The burden of chronic kidney disease

Repeatability, Reproducibility, and Observer Variability of Cortical T1 Mapping for Renal Tissue Characterization

BACKGROUND

The global rise in kidney diseases underscores the need for reliable, noninvasive imaging biomarkers. Among these, renal cortical T1 has shown promise but further technical validation is still required.

PURPOSE

To evaluate the repeatability, reproducibility, and observer variability of kidney cortical T1 mapping in human volunteers without known renal disease.

STUDY TYPE

Prospective.

SUBJECTS

Three cohorts without renal disease: 1) 25 volunteers (median age 38 [interquartile range, IQR: 28-42] years, female N = 11) for scan-rescan assessments on GE 1.5 T and Siemens 1.5 T; 2) 29 volunteers (median age 29 [IQR: 24-40] years, female N = 15) for scan-rescan assessments on Siemens 3 T; and 3) 16 volunteers (median age 34 [IQR: 31-42] years, female N = 8) for cross-scanner reproducibility.

FIELD STRENGTH/SEQUENCES

1.5 T and 3 T, a modified Look-Locker imaging (MOLLI) sequence with a balanced steady-state free precession (bSSFP) readout.

ASSESSMENT

Kidney cortical T1 data was acquired on GE 1.5 T scanner, Siemens 1.5 T and 3 T scanners. Within-scanner repeatability and inter/intra-observer variability: GE 1.5 T and Siemens 1.5 T, and cross-scanner manufacturer reproducibility: Siemens 1.5 T-GE 1.5 T.

STATISTICAL TESTS

Bland Altman analysis, coefficient of variation (CoV), intra-class coefficient (ICC), and repeatability coefficient (RC).

RESULTS

Renal cortical T1 mapping showed high repeatability and reliability across scanner field strengths and manufacturers (repeatability: CoV 1.9%-2.8%, ICC 0.79-0.88, pooled RC 73 msec; reproducibility: CoV 3.0%, ICC 0.75, RC 90 msec). The method also showed robust observer variability (CoV 0.6%-1.4%, ICC 0.93-0.98, RC 22-48 msec).

DATA CONCLUSION

Kidney cortical T1 mapping is a highly repeatable and reproducible method across MRI manufacturers, field strengths, and observer conditions.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 2.

Renal satellite units in Pakistan: Challenges, efforts, and recommendations

This commentary delves into the complexities surrounding chronic kidney disease management in Pakistan, specifically examining the critical role played by renal satellite units in providing accessible dialysis services. Chronic kidney disease in Pakistan accounts for 3.9% of total deaths, warranting a focused exploration of challenges and potential solutions. RSUs, smaller entities affiliated with main renal units, emerge as key players in addressing issues of geographic accessibility and diminishing travel burdens for chronic kidney disease patients. Challenges such as financial constraints, limited resources, and staff shortages, particularly in rural settings, pose significant hurdles to the effective functioning of RSUs. This commentary emphasizes the importance of clear eligibility criteria, robust vascular access support, regular physician engagement, and the strategic integration of telemedicine. It explores diverse funding models, including government allocations, community contributions, and philanthropic partnerships, as potential solutions to alleviate cost-related concerns. The commentary advocates for a holistic, cost-effective approach to chronic kidney disease care, highlighting the transformative potential of renal satellite units in improving health outcomes across varied settings.

Symptom Burden in Patients on Maintenance Hemodialysis: Prevalence and Severity 17 Years Apart

Objectives: The aim of this study is to compare data from two cohorts separated by a 17-year interval. We assessed the prevalence and severity of symptoms with the "dialysis symptom index" in these two groups, recruited in 2007 and 2024, to determine how advancements in dialysis therapy have influenced the symptom burden's prevalence and severity. Methods: End-stage renal diseases patients receiving maintenance hemodialysis three times a week in the hemodialysis unit of the university hospital were recruited between February and March 2007. In May 2024, in the same unit, another population sample was recruited and studied, as in 2007. The Dialysis Symptom Index (DSI) was administered to each patient, during the dialysis treatment. The DSI is made up of 30 questions, each of which addresses a specific physical or emotional symptom. The total symptom burden score, representing the total number of symptoms reported as being present, and the total symptom severity score, which represents the sum of individual severity scores, were generated for each patient. Results: We studied 71 patients in 2007 and 61 patients in 2024. The demographic, clinical and laboratory characteristics of the two study populations did not differ significantly. The total symptom burden score did not differ significantly between 2007 and 2024. The prevalence of most symptoms was similar in the two groups. The prevalence of constipation, decreased interest in sex and difficulty in becoming sexually aroused was higher in 2024 than in 2007. The total symptom severity was similar in the two periods. The severity of most symptoms was similar in the two groups. The severity of decreased interest in sex and difficulty in becoming sexually aroused was higher in 2024 than in 2007. Conclusions: The present study shows that, 17 years apart, the prevalence and severity of the symptom burden in patients on maintenance hemodialysis did not change significantly. These results suggest that studies investigating the causes and the pathogenesis of symptoms of patients on maintenance hemodialysis are urgently needed in the next future, as well as studies on therapeutic strategies.

Anchor versus parachute suturing technique in arteriovenous fistula creation for hemodialysis

INTRODUCTION

Chronic kidney disease (CKD) affects 13% of the global population and requires renal replacement therapy due to ESRD. Hemodialysis (HD) is the most common dialysis modality for ESRD patients, but establishing vascular access is challenging due to high morbidity and mortality rates. Arteriovenous fistulas (AVFs) are the gold standard for vascular access, but many fail due to anastomotic hemodynamics, vein diameter, and anastomatic suture technique. A prospective study was conducted to evaluate the impact of two continuous suturing techniques, the anchor technique and the parachute technique, on AVFs' initial outcomes.

METHODS

This randomized, controlled study involved adult patients who presented for AVF creation at our center. We divided the patients into two groups: anchors and parachutes. Four skilled vascular access surgeons performed the procedures. The primary goal was functional maturation of the AVF, defined as an AVF fistula ready to be cannulated with a cannulating vein length of at least 10 cm, a diameter of more than 6 mm, a depth of less than 6 mm, and a flow rate of 600 mL/min. Secondary goals included patency and complications such as bleeding, infection, steal syndrome, and aneurysmal dilatation at the anastomosis site. AVFs were evaluated immediately after surgery and during follow-up visits at the outpatient clinic. A duplex scan was performed to measure flow at various intervals. All patients provided appropriate written consent.

RESULT

The study involved 186 patients, with 86 excluded. 100 were randomized, with 5 cases losing follow-up and 3 deaths within 12 months. The follow-up continued until January 2024, with a mean of 8.6 months. The Parachute technique shows higher technical success (p value = 0.046) and primary patency at 30 days (p value = 0.014) compared to Anchor, but there is no statistical significance between both groups regarding functional maturation at 6 weeks (p value = 0.352). The parachute technique has a higher hematoma rate than the anchor technique (p value = 0.025), while other complications like intra-operative bleeding, postoperative bleeding, pseudoaneurysm formation, thrombosis, steal syndrome, and seroma formation show no significant differences. Nine patients, five of whom were diabetic and underwent conservative management, exhibited mild to moderate steal syndrome. This suggests an increased risk of steal syndrome among diabetic patients.

CONCLUSION

The parachute technique for AVF creation offers better technical success and short-term primary patency outcomes, while both parachute and anchor techniques are equally effective for long-term functional maturation and overall complication rates.

Hematological changes, oxidative stress assessment, and dysregulation of aquaporin-3 channel, prolactin, and oxytocin receptors in kidneys of lactating Wistar rats treated with monosodium glutamate

High consumption of locally produced delicacies could expose nursing mothers to high monosodium glutamate (MSG) levels, frequently used as a necessary condiment in low-income countries. Thus, this study evaluated some novel preliminary changes in renal hormonal receptors, the aquaporin-3 channel, oxidative stress markers, and hematological indices induced by monosodium glutamate in lactating rats. Post-parturition, twenty-four (24) lactating Wistar rats were divided into four (4) groups of six rats each (n = 6). Oral administration of distilled water and MSG started three (3) days postpartum as follows: group 1: distilled water (1 ml/kg BW), group 2: MSG (925 mg/kg BW), group 3: MSG (1850 mg/kg BW), and group 4: MSG (3700 mg/kg BW). At the end of the experiment, which lasted fourteen (14) days, animals were sacrificed and samples of blood and tissues were obtained for biochemical analysis. MSG administration significantly (p < 0.05) increased ROS and MDA, with a significant (p < 0.05) decrease in kidney antioxidants. Serum creatinine, total, conjugated, and unconjugated bilirubin significantly (p < 0.05) increased with MSG administration. The prolactin receptor was significantly reduced (p < 0.05), while the oxytocin receptor and aquaporin-3 channel were significantly (p < 0.05) increased in the MSG-administered groups. There were significant (p < 0.05) changes in the hematological indices of the MSG-administered animals. Thus, the findings of this study suggest that high MSG consumption causes hematological alterations and may alter renal function via increased ROS production and dysregulation of the AQP-3 channel, prolactin, and oxytocin receptors in the kidneys of lactating Wistar rats.

