Chronic Kidney Disease Stage 3b Research Articles

28 “A Treatment Worse than the Disease”: A Case Report of Sodium Thiosulfate Toxicity in a Patient with Stage 3B Chronic Kidney Disease and Calciphylaxis

28 “A Treatment Worse than the Disease”: A Case Report of Sodium Thiosulfate Toxicity in a Patient with Stage 3B Chronic Kidney Disease and Calciphylaxis

Impact of Left Ventricular Assist Device Placement on Chronic Kidney Diseases: A Multicenter Longitudinal Study

Methods A retrospective multi-center cohort study was conducted, including all patients undergoing LVAD implantation. The Chronic Kidney Disease Epidemiology collaboration equation was used to determine the estimated glomerular filtration rate . Creatinine measurements were collected over a 2-year follow-up period. Patients stratification was based on their pre-operative CKD stage. Results Overall, 400 patients (mean age 52±14 years, 77% male) were included: 186 (47%) patients in CKD stage 1 & 2, 93 (23%) in CKD stage 3a, 82 (20%) in CKD stage 3b, and 39 (10%) patients were CKD stage 4 & 5. During a median follow-up of 458 days [141-1001], 46162 measurements of creatinine were available. Initial improvement of kidney function is noticed in every preoperative CKD stage group (P Conclusion Initial improvement of kidney function is noticed in all preoperative CKD stages. However, this improvement is of transient nature and the survival remains impaired in patients with diminished preoperative renal function.

Advanced Kidney Disease in the Left Ventricular Assist Device Population: Impact on Disease Progression, Morbidity and Mortality

Purpose Advanced kidney disease is often considered a relative contraindication to LVAD implantation and many implanting centers view stage 4 and 5 chronic kidney disease (CKD) as an absolute contraindication. We sought to analyze the impact of CKD at the time of LVAD implant on outcomes. Methods All LVAD patients between September 2007 and September 2017 with CKD at the time of LVAD implantation from a single institution were analyzed. Patients were stratified by CKD stage (CKD 1 through 5) at the time of implant and rates of worsening renal function, need for renal replacement therapy (RRT), hospitalizations, LVAD-related complications and death were analyzed. Results Of the 405 total patients, 191 patients (59% centrifugal, 80% male, average age 59 ± 11 years) had varying degrees of renal dysfunction at the time of LVAD implantation (17% CKD 1 or 2, 35% CKD 3a, 34% CKD 3b and 15% CKD 4 or 5). Patients with CKD 4 or 5 were more likely to require RRT than lesser CKD Stages 3b, 3a, and 1 or 2 (37.9% vs. 3.1%, vs. 7.6% vs. 0%, p trend Conclusion Patients with advanced CKD at the time of LVAD implant were more likely to have persistent renal dysfunction and require RRT thereafter. However, there were no statistically significantly differences in LVAD-related morbidity and mortality across the stages of CKD.

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

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

Evolution of chronic kidney disease after surgical aortic valve replacement or transcatheter aortic valve implantation

Immediate improvement in kidney function has been reported after surgical aortic valve replacement or transcatheter aortic valve implantation. Long-term data, however, are not available. To assess the evolution of kidney function in chronic kidney disease stage 3b-5, 1 year after surgical aortic valve replacement or transcatheter aortic valve implantation. All patients with chronic kidney disease stage 3b-5 undergoing surgical aortic valve replacement or transcatheter aortic valve implantation for aortic stenosis in a single centre were included. Kidney function was assessed 1 year postprocedure. Improvement or deterioration in estimated glomerular filtration rate was defined by an increase or decrease of 5mL/min/1.73 m2, respectively. Overall, 127 procedures were analysed (54 surgical aortic valve replacements and 73 transcatheter aortic valve implantations). Kidney function improved in 51% of patients at 1 year (45% of the surgical aortic valve replacement group versus 57% of the transcatheter aortic valve implantation group; P=0.21), and deteriorated in only 14% of patients at 1 year (18% of the surgical aortic valve replacement group versus 10% of the transcatheter aortic valve implantation group; P=0.22). Almost a quarter of patients (23%) had an improvement in estimated glomerular filtration rate of>15mL/min/1.73 m2, and this was consistent at later follow-up. Few patients went onto chronic dialysis at 1 year (three after surgical aortic valve replacement and one after transcatheter aortic valve implantation). Acute kidney injury was an independent prognostic factor for long-term deterioration in kidney function (odds ratio 2.1, 95% confidence interval 1.4-3.6; P=0.006). Aortic valve replacement, whether by surgical aortic valve replacement or transcatheter aortic valve implantation, improved estimated glomerular filtration rate at 1 year in more than half of patients with chronic kidney disease stage 3b-5.

