Proteinuria and decreased body mass index as a significant risk factor in developing end-stage renal disease

Background  Body mass index (BMI) is a significant predictor of developing end-stage renal disease (ESRD). The relation between a change in BMI (ΔBMI) and the incidence of ESRD has not been examined in any large epidemiologic studies. Methods  We determined the ΔBMI in subjects who participated in the Okinawa General Health Maintenance Association (OGHMA) screenings in 1983 and again in 1993. Screenees were free of ESRD at the 1993 screening and were then monitored until the end of 2000 to determine whether they developed ESRD. Participants were identified using ID numbers, birthdates, and other identifiers. Details of every ESRD patient treated in Okinawa are maintained in an independent community-based dialysis registry. Multivariate logistic analyses were performed to determine the significance of a ΔBMI on the incidence of ESRD using SAS. The ethics committee of the OGHMA approved the study protocol. Only coded data were used for this study. Results  Among the 92,364 subjects aged 30–89 years screened in 1983, 29,011 (31.4%) returned for the 1993 screening. The median ΔBMI was 2.1%, and the subjects were divided into two groups: ΔBMI < 2.1% (G1) and ΔBMI ≥ 2.1% (G2). The cumulative incidence of ESRD was 0.31% in G1 (ESRD in 44) and 0.14% in G2 (ESRD in 21). The odds ratio (95% confidence interval) of developing ESRD based on a ΔBMI was 2.268 (1.284–4.000, P < 0.01) after adjusting for age, sex, systolic blood pressure, BMI in 1983, and proteinuria. Conclusion  The findings of the present study suggest that a ΔBMI is an independent risk factor for the incidence of ESRD, especially for those with proteinuria. The reasons for the BMI change were not recorded in this study. Unintentional weight loss, however, might warrant evaluation for the presence or progression of chronic kidney disease.     

Predictors of diabetic end‐stage renal disease in Japan

SUMMARY: Diabetes mellitus (DM) has been the leading cause of incident dialysis in Japan since 1998, according to the Japanese Society for Dialysis Therapy (JSDT). In particular, the number of male DM dialysis patients is increasing. DM is becoming a worldwide epidemic in both developed and developing countries. Strategies to detect individuals at high‐risk of developing CKD and end‐stage renal disease (ESRD) are needed that can be implemented on a population‐basis. Among the commonly measured variables, dipstick urinalysis (proteinuria, haematuria), blood pressure, serum creatinine, body mass index (BMI), and serum uric acid are significant predictors of ESRD. Recently, we evaluated the effect of DM as a risk factor of developing ESRD. DM was diagnosed when the fasting plasma glucose (FPG) was 126 mg/dL or more in participants (n = 78529) of the 1993 screening program in Okinawa. The prevalence of DM was 5.2%. The odds ratio (95% CI) of DM for developing ESRD was 3.098 (1.738–5.525, P = 0.0001) after adjusting for possible confounding variables. Early detection and treatment of DM might prevent DM‐related ESRD. We examined 7125 non‐DM screenees who underwent a 1‐day health check between April 1997 and March 1998. They were followed‐up until March 2000 to determine whether they developed DM. Over the 2 years, the cumulative incidence of DM was 2.3%, 2.9% in men and 1.3% in women. Proteinuria was the most robust predictor of the development of DM; the adjusted relative risk (95% CI) was 1.90 (1.14–3.17). Obesity, per se, is also recognized as a risk factor for developing proteinuria. The higher the BMI, the higher the risk of developing ESRD; the adjusted odds ratio (95% CI) was 1.273 (1.121–1.446, P = 0.0002) for men. Other than being overweight (BMI = 25.0 kg/m²), a smoking habit was a significant predictor of developing proteinuria. The prevalence of obesity and DM is increasing in Japan. It is possible that the impact of obesity and complications of DM are different among races and ethnicities. Public relations regarding the risk of DM and its complications are especially important in Asian countries. Asians have more fat than non‐Asians, even at the same BMI levels. Knowledge of the predictors of DM‐ESRD is crucial as a first step toward prevention. Consistent with this notion, initiatives on the management of CKD and ESRD were recently organized in Japan and internationally.     

