Stable Chronic Kidney Disease Research Articles

ESPEN guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease

Acute kidney disease (AKD) - which includes acute kidney injury (AKI) - and chronic kidney disease (CKD) are highly prevalent among hospitalized patients, including those in nephrology and medicine wards, surgical wards, and intensive care units (ICU), and they have important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, whatever is the modality used, the possible impact on nutritional profiles, substrate balance, and nutritional treatment processes cannot be neglected. The present guideline is aimed at providing evidence-based recommendations for clinical nutrition in hospitalized patients with AKD and CKD. Due to the significant heterogeneity of this patient population as well as the paucity of high-quality evidence data, the present guideline is to be intended as a basic framework of both evidence and - in most cases - expert opinions, aggregated in a structured consensus process, in order to update the two previous ESPEN Guidelines on Enteral (2006) and Parenteral (2009) Nutrition in Adult Renal Failure. Nutritional care for patients with stable CKD (i.e., controlled protein content diets/low protein diets with or without amino acid/ketoanalogue integration in outpatients up to CKD stages four and five), nutrition in kidney transplantation, and pediatric kidney disease will not be addressed in the present guideline.

Systematic Review of Safety and Efficacy of COVID-19 Vaccines in Patients With Kidney Disease

Systematic Review of Safety and Efficacy of COVID-19 Vaccines in Patients With Kidney Disease

Urinary calprotectin, NGAL, and KIM-1 in the differentiation of primarily inflammatory vs. non-inflammatory stable chronic kidney diseases

Introduction It has been demonstrated that urinary neutrophil gelatinase-associated lipocalin (NGAL) and calprotectin are helpful biomarkers in the differentiation of intrinsic and prerenal acute kidney injury. Objective The present cross-sectional study investigates, whether urinary biomarkers are able to differentiate primarily inflammatory from non-inflammatory entities in chronic kidney disease (CKD). Methods Urinary calprotectin, NGAL, and kidney injury molecule-1 (KIM-1) concentrations were assessed in a study population of 143 patients with stable CKD and 29 healthy controls. Stable renal function was defined as an eGFR fluctuation ≤5 ml/min/1.73 m2 in the past 12 months. Pyuria, metastatic carcinoma, and renal transplantation were regarded as exclusion criteria. Diabetic nephropathy, hypertensive nephropathy, and polycystic kidney disease were categorized as ‘primarily non-inflammatory renal diseases’ (NIRD), whereas glomerulonephritis and vasculitis were regarded as ‘primarily inflammatory renal diseases’ (IRD). Results Urinary calprotectin and NGAL concentrations significantly differed between CKD and healthy controls (p < 0.05 each), whereas KIM-1 concentrations did not (p = 0.84). The three biomarkers did neither show significant differences in-between the individual entities, nor the two categories of IRD vs. NIRD (calprotectin 155.7 vs. 96.99 ng/ml; NGAL 14 896 vs. 11 977 pg/ml; KIM-1 1388 vs. 1009 pg/ml; p > 0.05 each). Albumin exceeds the diagnostic power of the investigated biomarkers by far. Conclusions The urinary biomarkers calprotectin, NGAL, and KIM-1 have no diagnostic value in the differentiation of primarily inflammatory vs. non-inflammatory etiologies of CKD.

Coronavirus disease 2019 vaccination in patients with chronic kidney diseases

Patients with chronic kidney disease (CKD) are at high risk for coronavirus disease 2019 (COVID-19). Government agencies or learned societies in many countries recommend prioritizing patients with CKD for COVID-19 vaccines. The immune response rate to the COVID-19 vaccines is lower in hemodialysis patients and kidney transplant recipients compared with that in healthy individuals, and increasing the number of vaccinations each member of these population may improve their immune response rate. There was no significant difference in the incidence of adverse reactions after vaccination between patients with CKD and healthy controls. Patients with stable CKD should be vaccinated against COVID-19 unless there were contraindications to vaccination. The mRNA vaccines, inactivated vaccines, and recombinant protein subunit vaccines are all safe for patients with CKD. Patients with CKD treated with rituximab or high-dose glucocorticoid need to weigh the benefits and risks before vaccination, and COVID-19 vaccines can be given when rituximab treatment ends for more than 6 months or after glucocorticoid reduction. Copyright © 2021 by the Chinese Medical Association.

