Chronic kidney disease and underdiagnosis of renal insufficiency among diabetic patients attending a hospital in Southern Ethiopia

Background

Diabetic patients with chronic kidney disease (CKD), as defined by a reduced glomerular filtration rate (GFR), are at greater risk for cardiovascular and renal events and mortality. The aim of this study was to determine the prevalence of CKD among diabetic patients attending a hospital in southern Ethiopia, and to assess underdiagnosis of renal insufficiency among those with normal serum creatinine.

Methods

A total of 214 randomly selected diabetics attending the follow-up clinic at Butajira hospital of southern Ethiopia participated in this study during the period from September 1 to October 31, 2013. All patients completed an interviewer-administered questionnaire and underwent clinical assessment. The simplified Modification of Diet in Renal Disease (MDRD) and Cockroft-Gault (C-G) equations were used to estimate GFR (eGFR) from serum creatinine.

Results

CKD, defined as eGFR?<?60 ml/min/1.73 m², was present in 18.2% and 23.8% of the study participants according to the MDRD and Cockcroft-Gault (C-G) equations, respectively. Only 9.8% of the total participants, and 48.7% (for the MDRD) and 37.3% (for C-G) of those with eGFR <60 ml/min/1.73 m² had abnormal serum creatinine values, i.e. > 1.5 mg/dl. Normal serum creatinine was observed in 90.2% of participants attending the hospital. A large proportion of participants ranging from 38.9-56.5% have shown to have mild to moderate renal insufficiency (stage 2–3 CKD) despite normal creatinine levels. CKD, eGFR?<?60 ml/min/1.73 m², was found in 10.4 and 16.9% of participants with normal serum creatinine using the MDRD and C-G equations, respectively.

Conclusion

CKD is present in no less than 18% of diabetics attending the hospital, but it is usually undiagnosed. A significant number of diabetics have renal insufficiency corresponding to stages 2–3 CKD despite normal creatinine levels. Therefore, GFR should be considered as an estimate of renal insufficiency, regardless of serum creatinine levels being in normal range.

     

重症心脏瓣膜病术后肾功能不全患者连续性肾替代治疗体会

目的总结重症心脏瓣膜术后发生。肾功能不全患者采用连续性肾替代治疗（continuous renal replacement therapy,CRRT）的经验。方法回顾性分析15例重症风湿性心脏瓣膜病术后合并肾功能不全,术后行床旁CRRT治疗,取得了良好效果的患者的临床资料,着重分析CRRT治疗方法和效果。其中10例为主动脉二尖瓣联合瓣膜病变患者,1例为主动脉瓣膜病变患者,其余为二尖瓣合并三尖瓣瓣膜病变患者。术前心功能评估为纽约心脏协会心功能Ⅲ～Ⅳ级,手术前后监测肾功能和尿量,术后行床旁CRRT的治疗．监测。肾功能。结果除1例合并顽固性心力衰竭患者死亡外,其余均治愈,最短5d,最长1个月肾功能恢复。结论重症心脏瓣膜术后肾功能不全患者．尽早行CRRT．效果好．恢复快。     

Renin gene expression in the adrenal and kidney of patients with primary aldosteronism.

mRNA levels for renin in the adrenal gland and kidney were measured by ribonuclease protection assay (RPA). Renin mRNA was not detected by RPA in aldosteronoma and kidney tissues obtained from two patients with primary aldosteronism (PA). In these patients, the PRA values, plasma concentrations of active renin (ARC), and total renin (TRC = ARC + prorenin) were below the assay limit (less than 0.03 ng/L.s, 2.5 ng/L, and 10 ng/L, respectively). On the other hand, renin mRNA was recognized by RPA in aldosteronoma and kidney tissues obtained from two other patients with PA treated with 50 mg/day spironolactone for more than 2 months. Their TRC values were 49.8 and 16.6 ng/L, but their PRA and ARC were undetectable. Renin mRNA content was greater in normal adrenocortical tissue and in the normal kidneys obtained from three hypertensive patients with renal cell carcinoma. In these patients, the mean values of PRA, ARC, and TRC were 0.28 +/- 0.03 (mean +/- SD) ng/L.s, 18.4 +/- 7.8 ng/L, and 110 +/- 15 ng/L, respectively. This is the first report of the lack of renin gene expression in aldosteronoma and kidney tissues obtained from untreated patients with PA. Furthermore, treatment with spironolactone resulted in an increase in the levels of renin mRNA in the aldosteronoma and kidney tissues of patients with PA.     

