Risk Of Chronic Renal Disease Research Articles

Coincidence of HCV and chronic kidney disease-a systematic review and meta-analysis

BackgroundThere are reported studies of Hepatitis C and chronic kidney disease association. However, how this liver virus infection affects the general population’s susceptibility to the onset of the kidney disease is still unknown.MethodsTo determine if a positive anti-HCV serologic status is linked to a greater incidence of chronic kidney disease in the general adult population, a systematic evaluation of the published medical literature since 2015 was conducted. A summary estimate of the relative risk of chronic kidney disease with HCV was produced using a random-effects model. Moreover, stratified analysis and meta-regression were performed.ResultsTwelve studies (n = 605858 patients) were filtered and included. Meta-analyses were conducted according to the outcome. Pooling results of longitudinal studies (n = 06 studies, n = 347120 unique patients) demonstrated an association between positive anti-HCV serologic status and increased incidence of CKD. The summary estimate for adjusted hazard ratio was 1.21 with (95% confidence interval 1.13; 1.29, P = 0.001), and between studies heterogeneity was noted (P value by Q test < 0.001). In the subset of Asian surveys, the risk of the occurrence of chronic kidney disease linked to HCV was 1.70 (95% confidence interval 1.40; 2.00) without heterogeneity (P value by Q test = 0.6).ConclusionsWe found a strong correlation between HCV infection and a higher risk of chronic renal disease in general global population.

Intraoperative hypotension during critical phases of liver transplantation and its impact on acute kidney injury: a retrospective cohort study

IntroductionAcute Kidney Injury (AKI) following Liver Transplantation (LT) is associated with prolonged ICU and hospital stay, increased risk of chronic renal disease, and decreased graft survival. Intraoperative hypotension is a modifiable risk factor associated with postoperative AKI. We aimed to determine in which phase of LT hypotension has the strongest association with AKI: the anhepatic or neohepatic phase. MethodsThis retrospective cohort study included adult patients undergoing LT between January 2010 and June 2022. Exclusion criteria were re-do or combined transplantations, preoperative dialysis, and early graft failure or death. Primary outcome was AKI as defined by KDIGO. Hypotension was Mean Arterial Pressure (MAP) below predefined thresholds in minutes. Risk adjusted logistic regression analysis considered hypotension in 3 periods: the total procedure, anhepatic phase, and neohepatic phase. ResultsOur cohort included 1153 patients. The median MELD-NA score was 19 (IQR 11–28), and 412 (35.9%) were living-related donations. AKI occurred in 544 patients (47.2%). The unadjusted model showed an association with AKI for MAP < 60 mmHg (OR = 1.011 [1.0, 1.022], p = 0.047) and MAP < 55 mmHg (OR = 1.023 [1.002, 1.047], p = 0.040) in the anhepatic phase, and for MAP < 60 mmHg (OR = 1.032 [1.01, 1.056], p = 0.006) in the neohepatic phase. The adjusted model did not reach significance in the subgroups but did in the total procedure: MAP < 60 mmHg (OR = 1.005 [1.002, 1.008], p < 0.001) and MAP < 55 mmHg (OR = 1.008 [1.003–1.013], p = 0.004). ConclusionIntraoperative hypotension is independently associated with AKI following LT. This association is seen during the anhepatic phase. Maintaining MAP above 60 mmHg may improve kidney function after LT.

The Significance of Exposure to Pregestational Type 2 Diabetes in Utero on Fetal Renal Size and Subcutaneous Fat Thickness.

Objectives To determine the relationship between exposure to pregestational type 2 diabetes (T2D) and renal size and subcutaneous fat thickness in fetuses during routine obstetrical ultrasound. Methods This was a case-control study (January 1, 2019 to December 31, 2019). Routine obstetrical ultrasounds performed between 18 and 22 weeks' gestation at a tertiary-care fetal assessment unit were reviewed. “Cases” comprised ultrasounds of fetuses exposed to pregestational T2D in utero. The control group was assembled from ultrasounds of healthy controls. Postprocessing measurements of fetal renal size and abdominal wall thickness from stored images were performed by two independent observers, and findings were compared between groups. Results There were 54 cases and 428 ultrasounds of healthy controls. The mean maternal age of cases was 32.1 years (SD 6.2) compared to 33.2 years (SD 5.3) for healthy controls, and the majority of ultrasounds were performed in multiparous patients (83%). At the 18 to 22 week ultrasound, there was a significant reduction in renal size amongst fetuses exposed to maternal T2D in utero compared to controls; among cases, the mean renal width was 8.0 mm (95% CI 7.8–8.1) compared to 11.4 mm (95% CI 10.6–12.7) in controls (p < 0.0001); the mean renal thickness among cases was 8.1 mm (95% CI 7.9–8.2) compared to 11.5 mm (95% CI 10.7–12.9) in controls (p=0.001). There was no obvious difference in estimated fetal weight between groups, yet fetuses exposed to maternal T2D had increased subcutaneous abdominal wall fat thickness at this early gestational age (p=0.008). Conclusions Fetal renal size in cases exposed to pregestational T2D is significantly smaller compared to controls, and subcutaneous abdominal wall fat is significantly thicker. Given emerging evidence about the developmental origins of disease, further study is needed to correlate the association between fetal renal size and fat distribution in the fetus and the long-term risk of chronic renal disease and diabetes in these offspring.

