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PubMed2005

Outcomes in patients with chronic kidney disease undergoing cardiac rehabilitation.

BACKGROUND: Chronic kidney disease (CKD) is associated with an adverse prognosis in patients with coronary heart disease. Cardiac rehabilitation (CR) improves morbidity and mortality among patients with coronary heart disease, but its impact on patients with concomitant CKD has not been described. METHODS: We compared baseline characteristics of patients with CKD (calculated glomerular filtration rate <60 mL/min per 1.73 m2) and without CKD who completed CR between 1996 and 2004 using t tests and chi2 tests. CR outcomes were evaluated by comparing the degree of change in clinical and behavioral variables within and between groups with paired and unpaired t testing, respectively, and by comparing the proportion of patients who achieved secondary prevention goals between groups using chi2 testing. RESULTS: Among 376 patients, CKD was present in 115 (31%). Patients with CKD were older, had more cardiac risk factors and comorbidities, and had lower functional capacity and perceived health status than patients without CKD. Both groups achieved significant improvements in diet scores, body weight, lipid profiles, 6-minute walk distances, physical activity level, and perceived health status. The proportion of patients who achieved secondary prevention goals was also similar, but patients with CKD continued to have lower high-density lipoprotein cholesterol, lower physical component health status summary scores, and lower functional capacity than patients without CKD. CONCLUSIONS: CKD is common among CR participants. Patients with CKD have a high cardiovascular risk factor and comorbidity burden. CR is as effective in improving coronary risk profiles among patients with CKD as it is among patients with normal renal function.

Aged↗
PubMed2003

Chronic kidney disease, anemia, and incident stroke in a middle-aged, community-based population: the ARIC Study.

BACKGROUND: Chronic kidney disease (CKD) has been linked to higher stroke risk. Anemia is a common consequence of CKD, and recent evidence suggests anemia may increase risk of cardiovascular events. The combined effect of CKD and anemia on stroke risk, however, has not been investigated thoroughly. We analyzed data from a middle-aged, community-based cohort to determine if CKD and anemia interacted to affect stroke risk. METHODS: Data on 13,716 participants in the prospective Atherosclerosis Risk in Communities (ARIC) Study were analyzed to assess the joint effect of CKD and anemia on risk of incident stroke during a 9-year follow-up period. CKD was defined as a creatinine clearance of <60 mL/min. Anemia was defined as hemoglobin levels of <13 g/dL for men or <12 g/dL for women. RESULTS: Overall, CKD was associated with an increase in stroke risk after adjustment for other factors [hazard ratio HR) 1.81; 95% CI 1.26 to 2.02]. However, this association was modified substantially by anemia. In the presence of anemia, CKD was associated with a substantially higher risk of stroke compared to no CKD (HR 5.43; 95% CI 2.04 to 14.41). In contrast, when anemia was not present, CKD was associated with only a modest, nonsignificant elevation in stroke risk (HR 1.41; 95% CI 0.93 to 2.14). The interaction between CKD and anemia on risk of stroke was statistically significant (P < 0.01). CONCLUSION: Among middle-aged, community-based persons, the combination of CKD and anemia was associated with a substantial increase in stroke risk, independent of other known risk factors for stroke.

Anemia↗
PubMed2005

Renal function, concomitant medication use and outcomes following acute coronary syndromes.

BACKGROUND: Chronic kidney disease (CKD) is highly prevalent in patients with cardiovascular disease. We explored the associations of CKD with outcomes using combined data from two large acute coronary syndrome (ACS) trials. We also explored the associations of CKD with prescription patterns for common cardiovascular medications and the association of these prescription patterns with clinical outcomes. METHODS: Patients were stratified by CKD stage using creatinine clearance (CrCl, ml/min) estimated by the modified MDRD equation using baseline core laboratory creatinine measures. Serum creatinine > or =1.5 mg/dl was an exclusion criterion for the SYMPHONY trials. Baseline characteristics and outcomes across CKD categories were compared and Cox proportional hazards regression was used to assess the relationship of renal insufficiency with clinical outcomes after adjusting for previously identified outcome predictors. Interactions between the use of specific medications and calculated CrCl were tested in the final Cox proportional hazards model predicting time to mortality. RESULTS: Of 13 707 patients analysed, 6840 had CKD stage I (CrCl > or =90 ml/min), 5909 stage II (CrCl 60-89 ml/min), 955 stage III (CrCl 30-59 ml/min) and three stage IV (CrCl <30 ml/min). Patients with more advanced CKD (III) were older, more often female, non-smokers and more likely to have co-morbid diseases including diabetes mellitus, hypertension and congestive heart failure. Cardiovascular medications were used less frequently in patients with CKD. Unadjusted survival was poorer in patients with CKD stages > or =II. In adjusted analyses, for those with CrCl < or =91, each 10 ml/min increase in CrCl was associated with a significantly decreased risk of mortality (hazards ratio 0.897, 95% confidence interval 0.815-0.986) (P = 0.024). The interaction between use of angiotensin-converting enzyme (ACE) inhibitors and CrCl was significantly associated with outcomes; the benefit of drug therapy was greater among patients with CKD. CONCLUSIONS: CKD is an independent predictor of risk among ACS patients, and is associated with less frequent use of proven medical therapies. More aggressive use of conventional cardiovascular therapies in patients with CKD and ACS may be warranted.

