Natural history of CKD stage 4 and 5 patients following referral to renal management clinic

Prospects for lithium treated patients with severe renal impairment

OBJECTIVES

To study the prospects for lithium treated patients who develop end stage renal disease (ESRD) and the role of renal replacement therapy (RRT).

METHODS

Retrospective analysis of survival, somatic comorbidity, lithium treatment and eligibility for renal replacement therapy in adult patients with at least one eGFR < 30 ml/min/1.73 m2. Subjects were selected from our laboratory database (s-Lithium and s-creatinine) from 1980 to 2017.

RESULTS

620 (14%) of 4396 patients with a lithium history had at least one measurement of eGFR < 30 ml/min/1.73 m2. 302 (49%) patients had a transient decrease in renal function with subsequent improvement, 135 (22%) patients died with acute renal failure, while 153 (25%) developed chronic kidney disease stage 4 (CKD4) and 33 (5%) required RRT. RRT-treated patients represent only a fraction of the total ESRD population. Median survival time from the debut of CKD4 was 13.9 years in patients < 65 years and 4.4 years in older patients. 100 of the 153 patients with CKD4 continued lithium treatment. There was no significant difference in survival after the debut of CKD4 between the patients who stopped lithium treatment and those who continued.

CONCLUSIONS

A measurement of eGFR < 30 ml/min/1.73 m2 reflects a significant loss of renal function. In half of the patients it was due to a transient functional disturbance without long-term consequences. A quarter of patients had acute renal failure and died within days while the remaining quarter progressed to CKD4. Despite irreversible renal damage, patient survival can be counted in several years after debut of renal insufficiency with appropriate care including RRT. As the treating psychiatrist, it is important to consult with nephrology when renal function starts to deteriorate, to optimise somatic treatment.

Urinary Liver-Type Fatty Acid Binding Protein, a Biomarker for Disease Progression, Dialysis and Overall Mortality in Chronic Kidney Disease

Chronic kidney disease (CKD) is a major public health concern with an increasing proportion of sufferers progressing to renal replacement therapy (RRT). Early identification of those at risk of disease progression could be key in improving outcomes. We hypothesise that urinary liver-type fatty acid binding protein (uL-FABP) may be a suitable biomarker for CKD progression and can add value to currently established biomarkers such as the urinary protein-to-creatinine ratio (uPCR). A total of 583 participants with CKD 1-5 (not receiving renal replacement therapy) entered a 2 yr prospective longitudinal study. UPCR and uL-FABP were measured at baseline and CKD progression was defined as either (i) a decline in eGFR of >5 mL/min/1.73 m2 or an increase in serum creatinine by 10% at 1 yr; (ii) a decline in eGFR of >6 mL/min/1.73 m2 or an increase in serum creatinine by 20% at 2 yrs; or (iii) the initiation of RRT. A combined outcome of initiating RRT or death was also included. Approximately 40% of participants showed CKD progression. uL-FABP predicted CKD progression at both years 1 and 2 (OR 1.01, p < 0.01). Sensitivity and specificity were comparable to those of uPCR (AUC 0.623 v 0.706) and heat map analysis suggested that uL-FABP in the absence of significant proteinuria can predict an increase in serum creatinine of 10% at 1 yr and 20% at 2 yrs. The risk of the combined outcome of initiating RRT or death was 23% higher in those with high uL-FABP (p < 0.01) independent of uPCR. uL-FABP appears to be a highly sensitive and specific biomarker of CKD progression. The use of this biomarker could enhance the risk stratification of CKD and its progression and should be assessed further.

Chronic kidney disease, risk of readmission, and progression to end-stage renal disease in 519,387 patients undergoing coronary artery bypass grafting

Objective

The association between chronic kidney disease and adverse outcomes after coronary artery bypass grafting is well established; in contrast, the association between chronic kidney disease and readmission has been less thoroughly investigated. We hypothesized that patients at higher chronic kidney disease stages have greater risk of readmission, poorer operative outcomes, and greater hospitalization cost.

Methods

Using the 2016-2018 Nationwide Readmissions Database, we identified 519,387 patients who underwent isolated coronary artery bypass grafting. Patients were stratified by chronic kidney disease stage based on International Classification of Diseases 10^th Revision classification. Multivariable logistic regression was used to assess risk factors for in-hospital mortality and 90-day readmission.