Metabolic syndrome and chronic kidney disease in Okinawa, Japan

We assessed the prevalence of chronic kidney disease (CKD) in a hospital-based screening program in Okinawa, Japan. The significance of metabolic syndrome as a determinant of CKD was examined using multivariate logistic regression analysis. A total of 6980 participants, aged 30-79 years, participated in a screening program in Tomishiro Chuo Hospital. Metabolic syndrome was defined according to the criteria of the Adult Treatment Panel III (ATP III). Data were also analyzed according to the modified criteria of the National Cholesterol Education Program (NCEP) that defines abdominal obesity as a waist circumference of > oe =85 cm in men and > or =90 cm in women. CKD was defined as dipstick proteinuria (> or =1+) or a reduced glomerular filtration rate (GFR). GFR was estimated using the abbreviated Modification of Diet in Renal Disease (MDRD) formula. The prevalence of metabolic syndrome and CKD was 12.8 and 13.7%, respectively. Metabolic syndrome was a significant determinant of CKD (adjusted odds ratio (OR) 1.537 and 95% confidence interval (CI) 1.277-1.850, P<0.0001). The adjusted OR (95% CI) was 1.770 (1.215-2.579, P=0.0029) for those with four metabolic syndrome risk factors compared to those with no metabolic syndrome risk factors. Metabolic syndrome was a significant determinant for younger participants (<60 years; OR 1.686, 95% CI 1.348-2.107, P<0.0001), but not for older participants (> or =60 years; OR 1.254, 95% CI 0.906-1.735, NS). The relationship between the number of metabolic syndrome risk factors and the prevalence of CKD was linear using the modified criteria. The results suggest that metabolic syndrome is a significant determinant of CKD in men under 60 years of age, in Okinawa, Japan.     

Pediatric nephrology patients are overweight: 20 years' experience in a single Canadian tertiary pediatric nephrology clinic

Background Obesity is an independent risk factor for chronic kidney disease (CKD). We compared the body composition of pediatric nephrology patients with that of the general child population over 2 decades. Methods About 4,959 patients above 2 years of age (mean: 9.6 ± 4.5) were referred to a tertiary pediatric nephrology clinic from 1985 to 2006. In 3,422 patients (69.0% with the same mean age) there were sufficient data to analyze body composition, expressed as body mass index (BMI) Z-score and calculated on the basis of normal data taken from the National (USA) Center for Health Statistics (2000). Results Hematuria (21.68%), recurrent urinary tract infections (16.09%), proteinuria (13.95%) and hypertension (8.27%) were the most common referral diagnoses. Mean BMI Z-score of the pediatric nephrology patients increased significantly from 0.29 ± 1.07 during the years 1985–1991 to 0.44 ± 1.27 in 1992–1999 and 0.87 ± 1.70 in 2000–2006 (P < 0.0001, ANOVA). Whereas the rate of the increase in BMI Z-score was not statistically different from that seen in the normal population, the young nephrology patients had over the entire time consistently significantly higher BMI Z-scores (average +0.72) than the comparable normal USA data. Several disease groups with potential for development of CKD had higher BMI Z-scores than found in the age- and sex-adjusted control data. Conclusions The increased rate of obesity in our studied population suggests that pediatric nephrology patients are at even greater risk for developing CKD later in life than could be predicted from their renal disease only. We recommend therapeutic intervention to address this potentially modifiable risk factor.     

