Hidden prevalence of chronic kidney disease in hypertensive patients: the strategic role of primary health care. Public Health. 2016;140:250-257. [PMID: 27036982 DOI: 10.1016/j.puhe.2016.02.029]

Risk Factor-Based Screening for Early Detection of Chronic Kidney Disease in Primary Care Settings: A Systematic Review

Rationale & Objective

Kidney failure can be prevented or delayed if chronic kidney disease (CKD) is detected and treated early. Targeted screening has been shown effective in detecting CKD worldwide, but a recently updated summary of evidence is lacking. We synthesized up-to-date evidence of the effectiveness of risk factor-based screening for the early detection of CKD among adults in primary care.

Study Design

We retrieved articles from Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and Scopus. Relevant gray literature and hand-searching bibliographies of key articles were also performed.

Setting & Study Populations

Adult patients (age ≥ 18 years) with at least 1 known CKD risk factor in primary care.

Selection Criteria for Studies

Prospective studies applying CKD screening in adults based on at least 1 CKD risk factor.

Data Extraction

Data were abstracted from full texts and the risk of bias was assessed using the Joanna Briggs Institute critical appraisal tools.

Analytical Approach

No meta-analysis was conducted.

Results

In total, 24 studies from 11 countries fulfilled the inclusion criteria. Diverse screening tests, CKD definitions, formulas for estimating kidney function, and positive screening test cutoffs were used. Most studies (n = 22) employed estimated glomerular filtration rate (eGFR), albumin-creatinine ratio (ACR) (n = 14), and dipstick urinalysis (n = 9) for screening. The prevalence of reduced kidney function and/or kidney damage was between 2.9% and 56%, and confirmed CKD varied from 4.4% to 17.1%. Increased patient referrals and physician visits, higher patient satisfaction, and some form of patient willingness to pay for the services were reported because of screening.

Limitations

Meta-analysis was not conducted, and the findings might not be generalized to resource-limited settings.

Conclusions

Risk factor-based screening effectively identifies a substantial proportion of people with undiagnosed CKD, but there is still scope for improvement. We recommend future studies have robust designs and multidimensional interventions to establish the effectiveness of targeted CKD screening in primary care.

Prevalence of Chronic Kidney Disease among Diagnosed and Undiagnosed Hypertensive Individuals in the General Population of the Northern Region of Senegal

INTRODUCTION

Chronic kidney disease (CKD) is closely linked to high blood pressure (HBP), which is its leading cause in developing countries. Hypertension affects 1.2 billion people worldwide. However, a significant portion of individuals with HBP are undiagnosed, and their kidney function is even less known. The objective of this study was to determine the prevalence and associated factors of CKD among three sub-groups of blood pressure status (normotensive, diagnosed hypertension, and undiagnosed hypertension) individuals.

PATIENTS AND METHODS

We conducted a cross-sectional study in the general population of three northern regions in Senegal using a two-level cluster sampling method. The sample was constituted with a precision of 5% and a power of 80%, with an additional 10% attrition margin. Individuals aged 18-80 years were included in the study after consent. Pregnant women, hospitalized persons within the past 3 months, patients with general or urinary symptoms within the past 7 days and individuals undergoing renal replacement therapy were excluded. Investigators collected clinical and biological data at participants' homes using a modified version of the WHO's STEPwise questionnaire. Samples were collected for biochemical analysis (serum creatinine, lipid profile, and blood sugar). Estimated glomerular filtration rate was calculated using the CKD-EPI 2021 formula.

RESULTS

A total of 2,441 participants were included in the study with a mean age of 45.4 ± 16.0 years and a sex ratio M/F of 0.4. The overall prevalence of HBP and CKD were, respectively, 52.0% and 17.8%. Three out of every five hypertensive patients were undiagnosed. CKD was more frequent among known hypertensive patients (30.5%) compared to individuals with undiagnosed hypertension (19.1%) and normotensive individuals (10.9%). Multivariate analysis showed that CKD was associated with older age and female sex.

CONCLUSION

Undiagnosed hypertension is common among populations in northern Senegal. A high prevalence of CKD was found among both diagnosed and undiagnosed individuals with hypertension. Extending strategies for early detection and management in the general population could help prevent or reduce morbidity and mortality associated with CKD.