Results

Hospital readmission, in-hospital mortality, and cost progressively increased with worsening chronic kidney disease stage; patients with end-stage renal disease had the highest in-hospital mortality rate (7.2%), hospitalization costs ($59,616) (P < .001), and 90-day readmission rate (40%) (P < .001). Chronic kidney disease stage greater than 3 was associated with in-hospital mortality (odds ratio, 1.56, 95% confidence interval, 1.40-1.73; P < .001) and 90-day readmission (odds ratio, 1.66, 95% confidence interval, 1.56-1.76; P < .001). At 30 days after discharge, new-onset dialysis dependence was more frequent in patients readmitted with chronic kidney disease 4 to 5 (8.9%; n = 1495) than in patients with chronic kidney disease 1 to 3 (1.4%; n = 8623) and patients without chronic kidney disease (0.3%; n = 38,885). At 90 days after discharge, dialysis dependence increased to 11.1% (n = 1916) in readmitted patients with chronic kidney disease 4 to 5 but remained stable for patients with chronic kidney disease 1 to 3 (1.4%; n = 10,907) and patients without chronic kidney disease (0.3%; n = 50,200).

Conclusions

Chronic kidney disease stage is strongly associated with mortality, new-onset dialysis dependence, readmission, and higher cost after coronary artery bypass grafting. Patients with chronic kidney disease 4 and 5 and patients with end-stage renal disease are readmitted at the highest rates. Although further research is needed, a targeted approach may reduce costly readmissions and improve outcomes after coronary artery bypass grafting in patients with chronic kidney disease.

Multidisciplinary Team Care Delays the Initiation of Renal Replacement Therapy in Diabetes: A Five-year Prospective, Single-center Study

Objective Although recent reports have highlighted the benefits of multidisciplinary team care (MTC) for chronic kidney disease (CKD) in slowing the progress of renal insufficiency, its long-term effects have not been evaluated for patients with diabetes mellitus (DM). We compared the renal survival rate between MTC and conservative care (CC). Methods In this five-year, single-center, prospective, observational study, we examined 24 patients (mean age 65.5±12.1 years old, men/women 18/6) with DM-induced CKD stage ≥3 in an MTC clinic. The control group included 24 random patients with DM (mean age 61.0±12.8 years old, men/women 22/2) who received CC. MTC was provided by a nephrologist and medical staff, and CC was provided by a nephrologist. Results In total, 10 MTC and 20 CC patients experienced renal events [creatinine doubling, initiation of renal replacement therapy (RRT), or death due to end-stage CKD]. During the five-year observation period, there were significantly fewer renal events in the MTC group than in the CC group according to the cumulative incidence method (p=0.006). Compared to CC, MTC significantly reduced the need for urgent initiation of hemodialysis (relative risk reduction 0.79, 95% confidence interval [CI] 0.107-0.964). On a multivariate analysis, MTC (hazard ratio [HR], 0.434, 95% CI 0.200-0.939) and the slope of the estimated glomerular filtration rate during the first year (HR, 0.429 per 1 mL/min/m²/year, 95% CI 0.279-0.661) were negatively associated with renal events. Conclusion MTC for DM-induced CKD is an effective strategy for delaying RRT. Long-term MTC can demonstrate reno-protective effects.

Effect of multidisciplinary care of dialysis initiation for outpatients with chronic kidney disease

BACKGROUND

The aim of comprehensive multidisciplinary care (MDC) by the chronic kidney disease (CKD) team is not only to prevent worsening renal function, but also provide education on the selection of renal replacement therapy (RRT) by shared decision making (SDM). The purpose of this study was to examine the effects of MDC for predialysis outpatients on dialysis therapy, especially with regard to peritoneal dialysis (PD).

METHODS

This study evaluated 112 CKD patients who underwent dialysis at our hospital starting from 2012, with 53 outpatients receiving MDC from the CKD team and 59 outpatients not receiving MDC. Annual decreases in the estimated glomerular filtration rates (ΔeGFR), the duration from the time of intervention to dialysis initiation, the urgent dialysis rate using a temporary catheter, and the PD selection rate were compared and examined between the two groups. The ΔeGFR, the duration from intervention to PD initiation, and the PD retention rate were compared between 18 PD patients in the MDC group and 10 PD patients in the non-MDC group.

