Acute kidney injury in patients with chronic liver disease

Acute kidney injury(AKI) is a frequent clinical event in patients with liver disease, compounding their prognosis. Furthermore, it is likely that the occurrence of AKI has a detrimental impact on the subsequent renal function and the long-term survival of these patients. Recently, some authors advocated the use of new diagnostic criteria for detecting acute kidney injury in patients with cirrhosis. These criteria are based on the rapidity and extent of the creatinine increase comparing to the basal creatinine and also on the kinetics of diuresis decrease. Although their validity in this population requires further studies to be clearly established, these new criteria could have two advantages:(1) to allow earlier diagnosis of AKI and, thus, hepatorenal syndromefor which earlier intervention could improve patients' survival; and(2) to promote more intensive monitoring of renal function in these patients with high risk of AKI. Finally, recent practice guidelines about the prevention and treatment of general AKI have been published which should be useful in optimising the management of AKI in cirrhotic patients.     

The development of chronic kidney disease in Japanese patients with non-alcoholic fatty liver disease

Objective Chronic kidney disease (CKD) is present in patients with nonalcoholic fatty liver disease (NAFLD). The aim of this retrospective study was to assess the cumulative development incidence and predictive factors for new onset of CKD in Japanese patients with NAFLD. Methods A total of 5,561 NAFLD patients without CKD were enrolled. CKD was defined as either an estimated glomerular filtration rate of <60 mL/min/1.73 m(2) or dipstick proteinuria (≥+1). A blood sample and a urine sample were taken for routine analyses during follow-up. The mean observation period was 5.5 years. The primary goal is the new development of CKD. Independent factors associated with new development of CKD were analyzed by using the Kaplan-Meyer method and the Cox proportional hazards model. Results Of 5.561 NAFLD patients, 263 patients developed CKD. The cumulative development rate of CKD was 3.1% at the 5th year and 12.2% at the 10th year. Multivariate Cox proportional hazards analysis showed that CKD development in patients with NAFLD occurred when patient had low level of GFR of 60-75 mL/min/1.73 m(2) [hazard ratio:2.75; 95% confidence interval (CI)=1.93-3.94; p<0.001], age of ≥50 years (hazard ratio: 2.67; 95% CI=2.06-3.46; p<0.001), diabetes (hazard ratio: 1.92; 95% CI=1.45-2.54; p<0.001), hypertension (hazard ratio: 1.69; 95% CI=1.25-2.29; p<0.001), and elevated serum gamma-glutamyltransferase of ≥109 IU/L (hazard ratio: 1.35; 95% CI=1.02-1.78; p=0.038). Conclusion Our retrospective study indicates that the annual incidence of CKD in Japanese patients with NAFLD is about 1.2%. Five factors of low eGFR level, aging, type 2 diabetes, hypertension, and elevated gamma-glutamyltransferase, increases the risk of the development of CKD.     

Infections in patients with chronic kidney disease

There has been a notable lack of research activity regarding major infections in patients with advanced chronic kidney disease. To an outsider, this might seem unexpected, because uremia has long been considered a state of immune hyporesponsiveness and rates of major bacterial infection, like septicemia and pneumonia, are known to be orders of magnitude more likely in dialysis populations than in the general population. This article reviews recent literature on the topic, focusing predominantly on the clinical epidemiology of major bacterial infections in dialysis patients, the links between bacterial infections and cardiovascular disease, and randomized trials of interventions designed to prevent these infections.     

Hypertension in patients with chronic kidney disease

Hypertension is very common in patients with chronic kidney disease (CKD); it causes early loss of kidney function and accelerated cardiovascular morbidity and mortality. African American patients with hypertension and genetic disposition are at an even higher risk for renal disease and ultimately renal failure. Hypertensive patients with CKD should aim for stringent blood pressure (BP) control (target < 130/80 mm Hg) requiring more than one drug with renin-angiotensin-aldosterone system blockade as a component of therapy targeting both hyper tension and proteinuria. Management of hypertension in the dialysis population should focus on ambulatory measurements of BP and the use of longer-acting antihypertensive drugs, with their dosage and timing adjusted according to their dialytic clearances. Hypertension is also common among kidney transplant recipients and contributes to graft loss and premature death. The target BP in transplant recipients is the same as in the CKD population, with no preference for one drug group over another. Unless contraindicated, angiotensin-converting enzyme inhibitors remain the drugs of choice for hypertension in patients with autosomal-dominant polycystic kidney disease, in whom diastolic cardiac dysfunction is a prominent feature.     

