Prevalence,Predictors, and Outcomes of Pulmonary Hypertension in CKD

Pulmonary hypertension (PH) is associated with poor outcomes in the dialysis and general populations, but its effect in CKD is unclear. We evaluated the prevalence and predictors of PH measures and their associations with long–term clinical outcomes in patients with nondialysis-dependent CKD. Chronic Renal Insufficiency Cohort (CRIC) Study participants who had Doppler echocardiography performed were considered for inclusion. PH was defined as the presence of estimated pulmonary artery systolic pressure (PASP) >35 mmHg and/or tricuspid regurgitant velocity (TRV) >2.5 m/s. Associations between PH, PASP, and TRV and cardiovascular events, renal events, and all-cause mortality were examined using Cox proportional hazards models. Of 2959 eligible participants, 21% (n=625) had PH, with higher rates among those with lower levels of kidney function. In the multivariate model, older age, anemia, lower left ventricular ejection fraction, and presence of left ventricular hypertrophy were associated with greater odds of having PH. After adjusting for relevant confounding variables, PH was independently associated with higher risk for death (hazard ratio, 1.38; 95% confidence interval, 1.10 to 1.72) and cardiovascular events (hazard ratio, 1.23; 95% confidence interval, 1.00 to 1.52) but not renal events. Similarly, TRV and PASP were associated with death and cardiovascular events but not renal events. In this study of patients with CKD and preserved left ventricular systolic function, we report a high prevalence of PH. PH and higher TRV and PASP (echocardiographic measures of PH) are associated with adverse outcomes in CKD. Future studies may explain the mechanisms that underlie these findings.     

Renal disease in recipients of nonrenal solid organ transplantation

Worldwide, more than 250,000 individuals who have received a liver, heart, lung, or intestinal transplant are living longer. Twenty percent to 25% of these recipients experience perioperative acute renal failure, with 10% to 15% requiring renal replacement therapy. Chronic kidney disease (CKD) is also highly prevalent, affecting 30% to 50% of the nonrenal organ transplant population with an annual end-stage renal disease risk of 1.5% to 2.0%. Both acute renal failure and CKD contribute to increased morbidity and premature mortality. The dominant causative factor for renal disorders seen in nonrenal transplant recipients are the calcineurin inhibitors (CNI) and rapamycin analogues, which singly or in combination lead to a variety of nephrotoxic injury. However, 25% to 30% of nonrenal transplant recipients with CKD have other conditions such as hypertension, focal segmental glomerulosclerosis, diabetes mellitus, and hepatitis C infection as the principal underlying cause. Management strategies for renal disease in the nonrenal transplant recipients include the following: (1) delayed introduction of CNI after graft implantation, (2) withdrawal or minimization of long-term CNI therapy, (3) timely use of an appropriate dialysis modality, and (4) expeditious introduction of supportive measures such as anemia management, phosphate binding therapy, and dietary modification. Compared with maintenance dialysis, kidney transplantation reduces long-term mortality by 60% to 70% in nonrenal transplant recipients with end-stage renal disease.     

Human Heredity and Health (H3) in Africa Kidney Disease Research Network: A Focus on Methods in Sub-Saharan Africa

CKD affects an estimated 14% of adults in sub-Saharan Africa, but very little research has been done on the cause, progression, and prevention of CKD there. As part of the Human Heredity and Health in Africa (H3Africa) Consortium, the H3Africa Kidney Disease Research Network was established to study prevalent forms of kidney disease in sub-Saharan Africa and increase the capacity for genetics and genomics research. The study is performing comprehensive phenotypic characterization and analyzing environmental and genetic factors from nine clinical centers in four African countries (Ghana, Nigeria, Ethiopia, and Kenya) over a 5-year period. Approximately 4000 participants with specified kidney disease diagnoses and 4000 control participants will be enrolled in the four African countries. In addition, approximately 50 families with hereditary glomerular disease will be enrolled. The study includes both pediatric and adult participants age <1 to 74 years across a broad spectrum of kidney diseases secondary to hypertension-attributed nephropathy, diabetes, HIV infection, sickle cell disease, biopsy-proven glomerular disease, and CKD of unknown origin. Clinical and demographic data with biospecimens are collected to assess clinical, biochemical, and genetic markers of kidney disease. As of March 2015, a total of 3499 patients and controls have been recruited and 1897 had complete entry data for analysis. Slightly more than half (50.2%) of the cohort is female. Initial quality control of clinical data collection and of biosample and DNA analysis is satisfactory, demonstrating that a clinical research infrastructure can be successfully established in Africa. This study will provide clinical, biochemical, and genotypic data that will greatly increase the understanding of CKD in sub-Saharan Africa.     

Short-term outcomes after hospital discharge in patients admitted with heart failure in Abeokuta,Nigeria: Data from the Abeokuta Heart Failure Registry

Heart failure (HF) has emerged as a global epidemic in at-risk populations, including those living in high-income countries and, as recently described, in low- to middle-income regions of the world, such as sub-Saharan Africa.11-4 While there are well-established HF registries to capture both the characteristics and health outcomes among those hospitalised with AHF in Europe,5,6 North America,7,8 and the Asia–Pacific region,3,9,10 there are few reports from sub-Saharan Africa.11 This includes Nigeria (the most populous country in the region), where HF has emerged as a potentially large public health problem.1Although there have been many therapeutic gains in the management of chronic HF,12 leading to improved overall survival rates,13 there has been very little parallel success (pending further evaluation of the recently reported RELAX trial14 with regard to AHF). This is particularly important when one considers the high proportion of patients who still require hospitalisation for acute HF, and associated high levels of in-patient case fatality and poor short- to medium-term health outcomes.Given the paucity of data describing health outcomes in unselected patients hospitalised with AHF in Nigeria (and indeed the wider sub-Saharan Africa), we examined short- (30 days) to medium-term outcomes (180 days) in consecutive subjects with AHF recruited into the Abeokuta HF registry over a period of six months. Standardised data collected via the registry were used to both describe the baseline characteristics of the cohort and identify correlates of mortality during the six-month follow up.     

