慢性肾脏病患者发生心衰的危险因素分析

目的探讨慢性肾脏病（CKD）患者发生心衰的危险因素。方法将366例CKD患者按2002年K/DOQI慢性肾脏病的分期标准分为5期,再按是否发生心衰分为2组,比较两组患者年龄、既往病史、吸烟史、心电图T波改变、血红蛋白（Hb）、C反应蛋白（CRP）、血脂、血压等方面的变化以及住院期间两组患者的病死率。结果发生心衰组的年龄升高,有既往高血压、糖尿病、冠心病、吸烟史者、心电图T波改变均比未发生心衰组明显增多（P〈0.05）;心衰组C反应蛋白（CRP）、高密度脂蛋白胆固醇（HDL-L）、舒张压（DBP）均比未心衰组明显升高（P〈0.01）,而Hb、低密度脂蛋白胆固醇（LDL-L）则比未心衰组明显降低（P〈0.01）结论患者年龄升高、既往有心血管病史、吸烟、CRP水平、Hb水平是CKD患者发生心衰的独立危险因素,针对性地干预这些危险因素,有可能降低心衰的发生率和病死率,改善CKD患者的预后。     

慢性肾脏疾病增加慢性心力衰竭患者死亡率

目的探讨慢性肾脏疾病(CKD)对慢性心力衰竭(CHF)患者死亡率的影响。方法对2007年1月1日至2009年12月31日在北京协和医院心内科住院,年龄≥21岁,临床诊断为心力衰竭,且左心室射血分数(LVEF)≤45%的缺血性(心肌梗死后至少40 d以上)或非缺血性心肌病患者进行回顾性研究,根据肾小球滤过率(eGFR)情况分为两组,一组为eGFR<60 ml.min-1.1.73 m-2(CKD组),另一组为eGFR≥60 ml.min-1.1.73 m-2(对照组),并进行电话随访。结果共筛选242例患者,除外41例不符合入选标准者,对201例进行随访,14例(7%)失访,经过2～41个月[平均(20±9)个月]的随访,共36例(19%)发生全因死亡,包括CKD组21例(30%)和对照组15例(13%)(P=0.003)。结论 CKD增加CHF患者死亡率。合并CKD的CHF患者,积极处理CHF的同时应高度重视CKD处理。     

Riser pattern is a predictor of kidney mortality among patients with chronic kidney disease

Background: Hypertension is a crucial risk factor for cardiovascular death and loss of residual kidney function. Absence of the nocturnal decline in blood pressure (BP) predicts cardiovascular events and poor prognosis. However, characteristics of hypertension in moderate-to-severe chronic kidney disease (CKD) have not been fully evaluated. We aimed to assess the circadian variation of BP and kidney survival in CKD patients. Methods: Patients who were examined by 24-h ambulatory BP monitoring (ABPM) and estimated glomerular filtration rate (eGFR), <45 ml/min/1.73 m², were enrolled in the study. The impacts of BP circadian rhythm and brain natriuretic peptide (BNP) on kidney survival were evaluated. Results: A total of 124 patients were enrolled. The average age was 64 ± 14 years, 57% were male, and 43% had diabetes. Forty-five percent of patients had a non-dipper pattern, 35% had a riser pattern, 19% had a dipper pattern, and 1% had an extreme-dipper pattern. The prevalence of diabetes and plasma BNP levels was higher and eGFR was lower in the riser-pattern group than in the non-riser-pattern group. Kidney survival rates were significantly worse in the riser-pattern group than in the non-riser-pattern group (p < 0.05). Moreover, among riser and non-riser pattern groups divided by BNP levels, the riser group with higher BNP level showed the worst kidney survival (p < 0.05). Conclusion: The riser pattern is frequently associated with several conditions at higher risk for kidney survival. Patients with a rising pattern and higher BNP levels have a worse kidney prognosis.     

