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Am J Kidney Dis [journal]
- Plasma MicroRNA-186 and Proteinuria in Focal Segmental Glomerulosclerosis. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Sep 10.
MicroRNAs (miRNAs) are stable in circulation, and their unique expression profiles can serve as fingerprints for various diseases. This study explored whether plasma miRNAs could be used as biomarkers to evaluate disease activity in patients with focal segmental glomerulosclerosis (FSGS).Retrospective and prospective cohorts.78 patients with FSGS with nephrotic proteinuria (protein excretion > 3.5g/24 h), 35 patients with FSGS in complete remission, 63 patients with membranous nephropathy, 59 patients with diabetic nephropathy, and 69 apparently healthy controls were recruited. Plasma samples from 51 other patients with FSGS with nephrotic proteinuria were collected prospectively before and after steroid treatment.Plasma miRNA concentration.Complete remission (protein excretion < 0.4g/24 h), or no response (sustained protein excretion > 3.5g/24 h after 8 weeks of steroid treatment).Quantitative reverse transcription-polymerase chain reaction analysis of plasma miRNAs.Increases in miR-125b, miR-186, and miR-193a-3p levels were identified in a pooled plasma sample of 9 patients with FSGS compared with that of 9 healthy controls and were confirmed with individual samples from patients with FSGS (n=32) and healthy controls (n=30). Areas under the receiver operating characteristic curves of miR-125b, miR-186, miR-193a-3p, and the 3 miRNAs in combination were 0.882, 0.789, 0.910, and 0.963, respectively. miR-125b and miR-186 concentrations were significantly lower in patients with FSGS in complete remission (n=35) than those with nephrotic proteinuria (n=37). In a prospective study, miR-125b and miR-186 levels declined markedly in patients with FSGS with complete remission (n=29), but not those with no response (n=22), after steroid treatment. Plasma miR-125b and miR-186 levels were not elevated in patients with membranous nephropathy (n=63) and diabetic nephropathy (n=59) regardless of degree of proteinuria. Last, plasma miR-186, but not miR-125b, level was correlated with degree of proteinuria in patients with FSGS (151 samples).Relatively small cohort size.Plasma miR-186 may be a biomarker for FSGS with nephrotic proteinuria.
- Brain Atrophy in Peritoneal Dialysis and CKD Stages 3-5: A Cross-sectional and Longitudinal Study. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Sep 10.
Brain atrophy has been reported in patients with end-stage renal disease receiving hemodialysis, although its mechanism is unknown. However, little is known regarding brain atrophy in patients receiving peritoneal dialysis (PD). Therefore, we examined brain volume and its annual change over 2 years in PD patients compared with patients with non-dialysis-dependent chronic kidney disease (NDD-CKD).Cross-sectional and longitudinal cohort.62 PD patients and 69 patients with NDD-CKD with no history of cerebrovascular disease who underwent brain magnetic resonance imaging (MRI) were recruited in a cross-sectional study. Among them, 34 PD patients and 61 patients with NDD-CKD, who underwent a second brain MRI after 2 years, were recruited in a longitudinal study.PD therapy versus NDD-CKD.T1-weighted magnetic resonance images were analyzed. Total gray matter volume (GMV), total white matter volume (WMV), and cerebrospinal fluid space volume were segmented, and each volume was quantified using statistical parametric mapping software. Normalized GMV and WMV values were calculated by division of GMV and WMV by intracranial volume to adjust for variations in head size. We compared normalized GMV and normalized WMV between PD patients and patients with NDD-CKD in the cross-sectional study and the annual change in normalized GMV in the longitudinal study.In the cross-sectional study, normalized GMV, which was correlated inversely with age, was lower in PD patients than in patients with NDD-CKD. However, normalized WMV, which was not correlated with age, was comparable between the groups. Annual change in normalized GMV was significantly higher in PD patients than in patients with NDD-CKD. These differences remained significant even after adjustment for potential confounding factors.A short observation period and high dropout rate in the longitudinal study.Decline in normalized GMV is faster in PD patients than in patients with NDD-CKD.
- Does Acute Kidney Injury Cause Longer-Term Kidney Function Decline? [EDITORIAL]
- Am J Kidney Dis 2014 Sep 5.
- Surrogate Outcomes for ESRD Risk: The Case for a 30% Reduction in Estimated GFR Over 2 Years. [EDITORIAL]
- Am J Kidney Dis 2014 Sep 4.
- Improving Care Coordination Between Nephrology and Primary Care: A Quality Improvement Initiative Using the Renal Physicians Association Toolkit. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Aug 30.
