The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Management of Glomerular Diseases is an update to the KDIGO 2012 guideline. The aim is to assist clinicians ...caring for individuals with glomerulonephritis (GN), both adults and children. The scope includes various glomerular diseases, including IgA nephropathy and IgA vasculitis, membranous nephropathy, nephrotic syndrome, minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), infection-related GN, antineutrophil cytoplasmic antibody (ANCA) vasculitis, lupus nephritis, and anti–glomerular basement membrane antibody GN. In addition, this guideline will be the first to address the subtype of complement-mediated diseases. Each chapter follows the same format providing guidance related to diagnosis, prognosis, treatment, and special situations. The goal of the guideline is to generate a useful resource for clinicians and patients by providing actionable recommendations based on evidence syntheses, with useful infographics incorporating views from experts in the field. Another aim is to propose research recommendations for areas where there are gaps in knowledge. The guideline targets a broad global audience of clinicians treating GN while being mindful of implications for policy and cost. Development of this guideline update followed an explicit process whereby treatment approaches and guideline recommendations are based on systematic reviews of relevant studies, and appraisal of the quality of the evidence and the strength of recommendations followed the “Grading of Recommendations Assessment, Development and Evaluation” (GRADE) approach. Limitations of the evidence are discussed, with areas of future research also presented.
Electronic health record (EHR) based chronic kidney disease (CKD) registries are central to population health strategies to improve CKD care. In 2015, Partners Healthcare System (PHS), encompassing ...multiple academic and community hospitals and outpatient care facilities in Massachusetts, developed an EHR-based CKD registry to identify opportunities for quality improvement, defined as improvement on both process measures and outcomes measures associated with clinical care.
Patients are included in the registry based on the following criteria: 1) two estimated glomerular filtration rate (eGFR) results < 60 ml/min/1.73m
separated by 90 days, including the most recent eGFR being < 60 ml/min/1.73m
; or 2) the most recent two urine protein values > 300 mg protein/g creatinine on either urine total protein/creatinine ratio or urine albumin/creatinine ratio; or 3) an EHR problem list diagnosis of end stage renal disease (ESRD). The registry categorizes patients by CKD stage and includes rates of annual testing for eGFR and proteinuria, blood pressure control, use of angiotensin converting enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs), nephrotoxic medication use, hepatitis B virus (HBV) immunization, vascular access placement, transplant status, CKD progression risk; number of outpatient nephrology visits, and hospitalizations.
The CKD registry includes 60,503 patients and has revealed several opportunities for care improvement including 1) annual proteinuria testing performed for 17% (stage 3) and 31% (stage 4) of patients; 2) ACE-I/ARB used in 41% (stage 3) and 46% (stage 4) of patients; 3) nephrotoxic medications used among 23% of stage 4 patients; and 4) 89% of stage 4 patients lack HBV immunity. For advanced CKD patients there are opportunities to improve vascular access placement, transplant referrals and outpatient nephrology contact.
A CKD registry can identify modifiable care gaps across the spectrum of CKD care and enable population health strategy implementation. No linkage to Social Security Death Master File or US Renal Data System (USRDS) databases limits our ability to track mortality and progression to ESRD.
Amyloidosis represents a group of diseases with extracellular deposition of congophilic fibrils of similar morphology but differing chemical composition. The types commonly involving the kidney are ...AL (light chain amyloid) and AA (serum amyloid A). Familial amyloidosis can also affect the kidney, but we have not encountered such a case during the study period. Distinguishing between the AL and AA forms of amyloid is clinically important because of the different treatments and outcomes. The classification of amyloidosis is made by immunostaining with antibodies to kappa and lambda immunoglobulin light chains and for serum amyloid A protein.
To draw attention to the nonspecific immunofluorescence staining patterns in renal biopsies with amyloidosis, causing potential diagnostic pitfalls.
Renal biopsies from 15 patients, including 13 cases of AL and 2 cases of AA amyloidosis, were studied. Immunofluorescence staining with routine antibody panel and immunoperoxidase staining for amyloid A were performed.