Osmotic stress and mortality in elderly patients with kidney failure: a retrospective study.

PurposeWater balance disorders are associated with a high risk of death in elderly patients. The role of osmotic stress intensity and its direction toward hypo- or hypernatremia is a matter of controversy regarding patients’ survival. The aims of this study were, first, to measure the frequency of cellular hydration disorders in patients over 75 years old hospitalized in nephrology department for reversible acute renal failure, and second, to compare the impact of hyperhydration and hypohydration on the risk of death at 6 months.Patients and methodsWe retrospectively studied the data of 279 patients with chronic kidney disease (CKD), aged 75 years or older, with pre-renal azotemia who experienced dysnatremia. We classified them according to natremia levels and compared their outcome in univariate and multivariate analysis.ResultsThe patients were on average 83.2±5.4 years old. Among them, 128 were normonatremic, 82 were hyponatremic and 69 were hypernatremic. Osmotic stress intensity appreciated by the variation rate of natremia did not differ significantly between hyper- and hyponatremic patients. Patients had CKD stage 3B and 4 with acute kidney injury (AKI) of different severities. We observed that only hypernatremia was linked to death in the first 6 months following hospital discharge.ConclusionHypernatremia is a strong predictor of fatal outcome in elderly patients suffering from chronic kidney impairment and referred for pre-renal azotemia.

Effects of Bardoxolone Methyl on Magnesium in Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease

Background: Treatment with bardoxolone methyl (Bard) in a multinational phase 3 trial, Bardoxolone Methyl Evaluation in Patients with Chronic Kidney Disease and Type 2 Diabetes (BEACON), resulted in increases in estimated glomerular filtration rate with concurrent reductions in serum magnesium. We analyzed data from several trials to characterize reductions in magnesium with Bard. Methods: BEACON randomized patients (n = 2,185) with type 2 diabetes (T2DM) and stage 4 chronic kidney disease (CKD) 1:1 to receive Bard (20 mg) or placebo once daily. In a separate open-label study, magnesium levels from 24-hour urine and sublingual epithelial cell samples were analyzed in patients with stage 3b-4 CKD and T2DM administered 20 mg Bard for 56 consecutive days. Results: BEACON patients randomized to Bard experienced significant reductions in serum magnesium from baseline relative to patients randomized to placebo (–0.17 mEq/L, 95% CI –0.18 to –0.60 mEq/L; p < 0.001). A separate study showed intracellular and urinary magnesium levels were unchanged with Bard treatment. Conclusions: Bard treatment results in significant decreases in serum magnesium that are not associated with changes in intracellular and urinary magnesium levels, indicating that magnesium decreases are not due to renal magnesium wasting or total body magnesium depletion. Importantly, the decreases in serum magnesium with Bard are not associated with adverse effects on QT interval.

Prevalence and Correlates of Sarcopenia among Elderly CKD Outpatients on Tertiary Care.

