Risk Factors and Prevention of End Stage Renal Disease in Uruguay

Uruguay is a developing country with a privileged established program for renal replacement therapy (RRT) for all patients with end stage renal disease (ESRD) since 1981. In December 2004, the RRT prevalence reached 916 patients per million population. The ESRD incidence has not changed significantly in the last eight years, differing with what is observed in other countries. In contrast, the ESRD incidence secondary to diabetic nephropathy has shown a permanent increase. The prevention of chronic kidney disease (CKD) began in 1989 with the Program of Prevention and Treatment of Glomerulonephritis (PPTG), being extended in 2002 to all CKD and canalized through the National Program of Renal Healthcare (NPRH) since 2004. The registry of glomerulonephritis has been demonstrated in recent years: patients are referral to nephrologists earlier, there is an increase of the frequency of patients with “clinical remission,” and thus there is a decrease of the frequency of ESRD in the first three months after referral. The NPRH has been developed in a progressive way with the involvement of government authorities and the active participation of the nephrologists. A global prevention program, integrating the prevention of CKD, cardiovascular diseases, hypertension, and diabetes was developed. The first steps of the program have had important achievements: a rational reorientation of nephrologic care in the first level of attention, patient access to renoprotective medications without cost; a registration system of patients, the creation of a formal multidisciplinary team, and the instauration of a continuous medical education program.     

Incidence of Demodex Folliculorum in Patients with End Stage Chronic Renal Failure

Background. Demodex folliculorum (DF), found in the pilosebaceous unit, is the most common ectoparasite in humans. It has been implicated in various clinical lesions such as pustular folliculitis, papulopustular scalp eruption, perioral dermatitis, and skin lesions of immunosuppressed patients on chemotherapy or with acquired immunodeficiency syndrome (AIDS). Objective. We aimed to determine DF carriers and location of DF among patients on chronic dialysis because of end stage renal failure (ESRF), to compare them with healthy controls, and to examine the relationship between DF incidence and dialysis method and symptoms. Methods. Sixty-seven patients on dialysis and 67 healthy controls were taken into the study. The patient groups were classified according to the diseases causing ESRF [diabetes mellitus (DM), polycystic disease (PCD), glomerulonephritis (GN), hypertensive nephrosclerosis (HTNS), others (OT), unknown etiology (UE)], and mode of dialysis. Five standardized skin surface biopsies (SSSB) were taken. The determination of five and more living parasites/cm² area was diagnosed as infestation. Results. The mean mite count in the ESRF group, 6.12/cm², was significantly higher than that in controls, 0.31/cm², (Independent Samples Test, p = 0.000). The DF positivity according to primary disease causing ESRF revealed that it was most frequent in DM with 12 patients (44.4%), followed by UE with nine patients (33.4%). Conclusions. Our findings indicate that the DF number is increased in ESRF patients on dialysis treatment. We recommend that demodicidosis should be included in the differential diagnosis of facial eruptions in patients with ESRF.     

The Diabetic Foot in End Stage Renal Disease

Diabetic foot lesions remain a major cause of morbidity in patients with renal failure, especially those on dialysis. Foot complications are encountered at a more than twofold frequency in diabetic patients with end-stage renal disease, and the rate of amputations is 6.5–10 times higher in comparison to the general diabetic population. The causal pathways of the diabetic foot in renal failure are multiple and inter-related. Three major pathologies—neuropathy, ischemia, and infection—are the main contributory factors. Increased awareness of this condition and careful clinical examination are indispensable to avoid serious complications. Appropriate management needs to address all contributory factors. Treatment options include revascularization, off-loading to relieve high-pressure areas, and aggressive control of infection. Equally important is the collaboration between health care providers in a multidisciplinary foot care setting. Moreover, patient education on the measures required to achieve both primary and secondary prevention is of great value. Certainly, technical innovations have made considerable progress possible, but there is a need for further improvement to reduce the number of amputations.     

A Patient with Classical Polyarteritis Nodosa Evolving into End Stage Renal Failure

Classical polyarteritis nodosa (c-PAN) is a form of systemic necrotizing vasculitis mainly affecting medium-size arteries, is not associated with renal glomerular disease and acute renal failure. Perirenal hematoma can be seen in up to fifty percent of c-PAN patients and minority of them develop mild renal impairment. Herein, we describe a 34-year-old male with c-PAN who presented with rapidly progressive renal failure and evolved into end stage renal disease.     

