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American journal of kidney diseases [journal]
- Bioimpedance-Guided Fluid Management in Maintenance Hemodialysis: A Pilot Randomized Controlled Trial. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Feb 27.
Chronic subclinical volume overload happens very frequently in hemodialysis patients and is associated directly with hypertension, increased arterial stiffness, left ventricular hypertrophy, and ultimately higher mortality.Randomized controlled parallel-group trial.131 patients from one hemodialysis center, randomly assigned into 2 groups.Dry weight prescription using results derived from repeated 3-month bioimpedance measurements to guide ultrafiltration for strict volume control (bioimpedance group; n=62) compared with clinical judgment without bioimpedance measures (clinical-methods group; n=69) for 2.5 years.The primary outcome was all-cause mortality over 2.5 years (the duration of the intervention). Secondary outcomes were change in relative arterial stiffness, fluid overload, and blood pressure (BP) over 2.5 years.Bioimpedance measurements were performed using a Body Composition Monitor device. Pulse wave velocity analysis was performed at baseline, 2.5 years (end of intervention), and 3.5 years (end of study). Relative fluid overload and BP were assessed at 3-month intervals.The unadjusted HR for all-cause death in the bioimpedance group (vs the clinical-methods group) was 0.100 (95% CI, 0.013-0.805; P=0.03). After 2.5 years, we found a greater decline in arterial stiffness, relative fluid overload, and systolic BP in the bioimpedance group than the clinical-methods group. Between-group differences in change from baseline to the end of intervention were -2.78 (95% CI, -3.75 to 1.80)m/s for pulse wave velocity (P<0.001), -2.99% (95% CI, -5.00% to -0.89%) for relative fluid overload (P=0.05), and -2.43 (95% CI, -7.70 to 2.84)mmHg for systolic BP (P=0.4).Echocardiography was not performed as cardiovascular assessment and the caregivers were not masked to the intervention.Our study showed improvement in both surrogate and hard end points after strict volume control using bioimpedance to guide dry weight adjustment. These findings need to be confirmed in a larger trial.
- Genomic and Epigenomic Analyses of Monozygotic Twins Discordant for Congenital Renal Agenesis. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Feb 27.
Monozygotic twins have been widely studied to distinguish genetic and environmental factors in the pathogenesis of human diseases. For renal agenesis, the one-sided absence of renal tissue, the relative contributions of genetic and environmental factors to its pathogenesis are still unclear. In this study of a pair of monozygotic twins discordant for congenital renal agenesis, the genomic profile was analyzed from a set of blood samples using high-throughput exome-capture sequencing to detect single-nucleotide polymorphisms (SNPs), copy number variations (CNVs), and insertions and deletions (indels). Also, an epigenomic analysis used reduced-representation bisulfite sequencing to detect differentially methylated regions (DMRs). No discordant SNPs, CNVs, or indels were confirmed, but 514 DMRs were detected. KEGG analysis indicated the DMRs localized to 10 signaling pathways and 25 genes, including the mitogen-activated protein kinase pathway and 6 genes (FGF18, FGF12, PDGFRA, MAPK11, AMH, CTBP1) involved in organ development. Although methylation results from our adult patient and her sister may not represent the pattern that was present during kidney development, we could at least confirm a lack of obvious differences at the genome level, which suggests that nongenetic factors may be involved in the pathogenesis of renal agenesis.
- Awareness of CKD in China: A National Cross-sectional Survey. [LETTER]
- Am J Kidney Dis 2014 Feb 25.
- Cytomegalovirus glomerulopathy and cytomegalovirus interstitial nephritis on sequential transplant kidney biopsies. [Journal Article]
- Am J Kidney Dis 2014 Mar; 63(3):536-9.
Cytomegalovirus (CMV) nephropathy may be seen in kidney transplant biopsy specimens. We report a CMV-negative patient who received a kidney transplant from a CMV-positive donor and subsequently developed CMV glomerulopathy and CMV-associated interstitial nephritis, as observed in 2 sequential kidney biopsies. The first biopsy specimen showed CMV-positive endothelial cells in glomerular capillaries and CMV-infected monocytes in glomerular capillary lumens. The second biopsy specimen showed CMV-positive cells in the interstitium with associated lymphoplasmacytic infiltrate and tubular injury, but no evidence of direct CMV infection in tubular epithelial cells. Moreover, the second biopsy specimen showed persistent monocytes with cytoplasmic viral particles within glomerular capillary loops by electron microscopy. Our case shows that CMV glomerulopathy can be caused by direct CMV infection of glomerular capillary endothelial cells. CMV-positive circulating monocytes may play an important role in the different histopathologic manifestations of CMV nephropathy in kidney transplant grafts.