Patient and Clinician Perspectives: To Create a Better Future for Chronic Kidney Disease, We Need to Talk About Our Kidneys

Chronic kidney disease (CKD) affects more than one in ten people worldwide. However, results from the REVEAL-CKD study suggest that it is often not diagnosed. Many patients are therefore unaware that they have CKD, putting them at increased risk of disease progression and complications. Empowering patients with knowledge about CKD will allow them to become active participants in their own care, driving improvements in diagnosis rates and changing patient outcomes for the better. In this article, we provide patient and clinician perspectives on the importance of early CKD diagnosis and management. We present an overview of the tests commonly used to diagnose CKD in clinical practice, as well as actionable suggestions for patients, clinicians, and health policymakers that could help improve disease detection and treatment. Navdeep Tangri, a nephrologist and epidemiologist at the University of Manitoba, and Jane DeMeis, a patient living with chronic kidney disease, discuss how results from the REVEAL-CKD study highlight the need for change to improve management of chronic kidney disease. Video Abstract (MP4 141866 KB).

Management of Chronic Kidney Disease in Morocco: A Cost-of-Illness Study

INTRODUCTION

Chronic kidney disease (CKD) is a global public health problem. The aim of this study is to estimate the mean annual direct medical cost per patient with CKD before the start of renal replacement therapy (RRT) in Morocco.

METHODS

This is a cross-sectional cost-of-illness study, using a prevalence approach among adults with CKD before RRT in a Moroccan university hospital. Information on direct medical costs was collected from the patient's report and associated costs were estimated according to national tariff/fee catalogues. We computed annual direct medical costs using society perspective. Costs were then estimated and compared according to CKD stages, health insurance categories, and monthly income.

RESULTS

Eighty-eight participants were included; 63.6% of them were female, their mean age was 61.8±14.0 years, and 76.1% were in stages 4 or 5. The estimated annual direct medical cost of CKD was estimated at $ 2008.80 (95%CI 1528.28-2489.31), Hospitalization, diagnosis, and treatment represented the main expenses of the direct medical cost (32.2%, 29.7%, and 32.2%, respectively). The direct medical cost components were not significantly different between CKD stages.

CONCLUSION

The cost of CKD in Morocco in its early stages is still lower than the cost of RRT, which brings to light the necessity of secondary prevention of CKD to postpone or prevent the progression to end-stage renal disease.

Palliative Care for Patients with Kidney Disease

Interest in palliative care has increased in recent times, particularly in its multidisciplinary approach developed to meet the needs of patients with a life-threatening disease and their families. Although the modern concept of palliative simultaneous care postulates the adoption of these qualitative treatments early on during the life-threatening disease (and potentially just after the diagnosis), palliative care is still reserved for patients at the end of their life in most of the clinical realities, and thus is consequently mistaken for hospice care. Patients with acute or chronic kidney disease (CKD) usually experience poor quality of life and decreased survival expectancy and thus may benefit from palliative care. Palliative care requires close collaboration among multiple health care providers, patients, and their families to share the diagnosis, prognosis, realistic treatment goals, and treatment decisions. Several approaches, such as conservative management, extracorporeal, and peritoneal palliative dialysis, can be attempted to globally meet the needs of patients with kidney disease (e.g., physical, social, psychological, or spiritual needs). Particularly for frail patients, pharmacologic management or peritoneal dialysis may be more appropriate than extracorporeal treatment. Extracorporeal dialysis treatment may be disproportionate in these patients and associated with a high burden of symptoms correlated with this invasive procedure. For those patients undergoing extracorporeal dialysis, individualized goal setting and a broader concept of adequacy should be considered as the foundations of extracorporeal palliative dialysis. Interestingly, little evidence is available on palliative and end of life care for acute kidney injury (AKI) patients. In this review, the main variables influencing medical decision-making about palliative care in patients with kidney disease are described, as well as the different approaches that can fulfill the needs of patients with CKD and AKI.

Prevalence of Non-adherence to Prescribed Medications among Hemodialysis Patients in Makkah City

Patients with end-stage kidney disease (ESKD) are required to take multiple medications. Adherence to a complex regimen of medications is challenging and might lead to non-adherence. This study aimed to assess nonadherence to prescribed medications among patients with ESKD in Makkah City and determine the factors associated with a such behavior. A cross-sectional study was conducted at three governmental hospitals in Makkah City, Saudi Arabia. Descriptive statistics were performed to characterize participants, and a multivariable logistic regression analysis was used to determine factors associated with nonadherence to prescribed medications among patients with ESKD. In total, 358 patients have submitted completed surveys and were included in this study. A considerable number (45.25%) of participating patients were found to be nonadherent to prescribed medications. The factors: age, belief that taking medications as scheduled is important, adherence to dialysis sessions, and the number of comorbid diseases had significant and negative associations with nonadherence to prescribed medications. On the other hand, the factors: forgetfulness and having depression were significantly and positively associated with non-adherence to prescribed medications. Non-adherence to medications among patients on hemodialysis is a significant issue that leads to life-threatening complications. The factors identified as being significantly associated with nonadherence should be considered in designing future interventions to improve adherence to medications.

Global Estimates of Capacity for Kidney Transplantation in World Countries and Regions

BACKGROUND

Kidney transplantation (KT) is the optimal treatment for kidney failure and is associated with better quality of life and survival relative to dialysis. However, knowledge of the current capacity of countries to deliver KT is limited. This study reports on findings from the 2018 International Society of Nephrology Global Kidney Health Atlas survey, specifically addressing the availability, accessibility, and quality of KT across countries and regions.

METHODS

Data were collected from published online sources, and a survey was administered online to key stakeholders. All country-level data were analyzed by International Society of Nephrology region and World Bank income classification.

RESULTS

Data were collected via a survey in 182 countries, of which 155 answered questions pertaining to KT. Of these, 74% stated that KT was available, with a median incidence of 14 per million population (range: 0.04-70) and median prevalence of 255 per million population (range: 3-693). Accessibility of KT varied widely; even within high-income countries, it was disproportionately lower for ethnic minorities. Universal health coverage of all KT treatment costs was available in 31%, and 57% had a KT registry.

CONCLUSIONS

There are substantial variations in KT incidence, prevalence, availability, accessibility, and quality worldwide, with the lowest rates evident in low- and lower-middle income countries. Understanding these disparities will inform efforts to increase awareness and the adoption of practices that will ensure high-quality KT care is provided around the world.

Paraoxonase-1 Regulation of Renal Inflammation and Fibrosis in Chronic Kidney Disease

Papraoxonase-1 (PON1) is a hydrolytic lactonase enzyme that is synthesized in the liver and circulates attached to high-density lipoproteins (HDL). Clinical studies have demonstrated an association between diminished PON-1 and the progression of chronic kidney disease (CKD). However, whether decreased PON-1 is mechanistically linked to renal injury is unknown. We tested the hypothesis that the absence of PON-1 is mechanistically linked to the progression of renal inflammation and injury in CKD. Experiments were performed on control Dahl salt-sensitive rats (SSMcwi, hereafter designated SS rats) and Pon1 knock-out rats (designated SS-Pon1em1Mcwi, hereafter designated SS-PON-1 KO rats) generated by injecting a CRISPR targeting the sequence into SSMcwi rat embryos. The resulting mutation is a 7 bp frameshift insertion in exon 4 of the PON-1 gene. First, to examine the renal protective role of PON-1 in settings of CKD, ten-week-old, age-matched male rats were maintained on a high-salt diet (8% NaCl) for up to 5 weeks to initiate the salt-sensitive hypertensive renal disease characteristic of this model. We found that SS-PON-1 KO rats demonstrated several hallmarks of increased renal injury vs. SS rats including increased renal fibrosis, sclerosis, and tubular injury. SS-PON-1 KO also demonstrated increased recruitment of immune cells in the renal interstitium, as well as increased expression of inflammatory genes compared to SS rats (all p < 0.05). SS-PON-1 KO rats also showed a significant (p < 0.05) decline in renal function and increased renal oxidative stress compared to SS rats, despite no differences in blood pressure between the two groups. These findings suggest a new role for PON-1 in regulating renal inflammation and fibrosis in the setting of chronic renal disease independent of blood pressure.

Neurological Soft Signs in Non-diabetic End Stage Renal Disease Patients: Evaluation and Prediction

Patients on hemodialysis suffer from several serious complex neurological complications resulting in significant disability. Early detection of these complications during the asymptomatic phase may consent to early intervention to prevent or minimize the disability. To assess and predict neurological soft signs (NSS) in non-diabetic end-stage renal disease (ESRD) patients on hemodialysis (HD) who do not suffer any apparent neurological symptoms. An analytical, cross-sectional study was done in Hemodialysis units in the Suez Canal University Hospitals. 96 ESRD adult patients on hemodialysis are exposed to: Medical history was taken via personal interview, laboratory tests, and clinical assessment of NSS using Heidelberg scale, and brain CT was done for 50 high-risk patients (hypertensive or those on dialysis for more than 5 years) to detect the presence of any probable neuro-radiological brain abnormalities. 79.2% of our studied ESRD patients on HD had positive NSS with a mean value of total score 8.5 ± 5.9. Strong positive correlations were present between NSS and Hb levels, duration of hemodialysis, and hypertension. CT had revealed no abnormality. NSS represent a reliable, affordable tool for regular bedside assessment of ESRD patients with HD who do not suffer any neurological symptoms for early detection of asymptomatic neurological lesions, especially since the CT brain scan did not show such changes early. The duration of hemodialysis, Hb level, and hypertension were independent predictors for the occurrence of silent neurological lesions in ESRD patients.

