Terminal Chronic Kidney Disease Research Articles

Weighted gene co-expression network analysis of chronic kidney disease and hemodialysis patients

The group of heterogeneous disorders affecting the kidneys' structure and function is generally known as chronic kidney disease (CKD). In developed countries, most patients at the terminal CKD stage are treated with hemodialysis in order to increase their lifespan. Here, we used a microarray data set of patients with CKD, patients on hemodialysis, and healthy controls along with a weighted gene co-expression network analysis (WGCNA). We detected seven modules by using the WGCNA, and the blue, turquoise, and brown modules were highly enriched with differentially expressed genes (DEGs). Blue, turquoise, and brown module genes were the most significantly enriched in the gene ontology (GO) terms involved in oxidative phosphorylation, voltage-gated cation channel activity, and regulation of striated muscle cell differentiation, respectively. The brown module also included several GO terms involved in immunity. The turquoise module contained many genes that are known to cause neurological and heart diseases due to decreased expression. The brown module contained recombination signal binding protein for immunoglobulin κ J region (RBPJ) genes that are involved in vascular homeostasis and the survival of memory CD4-positive T cells. The decreased expression of RBPJ may be related to cardiovascular complications and susceptibility to infection. These findings contribute to a more complete understanding of the pathology of CKD and hemodialysis patients and complications including cardiovascular events and infectious diseases.

Profilaxis combinada con inmunoglobulina intravenosa y plasmaféresis en pacientes altamente sensibilizados, receptores de trasplante renal o combinado hígado-riñón: experiencia en un centro médico colombiano


 
 
 
 Introducción. El trasplante renal constituye la mejor opción de tratamiento para los pacientes con enfermedad renal crónica terminal. La supervivencia del injerto es de gran importancia y puede ser afectada por factores inmunológicos o no inmunológicos; esto unido al número de pacientes en las listas de espera, hace necesario definir estrategias de manejo que permitan tener mejores resultados a largo plazo. Objetivo. Determinar las características clínicas y humorales, y los de- senlaces en receptores de trasplante renal o combinado hígado-riñón, altamente sensibilizados, que recibieron profilaxis combinada con inmunoglobulina intravenosa y plasmaféresis en el Hospital San Vicente Fundación, en Colombia. Materiales y métodos. Se realizó un estudio retrospectivo, observacional, descriptivo, que incluyó los pacientes trasplantados entre el 4 de julio de 2010 y el 19 de abril de 2017. Como variables se incluyeron, entre otras, la etiología de la enfermedad renal crónica, el tipo de terapia recibida, y el tiempo en lista de espera en días. Como desenlace se evaluó la presencia de rechazo, el tipo de rechazo, la pérdida del injerto, las complicaciones y la muerte. Resultados. Del total de 25 pacientes, el 100% recibió inmunoglobulina intravenosa y el 84% plasmaféresis. El 12% presen-tó rechazo del injerto, todos de tipo humoral, y el 20% perdió el injerto. Discusión. A pesar de la gran variedad de protocolos propuestos en la literatura, en esta población especial no se ha establecido un protocolo óptimo de inmunosupresión. El protocolo en nuestra pequeña cohorte no tuvo un impacto negativo en el porcentaje de infecciones postrasplante ni en la pérdida del injerto renal, pero sí redujo el tiempo en las listas de espera; por lo tanto, se requieren estudios adicionales para confirmar los hallazgos encontrados en este estudio.
 
 
 

Assessment of Retinal Microangiopathy in Chronic Kidney Disease Patients.