Aged↗
PubMed2005

The unrecognized prevalence of chronic kidney disease in diabetes.

BACKGROUND: Diabetes mellitus and chronic kidney disease (CKD) are common and exhibit synergistic associations with premature mortality. Current diabetes guidelines in the UK recommend annual urinary albumin and serum creatinine determinations to screen for diabetic kidney disease. The aim of this study was to estimate the burden of CKD in patients with diabetes and examine the ability of serum creatinine and albuminuria to detect clinically meaningful CKD compared with estimated glomerular filtration rate (eGFR). METHODS: All adults known to have diabetes in primary and secondary care in Salford, UK, alive with independent renal function on 1 January 2004 were included in this observational study (n=7596). Demographic and laboratory parameters were obtained from the Electronic Patient Record. eGFR was determined using the 4-variable modification of diet in renal disease (MDRD) formula. Clinically meaningful CKD was defined as an eGFR <60 ml/min/1.73 m(2). RESULTS: Creatinine and albuminuria were measured in the preceding 2 years in 82.3 and 55.2% of subjects, respectively. In patients with CKD, normoalbuminuria was present in 48.8%, and serum creatinine was normal ( or=120 micromol/l) had a sensitivity and specificity of 45.3 and 100%, respectively, to identify CKD. The combination of abnormal creatinine and albuminuria had an improved performance but still failed to detect a large number with CKD (sensitivity 82.4%, specificity 75.4%). Serum creatinine failed to identify CKD more often in females (OR 8.22, CI 6.56-10.29). CONCLUSIONS: Undiagnosed CKD is common in diabetes. Current screening strategies, based on creatinine or albuminuria, fail to identify a considerable number of subjects with CKD. Incorporating eGFR into screening for CKD would identify individuals earlier in the natural history of the disease and enable early effective treatment to delay progression of CKD.

Adult↗
PubMed2006

Potential advantages and limitations of applying the chronic kidney disease classification to kidney transplant recipients.

The National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (K/DOQI) classification of Chronic Kidney Disease (CKD) characterizes patients by their level of kidney function and includes kidney transplant recipients (KTRs). Most KTRs have stage > or = 3 CKD (estimated glomerular filtration rate < 60 mL/min/1.73 m2) and may benefit from aggressive CKD care. Recent modifications to the K/DOQI CKD classification reflect the recognition of KTRs as a unique subset of CKD patients in whom the presentation, progression and implications of CKD may vary from those in nontransplant CKD populations. Currently, there is limited information about how adopting the CKD classification in KTRs will influence clinical management and outcomes. Appropriately designed studies are needed to develop transplant-specific CKD treatment recommendations, and to ensure patient, health provider and payer acceptance of the continued need for aggressive CKD care after transplantation. Education and implementation strategies will be required to ensure appropriate integration of the CKD classification and treatment guidelines into existing posttransplant care programs. The CKD classification thus represents an exciting potential strategy to improve clinical outcomes that should be adopted, further studied and modified to incorporate considerations unique to KTRs.

Cardiovascular Diseases↗
PubMed2005

Depression, stress, and quality of life in persons with chronic kidney disease: the Heart and Soul Study.

