Recognition Of Chronic Kidney Disease Research Articles

Renal Disease Burden Following Liver Transplantation

Significant chronic kidney disease (CKD) occurs following orthotopic liver transplant (OLT). Since CKD is associated with increased cardiovascular events, mortality, and hepatic allograft dysfunction, early recognition of CKD and implementation of changes may improve the long-term outcome. The purpose of this study was to determine the burden of renal disease following OLT. Patients and Methods We retrospectively reviewed our OLT recipients from 1997 until 2004. We calculated glomerular filtration rates (GFR) using the Modification of Diet in Renal Disease study (MDRD) method. The GFRs were further subdivided into pre-MELD and post-MELD eras. Results During the study period, we performed 407 OLTs. We censored data from living donor liver transplants ( n = 14), combined liver-kidney transplants ( n = 12), and from patients whom we did not have complete data for 6 months after transplant ( n = 40). Mean MELD score at the time of transplant was 18 ± 7 (mean ± standard deviation). The mean GFR at 6 months following OLT was 63.7 ± 30.2 mL/min per 1.73 m 2. Only 14% ( n = 47) of our patients had normal renal function at 6 months, while 78% ( n = 266) of our patients had mild to moderate risk for renal failure. Eight percent ( n = 28) had stage 4 or 5 CKD. There were no differences between the pre-MELD and post-MELD GFRs. Conclusions The burden of renal disease is significant in our patient population at 6 months posttransplantation. It may be important to introduce CKD management as early as 6 months after transplant to impact the outcomes of OLT recipients.

Identification and Referral of Patients With Progressive CKD: A National Study

It is unclear whether primary care physicians (PCPs) and nephrologists differ in their recognition of progressive chronic kidney disease (CKD), agree on diagnostic and referral strategies, and identify similar barriers to caring for patients. We conducted a national study of PCPs and nephrologists in the United States through a questionnaire describing a PCP caring for a patient with progressing CKD and questions to assess recognition of kidney dysfunction and approaches to diagnostic evaluation and referral. We identified participant and patient characteristics independently associated with CKD recognition and referral. We randomly identified a national sample of 304 physicians (126 nephrologists [39% response rate], 89 family physicians [28% response rate], and 89 general internists [28% response rate]). PCPs recognized CKD less (adjusted percentage, 59%; 95% confidence interval [CI], 47 to 69, family physicians; adjusted percentage, 78%; 95% CI, 67 to 86, general internists; adjusted percentage, 97%; 95% CI, 93 to 99, nephrologists; P < 0.01), differed from nephrologists in their recommendations for diagnostic testing, and recommended referral less (adjusted percentage, 76%; 95% CI, 65 to 84, family physicians; adjusted percentage, 81%; 95% CI, 70 to 89, general internists; adjusted percentage, 99%; 95% CI, 95 to 100, nephrologists; P < 0.01). PCPs differed from nephrologists in their expected intensity of specialists' involvement in care (16%, family physicians; 20%, general internists; 6%, nephrologists recommending nephrologist input monthly to every 6 months; P = 0.01). Lack of awareness of clinical practice guidelines and lack of clinical and administrative resources were identified as important barriers to care. PCPs recognize and recommend specialist care for progressive CKD less than nephrologists and differ in their clinical evaluations and expectations for referral. Improved dissemination of existing guidelines and targeted education in conjunction with efforts to build consensus among PCPs and nephrologists regarding their roles in the care of patients with CKD, including the collaborative development of clinical practice guidelines, could enhance patient care.

