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Am J Kidney Dis [journal]
- Histopathologic Effect of APOL1 Risk Alleles in PLA2R-Associated Membranous Glomerulopathy. [LETTER]
- Am J Kidney Dis 2014 Apr 11.
- Approach to the Hemodialysis Patient With an Abnormal Serum Bicarbonate Concentration. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Apr 12.
We present a patient receiving hemodialysis with a persistently high serum bicarbonate concentration to illustrate the evaluation and management issues for patients with both high (>25mEq/L) and low (<20mEq/L) pretreatment values. Patients with high serum bicarbonate concentrations typically are malnourished and have low rates of endogenous acid production. Evaluation should begin with assessment of whether an acute and potentially reversible cause of metabolic alkalosis is present. If not, management should be directed at treating malnutrition. By contrast, patients with low predialysis serum bicarbonate concentrations, in the absence of an acute and reversible cause, may benefit from increasing the level by an adjustment in dialysate bicarbonate concentration. However, the level at which one should intervene and to what extent serum bicarbonate concentration should be increased are unresolved issues. Whether such an intervention will reduce mortality risk has not been determined.
- Potentially Preventable Hospitalization as a Complication of CKD: A Cohort Study. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Apr 12.
Ambulatory care-sensitive conditions have been described as those that (if appropriately managed in an outpatient setting) generally do not require subsequent hospitalization. Our goal was to identify clinical populations of people who are at the highest risk of ambulatory care-sensitive conditions related to chronic kidney disease (CKD).Retrospective cohort study.2,003,054 adults (including 238,747 adults with CKD) residing in Alberta, Canada, with at least one serum creatinine measurement between 2002 and 2009.Estimated glomerular filtration rate and albuminuria categories, CKD status, demographics, and clinical characteristics.Hospitalization with heart failure, hyperkalemia, volume overload, or malignant hypertension.We used the Alberta Kidney Disease Network database, which incorporates data from Alberta Health, the Northern and Southern Alberta Renal Programs, and clinical laboratories in Alberta.During a median follow-up of 4.1 years, 43,863 participants were hospitalized for heart failure; 6,274 participants, for hyperkalemia; 2,035 participants, for volume overload; and 481 participants, for malignant hypertension. All 4 conditions were more common at lower estimated glomerular filtration rates and in the presence of albuminuria. In the subset of participants with CKD, heart failure, hyperkalemia, and volume overload were associated most strongly with older age, diabetes, chronic liver disease, and prior heart failure. Malignant hypertension was associated with prior hypertension, aboriginal status, and peripheral vascular disease. Remote-dwelling participants were more likely to experience heart failure and malignant hypertension than those living closer to providers.No data for medication use or potentially important process-based outcomes for study participants.Our findings suggest that future studies seeking to determine how to prevent ambulatory care-sensitive conditions in people with CKD should target remote dwellers and those with comorbid conditions such as concomitant heart failure and liver disease.
- Bone Disease in CKD: A Focus on Osteoporosis Diagnosis and Management. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Apr 10.
Osteoporosis is defined as a condition of impairment in bone strength due to low bone mineral density and poor bone quality and predisposes individuals to an increased risk of fractures. Osteoporosis may coexist with chronic kidney disease-mineral and bone disorder (CKD-MBD) and osteoporotic fractures occur in all stages of CKD. Management of osteoporosis in CKD should consider the pathophysiology of both disorders. Diagnosis and management of osteoporosis in patients with stages 1-3 CKD and patients without CKD are similar, but diagnosis and management decisions differ greatly once patients have stages 4-5 CKD. Discriminating between osteoporosis and CKD-MBD is best accomplished with quantitative bone histomorphometry. Biochemical markers, especially intact parathyroid hormone and bone-specific alkaline phosphatase, also may be helpful. When the diagnosis of osteoporosis is established, management in stages 4-5 CKD may include antiresorptive or anabolic agents, though evidence for efficacy is marginal in advanced CKD.
- Serum Testosterone Levels and Mortality in Men With CKD Stages 3-4. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Apr 10.
Hypogonadism in men (total testosterone<350ng/dL) is associated with higher risk of cardiovascular disease and mortality in men on dialysis therapy. We evaluated the association of hypogonadism with all-cause mortality in men with non-dialysis-dependent chronic kidney disease (CKD).Retrospective, cohort study.2,419 men with CKD stages 3-4 (estimated glomerular filtration rate, 15-59mL/min/1.73m(2)) who had total testosterone measured for cause between January 1, 2005, and October 31, 2011, at a tertiary-care center in Cleveland, OH.Total testosterone measured using an immunoassay measurement in 3 forms: (1) categorized as low or testosterone replacement therapy versus normal, (2) continuous log testosterone, and (3) quintiles (100-226, 227-305, 306-392, 393-511, and 512-3,153ng/dL).Factors associated with low total testosterone level and the association between low total testosterone level and all-cause mortality were evaluated using logistic regression, Cox proportional hazard models, and Kaplan-Meier survival curves.Hypogonadism was found in 1,288 of 2,419 (53%) men. In a multivariable logistic regression analysis, African American ethnicity and higher estimated glomerular filtration rate were associated with lower odds of having hypogonadism. Diabetes and higher body mass index were associated with higher odds of having hypogonadism. 357 of 2,419 (15%) patients died during a median follow-up of 2.3 years. In the multivariate Cox model, testosterone level<350ng/dL or testosterone replacement therapy was not associated with mortality. In a multivariable model also adjusted for testosterone supplementation, higher log testosterone was associated with significantly lower mortality (HR per 1log unit, 0.70; 95%CI, 0.55-0.89). When compared to the highest quintile, the second lowest quintile of testosterone was associated with higher mortality (HR, 1.53; 95%CI, 1.09-2.16).Single-center study, timing of testosterone testing, lack of adjustment for proteinuria, and sampling bias.Low total testosterone level may be associated with higher mortality in men with CKD stages 3-4, but more studies are needed.