RESULTS

The MDC group had a significantly lower ΔeGFR, significantly longer duration, and a significantly lower urgent dialysis initiation rate versus the non-MDC group. Moreover, there was a significantly higher PD selection rate, significantly prolonged duration, and significantly higher PD retention rate.

CONCLUSIONS

Multidisciplinary CKD team care for outpatients is effective in delaying the progression of CKD and avoiding the initiation of urgent dialysis; contributing to improved PD selectivity and continuity by SDM.

Sunitinib versus sorafenib for patients with advanced renal cell carcinoma with renal impairment before the immune-oncology therapy era

OBJECTIVES

The efficacy and safety of sunitinib versus sorafenib in patients with advanced renal cell carcinoma with renal impairment remains poorly documented.

PATIENTS AND METHODS

We assessed the efficacy and safety of sunitinib and sorafenib in patients with advanced renal cell carcinoma with an estimated glomerular filtration rate of 15-60 mL/min/1.73 m2 by reviewing the medical records of patients treated at Jichi Medical University Hospital, Japan, between May 2008 and August 2016.

RESULTS

Twenty-seven patients were treated with sunitinib and 14 with sorafenib. Median progression-free survival in sunitinib- and sorafenib-treated patients was comparable, at 6.6 vs 5.8 months, respectively (HR, 1.618; 95% CI, 0.689-3.798; P = 0.2691). Median overall survival was also comparable, at 65.9 vs 58.0 months (HR, 0.985; 95% CI, 0.389-2.479; P = 0.9748). Grade 3 or higher adverse events were significantly more frequent in the sunitinib-treated than sorafenib-treated patients (P = 0.0357). Compared to pre-treatment values, estimated glomerular filtration rate at the discontinuation of treatment was not decreased in either group. In contrast, estimated glomerular filtration rate was decreased on long-term treatment, particularly in previously nephrectomized patients.

CONCLUSIONS

Sunitinib and sorafenib had similar efficacy in patients with advanced renal cell carcinoma and severe renal impairment. Although renal function was not markedly impaired in either group, close attention to decreased renal function may be necessary in previously nephrectomized patients on long-term treatment.

Type 2 diabetes treatment and progression of chronic kidney disease in Italian family practice

AIMS

Progressive chronic kidney disease represents a dreadful complication of type 2 diabetes mellitus (T2DM). We tested the pattern of use and the renal effects of old glucose-lowering drugs in T2DM patients cared for by Italian general practitioners (GPs).

METHODS

Data of 2606 T2DM patients were extracted from the databases of GPs, who do not have access to the most recent glucose-lowering drugs in Italy. The rate of kidney function decline was calculated by CKD-EPIcr, based on two consecutive creatinine values.

RESULTS

Metformin was used in 55% of cases, either alone or with sulfonylureas/repaglinide, across the whole spectrum of CKD (from 66% in stage G1 to only 8% in G4). Sulfonylurea use peaked at 21-22% in stage G2-G3a, whereas repaglinide use significantly increased from 8% in G1 to 22% in G4. The median rate of CKD decline was - 1.64 mL/min/1.73 m2 per year; it was higher in G1 (- 3.22 per year) and progressively lower with CKD severity. 826 cases (31.7%) were classified as fast progressors (eGFR decline more negative than - 5 mL/min/1.73 m2 per year). The risk of fast progressing CKD was associated with increasing BMI, albuminuria, and sulfonylurea use, alone (OR, 1.47; 95% confidence interval, 1.16-1.85), or in association with metformin (OR, 1.40; 95% CI 1.04-1.88). No associations were demonstrated for metformin, cardiovascular and lipid lowering drug use.

CONCLUSION

In the setting of Italian family practice, sulfonylurea use is associated with progressive CKD in patients with T2DM. Metformin, at doses progressively reduced according to CKD stages, as recommended by guidelines, is not associated with fast progression.

