Background: Most studies looking at how the outcome of end-stage renal disease (ESRD) is affected by the timing and quality of the care received before initiation of renal replacement therapy (RRT) ...are inconclusive. Methods: Five hundred and two adult French patients (age, 62.8 ± 16 years) receiving their first RRT were enrolled in a 2-year, community-based, prospective study. Subjects were assigned to 1 of 5 groups depending on the time between their first serum creatinine reading above 2 mg/dL (177 μmol/L): chronic renal failure (CRF) and nephrology referral (NR) and RRT. Multivariate logistic regression was used to analyze 90-day survival data, and data concerning long-term survival and inclusion on the waiting list for renal transplantation were analyzed using Cox proportional hazards regression. Results:Overall survival rates were 88% at 90 days, 77.2% at 1 year, 65.2% at 2 years, and 54.2% at 3 years. The nephrology referral pattern was associated with age and systolic blood pressure, and independently predicted early death. Compared with group 1 (NR > 12 months), odds ratios (confidence interval 95%) were 2.7 (1.2 to 6.3) for group 2 (NR ≤ 12 months or >4 months), 2.8 (1.0 to 8.0) for group 3 (NR ≤ 4 months or >1 month), 4.9 (2.2 to 11.0) for group 4 (NR ≤ 1 month; CRF > 1 month), and 5.2 (2.2 to 12.3) for group 5 (NR ≤ 1 month; CRF ≤ 1 month). Independent predictors of death in 90-day survivors were age, cardiac disease with previous episodes of heart failure, vascular disease, low diastolic blood pressure, and group 3 referral pattern. Not being entered on the waiting list for renal transplantation was predicted by age, diabetes, vascular disease, and nonelective first dialysis. Conclusion:Late nephrology referral is strongly associated with early death. Emergency first dialysis is an independent risk factor for not being placed on the waiting list for transplantation. Among 90-day survivors, referral pattern has little influence on mortality, which is mainly determined by cardiovascular complications at initiation of RRT.
Conservative care is increasingly considered an alternative to kidney replacement therapy for kidney failure management, mostly among the elderly. We investigated its status and the barriers to its ...implementation from patients' and providers' perspectives.
We analysed data from 1204 patients with advanced chronic kidney disease (CKD) estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 enrolled at 40 nationally representative nephrology clinics (2013-16) who completed a self-administered questionnaire about the information they received and their preferred treatment option, including conservative care, if their kidneys failed. Nephrologists (n = 137) also reported data about their clinics' resources and practices regarding conservative care.
All participating facilities reported they were routinely able to offer conservative care, but only 37% had written protocols and only 5% had a person or team primarily responsible for it. Overall, 6% of patients were estimated to use conservative care. Among nephrologists, 82% reported they were fairly or extremely comfortable discussing conservative care, but only 28% usually or always offered this option for older (>75 years) patients approaching kidney failure. They used various terminology for this care, with conservative management and non-dialysis care mentioned most often. Among patients, 5% of those >75 years reported receiving information about this option and 2% preferring it.
Although reported by nephrologists to be widely available and easily discussed, conservative care is only occasionally offered to older patients, most of whom report they were not informed of this option. The lack of a person or team responsible for conservative care and unclear information appear to be key barriers to its implementation.
Fibrinogen A α-chain amyloidosis (AFib amyloidosis) is a form of amyloidosis resulting from mutations in the fibrinogen A α-chain gene (FGA), causing progressive kidney disease leading to kidney ...failure. Treatment may include kidney transplantation (KT) or liver-kidney transplantation (LKT), but it is not clear what factors should guide this decision. The aim of this study was to characterize the natural history and long-term outcomes of this disease, with and without organ transplantation, among patients with AFib amyloidosis and various FGA variants.
Case series.
32 patients with AFib amyloidosis diagnosed by genetic testing in France between 1983 and 2014, with a median follow-up of 93 (range, 4-192) months, were included.
Median age at diagnosis was 51.5 (range, 12-77) years. Clinical presentation consisted of proteinuria (93%), hypertension (83%), and kidney failure (68%). Manifestations of kidney disease appeared on average at age 57 (range, 36-77) years in patients with the E526V variant, at age 45 (range, 12-59) years in those with the R554L variant (P<0.001), and at age 24.5 (range, 12-31) years in those with frameshift variants (P<0.001). KT was performed in 15 patients and LKT was performed in 4. In KT patients with the E526V variant, recurrence of AFib amyloidosis in the kidney graft was less common than with a non-E526V (R554L or frameshift) variant (22% vs 83%; P=0.03) and led to graft loss less frequently (33% vs 100%). Amyloid recurrence was not observed in patients after LKT.
Analyses were based on clinically available historical data. Small number of patients with non-E526V and frameshift variants.
Our study suggests phenotypic variability in the natural history of AFib amyloidosis, depending on the FGA mutation type. KT appears to be a viable option for patients with the most common E526V variant, whereas LKT may be a preferred option for patients with frameshift variants.
In the general population, urinary sodium-to-potassium (uNa/K) ratio associates more strongly with high blood pressure (BP) than either urinary sodium or potassium alone. Whether this is also the ...case among patients with chronic kidney disease (CKD) is unknown.
We studied the associations of spot urine sodium-to-creatinine (uNa/Cr), potassium-to-creatinine (uK/Cr), and uNa/K ratios with a single office BP reading in 1660 patients with moderate to severe CKD at inclusion in the CKD-REIN cohort.