Introduction:Optical coherence tomography angiography (OCT-A) is a useful diagnostic tool for assessing eyes’ health in patients with chronic diseases, such as diabetes, hypertension, Parkinson’s disease and chronic kidney disease (CKD).Aim:To detect changes in macular structure and retinal vascular meshwork in the macular area and peripapillary in patients with chronic kidney disease (CKD).Methods:This cross-sectional study included 80 eyes of patients with CKD in stages 2, 3 or 4, who were followed-up in the Nephrology Clinic of University Clinical Center Sarajevo. All patients were categorized according to the stage of CKD. All patients were scanned by a high-speed 840-nm-wavelength spectral-domain optical coherence tomography instrument (RTVue XR Avanti; Optovue, Inc, Fremont, California, USA). Blood flow was detected using a split-spectrum amplitude-decorrelation angiography algorithm. A fully automated microstructural analysis of the foveal avascular zone (FAZ), FAZ perimeter, foveal vessel density in a 300-μm area around the FAZ (FD), nonflow area, flow index in superficial and deep vascular plexus, choriocapillary flow, vascular density, radial peripapillary capillary density was performed.Results:When comparing patients with CKD stage 2 and stage 3 there were no statistically significant changes in microvascular parameters on OCT angiography, as well as when comparing patients with CKD stage 3 and stage 4. But in the comparison between patients with less developed CKD (stage 2) and terminal CKD (stage 4) there was a significant difference between some microvascular parameters such as FAZ area, FAZ perimeter, choriocapillary flow.Conclusion:Many studies demonstrated that evaluation of the microvascular changes in different retinal layers using SS-OCTA may be considered as a key to assessing the systemic perfusion status. Evaluation of retinal microvasculature may ease the management and approach of patients with CKD, having in mind that the retinal and the kidney vascular network are, concerning structure, development and the function, very similar.

Digestive Pathologies during Chronic Renal Failure in the Nephrology and Haemodialysis Department at the University Hospital Center of Point G in Mali

Introduction: Chronic kidney disease (CKD) is the progressive and irreversible loss of kidney function. It exposes to many complications, among which, digestive complications. In Mali, we do not have data on the prevalence of digestive pathologies in people with chronic renal failure, hence the interest of this study. Objective: To determine the prevalence of digestive pathologies and to describe their manifestations during chronic renal failure. Patients and Methods: This was a prospective cross-sectional study conducted from September 2016 to August 2017, a period of 12 months. Included were patients hospitalized in our department with CKD who received digestive endoscopy and/or liver serology. Results: Seventy-one patients underwent digestive endoscopy with oesogastroduodenal fibroscopy (60 patients), rectoscopy (6 patients) and anoscopy (5 patients), i.e. 15.9% of those hospitalized. The mean age of the patients was 48 ± 14 years with extremes of 15 and 84 years. The sample consisted of 59.2% men versus 40.8% women, for a sex ratio of 1.5. The functional signs are in order of frequency: vomiting (72.4%), anorexia (51.3%) and epigastralgia (48.7%). Terminal CKD by creatinine clearance accounted for 88.2% of cases, of which 47.4% were monitored by hemodialysis. Hepatitis C virus infection was present in 21.3% of cases, hepatitis B (18%) and HIV (7.5%). Endoscopic examinations were represented by fibroscopy (84.5%), rectoscopy (8.5%) and anuscopy (7%). The fibroscopic lesions were respectively gastric (96.8%), duodenal (14.1%) and esophageal (12.5%). They were dominated by gastritis (40.5%), duodeno-gastric reflux (16.4%), pyloric gap (12.6%). Rectoscopy found 4 cases of hemorrhoids, 2 cases of rectitis and no lesions were observed at anuscopy. Conclusion: The prevalence of these digestive manifestations and the endoscopic lesions encountered indicate the importance of digestive endoscopy and the performance of hepatic serologies in chronic renal failure patients with digestive symptoms and/or treated by hemodialysis.

Health-Related Quality of Life in Patients with Chronic Kidney Disease in Hemodialysis in Medellín (Colombia).

