Chronic kidney disease predicts poor prognosis in patients with stable premature coronary artery disease

ObjectiveThis study was performed to determine the prevalence of chronic kidney disease (CKD) as well as its association with mid-term prognosis in patients with stable premature coronary artery disease (CAD) in a Chinese population.MethodsFive hundred and twelve patients from Jiangsu Province, China with stable, premature CAD were enrolled using an estimated glomerular filtration rate (eGFR) to determine the presence of CKD. The patients were then monitored over a two-year follow up during which major adverse cardiac events (MACEs) were recorded and analyzed.ResultsOne hundred and eighty-three patients (35.74%) were determined to have CKD. Having CKD was associated with a higher ratio of type 2 diabetes mellitus, multi-vessel disease, higher levels of fasting blood sugar and lower levels of left ventricular ejection fraction (all P < 0.05). Patients with CKD had significantly higher incidences of composite MACEs than the non-CKD group at the end of the two- (45.35% vs 30.72%, P = 0.001) but not one-year follow up (30.64% vs 25.32%, P = 0.209). Furthermore, as eGFR decreased, more MACEs occurred (all P < 0.05). Multivariate analysis confirmed that both CKD (P < 0.001) and multi-vessel disease (P < 0.001) are independent risk factors for MACEs.ConclusionChinese patients diagnosed with stable, premature CAD and CKD have more risk factors and worse two-year outcomes than those with only CAD.     

Chronic kidney disease

Chronic kidney disease is a general term for heterogeneous disorders affecting kidney structure and function. The 2002 guidelines for definition and classification of this disease represented an important shift towards its recognition as a worldwide public health problem that should be managed in its early stages by general internists. Disease and management are classified according to stages of disease severity, which are assessed from glomerular filtration rate (GFR) and albuminuria, and clinical diagnosis (cause and pathology). Chronic kidney disease can be detected with routine laboratory tests, and some treatments can prevent development and slow disease progression, reduce complications of decreased GFR and risk of cardiovascular disease, and improve survival and quality of life. In this Seminar we discuss disease burden, recommendations for assessment and management, and future challenges. We emphasise clinical practice guidelines, clinical trials, and areas of uncertainty.     

Chronic kidney disease in Japan

Chronic kidney disease (CKD) is defined as either kidney damage with urine, imaging, and histologic abnormalities, or a low estimated glomerular filtration rate (GFR) for more than 3 months. The GFR is calculated using either the Modification of Diet in Renal Disease (MDRD) Study equation or the Cockcroft-Gault formula. CKD is a risk factor for end-stage renal disease (ESRD) and cardiovascular disease. In Japan, the prevalence of ESRD is increasing and is currently more than 2,000 per million population. More than 40% of incident ESRD is due to diabetes mellitus (DM). The prevalence of a low GFR (< 60 ml/min/1.73 m(2)) is estimated to be 20% of the adult population. Studies based on several community-based screening programs suggest that Japan has a higher prevalence of CKD than any other country. Early detection and treatment of CKD are necessary to decrease the incidence of ESRD and cardiovascular disease.     

埋藏式心脏转复除颤器安置后电风暴的处理与预后

目的通过分析埋藏式心脏转复除颤器(ICD)患者的长期随访资料,总结电风暴(ES)的诱发因素、临床处理及预后。方法48例患者共植入50台ICD,ES定义为24hICD正确检测到≥3次室性快速性心律失常,并促发ICD电治疗。结果随访时间中位数为16.9个月。共6例发生了8次ES。常见诱因为严重感染、心力衰竭和肾功能衰竭等。通过纠正诱因,使用抗心律失常药物,能有效减少和避免ICD电治疗。ES发生后,死亡率明显增高。结论ICD患者发生ES有比较明确的诱发因素,并且ES具有一定的预后判断价值。     

Chronic kidney disease in postmenopausal women

Menopause is derived from the Greek words men (month) and pauses (cessation) and means permanent cessation of menstruation after the loss of ovarian activity. Chronic kidney disease (CKD) has recently been associated with cardiovascular events in several studies. CKD patients have a heavy burden of traditional cardiovascular risk factors in addition to a range of nontraditional risk factors such as inflammation and abnormal metabolism of calcium and phosphate. In this review, the association of CKD and cardiovascular disease (CVD), as well as of osteoporosis in postmenopausal women is discussed. CKD mineral and bone disorder, characterized by disturbances of calcium/phosphate/parathyroid hormone, bone abnormalities and vascular and soft tissue calcification, is highly prevalent in CKD and is a strong, independent predictor of bone fracture, CVD and death. Estrogen has been shown to: (a) decrease the expression of angiotensin type 1 receptors in vasculature and kidneys; (b) reduce the expression and activity of angiotensin-converting enzyme, and (c) cause the release of angiotensinogen substrate from the liver. However, the degree of activation or suppression of the renin-angiotensin-aldosterone system by estrogen has not been clearly established. Clinical data on the effects of estrogen therapy on bone mineral densities are extremely limited in the ESRD population. CVD is the most common cause of death in postmenopausal women with CKD and many contributing factors have been explored. Future research for prevention of CVD in postmenopausal women with CKD would focus on the biology of vascular calcification as well as bone loss.     

