Chronic Kidney Disease Stage 3b Research Articles

Inflammation induces osteoclast differentiation from peripheral mononuclear cells in chronic kidney disease patients: crosstalk between the immune and bone systems.

Inflammation and immune system alterations contribute to bone damage in many pathologies by inducing the differentiation of osteoclasts (OCs), the bone resorbing cells. This link is largely unexplored in chronic kidney disease (CKD) and haemodialysis (HD) patients, in which reduced renal function is accompanied by an increased inflammatory state and skeletal abnormality. We used ex vivo culture experiments to investigate the osteoclastogenic potential of peripheral blood mononuclear cells (PBMCs) of CKD and HD patients, focusing on immune cell subsets and inflammatory cytokines such as LIGHT and receptor activator of nuclear factor κB ligand (RANKL). We observed spontaneous osteoclastogenesis with a significant increase in OC formation and bone resorbing activity in late-stage CKD and HD patients when compared with early-stage CKD patients and healthy donors, likely due to an increased expression of RANKL and LIGHT (homologous to Lymphotoxins exhibiting Inducible expression and competing with herpes simplex virus Glycoprotein D for herpes virus entry mediator [HVEM], a receptor expressed by T lymphocytes) in PBMCs. Specific inhibition of these cytokines in PBMCs isolated from CKD stages 3b-5 and HD patients induced the reduction of OC formation in vitro. The phenotypic characterization of peripheral blood cells revealed a significant increase of OC precursors (CD14+CD11b+CD51/61+) and CD14+CD16+ monocytes in advanced CKD and HD patients compared with the control group. Our results suggest that circulating inflammatory monocytes from advanced CKD or HD patients trans differentiate into OCs in vitro and play a relevant role in mineral bone disorders and that LIGHT and RANKL represent new potential therapeutic targets in these settings.

Оценка влияния различных видов ишемии в хирургическом лечении рака единственной почки на прогрессию хронической болезни почек

Мета роботи: вперше провести оцінку впливу застосування різних видів ішемії в хірургічному лікуванні раку єдиної нирки на прогресію хронічної хвороби нирок.Матеріали і методи. Проведено ретроспективний аналіз результатів лікування 68 пацієнтів, яким було виконано резекцію з приводу нирково-клітинного раку (НКР) єдиної нирки. Всі хворі проходили стаціонарне лікування у відділенні пластичної та реконструктивної урологій Національного інституту раку, урологічному відділі Львівської обласної клінічної лікарні.Результати досліджень та їх обговорення. До проведення хірургічного лікування раку нирки (РН) на 2 стадії хронічної хвороби нирок (ХХН ) був один пацієнт першої групи, один пацієнт другої групи та 6 хворих третьої групи. Відповідно 3а стадію ХХН було діагностовано у 5 хворих першої групи, 4 хворих другої групи та 19 пацієнтів третьої групи. 3b стадію ХХН діагностовано у 4 хворих першої групи, 3 хворих другої групи та 12 хворих третьої групи. З четвертою стадією ХХН, до проведення хірургічного лікування, було 3 хворих першої групи, один хворий другої групи та 7 хворих третьої групи. 5 стадію ХХН спостерігали лише у 2 хворих третьої групи. Через три місяці після проведеного хірургічного лікування прогресування ХХН спостерігали у 3пацієнтів першої групи, що становило 23, 1 %. У 2хворих другої групи, що, відповідно, складало 22, 2 %. В третій групі дослідження через три місяці після проведеного хірургічного лікування прогресування ХХН спостерігали у 5 хворих, що становило 10, 9 % випадків.

