Background: Chronic Kidney Disease (CKD) is a growing public health problem. Many risk factors were identified and interventions were applied accordingly, but the incidence of end-stage renal disease continued increasing. Some other risk factors may be ignored. Gut microbiota has been recognized as an important endogenous organ. The kidney-gut axis would contribute to gut dysbiosis, which might worsen CKD. Constipation, commonly seen in CKD, was one of the clinical presentation of gut dysbiosis. The clinical impact of constipation to CKD remains unknown. Our study aimed at assessing the risk of ESRD between CKD patients with and without constipation in a nationwide database.
With the high prevalence of pain in CKD patients under- going HD, providers must not be idle in the care of these patients, with resultant poor pain management outcomes. Undoubtedly, pain management in this population is com- plicated and requires the assessment of many components including alterations in pharmacokinetics, specific drug properties, comorbid disease states, physical impact of dialy- sis on the drug administered, and drug–drug interactions. Utilization of drugs metabolized through hepatic phase II metabolism may offer a much safer option; however, clinical trials are lacking. In the absence of evidence-based guide- lines, one must use the known pharmacology to design the safest and most efficacious patient-centered treatment plan.
All patients with ESRD admitted for HD who received at least 4 weeks of renal replacement therapy were in- cluded in this study. Socio-demographic and anthropo- metric parameters of interest were age, gender, weight and height. For clinical parameters, systolic blood pres- sure (SBP) and diastolic blood pressure (DBP) were mea- sured before the first session of HD using an electronic sphygmomanometer. Pulse pressure (PP) was calculated as the difference between SBP and DBP. The current medical treatment and complications at the initiation of HD were recorded on the appropriate form. Twenty- four-hour urine collection was used to measure RUV before beginning HD, and a similar urine collection protocol was used on days between dialysis 6 and 12 months later. The definition of volemia combined measurements of venous pressure, blood pressure and weight gain. For the evaluation of central venous pres- sure, we first performed a clinical assessment by placing the patient lying at 45° from the bed plane and appreci- ating the visibility of the jugular vein for a clinical esti- mation of 5–7 cm H2O. Patients with a value greater than 7 cm H2O benefited from the measure of central venous pressure. Hypervolemia was defined as a central venous pressure ≥ 13 cm H2O . If the clinical esti- mate was below 5 cm H2O with decreased weight and blood pressure, patients were considered hypovolemic. Left ventricular hypertrophy (LVH) was noted when the thickness of the interventricular septum and posterior left ventricular wall was greater than 11 mm at the end of dia- stole or when the left ventricular mass was greater than or equal to 120 g/m2 . Heart failure was defined on the basis of signs of pulmonary and peripheral stasis and a systolic ejection fraction of the left ventricle < 40% . Chronic tubulointerstitial nephropathy was defined as End stage renal disease with the absence or modest degree of the two principal hallmarks of glomerular and vascular diseases of the kidney: salt retention, manifested by edema and hypertension; and proteinuria, which usually is mod- est and less than 1 to 2 g/d in TIN.
Unlike opportunistic screening, population screening is accompanied by stringent quality control measures and careful programme monitoring. Sufficient evidence for benefit together with acceptable harms and costs to society are needed before launching a programme. A screening programme is a complex process organized at the population level involving multiple actors of the health care system that should ideally be supervised by public health authorities and evaluated by an independent and trustful body. Chronic kidney disease is defined by reduced glomerular filtration rate and/or presence of kidney damage for at least three months. Chronic kidney disease is divided into 5 stages with stages 1 to 3 being usually asymptomatic. Chronic kidney disease affects one in ten adults worldwide and its prevalence sharply increases with age. Kidney function is measured using serum creatinine-based, and/or cystatin C-based, equations. Markers of renal function show high intra-individual and inter-laboratory variabilities, highlighting the need for standardized procedures. There is also large inter-individual variability in age-related kidney function decline. Despite these limitations, chronic kidney disease, as currently defined, has been consistently associated with high cardiovascular morbidity and mortality and high risk of end-stage renal disease. Major modifiable risk factors for chronic kidney disease are diabetes, hypertension, obesity and cardiovascular disease. Several treatment options, ranging from antihypertensive and lipid-lowering treatments to dietary measures, reduce all-cause mortality and/or end-stage renal disease in patients with stages 1 – 3 chronic kidney disease. So far, no randomized controlled trial comparing outcomes with and without population screening for stages 1 – 3 chronic kidney disease has been published. Population screening for stages 1 – 3 chronic kidney disease is currently not recommended because of insufficient evidence for benefit. Given the current and future burden attributable to chronic kidney disease, randomized controlled trials exploring benefits and harms of population screening are clearly needed to prioritize resource allocations.