心室电风暴

心室电风暴是由于心室电活动极度不稳定所导致的最危重的恶性心律失常,是心源性猝死的重要机制。迅速识别、紧急救援,可降低死亡率,改善预后。     

Management of monomorphic ventricular tachycardia electrical storm in structural heart disease

Electrical storm (ES) is a life-threatening condition that is defined by three or more episodes of sustained ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate shocks from an implantable cardioverter defibrillator (ICD) within 24 hours. The most common form of ES is monomorphic VT. It carries poor outcome despite all available intervention therapies. The therapies include rapid recognition of the condition, treatment of the reversible causes, ICD-reprogramming, antiarrhythmic drugs, sedation, and catheter ablation (CA). The first line antiarrhythmic drugs are amiodarone and β-blockers with superiority of propranolol over the others. The long-term use of the antiarrhythmic drugs is limited due to their adverse effects and drug-related proarrhythmic effect. The basic mechanism of monomorphic VT is re-entry pathway which can be targeted by CA. CA should be considered in drug refractory ES and patients should be referred in early course of disease. There are reported studies which showed the superiority of CA over the medical treatment in reducing the arrythmia burden and ICD appropriate shock. The survival benefit has been reported after successful ablation of ES in case series but to date no randomized control trial shows mortality benefit.     

QRS时限预测心律转复除颤器植入术后电风暴患者的远期预后

目的探讨影响植入型心律转复除颤器（IcD）术后发生电风暴（ES）患者远期预后的预测因子。方法回顾性分析2003年1月至2011年9月在南京医科大学第一附属医院心脏科植入ICD术后发生Es进行或未进行射频导管消融的47例患者的相关临床参数。结果47例患者平均年龄（51±14）岁,平均随访18个月,心脏性死亡10例。多因素Cox回归分析显示QRS时限为影响ICD术后发生Es患者生存情况的预测因子[危险比（HR）=1．042,P=0．012],射频导管消融治疗不能改善患者的预后（HR=0．034,P=0．347）。对于QRS时限≥110ms的患者,射频导管消融治疗也不能影响患者的生存情况（HR=0．037,P=0．395）。结论QRS时限可作为ICD植人术后发生Es患者远期预后的预测因子,射频导管消融并不能改善此类患者的预后。     

Chronic kidney disease and cardiovascular risk

Chronic kidney disease (CKD) is a global public health concern, and there is emerging a strong relationship between CKD and increased cardiovascular disease (CVD) risk. CKD in the presence of other co-morbidities such as type 2 diabetes mellitus (T2DM) and hypertension (HTN) can lead to early progression to end-stage renal disease (ESRD/stage V CKD) and confer a greater risk for CVD morbidity and mortality. CVD events are the leading cause of premature death in patients with CKD, even before their progression to ESRD, with the rate of CVD progression being twice as common compared with the general population. The higher mortality from CVD persists even after adjusting for most of the traditional risk factors, suggesting the possible contributions of uremia-related, nontraditional risk factors. This has led to the current understanding that the pathophysiology of CVD in CKD involves a complex interplay of both the traditional as well as nontraditional, uremia-related risk factors. This review will elaborate on the pathophysiology of CVD in CKD and will discuss the role of microalbuminuria (MAU)-proteinuria as a potential diagnostic and prognostic tool for CVD in CKD risk assessment.     

Chronic kidney disease--a disease domain complex

Chronic kidney disease (CKD) is a silent disorder that is under-recognized. It is most often diagnosed by biochemical abnormalities. The combination of age, ethnicity, gender, and serum creatinine yields the best overall index of kidney function, and the estimated glomerular filtration rate (GFR) must be readily available for clinical practitioners to facilitate identification of CKD. The detection of persistent proteinuria also heralds the presence of CKD, but this sign is often ignored. A detailed case study is presented to demonstrate the evolution of CKD and its insidious progression to a multifaceted and complex disorder. Delineation of the complications of CKD permits the adaptation of a collaborative action plan between primary care physicians and nephrologists, and sample approaches are outlined.     

肝移植术后尿检异常,肾功能不全

48岁男性,乙型病毒性肝炎肝硬化12年。亲体肝移植术后3年,术后采用他克莫司+霉酚酸酯+泼尼松抗排斥治疗。近1年患者出现尿检异常伴血清肌酐升高。肾活检示75%的肾小球废弃,肾小管间质弥漫纤维化,肾间质血管病变重,免疫荧光检查证实IgA与C3弥漫分布于肾小球系膜区。诊断考虑肝移植后慢性肾脏病变。