Chronic kidney disease and cardiovascular risk in six regions of the world (ISN-KDDC): a cross-sectional study

Long-term incense use and the risk of end-stage renal disease among Chinese in Singapore: the Singapore Chinese health study

BACKGROUND

Experimental studies have shown that exposure to incense burning may have deleterious effects on kidney function and architecture. However, the association between chronic exposure to incense smoke and risk of end-stage renal disease (ESRD) has not been reported in epidemiologic studies.

METHODS

We investigated this association in the Singapore Chinese Health Study, a prospective population-based cohort of 63,257 Chinese men and women of 45-74 years of age in Singapore during recruitment from 1993 to 1998. Information on the practice of incense burning at home, diet, lifestyle and medical history was collected at baseline interviews. ESRD cases were identified through linkage with the nationwide Singapore Renal Registry through 2015. We used Cox proportional hazards regression analysis to estimate hazard ratio (HR) and 95% confidence interval (CI) of ESRD associated with domestic incense burning.

RESULTS

Among cohort participants, 76.9% were current incense users. After an average 17.5 years of follow-up, there were 1217 incident ESRD cases. Compared to never users, the multivariable-adjusted HR for ESRD risk was 1.05 (95% CI, 0.80 to 1.38) for former users and 1.26 (95% CI, 1.02 to1.57) for current users of incense. In analysis by daily or non-daily use and duration, the increased ESRD risk was observed in daily users who had used incense for > 20 years; HR was 1.25 (95% CI, 1.07 to 1.46). Conversely, the risk was not increased in those who did not use incense daily or who had used daily but for ≤20 years.

CONCLUSIONS

Our findings demonstrate that long-term daily exposure to domestic incense burning could be associated with a higher risk of ESRD in the general population.

Characteristics of Burden, Coping Strategies, and Quality of Life: The Effect of Age, Gender, and Social Variables in Caregivers of Renal Transplanted Patients from Southern Andhra Pradesh, India

Background:

Evaluation of burden, coping strategies, and quality of life (QOL) in caregivers may lead to specific interventions to reduce the burden among caregivers.

Methods:

In this prospective study, characteristics of burden, coping strategies, and QOL in caregivers was investigated and also studied the effect of age, gender, and social variables on these concepts.

Results:

Mean burden score of the caregivers was 28.66 ± 2.02. Thirty percent of caregivers had mild-to-moderate burden followed by moderate-to-severe burden (20%). Seeking social support was the dominant coping strategy used by the caregivers. Role limitations due to the physical health (RLDPH) and role limitations due to emotional problem (RLDEP) were compromised subscales of QOL. The mean score of RLDPH (P = 0.007) and RLDEP (P = 0.014) were found to be significantly higher in males than that of females. Marital status, education, type of relationship with the patient, religion, occupation, and duration of care giving showed significant effect on burden, coping strategies, and QOL. Lower emotional well-being (P = 0.003) and escape avoidance (P = 0.000) in males and lower physical component (PC) (P = 0.002) in females and lower PC (P = 0.000) and escape avoidance (P = 0.001) were found to be the significant predictors of burden in caregivers of renal transplanted patients.

Conclusion:

Predictors of burden and QOL subscales varies by gender. Social and clinical variables influence the QOL subscales. Gender- and social group-specific interventions rather than global interventions may reduce the burden of caregivers.

The Biological Role of Klotho Protein in the Development of Cardiovascular Diseases

Klotho is a membrane-bound or soluble antiaging protein, whose protective activity is essential for a proper function of many organs. In 1997, an accidental insertion of a transgene led to creation of transgenic mice with several age-related disorders. In Klotho-deficient mice, the inherited phenotypes closely resemble human aging, while in an animal model of Klotho overexpression, the lifespan is extended. Klotho protein is detected mainly in the kidneys and brain. It is a coreceptor for fibroblast growth factor and hence is involved in maintaining endocrine system homeostasis. Furthermore, an inhibition of insulin/insulin-like growth factor-1 signaling pathway by Klotho regulates oxidative stress and reduces cell death. The association between serum Klotho and the classic risk factors, as well as the clinical history of cardiovascular disease, was also shown. There are a lot of evidences that Klotho deficiency correlates with the occurrence and development of coronary artery disease, atherosclerosis, myocardial infarction, and left ventricular hypertrophy. Therefore, an involvement of Klotho in the signaling pathways and in regulation of a proper cell metabolism could be a crucial factor in the cardiac and vascular protection. It is also well established that Klotho protein enhances the antioxidative response via augmented production of superoxide dismutase and reduced generation of reactive oxygen species. Recent studies have proven an expression of Klotho in cardiomyocytes and its increased expression in stress-related heart injury. Thus, the antioxidative and antiapoptotic activity of Klotho could be considered as the novel protective factor in cardiovascular disease and heart injury.

Chronic kidney disease in the emergency centre: A prospective observational study

Introduction

Late presentation, usually to the emergency centre (EC), is frequently reported among patients with chronic kidney disease (CKD) in resource-limited settings, and is known to be associated with poor outcomes. This study aims to describe the pattern of EC presentation of adults with CKD in Southwest Nigeria.

Methods

This was a prospective observational study of 158 consecutively presenting CKD patients at the EC of two tertiary hospitals in Southwest Nigeria. Patients 18 years of age or older who were admitted into the EC at either study site with an admitting diagnosis of CKD and who consented to participate in the study were recruited. Socio-demographic characteristics, primary reason(s) for admission into the EC, requirement for dialysis, as well as the indication for dialysis were documented. The patients were followed-up for the duration of their stay in the EC and the outcome of EC admission documented.

Results

Overall, 54 (34.2%) were females, median age was 49 years and 74.1% were not known to have CKD prior to EC admission. The commonest indications for admission into the EC were uraemia, sepsis and hypertensive crisis, with 73.4% of the patients having at least one indication for dialysis at EC admission. The commonest indications for dialysis were uraemia, marked azotaemia and acute pulmonary oedema. The median time to first session of dialysis was 48 h and 24.1% of patients who required dialysis were not dialysed. Death during the period of EC admission occurred in 14 (8.9%) patients all of whom were not previously known to have CKD.

Discussion

There is a large pool of undiagnosed CKD among the general population. In many of these, the diagnosis will likely be made only when they present to the EC with complications. Late diagnosis is associated with worse outcomes.

Nephrology in Bosnia and Herzegovina: impact of the 1992-95 war

It has now been more than two decades since the end of the 1992–95 war in Bosnia and Herzegovina. This may well be the proper time to provide the nephrology community with an appraisal of the care of patients with chronic kidney disease in the pre-war, war and post-war periods in the European transitional country. This report on nephrology in Bosnia and Herzegovina draws attention to the hurdles faced for three turbulent years on that burdensome path of providing quality care, and the chance it offered in developing a successful transplant programme while facing the dreadful chaos of war and a migrant crisis. The perception of war and natural disasters is quite different, from the victim’s point of view, from the standardized and well-arranged healthcare systems in the developed world. The guidelines, written in peace, are extremely useful, but are often hard to follow during natural disasters or barbarous wars. Each of the periods described had its specificities as well as its good and bad sides. Despite the unquestionable destructive nature of the war, it was a catalyst for nephrology in Bosnia and Herzegovina to move forward.

Prevalence of chronic kidney disease in South Asia: a systematic review

Background

Chronic kidney disease (CKD) is becoming a major public health problem around the world. But the prevalence has not been reported in South Asian region as a whole. This study aimed to systematically review the existing data from population based studies in this region to bridge this gap.

