Chronic Kidney Disease Japan Cohort (CKD-JAC) study: design and methods

The prevalence and incidence of end-stage renal disease (ESRD) in Japan are the highest and the third highest, respectively, in the world, while the incidence of cardiac death in Japan is the lowest among developed countries. A recent study showed that the prevalence of chronic kidney disease (CKD), defined as an estimated glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m(2), is extremely high in Japan, about 20% of the adult population. However, the risk of ESRD and cardiovascular disease (CVD) in the CKD population has not been determined nationwide. For this observational study, we will establish a Chronic Kidney Disease Japan Cohort (CKD-JAC) by enrolling 3,000 patients with CKD in 17 clinical centers around Japan, which will be used to determine the incidence of ESRD and CVD in Japanese CKD patients. Risk factors associated with the development of CVD will also be examined. Comorbidity of diabetes in CKD patients will be analyzed to determine whether it is a risk for rapid progression of CKD and high incidence of CVD. In addition, we will study whether the burden of CKD decreases the QOL of patients, and increases hospitalization or health resource utilization. Insights from the CKD-JAC study will provide a basis for future interventional trials focused on reducing the burden of ESRD and CVD in patients with CKD in Japan.     

Cardiovascular disease risk factors in chronic kidney disease: overall burden and rates of treatment and control

BACKGROUND: Mild to moderate chronic kidney disease (CKD) is associated with increased risk for cardiovascular disease. The burden of cardiovascular disease risk factors in this setting is not well described. METHODS: We compared the age- and sex-adjusted prevalence of cardiovascular disease risk factors and their treatment and control among persons with and without CKD in 3258 Framingham offspring cohort members who attended the seventh examination cycle (1998-2001). Glomerular filtration rate (GFR) was estimated using the simplified Modification of Diet in Renal Disease Study equation. We defined CKD as a GFR of less than 59 mL/min per 1.73 m(2) in women and less than 64 mL/min per 1.73 m(2) in men. RESULTS: Those with CKD were older, more likely to be obese (33.5% vs 29.3%; P=.02), and more likely to have low levels of high-density lipoprotein cholesterol (45.2% vs 29.4%; P<.001) and high triglyceride levels (39.9% vs 29.8%; P<.001). Those with CKD had a higher prevalence of hypertension (71.2% vs 42.7%; P<.001) and hypertension treatment (86.0% vs 72.5%; P<.001), but were less likely to achieve optimal blood pressure control (27.0% vs 45.5%; P<.001). Participants with CKD had a higher prevalence of elevated low-density lipoprotein cholesterol levels (60.5% vs 44.7%; P=.06) and lipid-lowering therapy (57.1% vs 42.6%; P=.09), although this was not statistically significant. A greater proportion of individuals with CKD than those without had diabetes (23.5% vs 11.9%; P=.02) and were receiving diabetes treatment (63.6% vs 46.9%; P=.05), but were less likely to achieve a hemoglobin A(1c) level of less than 7% (43.8% vs 59.4%; P=.03). CONCLUSIONS: Chronic kidney disease is associated with a significant burden of cardiovascular disease risk factors in the community. The diagnosis of CKD should alert the practitioner to look for potentially modifiable cardiovascular risk factors.     

Changes in the demographics and prevalence of chronic kidney disease in Okinawa, Japan (1993 to 2003).

To compare the risk factor demographics and the prevalence of chronic kidney disease (CKD), we analyzed two databases from the 1993 (N=143,948) and 2003 (N=154,019) mass screenings in Okinawa, Japan (Okinawa General Health Maintenance Association registry). We estimated the glomerular filtration rate (GFR) using serum creatinine (SCr) levels. SCr was measured by the modified Jaffe method in 1993 and by enzyme assay in 2003; the relation between the two methods was: SCr (Jaffe) = 0.194 + 1.079 x SCr (enzyme). CKD prevalence was compared using the estimated GFR calculated by the abbreviated Modification of Diet in Renal Disease (MDRD) equation. SCr was measured in 66.2% (1993) and 69.8% (2003) of the total screenees. Proteinuria was present in 3.4% (1993) and 4.3% (2003) of the total screened population, respectively. The prevalence of CKD (GFR<60 ml/min/1.73 m(2)) was similar between the two databases, being 15.7% in 1993 and 15.1% in 2003. However, the demographics of the CKD risk factors changed during the study period. The mean level of systolic blood pressure decreased, whereas the prevalence of obesity and the mean levels of serum cholesterol and fasting plasma glucose increased. In 2003, the estimated prevalence of metabolic syndrome in the general population of Japan calculated using the modified National Cholesterol Education Program (NCEP) criteria was 19.1%. The prevalence of CKD was significantly associated with that of metabolic syndrome: the age- and sex-adjusted odds ratio was 1.332 (95% confidence interval [CI], 1.277-1.389; p<0.0001). In conclusion, the demographics of the participants of the general screenings in Okinawa, Japan differed between the 1993 and 2003 screenings, but the prevalence of CKD seemed to be similar, or at least did not increase substantially, between the two databases.     