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All patients admitted to the MICU who had levels of 25 (OH)D available were included in the study. Patients readmitted to MICU during the same period of hospita- lization were excluded, those patients either already had 25(OH)D levels available from the first MICU admission and repeated levels were not performed within 24 hours of MICU readmission or did not any level available. The data were collected as part of a performance improve- ment project looking to the prevalence of 25(OH)D defi- ciency in our MICU. 25(OH)D levels were collected randomly during the first 24 hours of admission to the intensive care unit. There were no strict criteria to obtain 25(OH)D levels. The physicians received educa- tion regarding the high prevalence of hypovitaminosis in our community and were encouraged to evaluate for hypovitaminosis when patients were admitted to the hospital. Baseline demographics (age, gender, and race), history of end stage renal disease (ESRD) or chronic kid- ney disease (CKD), as well as acute physiology and chronic health evaluation (APACHE) IV were collected. The APACHE derived risk of death during hospitaliza- tion was determined from the worst values obtained within 24 hours of MICU admission. Clinical and laboratory variables obtained during the first 24 hours of hospital admission included serum levels of total cal- cium, phosphate, creatinine, glucose, albumin and 25 (OH)D. Utilization and duration of invasive mechanical ventilation, ICU length of stay (LOS), and hospital mor- tality were analyzed. Length of stay in the MICU was defined as the time from ICU admission to time of transfer out of the MICU. This study was approved by
Background: Vascular calcification is a common complication associated with chronic kidney disease and the major cause of cardiovascular disease in patients with end-stage renal disease. The vascular calcification risk burden is still unknown in China. This study aims to investigate the prevalence of vascular calcification and assess the predictive value of vascular calcification in patients with stage 5 chronic kidney disease on dialysis in China. Methods/Design: This is a national, multicenter, non-interventional, prospective cohort study planning to recruit 1520 patients with end-stage renal disease receiving hemodialysis or peritoneal dialysis for at least 6 months in 24 dialysis centers in China. All the patients provided written informed consents before participating in this study. It will include a baseline visit and 24 months follow-up period with 4 other visits at 6-month intervals. Vascular calcification images will be obtained to determine the prevalence of vascular calcification, coronary artery
doctors’ recommendations. As well, higher scores on the powerful others subscale predicted compliance with doctors’ recommendations regarding having a mammogram. Chance locus of control has been found to positively correlate with irrational health beliefs and self-reported medication adherence (McDonald-Miszczak et al., 2000). Results obtained by Steptoe and Wardle (2001) suggest that unhealthy lifestyles may be associated with a greater sense of powerlessness over one’s health, as exhibited by beliefs in the roles of chance and powerful others in determining one’s health (Turriff-Jonasson, 2004). The majority of studies looking at chronic illness and MHLOC have found that higher Internal Locus of Control is predictive of advantageous psychosocial adjustment. This conclusion has been made with cancer patients, individuals during end-stage renal disease chronic pain patients, and individuals with spinal- cord injury (Hatamlo Sadabadi, 2009). However, some studies have found no association between MHLOC and psychosocial adjustment in cancer or between MHLOC and psychological distress in cardiac illness (Fowers, 1994). Also, in several studies on patients with chronic illness (e.g. cardiovascular disease, cancer, end-stage renal disease, spinal cord injuries, traumatic brain injuries, and chronic pain), Internal HLOC was positively related to psychological adjustment and higher perceived health status (Blood, Dineen, Kauffman & Raimondi, 1993; Pucheu, Consoli, D’Auzac, Français & Issad 2004). However, other studies have reported a less clear relationship between HLOC and adjustment to illness (De Boer, Ryckman, Pruyn & Van den Borne, 1999; Fowers, 1994; Friedman, Baer, Lewy & Lane, 1988), and a few studies have found that a more external control orientation is associated with better adjustment (Burish et al, 1984; Franco et al, 2000).
