Examining chronic kidney disease management in a single center

AIMS: The management of patients with chronic kidney disease in outpatient clinics was assessed for the ability to achieve targets of care advocated in clinical practice guidelines. METHODS: 272 records of outpatients with increased serum creatinine (> or = 1.5 mg/dl for women, > or = 2.0 mg/dl for men) were reviewed for details of their assessment and management. Prevailing data on blood pressure, anemia, bone disease and lipid status as well as therapeutic changes were evaluated. RESULTS: The subjects were aged 64 +/- 18 years, serum creatinine 2.6 +/- 1.1 mg/dl, and calculated GFR (MDRD formula) 19.2 +/- 9.9 ml/min. Median UproV was 1.0 (0.024 - 12.4) g/day. Causes of CKD were diabetes (33.5%), HTN (8.8%), GN (19.5%), and adult PKD (3.3%). Treatment targets were BP < 130/85 mmHg, Hct > or = 36%, serum Ca++ > or = 8.5 mg/dl, serum Po4 < 4.5 mg/dl and cholesterol < 200 mg/dl. Of the patients with abnormal findings, mean values for SBP were 153 +/- 17 mmHg, DBP 93 +/- 6 mmHg, Hct 31.7 +/- 2.9%, Ca++ 8.0 +/- 0.7 mg/dl, PO4 5.6 +/- 1.0 mg/dl, and cholesterol 236 +/- 37 mg/dl. Only a minority of patients with abnormal values had their treatment altered. Furthermore, only 54% of patients with hypertension were treated with either ACEi or ARB therapy. Finally, only 6% of patients with hypercholesterolemia had fasting lipid levels measured. CONCLUSION: This data suggests that treatment of patients with CKD has improved, but that many opportunities exist to optimize their care.     

Dietary protein restriction benefits patients with chronic kidney disease

The prevalence of chronic kidney disease (CKD) is rapidly increasing so every strategy should be used to avoid the complications of CKD. Most CKD symptoms or uraemia are caused by protein intolerance; symptoms arise because the patient is unable to excrete metabolic products of dietary protein and the ions contained in protein-rich foods. Consequently, CKD patients accumulate salt, phosphates, uric acid and many nitrogen-containing metabolic products, and secondary problems of metabolic acidosis, bone disease and insulin resistance become prominent. These problems can be avoided with dietary planning. Protein-restricted diets do not produce malnutrition and with these diets even patients with advanced CKD maintain body weight, serum albumin and normal electrolyte values. Non-compliance is a problem, but this can be detected using standard techniques to provide the patient with appropriate responses. The role of dietary protein restriction in the progression of CKD has not been proven, but it can reduce albuminuria and will prevent uraemic symptoms. Until a means of preventing kidney disease or progression is found, safe methods of management such as dietary manipulation should be available for CKD patients.     

Clinical characteristics and predictors of progression of chronic kidney disease in autosomal dominant polycystic kidney disease: a single center experience

Background

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary renal disease. The course and progression of the disease is highly variable. In this study, we aimed to investigate the impact of clinical characteristics and basic biochemical parameters on progression of chronic kidney disease (CKD) in ADPKD patients.

Materials and methods

A total of 323 consecutive patients with ADPKD were enrolled into the study and followed with a mean duration of 100 ± 38 months. Patients were grouped as rapid progressors (RP) and slow progressors (SP) according to median rates of decline in glomerular filtration rate (ΔGFR) per year, namely 1 ml/min/year.

Results

History of macroscopic hematuria, urinary stone and smoking were more common in male patients; hepatic and other organ cysts were more common in female patients. ?GFR/year was similar between males and females [0.95 (0–3.02) vs. 1.11 (0.10–2.74) ml/min/year, p = 0.21]. History of smoking and pack-year of cigarettes smoked were significantly higher in the RP compared to the SP group (36 vs. 18 %, p = 0.01 and 5.24 ± 1.20 vs. 3 ± 1.32 pack-year, p = 0.02, respectively). Baseline 24 h-proteinuria was found to be significantly correlated with the percent decline of GFR (?%GFR) per year (r = 0.303, 0.001). In Cox regression analysis for predicting the progression of CKD, age, hypertension, urinary stone and proteinuria were retained as the significant independent factors predicting progression of CKD in the model.

Conclusion

Baseline proteinuria was significantly correlated with ?%GFR per year. Hypertension and proteinuria were found to be the major treatable risk factors for the progression of CKD in ADPKD patients.     