Influence of smoking and obesity on the development of proteinuria

BACKGROUND: Proteinuria is a significant risk factor for end-stage renal disease. Previous evidence suggested that smoking and obesity increase the risk of proteinuria. However, it is unclear whether these risk factors predict the development of proteinuria independently of hypertension and diabetes mellitus. The aim of this study was to analyze the effects of obesity and smoking on the development of proteinuria in a screened cohort of subjects with normal kidney function. METHODS: A total of 5403 subjects (3403 men and 2000 women) who participated in the 1997 and 1999 health screening examinations in Okinawa Japan, and who were normal renal function (serum creatinine < or =1.2 mg/dL in men, < or =1.0 mg/dL in women) and negative proteinuria by dipstick examination in 1997 were eligible for study. Logistic analysis was used to examine the relation between the baseline state of smoking or obesity in 1997, and the development of proteinuria in 1999, adjusted for age, sex, and other confounding factors. RESULTS: Proteinuria developed in 5.8% of participants (6.7% in men, 4.4% in women; dipstick score, 1+ in 277, 2+ in 37, and > or =3+ in 4 participants). The incidence of proteinuria was positively associated with the number of cigarettes smoked per day (P = 0.04), and a body mass index (P < 0.0001) at baseline. Analysis showed that the relative risk (95% confidence interval) of developing proteinuria was 1.32 (1.00 to 1.74), P = 0.04 for cigarette smoking, 1.45 (1.13 to 1.86), P = 0.002 for obesity, 1.56 (1.19 to 2.06), P = 0.001 for hypertension, and 2.27 (1.55 to 3.32), P < 0.0001 for diabetes mellitus. Stratified with men and women, the relative risk was 1.28 (0.96 to 1.72), P = 0.09 for smoking, and 1.60 (1.19 to 2.14), P = 0.001 for obesity in men; the relative risk was 1.30 (0.44 to 3.80), P = 0.62 for smoking, and 1.04 (0.63 to 1.72), P = 0.87 for obesity in women. CONCLUSIONS: Hypertension and diabetes mellitus were superior to smoking and obesity in predicting the development of proteinuria in all subjects. Stratified with men and women, obesity was a significant risk factor for the development of proteinuria independently of both hypertension and diabetes mellitus in men. The risk of developing proteinuria also tended to be increased with cigarette smoking in men. Smoking and obesity in women were not significant in this data set.     

Proteinuria and the risk of developing end-stage renal disease

BACKGROUND: Dipstick urinalysis for proteinuria and hematuria has been used to screen renal disease, but evidence of the clinical impact of this test on development of end-stage renal disease (ESRD) is lacking. METHODS: We assessed development of ESRD through 2000 in 106,177 screened patients (50,584 men and 55,593 women), 20 to 98 years old, in Okinawa, Japan, who participated in community-based mass screening between April 1983 and March 1984. We used data from the Okinawa Dialysis Study Registry to identify ESRD patients. Multivariate logistic analyses were performed to calculate adjusted odds ratio and 95% confidence interval (95% CI) for the significance of proteinuria and hematuria on the risk of developing ESRD with confounding variables such as age, gender, blood pressure, and body mass index. A similar analysis was repeated in a subgroup of screened patients in whom serum creatinine data existed. RESULTS: During 17 years of follow-up, 420 screened persons (246 men and 174 women) entered the ESRD program. We identified a strong, graded relationship between ESRD and dipstick urinalysis positive for proteinuria; adjusted odds ratio (95% CI) was 2.71 (2.51 to 2.92, P < 0.001). Similar trends were observed after adding serum creatinine data. Compared with dipstick-negative proteinuria, adjusted odds ratio (95% CI) of proteinuria (1+) was 1.93 (1.53 to 2.41, P < 0.001) in men and 2.42 (1.91 to 3.06, P < 0.001) in women. CONCLUSION: Proteinuria was a strong, independent predictor of ESRD in a mass screening setting. Even a slight increase in proteinuria was an independent risk factor for ESRD. Therefore, asymptomatic proteinuria warrants further work-up and intervention.     

Detection and prevention of chronic kidney disease in Indonesia: Initial community screening