- Blood Transfusion Practices in Dialysis Patients in a Dynamic Regulatory Environment. [JOURNAL ARTICLE]
- Am J Kidney Dis 2014 Feb 19.
In 2011, Medicare implemented a prospective payment system (PPS) covering an expanded bundle of services that excluded blood transfusions. This led to concern about inappropriate substitution of transfusions for other anemia management methods.Medicare claims were used to calculate transfusion rates among dialysis patients pre- and post-PPS. Linear probability regressions adjusted transfusion trends for patient characteristics.Dialysis patients for whom Medicare was the primary payer between 2008 and 2012.Pre-PPS (2008-2010) versus post-PPS (2011-2012).Monthly and annual probability of receiving one or more blood transfusions.Monthly rates of one or more transfusions varied from 3.8%-4.8% and tended to be lowest in 2010. Annual rates of transfusion events per patient were ∼10% higher in relative terms post-PPS, but the absolute magnitude of the increase was modest (∼0.05 events/patient). A larger proportion received 4 or more transfusions (3.3% in 2011 and 2012 vs 2.7%-2.8% in prior years). Controlling for patient characteristics, the monthly probability of receiving a transfusion was significantly higher post-PPS (β=0.0034; P<0.001), representing an ∼7% relative increase. Transfusions were more likely for females and patients with more comorbid conditions and less likely for blacks both pre- and post-PPS.Possible underidentification of transfusions in the Medicare claims, particularly in the inpatient setting. Also, we do not observe which patients might be appropriate candidates for kidney transplantation.Transfusion rates increased post-PPS, but these increases were modest in both absolute and relative terms. The largest increase occurred for patients already receiving several transfusions. Although these findings may reduce concerns regarding the impact of Medicare's PPS on inappropriate transfusions that impair access to kidney transplantation or stress blood bank resources, transfusions should continue to be monitored.
- Quiz Page March 2014: A Patient With Malignant Hypertension, Thrombotic Microangiopathy, and Nephrotic-Range Proteinuria. [Journal Article]
- Am J Kidney Dis 2014 Mar; 63(3):A23-5.
- Zero dark thirty: a nephrologist at the movies. [Editorial]
- Am J Kidney Dis 2014 Mar; 63(3):A20-2.
- Intravenous iron dose and frequency determine infection risks. [Letter]
- Am J Kidney Dis 2014 Mar; 63(3):540-1.
- The KDOQI US Commentary on KDIGO Anemia Guideline and Quality of Life. [Letter]
- Am J Kidney Dis 2014 Mar; 63(3):540.
- Urinary Lithogenic Risk Profile in Recurrent Stone Formers With Hyperoxaluria: A Randomized Controlled Trial Comparing DASH (Dietary Approaches to Stop Hypertension)-Style and Low-Oxalate Diets. [Journal Article]
- Am J Kidney Dis 2014 Mar; 63(3):456-63.
Patients with nephrolithiasis and hyperoxaluria generally are advised to follow a low-oxalate diet. However, most people do not eat isolated nutrients, but meals consisting of a variety of foods with complex combinations of nutrients. A more rational approach to nephrolithiasis prevention would be to base dietary advice on the cumulative effects of foods and different dietary patterns rather than single nutrients.Randomized controlled trial.Recurrent stone formers with hyperoxaluria (urine oxalate > 40mg/d).The intervention group was asked to follow a calorie-controlled Dietary Approaches to Stop Hypertension (DASH)-style diet (a diet high in fruit, vegetables, whole grains, and low-fat dairy products and low in saturated fat, total fat, cholesterol, refined grains, sweets, and meat), whereas the control group was prescribed a low-oxalate diet. Study length was 8 weeks.Primary: change in urinary calcium oxalate supersaturation.Changes in 24-hour urinary composition.57 participants were randomly assigned (DASH group, 29; low-oxalate group, 28). 41 participants completed the trial (DASH group, 21; low-oxalate group, 20). As-treated analysis showed a trend for urinary oxalate excretion to increase in the DASH versus the low-oxalate group (point estimate of difference, 9.0mg/d; 95% CI, -1.1 to 19.1mg/d; P=0.08). However, there was a trend for calcium oxalate supersaturation to decrease in the DASH versus the low-oxalate group (point estimate of difference, -1.24; 95% CI, -2.80 to 0.32; P=0.08) in association with an increase in magnesium and citrate excretion and urine pH in the DASH versus low-oxalate group.Limited sample size, as-treated analysis, nonsignificant results.The DASH diet might be an effective alternative to the low-oxalate diet in reducing calcium oxalate supersaturation and should be studied more.