Patients' median age was 68 (interquartile range IQR, 59–76) years; most were men (65%), had moderate CKD (57%), and albuminuria (72%). Mean systolic and diastolic BP was 142/78 mm Hg. Spot uNa/Cr and uNa/K ratios were positively associated with systolic, mean arterial, and pulse pressures. The mean adjusted difference in systolic BP between the highest and the lowest quartile (Q4 vs. Q1) was 4.24 (95% confidence interval CI, 1.53–6.96) mm Hg for uNa/Cr and 4.79 (95% CI, 2.18–7.39) mm Hg for uNa/K. Quartiles of spot uK/Cr were not associated with any BP index. The higher the quartile of uNa/K, the higher the prevalence ratio of uncontrolled (Q4 vs. Q1, 1.43; 95% CI, 1.19–1.72) or apparently treatment-resistant hypertension (Q4 vs. Q1, 1.35; 95% CI, 1.14–1.60). Findings were consistent in a subset of 803 individuals with 2 BP readings.
In patients with CKD, higher urinary sodium excretion is associated with higher BP, but unlike in general population, lower potassium excretion is not. Urinary Na/K does not add significant value in assessing high BP risk, except perhaps for hypertension control assessment.
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We compared, in patients contraindicated for kidney transplant, outcomes between those patients who were only on hemodialysis (HD) and those who were given peritoneal dialysis (PD) as first renal ...replacement therapy (RRT).
Prospective, population-based cohort study of incident cases of end-stage renal disease between June 1997 and June 1999.
A network of dialysis care: NEPHROLOR, that is, all the renal units in Lorraine, one of the 22 French administrative regions (population over 2.3 million people).
387 patients were contraindicated for kidney transplant during the first 2 years of RRT: 284 were on HD, 103 on PD. Mean age was 67.6 +/- 11.3 years for HD patients and 70.8 +/- 11.4 years for PD patients (p = 0.015).
Mortality until June 2003, hospitalization over the 2 first years of RRT, and Kidney Disease and Quality of Life Short Form (KDQOL-SF) 6 and 12 months after initiation of RRT.
HD patients were more likely to die from cardiac or cerebrovascular causes, PD from cachexia or withdrawal from dialysis. Whatever mode of RRT, the unadjusted 2-year and 5-year survival rates were similar (p = 0.98). The rate of total duration of hospital stay per month of RRT was similarin HD and PD groups: 2.7 +/- 4.5 and 2.9 +/- 4.2 days respectively (p = 0.7). PD was associated with better quality of life than HD. The dimensions Role limitation due to emotional function, Burden of kidney disease, and Role limitation due to physical function ranked first, second, and third for PD.
In Lorraine, end-stage renal disease patients who were given PD as first-line RRT had no excess of death risk or hospitalizations, and better quality of life the first year of RRT.
This research aims to determine five steroids and four non-steroidal anti-inflammatory drugs in milk and egg samples collected from rural Roma communities in Transylvania, Romania. Target compounds ...were extracted from selected matrices by protein precipitation, followed by extract purification by dispersive liquid-liquid microextraction based on solidification of floating organic droplets. The extraction procedure was optimized using a 2
full factorial experimental design. Good enrichment factors (87.64-122.07 milk; 26.97-38.72 eggs), extraction recovery (74.49-103.76% milk; 75.64-108.60% eggs), and clean-up of the sample were obtained. The method detection limits were 0.74-1.77 µg/L for milk and 2.39-6.02 µg/kg for eggs, while the method quantification limits were 2.29-5.46 µg/L for milk and 7.38-18.65 µg/kg for eggs. The steroid concentration in milk samples was <MDL up to 4.30 µg/L, decreasing from 17α-ethinyl estradiol, 17β-estradiol, and estrone to estriol. The NSAID concentration was <MDL up to 3.41 µg/L, decreasing from ibuprofen, diclofenac, and ketoprofen to naproxen. The steroid concentration in the egg samples was <MDL to 2.79 µg/kg, with all steroids detected, while the concentration of NSAIDs was <MDL to 2.28 µg/kg, with only ibuprofen, ketoprofen, and naproxen detected. The developed protocol was successfully applied to the analysis of target compounds in real milk and egg samples.
This paper aims to assess the pollution by determining the sources of persistent organic pollutants (POPs) in 22 rural Roma communities in Transylvania in order to assess the human health risk ...associated with this exposure. For this, 16 polycyclic aromatic hydrocarbons (PAHs), 20 organochlorine pesticides (OCPs) and 12 polychlorinated biphenyls (PCBs) were determined in 22 soil samples collected from selected areas by gas chromatography coupled with mass spectrometry for PAHs and with electron capture detector for all halogenated compounds. Target compounds were isolated from soil by ultrasound-assisted extraction. We found that POP concentrations in soil ranged from 4.86 to 451.85 ng/g dw for PAHs, from 25.62 to 139.30 ng/g dw for OCPs, and from 0.22 to 49.12 ng/g dw for PCBs. The diagnostic ratios ƩLMW/ƩHMW, ANT/(ANT + PHE), and FLT/(FLT + PYR) strongly suggest a pyrogenic model of PAHs, such as biomass, coal, and petroleum combustion, while the isomer ratios ƩDDT/ƩHCH, α-HCH/γ-HCH and (DDE + DDD)/ƩDDT suggest that OCP residues originate from their ancient uses. Non-carcinogenic (HI) and carcinogenic (CR) risks of these organic compounds present in the soil through non-dietary pathways were in the very low-risk category (ranging from 10−8 to 10−4), indicating an absence of these risks from the investigated POPs in the studied area.
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