Aim:   This survey evaluated the prevalence of chronic kidney disease (CKD if estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m²) and its risk factors amongst subjects from urban and semi-urban areas.
Methods:   History of hypertension, diabetes mellitus, kidney disease, cardio- and cerebrovascular diseases of subjects and their families was recorded. Blood pressure was determined as the mean of three readings in the sitting position and hypertension classified according to the Joint National Committee VII. Urinalysis was assessed using Combi 10R dipstick test. Random blood glucose and serum creatinine were measured in subjects with either hypertension, proteinuria, glycosuria and/or a history of diabetes. eGFR was calculated according Cockcroft–Gault (CG) adjusted by body surface area (BSA), Modification of Diet in Renal Disease (MDRD) and Chinese MDRD equations.
Results:   Of 9412 subjects recruited, 64.1% were female. Persistent proteinuria was found in almost 3%. Systolic and diastolic hypertension was found in 10%, isolated systolic hypertension in 4.8% and isolated diastolic hypertension in 4.6%. CKD was found in 12.5% (CG), 8.6% (MDRD) or 7.5% (Chinese MDRD) of subjects with either hypertension, proteinuria and/or diabetes. Proteinuria, systolic blood pressure and a history of diabetes mellitus were independent predictors of impaired eGFR. Obesity and smoking history were found in 32.5% and 19.8%, respectively.
Conclusion:   The present study showed a high prevalence of CKD in representative urban and semi-urban areas and argues for screening and treatment of all Indonesians, particularly those at an increased risk of CKD.     

Impact of body mass index on hepatocellular carcinoma recurrence after liver transplantation through long-term follow-up

BackgroundObesity is associated with increased oncological risk and outcomes but the evidence surrounding the effect of body mass index (BMI) on increased risk of hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) is still questionable. The purpose of this retrospective study of a large cohort of adult patients transplanted for HCC was to investigate the effect of BMI on the incidence of HCC recurrence and outcome.MethodsData from 427 adult recipients transplanted for HCC between 2000 and 2017 were collected. Patients were classified at time of LT according to the World Health Organization BMI classification into 3 groups; group 1: BMI <25 (n=166), group 2: BMI 25–29.9 (n=150) and group 3: BMI ≥30 (n=111).ResultsThere were no significant changes of mean BMI overtime 26.8±5.0 kg/m2 at time of LT and 28.8±23.1 at 5 years. The recurrence rates of HCC after LT in the three groups were 19%, 16% and 17% respectively. The 5, 10 and 15-year recurrence free survival (RFS) rates were respectively 68.6%, 47.3% and 40.8% in group 1, 73.3%, 66.2% and 49.5% in group 2 and 68.8%, 57.5% and 47.7% in group 3 (log rank P=0.47).ConclusionsRecipient BMI at time of transplant and during follow-up didn’t impact the incidence of HCC recurrence nor long-term patient survival, irrespective to the status of the patients and their tumor characteristic at time of LT. The present study clearly confirms that obesity should not be considered, when selecting patients with HCC to LT, as a predictive factor of recurrence.     

Prevalence and risk factors of undetected proteinuria in an elderly South-East Asian population

BACKGROUND: Urinalysis is not a standard component of health screening in the elderly population. OBJECTIVE: We investigated the prevalence and risk factors of undetected renal disease as defined by proteinuria (PR) in an elderly South-East Asian population. METHOD: There were 19,848 participants of age >or=65 years in National Kidney Foundation's Nationwide Screening programme at Singapore. Mean age was 70.6 +/- 5.3 years. After excluding the 1.1% who had pre-existing renal disease, 8.5% were identified to have previously undetected PR defined as >or=1+ protein on urine dipstick analysis. Multivariate regression revealed that male gender (OR = 1.2, reference category (Ref): female), known diabetes (odds ratio (OR) = 2.28; P < 0.0001), hypertension (OR = 1.62; P = 0.0001), presence of elevated blood pressure (BP) (>or=120/90 mmHg) on screening (OR = 1.38, 1.89, 3.45 for mild, moderate and severe BP, respectively, all P < 0.0001), elevated body mass index (BMI) (OR = 1.3 for BMI >or=23 vs BMI < 23 kg/m(2)), and smoking (OR = 1.2, ref: non-smokers) were significantly associated with PR. Finally, a progressive increase in OR for PR was observed with stepwise increase in age (years) (OR for 67-68.9: 1.2, P = 0.025; 69-72.9, 1.49, P = 0.49; >or=73: 1.56, P < 0.0001, Ref: 65-66.9 years). CONCLUSION: We conclude that there is high prevalence of previously undetected proteinuria in elderly South-East Asians. Because proteinuria is a risk factor for cardiovascular disease, our findings support inclusion of urinalysis in routine health screening for this population.     