Management of patients with chronic kidney disease

Chronic kidney disease (CKD) is a silent disease which worsens gradually to end-stage kidney disease (ESKD). US kidney disease outcomes quality initiative (KDOQI) guidelines indicate five stages of CKD based on the severity of kidney function which is assessed by estimating the glomerular filtration rate (GFR) by the modification of diet in renal disease (MDRD) formula. The management of CKD patients with mild renal damage (stage 1–2 KDOQI) is articulated on the reduction of proteinuria (<500 mg/day), reduction of sitting systolic and diastolic blood pressure (<130/80 mmHg), salt restriction diet, diuretics (furosemide, spironolactone), antihypertensive agents (ACE inhibitors or ARBs (angiotensin II receptor blockers) or both as first-line therapy), additional other antihypertensives (aliskiren, non-dihydropyridine calcium channel blockers, beta blockers), body weight reduction, cigarette smoking stopping, allopurinol therapy and non-use of some drugs (non-steroidal anti-inflammatory agents, acetaminophen, bisphosphonates, oral estrogens) and herbals. The management of CKD patients with moderate-severe renal damage (stage 3–5 KDOQI) is based on the above recommendations plus low protein diet, correction of hyperkalaemia, metabolic acidosis, and administration of vitamin D derivates and erythropoietin for the correction of mineral metabolism disorders and anemia, respectively. In conclusion, patients with CKD (stage 1–2 KDOQI) may be correctly managed by primary care physicians, individuals in stage 3–5 KDOQI need the supervision of nephrologists to assess those patients who progress to ESKD and require renal replacement therapy.     

Management of patients with chronic kidney disease

Chronic kidney disease (CKD) is a silent disease which worsens gradually to end-stage kidney disease (ESKD). US kidney disease outcomes quality initiative (KDOQI) guidelines indicate five stages of CKD based on the severity of kidney function which is assessed by estimating the glomerular filtration rate (GFR) by the modification of diet in renal disease (MDRD) formula. The management of CKD patients with mild renal damage (stage 1-2 KDOQI) is articulated on the reduction of proteinuria (<500?mg/day), reduction of sitting systolic and diastolic blood pressure (<130/80?mmHg), salt restriction diet, diuretics (furosemide, spironolactone), antihypertensive agents (ACE inhibitors or ARBs (angiotensin II receptor blockers) or both as first-line therapy), additional other antihypertensives (aliskiren, non-dihydropyridine calcium channel blockers, beta blockers), body weight reduction, cigarette smoking stopping, allopurinol therapy and non-use of some drugs (non-steroidal anti-inflammatory agents, acetaminophen, bisphosphonates, oral estrogens) and herbals. The management of CKD patients with moderate-severe renal damage (stage 3-5 KDOQI) is based on the above recommendations plus low protein diet, correction of hyperkalaemia, metabolic acidosis, and administration of vitamin D derivates and erythropoietin for the correction of mineral metabolism disorders and anemia, respectively. In conclusion, patients with CKD (stage 1-2 KDOQI) may be correctly managed by primary care physicians, individuals in stage 3-5 KDOQI need the supervision of nephrologists to assess those patients who progress to ESKD and require renal replacement therapy.     

Diagnosis of cardiovascular disease in patients with chronic kidney disease

The major forms of cardiovascular disease including coronary atherosclerosis, valvular disease, myocardial dysfunction, and arrhythmias are observed either alone or in combination in a large fraction of patients with chronic kidney disease (CKD). As CKD progresses, these cardiovascular conditions become more prevalent and severe. The clinical implications of combined heart and kidney disease include challenges in diagnosis and management. In addition, the terminal events in CKD commonly involve one of these four domains of cardiovascular disease. This paper will explore the issue of early diagnosis of heart disease in patients with CKD with the major goal being early intervention to lessen the impact of this comorbidity.     