肾功能不全患者冠心病的抗栓药物治疗

慢性肾脏病常并发冠心病,需要积极治疗包括抗栓药物治疗,以减少心血管事件发生率及病死率。但是,肾功能不全患者出血风险增加,如果抗栓药物使用不当,即可诱发严重出血。文章将对肾功能不全时如何使用抗血小板药物、抗凝药物及纤溶药物作一讨论。     

Cardiovascular complications in patients with chronic renal insufficiency and chronic kidney failure

Patients with chronic renal failure have, as compared with age-matched controls with normal renal function, a markedly higher cardiovascular mortality. The reason is probably accelerated atherosclerosis and left ventricular hypertrophy as a result of accumulation of "classical" cardiovascular risk factors and the presence of some risk factors relatively specific for "uraemia" (e.g. anaemia, hyperhydratation, dyslipidaemia). It is assumed that the reversibility of left ventricular hypertrophy is limited in chronic renal failure due to more marked myocardial fibrosis ("uraemic cardiomyopathy"). Its regression can be achieved by treatment of hypertension with inhibitors of angiotensin converting enzyme with a positive effect on cardiovascular mortality. Regression of left ventricular hypertrophy occurs also in some patients after renal transplantation. Treatment of anaemia reduces the risk of progressive left ventricular dilatation. The cardiovascular risk increases probably already a relatively slight decline of glomerular filtration which need not lead to a significant rise of serum creatinine. The cardiovascular risk obviously increases further with progression of chronic renal insufficiency. Patients with a reduced renal function and chronic renal insufficiency have lower target blood pressure and should have also lower target values e.g. of serum cholesterol. Therapeutic procedures in these patients should not be focused only on a slower progression of chronic renal insufficiency but also on reduction of their high cardiovascular risk.     

Impact of primary aldosteronism on renal function in patients with type 2 diabetes

Aims/IntroductionRenal dysfunction might quickly progress in patients with type 2 diabetes mellitus, when accompanied by hypertension. However, whether primary aldosteronism (PA), which autonomously over‐secretes aldosterone, causes additional renal damage in patients with type 2 diabetes mellitus is unclear. We evaluated the impact of PA on renal function in patients with type 2 diabetes mellitus.Materials and MethodsA retrospective review of all patients with type 2 diabetes mellitus who visited Yokohama Rosai Hospital’s (Yokohama Japan) outpatient department between April 2017 and March 2018 was carried out. Records of patients with PA who underwent PA treatment by adrenalectomy or mineralocorticoid receptor antagonists (PA group) and those without PA (non‐PA group) were extracted, and renal function was compared between the two groups. Untreated PA patients were excluded, as their renal function might be overestimated as a result of glomerular hyperfiltration.ResultsThere were 83 patients in the PA group and 1,580 patients in the non‐PA group. The PA group had significantly lower estimated glomerular filtration rates than the non‐PA group (66.3 [52.4–78.2] vs 70.5 [56.0–85.6] mL/min/1.73 m², P = 0.047). Multiple regression analysis showed that PA was a factor for decreased estimated glomerular filtration rate, independent of age, sex, glycated hemoglobin, diuretic use and hypertension (P = 0.025). PA induced a 3.7‐mL/min/1.73 m² (95% confidence interval 0.47–6.9) decrease in estimated glomerular filtration rate, equivalent to that induced by 4.4 years of aging.ConclusionsOur results show that in patients with type 2 diabetes mellitus, PA is an independent risk factor for renal dysfunction. To prevent the progression of renal failure, PA should not be overlooked.     

Risk of primary adrenal insufficiency in patients with celiac disease

OBJECTIVES: Earlier research has suggested a positive association between Addison's disease (AD) and celiac disease (CD). We have here investigated the risk of AD in individuals with CD from a general population cohort. METHODS: Through the Swedish national registers we identified 14,366 individuals with a diagnosis of CD (1964-2003) and 70,095 reference individuals matched for age, sex, calendar year, and county of residence. We used Cox regression to estimate hazard ratios (HRs) for subsequent AD. Analyses were restricted to individuals with more than 1 yr of follow-up and without AD prior to study entry or within 1 yr after study entry. Conditional logistic regression estimated the odds ratio for CD in individuals with prior AD. RESULTS: There was a statistically significantly positive association between CD and subsequent AD [HR = 11.4; 95% confidence interval (CI) = 4.4-29.6]. This risk increase was seen in both children and adults and did not change with adjustment for diabetes mellitus or socioeconomic status. When we restricted reference individuals to inpatients, the adjusted HR for AD was 4.6 (95% CI = 1.9-11.4). Individuals with prior AD were at increased risk of CD (odds ratio = 8.6; 95% CI = 3.4-21.8). CONCLUSIONS: This study found a highly increased risk of AD in individuals with CD. This relationship was independent of temporal sequence. We therefore recommend that individuals with AD should be screened for CD. We also suggest an increased awareness of AD in individuals with CD.     