Antiproteinuric effect of oral paricalcitol in chronic kidney disease

BACKGROUND: Proteinuria is a marker of cardiovascular and renal disease in patients with chronic kidney disease (CKD), and reduction in proteinuria has been associated with improved cardiovascular and renal outcomes. While active vitamin D and its analogs have been shown to have renal protective effects in animals, these hormones have not been shown to reduce proteinuria in CKD patients. METHODS: In three double-blind, randomized, placebo-controlled studies to evaluate the safety and efficacy of oral paricalcitol, 220 CKD stage 3 and 4 patients with secondary hyperparathyroidism (SHPT) were randomized to oral paricalcitol (N= 107, mean dose 9.5 microg/week) or placebo (N= 113) and followed for up to 24 weeks. In conjunction with other safety measures, proteinuria was measured by dipstick and read by an automated reader at the beginning and end of trial. We subsequently analyzed the dipstick data to evaluate the effect of paricalcitol on proteinuria. RESULTS: At baseline, proteinuria was present in 57 patients randomized to oral paricalcitol and 61 patients randomized to placebo (NS). At the final visit, 29/57 (51%) of the paricalcitol patients compared to 15/61 (25%) placebo patients had reduction in proteinuria, P= 0.004 (odds for reduction in proteinuria 3.2 times greater for paricalcitol patients, 95% CI 1.5-6.9). For the patients who had both proteinuria at baseline and parathyroid hormone (PTH) suppression (end point defined as 2 consecutive > or =30% decreases in iPTH from baseline), 27/51 (53%) patients had a reduction in the proteinuria in the paricalcitol group and 0/7 (0%) had a reduction in proteinuria in the placebo group. Reduction of proteinuria favored patients on paricalcitol, regardless of age, sex, race, diabetes mellitus, hypertension, or use of therapies to block the renin-angiotensin-aldosterone system (RAAS). CONCLUSION: Our results demonstrate that the reduction in proteinuria was associated with paricalcitol treatment, and the reduction in proteinuria was independent of concomitant use of agents that block the RAAS. Paricalcitol as a potential pharmacologic means of reducing proteinuria in CKD patients warrants further investigation.     

慢性肾脏病患者中慢性前列腺炎的发生率及其影响因素

目的：研究慢性肾脏病（CKD）患者中慢性前列腺炎（CP）的发生率及其影响因素。方法：对273例明确病理诊断的CKD男性患者进行前列腺液常规检查，比较不同类型肾脏病、不同年龄段和不同程度蛋白尿、血尿、肾功能对CP发生率的影响。结果：273例CKD患者中91例患者伴有CP，总的发生率33．3％；膜性肾病患者CP发生率最高60．0％，较非IgA肾病的系膜增生性肾小球肾炎（25．5％）、乙肝相关性肾炎（24．2％）及局灶节段肾小球硬化症患者（0％）高（P〈0．05）。IgA肾病（IgAN）患者CP发生率39．7％较非IgA系膜增生性肾小球肾炎患者高（P〈0．05）。随年龄增加CP的发生率升高但是各组间无统计学差别；不同程度蛋白尿、血尿、肾功能组间CP的发生率无差别。结论：CKD是CP的高发人群，随年龄增加CKD患者中CP的发生率有增加的趋势，肾脏病病理类型是影响CP的发生率的主要因素；CP与部分CKD间存在一定的联系。     

Pros and Cons of Body Mass Index as a Nutritional and Risk Assessment Tool in Dialysis Patients

Obesity is a problem of serious concern among chronic kidney disease (CKD) patients; it is a risk factor for progression to end‐stage renal disease and its incidence and prevalence in dialysis patients exceeds those of the general population. Obesity, typically assessed with the simple metric of body mass index (BMI), is considered a mainstay for nutritional assessment in guidelines on nutrition in CKD. While regular BMI assessment in connection with the dialysis session is a simple and easy‐to‐use monitoring tool, such ease of access can lead to excess‐of‐use, as the value of this metric to health care professionals is overestimated. This review examines BMI as a clinical monitoring tool in CKD practice and offers a critical appraisal as to what a high or a low BMI may signify in this patient population. Topics discussed include the utility of BMI as a reflection of body size, body composition and body fat distribution, diagnostic versus prognostic performance, and consideration of temporal trends over single assessments.     

