Chronic renal failure. The primary care physician's role

Recent developments in understanding of the pathophysiology of chronic renal failure have provided a sound basis for several measures which, when instituted early in the course of renal disease, can delay progression to end-stage kidney disease and considerably improved the symptoms of uremic syndrome. This article outlines the key role that the primary care physician plays in early diagnosis of chronic renal disease and institution of appropriate therapy well before the nephrologist's services are needed.     

Diagnosis and Treatment of Anemia of Chronic Kidney Disease in the Primary Care Setting: A Primer for Nurse Practitioners

Anemia of chronic kidney disease (CKD) is associated with increased cardiovascular morbidity, health care costs, and mortality. Both early CKD and its attendant anemia may be asymptomatic and thus often go undetected. Appropriate anemia treatment may improve cardiovascular prognosis, physical activity, and quality of life in CKD patients not requiring dialysis. Primary care nurse practitioners are ideally positioned to detect and treat CKD-related anemia. This review discusses the pathophysiology, consequences, and primary detection and management of anemia of CKD.     

慢性心衰-心肾综合征及生物标志物

慢性心衰不仅是一种疾病诊断,更是一种复杂的临床综合征,在合并慢性肾病尤其是终末期肾病患者中,心衰发病率增加是死亡的主要原因。心脏和肾脏之间存在密切而复杂的关系(即所谓"心肾综合征"),心衰患者一旦合并慢性肾病或肾损伤均显示预后不良。因而,对于这类高风险患者应予以早期诊断并积极干预治疗。一些标志物已被证明在心血管疾病的诊断和预后评价中具有新的、重要的作用,由于其与慢性心衰-心肾综合征具有密切关系而备受关注,具有高度敏感性和特异性的生物标志物成为近年来研究的热点。     

Slowing the Progression of Chronic Kidney Disease

The increasing incidence and prevalence of chronic kidney disease (CKD) make treatment and management to slow the progression of this condition of essential interest to nurse practitioners (NPs) in primary care settings. Early identification and monitoring of patients at risk for CKD can be facilitated by annual testing for albuminuria and serial monitoring of estimated glomerular filtration rate and serum creatinine. Diagnostic evaluation used to determine underlying cause, type, and severity of CKD can help to reduce associated cardiovascular complications by preserving cardiac function. Aggressive primary care treatment and management during the early stages of CKD can reduce associated morbidity and mortality and reduce costs associated with end-stage renal disease.     

Interpreting troponin in renal disease: A narrative review for emergency clinicians

IntroductionPatients with chronic kidney disease (CKD)/end stage renal disease (ESRD) can experience several severe complications, including acute coronary syndrome (ACS). While troponin is the biomarker of choice for evaluation of ACS, interpretation of troponin in CKD/ESRD can be challenging.ObjectiveThis narrative review evaluates troponin elevation in patients with CKD/ESRD, pitfalls in the evaluation with troponin, and an approach to using troponin in these high-risk patients.DiscussionPatients with CKD/ESRD are at greater risk for ACS and possess higher levels of circulating troponin. Relatedly, these patients often present atypically for ACS. Several pitfalls must be considered in the use of troponin when evaluating for ACS. While troponin elevation in patients with CKD/ESRD is often considered to be due to underlying renal disease, this elevation has several etiologies including uremic skeletal myopathy, microinfarctions, left ventricular hypertrophy (LVH), decreased clearance, and unrecognized congestive heart failure (CHF). Utilizing troponin assays in this patient population requires a nuanced approach, as the sensitivity and specificity for troponin testing in CKD varies. Concern for ACS with elevated troponin warrants treatment for ACS until proven otherwise, with consideration of atypical presentations along with other causes for patient symptoms that may result in troponin elevation.ConclusionsPatients with CKD/ESRD presenting with symptoms concerning for ACS are challenging. The utilization of troponin assays is important in this population given their high risk of ACS but requires an educated and nuanced approach.     

Identification, management and referral of adults with chronic kidney disease: concise guidelines

Chronic kidney disease (CKD) is often thought to be a relatively rare condition requiring specialist care. However, early CKD is common and referral of all patients would completely overwhelm existing specialist services. The purpose of this concise guidance is to inform general physicians and general practitioners about the identification and management of CKD, and who to refer for specialist care.     

Dialysis and fatigue: implications for nurses--a case study analysis

Fatigue is one of the most common symptoms experienced by patients receiving dialysis. When patients with chronic kidney disease (CKD) and end-stage renal disease are admitted to acute care settings, they require management of their often profound fatigue. CKD, renal pathology, and renal fatigue are examined in relation to a case study.     