Echocardiography in patients with chronic kidney diseases

Vast majority of chronic kidney disease patients die from cardiovascular complications. Echocardiography is a fundamental method, which reveals many of them. They include especially dilatation and systolic dysfunction of the left ventricle and atrium, left ventricular hypertrophy, diastolic dysfunction of the left ventricle, heart calcification, which could lead up to the development of stenotic valvular disease, right ventricular dysfunction and pulmonary hypertension. Patients with chronic kidney failure differ from the general population by cyclic changes of hydration and by the presence of a low resistant arteriovenous shunt (hemodialysis access). These factors significantly affect the actual echocardiographic finding.     

Device therapy in heart failure patients with chronic kidney disease

Heart failure (HF) and chronic kidney disease (CKD) both carry significant risk for sudden cardiac death, hospitalization, and mortality; when combined, however, they markedly increase the risk of morbidity and mortality. Device therapies such as implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) are treatments proven to have significant benefit on clinical outcomes in select patients with HF. However, the majority of studies supporting the use of these devices have limited data on patients with CKD or end-stage renal disease. In this review, we discuss the intersection of HF and CKD as it relates to progressive HF and the risk of sudden death. Although these disorders are common and have a poor prognosis, the evidence available for guiding treatment decisions for the use of ICD and CRT devices in these patients is lacking. Given this lack of clear evidence, pragmatic clinical trials and comparative effectiveness studies are needed to help identify the appropriate use of ICD and CRT devices in this high-risk population of patients with HF and CKD.     

The role of melatonin in patients with chronic kidney disease undergoing haemodialysis

Patients with chronic kidney disease including those undergoing haemodialysis have deranged sleep-wake pattern. In large part this is due to an abnormal circadian cycle of melatonin, a hormone secreted by the pineal gland in the evening and induces sleep. Subjects undergoing automated peritoneal dialysis or nocturnal haemodialysis have better sleep profile compared to those on daytime dialysis. Studies have shown that exogenous melatonin improves sleep-wake cycle in daytime haemodialysis patients. However, large randomised controlled trials are needed in order to establish its role in this patient population.     

Impaired frontal executive function and predialytic chronic kidney disease

OBJECTIVES: To investigate the nature of frontal dysfunction associated with chronic kidney disease (CKD) in people without stroke or depressive disorders. DESIGN: Cross‐sectional. SETTING: Community based. PARTICIPANTS: Five hundred twenty‐nine community‐dwelling participants. MEASUREMENTS: Participants with CKD were classified into one of three diagnostic groups based on their estimated glomerular filtration rate (eGFR): normal (≥60.0 mL/min per 1.73 m²), mild CKD (45.0–59.9 mL/min per 1.73 m²), or moderate to severe CKD (<45.0 mL/min per 1.73 m²). Cognitive function was assessed using the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease Neuropsychological Assessment Battery, lexical fluency, digit span test, and the 64‐card Wisconsin Card Sorting Test. RESULTS: Perseverative responses and perseverative errors were significantly more prevalent in the group with moderate to severe CKD than in those without CKD and those with mild CKD. The mean number of perseverative responses was 28.6±16.9 in participants with moderate to severe CKD, 19.0±11.4 in those with mild CKD, and 17.1±10.6 in those without CKD (P<.001, ANCOVA). The mean number of perseverative errors was 23.1±12.3 in participants with moderate to severe CKD, 16.2±8.3 in those with mild CKD, and 14.8±7.8 in those without CKD (P<.001, analysis of covariance). The odds ratios in the fully adjusted model for the presence of moderate to severe CKD for perseverative responses and perseverative errors were 4.82 (95% confidence interval (CI)=2.14–10.85, P<.001) and 5.01 (95% CI=2.22–11.28, P<.001), respectively. CONCLUSION: Frontal dysfunction, particularly perseverative errors and responses, was associated with moderate to severe CKD in the population studied.     