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.     

Risk factors for chronic kidney disease in a community-based population: a 10-year follow-up study

The purpose of this study was to explore risk factors affecting the incidence of chronic kidney disease (CKD) in general population. We conducted a 10-year follow-up study with 123 764 (male: 41 012, female: 82 752) adults aged 40 years and over who received community-based annual examinations. The primary outcome for the analysis was the development of CKD during the follow-up period. Predictors for the development of CKD were obtained by the significant hazard ratios (HR) in Cox regression model by sex. During the follow-up period, 4307 subjects (male: 2048, female: 2259) developed CKD stage I or II, and 19 411 subjects (male: 4257, female: 15 154) developed CKD stage III or higher. The baseline-adjusted predictor of developing CKD included age, glomerular filtration rate, hematuria, hypertension, diabetes, serum lipids, obesity, smoking status, and consumption of alcohol. Treated diabetes in male subjects, and treated hypertension, systolic blood pressure >160 mm Hg and/or diastolic blood pressure >100 mm Hg, diabetes, and treated diabetes in female subjects were associated with more than a doubling of the HR. For the development of CKD stage III or higher, proteinuria of >or= + +, and proteinuria and hematuria were associated with more than a doubling of the HR in male subjects. The prevalence of newly developed CKD over 10 years was 23 718 subjects (19.2%) in adults. This study suggested that not only hypertension and diabetes but also several metabolic abnormalities were independent risk factors for developing CKD.     

Obesity-related glomerulopathy: an emerging epidemic

BACKGROUND: We report the first large renal biopsy-based clinicopathologic study on obesity-related glomerulopathy. METHODS: Obesity was defined as body mass index (BMI)> 30 kg/m2. Obesity-related glomerulopathy (ORG) was defined morphologically as focal segmental glomerulosclerosis and glomerulomegaly (O-FSGS; N = 57) or glomerulomegaly alone (O-GM; N = 14). RESULTS: Review of 6818 native renal biopsies received from 1986 to 2000 revealed a progressive increase in biopsy incidence of ORG from 0.2% in 1986-1990 to 2.0% in 1996-2000 (P = 0.0001). Mean BMI in ORG was 41.7 (range 30.9 to 62.7). Indications for renal biopsy included proteinuria (N = 40) or proteinuria and renal insufficiency (N = 31). Seventy-one patients with ORG were compared to 50 patients with idiopathic FSGS (I-FSGS). Patients with ORG were older (mean 42.9 vs. 32.6 years, P < 0.001) and more often Caucasian (75% vs. 52%; P = 0.003). ORG patients had a lower incidence of nephrotic range proteinuria (48% vs. 66%; P = 0.007) and nephrotic syndrome (5.6% vs. 54%; P < 0.001), with higher serum albumin (3.9 vs. 2.9 g/dL; P < 0.001), lower serum cholesterol (229 vs. 335 mg/dL; P < 0.001), and less edema (35% vs. 68%; P = 0.003). On renal biopsy, patients with ORG had fewer lesions of segmental sclerosis (10 vs. 39%; P < 0.001), more glomerulomegaly (100% vs. 10%; P < 0.001), and less extensive foot process effacement (40 vs. 75%; P < 0.001). Glomerular diameter in ORG (mean 226 mu) was significantly larger than age- and sex-matched normal controls (mean 168 mu; P < 0.001). Follow-up was available in 56 ORG patients (mean 27 months) and 50 idiopathic FSGS controls (mean 38 months). A total of 75% of ORG patients received angiotensin-converting enzyme (ACE) inhibition or A2 blockade while 78% of the I-FSGS patients received immunosuppressive therapy. ORG patients had less frequent doubling of serum creatinine (14.3% vs. 50%; P < 0.001) and progression to ESRD (3.6% vs. 42%; P < 0.001). On multivariate analysis, presenting serum creatinine and severity of proteinuria were the only predictors of poor outcome in ORG. CONCLUSION: ORG is distinct from idiopathic FSGS, with a lower incidence of nephrotic syndrome, more indolent course, consistent presence of glomerulomegaly, and milder foot process fusion. The ten-fold increase in incidence over 15 years suggests a newly emerging epidemic. Heightened physician awareness of this entity is needed to ensure accurate diagnosis and appropriate therapy.     

