Association of blood pressure variability and neurocognition in children with chronic kidney disease

Background

Children with chronic kidney disease (CKD) and hypertension have increased blood pressure variability (BPV), which has been associated with lower neurocognitive test scores in adults. Children with CKD are at risk for decreased neurocognitive function. Our objective was to determine whether children with CKD and increased BPV had worse performance on neurocognitive testing compared with children with CKD and lower BPV.

Methods

This was a cross-sectional and longitudinal analysis of the relation between BPV and neurocognitive test performance in children ≥6 years enrolled in the Chronic Kidney Disease in Children (CKiD) study. Visit-to-visit BPV was assessed by the standard deviation of visit BPs (BPV-SD) and average real variability (ARV). Ambulatory BPV was assessed by SD of wake and sleep periods on 24-h ambulatory BP monitoring.

Results

We assessed 650 children with a mean follow-up period of 4.0 years. Children with systolic visit-to-visit BPV in the upper tertile had lower scores on Delis–Kaplan Executive Function System (D-KEFS) Verbal Category Switching than those with BPV in the lower tertile (BPV-SD, 8.3 vs. 9.5, p?=?0.006; ARV, 8.5 vs. 9.6, p?=?0.02). On multivariate analysis, the association between lower Category Switching score and increased BPV remained significant after controlling for mean BP, demographic characteristics, and disease-related variables [BPV-SD, β?=??0.7, 95 % confidence interval (CI) ?1.28 to ?0.12; ARV, β = ?0.54, CI ?1.05 to ?0.02). Ambulatory BPV was not independently associated with any cognitive measure.

Conclusions

Higher systolic visit-to-visit BPV was independently associated with decreased D-KEFS Category Switching scores in children with mild-to-moderate CKD.

     

Prevalence of chronic kidney disease risk factors among low birth weight adolescents

Background

By adulthood, low birth weight infants have an increased risk for chronic kidney disease (CKD). The extent to which objective CKD risk factors are present at earlier ages is unclear.

Methods

We analyzed 5352 participants aged 12–15 years in the National Health and Nutrition Examination Survey, 1999–2012. Participants were classified as low birth weight (LBW; < 2500 g), very low birth weight (VLBW; < 1500 g), or normal (2500–4000 g) by parental/proxy recall. Albuminuria (albumin/creatinine 30 – <300 mg/g), decreased estimated glomerular filtration rate (eGFR; < 90 ml/min/1.73 m²; Counahan–Barratt), and elevated systolic blood pressure (BP; ≥ 95th percentile for age, height, and sex) were considered CKD risk factors.

Results

While albuminuria did not vary by birth weight, elevated blood pressure (BP) and decreased eGFR occurred more frequently in LBW/VLBW adolescents (elevated BP: LBW 6.0 %, VLBW 11.2 %, normal 2.4 %; decreased eGFR: LBW 23.2 %, VLBW 32.5 %, normal 16.1 %). After multivariable adjustment, LBW/VLBW adolescents had greater odds for both elevated BP (LBW: OR 2.90, 95 % CI 1.48–5.71; VLBW: 5.23; 1.11–24.74) and decreased eGFR (LBW: 1.49, 95 % CI 1.06–2.10; VLBW 2.49, 95 % CI 1.20–5.18).

Conclusions

In the U.S. population, both decreased eGFR and elevated systolic BP occur frequently among adolescents with history of LBW/VLBW.

     

Decline in estimated glomerular filtration rate is associated with risk of end-stage renal disease in type 2 diabetes with macroalbuminuria: an observational study from JDNCS

Background

There is increased interest in surrogate endpoints for clinical trials of chronic kidney disease.

Methods

In this nationwide observational study of 456 patients with type 2 diabetes and clinically suspected diabetic nephropathy followed for a median of 4.2 years, we evaluated the association between estimated glomerular filtration rate (eGFR) and albuminuria at baseline or during follow-up and risk of ESRD.

Results

Low eGFR (<60 mL/min/1.73 m²) and macroalbuminuria at enrollment were independently associated with risk of ESRD. In patients with macroalbuminuria, both ≤?50% change and ?50 to ?30% change in eGFR over 1 and 2 years were predictive of ESRD. The higher cut point (≥50% decline in eGFR) was more strongly predictive but less common. Remission of macroalbuminuria to normo-/microalbuminuria at 1 and 2 years was associated with a lower incidence of ESRD than no remission; however, it was not a determinant for ESRD independently of initial eGFR and initial protein-to-creatinine ratio.