Association of morning hypertension with chronic kidney disease progression and cardiovascular events in patients with chronic kidney disease and hypertension

Background and aimAssociations of morning hypertension with chronic kidney disease are rarely investigated in prospective studies. We aim to investigate the predictive value of uncontrolled morning hypertension (UMH) to chronic kidney disease (CKD) progression and cardiovascular (CV) events in patients with CKD and hypertension.Methods and resultsIn this prospective two-center observational study, 304 hypertensive patients with CKD were enrolled. Time to total mortality, CKD progression and CV events was recorded; Kaplan–Meier survival function estimates and Multivariable Cox proportional hazard model were used to investigate associations between UMH and outcomes. The study protocol was approved by the Institutional Review Board (http://www.thaiclinicaltrials.org; TCTR20180313004). After a follow-up for median 30 months, 23 (7.6%) patients died, 34 (11.2%) had CKD progression, and 95 (31.3%) occurred new-onset CV events, respectively. UMH was shown to be a strong predictor of CKD progression [hazard ratio (HR) 2.46, 95% confidence interval (CI) 1.22–4.94] and CV events (HR 1.69, 95% CI 1.12–2.53). When morning hypertension was analyzed as a continuous variable, morning systolic blood pressure (per 10 mmHg) was also shown to be predictive to CKD progression (HR 1.28, 95% CI 1.07–1.53, P < 0.01) and CV events (HR 1.15, 95% CI 1.03–1.28, P < 0.01).ConclusionsUMH is strongly associated with CKD progression and CV events in patients with CKD and hypertension. UMH in CKD patients deserves further attentions.     

慢性肾脏病患者血管钙化相关生物学标志物

血管钙化是慢性肾脏病患者心血管死亡的主要原因,是患者死亡率强有力的预测因子。随着慢性肾脏病的进展,血管钙化发生率不断增加。因此需要找到预测血管钙化的生物标志物,用来预测未来心血管事件发生率和致死率,进行相应干预,改善患者预后。现已有不少关于慢性肾脏病患者血管钙化生物标志物的相关研究,文章就这些生物标志物进行了简要的综述。     

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     

慢性肾脏病合并心肾综合征的处理策略

慢性肾脏病(CKD)合并心肾综合征(CRS)在老年患者中较为常见,临床表现比较复杂。CKD合并CRS的临床处理原则是根据心、肾功能损伤的原因和临床表现对CRS进行分型,准确判断病情恶化的主要症结,依据不同的情况分别进行处理。纠正贫血、减轻水钠潴留以及改善利尿剂抵抗是此类患者治疗中的共性问题。ACEI、β受体阻滞剂和强心苷类药物在这些患者中应用安全有效,但需要小心用药、严密监测。CRS干预治疗的长期效果尚需更多的前瞻性临床研究。     

急性卒中患者的慢性肾脏病患病率和危险因素评价

目的 探讨卒中人群中慢性肾脏病(chronic kidney disease,CKD)的患病率以及该类患者的卒中危险因素和预后特点.方法 连续收集270例住院治疗的急性卒中患者,横贯性评价其CKD患病情况,比较270例卒中患者中入院美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分相近的53例CKD患者与106例无CKD患者的各种危险因素和近期预后.肾小球滤过率(glomerular filtration rate,GFR)＜60 ml/(min·1.73 m2)和(或)随机尿白蛋白/尿肌酐比值(albumin-to-creatinine-ratios,ACR)＞30 mg/g且持续3个月以上者定义为CKD,依据肾脏病饮食改良(Modification of Diet in Renal Disease equation,MDRD)简化公式估算GFR.近期预后采用改良Rankin量表(modified Rankin Scale,mRS)评价.结果 本组卒中患者CXD患病率为19.6%,主要为早、中期CKD.CKD组高血压(81.13%)、糖尿病(33.96%)和卒中病史(45.28%)比例均显著高于无CKD组(分别为64.15%、18.86%和27.36%)(P均＜0.05);伴CKD者收缩压[(151.74±20.98)mm Hg]和低密度脂蛋白[(3.03±0.96)mmol/L]显著高于无CKD组[收缩压为(144.30±21.64)mm Hg,低密度脂蛋白为(2.75±0.76)mmol/L](P均＜0.05);另外,CKD组红细胞沉降率(39 mm/h,中位数)、超敏C-反应蛋白(5.12 mg/L,中位数)、甲状旁腺素[(81.01±26.78)pg/ml]水平均显著高于无CKD组[分别为20 mm/h、3.36 mg/L和(46.95±24.63)pg/m]](P均＜0.05);CKD组还存在低血钙和高血磷的改变趋势.CKD组发病3个月后mRS评分≥13分的患者比例(66.03%)显著高于无CKD组(46.23%)(P＜0.05),3个月时的病死率(9.43%)也有增高的趋势(P=0.073).结论 卒中人群的CKD患病率较高,主要为早、中期CKD.伴CKD者卒中危险因素多于无CKD者,且预后也更差.     

