Decline in kidney function before and after nephrology referral and the effect on survival in moderate to advanced chronic kidney disease.

BACKGROUND: The burden of chronic kidney disease (CKD) is high, but its natural history and the benefit of routine nephrology care is unclear. This study investigated the decline in kidney function prior to and following nephrology referral and its association with mortality. METHODS: This study provides a retrospective review of the individual rates of glomerular filtration rate (GFR) decline (millilitre per minute per 1.73 m(2)/year) for the 5 years before and after referral in 726 new referrals with stages 3-5 CKD to one renal unit between 1997 and 2003. Blood pressures are averages at referral, 1 and 3 years post referral. Logistic regression and Cox's models tested factors predicting post-referral GFR decline and the impact on mortality. RESULTS: Mean (SD) age was 72 (14), and 389 (54%) patients had stages 4-5 CKD. GFR decline slowed significantly from -5.4 ml/min/1.73 m(2)/year (-13. to -2) before to -0.35 ml/min/1.73 m(2)/year (-3 to +3) after referral (P < 0.001). Blood pressure also reduced significantly (155/84 to 149/80, P < 0.05) with most changes occurring within 1 year of referral. Factors predicting a non-progressive post-referral decline included a lower systolic blood pressure at referral and 1 year after referral, a CKD diagnosis other than diabetic nephropathy, less baseline proteinuria and a non-progressive pre-referral GFR decline. A non-progressive post-referral GFR decline was independently associated with significantly better survival (hazard ratio 0.55, 95% CI 0.40-0.75, P 相似文献   

Preservation of residual renal function and factors affecting its decline in patients on peritoneal dialysis

SUMMARY:     The decline of residual renal function (RRF) in peritoneal dialysis (PD) patients was analysed and assessed, and risk factors affecting its decline were identified. Residual glomerular filtration rate (GFR) was calculated from averaging the urea and creatinine clearance by 24-h urine collection, and peritoneal solute removal was evaluated by creatinine clearance calculated from 24-h effluent collection. Both GFR and peritoneal solute removal were chronologically examined in 34 PD patients from the time of initiation, and risk factors associated with rapid GFR decline were investigated. The RRF contributed to 43.1 ± 17.6% of total (peritoneal and renal) weekly creatinine clearance at 1 month after initiation of PD. Residual GFR, however, declined continuously with time (−0.19 ± 0.14 mL/min per month), and the reduction rate was high with a higher GFR, higher normalized dietary protein intake, higher urine volume and higher urine protein excretion at the initiation of PD. Other factors related to the rapid decline of GFR were: being older than 60 years of age, automated peritoneal dialysis (APD) rather than continuous ambulatory peritoneal dialysis, mean blood pressure higher than 110 mmHg, and serum human atrial natriuretic peptide level higher being than 60 pg/dL. These data suggest that while RRF plays an important role in the removal of uraemic solute in PD patients, they show a significant decrease over 2 years. The factors related to the rapid decline of GFR corresponded to older age, modality of PD (APD), higher GFR and higher amount of urine protein at initiation, higher dietary protein intake, and inadequate control of hypertension and body fluid volume.     

Estimation of the glomerular filtration rate in children and young adults by means of the CKD-EPI equation with age-adjusted creatinine values

1. Download : Download high-res image (324KB)
2. Download : Download full-size image

     

Estimated Glomerular Filtration Rate from Serum Cystatin C: Significant Differences among Several Equations Results

Objectives: Several equations for the estimation of glomerular filtration rate (GFR) from serum cystatin C have been reported. We compared the results obtained using these equations to test the homogeneity of their results as well as their usefulness in clinical practice. Design and methods: Seven hundred and twenty-seven outpatients were studied. Of these, 439 were male and 288 were female, and their mean age was 60.8 ± 24.1 years. GFR was estimated from serum creatinine using the abbreviated Modification of Diet in Renal Disease (MDRD-4) equation. GFR was estimated from serum cystatin C levels using five different equations. Results: The simplest (100/cystatin C) formula rendered the highest estimated GFR and the Hoek’s equation rendered the lowest GFR, even significantly lower than the MDRD-4 equation (p < 0.001, Student’s t-test). From the simplest formula to the Hoek equation the mean difference calculated was 25.1 ± 8.7 mL/min (p < 0.001, Student’s t-test). No differences by gender were found among the results of different equations. All cystatin C-derived equations reduced the number of patients diagnosed of chronic renal failure when compared with MDRD-4 formula. No patient with normal renal function was shifted to the renal disease group. Conclusions: A higher value could be expected when GFR is estimated from cystatin C. Nevertheless, vast differences were found in the results when tested using several equations. Physicians should be aware of this problem to avoid a wrong clinical diagnosis of renal function.     

