慢性阻塞性肺疾病合并慢性肾脏病危险因素分析

目的探讨住院COPD患者合并慢性肾脏病的患病率及危险因素。方法对2012年1月至2013年11月住院确诊的COPD患者进行慢性肾脏病的患病率及危险因素回顾性凋查。结果在资料完整的948例COPD患者人群中,慢性肾脏病总的患病率约为24．5％,COPD合并慢性肾脏病组PaCO2、吸烟指数、血尿酸水平、糖尿病及高血压病患病率较无合并慢性肾脏病组高,而PaO2、体质量指数较无合并慢性肾脏病组低,差异有统计学意义。COPD患者合并慢性肾脏病与COPD严重程度分级无明显的相关性。经多因素Logistic回归分析表明：低氧血症、高碳酸血症、糖尿病、高血压病是COPD合并慢性肾脏病的危险因素（OR值分别为2．34、3．25、2．67和1．8,9,5％（71分别为2．01～2．75、2．95～3．77、1．99～3．27、1．18～2．63,P值均〈0．05）。结论COPD合并慢性肾脏病的患病率高,低氧血症、高碳酸血症、糖尿病、高血压病是COPD合并慢性肾脏病的危险因素,应引起重视。     

慢性肾脏疾病增加慢性心力衰竭患者死亡率

目的探讨慢性肾脏疾病(CKD)对慢性心力衰竭(CHF)患者死亡率的影响。方法对2007年1月1日至2009年12月31日在北京协和医院心内科住院,年龄≥21岁,临床诊断为心力衰竭,且左心室射血分数(LVEF)≤45%的缺血性(心肌梗死后至少40 d以上)或非缺血性心肌病患者进行回顾性研究,根据肾小球滤过率(eGFR)情况分为两组,一组为eGFR<60 ml.min-1.1.73 m-2(CKD组),另一组为eGFR≥60 ml.min-1.1.73 m-2(对照组),并进行电话随访。结果共筛选242例患者,除外41例不符合入选标准者,对201例进行随访,14例(7%)失访,经过2～41个月[平均(20±9)个月]的随访,共36例(19%)发生全因死亡,包括CKD组21例(30%)和对照组15例(13%)(P=0.003)。结论 CKD增加CHF患者死亡率。合并CKD的CHF患者,积极处理CHF的同时应高度重视CKD处理。     

慢性肾脏病并发脓毒血症40例的临床分析

目的:分析慢性肾脏病(CKD)并发脓毒血症的临床特征,为临床诊治提供依据.方法:回顾性分析慢性肾脏病并发脓毒血症40例的临床病历资料.结果:在40例CKD的患者中,肾衰竭30例(75％),深静脉置管22例(55％),使用免疫抑制剂和糖皮质激素12例(30％),18例患者合并泌尿系统和呼吸系统感染.分离的病原菌中,大肠埃希菌13例,金黄色葡萄球菌(金葡菌)11例(60％),其它16例；有4例(10％)合并了真菌感染.金葡菌对青霉素G均耐药,对环丙沙星和克林霉素耐药＞50％.死亡8例,32例经有效抗生素治疗3～4周康复.结论:CKD患者易罹患脓毒血症,除与贫血、低蛋白血症和其它的感染因素有关外,与肾功能的下降、深静脉留置导管和免疫抑制剂的应用相关.     

慢性肾脏病患者发生心衰的危险因素分析

目的探讨慢性肾脏病（CKD）患者发生心衰的危险因素。方法将366例CKD患者按2002年K/DOQI慢性肾脏病的分期标准分为5期,再按是否发生心衰分为2组,比较两组患者年龄、既往病史、吸烟史、心电图T波改变、血红蛋白（Hb）、C反应蛋白（CRP）、血脂、血压等方面的变化以及住院期间两组患者的病死率。结果发生心衰组的年龄升高,有既往高血压、糖尿病、冠心病、吸烟史者、心电图T波改变均比未发生心衰组明显增多（P〈0.05）;心衰组C反应蛋白（CRP）、高密度脂蛋白胆固醇（HDL-L）、舒张压（DBP）均比未心衰组明显升高（P〈0.01）,而Hb、低密度脂蛋白胆固醇（LDL-L）则比未心衰组明显降低（P〈0.01）结论患者年龄升高、既往有心血管病史、吸烟、CRP水平、Hb水平是CKD患者发生心衰的独立危险因素,针对性地干预这些危险因素,有可能降低心衰的发生率和病死率,改善CKD患者的预后。     