Prognosis of CKD Patients Receiving Outpatient Nephrology Care in Italy

Summary

Background and objectives

Prognosis in nondialysis chronic kidney disease (CKD) patients under regular nephrology care is rarely investigated.

Design, setting, participants, & measurements

We prospectively followed from 2003 to death or June 2010 a cohort of 1248 patients with CKD stages 3 to 5 and previous nephrology care ≥1 year in 25 Italian outpatient nephrology clinics. Cumulative incidence of ESRD or death before ESRD were estimated using the competing-risk approach.

Results

Estimated rates (per 100 patient-years) of ESRD and death 8.3 (95% confidence interval [CI], 7.4 to 9.2) and 5.9 (95% CI 5.2 to 6.6), respectively. Risk of ESRD and death increased progressively from stages 3 to 5. ESRD was more frequent than death in stage 4 and 5 CKD, whereas the opposite was true in stage 3 CKD. Younger age, lower body mass index, proteinuria, and high phosphate predicted ESRD, whereas older age, diabetes, previous cardiovascular disease, ESRD, proteinuria, high uric acid, and anemia predicted death (P < 0.05 for all). Among modifiable risk factors, proteinuria accounted for the greatest contribution to the model fit for either outcome.

Conclusions

In patients receiving continuity of care in Italian nephrology clinics, ESRD was a more frequent outcome than death in stage 4 and 5 CKD, but the opposite was true in stage 3. Outcomes were predicted by modifiable risk factors specific to CKD. Proteinuria used in conjunction with estimated GFR refined risk stratification. These findings provide information, specific to CKD patients under regular outpatient nephrology care, for risk stratification that complement recent observations in the general population.     

Slower decline of glomerular filtration rate in the Japanese general population: a longitudinal 10-year follow-up study.

The prevalence of stage 3 to 5 chronic kidney disease (CKD) in Japan (18.7%) is considerably higher than that in the United States (4.5%). This study investigated in the Japanese general population whether this higher prevalence of CKD might reflect to a progressive decline of renal function, and in turn to the increased risk of end-stage renal disease. A decline in renal function over 10 years was examined in 120,727 individuals aged 40 years or older who participated in the annual health examination program of the two periods over 10 years, 1988-1993 and 1998-2003. Renal function was assessed with estimated glomerular filtration rate (GFR) using the abbreviated Modification of Diet in Renal Disease (MDRD) Study equation modified by a Japanese coefficient. The rate of GFR decline in the participants was 0.36 mL/min/1.73 m2/year on average. In the male population aged 50-79, the mean rate of GFR decline was significantly higher in the presence of hypertension than in its absence. The rate of GFR decline was more than two times higher in participants with proteinuria than in those without proteinuria in both sexes. The rate was significantly higher in participants with an initial GFR<50 mL/min/1.73 m2 among the groups younger than age 70 and in participants with an initial GFR<40 mL/min/1.73 m2 in the group with age 70-79. Based on the slow rate of GFR decline, we concluded that the decline in renal function progresses slowly in the Japanese general population. Hypertension, proteinuria and lower GFR were found to be significant risk factors for a faster decline of GFR.     