Temporal validation of the CT-PIRP prognostic model for mortality and renal replacement therapy initiation in chronic kidney disease patients

Background

A classification tree model (CT-PIRP) was developed in 2013 to predict the annual renal function decline of patients with chronic kidney disease (CKD) participating in the PIRP (Progetto Insufficienza Renale Progressiva) project, which involves thirteen Nephrology Hospital Units in Emilia-Romagna (Italy). This model identified seven subgroups with specific combinations of baseline characteristics that were associated with a differential estimated glomerular filtration rate (eGFR) annual decline, but the model’s ability to predict mortality and renal replacement therapy (RRT) has not been established yet.

Methods

Survival analysis was used to determine whether CT-PIRP subgroups identified in the derivation cohort (n = 2265) had different mortality and RRT risks. Temporal validation was performed in a matched cohort (n = 2051) of subsequently enrolled PIRP patients, in which discrimination and calibration were assessed using Kaplan-Meier survival curves, Cox regression and Fine & Gray competing risk modeling.

Results

In both cohorts mortality risk was higher for subgroups 3 (proteinuric, low eGFR, high serum phosphate) and lower for subgroups 1 (proteinuric, high eGFR), 4 (non-proteinuric, younger, non-diabetic) and 5 (non-proteinuric, younger, diabetic). Risk of RRT was higher for subgroups 3 and 2 (proteinuric, low eGFR, low serum phosphate), while subgroups 1, 6 (non-proteinuric, old females) and 7 (non-proteinuric, old males) showed lower risk. Calibration was excellent for mortality in all subgroups while for RRT it was overall good except in subgroups 4 and 5.

Conclusions

The CT-PIRP model is a temporally validated prediction tool for mortality and RRT, based on variables routinely collected, that could assist decision-making regarding the treatment of incident CKD patients. External validation in other CKD populations is needed to determine its generalizability.

Usefulness of multidisciplinary care to prevent worsening renal function in chronic kidney disease

BACKGROUND

Comprehensive education about lifestyle, nutrition, medications and other types of treatment is important to prevent renal dysfunction in patients with chronic kidney disease (CKD). However, the effectiveness of multidisciplinary care on CKD progression has not been evaluated in detail. We aimed to determine whether multidisciplinary care at our hospital could help prevent worsening renal function associated with CKD.

METHODS

A total of 150 pre-dialysis CKD outpatients accompanied (n = 68) or not (n = 82) with diabetes mellitus (DM) were enrolled into this study. We assessed annual decreases in estimated glomerular filtration rates (ΔeGFR), and measured systolic blood pressure (SBP), diastolic blood pressure (DBP), hemoglobin (Hb), uric acid (UA), low-density lipoprotein cholesterol (LDL), hemoglobin A1c (HbA1c) values and urinary protein to creatinine ratios (UPCR) 12 months before and after multidisciplinary care. In addition, changes in the number of medications and prescription ratio before and after multidisciplinary care were assessed in 90 patients with CKD who could confirm their prescribed medications.

RESULTS

The ΔeGFR significantly improved between before and after multidisciplinary care from - 5.46 to - 0.56 mL/min/1.73 m²/year, respectively. The number of medications and prescription ratio showed no significant changes before and after multidisciplinary care. The ratios of improved ΔeGFR were found in 66.7% of all patients, comprising 63.1% of males and 76.9% of females, 64.8% without DM and 69.4% with DM. Values for UA, LDL, and HbA1c were significantly reduced among patients with improved ΔeGFR.

CONCLUSION

Comprehensive multidisciplinary care of outpatients might help prevent worsening renal function among patients with CKD.

Long-term outcomes of patients with type 2 diabetes attending a multidisciplinary diabetes kidney disease clinic

BACKGROUND

The best model of care to retard diabetic kidney disease (DKD) in the clinic is underexplored. In this study we investigated the long-term renal outcomes of a joint endocrinologist-nephrologist clinic.

METHODS

The present study was a nested case-control study derived from a cohort of patients with type 2 diabetes mellitus (T2DM) seen prospectively at a secondary care diabetes center (DC). Cases ("DKD clinic group") were patients seen at the CKD clinic after being referred by physicians in DCs for management of DKD. Controls ("non-DKD clinic group") were patients from the same DC (i.e. same source population) with the same inclusion criteria of Stages 3-4 chronic kidney disease (CKD) at baseline but not seen at the DKD clinic. The outcome was Stage 5 CKD, defined as an estimated glomerular filtration rate <15 mL/min per 1.73 m² .

