Self-reported screening of nephrologists for chronic kidney disease: a nationwide survey

Background  

The incidence of chronic kidney disease (CKD) is increasing, with major health and economic implications. World Kidney Day was established to increase the general public's awareness of CKD. The purpose of this report was to document the self-awareness of CKD by nephrologists practicing in one country, Nigeria.     

Cost-effectiveness of chronic kidney disease mass screening test in Japan

Background  

Chronic kidney disease (CKD) is a significant public health problem. Strategy for its early detection is still controversial. This study aims to assess the cost-effectiveness of population strategy, i.e. mass screening, and Japan’s health checkup reform.     

Hematuria and proteinuria in a mass school urine screening test

A total of 1,044 school children identified with hematuria and/or proteinuria during a mass school urine screening test were referred to pediatric nephrologists at 13 hospitals in Korea. These children had isolated hematuria (IH) (60.1%), isolated proteinuria (IP) (26.4%: transient, 19.6%; orthostatic, 4.9%; persistent, 1.9%) or combined hematuria and proteinuria (CHP) (13.5%). The patients history, physical examination, laboratory tests, kidney ultrasound and Doppler ultrasonography were obtained. Renal biopsies were performed on 113 children who showed severe proteinuria, hypertension, abnormal renal function, family history of chronic renal disease, systemic diseases or persistent hematuria and/or proteinuria for more than 12 months. IgA nephropathy (IgAN), thin basement membrane nephropathy (TBMN), membranoproliferative glomerulonephritis (MPGN), focal segmental glomerulosclerosis (FSGS), other GN, Alport syndrome and lupus nephritis were detected. IgAN and TBMN were the most common causes in the CHP group and IH group, respectively. Abnormal findings on the renal ultrasound with or without Doppler ultrasonography were noted in 147 cases (suspected nutcracker phenomenon, 65; increased parenchymal echogenicity, 40; hydronephrosis, 15). This study showed that the use of a mass school urine screening program can detect chronic renal disease in its early stage and recommends that more attention should be paid to identifying those children with CHP and massive proteinuria. A school urine screening program can detect chronic renal disease in its early stage. When mass screening is used, the initial aggressive diagnostic procedures such as renal biopsy are not needed. In addition, a regular follow-up for those children with IH and IP is certainly warranted.     

Variability of ferritin measurements in chronic kidney disease; implications for iron management

Serum ferritin levels are a proxy measure of iron stores; and existing guidelines for managing anemia in hemodialysis patients suggest that serum ferritin concentrations should be maintained at >200 ng/ml. The KDOQI recommendations further state there is insufficient evidence advocating routine intravenous iron when ferritin levels exceed 500 ng/ml. Here we determined the interassay differences and short-term intraindividual variability of serum ferritin measurements in patients on chronic hemodialysis to illustrate how these variances may affect treatment decisions. Intermethod variations of up to 150 ng/ml were found comparing six commonly used ferritin assays that evaluated thirteen pools of serum from hemodialysis and nonhemodialysis patients. The intraindividual variability for ferritin in 60 stable hemodialysis patients ranged between 2-62% measured over an initial two-week period and from 3-52% when factored over a six-week period. Our results suggests that single serum ferritin values should not be used to guide clinical decisions regarding treatment of chronic hemodialysis patients with intravenous iron due to significant analytical and intraindividual variability.     

Hypertension in children with chronic kidney disease: pathophysiology and management

Arterial hypertension is very common in children with all stages of chronic kidney disease (CKD). While fluid overload and activation of the renin–angiotensin system have long been recognized as crucial pathophysiological pathways, sympathetic hyperactivation, endothelial dysfunction and chronic hyperparathyroidism have more recently been identified as important factors contributing to CKD-associated hypertension. Moreover, several drugs commonly administered in CKD, such as erythropoietin, glucocorticoids and cyclosporine A, independently raise blood pressure in a dose-dependent fashion. Because of the deleterious consequences of hypertension on the progression of renal disease and cardiovascular outcomes, an active screening approach should be adapted in patients with all stages of CKD. Before one starts antihypertensive treatment, non-pharmacological options should be explored. In hemodialysis patients a low salt diet, low dialysate sodium and stricter dialysis towards dry weight can often achieve adequate blood pressure control. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers are first-line therapy for patients with proteinuria, due to their additional anti-proteinuric properties. Diuretics are a useful alternative for non-proteinuric patients or as an add-on to renin–angiotensin system blockade. Multiple drug therapy is often needed to maintain blood pressure below the 90th percentile target, but adequate blood pressure control is essential for better renal and cardiovascular long-term outcomes.     