Risks of cardio-vascular diseases among highly active antiretroviral therapy (HAART) treated HIV seropositive volunteers at a treatment centre in Lagos, Nigeria.

Introductionhighly active antiretroviral therapy (HAART) has led to a decline in HIV-induced morbidity and mortality in recent years. However, it has been opined that this has led to elevated risks of cardiovascular diseases (CVDs). This study assessed the risks of CVDs among HAART experienced individuals living with HIV.Methodsa cross sectional study involving 196 adults consisting of 118 HAART experienced and 78 HAART naïve was conducted. Anthropometric and blood pressure measurements were recorded for all participants. Blood samples obtained from the volunteers were used to determine glucose, creatinine, HIV viral load, CD4 count and lipid profile using standard methods. Lipid ratios, atherogenic indices and QRISK3 risk score were calculated.Resultsthe median CD4 lymphocyte, mean body mass index (BMI) and HDL-c in HAART experienced participants were higher (P<0.05) than HAART naive individuals. The QRISK3 risk score and creatinine were higher (p<0.05) among HAART experienced group. In HAART experienced group, the risk of hypertension, increased low-density lipoprotein (LDL-c), atherogenic index of plasma (AIP) and QRISK3 were 3.7, 2.0, 2.38 and 3.85 times (p<0.05) higher respectively than in HAART naive. Atherogenic coefficient (AC) increase was more prevalent among male (p<0.05) participants. Risk of chronic renal disease (eGFR), hypertension and CVD (as measured by QRISK3) was higher (p<0.05) among the female and older participants respectively.Conclusionthe risk of CVDs and renal disease appeared to be higher among HAART experienced volunteers and older (>45 years) volunteers. The risk of renal disease appeared higher in females.

Assessment of lead food contamination and dietary intake in a Northern Italian population

Abstract Background Lead is a heavy metal naturally occurring in the environment and also released by some anthropogenic activities. Food is one the major sources of human exposure for non-occupationally exposed individuals. In this study, we aimed at characterizing lead (Pb) content in foods consumed in Northern Italy population, in order to estimate its dietary intake. Methods We measured lead content in 908 food and beverage samples bought at small shops and supermarkets of the Northern Italy provinces of Modena and Reggio Emilia, through inductively coupled plasma mass spectrometry. We used a validated semi-quantitative food frequency questionnaire to assess the dietary habits of a representative sample of 719 individuals (319 males and 400 females) aged 18-87 years residing in Northern Italy (Emilia Romagna). We estimated weekly dietary intakes of Pb, and we compared them with safety standards set by the European Food Safety Authority (EFSA). Results In this population, vegetables and vegetables products were the main contributors to Pb intake. The highest levels of Pb were in edible offal, and then in crustaceans, dry fruits, chocolate free sweet confectionery, and coffee and tea as beverages. In general, Pb levels in our samples were comparable and did not exceed the average contamination levels reported by EFSA in various European countries. We found a comparable average Pb intake in both sexes. Average weekly intake of Pb was below EFSA recommended provisional tolerable weekly intake. Conclusions Our study provides an updated assessment of lead exposure through diet in a Northern Italian community. Although environmental lead contamination and exposure have markedly decreased in the last decades, recent evidence pointed out that a safety threshold value cannot yet be established for prevention of adverse effects due to lead exposure, since even low levels of lead intake may still increase the risk of chronic renal disease and hypertension. Key messages Food is one the major lead sources of human exposure for non-occupationally exposed individuals. Lead levels in Northern Italian population studied are comparable and do not exceed the average contamination levels reported by European Food Safety Authority in various European countries.