Incidence of cancer in kidney transplantation waiting list patients: a single center experience

Introduction

It is widely accepted that the risk of malignancies is significantly increased among patients with end-stage kidney disease (ESKD) and after kidney transplantation compared with the general population. Only a few data are available on kidney transplantation waiting list patients. The aim of this study was to investigate solid organ cancer incidence among subjects on the waiting list at a single center.

Materials and Methods

We retrospectively reviewed the records of all patients enrolled on our kidney transplantation waiting list between August 1, 2008 and July 31, 2010, seeking to evaluate the causes of withdrawal from the list, incidence of cancer, type of neoplasm, and its correlation with clinical features. We estimated the ratio of observed to expected numbers of cancers, the standardized incidence ratio (SIR).

Results

Among 1184 patients, we excluded 569 patients from the waiting list including 26 (4.56%) who displayed malignancies. The overall incidence of cancer was 0.11 events/person-months and the overall prevalence of cancer was 2.2%. In 97% of patients, the malignant disease was confined to the primitive organ of origin without secondary dissemination. We observed a prevalence of cancers related to ESKD (17; 65.38%). The SIR for all cancer types in our population compared with the general population was 2.22. The SIR for native kidney and thyroid cancers among our population compared with the general population was >10.

Conclusion

The incidence of cancer was significantly increased among kidney transplantation waiting list patients compared with the general population. Our study highlighted the importance of a careful, targeted neoplastic screening. It could be particularly important for ESKD-related malignancies like native kidney tumors or thyroid cancers.     

Mineral and bone disorder in patients with chronic kidney disease: a cross - sectional single center study

Objective To investigate and analyze the mineral and bone disorder (MBD) in the patients with chronic kidney disease (CKD), reveal the change of related indexes of CKD-MBD. Methods A cross-sectional study was carried out in the First Affiliated Hospital of Harbin Medical University. From October 2011 to May 2014, 1318 inpatients and hemodialysis outpatients were enrolled. Parameters related to MBD, including serum phosphorus (P), total calcium (t - Ca), intact parathyroid hormone (iPTH) and alkaline phosphatase (AKP) were analyzed. Last, it was analyzed with multiple regression analysis to related factors of the secondary hyperparathyroidism (SHPT) in patients with CKD. Results Serum calcium, phosphorus and iPTH had no obvious abnormalities at the early stages of CKD [GFR＞60 ml•min-1•(1.73 m2）-1], and relatively stable before GFR＞30 ml•min-1•(1.73 m2)-1. After entering the CKD4 stage, serum phosphorus, iPTH increased sharply and serum calcium decreased obviously along with the decreased glomerular filtration rate (GFR). Serum P, t-Ca and iPTH levels were statistically significant in CKD 1 to 5D patients, respectively, serum P: (1.13±0.20) mmol/L, (1.14±0.22) mmol/L, (1.26±0.23) mmol/L, (1.48±0.34) mmol/L, (2.05±0.61) mmol/L and (2.08±0.58) mmol/L; serum t-Ca (mmol/L) (2.35±0.13) mmol/L, (2.35±0.12) mmol/L, (2.35±0.15) mmol/L, (2.26± 0.18) mmol/L, (2.07±0.29) mmol/L and (2.31±0.26) mmol/L; iPTH: 57.8(45.6, 91.8) ng/L, 54.1(37.8, 74.6) ng/L, 71.6(45.8, 102.2) ng/L, 131.1(81.7, 205.1) ng/L, 277.5(173.6, 395.3) ng/L and 354.9 (194.4, 720.3) ng/L; The stepwise logistic regression analysis showed: hypocalcemia (OR=3.32, P＜0.01) and decreased GFR (OR=5.28, P＜0.01) were independent risk factors of iPTH elevation at stage CKD3～5. Conclusions From the beginning of the CKD3 stage, serum t - Ca, P, iPTH level began to be relatively abnormal as renal function declined. Hyperphosphatemia, SHPT has not been improved significantly in CKD5D stage patients even with hemodialysis. The regulation of hemodialysis on serum calcium showed "overcorrecting" phenomenon.     

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

Background

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.

Method

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.

Results

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.

Conclusions

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.