Methods

Articles published and reported prevalence of CKD according to K/DOQI practice guideline in eight South Asian countries between December 1955 and April 2017 were searched, screened and evaluated from seven electronic databases using the PRISMA checklist. CKD was defined as creatinine clearance (CrCl) or GFR less than 60 ml/min/1.73 m².

Results

Sixteen population-based studies were found from four South Asian countries (India, Bangladesh, Pakistan and Nepal) that used eGFR to measure CKD. No study was available from Sri Lanka, Maldives, Bhutan and Afghanistan. Number of participants ranged from 301 in Pakistan to 12,271 in India. Majority of the studies focused solely on urban population. Different studies used different equations for measuring eGFR. The prevalence of CKD ranged from 10.6% in Nepal to 23.3% in Pakistan using MDRD equation. This prevalence was higher among older age group people. Equal number of studies reported high prevalence among male and female each.

Conclusions

This systematic review reported high prevalence of CKD in South Asian countries. The findings of this study will help pertinent stakeholders to prepare suitable policy and effective public health intervention in order to reduce the burden of this deadly disease in the most densely populated share of the globe.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1072-5) contains supplementary material, which is available to authorized users.

An African perspective on the genetic risk of chronic kidney disease: a systematic review

BACKGROUND

Individuals of African ethnicity are disproportionately burdened with chronic kidney disease (CKD). However, despite the genetic link, genetic association studies of CKD in African populations are lacking.

METHODS

We conducted a systematic review to critically evaluate the existing studies on CKD genetic risk inferred by polymorphism(s) amongst African populations in Africa. The study followed the HuGE handbook and PRISMA protocol. We included studies reporting on the association of polymorphism(s) with prevalent CKD, end-stage renaldisease (ESRD) or CKD-associated traits. Given the very few studies investigating the effects of the same single nucleotide polymorphisms (SNPs) on CKD risk, a narrative synthesis of the evidence was conducted.

RESULTS

A total of 30 polymorphisms in 11 genes were investigated for their association with CKD, ESRD or related traits, all using the candidate-gene approach. Of all the included genes, MYH9, AT1R and MTHFR genes failed to predict CKD or related traits, while variants in the APOL1, apoE, eNOS, XPD, XRCC1, renalase, ADIPOQ, and CCR2 genes were associated with CKD or other related traits. Two SNPs (rs73885319, rs60910145) and haplotypes (G-A-G; G1; G2) of the apolipoprotein L1 (APOL1) gene were studied in more than one population group, with similar association with prevalent CKD observed. The remaining polymorphisms were investigated in single studies.

CONCLUSION

According to this systematic review, there is currently insufficient evidence of the specific polymorphisms that poses African populations at an increased risk of CKD. Large-scale genetic studies are warranted to better understand susceptibility polymorphisms, specific to African populations.

A comparison of metrics and performance characteristics of different search strategies for article retrieval for a systematic review of the global epidemiology of kidney and urinary diseases

BACKGROUND

Conducting a systematic review requires a comprehensive bibliographic search. Comparing different search strategies is essential for choosing those that cover all useful data sources. Our aim was to develop search strategies for article retrieval for a systematic review of the global epidemiology of kidney and urinary diseases, and evaluate their metrics and performance characteristics that could be useful for other systematic epidemiologic reviews.

METHODS

We described the methodological framework and analysed approaches applied in the previously conducted systematic review intended to obtain published data for global estimates of the kidney and urinary disease burden. We used several search strategies in PubMed and EMBASE, and compared several metrics: number needed to retrieve (NNR), number of extracted data rows, number of covered countries, and when appropriate, sensitivity, specificity, precision, and accuracy.

RESULTS

The initial search obtained 29,460 records from PubMed, and 4247 from EMBASE. After the revision, the full text of 381 and 14 articles respectively was obtained for data extraction (the percentage of useful records is 1.3% for PubMed, 0.3% for EMBASE). For PubMed we developed two search strategies and compared them with a 'gold standard' formed by merging their results: free word search strategy (FreeWoSS) was based on the search for keywords in all fields, and subject headings based search strategy (SuHeSS) used only MeSH-mapped conditions and countries names. SuHeSS excluded almost 15% of useful articles and data rows extracted from them, but had a lower NNR of 40 and higher specificity. FreeWoSS had better sensitivity and was able to cover the vast majority of articles and extracted data rows, but had a higher NNR of 65.

CONCLUSIONS

The sensitive FreeWoSS strategy provides more data for modelling, while the more specific SuHeSS strategy could be used when resources are limited. EMBASE has limited value for our systematic review.

Cost of chronic kidney disease attributable to diabetes from the perspective of the Brazilian Unified Health System

INTRODUCTION

Diabetes is the most common cause of chronic kidney disease, with a high economic impact on health systems.

OBJECTIVE

To estimate the cost of chronic kidney disease (CKD) and end-stage kidney disease (ESKD) attributable to diabetes, stratified by sex, race/skin color, and age, from the perspective of the Brazilian public health system between 2010 and 2016.

METHODS

Population attributable risk (PAR) was calculated from the Brazilian prevalence of diabetes and the relative risk (or odds ratio) of persons with diabetes developing CKD and ESKD as compared to non-diabetic subjects. The variables of interest were sex, race/skin color, and age. A top-down approach was used to measure the direct costs of the disease reimbursed by the Brazilian Ministry of Health, using data from outpatient and inpatient records.

RESULTS

The cost of CKD and ESKD attributable to diabetes in the period 2010-2016 was US$1.2 billion (US$180 million per year) and trending upward. Female sex, age 65-75, and black race/skin color contributed substantially to the costs of CKD and ESKD (US$475 million, US$63 million, and US$25 million respectively). The clinical procedures accounting for the greatest share of disease-attributable costs are hemodialysis and peritoneal dialysis.

CONCLUSION

Diabetes accounted for 22% of the costs of CKD and ESKD. Female sex, age 65-75 years, and black race/skin color were the variables which contributed most to disease-related expenditure. The economic burden of CKD may increase gradually in the coming years, with serious implications for the financial sustainability of the Brazilian public health system.

Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies

INTRODUCTION

Chronic kidney disease (CKD) requires patients and caregivers to invest in self-care and self-management of their disease. We aimed to describe the work for adult patients that follows from these investments and develop an understanding of burden of treatment (BoT).

METHODS

Systematic review of qualitative primary studies that builds on EXPERTS1 Protocol, PROSPERO registration number: CRD42014014547. We included research published in English, Spanish and Portuguese, from 2000 to present, describing experience of illness and healthcare of people with CKD and caregivers. Searches were conducted in MEDLINE, Embase, CINAHL Plus, PsycINFO, Scopus, Scientific Electronic Library Online and Red de Revistas Científicas de América Latina y el Caribe, España y Portugal. Content was analysed with theoretical framework using middle-range theories.

RESULTS

Searches resulted in 260 studies from 30 countries (5115 patients and 1071 carers). Socioeconomic status was central to the experience of CKD, especially in its advanced stages when renal replacement treatment is necessary. Unfunded healthcare was fragmented and of indeterminate duration, with patients often depending on emergency care. Treatment could lead to unemployment, and in turn, to uninsurance or underinsurance. Patients feared catastrophic events because of diminished financial capacity and made strenuous efforts to prevent them. Transportation to and from haemodialysis centre, with variable availability and cost, was a common problem, aggravated for patients in non-urban areas, or with young children, and low resources. Additional work for those uninsured or underinsured included fund-raising. Transplanted patients needed to manage finances and responsibilities in an uncertain context. Information on the disease, treatment options and immunosuppressants side effects was a widespread problem.

