Signs Of Renal Disease Research Articles

#1468 Alport syndrome family screening and management—experience of a tertiary center

Abstract Background and Aims Alport syndrome (AS) is the most common cause of inherited chronic kidney disease. This disorder is caused by deleterious variants on COL4A3, COL4A4 or COL4A5 genes. These genes codify the proteins that constitute collagen type IV of the glomerular basement membrane (GBM). Importantly, AS patients can develop chronic kidney disease (CKD) kidney disease that can be delayed or possibly prevented by timely initiation of therapy. The identification of at-risk relatives and their genetic testing allow to identify AS patients and initiate appropriate renal care and avoid unnecessary vigilance if the test is negative. Our aim was to assess the outcomes of Alport Syndrome cascade family screening in a tertiary hospital. Method In this study, we retrospectively assessed familial relatives at risk of AS index cases in our Nephrogenetics consult, from January 2018 to November 2023. After referral, routine tests to detect renal disease were done and AS gene panel was performed. Demographic and clinical data were also compiled. Results A total of 75 at-risk relatives were assessed, belonging to 26 families with a COL4A variant identified in the index case. Relatives at risk were mostly referred by primary care doctors (n = 52, 69.3%), with other 15 patients (20%) directly scheduled for consultation, and 8 (10.7%) referred by a nephrology clinic. In this cohort, an AS diagnosis was confirmed in 43 relatives (57.3%), with an additional 13 (17.3%) of the at-risk relatives with ongoing biochemical or molecular analyses. In 19 (25.4%) relatives the molecular study allowed the exclusion of AS. In the subgroup of patients diagnosed with AS (n = 43): median age at molecular diagnosis was 40.5 years (IQR 20.2-56.5years) and 26 (60.5%) were female. Thirty-five patients (81.4%) patients had autosomal dominant AS: 32 had a variant in COL4A3 (6 different variants were found: 4 were pathogenic or likely pathogenic and 2 were of uncertain significance) and 3 patients on COL4A4. COL4A5 variants were identified in 8 patients, 5 of them were female. Three (7%) patients presented with intermittent hematuria, 14 (32.6%) patients presented isolated hematuria, 10 (23.2%) patients had urinary protein/creatine (Up/cr) <0,3g/g, 7 (16.2%) presented Up/cr between 0.3g/g and 1g/g, 3 (7%) patients had Up/cr >1g/g; Six (14%) had CKD. Twenty-two (51.2%) patients were started on a renin angiotensin system inhibitor (RASi) and 5 (11.6%) were already under a RASi. At the last visit in this group of AS patients, the mean epiTFG was 104.2 ml/min (IQ 85.6-120-5 ml/min) and 6 (14%%) patients had epiTFG below 60 ml/min; mean Uprot/creat was 0.11g/g (IQR 0.06-0.32), 12 (28%) patients had no proteinuria. In the subgroup of relatives at risk were AS excluded (n = 19): median age was 38.5 years (IQR 20.2-56.0) and 11 (58%) were female. One patient had CKD, 7 (36.8%) had no signs of renal disease and 8 (42%) patients had intermittent hematuria. Conclusion Our retrospective review showed that the systematic screening of relatives at risk in our hospital was met with a high discovery rate of AS patients. Since there is clinical benefit in an early AS diagnosis, namely through improved renal care and prevention of disease progression, timely genetic/biochemical screening of at-risk relatives is advisable. Additionally, by discharging the relatives with a negative test, this is a more cost-effective approach than providing continuous vigilance to all.