Serum hepcidin may be a novel uremic toxin, which might be related to erythropoietin resistance

The clinical importance of serum hepcidin in non-dialysis chronic kidney disease (CKD) patients is unclear. The database of a large-scale multicentre prospective study in Korea of 2238 patients enrolled from 2011–2016 was analysed. After excluding patients with missing serum hepcidin (n = 125) and haemoglobin (n = 23) levels, the study included 2090 non-dialysis CKD patients. Markers of inflammation and iron status were positively associated with serum hepcidin level, regardless of CKD stage. However, estimated glomerular filtration rate was inversely associated with serum hepcidin level, particularly in patients with CKD stages 3b–5 but not in those with CKD stages 1–3a. Use of erythropoiesis-stimulating agents was associated with increased serum hepcidin levels, particularly in patients with CKD stages 3b–5 but not in those with CKD stages 1–3a, and serum hepcidin levels positively correlated with the dose of erythropoiesis-stimulating agent. These findings suggest that serum hepcidin may be a uremic toxin and play an important role in erythropoietin resistance. However, future prospective studies are needed to confirm our results.

Case Report Ramsay Hunt Syndrome presenting as “a window’’ to HIV diagnosis in 48 year old African female: A case report

Background: Ramsay Hunt Syndrome in adults is reported in a number of case reports as an uncommon presentation of Varicella zoster Virus infection. Ramsay Hunt Syndrome occurs when there is reactivation of the latent Varicella zoster virus present in the ganglia due to previous varicella infection. Following a breakdown of the immune system, latent Varicella zoster infection can be activated. HIV (Human Immunodeficiency Virus infection), causes immunosuppression and hence reactivation of Varicella zoster. The diagnosis of Ramsay Hunt Syndrome, gives a window of opportunity to investigate for HIV. Here we report our first case of Ramsay Hunt syndrome as a presenting feature of HIV disease in an apparently healthy looking 48 year old black African female who was unaware of her HIV status at the time of presentation.
 This case is reported in order to highlight the need to use Ramsay Hunt Syndrome as a window of opportunity to screen for underlying HIV.
 Case presentation: A 48 year old black African female who was unaware of her HIV status, presented to our outpatients department with a two day history of painful right ear pain, vesicles on the right pinna and inability to completely close her right eye, her mouth was deviated to the left, with a wrinkle free frown. She denied any alteration in taste sensation and hyperacusis. She had a grade IV House-Brackmann facial paralysis.A diagnosis of Ramsay Hunt Syndrome was made and an HIV test was offered, the test was positive for HIV.A subsequent HAART (Highly Active Antiretroviral Therapy) work up, revealed CKD 3B (Chronic Kidney Disease stage 3B) and a CD4 (cluster of differentiation 4) count of 217 cells/µl .She was started on antiretroviral therapy 2 weeks after completing a 10 day regimen of acyclovir. In addition to her drug treatment she received ocular care and physiotherapy. Four months on her facial nerve function has improved modestly.
 Conclusion: An HIV test should be an indispensable part of the Ramsay Hunt syndrome workup, as its diagnosis gives a window of opportunity to diagnose HIV and offer life- saving HAART.

Spot Urine-guided Salt Reduction in Chronic Kidney Disease Patients

Dietary salt restriction is important in patients with chronic kidney disease (CKD) to reduce hypertension, cardiovascular events, progression of CKD, and mortality. However, recommending salt reduction for patients is difficult without knowing their actual sodium intake. This study evaluated the effectiveness of spot urine-guided salt reduction in CKD outpatients. A prospective cohort study was used. This study included a total of 127 adult outpatients (aged 60±18years, 80 males) with CKD. Their baseline estimated glomerular filtration rate was 51.4±25.1 (mL/minute/1.73 m2), and 64 (50%) of them were with CKD stage 3a or 3b (both 32 [25%]). We informed the patients of their individual spot urine-estimated salt intake every time they visited the outpatient clinic. Based on the data, the nephrologist encouraged the patients to achieve their salt restriction goal. The primary outcome was the estimated salt excretion, and the secondary outcome was the urinary protein-to-Cr ratio (UPCR). Multiple regression analyses were performed to clarify the contributing factors of changes in both outcomes. Over a follow-up of 12months, the median number of patients' visits was 7 (5-8). The estimated salt intake was significantly reduced from 7.98±2.49g/day to 6.77±1.77g/day (P<.0001). The median UPCR was also reduced from 0.20 (0.10-0.80) to 0.10 (0.10-0.48) (P<.0001). On multiple regression analysis, a reduction in UPCR was positively associated with the baseline UPCR and a reduction in systolic blood pressure significantly (P<.0001 and P<.01, respectively) as well as positively correlated with a reduction in the estimated salt intake, with borderline significance (P=.08). Providing spot urine-estimated salt intake feedback effectively motivated CKD patients to reduce their salt intake. Spot urine-guided salt reduction may slow CKD progression through decreased urinary protein excretion.