PurposeHemodialysis is a treatment that is essential for the survival of patients with terminal chronic kidney disease. However, it is highly invasive, non-curative, and physically, psychologically, socially, and financially demanding, which has an impact on the patient’s health-related quality of life (HRQL). In Colombia, research from the point of view of patients undergoing hemodialysis is scarce.Patients and methodsWe conducted a cross-sectional study involving 142 patients undergoing hemodialysis. We used an instrument that included the demographic and clinical information as well as the Charlson Comorbidity Index and Karnofsky Performance Status Scale. HRQL was assessed using EQ-5D-5L and KDQOL-36. The analysis was done using measures of central tendency for quantitative variables and relative frequencies for qualitative variables, in addition bivariate and multivariate regression analyses were conducted.ResultsBased on the scores of the EQ-5D-5L scale, it was found that 14.5% subjects showed severe mobility problems, 5.8% were unable to bathe or dress by themselves, 12.9% were unable to perform usual activities, 13.5% were experiencing pain or discomfort (between strong and extreme), and 58.6% showed a certain degree of anxiety or depression. The KDQOL-36 scores were 67.4 ± 19.4 for the symptoms domain and 35.0 ± 27.5 for the disease burden domain. Results of the linear regression analysis showed that the main factors associated with HRQL were the Karnofsky Index and serum albumin levels (p < 0.05).ConclusionThe result of this study revealed the impact on the quality of life of Colombian patients undergoing hemodialysis with chronic kidney disease who were highly affected by the disease burden. KDQOL-36 has excellent properties of reliability, internal consistency, and discriminant power; thus, its use is recommended in subsequent studies to monitor HRQL in this population.

Clinical conditions and history of illness among terminal chronic kidney disease patients

&lt;p&gt;End-stage renal disease (ESRD) is one of the public health problems in Indonesia. This study aimed to determine the clinical condition of premorbid and the incidence of ESRD. The study design is a case-control. The number of volunteers involved in this study was 100 patients. The cases were ESRD patients who were determined by the criteria of Pernefri and the controls were patients from the same hospital who were not ESRD by the requirements of ESRD Pernefri. Inclusion criteria of the study sample were ESRD sufferers need routine hemodialysis and doctor's diagnosis supported by laboratory data, 15-75 years old and willing to fill out inform consent. Exclusion criteria for the study sample were patients with congenital kidney disease, Have a history of kidney transplants, and mental disorder. We collected demographic data, and patient’s clinical and drug history from medical records. Chi-square analysis with 2x2 tables and the Fisher's exact test were used to determine the relationship of clinical conditions and history of disease with the incidence of ESRD. The results showed that anemia, hyperglycemia, and hypertriglyceridemia were related to the prevalence of ESRD. History of hypertension, diabetes mellitus, dyslipidemia, and family history of ESRD are associated with an increased incidence of ESRD.&lt;/p&gt;

Glucocorticoids Decrease Longitudinal Bone Growth in Pediatric Kidney Transplant Recipients by Stimulating the FGF23/FGFR3 Signaling Pathway.

Renal transplantation (RTx) is an effective therapy to improve clinical outcomes in pediatric patients with terminal chronic kidney disease. However, chronic immunosuppression with glucocorticoids (GCs) reduces bone growth and BMD. The mechanisms causing GC-induced growth impairment have not been fully clarified. Fibroblast growth factor 23 (FGF23) is a peptide hormone that regulates phosphate homeostasis and bone growth. In pathological conditions, FGF23 excess or abnormal FGF receptors (FGFR) activity leads to bone growth impairment. Experimental data indicate that FGF23 expression is induced by chronic GC exposure. Therefore, we hypothesize that GCs impair bone growth by increasing FGF23 expression, which has direct effects on bone growth plate. In a post hoc analysis of a multicentric randomized clinical trial of prepubertal RTx children treated with early GC withdrawal or chronic GC treatment, we observed that GC withdrawal was associated with improvement in longitudinal growth and BMD, and lower plasma FGF23 levels as compared with a chronic GC group. In prepubertal rats, GC-induced bone growth retardation correlated with increased plasma FGF23 and bone FGF23 expression. Additionally, GC treatment decreased FGFR1 expression whereas it increased FGFR3 expression in mouse tibia explants. The GC-induced bone growth impairment in tibiae explants was prevented by blockade of FGF23 receptors using either a pan-FGFR antagonist (PD173074), a C-terminal FGF23 peptide (FGF23180-205) which blocks the binding of FGF23 to the FGFR-Klotho complex or a specific FGFR3 antagonist (P3). Finally, local administration of PD173074 into the tibia growth plate ameliorated cartilage growth impairment in GC-treated rats. These results show that GC treatment partially reduces longitudinal bone growth via upregulation of FGF23 and FGFR3 expression, thus suggesting that the FGF23/Klotho/FGFR3 axis at the growth plate could be a potential therapeutic target for the management of GC-induced growth impairment in children.