Conclusion

These results suggest that a ≥30% decline in eGFR over 1 or 2 years adds prognostic information about risk for ESRD in patients with type 2 diabetes and macroalbuminuria, supporting the consideration of percentage decline in eGFR as a surrogate endpoint among macroalbuminuric cases in type 2 diabetes. On the other hand, our study suggests that additional analyses on the relationship between remission of macroalbuminuria and risk of ESRD are needed in type 2 diabetes.

     

A clinical evaluation of renal amyloidosis in the Japan renal biopsy registry: a cross-sectional study

Background and aim

The available clinical data are limited in a rare glomerular disease, renal amyloidosis. We aimed to clarify the clinical features of renal amyloidosis from database of the Japan Renal Biopsy Registry (J-RBR).

Methods

We performed a cross-sectional study with database of the J-RBR of the Japanese Society of Nephrology. We identified 281 cases of renal amyloidosis from 20,997 cases enrolled into the J-RBR from 2007 to 2014. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were compared among the levels of ages, amount of urine protein excretion (AUPE) or CKD G stages.

Results

The prevalence of renal amyloidosis was 1.3 % (281/20,997). DBP significantly decreased in higher age quartiles (P = 0.034). SBP and DBP did not increase in the progression of AUPE levels and CKD G stages. In multiple regression analysis, eGFR was a significant independent factor for SBP in all cases and a subgroup without hypertensive agents. There was a reverse significant relationship between SBP and eGFR.

Conclusion

Blood pressure did not significantly increase in elderly and much proteinuric condition in renal amyloidosis. The progression of CKD and decrease of eGFR did not produce the higher SBP. The mechanism underlying these results remains unclear; however, they are unique features of renal amyloidosis. The couple of hypotensive and hypertensive conditions might produce no relationship between blood pressure and CKD stages.

     

Assessment of kidney function in children by enzymatic determination of 2- or 24-h creatinine clearance: comparison with inulin clearance

Background

Although renal inulin clearance (Cin) is the gold standard for evaluation of kidney function, it cannot be measured easily. Therefore, creatinine clearance (Ccr) is often used clinically to evaluate kidney function. Enzymatically measured Ccr was recently found to be much higher than Cin because of the tubular secretion of creatinine (Cr). This study compared three measures of renal clearance, inulin, 2-h Ccr, and 24-h Ccr, in children.

Methods

Kidney function was evaluated in 76 children (51 males and 25 females) aged 1 month to 18 years with chronic kidney disease (CKD) by three renal clearance methods at almost the same time.

Results

Correlations between each pair of three renal clearance measurements were determined. Approximate glomerular filtration rate (GFR) was equal to 62 % of 2-h Ccr or 76 % of 24-h Ccr.

Conclusion

Cr secretion by renal tubules was approximately 50 % of the GFR. In this study, we indicate that the measurements of 2-h Ccr or 24-h Ccr do not show true GFR but we could infer approximate GFR from the values. The use of 2- or 24-h Ccr might contribute to the treatment of pediatric CKD patients.

     

Kidney morphological parameters measured using noncontrast-enhanced steady-state free precession MRI with spatially selective inversion recovery pulse correlate with eGFR in patients with advanced CKD

Background

It is well known that atrophic renal changes are associated with chronic kidney disease (CKD) progression, but conventional diagnostic imaging methods such as noncontrast-enhanced computed tomography and magnetic resonance imaging (MRI) have been insufficient for precisely assessing kidney function because they cannot clearly distinguish between the medulla and cortex. Hence, here we used noncontrast-enhanced steady-state free precession (SSFP) MRI with a spatially selective inversion recovery (IR) pulse to improve visibility for renal corticomedullary differentiation and evaluated the association between morphological parameters and kidney function in patients with CKD.

Methods

Kidney corticomedullary contrast ratio, cortical and medullary areas, and minimal cortical thickness of 107 patients with CKD G1–G5 were measured using SSFP MRI with a spatially selective IR pulse and the association between these morphological parameters and kidney function were evaluated.

Results

Corticomedullary contrast ratio was significantly improved on SSFP MRI compared with conventional in-phase T1-weighted gradient-echo MRI and positively correlated with estimated glomerular filtration ratio (eGFR), raw eGFR, and 24-h creatinine clearance. The medullary and cortical areas and minimal cortical thickness also positively correlated with those of kidney functional markers and the age. In patients with CKD and diabetes mellitus (DM), the correlation coefficients between raw eGFR and morphological parameters were higher than those in patients without DM, while minimal cortical thickness was larger in CKD patients with DM with a raw eGFR ≥ 45 mL/min.