Outcome of fetuses with lower urinary tract obstruction and normal amniotic fluid volume in second trimester of pregnancy.

Congenital lower urinary tract obstruction (LUTO) is a rare condition with high perinatal mortality and morbidity when associated with severe oligohydramnios or anhydramnios in the second trimester of pregnancy. Severe pulmonary hypoplasia and end-stage renal disease are the underlying causes of poor neonatal outcome in these cases. However, little is known about the subset of fetal LUTO that is associated with a normal volume of amniotic fluid at midgestation. The objective of the current study was to describe the natural history, underlying causes, survival and postnatal renal function outcomes in pregnancies with fetal LUTO and normal amniotic fluid volume during the second trimester of pregnancy. This was a retrospective study of all pregnancies with fetal LUTO and normal amniotic fluid volume in the second trimester that received prenatal and postnatal care at our quaternary care institution between 2013 and 2017. Data on demographic characteristics, fetal interventions, perinatal survival, need for neonatal respiratory support, postnatal renal function and need for dialysis at the age of 1 and 24 months were analyzed. Of the 18 fetuses that met the study criteria, 17 (94.4%) survived the perinatal period. Eleven (61.1%) pregnancies developed oligohydramnios in the third trimester, six of which were eligible for and underwent fetal intervention with vesicoamniotic shunt placement, which was performed successfully in all six cases. Two (11.1%) neonates required respiratory support owing to pulmonary hypoplasia. At the age of 2 years, 14 children had follow-up information available, two (14.3%) of whom had normal renal function, eight (57.1%) had developed some degree of chronic kidney disease (Stage 1-4) and four (28.6%) had developed end-stage renal disease (ESRD), including two who had already manifested ESRD in the neonatal period. Most fetuses diagnosed prenatally with LUTO that is associated with a normal volume of amniotic fluid at midgestation will have a favorable outcome in terms of perinatal survival and few will need long-term respiratory support. However, these children are still at increased risk for chronic renal disease, ESRD and need for renal replacement therapy. Larger multicenter studies are needed to characterize the prenatal factors associated with postnatal renal function, and to investigate the role of fetal intervention in the group of fetuses that present with late-onset oligohydramnios and evidence of preserved fetal renal function. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Gout is associated with a higher risk of chronic renal disease in older adults: a retrospective cohort study of U.S. Medicare population

BackgroundHyperuricemia and gout have been linked to chronic kidney disease (CKD). Whether the increased risk of CKD in gout is due to shared risk factors such as hypertension, diabetes or heart disease, or due to gout itself is not known. Studies in older adults, who tend to have a high incidence of CKD, are limited. Our objective was to assess whether gout was associated with incident CKD in older adults.MethodsUsing the 5% random sample of Medicare claims, we assessed whether gout is associated with higher risk of incident (new) CKD in adults 65 years or older, using multivariable-adjusted Cox regression analyses, adjusting for demographics (age, gender, race), medical comorbidity and common medications. We calculated hazard ratios (HR) and 95% confidence interval (CI). Sensitivity analyses varied comorbidity variable (models 2, 3), or limited CKD to the most specific codes.ResultsOf the 1,699,613 eligible people, 168,065 developed incident CKD; 150,162 people without gout and 17,903 people with gout. Respective crude incidence rates were 15.6 vs. 78.1 per 1000 person-years. We found that gout was associated with a higher risk of incident CKD in multivariable-adjusted analyses, HR was 3.05 (95% CI, 2.99, 3.10), with minimal attenuation in sensitivity analyses, with HR 2.96 (95% CI, 2.91, 3.01) (model 2, categorical Charlson-Romano) and 2.59 (95% CI, 2.54, 2.63) (model 3, individual Charlson-Romano comorbidities plus hypertension, heart disease, obesity, coronary artery disease). Sensitivity analyses that limited the CKD diagnostic codes to more specific codes, confirmed findings from the main models with respective HRs of 3.10 (95% CI, 3.05, 3.15; Model 1), 3.03 (95% CI, 2.97, 3.08; Model 2) and 2.60 (95% CI, 2.56, 2.65; Model 3).ConclusionGout was associated with a 3-fold higher risk of CKD, confirmed in multiple sensitivity analyses. Future studies should provide insights into underlying mechanisms that are responsible for an increased CKD risk in gout.