Evaluation of platelet function in cats with and without kidney disease: a pilot study.

The aims of this study were to determine if stable chronic kidney disease (CKD) cats and uremic crisis cats have altered platelet function, and to determine the prevalence of positive fecal occult blood in CKD cats. Platelet function in normal cats, clinically stable International Renal Interest Society (IRIS) stage 2-4 CKD cats and CKD cats experiencing a uremic crisis were evaluated using impedance aggregometry. Area under the curve (AUC) at 6 mins was calculated for saline, adenosine diphosphate (AUCADP) and arachidonic acid (AUCASPI). The AUC in addition to hematocrit, platelet count and mean platelet volume (MPV) were compared between groups using the Kruskal-Wallis test followed by Dunn's post-hoc analysis. Guaiac fecal occult blood tests were performed on fecal samples and results were compared between groups using a χ2 for trend test. AUCADP (P = 0.04) and AUCASPI (P = 0.05) were significantly higher in uremic crisis cats compared with normal cats at 6 mins. Hematocrit was significantly higher in normal cats when compared with IRIS stage 3 and 4 (P = 0.002) and uremic crisis (P = 0.0008) cats, with no difference among groups for platelet count or MPV. The proportion of cats with positive fecal occult blood samples was significantly different between groups (P = 0.0017); 50% uremic crisis cats, 33% IRIS stage 3 and 4 cats, and 10% IRIS stage 2 cats were positive, while no normal cats were positive. The proportion of cats with platelet clumping was significantly different between groups (P = 0.03). Platelet hyper-reactivity may be occurring in CKD cats experiencing a uremic crisis. The etiology of positive fecal occult blood samples in CKD cats is unclear and did not appear to be related to decreased platelet function as measured in this study and requires further investigation.

Urinay neutrophil gelatinase-associated lipocalin as a biomarker in different renal problems

Background/aimNeutrophil gelatinase-associated lipocalin (NGAL) is used previously to estimate the etiology, severity, and clinical outcomes of acute kidney injury (AKI). However, the role of urinary NGAL (uNGAL) in the postrenal setting is not clear. In our study, we aimed to discover the cut-off value of uNGAL that can be used in the differential diagnosis of underlying AKI etiologies.Materials and methodsIn this prospective cross-sectional study, we examined 82 subjects in four groups: patients that had (1) postrenal AKI; (2) AKI other than postrenal etiologies; (3) stable chronic kidney disease; and (4) healthy subjects. A renal function assessment was carried out by measuring serum creatinine (sCr) and uNGAL at the time of diagnosis [0th min (T0)]. We followed the study group for three months. ResultsAt the time of diagnosis, sCr (T0) was highest in the postrenal AKI and AKI groups in contrast to stable chronic kidney disease patients and healthy subjects (P < 0.001), as expected. T0 median uNGAL was highest in the postrenal group (P < 0.001). Area under curve (AUC) of uNGAL to estimate postrenal AKI presence was 0.957 (95% CI, 0.897–1.000; P < 0.001). The cut-off point of uNGAL was 42.625 ng/mL for this estimation. ConclusionPatients with AKI must be classified according to the underlying etiologies as soon as possible. uNGAL may be useful to estimate the etiologies, and whether the problem is acute or chronic in the course. In postrenal kidney problems, to plan the urgency of the urologic procedures, it is crucial.

Urinary neutrophil gelatinase-associated lipocalin determines short-term mortality and type of acute kidney injury in cirrhosis.