Risk of End‐Stage Renal Disease Among Liver Transplant Recipients With Pretransplant Renal Dysfunction

Guidelines recommend restricting simultaneous liver–kidney (SLK) transplant to candidates with prolonged dialysis or estimated glomerular filtration rate (eGFR) <30 mL/min/1.73m² for 90 days. However, few studies exist to support the latter recommendation. Using Scientific Registry of Transplant Recipients and Medicare dialysis data, we assembled a cohort of 4997 liver transplant recipients from February 27, 2002–January 1, 2008. Serial eGFRs were calculated from serum creatinines submitted with MELD reports. We categorized recipients by eGFR patterns in the 90 days pretransplant: Group 1 (eGFR always >30), Group 2 (eGFR fluctuated), Group 3 (eGFR always <30) and Group 4 (short‐term dialysis). For Group 2, we characterized fluctuations in renal function using time‐weighted mean eGFR. Among liver‐alone recipients in Group 3, the rate of end‐stage renal disease (ESRD) by 3 years was 31%, versus <10% for other groups (p < 0.001). In multivariable Cox regression, eGFR Group, diabetes (HR 2.65, p < 0.001) and black race (HR 1.83, p = 0.02) were associated with ESRD. Among liver‐alone recipients in Group 2, only diabetics with time‐weighted mean eGFR <30 had a substantial ESRD risk (25.6%). In summary, among liver transplant candidates not on prolonged dialysis, SLK should be considered for those whose eGFR is always <30 and diabetic candidates whose weighted mean eGFR is <30 for 90 days.     

Relationship between GSTs gene polymorphism and susceptibility to end stage renal disease among North Indians

BACKGROUND AND OBJECTIVE: Glutathione-S-transferase (GST) is the superfamily of genes that provides protection to the cells against reactive oxygen species and plays a vital role in phase II of biotransformation of many substances. Overexpression of GST (EC 2.5.1.18) has been documented in the erythrocytes of patients with chronic renal failure, which may be of clinical relevance. Keeping this background in mind, we have investigated the relationship between human GST gene polymorphism in end stage renal disease (ESRD) patients. DESIGN AND METHODS: We have assessed 184 patients with ESRD and 569 age-and sex-matched controls from North India. The GSTT1 and GSTM1 null genotypes were identified by polymerase chain reaction (PCR). GSTP1-313 A/G mutation was determined by PCR followed by restriction enzyme digestion. RESULTS: The gene frequency of GSTM1, GSTT1, and GSTP1 polymorphism were evaluated. We observed that GSTM1 null genotype was present in 46.74% of the ESRD patients while GSTT1 null genotype was present in 58.7% of the ESRD subjects. The genotypic distribution of GSTP1 was Ile(105)/Ile(105) in 47.3%, Ile(105)/Val(105) in 30.97% and Val(105)/Val(105) in 21.74% of ESRD patients. There was a significant association of null alleles of the GSTM1 (p = 0.0386; OR = 1.445, 95% CI = 1.033-2.021) and GSTT1 (p < or = 0.0001; OR = 4.568, 95% CI = 3.215-6.492) and in the -313 G alleles (Val) of the GSTP1 gene (p = 0.0032; OR = 1.956, 95% CI = 1.265-3.024) with end stage renal disease. The combined analysis of the three genotypes showed a further increased risk to ESRD (p < or = 0.0001; OR = 9.01, 95% CI = 5.55-14.626). Interpretations and CONCLUSIONS: The null / low polymorphism of the detoxifying enzymes GSTT1, GSTM1, and GSTP1 are associated with the risk of developing ESRD in North Indian patients.     

Intermediate Syndrome after Organophosphate Intoxication in Patient with End-Stage Renal Disease

A 42-year-old woman with a 24-year history of systemic lupus erythematous and lupus nephritis for 8 years who had been receiving regular hemodialysis for 4 years for nonoligoric end-stage renal disease (ESRD) ingested about 100 mL of 40.8% chlorpyrifos in a suicide attempt. On admission to our emergency department, she was drowsy. Gastric lavage, activated charcoal, pralidoxime (PAM), and atropine were administered 4 h later. Her consciousness level improved gradually with treatment, which included hemodialysis. However, on the second hospital day, intermittent fever to 38.4°C, sore throat, and trismus were noted. About 45 h after chlorpyrifos ingestion, the patient developed profound motor paralysis followed by respiratory arrest, consistent with the diagnosis of intermediate syndrome (IMS), even with adequate atropine and PAM. Chorealike involuntary movements of her upper limbs were noticed on the fifth day. Intermittent tonic-clonic seizures, each attack lasting for 3 to 5 min, appeared on the 13th day, which responded well to intravenous diazepam and phenytoin. She was discharged on the 18th day. This case suggests that patients with ESRD suffering chlorpyrifos intoxication are at risk of IMS. Prompt endotracheal intubation, intensive care, and hemodialysis are necessary for life support.     