Acute Kidney Injury in Children With Type 1 Diabetes Hospitalized for Diabetic Ketoacidosis

Acute kidney injury (AKI) in children is associated with poor short-term and long-term health outcomes; however, the frequency of AKI in children hospitalized for diabetic ketoacidosis (DKA) has not been previously examined. To determine the proportion of children hospitalized for DKA who develop AKI and to identify the associated clinical and biochemical markers of AKI. This medical record review of all DKA admissions from September 1, 2008, through December 31, 2013, was conducted at British Columbia Children's Hospital, the tertiary pediatric hospital in British Columbia, Canada. Children aged 18 years or younger with type 1 diabetes and DKA and with complete medical records available for data analysis were included (n = 165). All data collection occurred between September 8, 2014, and June 26, 2015. Data analysis took place from August 25, 2015, to June 8, 2016. Acute kidney injury was defined using Kidney Disease/Improving Global Outcomes serum creatinine criteria. Multinomial logistic regression was used to identify potential factors associated with AKI. Of the 165 children hospitalized for DKA, 106 (64.2%) developed AKI (AKI stage 1, 37 [34.9%]; AKI stage 2, 48 [45.3%]; and AKI stage 3, 21 [19.8%]). Two children required hemodialysis. In the adjusted multinomial logistic regression model, a serum bicarbonate level less than 10 mEq/L (compared with ≥10 mEq/L) was associated with a 5-fold increase in the odds of severe (stage 2 or 3) AKI (adjusted odds ratio [aOR], 5.22; 95% CI, 1.35-20.22). Each increase of 5 beats/min in initial heart rate was associated with a 22% increase in the odds of severe AKI (aOR, 1.22; 95% CI, 1.07-1.39). Initial corrected sodium level of 145 mEq/L or greater (compared with 135-144 mEq/L) was associated with a 3-fold increase in the odds of mild (stage 1) AKI (aOR, 3.29; 95% CI, 1.25-8.66). There were no cases of mortality in patients with or without AKI. This study is the first to date to document that a high proportion of children hospitalized for DKA develop AKI. Acute kidney injury was associated with markers of volume depletion and severe acidosis. Acute kidney injury is concerning because it is associated with increased morbidity and mortality as well as increased risk of chronic renal disease, a finding that is especially relevant among children who are already at risk for diabetic nephropathy. Strategies are needed to improve the diagnosis, management, and follow-up of AKI in children with type 1 diabetes.

Risk of renal disease in patients with both type 1 diabetes and coeliac disease

Our aim was to study the risk of renal disease in patients with type 1 diabetes (T1D) and coexisting coeliac disease (CD). Individuals with T1D were defined as having a diagnosis of diabetes recorded at ≤30 years of age in the Swedish Patient Register between 1964 and 2009. Individuals with CD were identified through biopsy reports with villous atrophy (Marsh stage 3) from 28 pathology departments in Sweden between 1969 and 2008. We identified 954 patients with both T1D and CD. For each patient with T1D + CD, we selected five age- and sex-matched reference individuals with T1D only (n = 4,579). Cox regression was used to estimate the following risks: (1) chronic renal disease and (2) end-stage renal disease in patients with CD + T1D compared with T1D patients only. Forty-one (4.3%) patients with CD + T1D and 143 (3.1%) patients with T1D only developed chronic renal disease. This corresponded to an HR of 1.43 for chronic renal disease (95% CI 0.94, 2.17) in patients with CD + T1D compared with T1D only. In addition, for end-stage renal disease there was a positive (albeit statistically non-significant) HR of 2.54 (95% CI 0.45, 14.2). For chronic renal disease, the excess risk was more pronounced after >10 years of CD (HR 2.03, 95% CI 1.08, 3.79). Risk estimates were similar when we restricted our cohort to the following T1D patients: (1) those who had an inpatient diagnosis of T1D; (2) those who had never received oral glucose-lowering medication; and (3) those who had not received their first diabetes diagnosis during pregnancy. Overall this study found no excess risk of chronic renal disease in patients with T1D and CD. However, in a subanalysis we noted a positive association between longstanding CD and chronic renal disease in T1D.