Background and AimAcute kidney injury increases mortality in cirrhotic patients by four fold. This study aimed to determine the usefulness of urinary neutrophil gelatinase‐associated lipocalin (uNGAL) for differential diagnosis for acute kidney injury and for predicting short‐term mortality in cirrhotic patients.MethodsWe enrolled 94 patients of decompensated cirrhosis. uNGAL was measured upon hospital admission in all patients. Patients with urinary tract infection and anuria were excluded. Patients were followed for 30 days or until death.ResultsTen (9%) patients had normal kidney function, 9 (11.37%) stable chronic kidney disease, 32 (29.50%) prerenal azotemia, 33 (36.37%) hepatorenal syndrome (HRS), and 10 (13.64%) intrinsic acute kidney injury (iAKI). Prerenal azotemia had lower median uNGAL values compared to HRS and iAKI (95.50 vs 465.00 vs 1217.50, P < 0.001). uNGAL levels were significantly higher in patients who died within 30 days (717.17 ± 494.26 vs 331.65 ± 313.65 ng/mL, P −0.0017). On univariate analysis, serum creatinine (sCr), uNGAL, Model for End‐Stage Liver Disease (MELD) score on admission, and length of stay were significant, and on multivariate analysis, uNGAL and hepatic encephalopathy (HE) were significant in predicting mortality.ConclusionsuNGAL at baseline serves as an early marker in differentiating HRS, prerenal AKI, and iAKI in cirrhotic patients, where sCr values are not useful. Patients with higher uNGAL levels had higher transplant‐free mortality at 30 days.

Impact of superimposed nephrological care to guidelines-directed management by primary care physicians of patients with stable chronic kidney disease: a randomized controlled trial

BackgroundOptimal clinical care of patients with chronic kidney disease (CKD) requires collaboration between primary care physicians (PCPs) and nephrologists. We undertook a randomised trial to determine the impact of superimposed nephrologist care compared to guidelines-directed management by PCPs in CKD patients after hospital discharge.MethodsStage 3b-4 CKD patients were enrolled during a hospitalization and randomised in two arms: Co-management by PCPs and nephrologists (interventional arm) versus management by PCPs with written instructions and consultations by nephrologists on demand (standard care). Our primary outcome was death or rehospitalisation within the 2 years post-randomisation. Secondary outcomes were: urgent renal replacement therapy (RRT), decline of renal function and decrease of quality of life at 2 years.ResultsFrom November 2009 to the end of June 2013, we randomised 242 patients. Mean follow-up was 51 + 20 months. Survival without rehospitalisation, GFR decline and elective dialysis initiation did not differ between the two arms. Quality of life was also similar in both groups. Compared to randomised patients, those who either declined to participate in the study or were previously known by nephrologists had a worse survival.ConclusionThese results do not demonstrate a benefit of a regular renal care compared to guided PCPs care in terms of survival or dialysis initiation in CKD patients. Increased awareness of renal disease management among PCPs may be as effective as a co-management by PCPs and nephrologists in order to improve the prognosis of moderate-to-severe CKD.Trial registrationThis study was registered on June 29, 2009 in clinicaltrials.gov (NCT00929760) and adheres to CONSORT 2010 guidelines.

Identification of sarcopenia and dynapenia in CKD predialysis patients with EGWSOP2 criteria: An observational, cross-sectional study.

Using the new European Working Group on Sarcopenia in Older People (EWGSOP2) criteria, we identified sarcopenic and dynapenic patients in a cohort of predialysis patients with chronic kidney disease (CKD), and evaluated their clinical and laboratory characteristics. The study population consisted of 85 (55 men) clinically stable predialysis CKD patients (92.9% in stages 3-5), with a median age of 65.0 (52.5-72.0) y. We classified as sarcopenic the patients with handgrip strength (HGS) and muscle mass both lower than the respective EWGSOP2 cutoff values and as dynapenic those in whom only HGS was less than these reference values. HGS was measured with a hand dynamometer, whereas muscle mass was measured by bioimpedance analysis. Renal function was evaluated as Modification of Diet in Renal Disease estimated glomerular filtration rate. The prevalence of sarcopenia and dynapenia was, respectively, 7.1% and 17.6%. As reported in previous studies, serum albumin and hemoglobin were lower in sarcopenic patients than in patients with preserved muscle mass and strength. However, unlike in these studies, sarcopenia prevalence did not increase with CKD stage, and estimated glomerular filtration rate was similar between groups. Moreover, no difference was identified in any of the aforementioned parameters between dynapenic patients and patients with preserved muscle mass and strength. The EWGSOP2 criteria identified sarcopenia in CKD with a prevalence similar to previous diagnostic criteria. In addition, they found that dynapenia was highly prevalent. Nevertheless, the EWGSOP2 criteria could be better adapted to CKD patients to improve their ability to detect high-risk sarcopenic and dynapenic patients.