Ethnic and Gender Related Differences in the Risk of End‐Stage Renal Disease After Living Kidney Donation

There is limited data pertaining to the risk of End Stage Renal Disease (ESRD) after living kidney donation. The Organ Procurement and Transplantation Network and the Center for Medicare and Medicaid Services databases were used to identify living kidney donors (LKDs) who subsequently developed ESRD and to calculate LKD ESRD rates. We found 126 cases of ESRD among 56 458 LKDs (0.22%) who donated during October 1, 1987–March 31, 2003. The overall LKD ESRD rate was 0.134 per 1000 years at risk, with an average duration of follow‐up of 9.8 years. ESRD rates for LKDs overall and for Black, White, male and female donors compared favorably to the ESRD incidence in the general population. The LKD ESRD rate was nearly five times higher for Blacks than for Whites and two times higher for males than females. However, these ethnic and gender‐related differences were similar to those previously reported for ESRD in the general population. Our findings do not show an increase in the risk of ESRD for LKDs and support the current practice of living kidney donation. Further research is needed to determine if improved donor screening or follow‐up will reduce the risk of postdonation ESRD.     

Renal Failure and Concurrent RAAS Blockade in Older CKD Patients with Renal Artery Stenosis: An Extended Mayo Clinic Prospective 63-Month Experience

Concerns have been raised regarding a possible link between the increasing utilization of RAAS blocking strategies in the United States and the increasing ESRD epidemic. Most reports of accelerated renal failure in CKD patients with renal artery stenosis on RAAS blockade are retrospective. We hypothesized that this syndrome is therefore poorly understood, may be under-recognized, and demanded prospective analysis. As part of a larger cohort of 100 CKD patients on RAAS blockade presenting with worsening renal failure (>25% increased serum creatinine from baseline) while concurrently on an ACE inhibitor and/or an angiotensin receptor blocker, 26 patients (26%) enrolled between September 2002 and February 2005 had hemodynamically significant renal artery stenosis. RAAS blockade was discontinued, standard nephrology care applied, and eGFR by MDRD monitored. They consisted of 26 Caucasian patients, M:F = 10:16, age 75.3 ± 6.4 (63–87) years. Mean follow-up was 26.4 ± 16.4 (1–49) months. Duration of RAAS blockade prior to enrollment was 20.2 ± 16.4 (0.5–48) months. Contrary to previous reports, precipitating factors were often absent (15/26), unilateral RAS lesions in patients with dual kidneys was common (19/26), and progression to ESRD was frequent (5/26). Four-fifths of the ESRD patients were dead after 5.5 ± 4.1 (1–11) months. A fifth patient with improved eGFR died after 14 months from metastatic gastric cancer. Excluding five patients who progressed to ESRD and two patients lost early to follow-up, in 19 patients, eGFR increased from 27.8 ± 9.5 (11–47) to 36.7 ± 16 (14–68) mL/min/1.73 m² BSA (p = 0.014) after 34.8 ± 10.1 (14–49) months of follow-up. This improvement in eGFR was evident after weeks to months of stopping RAAS blockade in these patients with and without renal PTA and stenting. Nevertheless, renal PTA/stenting further improved eGFR in selected patients. We conclude that renal failure/ESRD associated with concurrent RAAS blockade in older CKD patients with renal stenosis remains poorly understood and mostly unrecognized. Unilateral lesions in patients with dual kidneys, absent precipitating factors, and progression to ESRD with high mortality, despite discontinuation of RAAS blockade, are more common than previously thought. Lower baseline eGFR (<35) predicted ESRD. Our findings call for a larger prospective study, especially given growing concerns of iatrogenic renal failure from RAAS blockade in the aging U.S. population. An aging U.S. population further raises the probability of the presence of increasing and unrecognized renal artery stenosis in our CKD patient population.     