Current chronic kidney disease practice patterns in the UK: a national survey

BACKGROUND: There is an increasing focus on improving the detection and management of patients with chronic kidney disease (CKD). Data on CKD prevalence based on population sampling are now available, but there are few data about CKD patients attending nephrology services or how such services are organized. AIM: To survey services for CKD patients nationally. METHODS: A pre-piloted questionnaire was sent to all 72 renal units in the UK, referring to the situation in June 2004. RESULTS: Seventy units (97%) responded. The median ratio of prevalent CKD patients/prevalent renal replacement therapy (RRT) patients in the 25 units with data was 3.7 (IQR 2.7-5.7) and the median ratio of CKD stage 4 and 5 patients/prevalent RRT patients was 0.6 (IQR 0.4-1.1). This gives an estimated 140 000 CKD patients under the care of UK nephrologists, with 23 000 at CKD stage 4 or 5 (excluding those on RRT). Very few units had a full complement of the recommended multi-skilled renal team. Counsellors and psychologist were the most common perceived shortages. Of 70 responding units, 50 (74%) were using low clearance clinics for management of advanced CKD patients. Elective dialysis access services often had long delays, with median waiting time for vascular access ranging between 1 and 36 weeks, and for Tenchkoff catheter, between 0 and 12 weeks. DISCUSSION: CKD patients are a significant workload for UK nephrologists. Current provision of service is variable, and services need to be re-designed to cope with the expected future increase of referral of CKD patients.     

Systemic complications of chronic kidney disease. Pinpointing clinical manifestations and best management

The kidney plays a critical role in the maintenance of homeostasis. As kidney function diminishes, excretory, regulatory, and endocrine function is lost, and complications develop in essentially every organ system. Kidney failure is the last stage in the continuum of progressive CKD. Management of the complications associated with CKD mainly includes dietary counseling, adequate control of volume and blood pressure, and use of phosphate binders, calcitriol (Calcijex, Rocaltrol), and erythropoietin. Many of these complications can be prevented or attenuated with optimal CKD care, which involves early detection of progressive kidney disease, interventions to retard its progression, prevention of uremic complications, attenuation of comorbid conditions, adequate preparation for kidney replacement therapy, and timely initiation of dialysis (figure 2). Closer attention to CKD care is likely to be the key to improved outcomes among patients with kidney failure.     

25例高转换型肾性骨病的骨组织学研究

目的通过对慢性肾脏病(chronic kidney disease,CKD)5期维持性血液透析(maintenance hemodialysis,MHD)患者行骨活检获得骨标本,对骨病理进行骨形态计量学分析,观察各型骨病尤其是高转换型肾性骨病的骨病理学特点并探讨临床各项常用无创性检查的意义。方法选择40例CKD5期MHD患者和3例正常人进行髂骨活检术,获得骨标本。采用全自动图像分析系统进行骨组织形态计量学测定。外周血各项检测指标和临床常用的骨密度和骨骼摄片与骨病理学指标行相关分析。结果25例CKD5期MHD患者经骨病理学检查证实为高转换型骨病,占同期骨活检的62.5%(25/40),骨病理学检查以破骨细胞活化形成骨吸收陷窝伴或不伴骨矿化不全为特点。外周血钙、骨钙素水平与骨病理指标呈显著正相关。骨密度和骨骼摄片的阳性率低于骨活检。结论通过对CKD5期MHD患者行骨活检发现,高转换性肾性骨病的比例仍占大多数。在高转换型肾性骨病中,目前的各种无创性检查中血钙、骨钙素可能具有一定的预测价值。骨活检仍是诊断肾性骨病的金指标。     

慢性肾脏病合并心力衰竭的治疗

心力衰竭在慢性肾脏病(CKD)和终末期肾病(ESRD)患者中普遍存在,其严重程度与上述患者的病死率 呈正相关。然而,由于支持相应指南的循证医学证据不足,CKD患者合并心力衰竭的治疗策略目前尚不明确。目前 大多数随机对照研究均将严重肾功能不全的人群排除在外,而现行的心力衰竭指南又以此作为循证医学证据,故适应 大多数人群的心力衰竭指南并不适合CKD合并心力衰竭的患者。     

慢性肾脏病合并感染的治疗

慢性肾脏病(ChronicKidneyDiseases,CKD)是临床上常见的疾病,是肾小球肾炎、肾盂肾炎、肾病综合 征、肾小管间质性疾病、糖尿病肾病、高血压肾病、肾血管性疾病等绝大多数肾脏疾病的统称。CKD患者极易并发各 种感染,促使肾功能进一步恶化造成慢性肾脏衰竭(ChronicRenalFailure,CRF),直接影响患者的生存质量,并常常 是患者的直接死因。因此,了解CKD感染的危险因素及其特点,并积极控制感染,是提高CKD诊疗水准、改善患者预 后的一项重要措施。     

Obesity and coronary artery disease risk in Native Americans

With the aging of the US population and the increase in hypertension, diabetes mellitus, and obesity, the prevalence of chronic kidney disease (CKD) is increasing in the United States. Its prevalence rate has risen to 13.1% of the US population. Patients with CKD experience poor outcomes and have high health care costs. Chronic kidney disease is also a major cardiovascular disease risk factor. In fact, most people with CKD die of heart disease before they progress to end-stage renal disease. The National Kidney Foundation has produced evidencebased guidelines known as the Kidney Disease Outcomes Quality Initiative (KDOQI). These guidelines outline many things that the primary care physician can do to delay the progression of CKD, and to arrange for early referral for the prevention of future complications. However, there is limited knowledge and uptake of these guidelines because of their length and and complexity. Patients with CKD risk factors, hypertension, diabetes mellitus, cardiovascular disease, a family history of CKD, and those older than 60 years should be screened using 2 tests: 1) the estimated glomerular filtration rate and 2) the urinary albumin-creatinine ratio. These tests allow the diagnosis and stratification of CKD into 5 stages. This article synthesizes the key evidence-based behaviors and clinical action plan that primary care physicians can implement to treat CKD and its complications.     