CONCLUSIONS

Being a person with end-stage kidney disease always implied high burden, time-consuming, invasive and exhausting tasks, impacting on all aspects of patients' and caregivers' lives. Further research on BoT could inform healthcare professionals and policy makers about factors that shape patients' trajectories and contribute towards a better illness experience for those living with CKD.

PROSPERO REGISTRATION NUMBER

CRD42014014547.

Disparities in Chronic Kidney Disease Prevalence among Males and Females in 195 Countries: Analysis of the Global Burden of Disease 2016 Study

BACKGROUND

Chronic kidney disease (CKD) imposes a substantial burden on health care systems. There are some especially vulnerable groups with a high CKD burden, one of which is women. We performed an analysis of gender disparities in the prevalence of all CKD stages and renal replacement therapy (defined as impaired kidney function [IKF]) in 195 countries.

METHODS

We used estimates produced by the Global Burden of Disease (GBD) Study 2016 revision using a Bayesian-regression analytic tool, DisMoD-MR 2.1. Data on gross domestic product based on purchasing power parity per capita (GDP PPP) was obtained via the World Bank International Comparison Program database. To estimate gender disparities, we calculated the male:female all-age prevalence rate ratio for each IKF condition.

RESULTS

In 2016, the global number of individuals with IKF reached 752.7 million, including 417.0 million females and 335.7 million males. The most prevalent form of IKF in both groups was albuminuria with preserved glomerular filtration rate. Geospatial analysis shows a very heterogeneous distribution of the male:female ratio for all IKF conditions, with the most prominent contrast found in kidney transplant patients. The median male:female ratio varies substantially according to GDP PPP quintiles; however, countries with different economic states could have similar male:female ratios. A strong correlation of GDP PPP with dialysis-to-transplant ratio was found.

CONCLUSIONS

The GBD study highlights the prominent gender disparities in CKD prevalence among 195 countries. The nature of these disparities, however, is complex and must be interpreted cautiously taking into account all possible circumstances.

The Potential Impact of Public Health Interventions in Preventing Kidney Disease

The years of life lost and years lived with disability resulting from chronic kidney disease (CKD) increased globally by 90% and 49.5%, respectively, between 1990 and 2013. In addition to the traditional factors, infections, low birthweight, environmental factors, and low socioeconomic status contribute to the CKD burden in low- and middle-income countries. System-level challenges such as poor appreciation of the burden, insufficient human resources, high health care costs, poor referral pathways, unreliable health information systems, and inadequate medicine supply pose barriers to CKD control. In this article, we present evidence that the CKD burden in low- and middle-income countries is related to system-wide issues, which could be reduced effectively using innovative, affordable, and scalable interventions. A multipronged approach is required including improving socioeconomic determinants of health, enabling the environment for healthy decision making, and sustainable interventions. Innovative approaches include promoting healthy behaviors, counseling, and education in primary care, task-sharing between physicians and nonphysicians, using technology to train nonphysicians to screen, diagnose, refer, follow-up, and educate patients, and ensuring quality. Stronger political will and system-level change are needed to prevent and manage CKD if the sustainable development goals of reducing premature mortality from noncommunicable diseases by 2030 are to be attained.

The Global Epidemiology of Diabetes and Kidney Disease

The prevalence of diabetes is increasing worldwide, with the greatest increases occurring in low- and middle-income countries. In most developed countries, type 2 diabetes is presently the leading cause of end-stage renal disease and also contributes substantially to cardiovascular disease. In countries with weaker economies type 2 diabetes is rapidly replacing communicable diseases as a leading cause of kidney disease and is increasingly competing for scarce health care resources. Here, we present a narrative review of the prevalence and incidence of diabetes-related kidney disease worldwide. Mortality among those with diabetes and kidney disease will also be explored. Given the high morbidity and mortality associated with chronic kidney disease, we will also examine the level of awareness of this disease among people who have it.

Mortality in Elderly Waiting-List Patients Versus Age-Matched Kidney Transplant Recipients: Where is the Risk?

The number of elderly patients on the waiting list (WL) for kidney transplantation (KT) has risen significantly in recent years. Because KT offers a better survival than dialysis therapy, even in the elderly, candidates for KT should be selected carefully, particularly in older waitlisted patients. Identification of risk factors for death in WL patients and prediction of both perioperative risk and long-term post-transplant mortality are crucial for the proper allocation of organs and the clinical management of these patients in order to decrease mortality, both while on the WL and after KT. In this review, we examine the clinical results in studies concerning: a) risk factors for mortality in WL patients and KT recipients; 2) the benefits and risks of performing KT in the elderly, comparing survival between patients on the WL and KT recipients; and 3) clinical tools that should be used to assess the perioperative risk of mortality and predict long-term post-transplant survival. The acknowledgment of these concerns could contribute to better management of high-risk patients and prophylactic interventions to prolong survival in this particular population, provided a higher mortality is assumed.

Prevalence of hypertension in older people in Africa: a systematic review and meta-analysis

OBJECTIVE

The prevalence of hypertension in older people living on the African continent has not been comprehensively assessed. We aimed to provide accurate estimates of hypertension prevalence and variations by major predictive characteristics in this population to assist prevention and monitoring efforts.

METHODS

For this systematic review and meta-analysis, we searched major electronic databases for population-based studies on hypertension prevalence reported from 1 January 2000 to 5 March 2016. Two independent reviewers undertook quality assessment and data extraction. We stabilized the variance of study-specific prevalence with the Freeman-Tukey single arcsine transformation before pooling the data with random-effects models.

RESULTS

From the 2864 citations identified via searches, 91 studies providing 156 separate data contributions involving 54 198 individuals met the inclusion criteria. The overall prevalence of hypertension was 55.2% (95% confidence interval 53.1-57.4). Prevalence was higher in urban compared with rural settings [59.0% (55.3-62.6) vs. 48.0% (43.8-52.3), P < 0.001]. Prevalence did not differ significantly between STEPwise approach to surveillance (STEPS) and non-STEPS studies, across age groups, sex, sample size, year of publication, region, or population coverage. In cumulative meta-analysis, no temporal trend was identified over the years considered in this review. In influence analysis, no individual study was found to have a strong effect on the pooled prevalence estimate. There was substantial heterogeneity across studies (all I(2) > 94%, P < 0.001) and no evidence of publication bias.

CONCLUSION

Our findings highlight the need to implement timely and aggressive strategies for prevention, detection, and control of hypertension among older people in Africa.Registration: PROSPERO ID CRD42016034003.

The Landscape of Diabetic Kidney Disease in the United States

PURPOSE OF REVIEW

The purposes of this review are to identify population characteristics of important risk factors for the development and progression of diabetic kidney disease (DKD) in the United States and to discuss barriers and opportunities to improve awareness, management, and outcomes in patients with DKD.

RECENT FINDINGS

The major risk factors for the development and progression of DKD include hyperglycemia, hypertension, and albuminuria. DKD disproportionately affects minorities and individuals with low educational and socioeconomic status. Barriers to effective management of DKD include the following: (a) limited patient and healthcare provider awareness of DKD, (b) lack of timely referrals of patients to a nephrologist, (c) low patient healthcare literacy, and (d) insufficient access to healthcare and health insurance. Increased patient and physician awareness of DKD has been shown to enhance patient outcomes. Multifactorial and multidisciplinary interventions targeting multiple risk factors and patient/physician education may provide better outcomes in patients with DKD.

