Suchergebnisse

In his review article in the March 2015 edition ofCME, Prof. A M Meyers refers to chronic kidneydisease as 'an important disease group that threatenshealth'. I fully concur with this observation andwish to go a step further and assert that kidneydisease, together with other related non-communicable diseases(NCDs), poses not only a threat to health but also to theoverall development of South Africa (SA). It is now almost 4 yearssince the adoption of the Political Declaration of the High-levelMeeting of the General Assembly on the Prevention and Controlof Non-communicable Diseases (September 2011), where itwas emphatically stated that member States that have signed theDeclaration (including SA) 'Acknowledge that the global burdenand threat of non-communicable diseases constitutes one of themajor challenges for development in the twenty-first century,which undermines social and economic development throughoutthe world, and threatens the achievement of internationallyagreed development goals'.

Munuaisten vajaatoiminta on diabeteksen ja sydän- ja verisuonisairauksien yleistymisen takia maailmassa voimakkaasti lisääntymässä oleva sairaus. Munuaisten tehtävä elimistössä on aineenvaihdunnan tuotteiden poisto ja vesitasapainon säätely, jolloin munuaisen glomeruluksissa eli munuaiskeräsissä verenkierrosta suodattuu virtsatiehyeisiin virtsaa. Munuaiset säätelevät myös kalsiumin, fosfaatin ja D-vitamiinin aineenvaihduntaa ja vaikuttavat punasolutuotantoon tuottamalla erytropoietiinia. Munuaisten vajaatoiminnassa glomerulusfiltraatio (GFR) heikentyy. Tällöin kertyviä haitallisia aineenvaihduntatuotteita voidaan poistaa keinomunuais- eli dialyysihoidolla. Munuaisten vajaatoiminnassa immuunipuolustus on heikentynyt, ja riski infektioille lisääntynyt. Infektiot ovat toiseksi yleisin kuolinsyy dialyysipotilailla sydän- ja verisuonisairauksien jälkeen. Immuniteettiä heikentävät puolustuskykyä tukevien tulehdusvälittäjäaineiden puute, toksiset aineenvaihduntatuotteet, ja verikontakti vieraiden materiaalien kanssa hemodialyysihoidossa. Fosfaatin kertymiseen liittyvä sekundaarinen lisäkilpirauhasen liikatoiminta eli hyperparatyreoosi on immuunisoluille toksista. Kalsitriolin eli aktiivisen D-vitamiinin puute voimistaa hyperparatyreoosia. Terveillä kalsitrioli hillitsee immuunivastetta, ja D-vitamiinipuutokseen liittyy lisääntynyt riski mm. autoimmuunitauteihin ja pahanlaatuisiin sairauksiin. Vaurioitunut munuainen ei kykene muuntamaan kalsitriolin esiastetta kalsitrioliksi, josta seuraa D-vitamiinipuutos. Se ei myöskään kykene tuottamaan riittävästi erytropoietiinia (Epoa), joka johtaa anemiaan. Tässä väitöskirjatyössä tutkittiin soluvälitteistä immuniteettiä ja rokotevastetta munuaisten eriasteista vajaatoimintaa sairastavilla potilailla sekä koe-eläimillä. Influenssarokotevastetta verrattiin normaalin munuaistoiminnan omaavien sydänpotilaiden vasteisiin. Lisäksi tutkittiin potilaiden ja kontrollien seeruminäytteistä, sekä influenssan sairastaneiden varusmiesten näytteistä, säilyykö vaste seuraavien vuosien epidemioista eristettyjä virusantigeenejä kohtaan. Selvitettiin fosfaatinsitojana käytetyn ravinnon kalsiumkarbonaattilisän vaikutusta tetanusrokotevasteeseen rotilla, joille oli tehty munuaisten osapoistoleikkaus. Tutkittiin myös kalsitriolin ja Epo-hoidon aloituksen vaikutuksia soluvälitteiseen immuniteettiin. Munuaisten vajaatoimintaa sairastavien potilaiden influenssarokotevaste oli lähes kontrollien luokkaa, eikä hemodialyysipotilaiden vasta-ainevaste epidemiaviruksia kohtaan ollut kontrolleja huonompi. Suonensisäinen kalsitriolihoito kohensi influenssarokotevastetta hemodialyysipotilailla (lähes merkitsevästi, p=0.06). Rotilla, joilla oli munuaisten vajaatoiminta, todettiin selvästi heikentynyt tetanusrokotevaste, joka korreloi glomerulusfiltraatioon sekä fosfaatti- ja lisäkilpirauhashormonitasoon. Ravinnon kalsiumkarbonaattilisä kohensi tetanusrokotevastetta rotilla. Soluviljelmille annosteltu kalsitrioli hemodialyysipotilailla heikensi lymfosyyttistimulaatiovastetta mutta pulssittain annettuna pikemminkin kohensi sitä (tilastollisesti ei-merkitsevästi). Epo heikensi lymfosyyttiproliferaatiota ja vähensi lymfosyyttien ja niiden alaluokkien määrää. Johtopäätökset: Munuaisten vajaatoiminnassa influenssarokotevaste on kontrollien kaltainen. Vain hemodialyysipotilailla se on osittain heikentynyt. Korkea-annoksinen kalsitrioli koeolosuhteissa ja Epo-hoidon aloitus vaimentavat soluvälitteistä immuniteettiä. Kalsitriolilla ja fosfaatinsitojana käytetyllä kalsiumkarbonaatilla on suotuisa vaikutus rokotevasteeseen. ; Background. Chronic kidney disease (CKD) is a globally increasing condition that almost always finally leads to renal replacement therapy (dialysis treatment). CKD is also a state of immunodeficiency with increased susceptibility to infections that are the second most common cause of death after vascular diseases among dialysis patients (Rocco et al. 2002; Collins et al. 2006; Inaguma et al. 2008). In an earlier Finnish doctoral study in 1985, lymphocyte antigen responses of hemodialysis (HD) patients were only 60% of the controls (Huttunen 1985). The vaccination response is also impaired e.g. against influenza (Beyer et al. 1987; Cavdar et