BACKGROUND: The effect of mild chronic kidney disease (CKD) on depression, stress, quality of life (QOL), and health status is not well understood. We compared these outcomes in subjects with and without CKD. METHODS: We performed a cross-sectional study of 967 outpatients enrolled in the Heart and Soul Study. CKD was defined as a measured creatinine clearance < 60 ml/min. Outcome measures included depressive symptoms measured using the Patient Health Questionnaire (PHQ), stress measured using the Perceived Stress Scale (PSS), and QOL and overall health rated as excellent, very good, good, fair, or poor. RESULTS: The prevalence of depressive symptoms (17 vs. 19%, p = 0.4) or perceived stress (11 vs. 16%, p = 0.09) did not vary significantly by CKD. The prevalence of fair or poor QOL was not significantly different in subjects with CKD, compared with those without CKD (24 vs. 23%, p = 0.65). Age-adjusted analyses revealed a significant association of CKD with QOL (p = 0.003), however, this association no longer reached statistical significance after adjustment for confounders (p = 0.06). Subjects with CKD were more likely to report poor or fair overall health than subjects without CKD (42 vs. 34%, p = 0.03). After multivariate adjustment, CKD remained significantly associated with worse overall health (OR = 1.65, 95% CI 1.21-2.24, p = 0.001), and modestly associated with QOL (OR = 1.31, 95% CI 0.99-1.75, p = 0.06), but had no association with depression (p = 0.48) or stress (p = 0.24). CONCLUSION: In this study of persons with coronary artery disease, subjects with CKD had reduced overall health and modestly reduced QOL; however, mental health was similar in those with and without CKD. These findings suggest that self- assessed overall health may decline at earlier stages of renal dysfunction than mental health outcomes or QOL.

Aged↗
PubMed2004

Association between chronic kidney disease and coronary artery calcification: the Dallas Heart Study.

The hypothesis that chronic kidney disease (CKD) is associated with increased coronary artery calcification (CAC) was tested using data from the Dallas Heart Study, a representative sample of Dallas County residents aged 30 to 65 yr. CKD was defined as presence of microalbuminuria and GFR > or =60 ml/min per 1.73 m(2) (stage 1 to 2), or GFR <60 ml/min per 1.73 m(2) (stage 3 to 5), excluding end-stage kidney disease. Logistic regression was used to examine the association between stages of CKD and CAC scores >10, >100, and >400 versus scores < or =10 compared with no CKD while adjusting for covariates. Analyses were repeated after stratifying by presence of diabetes. The mean age was 43.9 yr, and hypertension and diabetes were noted in 31.0 and 9.8%, respectively. No association was noted between stage 1 to 2 CKD and increased CAC scores. Compared with no CKD, stage 3 to 5 CKD was associated with CAC scores >100 (odds ratio, 2.85; 95% confidence interval, 0.92 to 8.80) and >400 (odds ratio, 8.35; 95% confidence interval, 1.94 to 35.95) in the total population after adjustment for covariates, but these associations were substantially reduced after exclusion of participants with diabetes. Participants with diabetes and stage 3 to 5 CKD had a ninefold increased odds of CAC scores >10 versus scores < or =10 compared with participants with diabetes and without CKD, whereas no association was noted between stage 3 to 5 CKD and CAC scores >10 in the nondiabetic population. In conclusion, stage 3 to 5 CKD is associated with increased CAC scores, but this association may be substantially stronger among adults with diabetes. These findings need to be confirmed in study populations that include adults >65 yr of age and a larger number of CKD cases.

Adult↗
PubMed2004

Chronic kidney disease is associated with oxidative stress independent of hypertension.