Natural history of older adults with impaired kidney function: the InCHIANTI study

The aim of this study was to assess the kidney function of an older community-dwelling population at baseline and appraise its evolution after 3 years of follow-up in terms of chronic kidney disease (CKD) stage progression, magnitude of glomerular filtration rate (GFR) changes, and value of serum creatinine. This was a prospective population-based study of 676 Italian participants, aged 65 years and older. GFR was estimated using the Cockcroft-Gault equation and the Modification of Diet in Renal Disease Study equation. Using the Cockcroft-Gault equation. A total of 33% of participants had criteria of CKD (GFR??90?mL/min) at baseline worsened to stage 2 and 10% worsened to stage 3. An abnormal high level of serum creatinine at baseline did not help to predict who might worsen at follow-up. Older people with CKD displayed a low progression of renal disease and therefore are at higher risk for co-morbidities related to CKD than for progression to end-stage renal disease.     

Chronic kidney disease incidence, and progression to end-stage renal disease, in HIV-infected individuals: a tale of two races

BACKGROUND: Little is known about the racial differences in the incidence and progression of HIV-related chronic kidney disease (CKD) that underlie African American-white disparities in HIV-related end-stage renal disease (ESRD). METHODS: In a cohort in Baltimore, Maryland, we measured CKD incidence, glomerular filtration rate (GFR) slope, and progression to ESRD in 3332 African American and 927 white HIV-infected subjects. RESULTS: A total of 284 subjects developed CKD, 100 (35%) of whom subsequently developed ESRD. African American subjects were at slightly increased risk for incident CKD, compared with white subjects (hazard ratio [HR], 1.9 [95% confidence interval {CI}, 1.2-2.8]). However, once CKD had commenced, the African American subjects developed ESRD markedly faster than did the white subjects (HR, 17.7 [95% CI, 2.5-127.0]), and, correspondingly, their GFR decline after diagnosis of CKD was 6-fold more rapid (P < .001). In the subset of African American subjects for whom kidney-biopsy data were available, progression to ESRD was significantly faster than that in white subjects with CKD, irrespective of the presence of HIV-associated nephropathy. CONCLUSIONS: The results of this study suggest that African American-white disparities in HIV-related ESRD are explained predominantly by a more aggressive natural disease history in African Americans and less by racial differences in CKD incidence.     

Treatment of metabolic bone disease in patients with chronic renal disease: A perspective for rheumatologists

As glomerular filtration rate (GFR) declines from age-related bone loss or disease that specifically induces a decline in GFR, there are a number of metabolic bone conditions that may accompany the decline in GFR. These metabolic bone conditions span a spectrum from mild-to-severe secondary hyperparathyroidism in early stages of chronic kidney disease (CKD) to the development of additional heterogeneous forms of bone diseases each with distinctly quantitative bone histomorphometric characteristics. Osteoporosis can also develop in patients with CKD and end-stage renal disease (ESRD) for many reasons beyond age-related bone loss and postmenopausal (PMO) bone loss. Diagnosing osteoporosis in patients with severe CKD or ESRD is not as easy to do as it is in patients with PMO. The diagnosis of osteoporosis in patients with CKD/ESRD must be done by first excluding other forms of renal osteodystrophy, through biochemical profiling or by double tetracycline-labeled bone biopsy and the finding of low trabecular bone volume. In such patients oral bisphosphonates seem to be safe and effective down to GFR levels of 15 mL/min. In patients with stage 5 CKD, who are fracturing because of osteoporosis or who are on chronic glucocorticoids, reducing the oral bisphosphonate dosage to half of its usual prescribed dosing for PMO seems reasonable from known bisphosphonate pharmacokinetics. However, we need better scientific data to fully understand bisphosphonate usage in this population. This paper deals with the evidence available to understand management of patients with CKD and opinions on what might be a reasonable clinical approach where evidence is currently lacking.     

Epidemiology of vascular disease in renal failure.

Cardiovascular disease (CVD) is the leading cause of death in the general population and a major cause of morbidity and mortality chronic kidney disease (CKD) and end-stage renal disease (ESRD) patients. The high prevalence of CVD in incident dialysis populations suggests that CVD begins during or before the stage of chronic renal insufficiency. While traditional risk factors observed in the general population may play a role in the progression of CVD in CKD and ESRD patients, the presence of several nontraditional factors related to the extent of uremia seems to be the more significant feature of CVD in this patient population. Recently, there have been significant advances in our understanding of how inflammation contributes to the pathogenesis of atherosclerosis and myocardial infarction. The fact that chronic inflammation and CVD are highly prevalent in ESRD patients, it is probable that chronic inflammation may be a causative factor for accelerated atherosclerosis observed in CKD and ESRD patients. Given the extent of the problem, efforts to lower the mortality rate among ESRD patients will require new approaches to reduce and/or prevent cardiovascular morbidity and mortality.     