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streptococcal glomerulonephritis (PSGN). In some populations PSGN is recognized as a risk factor for chronic kidney disease (CKD) and end-stage renal disease (ESRD). It was found that a significantly greater proportion of subjects with past history of PSGN than without the history exhibited seroreactions to streptococcal antigens called streptococcal inhibitor of complement (SIC) and to distantly related SIC (DRS). These antigens are expressed by major PSGN-associated GAS types. We therefore predicted that in populations such as India, which is endemic for streptococcal diseases and which has high prevalence of CKD and ESRD, greater proportions of CKD and ESRD patients exhibit seroreaction to SIC and DRS than healthy controls.
Renal replacement therapy (RRT), including renal dia- lysis and transplantation, for end-stage renal disease (ESRD) is a high-cost, albeit life-saving service. On a glo- bal level, it is estimated that 1 in every 20 people have chronic kidney disease (CKD). ESRD – the last and most critical stage of CKD – is a growing problem in most countries. Its incidence is increasing globally at an an- nual growth rate of 8% . The 2014 United States Renal Data System report shows that the incidence of ESRD increased by 10% (per million population) from 2006 to 2012 in Korea, Malaysia, Mexico, Thailand, and the USA . People over 65 years of age are more vul- nerable to CKD than those in other age groups, and also have a higher probability of death . The vascular and systemic complications in this subpopulation does not make them optimal candidates for renal transplantation, and they are less likely to receive a kidney from a living related donor. The costs for RRT are generally too high for most patients in developing countries to afford . Furthermore, kidney donor and transplantation services are not widely available in resource-limited settings . Liyanage et al.  estimated that, in 2010, around 2.3 million people died from lack of access to RRT, and worldwide use of RRT will double from 2.6 million to 5.4 million people by 2030. Providing treatment for ESRD patients is becoming more of a concern, especially
Secondary hyperparathyroidism (sHPT) is a frequent complication of chronic renal insufficiency (CRI), espe- cially end-stage renal disease (ESRD) [1, 2]. Advances in the medical treatment of sHPT have reduced the need for surgery, however 5 – 10 % of patients still require parathy- roidectomy [2 – 4]. Surgical management of sHPT is vary- ing [2, 3]. It can be performed using either subtotal parathyroidectomy or total parathyroidectomy (TPTX) with or without autotransplantation (AT) [2, 3, 5, 6]. AT of parathyroid grafts into the sternocleidomastoid muscle
This study reinforces the economic and public health burden of CKD and OKD in the US. Given the huge eco- nomic burden of CKD, implementation of aggressive strat- egies by healthcare providers and policymakers to decrease the burden of CKD is of the essence. The high burden of CKD can be addressed in several ways: early recognition/ diagnosis, promotion of lifestyle modification, prevention, and aggressive treatment of risk factors for disease progres- sion. The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend minimization of exposure to nephrotoxins in people with CKD . In addition, stud- ies [30–33] recognize that CKD is a risk factor for acute kidney injury (AKI) and preventable medical errors, and the impact of AKI on CKD progression. Early recognition is ultimately pivotal to all strategies geared towards reduc- tion of the economic burden of CKD and the onus lies on healthcare providers, namely primary care and specialty physicians, nurses and nurse practitioners, pharmacists etc. By putting in place pointers to identify high-risk CKD indi- viduals, the healthcare environment can prevent avoidable exposure to nephrotoxins, which leads to complications and accelerates CKD progression. Furthermore, empower- ing individuals with CKD with adequate and necessary knowledge about the disease can help avoid expensive outcomes – end stage renal disease (ESRD) and risky Table 3 Two-part regression model: Incremental effects of
This conclusion was especially apparent in the case of a 48-year old Australian Aboriginal woman who was ad- mitted to a local hospital with end stage renal disease. She ultimately declined hemodialysis treatment because a relative had died of chronic kidney disease (CKD), and she left against medical advice . The renal outreach team agreed that neither their concerns nor the treat- ment plans had been appropriately communicated to the patient. Therefore, the team made the decision to drive 6 h to the patient’s home and discuss the situation again with the patient and her family. The patient again refused dialysis stating she wanted to remain at home close to her family but this time she did so with a full understanding of the ramifications. The community primary care team was provided with necessary education and tools to manage her ESRD. She was ultimately referred to the palliative care service. The enhanced relationship permitted the team to remain involved in her care remotely and help to maintain the patient’s quality of life well into her final days. Considered with the study above, it is evident why communication and interpersonal skills are such vital components of clinical excellence in nephrology.