Conclusion

Kidney morphological parameters measured with SSFP MRI were clearly correlated with kidney function in patients with CKD, including those with advanced kidney dysfunction.

     

Significance of early detection of acute kidney function worsening among outpatients having CKD using automatic calculation system for the rate of eGFR decline

Background

To retard progression of chronic kidney disease (CKD) and reduce end-stage kidney disease, it is important to detect acute kidney function worsening on CKD (AW-CKD) immediately and bring back their kidney functions to baselines by appropriate treatment. However, in general outpatient practice, it is difficult to detect the change in the slope of estimated glomerular filtration rate (eGFR).

Methods

We made automatic calculation system for the rate of eGFR decline (ΔeGFR), and retrospectively observed the situation of AW-CKD among outpatients, who had visited all clinical departments of Steel Memorial Hirohata Hospital between May and August 2016, using the system. The patients with ΔeGFR over 20 mL/min/1.73 m²/year were classified into “Detected cases”, who were immediately detected AW-CKD by the attending physicians, and “Not detected cases”. For each stratum of ΔeGFR, subsequent eGFR recovery rates between two groups were compared.

Results

Among 6719 outpatients, 865 had CKD stages G3–5 and of which 196 had ΔeGFR over 20 mL/min/1.73 m²/year. We revealed that, in cases of ΔeGFR over 30 mL/min/1.73 m²/year, eGFR recovery rates in “Detected cases” were significantly higher than those in “Not detected cases” (103.2 vs 43.9%, p?<?0.001). There were no differences in the clinical backgrounds except kidney function between two groups.

Conclusion

In general outpatient practice, a substantial number of AW-CKD was latent. It is expected to improve kidney prognoses of outpatients having CKD through immediately detecting the patients, whose ΔeGFR over 30 mL/min/1.73 m²/year using the system and alerting the attending physicians on the electronic medical record.

     

Left ventricular hypertrophy predicts the decline of glomerular filtration rate in patients with type 2 diabetes mellitus

Purpose

The heart and kidney are of utmost importance for the maintenance of cardiovascular (CV) homeostasis. The relationship between cardiac remodeling, especially the left ventricular hypertrophy (LVH) and renal damage reflected by the estimated glomerular filtration rate (eGFR), decline in type 2 diabetes mellitus (T2DM) patients is unclear. And it is also unknown whether cardiac remodeling can be used to assess the eGFR decline in T2DM patients.

Methods

We retrospectively analyzed the relationship between cardiac remodeling especially the LVH and the eGFR decline for 265 patients with T2DM, who were diagnosed between 2011 and 2015 and followed for ≥?3 months. The parameters of cardiac remodeling were determined using Doppler echocardiography.

Results

In the Cox regression model, the parameters of cardiac remodeling were associated with the composite endpoint in different models. These associations were independent of age, body mass index (BMI), history of hypertension, duration of diabetes, the baseline eGFR, 24-h urinary protein, or using angiotensin-converting enzyme inhibitors (ACEI) and (or) angiotensin receptor blockers (ARB). The risk of composite endpoint in patients with T2DM was higher (hazard ratio, 10.832; p?<?0.001 for trend) in the group with the highest number of abnormal echocardiographic parameters, than in the group with no abnormal echocardiographic parameters. In receiver operating characteristics (ROC) curve analyses, the parameter of left ventricular posterior wall (LVPW) thickness was superior to the other parameters of cardiac remodeling as represented by the higher area under the curve (AUC) values generated according to the sensitivity and specificity.

Conclusion

Echocardiographic parameters are strongly correlated with the eGFR decline in patients with T2DM. Moreover, the severity of cardiac remodeling, especially the LVH is closely associated with the eGFR decline in patients with T2DM. Therefore, the recognition of cardiac structural alterations in patients with T2DM may evaluate renal damage at an early stage.

     

Effect of sample time on urinary lithogenic risk indexes in healthy and stone-forming adults and children

Background

The diagnosis and follow-up of stone forming patients is usually performed by analysis of 24-h urine samples. However, crystallization risk varies throughout the day, being higher at night. The main objective of this study is to evaluate the urinary crystallization risk in adults and children by calculating risk indexes based on different collection periods.

