Cost-utility analysis of empagliflozin on chronic kidney disease progression in Thailand

OBJECTIVE

The prevalence of chronic kidney disease (CKD) in Thailand is high and kidney disease progression remains a problem. Empagliflozin has been known to be used to slow CKD progression, but its accessibility remains limited. This study aimed to assess the cost-utility of empagliflozin for CKD progression in Thailand.

METHODS

A state-transition model was developed consisting of eight health states: five eGFR health states (G2, G3a, G3b, G4, and G5), dialysis, kidney transplantation, and death. Empagliflozin 10 mg was assessed as an add-on treatment to standard of care (SoC). The efficacy of empagliflozin was derived from the EMPA-KIDNEY trial, while other inputs were obtained from a comprehensive literature review. The incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) was calculated. A probabilistic sensitivity analysis (PSA) was performed to explore uncertainties.

RESULTS

Empagliflozin could improve QALYs by 0.62 and 0.71 for patients with CKD without and with diabetes mellitus (DM) compared with SoC, respectively. However, it required higher total lifetime costs of 77,966 Thai baht (THB) and 59,454 THB for patients with CKD without and with DM, respectively. The ICER for CKD without DM was 126,201 THB/QALY, while the ICER for CKD with DM was 83,473 THB/QALY. The PSA indicated that empagliflozin had a 64.00% probability of being cost-effective for CKD without DM and an 89.18% probability for CKD with DM.

LIMITATIONS

An important limitation was that the treatment effects of empagliflozin were derived from the EMPA-KIDNEY, which was conducted in DM patients and assumed to be the same for non-DM patients because of the limited evidence in non-DM patients.

CONCLUSION

At the current willingness-to-pay threshold of 160,000 THB/QALY, empagliflozin was cost-effective for treating patients with CKD without or with DM.

Latent Toxoplasma gondii infection and associated risk factors among patients with chronic kidney disease: a registry-based study

BACKGROUND

Patients with chronic kidney disease (CKD) are susceptible to acquiring opportunistic parasites due to acquired immunodeficiency caused by uremia. Therefore, the present case-control study attempted to determine the prevalence of T. gondii infection and also associated risk factors among patients with CKD under hemodialysis and healthy controls who were registered at the Iranian National Registry Center for Toxoplasmosis (INRCT) in Mazandaran Province, northern Iran.

METHODS

212 cases with CKD and 200 healthy controls were enrolled in this study. Informed consent as well as a questionnaire were obtained from all subjects. Blood samples were collected from each participant and the serum was screened for anti-Toxoplasma antibodies (IgG and IgM). PCR assay was performed to detect circulating T. gondii in the blood samples of patients and controls using the primer pair targeting the RE gene.

RESULTS

Out of 412 participants, 67.92% of patients and 15.5% of control subjects were positive for anti-Toxoplasma IgG, but all participants were negative for anti-Toxoplasma IgM. Also, considering PCR assays with RE target, the prevalence of T. gondii infection was 24.1% in case subjects, while none of the control subjects tested positive. Among the PCR positive, 34 (66.7%) had Toxoplasma IgG positivity. The results from the multiple multinomial logistic regression revealed that the seroprevalence of anti-T. gondii IgG antibodies in patients with CKD was 3.12 times higher than in healthy controls (OR = 3.12; 95% CI = 0.43, 14.8; P < 0.001). Also, there was a significant association between seroprevalence of T. gondii infection and age, having a cat at home, and level of glomerular filtration rate (GFR) in these patients.

CONCLUSION

Our findings demonstrate a highly significant association between latent T. gondii infection and CKD, mostly in the late stages. Thus, regular screening for T. gondii infection in these patients is strongly recommended to prevent the reactivation of latent infections. A combination of serological screening, chemoprophylaxis, and PCR follow-up for patients at risk of reactivation should effectively reduce the likelihood of latent infection reactivation.

CLINICAL TRIAL NUMBER

Not applicable.

Development of Chronic Kidney Disease Screening Integrative Care Model Led by Community Pharmacists

BACKGROUND

The prevalence of chronic kidney disease (CKD) is rising, increasing demand for renal replacement therapy (RRT). Community pharmacies, as accessible healthcare hubs, can play a pivotal role in CKD prevention. This study aimed to develop care models for community pharmacies to optimize medication use, encourage behavior modification, and promote self-management among at-risk individuals.

METHODS

Conducted between June 2017 and July 2018, this study utilized an action research approach. Microalbuminuria was assessed using urine dipsticks, and pharmacists applied behavioral change and self-management support (SMS) strategies to slow CKD progression. Participants were categorized by albuminuria levels and enrolled in pharmacist-led care programs, with follow-up assessments at weeks 0 and 12.

RESULTS

Of 521 participants screened, 57% tested positive for albuminuria. For these individuals, serum creatinine testing and referrals to primary care were initiated. Self-management behavior assessment (S1) scores significantly improved (p = 0.024). Key factors associated with urine albumin levels included age < 60 years (OR = 0.44), diabetes (OR = 3.69), hypertension (OR = 2.01), BMI < 27.5 kg/m2 (OR = 0.42), eGFR ≥ 60 mL/min/1.73 m2 (OR = 3.34), lower systolic (OR = 0.55) and diastolic blood pressure (OR = 0.34), and fasting plasma glucose < 126 mg/dL (OR = 0.29).

CONCLUSIONS

Community pharmacist-led albuminuria screening effectively supports CKD prevention and enhances self-awareness within communities.

Impaired creatinine-based estimated glomerular filtration rate in Thai individuals switching to dolutegravir: illustrating the role of cystatin C testing to aid clinical decision making

INTRODUCTION

Data about impact of switch to dolutegravir (DTG)-based antiretroviral therapy (ART) on estimated glomerular filtration rate (eGFR) in Asians are scarce. RV254/SEARCH010 is a prospective observational cohort in Bangkok, Thailand with ART initiation during acute HIV infection (AHI) where participants switched to DTG-based ART.

METHODS

Participants started Efavirenz (EFV)-based ART during AHI (n = 214) and switched to DTG-based ART after a median of 97 weeks (IQR 61-145). GFR was estimated by serum creatinine (eGFRcre) every 24 weeks before and after switch. Estimated GFR by cystatin C (eGFRcystC) was ordered at clinician's discretion for decreased eGFRcre after switch. Random-effect linear regression model was used to assess changes in eGFRcre over 96 weeks from starting ART, and from switching to DTG.

RESULTS

At study entry, 20 participants (9.3%) had eGFRcre < 90 ml/min/1.73 m2. During EFV-based ART, an additional 17 (8%) developed eGFRcre < 90 ml/min/1.73 m2, nearly all transient, while mean eGFRcre remained stable and within normal range. At switch to DTG, 21 (9.8%) had eGFRcre < 90 ml/min/1.73 m2 but an additional 116 (54%) developed eGFRcre < 90 ml/min/1.73 m2 during follow-up with eGFRcre decrease being mostly persistent. Mean eGFRcre decreased 20.8% from 117.0 to 92.4 ml/min/1.73 m2 (p < 0.001). Among 20 post-switch participants with eGFRcystC measured within 4 weeks of eGFRcre < 90 mL/min/1.73 m2, 13 (65%) had normal kidney function by eGFRcystC.

CONCLUSIONS

Persistent eGFRcre decrease to < 90 ml/min/1.73 m2 after switch to DTG was common in this Thai population. eGFRcystC was helpful to identify individuals with clinically significant decrease in kidney function and obviate unnecessary ART modifications. Trial registration Clinical Trials Registry Number: ClininicalTrials.gov NCT00796146.

Utility of a novel point-of-care test for albuminuria in communities at high risk for chronic kidney disease in Thailand

Introduction

Chronic kidney disease (CKD) is a major public health concern, and early detection is crucial to prevent adverse outcomes. Albuminuria is an early marker and key prognostic marker in CKD, but reliable tools for its detection are limited particularly in low resource settings. We tested the utility of a novel, affordable point-of-care test (POCT) for albuminuria among high-risk individuals for CKD.

Methods

This is a community-based cross-sectional study covering 17 primary subdistrict healthcare units in Ban Phaeo District, Samut Sakhon Province, Thailand. The inclusion criteria were asymptomatic adult participants diagnosed with hypertension, diabetes and/or aged over 60 years. We measured serum creatinine and quantitative urine albumin-creatinine ratio (UACR) and administered POCT urine albumin strip test (Albii, K. BioSciences, Bangkok, Thailand) and urine dipstick test for protein. Participants with albuminuria or estimated glomerular filtration rate (eGFR) by CKD-EPI 2009 equation <60 mL/min/1.73 m2 were considered to have suspected CKD. We evaluated diagnostic performance of POCT urine albumin strip.

Results

Among 2307 participants, 489 (20.3%) participants had reduced eGFR and/or albuminuria. The median eGFR was 93.23 (87.82, 98.73) mL/min/m2, and the median UACR was 9.15 (5.09, 20.96) mg/g. The POCT urine albumin strip showed a sensitivity of 0.70, specificity of 0.97 and accuracy of 0.92 compared with the quantitative UACR. Conversely, the POCT urine dipstick for protein had poor sensitivity, positive predictive value and accuracy.