Background: Sarcopenia is a widespread concern in chronic kidney disease (CKD) as well in elderly patients and is one of the main reasons why low-protein diets for this population are controversial. The aim of this study was to assess the prevalence and correlates of sarcopenia among elderly male patients affected by CKD followed up in an outpatient nephrology clinic, where moderate protein restriction (0.6–0.8 g/Kg/day) is routinely recommended to patients in CKD stage 3b-5 not on dialysis. Methods: This observational study included 80 clinically-stable male out-patients aged >60, affected by stage 3b-4 CKD. Forty patients aged ≥75 (older seniors) were compared to the other forty patients aged 60–74 (younger seniors). All patients underwent a comprehensive nutritional and functional assessment. Results: Older seniors showed lower serum albumin, hand-grip strength, body mass index (BMI), skeletal muscle mass, and resting energy expenditure. Protein intake was significantly lower in older seniors whereas energy intake was similar. Average daily physical activity was lower in the older seniors than in the younger ones. Sarcopenia was more prevalent in older than in younger seniors. Among older seniors, sarcopenic and non-sarcopenic ones differed in age and performance on the Six-Minute Walk test, whereas the estimated glomerular filtration rate (eGFR), biochemistry, dietary protein, and energy intakes were similar. Conclusions: Older senior CKD male patients have lower muscle mass, muscle strength, and physical capacity and activity levels, with a higher prevalence of sarcopenia than younger patients. This occurs at the same residual renal function and metabolic profile and protein intake. Energy intake was at the target in both subgroups. In this CKD cohort, sarcopenia was associated with age and physical capacity, but not with eGFR or dietary intakes.

Cardiac valve calcification and use of anticoagulants: Preliminary observation of a potentially modifiable risk factor

AimsDirect oral anticoagulant (DOAC) has been recently introduced in the clinical practice. Rather than interfering with vitamin K-dependent posttranscriptional modification of various proteins, DOACs selectively inhibit factors involved in the coagulation cascade. In particular, in contrast with Warfarin, Rivaroxabn does not interfere with activation of matrix Gla Protein (MGP), a potent vascular calcification Inhibitor. We herein sought to investigate the impact of Rivaroxaban and Warfarin on cardiac valve calcifications in a cohort of moderate-to advanced CKD patients. Methods and resultsThis is a multicenter, observational, retrospective, longitudinal study. Consecutive CKD stage 3b – 4 (according to KDIGO guidelines) patients from 8 cardiologic outpatient clinics were enrolled between May 2015 and October 2017. All patients received anticoagulation (100 Warfarin vs 247 Rivaroxaban) as part of their non-valvular atrial fibrillation management. Cardiac valve calcification was evaluated via standard trans-thoracic echocardiogram. 347 patients (mean age: 66 years; mean eGFR: 37 ml/min/1.73 m2) were studied. Over a mean follow-up period of 16 months, Rivaroxaban compared to Warfarin reduced both mitral and aortic valve calcifications (p < 0.001) independently of the degree of calcifications at baseline and potential confounders. Notably, Rivaroxaban use was also associated with a significant reduction in C reactive protein (CRP) (p < 0.001) during follow-up. ConclusionThis study generates the hypothesis that the use of Rivaroxaban associates with a reduction of cardiac valve calcification deposition and progression as compared to Warfarin, in a cohort of CKD stage 3b-4 patients. Future endeavors are needed to confirm and to establish the mechanisms responsible for these findings.