Results from a cross-specialty consensus on optimal management of patients with chronic kidney disease (CKD): from screening to complications

BACKGROUND

Chronic kidney disease (CKD) affects around 10% of the global population and has been estimated to affect around 50% of individuals with type 2 diabetes and 50% of those with heart failure. The guideline-recommended approach is to manage with disease-modifying therapies, but real-world data suggest that prescribing rates do not reflect this in practice.

OBJECTIVE

To develop a cross-specialty consensus on optimal management of the patient with CKD using a modified Delphi method.

DESIGN

An international steering group of experts specialising in internal medicine, endocrinology/diabetology, nephrology and primary care medicine developed 42 statements on aspects of CKD management including identification and screening, risk factors, holistic management, guidelines, cross-specialty alignment and education. Consensus was determined by agreement using an online survey.

PARTICIPANTS

The survey was distributed to cardiologists, nephrologists, endocrinologists and primary care physicians across 11 countries.

MAIN OUTCOMES AND MEASURES

The threshold for consensus agreement was established a priori by the steering group at 75%. Stopping criteria were defined as a target of 25 responses from each country (N=275), and a 4-week survey period.

RESULTS

274 responses were received in December 2022, 25 responses from Argentina, Australia, Brazil, Guatemala, Mexico, Singapore, South Korea, Taiwan, Thailand, Turkey and 24 responses from Egypt. 53 responses were received from cardiologists, 52 from nephrologists, 55 from endocrinologists and 114 from primary care physicians. 37 statements attained very high agreement (≥90%) and 5 attained high agreement (≥75% and <90%). Strong alignment between roles was seen across the statements, and different levels of experience (2-5 years or 5+ years), some variation was observed between countries.

CONCLUSIONS

There is a high degree of consensus regarding aspects of CKD management among healthcare professionals from 11 countries. Based on these strong levels of agreement, the steering group derived 12 key recommendations focused on diagnosis and management of CKD.

What is the prevalence of chronic kidney disease among hypertensive non-diabetic Egyptian patients attending primary healthcare?

BACKGROUND

Although chronic kidney disease (CKD) is considered the major cause of morbidity and mortality in hypertension, the recognition and prevention of CKD remain deficient. CKD is one of the major health challenges in Egypt. CKD affects approximately 13% of the adult population, resulting in significant morbidity, mortality, and health care costs. Patients with more progressive stage 3 or stage 4 CKD experience a high rate of cardiovascular events and death compared to earlier stages of CKD.

AIM

This study was performed to determine the prevalence and risk factors of CKD among hypertensive non-diabetic patients attending primary health care (PHC) centers in Cairo.

METHODOLOGY

The study type is a cross-sectional study. Study setting: Two PHC centers: Saraya El-kobba and El-Sharabya. Sampling method: Recruitment of participants was done in one day weekly. Any known essential hypertensive patients aged 18 or more registered in the two PHC centers in Cairo.

RESULTS

The prevalence of CKD was 33% among the hypertensive non-diabetic patients. Among CKD participants, the prevalence is more common in females (59.7%) than males (40.3%), in those who completed primary education and in the illiterates and low socioeconomic class. Surprisingly, it is more common in patients with positive family history of CKD and patients with ischemic heart disease and the antihypertensive drugs use.

CONCLUSION

CKD has a high prevalence among hypertensive non-diabetic patients, and it has a significant morbidity and mortality among those patients.

Prevalence of chronic kidney disease and associated factors among patients with chronic illness in Ethiopia: A systematic review and meta-analysis

Objective:

The main aim of this systematic review and meta-analysis is to provide summarized evidence on the prevalence of chronic kidney disease and associated factors among patients with chronic illness in Ethiopia.

Method:

Databases of MEDLINE/PubMed, Embase, Google Scholar, CINAHL, Cochrane library, and ScienceDirect were searched. In addition, gray literatures were searched manually from university repositories. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used to select potential studies. Microsoft Excel 2013 sheet template was used to extract data. The quality of included studies was assessed by utilizing the Newcastle-Ottawa Scale. STATA software version 14.0 is used to compute the estimated pooled prevalence and associated factors of chronic kidney disease.