Renal rehabilitation as a management strategy for physical frailty in CKD

An aging population and the increasing prevalence of lifestyle-related diseases have led to a worldwide increase in the rate of chronic kidney disease requiring renal replacement therapy. The mean age of individuals requiring dialysis therapy has been increasing, and Japanese patients are aging more rapidly than those in the USA and Europe. Patients undergoing renal replacement therapy are at increased risk of sarcopenia/frailty compared with people with normal kidney function due to comorbid burden, long-standing malnutrition, chronic inflammation, metabolic acidosis, anabolic resistance, hormonal changes, physical inactivity and amino acid loss via dialysis treatment in addition to aging. Sarcopenia and frailty are serious global health problems that can decrease access to kidney transplantation and lead to various adverse health outcomes, including functional dependence, hospitalizations and deaths in patients on dialysis treatment. However, sarcopenia/frailty fortunately is potentially modifiable by early identification of poor physical functioning, sustainment and enhancement of daily physical activity, and participation in exercise treatments. The Japanese Society of Renal Rehabilitation was established in 2011 and published a clinical practice guideline for “Renal Rehabilitation” targeting nondialysis-dependent and dialysis-dependent patients and renal transplant recipients, in 2019. The guideline emphasized the importance of physical management for patients with kidney diseases in addition to nutritional supports and anemia management. Kidney health professionals should manage sarcopenia and physical frailty as a part of routine clinical care for patients undergoing hemodialysis to improve poor physical functioning, functional dependence, decreased quality of life and poor prognosis.

Effects of intradialytic exercise for advanced-age patients undergoing hemodialysis: A randomized controlled trial

Previous reports have shown the benefits of intradialytic exercise to patients undergoing hemodialysis. However, most of those studies assessed the effects of exercise in middle-aged patients and little is known about advanced-age patients undergoing hemodialysis. Therefore, the present randomized controlled trial was performed to determine the effectiveness of exercise therapy in advanced-age patients undergoing hemodialysis. This non-blinded, randomized controlled parallel trial enrolled a total of 101 patients who were randomly assigned to intradialytic exercise (n = 51) or usual care (n = 50) groups. The training program included both resistance and aerobic exercises and was performed three times per week for 6 months. The aerobic exercise intensity was adjusted to a target Borg score of 13 for 20 minutes. Four types of resistance exercises were performed using elastic tubing, with three sets of 10 exercises performed at moderate intensity (13/20 on the Borg scale). The usual care group received standard care. Lower extremity muscle strength, Short Physical Performance Battery score, and 10-m walking speed were the outcomes and were evaluated before the hemodialysis session and after 6 months of training. There were statistically significant improvements in Short Physical Performance Battery score (effect size, 0.57; 95% confidence interval, 0.15‒1.95) in the exercise group relative to the control group. There were no statistically significant differences in lower extremity muscle strength or in the 10-m walking speed between the two groups. These findings suggest that 6 months of intradialytic training could improve physical function in older patients undergoing hemodialysis.

An Evaluation of Socio-Demographic and Risk Factor Profile in End-Stage Renal Disease Patients: A Cross-Sectional Assessment

Background The global incidence and prevalence of chronic kidney disease (CKD) is skyrocketing. In Asia, the prevalence of CKD varies from 10%-18%. However, as Asia is largely populated by developing countries with nascent health care systems, there is a dearth of research and data. It is estimated that a large number of cases go unreported. As a result, the exact disease burden remains unclear. The knowledge about risk factors and their proportionate role in CKD is indispensable in regards to patient management and care.  Objective The early recognition of the most important risk factors for end-stage renal disease (ESRD) is key to early diagnosis, successful treatment, and general heightened awareness regarding CKD. In developing countries, the provision of medical services, in general, and nephrological services, in particular, is wholly inadequate. The insufficiency of solid and regularly updated data compounds the problem. This research study aims to partake in catering to that need. Methodology A structured questionnaire was used to obtain quantitative and categorical data from 119 ESRD patients in the nephrology ward, Allied Hospital, Faisalabad through non-probability sampling. Socio-demographic profile of the patients and information regarding the presence or absence of risk factors were collected. The resulting dataset was analyzed using R version 3.6.3 (R Foundation for Statistical Computing, Vienna, Austria) for data visualization and descriptive analysis. Results The most common age group for ESRD presentation was 46-60 years (52.1%). Among the 119 ESRD patients, the most frequent risk factor was hypertension with 85.7% of the patients presenting with the condition, followed by diabetes mellitus (DM) in 54.6%, renal calculi in 28.6%, glomerulonephritis (GN) in 31.1%, Family history of CKD in 24.4%, and polycystic kidney disease (PKD) in 5% of the patients. Gender-wise distribution of the patients shows that the proportion of patients with hypertension, renal calculi, and family history of CKD varied very little among the two groups. Conclusion In conclusion, our study has reinforced the existing body of knowledge and brought some fresh evidence regarding the prevalence of risk factors in ESRD to light. Hypertension and DM, together, represent the vast majority of cases with ESRD. However, hypertension far outpaces DM as the leading risk factor. Nephrolithiasis was also present in a considerable minority, with a figure much higher than previously reported. Finally, a relatively younger age group (45-60 years) formed the majority of the ESRD patients which is a concerning development. It points to early progression of CKD to ESRD. Long-term adequate control of these risk factors limits disease progression.

Structural equation model of affecting factors on elder abuse to patients under hemodialysis by family caregivers

BACKGROUND

The objectives of the present study were to determine the prevalence of older adults with hemodialysis (HD) abuse by family caregivers and the factors affecting it.

METHOD

This is a correlational-causal study, which is conducted in 2018 in Iran. The sample size was 367 in both groups (the older adults and their family caregivers). Data collection was done using an individual-social information questionnaire for the older adults under hemodialysis and their family caregivers, the questionnaire of elder abuse by family caregivers to the older people under hemodialysis, Zarit Burden Interview and the scale of instrumental activities of daily living (IADL). Data were analyzed by the structural equation model (SEM) method. The Fitness of proposed pattern was measured using the following indexes: chi-square/degree of freedom ratio (CMIN/DF), Normed Fit Index (NFI), comparative fit index (CFI), goodness of fit index (GFI), and standardized root mean squared residual (SRMR). The significant level in this study was considered p < 0.05.

RESULTS

The results of the present study showed that more than 70 % of the older adults suffer from elder abuse by family caregivers on average. The highest median elder abuse was related to emotional misbehavior (21.46 ± 6.09) and financial misbehavior (19.07 ± 5.33), respectively. Moderate care burden was experienced by 63.2 % of caregivers. The percentage of older women and men, who needed help with daily activities was 81.4 and 80.5 %, respectively. The results showed that the caregivers' level of education and care burden with standard beta coefficient of -0.251 and 0.200 and the educational level of older adults and IADL with the best beta coefficient of -0.299 and - 0.234, had the highest regression effect on elder abuse respectively. According to the results, the model-fit indices of the hypothesized model was meet the criteria, with the NFI = 0.951, GFI = 0.970, CFI = 0.967, and SRMR = 0.041. The outcome was suitable for the recommended level, so the hypothetical model appeared to fit the data.

CONCLUSIONS

The results of the present study showed that the prevalence of elder abuse by family caregivers among the older adults under hemodialysis is high. Providing psychological counseling can reduce the consequences of elder abuse.

Implications of oxidative stress in chronic kidney disease: a review on current concepts and therapies

Moderate levels of endogenous reactive oxygen species (ROS) are important for various cellular activities, but high levels lead to toxicity and are associated with various diseases. Levels of ROS are maintained as a balance between oxidants and antioxidants. Accumulating data suggest that oxidative stress is a major factor in deterioration of renal function. In this review, we highlight the possible mechanism by which oxidative stress can lead to chronic kidney disease (CKD). This review also describes therapies that counter the effect of oxidative stress in CKD patients. Numerous factors such as upregulation of genes involved in oxidative phosphorylation and ROS generation, chronic inflammation, vitamin D deficiency, and a compromised antioxidant defense mechanism system cause progressive detrimental effects on renal function that eventually lead to loss of kidney function. Patients with renal dysfunction are highly susceptible to oxidative stress, as risk factors such as diabetes, renal hypertension, dietary restrictions, hemodialysis, and old age predispose them to increased levels of ROS. Biomolecular adducts (DNA, proteins, and lipids) formed due to reaction with ROS can be used to determine oxidative stress levels. Based on the strong correlation between oxidative stress and CKD, reversal of oxidative stress is being explored as a major therapeutic option. Xanthine oxidase inhibitors, dietary antioxidants, and other agents that scavenge free radicals are gaining interest as treatment modalities in CKD patients.