BACKGROUND: Oxidative stress is implicated in the pathogenesis of chronic kidney disease (CKD) and essential hypertension (EHTN). However, the role of hypertension in causing increased oxidative stress in patients with CKD is unknown. METHODS: We performed a case control study in patients with EHTN and those with equal blood pressure assessed by ambulatory blood pressure monitoring but with concomitant CKD. Those with diabetes mellitus and those taking renin angiotensin inhibitors were excluded. Biomarkers of oxidative stress, malondialdehyde (MDA) and protein carbonylation and total glutathione levels were measured. RESULTS: Average (SD) 24-hour ambulatory blood pressure in 12 patients with CKD was 134 (17)/75 (16) compared to 134 (10)/80 (9) in 11 patients with EHTN (p = NS). Plasma MDA in CKD was 0.89 +/- 0.38 micromol/l compared to 0.68 +/- 0.16 micromol/l in EHTN (p = 0.07). Urinary MDA/creatinine ratio was 1.78 (0.31) in CKD vs 1.43 (0.69) micromol/g in those with EHTN (p = 0.04). Thus, lipid peroxidation was increased in urine of CKD patients. Patients with CKD had higher (1.04 (0.20) nmol) carbonyl/mg protein compared to those with EHTN (0.80 (0.21) nmol carbonyl/mg protein) (p = 0.03). Thus, protein carbonylation was increased in CKD patients. Total glutathione in CKD and EHTN patients was 6.6 (1.8) ng/ml and 7.3 (3.1) ng/ml (p = NS). There was a good correlation between biomarkers of lipid (MDA) and protein oxidation (protein carbonyls) (r = 0.6, p = 0.004). CONCLUSIONS: Biomarkers of lipid and protein oxidation are higher in patients with CKD compared to EHTN despite similar blood pressure. Thus, nonhemodynamic factors such as inflammation and altered cellular redox state may play a greater role in the generation of oxidative stress in CKD.

Aged↗
PubMed2006

Impact of chronic kidney disease on health-related quality-of-life improvement after coronary artery bypass surgery.

BACKGROUND: Little is known about the impact of chronic kidney disease (CKD) on health-related quality-of-life outcomes after coronary artery bypass grafting (CABG). METHODS: Our objective was to examine the changes in physical function (PF) and mental health (MH) 6 months after CABG in 1055 patients with and without CKD. The primary end points were mean change in score and status of "improved" or "worsened" in both PF and MH subscales of the Medical Outcomes Trust Short Form 36-Item Health Survey from baseline to 6 months after CABG, stratified by CKD stage (0-5). RESULTS: Absolute PF and MH scores at baseline and at 6 months varied by renal impairment level. Patients with severe CKD (stages 4-5) had a mean (SD) decrease in PF score at 6 months of 3 (3) compared with increases in the rest of the cohort (P<.001). After adjustment for baseline score, 21% of patients with advanced CKD experienced worsened PF scores, compared with 0% of patients with stages 0 to 2 and stage 3 CKD (P<.001). In contrast to PF scores, patients with and without CKD had similar improvements in mean MH scores at 6 months, and patients with stages 4 to 5 CKD had the highest frequency of those with improved MH scores (77%). After adjustment, no patients experienced worsened MH scores. CONCLUSIONS: After 6 months, patients with severe CKD who underwent CABG had improvement in MH but not improvement in PF and may have had worsened PF compared with those without severe CKD. Comparable evidence regarding quality-of-life outcomes in the absence of CABG is needed to more fully inform decision making regarding patients with severe CKD and coronary artery disease.

Activities of Daily Living↗
PubMed2026

Efficacy and safety of revascularization in patients with chronic limb-threatening ischemia by kidney function.

BACKGROUND: The optimal revascularization strategy for patients with chronic limb-threatening ischemia (CLTI) with chronic kidney disease (CKD) remains unknown. We evaluated whether the efficacy and safety of surgical vs endovascular revascularization differ by kidney function. METHODS: In this post hoc secondary analysis of BEST-CLI trial (NCT02060630), 1,704 patients with CLTI were stratified by baseline estimated glomerular filtration rate (eGFR, mL/min/1.73 m&#xb2;): non-CKD (eGFR &#x2265; 90), mild-moderate CKD (eGFR 45-89), advanced CKD (eGFR < 45 or dialysis). The primary outcome was a composite of major adverse limb events (MALE) or death. We estimated the difference in restricted mean time lost (RMTL, in days) adjusted for inverse probability treatment weights. RESULTS: Surgical revascularization was significantly associated with fewer days with MALE or death in non-CKD (RMTL difference: -127.8 days; 95% CI -176.1, -79.6) and mild-moderate CKD (-63.2 days; 95% CI -104.7, -21.8) but not in advanced CKD (-16.4 days; 95% CI -78.8, 46.0; P interaction = .02). This attenuation reflected a diminishing mortality benefit with more severe CKD (P interaction = .01), whereas the association with fewer days with MALE remained consistent across CKD strata (P interaction = .34). Major adverse cardiovascular events and serious adverse events were more common with more severe CKD but did not differ significantly by treatment. CONCLUSIONS: Surgical vs endovascular revascularization was consistently associated with fewer days with MALE across CKD strata. However, its association with mortality varied by kidney function, attenuating the overall benefit for the composite endpoint of MALE or death. These results support individualized revascularization strategies, but require prospective confirmation. TRIAL REGISTRATION: The BEST CLI trial is registered at ClinicalTrials.gov (NCT02060630).