Conclusion

The urine albumin test strip is a highly effective tool to conduct point-of-care identification for early CKD among high-risk populations. Given the test's diagnostic performance and ease of use, such test should be incorporated into health policy.

Major adverse kidney events in multidisciplinary chronic kidney disease care compared with usual outpatient care: a propensity score matched analysis

BACKGROUND

Chronic kidney disease (CKD) is a public health problem worldwide. Multidisciplinary care has been recommended in clinical practice to delay disease progression and minimize complications. However, the effectiveness of multidisciplinary care on major adverse kidney events in CKD patients is still inconclusive.

METHODS

We conducted a cohort study in patients with CKD stages G3b to 4 who were followed up at Bhumibol Adulyadej Hospital from 2014 to 2020. Propensity score matching by age, sex, CKD staging, Diabetes Mellitus (DM), blood pressure and rate of estimated Glomerular Filtration Rate (eGFR) decline before inclusion between patients in multidisciplinary CKD care (MDC) and usual outpatient care (UOC) was performed. The primary outcome was a composite of cardiovascular or renal mortality, 40% eGFR decline and initiation of long-term kidney replacement therapy.

RESULTS

After 1:1 propensity score matching, 822 patients were included. Mean age was 70.9 years, 64% had diabetes. During the mean follow-up of 3.3 years, rate of reaching the primary endpoint was lower in the multidisciplinary CKD care group than in the usual outpatient care group (24.1% vs. 38.9%; hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.52-0.86; P = 0.002). The multidisciplinary CKD care group benefited more than the usual outpatient care group with regard to 40% eGFR decline (21.7% vs. 35.0%; HR, 0.67; 95%CI 0.52-0.88; P = 0.004), all-cause mortality (8.5% vs. 19.5%; HR, 0.60; 95%CI 0.40-0.90; P = 0.014), non-cardiovascular death (6.1% vs. 15.1%; HR, 0.56; 95%CI 0.35-0.90; P = 0.015) and hospitalizations per year (1.0 ± 1.5 vs. 1.6 ± 2.0; P < 0.001). According to subgroup analysis, diabetes mellitus patients benefited the most from multidisciplinary CKD care.

CONCLUSIONS

In a tertiary care hospital, multidisciplinary CKD care showed benefits over usual outpatient care on kidney outcomes in patients with CKD stages G3b and 4. The benefit was enhanced in DM patients.

Effects of MAFLD defined by fatty liver index or ultrasonography on kidney function decline in the general population

This study aimed to investigate whether metabolic dysfunction-associated fatty liver disease (MAFLD) defined by the fatty liver index (FLI) affects the decline in kidney function and whether this relationship is still observed in MAFLD defined by ultrasonography (USG). A retrospective cohort study was conducted using de-identified data from participants who received health checkups at Samsung Changwon Hospital between 2002 and 2018. The primary and secondary exposures were the presence of FLI- and USG-defined MAFLD, respectively. The primary outcome was 5-years slope of eGFR. The secondary outcome was a rapid decline in kidney function, defined as a 5-years slope of estimated glomerular filtration rate (eGFR) of less than - 3 mL/min/1.73 m2 per year. A total of 37,500 participants were included in the analysis. Participants with FLI-defined MAFLD had a larger decline in 5-year eGFR slope than those without FLI-defined MAFLD (beta coefficients - 0.11; 95% CI - 0.14 to - 0.08). Participants with FLI-defined MAFLD had a higher risk of rapid kidney function decline than those without FLI-defined MAFLD (odds ratio 1.33; 95% confidence intervals (CIs) 1.05-1.69). However, USG-defined MAFLD was less related to kidney function decline. In conclusion, the presence of FLI-defined MAFLD was associated with larger and faster kidney function decline.

Economic Evaluation of an Integrated Care Program Compared to Conventional Care for Patients With Chronic Kidney Disease in Rural Communities of Thailand

Introduction

An integrated care program for chronic kidney disease (CKD) in Thailand has shown its effectiveness in delaying the decline in kidney function, as evidenced by the Effectiveness of Integrated Care on Delaying Progression of Stages 3 to 4 CKD in Rural Communities of Thailand (ESCORT-1) randomized control trial and the ESCORT-2 prospective cohort study. Designed for sustainability within the primary healthcare system, the program optimizes the use of the existing workforce by fostering collaboration among local multidisciplinary care teams (MDCTs) and community care networks (CCNs).

Methods

A Markov model with a lifetime horizon was used to conduct a cost-utility analysis from a societal perspective. Individual participant level data from ESCORT studies, national registries, and relevant literature were used to estimate model parameters. A budget impact analysis from the payer's perspective was also assessed over a 5-year period.

Results

The integrated care program yielded a dominant result with 1.84 quality-adjusted life years (QALYs) gained with "less" lifetime cost, resulting in a negative incremental cost-effectiveness ratio (ICER). Probabilistic analysis showed that the intervention being cost-effective almost 100% of the time at the local willingness-to-pay threshold. The intervention maximized cost-effectiveness when delivered as early as possible, both in terms of age and stage. The budget impact analysis estimated that the introduction of the intervention could save about 7% of the Thai government's total health expenditure or 205 billion Thai-Baht ($5.9 billion) over 5 years with cost savings beginning from the third year onwards.

Conclusion

The integrated care program for CKD offers potential benefits and cost savings for patients, caregivers, and payers. Future efforts should focus on the screening and implementation processes across various regions and healthcare settings.

Effects of particulate matter (PM2.5) concentration and components on mortality in chronic kidney disease patients: a nationwide spatial-temporal analysis

Chronic kidney disease (CKD) is a major global public health issue and the leading cause of death in Thailand. This study investigated the spatial-temporal association between PM2.5 and its components (organic carbon, black carbon, dust, sulfate, and sea salt) and CKD mortality in Thailand from 2012 to 2021. The Modern-Era Retrospective analysis for Research and Application version 2 (MERRA-2), a NASA atmospheric satellite model, was assessed for the temporal data of PM2.5 concentration and aerosol components. Spatial resources of 77 provinces were integrated using the Geographical Information System (GIS). Multivariate Poisson regression and Bayesian inference analyses were conducted to explore the effects of PM2.5 on CKD mortality across the provinces. Our analysis included 718,686 CKD-related deaths, resulting in a mortality rate of 1107 cases per 100,000 population where was the highest rate in Northeast region. The average age of the deceased was 72.43 ± 13.10 years, with males comprising 50.46% of the cases. Adjusting for age, sex, underlying diseases, co-morbidities, CKD complications, replacement therapy, population density, and income, each 1 µg/m3 increase in PM2.5, black carbon, dust, sulfate, and organic carbon was significantly associated with increased CKD mortality across 77 provinces. Incidence rate ratios were 1.04 (95% CI 1.03-1.04) for PM2.5, 1.11 (95% CI 1.10-1.13) for black carbon, 1.24 (95% CI 1.22-1.25) for dust, 1.16 (95% CI 1.16-1.17) for sulfate, and 1.05 (95% CI 1.04-1.05) for organic carbon. These findings emphasize the significant impact of PM2.5 on CKD mortality and underscore the need for strategies to reduce PM emissions and manage CKD co-morbidities effectively.

Prevention, diagnosis, and treatment of urolithiasis in geriatric patients - differences, similarities and caveats in comparison to the general population

PURPOSE OF REVIEW

Purpose of the review is to address management and prevention of urolithiasis in elderly patients examining the dynamic interplay between general measures, dietary adjustments, lifestyle modifications, and targeted pharmacological and/ or surgical interventions. The goal is to provide understanding of the evolving strategies required for effective urolithiasis prevention in the geriatric population.

RECENT FINDINGS

Age-specific diagnostic considerations are necessary because urolithiasis in the elderly population is characterized by bigger stones, greater peri-operative risks, and heightened symptom severity. When comorbidities are present, conservative treatments - especially analgesia - provide difficulties. Surgical procedures prove to be safe and effective, with complication rates and practical application comparable to younger cohorts. Prevention approaches that include lifestyle changes and the investigation of novel pharmaceutical options such as sodium-dependent glucose co-transporter 2 (SGLT-2)-inhibitors are promising in the management of urolithiasis in the elderly population.

SUMMARY

Our review offers a thorough investigation of urolithiasis in the elderly population, elucidating distinct clinical manifestations, complex diagnostic issues, and treatment implications. The safety and effectiveness of ureteroscopy in older patients, as well as the possible prophylactic function of SGLT-2-I, offer crucial insights for clinicians. Subsequent studies are necessary to enhance age-specific therapies, addressing the distinct obstacles presented by urolithiasis in the elderly population within this rapidly growing demographic.

Chronic kidney disease in America, Africa, and Asia: Overview of treatment cost and options

Chronic kidney disease (CKD) is one of the non-infectious diseases that threaten patients' lives on a daily basis. Its prevalence is high, but under-reported by patients and those living with the disease, as it is silent and asymptomatic in the early stages. Kidney disease increases the risk of heart and vascular disease. These problems can manifest themselves slowly, over a long period of time. Early detection and treatment can often prevent chronic kidney disease from worsening. As kidney disease progresses, it can lead to kidney failure, requiring dialysis or a kidney transplant to stay alive. In this narrative review, we will mainly discuss different treatment option costs in different countries and how much they cost healthcare systems in countries in three different continents.