Characterizing Cardiac Involvement in Chronic Kidney Disease Using CMR-a Systematic Review

PURPOSE OF REVIEW

The aim of the review was to identify and describe recent advances (over the last 3 years) in cardiac magnetic resonance (CMR) imaging in patients with chronic kidney disease (CKD). We conducted a literature review in line with current guidelines.

RECENT FINDINGS

The authors identified 22 studies. Patients with CKD had left ventricular global and regional dysfunction and adverse remodeling. Stress testing with CMR revealed a reduced stress-response in CKD patients. Native T1 relaxation times (as a surrogate markers of fibrosis) are elevated in CKD patients, proportional to disease duration. Patients with CKD have reduced strain magnitudes and reduced aortic distensibility.

SUMMARY

CMR has diagnostic utility to identify and characterize cardiac involvement in this patient group. A number of papers have described novel findings over the last 3 years, suggesting that CMR has potential to become more widely used in studies in this patient group.

Screening for chronic kidney disease in a community-based diabetes cohort in rural Guatemala: a cross-sectional study

OBJECTIVE

Screening is a key strategy to address the rising burden of chronic kidney disease (CKD) in low-income and middle-income countries. However, there are few reports regarding the implementation of screening programmes in resource-limited settings. The objectives of this study are to (1) to share programmatic experiences implementing CKD screening in a rural, resource-limited setting and (2) to assess the burden of renal disease in a community-based diabetes programme in rural Guatemala.

DESIGN

Cross-sectional assessment of glomerular filtration rate (GFR) and urine albumin.

SETTING

Central Highlands of Guatemala.

PARTICIPANTS

We enrolled 144 adults with type 2 diabetes in a community-based CKD screening activity carried out by the sponsoring institution.

OUTCOME MEASURES

Prevalence of renal disease and risk of CKD progression using Kidney Disease: Improving Global Outcomes definitions and classifications.

RESULTS

We found that 57% of the sample met GFR and/or albuminuria criteria suggestive of CKD. Over half of the sample had moderate or greater increased risk for CKD progression, including nearly 20% who were classified as high or very high risk. Hypertension was common in the sample (42%), and glycaemic control was suboptimal (mean haemoglobin A1c 9.4%±2.5% at programme enrolment and 8.6%±2.3% at time of CKD screening).

CONCLUSIONS

The high burden of renal disease in our patient sample suggests an imperative to better understand the burden and risk factors of CKD in Guatemala. The implementation details we share reveal the tension between evidence-based CKD screening versus screening that can feasibly be delivered in resource-limited global settings.

Agomelatine versus paroxetine in treating depressive and anxiety symptoms in patients with chronic kidney disease

OBJECTIVE

Depressive and anxiety symptoms could affect the quality of life and prognostic outcomes in chronic kidney disease (CKD) patients, but only a few studies focus on the interventions to manage or prevent these symptoms in CKD patients. Therefore, this study was conducted to compare the efficacy and acceptability of agomelatine versus paroxetine in treating depressive and anxiety symptoms in CKD patients.

METHODS

CKD stage 2-4 patients with depressive and anxiety symptoms were included. The first patient was randomized in April 2013 and the last clinic visit occurred in March 2017. The included patients were randomly assigned to receive paroxetine 20-40 mg/day or agomelatine 25-50 mg/day. The treatment was continued for 12 weeks. The Hamilton Depression Rating Scale (HDRS) (17-item) and Hamilton Anxiety Rating Scale (HARS) were the primary outcome measures, and the response rate, remission rate, and Activities of Daily Living (ADL) scale were the secondary outcome measures. Meanwhile, the adverse events were recorded during the whole treatment period.

RESULTS

At baseline and week 4, both groups had similar average HDRS and HARS scores. But at week 8 and 12, compared to the patients receiving paroxetine, the patients receiving agomelatine had significantly lower average HDRS scores (p=0.002, p=0.001, respectively) and HARS scores (p<0.00001, p<0.00001, respectively). At week 12, the patients receiving agomelatine had a non-significantly lower average ADL score, and non-significantly higher response and remission rates. The adverse events in both groups were mild and transient.

CONCLUSION

These results demonstrated that the agomelatine had some advantages over par-oxetine in treating CKD stage 2-4 patients with depressive and anxiety symptoms, and future studies are needed to further explore its efficacy and acceptability.

Relationships of kidney injury molecule-1 with renal function and cardiovascular risk factors in the general population

BACKGROUND

Kidney injury molecule-1 (KIM-1) has been associated with kidney damage in patients with preexisting renal disease. However, little is known about the relationships of KIM-1 with renal function and cardiovascular risk factors in healthy individuals from the general population.

METHODS

Healthy individuals aged 25-41years were enrolled in a population-based study. Main exclusion criteria were a BMI >35kg/m², preexisting kidney disease or established cardiovascular disease. KIM-1 was measured from frozen plasma samples using a high-sensitivity assay. Multivariable linear regression models were constructed to assess the relationships of KIM-1 with renal function and various cardiovascular risk factors.

RESULTS

We included 2060 individuals (47% men, median (interquartile range) age: 37 (31-40) years) in this analysis. Median KIM-1 levels were 82.5 (IQR 59.4-112.7) pg/ml. We found no significant relationship of KIM-1 with creatinine (adjusted β-coefficient (95% confidence interval) 0.0005 (-0.002; 0.003), p=0.61) and cystatin C (-0.02 (-0.21; 0.17), p=0.84). There were significant linear relationships of log-transformed KIM-1 with systolic blood pressure (adjusted β-coefficient (95% confidence interval) 0.07 (0.04; 0.09), p<0.0001), diastolic blood pressure (0.04 (0.02; 0.07), p=0.001), low-density lipoprotein cholesterol (0.09 (0.06; 0.11), p<0.0001), high-density lipoprotein cholesterol (0.07 (0.05; 0.1), p<0.0001), high-sensitivity C-reactive protein (0.05 (0.03; 0.07), p<0.0001), age (0.09 (0.07; 0.11), p<0.0001), BMI (0.04 (0.01; 0.06), p=0.005) and current smoking (0.12 (0.07; 0.17), p<0.0001).

CONCLUSION

Among healthy adults from the general population, plasma levels of KIM-1 were not associated with renal function but were independently related to multiple cardiovascular risk factors.

Chronic kidney disease

Chronic kidney disease (CKD) is defined by persistent urine abnormalities, structural abnormalities or impaired excretory renal function suggestive of a loss of functional nephrons. The majority of patients with CKD are at risk of accelerated cardiovascular disease and death. For those who progress to end-stage renal disease, the limited accessibility to renal replacement therapy is a problem in many parts of the world. Risk factors for the development and progression of CKD include low nephron number at birth, nephron loss due to increasing age and acute or chronic kidney injuries caused by toxic exposures or diseases (for example, obesity and type 2 diabetes mellitus). The management of patients with CKD is focused on early detection or prevention, treatment of the underlying cause (if possible) to curb progression and attention to secondary processes that contribute to ongoing nephron loss. Blood pressure control, inhibition of the renin-angiotensin system and disease-specific interventions are the cornerstones of therapy. CKD complications such as anaemia, metabolic acidosis and secondary hyperparathyroidism affect cardiovascular health and quality of life, and require diagnosis and treatment.