Vascular calcification and arterial stiffness in chronic kidney disease: implications and management

Cardiovascular (CV) disease is the commonest cause of mortality in patients with chronic kidney disease (CKD). Vascular calcification (VC), induced by calcium and phosphate excess and uraemia, is a major risk factor and is independently associated with CV events and death. Local and systemic calcium-regulatory proteins as well as inhibitory extracellular factors are involved in the pathogenesis of VC. In CKD the balance becomes dysregulated leading to differentiation of vascular smooth muscle cells into phenotypically distinct osteoblast-like cells with subsequent ossification of the arterial wall. Associated with imbalances in mineral metabolism, VC has intimate interactions with bone mineralization and enhanced bone resorption. Arterial stiffness represents the functional disturbance of VC, with reduced compliance of large arteries, and predominantly results from greater medial calcification. As with VC, arterial stiffness is an independent predictor of CV mortality and patients with CKD have greater arterial stiffness than the general population resulting in the principal consequences of left ventricular hypertrophy and altered coronary perfusion. Both VC and arterial stiffness can be measured through non-invasive techniques involving computed tomography, ultrasound, echocardiography, and pulse wave velocity. Management in CKD is difficult but detection, prevention and treatment is crucial to reduce CV mortality. The optimal control of mineral metabolism, especially hyperphosphatemia with non-calcium based phosphate binders, has been shown to be effective to reduce VC, and attenuation of arterial stiffness, especially with good blood pressure control, can have a favourable effect with regression of left ventricular hypertrophy. The use of bisphosphonates, calcimimetics, vitamin D therapy and newer experimental treatments, as well as nocturnal dialysis, may have potential benefit.     

慢性肾脏病的流行病学研究

在人类的发展史中，疾病谱的变迁可以分为3个阶段：“瘟疫与饥荒的年代”，“传染性疾病时代”和“退行性疾病及人为疾病时代”。目前慢性非感染性疾病已经成为人类面临的主要健康问题，其中包括慢性肾脏病(CKD)。美国肾脏数据登记系统(USRDS)的数据显示，从1988年至2002年美国终末期肾病(ESRD)的年发病率由39．4／百万人口上升至98-3／百万人。据估计，未来10年该数据仍将以每年4．1％的百分比上升。在我国，1999年全国透析移植登记报告的数据显示当年新进入透析的患者占透析患者总数的41、7％，     

Exercise for children with chronic kidney disease and end-stage renal disease

It is well known that adults suffering from chronic kidney disease (CKD) experience muscle wasting and excessive fatigue, which results in a reduced exercise capacity and muscle weakness compared to their healthy counterparts, but research suggests that this can be improved through exercise. There is very limited data available regarding exercise tolerance in children with CKD and even less on the effects of exercise training programs. However, the available evidence does suggest that like adults, children also suffer from poor exercise capacity and reduced muscle strength, although the reasons for these limitations remain unclear. Studies that have attempted to implement exercise training programs in pediatric CKD populations have experienced high dropout rates, suggesting that the approach used to implement such programs in children needs to be different from the approach used for adults. This review summarizes the current knowledge regarding exercise capacity and muscle strength in children with CKD, the methods used to perform these assessments, and the possible causes of physical limitations. The results of exercise training studies, and the potential reasons as to why training programs have proved relatively unsuccessful are also discussed.     

A nationwide prospective cohort study of patients with advanced chronic kidney disease in Japan: The Reach-J CKD cohort study

Background

Epidemiology and outcomes of Japanese patients with advanced chronic kidney disease (CKD)—an estimated glomerular filtration rate (eGFR) < 45 ml/min/1.73 m²—has remained largely unexamined.

Methods

We conducted a nationwide survey to determine the distribution of Japanese CKD patients, and are conducting a cohort study of these patients. A questionnaire eliciting details about facilities and their CKD practices was sent to all clinics/hospitals with nephrologists. Based on the survey results, we recruited 2400 advanced CKD patients receiving nephrologist care from at least 30 representative facilities throughout Japan, selected randomly with stratification by region and facility size. Through patient questionnaires and nephrologist-practice surveys aligned with the international CKD Outcomes and Practice Patterns Study (CKDopps), we shall annually or semi-annually collect patient, physician and clinic data prospectively, detailing CKD practices for 5 years, with a primary outcome of death or renal replacement therapy initiation, and secondary outcomes being decline of eGFR by 30% or 50%, CKD progression to CKD G5, or a cardiovascular event.

