Abstract Background Few studies have defined alternate pathways by which chronic kidney disease (CKD) patients transition into end-stage renal disease (ESRD). Methods We studied all consecutive patients initiated on maintenance hemodialysis or peritoneal dialysis over several years at two dialysis units in Northern California. Rapid decline in kidney function was considered to have occurred if a patient was documented to have estimated GFR > 30 ml/min/1.73 m2 within three months prior to the initiation of chronic dialysis. Results We found that 8 out of 105 incident chronic dialysis patients one dialysis unit (7.6%; 95% confidence interval 3.4-14.5%) and 9 out of 71 incident patients at another (12.7%, 95% CI 6.0%-22.7%) suffered rapid decline in kidney function that was the immediate precipitant for the need for permanent renal replacement therapy. All these patients started hemodialysis and all relied on catheters for vascular access. Documentation submitted to United States Renal Data System did not fully reflect the health status of these patients during their "pre-ESRD" period. Conclusions A sizeable minority of ESRD cases are preceded by rapid declines in kidney function. The importance of these periods of rapid decline may have been under-appreciated in prior studies of the natural history of CKD and ESRD.

There is increasing recognition that acute kidney injury (AKI) and chronic kidney disease (CKD) are closely linked and likely promote one another. Underlying CKD now is recognized as a clear risk factor for AKI because both decreased glomerular filtration rate and increased proteinuria have been shown to be associated strongly with AKI. A growing body of literature also provides evidence that AKI accelerates the progression of CKD. Individuals who suffered dialysis-requiring AKI are particularly vulnerable to worse long-term renal outcomes, including end-stage renal disease. The association between AKI and subsequent renal function decline is amplified by pre-existing severity of CKD, higher stage of AKI, and the cumulative number of AKI episodes. However, residual confounding and ascertainment bias may partly explain the epidemiologic association between AKI and CKD in observational studies. As the number of AKI survivors increases, we need to better understand other clinically important outcomes after AKI, identify those at highest risk for the most adverse sequelae, and develop strategies to optimize their care.

© 2015 Zhang et al. Background: Few studies have focused on investigating hypoalbuminemia in patients during earlier stages of chronic kidney disease (CKD). In particular, little is known about the role of gastrointestinal (GI) symptoms. Our goal in this p

Purpose of review

Atrial fibrillation is the most common sustained arrhythmia in patients with kidney disease. The purpose of this review is to describe the burden of atrial fibrillation in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD), postulate possible mechanisms to explain this burden of disease, understand the clinical consequences of atrial fibrillation and review the treatment options for atrial fibrillation specific to patients with kidney disease.

Recent findings

Recent literature has revealed that the clinical multiorgan impact of atrial fibrillation in patients with CKD and ESRD is substantial. Although novel oral anticoagulants to treat atrial fibrillation and prevent associated complications have been tested in large trials in the general population, there is a paucity of data on the efficacy and safety of these agents in patients with advanced CKD and ESRD.

Summary

Atrial fibrillation is a significant comorbidity in patients with CKD and ESRD with important prognostic implications. More research is needed to understand the mechanisms that contribute to the disproportionate burden of this arrhythmia in patients with kidney disease and in to treatment options specific to this population of high-risk patients.

There have been considerable advances in the past few years in our understanding of how chronic kidney disease (CKD) predisposes to acute kidney injury (AKI) and vice versa. This review shows, however, that few studies have focused on the elderly or conducted stratified analysis by age. It does appear that elderly patients with estimated glomerular filtration rate (eGFR) 45-59 ml/min/1.73 m(2) are at higher risk for AKI compared with their counterparts with eGFR >60 ml/min/1.73 m(2). This is a similar relationship to that seen in younger patients, although effect size appears smaller. As the incidence of AKI has been increasing over the past several years, the proportion of elderly patients surviving after AKI has also been increasing. Since AKI heightens the risk for the development and acceleration of CKD, this implies significant public health concerns with regard to the absolute number of elderly persons developing incident CKD.