Tumour diameter and decreased preoperative estimated glomerular filtration rate are independently correlated in patients with renal cell carcinoma

Study Type – Diagnosis (exploratory cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? For over 30 years it has been recognized that there is an association between end‐stage renal disease (ESRD) and the development of malignancy, particularly renal cortical tumour. Observational studies have consistently shown that patients with severely decreased glomerular filtration rate (GFR) develop cancer more frequently than their age‐ and exposure‐matched controls. This study is the first of its kind to look directly at the relationship between GFR and tumour size, in an effort to begin to examine the relationship between kidney function and oncogenesis.

OBJECTIVE

? To examine the relationship between tumour diameter and estimated GFR (eGFR) in patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

? In total, 1009 patients undergoing partial or radical nephrectomy for unilateral RCC were identified in the Columbia Urologic Database. ? eGFR was calculated using the modification of diet in renal disease equation using demographic data and preoperative serum creatinine values. ? Data on patient demographics, tumour characteristics, and comorbidities were analyzed using univariate and multivariate regression analysis.

RESULTS

? Mean (sd , range) tumour diameter was 5.29 (3.8, 0.3–29) cm. Mean (sd , range) eGFR was 75 (23.4, 3–173) mL/min per 1.73 m². ? In multivariate regression analysis, tumour diameter independently predicted decreased preoperative eGFR (coefficient, ?0.513; P= 0.008) when controlling for hypertension and race. ? Consistent with this, decreased preoperative eGFR independently predicted increased tumour diameter (coefficient, ?0.013; P= 0.007) when controlling for race, histology and smoking status.

CONCLUSION

? Tumour diameter and decreased preoperative eGFR are independently correlated in patients with RCC.     

Chronic kidney disease post-liver transplantation.

BACKGROUND: Renal disease is a recognized complication of orthotopic liver transplantation (OLT). We aimed to determine the incidence of all stages of chronic kidney disease (CKD), as defined in the Kidney Disease Outcomes Quality Initiative Guidelines. We also wanted to determine the risk factors for development of CKD and its impact on patient survival. METHODS: All patients who underwent cadaveric OLT, from January 1993 until July 2004, were analysed. The glomerular filtration rate (GFR) was determined using the equation developed by the Modification of Diet in Renal Disease Study. Thirty potential risk factors were examined by univariate and multivariate ordinal logistic regression analysis. Kaplan-Meier survival analysis, the log-rank test and Cox regression analysis were performed to evaluate the survival data. RESULTS: A total of 230 patients were included (107 males and 123 females) with a mean age of 47.7 years (4.5-70.35). Mean follow-up was 5.57 years (0.53-16.5). The following was the 10 year cumulative incidence for each stage of CKD: 0/1, 9.61%; 2, 53.71%; 3, 56.77%; 4, 6.11%; 5, 2.62%. Female gender, age, pre-OLT proteinuria, lower GFR from 1 year and higher creatinine from 6 months were associated with progression of CKD. The use of tacrolimus had a favourable impact. A GFR <30 ml/min, the need for re-transplantation and fulminant hepatic failure were all associated with reduced patient survival. CONCLUSIONS: Moderate CKD was very prevalent. We identified the risk factors for progression of CKD and also that severe CKD was associated with reduced patient survival.     

Plasma levels of lipoprotein (a) do not predict progression of human chronic renal failure

Chronic renal failure is frequently accompanied by elevatedplasma levels of lipoprotein (a) [Lp(a)] Elevated Lp(a) levelshave been proposed to contribute not only to increased riskof atherosclerotic and thrombotic complications but also tothe progression of renal insufficiency. To investigate whetherhigher Lp(a) plasma concentrations are associated with an acceleratedrateof progression of renal insufficiency, we have correlated baselineplasma concentrations of Lp(a) with the progressive declineof renal function in an observational study of human chronicrenal disease. Forty-nine non-diabetic patients (40 men, ninewomen) were studied as part of an observational study of patientswith moderately advanced renal insufficiency. The average follow-uptime of the patient population was 3.1 years, and the mean rateof decline in glomer ular filtration rate (⁵¹Cr-EDTA clearance)was –2.8 (SD 4.1) ml/min/1.73 m² The mean plasma concentrationof Lp(a) at the beginning of the study was 19.2 (SD 18.6) mg/100ml with a median value of 12.2 mg/100 ml. There was no associationbetween the initial plasma concentration of Lp(a) and the rateof progression as assessed by linear regression analysis. Furthermore,the progression rate in patients with in the highest quartileof the Lp(a) distribution (30 mg/100 ml) did not differ fromthat in patients with lower levels of Lp(a). In contrast, increasedlevels of apolipoprotein (apo) B, low-density lipoprotein (LDL)-cholesterol,and proteinuria were all significantly associated with a morerapid decline in renal function. Based on these results, itwas concluded that elevated plasma levels of Lp(a) are not associatedwith an increased rate of progression of renal insufficiencyin human chronic renal disease. However, the results of thisstudy suggest that other apoB-containing lipoproteins may playa significant role in this process.     