Body Mass Index, Fatty Liver Index and Other Metabolic Disturbances Differentially Affect Albuminuria and Glomerular Filtration Rate in the General Population

Objective: Obesity and diabetes mellitus increase the risk of chronic renal disease. However, whether body mass index (BMI) and metabolic disturbances are associated with renal dysfunction and affect similarly albuminuria and estimated glomerular filtration rate (eGFR) are less clear. Hence, the aim of this study was to describe these associations in the general French population. Methods: We realised a large cross-sectional study of 118,314 subjects aged ≥ 40 years undergoing a medical examination in 11 French regional health centers. Results: Renal dysfunction ((abnormal albuminuria (≥ 30 mg/g) and/or low eGFR ( 40: 7.35 [5.89-9.15]) had a greater risk of abnormal albuminuria than subjects with normal weight. In contrast, the relationship between BMI - or other metabolic disturbances- and low eGFR was continuous. Metabolic disturbances increased the risk of abnormal albuminuria to a greater extent than the risk of abnormal eGFR. High fatty liver index and high calculated risk of developing diabetes were risk factors for both abnormal albuminuria and low eGFR. Conclusion: There is a J-curve relationship between BMI and abnormal albuminuria, in contrast to the continuous association between other metabolic disturbances and abnormal eGFR. All metabolic disturbances are associated with abnormal albuminuria, but the association with abnormal eGFR is less clear, suggesting a stronger relationship with endothelial than renal dysfunction. Abnormal albuminuria and eGFR may precede the onset of diabetes.

Risk Factors for Renal Scar Formation in Infants With First Episode of Acute Pyelonephritis: A Prospective Clinical Study

We prospectively determined the risk factors for renal scar formation after the first episode of acute pyelonephritis as confirmed on dimercapto-succinic acid scintigraphy in children younger than 1 year. A total of 213 infants with acute pyelonephritis were enrolled in the study. Infants with urological abnormalities other than vesicoureteral reflux were excluded from analysis. Followup scanning was performed 6 months after acute pyelonephritis and voiding cystourethrography was performed after the acute phase of infection. Possible risk factors were evaluated including gender, peak fever, duration of fever before and after treatment with antibiotics, white blood cell count, C-reactive protein concentration, presence of vesicoureteral reflux and reflux grade. Six months after acute pyelonephritis 37 of 213 (17.4%) infants and 41 of 248 (16.5%) renal units with acute photon defects on initial dimercapto-succinic acid scintigraphy had renal scars. The rates of scar formation were significantly higher in infants with vesicoureteral reflux than in those without (39.4% vs 7.5%, p <0.001, OR 9.433) and in renal units with vesicoureteral reflux than in those without (39.4% vs 8.2%, p <0.001, OR 7.237). Renal scar formation was related to reflux grade (none-8.2%, grade I-20%, grade II-22.7%, grade III-40%, grade IV-70%, grade V-55.6%, p <0.001) but not to any other clinical or laboratory variables. The presence of vesicoureteral reflux was the only independent risk factor for renal scar formation after acute pyelonephritis in infants. The prevalence of renal scarring was significantly correlated with reflux grade. Voiding cystourethrography is necessary in infants after the first acute pyelonephritis episode is confirmed on dimercapto-succinic acid renal scintigraphy.

Association between arsenic exposure from drinking water and proteinuria: results from the Health Effects of Arsenic Longitudinal Study

Proteinuria has been recognized as a marker for an increased risk of chronic renal disease. It is unclear whether arsenic (As) exposure from drinking water is associated with proteinuria. We evaluated the association between As exposure from drinking water and proteinuria in 11,122 participants in the Health Effects of Arsenic Longitudinal Study (HEALS). Proteinuria was detected by urinary dipstick tests at baseline and at 2-year intervals. As exposure variables included baseline well As and changes in urinary As during follow-up modelled as time-dependent variables in the analyses. At baseline, well As was positively related to prevalence of proteinuria; prevalence odds ratios (PORs) for proteinuria in increasing quintiles of well As (≤ 7, 8-39, 40-91, 92-179 and 180-864 µg/l) were 1.00 (ref), POR 0.99 [95% confidence interval (CI) 0.77-1.27], POR 1.23 (95% CI 0.97-1.57), POR 1.50 (95% CI 1.18-1.89) and POR 1.59 (95% CI 1.26-2.00) (P for trend <0.01). Hazard ratios for incidence of proteinuria were POR 0.83 (95% CI 0.67-1.03) and POR 0.91 (95% CI 0.74-1.12) for participants with a decreasing level of >70 and 17-70 µg/l in urinary As over time, respectively, and were POR 1.17 (95% CI 0.97-1.42) and POR 1.42 (95% CI 1.16-1.73) for participants with an increasing level of 16-68 and >68 µg/l in urinary As over time, respectively, compared with the group with relatively little changes in urinary As as the reference group (urinary As -16 to 15 µg/l). The findings suggest that there are adverse effects of As exposure on the risk of proteinuria and the effects are modifiable by recent changes in As exposure.