Renal Phenotype in Mitochondrial Diseases: A Multicenter Study

Aims: This study aimed to investigate associations between renal and extrarenal manifestations of mitochondrial diseases and their natural history as well as predictors of renal disease severity and overall disease outcome. The secondary aim was to generate a protocol of presymptomatic assessment and monitoring of renal function in patients with a defined mitochondrial disease. Methods: A multicenter, retrospective cohort study was performed by the Mitochondrial Clinical and Research Network (MCRN). Patients of any age with renal manifestations associated with a genetically verified mitochondrial disease were included from 8 expert European centers specializing in mitochondrial diseases: Gothenburg, Oulu, Copenhagen, Bergen, Helsinki, Stockholm, Rotterdam, and Barcelona. Results: Of the 36 patients included, two-thirds had mitochondrial DNA-associated disease. Renal manifestations were the first sign of mitochondrial disease in 19%, and renal involvement was first identified by laboratory tests in 57% of patients. Acute kidney injury occurred in 19% of patients and was the first sign of renal disease in the majority of these. The most common renal manifestation was chronic kidney disease (75% with stage 2 or greater), followed by tubulopathy (44.4%), the latter seen mostly among patients with single large-scale mitochondrial DNA deletions. Acute kidney injury and tubulopathy correlated with worse survival outcome. The most common findings on renal imaging were increased echogenicity and renal dysplasia/hypoplasia. Renal histology revealed focal segmental glomerulosclerosis, nephrocalcinosis, and nephronophthisis. Conclusion: Acute kidney injury is a distinct renal phenotype in patients with mitochondrial disease. Our results highlight the importance to recognize renal disease as a sign of an underlying mitochondrial disease. Acute kidney injury and tubulopathy are 2 distinct indicators of poor survival in patients with mitochondrial diseases.

MARCADORES DA FUNÇÃO RENAL ATRAVÉS DA FILTRAÇÃO GLOMERULAR: UMA REVISÃO BIBLIOGRÁFICA

Currently, renal disease is a major public health problem that affects thousands of people in Brazil and worldwide, the kidneys are physiologically dynamic components of the system performing many functions, including the formation of urine, so it is paramount to early diagnosis the disease. The glomerular filtration rate is the main indicator of renal function in healthy subjects and patients. In this article the main markers of renal injury are assessed: creatinine, urea, proteinuria, cystatin, microalbuminuria. Early markers of renal damage are important because the glomerular filtration rate is reduced before the onset of symptoms or signs of renal disease are therefore important in the diagnosis of renal injury

CYSTATIN–C AS AN EARLY INDICATOR FOR INCIPIENT RENAL DISEASE IN RHEUMATOID ARTHRITIS-A HOSPITAL BASED CROSS SECTIONAL STUDY

Background: The aim of the present study was to examine the diagnostic capacity of this new parameter towards early signs of renal disease in patients suffering from prolonged RA requiring potential nephrotoxic therapy.
 Methods: The present study was a cross sectional observational type of study conducted in the department of medicine Mathura Das Mathur Hospital, Dr. S.N. Medical College, Jodhpur. A total of 50 subjects that fulfilled the inclusion and exclusion criteria were enrolled in the study after informed and written consent. As per methodology complete blood count, ESR, liver function test, kidney function test, cystatin-c, urine complete, 24 hours urine creatinine, USG abdomen for kidney size were performed.
 Results: cystatin–C level below 0.95 mg/dl was considered normal. 19 patients have normal and 31 patients have abnormal more than 0.95 mg/dl.
 Conclusion: In conclusion, as compared to serum creatinine, the determination of serum cystatin C is comparably simple, but by far more sensitive for the diagnosis of incipient renal damage in RA, and therefore valuable for clinical screening particularly in cases with prolonged antirheumatic treatment.
 Keywords: Cystatin C, RA, KFT

ULTRASONOGRAPHIC STUDY OF HUMAN RENAL VOLUME AND ITS CORRELATION WITH BODY MASS INDEX IN A TERTIARY TEACHING HOSPITAL.

Kidney is a paired organ whose functions include removing waste products from the blood and regulating the amount of fluid in the body. The basic units of the kidneys are called nephrons.
 They are situated posteriorly behind the peritoneum on each side of the vertebral column and are surrounded by adipose tissue. Superiorly they are level with the upper border of the 12th thoracic vertebra, inferiorly with the third lumbar vertebra. The kidney continues to grow in size after birth and reaches the near adult size of 10 cm by 12 years of age. Renal size decreases with increasing age among patients older than 60 years. Decrease or increase in kidney size is an important sign of renal disease. Decrease or increase in kidney size is an important sign of renal disease. Since the change in renal length may be an evidence of disease, it is important that we have normal reference values in relation to their age, gender, height, weight and body mass index and body surface area.in the present study the ultrasonographic assessment of left and right renal volume in different age groups and its relationship with body mass index of individuals was observed.
 Keywords: ultrasonography, Renal volume, Body mass index

Patient Outcomes of Henoch–Schönlein Purpura Nephritis According to the New Semiquantitative Classification