Estimation of residual renal function using beta-trace protein: Impact of dialysis procedures.

Beta-trace protein (BTP), a low molecular weight protein of 23-29kDa, has been proposed as a promising biomarker to estimate residual renal function (RRF) in patients on maintenance hemodialysis (HD). Indeed, BTP is cleared by native kidney but not during conventional HD session. By contrast, the removal rate of BTP using convective processes (mainly hemodiafiltration [HDF]) and peritoneal dialysis (PD) has been little or not investigated. Therefore, an aim of this study was to evaluate the impact of dialysis procedures (high-flux HD, on-line post-dilution HDF and PD) on BTP removal in comparison with beta-2 microglobulin (B2M) and cystatin C (CYSC) removals after a single session. In addition, the ability of BTP to predict RRF in PD was assessed. This observational cross-sectional study included a total of 82 stable chronic kidney disease patients, 53 patients were on maintenance dialysis (with n=26 in HD and n=27 in HDF) and 29 were on PD. Serum concentrations of BTP, B2M, and CYSC were measured (a) before and after a single dialysis session in HD and HDF anuric patients to calculate reduction percentages, (b) in serum, 24-hour-dialysate and 24-hour-urine in PD patients to compute total, peritoneal, and urinary clearance. RRF was estimated using four equations developed for dialysis patients without urine collection and compared to the mean of the urea and creatinine clearances in PD. The concentrations of the three studied molecules were significantly reduced (P<.001) after dialysis session with significantly higher reduction ratio using HDF compared to HD modality (P<.001): BTP 49.3% vs 17.5%; B2M 82.3% vs 69.7%; CYSC 77.4% vs 66% in HDF and HD, respectively. In non-anuric PD patients, B2M and CYSC were partly removed by peritoneal clearance (72.3% and 57.6% for B2M and CYSC, respectively). By contrast, BTP removal by the peritoneum was negligible and a low bias for the BTP-based equation to estimate RRF (-1.4mL/min/1.73m2 ) was calculated. BTP is significantly removed by high-flux HD or HDF, thereby compromising its use to estimate RRF. By contrast, BTP appears as a promising biomarker to estimate RRF in PD patients since it is not affected by peritoneal clearance, unlike B2M and CYSC, and it is well correlated to RRF.

Copeptin is independently associated with vascular calcification in chronic kidney disease stage 5

BackgroundVascular calcification (VC) is an independent predictor of cardiovascular disease (CVD) present in 30–70% of patients with chronic kidney disease (CKD). Copeptin is a sensitive surrogate marker of arginine vasopressin (AVP), which is involved in many pathophysiologic processes in CKD. The aim of the present study was to explore the association of copeptin with VC in CKD stage 5.MethodsCopeptin was investigated in conjunction with living donor kidney transplantation in 149 clinically stable CKD stage 5 patients (CKD5), including 53 non-dialyzed (CKD5-ND) and 96 dialysis patients treated by peritoneal dialysis (PD) (n = 43) or hemodialysis (HD) (n = 53). We analyzed the association of copeptin with presence and extent of VC ascertained both histologically in biopsies from the inferior epigastric artery (n = 137) and by coronary artery calcification (CAC) score measured by computed tomography.ResultsPatients with higher copeptin were older, had higher systolic blood pressure, higher prevalence of CVD and their preceding time on chronic dialysis was longer. In Spearman’s rank correlations (Rho), copeptin concentrations were significantly associated with CAC score (Rho = 0.27; p = 0.003) and presence of medial VC (Rho = 0.21; p = 0.016). Multivariate logistic regression analysis showed that 1-SD higher age, male gender, diabetes and 1-SD higher copeptin were significantly associated with the presence of moderate-extensive VC.ConclusionsHigh circulating levels of copeptin in CKD5 patients are independently associated with the degree of medial calcification ascertained by histology of arterial biopsies. Thus, plasma copeptin may serve as a marker of the uremic calcification process.