Metformin therapy in patients with chronic kidney disease

Metformin therapy is limited in patients with chronic kidney disease (CKD) due to the potential risk of lactic acidosis. This open‐label observational study investigated metformin and lactate concentrations in patients with CKD (n = 22; creatinine clearances 15–40 ml/min) and in two dialysed patients. Patients were prescribed a range of metformin doses (250–2000 mg daily) and metformin concentrations were compared with data from healthy subjects (scaled to 1500 mg twice daily). A subset of patients (n = 7) was controlled on low doses of metformin (250 or 500 mg daily). No correlation between metformin and lactate concentrations was observed. Three patients had high lactate concentrations (>2.7 mmol/l) and two had high metformin concentrations (3–5 mg/l), but none had any symptoms of lactic acidosis. Reducing metformin dosage and monitoring metformin concentrations will allow the safe use of metformin in CKD, provided that renal function is stable.     

Vascular calcification in patients with chronic kidney disease

Vascular calcification is very prevalent in patients with chronic kidney disease (CKD). In addition to having more traditional cardiovascular (CV) risk factors, CKD patients also have a number of non-traditional CV risk factors that may play a prominent role in the pathogenesis of vascular calcification. The transformation of vascular smooth muscle cells into osteoblast-like cells seems to be a key element in the pathogenesis of vascular calcification in the presence of calcium (Ca) and phosphorus (P) deposition due to abnormal bone metabolism and impaired renal excretion. Vascular calcification causes increased arterial stiffness, left ventricular hypertrophy, decreased coronary artery perfusion, myocardial ischemia, and increased cardiovascular morbidity and mortality. Although current treatment strategies focus on correcting abnormal Ca, P, parathyroid hormone, or vitamin D levels in CKD, a better understanding of the mechanisms of abnormal tissue calcification may lead to the development of new therapeutic agents that are capable of reducing vascular calcification and improving the CV outcome of CKD patients. This review article summarizes the following: (i) the pathophysiological mechanism responsible for vascular calcification; (ii) the methods of detecting vascular calcification in CKD patients; and (iii) the treatment of vascular calcification in CKD patients.     

Cardiovascular imaging in patients with chronic kidney disease

Cardiovascular disease is highly prevalent in chronic kidney disease and has been associated with increased morbidity and mortality. Several morphological and functional tests are available to assess the cardiovascular system. Since structural and functional cardiovascular abnormalities have prognostic implications, their identification may become crucial for the implementation of effective preventive and therapeutic strategies. We review the most frequently used imaging methods to investigate structural and functional cardiovascular changes in patients with chronic kidney disease.     

Hepatocellular carcinoma in patients with chronic kidney disease

AIM: To investigate outcomes of hepatocellular carcinomas (HCCs) in patients with chronic kidney disease (CKD). METHODS: Four hundred and forty patients referred between 2000 and 2002 for management of HCCs were categorized according to their CKD stage, i.e. , estimated glomerular filtration rate (eGFR) > 90 (stage 1), 60-90 (stage 2), 30-60 (stage 3), 15-30 (stage 4), and < 15 (stage 5) mL/min per 1.73 m 2 , respectively. Demographic, clinical and laboratory data were collected and mortality rates and cause of mortality were analyzed. The mortality data were examined with Kaplan-meier method and the significance was tested using a log-rank test. An initial univariate Cox regression analysis was performed to compare the frequency of possible risk factors associated with mortality. To control for possible confounding factors, a multivariate Cox regression analysis (stepwise backward approach) was performed to analyze those factors that were significant in univariate models (P < 0.05) and met the assumptions of a proportional hazard model. RESULTS: Most HCC patients with CKD were elderly, with mean age of diagnosis of 60.6 ± 11.9 years, and mostly male (74.8%). Hepatitis B, C and B and C coinfection virus were positive in 61.6%, 45.7% and 14.1% of the patients, respectively. It was found that patients with stages 4 and 5 CKD were not only older (P = 0.001), but also had higher hepatitis C virus carrier rate (P = 0.001), lower serum albumin level (P = 0.001), lower platelet count (P = 0.037), longer prothrombin time (P = 0.001) as well as higher proportions of advanced cirrhosis (P = 0.002) and HCCs (P = 0.001) than patients with stages 1 and 2 CKD. At the end of analysis, 162 (36.9%) patients had died. Kaplan-Meier analysis revealed that patients with stages 4 and 5 CKD suffered lower cumulative survival than stages 1 and 2 CKD (log-rank test, χ 2 = 11.764, P = 0.003). In a multivariate Cox-regression model, it was confirmed that CKD stage [odds ratio (OR) = 1.988, 95%CI: 1.012-3.906, P = 0.046)], liver     