Integrated Care Model by the Village Health Volunteers to Prevent and Slow down Progression of Chronic Kidney Disease in a Rural Community, Thailand

INTRODUCTION

Chronic kidney disease (CKD) is a major health problem in Thailand and health behaviors are central to its risk and progression. Because of the shortage of healthcare personnel, village health volunteers (VHVs) have been collaborating in the primary health care system. However, the contribution of VHVs to CKD reduction has not been evaluated yet. This study aimed to evaluate the efficacy of the VHV-integrated model in preventing and slowing down CKD and its risk factors.

METHODS

The population-based cohort study was conducted in a rural community of Thailand between 2017 and 2019. Baseline clinical and behavioral characteristics including CKD, diabetes, hypertension, and other high-risk factors of the participants were collected. The integrated care model was initiated by the multidisciplinary care team that facilitated, empowered, and trained VHVs targeting risk factors of CKD, health literacy, and health promotion. Then the participants were educated and trained for lifestyle modification and were monitored continuously for 18 months by VHVs. Changes in the CKD risk factors, and kidney functions before and after the application of integrated care model were compared.

RESULTS

A total of 831 subjects participated in the study with an average age of 57.5 years, and 69.5% were female. Among them, 222 participants (26.7%) were diagnosed as having CKD, the vast majority (95%) of which were in the early stages (G1-G3 and A1-A2). CKD risk factors such as high salt intake, smoking, alcohol consumption, self-NSAID (non-steroidal anti-inflammatory drugs) use were significantly decreased after application of the care model. Also, hemoglobin A1c was significantly reduced in diabetic patients, and blood pressure was controlled better than before in the hypertensive patients. Most importantly, a decline of estimated glomerular filtration rate of the CKD group was improved and lower than the non-CKD group.

CONCLUSION

The integrated care model through VHV significantly attenuated the risk factors associated with CKD in the general and high-risk population and effectively slowed down the progression of CKD.

Cost-effectiveness of add-on empagliflozin versus standard of care in management of CKD in Malaysia, Thailand and Vietnam - findings from a modelling study assessing an EMPA-KIDNEY eligible population, using CKD progression model

BACKGROUND AND OBJECTIVES

Nearly one in ten individuals in South-East Asia are estimated to be affected by chronic kidney disease (CKD). The burden of end-stage kidney disease is significant and can be heavy on the healthcare system. The recent EMPA-KIDNEY trial demonstrated a significant reduction in the risk of kidney disease progression or cardiovascular death in patients with CKD with a broad range of kidney function using add-on empagliflozin versus standard of care (SoC) alone. The objective of this study was to estimate the economic benefit of empagliflozin for patients with CKD in Malaysia, Thailand and Vietnam.

METHODS

An individual patient level simulation model with an annual cycle that estimates the progression of kidney function and associated risk-factors was employed. Local costs and mortality rates were estimated from a wide range of published literature. A healthcare perspective was used over a 50-year time horizon.

RESULTS

The use of add-on empagliflozin versus SoC alone was found to be cost-saving in Malaysia and Thailand and cost-effective (ICER: 77,838,407 Vietnam Dong/QALY vs. a willingness to pay threshold of 96,890,026/QALY) in Vietnam. The bulk of the costs avoided over a lifetime is derived from the prevention or delay of dialysis initiation or kidney transplant - the cost offsets were nearly twice the additional treatment cost. The results were similar in patients with and without diabetes and across broad range of albuminuria.

CONCLUSIONS

The use of add-on empagliflozin in a broad population of patients with CKD is expected to be cost-saving in Malaysia and Thailand and cost-effective in Vietnam and will help alleviate the increasing burden of CKD in the region.

Correlation of the Dietary Protein Intake between Those Estimated from a Short Protein Food-Recall Questionnaire and from 24-Hour Urinary Urea-Nitrogen Excretion in Stages 3-4 Chronic Kidney Disease Patients

Introduction

High protein intake may accelerate progression of chronic kidney disease (CKD). Estimation of dietary protein intake (DPI) is indispensable for management of CKD, but to achieve optimum DPI is quite challenging in routine clinical practice. We recently studied a beneficial effect of utilizing integrated care on the management of CKD at the rural community level. In that study, we created a short protein food-recall questionnaire (S-PFRQ) as a working tool to estimate DPI of the CKD patients during home visit by community health personnel. Herein, we reported the initial evaluation of the reliability of S-PFRQ from our previous study.

Objective

We compared the amount of DPI obtained from S-PFRQ with that obtained from protein-equivalent of total nitrogen appearance (PNA).

Methods

In the previous ESCORT-2 study, 914 patients with CKD stage 3 or 4, who were living in the rural area of Thailand, were prospectively followed while receiving integrated care for 36 consecutive months. During home visits by community nurses from subdistrict health centers, dietary food recall was made, recorded in S-PFRQ, and DPI was obtained. Among these, sixty patients were randomly selected, and 24-h urine was collected for urinary urea-N and estimation of PNA. A correlation was made between DPI obtained from S-PFRQ and PNA.

Results

The DPIs derived from S-PFRQ and PNA were 28.8 ± 14.8 and 39.26 ± 17.79 g/day, respectively. The mean difference and 95% CI between the 2 methods was -10.43 (-7.1 to -13.8) g/day, respectively (P < 0.001). Interclass correlation between these 2 methods was 0.24, P = 0.007. The difference between the 2 methods remained constant across different amounts of DPI.

Conclusion

The DPI estimated from S-PFRQ significantly correlated to that from PNA. However, the S-PFRQ method yielded a DPI value which was about 10 g of protein or 25% less than the PNA method. Despite this amount of difference, this S-PFRQ is user-friendly and could be used during field work as an easy and simple tool for DPI estimation in resource-limiting condition.

Study of left ventricular systolic dysfunction, left ventricular diastolic dysfunction and pulmonary hypertension in CKD 3b-5ND patients-A single centre cross-sectional study

INTRODUCTION

Cardiovascular diseases are associated with increased morbidity and mortality among CKD (chronic kidney disease) population. Recent studies have found increasing prevalence of PH (pulmonary hypertension) in CKD population. Present study was done to determine prevalence and predictors of LV (left ventricular) systolic dysfunction, LVDD (left ventricular diastolic dysfunction) and PH in CKD 3b-5ND (non-dialysis) patients.

METHODS

A cross sectional observational study was done from Jan/2020 to April/2021. CKD 3b-5ND patients aged ≥15 yrs were included. Transthoracic 2D (2 dimensional) echocardiography was done in all patients. PH was defined as if PASP (pulmonary artery systolic pressure) value above 35mm Hg, LV systolic dysfunction was defined as LVEF (left ventricular ejection fraction)≤50% and LVDD as E/e' ratio >14 respectively. Multivariate logistic regression model was done to determine the predictors.

RESULTS

A total of 378 patients were included in the study with 103 in stage 3b, 175 in stage 4 and 100 patients in stage 5ND. Prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%. Predictors of PH were duration of CKD, haemoglobin, serum 25-OH vitamin D, serum iPTH (intact parathyroid hormone) and serum albumin. Predictors of LVDD were duration of CKD and presence of arterial hypertension. Predictors of LV systolic dysfunction were eGFR (estimated glomerular filtration rate), duration of CKD, serum albumin and urine protein.

CONCLUSION

In our study of 378 CKD 3b-5ND patients prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%.

Optimising blood glucose control with portioned meal box in type 2 diabetes mellitus patients: a randomised control trial

Background

The impact of dietary factors on glycaemic control in type 2 diabetes mellitus (T2DM) is well established. However, the effectiveness of transforming portion control into a practical innovation for glycaemic control in T2DM has not yet been established for counselling in nutrition. The aim of this study was to compare the effect of general counselling in nutrition (GCN) and a portioned meal box (PMB) on fasting blood glucose, glycated haemoglobin (HbA1c) and body composition.

Methods

A randomised, parallel intervention trial was conducted over 12 weeks, with GCN: carbohydrate portion control concept by using food exchange lists (n = 25) and PMB: portioned meal box was set by energy requirements (n = 25).

Results

Both GCN and PMB demonstrated reductions in HbA1c levels at the 6th and 12th weeks compared to baseline. However, no significant difference in HbA1c was observed between GCN and PMB at either the 6th or 12th week. Using PMB at least four times a week significantly decreased HbA1c during the intervention period (p = 0.021 and p < 0.001 for weeks 6 and 12 when compared with baseline, respectively). Changes in body composition were observed: body weight decrease in PMB only, body fat decrease and constant muscle mass in both groups. Both methods tended to relieve hunger and increased satiety in both groups. The satisfaction evaluation showed that participants preferred to use PMB over GCN (p = 0.001). Additionally, participants consumed less energy, carbohydrate and fat in PMB (p = 0.001, p = 0.019, and p = 0.001, respectively) and less energy and fat in GCN (p = 0.006 and p = 0.001, respectively).