两型原发性醛固酮增多症患者胰岛素敏感性的比较及其胰岛素敏感性与病情的关系

目的 分析和比较两型原发性醛固酮增多症（PA）患者胰岛素敏感性及其治疗前后胰岛素敏感性与病情的关系。方法 本院确诊PA患者32例,其中肾上腺皮质腺瘤（APA）20例,特发性醛固酮增多症（IHA）12例,观察治疗前后体质量指数、血压、血浆醛固酮、空腹血糖、空腹胰岛素及胰岛素抵抗指数（HOMA-IR）等指标的变化。结果 PA组患者治疗后收缩压［（140±8.6）mmHg］、舒张压［（82±9）mmHg］、空腹胰岛素［（7.6±1.8）mmol/L）］、空腹血糖［（5.0±0.7）mmol/L］、HOMA-IR（1.6±0.4）均低于治疗前［收缩压（178±10）mmHg、舒张压（105±11）mmHg、空腹胰岛素（10±3）mmol/L、空腹血糖（5.6±1.1）mmol/L、HOMA-IR（2.4±0.9）,均P<0.01］;治疗前IHA组血浆醛固酮水平［（228±52）ng/L］低于治疗前APA组［（344±41）ng/L,P<0.01）］;治疗前IHA组胰岛素抵抗患者所占百分率（58%）显著高于APA组（20%,P<0.05）;APA手术组醛固酮水平（82±23）ng/L低于治疗前［(344±41) ng/L,P<0.01）］;治疗后APA组血钾（4.0±0.4）mmol/L、HIA组血钾（4.1±0.4）mmol/L分别较治疗前［（3.2±0.4）mmol/L、（3.4±0.3）mmol/L］高（P<0.01）。结论 PA患者部分存在胰岛素抵抗。PA患者在进行肾上腺腺瘤切除或应用螺内酯治疗后胰岛素敏感性可有一定程度恢复。     

Genetic alterations in patients with primary aldosteronism.

The syndrome of primary aldosteronism is characterized by hypertension with excessive production of aldosterone, potassium loss, and suppression of the renin-angiotensin system. The most common clinical subtypes of primary aldosteronism are aldosterone-producing adrenocortical adenoma (APA) and bilateral adrenal cortical hyperplasia (idiopathic hyperaldosteronism, or IHA). It has been reported that renin suppression and aldosterone levels are lower and hypokalemia milder in patients with IHA than in patients with APA. In the present study, we investigated the genetic analysis of aldosterone synthase gene, CYP11B2 in patients with primary aldosteronism and review the recent studies. The chimeric CYP11B1/CYP11B2 gene, which is a candidate gene for glucocorticoid-remediable hyperaldosteronism, was not found in either the DNA from aldosteronoma or in the genomic DNA from patients with APA or IHA. Mutations in the CYP21 or CYP11B1 gene were not present in patients with APA. No mutations in the coding region of the CYP11B2 gene were found in patients with IHA or APA. The level of CYP11B2 messenger RNA (mRNA) was much higher in the aldosteronoma portion than in nonadenomatous portion. The overexpression of CYP11B2 mRNA seen in the mononuclear leukocytes of patients with IHA suggests that unidentified aldosterone-stimulating factors or abnormalities of the CYP11B2 promoter region may cause the overproduction of aldosterone characteristic of IHA. The variants of the CYP11B2 gene may also contribute to dysregulation of aldosterone synthesis and lead to susceptibility to IHA.     

