2.5%/year; group 4, 2.5≤ < 5%/year; and group 5, ≥5%/year. The incidences of end-stage renal disease (ESRD) and the composite outcome of cardiovascular disease (CVD) and death were calculated in each group and compared to group 3 as reference. During a median 4.4years of follow-up, 414 ESRD, and 188 composite of CVD and mortality events occurred. Both weight gain and loss were independent risk factors for adverse outcomes. There was a U-shaped correlation between the degree of longitudinal weight change and ESRD (hazard ratio 3.61, 2.15, 1.86 and 3.66, for group 1, 2, 4 and 5, respectively) and composite of CVD and death (hazard ratio 2.92, 2.15, 1.73 and 2.54, respectively), when compared to the reference group 3. The U-shape correlation was most prominent in the subgroup of estimated glomerular filtration rate <45mL/min/1.73m2. Both rapid weight gain and weight loss are associated with high risk of adverse outcomes, particularly in the advanced CKD.

P0784RAPID WEIGHT CHANGE OVER TIME IS A RISK FACTOR FOR ADVERSE OUTCOMES IN PREDIALYSIS CHRONIC KIDNEY DISEASE: RESULTS FORM KNOW-CKD STUDY

Abstract Background and Aims Both obesity and underweight are related to the adverse outcomes in the chronic kidney disease (CKD). However, the effects of longitudinal weight changes on predialysis CKD population has not been studies so far. In this study, we analysed the effects of longitudinal body weight changes on the adverse outcomes in the predialysis CKD population, using the multicentre prospective cohort study in Korean pre-dialysis CKD cohort, so called KNOW-CKD. Method In this longitudinal analysis, total 2,022 patients were included. Longitudinal weight changes of study population were calculated into the percent change per year using regression analysis and classified into five groups: group 1; ≤ -5%/year (74 subjects), group 2; -5&amp;lt; to ≤-2.5 %/year (122 subjects), group 3; -2.5&amp;lt; to &amp;lt;2.5%/year (1642 subjects), group 4; 2.5≤ &amp;lt;5 %/year (123 subjects), and group 5; ≥ 5 %/year (61 subjects). The risk of end-stage renal disease (ESRD) development and composite outcome of cardiovascular disease (CVD) and all-cause death were compared according to the longitudinal weight changes. Results During the median 4.4 years of follow-up, total 414 and 188 events of ESRD and composite outcome of CVD and death occurred. When cause-specific regression analysis was conducted before and after adjusting age, sex, body mass index, mean blood pressure, estimated glomerular filtration rate, urine albumin-to-creatinine ratio, diabetics, cardiovascular disease, and modified Charlson Comorbidity Index score, all groups showed significant increased HR compared to group 3 for the ESRD. There was U-shape correlation between the degree of longitudinal body weight changes and the renal outcome (HR 3.89, 2.00, 1.89 and 3.34, P &amp;lt;0.001, &amp;lt;0.001, =0.001 and &amp;lt;0.001 for group 1, 2, 4 and 5, respectively). Also similar U-shape relationship was seen with composite outcome, (HR 3.14, 2.05, 1.65 and 2.68, P &amp;lt;0.001, 0.007, 0.123 and 0.007 for group 1, 2, 4 and 5, respectively) when compared to the reference group 3 When spline curve was drawn between the longitudinal body weight changes and adjusted HR for ESRD and composite of CVD and death, clear U-shape relationship was observed (Figure). The U-shape correlation was highlighted in the subgroup of estimated glomerular filtration rate &amp;lt;45 mL/min/1.73m2. Conclusion Both rapid weight reduction and gain are independent risk factor for the ESRD development and composite outcome of CVD and death in predialysis CKD patients, especially in advanced CKD stages. Therefore, monitoring bodyweight changes are important and more studies are needed to give safe guideline to the predialysis CKD for maintaining optimal nutritional status.

Can we IMPROVE cardiovascular outcomes through phosphate lowering in CKD? Rationale and protocol for the IMpact of Phosphate Reduction On Vascular End-points in Chronic Kidney Disease (IMPROVE-CKD) study

IntroductionPatients with chronic kidney disease (CKD) are at heightened cardiovascular risk, which has been associated with abnormalities of bone and mineral metabolism. A deeper understanding of these abnormalities should facilitate...

Do the benefits of using calcitriol and other vitamin D receptor activators in patients with chronic kidney disease outweigh the harms?