al. 2003). Uremic toxins, lack of supportive cytokines, constructive cellular factors, dialysis modality and the membranes used in HD are all involved in the immune suppression. An important cause of dysfunction in the cells of the immune system is intracellular hypercalcemia related to secondary hyperparathyroidism (SHPT) caused by retention of phosphate in CKD. Patients with advanced CKD also by nature develop hypovitaminosis D, because the kidneys have lost their ability to synthesize calcitriol, which is known to have immunoregulatory actions. This contributes to SHPT and the numerous immune abnormalities. Initiation of erythropoietin (Epo) treatment has also been shown to affect the immune functions. By and large, the effects of the treatments of CKD on immune functions remain to be clarified. Aims. In this series of studies we aimed to study the influenza vaccination response against vaccine antigens in CKD of various degrees (I) and HD-patients cross-reacting antibody responses to wild influenza virus antigens (II). We also aimed to study whether phosphate binding with calcium carbonate could increase the reduced tetanus vaccination response in uremic rats (IV). We aimed to study the immune effects of ancillary treatments in CKD, calcitriol (III) and Epo (V), on lymphocyte functions. Subjects and methods. The groups in the clinical studies consisted of patients with all stages of CKD and controls from Tampere University Hospital. Pre-dialysis (Pre-D), HD, peritoneal dialysis (PD) and cardiac control patients were vaccinated against influenza and their antibody response against the influenza vaccine antigens A/H3N2, A/H1N1 and B was measured. HD patients sera were additionally studied for cross-reactivity against subsequent years virus isolates of A/H3N2 subtype. In vitro calcitriol was added in lymphocyte cultures of HD patients in a lymphocyte antigen response study using tuberculin (PPD) and tetanus toxoid (TT) as antigens. In the experimental study rats underwent a 5/6-nephrectomy or a sham operation, and thereafter they were given a high or control calcium carbonate diet, and their tetanus vaccination response was evaluated. Pre-D patients were tested with 1) antibody tests to Ebstein-Barr virus (EBV) and cytomegalovirus (CMV), 2) lymphocyte subclass analyses and 3) lymphocyte proliferation tests using phytohemagglutinin (PHA), pokeweed mitogen (PWM), PPD and TT as stimulants, before and three months after they begun with Epo treatment. Results. Influenza vaccination of CKD patients resulted in post-vaccination titres that were almost comparable to those of the controls. Against A/H3N2 antigen they were 84%, 84% and 96% of the controls titres (pre-D, HD and PD, respectively). Sixty-one percent of controls and 67% of PD patients reached a protective titre against A/H3N2 but no more than 35% of pre-D and 36% of HD patients. However, the proportion of CKD and control patients that reached protective titres was clearly higher for the two other antigens A/H1N1 and B. Among HD patients, those on intravenous (i.v.) calcitriol seemed to have a better protection than those without i.v. calcitriol (p=0.06, borderline significant). The antibodies efficiently cross-reacted against wild influenza virus A/H3N2 antigens, similarly in HD patients and controls and even in healthy military conscripts who had suffered from an influenza A infection previously. In the lymphocyte proliferation studies, the effect of in vitro pulse (mimicking i.v.) calcitriol therapy among HD patients had a statistically non-significant enhancing effect on lymphocyte antigen stimulation cultures, whereas having calcitriol continuously in the culture medium was even immunosuppressive to TT (p=0.001). High calcium diet was beneficial to the tetanus vaccination response of rats with 5/6-nephrectomy: the response of the Ca-NTX rats with high calcium diet was almost as high as (75% of) that of sham-operated (Sham) rats (p=NS), while the NTX rats with control calcium diet had a reduced response (42%) compared to the Sham rats, p The initiation of Epo treatment in pre-D patients caused lymphopenia and a decrease in lymphocyte proliferation, but no changes in the general antibody production against EBV and CMV. The changes in iron status, reticulocytes, hemoglobin or glomerular filtration rate (GFR) did not explain the decline. Conclusions. The influenza vaccination responses of regularly monitored patients with CKD were comparable to controls. Especially HD patients cross-reactivity against several wild viruses was not inferior to that of the controls. In 5/6-NTX animals, the impaired tetanus vaccination response correlated both to GFR and to the control of hyperphosphatemia and PTH level. Calcitriol in vivo borderline significantly (p=0.06) enhanced the influenza vaccine response and calcitriol in vitro pulse treament slightly (non-significantly) enhanced lymphocyte antigen proliferation of HD patients. Incubation with calcitriol in vitro continuously was immunosuppressive to TT response (p=0.001). Epo had initial immune depressing actions to lymphocyte number and function. There seemed to be clinical benefits of calcitriol and phosphate binding therapies in vaccination response in CKD.