Both the US Department of Veterans Affairs and De- partment of Defence (2014) on their Clinical Practice Guideline for the Management of Chronic Kidney Dis- ease in Primary Care (strong recommendation); and Public Health Agency of Canada (in their Canadian Im- munisation Guide 2016) have extended the recommen- dation to include patients with chronic kidney disease or chronic renal disease [42, 43]. The Kidney Disease: Im- proving Global Outcomes (KDIGO) and the National Kidney Foundation’s Kidney Disease Outcome: Quality Improvement (KDOQI) have not specifically advocated for varicella vaccination post-transplant, the reason be- ing varicella vaccine is a live-attenuated vaccine [44, 45]. At present, there is yet to be any recommendation by both KDIGO and KDOQI on pre-transplant vaccinations in general. While post-exposure prophylaxis with vari- cella immunoglobulin, and primary varicella treatment with acyclovir or valaciclovir has been recommended; they are still silent with regards to VZV immunisation as a preventive method [43, 45].
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CI: confidence interval; CKD: chronic kidney disease; EIA: enzyme immunoassay; ESRD: end stage renal disease; ESRF: end stage renal failure; GFR: glomerular filtration rate; HD: haemodialysis; HDU: high dependency unit; IBM: International Business Machine Corporation; ICD: International Classification of Diseases; ICU: intensive care unit; IFA: indirect fluorescent antibody; IgG: immunoglobulin G; IgM: immunoglobulin M; IQR: interquartile range; km 2 : kilometre square; min: minute; ml: millilitre; n: number; p: p -value; RRT: replacement therapy; SGH: Singapore General Hospital; USA: United States of America; vs: versus; VZV: varicella zoster virus
Objective: Hepatitis C is a liver disease caused by the hepatitis C virus, the virus can cause both acute and chronic hepatitis. Hepatitis C virus (HCV) is a known risk factor for chronic kidney disease (CKD) and end-stage renal disease (ESRD). HCV infection in CKD patients is also associated with increased healthcare costs and utilization, with further increases in those with ESRD. It should be also noted that survival among HCV-infected patients with chronic kidney disease without undertaking any treatment is low, various mechanisms such as increased liver- related mortality, low quality of life and high cardiovascular risk can explain this finding. The benefits of treatment may extend beyond the liver, with improvements in both cardiovascular and renal outcomes in patient with chronic kidney disease. Previously PEG-INTERFRON Based regimens have been used for treatment of CKD or ESRD Patients with chronic Hepatitis C but this treatment plan was associated with higher adverse effects and less efficacy. Nowadays new researches have shown the efficacy of the Direct Anti-Viral Agents (DAAs) In such patients.
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Cardiovascular disease accounts for over 50% of mortality among patients with chronic kidney disease before reaching end-stage renal disease.The prevalence of chronic kidney disease continues to increase worldwide, and the relationship between renal impairment (RI) and risk of coronary artery disease is well established .Patients with RI typically present with advanced and more complex coronary artery disease compared to patients without RI, as indicated by a higher proportion of multivessel disease, left main disease, ostial lesions, heavily calcified lesions, and lesions located in vein grafts. Percutaneous coronary intervention (PCI) is the most commonly utilized revascularization modality for treatment of CAD both in patients with acute coronary syndromes (ACS) and those with stable ischemic heart disease (SIHD). In patients undergoing coronary revascularization for either stable coronary artery disease or acute myocardial infarction, CKD is one of the strongest risk factors for short- and long term mortality. There is evidence that coronary revascularization reduces the cardiac mortality and improves prognosis compared to medical treatment for CKD patients with CAD. With regard to evidence of best mode of coronary revascularization, percutaneous coronary intervention (PCI) are two alternative methods, but it remains controversial as which one is associated with reduced major adverse cardiac and cerebral events (MACCE), reduced risk of worsening kidney function and need of hemodialysis and reduced in-hospital stay for CKD patients. PCI in patients with CKD is also high-risk due to their increased incidence of worsening kidney function, restenosis, and mortality. To the best of our knowledge, there is paucity of prospective study results