     

Incidental kidney stones: a single center experience with kidney donor selection

The presence of kidney stones has been a relative contraindication for living donation. With the widespread use of more sensitive imaging techniques as part of the routine living donor workup, kidney stones are more frequently detected, and their clinical significance in this setting is largely unknown. Records from 325 potential kidney donors who underwent MRA or CT-angiography were reviewed; 294 proceeded to donation. The prevalence of kidney stones found incidentally during donor evaluation was 7.4% (24 of 325). Sixteen donors with stones proceeded with kidney donation. All incidental calculi were nonobstructing and small (median 2 mm; range 1-9 mm). Eleven recipients were transplanted with allografts containing stones. One recipient developed symptomatic nephrolithasis after transplantation. This recipient was found to have newly formed stones secondary to hyperoxaluria, suggesting a recipient-driven propensity for stone formation. The remaining ten recipients have stable graft function, postoperative ultrasound negative for nephrolithiasis, and no sequelae from stones. No donor developed symptomatic nephrolithiasis following donation. Judicious use of allografts with small stones in donors with normal metabolic studies may be acceptable, and careful follow-up in recipients of such allografts is warranted.     

Simultaneous combined liver and kidney transplantation: a single center experience

Chava SP, Singh B, Stangou A, Battula N, Bowles M, O’Grady J, Rela M, Heaton ND. Simultaneous combined liver and kidney transplantation: a single center experience.
Clin Transplant 2010: 24: E62–E68. © 2010 John Wiley & Sons A/S. Abstract Renal dysfunction is common in patients awaiting liver transplantation (LT) and affects outcome following LT. Combined liver and kidney transplantation (CLKT) has been proposed as effective treatment for patients with chronic diseases of both organs, some with hepatorenal syndrome and for liver‐based metabolic diseases affecting kidney. This study is undertaken to analyze results of CLKT at a single center. Of 2690 LTs performed between 1992 and 2007, there were 39 CLKTs; most common indications were metabolic, cirrhosis and polycystic disease. With follow‐up of up to 170 months, 11 died (overall survival 71.8%); one‐, five‐, and 10‐yr patient and liver graft survival is 77%, 73.7%, and 73.7%, respectively, and kidney graft survival is 77%, 70%, and 70%, respectively. Survival among metabolic group (78.6%) appeared to be better than non‐metabolic group (68%); however, this difference was not significant (p = 0.39). Fifteen surviving patients (53.6%) have mild/moderate renal impairment (creatinine ≥125 μmol/L). None has severe renal failure (serum creatinine ≥250 μmol/L) or end‐stage renal disease requiring hemodialysis. CLKT has good results in selected groups of patients. It provides protection to kidney allograft in liver‐based metabolic diseases affecting kidney. The rate of acute rejection episodes of kidney is low. Significant proportion develops long‐term mild/moderate renal dysfunction. Careful attention to immunosuppression to minimize nephrotoxicity may help.     

Chronic kidney disease after autologous stem cell transplantation: analysis of a single center experience

Purpose

Chronic kidney disease (CKD) after allogeneic hematopoietic stem cell transplantation (HSCT) has increasingly been reported. However, CKD after autologous HSCT, especially changes in renal pathology, has rarely been reported. This study aimed to evaluate the frequency of CKD among patients who received autologous HSCT for hematological and nonhematological disorders, and analyze its clinical and pathological features.

Methods

We performed a retrospective study to evaluate the frequency of CKD after autologous HSCT and analyzed clinical and pathological features of CKD. Clinical records of patients who underwent autologous HSCT at the First Affiliated Hospital of Guangxi Medical University between May 2000 and November 2010 were screened. Clinical data of those with kidney injury on presentation and follow-up were acquired from hospital records.

Results

A total of 41 patients who received autologous HSCT were identified. CKD developed in six patients (14.6 %). Among the six patients, all had various degrees of proteinuria and three patients had nephrotic syndrome. Impaired renal function occurred in three patients. Three patients with nephrotic syndrome received only prednisone. Two patients obtained complete remission, and one had partial remission. What is particularly worth mentioning is, in two patients who received renal biopsy in our study, the pathological changes were mesangial proliferative glomerulonephritis.

Conclusions

Mesangial proliferative glomerulonephritis may not be as uncommon as previously thought in CKD patients after autologous HSCT. Presentation of nephrotic syndrome is common in CKD after HSCT and prednisone alone are effective.     