European Best Practice Guideline on Management of Patients with Diabetes and Chronic Kidney Disease Stage 3b or Higher (eGFR &lt;45 mL/min)

European Best Practice Guideline on Management of Patients with Diabetes and Chronic Kidney Disease Stage 3b or Higher (eGFR &lt;45 mL/min)

Prognostic Implications of Left Ventricular Global Longitudinal Strain in Predialysis and Dialysis Patients

Chronic kidney disease (CKD) is a worldwide growing epidemic associated with an increased risk of cardiovascular morbidity and mortality. Left ventricular (LV) global longitudinal strain (GLS) is a measure of LV systolic function associated with prognosis in the general population. However, little is known about the association between LV GLS and survival in patients with CKD. The aim of the present study was to investigate the prognostic implications of LV GLS in predialysis and dialysis patients specifically. LV GLS was measured in a retrospective cohort of predialysis and dialysis patients (CKD stage 3b to 5) who underwent clinically indicated echocardiography between 2004 and 2015. Patients were divided into 4 groups according to quartiles of LV GLS: first quartile (LV GLS ≤10.6%, worst function), second quartile (LV GLS 10.7% to 15.1%), third quartile (LV GLS 15.2% to 17.8%), and fourth quartile (LV GLS ≥17.9%, best function). The primary end point was all-cause mortality. Of 304 patients (62 ± 14years, 66% male), 65% were in predialysis and 35% in dialysis. During a median follow-up of 29months (interquartile range 16 to 58months), 34% of patients underwent renal transplantation and 36% died. Patients with LV GLS ≤10.6% showed significantly worse prognosis compared with the other groups (log-rank test, p <0.001). LV GLS ≤10.6% was significantly associated with increased risk of all-cause mortality (hazard ratio 2.18, 95% CI 1.17 to 4.06, p= 0.014) after correcting for age, gender, albumin levels, atrial fibrillation, and renal transplantation. In conclusion, in predialysis and dialysis patients, severely impaired LV GLS is independently associated with an increased risk of mortality.

Ramsay Hunt syndrome presenting as “a window'' to HIV diagnosis in 48 year old African female: A case report

Background: Ramsay Hunt syndrome in adults is reported in a number of case reports as an uncommon presentation of Varicella - zoster Virus infection. Ramsay Hunt syndrome occurs when there is reactivation of the latent Varicella - zoster virus present in the ganglia due to previous varicella infection. Following a breakdown of the immune system, latent Varicella - zoster infection can be activated. Human Immunodeficiency Virus infection (HIV), causes immunosuppression and hence reactivation of Varicella - zoster. The diagnosis of Ramsay Hunt syndrome, gives a window of opportunity to investigate for HIV. Here we report our first case of Ramsay Hunt syndrome as a presenting feature of HIV disease in an apparently healthy looking 48 year old black African female who was unaware of her HIV status at the time of presentation.&#x0D; This case is reported in order to highlight the need to use Ramsay Hunt syndrome as a window of opportunity to screen for underlying HIV.&#x0D; Case presentation: A 48 year old black African female who was unaware of her HIV status, presented to our outpatients department with a two day history of painful right ear pain, vesicles on the right pinna and inability to completely close her right eye, her mouth was deviated to the left, with a wrinkle free frown. She denied any alteration in taste sensation and hyperacusis. She had a grade IV House-Brackmann facial paralysis. A diagnosis of Ramsay Hunt syndrome was made and an HIV test was offered, the test was positive for HIV. A subsequent Highly Active Antiretroviral Therapy (HAART) work up, revealed Chronic Kidney Disease stage 3B (CKD 3B) and a cluster of differentiation 4(CD4) count of 217 cells/μl .She was started on antiretroviral therapy 2 weeks after completing a 10 day regimen of acyclovir. In addition to her drug treatment she received ocular care and physiotherapy. Four months on her facial nerve function has improved modestly.&#x0D; Conclusion: An HIV test should be an indispensable part of the Ramsay Hunt syndrome workup, as its diagnosis gives a window of opportunity to diagnose HIV and offer life- saving HAART.