High-sensitivity Troponin I Predicts Galectin-3 in Chronic Kidney Disease Patients

Plasma galectin-3 (pG3) regulates inflammation. B-type natriuretic peptide (BNP), high-sensitivity Troponin I (hsTnI), and pG3 concentrations are elevated in chronic kidney disease (CKD) patients. The associations of pG3 with hsTnI/BNP are unclear. We explored the relationship of hsTnI and BNP with pG3 in Asian CKD patients and healthy controls. We retrieved prospectively collected frozen plasma samples from 163 stable CKD patients and 105 healthy controls. BNP, hsTnI and pG3 were assayed. pG3 was assessed for associations with age, gender, ethnicity, blood pressures; height, weight, body mass index (BMI), previously diagnosed CKD, diabetes, hypertension, coronary artery disease, estimated glomerular filtration rate (eGFR); C-reactive protein, beta-trace protein, 24h urine protein, serum albumin, uric acid and cystatin C. We created two models predicting pG3 using multiple linear regression. Akaike Information Criterion (AIC) was used for comparison. Significance was taken at P < 0.05. CKD versus healthy participants: mean BMI (28.2 vs. 24.9kg/m2), median serum creatinine (159 vs. 69µmol/L; 1.8 vs. 0.78mg/dL), median eGFR (49 vs. 104mL/min/1.73m2), median pG3 (29.4 vs. 15.4ng/mL), median BNP (136 vs. 23pg/mL), and median hsTnI (12.5 vs. 2.6pg/mL). By univariate analysis, all variables are associated with pG3 except weight, gender and diagnosis of cerebrovascular or peripheral vascular diseases. A parsimonious model selected for hsTnI, BMI, serum albumin, cystatin C and eGFR (AIC = 77.6). BNP and hsTnI are associated with pG3 in Asian CKD patients. hsTnI is a better predictor of pG3.

Genetic polymorphism in C3 is associated with progression in chronic kidney disease (CKD) patients with IgA nephropathy but not in other causes of CKD.

The R102G variant in complement 3 (C3) results in two allotypic variants: C3 fast (C3F) and C3 slow (C3S). C3F presents at increased frequency in patients with chronic kidney disease (CKD), our aim is to explore its role in CKD progression and mortality. Delta (Δ) eGFR for 2038 patients in the Salford Kidney Study (SKS) was calculated by linear regression; those with ≤-3ml/min/1.73m2/yr were defined as rapid progressors (RP) and those with ΔeGFR between -0.5 and +1ml/min/1.73m2/yr, labelled stable CKD patients (SP).A group of 454 volunteers was used as a control group. In addition, all biopsy-proven glomerulonephritis (GN) patients were studied regardless of their ΔeGFR. R102G was analysed by real-time PCR, and genotypic and allelic frequencies were compared between RP and SP along with the healthy control group. There were 255 SP and 259 RP in the final cohort. Median ΔeGFR was 0.07 vs. -4.7 ml/min/1.73m2/yr in SP vs. RP. C3F allele frequency was found to be significantly higher in our CKD cohort (25.7%) compared with the healthy control group (20.6%); p = 0.008.However, there was no significant difference in C3F allele frequency between the RP and SP groups. In a subgroup analysis of 37 patients with IgA nephropathy in the CKD cohort (21 RP and 16 SP), there was a significantly higher frequency of C3F in RP 40.5% vs. 9.4% in SP; p = 0.003. In the GN group, Cox regression showed an association between C3F and progression only in those with IgA nephropathy (n = 114);HR = 1.9 (95% CI 1.1-3.1; p = 0.018) for individuals heterozygous for the C3F variant, increased further for individuals homozygous for the variant, HR = 2.8 (95% CI 1.2-6.2; p = 0.014). The C3 variant R102G is associated with progression of CKD in patients with IgA nephropathy.

Does Exposure to Computed Tomography Contrast Media Increase Risk of End-Stage Renal Disease?