Do attributes of persons with chronic kidney disease differ in low-income and middle-income countries compared with high-income countries? Evidence from population-based data in six countries

Kidney biopsies to elucidate the cause of chronic kidney disease (CKD) are performed in a minority of persons with CKD living in high-income countries, since associated conditions—that is, diabetes mellitus, vascular disease or obesity with pre-diabetes, prehypertension or dyslipidaemia—can inform management targeted at slowing CKD progression in a majority. However, attributes of CKD may differ substantially among persons living in low-income and middle-income countries (LMICs). We used data from population or community-based studies from five LMICs (China, urban India, Moldova, Nepal and Nigeria) to determine what proportion of persons with CKD living in diverse regions fit one of the three major clinical profiles, with data from the US National Health Nutrition and Examination Survey as reference. In the USA, urban India and Moldova, 79.0%–83.9%; in China and Nepal, 62.4%–66.7% and in Nigeria, 51.6% persons with CKD fit one of three established risk profiles. Diabetes was most common in urban India and vascular disease in Moldova (50.7% and 33.2% of persons with CKD in urban India and Moldova, respectively). In Nigeria, 17.8% of persons with CKD without established risk factors had albuminuria ≥300 mg/g, the highest proportion in any country. While the majority of persons with CKD in LMICs fit into one of three established risk profiles, the proportion of persons who have CKD without established risk factors is higher than in the USA. These findings can inform tailored CKD detection and management systems and highlight the importance of studying potential causes and outcomes of CKD without established risk factors in LMICs.

Prevalência de doença renal crônica em adultos no Brasil: revisão sistemática da literatura

Resumo Introdução A doença renal crônica é um problema global de saúde pública, e no Brasil sua prevalência é incerta. Objetivo Estimar a prevalência de doença renal crônica em adultos do Brasil. Método Realizou-se revisão sistemática com buscas no MEDLINE, Embase e outras bases. Dois pesquisadores selecionaram os estudos, extraíram os dados e avaliaram a qualidade. Resultados Incluímos 16 estudos: inquéritos populacionais que utilizaram critério autorreferido encontraram prevalência nacional de 4,57% (1998) a 1,43% (2013); naqueles que usaram hipercreatininemia, a prevalência foi 3,46% em Bambuí (1997) e 3,13% em Salvador (2000). Estudos com amostras não representativas usaram critérios clínico-laboratoriais e tiveram maiores prevalências: entre 6,26-7,26% em campanhas de saúde (2002-2010), 8,94% em servidores públicos (2008-2010), 9,62% em usuários de laboratório privado (2003), 27,20% em pacientes hospitalizados (2013) e 1,35-13,63% na atenção primária (2010-2012). Pacientes em terapia dialítica representam 0,05% da população. Discussão Os estudos com representatividade populacional não aferiram a doença adequadamente, e investigações com melhores critérios diagnósticos tiveram amostragem por conveniência. A heterogeneidade entre pesquisas inviabilizou a elaboração de meta-análise. Conclusão A prevalência de doença renal crônica variou de acordo com o método empregado na definição da doença. Pelos critérios populacionais, 3-6 milhões teriam a doença. Aproximadamente 100.000 recebem diálise no Brasil.

Action plan for determining and monitoring the prevalence of chronic kidney disease

Chronic kidney disease (CKD) continues to remain high globally, up to 13.4% by one estimate. Although the number, geographic distribution, size, and quality of the studies examining CKD prevalence and incidence have increased over the past decade, the global capacity for CKD surveillance is still far less developed than that for hypertension, diabetes, and cardiovascular disease. Estimating CKD prevalence is constrained by inadequate standardization of serum creatinine and urine albumin assays, heterogeneity in study designs, lack of national registries in many countries, incomplete adoption of disease classification guidelines, and inconsistent use of evidence-based equations for estimating glomerular filtration rate. Goal 1: Improve monitoring of CKD prevalence. To achieve this, disseminate the rationale for CKD prevalence monitoring, achieve uniform measurement of CKD markers, promote inclusion of CKD measurements in all large chronic disease cohorts and health surveys, harness administrative claims data for CKD surveillance, and incorporate the new CKD classification system in the International Classification of Diseases. Goal 2: Improve CKD monitoring of populations underrepresented in studies to date. To achieve this, establish registries of chronic dialysis and transplantation in all countries; establish registries for special CKD groups, such as children, patients with rare diseases, and patients with special etiologies of CKD. Goal 3: Improve identification of individuals with CKD. To achieve this, implement the Kidney Disease: Improving Global Outcomes guidelines for screening and testing, carry out randomized studies on screening strategies, ensure that estimated glomerular filtration rate is reported with all reports of serum creatinine, and leverage new software for identification and follow-up of CKD cases.

Predialysis chronic kidney disease correlates with increased risk of pyogenic liver abscess: a population-based cohort study

BACKGROUND/OBJECTIVE

The incidence of pyogenic liver abscess in Taiwan appears to be much higher than that in western countries. However, little is known about the incidence of pyogenic liver abscess among patients with predialysis chronic kidney disease. The objective of this study was to assess the association between predialysis chronic kidney disease and the risk of pyogenic liver abscess in Taiwan.

METHODS

This population-based, retrospective, cohort study was conducted to analyse the database of the Taiwan National Health Insurance Program. There were 81118 subjects aged 20-84 years with newly diagnosed chronic kidney disease as the predialysis chronic kidney disease group since 2000-2010, and 81118 randomly selected subjects without chronic kidney disease as the nonchronic kidney disease group. The predialysis chronic kidney disease group and the nonchronic kidney disease group were matched with sex, age and comorbidities. The incidence of pyogenic liver abscess at the end of 2013 was calculated in both groups. Subjects who currently received dialysis therapy before the endpoint were excluded from the study. The multivariable Cox proportional hazards regression model was used to assess the hazard ratio (HR) and 95% confidence interval (CI) for the risk of pyogenic liver abscess associated with predialysis chronic kidney disease and other comorbidities including alcohol-related disease, biliary stone, chronic liver disease and diabetes mellitus.

RESULTS

The overall incidence of pyogenic liver abscess was 1·65-fold higher in the predialysis chronic kidney disease group than that in the nonchronic kidney disease group (1·38 vs. 0·83 per 1000 person-years, 95% CI 1·59, 1·71). After adjustment for covariables, the adjusted HR of pyogenic liver abscess was 1·51(95% CI 1·30, 1·76) for the predialysis chronic kidney disease group, comparing with the nonchronic kidney disease group. In addition, the adjusted HR would increase to 3·31 (95% CI 2·61, 4·19) for subjects with predialysis chronic kidney disease and with any comorbidity studied.

CONCLUSION

Predialysis chronic kidney disease is associated with 1·5-fold increased risk of pyogenic liver abscess. There seem to be a synergistic effect on the risk of pyogenic liver abscess between predialysis chronic kidney disease and comorbidities.

Establishing the presence or absence of chronic kidney disease: Uses and limitations of formulas estimating the glomerular filtration rate

The development of formulas estimating glomerular filtration rate (eGFR) from serum creatinine and cystatin C and accounting for certain variables affecting the production rate of these biomarkers, including ethnicity, gender and age, has led to the current scheme of diagnosing and staging chronic kidney disease (CKD), which is based on eGFR values and albuminuria. This scheme has been applied extensively in various populations and has led to the current estimates of prevalence of CKD. In addition, this scheme is applied in clinical studies evaluating the risks of CKD and the efficacy of various interventions directed towards improving its course. Disagreements between creatinine-based and cystatin-based eGFR values and between eGFR values and measured GFR have been reported in various cohorts. These disagreements are the consequence of variations in the rate of production and in factors, other than GFR, affecting the rate of removal of creatinine and cystatin C. The disagreements create limitations for all eGFR formulas developed so far. The main limitations are low sensitivity in detecting early CKD in several subjects, e.g., those with hyperfiltration, and poor prediction of the course of CKD. Research efforts in CKD are currently directed towards identification of biomarkers that are better indices of GFR than the current biomarkers and, particularly, biomarkers of early renal tissue injury.