Methods

The study included 149 adults (82 healthy and 67 stone-formers) and 108 children (87 healthy and 21 stone-formers). 24-h urine was collected, divided into 12-h?daytime sample (8?am to 8?pm), and 12-h overnight sample (8?pm to 8?am next morning). Solute concentrations, the calcium to citrate ratio (Ca/Cit), and the ion activity product of calcium oxalate (AP[CaOx]) and calcium phosphate (AP[CaP]) were calculated in each 12-h sample and in overall 24-h urine. Assessments were also related to stone type.

Results

Ca/Cit and AP(CaOx) were significantly higher in stone forming patients than in healthy subjects. The 12-h overnight samples had the highest values for both risk indexes, confirming a greater risk for crystallization at night. The AP(CaP) index was significantly higher in patients with pure hydroxyapatite stones than healthy controls, but was not significantly different between stone-formers overall and healthy controls.

Conclusions

The calculation of risk indexes is a simple method that clinicians can use to estimate crystallization risk. For this purpose, the use of 12-h overnight urine may be a reliable alternative to 24-h collections.

     

Genetic and environmental influences on the associations between change in kidney function and changes in cardiometabolic factors in Koreans

Background

This study aimed to evaluate genetic and environmental relations between change in estimated glomerular filtration rate (eGFR) and changes in cardiometabolic factors.

Methods

In 1772 Korean adults without diabetes and chronic kidney disease at baseline, changes in eGFR using the Chronic Kidney Disease Epidemiology Collaboration equation, blood pressure (BP), fasting serum glucose (FSG), insulin, homeostasis model assessment of insulin resistance index (HOMA-IR), hemoglobin A1c, triglycerides, high and low density lipoprotein cholesterol (HDL and LDL), uric acid, white blood cell (WBC) count, and body mass index (BMI) were calculated as follows: (value at follow-up ? value at baseline) × 100/[value at baseline × follow-up interval (years)].

Results

eGFR change was associated with 10 % changes in FSG (Odds ratio, OR = 1.36), uric acid (OR = 2.49), HDL (OR = 0.69), LDL (OR = 1.26), and WBC (OR = 1.15) after adjusting for age, sex, intra-familial and twin correlations, smoking, alcohol use, and physical activity at baseline, and BMI change using a generalized estimating equation. In bivariate variance-component analysis, eGFR change had additive genetic correlations (\(\rho_{\text{G}}\)) with changes in insulin (?0.26), HOMA-IR (?0.24), diastolic BP (?0.15), uric acid (?0.45), triglycerides (?0.30), WBC (?0.46), and HDL (0.41), and environmental correlations (\(\rho_{\text{E}}\)) with changes in FSG (?0.11), uric acid (?0.32), LDL (?0.14), and WBC (0.10). In co-twin control analyses in 319 monozygotic twin pairs, the ORs for having a greater eGFR decline with a 1 % increase in diastolic BP, uric acid, and LDL were 1.04, 1.09, and 1.03, respectively after adjusting for change in BMI and health behaviors at baseline.

Conclusions

In these Korean twins and families, additive genetic influences and environmental effects play significant roles in the associations between eGFR change and changes in cardiometabolic factors.

     

Change in kidney function after unilateral adrenalectomy in patients with primary aldosteronism: identification of risk factors for decreased kidney function

Purpose

Glomerular filtration rate (GFR) has been reported to decrease after unilateral adrenalectomy in patients with primary aldosteronism (PA). The aim of this study was to identify clinical predictors for decreased GFR after adrenalectomy in patients with PA.

Methods

The records of 187 patients (98 patients with PA and 89 with non-PA adrenal disease) who were followed up for at least 6 months after unilateral adrenalectomy were retrospectively analyzed. Estimated GFR (eGFR) was investigated at 1, 3, and 6 months postoperatively. Preoperative risk factors for eGFR% decline at 1 month ([preoperative eGFR?eGFR at 1 month]/preoperative eGFR?×?100) and postoperative CKD development were investigated.

Results

The eGFR decreased significantly at 1 month and remained stable in the PA group. However, there were no significant changes in eGFR in the non-PA group over the 6-month period. In the PA group, a high preoperative eGFR and high aldosterone to renin ratio (ARR) were independently associated with eGFR% decline at 1 month. In patients with PA but without preoperative CKD (n?=?68), a low preoperative eGFR and high ARR were independent risk factors for developing postoperative CKD. The best preoperative cut-off values of eGFR and ARR for predicting the development of postoperative CKD were ≤?102 ml/min/1.73 m² and ≥?448 ng/dl:ng/ml/h, respectively.