Worldwide, both hypertension and chronic kidney disease are major public health problems, due to their epidemic proportions and their association with high cardiovascular mortality. In 2003, the first Prevalence, awareness, treatment, and control of hypertension in Turkey (the PatenT) study was conducted in a nationally representative population (n=4910) by the Turkish Society of Hypertension and Renal Diseases, and showed that overall age- and sex-adjusted prevalence of hypertension in Turkey was 31.8%. The PatenT study also reported that overall awareness (40.7%), treatment (31.1%), and control rates (8.1%) of hypertension were strikingly low. Only 20.7% of the patients who were aware of their hypertension and receiving treatment had their blood pressure controlled to <140/90 mm Hg. In the Chronic Renal Disease in Turkey (CREDIT) study (n=10,748), the overall prevalence of chronic kidney (including all stages) disease was 15.7% and increased with advancing age. In the same population, the prevalence of hypertension, diabetes mellitus, dyslipidemia, obesity, and metabolic syndrome were reported as 32.7%, 12.7%, 76.3%, 20.1%, and 31.3%, respectively. The prevalence and awareness of hypertension in CREDIT population was 32.7% and 48.6%, respectively. According to the data obtained from national surveys, the prevalence of hypertension and chronic kidney disease in Turkey is alarmingly high. To improve prevention, early diagnosis, and treatment of these major public health problems, appropriate health strategies should be implemented by the government, together with medical societies, non-governmental organizations, industry, health-care providers, and academia.

Worldwide, both hypertension and chronic kidney disease are major public health problems, due to their epidemic proportions and their association with high cardiovascular mortality. In 2003, the first Prevalence, awareness, treatment, and control of hypertension in Turkey (the PatenT) study was conducted in a nationally representative population (n=4910) by the Turkish Society of Hypertension and Renal Diseases, and showed that overall age- and sex-adjusted prevalence of hypertension in Turkey was 31.8%. The PatenT study also reported that overall awareness (40.7%), treatment (31.1%), and control rates (8.1%) of hypertension were strikingly low. Only 20.7% of the patients who were aware of their hypertension and receiving treatment had their blood pressure controlled to <140/90 mm Hg. In the Chronic Renal Disease in Turkey (CREDIT) study (n=10,748), the overall prevalence of chronic kidney (including all stages) disease was 15.7% and increased with advancing age. In the same population, the prevalence of hypertension, diabetes mellitus, dyslipidemia, obesity, and metabolic syndrome were reported as 32.7%, 12.7%, 76.3%, 20.1%, and 31.3%, respectively. The prevalence and awareness of hypertension in CREDIT population was 32.7% and 48.6%, respectively. According to the data obtained from national surveys, the prevalence of hypertension and chronic kidney disease in Turkey is alarmingly high. To improve prevention, early diagnosis, and treatment of these major public health problems, appropriate health strategies should be implemented by the government, together with medical societies, non-governmental organizations, industry, health-care providers, and academia.