Age-related difference in health care use and costs of patients with chronic kidney disease and matched controls: analysis of Dutch health care claims data

Background

The financial burden of chronic kidney disease (CKD) is increasing due to the ageing population and increased prevalence of comorbid diseases. Our aim was to evaluate age-related differences in health care use and costs in Stage G4/G5 CKD without renal replacement therapy (RRT), dialysis and kidney transplant patients and compare them to the general population.

Methods

Using Dutch health care claims, we identified CKD patients and divided them into three groups: CKD Stage G4/G5 without RRT, dialysis and kidney transplantation. We matched them with two controls per patient. Total health care costs and hospital costs unrelated to CKD treatment are presented in four age categories (19–44, 45–64, 65–74 and ≥75 years).

Results

Overall, health care costs of CKD patients ≥75 years of age were lower than costs of patients 65–74 years of age. In dialysis patients, costs were highest in patients 45–64 years of age. Since costs of controls increased gradually with age, the cost ratio of patients versus controls was highest in young patients (19–44 years). CKD patients were in greater need of additional specialist care than the general population, which was already evident in young patients.

Conclusion

Already at a young age and in the earlier stages of CKD, patients are in need of additional care with corresponding health care costs far exceeding those of the general population. In contrast to the general population, the oldest patients (≥75 years) of all CKD patient groups have lower costs than patients 65–74 years of age, which is largely explained by lower hospital and medication costs.

Quantitative assessment of renal structural and functional changes in chronic kidney disease using multi-parametric magnetic resonance imaging

Background

Multi-parametric magnetic resonance imaging (MRI) provides the potential for a more comprehensive non-invasive assessment of organ structure and function than individual MRI measures, but has not previously been comprehensively evaluated in chronic kidney disease (CKD).

Methods

We performed multi-parametric renal MRI in persons with CKD (n = 22, 61 ± 24 years) who had a renal biopsy and measured glomerular filtration rate (mGFR), and matched healthy volunteers (HV) (n = 22, 61 ± 25 years). Longitudinal relaxation time (T₁), diffusion-weighted imaging, renal blood flow (phase contrast MRI), cortical perfusion (arterial spin labelling) and blood-oxygen-level-dependent relaxation rate (R₂*) were evaluated.

Results

MRI evidenced excellent reproducibility in CKD (coefficient of variation <10%). Significant differences between CKD and HVs included cortical and corticomedullary difference (CMD) in T₁, cortical and medullary apparent diffusion coefficient (ADC), renal artery blood flow and cortical perfusion. MRI measures correlated with kidney function in a combined CKD and HV analysis: estimated GFR correlated with cortical T₁ (r = −0.68), T₁ CMD (r = −0.62), cortical (r = 0.54) and medullary ADC (r = 0.49), renal artery flow (r = 0.78) and cortical perfusion (r = 0.81); log urine protein to creatinine ratio (UPCR) correlated with cortical T₁ (r = 0.61), T₁ CMD (r = 0.61), cortical (r = −0.45) and medullary ADC (r = −0.49), renal artery flow (r = −0.72) and cortical perfusion (r = −0.58). MRI measures (cortical T₁ and ADC, T₁ and ADC CMD, cortical perfusion) differed between low/high interstitial fibrosis groups at 30–40% fibrosis threshold.

Conclusion

Comprehensive multi-parametric MRI is reproducible and correlates well with available measures of renal function and pathology. Larger longitudinal studies are warranted to evaluate its potential to stratify prognosis and response to therapy in CKD.

Initiation of Hemodialysis After Eight Years Following the Diagnosis of Stage 5 Chronic Kidney Disease: A Case Report

With the growing global rates of diabetes and hypertension, chronic kidney disease (CKD) appears to be a major contributor to morbidity and all-cause mortality. In recent years, there has been growing controversy regarding the optimal timing for the initiation of hemodialysis in this patient cohort. In this report, we present the case of a 52-year-old female with a 15-year history of CKD who was admitted to the hospital with clinical manifestations of uremia, volume overload, and symptomatic anemia. The patient presented with fatigue, nausea, progressive shortness of breath, and lightheadedness for two weeks, which had limited the activities of daily living. For the past eight years, her estimated glomerular filtration rate (GFR) had ranged from 5 to 15 mL/min/1.73 m2, consistent with kidney failure seen in stage 5 CKD. Prior to her recent admission, the patient had been grossly asymptomatic and had been responsive to medical therapy. After appropriate management with hemodialysis, a transfusion of packed red blood cells, and medication adjustment, the patient was scheduled for maintenance dialysis through an arteriovenous fistula. She had no further complaints and her laboratory abnormalities were found normalized at the six-month follow-up. This case report presents the survival and outcome of a patient with stage 5 CKD, who was only initiated on hemodialysis eight years after her diagnosis.

The effects of amino acid/protein supplementation in hemodialysis patients: study protocol for a systematic review and meta-analysis

Background

Multiple factors including older age, comorbidities, inflammation, metabolic acidosis, dialysis-related hypercatabolism and anabolic resistance of skeletal muscle, extraction of circulating amino acids through hemodialysis and inadequate dietary protein intake due to anorexia, and strictly limited dietary phosphorus intake are likely to contribute to the high prevalence of malnutrition and metabolic abnormalities, more aptly called protein-energy wasting, in patients on hemodialysis. The consensus from the International Society of Renal Nutritional and Metabolism states that nutritional supplementation is effective for replenishing protein and energy stores. Although we hypothesize that amino acid/protein supplementation can overcome the anabolic resistance of skeletal muscle tissue and attenuate or even prevent the accelerated loss of skeletal muscle mass and strength through nutritional status improvement in patients on hemodialysis, whether amino acid and/or protein administration is associated with improvements in these outcomes is unknown. The main objective of this study is to systematically review the impact of amino acid/protein supplementation on skeletal muscle mass, muscle strength, physical function, and quality of life in end-stage renal disease patients requiring hemodialysis.

Methods

Published randomized controlled trials (RCTs) assessing the effectiveness of amino acid/protein supplementation in hemodialysis patients with respect to body composition, muscle mass, muscle strength, physical function, and quality of life will be included. The bibliographic databases include MEDLINE, the Web of Science, the Cochrane Central Register of Controlled Trials, and Embase. The risk of bias of the included RCTs will be assessed using the Cochrane Collaboration’s tool by two independent reviewers. The primary outcome will be skeletal muscle mass, muscle strength, and physical function, and the secondary outcome will be quality of life. This review protocol is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) 2015 checklist.

Ethics and dissemination

Ethical approval is not required because this study does not include confidential personal data or involve patient interventions. This review is expected to inform readers on the effect of amino acid/protein supplementation in patients undergoing hemodialysis. The findings will be presented at conferences and submitted to a peer-reviewed journal for publication.

Trial registration

The trial registration number is (CRD42020181087), and the trial was registered on 5 July 2020.

Prevalence and Risk Factors of Hyperuricemia in Patients with Chronic Kidney Disease and Non-Alcoholic Fatty Liver

Background/Aims

The number of patients with nonalcoholic fatty liver disease (NAFLD) and chronic kidney disease (CKD) is on the rise. Epidemiological studies have shown the role of hyperuricemia in the development of NAFLD and CKD through oxidative stress and inflammatory mediators. Therefore, this study was conducted to investigate the prevalence and risk factors of hyperuricemia in patients with CKD and NAFLD in Iran.

Patients and Methods

This study was conducted in 450 CKD patients. NAFLD was diagnosed by ultrasonography. According to the serum uric acid level, all CKD⁺ NAFLD⁺ patients were divided into non-hyperuricemia and hyperuricemia groups. The patients' demographic and clinical data such as age, sex, abdominal obesity, metabolic syndrome, diabetes, hypertension, CRP, hepatic steatosis, blood pressure, serum uric acid (UA), lipid and creatinine were collected for analysis.

Results

A total of 279 cases (62%) were diagnosed with NAFLD. The prevalence rate of NFALD in CKD patients was significantly lower in normal UA level than hyperuricemia (42.7% vs 57.3%) (P=0.039). The prevalence of hyperuricemia was about 57.3% in patients with CKD and NAFLD. Accordingly, 279 CKD patients with NAFLD were enrolled and divided into hyperuricemia (n =160) and non-hyperuricemia groups (n =119). Patients with hyperuricemia showed higher creatinine and lipid levels, and a lower GFR compared to patients with normal uric acid levels (P< 0.05). However, no significant difference was observed in age, sex, abdominal obesity, metabolic syndrome, hypertension, type 2 diabetes, CRP, and steatosis between hyperuricemia and non-hyperuricemia groups (P>0.05). Three factors, including type 2 diabetes, hyperlipidemia, and a low GFR, serve as independent risk factors for hyperuricemia (P<0.05).

Conclusion

The results showed a high prevalence of hyperuricemia in patients with CKD and NAFLD. A more comprehensive strategic management is necessary to address the potential harmful effects of hyperuricemia on the health of CKD⁺ NAFLD⁺ cases.

Knowledge and Practices towards Prevention and Early Detection of Chronic Kidney Disease and Associated Factors among Hypertensive Patients in Gondar Town, North West Ethiopia

BACKGROUND

Chronic kidney disease is a global health problem with serious adverse effects, including kidney failure, cardiovascular disease, and premature death. Improving awareness and practice on the impact, prevention, and early detection of chronic kidney disease will reduce the significant economic and public health burden.