Conclusion

A better diet, either through GCN or PMB, can play an important role in improving dietary intake compliance and controlling blood glucose.

Renal Survival of Chronic Kidney Disease Patients in a Tertiary Referral Hospital in Malaysia

Chronic kidney disease (CKD) represents a major public health issue, which then progresses to end-stage renal disease (ESRD) sooner or later. This retrospective cohort study aimed to determine the renal survival time of CKD patients. In total, 247 CKD patients in one of the tertiary referral hospitals in Malaysia between January 2005 and December 2015 were enrolled. All CKD patients were included if they were dependent on dialysis. Patients who were transferred out and those with incomplete records were excluded from the study. The renal survival time was calculated from the time of the first diagnosis of CKD to a confirmed ESRD diagnosis or the use of dialysis. In total, 193 (78.1%) CKD patients progressed to ESRD. The mean age of the ESRD patients was 53 years old. The majority of ESRD patients were male (57.0%) and of Malay ethnicity (89.6%). The most common comorbidities among ESRD patients were hypertension (92.2%) and diabetes mellitus (85.5%). The majority of patients were in Stage IV and V (97.9%). The overall renal survival time of CKD patients who develop ESRD was 26 months (95% confidence interval: 20.41, 31.59). Patients who smoked (P = 0.001), had hyperlipidemia (P <0.001) and consumed lipid-lowering agents (P = 0.004) had a significant P-value in the log-rank test. The progression of CKD from diagnosis to ESRD was within 2 years. Therefore, early recognition of CKD is important to improve patients' outcomes and prolong their renal survival time.

Modelling the potential public health impact of different vaccination strategies with an omicron-adapted bivalent vaccine in Thailand

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing COVID-19 has continuously evolved, requiring the development of adapted vaccines. This study estimated the impact of the introduction and increased coverage of an Omicron-adapted bivalent booster vaccine in Thailand.

RESEARCH DESIGN AND METHODS

The outcomes of booster vaccination with an Omicron-adapted bivalent vaccine versus no booster vaccination were estimated using a combined cohort Markov decision tree model. The population was stratified into high- and standard-risk subpopulations. Using age-specific inputs informed by published sources, the model estimated health (case numbers, hospitalizations, and deaths) and economic (medical costs and productivity losses) outcomes in different age and risk subpopulations.

RESULTS

Booster vaccination in only the elderly and high-risk subpopulation was estimated to avert 97,596 cases 36,578 hospitalizations, 903 deaths, THB 3,119 million in direct medical costs, and THB 10,589 million in indirect medical costs. These benefits increased as vaccination was expanded to other subpopulations. Increasing the booster vaccination coverage to 75% of the standard-risk population averted more deaths (95%), hospitalizations (512%), infections (782%), direct costs (550%), and indirect costs (687%) compared to the base case.

CONCLUSIONS

Broader vaccination with an Omicron-adapted bivalent booster vaccine could have significant public health and economic benefits in Thailand.

Slight Changes in the Gut Microbiome in Early-stage Chronic Kidney Disease of Unknown Etiology

Gut dysbiosis and changes in short-chain fatty acids (SCFAs) occur in end-stage chronic kidney disease (CKD); however, the degree of these changes in the gut microbiome and serum SCFA profiles in the early stages of CKD,‍ ‍particularly in‍ ‍CKD‍ ‍of unknown etiology (CKDu), is unclear. We herein investigated the gut microbiome and SCFA profiles of early-stage CKD patients (CKD stages 1-3) in a community in Khon Kaen Province, Thailand. Seventy-two parasite-free participants were distributed among a healthy control group (HC, n=18) and three patient groups (an underlying disease group [UD, n=18], early-stage CKD with underlying disease [CKD-UD, n=18], and early-stage CKD of unknown etiology, [CKDu, n=18]). Fecal DNA was individually extracted and pooled for groups of six individuals (three pools in each group) to examine the composition of the gut microbiome using next-generation sequencing. A SCFA ana-lysis was performed on serum samples from each individual using gas chromatography-mass spectrometry. The results revealed that microbial abundance differed between the healthy group and all patient groups (UD, CKD-UD, and CKDu). [Eubacterium]_coprostanoligenes_group was more abundant in the CKDu group than in the HC and CKD-UD groups. Furthermore, serum concentrations of acetate, a major SCFA component, were significantly lower in all patient groups than in the HC group. The present results indicate that minor changes in the gut microbiome and a significant decrease in serum acetate concentrations occur in early-stage CKDu, which may be important for the development of prevention strategies for CKD patients.

Associations between co-exposure to multiple metals and renal function: a cross-sectional study in Guangxi, China

The association between co-exposure to multiple metals and renal function is poorly understood. We aimed to evaluate the individual and joint effects of metal exposure on renal function in this study. We performed a cross-sectional study including 5828 participants in Guangxi, China, in 2019. Urine concentrations of 17 metals were detected by inductively coupled plasma mass spectrometry (ICP-MS). Logistic regression model and restricted cubic spline (RCS) were applied to investigate the association of individual metal exposure with renal dysfunction. Weighted quantile sum (WQS) regression and Bayesian kernel machine regression (BKMR) were used to assess the co-exposure effects of the metals. Participants with the highest quartile of urinary Cu were at 1.84-fold (95% confidence interval (CI): 1.20-2.87) increased risk of renal dysfunction compared with the lowest quartile. The highest quartiles of urinary Sr, Cs, V, Ba, and Se were associated with 0.27-fold (95% CI: 0.17-0.43), 0.33 (95% CI: 0.19-0.53), 0.41 (95% CI: 0.25-0.65), 0.58 (95% CI: 0.36-0.90), and 0.33 (95% CI: 0.19-0.56) decreased risk of renal dysfunction compared with their lowest quartile, respectively. Furthermore, urinary Ba and Cu were non-linearly correlated with renal dysfunction. The WQS analysis showed that mixed metal exposure was inversely associated with renal dysfunction (OR = 0.47, 95% CI: 0.35-0.62), and Sr accounted for the largest weight (52.2%), followed by Cs (32.3%) in the association. Moreover, we observed a potential interaction between Cu, Cs, and Ba for renal dysfunction in BKMR model. Exposure to Se, Sr, Cs, V, and Ba is associated with decreased risk of renal dysfunction, whereas an increased risk is associated with Cu exposure. Co-exposure to these metals is negatively associated with renal dysfunction, and Sr and Cs are the main contributors to the associations.

Association of low cadmium and mercury exposure with chronic kidney disease among Chinese adults aged ≥80 years: A cross-sectional study

BACKGROUND

The heavy metals cadmium (Cd) and mercury (Hg) are known to be widespread environmental contaminants and high occupational exposure adversely affects the risk of chronic kidney disease (CKD). However, evidence from epidemiological studies linking low Cd and Hg exposure (or non-industrial) to the risk of progression to CKD are conflicting. This study aimed to explore the association of low Cd and Hg exposure with the risk of CKD in Chinese adults aged ≥80 years.

METHODS

The participants were recruited for the Healthy Aging and Biomarkers Cohort Study in 2017, an ongoing perspective survey conducted in longevity areas in China initially involving 3016 older adults. We used logistic regression models to estimate odds ratios (ORs) with 95% confidence intervals of CKD setting Cd and Hg as categorical variables. Logistic regression with restricted cubic spline was used to characterize a dose-response relationships between Cd or Hg concentrations and the risk of CKD in the study population.

RESULTS

The ORs for the risk of CKD comparing the fourth to the first quartile of blood Cd, blood Hg, urine Cd, and urine Hg were 1.77, 1.57, 2.03, and 1.50, respectively. Restricted cubic spline models showed that blood Cd and urine Hg were significantly linearly correlated with the risk of CKD, while blood Hg and urine Cd were non-linearly correlated with the risk of CKD with a steeper slope at concentrations <2.30 μg/L and 3.30 μg/g creatinine.

CONCLUSIONS

Our findings suggest that even low Cd and Hg exposure (or non-industrial) were associated with increased risk of CKD in Chinese oldest old, although we did not find a significant multiplicative and additive interaction between Cd and Hg levels in relation to the risk of CKD.

Gender-associated cardiometabolic risk profiles and health behaviors in patients with type 2 diabetes: a cross-sectional analysis of the Joint Asia Diabetes Evaluation (JADE) program

Background

In Asia, diabetes-associated death due to cardiorenal diseases were 2-3 times higher in women than men which might be due to gender disparity in quality of care and health habits.

Methods

Adults with type 2 diabetes (T2D) from 11 Asian countries/areas were assessed using the same protocol (2007-2015). We compared treatment target attainment (HbA_1c < 7%, blood pressure [BP] < 130/80 mmHg, risk-based LDL-cholesterol, lack of central obesity [waist circumference <90 cm in men or <80 cm in women), use of cardiorenal-protective drugs (renin-angiotensin system [RAS] inhibitors, statins), and self-reported health habits including self-monitoring blood glucose (SMBG) by gender. Analyses were stratified by countries/areas, age of natural menopause (<50 vs. ≥50 years), and comorbidities (atherosclerotic cardiovascular disease [ASCVD], heart failure, kidney impairment [eGFR < 60 mL/min/1.73 m²]).