Nutritional management of chronic kidney disease in pets
Renea Creech and Kim Wilson outline the challenges of Chronic Kidney Disease in pets, the irreversible loss of kidney function, and how nutrition can help. Approximately one in three cats and one in ten dogs are likely to develop kidney disease in their lifetime. (1,2) Increased incidence of diagnosis occurs in older pets, particularly in cats. (3,4) A longevity study showed renal disorders were a major cause of death in cats over five years (5), and upwards of 80% aged over 15 years are affected by Chronic Kidney Disease (CKD) or other renal disorders. (3,4) Clinical signs include vomiting, decreased appetite, increased water intake, and total and lean body mass loss. Veterinarians often analyse urine and blood samples to determine biomarker levels such as serum creatinine and symmetric dimethylarginine (SDMA). The International Renal Interest Society provides veterinarians with guidance for diagnosing and managing kidney disease based on staging, with stage 1 representing early CKD and stage 4 severe CKD. (6)

The main research goal in patients with chronic kidney disease (CKD) is the development of new therapeutic approaches capable of slowing down the progression to end-stage renal disease. The aim of this work was to evaluate the effects of long-term administration of chaetomellic acid A (CAA), which selectively blocks H-Ras farnesylation, on chronic kidney lesions in 5/6 nephrectomized Wistar rats, an animal model of chronic renal disease. Materials and Methods: Sixty male Wistar rats were sham-operated (SO) or submitted to 5/6 nephrectomy (RMR). One week after surgery, surviving animals were distributed into four groups: SO–SO rats receiving no treatment (n = 13); SO+CAA–SO rats receiving CAA treatment (n = 13); RMR–RMR rats receiving no treatment (n = 14); RMR+CAA–RMR rats receiving CAA treatment (n = 13). CAA was administered intraperitoneally three times a week for 6 months. Renal fibrosis was evaluated by ultrasonography and histopathological analysis. All experimental procedures followed the European (European Directive 2010/63/EU) and National (Decree-Law 113/2013) legislation on the protection of the animals used for scientific purposes. Results: The kidneys of the RMR animals treated with CAA showed a significant decrease in medullary echogenicity (P <0.05) compared with the RMR rats that received no treatment. Glomerulosclerosis and arteriolosclerosis scores were significantly lower (P <0.001) in the RMR+CAA group when compared with the RMR group. Conclusion: These data suggest that pharmacological inhibition of H-Ras proteins activation may be a future strategy in the prevention of end-stage renal disease. ; info:eu-repo/semantics/publishedVersion

An increased risk of cardiovascular disease, independent of conventional risk factors, is present even at minor levels of renal impairment and is highest in patients with end-stage renal disease (ESRD) requiring dialysis. Renal dysfunction changes the level, composition and quality of blood lipids in favour of a more atherogenic profile. Patients with advanced chronic kidney disease (CKD) or ESRD have a characteristic lipid pattern of hypertriglyceridaemia and low HDL cholesterol levels but normal LDL cholesterol levels. In the general population, a clear relationship exists between LDL cholesterol and major atherosclerotic events. However, in patients with ESRD, LDL cholesterol shows a negative association with these outcomes at below average LDL cholesterol levels and a flat or weakly positive association with mortality at higher LDL cholesterol levels. Overall, the available data suggest that lowering of LDL cholesterol is beneficial for prevention of major atherosclerotic events in patients with CKD and in kidney transplant recipients but is not beneficial in patients requiring dialysis. The 2013 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Lipid Management in CKD provides simple recommendations for the management of dyslipidaemia in patients with CKD and ESRD. However, emerging data and novel lipid-lowering therapies warrant some reappraisal of these recommendations. ; AO was supported by Spanish Government ISCIII FEDER funds (PI16/02057, ISCIII-RETIC REDinREN RD16/0009) and Community of Madrid (B2017/BMD-3686 CIFRA2-CM).