Of the 13 cases of AL amyloidosis, 2 cases showed little difference in staining intensity between kappa and lambda light chains (2+ and 3+, respectively) and 4 cases showed only moderate intensity (2+) of the predominant light chain. The 2 cases diagnosed as AA amyloidosis also exhibited staining for light chains. One case had strong (3+) signal for kappa and moderate (2+) for lambda light chain, while the other showed weaker staining.
Immunofluorescence staining for immunoglobin light chains on renal biopsy, as the first step to differentiate between AL and AA amyloidosis, may sometimes be inconclusive or even misleading. Applying amyloid A immunostain on a routine basis and detailed clinical history are essential to avoid misclassification.
Rationale & Objective: To design and implement clinical decision support incorporating a validated risk prediction estimate of kidney failure in primary care clinics and to evaluate the impact on ...stage-appropriate monitoring and referral. Study Design: Block-randomized, pragmatic clinical trial. Setting & Participants: Ten primary care clinics in the greater Boston area. Patients with stage 3-5 chronic kidney disease (CKD) were included. Patients were randomized within each primary care physician panel through a block randomization approach. The trial occurred between December 4, 2015, and December 3, 2016. Intervention: Point-of-care noninterruptive clinical decision support that delivered the 5-year kidney failure risk equation as well as recommendations for stage-appropriate monitoring and referral to nephrology. Outcomes: The primary outcome was as follows: Urine and serum laboratory monitoring test findings measured at one timepoint 6 months after the initial primary care visit and analyzed only in patients who had not undergone the recommended monitoring test in the preceding 12 months. The secondary outcome was nephrology referral in patients with a calculated kidney failure risk equation value of >10% measured at one timepoint 6 months after the initial primary care visit. Results: The clinical decision support application requested and processed 569,533 Continuity of Care Documents during the study period. Of these, 41,842 (7.3%) documents led to a diagnosis of stage 3, 4, or 5 CKD by the clinical decision support application. A total of 5,590 patients with stage 3, 4, or 5 CKD were randomized and included in the study. The link to the clinical decision support application was clicked 122 times by 57 primary care physicians. There was no association between the clinical decision support intervention and the primary outcome. There was a small but statistically significant difference in nephrology referral, with a higher rate of referral in the control arm. Limitations: Contamination within provider and clinic may have attenuated the impact of the intervention and may have biased the result toward null. Conclusions: The noninterruptive design of the clinical decision support was selected to prevent cognitive overload; however, the design led to a very low rate of use and ultimately did not improve stage-appropriate monitoring. Funding: Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award K23DK097187. Trial Registration: ClinicalTrials.gov Identifier: NCT02990897.
To design and implement clinical decision support incorporating a validated risk prediction estimate of kidney failure in primary care clinics and to evaluate the impact on stage-appropriate ...monitoring and referral.
Block-randomized, pragmatic clinical trial.
Ten primary care clinics in the greater Boston area. Patients with stage 3-5 chronic kidney disease (CKD) were included. Patients were randomized within each primary care physician panel through a block randomization approach. The trial occurred between December 4, 2015, and December 3, 2016.
Point-of-care noninterruptive clinical decision support that delivered the 5-year kidney failure risk equation as well as recommendations for stage-appropriate monitoring and referral to nephrology.
The primary outcome was as follows: Urine and serum laboratory monitoring test findings measured at 1 timepoint 6 months after the initial primary care visit and analyzed only in patients who had not undergo the recommended monitoring test in the preceding 12 months. The secondary outcome was nephrology referral in patients with a calculated kidney failure risk equation value of >10% measured at 1 timepoint 6 months after the initial primary care visit.
The clinical decision support application requested and processed 569,533 Continuity of Care Documents during the study period. Of these, 41,842 (7.3%) documents led to a diagnosis of stage 3, 4, or 5 CKD by the clinical decision support application. A total of 5,590 patients with stage 3, 4, or 5 CKD were randomized and included in the study. The link to the clinical decision support application was clicked 122 times by 57 primary care physicians. There was no association between the clinical decision support intervention and the primary outcome. There was a small but statistically significant difference in nephrology referral, with a higher rate of referral in the control arm.
Contamination within provider and clinic may have attenuated the impact of the intervention and may have biased the result toward null.
The noninterruptive design of the clinical decision support was selected to prevent cognitive overload; however, the design led to a very low rate of use and ultimately did not improve stage-appropriate monitoring.
Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award K23DK097187.
ClinicalTrials.gov Identifier: NCT02990897.
BACKGROUND: Although the role of vitamin D deficiency in causing osteomalacia is well recognised, there is limited evidence to suggest that vitamin D deficiency is associated with osteoporosis. One ...community based study has suggested a reduction in bone density in females with low vitamin D levels, while another has shown no effect of isolated vitamin D deficiency on population fracture rates. We aimed to assess bone density in a cohort of women with low vitamin D levels but no other identified risk factors for osteoporosis. We wished to see if there was any relationship between the two, in order to clarify whether measurement of vitamin D was justified in aiding selection of patients for DXA, and whether DXA was justified in patients found to have isolated vitamin D deficiency. METHODS: We identified 70 women referred to an open access DXA scanning service by their GP with low vitamin D levels (under 48 nmol/l) as their only risk factor. We performed DXA of hip and spine and recorded the absolute bone density and Z scores for each patient, together with their vitamin D levels. We calculated the mean (SD) values for Z score at hip and spine, and compared these to a control group of women referred for baseline DXA prior to commencing aromatase inhibitors for breast cancer. We also compared the results with those obtained from the rest of the GP database for women referred up with a 10 year risk of osteoporotic fractures calculated at over 10% using FRAX. These statistical comparisons were made using unpaired Students t test. Mean values for Z scores at hip and spine were calculated and compared within the index group for those with vitamin D levels above and below 20 nmol/l using Students t test. Correlation coefficients between vitamin D levels and Z scores at hip and spine were also calculated for the index group. RESULTS: Mean (SD) values for Z scores in the hip and spine for patients with isolated vitamin D deficiency were +0.30 (0.87) and +0.46 (0.92) respectively. These were not significantly different from controls whose corresponding values were +0.17 (0.34) and +0.49 (0.45). By contrast, patients with a 10 year risk of fracture of over 10% had lower values at hip -0.01 (0.07) and spine -0.13 (0.09) p = 0.01. Mean Z scores for those with very low vitamin D levels (under 20 nmol/l) were not significantly different at either site when compared to those with less severe deficiency (20-48 nmol/l) p = 0.26. There was no correlation between vitamin D levels and Z scores at hip or spine r = 0.01 CONCLUSIONS: There was no overall decrease in bone density associated with low vitamin D levels in women in our study. There is no evidence to support the routine measurement of vitamin D to select patients for DXA scanning. There is no reason to perform DXA scans in those patients who have an isolated vitamin D deficiency in the absence of defined risk factors for osteoporosis. Disclosure statement: The authors have declared no conflicts of interest.
In Reply Nadasdy, Tibor; Satoskar, Anjali A.; Cowden, Daniel J. ...
Archives of pathology & laboratory medicine (1976),
01/2008, Letnik:
132, Številka:
1
Journal Article
Hepatic phosphatidylcholine (PC) from the immature fetal guinea pig at day 55 of gestation comprised mainly unsaturated molecular species containing C18:2(n-6) and C22:6(n-3) at the sn-2 position, ...reflecting placental permeability to essential fatty acids. At both day 55 and term (day 68), Me-14Ccholine was incorporated in utero over 3 h largely into sn-1-C16:0 PC species, with incorporation into sn-1-C18:0 PC species increasing by 18 h of incubation. Comparison of specific radioactivities after 3 h and 18 h suggests PC acyl remodelling by phospholipase A1. No incorporation into C20:4(n-6)-containing PC species could be detected of either Me-14Ccholine in vivo or CDP-Me-14Ccholine in isolated microsomes. The major phosphatidylethanolamine (PE) species were 16:0/22:6 and 18:0/22:6. Although 14Cethanolamine was initially incorporated mainly into sn-1-C16:0 species, specific-radioactivity analysis suggested differential turnover rather than acyl remodelling. 1,2-14CEthanolamine and Me-14Cmethionine incorporation into PC molecular species indicated that both newly synthesized and total PE pools were available for N-methylation. Since the PC pool synthesized from PE included C20:4- and C22:6-containing species, N-methylation may provide a mechanism for supplying essential long-chain fatty acids to developing tissues that can be regulated independently from bulk PC synthesis.
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