Mortalidad de pacientes con enfermedad renal crónica terminal en un hospital de Huánuco, 2012-2016

Introducción. La enfermedad renal crónica (ERC) es considerada un problema de salud pública mundial y constituye una pérdida progresiva de la función renal. En el estadio 5, conocido como enfermedad renal crónica terminal, el paciente requiere terapia de reemplazo renal (TRR). Este trabajo se busca plasmar si el tipo de diálisis, el tipo de acceso y el tiempo total de TRR tienen relación con la mortalidad de pacientes con ERC en estadio cinco del hospital II-EsSalud de Huánuco. Métodos. Diseño Observacional, analítico, retrospectivo de casos y controles. Se identificaron 50 casos y 50 controles. Se realizaron análisis estadísticos a través de la prueba de Chi-2, Odds ratio con un nivel de confianza al 95%. Resultados. Se halló la asociación entre la mortalidad y los factores de riesgo estudiados como: el tipo de diálisis [P= 0,012; OR= 3,85 (IC 95%: 1,27 – 11,63)], el tipo de accesos [P= 0,017; OR= 4,04 (IC 95%:1,21- 13,43)] y el tiempo total de TRR [P= 0,037; OR=3,16 (IC 95%:1,03 – 9,68)], y el 67,7% de pacientes fue de sexo masculino. Se observó que se asociaban con mortalidad: la edad del paciente &gt; 75 años, el género masculino, la frecuencia de más de 3 diálisis por semana y el lugar de procedencia. Conclusiones. Existe asociación entre el tipo de diálisis, el tipo de acceso y el tiempo total de TRR con la mortalidad de pacientes con ERC terminal.

Android/gynecoid ratio as a prognostic factor for dyslipidemia in pediatric patients with chronic kidney disease

Background: there are multiple factors that increase the presence of dyslipidemia in chronic kidney disease (CKD). Objective: to determine if the android/gynecoid ratio (A/GR) has utility as a cardiometabolic factor for dyslipidemia in pediatric patients with chronic renal failure. Materials and methods: cohort study. Patients with terminal CKD in peritoneal dialysis and hemodialysis were included. Determinations of body composition, body mass index (BMI), and lipid profile were assessed for each patient. Subsequently, somatometry and lipid profile were performed at 6 and 12 months of follow-up. Statistical analysis: to identify the difference between the initial somatic and biochemical variables, and at 6 and 12 months, the Friedman test was applied. The Spearman coefficient determined the correlation of bodily and biochemical variables. Results: twenty-one patients were analyzed. Tryglycerides (TGL) serum at 12 months of follow-up increased significantly (6 vs 12 months, p = 0.05), without evidence of an increase in the Z score of the BMI (p = 0.98) or total cholesterol (p = 0.49). Body fat, fat percentage and Z score BMI did not correlate with changes in cholesterol and triglyceride levels at 6 and 12 months; however, the A/GI presented a statistically significant association with the change in serum concentrations of TGL at 6 (r = 0.65, p = 0.003) and 12 months of follow-up (r = 0.54, p = 0.02). Conclusions: the A/GI showed an association with the increase in the serum concentration of TGL at 12 months of follow-up.