Malnutrition in developing countries: nutrition disorders,a leading cause of ill health in the world today

Shockingly, malnutrition remains a dominant cause of mortality, morbidity and lost potential in today's children. In 2017, more than 1 in 5 children did not achieve their growth potential and were at risk of the associated long-term deficits in cognitive development. Stunting affects almost 40% of children in South Asia and the number of stunted children in Africa is rising. More than 1 in 14 of the world's children are wasted. Forty-five percent of all deaths in under-fives are attributable to undernutrition. Meanwhile, overweight affects 1 in 20 of the world's children. One in four overweight children live in Asia and numbers are expected to increase. Management of severe acute malnutrition (SAM) is a huge challenge in low resource healthcare settings and mortality rates remain high. Current interventions to prevent malnutrition have limited impact. More effective prevention and treatment of malnutrition is needed urgently.     

Chronic Renal Insufficiency Cohort (CRIC) Study: Baseline Characteristics and Associations with Kidney Function

Background and objectives: The Chronic Renal Insufficiency Cohort (CRIC) Study was established to examine risk factors for the progression of chronic kidney disease (CKD) and cardiovascular disease (CVD) in patients with CKD. We examined baseline demographic and clinical characteristics.Design, setting, participants, & measurements: Seven clinical centers recruited adults who were aged 21 to 74 yr and had CKD using age-based estimated GFR (eGFR) inclusion criteria. At baseline, blood and urine specimens were collected and information regarding health behaviors, diet, quality of life, and functional status was obtained. GFR was measured using radiolabeled iothalamate in one third of participants.Results: A total of 3612 participants were enrolled with mean age ± SD of 58.2 ± 11.0 yr; 46% were women, and 47% had diabetes. Overall, 45% were non-Hispanic white, 46% were non-Hispanic black, and 5% were Hispanic. Eighty-six percent reported hypertension, 22% coronary disease, and 10% heart failure. Mean body mass index was 32.1 ± 7.9 kg/m², and 47% had a BP >130/80 mmHg. Mean eGFR was 43.4 ± 13.5 ml/min per 1.73 m², and median (interquartile range) protein excretion was 0.17 g/24 h (0.07 to 0.81 g/24 h). Lower eGFR was associated with older age, lower socioeconomic and educational level, cigarette smoking, self-reported CVD, peripheral arterial disease, and elevated BP.Conclusions: Lower level of eGFR was associated with a greater burden of CVD as well as lower socioeconomic and educational status. Long-term follow-up of participants will provide critical insights into the epidemiology of CKD and its relationship to adverse outcomes.The prevalence of ESRD that requires renal replacement therapy has risen dramatically in the United States during the past three decades (1). Non–dialysis-requiring chronic kidney disease (CKD) is substantially more common than ESRD, with an estimated 15 million adults in the United States having CKD of stage 3 or worse (as defined by an estimated GFR [eGFR] of <60 ml/min per 1.73 m²) (2) Furthermore, CKD frequently progresses in severity, but the factors that are responsible for accelerated decline need further elucidation. In addition, recent studies have highlighted an important association between even mild CKD and increased risk for cardiovascular disease (CVD) (3), but the mechanisms for this association remain unclear.In response to the epidemic of CKD and our incomplete understanding of factors that govern its progression and associated morbidity, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) established the Chronic Renal Insufficiency Cohort (CRIC) Study in 2001. The broad aims of the CRIC Study are to examine risk factors for the progression of kidney disease and CVD in patients with CKD and to develop predictive models to identify high-risk subgroups. The design and methods of the CRIC Study have been previously reported (4). In this article, we characterize the eligibility and recruitment methods, describe the baseline characteristics of patients enrolled in the cohort, and report initial analyses of correlates of level of eGFR.     

Meeting the challenge to improve the treatment of hypertension in blacks

Hypertension is more prevalent and severe in African descendent populations living outside Africa than in any other population. Given this greater burden of hypertension in blacks, it is increasingly necessary to refine strategies to prevent the disorder as well as improve its treatment and control. This review assesses results from clinical trials on lifestyle and pharmacologic interventions to identify which approaches most effectively prevent adverse hypertension-related outcomes in African descendent populations. The Dietary Approaches to Stop Hypertension (DASH) study provided evidence that a carefully controlled diet rich in fruits, vegetables, low-fat dairy foods, and reduced in saturated fat, total fat, and cholesterol (i.e., the DASH diet) reduces blood pressure in blacks and is well accepted. The combination of the DASH diet with reduction in dietary sodium below 100 mmol/d may provide a reduction in blood pressure beyond that reached by the DASH diet alone. Physical exercise and interventions to reduce psychological stress may also reduce blood pressure in blacks. Strong evidence from numerous studies is a compelling argument for continuing to recommend diuretics and beta blockers as first-line antihypertensive therapy for persons of all races. Some new studies also favor angiotensin-converting enzyme inhibitors as first-line antihypertensive drugs. The African American Study of Kidney Disease and Hypertension provided evidence that an angiotensin-converting enzyme inhibitor-based treatment program is more beneficial than calcium channel blockers and beta blockers in reducing the progression of renal failure in blacks with hypertensive nephropathy. Studies in patients with diabetes have also shown evidence that both angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists are more effective than other classes of antihypertensives in reducing adverse renal events. Studies to evaluate the effects of the new antihypertensives in improving outcomes in blacks living outside the United States are needed.