Prevalence and Predictors of Arrhythmia in End Stage Renal Disease Patients on Hemodialysis

Background. Sudden death is common in end-stage renal disease (ESRD). Cardiac arrhythmia is observed frequently in patients with ESRD and is thought to be responsible for this high rate of sudden death. This study investigated the prevalence and the predictors of arrhythmia in patients on maintenance dialysis. Methods. Ninety-four patients on hemodialysis program were enrolled in the study. Routine laboratory results were noted. Arrhythmia, periods of silent ischemia, and heart-rate variability analyses were obtained from 24-hour Holter monitor recordings. Corrected QT (QTc) dispersion was calculated from 12-lead surface EKG. Echocardiographic and tissue Doppler examinations were performed on interdialytic days as well. Ventricular arrhythmia was classified according to Lown classification; classes 3 and above were accepted as complex ventricular arrhythmia (CVA). Results. The mean age was 52.5±13.2 years; 44 (46.8%) were women. Ventricular premature contractions were detected in 80 (85.1%) patients, of whom 35 (37.2%) were classified as complex ventricular arrhythmia (CVA). Coronary artery disease, hypertension, and QTc dispersion appeared as independent factors predictive of CVA development. Atrial premature contractions (APC) were detected in 53 patients (56.4%) and supraventricular arrhythmia in 15 (16%) patients; all were identified as atrial fibrillation. Duration of dialysis therapy was found as an independent predictor of APC. Conclusion. Arrhythmia is frequently observed in ESRD patients receiving hemodialysis and may be responsible for the high rate of sudden mortality. Hypertension, CAD, and QTc dispersion are independent predictors of CVA, and duration of dialysis therapy is an independent factor affecting APC development in these patients.     

DAA‐based antiviral treatment of patients with chronic hepatitis C in the pre‐ and postkidney transplantation setting

DAA‐based regimens for chronic hepatitis C infection encourage treatment of “difficult‐to‐treat” cohorts. This study investigated efficacy and safety of DAA‐based regimens in HCV patients on dialysis or postkidney or liver/kidney transplantation. Twenty‐five patients treated with DAA combinations were evaluated: 10 were on dialysis (eight: hemodialysis, two: peritoneal dialysis), eight were kidney transplant recipients, and seven were liver/kidney transplant recipients. Except for one patient treated with daclatasvir ([DCV]/60 mg/QD)/simeprevir ([SMV]/150 mg/QD), the others received sofosbuvir‐based regimens ([SOF];400 mg/QD) combined with SMV:eight, DCV:13 or either ledipasvir ([LDV]90 mg/QD), ribavirin ([RBV];weight based) or pegylated interferon/RBV. HCV‐RNA was determined by Abbott RealTime (LLOQ]:12 IU/ml) or Roche AmpliPrep/COBAS TaqMan assay (LLOQ:15 IU/ml); treatment response evaluated every 4 weeks, at the end of treatment, and 4 and 12 weeks thereafter. Twenty‐four (96%) patients achieved SVR 12/24 (ITT‐analysis). Mean treatment duration was 15.1 ± 5.1 weeks (±SD), and two patients terminated prematurely – both reached SVR12. Six patients were hospitalized due to complications of underlying disease. One patient achieved SVR24 but was re‐infected (week 27). Kidney function remained stable; serum creatinine increased in only one patient – SOF was reduced to 400 mg/48 h. Treatment with DAA combinations in renally impaired HCV patients is highly effective and well tolerated. These findings call for further controlled trials and data from real‐life cohorts.     

Prevalence of depression and anxiety and their predictors among patients undergoing maintenance hemodialysis in Northern China: a cross-sectional study