Prevalence, incidence and associated mortality of cardiovascular disease in patients with chronic kidney disease in low- and middle-income countries: a protocol for a systematic review and meta-analysis

INTRODUCTION

Chronic kidney disease (CKD) is a global public health problem, with cardiovascular disease (CVD) being the major cause of mortality in these patients. Despite a high burden of CKD among patients in low/middle-income countries (LMICs), evidence on the distribution of CVD among these patients is lacking. This review seeks to determine the prevalence, incidence and mortality risks of CVD in patients with CKD in LMICs.

METHODS AND ANALYSIS

A systematic search of Medline, Scopus, Embase, Cumulative Index of Nursing and Allied Health and WHO Global Health Library databases for published studies reporting on the prevalence, incidence and associated mortality risk of CVD in CKD patients in LMICs will be conducted from 1 May 1987 to 1 July 2017 with no language restriction. Two authors will independently screen, select studies, extract data and assess the risk of bias in each study. Clinically homogeneous studies will be pooled after assessing for clinical and statistical heterogeneity using the χ2 test on Cochrane's Q statistic which is quantified by I2 values; assuming that I2 values of 25%, 50% and 75% represent low, medium and high heterogeneity, respectively. Funnel-plot analysis and Egger's test will be used to detect publication bias. Results will be presented according to WHO Regions (Africa, Americas, Eastern Mediterranean, Europe, South-East Asia and Western Pacific).

ETHICS AND DISSEMINATION

This proposed study will not require ethical approval as it will be based on published data. We will publish the final report of this review in a peer-reviewed journal, and the findings will be disseminated to the appropriate health authorities.

A comparison of anxiety and depression between pre-dialysis chronic kidney disease patients and hemodialysis patients using hospital anxiety and depression scale

Objective:

Tocompare frequency of anxiety and depression between pre-dialysis chronic kidney disease (CKD) and hemodialysis patients (ESRD) in Pakistan.

Methods:

This study was conducted in an out-patient department and hemodialysis unit of Sharif Medical City Hospital. Inclusion criteria included age above 18 years and a diagnosis of CKD including both pre-dialysis CKD and ESRD patients. Patients were screened for anxiety and depression using hospital anxiety and depression scale (HADS).

Results:

A total of 156 patients were included in the study. Out of these patients, 81 (51.9%) had ESRD and 75 (48.1%) had pre-dialysis CKD. Mean age of all patient was 47.3±18.3 years, 96 (61.5%) were males and 60 (38.5%) were females. Median duration of renal disease was 16 months (IQR 8-36 months). Anxiety and depression were present in 111 (71.2%) and 113 (72.4%) of all patients respectively. Moderate to severe anxiety and depression were present in 54 (34.6%) and 60 (38.5%) patients respectively. In multiple logistic regression model, after adjusting for other variables, ESRD vs. pre-dialysis CKD was significantly associated with moderate to severe depression (AOR 2.26 (1.1-5.1).

Conclusion:

Both anxiety and depression are common in pre-dialysis CKD and ESRD patients. Patients with ESRD have higher frequency of depression compared to pre-dialysis CKD patients.

Plasma levels of endothelin-1 and renal function among young and healthy adults

Background:

Endothelin-1 (ET-1), a vasoconstrictive and pro-inflammatory peptide, is associated with several cardiovascular risk factors and outcomes. We aimed to investigate the association of plasma ET-1 levels and renal function among young and healthy adults.

Methods:

Individuals aged 25–41 years were enrolled in a population-based cohort study. Main exclusion criteria were established kidney disease, cardiovascular diseases, diabetes mellitus and a body mass index>35 kg/m2. Fasting venous plasma samples were used to measure creatinine, cystatin C and ET-1. The estimated glomerular filtration rate (eGFR) was calculated using the creatinine based chronic kidney disease epidemiology collaboration (CKD-EPI) formula. Multivariable regression models were constructed to assess interrelationships of plasma ET-1 with parameters of renal function.

Results:

Median age of the 2139 participants was 37 years, 47% males. Median creatinine and eGFR were 67 μmol/L and 112 mL/min/1.73 m2, respectively. Using quartile one as the reference group, the β-coefficients (95% confidence intervals [CIs]) for eGFR were 0.06 (− 1.22 to 1.35),−0.66 (− 1.95 to 0.62) and−1.70 (− 3.01 to−0.39) for quartiles 2–4 (p-for-trend=0.0056), respectively and β-coefficients (95% CIs) for cystatin C were 0.002 (− 0.01 to 0.02), 0.02 (0.003–0.03) and 0.03 (0.01–0.04) for quartiles 2–4 (p-for-trend<0.0001), respectively. Using ET-1 as a continuous variable, the β-coefficient (95% CI) for eGFR per 1-unit increase was−1.82 (− 3.19 to−0.44, p=0.0095) and 0.02 (0.01–0.04, p=0.0003) for cystatin C. Similar results were found between creatinine and ET-1 levels.

Conclusions:

ET-1 levels are strongly associated with parameters of renal function among young and healthy adults, suggesting an important role of ET-1 and endothelial function in the regulation of kidney function.

Assessment of quality of life in patients undergoing hemodialysis using WHOQOL-BREF questionnaire: a multicenter study

Background

Assessment of quality of life (QOL) of patients with end-stage renal disease has become increasingly important, both in order to evaluate the influence of the disease on patients and the type of renal replacement therapy they require. Therefore, in this study, we aimed to assess QOL in patients undergoing hemodialysis and evaluated the effects of various sociodemographic factors affecting QOL of such patients in Nepal.

Methods

A cross-sectional study was conducted among 150 patients with chronic kidney disease undergoing hemodialysis at two major centers in Nepal. Demographic data including age, sex, ethnicity, educational status, marital status, employment, income, duration of illness, and duration on hemodialysis were collected. QOL was assessed using the World Health Organization Quality of life (WHOQOL-BREF) questionnaire. Four domains (physical, psychological, social, and environmental) and two items (overall perception of QOL and health) of the WHOQOL-BREF were the primary end points of this study. Bivariate relationship between sociodemographic factors and QOL scores were analyzed using independent samples t-test and one-way analysis of variance. Multiple linear regression analysis was performed to determine independent predictors of QOL.

Results

Following QOL scores were recorded: environmental domain (53.17±15.59), psychological domain (51.23±18.61), social domain (49.86±21.64), and physical domain (45.93±16.90). Older age was associated with a better QOL score in the social domain (p=0.005), and employed patients scored better in the environmental domain (p=0.019). Unemployed patients and those of the Terai/Madhesi ethnic group had significantly low scores in overall perception of health (p<0.05) as compared to other groups. Low income status and increased duration on hemodialysis were found to be the only independent negative predictors of QOL in patients with hemodialysis (p<0.05).

Conclusion

Patients with chronic kidney disease on dialysis had overall low QOL scores in all four domains. Age, ethnicity, employment status, income, and duration on hemodialysis affected one or more domains of QOL in such patients. Low income status and increased duration on hemodialysis were the only independent negative predictors of QOL of patients on maintenance hemodialysis.