Low renal replacement therapy incidence among slowly progressing elderly chronic kidney disease patients referred to nephrology care: an observational study

BackgroundElderly patients with advanced chronic kidney disease (CKD) have a high risk of death before reaching end-stage kidney disease. In order to allocate resources, such as advanced care nephrology where it is most needed, it is essential to know which patients have the highest absolute risk of advancing to renal replacement therapy (RRT).MethodsWe included all nephrology-referred CKD stage 3b-5 patients in Sweden 2005–2011 included in the Swedish renal registry (SRR-CKD) who had at least two serum creatinine measurements one year apart (+/− 6 months). We followed these patients to either initiation of RRT, death, or September 30, 2013. Decline in estimated glomerular filtration rate (eGFR) (%) was estimated during the one-year baseline period. The patients in the highest tertile of progression (>18.7% decline in eGFR) during the initial year of follow-up were classified as “fast progressors”. We estimated the cumulative incidence of RRT and death before RRT by age, eGFR and progression status using competing risk models.ResultsThere were 2119 RRT initiations (24.2%) and 2060 deaths (23.5%) before RRT started. The median progression rate estimated during the initial year was −8.8% (Interquartile range [IQR] - 24.5–6.5%). A fast initial progression rate was associated with a higher risk of RRT initiation (Sub Hazard Ratio [SHR] 2.24 (95% confidence interval [CI] 2.00–2.51) and also a higher risk of death before RRT initiation (SHR 1.27 (95% CI 1.13–1.43). The five year probability of RRT was highest in younger patients (<65 years) with fast initial progression rate (51% in CKD stage 4 and 76% in stage 5), low overall in patients >75 years with a slow progression rate (7, 13, and 25% for CKD stages 3b, 4 and 5 respectively), and slightly higher in elderly patients with a fast initial progression rate (28% in CKD stage 4 and 47% in CKD stage 5) or with diabetic kidney disease.ConclusionsThe 5-year probability of RRT was low among referred slowly progressing CKD patients >75 years of age because of the competing risk of death.

Acute and chronic kidney disease in elderly patients with hip fracture: prevalence, risk factors and outcome with development and validation of a risk prediction model for acute kidney injury

BackgroundHip fracture is a common injury in older people with a high rate of postoperative morbidity and mortality. This patient group is also at high risk of acute kidney injury (AKI) and chronic kidney disease (CKD), but little is known of the impact of kidney disease on outcome following hip fracture.MethodsAn observational cohort of consecutive patients with hip fracture in a large UK secondary care hospital. Predictive modelling of outcomes using development and validation datasets. Inclusion: all patients admitted with hip fracture with sufficient serum creatinine measurements to define acute kidney injury. Main outcome measures – development of acute kidney injury during admission; mortality (in hospital, 30-365 day and to follow-up); length of hospital stay.ResultsData were available for 2848 / 2959 consecutive admissions from 2007-2011; 776 (27.2%) male. Acute kidney injury occurs in 24%; development of acute kidney injury is independently associated with male sex (OR 1.48 (1.21 to 1.80), premorbid chronic kidney disease stage 3B or worse (OR 1.52 (1.19 to 1.93)), age (OR 3.4 (2.29 to 5.2) for >85 years) and greater than one major co-morbidities (OR 1.61 (1.34 to 1.93)). Acute kidney injury of any stage is associated with an increased hazard of death, and increased length of stay (Acute kidney injury: 19.1 (IQR 13 to 31) days; no acute kidney injury 15 (11 to 23) days). A simplified predictive model containing Age, CKD stage (3B-5), two or more comorbidities, and male sex had an area under the ROC curve of 0.63 (0.60 to 0.67).ConclusionsAcute kidney injury following hip fracture is common and associated with worse outcome and greater hospital length of stay. With the number of people experiencing hip fracture predicted to rise, recognition of risk factors and optimal perioperative management of acute kidney injury will become even more important.