METHODS

A cross-sectional study was conducted to determine knowledge and practice towards prevention and early detection of chronic kidney disease and its associated factors among hypertensive patients in Gondar town in 2019. The study included hypertensive patients visiting health institutions from February to March 2019. Data was collected using a semistructured questionnaire and individuals who fulfilled our inclusion criteria were selected using a systemic random sampling technique. Epi Info software version 7 was used for data entry, and SPSS version 20 was used for descriptive and logistic regression analysis.

RESULT

Out of a total of 442 participants, 434 completed the questionnaire, with a response rate of 98.1%. Of the total, 298 (68.7%) had good knowledge of chronic kidney disease with a mean knowledge score of 8.78 ± 2.80 and 210 (48.4%) had good practice with mean practice score of 6.58 ± 1.61. Educational status, residence, and duration of hypertension were significantly associated with the knowledge and practice scores of the participants in the multivariate logistic regression analysis.

CONCLUSION

More than half of the participants had good knowledge about chronic kidney disease and its risk factors. However, the level of preventive practice among participants was low. The educational status, residence, and duration of hypertension were significantly associated variables with knowledge and practice scores in multivariate logistic regression.

Changes in Quality of Life in Older Hemodialysis Patients: A Cohort Study on Dialysis Outcomes and Practice Patterns

BACKGROUND

Despite improvements in dialysis treatment, mortality rates remain high, especially among older hemodialysis patients. Quality of life (QOL) among hemodialysis patients is strongly associated with higher risk of death. This study aimed to describe the health-related QOL and its change in older maintenance hemodialysis patients and to demonstrate characteristics associated with health-related QOL.

METHODS

Data on 892 maintenance hemodialysis patients aged 60 years or older who were surveyed using the Kidney Disease Quality of Life Short Form at baseline and 2 years after study enrollment in phases 4 (2009-2011) and 5 (2012-2014) of the Japanese Dialysis Outcomes and Practice Patterns Study were analyzed. We categorized participants into 3 age groups (60-69, 70-79, and ≥80 years) and described baseline physical component summary (PCS) and mental component summary (MCS) scores, as well as their distribution of changes after 2 years across each category.

RESULTS

Hemodialysis patients aged 70-79 years and ≥80 years had lower PCS scores than those aged 60-69 years (median: 70-79 years = 43.1; interquartile range [IQR], 35.2-49.4; ≥80 years = 38.8; IQR, 31.6-43.8; 60-69 years = 45.4; IQR, 37.5-51.4; p < 0.001). In contrast, MCS scores did not significantly differ by age category (70-79 years = 45.6; IQR, 38.4-53.7; ≥80 years = 45.4; IQR, 36.9-55.1; 60-69 years = 46.8; IQR, 39.5-55.7; p = 0.1). As dialysis vintage lengthened, the PCS score significantly became lower, whereas no association was found with change in the MCS score. The MCS score declined over time in older patients, especially among those aged 80 years and older after 2 years' follow-up.

CONCLUSIONS

Physical QOL became worse as dialysis vintage lengthened. In contrast, mental QOL declined over time within a relatively short period among older maintenance hemodialysis patients.

Relationship between Prolactin, Chronic Kidney Disease, and Cardiovascular Risk

CKD has a high prevalence worldwide, mainly due to its main etiologies-diabetes and hypertension. It has high cardiovascular morbidity and mortality, with traditional risk factors such as atherosclerosis, hypertension, diabetes, smoking, and left ventricular hypertrophy being common. Nontraditional cardiovascular risk factors, such as anemia, hyperparathyroidism, chronic inflammation, and microalbuminuria, are also well studied. Prolactin is a hormone not only related to lactation but also being considered a uremic toxin by some authors. It accumulates with loss of renal function, and it is associated with cardiovascular outcomes in both normal renal function population and CKD population. The purpose of this narrative review is to raise the main common aspects of CKD, prolactinemia, and cardiovascular risk.

Quantitative assessment of renal structural and functional changes in chronic kidney disease using multi-parametric magnetic resonance imaging

BACKGROUND

Multi-parametric magnetic resonance imaging (MRI) provides the potential for a more comprehensive non-invasive assessment of organ structure and function than individual MRI measures, but has not previously been comprehensively evaluated in chronic kidney disease (CKD).

METHODS

We performed multi-parametric renal MRI in persons with CKD (n = 22, 61 ± 24 years) who had a renal biopsy and measured glomerular filtration rate (mGFR), and matched healthy volunteers (HV) (n = 22, 61 ± 25 years). Longitudinal relaxation time (T1), diffusion-weighted imaging, renal blood flow (phase contrast MRI), cortical perfusion (arterial spin labelling) and blood-oxygen-level-dependent relaxation rate (R2*) were evaluated.

RESULTS

MRI evidenced excellent reproducibility in CKD (coefficient of variation <10%). Significant differences between CKD and HVs included cortical and corticomedullary difference (CMD) in T1, cortical and medullary apparent diffusion coefficient (ADC), renal artery blood flow and cortical perfusion. MRI measures correlated with kidney function in a combined CKD and HV analysis: estimated GFR correlated with cortical T1 (r = -0.68), T1 CMD (r = -0.62), cortical (r = 0.54) and medullary ADC (r = 0.49), renal artery flow (r = 0.78) and cortical perfusion (r = 0.81); log urine protein to creatinine ratio (UPCR) correlated with cortical T1 (r = 0.61), T1 CMD (r = 0.61), cortical (r = -0.45) and medullary ADC (r = -0.49), renal artery flow (r = -0.72) and cortical perfusion (r = -0.58). MRI measures (cortical T1 and ADC, T1 and ADC CMD, cortical perfusion) differed between low/high interstitial fibrosis groups at 30-40% fibrosis threshold.

CONCLUSION

Comprehensive multi-parametric MRI is reproducible and correlates well with available measures of renal function and pathology. Larger longitudinal studies are warranted to evaluate its potential to stratify prognosis and response to therapy in CKD.

Deceleration of Disease Progress Through Ayurvedic Treatment in Nondialysis Stages IV-V Patients with Chronic Renal Failure: A Quasi-Experimental Clinical Pilot Study with One Group Pre- and Postdesign and Two Premeasurements

Objective: The aim of this study was to evaluate the effects of Ayurvedic treatment on deceleration of the disease progress of nondialysis patients with stage IV or V chronic renal failure (CRF). Materials and Methods: A complex oral and proctocolonic Ayurvedic multiherbal medication was administered daily for 1 month to inpatients. Thereafter, patients were treated as outpatients with oral medication for additional 5 months. Four renal function tests (RFTs) were evaluated at various time points (TPs): (1) 6 months before baseline (TP -6), (2) at baseline (TP 0), and (3) after completion of 6 months of treatment (TP +6). Repeated-measures analysis of variance (ANOVA) with Greenhouse-Geisser correction and Friedman's ANOVA by ranks were used to analyze the RFTs. For post hoc tests, the Bonferroni correction was applied. Bias-corrected effect sizes (Hedges) for the treatment were calculated. Results: Sixty-four nondialysis CRF patients with laboratory investigations of the preceding 6 months were included; 12 patients discontinued the treatment. Fifty-two patients with stage IV or V at baseline completed the study. Mean concentrations of estimated glomerular filtration rate (eGFR), serum creatinine, and hemoglobin differed significantly between TPs (eGFR: F = 15.3, p < 0.001; serum creatinine: F = 29.3, p < 0.001; blood urea: F = 2.0, p = 0.159; hemoglobin: F = 53.9, p < 0.001). Pairwise comparisons of the mean differences between TPs are significant for eGFR, creatinine, and hemoglobin. For blood urea, a significant decrease was observed for the treatment period [15.9(↓) mg/dL, standard error 4.0; n = 52], but a nonsignificant increase was observed for the pretreatment period [16.2(↑) mg/dL, standard error 9.8] due to insufficient data for TP -6 (n = 26). The effect sizes for eGFR, creatinine, blood urea, and hemoglobin were medium (0.45, 0.53, 0.44, and 0.30). Conclusions: After 6 months of treatment, statistically and clinically significant improvements of eGFR, creatinine, blood urea, and hemoglobin and a significant shift to better CRF stages were observed. Several cardinal symptoms were also significantly reduced. Randomized controlled trials are warranted to evaluate the effects in comparison to usual care.

Exploring the putative interactions between chronic kidney disease and chronic periodontitis

Chronic kidney disease (CKD) and chronic periodontitis (CP) are both common diseases, which are found disproportionately comorbid with each other and have been reported to have a detrimental effect on the progression of each respective disease. They have an overlap in risk factors and both are a source of systemic inflammation along with a wide selection of immunological and non-specific effects that can affect the body over the lifespan of the conditions. Previous studies have investigated the directionality of the relationship between these two diseases; however, there is a lack of literature that has examined how these diseases may be interacting at the localized and systemic level. This review discusses how oral microorganisms have the ability to translocate and have distal effects and provides evidence for microbial involvement in a systemic disease. Furthermore, it summarizes the reported local and systemic effects of CKD and CP and discusses how the interaction of these effects may be responsible for directionality associations reported.