Effect of Statins on Renal Function in Chronic Kidney Disease Patients

Dyslipidemia is associated with glomerular injury. However, the effect of statins on chronic kidney disease (CKD) progression remains controversial. We aimed to investigate the efficacy of statins for renal protection in patients with CKD. The retrospective cohort study comprised 3441 patients diagnosed with CKD in multiple medical centers. We divided the patients into two cohorts based on statin prescription, and compared proportions and risks of CKD progression events between the two groups. CKD progression event was defined as an average annual decline of eGFR >5 mL/min/1.73 m2 or advancement to the dialysis stage. The result revealed that among all incident patients with CKD, 28.7% and 30.3% of the users and nonusers demonstrated CKD progression, respectively. The crude odds ratio (OR) of CKD progression was 0.93 [95% confidence interval (CI) 0.78–1.10]. After adjustment for baseline characteristics, the adjusted OR was 0.80 (95% CI 0.63–1.01). The sensitivity analysis results showed consistent OR for CKD progression, stratification by age, sex, Charlson score, and statins use within 1 year before index date. The effect of statins was significant in patients with CKD stage 3B-5 (OR 0.68, 95% CI 0.48–0.95), but not statistically significant in those with CKD stage 1–3A (OR 0.97, 95% CI 0.68–1.38). The effect of statins was significant in patients with proteinuria ≥1000 mg/day (OR 0.63, 95% CI 0.43–0.92), but not statistically significant in those with proteinuria <1000 mg/day (OR 1.02, 95% CI 0.74–1.41).

Hereditary Hemochromatosis and Dieulafoyʼs Lesion - A Plausible Association

Hereditary hemochromatosis (HH), is an autosomal recessive disorder most commonly due to mutations in the HFE gene. The condition's pathophysiologic predisposition to increased iron uptake can lead to the development of life-threatening complications of liver disease, heart disease, and diabetes. A Dieulafoy's lesion is a dilated aberrant submucosal vessel that erodes the overlying epithelium in the absence of a primary ulcer. The lesions are usually located in the proximal stomach along the lesser curvature, although they have been found in all areas of the gastrointestinal tract, including the esophagus, duodenum, and colon. Here, we present a case of a 68-year-old man with HH that presented with melena of 2 weeks duration associated with a Hemoglobin drop from 14 to 8.8 g/dL. He reported increasing fatigue, weakness, and dyspnea on exertion. He denied hematemesis, bright red blood per rectum, use of iron or bismuth supplements. On physical exam his abdomen was soft, non-distended, with normoactive bowel sounds. Rectal exam showed no fissures, normal rectal tone, no palpable masses. Some flecks of brown and black stool were present. He was stabilized and taken for endoscopy the following day. Endoscopy showed a Dieulafoy's lesion at the duodenal sweep, which was actively oozing blood. Even after multiple attempts to electrocauterize and place a hemoclip, there was still residual bleeding. The patient was subsequently transferred to interventional radiology for gastroduodenal artery embolization. Unfortunately, despite multiple intraoperative angiograms, the vessel was unaccessible. His vitals and hemoglobin were monitored, as dark stool transitioned to brown. He was continued on oral pantoprazole twice a day and scheduled with close follow up. We propose that there may be an association between HH and Dieulafoy's lesions. The etiology of Dieulafoy's lesion is not well understood. Patients who bleed from Dieulafoy's lesions are typically men with comorbidities including cardiovascular disease, hypertension, chronic kidney disease, diabetes, alcohol abuse, NSAID use, and advanced liver disease. Many of these comorbidities are inherently present in individuals with HH, as a part of the disease process. The patient mentioned above had cardiovascular disease, diabetes, and liver disease secondary to HH. He also had chronic kidney disease stage 3B secondary to diabetes and hypertension. He did not use NSAIDs or alcohol.

Potential Complications of Hyperbilirubinemia on Therapy With Glecaprevir and Pibrentasvir for Therapy of Hepatitis C in Complex Real World Patients