Outcomes of kidney transplant tourism in children: a single center experience

Transplant tourism is a necessity for children with end-stage renal disease living in regions without established local transplantation programs. The use of kidneys from living unrelated donors (LURDs) was common practice in Asia prior to the recent global condemnation of commercial organ transplantation. Objective information on the outcomes of pediatric transplant tourism is scarce. Here, we report the Dubai experience with 45 renal allograft transplantations performed outside the United Arab Emirates (UAE) between 1993 and 2009. Transplantation from 33 LURDs, ten living related donors (LRDs) and two deceased donors was performed in 14 different countries. The mean number of human leukocyte antigen (HLA) A/B/DR allele matches was 1.4 ± 0.8 in the LURD graft recipients and 3.9 ± 0.7 in the LRD recipients. Outcomes were compared with those of a matched group of 3,150 pediatric LRD transplantations from the Collaborative Transplant Study (CTS). Ten-year patient survival was 100% in the LRD patients, 91.2% in the LURD patients, and 92% in the CTS patients. The three deaths in the LURD group occurred within the first 4 months after transplantation and were related to acute rejection. One-year and 10-year graft survival was 100% in the LRD group and 94.8% and 66.7% in the CTS-LRD groups, vs 87.8% and 43.4% in the LURD group. Major viral infections [Epstein–Barr virus (EBV), cytomegalovirus (CMV), varicella zoster (VZV)] were four-times more common in patients that had received LURD grafts than in those that had received LRD grafts. In conclusion, whereas LRD kidney transplantation performed abroad yields excellent long-term results, transplantation of LURD kidneys is fraught with a high complication rate affecting graft and even early patient survival.     

Bladder management practices in spinal cord injury patients: A single center experience from a developing country

Context/Objective: Inadequate bladder management in spinal cord injury (SCI) patients results in significant morbidity and even mortality. Clean intermittent catheterization (CIC) is the recommended option for SCI patients. The objective of the study was to document the bladder management practices of SCI patients in a developing country.

Design: Questionnaire based cross sectional survey

Setting: Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan

Participants: All patients with SCI (irrespective of duration, level and etiology)

Interventions: Data documentation included demographics, level, severity and time since injury, bladder management techniques used, details of CIC, results of Urodynamic studies (if available), complications resulting from bladder management technique and patient awareness of the yearly follow up. SPSS V 20 was used for analysis.

Outcome Measures: Not applicable

Results: Thirty four consenting patients were enrolled. All were males. Mean age was 31.24 ± 10.9. Most (17) of the patients were thoracic level paraplegics, while 12 patients had sustained a cervical SCI. Majority (23) had complete injury (ASIA A). Fifteen patients used CIC for bladder management followed by in dwelling Foley catheters in thirteen patients. Those using CIC performed the procedure every four hours and used disposable catheters. The same ‘disposable’ catheter was used for 5-7 days by half of these patients. Only Six patients independently performed CIC. Three patients on CIC reported urinary tract infection.

Conclusions: In the largest spinal rehabilitation unit of a developing country; Pakistan CIC was the preferred method of bladder management followed by indwelling catheter. Re-use of disposable catheters is a common practice due to cost issues. The rate of UTI was significantly lower in patients on CIC.     

慢性肾脏病患者饮食管理体验质性研究的Meta整合

目的 深入了解慢性肾脏病患者饮食管理过程的真实体验,以期为慢性肾脏病患者展开针对性的饮食干预提供依据。方法 检索PubMed、Web of Science、EBSCO、ScienceDirect及中国知网、万方数据库、中国生物医学文献数据库等数据库从建库至2020年2月慢性肾脏病患者饮食管理相关的质性研究。根据澳大利亚JBI循证卫生保健中心质性研究质量评价标准进行文献质量评价,采用汇集性整合的方法进行整合。结果 共纳入15篇文献,提炼63个结果,归纳形成9个类别,整合出3个结果,即慢性肾脏病饮食对患者造成的影响（疾病造成的饮食相关症状困扰、情感体验,生活限制和文化冲突）、应对方式（积极应对和消极应对）、需求（需要知识与技能、需要专业人员支持、需要家庭与朋友支持）。结论 慢性肾脏病饮食对患者身心、生活、社交等多方面造成一定影响,医务工作人员在患者饮食管理过程中应该重视患者的应对方式,情感体验与不同需求,针对患者需求,给予患者指导与帮助,以树立患者饮食管理信念,引导患者积极应对,提高慢性肾脏病饮食管理的有效性。     

Surgical treatment of Peyronie's disease: a single center experience with 145 patients