Abstract Background Creatinine secretion, as quantified by the ratio of creatinine clearance (CrCl) to glomerular filtration rate (GFR), may introduce another source of error when using serum creatinine concentration to estimate GFR. Few studies have examined determinants of the CrCl/GFR ratio. We sought to study whether higher levels of albuminuria would be associated with higher, and being non-Hispanic black with lower, CrCl/GFR ratio. Methods We did a cross-sectional analysis of 1342 patients with chronic kidney disease from the Chronic Renal Insufficiency Cohort (CRIC) who had baseline measure of iothalamate GFR (iGFR) and 24-hour urine collections. Our predictors included urine albumin as determined from 24-hour urine collections (categorized as: <30, 30-299, 300-2999 and ≥3000 mg), and race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic). Our outcome was CrCl/iGFR ratio, a measure of creatinine secretion. Results Mean iGFR was 48.0 ± 19.9 mL/min/1.73 m2, median albuminuria was 84 mg per day, and 36.8% of the study participants were non-Hispanic black. Mean CrCl/iGFR ratio was 1.19 ± 0.48. There was no association between the CrCl/iGFR ratio and urine albumin (coefficient 0.11 [95% CI−0.01-0.22] for higest verus lowest levels of albuminuria, p = 0.07). Also, there was no association between race/ethnicity and CrCl/iGFR ratio (coefficient for non-Hispanic blacks was−0.03 [95% CI−0.09-0.03] compared with whites, p = 0.38). Conclusions Contrary to what had been suggested by prior smaller studies, CrCl/GFR ratio does not vary with degree of proteinuria or race/ethnicity. The ratio is also closer to 1.0 than reported by several frequently cited reports in the literature.

Background

Urine albumin-creatinine ratio (ACR) and protein-creatinine ratio (PCR) are important markers of kidney damage and are used for prognosis in persons with chronic kidney disease (CKD). Despite how commonly these measurements are done in clinical practice, relatively few studies have directly compared the performance of these 2 measures with regard to associations with clinical outcomes, which may inform clinicians about which measure of urinary protein excretion is best. We studied the association of ACR and PCR with common complications of CKD.

Study design

Cross-sectional study.

Setting & participants

3,481 participants with CKD in the Chronic Renal Insufficiency Cohort (CRIC) Study.

Predictors

ACR and PCR.

Outcomes

We examined the association between ACR and PCR with measures of common CKD complications: serum hemoglobin, bicarbonate, parathyroid hormone, phosphorus, potassium, and albumin.

Measurements

Restricted cubic spline analyses adjusted for estimated glomerular filtration rate (eGFR; calculated by the MDRD [Modification of Diet in Renal Disease] Study equation) were performed to study the continuous association with our predictors with each outcome.

Results

Mean eGFR was 43±13 (SD)mL/min/1.73 m2 and median values for PCR and ACR were 140 and 46 mg/g, respectively. In continuous analyses adjusted for eGFR, higher ACRs and PCRs were similar and both were associated with lower serum hemoglobin, bicarbonate, and albumin levels and higher parathyroid hormone, phosphorus, and potassium levels. Across all outcomes, the associations of ACR and PCR were similar, with only small absolute differences in the outcome measure. Similar associations were seen in patients with diabetes mellitus.

Limitations

Participants largely had moderate CKD with low values for ACR and PCR, so results may not be generalizable to all CKD populations.

Conclusions

In persons with CKD, ACR and PCR are relatively similar in their associations with common complications of CKD. Thus, routine measurement of PCR may provide similar information as ACR in managing immediate complications of CKD.

Objective

To compare different blood pressure (BP) levels in their association with the risk of renal outcomes in type 1 diabetes and to determine whether an intensive glycemic control strategy modifies this association.

Research design and methods

We included 1,441 participants with type 1 diabetes between the ages of 13 and 39 years who had previously been randomized to receive intensive versus conventional glycemic control in the Diabetes Control and Complications Trial (DCCT). The exposures of interest were time-updated systolic BP (SBP) and diastolic BP (DBP) categories. Outcomes included macroalbuminuria (>300 mg/24 h) or stage III chronic kidney disease (CKD) (sustained estimated glomerular filtration rate <60 mL/min/1.73 m²).

Results

During a median follow-up time of 24 years, there were 84 cases of stage III CKD and 169 cases of macroalbuminuria. In adjusted models, SBP in the <120 mmHg range was associated with a 0.59 times higher risk of macroalbuminuria (95% CI 0.37-0.95) and a 0.32 times higher risk of stage III CKD (95% CI 0.14-0.75) compared with SBPs between 130 and 140 mmHg. DBP in the <70 mmHg range were associated with a 0.73 times higher risk of macroalbuminuria (95% CI 0.44-1.18) and a 0.47 times higher risk of stage III CKD (95% CI 0.21-1.05) compared with DBPs between 80 and 90 mmHg. No interaction was noted between BP and prior DCCT-assigned glycemic control strategy (all P > 0.05).

Conclusions

A lower BP (<120/70 mmHg) was associated with a substantially lower risk of adverse renal outcomes, regardless of the prior assigned glycemic control strategy. Interventional trials may be useful to help determine whether the currently recommended BP target of 140/90 mmHg may be too high for optimal renal protection in type 1 diabetes.

Background: Little is known about the targets and expectations of practicing nephrologists with regard to timing of preemptive AV access surgery and how these relate to actual observed practice patterns in clinical care. Methods. We administered a 8-questi