Introduction Treatment of Hepatitis C (HCV) in the cirrhotic and renal insufficiency population is complex. Here we present 2 patients: one with HCV genotype 1b cirrhosis and another with HCV genotype 3 in a transplanted liver with unusual complications on therapy with glecaprevir/pibrentasvir. Case 1 A 64 year-old female presented with history of alcohol abuse and treatment naïve HCV genotype 1b with compensated cirrhosis and chronic kidney disease (CKD) stage 3. Glecaprevir/pibrentasvir was approved for 12 weeks. Baseline bilirubin of 1.1 rose by two weeks on therapy to 6.1. Labs were monitored over time but given persistent elevation and recent alcohol use therapy was held. Labs 1 week following glecaprevir/pibrentasvir cessation showed rapid improvement of bilirubin to 1.9. In total, this patient received a total of three weeks of treatment and did have sustained viral response at 8 weeks after treatment. Case 2 A 33 year-old female with dual kidney-liver transplant with recurrent CKD stage 3B, mitral valve and aortic valve replacement and pacemaker presents with treatment naïve genotype 3 HCV without known recurrence of cirrhosis on imaging. Patient was started on glecaprevir/pibrentasvir for planned 12 week course. Patient was admitted to the hospital with acute jaundice leading to fluid overload and acute tubular necrosis requiring dialysis. Prior to glecaprevir/pibrentasvir therapy bilirubin was 1.4. After 2 weeks on treatment bilirubin rose to 7.6 with fluid overload and renal failure. After glecaprevir/pibrentasvir was held bilirubin improved to 4.6 within one week. Discussion Glecaprevir/pibrentasvir is approved for treatment of HCV with compensated cirrhosis including patients with severe renal impairment (CKD Stage 4 and 5). Our study highlights potential risks when treating patients with compensated cirrhosis and renal insufficiency. Glecaprevir/pibrentasvir is not indicated for patients with decompensated cirrhosis and has been reported to cause hyperbilirubinemia in a small number of patients in clinical studies. Given these two cases, it remains prudent to be wary of hyperbilirubinemia as a side effect and potential for cirrhotic decompensation with renal failure during treatment of complex liver patients.

Nondipping pattern on 24-h ambulatory blood pressure monitoring is associated with left ventricular hypertrophy in chronic kidney disease.

Few studies have assessed the role of 24-h ambulatory blood pressure monitoring (ABPM) in adults with nondialysis chronic kidney disease (CKD). We examined the potential determinants of left ventricular hypertrophy (LVH) and mass index (LVMI) in this population. We carried out a cross-sectional study on 69 stage 3b-5 CKD adults who had ABPM and transthoracic echocardiography performed simultaneously. Hypertension (HT) was defined as 24 h blood pressure (BP) of at least 130/80 mmHg. ABPM parameters considered were BP dipping status, BP load, and the BP night-time/daytime ratio. We performed stepwise backward multivariate linear and logistic regression to assess the determinants of LVH and LVMI. ABPM parameters were considered the main independent variables, whereas HT, angiotensin-converting enzyme inhibitor/angiotensin II receptor antagonist use, glomerular filtration rate of less than 30 ml/min/1.72 m, diabetes, smoking, age, sex, hemoglobin, and parathyroid hormone levels were considered covariates. LVH was present in 22 (31.8%) patients. In linear regression analysis, systolic [β=-13.8, 95% confidence interval (CI)=-26.3 to -1.3, P=0.031] and mean (β=-13.5, 95% CI=-25.7 to -1.2, P=0.031) nondipping status was associated with increased LVMI. BP load and night-time/daytime ABPM ratio were not associated with LVMI. In logistic regression analysis, systolic nondipping status (odds ratio=0.27, 95% CI=0.08-0.91, P=0.036) was associated with LVH. Among covariates, estimated glomerular filtration rate of less than 30 ml/min/1.72 m and HT were associated with LVH and increased LVMI. At 1-year follow-up, mean nondipping status on the initial ABPM remained associated significantly with increased LVMI (β=-19.8, 95% CI=-36.6 to -3.0, P=0.022). These data confirm the high incidence of LVH among nonrenal replacement therapy CKD patients and suggest that the nondipping phenomenon on ABPM is associated independently with LVH and increased LVMI in this population.

Clinical Characteristics and Postoperative Outcomes of Primary Aldosteronism in the Elderly.