Background: A new semiquantitative classification (SQC) for pediatric Henoch–Schönlein nephritis (HSN) was defined recently. The outcomes of pediatric HSN patients are reevaluated according to the new classification. Methods: Primary kidney biopsies from 80 HSN patients were scored using the new SQC. The International Study of Kidney Disease in Children (ISKDC) and SQC classifications were compared in terms of the patient outcomes. Outcomes were defined as: Outcome A (n = 44) patients with no sign of renal disease, Outcome B (n = 32) patients with minor urinary abnormalities, and Outcome C (n = 4) patients with active renal disease. Results: The patients with outcome C had significantly higher biopsy scores and chronicity indices than patients in group A. There was no significant difference in areas under the curve between total biopsy SQC scores and ISKDC findings. Conclusions: Our results suggest that the modified SQC is not more sensitive than ISKDC classification for predicting the outcome in HSN cases.

Nephrology for urologists

By the very nature of things there are many overlaps between urology and nephrology. A close cooperation between the two disciplines is necessary for the benefit of the patient. From a nephrological perspective this article explains when and why participation of a nephrologist in treatment is recommended. In this context three essential points are explained: with respect to early recognition, renal hematuria, microalbuminuria, proteinuria, limited renal filtration function and glomerular filtration rate (GFR) are signs of renal disease; however, even patients with renal cysts should consult a nephrologist as early as possible due to the currently available treatment options. A delay in progression is possible and necessary for all chronic kidney diseases, independent of the trigger. Even when changes in the life style of the patient is troublesome and the adjustment of hypertension and hyperlipidemia sounds banal, their consistent implementation can result in a marked delay in the necessity for dialysis. The treatment of renal comorbidities is decisive and depends on the severity of the kidney disease. This includes the treatment of renal anemia, arterial hypertension, metabolic acidosis, uremic complications, electrolyte and water balance dysregulation and secondary hyperparathyroidism. By treating these comorbidities a marked reduction in the increased cardiovascular risk of nephrology patients can be achieved.

Copious Podocyturia without Proteinuria and with Normal Renal Function in a Young Adult with Fabry Disease.

The time for starting a patient with Fabry disease on enzyme replacement therapy is still a matter of debate, particularly when no overt classical clinical signs or symptoms are present. With respect to Fabry nephropathy, a dual problem coexists: the reluctance of many nephrologists to start enzyme replacement infusion until signs of renal disease appear as the appearance of proteinuria or an elevation in serum creatinine and the lack of validated biomarkers of early renal damage. In this regard, proteinuria is nowadays considered as an early and appropriate marker of kidney disease and of cardiovascular morbidity and mortality. However, in this report we demonstrate that podocyturia antedates the classical appearance of proteinuria and could be considered as an even earlier biomarker of kidney damage. Podocyturia may be a novel indication for the initiation of therapy in Fabry disease.

A Case of Nondiabetic Ketoacidosis in Third Term Twin Pregnancy

We report on a case of nondiabetic ketoacidosis due to mild starvation in a third term twin pregnancy. The aim was to present a case report and review of the literature in nondiabetic ketoacidosis in pregnancy, including precipitating factors and underlying pathophysiology. The case report includes collation of earlier data and literature review. The patient was admitted to the obstetrics ward of a large general hospital and, after cesarean section, was transferred to the intensive care unit. We present the case of a 26-yr-old obese patient with a 35-wk twin pregnancy. We provided appropriate management with fluid infusion after cesarean delivery. The patient and her two daughters survived, and no disabilities were foreseen. Alcohol, methanol, and lactic acid levels were normal. No signs of renal disease or diabetes were present. Pathological examination revealed no abnormalities of the placentae. Toxicological tests revealed a salicylate level of less than 5 mg/liter, an acetaminophen level of less than 1 mg/liter, and an acetone level of 300 mg/liter (reference, 5-20 mg/liter). We present a case of third term twin pregnancy with high anion gap metabolic acidosis due to (mild) starvation. Starvation, obesity, third term twin pregnancy, and perhaps a gastroenteritis were the ultimate provoking factors. In the light of the erroneous suspicion of sepsis and initial fluid therapy lacking glucose, one wonders whether, under a different fluid regime, cesarean section could have been avoided. Severe ketoacidosis in the pregnant woman is associated with impaired neurodevelopment. It therefore demands early recognition and immediate intervention.