Individuals at risk for chronic kidney disease (CKD), including those with diabetes mellitus and hypertension, are prevalent in primary care physician (PCP) practices. A major systemic barrier to mitigating risk of progression to kidney failure and to optimal care is failure of communication and coordination among PCPs and nephrologists.Quality improvement. Longitudinal practice-level study of tool-based intervention in nephrology practices and their referring PCP practices.9 PCP and 5 nephrology practices in Philadelphia and Chicago.Tools from Renal Physicians Association toolkit were modified and provided for use by PCPs and nephrologists to improve identification of CKD, communication, and comanagement.CKD identification, referral to nephrologists, communication among PCPs and nephrologists, comanagement processes.Pre- and postimplementation interviews, questionnaires, site visits, and monthly teleconferences were used to ascertain practice patterns, perceptions, and tool use. Interview transcripts were reviewed for themes using qualitative analysis based on grounded theory. Chart audits assessed CKD identification and referral (PCPs).PCPs improved processes for CKD identification, referral to nephrologists, communication, and execution of comanagement plans. Documentation of glomerular filtration rate was increased significantly (P=0.01). Nephrologists improved referral and comanagement processes. PCP postintervention interviews documented increased awareness of risk factors, the need to track high-risk patients, and the importance of early referral. Final nephrologist interviews revealed heightened attention to communication and comanagement with PCPs and increased levels of satisfaction among all parties.Nephrology practices volunteered to participate and recruit their referring PCP practices. Audit tools were developed for quality improvement assessment, but were not designed to provide statistically significant estimates.The use of specifically tailored tools led to enhanced awareness and identification of CKD among PCPs, increased communication between practices, and improvement in comanagement and cooperation between PCPs and nephrologists.
- Peritoneal Solute Transport and Inflammation. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Aug 29.
The speed with which small solutes cross the peritoneal membrane, termed peritoneal solute transport rate (PSTR), is a key measure of individual membrane performance. PSTR can be quantified easily by using the 4-hour dialysate to plasma creatinine ratio, which, although only an approximation to the diffusive characteristics of the membrane, has been well validated clinically in terms of its relationship to patient survival and changes in longitudinal membrane function. This has led to changes in peritoneal dialysis modality use and dialysis prescription. An important determinant of PSTR is intraperitoneal inflammation, as exemplified by local interleukin 6 production, which is largely independent of systemic inflammation and its relationship to comorbid conditions and increased mortality. There is no strong evidence to support the contention that the peritoneal membrane in some individuals with high PSTR is qualitatively different at the start of treatment; rather, it represents a spectrum that is determined in part by genetic factors. Both clinical and experimental evidence support the view that persistent intraperitoneal inflammation, detected as a continuously high or increasing PSTR, may predispose the membrane to progressive fibrosis.
- Knowledge and Attitudes of Canadian First Nations People Toward Organ Donation and Transplantation: A Quantitative and Qualitative Analysis. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Aug 27.
Organ donation and transplantation rates are low for aboriginal people in Canada, despite a high demand.An explanatory mixed-methods design was used to describe knowledge of and preferences for organ donation and transplantation among First Nations people and identify factors that may influence these preferences.We recruited on- and off-reservation First Nations adults.A 45-item survey was administered to 198 participants, of whom 21 were assessed further with a qualitative interview using a multiple case study approach.In an iterative process, themes were identified from qualitative data using critical realism as the theoretical framework. Critical realism is an approach that describes the interface between natural and social worlds to explain human behavior.Although 83% of participants were in favor of transplantation, only 38% were willing to donate their organs after death, 44% had not thought about organ donation, and 14% did not believe it was important. Only 18.7% of participants reported that their cultural beliefs influenced their views on organ donation and transplantation. In the multivariable analysis, the only factors associated with willingness to donate organs were higher education and considering organ donation important. Four themes emerged from qualitative data: importance of traditional beliefs, recognition of need due to the epidemic of diabetes among Canadian aboriginal people, reconciliation between traditional beliefs and need, and general apathy in the community.Cultural, socioeconomic, and political diversity exist between and within aboriginal groups. Findings may not be generalizable to other aboriginal communities.Willingness to donate organs was lower in these First Nations participants compared to the general population. Education to address knowledge deficits, emphasize the negative impact of organ failure on the community, and contextualize organ donation within the older traditional native beliefs to help First Nations people understand how organ donation may be integrated into native spirituality likely is required to increase donation rates.
- Serum Bicarbonate and Bone Mineral Density in US Adults. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Aug 26.