Primary aldosteronism (PA) in the elderly has increased in importance in association with population aging. To investigate the characteristics and outcomes of elderly patients with PA undergoing adrenalectomy. Using a database of patients with PA who underwent adrenal venous sampling (AVS), we compared elderly patients (≥65 years old) with nonelderly patients (<65 years old) in terms of characteristics, subtype classification in ACTH-stimulated AVS, and outcomes after adrenalectomy. The elderly group had a higher prevalence of comorbidities than the nonelderly group. The proportion of the unilateral subtype [defined as a lateralization index (LI) >4] was comparable between the age groups. In patients who received adrenalectomy, biochemical cure was comparable between the groups, whereas persistent hypertension was more common in the elderly group. The prevalences of hyperkalemia and renal impairment (chronic kidney disease stage 3b or higher) were higher in the elderly group. Multiple regression analysis showed that the duration of hypertension predicted persistent hypertension and hyperkalemia and that preoperative estimated glomerular filtration rate predicted renal impairment in the elderly group. LI >4 in AVS was an independent predictor of biochemical cure after adrenalectomy in the elderly group but not in the nonelderly group. Age was negatively associated with biochemical cure in patients with LI ≤4. Adrenalectomy contributes to biochemical improvement in elderly patients if determined in accordance with AVS. The treatment strategy should be determined considering the high postoperative incidence of persistent hypertension and hyperkalemia in elderly patients with a long history of hypertension or renal impairment in those with reduced renal function.

Chronic Kidney Disease Is Associated With Greater Bone Marrow Adiposity

Bone marrow adiposity is associated with aging, osteoporosis, and reduced hematopoiesis, as well as anorexia nervosa, but little is known about the underlying mechanisms that affect marrow adiposity. Chronic kidney disease (CKD) may influence bone marrow adipose tissue (BMAT), possibly through loss of lean mass or higher circulating levels of sclerostin. To test these hypotheses, we investigated the cross-sectional association between estimated glomerular filtration rate (eGFR) as a measure of kidney function and 1 H-MRS-based measurement of vertebral BMAT (L1 to L4) in 475 older adults from the Age Gene/Environment Susceptibility (AGES)-Reykjavik study. Mean BMAT was compared in those with eGFR >60 (n = 297) versus those with eGFR 45 to 60 (n = 120) or eGFR <45 (n = 58) using linear regression models. Participants had a mean age of 81.5 (SD 4.1) years, mean eGFR of 64.3 (SD 16.1) mL/min/1.734 cm2 , mean BMAT of 54.5% (SD 8.5); 48.2% were women. In unadjusted and adjusted models (age, visit window, gender, diabetes and visceral adipose tissue), BMAT was higher in those with eGFR <45 (adjusted mean 58.5%; 95% CI, 56.2 to 60.7) compared with those with eGFR >60 (adjusted mean 53.8%; 95% CI, 52.8 to 54.8) (p = 0.0002). BMAT did not differ in those with eGFR 45 to 60 (adjusted mean 54.3%; 95% CI, 52.8 to 55.9) compared with those with eGFR >60 (p = 0.58). In a subgroup of participants with serum sclerostin available (n = 253), additional adjustment for sclerostin attenuated the difference in adjusted mean vertebral BMAT between those with eGFR <45 versus >60 from 3.7% (p = 0.04) to 2.4% (p = 0.20). CKD stage 3b or worse was associated with greater bone marrow adiposity; this association may be partially mediated by sclerostin. © 2018 American Society for Bone and Mineral Research.

