Chronic kidney disease-associated pruritus (CKD-aP) is a common condition amongst patients with advanced chronic kidney disease (CKD). Several studies have confirmed that more than four out of ten early-stage CKD patients suffer from this condition, while its prevalence among CKD patients on dialysis reaches up to seven out of ten. It is noted to be associated with other disabling symptoms and serious outcomes. It has significant impact on sleep, mood, daily activities, and quality of life of CKD patients, and increased mortality risk of patients on hemodialysis. The Dialysis Outcomes and Practice Patterns Study found 17% higher mortality among patients with moderate to extreme pruritus compared with patients with no or mild pruritus. Despite its high prevalence, ill-effect, and suffering associated with it, CKD-aP remains surprisingly under-reported on the patient's part and under-recognized by the healthcare team. Even upon being noticed, it remains unattended and poorly treated. Its etiopathogenesis is complex and not fully understood. Many treatment options are available but good quality evidence about most of those is absent, and to date, only two medications are approved for use in this condition. While a validated guideline is very much required for the benefit of the patients and caretakers, further research on several aspects of this issue is required.
Introduction: Lung ultrasound (LUS) is used for dry weight guidance by assessment of pulmonary congestion in hemodialysis (HD) patients. The aim of this study was to estimate amounts of accumulated fluid by total LUS scores (TLUSS), which were scarcely reported in HD patients who were normal or had a mild functional abnormality. In addition, the correlations between the LUS score of each area and TLUSS were determined to suggest fewer specific areas valuable to shorten the examination time of LUS.
Methods: This cohort study was conducted in adult HD patients who have New York Heart Association Classes I-II. LUS and multifrequency bioimpedance (BIA) were performed at baseline and the individual prescribed dry weight was set. Then each LUS was conducted at 28 areas of bilateral intercostal spaces and calculated as TLUSS weekly for eight weeks in which dry weight was adjusted. The second BIA was also measured at week eight. The difference of pre-HD weight and target weight (weight gain; WG) represented the amount of fluid accumulation.
Results: Twenty patients with a mean age of 62.2±14.0 years were enrolled. One hundred and sixty-six LUS were performed in which forty episodes of them were simultaneously measured with BIA. Optimum dry weight adjusted by TLUSS which benefited in mean reductions of blood pressure, and cardiothoracic ratios. WG amounts were significantly correlated with TLUSS (r=0.38), and with extracellular fluid (r=0.35) and overhydration fluid (r=0.39) assessed by BIA. Estimations of mean fluid overload were 2.18 (TLUSS ≤15), 2.72 (TLUSS 16-24), 3.17 (TLUSS 25-33), 3.65 (TLUSS 34-38) and 5.03 (TLUSS ≥39) in liters. The cut-off points of sum scores of 12 specific lung areas represented the none-mild were <8, moderate at 8-16, and severe pulmonary congestions were >16.
Conclusion: TLUSS estimated accumulated fluid useful for volume and blood pressure controls. Performance of LUS in 12 specific lung areas may reduce spending time and support routine uses of LUS in clinical practice.
Purpose: Potential adverse outcomes of Proton pump inhibitors (PPIs) have increasingly been reported. The potential risks to PPIs include hypomagnesemia and chronic kidney disease (CKD). Unlike a real-world electronic medical record (RW-EMR) with active-comparator design, claim databases and special population cohort with non-user design, using in previous studies, resulted in a wide range of strength of association with indication bias. This study aimed to measure the total effect of association between PPIs use and CKD incidence using Thai RW-EMR.
Patients and methods: A retrospective hospital-based cohort was applied into this study. Electronic medical records and administrative data of out- and inpatient were retrieved from October 1st, 2010 to September 30th, 2017. On-treatment with grace period as well as propensity score matching was used in data analysis. Cox proportional hazard models were applied to evaluate the PPIs-CKD association.
Results: Of all 63,595 participants, a total of 59,477 new PPIs and 4118 Histamine 2-receptor antagonist (H2RA) users were eligible for follow-up. As compared with H2RA, the PPI users were non-elderly and more likely being female. The association of PPIs with CKD was statistically significant (adjusted hazard ratio [HR] = 3.753, 95% CI = 2.385-5.905). The HR were not statistically different by concomitant use PPIs with NSAIDs and by medication possession ratio levels.
Conclusion: The association between PPIs and CKD incidence was statistically significant in this hospital-based cohort. However, self-treatment with over-the-counter PPIs, as well as, smoking, drinking alcohol and body mass index could not be fully retrieved, affecting the estimation of treatment effect.