Comparison of renal and vascular protective effects between telmisartan and amlodipine in hypertensive patients with chronic kidney disease with mild renal insufficiency

The present study was conducted to compare the renal and vascular protective effects of telmisartan and amlodipine in untreated hypertensive chronic kidney disease (CKD) patients with moderate renal insufficiency. Thirty hypertensive CKD patients were randomly assigned to receive telmisartan 40 mg (n = 15) or amlodipine 5 mg (n = 15) once daily for 12 months. Changes in blood pressure, serum creatinine, 24-h creatinine clearance (Ccr), proteinuria, brachial-ankle pulse wave velocity (baPWV), intima-media thickness (IMT), plasma interleukin-6 (IL-6), plasma matrix metalloproteinase (MMP)-9 and lipid profiles were monitored in all patients. Before treatment, there were no significant differences in these parameters between the telmisartan and amlodipine groups. Over the 12 month observation period, blood pressure decreased equally in both groups. However, serum creatinine, proteinuria, baPWV, IMT, plasma levels of IL-6 and MMP-9 and total cholesterol decreased and 24-h Ccr increased more strikingly in the telmisartan group than the amlodipine group. These data suggest that telmisartan is more effective than amlodipine for protecting renovascular functions, and potentially for ameliorating atherosclerosis, in hypertensive CKD patients with moderate renal insufficiency.     

Model for end-stage liver disease score versus Child score in predicting the outcome of surgical procedures in patients with cirrhosis

AIM： To determine factors affecting the outcome of patients with cirrhosis undergoing surgery and to compare the capacities of the Child-Turcotte-Pugh （CTP） and model for end-stage liver disease （MELD） score to predict that outcome. METHODS： We reviewed the charts of 195 patients with cirrhosis who underwent surgery at two teaching hospitals over a five-year period. The combined endpoint of death or hepatic decompensation was considered to be the primary endpoint. RESULTS： Patients who reached the endpoint had a higher MELD score, a higher CTP score and were more likely to have undergone an urgent procedure. Among patients undergoing elective surgical procedures, no statistically significant difference was noted in the mean MELD （12.8 ＋ 3.9 vs 12.6 ＋ 4.7, P = 0.9） or in the mean CTP （7.6 ± 1.2 vs 7.7 ± 1.7, P = 0.8） between patients who reached the endpoint and those who did not. Both mean scores were higher in the patients reaching the endpoint in the case of urgent procedures （MELD： 22.4 ± 8.7 vs 15.2 ± 6.4, P = 0.0007; CTP： 9.9 ± 1.8 vs 8.5 ± 1.8, P = 0.008）. The performances of the MELD and CTP scores in predicting the outcome of urgent surgery were only fair, without a significant difference between them （AUC = 0.755 ± 0.066 for MELD vs AUC = 0.696 ± 0.070 for CTP, P = 0.3）. CONCLUSION： The CTP and MELD scores performed equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.     

A risk score for predicting postoperative complications in non-intubated thoracic surgery

BackgroundThe risk factors for postoperative complications in non-intubated video-assisted thoracoscopic surgery (VATS) have not been observed before. Here to develop a simple risk score to predict the risk of postoperative complications for patients who scheduling non-intubated VATS, which is beneficial to guide the clinical interventions.MethodsA total of 1,837 patients who underwent non-intubated VATS were included from January 2011 to December 2018. A development data set and a validation data set were allocated according to an approximate 3:2 ratio of total cases. The stepwise logistic regression was used to establish a risk score model, and the methods of bootstrap and split-sample were used for validation.ResultsMultivariable analysis revealed that the forced expiratory volume in the first second in percent of predicted, the anesthesia method, blood loss, surgical time, and preoperative neutrophil ratio were risk factors for postoperative complications. The risk score was established with these 5 factors, varied from 0 to 53, with the corresponding predicted probability of postoperative complications occurrence ranged from 1% to 92% and was calibrated (Hosmer-Lemeshow χ² =6.261; P=0.618). Good discrimination was acquired in the development and validation data sets (C-statistic 0.705 and 0.700). A positive correlation was between the risk score and postoperative complications (P for trend <0.01). Three levels of low-risk (0–15 points], moderate-risk (15–30 points], and high-risk (>30 points] were established based on the score distribution of postoperative complications.ConclusionsThis simple risk score model based on risk factors of postoperative complications can validly identify the high-risk patients with postoperative complications in the non-intubated VATS, and allow for early interventions.     

非酒精性脂肪性肝病相关慢性肾病研究进展

非酒精性脂肪性肝病是与胰岛素抵抗和遗传易感性密切相关的代谢应激性肝损伤。该病已经成为全球性的公共卫生问题之一。近几年来,有研究显示非酒精性脂肪性肝病可能与慢性肾病越来越高的患病率有关。本文将重点阐述这两个疾病的相互关系以及相关发生机制,比如胰岛素抵抗、炎症、氧化应激、高凝状态、胎球蛋白-A和脂联素等在该病发病中的作用,为更全面管理非酒精性脂肪性肝病患者和慢性肾病患者提供有用的建议。