“Reencontrándome a través de la diálisis peritoneal”: un abordaje fenomenológico

Objetivo: Describir la experiencia de personas con enfermedad renal crónica en terapia de diálisis peritoneal que asisten a una unidad renal de Huila-Colombia. Material y Método: Investigación cualitativa fenomenológica descriptiva, se realizaron entrevistas en profundidad a 16 participantes que cumplieron los criterios de inclusión. El análisis se realizó a partir del abordaje de Collaizzi. Resultados: 361 descripciones significativas, 94 unidades de significado, y 6 temas comunes: enfrentando la realidad, pérdidas, corporalidad, limitaciones, soporte y ganancias, describen la experiencia. Conclusiones: Padecer una enfermedad renal crónica terminal representa la lucha que tiene el paciente frente a los cambios en su aspecto físico, el auto reconocimiento y las limitaciones que tiene el servicio de salud del país, sin embargo, se refleja también, la transformación tras aceptar la condición, involucrando la terapia dialítica a su vida, permitiendo reencontrarse a través de ella.

Tumors in Native Kidney and Renal Grafts After Renal Transplantation. Experience of Our Centre

Introduction Kidney transplantation is the best treatment for terminal chronic kidney disease. The development of cancer has been considered the most common long-term complication of immunosuppressive therapy. No greater incidence of renal cancer has been observed in general transplanted patients (3%), but there is a greater incidence among kidney transplant patients. Tumor on the graft is very rare (0.5%). The objective of the present study is to analyze the development of renal tumors on native kidney and renal graft in our population. Material and Methods Between November 1979 and December 2016 we hace performed 1,729 kidney transplants. We have analyzed data regarding recipient and donor. The histological result, time of appearance or treatment, was collected from our database. Results We have reported 26 cases (1.5%), 19 on native kidneys (1%) and 7 on kidney graft (0.4%). The average age of the recipients was 47.4 years (18-79.5), 49.7 (35.2-79.5) among the patients who developed cancer on the native kidney and 42.7 (18.5-58.4). ) among those who developed it on the graft. There were 10 women, 7 among the patients with tumor on native kidney (36.8%) and 3 among the tumors of the graft (42.8%). The average age of the donor was 48.6 years in the total group (5-86), being 45.1 (5-86) among the donors of the patients with tumor on native kidney and 56.6 (41-79) in the rest. 17 tumors were clear cell renal adenocarcinoma (15 in native kidney and 2 in graft), 1 adenoma and oncocytoma in native kidney, 2 high-grade papillary urothelial carcinomas in native kidney and 5 on graft (p <0.05), and 1 tumor mixed solid papillary / clear cells in native kidney. The average time of onset was 2,918.8 days (8 years) among all cancers detected, being 3,017.7 (8.3 years) in the patients with native kidney and 2,650.3 (7.3 years) in the graft. The treatment in the native kidney group consisted of nephrectomies except for 2 tumorectomies, as well as among the graft neoplasms, which were treated with a transplantectomy except for a partial nephrectomy. Conclusions Cancer on native kidney and renal graft are infrequent and appear after several years after transplant date. The histological type papillary urothelial carcinoma has an increased incidence in relation to the general population, and significantly on the renal graft. The treatment is surgical and in the majority of cases it was associated with a transplant in our patients.

Clinical and hematological data to group different chronic kidney disease patients: A practical approach to establish different groups of patients.

Chronic kidney disease (CKD) is the convergent point of several pathological processes, and its evolution is insidious and characterized by a progressive and irreversible loss of kidney function. This impaired function induces the accumulation of uremic toxins and individuals with terminal CKD often have altered physiological responses, including a persistent state of immuno-suppression and development of diseases. A better characterization and stratification of these patients with CKD in different immuno-compromised groups would contribute to more effective and personalized treatments. The focus of this study was to use two parameters to stratify patients with CKD into four separate groups that are representative of different immunological status. Patients with CKD were chosen randomly and stratified into four separate groups according to the period of time receiving dialysis treatment and leukocyte blood counts. The amount of apoptotic CD4 T cells were measured in each group of patients, and clinical/hematological parameters were correlated by multivariate analysis with each group. Observations reveal that one of the four groups of patients with CKD (group 3) had more apoptotic CD4 T cells than the other group; this group also had an increased malnutrition inflammation score (MIS), an elevated Kt/V, and a higher incidence of smoking. A simple two-parameter-based stratification strategy could be used to design effective immunological therapies that differentiate the degrees of immuno-suppression across groups of patients with CKD.