The majority of type 2 diabetic patients in Finnish primary care are at very high risk of cardiovascular events: A cross-sectional chart review study (STONE HF)

AimsTo characterize clinical profiles, prevalence of chronic kidney disease (CKD), and treatment patterns in type 2 diabetes (T2D) and heart failure (HF) patients in Finnish primary care.MethodsA total of 1385 patients (1196 with T2D, 50 with HF, and 139 with T2D and HF) in 60 Finnish primary care centers were recruited to this cross-sectional study. Data on demographic and clinical characteristics, laboratory measurements, and medications were collected retrospectively from medical records. T2D patients were classified according to their risk of cardiovascular (CV) events as very high-risk (62%) and other patients (38%).ResultsOf the T2D patients, 10% (139/1335) had a diagnosis of HF and 42% (457/1090) had stage 3–5 CKD and/or albuminuria based on laboratory measurement. Of the HF patients, 74% (139/189) had T2D and 78% (114/146) had stage 3–5 CKD and/or albuminuria. Metformin was the most frequently used medication in both very high-risk patients (74%) and other patients (86%). SGLT2 inhibitors and/or GLP-1 analogues were used by 37% of very high-risk patients compared to 42% in other patients.ConclusionsThe majority of T2D patients in Finnish primary care are at very high risk of cardiovascular events. However, the implementation of treatments with proven cardioprotective effects in very high-risk patients is currently suboptimal.     

Chronic kidney disease,lipids and apolipoproteins,and coronary heart disease: The ARIC Study

Background

Chronic kidney disease (CKD) is associated with elevated apolipoprotein B to A-1 ratio (ApoB/A1). It is not known whether these markers are more strongly associated with the risk of coronary heart disease (CHD) in CKD compared to traditionally measured lipids and lipoprotein cholesterol ratios.

Methods

We studied the association of lipids and apolipoproteins including non-HDL-cholesterol to HDL-cholesterol ratio (NonHDLc/HDLc) and ApoB/A1 with incident CHD in 10,137 individuals free of CHD at baseline (visit four) in the Atherosclerosis Risk in Communities (ARIC) study. An estimated glomerular filtration rate of 15 to <60 ml/min/1.73 m² based on a cystatin C measurement was used to define CKD (Stage 3–4). Cox proportional hazards regression models were used to determine the association of lipids and apolipoprotein measurements with the risk of CHD in those with and without CKD after adjustment for demographic and known clinical cardiovascular risk factors.

Results

CKD was present in 1217 (12%) individuals free of CHD at baseline. The median follow-up time was 11.1 years. A CHD event developed in 498 out of 8920 individuals without CKD (incidence rate: 5.2 events per 1000 person-years) and in 138 out of 1217 individuals with CKD (incidence rate: 12.0 events per 1000 person–years; P < 0.001). Those with CKD had a lower concentration of ApoA1: median (in g/L) and interquartile range (IQR) = 1.40 (1.38–1.42) vs. 1.48 (1.47–1.49) P < 0.001; and a higher ApoB/A1 = 0.75 (0.73–0.77) vs. 0.71 (0.70–0.72) P < 0.001; than those without CKD (eGFR ≥ 60 ml/min/1.73 m²). Among individuals with CKD, ApoB/A1 and NonHDLc/HDLc were both associated with the risk of CHD: hazard ratios (HR) and 95% confidence intervals (CI) per one standard deviation increase = 1.22 (1.02–1.46) for ApoB/A1 and 1.30 (1.07–1.57) for NonHDLc/HDLc with no significant differences detected (P for interaction >0.1) when comparing these estimates to those of participants without CKD.

Conclusions

Although CKD is associated with a lower ApoA1 concentration and with a higher ApoB/A1, we found no evidence that these apolipoproteins are more strongly associated with CHD incidence in CKD compared to NonHDLc/HDLc.     