A Functional Landscape of CKD Entities From Public Transcriptomic Data

Introduction

To develop effective therapies and identify novel early biomarkers for chronic kidney disease, an understanding of the molecular mechanisms orchestrating it is essential. We here set out to understand how differences in chronic kidney disease (CKD) origin are reflected in gene expression. To this end, we integrated publicly available human glomerular microarray gene expression data for 9 kidney disease entities that account for most of CKD worldwide. Our primary goal was to demonstrate the possibilities and potential on data analysis and integration to the nephrology community.

Methods

We integrated data from 5 publicly available studies and compared glomerular gene expression profiles of disease with that of controls from nontumor parts of kidney cancer nephrectomy tissues. A major challenge was the integration of the data from different sources, platforms, and conditions that we mitigated with a bespoke stringent procedure.

Results

We performed a global transcriptome-based delineation of different kidney disease entities, obtaining a transcriptomic diffusion map of their similarities and differences based on the genes that acquire a consistent differential expression between each kidney disease entity and nephrectomy tissue. We derived functional insights by inferring the activity of signaling pathways and transcription factors from the collected gene expression data and identified potential drug candidates based on expression signature matching. We validated representative findings by immunostaining in human kidney biopsies indicating, for example, that the transcription factor FOXM1 is significantly and specifically expressed in parietal epithelial cells in rapidly progressive glomerulonephritis (RPGN) whereas not expressed in control kidney tissue. Furthermore, we found drug candidates by matching the signature on expression of drugs to that of the CKD entities, in particular, the Food and Drug Administration-approved drug nilotinib.

Conclusion

These results provide a foundation to comprehend the specific molecular mechanisms underlying different kidney disease entities that can pave the way to identify biomarkers and potential therapeutic targets. To facilitate further use, we provide our results as a free interactive Web application: https://saezlab.shinyapps.io/ckd_landscape/. However, because of the limitations of the data and the difficulties in its integration, any specific result should be considered with caution. Indeed, we consider this study rather an illustration of the value of functional genomics and integration of existing data.

Real-world data on healthcare resource consumption and costs before and after kidney transplantation

End-stage renal disease (ESRD) is increasing worldwide as a consequence of population aging and increasing chronic illness. Treatment consists mostly of dialysis and kidney transplantation (KTx), and KTx offers advantages for life expectancy and long-term cost reductions compared with dialysis. This study uses the administrative database of the Lombardy Region to analyze the costs of a cohort of patients with ESRD receiving KTx, covering a time period of 24 months before transplant to 12 months after. During 2011, 276 patients underwent kidney transplantation (8.7% preemptive and 91.3% non-preemptive). In the period before transplantation, the main cost driver was dialysis (66.6% for the period from -24 to -12 months and 73.8% for the period from -12 to 0 months), while in the 12 months after KTx, the most relevant cost was surgery. The total cost -24 to -12 months pre-KTx was 35 049.2€; the cost -12 to 0 months was 36 745.9€; and the cost 12 months after KTx was 43 805.8€. Non-preemptive patients showed much higher costs both pre- and post-KTx than preemptive patients. This study highlights how KTx modifies the resource consumption and costs composition of patients with ESRD vs those undergoing dialysis treatment and how KTx may be economically beneficial, especially preemptive intervention.

Exercise interventions for improving objective physical function in patients with end-stage kidney disease on dialysis: a systematic review and meta-analysis

Patients with end-stage kidney disease on dialysis have increased mortality and reduced physical activity, contributing to impaired physical function. Although exercise programs have demonstrated a positive effect on physiological outcomes such as cardiovascular function and strength, there is a reduced focus on physical function. The aim of this review was to determine whether exercise programs improve objective measures of physical function indicative of activities of daily living for patients with end-stage kidney disease on dialysis. A systematic search of Medline, Embase, the Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature identified 27 randomized control trials. Only randomized control trials using an exercise intervention or significant muscular activation in the intervention, a usual care, nonexercising control group, and at least one objective measure of physical function were included. Participants were ≥18 yr of age, with end-stage kidney disease, undergoing hemo- or peritoneal dialysis. Systematic review of the literature and quality assessment of the included studies used the Cochrane Collaboration’s tool for assessing risk bias. A meta-analysis was completed for the 6-min walk test. Data from 27 studies with 1,156 participants showed that exercise, regardless of modality, generally increased 6-min walk test distance, sit-to-stand time or repetitions, and grip strength as well as step and stair climb times or repetitions, dynamic mobility, and short physical performance battery scores. From the evidence available, exercise, regardless of modality, improved objective measures of physical function for end-stage kidney disease patients undergoing dialysis. It is acknowledged that further well-designed randomized control trials are required.

Decline in the Functional Status and Mortality in Patients on Hemodialysis: Results from the Japan Dialysis Outcome and Practice Patterns Study

OBJECTIVES

Patients with end-stage renal disease (ESRD) treated with hemodialysis suffer a high burden of poor functional status. Poor functional status is known as a strong, consistent predictor of mortality. However, little is known about the trajectory of functional status and its association with clinical outcomes in the ESRD population. We examined the association between a change in the functional status over time and all-cause mortality among patients on hemodialysis.

DESIGN AND METHODS

This was a prospective cohort study of 817 patients with ESRD on hemodialysis with repeat measures of functional status, who enrolled in the Japan Dialysis Outcomes and Practice Patterns Study phase V. The functional status was assessed based on the Katz Index and Lawton-Brody instrumental activities of daily living scale, and the assessments were conducted twice over a median of 361 (range: 339-378) days between 2012 and 2013. We classified patients into 2 groups based on having or not having at least a 1-point decline in the functional status score. To evaluate the association between the decline in the functional status and all-cause mortality with adjustment for potential confounders, a Cox regression analysis was conducted.

RESULTS

Over the study period, 19.9% of the patients showed a decline in the functional status score. During the follow-up period, 44 (5.4%) patients died. Using the Cox regression analysis and adjusting for potential confounders, it was determined that the decline in functional status score was significantly associated with higher mortality (incidence rate: 2.2 vs. 7.0 per 100 person-years; adjusted hazard ratio: 2.68; 95% confidence interval: 1.31-5.50).

CONCLUSIONS

The present study provides evidence that ESRD patients on hemodialysis demonstrating a decline in the functional status are at elevated risk of mortality. Our findings strengthen the evidence underpinning the importance of interventions to maintain the functional status in this vulnerable population.

Haematological profile of chronic kidney disease in a mixed-ancestry South African population: a cross-sectional study

OBJECTIVES

The objectives were to characterise the haematological profile of screen-detected chronic kidney disease (CKD) participants and to correlate the complete blood count measures with the commonly advocated kidney function estimators.

METHODS

The current cross-sectional study used data, collected between February 2015 and November 2016, of 1564 adults of mixed-ancestry, who participated in the Cape Town Vascular and Metabolic Health study. Kidney function was estimated using the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. CKD was defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m², and anaemia as haemoglobin level <13.5 g/dL (men) and <12 g/dL (women).

RESULTS

Based on the MDRD and CKD-EPI equations, the crude prevalence of CKD was 6% and 3%. Irrespective of the equation used, median red blood cell (RBC) indices were consistently lower in those with CKD compared with those without CKD (all p<0.0001). Despite not showing any significant difference in total white blood cell (WBC) count between the two groups, the number of lymphocytes were lower (p=0.0001 and p<0.0001 for MDRD and CKD-EPI, respectively) and neutrophil count (both p<0.0297) and the ratio of lymphocytes to neutrophil (both p<0.0001) higher in the CKD group compared with those without CKD; with the remaining WBC indices similar in the two groups. The platelet count was similar in both groups. Of the screen-detected CKD participants, 45.5% (MDRD) and 57.8% (CKD-EPI) were anaemic, with the prevalence increasing with increasing severity of CKD, from 37.2% (stage 3) to 82.4% (stages 4-5). Furthermore, CKD-EPI-estimated kidney function, but not MDRD, was positively associated with RBC indices.

CONCLUSION

Though it remains unclear whether common kidney function estimators provide accurate estimates of CKD in Africans, the correlation of their estimates with deteriorating RBC profile, suggests that advocated estimators, to some extent approximate kidney function in African populations.

Transposed Basilic Vein Fistula: A Credible Option

Objective: Native fistula creation for hemodialysis in patients who have exhausted all their superficial veins presents a challenge to vascular practice. We review our experience in transposed basilic vein fistula (BVT) creation and its usage for hemodialysis.

Materials and Methods: We analyzed the hospital operative registry from January 2009 till June 2012 to identify the total number of BVT created in our center. Medical records of all patients were traced, and patients were interviewed using a standard proforma. In our center, BVT is performed as a two-stage procedure. All patients were routinely assessed with duplex scan preoperatively and postoperatively.

Results: Two hundred thirty-nine patients were recruited in the study. Of these patients, 50.6% were male and 49.4% were female. Mean age was 53.4 years. Of these patients, 81.2% had history of other previous fistula creation. Risk factors profile includes diabetes mellitus in 59.8%, hypertension in 86.2%, and smoking in 13.0%. Of these patients, 84.5% had no operative complication. Commonest complication was wound infection, 6.3%, followed by hemorrhage or hemotoma required surgical intervention, 5.9%, and pseudoaneurysm, 1.3%. Primary and secondary patencies were at 84.2% and 86.1% at 1 year and 67.7% and 70.5% at 3 years, respectively.