OBJECTIVES: To assess the outcomes of the surgical techniques used in Peyronie's disease (PD) surgery. PATIENTS AND METHODS: One hundred fifty patients received surgical treatment for PD. Fifteen and 75 patients underwent simple corporoplasties and incision of the plaque, and venous (IV) grafting, respectively, whereas 60 patients with erectile dysfunction underwent penile prosthesis implantation. At follow-up, the erectile function and penile deformity were assessed at 3 and 12 mo postoperatively, and every 6 mo thereafter. RESULTS: Postoperative results were satisfactory in 14 of 15 patients with simple corporoplasties, with a mean angle of deformity and follow-up of 51.0 degrees +/-14.9 degrees and 21.0+/-9.7 mo, respectively. Among patients undergoing IV grafting with sapheneous vein (mean curvature angle: 61.6 degrees +/-19.5 degrees ), 70 were regularly seen with a mean follow-up of 41.7+/-35.1 mo. Penile curvature was completely straightened in 53 (75.7%) patients, whereas 12.8% and 11.4% had residual curvature less than 20 degrees and more than 20 degrees , respectively. The mean degree of penile curvature of patients with penile prosthesis was 46.9 degrees +/-20.1 degrees . Straightening of the penis was accomplished with implantation of the prosthesis only, manual modeling, plaque incision and grafting (autologous rectus fascia in the majority), incision of the plaque, and penile plication in 35%, 30%, 33.3%, 1.6%, and 1.6%, respectively. In the prosthesis group, two patients had recurrent curvatures. CONCLUSIONS: IV grafting is a good option with satisfactory mid- and long-term outcome. Insertion of the prosthesis only and manual modeling correct the curvature in the majority of the patients. For the remaining patients, autologous rectus fascia is an appropriate graft material.     

Cadaveric kidney transplantation: five years experience at a single center

BACKGROUND: In the past, the majority of renal transplantations in Iran were from living donors, but recently cadaveric donation of organs is increasing. We reviewed our experience on kidney transplantation from cadaveric donors for the past 5 years in our center. METHODS: Between July 1998 and September 2004, 122 kidneys were removed from 61 cases of brain-dead patients and transplanted in 114 patients with end-stage renal disease in our center. Two kidneys had tumoral involvement and were discarded. Three kidneys were transplanted in other centers and three patients received en bloc kidney transplantations. In addition, we performed nine cases of heart, one case of liver, and one case of lung transplantations. All the recipients were followed for at least 1 year and posttreatment renal function and graft survival were determined. RESULTS: All cadaveric donors were brain dead due to car (30%) and motocycle (70%) accidents, with ages ranging from 5 to 56 years (mean, 24/4 years). The mean warm and total cold ischemia times were 7 minutes and 8.1 hours, respectively. The mean distance between harvesting center and our hospital was 65 km. The 1-year graft survival was 92.3%, with mean serum creatinine of 1.76 +/- 0.79 at 1 year. Of other transplanted organs, the liver and lung recipients died 24 hours and 45 days after operation. Among heart recipients, four are still alive. CONCLUSION: Cadaveric donors in developing countries including Iran can be excellent sources of organ donation.     

Aortoiliac surgery concomitant with kidney transplantation: a single center experience

Abstract: Introduction: Aortoiliac pathology in kidney allograft recipients is not rare but treatment timing is controversial. As most publications on this topic are case reports it’s difficult to evaluate long‐term outcomes of those clinical challenges. Herein we report long‐term results of these procedures. Methods: From 1970 to 2006, 1544 kidney transplants were performed in our center. Thirty patients underwent aortoiliac surgery simultaneously with kidney transplantation. We analyzed their clinical records to come up with outcomes of these complex clinical challenges. Results: Vascular pathology was distributed as following: 19 stenoses treated with endarterectomy (15), aortoiliac bypass (two), aorto‐bi‐iliac bypass (one) and aorto‐bifemoral bypass (one); and 11 aneurysms treated with arterioplasty (four), aorto‐bi‐iliac bypass (four) and iliac‐iliac bypass (three). In 24 cases (80%) the necessity of vascular surgery was established intraoperatively as vessels’ conditions did not permit safe anastomoses and jeopardized graft survival. Mean follow‐up was 59 months (12–125). Five (16.7%) grafts were lost and three (10%) patients died in the first post‐operative month: acute myocardial infarction (two) and non‐viable kidney (one). Three patients died six, seven and 10 yr after the procedure. Nineteen patients are currently well with functioning grafts. Conclusions: Surgical correction of aortoiliac pathology may be performed simultaneously with kidney transplantation with acceptable outcome. This complex surgery can be performed in centers with experienced vascular surgeons. Specific vascular imaging should be performed regularly on patient at risk of aortoiliac disease before insertion and while on waiting list.