Results

Of 790 eligible, responding facilities, 330 (41.8%) treat ≥80 advanced CKD patients in the average 3-month period. Regional distribution of these facilities is similar to that of persons in the general population. Hence, the 30 facilities selected for data collection appear to be geographically representative in Japan.

Conclusions

Our study will enhance understanding of various CKD practices and biological data associated with CKD progression, and allow international comparisons using the CKDopps platform. This will provide evidences to improve the health and quality of life for patients with advanced CKD.

     

An expanded nationwide view of chronic kidney disease in Aboriginal Australians

We summarize new knowledge that has accrued in recent years on chronic kidney disease (CKD) in Indigenous Australians. CKD refers to all stages of preterminal kidney disease, including end‐stage kidney failure (ESKF), whether or not a person receives renal replacement therapy (RRT). Recently recorded rates of ESKF, RRT, non‐dialysis CKD hospitalizations and CKD attributed deaths were, respectively, more than sixfold, eightfold, eightfold and threefold those of non‐Indigenous Australians, with age adjustment, although all except the RRT rates are still under‐enumerated. However, the nationwide average Indigenous incidence rate of RRT appears to have stabilized. The median age of Indigenous people with ESKF was about 30 years less than for non‐Indigenous people, and 84% of them received RTT, while only half of non‐Indigenous people with ESKF did so. The first‐ever (2012) nationwide health survey data showed elevated levels of CKD markers in Indigenous people at the community level. For all CKD parameters, rates among Indigenous people themselves were strikingly correlated with increasing remoteness of residence and socio‐economic disadvantage, and there was a female predominance in remote areas. The burden of renal disease in Australian Indigenous people is seriously understated by Global Burden of Disease Mortality methodology, because it employs underlying cause of death only, and because deaths of people on RRT are frequently attributed to non‐renal causes. These data give a much expanded view of CKD in Aboriginal people. Methodologic approaches must be remedied for a full appreciation of the burden, costs and outcomes of the disease, to direct appropriate policy development.     

Quality of life for children with chronic kidney disease

Medical care advancements for children with chronic kidney disease (CKD) receiving hemodialysis, peritoneal dialysis, or with a renal transplant have resulted in relatively improved long-term patient survival compared with adult patients with CKD. Optimal care for the pediatric patient with CKD requires attention not only to medical management, but also the psychosocial and developmental factors that either will ensure or prevent a pediatric patient's successful transition into adulthood. We review the range of issues that impact pediatric CKD patients' health-related quality of life (HRQOL), the history of pediatric CKD patients' HRQOL investigation, and the instruments currently available to assess HRQOL.     

A comparative study of three kidney biomarker tests in autosomal-dominant polycystic kidney disease

BACKGROUND: The relationship between the progress of tubular damage and renal insufficiency in autosomal-dominant polycystic kidney disease (ADPKD) is a subject of doubtless interest, and is the object of this present work. METHODS: A total of 92 adult ADPKD patients of both genders were studied, none of which presented end-stage renal disease (ESRD), and classified according to an ultrasound score based on kidney size and number of cysts. Urinary albumin and beta-N-acetylhexosaminidase (Hex) and its isoenzymes were determined, together with serum glutathione peroxidase, cystatin C, creatinine, and urea. RESULTS: A frequent elevation of the urinary Hex was found and an alteration of its isoenzymatic profile, with 31% of the normotensive patients with normoalbuminuria already presenting an increased proportion of Hex B isoenzyme. Keeping age constant, a partial significant correlation was found between the ultrasound score and the proportion of Hex B (r = 0.352, P < 0.05), but not with albuminuria or cystatin C. In 42 patients the different biochemical variables were again determined after 1 year, finding that in the 13 normotensive patients with normoalbuminuria there had been a significant decrease in the concentration of cystatin C (P < 0.05), and a significant increase in the urinary excretion of albumin and Hex B isoenzyme (P < 0.05). By the other hand, in the other 29 patients with micro- or macroalbuminuria and hypertension, no significant differences were found. CONCLUSION: The results point toward an important participation of tubular damage in the pathogenesis of this disease. It may also be suggested that in normotensive and normoalbuminuric ADPKD patients, a gradual increase of glomerular filtration would be produced. After the start of hypertension and microalbuminuria, the glomerular filtration rate (GFR) would decrease progressively, although more slowly.     