Conclusions

Renal function deteriorated significantly after unilateral adrenalectomy in patients with PA. Clinicians must pay attention to postoperative renal function in PA patients at elevated risk of developing decreased kidney function.

     

Non-acid Gastroesophageal Reflux Measured Using Multichannel Intraluminal Impedance in Older Patients

Background

Diagnosing gastroesophageal reflux disease is challenging in the older population, as comorbid conditions can obscure the disease.

Methods

This prospective study included 97 participants: 25 healthy controls (group 1), 46 reflux patients aged 26–64 (group 2), and 26 patients over 65 (group 3). Esophageal motility was assessed using conventional esophageal manometry, and 24-h pH-metry and non-acid reflux episodes were assessed using multichannel intraluminal impedance.

Results

Among the older patients (group 3), 34% had reflux disease. The rate of lower esophageal sphincter insufficiency in group 3 was comparable with that in group 2 and significantly different from group 1. Gastric 24-h pH-metry showed no significant differences between the groups. Esophageal pH-metry results for groups 1 and 3 differed significantly from those in group 2. Impedance assessment showed that older patients have non-acid reflux episodes in the recumbent position significantly more often in comparison with controls and reflux patients. Reflux patients and older patients had proximal reflux episodes significantly more often than healthy volunteers.

Conclusions

Patients aged over 65 have non-acid reflux, particularly in the recumbent position, significantly more often than normal individuals and patients with reflux disease. Non-acid reflux may mimic a negative DeMeester score in older patients with severe reflux disease.

     

Transition from acute kidney injury to chronic kidney disease: a single-centre cohort study

Background

The incidence of acute kidney injury (AKI) is increasing. AKI is currently recognised as an inducer of chronic kidney disease (CKD) and this is known as the ‘AKI–CKD transition’. This study aimed to evaluate the rate of decline in estimated glomerular filtration rate (eGFR) associated with AKI events in individuals with and without pre-existing CKD.

Methods

Inpatients aged 18–80 years were retrospectively enrolled. AKI was diagnosed according to the kidney disease improving global outcomes (KDIGO) criteria using serum creatinine levels. Patients with a history of AKI events were divided into four groups according to eGFR before and after the AKI events. In each group, the eGFR levels after an AKI event were compared to those before the AKI event. Patients were further divided into eight groups according to clinical background based on underlying diseases, medications, and surgical history.

Results

We analysed data from 9651 patients with AKI. Not surprisingly, we found that eGFR levels during the first AKI event were significantly lower than levels before the event in each group. Furthermore, eGFR levels after the first AKI event were significantly lower than those before the first AKI event, and the eGFR levels after the second AKI event were significantly lower than those after the first AKI event. These trends were similar in each group irrespective of clinical background.

Conclusions

Our study revealed that AKI events can cause a decline in kidney function and, as more AKI events occur, acceleration of this decline.

     

Dor Vs Toupet Fundoplication After Laparoscopic Heller Myotomy: Long-Term Randomized Controlled Trial Evaluated by High-Resolution Manometry

Background

Laparoscopic Heller myotomy (LHM) with partial fundoplication is an effective treatment for achalasia. However, the type of fundoplication is still a subject of debate.

Aim

The aim of the study is to identify which partial fundoplication leads to better control of acid exposure, manometric parameters, and symptoms scores.

Methods

A randomized controlled trial was performed to compare Dor vs Toupet fundoplication after LHM. The preoperative diagnosis was made by high-resolution manometry (HRM), upper endoscopy, and barium esophagogram. Preoperative and postoperative symptoms were evaluated with Eckardt, GERD-HRQL, and EAT-10 questionnaires.

Results

Seventy-three patients were randomized, 38 underwent Dor and 35 Toupet. Baseline characteristics were similar between groups. Postoperative HRM showed that the integrated relaxation pressure (IRP) and basal lower esophageal sphincter (LES) pressure were similar at 6 and 24 months. The number of patients with abnormal acid exposure was significantly lower for Dor (6.9%) than that of Toupet (34.0%) at 6 months, but it was not different at 12 or 24 months. No differences were found in postoperative symptom scores at 1, 6, or 24 months.

Conclusion

There were no differences in symptom scores or HRM between fundoplications in the long term. A higher percentage of abnormal 24-h pH test were found for the Toupet group, with no difference in the long term.

     

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.

     

Increased non-HDL-C level linked with a rapid rate of renal function decline in HIV-infected patients

Background

The risk of developing CKD is increased in HIV-infected patients; however, the relationship between renal function decline and lipid abnormalities currently remains unclear in these patients.