Conclusion: BVT is a credible option for challenging patients with absence of superficial veins for native fistula creation with good patency and low operative complication rate. Preoperative ultrasound assessment improves patient selection and outcome of BVT.

End-of-life care for people with chronic kidney disease: cause of death, place of death and hospital costs

Background

End-of-life care for people with chronic kidney disease (CKD) has been identified as an area of great clinical need internationally. We estimate causes and place of death and cost of hospital care for people with CKD in England in the final 3 years of life.

Methods

Hospital Episode Statistics data were linked to Office for National Statistics mortality data to identify all patients in England aged ≥18 years who died 1 April 2006-31 March 2010, and had a record of hospital care after 1 April 2003 (the study group). The underlying cause and place of death were examined in Office for National Statistics data, for patients without and with CKD (identified by International Classification of Diseases version 10 codes N18, I12 and I13). Costs of hospital admissions and outpatient attendances were estimated using National Health Service Reference Cost data. Associations between CKD and hospital costs, and between place of death and hospital costs in those with CKD, were examined using multivariate regressions.

Results

There were 1 602 105 people in the study group. Of these, 13.2% were recorded as having CKD. The proportion of deaths at home was 10.7% in people with CKD and 17.2% in the age- and gender-matched non-CKD group. Regression analysis suggests that CKD was associated with an increase in hospital costs of £3380 in the last 12 months of life, holding constant place of death, comorbidities and other variables. For the CKD group, home death was associated with a reduction in hospital costs of £2811 in the 12 months before death. The most commonly recorded cause of death in people with CKD was heart disease. CKD was not mentioned on the death certificate in two-thirds of deaths in people with the condition.

Conclusions

People with CKD are less likely to die at home than those without CKD. The condition is associated with increased hospital costs at the end of life regardless of place of death. Home death in CKD is associated with a substantial reduction in hospital costs at the end of life.

Transcriptome analysis supports viral infection and fluoride toxicity as contributors to chronic kidney disease of unknown etiology (CKDu) in Sri Lanka

PURPOSE

Chronic kidney disease of unknown etiology (CKDu), having epidemic characteristics, is being diagnosed increasingly in certain tropical regions of the world, mainly Latin America and Sri Lanka. They have been observed primarily in farming communities and current hypotheses point toward many environmental and occupational triggers. CKDu does not have common etiologies of chronic kidney disease (CKD) such as hypertension, diabetes, or autoimmune disease. We aimed to understand the molecular processes underlying CKDu in Sri Lanka using transcriptome analysis.

METHODS

RNA extracted from whole blood was reverse transcribed and used for microarray analysis using the Human HT-12 v.4 array (Illumina). Pathway analysis was carried out using ingenuity pathway analysis (IPA-Qiagen). Microarray results were validated using real-time PCR of five selected genes.

RESULTS

Pathways related to innate immune response, including interferon signaling, inflammasome signaling and TREM1 signaling had the most significant positive activation z scores, where as EIF2 signaling and mTOR signaling had the most significant negative activation z scores. Pathways previously linked to fluoride toxicity; G-protein activation, Cdc42 signaling, Rac signaling and RhoA signaling were activated in CKDu patients. The most significantly activated biological functions were cell death, cell movement and antimicrobial response. Significant toxicological functions were mitochondrial dysfunction, oxidative stress and apoptosis.

CONCLUSIONS

Based on the molecular pathway analysis in CKDu patients and review of literature, viral infections and fluoride toxicity appear to be contributing to the molecular mechanisms underlying CKDu.

Expenses of the Brazilian Public Healthcare System with chronic kidney disease

INTRODUCTION

The prevalence of chronic kidney disease (CKD) is increasing worldwide, with costs that can be impeditive.

OBJECTIVE

To establish the expenses of the Brazilian Public Healthcare System (SUS), with hospitalizations due to CKD and related diseases; evaluating expenses with renal replacement therapy (RRT).

METHODS

We have assessed the values paid by the SUS in the triennium 2013-2015, for estimating annual expenses with CKD treatment and hospitalization, associated diseases, and exams.

RESULTS

There was an increase in hospitalization by all causes in Brazil during this triennium. CKD and associated diseases corresponded to 1.82% and 5.79% of hospitalizations due to all causes in Brazil, and 2.87% and 10.10% of all expenses, respectively. Kidney grafts from deceased donors corresponded to 76% of hospitalizations and 80% of expenses with transplantation. There was a decrease in transplantation from living donors. There was an increase in the number of exams of 11.94% and of 10.95% in the expenses. There was a decrease in the number of procedures and expenses in intermittent peritoneal dialysis (IPD) and related procedures; but other procedures increased. Hemodialysis (3 weekly sessions) corresponded to 95.96% of procedures and 96.07% of expenses with dialysis in general.

CONCLUSION

Renal diseases and some of the main related diseases corresponded to 12.97% of the expenses in the triennium 2013-2015, and RRT to more than 5% of the SUS expenses with medium and high complexity healthcare. Such high expenses determine great concerns on the future maintenance of treatment for stage-5 CKD in Brazil and countries in similar or worse conditions of development.

Path Analysis on Medical Expenditures of 855 Patients with Chronic Kidney Disease in a Hospital in Beijing

BACKGROUND

Investigate into the medical expenditures of chronic kidney disease (CKD) patients through path analysis method of three consecutive years within a Grade-A tertiary hospital in Beijing to conduct the main influencing factors in diagnosis-related groups (DRGs) grouping of the diagnosis, and reassess the present grouping process to provide information and reference on cost control for hospitals and medical management departments.

METHODS

Eight hundred and fifty-five inpatient cases whose first diagnosis were defined as CKD in the year 2014-2016 within the hospital were selected as the sample of the study, multiple linear regression and path analysis method were adopted in DRGs grouping process to investigate the main influencing factors of total medical expenditures and DRGs grouping process.

RESULTS

The maximum proportion of the medical costs within CKD patients was the costs on treatment, with the highest of 35.3% on the year 2014, the second was the costs on drug, which accounted for <30% during consecutive years, and the third was the costs on examination, which accounted for about 20% on average. The main influencing factors of medical expenditures included the type of dialysis, length of hospitalization, the admission of Intensive Care Unit (ICU), and so on. The coefficients toward the effect for total costs were 0.416, 0.376, and 0.094, respectively.

CONCLUSIONS

It is suggested that the type of dialysis and the admission of ICU were the major influencing factors of inpatient medical expenditures on CKD patients, and should be taken into consideration into the reassessment of DRGs grouping process to realize the localization and generalization of prospective payment system based on DRGs within the regional area and promote the implementation of medical cost control measures to reduce the economic burdens among patients and the society.

Translation of the 5D Itching Scale from English to Malay, and Its Validation among Patients with Chronic Kidney Disease in Malaysia

Introduction

Several tools have been developed to assess the severity of pruritus. In Malaysia, no tool has been validated to assess pruritus in patients with chronic kidney disease (CKD). Therefore, the aim of our study was to validate the Malay 5D itching scale (M5D-IS) among patients with CKD in Malaysia.

Method

The English version of the 5D-IS was translated into Malay according to International Guidelines. Face and content validity was determined by an expert panel and pilot tested in patients with end-stage renal disease (ESRD). The M5D-IS was then validated in a tertiary hospital in Malaysia from May to June 2016. We recruited patients with (i.e., patients with ESRD) and without pruritus (i.e., patients with stage 1–3 CKD) (to determine if the M5D-IS could discriminate between the two groups), and administered the M5D-IS at baseline and 2 weeks later. Exploratory factor analysis was used to examine the construct validity. Internal consistency was assessed using Cronbach’s alpha and intraclass correlation coefficient was calculated to assess the reliability of the instrument.

Results

A total of 70 participants were recruited (response rate = 100%). The majority were males (51.4%) and Malay (67.1%). Exploratory factor analysis revealed that the 5D-IS had 2-factor loadings: “daily routine activity” and “pattern of itching,” which explained 77.7% of the variance. The overall score of the M5D-IS, as well as for each domain, was significantly worse in participants with pruritus (9.83 ± 0.35), compared to those without pruritus (5.51 ± 0.93, p < 0.001). The overall Cronbach’s alpha for the M5D-IS was (0.861), indicating adequate internal consistency. At test–retest, the intraclass correlation coefficient was significantly correlated.

Conclusion

The M5D-IS was found to be a valid and reliable instrument to assess pruritus among patients with CKD in Malaysia.

Validity and reliability of the Urdu version of the 5D itching scale to assess pruritus among patients with chronic kidney disease in Pakistan

Background

Chronic kidney disease (CKD) has become a major public health issue worldwide in the past few years. Pruritus is a common, well-recognized complication often seen in patients with chronic renal failure. For assessment of pruritus, different tools are used but these tools are unable to identify the changes and variations in the severity of pruritus. The aim of our study was to validate the Urdu-version of the Urdu-version of the 5D itch scale among patients suffering from chronic kidney disease in Pakistan.

Method

The 5D itch scale was translated from English into Urdu following translation guidelines for translation. Face and content validity was determined by a panel of experts and piloted. For retest, the Urdu version of the 5D itch scale was administered at baseline and two weeks.