It has been widely demonstrated that patient education and empowerment, especially involving shared treatment decisions, improve patient outcomes in chronic medical conditions, including chronic kidney disease requiring kidney replacement therapies. Accordingly, regulatory agencies in the US and worldwide recommend shared decision-making for finalizing one's choice of kidney replacement therapy. It is also recognized that the US needs to substantially increase home dialysis utilization to leverage its positive impacts on patient and healthcare cost-related outcomes. This perspective highlights how the routine clinical use of the recommended practice of shared decision-making can exist in synergy with the system's goal for increased home dialysis use. It introduces a pragmatic provider checklist, The Nephrologist's Shared Decision-Making Checklist, grounded in the relevant theories of shared decision-making, and, unlike some research assessments and extant tools, is easy to understand and implement in clinical practice. This qualitative Checklist can help providers ensure that they have co-constructed an SDM experience with the patient and involved caretakers, helping them benefit from the improved outcomes associated with SDM.
Introduction: Circulating uric acid, ferritin, albumin, intact parathyroid hormone and gamma-glutamyl transferase each participate in biochemical reactions that reduce or/and enhance oxidative stress, which is considered the final common pathway through which pathophysiological mechanisms cause uremic cardiomyopathy. We hypothesized that the respective biomarkers may be involved in the development of uremic cardiomyopathy characteristics and can be useful in their identification among chronic kidney disease patients.
Methods: We assessed traditional and non-traditional cardiovascular risk factors including biomarker concentrations and determined central systolic blood pressure using SphygmoCor software and cardiac structure and function by echocardiography in 109 (64 non-dialysis and 45 dialysis) patients. Associations were evaluated in multivariate regression models and receiver operator characteristic (ROC) curve analysis.
Results: Each biomarker concentration was associated with left ventricular mass beyond stroke work and/or inappropriate left ventricular mass in all, non-dialysis and/or dialysis patients. Ferritin, albumin and gamma-glutamyl transferase levels were additionally associated with E/e' in all, non-dialysis and/or dialysis patients. Dialysis status influenced the relationship of uric acid concentrations with inappropriate left ventricular mass and those of gamma-glutamyl transferase levels with left ventricular mass and inappropriate left ventricular mass. In stratified analysis, low uric acid levels were related to inappropriate left ventricular mass in dialysis but not non-dialysis patients (interaction p=0.001) whereas gamma-glutamyl transferase concentrations were associated with left ventricular mass and inappropriate left ventricular mass in non-dialysis but not dialysis patients (interaction p=0.020 to 0.036). In ROC curve analysis, uric acid (area under the curve (AUC)=0.877), ferritin (AUC=0.703) and albumin (AUC=0.728) concentrations effectively discriminated between dialysis patients with and without inappropriate left ventricular hypertrophy, left ventricular hypertrophy, and increased E/e,' respectively.
Conclusion: Uric acid, ferritin, albumin, parathyroid hormone and gamma-glutamyl transferase were associated with uremic cardiomyopathy characteristics and could be useful in their identification. Our findings merit validation in future longitudinal studies.
Objective: Promising results of CHA2DS2-VASc score have been reported for the prediction of contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI). However, data of its predictive strength in the context of primary PCI are not available. Therefore, in this study, we have assessed predictive value of CHA2DS2-VASc score for CI-AKI after primary PCI.
Methods: This analytical cross-sectional study was conducted between January 2021 and June 2021 at the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. Inclusion criteria of the study was consecutive adult patients who had undergone primary PCI. Baseline CHA2DS2-VASc score was calculated, and either a 25% or 0.5 mg/dL increase in post-procedure serum creatinine level as compared to baseline level was categorized as CI-AKI.
Results: A total of 691 patients were included, of which 82.1% (567) were male. CI-AKI after primary PCI was observed in 63 (9.1%) patients, out of which 66.7% (42) of patients had CHA2DS2-VASc score of ≥2. The area under the curve (AUC) for the score was 0.725 [0.662 to 0.788] with a sensitivity and specificity of 66.7% [63.1% to 70.2%] and 66.7% [53.7% to 78.1%], respectively, at a cut-off value of ≥2. In multivariable analysis, left ventricular ejection fraction ≤30% and CHA2DS2-VASc ≥2 were found to be independent predictors with adjusted odds ratios of 2.19 [1.06-4.5] and 2.13 [1.13-4.01], respectively.
Conclusion: CHA2DS2-VASc score has a good predictive value for the prediction of CI-AKI after primary PCI. Criteria of CHA2DS2-VASc ≥2 can be used for the risk stratification of CI-AKI after primary PCI.
Introduction: Pulmonary hypertension (PH) is an underestimated cardiovascular consequence and a mortality predictor in patients on hemodialysis (HD). Thus, we studied its prevalence, risk factors, association with inflammation/oxidative stress, and cardiac changes in HD patients.