Managing Chronic Kidney Disease and Chemotherapy-Induced Peripheral Neuropathy with Acupuncture and Herbal Medicine: A Case Study

This case study details the treatment of a 59-year-old male with Stage 3B chronic kidney disease (CKD) and chemotherapy-induced peripheral neuropathy of the left limbs using acupuncture and bulk herbs. After 6 weeks of combined acupuncture and herbal treatments, glomerular filtration rate increased significantly from 37 mL/min to 51 mL/min and serum creatinine level decreased from 1.85 mg/dL to 1.41 mg/dL. After a course of 15 acupuncture treatments over 4 months with some appointments in closer proximity, the patient additionally reported increased sensation of his left limbs. Since there are limited treatments for CKD, others with CKD may benefit from acupuncture and herbal treatments. This study offers an approach to managing CKD and chemotherapy-induced peripheral neuropathy more effectively using herbs and acupuncture supported by biomedical verification results.

Клинические рекомендации по лечению пожилых пациентов с хронической болезнью почек стадии 3Б и выше (рСКФ &lt; 45 мл/мин/1,73 м)

Клинические рекомендации по лечению пожилых пациентов с хронической болезнью почек стадии 3Б и выше (рСКФ &lt; 45 мл/мин/1,73 м)

Clinical Practice Guideline on management of older patients with chronic kidney disease stage 3b or higher (eGFR

The population of patients with moderate and severe CKD is growing. Frail and older patients comprise an increasing proportion. Many studies still exclude this group, so the evidence base is limited. In 2013 the advisory board of ERBP initiated, in collaboration with European Union of Geriatric Medicine Societies (EUGMS), the development of a guideline on the management of older patients with CKD stage 3b or higher (eGFR >45 mL/min/1.73 m2). The full guideline has recently been published and is freely available online and on the website of ERBP (www.european-renal-best-practice.org). This paper summarises main recommendations of the guideline and their underlying rationales.

Australian general practitioners’ current practice for chronic kidney disease (CKD) detection and management

Background Guidelines for early detection of chronic kidney disease (CKD) emphasise regular testing of kidney health in high-risk individuals. However, evidence suggests that CKD is not being adequately detected or appropriately managed in primary care. Aims Assess Australian general practitioners’ (GP) current practice in relation to CKD detection and management. Methods This was a cross-sectional study utilising a random sample of GPs identified by interrogation of the national online telephone directory, and stratified by geographical location. Data collection occurred between October 2014 and January 2015. Of 2,815 eligible contacts, the final response rate was 23 per cent. Results Of the 656 respondents, over 90 per cent assessed kidney health at least annually in people with diabetes or high blood pressure, and 71 per cent correctly assessed kidney health every 3–6 months in a patient with Stage 3b CKD. The tests most commonly used to assess kidney health were serum creatinine (with eGFR), blood pressure and urine albumin creatinine ratio. The most commonly reported CKD management strategies were ‘blood pressure reduction using pharmacological agents’ (81 per cent) and ‘glycaemic control if diabetes present’ (64 per cent). Knowledge testing highlighted that 32 per cent of respondents were not able to correctly identify how to properly assess absolute cardiovascular risk, and this was significantly more common in more experienced GPs (p=0.003). Conclusion The results indicate that Australian GPs are mainly practising in accordance with current guidelines for detection and management of patients with CKD, but with room for improvement in some areas.