Cardiovascular Screening and Early Detection of Heart Disease in Adults With Chronic Kidney Disease

Cardiovascular disease (CVD) and chronic kidney disease (CKD) are among the most common disease states that nurse practitioners encounter in various health care settings. In many cases, patients with CVD and CKD have overlapping risk factors and underlying medical conditions. CVD is one of the most common causes of death in patients with CKD, and therefore, appropriate recognition and screening are important for preventing disease progression and complications. Nurse practitioners can become familiar with various risk factors, screen patients, and provide nonpharmacologic and pharmacologic measures for CVD in CKD patients.     

Obesity in CKD

Metabolic syndrome, characterized by truncal obesity, hypertriglyceridemia, elevated blood pressure, and insulin resistance, is recognized increasingly as a major risk factor for kidney disease and also is a common feature of patients who are on dialysis. Obesity is considered a major generator of metabolic syndrome. Early in the course of obesity-initiated metabolic syndrome, structural and functional changes similar to diabetic kidney disease occur. Previous studies examined the histologic and functional changes that occur in the kidney in the early stages of obesity caused by a high-fat diet. They reported that a high-fat diet caused increased arterial pressure, hyperinsulinemia, activation of the renin-angiotensin system, glomerular hyperfiltration, and structural changes in the kidney that may be the precursors of more severe glomerular injury associated with prolonged obesity. Among several factors causing renal injury, Rho-kinase also plays an important role in the pathogenesis of obesity-related renal disease. We further propose that perinephric adipose tissues could be a source of inflammatory chemokines, which acts in concert with the renal Rho-kinase stimulated in situ to exacerbate renal inflammation. In this review, we note the mechanisms inducing chronic kidney disease (CKD) by obesity, especially the relation between insulin resistance and CKD.     

慢性肾脏病患者外周血干细胞因子水平的测定

背景:干细胞因子是一种多功能细胞因子,在肾间质纤维化过程中起至关重要的作用。目的:观察慢性肾脏病患者外周血干细胞因子水平的变化及其临床意义。方法:采用ELISA法检测22例健康对照者和116例慢性肾脏病患者外周血干细胞因子水平,分析其与肾损害程度、贫血、脂质代谢紊乱、心血管病变、尿毒症皮肤瘙痒等的相关性。结果与结论:慢性肾脏病患者外周血干细胞因子水平明显高于对照组(P<0.01);随着肾功能减退,外周血干细胞因子水平逐渐升高,各组间相比差异有显著性意义(P<0.05),且其水平与慢性肾脏病分期、血肌酐、尿素氮、C-反应蛋白、血酯、甲状旁腺激素呈正相关,与血红蛋白呈负相关,提示外周血干细胞因子的升高可能与慢性肾脏病进展、并发贫血等并发症的发生发展有重要关系。     

急性肾损伤后慢性肾脏病发病机制及其诊治进展

急性肾损伤后常出现肾小管间质纤维化等慢性肾脏病表现,甚至进展至终末期肾病,发病机制包括小管上皮细胞适应不良性修复、免疫炎症过度反应、毛细血管稀疏、氧化应激等。随着人们对急性肾损伤后慢性化转归机制的深入认识,近年来相关的干预新靶点和新策略相继问世,展示了人类攻克急性肾损伤预后不良的良好前景。     

Is “chronic kidney disease” a disease?

Several philosophers of medicine have attempted to answer the question “what is disease?” In current clinical practice, an umbrella term “chronic kidney disease” (CKD) encompasses a wide range of kidney health states from commonly prevalent subclinical, asymptomatic disease to rare end‐stage renal disease requiring transplant or dialysis to support life. Differences in severity are currently expressed using a “stage” system, whereby stage 1 is the least severe, and stage 5 the most. Early stage CKD in older patients is normal, of little concern, and does not require treatment. However, studies have shown that many patients find being informed of their CKD distressing, even in its early stages. Using existing analyses of disease in the philosophy literature, we argue that the most prevalent diagnoses of CKD are not, in fact, diseases. We conclude that, in many diagnosed cases of CKD, diagnosing a patient with a “disease” is not only redundant, but unhelpful.     

Treatment options for end stage renal disease

The latest National Health and Nutrition Study revealed an increasing incidence of kidney disease among aging baby boomers, as the incidence of diabetes mellitus and hypertension rises. Because of this trend, a greater proportion of a primary care physician's practice will involve patients with chronic kidney disease, and consequently, end stage renal disease. Unfortunately, far too many of these chronic kidney disease patients are referred to a nephrologist very late. More often than not, the opportunity for secondary preventive intervention, with the goal of avoiding renal replacement therapy, is lost. This article addresses the various treatment options for patients with end stage renal disease.