Risk scores to predict decreased glomerular filtration rate at 10 years in an Asian general population

BACKGROUND

Asians have among the highest prevalence of chronic kidney disease (CKD) or end-stage renal disease in the world. A risk score capable of identifying high risk individuals at the primary care level could allow targeted therapy to prevent future development of CKD. Risk scores for new CKD have been developed in US general populations, but the impact of various risks factors for development of CKD may differ in Asian subjects. In this study, we aimed to develop risk models and simplified risk scores to predict the development of decreased glomerular filtration rate (GFR) at 10 years in an Asian general population using readily obtainable clinical and laboratory parameters.

METHODS

Employees of EGAT (The Electric Generating Authority of Thailand) were studied prospectively. Multivariable logistic regression models were used to assess risk factors and used to derive risk models and risk scores for developing decreased GFR at 10 years: Model 1 (Clinical only), Model 2 (Clinical + Limited laboratory tests), and Model 3 (Clinical + Full laboratory tests). The performance of the risk models or risk scores to predict incident cases with decreased GFR were evaluated by tests of calibration and discrimination.

RESULTS

Of 3186 subjects with preserved GFR (eGFR ≥60) at baseline, 271 (8.5%) developed decreased GFR (eGFR < 60) at 10 years. Model 1 (Age, sex, systolic blood pressure, history of diabetes, and waist circumference) had good performance (χ2 = 9.02; AUC = 0.72). Model 2 (Age, Sex, systolic blood pressure, diabetes, glomerular filtration rate) had better discrimination (χ2 = 10.87, AUC = 0.79) than Model 1. Model 3 (Model 2+ Uric acid, Hemoglobin) did not provide significant improvement over Model 2. Based on these findings, simplified categorical risk scores were developed for Models 1 and 2.

CONCLUSIONS

Clinical or combined clinical and laboratory risk models or risk scores using tests readily available in a resource-limited setting had good accuracy and discrimination power to estimate the 10-year probability of developing decreased GFR in a Thai general population. The benefits of the risk scores in identifying high risk individuals in the Thai or other Asian communities for special intervention requires further studies.

Global Cardiovascular and Renal Outcomes of Reduced GFR

The burden of premature death and health loss from ESRD is well described. Less is known regarding the burden of cardiovascular disease attributable to reduced GFR. We estimated the prevalence of reduced GFR categories 3, 4, and 5 (not on RRT) for 188 countries at six time points from 1990 to 2013. Relative risks of cardiovascular outcomes by three categories of reduced GFR were calculated by pooled random effects meta-analysis. Results are presented as deaths for outcomes of cardiovascular disease and ESRD and as disability-adjusted life years for outcomes of cardiovascular disease, GFR categories 3, 4, and 5, and ESRD. In 2013, reduced GFR was associated with 4% of deaths worldwide, or 2.2 million deaths (95% uncertainty interval [95% UI], 2.0 to 2.4 million). More than half of these attributable deaths were cardiovascular deaths (1.2 million; 95% UI, 1.1 to 1.4 million), whereas 0.96 million (95% UI, 0.81 to 1.0 million) were ESRD-related deaths. Compared with metabolic risk factors, reduced GFR ranked below high systolic BP, high body mass index, and high fasting plasma glucose, and similarly with high total cholesterol as a risk factor for disability-adjusted life years in both developed and developing world regions. In conclusion, by 2013, cardiovascular deaths attributed to reduced GFR outnumbered ESRD deaths throughout the world. Studies are needed to evaluate the benefit of early detection of CKD and treatment to decrease these deaths.

Psychosocial Interventions for Depressive and Anxiety Symptoms in Individuals with Chronic Kidney Disease: Systematic Review and Meta-Analysis

Purpose: Depressive and anxiety symptoms are common amongst individuals with chronic kidney disease and are known to affect quality of life adversely. Psychosocial interventions have been shown to decrease depressive and anxiety symptoms in various chronic diseases, but few studies have examined their efficacy in people with chronic kidney disease and no meta-analysis has been published. Thus, the aim of the present systematic review and meta-analysis was to evaluate the effects of psychosocial interventions on depressive and anxiety symptoms as well as quality of life in individuals diagnosed with chronic kidney disease and/or their carers.

Methods: In this systematic review and meta-analysis, we included published randomized controlled trials comparing psychosocial interventions versus usual care for impacting depressive and anxiety symptoms and quality of life.

Results: Eight studies were included in the systematic review and six of these were subjected to meta-analysis. Psychosocial interventions were associated with a medium effect size for reduction in depressive symptoms and a small effect size for improved quality of life in the in individuals with chronic-kidney-disease and their carers. Some evidence suggested a reduction in anxiety.

Conclusion: Psychosocial interventions appear to reduce depressive symptoms and improve quality of life in patients with chronic-kidney-disease and their carers and to have some beneficial impact on anxiety. However, the small number of identified studies indicates a need for further research in this field.

Chronic kidney disease in low-income to middle-income countries: the case for increased screening

Chronic kidney disease (CKD) is fast becoming a major public health issue, disproportionately burdening low-income to middle-income countries, where detection rates remain low. We critically assessed the extant literature on CKD screening in low-income to middle-income countries. We performed a PubMed search, up to September 2016, for studies on CKD screening in low-income to middle-income countries. Relevant studies were summarised through key questions derived from the Wilson and Jungner criteria. We found that low-income to middle-income countries are ill-equipped to deal with the devastating consequences of CKD, particularly the late stages of the disease. There are acceptable and relatively simple tools that can aid CKD screening in these countries. Screening should primarily include high-risk individuals (those with hypertension, type 2 diabetes, HIV infection or aged >60 years), but also extend to those with suboptimal levels of risk (eg, prediabetes and prehypertension). Since screening for hypertension, type 2 diabetes and HIV infection is already included in clinical practice guidelines in resource-poor settings, it is conceivable to couple this with simple CKD screening tests. Effective implementation of CKD screening remains a challenge, and the cost-effectiveness of such an undertaking largely remains to be explored. In conclusion, for many compelling reasons, screening for CKD should be a policy priority in low-income to middle-income countries, as early intervention is likely to be effective in reducing the high burden of morbidity and mortality from CKD. This will help health systems to achieve cost-effective prevention.

ACE and SGLT2 inhibitors: the future for non-diabetic and diabetic proteinuric renal disease

Most chronic nephropathies progress relentlessly to end-stage kidney disease. Research in animals and humans has helped our understanding of the mechanisms of chronic kidney disease progression. Current therapeutic strategies to prevent or revert renal disease progression focus on reduction of urinary protein excretion and blood pressure control. Blockade of the renin-angiotensin system (RAS) with angiotensin-converting enzyme inhibitors and/or angiotensin II type 1 receptor blockers is the most effective treatment to achieve these purposes in non-diabetic and diabetic proteinuric renal diseases. For those individuals in which nephroprotection by RAS blockade is only partial, sodium-glucose linked cotransporter-2 (SGLT2) inhibitors could be a promising new class of drugs to provide further renoprotective benefit when added on to RAS blockers.

Prevalence of chronic kidney disease associated with cardiac and vascular complications in hypertensive patients: a multicenter, nation-wide study in Thailand

BACKGROUND

Hypertension and chronic kidney disease (CKD) are common conditions and both are major risk factors for cardiovascular events. The objectives were 1) to study the prevalence of CKD in hypertensive patients and 2) to study the association of CKD with cardiac and vascular complications in a multicenter, nation-wide fashion.

