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.     

Low Socioeconomic Status Associates with Higher Serum Phosphate Irrespective of Race

Hyperphosphatemia, which associates with adverse outcomes in CKD, is more common among blacks than whites for unclear reasons. Low socioeconomic status may explain this association because poverty both disproportionately affects racial and ethnic minorities and promotes excess intake of relatively inexpensive processed and fast foods enriched with highly absorbable phosphorus additives. We performed a cross-sectional analysis of race, socioeconomic status, and serum phosphate among 2879 participants in the Chronic Renal Insufficiency Cohort Study. Participants with the lowest incomes or who were unemployed had higher serum phosphate concentrations than participants with the highest incomes or who were employed (P < 0.001). Although we also observed differences in serum phosphate levels by race, income modified this relationship: Blacks had 0.11 to 0.13 mg/dl higher serum phosphate than whites in the highest income groups but there was no difference by race in the lowest income group. In addition, compared with whites with the highest income, both blacks and whites with the lowest incomes had more than twice the likelihood of hyperphosphatemia in multivariable-adjusted analysis. In conclusion, low socioeconomic status associates with higher serum phosphate concentrations irrespective of race. Given the association between higher levels of serum phosphate and cardiovascular disease, further studies will need to determine whether excess serum phosphate may explain disparities in kidney disease outcomes among minority populations and the poor.Racial disparities in kidney disease outcomes are among the most glaring inequities in the United States health care system.^1–5 Despite a similar prevalence of early-stage chronic kidney disease (CKD), blacks are up to 4 times more likely to progress to ESRD than whites.^1–4 In addition, compared with whites, blacks have higher rates of cardiovascular disease and mortality in early CKD.^6,7 Although these differences have largely been attributed to socioeconomic inequalities leading to inadequate access to medical care among minority populations,^5,8 increasing evidence suggests that biologic factors, such as disorders of mineral metabolism, also contribute to racial disparities in CKD outcomes.^9,10Increased serum phosphate is associated with cardiovascular disease, kidney disease progression, and death.^11–15 Although the mechanisms for these relationships are unclear, experimental data showing that excess phosphate promotes vascular calcification, endothelial dysfunction, and renal injury suggest a causal link between an elevated serum phosphate and adverse health outcomes.^16–19 Large cohort studies have shown that hyperphosphatemia is more common and more severe in blacks than in whites, both among patients with CKD and among individuals with normal kidney function.^20–22 Given the emerging connections between increased serum phosphate and accelerated cardiovascular and kidney disease progression, understanding the mechanisms underlying the excess prevalence of hyperphosphatemia among blacks may elucidate novel approaches for reducing racial disparities in CKD outcomes.Racial and ethnic minorities disproportionately reside in low-income neighborhoods that have limited access to healthy food choices, resulting in the overconsumption of inexpensive processed and fast foods that are rich in highly absorbable phosphorus additives.^23–27 High intake of these foods has been associated with increased serum phosphate in CKD,²⁵ and dietary counseling aimed at reducing the consumption of these foods lowered serum phosphate in hemodialysis patients.²⁸ Furthermore, increasing poverty was independently associated with higher serum phosphate levels and greater likelihood of hyperphosphatemia in a cohort of over 14,000 adults with largely preserved kidney function in the Third National Health and Nutrition Examination Survey.²⁹ Collectively, these observations suggest that lower socioeconomic status may contribute to elevated serum phosphate concentrations by promoting excess dietary phosphorus intake. Whether this accounts for higher serum phosphate concentrations among blacks compared with whites with CKD is unclear. We examined the associations between race, socioeconomic status, and serum phosphate concentrations among participants in the Chronic Renal Insufficiency Cohort (CRIC) Study.     

Expanded criteria donors: process and outcomes

Expanded criteria donor (ECD) kidneys are transplantable deceased donor (DD) kidneys for which the average patient, graft survival, and renal function are inferior when compared to standard criteria DD kidneys. Although the term ECD kidneys has been used since the early 1990s to describe kidneys with various characteristics associated with poorer outcomes, the concept has been formally implemented in U.S. organ allocation. A DD kidney is considered to be an ECD organ if the estimated adjusted risk of graft failure is > or = 70% (RR > or = 1.70) compared to DD kidneys with standard characteristics of transplant suitability. The donor characteristics that define an ECD kidney include age > or = 60 years, or age 50-59 years plus two of the following: cerebrovascular accident as the cause of death, preexisting hypertension, or terminal serum creatinine greater than 1.5 mg/dl. In the aggregate, recipients of ECD kidneys have improved survival compared to end-stage renal disease (ESRD) patients on the kidney transplant waiting list. Patient survival is 5% lower at 1 year and 8-12% lower at 3-5 years for ECD kidney recipients. Adjusted graft survival in ECD kidneys is 8% lower at 1 year and 15-20% lower at 3-5 years after transplantation compared to standard criteria donor kidneys. However, patients less than 40 years of age, African Americans, Asians for whom the median waiting time is less than 1350 days receive no survival benefit from ECD kidney transplantation. Informed choice by the potential recipient is a prominent feature of the allocation policy regarding ECD kidneys. Since there are recipient characteristics associated with no survival benefit following ECD transplantation, nephrologists who refer patients for kidney transplantation should be familiar with the combination of donor and recipient factors that are likely to yield detrimental results.     