End-stage renal disease predicts complications in pacemaker and ICD implants

End‐Stage Renal Disease Predicts Complications in Pacemaker and ICD Implants. Introduction: Patients with chronic kidney disease (CKD) have increased morbidity following invasive procedures. We hypothesized that patients with CKD have higher complication rates following device implantation than patients with normal renal function. Methods: We reviewed the medical records of patients undergoing ICD or pacemaker implantation from August 2004 to August 2007. The estimated glomerular filtration rate (GFR) was calculated using the Cockroft–Gault equation. Those with GFR ≥ 90 cc/min served as controls. The remainder was grouped according to American Kidney Foundation stages of CKD. Bleeding complications were defined as need for pocket exploration or blood transfusion; cardiac tamponade; or hematoma requiring pressure dressing, change in medications or prolonged hospitalization. Infection was defined as infection of the pocket or lead system, or development of bacteremia/sepsis within 60 days. Results: There were 82 bleeding complications (5.7%) and 7 infections (0.5%) temporally related to device implantation in 1,440 patients. End‐stage renal disease (ESRD), defined as GFR < 15 mL/min or need for dialysis, was identified in 32 patients. Infection rates were significantly higher in patients with ESRD versus controls (12.5% vs 0.2%; P < 0.0001). A significant increase in bleeding complications was observed in ESRD versus controls (21.9% vs 3.2%, respectively; P<0.0001). Bleeding complications were considerably greater than controls in moderate (GFR 30–59 mL/min) and severe (GFR 15–29 mL/min) CKD (7.4% and 9.8% vs 3.2%, respectively; P < 0.005). Conclusion: ESRD markedly increases bleeding and device‐related infections. The risk of both complications parallels the severity of CKD. Further research is needed to reduce adverse outcomes in this high‐risk population. (J Cardiovasc Electrophysiol, Vol. 22, pp. 1099‐1104, October 2011)     

Chronic kidney disease and heart failure--Bidirectional close link and common therapeutic goal

Chronic kidney disease (CKD) is common and the estimated prevalence is about 9-13% in the general adult population. CKD is defined by the presence of kidney damage or decreased glomerular filtration rate. Individuals with CKD have a far greater likelihood of cardiovascular death than progression to end-stage renal disease. Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder and the prevalence is reported to be 2-3% in the general population. The prognosis of HF patients is still poor despite recent advances in HF treatment. Both diseases are major and growing public health problems because aging of the population contributes to the increasing incidence of those diseases. More than 40% of HF patients have CKD and the close relationship between CKD and HF worsens their prognoses. All physicians must evaluate kidney function using estimated glomerular filtration rate calculated by the new Japanese equation in patients with HF. Accurate evaluation of pathophysiology between the two diseases and appropriate intervention are necessary to improve the prognosis of patients with the diseases.     

Risk of ESRD and Death in Patients with CKD Not Referred to a Nephrologist: A 7-Year Prospective Study

Background and objectives

Rising prevalence of CKD requires active involvement of general practitioners to limit ESRD and mortality risk. However, the outcomes of patients with CKD exclusively managed by general practitioners are ill defined.

Design, setting, participants, & measurements

We prospectively evaluated 30,326 adult patients with nondialysis CKD stages 1–5 who had never received consultation in tertiary nephrology care recruited from 700 general practitioner offices in Italy during 2002 and 2003. CKD stages were classified as stages 1 and 2 (GFR≥60 ml/min per 1.73 m² and either albuminuria or an International Classification of Diseases, Ninth Revision, Clinical Modification code for kidney disease), stage 3a (GFR=59–45), stage 3b (GFR=44–30), stage 4 (GFR=29–15), and stage 5 (GFR<15). Primary outcome was the risk of ESRD (dialysis or transplantation) or all-cause death.