Humans↗
PubMed2005

Management of peripheral arterial disease in chronic kidney disease.

PAD has been overlooked in many epidemiologic studies evaluating cardiovascular risk associated with renal disease. Conversely, CKD has not been evaluated as a potential risk factor in epidemiologic studies of PAD. PAD, however,seems to be more prevalent among patients with even moderate CKD than in the general population and is most common among chronic dialysis patients, one third or more of whom have a low ABI. Patients with CKD also seem to be at increased risk for developing claudication and for requiring surgical intervention for lower extremity PAD. Furthermore, even moderate CKD seems to be a risk factor for postoperative death and complications after both lower extremity amputation and revascularization procedures. Conversely, even asymptomatic PAD seems to be a risk factor for death among dialysis patients. In the general population, statins, antiplatelet agents (particularly clopidogrel), antihypertensive agents, and ACE inhibitors all have a proven benefit in reducing cardiovascular events in patients with PAD and in some instances may also reduce PAD events. Available evidence suggests that patients with CKD also experience cardio-vascular risk reduction with statin and ACE-inhibitor therapy, but these therapies have not been shown to reduce PAD events specifically in patients with CKD. Further studies are needed to identify interventions that can specifically reduce the incidence of PAD complications in patientswith CKD. Although it is clear that mortality and complication rates after both lower extremity amputation and revascularization are increased in patients with even moderate CKD, currently available observational studies do not provide clear guidance for surgical decision making in CKD patients with limb-threatening ischemia. Further studies are needed to evaluate the risksand benefits of amputation over revascularizationamong patients with CKD and to investigatereasons for the high mortality associated with these procedures in this patient group. Further studies are also needed to measure the impact of CKD on care processes for PAD with the goal of identifying target areas for improvement.

Chronic Disease↗
PubMed2001

Prevalence and characteristics of individuals with chronic kidney disease in a large health maintenance organization.

This study is designed to estimate the prevalence of and gain further insight into the characteristics of the chronic kidney disease (CKD) population in a large US health maintenance organization (HMO) to better understand the CKD population in the United States overall. Analyses were performed using data from a staff and network model HMO in the southwestern United States with more than 150,000 members per year during 1994 to 1997. The estimated prevalence of CKD in the HMO population varied from 0.4% to 7.1%, depending on the definition of CKD used. Regardless of the definition, CKD was more common in men compared with women and in patients with diabetes mellitus and/or hypertension. Applying the age- and sex-specific prevalence rates in the HMO to the US population in 1990, we estimate there were approximately 9.1 million Americans with at least one elevated sex-specific creatinine (Cr) value and approximately 4.2 million Americans with at least two elevated Cr values separated by 90 days or greater, a more rigorous definition of CKD. From these results, it is apparent that there are a large number of patients in the United States with CKD. Most have not been identified because screening for CKD generally is not performed. Considering the high prevalence of CKD and the high cost and clinical morbidity associated with end-stage renal disease (ESRD), it is clear that CKD is an important public health problem. Early identification of patients with CKD would allow treatment that could slow the progression to ESRD, improve clinical outcomes, and constrain the growth of costs in the ESRD program. The time has come for a structured public and professional educational program to address this serious condition.

Adult↗
PubMed2005

Application of GFR-estimating equations in Chinese patients with chronic kidney disease.