Chronic kidney disease: A likely underestimated component of multimorbidity in older patients with chronic obstructive pulmonary disease

The coexistence of chronic kidney disease and chronic obstructive pulmonary disease, two age‐related conditions, has important clinical and prognostic implications. Respiratory failure is associated with important changes in glomerular and tubulointerstitial function. In contrast, renal failure can affect lung function, mainly by adding a restrictive component or causing complications, such as uremic pulmonary edema and pleural effusion. The effect of age on renal and pulmonary function adds to the complexity of the interplay between the kidney and the lung in these patients. Chronic kidney disease also represents an important risk factor for adverse drug reactions in older chronic obstructive pulmonary disease patients in which multimorbidity and polypharmacy are highly prevalent. Finally, an additive effect of chronic kidney disease and chronic obstructive pulmonary disease might also contribute to the pathophysiology of sarcopenia. Nevertheless, several gaps in our knowledge of the lung–kidney interplay still exist, thus suggesting further basic and clinical research on this topic. Geriatr Gerontol Int 2017; 17: 1770–1788.     

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.     

Bone loss in diabetic patients with chronic kidney disease.

OBJECTIVE: We investigated whether loss of bone is detectable during follow-up of diabetic patients with chronic kidney disease (CKD). RESEARCH DESIGN AND METHODS: In 40 initially non-dialysed diabetic patients with CKD (isotopic glomerular filtration rate < 60 ml/min/1.73 m(2) or albumin excretion rate > 30 mg/24 h), body composition (DEXA scan) and glomerular filtration rate (GFR determined from (51)Cr-EDTA clearance) were measured at a 2-year interval, and compared by paired t-tests. RESULTS: The 40 patients, mainly with Type 2 diabetes (n = 28), were men (n = 28), aged 65 +/- 11 years, with diabetes duration 18 +/- 11 years. GFR was initially 38.0 (range 8-89) ml/min/1.73 m(2). CKD progressed during follow-up: eight started haemodialysis and GFR declined in the 32 others (P < 0.05 vs. initial). T-scores for total body (initial -0.61 +/- 1.11, final -1.11 +/- 1.40; P < 0.001) and femoral neck (initial -1.88 +/- 0.15, final -2.07 +/- 0.15; P < 0.05) declined. Ten patients were osteopaenic at baseline (no osteoporosis), whereas most were osteopaenic (n = 21, P < 0.05) and five were osteoporotic at final assessment. The 16 patients who became osteopaenic or osteoporotic during follow-up did not differ from the others for the type of diabetes, age, GFR, albumin excretion rate, HbA(1c), GFR reduction and the requirement for dialysis during follow-up. They were all men (P < 0.01 by chi-squared test), with reduced initial total body T-score (-1.20 +/- 0.82, others -0.32 +/- 1.13; P < 0.05) and a lower body mass index (24.6 +/- 4.3; others 27.7 +/- 4.3; P < 0.05). CONCLUSION: Bone loss, especially in the femoral neck, is progressive in diabetic patients with CKD.     

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.