Results

Overall 64% of patients were in stage 3a, and 4.5% of patients were in stages 3b–5. Patients with stages 1 and 2 were younger, were predominantly men, more frequently had diabetes, and had lower prevalence of previous cardiovascular disease than patients with stages 3a–5. Hypertension was frequent in all CKD stages (80%–94%), whereas there was a lower prevalence of dyslipidemia, albuminuria, and obesity associated with more advanced CKD. During the follow-up (median=7.2 years; interquartile range=4.7–7.7), 6592 patients died and 295 started ESRD. Compared with stages 1 and 2 (reference), mortality risk (hazard ratio, 95% confidence interval) was higher in stages 3b–5 (1.66, 1.49–1.86, 2.75, 2.41–3.13 and 2.54, 2.01–3.22, respectively) but not stage 3a (1.11, 0.99–1.23). Similarly, ESRD risk (hazard ratio, 95% confidence interval) was not higher at stage 3a (1.44, 0.79–2.64) but was greater in stages 3b–5 (11.0, 6.3–19.5, 91.2, 53.2–156.2 and, 122.8, 67.9–222.0, respectively). Among modifiable risk factors, anemia and albuminuria significantly predicted either outcome, whereas hypertension only predicted mortality.

Conclusions

In patients with CKD not referred to nephrology, risks of ESRD and mortality were higher in those with CKD stages 3b–5.     

Outcomes after percutaneous coronary interventions in patients with chronic kidney disease

Introduction Chronic kidney disease (CKD) is a significant contributor to cardiovascular morbidity and mortality. Patients with CKD are known to have a greater prevalence of cardiovascular disease than the general population, and patients with concurrent CKD and coronary artery disease (CAD) have greater mortality than patients without CKD.The rate of cardiovascular mortality is approximately 50%, five to 10 times higher than the general population.     

Comparison of four equations for estimation of glomerular filtration rate in predicting cardiovascular events and subclinical vascular disease in patients with type-2 diabetes

AimsChronic kidney disease (CKD), defined by a low glomerular filtration rate (GFR), is a predictor of cardiovascular disease in patients with type-2 diabetes (T2D). We aimed to compare four GFR equations in predicting future cardiovascular events in T2D and the presence of subclinical vascular disease.MethodsFour equations were used to estimate GFR in asymptomatic T2D patients consulting our centre for cardiovascular assessment. Follow-up was performed to collect cardiovascular events. Cox proportional hazard ratio (HR) was used to build and compare prediction models, and the incremental value of the addition of GFR with any of the 4 formulas was evaluated. The ability to triage patients with and without CVD events according to GFR were assessed by comparing the receiver operator characteristics (ROC) curves with the 4 models.ResultsAmong 829 asymptomatic T2D patients, the CKD prevalence was 20.2% for Modification of Diet in Renal Disease (MDRD), 17.3% for Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), 20.7% for Lund-Malmö Revised (LMR) and 21.4% for Full Age Spectrum (FAS). All the estimated GFRs were well correlated from one formula to another, with stronger agreement to define CKD (GFR <60 mL/min/1.73 m²) between MDRD and CKD-EPI, and between LMR and FAS. The 5-year incidence of cardiovascular events was 8% (n = 63). After adjustment on covariables, CKD was significantly associated with cardiovascular events when defined by MDRD (HR = 2.04; 1.15–3.60) and CKD-EPI (HR = 1.90; 1.05–3.41) but missed statistical significance when using LMR (HR = 1.74; 0.97–3.14) or FAS (HR = 1.71; 0.94–3.14). Only the prediction models including MDRD and CKD-EPI provided a significant incremental information to the predictive model without GFR, but the area under the ROC curves were similar with the 4 models: 0.60 [0.54–0.68] for MDRD, 0.61 [0.49–0.65] for CKD-EPI and 0.62 [0.55–0.69] for LMR and FAS, without any significant difference among formulas.ConclusionIn asymptomatic T2D patients, MDRD and CKD-EPI may be preferable when more specificity is desired (stronger association between GFR and CVD events), while LMR and FAS appear more sensitive by including a higher number of patients with GFR <60 mL/min/1.73 m².     