The primary indication for administration of calcitriol or other vitamin D receptor activators (VDRA) in chronic kidney disease (CKD) is secondary hyperparathyroidism (SHPT). Prevention and treatment of SHPT appears important, as imbalances in mineral metabolism are associated with renal osteodystrophy, and higher parathyroid hormone (PTH) levels are associated with increased rates of mortality and morbidity in CKD patients. There is, however, a lack of controlled trial data that show lowering PTH with calcitriol/VDRA equates to improved clinical outcomes. Recent randomized controlled trials have concentrated on potential benefits of calcitriol/VDRA on cardiovascular outcomes and reduction of proteinuria and on possible differences between calcitriol and the various VDRA. Several systematic reviews and meta-analyses have also been published, evaluating the benefits and harms of calcitriol/VDRA. Concerns have been raised about the effectiveness of calcitriol/VDRA for suppression of SHPT in the CKD stages 3-5 population, as well as potential adverse outcomes such as hypercalcaemia and elevation in FGF23 levels, suggesting their routine use to treat SHPT in the pre-dialysis CKD population may not be favourable. Conversely, concerns still exist about the wide PTH range in advanced CKD, and that high values may negatively impact bone quality, result in the progression of parathyroid hyperplasia and decrease the effectiveness of treatments to reduce PTH. We discuss the current controversies relating to the challenges in the management of SHPT in patients with CKD stages 3-5 and the need for more evidence to determine the efficacy or harm of using calcitriol/VDRA in this population.

Nontraditional cardiovascular biomarkers and estimation of cardiovascular risk in predialysis chronic kidney disease patients and their correlations with carotid intima media thickness.

Background:Cardiovascular biomarkers such as N-terminal pro-B-type natriuretic peptide (NT-proBNP), cardiac troponin T (cTnT), hs-CRP (high sensitivity C-reactive protein), and albuminuria predict underlying heart disease in the general population as well as CKD patients.Objectives:We aimed to study the association of NT-proBNP, cTnT, hs-CRP, and spot urine albumin creatinine ratio with carotid intima media thickness (CIMT) for cardiovascular risk estimation in predialysis CKD (chronic kidney disease) patients.Patients and Methods:This cross-sectional study included a total of 120 adult predialysis CKD patients. Forty patients were allocated in each predialysis CKD group of stages 3, 4, and 5. Serum cTnT and hs-CRP, plasma NT-proBNP, and single spot urine albumin creatinine ratio (ACR) were measured. Ultrasonographic examination of carotid artery was done with 7.5 MHz linear probe in B mode ultrasonography and carotid intima media thickness was measured.Results:Mean values ± standard deviation of plasma NT-proBNP (pg/mL), serum hs-CRP (mg/L), spot urine ACR (mg/g of creatinine), and CIMT (mm) were 585.68 ± 514.84, 5.96 ± 2.52, 719.37 ± 411.36, and 0.78 ± 0.15, respectively in predialysis CKD patients (n = 120). Serum cTnT level was high in 40% of predialysis CKD patients. Among cardiovascular biomarkers, plasma NT-proBNP had maximum strength of correlation (Spearman Rho correlation coefficient; r = 0.575 and P < 0.0001) with the carotid intima media thickness followed by serum cTnT (Spearman Rho correlation coefficient; r = 0.419 and P < 0.0001), spot urine albumin creatinine ratio (Spearman Rho correlation coefficient; r = 0.322 and P < 0.0001), and serum hs-CRP (Spearman Rho correlation coefficient; r = 0.246 and P = 0.007).Conclusions:Nontraditional cardiovascular biomarkers such as plasma NT-proBNP, serum cTnT, serum hs-CRP, and spot urine ACR significantly correlate with CIMT. These biomarkers can estimate the cardiovascular risk in a predialysis CKD population with expected high cardiac morbidity and mortality.

Iron status and benefit of the use of parenteral iron therapy in pre-dialysis Chronic Kidney Disease patients

Anaemia is a major cardiovascular risk factor in chronic kidney disease (CKD). Treatment and correction of anaemia leads to improvement of cardiovascular status and quality of life of patients with CKD. This interventional open labeled randomised controlled study comparing the effect of intravenous and oral iron therapy in improving red cell indices and iron status in anaemic pre-dialysis Chronic Kidney Disease was carried out to determine iron status in anaemic pre-dialysis CKD patients to assess the benefit of parenteral iron supplementation as against empirical oral iron in CKD patients with iron deficiency. Sixty consecutive pre-dialysis chronic kidney disease patients attending the renal clinic over a six month period were screened. Forty- one subjects (68.3%) were found to be anaemic and were subsequently studied. The ages of the patients ranged between 19 and 71 years with a mean age of 39 years. The mean serum creatinine and mean creatinine clearance were 201.80 (70.25)?mol/L and 37.90 (± 12.17)ml/minute respectively. The haematocrit concentration was found to correlate inversely with the level of serum creatinine and 56.1% of the anaemic patients had iron deficiency. The mean PCV rise in the intravenous iron group was 2.42 (± 1.98)% and this was statistically significant (p=0.002) while the mean PCV difference was 0.909 (± 0.94)% in the oral iron group. Intravenously administered iron alone permitted anaemia correction in about one-third of these patients without any life threatening adverse drug event. Anaemia is very common in the pre-dialysis CKD population and the prevalence of iron deficiency is high. Intravenous iron supplementation is an effective and safe treatment for the anaemia in the pre-dialysis CKD patients. Response to oral iron was poor.