Peritoneal Dialysis: A Primary Care Perspective

As the population of chronic kidney disease (CKD) and end-stage renal disease (ESRD) grows at an alarming rate, primary care physicians will increasingly be involved in the management of these patients. Early recognition of CKD and timely referral to a nephrologist when glomerular filtration rate approaches 30 mL/min/1.73 m(2) is extremely important to improve ESRD outcome and appropriate selection of dialysis modality. Peritoneal dialysis (PD) remains a viable treatment option for ESRD patients. PD is less expensive dialysis modality and may provide a survival advantages over hemodialysis in first 2 to 4 years of treatment. Preserving residual renal function (RRF) is of paramount importance to prolong the survival outcomes in PD patients. Thus preservation of RRF is an important goal in the management of PD patients. Every effort should be made to avoid nephrotoxic drugs like aminoglycosides and nonsteroidal anti-inflammatory drugs, and limit the use of radiocontrast agents in PD patients with RRF. Judicious use of prophylactic antibiotics to prevent peritonitis would further help to reduce morbidity from PD. Protecting peritoneal membrane from long-term toxic and metabolic effects of the conventional glucose-based solutions is another objective to further improve PD outcome. Development of new, more biocompatible PD solutions holds promise for the future. One such solution, icodextrin, is now approved for use in the United States. Although extremely safe to use, it is associated with unique metabolic effects that may concern primary care physicians. They include false elevation of blood glucose, a reversible increase in serum alkaline phosphatase and a false decline in serum amylase. Monitoring of glycemia by assays that use glucose dehydrogenase pyrroloquinoline quinone enzymes should be avoided and serum amylase alone should not be relied on in diagnosing pancreatitis in patients on icodextrin.

Chronic kidney disease in Nigeria: primary care physicians must intervene earlier

Chronic Kidney disease (CKD) is one of the world's major public health problems and the prevalence of Kidney failure is rising steadily. Patients with early stages of CKD are primarily silent with long latent period, and may in fact be masked by other conditions. Progressive damage is invariable and progression to ESRD is the rule. Failure to recognize CKD early is a missed opportunity to prevent or delay the development of ESRD or other cardiovascular events complicating CKD. To evaluate the present practice of Medical officers within the primary and secondary health care centres in Kaduna State to see how this could help in early detection of CKD. Cross sectional descriptive study. Medical doctors working within Kaduna State of Nigeria both in the private and public sector excluding specialists and those in the university teaching hospital. Interview using self administered questionnaire. Percentage of patients tested for symptomless urinary abnormalities when seen by the doctor. A total of 96 completed and returned questionnaires were analysed. Sixty five percent (65%) of the doctors tested less than ten percent (10%) of their patients for proteinuria and eighty five percent (85%) of the doctors tested less than ten percent (10%) of their patients for haematuria. Only thirty percent (30%) of the doctors tested for proteinuria in thirty nine percent (39%) of those they were treating for Diabetes Mellitus and only thirty five percent (35%) of the doctors tested for proteinuria in twenty nine percent (29%) of those with hypertension. Screening for CKD is hardly considered in the routine practice of the primary and secondary care medical officers who have the first contact with patients and are in the best position to screen for CKD and provide opportunity for early detection, evaluation and prevention of progression to ESRD. Failure to recognize CKD early is a missed opportunity to improve patient outcome therefore the primary care physicians must intervene earlier to ensure early recognition of CKD. Nigerian Medical Practitioner Vol. 49(1&2) 2006: 18-23

SHAPE UP-a management program for chronic kidney disease

Chronic kidney disease (CKD) is a disease of epidemic proportions, affecting 11% of the population and having far-reaching consequences in quality of life, mortality, and overall cost of health. So far, CKD care has been suboptimal. Evidence-based guidelines for management of patients with CKD have been established by the National Kidney Foundation. Early recognition of CKD and its associated complications and timely referral to a nephrologist are the key components of management. Coordinated care and effective communication between the primary care physician, the nephrologist, and other providers are critical to improve the outcome. Using a simple mnemonic, SHAPE UP, we outline a program for comprehensive care of patients with CKD. We believe that implementing this program in medical and renal clinics will enhance the care of CKD patients.