NONVALVULAR ATRIAL FIBRILLATION AND DIABETIC NEPHROPATHY: EPIDEMIOLOGY, PROGNOSIS, AND CHOICE OF ANTICOAGULANT THERAPY.

In this review we present data on prevalence of atrial fibrillation (AF) among patients with type 2 diabetes (T2D), diabetic nephropathy and chronic kidney disease (CKD). Patients with nonvalvular AF and T2D combined with CKD have elevated risk of both bleeding and thromboembolic complications, as well as of all cause death. Efficacy and safety of novel oral anticoagulants (NOAC) depend on comorbidities and can be determined by the presence of T2D and/or diabetic nephropathy. Use of warfarin in CKD in some cases provides no preventive effect relative to risk of stroke and is characterized by increased risk of bleeding because of poor INR control, and possibly development of calcification of arteries. Presence of diabetic nephropathy requires monitoring of renal filtration function for correction of doses or selection of another anticoagulant. Lack of data from randomized controlled trials hampers choice of anticoagulant therapy in patients with terminal CKD on hemodialysis or after renal transplantation.

Минеральные и костные нарушения при хронической сердечной недостаточности

In many patients, chronic heart failure (CHF) is associated with chronic kidney disease (CKD). Virtually all patients with terminal CKD and many patients with early CKD display various disorders of mineral and bone metabolism (MBM) related with all-cause mortality and high risk of cardiovascular complications. This review addressed disorders of mineral and bone metabolism in patients with CHF, including hypocalcemia, hyperphosphatemia, vitamin D insufficiency/deficiency, secondary hyperparathyroidism, changed levels of FGF23 and Klotho, osteoporosis, osteopenia, their clinical and prognostic significance, and possibilities of their correction.

Beyond quality of life: a cross sectional study on the mental health of patients with chronic kidney disease undergoing dialysis and their caregivers

BackgroundPatients with terminal chronic kidney disease (CKDT) requiring renal replacement therapies (RRT) undergo important changes in living habits and frequently need caregiving. These patients and their caregivers are risk groups for the development of physical and psychological symptoms. This study aimed to evaluate the prevalence of anxiety, depression, stress, fatigue, social support, and quality of life in patients with CKD and their caregivers.MethodThis cross sectional study was conducted with 21 patients and their caregivers, from January to September 2015. We included patients aged over 18 years, with at least 6 months on dialysis treatment, and caregivers who were family members. The participants’ social, demographic, clinical, laboratory, and psychological variables were evaluated. A descriptive analysis and an examination of the association between patients and caregivers were performed.ResultsAmong patients, we observed that 38.1% had symptoms that indicated anxiety and depression. The average score for practical social support was 3.15 ± 0.769 and that for emotional social support was 3.16 ± 0.79. As for fatigue, 14.3% of patients reported being ‘extremely tired’ and 14.3% reported that they engaged in all the activities they usually performed before the illness. Further, 57.1% presented stress, and of these, 66.7% were at the resistance stage, with predominance of psychological symptoms in 60.0%. The quality of life domain in terms of functional capacity (FC) presented a correlation with haemoglobin level (r = 0.581, p = 0.006) and non-anaemic patients presented better FC. Among caregivers, we observed symptoms that indicated anxiety and depression in 33.3% of the sample. Caregivers exhibited an average score of 2.88 ± 0.77 for practical social support and 3.0 ± 0.72 for emotional social support. Further, 14.3% reported being ‘extremely tired’ and 28.8% reported that they engaged in all activities that they usually performed before the patient’s illness. When comparing the two groups (patients vs. caregivers), we observed that they presented similar results for the presence of anxiety, depression, and fatigue. Caregivers received less social support than patients did. Both groups presented similar predominance of stress levels; however, patients presented more predominance of psychological symptoms. With reference to quality of life, patients and caregivers presented similar results on the social aspects, vitality, mental health, and mental domains.ConclusionThe mental health characteristics of patients and caregivers were similar, and within the context of dialysis for renal disease, both must undergo specific interventions.