Rationale and Design of a Randomized Placebo-Controlled Clinical Trial Assessing the Renoprotective Effects of Potassium Supplementation in Chronic Kidney Disease

Background/Aims: Dietary potassium (K⁺) has beneficial effects on blood pressure and cardiovascular (CV) outcomes. Recently, several epidemiological studies have revealed an association between urinary K⁺ excretion (as proxy for dietary intake) and better renal outcomes in subjects with chronic kidney disease (CKD). To address causality, we designed the “K⁺ in CKD” study. Methods: The K⁺ in CKD study is a multicenter, randomized, double blind, placebo-controlled clinical trial aiming to include 399 patients with hypertension, CKD stage 3b or 4 (estimated glomerular filtration rate [eGFR] 15–44 mL/min/1.73 m²), and an average eGFR decline > 2 mL/min/1.73 m²/year. As safety measure, all included subjects will start with a 2-week open-label phase of 40 mmol potassium chloride daily. Patients who do not subsequently develop hyperkalemia (defined as serum K⁺ >5.5 mmol/L) will be randomized to receive potassium chloride, potassium citrate (both K⁺ 40 mmol/day), or placebo for 2 years. The primary end point is the difference in eGFR after 2 years of treatment. Secondary end points include other renal outcomes (> 30% decrease in eGFR, doubling of serum creatinine, end-stage renal disease, albuminuria), ambulatory blood pressure, CV events, all-cause mortality, and incidence of hyperkalemia. Several measurements will be performed to analyze the effects of potassium supplementation, including body composition monitoring, pulse wave velocity, plasma renin and aldosterone concentrations, urinary ammonium, and intracellular K⁺ concentrations. Conclusion: The K⁺ in CKD study will demonstrate if K⁺ sup­plementation has a renoprotective effect in progressive CKD, and whether alkali therapy has additional beneficial effects.

Association of renal function with bone mineral density and fracture risk in the Longitudinal Aging Study Amsterdam

SummaryEarly renal dysfunction is associated with a 38% increased fracture risk in individuals aged 65 years and older. In men but not women, early renal dysfunction is associated with decreased femoral neck bone mineral density (BMD) which can be partially explained by increased parathyroid hormone (PTH) concentrations.IntroductionIt is uncertain whether early renal dysfunction is associated with osteoporosis and increased fracture risk. The aim of this study was to determine the relationship of decreased renal function with BMD and fracture risk and the role of PTH therein.MethodsWe analyzed data of participants aged 65 years and older from the Longitudinal Aging Study Amsterdam. A 6-year fracture follow-up was obtained in 1477 participants. BMD was measured by dual-energy x-ray absorptiometry (n = 535) and vertebral fractures by lateral spinal radiograph (n = 527) in a subsample at baseline. Glomerular filtration rate (eGFR) was estimated according to the modification of diet in renal disease equation and assessed by the five stages of chronic kidney disease (CKD).ResultsIn men and women, eGFR < 57 ml/min/1.73 m2 (lowest quartile) compared to eGFR > 74 ml/min/1.73 m2 (highest quartile) was associated with a 38% increase in fracture risk after adjustment for relevant confounders [hazard ratio (95%CI): 1.38 (1.17 to 1.61)]. Also, CKD stages 3a and 3b were associated to a 28 and 46% increase in fracture risk, respectively, as compared to CKD stages 1 and 2 together (eGFR > 60 ml/min/1.73 m2) after adjustment for confounders. Renal function was not associated with prevalent vertebral fractures. In men, but not women, lowest quartile of eGFR was related to lower femoral neck BMD as compared to the highest quartile eGFR [unstandardized B (95%CI) − 0.052 g/cm2 (− 0.098 to − 0.006)], after adjustment for relevant confounders. Further adjustment for PTH attenuated this relationship by 27%.ConclusionsIn men and women, early decreased renal function (eGFR < 60 ml/min/1.73 m2) was related to increased incident any fracture risk but not with increased prevalence of vertebral fractures. In men, but not women, early renal dysfunction was related to lower femoral neck BMD which could statistically be partially explained by increased PTH concentrations.