Results

A total of 50 participants with end stage renal disease were recruited, and of these, 64% were males. Exploratory factor analysis revealed that the 5D–IS had 2-factor loadings: “Pattern and activity” and “Distribution” with Kaiser–Mayer–Olkin (KMO) = 0.802, Bartlett’s test of sphericity was significant (df = 28, p < 0.001). At test re-test, Cronbach’s alpha was 0.914, while the intra class correlation was 0.9160 (95% confidence interval 0.941–0.975), which is a highly significant correlation (p < 0.0001).

Conclusion

The Urdu version of the 5D itch scale was found to be a valid and reliable instrument for assessing pruritus and its severity in patients with chronic kidney disease in Pakistan.

Electronic supplementary material

The online version of this article (10.1186/s12882-017-0717-0) contains supplementary material, which is available to authorized users.

Kindlin-2 Association with Rho GDP-Dissociation Inhibitor α Suppresses Rac1 Activation and Podocyte Injury

Alteration of podocyte behavior is critically involved in the development and progression of many forms of human glomerular diseases. The molecular mechanisms that control podocyte behavior, however, are not well understood. Here, we investigated the role of Kindlin-2, a component of cell-matrix adhesions, in podocyte behavior in vivo Ablation of Kindlin-2 in podocytes resulted in alteration of actin cytoskeletal organization, reduction of the levels of slit diaphragm proteins, effacement of podocyte foot processes, and ultimately massive proteinuria and death due to kidney failure. Through proteomic analyses and in vitro coimmunoprecipitation experiments, we identified Rho GDP-dissociation inhibitor α (RhoGDIα) as a Kindlin-2-associated protein. Loss of Kindlin-2 in podocytes significantly reduced the expression of RhoGDIα and resulted in the dissociation of Rac1 from RhoGDIα, leading to Rac1 hyperactivation and increased motility of podocytes. Inhibition of Rac1 activation effectively suppressed podocyte motility and alleviated the podocyte defects and proteinuria induced by the loss of Kindlin-2 in vivo Our results identify a novel Kindlin-2-RhoGDIα-Rac1 signaling axis that is critical for regulation of podocyte structure and function in vivo and provide evidence that it may serve as a useful target for therapeutic control of podocyte injury and associated glomerular diseases.

Measurement properties of patient-reported outcome measures (PROMs) used in adult patients with chronic kidney disease: A systematic review

Background

Patient-reported outcome measures (PROMs) can provide valuable information which may assist with the care of patients with chronic kidney disease (CKD). However, given the large number of measures available, it is unclear which PROMs are suitable for use in research or clinical practice. To address this we comprehensively evaluated studies that assessed the measurement properties of PROMs in adults with CKD.

Methods

Four databases were searched; reference list and citation searching of included studies was also conducted. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist was used to appraise the methodological quality of the included studies and to inform a best evidence synthesis for each PROM.

Results

The search strategy retrieved 3,702 titles/abstracts. After 288 duplicates were removed, 3,414 abstracts were screened and 71 full-text articles were retrieved for further review. Of these, 24 full-text articles were excluded as they did not meet the eligibility criteria. Following reference list and citation searching, 19 articles were retrieved bringing the total number of papers included in the final analysis to 66. There was strong evidence supporting internal consistency and moderate evidence supporting construct validity for the Kidney Disease Quality of Life-36 (KDQOL-36) in pre-dialysis patients. In the dialysis population, the KDQOL-Short Form (KDQOL-SF) had strong evidence for internal consistency and structural validity and moderate evidence for test-retest reliability and construct validity while the KDQOL-36 had moderate evidence of internal consistency, test-retest reliability and construct validity. The End Stage Renal Disease-Symptom Checklist Transplantation Module (ESRD-SCLTM) demonstrated strong evidence for internal consistency and moderate evidence for test-retest reliability, structural and construct validity in renal transplant recipients.

Conclusions

We suggest considering the KDQOL-36 for use in pre-dialysis patients; the KDQOL-SF or KDQOL-36 for dialysis patients and the ESRD-SCLTM for use in transplant recipients. However, further research is required to evaluate the measurement error, structural validity, responsiveness and patient acceptability of PROMs used in CKD.

Exercise Training in Elderly People Undergoing Hemodialysis: A Systematic Review and Meta-analysis

Introduction

Previous reviews have indicated the effectiveness of exercise in people undergoing hemodialysis. However, these analyses did not take into account whether the subjects were elderly. We performed a systematic review of the effects of exercise training in elderly people undergoing hemodialysis and updated the evidence of exercise for people undergoing hemodialysis by adding recent research data.

Methods

We searched 8 electronic databases up to June 2016. Inclusion criteria were as follows: randomized controlled trial, English publication, subjects aged 18 and older undergoing hemodialysis, evaluation of physical function as an outcome of exercise intervention. We defined elderly as age 60 years and older. The main outcomes were exercise tolerance (peak/maximum oxygen consumption) and walking ability (6-minute walk distance). Secondary outcomes were lower extremity muscle strength and quality of life.

Results

After screening of 10,923 references, 30 comparisons were entered into the analysis. However, because we found only 1 study in which elderly subjects were treated, we could not perform a meta-analysis for these people. For the general population undergoing hemodialysis, supervised exercise training was shown to significantly increase peak/maximum oxygen consumption (standard mean difference, 0.62; 95% confidence interval 0.38-0.87; P < 0.001), 6-minute walk distance (standard mean difference, 0.58; 95% confidence interval 0.24-0.93; P < 0.001), lower extremity muscle strength (standard mean difference, 0.94; 95% confidence interval 0.67-1.21; P < 0.001), and quality of life (standard mean difference, 0.53; 95% confidence interval 0.52-0.82; P < 0.001).

Discussion

Our analysis on the effectiveness of exercise training in elderly people undergoing hemodialysis as compared with nonelderly people was somewhat inconclusive. Future studies should be carried out for elderly people to identify the most favorable exercise program for this population.

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.

Dementia is a risk factor for major adverse cardiac and cerebrovascular events in elderly Korean patients initiating hemodialysis: a Korean national population-based study

Background

Dementia is common in end-stage renal disease (ESRD) patients on hemodialysis (HD) and is associated with worse outcomes. This study aimed to investigate the risk of major adverse cardiac and cerebrovascular event (MACCE) in elderly patients with dementia initiating HD.

Methods

Using the database from the Health Insurance Review & Assessment Service, we analyzed 10,171 patients aged 65 years or older who had initiated dialysis from 2005 to 2008. MACCE was defined as a composite outcome of all-cause mortality, nonfatal acute myocardial infarction, target vessel revascularization, and nonfatal ischemic and hemorrhagic stroke. The Kaplan-Meier method and Cox proportional hazards model were used, and further comparisons using propensity-score matching at 1:2 ratio were also performed.

Results

A total of 303 elderly patients (3.0%) had dementia at initiating HD. During follow-up, dementia was a significant predictor of MACCE after adjustment for confounding variables. In addition, further analyzed in the propensity-score matched groups, dementia was an independent predictor of both nonfatal ischemic stroke and all-cause mortality.

Conclusions

Dementia is an independent risk factor for mortality and ischemic stroke in elderly ESRD patients initiating HD. Patients with dementia who start dialysis should be closely monitored to reduce the risk of mortality and ischemic stroke.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-017-0547-0) contains supplementary material, which is available to authorized users.

Impact of Malnutrition, Inflammation, and Atherosclerosis on the Outcome in Hemodialysis Patients

Malnutrition, inflammation, and atherosclerosis are significant problems in patients on hemodialysis. A prospective, observational study in 100 hemodialysis patients for 2 years was conducted. The primary outcomes were hospitalizations and mortality at the end of 2 years. The mean age was 61 ± 11.3 years and 69% were male. Seven patients did not complete the study (five underwent transplant and two were shifted to other units). Serum albumin was significantly lower in malnourished patients at 6 months from the beginning of the study period (3.58 vs. 3.79 g/dl, P = 0.001). Malnutrition based on subjective global assessment (SGA) was seen in 30 (32%) patients: mild to moderate in 27 (29%) and severe in 3 (3%). Inflammation was seen in 73 (78.5%) patients and intimal-medial thickness of >1.1 mm indicating significant atherosclerosis was seen in 73 (78.5%) patients. Modified SGA score and malnutrition-inflammation score (MIS) were significantly more in the malnourished group. Statistically significant association was seen between hospitalization and mortality in the malnourished population, and the odds ratio of death in malnourished patients was 9.83 (95% confidence interval: 2.8-34.3, P < 0.001). There was a moderate correlation between malnutrition assessed by modified SGA and MIS score (r = 0.54, P < 0.001). Mortality rate was 37% in patients with mild to moderate and 67% in severe malnutrition. Hospital admission was seen in 43 (46%) patients and was significantly more common in malnourished compared to well-nourished patients (77% vs. 32%, P < 0.001). Multiple logistic regression analysis showed that malnutrition by Modified SGA was the only significant variable associated with mortality at 2 years, and addition of MIS score did not improve the predictive ability of the model to modified SGA. We recommend the use of modified SGA and serial serum albumin to monitor nutrition in hemodialysis patients.