BackgroundThere are many studies on acute kidney injury (AKI) after exposure to contrast media in patients with chronic kidney disease (CKD). However, whether the risk of end-stage renal disease (ESRD) increases after exposure to contrast media in the long term, regardless of development of AKI after such exposure, has not been studied.Material/MethodsThe electronic health records of patients diagnosed with CKD and followed up from 2014 to 2018 at a tertiary university hospital were retrospectively collected. Patients were divided into patients who progressed to ESRD (ESRD group) and those who did not (non-ESRD group). Patients in the non-ESRD group were matched 1: 1 to those in the ESRD group by using disease risk score generation and matching. Multivariate logistic regression analysis was performed to assess the effect of contrast media exposure on progression to ESRD.ResultsIn total, 179 patients were enrolled per group; 178 (99.4%) were in CKD stage 3 or above in both groups. Average serum creatinine was 4.31±3.02 mg/dl and 3.64±2.55 mg/dl in the ESRD and non-ESRD groups, respectively (p=0.242). Other baseline characteristics were not statistically significant, except for the number of times contrast-enhanced computed tomography (CECT) was performed (0.00 [Interquartile range (IQR) 0.00–2.00] in the ESRD group and 0.00 [IQR 0.00–1.00] in the non-ESRD group [p=0.006]); in multivariate logistic regression, this number (OR=1.24, 95% CI=1.08–1.47, p=0.006) was significantly related to progression to ESRD.ConclusionsThe use of CECT increased the risk of ESRD 1.2-fold in advanced and stable CKD outpatients after 5-year follow-up.

Overhydration Measured by Bioimpedance Spectroscopy and Urinary Serine Protease Activity Are Risk Factors for Progression of Chronic Kidney Disease

Background: Overhydration (OH) is common in chronic kidney disease (CKD) and might be related to the excretion of urinary serine proteases. Progression of CKD is associated with proteinuria; however, the interrelations of urinary serine proteases, OH, and progression of CKD remain unclear. Methods: In n = 179 patients with stable nondialysis-dependent CKD of all stages, OH was measured using bioimpedance spectroscopy (Body Composition Monitor; Fresenius), and urinary serine protease activity was determined using the peptide substrate S-2302. After a median follow-up of 5.9 (IQR: 3.9–6.5) years, progression to end-stage renal disease (ESRD) was analyzed retrospectively. Results: OH correlated with baseline MDRD-eGFR, urinary albumin creatinine ratio (ACR), and urinary aprotinin-sensitive serine protease activity. Progression to ESRD occurred in n = 33 patients (19%) and correlated with OH and urinary serine protease activity as well as MDRD-eGFR and ACR. Patients were divided into 2 groups determined by cutoff values from receiver operating characteristics for MDRD-eGFR (32 mL/min/1.73 m²), ACR (43 mg/g creatinine), urinary serine protease activity (0.9 RU/g creatinine), and OH (1 L/1.73 m²). Across these cutoff values, Kaplan-Meier curves for renal survival showed significant separations of the groups. In Cox regression adjusted for MDRD-eGFR, ACR, P-NT-pro-BNP, systolic blood pressure, and diabetes mellitus, patients with OH >1 L/1.73 m² had a 3.32 (95% CI: 1.26–8.76)-fold higher risk for progression to ESRD. Conclusions: Our results corroborate that OH detected by bioimpedance spectroscopy in CKD patients is an independent risk factor for progression to ESRD in addition to GFR and albuminuria. Urinary serine protease activity is associated with OH and progression of CKD and provides a possible underlying mechanism.

368 Left Atrial Reservoir Strain is an Independent Predictor of End Stage Renal Impairment in Patients With Chronic Kidney Disease