The role of kidney biopsy in a patient with juvenile SLE with no urine abnormity or no signs of renal failure

Background Lupus nephritis belongs to the most serious organ involvements in juvenile systemic lupus erythematosus (SLE) and its adequate treatment is crucial for the prognosis of the disease. The intensity of the treatment should be determined by the kidney biopsy findings scored by the WHO or ISN/RPS classifications. Considering the benefits and risks of the kidney biopsy, some authors have suggested indications for its performance in lupus nephritis based on clinical manifestations comprising significant proteinuria, haematuria with proteinuria, presence of cellular casts and elevated serum creatinine. However, many studies have revealed notable discrepancies between the clinical signs and biopsy findings. Thus, performing kidney biopsy especially in a juvenile SLE patient with no clinical signs of renal disease remains controversial. Aim To emphasize the role of renal biopsy in patients with juvenile SLE with normal clinical kidney manifestations. Methods

Laboratory diagnostics in the elderly: cardiovascular disease

Increased life expectancy in industrialized countries has led to the progressive aging of the general population, this event is associated with a concomitant increase of Cardiovascular Disease (CVD) that represents not only the main cause of death but also one of the major causes of morbidity, inability and reduction of life quality in the elderly population. In the Western countries, Arterial Hypertension (AH) affects more than 50% of the elderly, and Heart Failure (HF) represents the most frequent diagnosis among hospital discharges among the elderly. The prevalence of type 2 diabetes mellitus (DM) also increases in the elderly population, reaching about the 7-10%. In this context, the role of laboratory diagnostics is fundamental to support the diagnosis, for monitoring drug therapy and its possible side effects. In patients with recent diagnosis of AI, it is crucial to perform a complete hemocromocytometric analysis, the evaluation of lipid and glucidic metabolism parameters, serum electrolytes, and creatinine and uric acid to evaluate renal function. Hemoglobin and hematocrit values can establish the presence of anemia, which can be a sign of renal disease. Fasting glucose can be used to define the diagnosis of DM, and in patients with previous a diagnosis it is useful to control the metabolic status that is correlated to the development of cardiovascular complications. Moreover in hypertensive patients, the presence of high blood glucose levels can mask a secondary form of AH, as do the potassium serum levels. In addition, in the elderly an impairment of the thyroid function should also be evaluated, as a possible cause of atrial fibrillation, that is the most frequent tachyarrhythmia in over 65 year olds. Finally, the diagnosis of HF in the elderly with different comorbidities can represent a very strong challenge; in this case, laboratory diagnostics can support the clinician in the diagnostic and therapeutic process. It is advisable to measure BNP/NT-proBNP to exclude/confirm the diagnosis of HF in patients with ambiguous clinical signs and symptoms that can be confused with other clinical conditions. Moreover, it is important to dose some laboratory parameters related to renal function to monitor possible side effects of drugs employed in chronic HF (CHF). Thus, in the management of the elderly affected by CVD, the laboratory is crucial and the kind and the frequency of laboratory tests are above all oriented by the patient’s clinical symptoms and signs, by the presence of target organ damage and the possible side effects of the employed drugs.

C3 NEPHRITIC FACTOR IN A PATIENT WITH RECURRENT NEISSERIA MENINGITIDIS INFECTIONS

A 15-year-old female experienced two systemic infections with N.meningitidis (group C and B) within a two months period. Classical as well as alternative pathway CH50 determinations on the patients serum showed no lysis. All individual complement factor concentrations, except for C3, were found to be within the reference area. Crossed immunoelectrophoretic analysis of C3 revealed no demonstrable native C3. The patient had normal levels of C3c and a markedly elevated C3d concentration. Serum from the patient was found to convert all native C3 in normal sera within 10 minutes at 37 degrees C. The active converting principle, present in the IgG fraction activated C3 in C4-depleted serum, and had a dose dependent stabilizing effect on the EA-C3bBb complex. The isolated factor showing the characteristics of C3 nephritic factor (C3 NeF), was unchanged in the patients serum over a ten months observation period. Circulating immune complexes (IC) could not be demonstrated by a C1q-dependent assay but the patients capacity to solubilize preformed IC in vitro was virtually abolished. The patient had no signs of renal disease or lipodystrophy.