Association of Adiponectin with Carotid Arteriosclerosis in Predialysis Chronic Kidney Disease

Background/Aims: Adiponectin is an adipocyte-derived protein with antiatherogenic properties. Chronic kidney disease (CKD) is one of the risk factors for cardiovascular disease. We investigated the potential association between adiponectin and carotid arteriosclerosis in patients with predialysis CKD. Methods: We enrolled 95 CKD patients without dialysis and 81 non-CKD patients. Intima-media thickness (IMT) and plaque score (PS) in the common carotid artery were measured using an ultrasound system. Carotid arteriosclerosis was defined as IMT >1.2 mm and/or PS >5.0 mm. Results: The prevalence of CKD was independently associated with carotid arteriosclerosis after adjustment for other risk factors. Higher adiponectin levels were observed in CKD patients compared with non-CKD patients. Adiponectin levels were not independently correlated with the presence of carotid arteriosclerosis in all subjects. To evaluate the association between adiponectin and carotid arteriosclerosis among a CKD population, we divided the CKD patients into 2 groups according to a cutoff level of adiponectin determined by ROC analysis. The prevalence of carotid arteriosclerosis was significantly higher in the low-adiponectin group than in the high-adiponectin group among CKD patients. After adjusting for other risk factors, low levels of adiponectin were independently correlated with carotid arteriosclerosis in CKD patients. Conclusion: Our data document that adiponectin is associated with increased risk of carotid atherosclerosis in a predialysis CKD population.

Risk factors for high erythropoiesis stimulating agent resistance index in pre-dialysis chronic kidney disease patients, stages 4 and 5

Anemia is common in patients with chronic kidney disease (CKD). Recently, the erythropoiesis-stimulating agent/hemoglobin level (ESA/Hb) index emerged as a new factor associated with increased morbidity and mortality in this population. In this study, we evaluated the factors that influence the ESA/Hb index in a pre-dialysis CKD population. Ninety-five patients were evaluated for clinical and laboratory parameters, nutritional status and ESA/Hb index. For comparison, we divided our population into 3 groups: G I--no ESA treatment, G II--patients with ESA/index below 50th percentile and G III--patients with ESA/Hb index above 50th percentile. We performed single and multiple regression models and logistic regression analysis. In a multiple regression model, age (t = -3.456, P = 0.001), SGA (t = 2.059, P = 0.047), ferritin (t = 2.386, P = 0.027), Ca × P (t = 2.066, P = 0.043), TNF-α (t = 2.673, P = 0.009) and IL-6 (t = 2.939, P = 0.004) independently influenced the ESA/Hb index. At logistic regression analysis, gender, cardiovascular disease and TNF-α were independently associated with ESA/Hb higher than 50th percentile compared to the other patients (R(2) = 0.457). In a pre-dialysis population, female gender, cardiovascular disease, malnutrition and inflammation are associated with a higher ESA/Hb index.

Posttransplant anemia in solid organ recipients

Posttransplantation anemia (PTA) is a prevalent sequela of solid organ transplantation and a potential independent risk factor for cardiovascular morbidity and mortality in kidney transplant recipients. There are multiple causes of PTA, some of which are associated with early phase anemia (<6 months), whereas others more often induce anemia in the late posttransplant phase (>6 months). Although impaired kidney function contributes to PTA, it is only one of many factors that result in anemia in transplant recipients. Other causes include iron deficiency, medications, infections, acute rejection, inflammation, and erythropoietin deficiency. Unlike in the predialysis chronic kidney disease population, the impact of anemia after kidney transplantation outcomes is unknown. This is in large part due to the absence of controlled trials that address whether correction of anemia improves allograft function or patient morbidity and mortality. Current guidelines recommend evaluation for hemoglobin level of less than 12 g/dL and treatment when the value falls less than 11 g/dL and a target of 11 to 12 g/dL. Additional treatments may entail removing the cause of the anemia, nutritional supplementation, and/or an erythrocyte stimulating agent.