ObjectiveTo investigate the prevalence of depression and anxiety in patients undergoing maintenance hemodialysis (MHD) in Hohhot, a large city on the northern border of China, and to identify independent risk factors for depression and anxiety in these patients.MethodsPatients receiving MHD for >3 months were enrolled in the four largest hemodialysis centers between September 2020 and December 2020. Depression and anxiety were assessed using the Zung self-rated depression scale (SDS) and Zung self-rated anxiety scale (SAS), respectively, with demographic and other data collected for logistic regression analyses.ResultsAmong 305 MHD patients included in this study, the prevalence of depression was 55.1%, including 27.5%, 21.0%, and 6.6% with mild, moderate and severe cases, respectively. The prevalence of anxiety was 25.9%, with 20.0%, 4.6%, and 1.3% having mild, moderate, and severe cases, respectively. An independent protective factor for depression was family income of ≥1415 US dollars/month relative to <157 US dollars/month (odds ratio [OR] 0.209, 95% confidence interval [CI] 0.065–0.673), and predictors of depression included ≥3 comorbidities (OR 18.527, 95% CI 1.674–205.028) and severe pruritus (OR 15.971, 95% CI 5.173–49.315). Independent predictors of anxiety included infrequent exercise (OR 3.289, 95% CI 1.411–7.664) and severe pruritus (OR 5.912, 95% CI 1.733–20.168). The correlation between depression and anxiety in these patients was significant (r_s = 0.775, p < 0.001).ConclusionMHD patients in Northern China had high prevalence rates of depression (55.1%) and anxiety (25.9%). Lower family income, more comorbidities, and a higher degree of pruritus were predictors of depression, while infrequent exercise and severe pruritus were predictors of anxiety. Depression correlated significantly with anxiety. Attention should be given to family income, comorbidity, exercise, and pruritus severity for improved management of depression and anxiety among MHD patients.     

终末期肾病并发急性左心衰应用序贯透析联合BiPAP治疗的临床研究

目的:观察序贯透析(SD)联合双水平气道正压通气(Bi PAP)治疗终末期肾病(ESRD)并发急性左心衰的可行性,以期为ESRD并发急性左心衰的患者提供新的、经济的、安全的治疗思路和方法。方法:选择2013年1月~2014年10月在东莞市清溪医院住院的ESRD并发急性左心衰患者60例为研究对象,随机分成:SD联合Bi PAP治疗观察组和连续肾脏替代疗法(CRRT)对照组,每组30例。比较两组肾功能相关临床指标、血气分析指标以及临床疗效。结果:治疗后两组血尿素氮(BUN)、血肌酐(Scr)肾功能指标,钾(K+)、钙(Ca2+)、磷(P3-)均出现显著减低(P<0.05和P<0.01),两组对上述指标的减低作用差异无统计学意义(P>0.05)。治疗后两组氧分压(Pa O2)、二氧化碳分压(Pa CO2)均得到显著改善(P<0.05和P<0.01),但观察组的改善作用优于对照组(P<0.05)。对照组透析时间为(64.32±12.96)h,显著高于观察组的(51.36±7.92)h,P<0.05。观察组的临床治疗有效率为96.7%(29/30),对照组为93.3%(28/30),两组之间差异无统计学意义(P>0.05)。对照组所用费用约为(9 274.5±814.6)元,显著高于观察组的(7 116.2±658.4)元,P<0.01。结论:SD联合Bi PAP治疗ESRD并发急性左心衰临床疗效与CRRT治疗差异无统计学意义,但联合治疗对于患者缺氧的纠正作用优于CRRT治疗,而且联合治疗操作简单,费用大幅减低,有利于基层医院的推广使用。     

Neighborhood Poverty and Kidney Transplantation Among US Asians and Pacific Islanders with End‐Stage Renal Disease

The degree to which low transplant rates among Asians and Pacific Islanders in the United States are confounded by poverty and reduced access to care is unknown. We examined the relationship between neighborhood poverty and kidney transplant rates among 22 152 patients initiating dialysis during 1995–2003 within 1800 ZIP codes in California, Hawaii and the US‐Pacific Islands. Asians and whites on dialysis were distributed across the spectrum of poverty, while Pacific Islanders were clustered in the poorest areas. Overall, worsening neighborhood poverty was associated with lower relative rates of transplant (adjusted HR [95% CI] for areas with ≥20% vs. <5% residents living in poverty, 0.41 [0.32–0.53], p < 0.001). At every level of poverty, Asians and Pacific Islanders experienced lower transplant rates compared with whites. The degree of disparity increased with worsening neighborhood poverty (adjusted HR [95% CI] for Asians–Pacific Islanders vs. whites, 0.64 [0.51–0.80], p < 0.001 for areas with <5% and 0.30 [0.21–0.44], p < 0.001 for areas with ≥20% residents living in poverty; race–poverty level interaction, p = 0.039). High levels of neighborhood poverty are associated with lower transplant rates among Asians and Pacific Islanders compared with whites. Our findings call for studies to identify cultural and local barriers to transplant among Asians and Pacific Islanders, particularly those residing in resource‐poor neighborhoods.