Chronic Renal Insufficiency Cohort (CRIC) Study: Baseline Characteristics and Associations with Kidney Function

Background and objectives: The Chronic Renal Insufficiency Cohort (CRIC) Study was established to examine risk factors for the progression of chronic kidney disease (CKD) and cardiovascular disease (CVD) in patients with CKD. We examined baseline demographic and clinical characteristics.Design, setting, participants, & measurements: Seven clinical centers recruited adults who were aged 21 to 74 yr and had CKD using age-based estimated GFR (eGFR) inclusion criteria. At baseline, blood and urine specimens were collected and information regarding health behaviors, diet, quality of life, and functional status was obtained. GFR was measured using radiolabeled iothalamate in one third of participants.Results: A total of 3612 participants were enrolled with mean age ± SD of 58.2 ± 11.0 yr; 46% were women, and 47% had diabetes. Overall, 45% were non-Hispanic white, 46% were non-Hispanic black, and 5% were Hispanic. Eighty-six percent reported hypertension, 22% coronary disease, and 10% heart failure. Mean body mass index was 32.1 ± 7.9 kg/m², and 47% had a BP >130/80 mmHg. Mean eGFR was 43.4 ± 13.5 ml/min per 1.73 m², and median (interquartile range) protein excretion was 0.17 g/24 h (0.07 to 0.81 g/24 h). Lower eGFR was associated with older age, lower socioeconomic and educational level, cigarette smoking, self-reported CVD, peripheral arterial disease, and elevated BP.Conclusions: Lower level of eGFR was associated with a greater burden of CVD as well as lower socioeconomic and educational status. Long-term follow-up of participants will provide critical insights into the epidemiology of CKD and its relationship to adverse outcomes.The prevalence of ESRD that requires renal replacement therapy has risen dramatically in the United States during the past three decades (1). Non–dialysis-requiring chronic kidney disease (CKD) is substantially more common than ESRD, with an estimated 15 million adults in the United States having CKD of stage 3 or worse (as defined by an estimated GFR [eGFR] of <60 ml/min per 1.73 m²) (2) Furthermore, CKD frequently progresses in severity, but the factors that are responsible for accelerated decline need further elucidation. In addition, recent studies have highlighted an important association between even mild CKD and increased risk for cardiovascular disease (CVD) (3), but the mechanisms for this association remain unclear.In response to the epidemic of CKD and our incomplete understanding of factors that govern its progression and associated morbidity, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) established the Chronic Renal Insufficiency Cohort (CRIC) Study in 2001. The broad aims of the CRIC Study are to examine risk factors for the progression of kidney disease and CVD in patients with CKD and to develop predictive models to identify high-risk subgroups. The design and methods of the CRIC Study have been previously reported (4). In this article, we characterize the eligibility and recruitment methods, describe the baseline characteristics of patients enrolled in the cohort, and report initial analyses of correlates of level of eGFR.     

Bestimmung der glomerul?ren Filtrationsrate bei chronischer Niereninsuffizienz

The estimated glomerular filtration rate (GFR) formulas in chronic kidney disease (CKD) EPI and modification of diet in renal disease (MDRD) are important for diagnosing CKD as they increase the sensitivity of isolated serum creatinine measurement; however, they do have limitations in accuracy (often less than 30%) and tend to underestimate true kidney function. In a recent meta-analysis the CKD-EPI formula showed a better accuracy in predicting cardiovascular mortality and end-stage renal disease compared to the MDRD formula. In special clinical situations kidney function should not only be estimated by these formulas but confirmed by creatinine clearance or cystatin C measurement. For prognostic evaluation extended parameters other than the CKD stage are needed.     