NON-DIPPING PHENOMENON MEASURED BY 24H-AMBULATORY BLOOD PRESSURE MONITORING IS A STRONG PREDICTOR OF LEFT VENTRICULAR HYPERTROPHY IN CHRONIC KIDNEY DISEASE

Objective: Few studies have assessed the role of 24 h ambulatory blood pressure monitoring (ABPM) in adults suffering from non-dialysis chronic kidney disease (CKD). We examined potential determinants of left ventricular hypertrophy (LVH) and mass index (LVMI) in this population. Design and method: We conducted a cross-sectional study on 69 stage 3b-5 CKD adults who had ABPM and transthoracic echocardiography performed simultaneously. Hypertension (HT) was defined as 24 h blood pressure (BP) > or = 130/80 mmHg. ABPM parameters considered were BP dipping status, BP load and BP nighttime/daytime ratio. We conducted stepwise backward multivariate linear and logistic regression to assess determinants of LVH and LVMI. ABPM parameters were considered main predictors whereas HT, ACEI/ARAII use, GFR < 30 ml/min/1.72m2, diabetes, smoking, age, gender, Hb and PTH levels were considered covariates. Results: LVH was present in 22 (31.8%) patients. In linear regression analysis, systolic (β=−13.8, 95% CI = −26.3; −1.3, p = 0.031) and mean (β=−13.5, 95% CI = −25.7; −1.2, p = 0.031) dipping statuses were negatively associated with LVMI. BP load and nighttime/daytime ABPM ratio were not associated with LVMI. In logistic regression analysis, systolic dipping status (OR = 0.27, 95% CI = 0.08; 0.91, p = 0.036) was negatively associated with LVH. Amongst covariates, eGFR < 30 ml/min/1.72m2 and HT were positively associated with LVH and LVMI. At one-year follow-up, mean dipping status on the initial ABPM remained significantly associated with LVMI (β=−19.8, 95% CI = −36.6; −3.0, p = 0.022). Conclusions: These data confirm the high incidence of LVH amongst non-RRT CKD patients and suggest that non-dipping phenomenon on ABPM is an independent and strong predictor of LVH and LVMI in this population.

European renal best practice interpretation of Clinical Practice Guideline on management of the elderly patients with chronic kidney disease stage 3b or higher in 2016

European renal best practice interpretation of Clinical Practice Guideline on management of the elderly patients with chronic kidney disease stage 3b or higher in 2016

Progression of renal function in patients with chronic kidney disease on a low-protein diet supplemented with aminoacids and ketoanalogues

chronic kidney disease (CKD) is a public health problem. Low-protein diets supplemented with ketoacids and essential aminoacids have proved effective at different CKD stages. to assess the progression of renal failure in adult patients with CKD stages 3b and 4 receiving a protein-controlled diet supplemented with aminoacids and ketoanalogues. retrospective, descriptive intervention study. The nutritional intervention consisted of a protein/calorie intake of 0.4-0.6 g/kg/day and 30-35 kcal/kg/day plus a tablet of ketoanalogues (Ketosteril®)/5 kg weight. We assessed nutritional condition, glomerular filtration (GF) and creatinine, urea and albumin levels at 0, 3, 6, 9 and 12 months. SPSS version 18 was used for data statistical analysis. thirty-three patients were studied (67% male; mean age 59.7 years, r: 24-87). Protein/calorie intake was 0.55 ± 0.20 g/kg/day and 34 ± 4.51 kcal/kg/day. Ketosteril® intake was 11.87 tablets/day (r: 9-14). Initial GF was 24.97 ± 6.64 ml/min/1.73 m2, showing a significant increase between three and 12 months (25.51 ± 8.57 and 29.26 ± 10.33 ml/min/1.73 m2; p = 0.006). Urea nitrogen decreased significantly at six months compared with the initial level (p < 0.005). Body mass index did not change significantly (initial, 26. 63 ± 4.08 kg/m2; after a year, 26.78 ± 3.98 kg/m2). Initial and final albumin levels were 3.53 ± 0.64 g/l and 4.00 ± 0.53 g/l, respectively (p = 0.79). a low-protein diet supplemented with ketoanalogues administered to patients with CKD stages 3b and 4 preserved nutritional condition and mineral balance, improved GF significantly and decreased urea levels.