BACKGROUND: To evaluate whether the Modification of Diet in Renal Disease (MDRD) equations could be applied accurately to Chinese patients with chronic kidney disease (CKD), glomerular filtration rates (GFRs) estimated by using MDRD equation 7 (7GFR), the abbreviated MDRD equation (aGFR), and the Cockcroft-Gault equation (cGFR) were compared in patients with different stages of CKD. METHODS: The study enrolled patients with CKD diagnosed according to the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative guidelines. All patients were older than 18 years and without acute renal function deterioration, edema, skeletal muscle atrophy, or amputation. Sex, age, body height, and body weight were recorded, and plasma creatinine levels were measured by means of Jaffe's kinetic method using a Hitachi 7600 analyzer (Hitachi, Tokyo, Japan; reagents from Roche Diagnostics, Mannheim, Germany). Creatinine, urea, and albumin were measured in a single clinical laboratory. Dual plasma sampling of technetium Tc 99m-labeled diethylene triamine pentaacetic acid plasma clearance was used as the reference standard GFR (sGFR) for comparison of 7GFRs, aGFRs, and cGFRs at different stages of CKD. RESULTS: The study enrolled 261 patients, including 146 men and 115 women. Causes of CKD included primary or secondary glomerular disease, obstructive kidney disease, chronic tubulointerstitial disease, and others. Values for 7GFR, aGFR, and cGFR were significantly greater than for sGFR in patients with CKD stages 4 to 5 (the lower the sGFR, the greater the difference); whereas 7GFR, aGFR, and cGFR were significantly lower than sGFR in patients with CKD stage 1. CONCLUSION: Our results show that in a Chinese population with CKD, MDRD equation 7 and the abbreviated MDRD equation overestimated GFR in patients with CKD stages 4 to 5 and underestimated GFR in those with CKD stage 1. These results indicate that careful modification of these equations may be necessary in Chinese populations with CKD.

Adult↗
PubMed2006

The association among smoking, heavy drinking, and chronic kidney disease.

Several factors for chronic kidney disease (CKD), including diabetes, hypertension, and obesity, are described consistently in the literature; studies describing modifiable lifestyle factors, including smoking and consumption of alcohol, are sparse, sometimes contradictory. The authors examined the factors associated with CKD in a population-based cohort in Wisconsin, with emphasis on smoking and consumption of alcohol. CKD was defined as an estimated glomerular filtration rate of less than 60 ml/minute per 1.73 m(2) from serum creatinine. The authors performed two analyses: 1) cross-sectional analysis among 4,898 persons with prevalent CKD (n = 324) as the outcome of interest and 2) longitudinal analysis among 3,392 CKD-free persons at baseline, with 5-year incident CKD (n = 114) between 1993 and 1995 as the outcome of interest. Smoking and heavy drinking, defined as consumption of four or more servings of alcohol per day, were associated with CKD, independent of several important confounders. Compared with that among never smokers, the odds ratio of developing CKD was 1.12 (95% confidence interval (CI): 0.63, 2.00) among former smokers and 1.97 (95% CI: 1.15, 3.36) among current smokers. Heavy drinking was associated with CKD, with an odds ratio of 1.99 (95% CI: 0.99, 4.01). Joint exposure to both current smoking and heavy drinking was associated with almost fivefold odds of developing CKD compared with their absence (odds ratio = 4.93, 95% CI: 2.45, 9.94). Smoking and consumption of four or more servings of alcohol per day are associated with CKD.

Adult↗
PubMed2006

Current chronic kidney disease practice patterns in the UK: a national survey.

BACKGROUND: There is an increasing focus on improving the detection and management of patients with chronic kidney disease (CKD). Data on CKD prevalence based on population sampling are now available, but there are few data about CKD patients attending nephrology services or how such services are organized. AIM: To survey services for CKD patients nationally. METHODS: A pre-piloted questionnaire was sent to all 72 renal units in the UK, referring to the situation in June 2004. RESULTS: Seventy units (97%) responded. The median ratio of prevalent CKD patients/prevalent renal replacement therapy (RRT) patients in the 25 units with data was 3.7 (IQR 2.7-5.7) and the median ratio of CKD stage 4 and 5 patients/prevalent RRT patients was 0.6 (IQR 0.4-1.1). This gives an estimated 140 000 CKD patients under the care of UK nephrologists, with 23 000 at CKD stage 4 or 5 (excluding those on RRT). Very few units had a full complement of the recommended multi-skilled renal team. Counsellors and psychologist were the most common perceived shortages. Of 70 responding units, 50 (74%) were using low clearance clinics for management of advanced CKD patients. Elective dialysis access services often had long delays, with median waiting time for vascular access ranging between 1 and 36 weeks, and for Tenchkoff catheter, between 0 and 12 weeks. DISCUSSION: CKD patients are a significant workload for UK nephrologists. Current provision of service is variable, and services need to be re-designed to cope with the expected future increase of referral of CKD patients.

Chronic Disease↗
PubMed2004

Medicare patients with cardiovascular disease have a high prevalence of chronic kidney disease and a high rate of progression to end-stage renal disease.