RESULTS

During the median follow-up period of 3.0 years (interquartile range 1.2-5.1 years), 240 patients (28.7%) reached Stage 5 CKD, with 45.8% and 54.2% of those reaching Stage 5 CKD in the DKD and non-DKD clinic groups, respectively. Multivariable Cox regression revealed that the DKD clinic group had a lower risk of progressing to Stage 5 CKD (hazard ratio 0.55; 95% confidence interval 0.36-0.83; P = 0.004) compared with the non-DKD clinic group.

CONCLUSIONS

Multidisciplinary endocrinology and nephrology care in the DKD clinic is associated with a lower risk of end-stage renal disease. These findings may inform future management strategies targeted at patients with T2DM and CKD, especially with regard to joint specialist management involving endocrinologists and nephrologists.

Diffusion-weighted imaging and pathology of chronic kidney disease: initial study

PURPOSE

To investigate the value of diffusion-weighted imaging (DWI) for assessing histopathologic changes observed in chronic kidney disease (CKD).

METHODS

Fifty-two patients with CKD underwent DWI before renal biopsy. The renal apparent diffusion coefficient (ADC) values and histopathologic changes were analyzed. The pathologic changes were scored using a semi-quantitative method (no lesion as 0, mild lesion as 1, moderate lesion as 2, and severe lesion as 3). The relationships between renal histopathologic scores, types, classification, and right renal ADCs were analyzed using ANOVA and Pearson's or Spearman's correlation tests.

RESULTS

Negative correlations were found between the right renal ADCs and scores of tubulointerstitial lesions (r = - 0.354, P = 0.012), the severity of tubular atrophy (r = - 0.439, P = 0.002), and the severity of interstitial fibrosis (r = - 0.272, P = 0.049). There were no correlations between the ADCs and scores of glomeruli and peritubular vessel lesions (P > 0.05). There were significant differences among groups based on pathology types (P = 0.009). There was no significant relationship between renal ADCs and the pathologic classification (P > 0.05).

CONCLUSIONS

DWI may be helpful to detect tubulointerstitial injury, including tubular atrophy and interstitial fibrosis. DWI may have the potential to serve as an effective auxiliary method to help nephrologists to evaluate patients with CKD.

Risk Prediction Models in CKD

Chronic kidney disease (CKD) currently affects 20 million Americans and is associated with increased morbidity and mortality. Resource-efficient and appropriate treatment of CKD benefits the patient and provides improved resource allocation for the health care system. Prediction models can be useful in efficiently allocating resources, and currently are being used at the bedside for several important clinical decisions. There is a paucity of prediction models in use in nephrology, but one such model, the Kidney Failure Risk Equation, uses routinely collected laboratory values and can inform clinical decisions related to the following: (1) triage of nephrology referrals, (2) evaluating the need for more intensive interdisciplinary clinic care, (3) determining the timing of modality education, and (4) dialysis access planning. The development of new models that predict survival and quality of life on dialysis, success on home modalities, failure of arteriovenous fistulas, and risk of cardiovascular disease in patients with CKD is needed.

A perspective on chronic kidney disease progression

Chronic kidney disease (CKD) will progress to end stage without treatment, but the decline of renal function may not be linear. Compared with glomerular filtration rate and proteinuria, new surrogate markers, such as kidney injury molecule-1, neutrophil gelatinase-associated protein, apolipoprotein A-IV, and soluble urokinase receptor, may allow potential intervention and treatment in the earlier stages of CKD, which could be useful for clinical trials. New omic-based technologies reveal potential new genomic and epigenomic mechanisms that appear different from those causing the initial disease. Various clinical studies also suggest that acute kidney injury is a major risk for progressive CKD. To ameliorate the progression of CKD, the first step is optimizing renin-angiotensin-aldosterone system blockade. New drugs targeting endothelin, transforming growth factor-β, oxidative stress, and inflammatory- and cell-based regenerative therapy may have add-on benefit.

Variability in estimated glomerular filtration rate values is a risk factor in chronic kidney disease progression among patients with diabetes

Background

It is unknown whether variability of estimated Glomerular Filtration Rate (eGFR) is a risk factor for dialysis or death in patients with chronic kidney disease (CKD). This study aimed to evaluate variability of estimated Glomerular Filtration Rate (eGFR) as a risk factor for dialysis or death to facilitate optimum care among high risk patients.