Findings

Among 106,376 patients (53.2% men; median (interquartile range) diabetes duration: 6.0 (2.0-12.0) years; mean ± SD HbA_1c 8.0 ± 1.9%; 27% insulin-treated), women were older and less likely to receive college education than men (28.9% vs. 48.8%). Women were less likely to smoke/drink alcohol and were physically less active than men. Women had lower BP (<130/80 mmHg: 29.4% vs. 25.7%), less general obesity (54.8% vs. 57.8%) but more central obesity than men (77.5% vs. 57.3%). Women were less likely to have ASCVD (12.8% vs. 17.0%) or heart failure (1.3% vs. 2.3%), but more likely to have kidney impairment (22.3% vs. 17.6%) and any-site cancer than men (2.5% vs. 1.6%). In most countries/areas, more men attained HbA_1c <7% and risk-based LDL-cholesterol level than women. After adjusting for potential confounders including countries and centres, men had 1.63 odds ratio (95% CI 1.51, 1.74) of attaining ≥3 treatment targets than women.

Interpretation

Asian women with T2D had worse quality of care than men especially in middle-income countries/areas, calling for targeted implementation programs to close these care gaps.

Sponsor

Asia Diabetes Foundation.

Funding

Nil.

Urinary neutrophil gelatinase‐associated lipocalin: A novel biomarker for predicting chronic kidney disease in patients with nonalcoholic fatty liver disease

Aims

Nonalcoholic fatty liver disease (NAFLD) and chronic kidney disease (CKD) are common diseases worldwide. Reports of a high prevalence of CKD in NAFLD patients have been documented. Urinary neutrophil gelatinase‐associated lipocalin (NGAL) is a reliable biomarker for renal dysfunction, and it is recommended for early detection of acute kidney injury (AKI) in cirrhotic patients. Currently, there is no evidence for using urine NGAL to predict CKD in NAFLD patients. We aim to determine the proportion of CKD and identify the predictive value of NGAL and other factors associated with CKD in these patients.

Methods

A single‐center, cross‐sectional study was conducted between July 2018 and December 2019 in consecutive NAFLD patients diagnosed by transient elastography (TE) or liver biopsy at a tertiary care university hospital in Bangkok, Thailand. Advanced liver fibrosis is defined as fibrosis stages 3–4. The definition of CKD is estimated glomerular filtration rate (eGFR) <60 ml⋅min−1⋅1.73 m−2 based on the Kidney Disease Improving Global Outcomes (KDIGO) guideline 2012. Urine NGAL level was measured by enzyme linked immunosorbent assay technique.

Results

A total of 101 NAFLD patients were included with a mean age of 54 ± 16 years. Among these patients, 14 (13.9%), 13 (12.9%), and 32 (31.7%) had fibrosis stages 2, 3, and 4, respectively. Nine percent (9 of 101) of patients with NAFLD with a mean eGFR of 42.66 ± 17.42 ml⋅min−1⋅1.73 m−2. The statistically significant factors associated with CKD were a higher level of urine NGAL (55.1 [25.15–150.60] vs. 15.1 [9.67–25.15] ng/ml; p = 0.006), a higher level of TE (17.3 [6.85–46.20] vs. 7.7 [5.6–11.7] kPa; p = 0.038), and a presence of advanced fibrosis (77.8% vs. 40.7%; p = 0.041), compared to those without CKD. Urine NGAL was the only significant factor associated with CKD in NAFLD patients. The cutoff level of urine NGAL at 36.75 ng/ml showed odds ratio of 21.27 (95% CI: 3.97–113.82; p < 0.001) and 1.02 (95% CI: 1.00–1.04; p = 0.024) by univariate and multivariate analyses, respectively. The selected urine NGAL cutoff demonstrated a sensitivity and specificity of 77.8% and 85.9% for predicting CKD, respectively.

Conclusions

The proportion of CKD in NAFLD patients was 9% and the presence of advanced fibrosis was a significant risk factor associated with CKD. Additionally, urine NGAL was significantly associated with CKD in NAFLD patients using a cutoff level of 36.75 ng/ml for predicting CKD with acceptable sensitivity and specificity. A larger prospective cohort study is needed to validate our findings.

Optimal Time for Recirculation with Ultrafiltration to Remove Disinfectant in Reused Dialyzer

The practice of dialyzer reuse is common in developing countries. One essential technique for safe dialyzer reprocessing is to remove disinfectants properly to the recommended standards before treatment initiation, using dialysis machine recirculation with ultrafiltration. This study was conducted to identify the most effective time for carrying out this procedure, and the factors affecting it. We studied 420 high-flux dialyzers with three different membrane types: FB210U (cellulose triacetate), F80S (polysulfone), and Elisio-210HR (polyethersulfone) at four reused cycles (5th, 10th, 15th, and 19th). Peracetic acid was used as the disinfectant at a concentration of 0.16%. The total cell volume (TCV) and clot inspection grade of the reused dialyzer were recorded before the procedure. The optimal time for disinfectant removal was independently determined by two observers using the residual peroxide strip test of the ultrafiltrate. We observed that disinfectant removal was dependent on the recirculation time and became undetectable at 5 minutes. The type of dialyzer had a significant effect on the effective recirculation time (shortest for FB210U followed by Elisio-210HR and F80S; p < 0.001), but the reused number, TCV, and clot inspection grade did not. It is conceivable that the dialyzer membrane type might affect peracetic acid removal. In conclusion, the interval for carrying out dialysis machine recirculation with ultrafiltration depends on the dialyzer type, and 5 minutes is the optimal time for the operation. This result can be implemented to improve further practice in dialyzer reprocessing.

High prevalence of chronic kidney disease and its related risk factors in rural areas of Northeast Thailand

In Thailand, chronic kidney disease (CKD) screening was reported in 2009 with an overall prevalence of 17.5% and the highest at 22.2% in the northeastern region. This study aimed to find out CKD prevalence of the Kidney Disease Improving Global Outcomes criteria and their related risk factors in the rural community. A population-based study was conducted in the rural sub-districts of northeastern Thailand. Data of socio-demographic status, lifestyle, underlying diseases, blood pressure, and body mass index were recorded. Blood and urine analysis was conducted along with ultrasonography of kidneys. Specimen collection and analyses were repeated after 3 months, and the factors associated with CKD were studied by logistic regression analysis. A total of 2205 participants with a mean age of 57.8 ± 11.7 years and female predominance (66.7%) completed the study. The prevalence of CKD was 26.8%, i.e., stages 1 (7.3%); stage 2 (9.0%); stage 3a (6.0%); stage 3b (2.8%); stage 4 (1.4%); and stage 5 (0.3%). Hypertension, diabetes mellitus, and renal stones were the major underlying diseases. Only 3.5% of the participants were aware of having CKD. An increase in age, male, unemployment, current smoking, diabetes, hypertension, underweight, anemia, hyperuricemia, and leukocytosis were significantly associated factors with the disease. The study revealed that CKD has developed as a significant public health problem in rural northeastern Thailand and one out of every four people has CKD. Therefore, early interventions are essential for the proper management and prevention of CKD.

Prevalence and Risk Factors of Urolithiasis Among the Population of Hail, Saudi Arabia

Background Urolithiasis is the formation of calculi in the urinary system. It is a public health concern worldwide that can lead to serious long-term consequences. Age, gender, dietary habits, and physical activity levels are all factors that increase the risk of urolithiasis formation. Furthermore, the presence of comorbid medical conditions such as diabetes and hypertension are other major risk factors. Among the most prominent determinants that raise the likelihood of acquiring urolithiasis is exposure to high temperatures, especially in middle-aged men. Consequently, Saudi residents are two and a half times more prone than the global average to develop urolithiasis, especially those in the Kingdom's hottest regions. Methodology This cross-sectional study assessed the self-reported prevalence and non-nutritional risk factors of urolithiasis among the population of Hail, Saudi Arabia, through an electronic questionnaire. The questionnaire contained 16 questions divided into three categories. Participants' permission was obtained before completing the questionnaire. The Statistical Package for Social Sciences (SPSS) version 22 (IBM Corp., Armonk, NY, USA) was used to analyze the data. Results Of the 1150 participants with a mean age of 26.3 ± 12.8 years old, nearly half were males (50.9%). Urolithiasis was detected among 158 (13.7%) participants. The following factors showed significant relation with having urolithiasis: increased age, male gender, a low level of education, diabetes, hypertension, and hyperthyroidism. A family history of renal stones was also associated with double the risk of having urolithiasis. Conclusion The results showed a high prevalence of urolithiasis in the Hail region, with many risk factors associated with it. It is important to support and promote awareness campaigns that address the critical risk factors of urolithiasis. Further studies should be conducted to arrive at a better understanding of the association between non-nutritional risk factors and developing urolithiasis.

Prevalence and risk factors associated with chronic kidney disease in Nepal: evidence from a nationally representative population-based cross-sectional study

OBJECTIVE

This study aimed to determine population-based prevalence of chronic kidney disease (CKD) and its associated factors in Nepal.