Anemia and Risk of Hospitalization in Pediatric Chronic Kidney Disease

Anemia is a well known complication of chronic kidney disease (CKD); however, the prevalence of anemia within CKD stages in the pediatric population has not been established. Additionally, the associated morbidity of anemia in the pediatric CKD population has not been elucidated. 2,779 patients ages 2 yr and older in the North American Pediatric Renal Trials and Collaborative Studies database with CKD stage II to V (excluding dialysis or previous transplant patients) were identified. Descriptive statistics and multivariate modeling using logistic regression was performed to determine the prevalence of anemia and to evaluate the correlation between baseline anemia and hospitalization. The prevalence of anemia (hematocrit < 33%) increased from 18.5% in CKD stage II to 68% in CKD stage V (predialysis). Anemic children were 55% more likely to be hospitalized when compared with nonanemic children (odds ratio 1.55; 95% confidence interval 1.23 to 1.94). Similar results were obtained using hematocrit cutoffs of 36 and 39%. In this pediatric predialysis CKD population, anemia increases with increasing CKD stage and is significantly associated with hospitalization risk. Hematocrit levels above 36 and 39% were not associated with increased risk of hospitalization. Further examination into the effect of correcting anemia on hospitalization rates may provide additional useful information.

Associations between vascular calcification, arterial stiffness and bone mineral density in chronic kidney disease

Vascular calcification (VC) and arterial stiffness are major contributors to cardiovascular (CV) disease in chronic kidney disease (CKD). Both are independent predictors of CV mortality and are inversely correlated with bone mineral density (BMD). Few studies have addressed the extent of VC in the pre-dialysis CKD population, with associated measurements of BMD and arterial compliance. We report cross-sectional data on 48 patients with CKD (GFR 17-55 ml/min) assessing the prevalence of VC and its associations. All patients had computed tomography (CT) scans through abdominal aorta and superficial femoral arteries (SFAs) to determine VC, pulse wave velocity (PWV) using SphygmoCor device (AtCor PWV Inc., Westmead, Australia) measuring arterial stiffness, and dual-energy X-ray absorptiometry (DEXA) scans to determine BMD, as well as serum markers of renal function and mineral metabolism. Patients, 71% male, 54% diabetic, had a median age 64.5 years. Mean estimated GFR was 35.1 +/- 10 ml/min. Mean PWV was 10.0 +/- 4.5 m/s and mean aortic VC score was 421.5 +/- 244 Hounsfield units, with 90% of subjects having some aortic VC present. In univariate linear regression analysis, aortic VC correlated positively with age (r 0.50, P < 0.001), triglycerides (r 0.47, P = 0.002) and PWV (r 0.33, P = 0.03). There was also greater VC with declining renal function (r -0.28, P = 0.05). There was no significant association between VC and serum markers of mineral metabolism, however phosphate and Ca x P correlated positively with PWV (r 0.35, P = 0.02, r 0.36, P = 0.02, respectively). There was also a positive association between PWV and triglycerides (P = 0.008), and a trend towards greater PWV with increasing age (P = 0.09). In multivariate regression analysis only increasing age and triglyceride levels were significantly associated with aortic VC and PWV. Mean spine and femoral T-scores on DEXA were 0.48 and -1.31 respectively, with 13% of subjects having femoral T-score <-2.5 (osteoporotic range). SFA VC inversely correlated with femoral T-scores (r -0.43, P = 0.004); however, there was a positive (likely false) association between spine T-scores and aortic VC (r 0.37, P = 0.01), related to the limitation of vertebral DEXA in CKD. There is a high prevalence of VC in pre-dialysis CKD patients, worse with increasing age, triglycerides and reducing renal function. Correlation exists between VC and PWV and determination of one or both may be useful for CKD patient CV risk assessment. Femoral BMD is inversely associated with SFA VC, but measurement of vertebral BMD by DEXA is unreliable in CKD patients with aortic VC.

Oral paricalcitol for the treatment of secondary hyperparathyroidism in chronic kidney disease.

Secondary hyperparathyroidism (SHPT) is commonly seen in patients with chronic kidney disease (CKD). Even in early CKD, parathyroid hormone (PTH) levels are elevated, maintaining mineral homeostasis at the cost of long-term bone health. One potent stimulus for PTH secretion is a deficiency of active vitamin D. Replacement with calcitriol, the active form of vitamin D, lowers PTH but often raises calcium and phosphorus levels, predisposing patients to an increased risk of ectopic calcifications. Paricalcitol is a vitamin D analog designed to treat SHPT without raising serum calcium and phosphorus levels. The intravenous preparation of paricalcitol is used routinely in the hemodialysis population and has demonstrated a survival benefit over calcitriol in hemodialysis patients. A new oral preparation has now been developed for use in the pre-dialysis CKD population. Thus far, oral paricalcitol has been shown to reduce PTH by an average of 42% in CKD patients, while having minimal effects on serum calcium and phosphorus. While long term effects of the oral preparation have yet to be studied, emerging evidence suggests that paricalcitol mediates a variety of beneficial effects through the activation of vitamin D receptors which may result in improved survival.