Abstract: Patients with chronic kidney disease (CKD), including those with end-stage renal dis- ease, treated with dialysis, or renal transplant recipients have an increased risk for cardiovascular disease (CVD) morbidity and mortality. Dyslipidemia, often present in this patient population, is an important risk factor for CVD development. Specific quantitative and qualitative changes are seen at different stages of renal impairment and are associated with the degree of glomeru- lar filtration rate declining. Patients with non-dialysis-dependent CKD have low high-density lipoproteins (HDL), normal or low total cholesterol (TC) and low-density lipoprotein (LDL) cholesterol, increased triglycerides as well as increased apolipoprotein B (apoB), lipoprotein(a) (Lp (a)), intermediate- and very-low-density lipoprotein (IDL, VLDL; “remnant particles”), and small dense LDL particles. In patients with nephrotic syndrome lipid profile is more athero- genic with increased TC, LDL, and triglycerides. Lipid profile in hemodialysis (HD) patients is usually similar to that in non-dialysis-dependent CKD patients. Patients on peritoneal dialysis (PD) have more altered dyslipidemia compared to HD patients, which is more atherogenic in nature. These differences may be attributed to PD per se but may also be associated with the selection of dialytic modality. In renal transplant recipients, TC, LDL, VLDL, and triglycerides are elevated, whereas HDL is significantly reduced. Many factors can influence post-transplant dyslipidemia including immunosuppressive agents. This patient population is obviously at high risk; hence, prompt diagnosis and management are required to improve their clinical outcomes. Various studies have shown statins to be effective in the cardiovascular risk reduction in patients with mild-to-moderate CKD as well as in renal transplant recipients. However, according to recent clinical randomized controlled trials (4D, A Study to Evaluate the Use of Rosuvastatin in Subjects on Regular Dialysis: an Assessment of Survival and Cardiovascular Events, and Study of Heart and Renal protection), these beneficial effects are uncertain in dialyzed patients. Therefore, further research for the most suitable treatment options is needed.
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Manifestations of target organ damage are: in kidneys – proteinuria, nephrosclerosis, chronic kidney disease & end stage renal disease, in heart – left ventricular hypertrophy, coronary artery disease, angina, myocardial infarction, systolic dysfunction, diastolic dysfunction, chronic heart failure, atrial fibrillation & ventricular fibrillation, in brain- transient ischaemic attack & stroke, in eye- retinopathy. 8
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Complications associated with RRT can result on several fronts. Access-related complications can result from cir- cuit disruptions with subsequent blood loss. Connections should be taped to prevent accidental disconnection. Since CRRT requires anticoagulation for longer periods, the risk for complications related to anticoagulation is higher, although this has not been the case in our experi- ence [1,12,13]. In intermittent therapies, large, rapid alterations in fluid and solutes occur over a short period, so hemodynamic instability–reflected by hypotension and cardiac arrhythmias–is encountered in approxi- mately 25-50% of dialysis patients . Recent studies have demonstrated regional wall motion abnormalities and myocardial stunning in IHD patients that correlate with the volume and rate of fluid removal . A major area of concern is that episodes of hypotension during dialysis can impact negatively on renal and patient out- comes. Most patients treated with CRRT maintain hemo- dynamic stability and tolerate the procedure well [12,13]. Continuous therapies have the potential for volume depletion, particularly if monitoring is inadequate and calculations are inaccurate. Because large volumes of fluid can be removed quickly, meticulous monitoring is essential, requiring a nurse-patient ratio of at least 1:1, if not more. A major concern is that the continuous nature of these therapies provides a greater opportunity for manipulations by inexperienced personnel. It has been our experience that these can be limited by standardiza- tion of protocols for use of these therapies and restricting their use to trained personnel.
The drugs such as diuretics, NSAIDS,ACE inhibitors, angiotensin receptor blockers,should be used caution with suspected true or effective hypovolemia or renovascular disease , they may precipitate ischemic AKI. Allopurinol and forced alkaline diuresis are useful prophylactic measures to prevent precipitation of uric acid crystals in renal tubules in patients at high risk for acute urate nephropathy ( cancer chemotheraphy in haematological malignancy).
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