Clinical Practice Guideline on management of older patients with chronic kidney disease stage 3b or higher (eGFR

The population of patients with moderate and severe CKD is growing. Frail and older patients comprise an increasing proportion. Many studies still exclude this group, so the evidence base is limited. In 2013 the advisory board of ERBP initiated, in collaboration with European Union of Geriatric Medicine Societies (EUGMS), the development of a guideline on the management of older patients with CKD stage 3b or higher (eGFR >45 mL/min/1.73 m2). The full guideline has recently been published and is freely available online and on the website of ERBP (www.european-renal-best-practice.org). This paper summarises main recommendations of the guideline and their underlying rationales.

Differential Characteristics of Kidney Transplant Recipients According to 1-Year Chronic Kidney Disease Stage 3a and Stage 3b Graft Function

The outcomes of transplantation have improved, but more than 50% of kidney transplantation (KT) recipients are still reported to have renal function of chronic kidney disease (CKD) stage 3 at 1 year after KT. We reviewed all 1235 patients who received a KT in our institution between 2008 and 2012. Among these recipients, 77 and 289 cases were included in the estimated glomerular filtration rate (eGFR) at 1 year after KT 30-44 (CKD stage 3b) group and eGFR 45-59 (CKD stage 3a) group, respectively. Longer duration of dialysis (odds ratio [OR] = 1.007, 95% confidence interval [CI], 1.000-1.014, P = 0.047), older donors (OR = 1.064, 95% CI, 1.031-1.098, P < 0.001), delayed graft function (OR = 3.601, 95% CI, 1.031-1.098, P < 0.001), BK virus infection (OR = 2.567, 95% CI, 1.242-5.305, P = 0.011), and pneumonia (OR = 4.451, 95% CI, 1.388-14.279, P = 0.012) were contributing factors to eGFR 30-44 mL/min. Especially, ureteral stricture occurred more frequently in eGFR 30-44 group of deceased donor KT. However, acute rejection was not a significant risk factor of lower eGFR. Graft survival was better in the eGFR 45-59 group. However, this difference was smaller in deceased donor KT. Infections and urologic complications are also important contributing factors of lower graft function in CKD stage 3. In addition, dividing CKD stage 3 into subgroups might be more useful in living donor kidney transplantation.

Nutritional support in the tertiary care of patients affected by chronic renal insufficiency: report of a step-wise, personalized, pragmatic approach.

BackgroundDietary treatment is helpful in CKD patients, but nutritional interventions are scarcely implemented. The main concern of the renal diets is its feasibility with regards to daily clinical practice especially in the elderly and co-morbid patients. This study aimed to evaluate the effects of a pragmatic, step-wise, personalized nutritional support in the management of CKD patients on tertiary care.MethodsThis is a case-control study. It included 823 prevalent out-patients affected by CKD stage 3b to 5 not-in-dialysis, followed by tertiary care in nephrology clinics; 305 patients (190 males, aged 70 ± 12 years) received nutritional support (nutritional treatment Group, NTG); 518 patients (281 males, aged 73 ± 13 years) who did not receive any dietary therapy, formed the control group (CG). In the NTG patients the dietary interventions were assigned in order to prevent or correct abnormalities and to maintain a good nutritional status. They included manipulation of sodium, phosphate, energy and protein dietary intakes while paying special attention to each patient’s dietary habits.ResultsPhosphate and BUN levels were lower in the NTG than in the CG, especially in stage 4 and 5. The prevalence of hyperphosphatemia was lower in the NTG than in CG in stage 5 (13.3 % vs 53.3 %, p < 001, respectively), in stage 4 (4.1 % vs 18.3 % vs, p < 0.001) and stage 3b (2.8 % vs 9.5 % p < 0.05). Serum albumin was higher in NTG than in CG especially in stage 5 . The use of calcium-free intestinal phosphate binders was significantly lower in NTG than in CG (11 % vs 19 % p < 0.01), as well as that of Erythropoiesis stimulating agents (11 % vs 19 %, p < 0.01), and active Vitamin D preparations (13 % vs 21 %, p < 0.01).ConclusionsThis case-control study shows the usefulness of a nutritional support in addition to the pharmacological good practice in CKD patients on tertiary care. Lower phosphate and BUN levels are obtained together with maintenance of serum albumin levels. In addition, a lower need of erythropoiesis stimulating agents, phosphate binders and active Vitamin D preparations was detected in NTG. This study suggests that a nutritional support may be useful in the management of the world-wide growing CKD burden.