Chronic metabolic acidosis leads to bone mineral loss and results in lower bone mineral density (BMD), which is a risk factor for osteoporosis-related fractures. The effect of low-level metabolic acidosis on bone density in the general population is unknown.Cross-sectional study.9,724 nationally representative adults 20 years or older in NHANES (National Health and Nutrition Examination Survey) 1999-2004.Serum bicarbonate level.Lumbar and total BMD, as well as low lumbar and total bone mass, defined as 1.0 SD below the sex-specific mean value of young adults.BMD was measured by dual-energy x-ray absorptiometry and serum bicarbonate was measured in all participants.Both men and women with lower serum bicarbonate levels were more likely to be current smokers and had higher body mass index and estimated net endogenous acid production. There was a significant linear trend across quartiles of serum bicarbonate with lumbar BMD in the total population, as well as in sex-specific models (P=0.02 for all 3 models, P=0.1 for interaction). For total BMD, a significant association was seen with serum bicarbonate level for women but not men (P=0.02 and P=0.1, respectively; P=0.8 for interaction), and a significant association was seen for postmenopausal women but not premenopausal women (P=0.02 and P=0.2, respectively; P=0.5 for interaction). Compared with women with serum bicarbonate levels <24mEq/L, those with serum bicarbonate levels ≥27mEq/L had 0.018-g/cm(2) higher total BMD (95% CI, 0.004-0.032; P=0.01) and 31% lower odds of having low total bone mass (OR, 0.68; 95% CI, 0.46-0.99; P=0.049).Cross-sectional study using a single measurement of serum bicarbonate. Subgroup differences are not definitive.Lower serum bicarbonate levels are associated with lower BMD in US adults. Further studies should examine whether serum bicarbonate levels should be incorporated into the diagnostic assessment and management of osteoporosis.
- Assessing Achievement in Nephrology Training: Using Clinic Chart Audits to Quantitatively Screen Competency. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Aug 23.
Entrustable professional activities (EPAs) are complex tasks representing vital physician functions in multiple competencies, used to demonstrate trainee development along milestones. Managing a nephrology outpatient clinic has been proposed as an EPA for nephrology fellowship training.Retrospective cohort study of nephrology fellow outpatient clinic performance using a previously validated chart audit tool.Outpatient encounter chart audits for training years 2008-2009 through 2012-2013, corresponding to participation in the Nephrology In-Training Examination (ITE). A median of 7 auditors (attending nephrologists) audited a mean of 1,686±408 (SD) charts per year. 18 fellows were audited; 12, in both of their training years.Proportion of chart audit and quality indicator deficiencies.Longitudinal deficiency and ITE performance.Among fellows audited in both their training years, chart audit deficiencies were fewer in the second versus the first year (5.4%±2.0% vs 17.3%±7.0%; P<0.001) and declined between the first and second halves of the first year (22.2%±6.4% vs 12.3%±9.5%; P=0.002). Most deficiencies were omission errors, regardless of training year. Quality indicator deficiencies for hypertension and chronic kidney disease-associated anemia recognition and management were fewer during the second year (P<0.001). Yearly audit deficiencies ≥5% were associated with an ITE score less than the 25th percentile for second-year fellows (P=0.03), with no significant association for first-year fellows. Auditor-reported deficiencies declined between the first and second halves of the year (17.0% vs 11.1%; P<0.001), with a stable positive/neutral comment rate (17.3% vs 17.8%; P=0.6), suggesting that the decline was not due to auditor fatigue.Retrospective design and small trainee numbers.Managing a nephrology outpatient clinic is an EPA. The chart audit tool was used to assess longitudinal fellow performance in managing a nephrology outpatient clinic. Failure to progress may be quantitatively identified and remediated. The tool identifies deficiencies in all 6 competencies, not just medical knowledge, the primary focus of the ITE and the nephrology subspecialty board examination.
- Dialysis Care and Death Following Hurricane Sandy. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Aug 22.
Hurricane Sandy affected access to critical health care infrastructure. Patients with end-stage renal disease (ESRD) historically have experienced problems accessing care and adverse outcomes during disasters.Retrospective cohort study with 2 comparison groups.Using Centers for Medicare & Medicaid Services claims data, we assessed the frequency of early dialysis, emergency department (ED) visits, hospitalizations, and 30-day mortality for patients with ESRD in Sandy-affected areas (study group) and 2 comparison groups: (1) patients with ESRD living in states unaffected by Sandy during the same period and (2) patients with ESRD living in the Sandy-affected region a year prior to the hurricane (October 1, 2011, through October 30, 2011).Regional variation in dialysis care patterns and mortality for patients with ESRD in New York City and the State of New Jersey.Frequency of early dialysis, ED visits, hospitalizations, and 30-day mortality.Of 13,264 study patients, 59% received early dialysis in 70% of the New York City and New Jersey dialysis facilities. The ED visit rate was 4.1% for the study group compared with 2.6% and 1.7%, respectively, for comparison groups 1 and 2 (both P<0.001). The hospitalization rate for the study group also was significantly higher than that in either comparison group (4.5% vs 3.2% and 3.8%, respectively; P<0.001 and P<0.003). 23% of study group patients who visited the ED received dialysis in the ED compared with 9.3% and 6.3% in comparison groups 1 and 2, respectively (both P<0.001). The 30-day mortality rate for the study group was slightly higher than that for either comparison group (1.83% vs 1.47% and 1.60%, respectively; P<0.001 and P=0.1).Lack of facility level damage and disaster-induced power outage severity data.Nearly half the study group patients received early dialysis prior to Sandy's landfall. Poststorm increases in ED visits, hospitalizations, and 30-day mortality were found in the study group, but not in the comparison groups.