Chronic kidney disease: evolving strategies for detection and management of impaired renal function

Nephrologists have long been concerned about late referral of patients with severe kidney disease, and resultant poor outcomes on dialysis. But there is an increasing realisation that mild to moderate chronic kidney disease is far more common than previously appreciated. Furthermore, the main consequence of chronic kidney disease is not progression to dialysis, but increased risk of cardiovascular disease. Chronic kidney disease is at least as common and important a risk factor for cardiovascular disease as diabetes mellitus. The MDRD formula is a well-validated formula to estimate glomerular filtration rate, which is now being widely implemented by clinical chemistry laboratories, and should increase the recognition of chronic kidney disease. The K/DOQI classification of chronic kidney disease has gained international acceptance and provides the structure to guide referral and management. This classification, and associated guidelines, also focus attention on areas where evidence is lacking, and which urgently require research. These current developments will substantially change and improve how chronic kidney disease is identified and managed.

Cardiovascular disease and the kidney

PREVIEWCardiovascular disease (CVD) is prevalent in patients with chronic kidney disease (CKD) and is responsible for the majority of morbidity and mortality in this patient population. Although many identifiable risk factors and therapeutic strategies exist for treatment of CVD, most of them are underused in the care of patients who have kidney disease. In this article, Drs Levin, Stevens, and McCullough highlight the issues concerning treatment of CVD in patients who have CKD. Early recognition of both CKD and attendant CVD is becoming the purview of the primary care physician in conjunction with members of subspecialty teams.

Spontaneous Renocolic Fistula: Report of a Case

A fistulous communication between the kidney and colon constitutes an exceedingly rare clinical entity, being referred to only casually in the average textbook of urology. Despite the fact that Hippocrates first made mention of this condition, Mertz (1), in 1931, succeeded in collecting only 26 cases over the intervening centuries. Since the excellent clinical and anatomical review of the subject by Vermooten and McKeown (2), 12 additional cases have appeared in the literature. The most recent, and by far the most unique, recorded by Markowitz and Katz (3), was a fistulous connection between the lower pole of a double kidney and the colon. Careful analysis of the literature does not tend to indicate an increased frequency of occurrence, but rather an earlier recognition of chronic kidney disease by improved diagnostic procedures and proper surgical management. The first thorough investigation of renocolic fistula was done by Rayer (4), who believed that a chronic infection of the kidney produced the initial lesion, the adjacent colon becoming attached by fibrous adhesions with subsequent ulceration and fistula formation. To date, no instance of the condition has been reported as a result of a primary bowel lesion. The investigations of Wesson (5), Ratliff and Barnes (6), and Higgins and Hicken (7), show fistula formation to be incident to a chronic suppurative process of the kidney with an associated perinephritis or perinephric abscess. Ratliff also points out that tuberculosis was the least frequently encountered causative agent, occurring only five times in 37 cases reviewed, while renal calculi accounted for 14 cases and 18 were collectively listed as of inflammatory origin. The outstanding symptoms of renocolic fistula are chills and fever, renal colic, and tumor in the flank, which disappears with dramatic suddenness following perforation and evacuation of pus into the bowel. Except in a few of the early cases which were discovered at necropsy, the diagnosis has been made by urographic methods. Hirsch and Bass (8) are of the opinion that the lesion may go undiagnosed unless retrograde studies are made. Wesson (5) and Feldman (9) have each diagnosed a case with the aid of a barium enema. Case History A 42-year-old Austrian-born housewife was admitted to the hospital because of intermittent pain in the chest. Approximately nine months prior to admission, without preceding injury, she experienced a dull aching pain in the lower left chest, which was not aggravated by deep breathing. She denied cough, hemoptysis, or dyspnea, but gave a history of associated high fever with chills and night sweats. A local physician treated her for “pleurisy,” and the symptoms gradually subsided. A month later, the pain recurred, but in a more disabling manner, and failed to respond to the therapeutic measures previously administered. One evening a diarrhea developed, which was followed by marked weakness and the patient fainted.