The risk of progression to ESRD among individuals with cardiovascular disease and chronic kidney disease (CKD) is not well defined. The purpose of this study was to describe the risk of ESRD among patients with cardiovascular disease. Charts were abstracted for randomly selected hospitalized Medicare beneficiaries with a diagnosis of either congestive heart failure (CHF) or acute myocardial infarction (AMI). The prevalence of CKD, based on the estimated modified diet in renal disease GFR of <60 ml/min per m2, was 60.4% of CHF patients and 51.7% of AMI patients. When compared with patients without CKD, the 30-d readmission rate was higher for CHF patients with CKD (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.18 to 2.44) and for AMI patients with CKD (OR, 1.78; 95% CI, 1.17 to 2.70). CHF patients (OR, 1.62; 95% CI, 1.15 to 2.30) and AMI patients (OR, 3.10; 95% CI, 1.98 to 4.84) with CKD were more likely to die during the year after discharge from the hospital. ESRD after discharge occurred in nine of 517 patients with AMI and 24 of 640 patients with CHF. CKD increased the risk of ESRD among CHF patients (OR, 34.5; 95% CI, 4.23 to 279.43) and AMI patients (0 and 3% for those without and with CKD, respectively). At discharge, 18% of AMI patients and 21% of CHF patients with CKD were discharged with a diagnosis of renal disease. CKD is highly prevalent among patients with cardiovascular disease and is associated with increased risk of adverse outcomes, including progression to ESRD. This study suggests that opportunities may exist to improve the detection of CKD in these patients who are hospitalized with cardiovascular disease.

Acute Disease↗
PubMed2006

Chronic kidney disease care delivered by US family medicine and internal medicine trainees: results from an online survey.

BACKGROUND: Complications of chronic kidney disease (CKD) contribute to morbidity and mortality. Consequently, treatment guidelines have been developed to facilitate early detection and treatment. However, given the high prevalence of CKD, many patients with early CKD are seen by non-nephrologists, who need to be aware of CKD complications, screening methods and treatment goals in order to initiate timely therapy and referral. METHODS: We performed a web-based survey to assess perceptions and practice patterns in CKD care among 376 family medicine and internal medicine trainees in the United States. Questions were focused on the identification of CKD risk factors, screening for CKD and associated co-morbidities, as well as management of anemia and secondary hyperparathyroidism in patients with CKD. RESULTS: Our data show that CKD risk factors are not universally recognized, screening for CKD complications is not generally taken into consideration, and that the management of anemia and secondary hyperparathyroidism poses major diagnostic and therapeutic difficulties for trainees. CONCLUSION: Educational efforts are needed to raise awareness of clinical practice guidelines and recommendations for patients with CKD among future practitioners.

Anemia↗
PubMed2003

National Kidney Foundation's Kidney Disease Outcomes Quality Initiative clinical practice guidelines for chronic kidney disease in children and adolescents: evaluation, classification, and stratification.

OBJECTIVES: A series of new guidelines has been developed by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative to improve the detection and management of chronic kidney disease (CKD). In most instances of CKD, the earliest manifestations of the disorder may be identified by relatively simple tests. Unfortunately, CKD is often "underdiagnosed," in part because of the absence of a common definition of CKD and a classification of the stages in its progression. The Kidney Disease Outcomes Quality Initiative clinical practice guidelines for CKD evaluation, classification, and stratification provide a basis to remedy these deficits. The specific goals of the guidelines described in this review are to provide: 1) an overview of the clinical practice guidelines as they pertain to children and adolescents, 2) a simple classification of the stages of CKD, and 3) a practical approach to the laboratory assessment of kidney disease in children and adolescents. METHODS: The guidelines were developed as part of an evidence-based evaluation of CKD and its consequences in patients of all ages. The data that were used to generate the guidelines in this article were extracted from a structured analysis of articles that reported on children with CKD. RESULTS AND CONCLUSIONS: This review presents the definition and 5-stage classification system of CKD developed by the work group assigned to develop the guidelines, and summarizes the major recommendations regarding the early detection of CKD. Major emphasis is placed on the identification of children and adolescents with CKD by measuring the protein-to-creatinine ratio in spot urine specimens and by estimating the glomerular filtration rate from serum creatinine using prediction equations.

Adolescent↗