Result:

Twelve articles that fulfilled the inclusion criteria were included. The pooled estimate of chronic kidney disease among patients with chronic illnesses in Ethiopia is 21.71% (95% confidence interval: 17.67, 25.74). The highest prevalence of chronic kidney disease among patients with chronic illnesses is from Oromia (32.55% (confidence interval: 19.91, 45.19)). Glomerular filtration rate showed a comparable pooled prevalence from Cockroft-Gault and MDRD methods; 22.38% (confidence interval: 15.83, 28.92), 22.18 (confidence interval: 18.01, 26.34), respectively. Hypertensives become more likely to have chronic kidney disease compared with normotensive patients, (odds ratio = 3.01, 95% confidence interval: 1.33, 6.81).

Conclusion:

Prevalence of chronic kidney disease among chronic illness patients was significantly high. Hypertension is significantly associated with chronic kidney disease. Hence, we recommend that continuous screening of possible risk factors and proper follow-up and management strategies should be designed.

Prevalence and Associated Factors of Chronic Kidney Disease among Adult Hypertensive Patients at Northwest Amhara Referral Hospitals, Northwest Ethiopia, 2020

BACKGROUND

Chronic kidney disease (CKD) is a progressive loss of the kidney function which leads to a decreased kidneys' ability to process waste in the blood and it affects the other important functions of the kidney. The disease has different stages that can alter the health status of individuals. During the early stages, patients may present with a normal or slight decrease in glomerular filtration rate (GFR) and albuminuria. Later, it progresses and leads to end-stage renal disease (ESRD) or kidney failure. Hypertension is considered as the major contributing risk factor of CKD.

OBJECTIVE

This study was aimed to assess the prevalence and associated factors of chronic kidney disease among adult hypertensive patients in referral hospitals of the Northwest Ethiopia.

METHODS

An institution-based cross-sectional study was conducted among 581 adult hypertensive patients in a chronic follow-up clinic in referral hospitals, Northwest Ethiopia, from July to August 2020. Systematic random sampling was used to select the study participants. Data were collected using the interviewer-administered questionnaire and participants medical records. Both bivariable and multiple logistic regression analyses were performed. Model fitness was assessed using a Hosmer-Lemeshow test.

RESULT

The total prevalence of CKD among adult hypertensive patients was 17.6% (95% CI: 14.7-20.8). Diastolic blood pressure ≥90 mmHg (AOR = 8.65; 95% CI: 4.77-15.68), duration of hypertension ≥10 years (AOR = 8.81; 95% CI: 2.47-31.45), stage II HTN (AOR = 2.61; 95% CI: 1.04-6.50), comorbid disease (AOR = 7.0; 95% CI: 2.20-22.21), proteinuria (AOR = 4.59; 95% CI: 2.08-10.12), dyslipidemia (AOR = 3.40; 95% CI: 1.56-7.24), and serum creatinine ≥1 mg/dl (AOR = 8.88; 95% CI: 4.40-17.91) were associated with chronic kidney disease among adult hypertensive patients.

CONCLUSION

In this study, the prevalence of CKD among hypertensive patients found was 17.6%. Regarding associated factors, dyslipidemia, proteinuria, comorbid disease, serum creatinine greater than 0.9 mg/dl, duration of hypertension greater than 10 years, and diastolic blood pressure greater than 90 mmHg are factors associated with the occurrence of chronic kidney disease among hypertensive patients.

Overexpression of miR-19a and miR-20a in iPS-MSCs preserves renal function of chronic kidney disease with acute ischaemia-reperfusion injury in rat