Kidney Disease Is a Negative Predictor of 30-Day Survival after Acute Ischaemic Stroke

Background/Aims: Impaired renal function is a strong risk factor for cardiovascular diseases and worsens a patient’s prognosis. Renal dysfunction predicts mortality after acute stroke in the long term. On the other hand, in-hospital mortality after acute stroke is strongly associated with disorders of consciousness at the onset of stroke, severity of stroke, body temperature, blood sugar and some other comorbidities. The aim of the study was to analyze the possible role of renal dysfunction and/or signs of renal disease (proteinuria) on 30-day mortality after acute ischaemic stroke (AIS) based on the hospital medical records of one county. Methods: Medical records of 312 consecutive patients admitted to Ostrołęka County Hospital (Department of Neurology) between March 2000 and October 2002 for AIS were retrieved retrospectively to determine factors influencing 30-day survival. None of patients received thrombolytic therapy. Results: Among the patients analyzed, 74 (23.7%) died during the 30-day period. In a simple Cox proportional hazards regression model, negative predictive factors were: older age, higher pulse rate, lower estimated glomerular filtration rate (eGFR), proteinuria, elevated plasma glucose level, diabetes mellitus, atrial fibrillation and chronic heart failure. In a multivariate analysis, independent negative predictors of 30-day morbidity were: age hazard ratio (HR) 1.05 (95% CI 1.02–1.08), eGFR <60 ml/min HR 1.75 (95% CI 1.21–2.19), dipstick proteinuria HR 2.28 (95% CI 1.74–2.82) and plasma glucose level >100 mg/dl HR 2.96 (95% CI 2.22–3.70). Conclusion: The results of this study identify decreased eGFR and presence of dipstick proteinuria as a strong negative predictor of 30-day survival after AIS in patients not treated with thrombolytic agents.

Follow-up of Bernese Mountain dogs and other dogs with serologically diagnosed Borrelia burgdorferi infection: What happens to seropositive animals?

BackgroundData on the long-term outcome of B. burgdorferi infections in adult dogs are sparse. The aim of the present study was to investigate whether Bernese Mountain dogs with serological evidence of natural B. burgdorferi infection more often develop signs such as lameness, azotemia or proteinuria during a follow-up period of 2.5 to 3.0 years. Seropositive Bernese Mountain dogs were compared to seronegative Bernese Mountain dogs and to seropositive and seronegative control dogs of other breeds.Dogs included in a previous study on the prevalence of antibodies against B. burgdorferi in Bernese Mountain dogs were re-evaluated. Antibodies against B. burgdorferi were determined using an ELISA with a whole-cell sonicate as antigen and results were confirmed using a Western blot assay.ResultsFifty-three Bernese Mountain dogs and 30 control dogs were re-evaluated. Re-evaluation was performed between 2.5 and 3.0 years (median 2.7 years) after the first assessment.The age of the dogs at the second evaluation ranged from 3 to 11 years (median 6 years). There were no significant differences with regard to poor general condition or lameness between the first and the second evaluation.At the first evaluation 22 (42%) of the Bernese Mountain dogs and 11 (37%) of the control dogs were considered positive for antibodies against B. burgdorferi. At the second evaluation 25 (47%) of the Bernese Mountain dogs and 12 (40%) of the control dogs were considered positive; 69% of the dogs showed the same serological result at both examinations and 31% were seroconverted or seroreverted. During the first examination, azotemia was diagnosed in 6 Bernese Mountain dogs and during the second examination in 11 Bernese Mountain dogs. No control dogs had azotemia in this study. In seropositive dogs there was no increase in lameness or signs of renal disease over time.ConclusionIt may be concluded that antibodies against B. burgdorferi determined by whole cell ELISA and confirmed by Western blot were neither associated with the development of lameness nor with signs of renal disease like azotemia or proteinuria in dogs observed over a period of 2.5 to 3.0 years.

Estimating and measuring glomerular filtration rate in children

Glomerular filtration rate is the best determinant of kidney function in children. A decline in glomerular filtration rate may be the only sign of renal disease. A knowledge of glomerular filtration rate allows the clinician to appropriately dose medications, administer fluids, and intervene early to prevent end-stage renal failure. The aim of this review is to discuss the current options for determining glomerular filtration rate in children and the latest advances in research on this topic. Owing to the limited availability of inulin, the gold standard for measuring glomerular filtration rate, and the concern for using radioactivity, the plasma disappearance of iohexol has been utilized to measure glomerular filtration rate in children, and this represents a practical option for glomerular filtration rate determination in both clinical and research studies. By contrast, creatinine-based estimates of glomerular filtration rate (e.g. Schwartz formula) are more practical for bedside use. To improve their precision, recent formulas have incorporated the use of additional endogenous markers, such as cystatin C, albumin, and blood urea nitrogen. Iohexol plasma clearances should be used to accurately measure glomerular filtration rate in children. New estimating equations with multiple endogenous markers are being developed for everyday clinical use. However, at present, there is no substitute for an accurate glomerular filtration rate determination, particularly in children with conditions affecting muscle mass or body habitus.