A PROGRAMME TO ENCOURAGE PARTICIPATION OF HAEMODIALYSIS PATIENTS IN AN EXERCISE REGIMEN

Recent research has reinforced the idea that haemodialysis (HD) patients should exercise to maintain their physical functioning and improve their quality of life. Some effective exercise programmes are available for HD patients. However, these programmes are not always completed by the patients who enrol in them, and therefore, these patients do not maintain long‐term physical activity. In this study, a support programme based on the concepts of self‐monitoring, verbal reinforcement and motivation was developed to encourage continued participation of HD patients in an exercise regimen. Intervention group participants were provided a support programme in addition to the exercise programme, whereas nonintervention group participants were only provided the exercise programme. The two groups were compared for 12 weeks. The intervention group participants showed a significantly higher rate of continuation of independent exercise than the nonintervention group participants.     

THE FLIP SIDE OF THE COIN—A DOCTOR'S EXPERIENCE OF RENAL FAILURE

Renal failure and its effects are taught well in the medical field, however the effects upon the individual is something which is often taught but not acknowledged. This is an account of my experience of renal failure in the United Kingdom, from a doctor's perspective with the intention that my experiences may enable others to understand the psychosocial element of this life changing disease.     

Effect of short-term synbiotic treatment on plasma p-cresol levels in patients with chronic renal failure: A randomized clinical trial

Background and aimsIn patients with chronic kidney disease (CKD), alterations in gut microbiome are posited to be responsible for gastrointestinal symptoms and generation of p-cresol, a uremic toxin that has been associated with CKD progression and cardiovascular mortality. This pilot study investigated whether Probinul-neutro^®, a synbiotic that normalizes intestinal microflora, may lower plasma p-cresol concentrations and reduce gastrointestinal symptoms in non-dialyzed CKD patients.Methods and resultsThis was a double-blind, randomized placebo-controlled trial. Thirty patients on 3–4 CKD stages were randomized to receive either Probinul neutro^® or placebo for 4 weeks. Total plasma p-cresol concentration was assessed at baseline, and 15 and 30 days after treatment start. At the same study times, ease and frequency of defecation, upper and lower abdominal pain, stool shape, borborygmi, and flatus were quantified by subjective assessment questionnaires. Compared to baseline total plasma p-cresol median concentrations on 15th and 30th day were significantly lower in patients receiving Probinul-neutro^® (2.31 and 0.78 vs. 3.05 μg/ml, p < 0.05; n = 18); no changes of plasma p-cresol concentrations were recorded in placebo-treated patients. No significant changes in gastrointestinal symptoms were observed during the study both in Probinul-neutro^®-treated and placebo-treated patients.ConclusionProbinul-neutro^® lowered total plasma p-cresol concentrations but did not ameliorate gastrointestinal symptoms in non-dialyzed CKD patients. Because high plasma concentrations of p-cresol in early phases of CKD are predictive of progression to end-stage renal disease, the results of our study suggest that synbiotics deserve attention as possible tools to delay CKD progression towards end-stage renal disease (ESRD).ClinicalTrials.gov identifierNCT02008331.     

Efficacy of Long‐Term Treatment With Tolvaptan to Prolong the Time Until Dialysis Initiation in Patients With Chronic Kidney Disease and Heart Failure

The short‐term effectiveness of tolvaptan (TLV) against heart failure has been established. TLV is known to decrease the worsening of renal function more than loop diuretics. Long‐term TLV administration decreases the rate of re‐hospitalization in heart failure and prevents deterioration of kidney function. If repeated hospitalization for heart failure can be prevented in patients having concurrent chronic kidney disease (CKD), the period until dialysis initiation may be prolonged. We investigated whether long‐term TLV management can extend the period until dialysis initiation in patients with CKD and heart failure. A retrospective, observational study was conducted among patients with CKD stage G4 and G5 admitted because of heart failure between April 2013 and July 2018. They were divided into those with TLV and those without TLV. They were followed up until August 2018 and relevant data was collected. Data from 115 patients (68 men and 47 women), with a mean age of 73.4 ± 11.9 (median 76.0 and IQR 66.5–82.0) years and a mean eGFR of 11.8 ± 5.7 (median 9.9 and IQR 7.5–14.8) mL/min/1.73m² were included in the analysis. Twenty‐five patients had received long‐term TLV treatment, and 90 had not. Multivariate analysis after adjustment showed that long‐term use of TLV significantly lowered the hazard ratio (HR) for time taken to reach dialysis initiation (HR: 0.3286, 95%CI: 0.1282–0.8423, P = 0.0205). Propensity score‐matched analysis showed similar results (HR: 0.3220, 95%CI: 0.1107–0.9369, P = 0.0376). In patients with CKD G4 and G5 and heart failure, long‐term treatment with TLV can prolong the time until dialysis initiation.     