This study tested the hypothesis that therapy with double overexpression of miR‐19a‐3p and miR‐20a‐5p (miR^DOE) to human inducible pluripotent stem cell–derived mesenchymal stem cells (iPS‐MSCs) was superior to iPS‐MSCs alone for preserving renal function in rat with pre‐existing chronic kidney disease (CKD), followed by ischaemia‐reperfusion (IR) injury. In vitro study demonstrated that the protein expressions of oxidative stress (NOX‐1/NOX‐2/NOX4/oxidized protein/p22phox), inflammatory downstream signalling (TLR2&4/MyD88/TRAF6/IKK‐ß/p‐NFκB/IL‐1ß/IL‐6/MMP‐9) and cell apoptosis/death signalling (cleaved caspase‐3/mitochondrial Bax/p‐ERKs/p‐JNK/p‐p38) at time‐points of 24‐hour/48‐hour cell cultures were significantly increased in p‐Cresol‐treated NRK‐52E cells than in the control that was significantly reversed by miR‐19a‐3p‐transfected iPS‐MSC (all P < .001). Animals were categorized into group 1 (sham‐operated control), group 2 (CKD‐IR), group 3 (CKD‐IR + oligo‐miR^DOE of iPS‐MSCs/6.0 ×10⁵/intra‐renal artery transfusion/3 hours after IR procedure), group 4 (CKD‐IR + iPS‐MSCs) and group 5 (CKD‐IR + miR^DOE of iPS‐MSCs/6.0 ×10^5/intra‐renal artery transfusion/3 hour after IR procedure). By day 35, the creatinine/BUN levels were lowest in group 1, highest in group 2 and significantly lower in group 5 than in groups 3 and 4 (all P < .0001) but they showed no difference between the latter two groups. The protein expressions of oxidative stress, inflammatory downstream signalling and cell apoptosis/death signalling exhibited an identical pattern of creatinine level among the five groups (all P < .00001). Also, the microscopic findings demonstrated that the kidney injury score/fibrotic area/number of inflammatory cells (CD14+/CD68+) exhibited an identical pattern of creatine level (all P < .0001). The miR^DOE of iPS‐MSCs was superior to iPS‐MSCs for preserving the residual kidney function and architecture in CKD‐IR rat.

Prevalence of chronic kidney disease in Brazilians with arterial hypertension and/or diabetes mellitus

The present study aimed to evaluate the prevalence of chronic kidney disease (CKD) in individuals with arterial hypertension (AH) and/or diabetes mellitus (DM) accompanied by Primary Health Care (PHC) in Brazil. The estimated glomerular filtration rate (eGFR) based on creatinine, and urinary albumin-to-creatinine ratio (ACR) were measured in 841 subjects with AH and/or DM, followed by PHC in the city of Viçosa. The CKD was diagnosed according to KDIGO criteria. Sociodemographic, clinical, and anthropometric factors related to the prevalence of CKD were investigated through multiple logistic regression. The prevalence of hidden CKD was 15.4%. Of these, 7.5% were identified by albuminuria (ACR ≥30 mg/g) with slightly decreased eGFR. Age, baseline disease, waist circumference (WC), and systolic blood pressure remained associated with CKD after multivariate analysis. The two major risk factors for hidden CKD were the presence of AH in association with DM and an increase in age. Hidden CKD was more common within people with AH and DM, and with high WC, glycosylated hemoglobin, and serum phosphorus as well as male gender and decreased serum albumin. This knowledge of risk associations can help avoid progression to CKD.

Antioxidant and nephroprotection activities of Combretum micranthum: A phytochemical, in-vitro and ex-vivo studies

Management of chronic renal failure is exceedingly expensive. Despite of encouraging experimental outcomes, there is a lack of potent nephroprotective drugable molecules in a clinics or market. To develop a nephroprotective phytomedicine, the present study was designed to do a literature survey on reported phytochemical and biological analysis of Combretum micranthum and to carry out chemoprofiling, in-vitro antioxidant and ex-vivo nephroprotective capacity of the title plant. The phytochemical and biological activity survey of C. micranthum has reveals the presence of many bioactive compounds such as flavonoids, terpenoids, steroids and alkaloids with many biological activities. Phytochemical investigation re-confirmed the presence of these compounds. Hydroalcoholic extract of C. micranthum (CM extract) showed a strong antioxidant activity by scavenging AAPH, DPPH, nitric oxide, hydrogen peroxide and chelating metal ions. CM extract exhibited significant (P < 0.001) dose dependent inhibition of ferric chloride-ascorbic acid induced lipid peroxidation. Diabetic nephropathy is a serious and common complication leading to end stage renal disease. Therefore, in the present study, glucose-induced toxicity was also studied in human embryonic kidney cells (HEK-293) as an in vitro model for diabetic nephropathy. The results showed that exposure of cells to high glucose (100 mM) for 72 h significantly reduced the cell viability resulting in morphological changes such as cell shrinkage, rounded cell shape and cytoplasmic vacuolation. Treatment with CM extract at 10 and 25 μg/mL resulted in significant improvement in cell viability from 10 to 23% compared to the high glucose control. This study demonstrated the potential antioxidant and nephroprotective properties of C. micranthum, justifying its traditional use in the treatment of various diseases.