Methods

A retrospective cohort study was conducted on 661 HIV-infected patients, whose estimated glomerular filtration rates (eGFRs) were consecutively measured over 6 years. The rate of declines in eGFR per year was calculated, with decreases being evaluated using a linear mixed effect model. The distribution of decreases in eGFR ≥ 30 % from baseline during the follow-up period was compared across quartiles of non-high-density lipoprotein cholesterol (HDL-C) levels using the Cochran–Armitage test. A multivariate logistic regression model was built to examine the relationship between dyslipidemia and decreases in eGFR.

Results

The prevalence of CKD increased from 8.5 to 21.2 % during the follow-up. The average of 6 annual eGFR decline rates was 2.01 ± 0.09 ml/min/1.73 m²/year, which was more than 6-fold higher than that of age-matched controls. The distribution of decreases in eGFR significantly increased across the quartiles of non-HDL-C (p value for trend = 0.0359). Non-HDL-C levels greater than the median value of the cohort were identified as a significant risk factor for decreased eGFR [odds ratio (95 % confidence interval), 1.77 (1.07–3.00)].

Conclusion

Increased non-HDL-C levels are a risk factor for renal function decline in HIV-infected patients.

     

Cigarette smoking and risk of albuminuria in patients with type 2 diabetes: a systematic review and meta-analysis of observational studies

Background

The aim of this study was to assess the effects of smoking on albuminuria risk in adults with type 2 diabetes mellitus (T2DM).

Methods

A literature search was conducted using MEDLINE, EMBASE, and China National Knowledge Infrastructure from the established date to October 2017. Summary relative risks (SRR) and 95% confidence intervals (CI) were computed utilizing a random effect inverse variance method.

Results

This meta-analysis included a total of 19 relevant observational studies (four prospective cohort, seven case–control, and eight cross-sectional studies), reporting 105,031 participants and 23,366 albuminuria events. Compared with never-smokers with T2DM, the SRRs of albuminuria were 1.43 (95% CIs 1.27–1.61) for ever-smokers, 2.61 (95% CIs 1.86–3.64) for current smokers, and 1.86 (95% CIs 1.37–2.52) for former smokers. Considerable heterogeneity was observed among these studies, and study design was a significant modifier for this association. There were significantly elevated risk associations for microalbuminuria (SRRs = 1.24, 95% CIs 1.05–1.46) and for macroalbuminuria (SRRs = 1.65, 95% CIs 1.03–2.66), respectively.

Conclusions

Our systematic review and meta-analysis indicates that cigarette smoking might be a potential factor for the development of albuminuria in adults with T2DM. Future studies are required to investigate the association between smoking cessation and intensity and incident albuminuria in adults with T2DM.

     

Patellaformen

Background

Patella height is discussed as a possible factor in the development of osteoarthritis of the knee.

Methods

PubMed literature search

Results

Contradictory results are found in the literature.

Conclusion

According to the literature, there is currently no evidence that abnormal patella height can induce osteoarthritis of the knee.

     

Implementation and evaluation of structured nephrology morbidity and mortality conferences: a quality education report

Background

Morbidity and Mortality Conferences (M&MCs) have for generations been part of the education of physicians, yet their effectiveness remains questionable. The Ottawa M&M Model (OM3) was developed to provide a structured approach to M&MCs in order to maximize the quality improvement impact of such rounds.

Study design

We conducted a retrospective assessment of the impact of implementing nephrology-specific M&MCs using the OM3.

Setting and participants

All physicians, residents and fellows from the division of nephrology at a large academic medical center were invited to participate.

Quality improvement plan

Structured M&MCs were implemented to identify preventable errors and generate actions to improve quality of care and patient safety.

Outcomes

Number and nature of cases reviewed, number and nature of recommendations generated through identification of preventable health system and/or cognitive factors.

Measurements

Morbidity and/or mortality in each case were identified. A determination of the underlying factors and preventability of these events was made. A qualitative review of resulting recommendations was performed.

Results

Over the course of sixteen 1-h long conferences, 52 cases were presented. For all cases presented, discussion, action items and information dissemination followed the OM3. As a result of the M&MCs, 29 recommendations (emanating from 27 cases) lead to improve care delivery.

Limitations

Limitations of this study include its retrospective nature and single-center design.

Conclusions

The implementation of regularly scheduled M&MCs at an academic nephrology program, using a structured model, identified preventable health-systems issues and cognitive errors. Approximately one-half of the cases reviewed generated actions for health care delivery improvement.