Methods

A longitudinal retrospective cohort study of 70,598 Veterans Health Administration veteran patients with diabetes and CKD (stage 3–4) in 2000 with up to 5 years of follow-up. VHA and Medicare files were linked to derive study variables. We used Cox proportional hazards models to evaluate association between time to initial dialysis/death and key independent variables: time-varying eGFR variability (measured by standard deviation (SD)) and eGFR means and slopes while adjusting for prior hospitalizations, and comorbidities.

Results

There were 76.7% older than 65 years, 97.5% men, and 81.9% Whites. Patients were largely in early stage 3 (61.2%), followed by late stage 3 (28.9%), and stage 4 (9.9%); 29.1%, 46.8%, and 73.3%, respectively, died or had dialysis during the follow-up. eGFR SDs (median: 5.8, 5.1, and 4.0 ml/min/1.73 m² ) and means (median: 54.1, 41.0, 27.2 ml/min/1.73 m²) from all two-year moving intervals decreased as CKD advanced; eGFR variability (relative to the mean) increased when CKD progressed (median coefficient of variation: 10.9, 12.8, and 15.4). Cox regressions revealed that one unit increase in a patient’s standard deviation of eGFRs from prior two years was significantly associated with about 7% increase in risk of dialysis/death in the current year, similarly in all three CKD stages. This was after adjusting for concurrent means and slopes of eGFRs, demographics, prior hospitalization, and comorbidities. For example, the hazard of dialysis/death increased by 7.2% (hazard ratio:1.072; 95% CI = 1.067, 1.080) in early stage 3.

Conclusion

eGFR variability was independently associated with elevated risk of dialysis/death even after controlling for eGFR means and slopes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-015-0025-5) contains supplementary material, which is available to authorized users.

Combination of ACE inhibitor with nicorandil provides further protection in chronic kidney disease

An inhibition in the renin-angiotensin system (RAS) is one of the most widely used therapies to treat chronic kidney disease. However, its effect is occasionally not sufficient and additional treatments may be required. Recently, we reported that nicorandil exhibited renoprotective effects in a mouse model of diabetic nephropathy. Here we examined if nicorandil can provide an additive protection on enalapril in chronic kidney disease. Single treatment with either enalapril or nicorandil significantly ameliorated glomerular and tubulointerstitial injury in the rat remnant kidney while the combination of these two compounds provided additive effects. In addition, an increase in oxidative stress in remnant kidney was also blocked by either enalapril or nicorandil while the combination of the drugs was more potent. A mechanism was likely due for nicorandil to preventing manganase superoxide dismutase (MnSOD) and sirtuin (Sirt)3 from being reduced in injured kidneys. A study with cultured podocytes indicated that the antioxidative effect could be mediated through sulfonylurea receptor (SUR) in the mitochondrial KATP channel since blocking SUR with glibenclamide reduced MnSOD and Sirt3 expression in podocytes. In conclusion, nicorandil may synergize with enalapril to provide superior protection in chronic kidney disease.

Chronic kidney disease prediction is an inexact science: The concept of “progressors” and “nonprogressors”

In 2002, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) instituted new guidelines that established a novel chronic kidney disease (CKD) staging paradigm. This set of guidelines, since updated, is now very widely accepted around the world. Nevertheless, the authoritative United States Preventative Task Force had in August 2012 acknowledged that we know surprisingly little about whether screening adults with no signs or symptoms of CKD improve health outcomes and that we deserve better information on CKD. More recently, the American Society of Nephrology and the American College of Physicians, two very well respected United States professional physician organizations were strongly at odds coming out with exactly opposite recommendations regarding the need or otherwise for ”CKD screening” among the asymptomatic population. In this review, we revisit the various angles and perspectives of these conflicting arguments, raise unanswered questions regarding the validity and veracity of the NKF KDOQI CKD staging model, and raise even more questions about the soundness of its evidence-base. We show clinical evidence, from a Mayo Clinic Health System Renal Unit in Northwestern Wisconsin, United States, of the pitfalls of the current CKD staging model, show the inexactitude and unpredictable vagaries of current CKD prediction models and call for a more cautious and guarded application of CKD staging paradigms in clinical practice. The impacts of acute kidney injury on CKD initiation and CKD propagation and progression, the effects of such phenomenon as the syndrome of late onset renal failure from angiotensin blockade and the syndrome of rapid onset end stage renal disease on CKD initiation, CKD propagation and CKD progression to end stage renal disease all demand further study and analysis. Yet more research on CKD staging, CKD prognostication and CKD predictions is warranted. Finally and most importantly, cognizant of the very serious limitations and drawbacks of the NKF K/DOQI CKD staging model, the need to individualize CKD care, both in terms of patient care and prognostication, cannot be overemphasized.