Patient referral is influenced by dialysis centre structure in the Diamant Alpin Dialysis cohort study.

BACKGROUND: Late referral (LR) to the nephrologist of patients with progressing chronic kidney disease (CKD) has numerous deleterious effects and is observed in many countries. The contributing factors associated with LR are controversial and poorly defined. We hypothesized that these factors might be better identified by analysing patients starting dialysis in three distinct European countries within the same area. METHOD: The referral and progression of kidney failure patterns were analysed with demographic, clinical and biological data in 279 non-selected consecutive patients starting dialysis in eight centres of three adjacent regions in France, Italy and Switzerland. RESULTS: Early referral (>6 months before the start of dialysis) was seen in 200 patients (71.6%), intermediate referral (1-6 months) in 42 (15.1%) and LR (<1 month) in 37 (13.3%). However inter-centre variations were between 2 and 19% for LR and 6-50% for combined late and intermediate referral. There were no differences at the national levels, but LR was more frequent in the large city centres than in the private or regional structures, with 31 out of 169 (18.3%), two out of 55 (5.4%) and four out of 55 (7.3%), respectively, of their patients (P<0.01). By multivariate analysis, it appears that, besides the presence of an active cancer and the CKD progression rate, the centre structure and the referring physician (primary care physicians and nephrologists are less responsible for LR than other medical specialists) play a significant role in the practice of LR. CONCLUSIONS: Within a dialysis cohort spread over adjacent regions of three countries, LR has the same global distribution pattern, indicating that different health and social security systems do not play a major role in inducing or preventing this practice. The contributing factors for LR that were identified are the type of the referring physician and the structure of the dialysis unit. Both factors are potential targets for an educational and collaborative approach.     

Renal Function and Serum Albumin at the Start of Dialysis in 514 Chinese ESRD In-Patients

Background. The dialysis population has grown rapidly in recent decades. Despite the high cost and poor outcomes of dialysis treatment for ESRD, there are scant data about the level of renal function and the relationship of renal function and serum albumin at the start of dialysis in Chinese ESRD patients. Method. We report the level of serum creatinine (Scr), glomerular filtration rate (GFR), and serum albumin (Salb) in 514 ESRD in-patients who began their dialysis treatment between January 2001 through December 2007 at two large dialysis centers in Changsha, Hunan, China. Data were obtained through reviewing the case records of all 514 patients. GFR was predicted by an equation developed from the Modification of Diet in Renal Disease Study. In addition, serum albumin was analyzed in relation to levels of predicted GFR. Results. The mean (SD) and median predialysis serum creatinine was 1121.92 ± 458.24 and 1032 μmol/L. The mean (SD) and median predicted GFR was 4.98 ± 2.24 and 4.47mL/min/1.73m². The proportion of patients with predicted GFR of >10, 5 to 10, and <5 mL/min/1.73m² was 3.7, 36.2, and 60.1%, respectively. The mean predicted GFR was significantly lower among younger patients, uninsured patients, unemployed or farmer patients, patients who were employed, students, patients who selected hemodialysis, patients with ESRD caused by diseases other than diabetes, patients with BUN above the mean, and patients with hemoglobulin beneath the mean. Compared with patients who started with GFR >5mL/min, the patients who started with GFR ≤5mL/min had significantly higher plasma urea and creatinine levels but significantly lower creatinine clearance (mL/min per 1.73m²) and parameters of nutritional status, such as serum albumin, body weight, and BMI. Conclusion. A wide variation existed in renal function at the initiation of dialysis in partial Chinese ESRD patients. Most patients start dialysis at very low levels of predicted GFR. The nutritional status in patients who start dialysis early was better than those in patients who start dialysis when GFR ≤ 5mL/min. Further studies are needed to analyze the impact of level of renal function and nutritional status at the start of dialysis on the outcomes of ESRD.     

Trajectories of glomerular filtration rate and progression to end stage kidney disease after kidney transplantation

1. Download : Download high-res image (426KB)
2. Download : Download full-size image