Kidney dysfunction after hematopoietic cell transplantation—Etiology,management, and perspectives

Kidney dysfunction is a common complication of hematopoietic cell transplantation (HCT) with proven negative impact on early and long-term mortality. Causes of this complication are diverse, usually overlapping, and poorly understood. Therefore, management implicates multidirectional investigations and simultaneous treatment of suspected causes. The etiology is frequently unconfirmed due to a lack of specific markers and prevalence of contraindications to renal biopsy among HCT recipients. Herein, we provide a summary of etiology and propose an algorithm for evaluation of kidney injury after HCT. We also map out the most urgent areas for research that aim to identify patients at risk of severe renal injury and develop nephroprotective strategies.     

Periodontal Pocket Depth,Hyperglycemia, and Progression of Chronic Kidney Disease: A Population-Based Longitudinal Study

Background

No large epidemiological study has been conducted to investigate the interaction and joint effects of periodontal pocket depth and hyperglycemia on progression of chronic kidney disease in patients with periodontal diseases.

Effects of Uremic Toxins from the Gut Microbiota on Bone: A Brief Look at Chronic Kidney Disease

Patients with chronic kidney disease (CKD) frequently have mineral and bone disorders (CKD‐MBD) that are caused by several mechanisms. Recent research has suggested that uremic toxins from the gut such as p‐cresyl sulfate (PCS) and indoxyl sulfate (IS) could also be involved in the development of bone disease in patients with CKD. IS and PCS are produced by microbiota in the gut, carried into the plasma bound to serum albumin, and are normally excreted into the urine. However, in patients with CKD, there is an accumulation of high levels of these uremic toxins. The exact mechanisms of action of uremic toxins in bone disease remain unclear. The purpose of this brief review is to discuss the link between uremic toxins (IS and PCS) and bone mineral disease in chronic kidney disease.     

慢性肾病患者动脉僵硬度与冠状动脉病变相关性

目的 探讨慢性肾病患者动脉僵硬度与冠状动脉(冠脉)病变的相关性及对冠心病风险评估的意义.方法 203例具有至少一项冠心病危险因素的患者中,慢性肾病(67例)和对照组(136例)两组,分别测定动脉僵硬度指标并行冠脉造影和估价Gemini冠脉病变严重程度.结果 慢性肾病组年龄较大,肱动脉收缩压、舒张压增高(P＜0.01).与对照组比较,慢性肾病组动脉僵硬度增加、冠心病发病率和冠脉病变程度增高.在校正年龄和外周血压影响后,两组动脉僵硬度指标仍有显著差异.PWV＞12和Aix@75＞25为预测冠心病发病的独立指标(P＜0.05).慢性肾病组中,PWV、Aix@75与冠心病发病率、冠脉病变严重度呈正相关(P＜0.01).在控制了多项影响因素后,相关性仍显著.结论 慢性肾病患者动脉僵硬度与冠心病发病以及冠脉病变严重程度呈 正相关.     

Chronic tophaceous gout as the first manifestation of gout in two cases and a review of the literature

ObjectivesAcute gout is a common arthritis that may eventually develop into chronic tophaceous gout (CTG). CTG usually is manifested by recurrent gout attacks. The diagnosis and treatment of CTG is challenging. Although the emergence of CTG without previous gout attacks is uncommon, it is important to recognize this unusual gout presentation.MethodsHerein, we present two cases of CTG, occurring in elderly patients with chronic kidney disease (CKD) on diuretics, who presented without a prior history of acute gout attacks. We also searched PUBMED, Ovid MEDLINE, and Google scholar (1970–2017), for “tophi as the initial manifestation of gout” and “chronic gout without previous attacks”, and extracted relevant data.ResultsThe search disclosed one retrospective study and several case reports and case series describing 96 patients. Clinical and laboratory data was extracted from 34 patients. We found that a specific group of patients, e.g., elderly patients, most often female patients, suffering from CKD, and treated with diuretics, are specifically reported in the English medical literature to present with CTG as their first manifestation of gout.ConclusionThe two cases and our literature review try to emphasize the many faces of chronic gout, in particular, its presentation without previous gout attacks.