Associations of baseline characteristics with evolution of eGFR in a referred chronic kidney disease cohort

BACKGROUND

Currently, most chronic kidney disease (CKD) classifications identify patients at different stages of CKD but do not identify risk of progression or adverse outcome. This analysis aims to describe associations between baseline characteristics and the evolution of estimated glomerular filtration rate (eGFR) and identify threshold values for clinical parameters that maximally discriminate progression to renal replacement therapy (RRT) in a referred cohort of patients with CKD stages 3-5.

DESIGN AND METHODS

A longitudinal mixed-effect model was used to determine annualized estimated change in eGFR and classification tree analysis to identify threshold values that maximally discriminate progression to RRT.

RESULTS

A total of 1316 patients were available for analysis with median follow-up of 33 months (interquartile range 20-60). Mixed model analysis suggested that the underlying diagnoses of autosomal dominant polycystic kidney disease and diabetic nephropathy exhibited on average a 2.7 (0.3) and 0.7 (0.3) ml/min/year faster rate of decline in eGFR, respectively, compared to those patients with biopsy-proven glomerulonephritis. In the regression tree analysis, we attempted to identify threshold values for clinical parameters that maximally discriminate progression to RRT. eGFR ≤24 ml/min was the first ranked discriminator, diastolic blood pressure appeared in the second and fourth rounds, eGFR appeared again in the third round together with cholesterol and systolic blood pressure, with basal metabolic index in the fourth.

CONCLUSION

This analysis highlights risk factors for progressive kidney disease and demonstrates the variability in evolution of eGFR across the cohort as well as the importance of underlying renal disease type on the progression of CKD.

In-hospital mortality in patients with renal dysfunction admitted for myocardial infarction: the Emilia-Romagna region of Italy database of hospital admissions

BACKGROUND

In-hospital mortality of patients with myocardial infarction (MI) in different European populations and renal dysfunction is variable. We aimed to evaluate in-hospital mortality for MI in chronic kidney disease (CKD), in end-stage renal disease (ESRD), and in subjects admitted for MI without renal dysfunction living in the Emilia-Romagna region of Italy.

METHODS

We considered all cases of MI (first event) recorded in the database of hospital admissions of the region Emilia-Romagna of Italy, from January 1999 to December 2009. The criterion for inclusion was the presence, as a first discharge diagnosis, of acute MI (International Classification of Diseases, 9th Revision, Clinical Modification). The Charlson comorbidity index (CCI), with the exclusion of CKD, was calculated. The outcome variable was in-hospital mortality for MI, and its association with comorbidities, CKD and ESRD, was analyzed.

RESULTS

During the considered period, 88,014 cases of first MI were recorded. The percentage of patients admitted with MI and died during hospitalization were higher in patients with ESRD (38.3 %) and CKD (16.5 %) than in those without renal dysfunction (14 %) (p < 0.01). In CKD and ESRD patients, data of in-hospital mortality for MI exhibited a twofold increase in the analyzed period. In-hospital mortality for MI was independently associated with age (OR 1.077, 95 % CI 1.075-1.080, p < 0.001), CCI excluding CKD (OR 1.101, 95 % CI 1.069-1.134, p < 0.001), cerebrovascular disease (OR 1.450, 95 % CI 1.349-1.557, p < 0.001), malignancy (OR 1.234, 95 % CI 1.153-1.320, p < 0.001), and ESRD (OR 4.137, 95 % CI 3.511-4.875, p < 0.001).

CONCLUSIONS

As for the Emilia-Romagna region of Italy, in-hospital mortality for MI is increasing over the last years, and mortality seems to be related with patients' comorbidities and presence of advanced stages of CKD.