Sitagliptin and shock wave-supported peripheral blood derived endothelial progenitor cell therapy effectively preserves residual renal function in chronic kidney disease in rat-role of dipeptidyl peptidase 4 inhibition

This study tested whether sitagliptin and shock wave (SW)-assisted circulatory-derived autologous endothelial progenitor cell (EPC) therapy would effectively preserve residual renal function in chronic kidney disease (CKD) induced by 5/6 left-nephrectomy/remove right kidney plus daily feeding high-protein diet (H^PD) in rat. Adult-male SD rats (n = 40) were categorized into group 1 (sham-operated control with H^PD), group 2 (H^PD-CKD), group 3 [H^PD-CKD + EPC (1.2 × 10⁶ cell)/intra-vessel administration by day 14 after CKD-induction], group 4 [H^PD-CKD + SW (0.12 mJ/mm²/180 shorts) at days 14/21/28 after CKD-induction by ultrasound-guided application] and group 5 [H^PD-CKD + SW + EPC + sitagliptin (Sita; 600 mg/kg/day since day 14 after CKD induction)]. All animals were euthanized by day 60. By day 60, renal blood flow (RBF) was highest in group 1 and progressively increased from groups 2 to 5, whereas the levels of creatinine/BUN/proteinuria exhibited an opposite pattern of RBF among the five groups (all p < 0.001). The circulating levels of GLP-1/SDF-1α and protein levels of angiogenesis (VEGF/SDF-1α/CXCR4) and GLP-1R in kidney were progressively increased from groups 1 to 5, whereas circulating DPP4 activity exhibited an opposite pattern of SDF-1α among the groups (all p < 0.0001). The protein expressions of oxidative-stress (NOX-1/NOX-2/oxidized protein), apoptosis (Bax/caspase-3/PARP), fibrosis (Smad3/TGF-ß) and inflammation (TNF-α/NF-κB/MMP-2) and kidney injury score displayed an opposite pattern, whereas the protein expressions of TMP2, endothelial-cell markers (CD31/eNOS) and podocyte integrity biomarkers (podocin/ZO-1/synaptopodin) exhibited an identical pattern of RBF among the groups (all p < 0.001). In conclusion Sita associated SW-assisted EPC effectively protected residual renal function in CKD.

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.

Investigated the safety of intra-renal arterial transfusion of autologous CD34+ cells and time courses of creatinine levels, endothelial dysfunction biomarkers and micro-RNAs in chronic kidney disease patients-phase I clinical trial

This was a phase I clinical trial to investigate the safety of autologous peripheral-blood-derived CD34+ cell therapy for patients with chronic kidney disease (CKD-treatment) (i.e., at Stages III and IV). Between November 2014 and October 2015, a total of 10 study patients were prospectively enrolled into this phase I trial. Patients who failed to enroll into the trial in the initial state of eligibility assessment were served as CKD-control group (n = 9). The health-control group was composed of 10 volunteers for the purposes of comparing (1) circulation level of endothelial progenitor cells (EPCs), (2) angiogenesis ability, and (3) anti-apoptotic miRNAs between healthy subjects and CKD patients. CD34+ cells (5.0 x 107) were transfused into right-renal artery after subcutaneous G-CSF injection (5μg/kg/twice a day for 4 days). Circulating EPC number, angiogenesis capacity (i.e., Matrigel assay) and anti-apoptotic miRNAs (miR-374a-5p/miR-19a-3p/ miR-106b-5p/miR-26b-5p/ miR-20a-5p) were significantly lower in CKD patients than in healthy subjects (all p < 0.001). Flow-cytometric analysis of renal-vein blood samplings (i.e., at 0/5/10/30 mins after cell transfusion) showed the EPC level was significantly progressively increased (p < 0.001). Procedural safety was 100% with all patients uneventfully discharged and one-year survival rate was 100%. The paired-t test showed serum creatinine maintained the same level between the baseline and at the end of one-year follow-up (all p > 0.4), whereas the net increase between initial and final creatinine level was higher in CKD-control than in CKD-treatment. In conclusion, CD34+ cell therapy was safe and maintained the renal function in stationary state at the end of study period.