Left atrial (LA) enlargement is commonly encountered in patients with chronic kidney disease (CKD) and is an independent predictor of adverse cardiovascular events. We sought to evaluate LA metrics as a prognostic marker for development of end stage renal disease. Patients with stable Stage 3 and 4 CKD, without prior cardiac history, were prospectively recruited and underwent a resting transthoracic echocardiogram (TTE) and stress echocardiogram. Patients with normal left ventricular (LV) function, without significant valvular disease and without ischaemia on stress testing were recruited and followed for up to 5 years for the end point of end stage renal disease (ESRD). 280 CKD patients (65.8±12.2 years, 63% male) were recruited and all patients completed follow-up over a mean period of 3.9±2.7 years. 50 patients developed ESRD. On log rank tests, older age (p<0.01), lower estimated glomerular filtration rate (eGFR) (p<0.01), greater urinary proteinuria (p<0.01), diabetes mellitus (p<0.01), anemia (p<0.01), higher indexed LV mass (p<0.01), larger LA volume indexed (LAVI) (p<0.01) and impaired LAs (p<0.01) was associated with development of ESRD. On multi-variable cox proportional hazards models, eGFR (p<0.01), LAVI (p<0.01) and LAs (p<0.01) were independent predictors of ESRD. Addition of LAs to eGFR and LAVI significantly increased the predictive power for prognostication with regards to development of ESRD (C statistic 0.828 vs C statistic 0.800, p=0.03). LAVI and LAs were independent predictors of ESRD in stable CKD patients with low cardiovascular risk. The addition of LA metrics to eGFR significantly improved the prediction of ESRD.

Protocol for a prospective, cluster randomized trial to evaluate routine and deferred dialysis initiation (RADDI) in Chinese population

BackgroundThe timing of when to initiate dialysis for progressive chronic kidney disease (CKD) patients has not been well established. There has been a strong trend for early dialysis initiation for these patients over the past decades. However, the perceived survival advantage of early dialysis has been questioned by a series of recent observational studies. The only randomized controlled trial (RCT) research on this issue found the all-cause mortality, comorbidities, and quality of life showed no difference between early and late dialysis starters. To better understand optimal timing for dialysis initiation, our research will evaluate the efficacy and safety of deferred dialysis initiation in a large Chinese population.MethodsThe trial adopts a multicenter, cluster randomized, single-blind (outcomes assessor), and endpoint-driven design. Eligible participants are 18–80 years old, in stable CKD stages 4–5 (eGFR > 7 ml/min /1.73 m2), and with good heart function (NYHA grade I or II). Participants will be randomized into a routine or deferred dialysis group. The reference eGFR at initiating dialysis for asymptomatic patients is 7 ml/min /1.73 m2 (routine dialysis group) and 5 ml/min/1.73 m2 or less (deferred dialysis group) in each group. The primary endpoint will be the difference of all-cause mortality and acute nonfatal cerebro-cardiovascular events between the two groups. The secondary outcomes include hospitalization rate and other safety indices. The primary and secondary outcomes will be analyzed by appropriate statistical methods.DiscussionThis study protocol represents a large, cluster randomized study evaluating deferred and routine dialysis intervention for an advanced CKD population. The reference eGFR to initiate dialysis for both treatment groups is targeted at less than 7 ml/min/1.73m2. With this design, we aim to eliminate lead-time and survivor bias and avoid selection bias and confounding factors. We acknowledge that the study has limitations. Even so, given the low-targeted eGFR values of both arms, this study still has potential economic, health, and scientific implications. This research is unique in that such a low targeted eGFR value has never been studied in a clinical trial.Trial registrationThe trial has been approved by ClinicalTrials.gov (Trial registration ID NCT02423655). The date of registration was April 22, 2015.

The influence of metabolic syndrome on chronic kidney disease patients′ clinical outcomes

Objective To investigate whether metabolic syndrome (MS) independently influences the renal outcomes of chronic kidney disease (CKD) 1-4 stage patients. Methods Since July 2006 to September 2008, a total of 766 clinically stable CKD patients in the hospital were enrolled in this prospective study and followed up until December 31th, 2016. The CKD patients were divided into MS group and non-MS group according to the Chinese Diabetes Society (CDS) criterion of MS. The renal outcomes that needs to initiate renal replacement therapy were observed and recorded during the follow-up. Kaplan-Meier analysis was used to evaluate the influence of MS on CKD patients′ renal outcomes. Cox regression analysis was used to assess the independent risk factors of renal outcome of CKD patients. Results Among 766 patients with CKD 1-4 stage, 97 patients initiated renal replacement therapy, and the prevalence of MS was 31.5%(241/766) in CKD patients. In the CKD 1-4 stage patients, the occurring rate of initiating renal replacement therapy was significantly higher in MS group than that of non-MS group (χ2=56.367, P<0.001). Cox regression analysis showed that 24-hour urine protein ≥1.0 g, MS and initial serum phosphate ≥1.3 mmol/L were the independent risk factors of initiating renal replacement therapy in CKD 1-4 stages. Conclusions More than 1/3 CKD patients are accompanied with MS. It has been demonstrated that MS, as well as 24-hour urine protein ≥1.0 g and initial serum phosphate ≥1.3 mmol/L, are the independent influencing factors of the renal outcomes in CKD 1-4 stage patients. Key words: Metabolic syndrome X; Kidney diseases; Kidney failure, chronic; Risk factors