Methods: This was a single-center cross-sectional observational study conducted at a tertiary care hospital. Patients aged >18 years on hemodialysis for at least three months were included and divided into those with and without PH; patients with secondary causes for PH were excluded. Clinical characteristics, HD-related factors, lab parameters (C-reactive protein and malondialdehyde with thiol assay were used as markers of inflammation and oxidative stress, respectively), and echocardiography details were compared. PH was defined as a mean pulmonary artery pressure of >25 mmHg at rest, and it was further divided as mild (25-40 mmHg), moderate (40-60 mmHg), and severe (>60 mmHg).
Results: Of 52 patients, 28 patients had PH (mild 24, moderate 4, and none had severe PH) with prevalence of 54%. No difference was found in clinical characteristics, dialysis-related factors, biochemical parameters including inflammation (C-reactive protein; p=0.76), or oxidative stress (thiol; p=0.36 and MDA; p=0.46) between the groups. When compared to individuals without PH, HD patients with PH exhibited significantly more mitral regurgitation (p=0.002).
Conclusion: Hemodialysis patients have a high prevalence of PH. PH was significantly associated with the presence of mitral regurgitation on echocardiography. Our study did not find differences in traditional risk factors, HD-related factors, and inflammation/oxidative markers between the groups with and without PH.
Background: It has been proposed that substituting citrate-acidified dialysate (CAD) solutions for acetate-acidified dialysate (AAD) could improve hemodynamics and dialysis tolerance and reduce the requirement for systemic anticoagulation. Citrate chelates ionized calcium, but long-term effects of CAD use during maintenance hemodialysis have not been well studied. While many studies of the effects of CAD on serum calcium and intact parathyroid hormone (iPTH) have been short-term or have been limited by sample size, we aimed to determine if there are any long-term (i.e., 6-month) changes from pre-dialysis iPTH levels when patients are switched from AAD to CAD.
Methods: This retrospective cohort study compared various clinical parameters, including pre-dialysis iPTH and serum calcium as well as single pool Kt/V, from eligible patients who received in-center hemodialysis thrice-weekly in geographically matched CAD (n=3) or AAD clinics (n=12). CAD clinics were defined as clinics converting from AAD to CAD if >85% of the patients were prescribed CAD after implementation of CAD within the clinic.
Results: Pre-dialysis iPTH was not significantly different from baseline to 6-month follow-up within either CAD or AAD clinics. Moreover, the mean change from baseline to month 6 in iPTH between patients (n=142) in CAD clinics (-17 pg/mL) and patients (n=671) in AAD clinics (13 pg/mL) was similar (p = 0.24). Likewise, the differences in the mean change in serum calcium concentrations and dialysis adequacy (single pool Kt/V) were not significant between CAD and AAD clinics. For subgroups of patients who were never prescribed cinacalcet or calcium-based phosphate binders, there were no significantly different categorical shifts in iPTH between CAD and AAD clinics.
Conclusion: Similar trends in single pool Kt/V, iPTH, and serum calcium levels were observed in clinics that switched from AAD to CAD versus the geographically matched AAD clinics. These results support CAD as a potential alternative to AAD in hemodialysis.
Introduction: Currently, there are no data on prevalence and associated risk factors of chronic kidney disease (CKD) among patients with hypertension in rural Sierra Leone.
Purpose: To estimate the prevalence and associated risk factors of CKD in rural Sierra Leone.
Patients and methods: A cross-sectional study of hypertension patients aged between 18 and 75 years attending a non-communicable disease clinic at Koidu Government Hospital, Kono District, Sierra Leone was conducted between February and December 2020. Using systematic random sampling, a structured questionnaire, which comprised of questions on social demographic characteristics and past and current clinical history, was administered followed by measurement of creatinine and urinary protein and glucose. Estimated glomerular filtration rate (eGFR) was estimated using CKD-epidemiology formula without race as a factor. Baseline eGFR between 60-89 min/mL/1.73m2 and <60 min/mL/1.73m2 defined reduced eGFR and renal impairment, respectively. Estimated GFR less than 60 min/mL/1.73m2 measured two times at least 3 months apart was used to define CKD.
Results: Ninety-six percent (n = 304) patients out of 317 patients were included in the study. Among all included patients, only 3.9% (n = 12) had eGFR of 90 min/mL/1.73m2 and above. The prevalence of renal impairment and CKD was 52% (158/304, CI 46.2-57.7) and 29.9% (91/304, CI 24.8-34.5), respectively. In adjusted logistic regression analysis, currently taking herbal medications as treatment of hypertension (OR 4.11 (CI 1.14-14.80), p = 0.03) and being overweight and/or obese (OR 2.16 (CI 1.24-3.78), p < 0.001) was associated with CKD. Additionally, receiving some education was associated with a 48% (OR 0.52 (CI 0.29-0.91), p = 0.02) reduced likelihood of CKD.
Conclusion: The prevalence of renal impairment and CKD is high among hypertensive patients in rural Sierra Leone. CKD was associated with current history of taking herbal medications and being overweight and/or obese. Additionally, CKD was associated with reduced likelihood in patients who received some education.
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