Risk for Renal Cell Carcinoma in Chronic Hepatitis C Infection

Chronic infection with hepatitis C virus (HCV) confers increased risk for chronic renal disease, and numerous reports suggest an association with renal cell carcinoma (RCC), a cancer with rapidly rising global incidence. We sought to determine whether HCV infection confers an increased risk for developing RCC. With the use of administrative data from a large, integrated, and ethnically diverse healthcare system, we did a cohort study of 67,063 HCV-tested patients between 1997 and 2006 who were followed for the development of RCC until April 2008. A search of the health system cancer registry for patients with the diagnosis of kidney cancer showed that RCC was diagnosed in 0.6% (17 of 3,057) of HCV-positive patients versus 0.3% (177 of 64,006) of HCV-negative patients. The mean age at RCC diagnosis was much younger in HCV-positive individuals (54 versus 63; P < 0.001). The univariate hazard ratio for RCC among HCV patients was 2.20 (95% confidence interval, 1.32-3.67; P = 0.0025). In a multivariate model that included the risk factors age, African-American race, male gender, and chronic kidney disease, the overall hazard ratio for RCC among HCV patients was 1.77 (95% confidence interval, 1.05-2.98; P = 0.0313). Chronic HCV infection confers a risk for the development of RCC. Clinicians should consider newly identified renal lesions in patients with chronic HCV infection with a heightened suspicion for neoplasm, and newly diagnosed cases of RCC may require more careful surveillance for the presence of HCV infection. Additional studies are required to confirm these findings and to explore potential mechanisms of oncogenesis.

Metabolic syndrome and chronic kidney disease

Obesity is fast becoming a bane for the present civilization, as a result of sedentary lifestyle, atherogenic diet, and a susceptible thrifty genotype. The concept of metabolic syndrome, which is a constellation of metabolic disturbances, has crystallized over the last 80 years with the aim of identifying those at greater risk of developing type 2 diabetes and cardiovascular disease. These patients have visceral obesity and insulin resistance characterized by hypertyriglyceridemia. Recently, it has been realized that they are also at an increased risk of chronic renal disease. Release of adipocytokines leads to endothelial dysfunction. There is also activation of systemic and local renin-angiotensin-aldosterone system, oxidative stress, and impaired fibrinolysis. This leads to glomerular hyperfiltration, proteinuria, focal segmental glomerulosclerosis (FSGS), and ultimately end-stage renal disease (ESRD). Treatment consists of lifestyle modifications along with optimal control of blood pressure, blood sugar and lipids. Metformin and thiazolidenidiones reduce insulin resistance; while angiotensin converting enzyme inhibitors and angiotensin receptor blockers reduce proteinuria and have a renoprotective effect. Exciting new medical therapies on the horizon include rimonabant a cannabinoid receptor type 1 antagonist, soy proteins, and peroxisome proliferator-activated receptor (PPAR) agonist. Bariatric surgery for morbid obesity has also been shown to be effective in treating metabolic syndrome.

Recommendations for early diagnosis of chronic kidney disease

Chronic kidney disease is an important component of chronic non - communicable diseases that are now of pandemic proportions and are the major cause of morbidity and mortality worldwide. Patients with reduced renal function represent a population not only at risk for progression of kidney disease and development of end stage renal disease (ESRD), but also at a greater risk of cardiovascular disease and mortality. Unfortunately, chronic kidney disease is under diagnosed and undetected resulting in lost opportunities for improving the clinical outcome. Early diagnosis with appropriate interventions will improve the quality of care of patients and prevent or delay progression to end stage renal disease. Our objective is to review existing recommendations and examine their adaptation to improving the quality of care for patients with chronic kidney disease in our environment. Hand searches of published articles and electronic data were the primary sources. Only articles published in the English language were consulted excluding case reports, letters and conference abstracts. Articles of original data were searched from 1980 while review articles and expert committee reports were from 2000. Early diagnosis of chronic kidney disease is crucial to improving the clinical outcome and reducing the incidence of end stage renal disease. Certain individuals with specific socio demographic and clinical factors are at increased risk of chronic renal disease. All individuals should be assessed as part of routine health encounter, to determine whether they are at increased risk of developing chronic kidney disease based on clinical and socio demographic factors. Individuals at increased risk of developing chronic kidney disease should undergo testing for markers of kidney damage, and to estimate the level of GFR. Individuals found to have chronic kidney disease should be evaluated and treated appropriately. A clinical action plan should be developed for each patient based on the type and stage of renal disease, co-morbid conditions, complications of the disease and risk factors for progression of renal disease or development of cardiovascular disease. Individuals at increased risk, but found not to have chronic kidney disease, should be advised to follow of risk factor reduction, if appropriate, and undergo repeat periodic evaluation.