STUDY DESIGN

The study was a nationwide population-based cross-sectional study.

SETTING AND PARTICIPANTS

Cross-sectional survey conducted in a nationally representative sample of 12 109 Nepalese adult from 2016 to 2018 on selected chronic non-communicable diseases was examined. Multistage cluster sampling with a mix of probability proportionate to size and systematic random sampling was used for the selection of individuals aged 20 years and above.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome in this study was population-based prevalence of CKD in Nepal. A participant was considered to have CKD if the urine albumin-to-creatinine ratio was greater than or equal to 30 mg/g and/or estimated glomerular filtration rate is less than 60 mL/min/1.73 m2 at baseline and in follow-up using modification of diet in renal disease study equations. The secondary outcome measure was factors associated with CKD in Nepal. The covariate adjusted association of risk factors and CKD was calculated using multivariable binary logistic regression.

RESULTS

The overall prevalence of CKD in Nepal was 6.0% (95% CI 5.5 to 6.6). Factors independently associated with CKD included older age (adjusted OR (AOR) 2.6, 95% CI 1.9 to 3.6), Dalit caste (AOR 1.6, 95% CI 1.1 to 2.3), hypertension (AOR 2.4, 95% CI 2.0 to 3.0), diabetes mellitus (AOR 3.2, 95% CI 2.5 to 4.1), raised total cholesterol (AOR 1.3, 95% CI 1.0 to 1.6) and increased waist-to-hip ratio (AOR 1.6, 95% CI 1.2 to 2.3).

CONCLUSION

This nationally representative study shows that the prevalence of CKD in the adult population of Nepal is substantial, and it is independently associated with several cardiometabolic traits. These findings warrant longitudinal studies to identify the causes of CKD in Nepal and effective strategies to prevent it.

Long-term air pollution exposure and decreased kidney function: A longitudinal cohort study in Bangkok Metropolitan Region, Thailand from 2002 to 2012

BACKGROUND

Kidney dysfunction is considered a cardiovascular risk factor. However, few longitudinal studies have examined the effects of air pollution on kidney function. We evaluated associations between long-term air pollution exposure and estimated glomerular filtration rate (eGFR) using data from a cohort of the Electricity Generating Authority of Thailand (EGAT) study in Bangkok Metropolitan Region, Thailand.

METHODS

This longitudinal study included 1839 subjects (aged 52-71 years in 2002) from the EGAT1 cohort study during 2002-2012. eGFR, based on creatinine, was measured in 2002, 2007, and 2012. Annual mean concentrations of air pollutants (i.e., particulate matter with an aerodynamic diameter ≤10 μm (PM₁₀), ozone (O₃), nitrogen dioxide (NO₂), sulfur dioxide (SO₂), and carbon monoxide (CO)) prior to a measurement of creatinine were assessed with the ordinary kriging method. Mixed-effect linear regression models were used to assess associations between air pollutants and eGFR, while controlling for potential covariates. eGFR values are expressed as percent change per interquartile range (IQR) increments of each pollutant.

RESULTS

Lower eGFR was associated with higher concentrations of PM₁₀ (-1.99%, 95% confidence interval (CI): -3.33, -0.63), SO₂ (-4.89%, 95%CI: -6.69, -3.07), and CO (-0.97%, 95%CI: -1.96, 0.03). However, after adjusting for temperature, relative humidity, PM₁₀, and SO₂, no significant association was observed between CO and eGFR.

CONCLUSIONS

Our findings support the hypothesis that long-term exposure to high concentrations of PM₁₀ and SO₂ is associated with the progression of kidney dysfunction in subjects of the EGAT cohort study.

Women and other risk factors for chronic kidney disease of unknown etiology in Thailand: National Health Examination V Survey

There are limited data on chronic kidney disease of unknown etiology (CKDu) from Southeast Asia. Initially described in working age men, a common approach to detect CKDu that includes all adults has recently been proposed. We determined the prevalence, and risk factors for CKDu using data from a cross-sectional, nationally representative survey of the adult population of Thailand. We used a proxy for CKDu as age < 70 with impaired kidney function (eGFR < 60) in the absence of diabetes and hypertension (CKDu1) and heavy proteinuria (CKDu2). Prevalence estimates were probability-weighted for the Thai population. The associations between risk factors and CKDu or elderly subjects with eGFR < 60 without traditional causes were assessed by multivariable logistic regression. Of 17,329 subjects, the prevalence were: eGFR < 60, 5.3%; CKDu1 0.78%; CKDu2, 0.75%. CKDu differed by 4.3-folds between regions. Women, farmers/laborers, older age, gout, painkillers, rural area, and stones were independent risk factors for CKDu. Women, age, rural, gout, painkillers were significant risk factors for both CKDu and elderly subjects. These data collected using standardized methodology showed that the prevalence of CKDu in Thailand was low overall, although some regions had higher risk. Unlike other countries, Thai women had a two-fold higher risk of CKDu.

Quantification of CYP3A and Drug Transporters Activity in Healthy Young, Healthy Elderly and Chronic Kidney Disease Elderly Patients by a Microdose Cocktail Approach

Background: Ageing and chronic kidney disease (CKD) affect pharmacokinetic (PK) parameters. Since mechanisms are related and remain unclear, cytochrome P450 (CYP) 3A and drug transporter activities were investigated in the elderly with or without CKD and compared to healthy adults using a microdose cocktail. Methods: Healthy young participants (n = 20), healthy elderly participants (n = 16) and elderly patients with CKD (n = 17) received, in study period 1, a single dose of microdose cocktail probe containing 30 µg midazolam, 750 µg dabigatran etexilate, 100 µg atorvastatin, 10 µg pitavastatin, and 50 µg rosuvastatin. After a 14-day wash-out period, healthy young participants continued to study period 2 with the microdose cocktail plus rifampicin. PK parameters including area under the plasma concentration-time curve (AUC), maximum plasma drug concentration (C_max), and half-life were estimated before making pairwise comparisons of geometric mean ratios (GMR) between groups. Results: AUC and C_max GMR (95% confidence interval; CI) of midazolam, a CYP3A probe substrate, were increased 2.30 (1.70-3.09) and 2.90 (2.16-3.88) fold in healthy elderly and elderly patients with CKD, respectively, together with a prolonged half-life. AUC and C_max GMR (95%CI) of atorvastatin, another CYP3A substrate, was increased 2.14 (1.52-3.02) fold in healthy elderly and 4.15 (2.98-5.79) fold in elderly patients with CKD, indicating decreased CYP3A activity related to ageing. Associated AUC changes in the probe drug whose activity could be modified by intestinal P-glycoprotein (P-gp) activity, dabigatran etexilate, were observed in patients with CKD. However, whether the activity of pitavastatin and rosuvastatin is modified by organic anion transporting polypeptide 1B (OATP1B) and of breast cancer resistance protein (BCRP), respectively, in elderly participants with or without CKD was inconclusive. Conclusions: CYP3A activity is reduced in ageing. Intestinal P-gp function might be affected by CKD, but further confirmation appears warranted. Clinical Trial Registration:http://www.thaiclinicaltrials.org/ (TCTR 20180312002 registered on March 07, 2018).

Specification and DNA Barcoding of Thai Traditional Remedy for Chronic Kidney Disease: Pikad Tri-phol-sa-mut-than

The Pikad Tri-phol-sa-mut-than (TS) remedy, a Thai traditional medicine, is officially recorded in Tamra Paetsart Sonkrau Chabub Anurak for its capabilities in treating kidney deficiency. TS remedy is composed of three fruit species—Aegle marmelos (L.) Corrêa., Coriandrum sativum L., and Morinda citrifolia L.—in an equal part by weight. The quality of the raw material is one of the essential factors that can affect the effectiveness and safety of treatment by herbal remedy. The pharmacognostic evaluation and DNA barcode of the three fruit species and TS remedy were performed in this study to authenticate them from contamination, and to provide the scientific database for further uses. Macroscopic and microscopic examination, chemical profile by TLC, and DNA barcoding were employed to positively identify the raw materials bought from the herbal market, especially the powder form. Consequently, the outcomes of this investigation can be used to develop an essential and effective tool for the authentication of crude drugs and herbal remedies.