Chronic kidney disease perspectives in Japan and the importance of urinalysis screening

There are racial differences in primary renal diseases for end-stage renal disease (ESRD) and the incidence and prevalence of cardiovascular disease (CVD). To reduce the number of patients with both ESRD and CVD, an effective screening method for CKD should be established. In Japan, screening with the urine dip-stick test for proteinuria has been used since 1972 targeting every child and worker and since 1983 for every resident over 40 years old. There are several reasons for continuing this screening program. First, the positive rate of proteinuria is high in the Japanese general population, especially subjects with neither hypertension nor diabetes. Most of these subjects have no symptoms, and the only sign of renal disease is asymptomatic urinary abnormalities. Second, the prevalence and incidence of glomerulonephritis, especially IgA nephropathy, are high in the Japanese and Asian races, and urinalysis is the only method for early detection of chronic glomerulonephritis. Third, 10-year survival of the ESRD patients due to glomerulonephritis was approximately twice that of ESRD patients due to diabetes and nephrosclerosis. Consequently, reducing the incidence of ESRD due to glomerulonephritis is one of the best ways to reduce the prevalence of ESRD. Furthermore, higher incidence of ESRD in Asian races than in Caucasians was reported. Proteinuria is known to be the best predictor for reducing renal function, and the urine dip-stick test for proteinuria is less expensive and is cost-effective. For an effective screening strategy to reduce the ESRD population in Japanese and Asians, universal screening with the urine dip-stick test for proteinuria could be one solution.

Effect of ACE and AT-2 inhibitors on mortality and progression to microalbuminuria in a nested case-control study of diabetic nephropathy in diabetes mellitus type 2: results from the GENDIAN study*

There is an established role of clinical risk factors such as arterial hypertension and smoking in causing cardiovascular morbidity and diabetic nephropathy (DNP). Genetic factors increase the risk for DNP. To examine the genetic risk, we initiated a case-control study with predefined follow-up examinations. We describe the study design and baseline characteristics under special consideration of comedication, and give preliminary results of the 4-year follow-up. We enrolled all 477 patients with DNP receiving maintenance hemodialysis in 30 centers in Southern Germany between August 1999 and January 2000. As controls, we enrolled all 482 diabetes mellitus type 2 patients without urinary microalbuminuria in two examinations on consecutive days and without other signs of renal disease in a large diabetes clinic from September 2000 to September 2001. Follow-up examinations are performed 4 and 6 years after inclusion by questionnaire and telephone interview to determine mortality and new morbidity. Controls progressing to novel DNP at follow-up, as defined by semiquantitative dipstick urinary albumin/creatinine ratio > 30 mg/g, are defined as cases in the study's nested case control component. At study inclusion in cases and controls, respectively, mean age was 67.3 +/- 8.2 and 58.1 +/- 11.2 years and duration of diabetes mellitus was 15.6 +/- 9.6 (at dialysis initiation) and 11.0 +/- 8.6 years. 328 controls (of which 25 had died and 14 did not perform urinalysis) were subjected to follow-up at 4 years, at a mean of 3.5 +/- 0.8 years after inclusion. 51.2% (n = 148) of living controls remained normalbuminuric, 33.9% (n = 98) had microor macroalbuminuria, and in 14.9% (n = 43) the dipstick test was inconclusive. There was no significant difference in progression to micro- or macroalbuminuria between controls treated with ACE or AT-2 inhibitors at baseline or not. Renal function as estimated by the abbreviated MDRD formula declined from 86.8 +/- 21.0 to 82.5 +/- 22.3 ml/min/1.73 m2 (p < 0.001). The decline was significant in patients on ACE or AT-2 inhibitors at baseline and not in patients without such medication at baseline. GENDIAN is a large case-control study designed to evaluate clinical and genetic determinants of DNP and other complications of long-standing diabetes mellitus type 2. We observed an association of ACE or AT-2 inhibitor therapy with cardiovascular comorbidity and a significant decline in renal function after a 4-year follow-up.