Screening for kidney disease in children on World Kidney Day in Jalisco,Mexico

World Kidney Day (WKD) is intended to raise awareness and increase detection of chronic kidney disease (CKD), but most emphasis is placed on adults rather than children. We examined yield of screening for CKD and hypertension among poor children in Mexico. On WKD (2006, 2007), children (age < 18 years) without known CKD were invited to participate at two screening stations. We measured body mass index (BMI), blood pressure, and serum creatinine, and performed dipstick urinalysis. The Schwartz equation was used to estimate glomerular filtration rate (GFR; reduced GFR defined as < 60 ml/min per 1.73 m²). Proteinuria and hematuria were defined by a reading of ≥ 1+ protein or blood on dipstick. Hypertension was defined by gender, age, and height-specific norms. In total, 240 children were screened (mean age 8.9 ± 4.1 years; 44.2% male). Proteinuria and hematuria were detected in 38 (16.1%) and 41 (17.5%), respectively; 15% had BMI > 95th percentile for age. Reduced GFR was detected in four (1.7%) individuals. Systolic hypertension was more prevalent in younger children (age 0–8 years, 19.6%; age 9–13 years, 7.1%; age 14–17 years, 5.3%) suggesting a possible white-coat effect. Hematuria, proteinuria, hypertension and obesity were frequently detected among children in a community based screening program in Mexico. This form of screening might be useful in identifying children with CKD and hypertension in developing nations.     

The Edmonton Obesity Staging System: assessing a potential tool to improve the management of obesity surgery in the Brazilian public health services

BackgroundLimited access to publicly funded, insurance-covered, and self-paid obesity surgery is a reality worldwide. Waiting lists for procedures are usually based on chronologic criteria and body mass index (BMI)-defined obesity categorization. Obesity classification systems assess overall health and have been proposed as an alternative.ObjectiveTo investigate the correlation between BMI-based classification and the Edmonton Obesity Staging System (EOSS) to support current evidence that the assessment of the clinical severity of obesity could be a helpful tool to maximize access to surgery.SettingUniversity hospital, Brazil.MethodsRetrospective analysis of all 2011 to 2014 adult patients who underwent obesity surgery under the public health system. Data on sex, age, presurgical BMI, and co-morbidities were extracted from hospital records. Spearman correlation coefficients were used to assess the strength and direction of the relationship between BMI classification and EOSS.ResultsOf 565 patients, 79% were female, mean age 44.1 ± 10.9 years and mean BMI 46.9 ± 6.2 kg/m². The most common EOSS stage was 2 (86.5%), followed by stages 3 (8.5%) and 1 (4.9%). There was no correlation between the severity of obesity measured by BMI and EOSS (ρ = −.030, P = .475). Older patients had higher Edmonton scores (ρ = .308, P < .001). No difference was observed regarding sex.ConclusionsNo correlation was found between EOSS and BMI and between these and sex. Age correlated with both obesity indicators. EOSS was reproducible in Brazilian surgical patients and may be an important tool from a health services perspective contributing to the more efficient use of limited resources for obesity surgery.     