Association of morning blood pressure surge with chronic kidney disease progression in patients with chronic kidney disease and hypertension

Blood pressure (BP) usually rise from being asleep to awake, which is named the morning blood pressure surge (MBPS). Researches have reported that elevated MBPS was related with CV events, incident CKD in hypertensive patients. However, there have been no studies that have investigated the association between MBPS and renal or heart outcomes in patients with CKD and hypertension, in these patients, the MBPS is much lower because of high prevalence of night hypertension and reduced BP dipping. In this prospective two‐center observational study, we enrolled patients with CKD and hypertension and the 24 h ambulatory blood pressure monitoring (ABPM) was conducted in all patients. Time to total mortality, CKD progression and CV events was recorded; Finally, a total of 304 patients were enrolled and 94 (30.9%) of them had elevated MBPS. After a follow‐up for median 30 months, 23 (7.6%), 34 (11.2%), and 95 (31.3%) patients occurred death, CKD progression and new‐onset CV events, respectively. The Cox regression analysis suggested the elevated MBPS was a strong predictor of CKD progression (HR 2.35, 95%CI 1.2 ‐4.63, p = .013), independent of morning BP, while no associations were found between elevated MBPS and CV events (HR 1.02, 95%CI 0.66 ‐1.57), as well as death (HR 1.08, 95%CI 0.46 ‐2.55). In conclusion, we provided the first evidence that elevated MBPS was an important risk factor of CKD progression in patients with CKD and hypertension. Appropriate evaluation and management of MBPS may be helpful to postpone CKD progression.     

慢性肾脏病患者发生心血管事件危险因素的研究

目的 探讨慢性肾脏病(CKD)患者发生院内心血管事件的相关危险因素及对CKD患者院内死亡的影响.方法 选取2006年我院557例患有3期或3期以上CKD的住院患者,分析影响CKD患者发生心血管事件的相关危险因素以及心血管事件对CKD患者院内死亡的影响.结果 557例CKD患者中,男性332例,女性225例;住院期间心血管事件的发生率为29.3%(163/557).发生心血管事件的独立危险因素包括:年龄、既往冠心病史、空腹血糖水平和血红蛋白水平.发生心血管事件患者的住院死亡率显著高于未发生心血管事件患者的住院死亡率(9.82%比2.28%,X2=15.3,P＜0.001).结论 对于CKD患者,除年龄、既往冠心病史和空腹血糖这些传统的心血管事件危险因素外,贫血是其较为独特的独立危险因素.     

Hypertension management in patients with chronic kidney disease

Hypertension is one of the major risk factors for the development and progression of chronic kidney disease. The loss of renal function leads to impaired renal autoregulation and renders the kidney vulnerable to the damaging effects of uncontrolled hypertension. Mounting evidence indicates that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers slow the progression of chronic kidney disease through effects beyond lowering blood pressure. Studies are needed to determine whether high doses of the single agent or combination therapy is most effective in providing renal protection. Urinary protein excretion is a useful tool for monitoring and titrating therapy to maximize renal protection. Changes in the serum creatinine concentration and hyperkalemia are complications of antihypertensive therapy in patients with chronic kidney disease that can be successfully managed to allow continued use of renin-angiotensin blockade.     

Vascular calcification in patients with chronic kidney disease

Chronic kidney disease (CKD) represents an extremely common condition, and cardiovascular diseases are frequently reported in this patient population. Traditional risk factors are not accurate prognostic predictors in CKD patients, and new potential markers to predict the cardiovascular involvement in uremic patients need to be identified. Vascular calcification (VC) represents a hallmark of the atherosclerotic process in CKD. This review summarizes the processes responsible for VC (particularly focusing on the mechanisms operative in the presence of renal dysfunction), discusses the utility of computer tomography modalities in the detection of VC in patients with CKD, and reports the potential role of VC as pathophysiological link between kidney disease and cardiovascular events.