Ethical implications of ethnic disparities in chronic kidney disease and kidney transplantation

Chronic kidney disease (CKD) is a major epidemic in underserved and minority populations largely due to excess rates of hypertensive and diabetic kidney disease. Multiple complex socioeconomic barriers to early diagnosis and optimal therapies as well as delayed referral for kidney transplantation have created disparities in CKD care provided to ethnic minorities. Disparities exist in wait list time and kidney transplant rates for Native Americans and blacks, independent of insurance status. Moreover, independent of genetic matching, long-term transplant outcomes in blacks remain significantly lower than all other ethnic groups, suggesting that poorly understood social factors contribute to these survival differences. The existence of these disparities raises ethical concerns of equity and social justice in terms of the allocation of scarce resources. Although current changes in allocation policies will improve some disparities, more efforts are ultimately needed to improve access to care and the overall health and survival for all individuals at risk for CKD, independent of their race, ethnicity, or socioeconomic status.     

Left ventricular mass and cardiac function in a population of children with chronic kidney disease

Background

Cardiovascular disease (CVD) is a common cause of morbidity and mortality in children with chronic kidney disease (CKD). Left ventricular hypertrophy (LVH) and diastolic dysfunction (LVDD) are early markers. The aims of this study were to evaluate (1) LVH and LVDD, using both conventional echocardiographic evaluation and Tissue Doppler Imaging (TDI), and (2) the correlation between cardiac disease and possible risk factors, in children with CKD.

Methods

The study cohort comprised 34 paediatric patients with CKD and 34 healthy children (mean ± standard deviation: age 9?±?4.6 and 8.2?±?4.3 years, respectively). Thirteen (38 %) patients were in CKD stage 2, 15 (44 %) in stage 3 and six (18 %) in stage 4–5. LVH was defined as a left ventricular mass index (LVMI) of >95th percentile (38 g/h^2.7).

Results

Left ventricular hypertrophy was present in 13 patients (38 %). Diastolic function evaluated with TDI (E′/A′ = early/late diastolic myocardial velocity) worsened with the reduction of glomerular filtration rate (p?=?0.020). There was a positive correlation between LVMI and body mass index-standard deviation score (p?=?0.020) and a negative correlation between E′/A′ and serum phosphorus and calcium levels and their respective product (p?=?0.004, p?=?0.017, p?<?0.001). The relaxation index E′ was reduced in 68 % of patients.

Conclusion

Based on our results, TDI is a simple procedure and would appear to be a more accurate diagnostic tool than conventional echocardiography in the early diagnosis of LVDD.     

Epidemiology of chronic kidney disease in children

In the past 30 years there have been major improvements in the care of children with chronic kidney disease (CKD). However, most of the available epidemiological data stem from end-stage renal disease (ESRD) registries and information on the earlier stages of pediatric CKD is still limited. The median reported incidence of renal replacement therapy (RRT) in children aged 0–19 years across the world in 2008 was 9 per million of the age-related population (4–18 years). The prevalence of RRT in 2008 ranged from 18 to 100 per million of the age-related population. Congenital disorders, including congenital anomalies of the kidney and urinary tract (CAKUT) and hereditary nephropathies, are responsible for about two thirds of all cases of CKD in developed countries, while acquired causes predominate in developing countries. Children with congenital disorders experience a slower progression of CKD than those with glomerulonephritis, resulting in a lower proportion of CAKUT in the ESRD population compared with less advanced stages of CKD. Most children with ESRD start on dialysis and then receive a transplant. While the survival rate of children with ERSD has improved, it remains about 30 times lower than that of healthy peers. Children now mainly die of cardiovascular causes and infection rather than from renal failure.     

Diabetes management issues for patients with chronic kidney disease

Chronic kidney disease is in continuous increase and can be found in up to 23% of patients with diabetes. Glycemic control is difficult to assess and medication therapy for diabetes may require dose adjustments part of the alteration of drug's pharmacokinetics and the insulin resistance which is predicting cardiovascular events. The recommended hemoglobin A1c goal is also lower than 7.0% without hypoglycemia. In this article, we review the therapeutic management of diabetic patients in chronic renal failure stage which is difficult and the ways to control blood glucose. Multidisciplinary approach, which is including management of comorbid diseases, is necessary to provide the optimal care of these patients.