Incidence of intramedullary nail removal after femoral shaft fracture healing

INTRODUCTION: There are limited data on hardware removal after femoral fracture healing. We determined the incidence of intramedullary nail (IMN) removal after midshaft femoral fractures. We also studied demographic factors influencing IMN removal. METHODS: The senior author reviewed all adult femoral fractures with IMN placement in the trauma practice between July 1990 and November 2003. There were a total of 74 IMNs in 68 subjects with midshaft fractures. The incidence of hardware removal was the primary outcome measure. We also analyzed age, sex, body mass index (BMI), mechanism of injury, IMN dimensions, occupation, and Workers' Compensation Board (WCB) insurance and litigation involvement. RESULTS: Overall incidence of IMN removal was 20% (15 of 74 fractures). No significant difference was found with age (p=0.965), sex (p=0.086), BMI (p=0.423), occupation (p=0.341), insurance involvement (p=0.229), WCB involvement (p=0.663) or IMN dimensions (width, p=0.752; length, p=0.312). Litigants had the highest incidence of IMN removal (p=0.004). DISCUSSION: All hardware was removed for pain or irritation. These results suggest that litigants require hardware removal more often than nonlitigants. A larger study is needed to identify specific criteria for hardware removal and to determine whether secondary gains affect the incidence of femoral removal.     

Epidemiology of renal and cardiovascular risk factors in Toba Aborigines

OBJECTIVES: To detect, educate, and control cardiovascular (CVD) risk factors, diabetes mellitus, hypertension, obesity, central obesity, and renal damage markers such as glomerular filtration rate (GFR) and proteinuria within a population of Toba aborigine people who live in the outskirts of Resistencia city, Chaco Province, Argentina. METHODS: A sample was selected from four Toba communities. Blood and urine samples were drawn in their own homes. Proteinuria was considered positive when a urinary protein/urinary creatinine rate (uPr/uCr) > or = 0.20. GFR was estimated by Levy formula, and the stages of chronic kidney disease (CKD) were as defined in the National Kidney Foundation Guidelines. RESULTS: In all, 385 subjects were included, 36% males, mean age = 36.1 years old. The prevalence of CVD risk factors was as follows: hypertension in 97 (25.2%), proteinuria in 84 (21.8%), CKD in 93 (24.2%) [Stage 1 in 26 (6.8%), Stage 2 in 46 (12%), and Stage 3 in 21 (5.5%)]. No subjects showed CKD Stage 4 or 5. Being overweight was found in 129 (33.5%), obesity in 82 (21.3%), central obesity in 190 (49.4%), and diabetes in 8 (2.1%). The presence of CKD was associated with an increased prevalence in central obesity, hypertension, and diabetes, but not obesity. The adjusted relative risk for proteinuria was 2.79 (p < or = 0.008) in subjects of at least 45 years of age, compared to subjects under 25 years. CONCLUSIONS: This group of aborigines showed a high prevalence of proteinuria and CVD risk factors and CKD not related to diabetes.     

Geographic difference in the prevalence of chronic kidney disease among Japanese screened subjects: Ibaraki versus Okinawa

BACKGROUND: In Japan, there is a geographic difference in the prevalence of end-stage renal disease (ESRD). Few epidemiologic studies, however, have compared the prevalence of chronic kidney disease (CKD) among different geographic areas. Other than genetic factors, socioeconomic conditions and lifestyle are targets for modification. METHODS: We examined the prevalence of CKD among two large community-based screened populations, 40 years of age and older, in Japan: Ibaraki (N = 187,863) and Okinawa (N = 83,150). Prevalence of CKD was defined as an estimated glomerular filtration rate (eGFR) of less than 60 ml/min/1.73 m(2) using the coefficient modified abbreviated Modification of Diet in Renal Disease (aMDRD) study equation using a standardized serum creatinine value. CKD prevalence was compared among screenees with (+) or without (-) hypertension (systolic blood pressure > or =140 mmHg, diastolic blood pressure > or =90 mmHg) and hyperglycemia (plasma glucose > or = 126 mg/dl). RESULTS: Both male and female participants in Okinawa had a significantly lower prevalence of hypertension (-)/hyperglycemia (-) than did patients in Ibaraki. The prevalence of CKD in Okinawa was higher than that in Ibaraki among screenees with hypertension (-)/hyperglycemia (-), and highest among screenees with hypertension (+)/hyperglycemia (-). CONCLUSION: The regional difference in CKD prevalence may underlie the variation in ESRD prevalence observed in Japan.