METHODS

This cross-sectional study evaluated patients aged 20 years or older who were diagnosed with hypertension and who had been treated for at least 12 months at 831 public hospitals in Thailand during the 2012 study period. Outcome measurements included calculated glomerular filtration rate (GFR) and cardiac and vascular complications that included coronary artery disease, stroke, peripheral arterial disease, heart failure, and atrial fibrillation. Multivariable modeling was conducted to determine independent factors associated with increased risk of cardiac and vascular complications.

RESULTS

A total of 28770 patients were enrolled. Average age was 62.8 years and 37% were male. Prevalence of CKD stage 3 and 4-5 was 33.2 and 4.3%, respectively. Prevalence of cardiac and vascular complications was 10.5% (5% having coronary artery disease, 3.9% stroke, 1.7% heart failure, and 1.2% atrial fibrillation). CKD was an independent risk factor associated with each of the complications and overall cardiac and vascular complications with an adjusted Odds ratio of 1.4 for CKD stage 3 and 1.9 for CKD stage 4-5.

CONCLUSION

Prevalence of CKD stage 3-5 in hypertensive population was 37.5%. CKD is an independent risk factor for adverse cardiac and vascular outcome.

The Impact of Kidney Development on the Life Course: A Consensus Document for Action

Hypertension and chronic kidney disease (CKD) have a significant impact on global morbidity and mortality. The Low Birth Weight and Nephron Number Working Group has prepared a consensus document aimed to address the relatively neglected issue for the developmental programming of hypertension and CKD. It emerged from a workshop held on April 2, 2016, including eminent internationally recognized experts in the field of obstetrics, neonatology, and nephrology. Through multidisciplinary engagement, the goal of the workshop was to highlight the association between fetal and childhood development and an increased risk of adult diseases, focusing on hypertension and CKD, and to suggest possible practical solutions for the future. The recommendations for action of the consensus workshop are the results of combined clinical experience, shared research expertise, and a review of the literature. They highlight the need to act early to prevent CKD and other related noncommunicable diseases later in life by reducing low birth weight, small for gestational age, prematurity, and low nephron numbers at birth through coordinated interventions. Meeting the current unmet needs would help to define the most cost-effective strategies and to optimize interventions to limit or interrupt the developmental programming cycle of CKD later in life, especially in the poorest part of the world.

Outcomes in adults and children with end-stage kidney disease requiring dialysis in sub-Saharan Africa: a systematic review

BACKGROUND

The burden of end-stage kidney disease (ESKD) in sub-Saharan Africa is unknown but is probably high. Access to dialysis for ESKD is limited by insufficient infrastructure and catastrophic out-of-pocket costs. Most patients remain undiagnosed, untreated, and die. We did a systematic literature review to assess outcomes of patients who reach dialysis and the quality of dialysis received.

METHODS

We searched PubMed, African Journals Online, WHO Global Health Library, and Web of Science for articles in English or French from sub-Saharan Africa reporting dialysis outcomes in patients with ESKD published between Jan 1, 1990, and Dec 22, 2015. No studies were excluded to best represent the current situation in sub-Saharan Africa. Outcomes of interest included access to dialysis, mortality, duration of dialysis, and markers of dialysis quality in patients with ESKD. Data were analysed descriptively and reported using narrative synthesis.

FINDINGS

Studies were all of medium to low quality. We identified 4339 studies, 68 of which met inclusion criteria, comprising 24 456 adults and 809 children. In the pooled analysis, 390 (96%) of 406 adults and 133 (95%) of 140 children who could not access dialysis died or were presumed to have died. Among those dialysed, 2747 (88%) of 3122 adults in incident ESKD cohorts, 496 (16%) of 3197 adults in prevalent ESKD cohorts, and 107 (36%) of 294 children with ESKD died or were presumed to have died. 2508 (84%) of 2990 adults in incident ESKD cohorts discontinued dialysis compared with 64 (5%) of 1364 adults in prevalent ESKD cohorts. 41 (1%) of 4483 adults in incident ESKD cohorts, 2280 (19%) of 12 125 adults in prevalent ESKD cohorts, and 71 (19%) of 381 children with ESKD received transplants. 16 studies reported on management of anaemia, 17 on dialysis frequency, eight on dialysis accuracy, and 22 on vascular access for dialysis INTERPRETATION: Most patients with ESKD starting dialysis in sub-Saharan Africa discontinue treatment and die. Further work is needed to develop equitable and sustainable strategies to manage individuals with ESKD in sub-Saharan Africa.

FUNDING

None.

Kidney Organoids: A Translational Journey

Human pluripotent stem cells (hPSCs) are attractive sources for regenerative medicine and disease modeling in vitro. Directed hPSC differentiation approaches have derived from knowledge of cell development in vivo rather than from stochastic cell differentiation. Moreover, there has been great success in the generation of 3D organ-buds termed 'organoids' from hPSCs; these consist of a variety of cell types in vitro that mimic organs in vivo. The organoid bears great potential in the study of human diseases in vitro, especially when combined with CRISPR/Cas9-based genome-editing. We summarize the current literature describing organoid studies with a special focus on kidney organoids, and discuss goals and future opportunities for organoid-based studies.

The global burden of chronic kidney disease: estimates, variability and pitfalls

Chronic kidney disease (CKD) is currently defined by abnormalities of kidney structure or function assessed using a matrix of variables - including glomerular filtration rate (GFR), thresholds of albuminuria and duration of injury - and is considered by many to be a common disorder globally. However, estimates of CKD prevalence vary widely, both within and between countries. The reasons for these variations are manifold, and include true regional differences in CKD prevalence, vagaries of using estimated GFR (eGFR) for identifying CKD, issues relating to the use of set GFR thresholds to define CKD in elderly populations, and concerns regarding the use of one-off testing for assessment of eGFR or albuminuria to define the prevalence of CKD in large-scale epidemiological studies. Although CKD is common, the suggestion that its prevalence is increasing in many countries might not be correct. Here, we discuss the possible origins of differences in estimates of CKD prevalence, and present possible solutions for tackling the factors responsible for the reported variations in GFR measurements. The strategies we discuss include approaches to improve testing methodologies for more accurate assessment of GFR, to improve awareness of factors that can alter GFR readouts, and to more accurately stage CKD in certain populations, including the elderly.

Understanding kidney care needs and implementation strategies in low- and middle-income countries: conclusions from a "Kidney Disease: Improving Global Outcomes" (KDIGO) Controversies Conference

Evidence-based cinical practice guidelines improve delivery of uniform care to patients with and at risk of developing kidney disease, thereby reducing disease burden and improving outcomes. These guidelines are not well-integrated into care delivery systems in most low- and middle-income countries (LMICs). The KDIGO Controversies Conference on Implementation Strategies in LMIC reviewed the current state of knowledge in order to define a road map to improve the implementation of guideline-based kidney care in LMICs. An international group of multidisciplinary experts in nephrology, epidemiology, health economics, implementation science, health systems, policy, and research identified key issues related to guideline implementation. The issues examined included the current kidney disease burden in the context of health systems in LMIC, arguments for developing policies to implement guideline-based care, innovations to improve kidney care, and the process of guideline adaptation to suit local needs. This executive summary serves as a resource to guide future work, including a pathway for adapting existing guidelines in different geographical regions.

Interplay between Diagnostic Criteria and Prognostic Accuracy in Chronic Kidney Disease

In a Perspective, Giuseppe Remuzzi and Richard Glassock discuss diagnostic criteria for chronic kidney disease and implications for disease progression.