Coeliac disease and risk of renal disease—a general population cohort study

Coeliac disease (CD) may be a risk factor for renal disease. We investigated the risk of any form of glomerulonephritis (GN) (acute, chronic and non-specified), chronic glomerulonephritis (CGN) and renal replacement therapy including dialysis treatment and kidney transplantation (KT) in patients with CD in a general population-based cohort study. We used Cox regression to assess the risk of renal disease in 14,336 patients who had received a diagnosis of CD (1964-2003) and 69,875 reference individuals matched for age, calendar year, sex and county. Patients were identified using the Swedish Hospital Discharge Registry. Follow-up began 1 year after study entry. CD was associated with an increased risk of any form of GN (hazard ratio (HR) = 1.64; 95% confidence intervals (CI) = 1.01-2.66; P = 0.046; 89 events), CGN (HR = 2.65; 95% CI = 1.34-5.24; P = 0.005; 39 events), dialysis (HR = 3.48; 95% CI = 2.26-5.37; P < 0.001; 102 positive events) and KT (HR = 3.15; 95% CI = 1.29-7.71; P = 0.012; 22 events). We suggest that immune characteristics associated with CD increase the risk of chronic renal disease. Individuals with CD may also be at a moderately increased risk of any form of GN.

Impact of implementation of the MELD scoring system on the prevalence and incidence of chronic renal disease following liver transplantation

The implementation of the model for end-stage liver disease (MELD) score decreased mortality of those awaiting liver transplantation (LT); however, the impact of the MELD allocation system on the risk of chronic renal disease after LT remains unknown. We conducted a non-concurrent single-center cohort study of 174 patients undergoing LT at our center. We compared patients who underwent LT one year prior to MELD implementation (pre-MELD cohort) to those patients who underwent LT 1 year following MELD implementation (MELD cohort). All patients were followed for at least 2 years after LT. Stage 3 chronic renal disease (CRD-3) was defined by an estimated creatinine clearance (CL(Cr)) below 60 ml/min/1.73 m2, and stage 4 chronic renal disease (CRD-4) was defined by an estimated CL(Cr) below 30 mL/min/1.73 m2 according to the validated Modification of Diet and Renal Disease (MDRD) formula. Requirement of kidney transplantation and need for hemodialysis were also evaluated following LT. The pre-MELD cohort (n=97) and the MELD cohort (n=77) were comparable in baseline characteristics, prevalence of diabetes and hypertension, and immunosuppression. Mean calculated MELD score in the pre-MELD cohort was significantly lower than in the MELD cohort (16 vs. 19, P < 0.05). The estimated CL(Cr) at time of LT was lower in the MELD cohort compared with the pre-MELD cohort (75 vs. 95, P < 0.01). However, the incidence and prevalence of CRD-3 and CRD-4 at 6, 12, and 24 months after LT were comparable between the two cohorts. Need for kidney transplantation or hemodialysis after LT was comparable between the groups. In multivariate analysis, serum creatinine at LT was the only variable associated with the development of CRD-3 in the first 2 years after LT. In conclusion, the implementation of the MELD allocation system is not associated with increased mortality or occurrence of CRD-3 or CRD-4 in the first 2 years after LT.

The Clustering of Other Chronic Inflammatory Diseases in Inflammatory Bowel Disease: A Population-Based Study

We aimed to discern the relative risk for several chronic inflammatory conditions in patients with ulcerative colitis (UC) and Crohn's disease. We used the population-based University of Manitoba IBD Database that includes longitudinal files on all patients from all health system contacts identified by International Classification of Diseases, 9th revision, Clinical Modification codes for visit diagnosis. From the provincial database we extracted a control cohort matching the IBD patients 10:1 by age, sex, and geography. We considered a potential comorbid disease to be present if the patient had 5 or more health system contacts for that diagnosis. The comorbid disease period prevalence was analyzed separately for patients with UC and Crohn's disease and a prevalence ratio was calculated comparing the IBD populations with the matched cohort. There were 8072 cases of IBD from 1984 to 2003, including UC (n = 3879) and Crohn's disease (n = 4193). There was a mean of approximately 16 person-years of coverage for both patients and control patients. Both UC and Crohn's disease patients had a significantly greater likelihood of having arthritis, asthma, bronchitis, psoriasis, and pericarditis than population controls. An increased risk for chronic renal disease and multiple sclerosis was noted in UC but not Crohn's disease patients. The most common nonintestinal comorbidities identified were arthritis and asthma. The finding of asthma as the most common comorbidity increased in Crohn's disease patients compared with the general population is novel. These may be diseases with common causes or complications of one disease that lead to the presentation with another. Studies such as this should encourage further research into the common triggers in the organ systems that lead to autoimmune diseases.