Aspectos celulares y moleculares de la nefropatía diabética, rol del VEGF-A

The prevalence of diabetes mellitus increased during the last century and it is estimated that 45% of the patients are not diagnosed. In South America the prevalence of diabetes and chronic kidney disease (CKD) increased, with a great disparity among the countries with respect to access to dialysis. In Ecuador it is one of the main causes of mortality, principally in the provinces located on the coast of the Pacific Ocean. The greatest single cause of beginning dialysis is diabetic nephropathy (DN). Even using the best therapeutic options for DN, the residual risk of proteinuria and of terminal CKD remains high. In this review we indicate the importance of the problem globally and in our region. We analyse relevant cellular and molecular studies that illustrate the crucial significance of glomerular events in DN development and evolution and in insulin resistance. We include basic anatomical, pathophysiological and clinical concepts, with special attention to the role of angiogenic factors such as the vascular endothelial growth factor (VEGF-A) and their relationship to the insulin receptor, endothelial isoform of nitric oxide synthase (eNOS) and angiopoietins. We also propose various pathways that have therapeutic potential in our opinion. Greater in-depth study of VEGF-A and angiopoietins, the state of glomerular VEGF resistance, the relationship of VEGF receptor 2/nephrin, VEGF/insulin receptors/nephrin and the relationship of VEGF/eNOS-NO at glomerular level could provide solutions to the pressing world problem of DN and generate new treatment alternatives.

Cellular and molecular aspects of diabetic nephropathy; the role of VEGF-A

The prevalence of diabetes mellitus increased during the last century and it is estimated that 45% of the patients are not diagnosed. In South America the prevalence of diabetes and chronic kidney disease (CKD) increased, with a great disparity among the countries with respect to access to dialysis. In Ecuador it is one of the main causes of mortality, principally in the provinces located on the coast of the Pacific Ocean. The greatest single cause of beginning dialysis is diabetic nephropathy (DN). Even using the best therapeutic options for DN, the residual risk of proteinuria and of terminal CKD remains high. In this review we indicate the importance of the problem globally and in our region. We analyse relevant cellular and molecular studies that illustrate the crucial significance of glomerular events in DN development and evolution and in insulin resistance. We include basic anatomical, pathophysiological and clinical concepts, with special attention to the role of angiogenic factors such as the vascular endothelial growth factor (VEGF-A) and their relationship to the insulin receptor, endothelial isoform of nitric oxide synthase (eNOS) and angiopoietins. We also propose various pathways that have therapeutic potential in our opinion. Greater in-depth study of VEGF-A and angiopoietins, the state of glomerular VEGF resistance, the relationship of VEGF receptor 2/nephrin, VEGF/insulin receptors/nephrin and the relationship of VEGF/eNOS-NO at glomerular level could provide solutions to the pressing world problem of DN and generate new treatment alternatives.