Dietary satisfaction and quality of life in chronic kidney disease patients on low-protein diets: a multicentre study with long-term outcome data (TOrino-Pisa study).

Concerns about adherence and quality of life (QoL) limit the diffusion of low-protein diets (LPDs) as a way to slow chronic kidney disease (CKD) progression and postpone dialysis. The aim of this multicentre study is to assess dietary satisfaction in stable CKD patients. This was a multicentre cross-sectional study with long-term follow-up data. Prevalent patients on LPD for at least 6 months were selected in four Italian centres. QoL was assessed using the World Health Organization Quality of Life questionnaire, and diet satisfaction with the Modification of Diet in Renal Disease satisfaction questionnaire. Comorbidity was assessed by Charlson Comorbidity Index, estimated glomerular filtration rate (eGFR) was calculated by the CKD Epidemiology Collaboration equation and protein intake by Maroni-Mitch formula. Survival was analysed with Kaplan-Meier curves and Cox Proportional Hazard Model. Four hundred and twenty-two CKD Stages 3-5 patients were enrolled. Over 95% were on moderately restricted diets (0.6 g/kg/day). Compliance was good (protein intake: 0.59 g/kg/day at baseline, 0.72 at the end of follow-up). Median dietary satisfaction was 4 on a 1-5 scale. QoL was not affected by the type of diet, but was influenced by age, comorbidity and setting of care. Two years later, at the end of follow-up, 66.6% of the patients were still on a diet; the main causes of discontinuation were dialysis and death. The dropout rate was low (5.5%); in Cox analysis, patient and renal survival were influenced by age and eGFR, but not by QoL, setting of care or type of diet. LPDs are compatible with high dietary satisfaction and minimal dropout, at least in patients who are able to follow such a diet for at least 6 months.

Effect of a Single Dialysis on Cognitive Function in Chronic Kidney Disease Stage 5 Hemodialysis Patients

Abstract Background: The incidence of cognitive impairment (CI) has been widely reported in various studies among chronic kidney disease (CKD) patients. Many factors influence cognitive function including hemodialysis (HD) process itself. There is much evidence that a single HD session brings about changes in the cognitive status of patients, but just a few studies assessing whether cognitive performance varies with dialysis. Aim: To know the effect of single dialysis session on cognitive function in HD patients. Method: Sixty medically stable CKD stage 5 patients on HD maintenance at least for three months were enrolled. Cognitive testing performed thrice, 1-2 hour prior dialysis (T1), 3-4 hour into the session (T2) and 24 hour after the session (T3) using a well-validated neuropsychological test battery, Montreal Cognitive Assessment (MoCA) Indonesian version which assess the domain of cognitive function including visuospatial, executive function, naming, memory, attention, language, abstraction, recall, and orientation. Result: among 60 patients complete testing, mean age 45,45 ± 11,28 years, dialysis vintage 10,12 ± 11,88 months, 44 patients (73,3%) had CI at baseline. Cognitive function decline during dialysis (T2) (MoCA INA score 21,65 to 19,67, p < 0.001) and visuospatial, executive function, attention, language and recall was impaired during dialysis. While cognitive function reached its best 24 hour after dialysis (MoCA INA score 23,65, p < 0.001) and all the domain of cognitive function was improved except naming that didn’t change over the dialysis session. Age and dialysis adequacy were associated with the decline. Conclusion: There is effect of a single HD session on global cognitive function where cognitive function was deteriorated during HD and reached its best 24 hour after HD. Keywords: cognitive function, chronic kidney disease, hemodialysis