Continuum of therapy in progressive renal diseases (from predialysis to transplantation): Analysis of a new organizational model

In the aging of Western populations, decreased mortality is counterbalanced by an increase in morbidity, particularly involving chronic diseases such as most renal diseases. The price of the successful care of chronic conditions, such as cardiovascular diseases or diabetes, is a continuous increase in new dialysis patients. However, the increased survival of patients on chronic renal replacement therapies poses new challenges to nephrologists and calls for new models of care. Since its split from internal medicine, nephrology has seen a progressive trend toward super specialization and the differentiation into at least 3 major branches (nephrology, dialysis, and transplantation), following a path common to several other fields of internal medicine. The success in the care of chronic patients is owed not only to a careful technical prescription, but also to the ability to teach self-care and attain compliance; this requires good medical practice and a sound patient-physician relationship. In this context, the usual models of care may fail to provide adequate coordination and, despite valuable single elements, could end up as an orchestra without a conductor. We propose an integrated model of care oriented to the type of patient (tested in our area especially for diabetic patients): the patient is followed-up by the same team from the first signs of renal disease to eventual dialysis or transplantation. This model offers an interesting alternative both for patients, who usually seek continuity of care, and for nephrologists who prefer a holistic and integrated patient-physician approach.

Nephropathy in patients with recently diagnosed type 2 diabetes mellitus in black Africans.

Albuminuria is long recognised as a sign of renal disease in diabetes. In type 1 diabetes, renal disease occurs after a longer duration of diabetic state. In type 2 diabetes, it is more variable. To determine the prevalence and any risk factors of albuminuria in short-term (< or = 2 yrs) type 2 diabetes. Cross sectional, descriptive study. Microalbuminuria was assessed using micro II strips. Outpatient diabetic clinic at Kenyatta National Hospital, Nairobi. Patients who were newly diagnosed or had had type 2 diabetes for two years or less. Microalbuminuria, lipids, glycated haemoglobin, fasting blood glucose and blood pressure. One hundred and thirty nine patients who had type 2 diabetes mellitus for < or = 2 yrs were seen, but only 100 patients were included in the study over a six month period. Their mean (SD) age was 53.7 (9.3) years. Mean (SD) duration of diabetes was 10.3 (7.5) months. Fifty per cent of the study patients were hypertensive. Only 48% had HbA1c < 8% while 36% had HbA1c > 9%. The lipid profile of total, LDL-HDL-cholesterol and triglycerides were predominantly within normal limits. Twenty six per cent were established to have albuminuria of which one patient had macroalbuminuria. Blood pressure, glycated haemoglobin and lipid parameters were not significantly different from patients without albuminuria Albuminuria occurred in a significant proportion of patients with short term type 2 diabetes. Comparable to studies done elsewhere on short-term type 2 diabetes, albuminuria is both a sign of nephropathy and a cardiovascular risk factor. It should be looked for in all patients with type 2 diabetes attending this clinic, even at diagnosis.

Diabetic Renal Disease in Patients with Type 2 Diabetes Mellitus

Over the last 35 years an increasing number of patients with type 2 diabetes mellitus have developed advanced renal disease and the need for dialysis. At present in the US, about 50% of the patients in dialysis units have type 2 diabetes mellitus. The explanation for the increase in the number of patients with type 2 diabetes mellitus in end-stage renal disease programs is not completely clear, but the overall number of patients with this type of diabetes is rapidly increasing - and is expected to continue to increase over the next years. The diagnosis of renal disease in type 2 diabetes mellitus is usually straightforward, and is mainly dependent upon measurements of urinary albumin or urinary protein excretion as well as serum creatinine measurements. Renal biopsies or exact glomerular filtration rate measurements are rarely necessary. Microalbuminuria is the first sign of renal disease in diabetes mellitus. It predicts overt nephropathy and cardiovascular disease. Several studies document that albuminuria and microalbuminuria can be reduced by treatment with antihypertensives, especially agents that block the renin angiotensin system. New studies show that end-stage renal disease can be postponed by the use of angiotensin II receptor antagonists. ACE inhibitors are also useful, and dual blockade of the renin angiotensin system has been utilized as well. However, generally speaking, patients with proteinuria have a poor prognosis. Screening for microalbuminuria is therefore proposed, and glycemic control and blood pressure should be optimized.