Assessment of oral and periodontal parameters in patients with end-stage chronic kidney disease

Aim: The purpose of the study was to assess the oral cavity status in patients with terminal chronic kidney disease (CKD) undergoing haemodialysis. Materials and Methods: The study comprised 69 patients with end-stage CKD undergoing haemodialysis regime. The data regarding the age, gender, environment, associated diseases were obtained from the clinical medical histories. The patients were submitted to clinical examination, which also included the periodontal probing and the gingival bleeding assessment. The type of edentulous ridge was recorded. Each patient filled a questionnaire offering data regarding the oral hygiene habits, diet, bad habits and the presence/absence of xerostomia. Results and Discussion: The main cause for end-stage CKD was renal, followed by diabetes mellitus and arterial hypertension. The main associated diseases to CKD were clearly secondary arterial hypertension and secondary anaemia; other associated diseases were represented by cardiac diseases, hepatitis, gastro-intestinal diseases, secondary hyperparathyroidism, cirrhosis, hypersplenism, epilepsy and neoplastic diseases. 62.31% of the patients accused frequent xerostomia. When recording the edentulous type, we observed a high percentage of complete tooth loss. Conclusions: There is a close link between the systemic changes in the CKD patient and the oral manifestations. Even 2 of the main causes of CKD (hypertension and diabetes mellitus) exert important changes on the tissues in the oral cavity, leading to significant tooth loss and masticatory impairment, thus, to a poor quality of life.

New red blood cell and reticulocyte parameters and reference values for healthy individuals and in chronic kidney disease

Introduction: The importance of local references values has been well described in the literature; this is because the characteristics of the population may influence the laboratory tests. Objective: To establish the reference range for traditional and extended red blood cell parameters and reticulocyte indices in order to investigate its application in patients with chronic kidney disease (CKD). Materials and methods: 249 blood donors (125 males and 124 females) were selected to establish the reference values. The hemodialysis sample consisted of 62 patients with terminal CKD (48 male and 14 female). All analyzes were performed using the Sysmex XE-5000 automated hematology analyzer. Results: Differences between reference values was observed in relation to gender: red blood cells (RBC), hemoglobin (HGB), hematocrit (HCT), mean corpuscular hemoglobin concentration (MCHC), percentage of hyperchromic red blood cells (%HYPER), percentage of microcytosis (%MICRO), percentage of macrocytosis (%MACRO), absolute reticulocyte count (RET), reticulocyte hemoglobin content (RET-He), immature reticulocyte fraction (IFR), low fluorescence reticulocytes (LFR), medium fluorescence reticulocytes (MFR), and high fluorescence reticulocytes (HFR). Individuals with CKD presented RBC, HGB, HCT, MCHC, red cell distribution width expressed as coefficient of variation (RDW-CV), percentage of hypochromic red blood cells (%HYPO), percentage of reticulocytes (RET%), RET (female group), IFR, LFR, MFR, and HFR results compatible with the anemic state, which can be observed in 91.8% of patients. All studied parameters were in the area under the curve (AUC) > 0.4. In male group, %HYPO (AUC: 0.806) and IFR (AUC: 0.762) presented higher AUC values, while female group presented %HYPO (AUC: 0.806), %HYPER (AUC: 0.815), and IFR (AUC: 0.660). Conclusion: The medical advancement, the development of new techniques and hematological parameters have revealed important information about functional integrity of bone marrow, diagnosis of anemia and recombinant human erythropoietin monitoring therapy used in hemodialysis patients.

Bone marrow cytological evaluation in dogs with chronic kidney disease

Since anemia is indicated as an important compromising factor for the quality of life of dogs with chronic kidney disease (CKD), bone marrow cytological analysis may provide more information on the hematological profile these dogs and, therefore, allow clinicians to not only choose the most adequate treatment but also monitor the response to therapy. The aim of this study was to investigate the feasibility with sternal bone marrow puncture in chronic kidney disease (CKD) using only local anesthesia and check if the cytological analysis is helpful to determine the hematological status. We found that erythroid hypoplasia occurred only in terminal CKD patients, and that the bone marrows of dogs with CKD stages 2 and 3 were quantitatively similar to those of elderly dogs. All dogs tolerated the bone marrow puncture using only local anesthesia with lidocaine and bone marrow cytological evaluation may be a useful tool for hematopoietic evaluation of anemic dogs with CKD.