急性卒中患者的慢性肾脏病患病率和危险因素评价

目的 探讨卒中人群中慢性肾脏病(chronic kidney disease,CKD)的患病率以及该类患者的卒中危险因素和预后特点.方法 连续收集270例住院治疗的急性卒中患者,横贯性评价其CKD患病情况,比较270例卒中患者中入院美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分相近的53例CKD患者与106例无CKD患者的各种危险因素和近期预后.肾小球滤过率(glomerular filtration rate,GFR)＜60 ml/(min·1.73 m2)和(或)随机尿白蛋白/尿肌酐比值(albumin-to-creatinine-ratios,ACR)＞30 mg/g且持续3个月以上者定义为CKD,依据肾脏病饮食改良(Modification of Diet in Renal Disease equation,MDRD)简化公式估算GFR.近期预后采用改良Rankin量表(modified Rankin Scale,mRS)评价.结果 本组卒中患者CXD患病率为19.6%,主要为早、中期CKD.CKD组高血压(81.13%)、糖尿病(33.96%)和卒中病史(45.28%)比例均显著高于无CKD组(分别为64.15%、18.86%和27.36%)(P均＜0.05);伴CKD者收缩压[(151.74±20.98)mm Hg]和低密度脂蛋白[(3.03±0.96)mmol/L]显著高于无CKD组[收缩压为(144.30±21.64)mm Hg,低密度脂蛋白为(2.75±0.76)mmol/L](P均＜0.05);另外,CKD组红细胞沉降率(39 mm/h,中位数)、超敏C-反应蛋白(5.12 mg/L,中位数)、甲状旁腺素[(81.01±26.78)pg/ml]水平均显著高于无CKD组[分别为20 mm/h、3.36 mg/L和(46.95±24.63)pg/m]](P均＜0.05);CKD组还存在低血钙和高血磷的改变趋势.CKD组发病3个月后mRS评分≥13分的患者比例(66.03%)显著高于无CKD组(46.23%)(P＜0.05),3个月时的病死率(9.43%)也有增高的趋势(P=0.073).结论 卒中人群的CKD患病率较高,主要为早、中期CKD.伴CKD者卒中危险因素多于无CKD者,且预后也更差.     

High Prevalence of Obstructive Sleep Apnea and Its Association with Renal Function among Nondialysis Chronic Kidney Disease Patients in Japan: A Cross-Sectional Study

Summary

Background and objectives

Obstructive sleep apnea (OSA) affects one of five adults in the general population. Although a high prevalence of OSA has been reported among dialysis patients, the association between nondialysis chronic kidney disease (CKD) and OSA has not been fully investigated. This cross-sectional study aimed to investigate the prevalence of OSA among nondialysis CKD patients in Japan and the association between renal function and OSA.

Design, setting, participants, & measurements

Consecutive nondialysis CKD patients hospitalized mainly for CKD educational program, regardless of their sleep complaints, were enrolled. The diagnosis of OSA and its severity were measured using a type 3 portable monitor.

Results

Overall (n = 100, 68.0% male, median age 66.5 years, body mass index [BMI] 23.1 kg/m², estimated GFR [eGFR] 28.5 ml/min per 1.73 m²), 65% were diagnosed as OSA: mild OSA (apnea-hypopnea index [AHI] 5.0 to 14.9) in 32%, moderate OSA (AHI 15.0 to 29.9) in 25%, and severe OSA (AHI ≥ 30.0) in 8%. Multivariate logistic regression analysis revealed that a 10-ml/min per 1.73 m² decrease in eGFR was associated with a 42% increased odds of OSA after adjustment for age, BMI, and diabetes mellitus. Moreover, in a generalized linear model, eGFR was inversely correlated with AHI after adjustment for covariates.

Conclusions

This study demonstrated a high prevalence of OSA among nondialysis CKD patients in Japan and that the increased risk of OSA was significantly associated with decreased GFR among these patients. Further investigations are warranted to determine OSA''s direct influence on cardiovascular disease.     

Detection of chronic kidney disease with laboratory reporting of estimated glomerular filtration rate and an educational program

BACKGROUND: Serum creatinine concentration is an inadequate screening test for chronic kidney disease, especially in elderly patients. We hypothesized that laboratory reporting of estimated glomerular filtration rate (GFR) accompanied with an educational intervention would improve recognition of chronic kidney disease (CKD). METHODS: We conducted a before-and-after study at an outpatient family medicine practice. Patients 65 years or older for whom a Cockcroft-Gault GFR could be calculated from their medical record were included. The intervention consisted of automatic reporting of estimated GFR by the hospital laboratory along with an educational intervention directed toward the primary care physicians. The primary outcome was the recognition of CKD (defined as a Cockroft-Gault GFR <60 mL/min [<1.0 mL/s]) by the primary care physician. Factors associated with the recognition of CKD were also determined. RESULTS: The study population comprised 324 patients. Prior to the study intervention, 22.4% of patients with CKD were recognized, which increased to 85.1% after the intervention. Before the intervention, recognition was more likely in male subjects (odds ratio, 4.3; 95% confidence interval, 1.9-9.8) and patients with diabetes (odds ratio, 3.4; 95% confidence interval, 1.6-7.6). These associations were no longer statistically significant after the intervention. CONCLUSION: Laboratory reporting of estimated GFR coupled with an educational program markedly improves the recognition of CKD in the primary care setting.