Hospital integration among rural districts to concentrate medical resources is one of the main projects of the Japanese government. In advance of this, we experienced hospital integration and screening for chronic kidney disease as definitive risk for end‐stage kidney disease and cardiovascular mortality. After that, high‐risk patients have been appropriately referred from generalists to nephrologists and/or cardiologists without acute deterioration of renal function or cardiac sudden death. [Image: see text]

Very few patients with end-stage kidney disease in South Africa receive renal replacement treatment (RRT), despite the rapidly growing demand, because of resource constraints. Nephrologists who agonise daily about who to treat and who not to, and have been doing so since the inception of dialysis in this country, welcomed the opportunity to interact with the National Department of Health at a recent summit of stakeholders. The major challenges were identified and recommendations for short- to long-term solutions were made. While the renal community can still improve efficiencies, it is clear that much of the responsibility for improving access to RRT and reducing inequities must be borne by the national government. The summit marks the first step in a process that we hope will ultimately culminate in universal access to RRT for all South Africans.

The prevalence of chronic kidney disease and its risk factors is increasing worldwide, and the rapid rise in global need for end-stage kidney disease care is a major challenge for health systems, particularly in low- and middle-income countries. Countries are responding to the challenge of end-stage kidney disease in different ways, with variable provision of the components of a kidney care strategy, including effective prevention, detection, conservative care, kidney transplantation, and an appropriate mix of dialysis modalities. This collection of case studies is from 15 countries from around the world and offers valuable learning examples from a variety of contexts. The variability in approaches may be explained by country differences in burden of disease, available human or financial resources, income status, and cost structures. In addition, cultural considerations, political context, and competing interests from other stakeholders must be considered. Although the approaches taken have often varied substantially, a common theme is the potential benefits of multi-stakeholder engagement aimed at improving the availability and scope of integrated kidney care.

Our objective is to analyze the economic burden of chronic kidney disease (CKD) in Vietnam, particularly in District 2 Hospital at Ho Chi Minh City in 2019. This is a descriptive cross-sectional study. The data source is the medical records of the patients. Encoding the data, analyzing treatment cost, regression modeling, and verification were performed using Stata 15 software. Patients with stage 3 CKD account for the highest proportion of the CKD patient population. CKD comorbidities include hypertension, diabetes, cardiovascular disease, and anemia, which increase the treatment fees of patients. Approximately half of the patients with CKD have diabetes or cardiovascular disease. Treatment costs increase as the condition of the patient worsens (except for stage 1 and 2 CKD). The total expenses of all CKD patients in District 2 Hospital were USD 916 423 988.60. Five main factors that affect the treatment fee of a patient: CKD stage, age, gender, and the presence of diabetes, cardiovascular disease, and anemia. The regression model correctly predicts 96% of cases and can explain 64.15% of the fluctuations in costs. The cost of CKD treatment was higher than Vietnam's per capita GDP in 2019, and the primary factors affecting costs are comorbidities and dialysis.

Background: In the UK, primary care records are electronic and require doctors to ascribe disease codes to direct care plans and facilitate safe prescribing. We investigated factors associated with coding of chronic kidney disease (CKD) in patients with reduced kidney function and the impact this has on patient management. Methods: We identified patients meeting biochemical criteria for CKD (two estimated glomerular filtration rates 90 days apart) from 1039 general practitioner (GP) practices in a UK audit. Clustered logistic regression was used to identify factors associated with coding for CKD and improvement in coding as a result of the audit process. We investigated the relationship between coding and five interventions recommended for CKD: achieving blood pressure targets, proteinuria testing, statin prescription and flu and pneumococcal vaccination. Results: Of 256 000 patients with biochemical CKD, 30% did not have a GP CKD code. Males, older patients, those with more severe CKD, diabetes or hypertension or those prescribed statins were more likely to have a CKD code. Among those with continued biochemical CKD following audit, these same characteristics increased the odds of improved coding. Patients without any kidney diagnosis were less likely to receive optimal care than those coded for CKD [e.g. odds ratio for meeting blood pressure target 0.78 (95% confidence interval 0.76-0.79)]. Conclusion: Older age, male sex, diabetes and hypertension are associated with coding for those with biochemical CKD. CKD coding is associated with receiving key primary care interventions recommended for CKD. Increased efforts to incentivize CKD coding may improve outcomes for CKD patients. ; The NCKDA is commissioned by the Healthcare QI Partnership (HQIP) and funded by NHS England, as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP), and the Welsh Government