A Comparison of Change in Measured and Estimated Glomerular Filtration Rate in Patients with Nondiabetic Kidney Disease

Background and objectives: All glomerular filtration rate (GFR) estimating equations have been developed from cross-sectional data. The aims of this study were to examine the concordance between use of measured GFR (mGFR) and estimated GFR (eGFR) in tracking changes in kidney function over time among patients with moderately severe chronic kidney disease.Design, setting, participants, & measurements: A retrospective cohort study of subjects who had been enrolled in the MDRD Study A and who had two or more contemporaneous assessments of mGFR and eGFR (n = 542; mGFR range, 25 to 55 ml/min per 1.73 m²) during the chronic phase (month 4 and afterwards). mGFR was based on urinary iothalamate clearance; eGFR was based on the 4-variable MDRD Study equation. Temporal changes in GFR were assessed by within-subject linear regression of time on GFR.Results: Median follow-up time for all subjects was 2.6 yr; median number of GFR measurements was six. The eGFR slope tended to underestimate measured decrements in GFR. The absolute value of the difference in mGFR and eGFR slopes was ≤2 ml/min per 1.73 m² per yr among 58.3% of subjects; the remainder of subjects had larger absolute differences. Among the 22 variables studied, none predicted a systematic difference between mGFR slope and eGFR slope.Conclusions: Although eGFR and mGFR exhibited similar relationships to 22 baseline variables, the overall bias seen in the full cohort suggests that clinicians and researchers should exercise caution when interpreting eGFR slope as a marker of progression of kidney disease.The glomerular filtration rate (GFR) is considered the best available index of kidney function in health and disease (1). GFR can be measured by clearance techniques involving endogenous (e.g., creatinine and urea) or exogenous (e.g., inulin, iohexol, and iothalamate) filtration markers, with the latter considered to be the gold-standard approach (2). Unfortunately, clearance measurements are both cumbersome and costly; thus, in clinical practice, GFR is often estimated based upon the serum creatinine concentration. Numerous GFR estimating equations have been developed, the most widely used of which was derived from the Modification of Diet in Renal Disease (MDRD) Study (3,4).Essentially all GFR estimating equations have been developed from cross-sectional data and perform well when used to classify individuals at single points in time, particularly for levels of GFR less than 60 ml/min per 1.73 m² (3,5–9). Ideally, these equations could also be used to monitor GFR changes over time in research and clinical practice. However, the validity of these equations for longitudinal application has not been sufficiently examined. Temporal changes in factors influencing creatinine production (e.g., muscle mass and dietary intake) and renal creatinine handling (e.g., tubular secretion), or extra-renal elimination (e.g., antibiotics) potentially further limit the accuracy of estimating equations or serum creatinine used alone as a filtration marker when applied over time (10). Understanding this potential limitation is of particular importance for two reasons: 1) the movement toward standardized reporting of estimated GFR (which may lead clinicians to draw longitudinal comparisons), and 2) the use of estimated GFR as an outcome measure in studies of preservation of kidney function.The MDRD Study is one of only a few trials that tracked decline in kidney function longitudinally in a population with chronic kidney disease (CKD) with measurement of GFR. Thus, data from this study provide a context in which to assess the longitudinal performance of GFR estimating equations. We undertook the following study: 1) to examine and characterize the correspondence between changes over time in measured GFR (mGFR) and estimated GFR (eGFR) and 2) to identify factors that may influence the relationship between longitudinal changes in mGFR and eGFR.     

Quantifying organ donation rates by donation service area

Previous measures of OPO performance based on population counts have been deemed inadequate, and the need for new methods has been widely accepted. This article explains recent developments in OPO performance evaluation methodology, including those developed by the SRTR. As a replacement for the previously established measure of OPO performance – donors per million population – using eligible deaths as a national metric has yielded promising results for understanding variations in donation rates among the donation service areas assigned to each OPO. A major improvement uses "notifiable deaths" as a denominator describing a standardized maximal pool of potential donors. Notifiable deaths are defined as in-hospital deaths among ages 70 years and under, excluding certain diagnosis codes related to infections, cancers, etc. A most proximal denominator for determining donation rates is "eligible deaths," which includes only those deaths meeting the criteria for organ donation upon initial assessment. Neither measure is based on the population of a geographic unit, but on restricted upper limits of deaths that could be potential donors in any one locale (e.g., hospital or OPO). The inherent strengths and weaknesses of metrics such as donors per eligible deaths, donors per notifiable deaths, and number of organs per donor are discussed in detail.