Invited Commentary

Invited Commentary

A postoperative 1-Year eGFR of More Than 45 ml/min May be the Cutoff Level for a Favorable Long-Term Prognosis in Renal Transplant Patients.

BACKGROUND One-year renal function after kidney transplantation (KT) classified by the Kidney Disease: Improving Global Outcomes (KDIGO) chronic kidney disease (CKD) staging has been reported to be associated with graft survival. However, the outcomes of KT are improving. Therefore, the distribution and prognostic value of 1-year estimated glomerular filtration rate (eGFR) in recently performed transplants were re-evaluated in this study. MATERIAL AND METHODS We reviewed all patients who received KT between 2008 and 2011 at our institution, and followed them until June 2015. The distribution of 1-year eGFR, graft survival according to CKD staging, the cutoff level for a favorable prognosis, and the occurrence of rejection and infection were analyzed. RESULTS A total of 758 patients were included in this study. Unlike previous studies, most patients (56.2%) were in the CKD stage 2 (eGFR 60-89) rather than stage 3 (eGFR 30-59). In addition, the CKD stage 3a (eGFR 45-59) group showed better graft survival than the CKD stage 3b (eGFR 30-44) group. However, CKD stage 2 and CKD stage 3a groups did not show significant differences in graft survival. Patients with postoperative 1-year eGFR ≥45 ml/min showed a more favorable outcome compared with those with postoperative 1-year eGFR <45 ml/min. One-year eGFR<45 ml/min, acute cellular rejection, antibody-mediated rejection, and CMV infection after 1 year were adjusted risk factors for graft failure. CONCLUSIONS A 1-year eGFR ≥45 ml/min may be the appropriate cutoff level for predicting favorable outcomes in KT. In addition, KDIGO CKD staging may no longer be useful in recently performed KT.

Prognostic value of proteinuria and glomerular filtration rate on Taiwanese patients with diabetes mellitus and advanced chronic kidney disease: a single center experience.

Several risk factors were associated with poor outcomes in diabetic patients with chronic kidney disease (CKD). However, few studies addressed the prognostic implications of these factors in advanced CKD. Our study aimed to provide more evidence for risk factor stratification of diabetic patients with advanced CKD. A total of 447 diabetic patients with advanced CKD, age of 18-80, who visited the nephrology out-patient clinic were enrolled. All patients were in stage 3B-5 CKD. The primary outcomes included long-term renal replacement therapy and mortality. The occurrence of cardiovascular events was also analyzed as secondary outcome. Multivariate Cox regression models were used to address each risk factor in this cohort. We also used this cohort to evaluate the validity of the modified diabetic nephropathy score. Patients with lower estimated glomerular filtration rate (eGFR) were associated with higher degree of proteinuria. In the multivariate Cox regression model, eGFR and the degree of proteinuria were both strong outcome predictors. The effects of glycosylated hemoglobin and blood pressure in this advanced CKD cohort were minimal. Elder patients with advanced CKD had a higher mortality rate, but commenced less renal replacement therapy. Applying these indicator analyses, we proposed a modified diabetic nephropathy score for outcome prediction. Our analysis demonstrated the impact of eGFR and proteinuria in the advanced CKD group. Indicators in early CKD possessed a different prognostic profile in this advanced CKD cohort, therefore, necessitating a modified scoring system.