- Identification of Incident CKD Stage 3 in Research Studies. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Apr 10.
In epidemiologic research, incident chronic kidney disease (CKD) commonly is determined by laboratory tests performed at planned study visits. Given the morbidity and mortality associated with CKD, persons with incident disease may be less likely to attend scheduled visits, affecting observed associations. The objective of this study was to quantify loss to follow-up by CKD status and determine whether supplementation with diagnostic code data improves capture of incident CKD.Prospective cohort study.11,560 participants in the Atherosclerosis Risk in Communities (ARIC) Study underwent continuous surveillance for hospitalizations and death from baseline visit (1996-1999) to follow-up visit (2011-2013). A subset of hospitalizations in Washington County, MD, was used in diagnostic code validation (n=2,540).Baseline demographics and comorbid conditions.Incident CKD stage 3 ascertained by follow-up visit (visit-based definition) or hospitalization surveillance (hospitalization-based definition).Visit-based definition: ≥25% decline from baseline estimated glomerular filtration rate to <60mL/min/1.73m(2) at follow-up visit; hospitalization-based definition: hospitalization CKD diagnostic code.Of 11,560 participants, 5,951 attended the follow-up visit and 9,264 were hospitalized. Never-hospitalized participants were younger, more often female, and had fewer comorbid conditions; 73.5% attended the follow-up visit. Incident CKD stage 3 occurred in 1,172 participants by the visit-based definition (251 were never hospitalized) and 1,078 participants by the hospitalization-based definition (237 attended the follow-up study visit). Sensitivity of the hospitalization-based CKD definition was 35.5% (95%CI, 31.6%-39.7%); specificity was 95.7% (95%CI, 94.2%-96.8%). Sensitivity was higher with later time period, older participant age, and baseline prevalent diabetes and CKD.A subset of hospitalizations was used for validation; 15-year gap between study visits.The sensitivity of diagnostic code-identified CKD is low and varies by certain factors; however, supplementing a visit-based definition with hospitalization information can increase disease identification during periods of follow-up without study visits.
- Loin Pain Hematuria Syndrome. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Apr 8.
Loin pain hematuria syndrome is a rare disease with a prevalence of ∼0.012%. The most prominent clinical features include periods of severe intermittent or persistent unilateral or bilateral loin pain accompanied by either microscopic or gross hematuria. Patients with loin pain hematuria syndrome initially present with hematuria, flank pain, or most often both hematuria and flank pain. Kidney biopsies from patients with loin pain hematuria typically reveal only minor pathologic abnormalities. Further, loin pain hematuria syndrome is not associated with loss of kidney function or urinary tract infections. Loin pain hematuria syndrome-associated hematuria and pain are postulated to be linked to vascular disease of the kidney, coagulopathy, renal vasospasm with microinfarction, hypersensitivity, complement activation on arterioles, venocalyceal fistula, abnormal ureteral peristalsis, and intratubular deposition of calcium or uric acid microcrystals. Many patients with loin pain hematuria syndrome also meet criteria for a somatoform disorder, and analgesic medications, including narcotics, commonly are used to treat loin pain hematuria syndrome-associated pain. Interventional treatments include renal denervation, kidney autotransplantation, and nephrectomy; however, these methods should be used only as a last resort when less invasive measures have been tried unsuccessfully. In this review article, we discuss and critique current clinical practices related to loin pain hematuria syndrome pathophysiology, diagnosis, treatment, and prognosis.
- Canadian Society of Nephrology Commentary on the 2012 KDIGO Clinical Practice Guideline for the Management of Blood Pressure in CKD. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Apr 8.
The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) provides the structural and evidence base for the Canadian Society of Nephrology (CSN) commentary on this guideline's relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 13 of the 21 KDIGO guideline statements. Specifically, we agreed that nonpharmacological interventions should play a significant role in the management of hypertension in patients with CKD. We also agreed that the approach to the management of hypertension in elderly patients with CKD should be individualized and take into account comorbid conditions to avoid adverse outcomes from excessive BP lowering. In contrast to KDIGO, the CSN Work Group believes there is insufficient evidence to target a lower BP for nondiabetic CKD patients based on the presence and severity of albuminuria. The CSN Work Group concurs with the Canadian Hypertension Education Program (CHEP) recommendation of a target BP for all non-dialysis-dependent CKD patients without diabetes of ≤140mm Hg systolic and ≤90mm Hg diastolic. Similarly, it is our position that in diabetic patients with CKD and normal urinary albumin excretion, raising the threshold for treatment from <130mm Hg systolic BP to <140mm Hg systolic BP could increase stroke risk and the risk of worsening kidney disease. The CSN Work Group concurs with the CHEP and the Canadian Diabetic Association recommendation for diabetic patients with CKD with or without albuminuria to continue to be treated to a BP target similar to that of the overall diabetes population, aiming for BP levels < 130/80mm Hg. Consistent with this, the CSN Work Group endorses a BP target of <130/80mm Hg for diabetic patients with a kidney transplant. Finally, in the absence of evidence for a lower BP target, the CSN Work Group concurs with the CHEP recommendation to target BP<140/90mm Hg for nondiabetic patients with a kidney transplant.
- Quiz page may 2014: acute kidney injury with red urine. [Journal Article]
- Am J Kidney Dis 2014 May; 63(5):A21-4.
- In Reply to 'Validating GFR Estimating Samples With Clinical Outcomes'. [Letter]
- Am J Kidney Dis 2014 May; 63(5):859-60.