Opisthorchis viverrini Infection Induces Metabolic and Fecal Microbial Disturbances in Association with Liver and Kidney Pathologies in Hamsters

Opisthorchis viverrini (Ov) infection causes hepatobiliary diseases and is a major risk factor for cholangiocarcinoma. While several omics approaches have been employed to understand the pathogenesis of opisthorchiasis, effects of Ov infection on the host systemic metabolism and fecal microbiota have not been fully explored. Here, we used a ¹H NMR spectroscopy-based metabolic phenotyping approach to investigate Ov infection-induced metabolic disturbances at both the acute (1 month postinfection, 1 mpi) and chronic (4 mpi) stages in hamsters. A total of 22, 3, and 4 metabolites were found to be significantly different in the liver, serum, and urine, respectively, between Ov+ and Ov- groups. Elevated levels of hepatic amino acids and tricarboxylic acid (TCA)-cycle intermediates (fumarate and malate) were co-observed with liver injury in acute infection, whereas fibrosis-associated metabolites (e.g., glycine and glutamate) increased at the chronic infection stage. Lower levels of lipid signals ((CH₂)_n and CH₂CH₂CO) and higher levels of lysine and scyllo-inositol were observed in serum from Ov+ hamsters at 1 mpi compared to Ov- controls. Urinary levels of phenylacetylglycine (a host-bacterial cometabolite) and tauro-β-muricholic acid were higher in the Ov+ group, which coexisted with hepatic and mild kidney fibrosis. Furthermore, Ov+ animals showed higher relative abundances of fecal Methanobrevibacter (Archaea), Akkermansia, and Burkholderia-Paraburkholderia compared to the noninfected controls. In conclusion, along with liver and kidney pathologies, O. viverrini infection resulted in hepatic and mild renal pathologies, disturbed hepatic amino acid metabolism and the TCA cycle, and induced changes in the fecal microbial composition and urinary host-microbial cometabolism. This study provides the initial step toward an understanding of local and systemic metabolic responses of the host to O. viverrini infection.

Depression and low physical activity are related to sarcopenia in hemodialysis: a single-center study

BACKGROUND

The number of patients who suffer from chronic renal failure (CRF) has widely increased worldwide. Patients with advanced stages of CRF experience a gradual and progressive loss of muscle and fat mass leading to decreased physical activity and mental health problems. The loss of muscle mass in CRF might contribute to the development of sarcopenia. Therefore, this study aimed to explore the prevalence of sarcopenia and to determine the relationship of physical activity and mental state of depression with sarcopenia in hemodialysis patients.

METHODS

A cross-sectional study was designed with a total of 104 male and female with a minimum age of 35 years. Based on the guidelines of the Asian Working Group for Sarcopenia in 2019, gait speed, muscle mass, and handgrip were used to define sarcopenia. In addition, participants were requested to perform a set of questionnaires to evaluate their physical activity and state of depression. Logistic regression analyses were used to explore the risk factors of sarcopenia.

RESULTS

Thirty-four (32.69%) of 104 participants had sarcopenia. Compared to the 70 individuals without sarcopenia, they had a low physical activity and a high depression score (ps < .05). Furthermore, low physical activity and high depression scores in combination with sarcopenia were associated with an increased mortality risk. Low physical activity and high depression scores were also independently associated with sarcopenia in hemodialysis patients after controlling for age (odds ratio = 3.23, and 4.92, respectively).

Hyperuricemia, urate-lowering therapy, and kidney outcomes: a systematic review and meta-analysis

BACKGROUND

Contradictory evidence exists for association of hyperuricemia and kidney function. To investigate the association of hyperuricemia and kidney function decline (hyperuricemia question) and effect of urate-lowering therapies (ULTs) on kidney function (ULT question), we performed a systematic review and meta-analysis.

METHODS

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and CINAHL were searched from inception to July 2020. We selected observational studies for the hyperuricemia question and controlled trials for the ULT question. Two investigators independently assessed study eligibility and abstracted the data. Risk of bias was assessed using the Newcastle-Ottawa Scale and Cochrane risk of bias tool. Meta-analysis was done using the inverse variance method and random effect model. We estimated odds ratio (OR), hazard ratio (HR), risk ratio (RR), and the mean difference (MD). Evidence certainty was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

Of 12,037 studies screened, 131 studies with 3,414,226 patients were included. Hyperuricemia was associated with a significant risk of rapid estimated glomerula filtration rate (eGFR) decline ⩾3 ml/min per 1.73 m2 per year (OR 1.38, 95% CI 1.20-1.59; low certainty), albuminuria (OR/HR 1.94, 95% CI 1.34-2.79; very low certainty), chronic kidney disease (OR/HR 2.13, 95% CI 1.74-2.61; very low certainty), and kidney failure (HR 1.53, 95% CI 1.18-1.99; very low certainty). Compared with control, ULT use for ⩾1 year was associated with significantly more improved eGFR (MD 1.81 ml/min per 1.73 m2, 95% CI 0.26-3.35; very low certainty), serum creatinine (MD -0.33 mg/dl, 95% CI -0.47 to -0.19; low certainty), and proteinuria (MD -5.44 mg/day, 95% CI -8.49 to -2.39; low certainty), but no difference in kidney failure.

CONCLUSION

Hyperuricemia is associated with worsening eGFR, albuminuria, chronic kidney disease, and kidney failure. ULT use for ⩾1 year may improve kidney function.

REGISTRATION

The protocol was registered at PROSPERO database, CRD42015013859.

Effectiveness of integrated care on delaying chronic kidney disease progression in rural communities of Thailand (ESCORT-2) trials

AIM

We conducted a prospective cohort study to evaluate the effectiveness of an integrated care model on delaying chronic kidney disease (CKD) progression in routine clinical practice in rural primary care setting.

METHODS

After enrolment, patients with stages 3 to 4 CKD patients from five district hospitals in a northern province of Thailand (400 km from Bangkok) received integrated care comprising hospital multidisciplinary care and home visits by community care teams. Clinical characteristics and biochemical data were collected at baseline and every 3-month interval thereafter for 36 months. The primary outcome was the rate of estimated glomerular filtration rate (eGFR) decline.

RESULTS

Nine hundred and fourteen stage -3 and - 4 CKD patients were enrolled. The mean age of our cohort was 62 years. Diabetic kidney disease (DKD) was the main cause of CKD (53%) whereas hypertension was the most common co-morbidity (92%). The mean rate of eGFR decline was -0.92 mL/min/1.73 m2 /year. The rate of eGFR decline among patients with DKD was about three times faster than patients without DKD. Patients with higher blood pressure, metabolic acidosis, proteinuria or anaemia had a faster rate of eGFR decline.

CONCLUSION

This integrated care model at the community level was effective in delaying CKD progression in routine clinical practice situation.

Development and validation of point-of-care testing of albuminuria for early screening of chronic kidney disease

INTRODUCTION

Chronic kidney disease (CKD) is a significant global health issue. As the prevalence of renal replacement therapy (RRT) in Thailand is increasing, early detection and management of CKD is the most important step to prevent CKD progression and the need for RRT. Current diagnostic tests for CKD are non-specific and expensive. We aimed to develop and validate antibody-based-albumin point-of-care testing (POCT) to detect patients with impaired kidney function at early stage.

METHODS

The prototype strip test was developed under the concept of competitive lateral flow immunochromatography assay, or strip test. Monoclonal antibodies (MAbs) to human serum albumin (HSA) were harvested from the hybridomas of spleen cells from immunized mice and mouse myeloma cells. Presence of MAbs was detected by enzyme-linked immunosorbent assay (ELISA). Spot urine was obtained from patients with kidney disease, type I, or type II Diabetes Mellitus upon their visit at King Chulalongkorn Memorial Hospital during 2018-2019. All samples were analyzed for urine albumin with our POCT (CU microalbumin) and the other two commercial POCTs (Microalbu PHAN and MICRAL). The results were validated against standard method for urine microalbumin measurement. A urine microalbumin concentration of less than 20 ug/ml was defined as normal. The sensitivity, specificity, and predictive values were calculated in comparison with the standard laboratory method.

RESULT

A total of 100 adult patients were included. CU microalbumin had a sensitivity of 86%, a specificity of 94%, and a positive predictive value of 96%. Our POCT showed good correlation with the laboratory results.

CONCLUSION

CU microalbumin correlated well with the standard method for quantitative measurement of urine albumin. Therefore, it has the potential for early screening of CKD, especially in primary health care facilities in resource limited settings.

Development and Validation of a Chronic Kidney Disease Prediction Model for Type 2 Diabetes Mellitus in Thailand

OBJECTIVES

The objective of this study was to investigate predictors and develop risk equations for stage-3 chronic kidney disease (CKD) in Thai patients with type 2 diabetes mellitus (DM).

METHODS

A retrospective cohort study was conducted in patients with type 2 DM. The outcome was the development of stage-3 CKD. The data set was randomly split into training and validation data sets. Cox proportional hazard regression was used for model development. Discrimination (Harrell's C statistic) and calibration (the Hosmer-Lemeshow chi-square test and survival probability curve) were applied to evaluate model performance.

RESULTS

In total, 2178 type 2 DM patients without stage-3 CKD, visiting the hospital from January 1, 2008, to December 31, 2017, were recruited, with median follow-up time of 1.29 years (interquartile range, 0.5-2.5 years); 385 (17.68%) subjects had developed stage-3 CKD. The final predictors included age, male sex, urinary albumin to creatinine ratio, estimated glomerular filtration rate, and hemoglobin A1c. Two 3-year stage-3 CKD risk models, model 1 (laboratory model) and model 2 (simplified model), had the C statistic in validation data sets of 0.890 and 0.812, respectively.

CONCLUSIONS

Two 3-year stage-3 CKD risk models were developed for Thai patients with type 2 DM. Both models have good discrimination and calibration. These stage-3 CKD prediction models could equip health providers with tools for clinical management and supporting patient education.