Analgesic Use and Renal Function in Men

Several case-control studies suggest an association between analgesic use and increased risk of chronic renal disease, but few cohort studies have examined this association. To determine whether analgesic use is associated with risk of renal dysfunction. Cohort study of analgesic use data from the Physicians' Health Study, which lasted 14 years from September 1982 to December 1995 with annual follow-up. A total of 11 032 initially healthy men who provided blood samples and self-report of analgesic use. Elevated creatinine level defined as 1.5 mg/dL (133 micromol/L) or higher and a reduced creatinine clearance defined as 55 mL/min (0.9 mL/s) or less, and self-reported use of acetaminophen, aspirin, and other nonsteroidal anti-inflammatory drugs (never [<12 pills]; 12-1499 pills; 1500-2499 pills; and >/=2500 pills). A total of 460 men had elevated creatinine levels (4.2%) and 1258 had reduced creatinine clearance (11.4%). Mean creatinine levels and creatinine clearances were similar among men who did not use analgesics and those who did, even at total intakes of 2500 or more pills. In multivariable analyses adjusted for age; body mass index; history of hypertension, elevated cholesterol, and diabetes; occurrence of cardiovascular disease; physical activity; and use of other analgesics, the relative risks of elevated creatinine level associated with intake of 2500 or more pills were 0.83 (95% confidence interval [CI], 0.50-1.39; P for trend =.05) for acetaminophen, 0.98 (95% CI, 0.53-1.81; P for trend =.96) for aspirin, and 1.07 (95% CI, 0.71-1.64; P for trend =.86) for other nonsteroidal anti-inflammatory drugs. No association was observed between analgesic use and reduced creatinine clearance. Moderate analgesic use in this cohort study of initially healthy men was not associated with increased risk of renal dysfunction.

Voiding cystourethrograms and urinary tract infections: how long to wait?

Many authorities recommend an interval of at least 3 to 6 weeks after a urinary tract infection (UTI) before performing a voiding cystourethrogram (VCUG). However, such an interval may reduce the likelihood of completing the procedure. This study was performed to investigate whether the length of the interval between a UTI and the performance of the VCUG influences the presence or severity of reflux, and whether it influences the likelihood of actually having the study performed. We reviewed 352 admissions of children under 10 years old whose discharge diagnoses indicated UTIs. These admissions occurred over a 27-month period between October 1994 and December 1996 at the Children's Hospital of Austin, Texas. We identified 213 patients with confirmed UTIs and no other previously defined urinary tract pathology. These patients were divided into 2 groups according to whether they had a VCUG scheduled to be performed either within 1 week after the diagnosis of a UTI (the early group), or later than 1 week after the diagnosis (the late group). We compared the presence and severity of reflux in the 2 groups as well as the proportion of scheduled VCUGs that were actually performed. Reflux was present in 19% of the patients studied within 1 week after UTI (95% confidence interval [CI]: 12.9-26.4) and in 18% of those studied after 1 week (95% CI: 6. 7-34.5). This difference was not statistically significant (chi(2) =. 034; DF = 1). However there was a substantial difference between the 2 groups with regard to the number of scheduled VCUGs actually performed. Whereas 100% of the scheduled VCUGs in the early group were performed, only 48% (95% CI: 35.9-60.1) of those scheduled in the late group were performed. This difference is statistically significant (chi(2) = 89.6; DF = 1). In the hospitalized children who underwent VCUGs within a week after diagnosis of UTI, the presence of reflux is not significantly different from those studied later. Furthermore, late scheduling of VCUGs resulted in failure to perform the procedure in more than half of the patients. Some of the patients who were not evaluated would be expected to have vesicoureteral reflux and thus be at risk for chronic renal disease. Therefore, the traditional recommendation to perform the VCUG at 3 to 6 weeks after the diagnosis of UTI should be reconsidered, especially for hospitalized children.