The changing patterns of access overtime to the renal replacement therapy programme in Thailand

Based on projected numbers, approximately only 50% of those requiring renal replacement therapy (RRT) receive it. Many patients who require RRT live in low- and middle-income countries. The objective of this study was to examine the changing pattern over time of entry into the RRT programme in Thailand following RRT's inclusion in the Universal Coverage Scheme. This study was an ecological study using the age-period-cohort analysis to look at dialysis registration and kidney transplant trends during RRT programme implementation. Data from 2008 to 2016 of patients diagnosed with end-stage renal disease (ESRD) were obtained from the National Health Security Office. The study found that the numbers of new patients with ESRD, aged 20-69, registered with the dialysis programme increased over time. For patients aged 20-40 years, the dialysis programme took up to 400 new patients for every 1000 new ESRD diagnoses. For kidney transplant, the rates increased slowly. The kidney transplant programme could at best treat only around 50 cases for every 1000 new ESRD diagnoses in patients aged 20-30 years. Findings of this study highlighted the importance of promoting strategies to reduce the increasing number of patients with kidney disease, to consider conservative therapy for older/frail patients, and to improve access to kidney transplantation and live-donation.

Plasma element levels and risk of chronic kidney disease in elderly populations (≥ 90 Years old)

Associations between plasma elements and chronic kidney disease (CKD) among the elderly are poorly understood. In this cross-sectional study, we explored the associations between exposure to four plasma elements and CKD in elderly people aged ≥90 years in longevity areas in China. We measured plasma selenium, manganese, iron, and zinc levels and used logistic regression models to investigate associations between CKD and these four plasma elements after adjusting for confounding factors among 461 participants aged ≥90 years in the fifth wave of the Chinese Longitudinal Healthy Longevity Study (CLHLS) conducted in 2009. The median plasma selenium, manganese, iron, and zinc levels were 120.51 μg/L, 26.64 μg/L, 2880.52 μg/L, and 1882.42 μg/L in the CKD group and 108.76 μg/L, 31.55 μg/L, 4512.00 μg/L, and 2294.24 μg/L in the non-CKD group, respectively. Single- and multiple-element multivariable models showed that plasma manganese, iron, and zinc were negatively associated with CKD. In the multiple-element multivariable models, the adjusted odds ratios for CKD were 0.48 (95% confidence interval [CI]: 0.27-0.86) for the second highest quartile of manganese, 0.37 (95% CI: 0.21-0.68) and 0.36 (95% CI: 0.19-0.65) for the third highest and highest quartiles of iron, respectively, and 0.53 (95% CI: 0.29-0.94) for the highest quartile of zinc, compared with the lowest quartiles of these three elements. Plasma manganese, iron, and zinc levels protect against CKD in elderly people aged ≥90 years in longevity areas.

CKDNET, a quality improvement project for prevention and reduction of chronic kidney disease in the Northeast Thailand

BACKGROUND

The incidence of chronic kidney disease (CKD) is high in the Northeast Thailand compared to other parts of the country. Therefore, a broad program applying all levels of care is inevitable. This paper describes the results of the first year trial of the Chronic Kidney Disease Prevention in the Northeast Thailand (CKDNET), a quality improvement project collaboratively established to curb CKD.

METHODS

We have covered general population, high risk persons and all stages of CKD patients with expansive strategies such as early screening, effective CKD registry, prevention and CKD comprehensive care models including cost effectiveness analysis.

RESULTS

The preliminary results from CKD screening in general population of two rural sub-districts show that 26.8% of the screened population has CKD and 28.9% of CKD patients are of unknown etiology. We have established the CKD registry that has enlisted a total of 10.4 million individuals till date, of which 0.13 million are confirmed to have CKD. Pamphlets, posters, brochures and other media of 94 different types in the total number of 478,450 has been distributed for CKD education and awareness at the community level. A CKD guideline that suits for local situation has been formulated to deal the problem effectively and improve care. Moreover, our multidisciplinary intervention and self-management supports were effective in improving glomerular filtration rate (49.57 versus 46.23 ml/min/1.73 m2; p < 0.05), blood pressure (129.6/76.1 versus 135.8/83.6 mmHg) and quality of life of CKD patients included in the program compared to those of the patients under conventional care. The cost effectiveness analysis revealed that lifetime cost for the comprehensive health services under the CKDNET program was 486,898 Baht compared to that of the usual care of 479,386 Baht, resulting in an incremental-cost effectiveness ratio of 18,702 Baht per quality-adjusted life years gained.

CONCLUSION

CKDNET, a quality improvement project of the holistic approach is currently applying to the population in the Northeast Thailand which will facilitate curtailing of CKD burden in the region.

Prevalence of chronic kidney disease and its associated factors in Malaysia; findings from a nationwide population-based cross-sectional study

Background

The prevalence of chronic kidney disease (CKD) in Malaysia was 9.07% in 2011. We aim to determine the current CKD prevalence in Malaysia and its associated risk factors.

Methods

A population-based study was conducted on a total of 890 respondents who were representative of the adult population in Malaysia, i.e., aged ≥18 years old. Respondents were randomly selected using a stratified cluster method. The estimated glomerular filtration rate (eGFR) was estimated from calibrated serum creatinine using the CKD-EPI equation. CKD was defined as eGFR < 60 ml/min/1.73m² or the presence of persistent albuminuria if eGFR ≥60 ml/min/1.73m².

Results

Our study shows that the prevalence of CKD in Malaysia was 15.48% (95% CI: 12.30, 19.31) in 2018, an increase compared to the year 2011 when the prevalence of CKD was 9.07%. An estimated 3.85% had stage 1 CKD, 4.82% had stage 2 CKD, and 6.48% had stage 3 CKD, while 0.33% had stage 4–5 CKD. Hypertension (aOR 3.72), diabetes mellitus (aOR 3.32), increasing BMI (aOR 1.06), and increasing age (aOR 1.06) were significantly associated with CKD.

Conclusion

Our study has shown that CKD has become one of the leading public health issues in Malaysia. Thus, there is an urgent need to screen for CKD and prevent its progression, associated morbidity, and mortality at the national level.

A single center's experience in pediatric cystine stone disease management: what changed over time?

The authors aimed to evaluate the factors affecting clinical outcomes of cystine stone disease in children and to understand the change in disease management over time. Between January 1991 and September 2017, the demographic and clinical data of pediatric patients with documented cystine stone disease were retrospectively analyzed. Patients with at least 12-month follow-up were included. Disease management and clinical outcomes were compared between the first and second 35 patients managed during the study's time frame. A total of 70 patients were included. The female to male ratio was 30/40. The mean age and follow-up period was 29.8 ± 40.1 months and 106.5 ± 56 months, respectively. The mean initial procedure number to treat the first stone episode was 2.4 ± 1.6. Single stone and single affected site were significant predictors for stone clearance. Overall, patients underwent a mean of 5.5 procedure during their follow-up. Recurrence was detected in 71.4% (50/70) of patients. Residual fragments and non-compliance to medical treatment after the initial intervention were significant predictors for recurrence within shorter interval period. 31.4% (22/70) of patients had renal atrophy during follow-up. They were older at the initial diagnosis and had average urine pH lower than 7.5. The first 35 patients had more open procedures. Still, they had more recurrence rate and tend to have more renal atrophy. As a conclusion, cystine stone disease has a recurrent course in children. Stone and fragments entirely removed (SaFER) concept with all minimally invasive methods available and strict follow-up should be the basis for any management plan.

Long-term effects of socioeconomic status on the incidence of decreased glomerular filtration rate in a Southeast Asian cohort

BACKGROUND

There is limited information on the role of low socioeconomic status (SES) in the development of new chronic kidney disease (CKD) in the general population, especially from developing countries. This study will test the hypothesis that low SES increases the risk of incidence of decreased glomerular filtration rate (GFR, used as an estimate for CKD) in a Thai worker cohort.

METHOD

In this prospective, longitudinal observational study, we evaluated the association of income and educational attainment on incident decreased GFR (iGFR <60 mL/min/1.73 m²) over a 27-year period in employees of Electricity Generating Authority of Thailand. In 1985, subjects participated in a health survey and were re-examined in 1997, 2002, 2007 and 2012. Education was classified into three categories: low, 0-8th grade; medium, 9-12th grade; and high, >12th grade. Income was categorised as follows: low <10 000 Thai Baht (THB)/month; medium, 10 000-20 000 THB/month; and high, >20 000 THB/month. HRs of iGFR<60 mL/min/1.73 m² were estimated using Cox interval-censored models with high income or education as the reference groups after adjustments for clinical risk factors.

RESULTS

Participants (n=3334) were followed for 23 (15, 27) years. When evaluated separately, both education and income were risk factors for iGFR<60 mL/min/1.73 m² (adjusted HR education: medium-1.26 (95% CI 1.13 to1.42) and low-1.57 (95% CI 1.36 to 1.81) and adjusted HR income: medium-1.21 (95% CI 0.97 to 1.50) and low-1.47 (95% CI 1.18 to 1.82)). When both income and education were included together, low and medium education remained independently associated with iGFR<60 mL/min/1.73 m².

CONCLUSIONS

Low education was independently associated with increased risk of decreased GFR in a Thai worker population. Strategies to identify risk factors among low SES may be useful to prevent early CKD.