Sustained uremic toxin control improves renal and cardiovascular outcomes in patients with advanced renal dysfunction: post-hoc analysis of the Kremezin Study against renal disease progression in Korea

BACKGROUND: We investigated the long-term effect of AST-120, which has been proposed as a therapeutic option against renal disease progression, in patients with advanced chronic kidney disease (CKD). METHODS: We performed post-hoc analysis with a per-protocol group of the K-STAR study (Kremezin study against renal disease progression in Korea) that randomized participants into an AST-120 and a control arm. Patients in the AST-120 arm were given 6 g of AST-120 in three divided doses, and those in both arms received standard conventional treatment. RESULTS: The two arms did not differ significantly in the occurrence of composite primary outcomes (log-rank P = 0.41). For AST-120 patients with higher compliance, there were fewer composite primary outcomes: intermediate tertile hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.38 to 1.01, P = 0.05; highest tertile HR 0.436, 95% CI 0.25 to 0.76, P = 0.003. The estimated glomerular filtration rate level was more stable in the AST-120 arm, especially in diabetic patients. At one year, the AST-120-induced decrease in the serum indoxyl sulfate concentration inversely correlated with the occurrence of composite primary outcomes: second tertile HR 1.59, 95% CI 0.82 to 3.07, P = 0.17; third tertile HR 2.11, 95% CI 1.07 to 4.17, P = 0.031. Furthermore, AST-120 showed a protective effect against the major cardiovascular adverse events (HR 0.51, 95% CI 0.26 to 0.99, P = 0.046). CONCLUSION: Long-term use of AST-120 has potential for renal protection, especially in diabetic patients, as well as cardiovascular benefits. Reduction of the serum indoxyl sulfate level may be used to identify patients who would benefit from AST-120 administration.

Clinical Characteristics and Renal Outcomes of Acute Focal Bacterial Nephritis in Children

PURPOSE: This study was performed to elucidate the clinical pictures of acute focal bacterial nephritis(nephronia) in children. METHODS: We reviewed 9 children with nephronia diagnosed by ultrasonography or computed tomography of kidneys from September 1994 to August 2004. RESULTS: The overall male to female ratio was 2:1, and the age distribution ranged from 0.1 to 6 years(mean 2.8+/-2.2). The cardinal symptoms were fever, chills, abdominal pain and dysuria/frequency. The initial leukocyte count was 21,000+/-5,600/uL; ESR, 60+/-23 mm/hr; CRP, 17+/-10 mg/dl. Pyuria was noted in every patient and persisted for 10.5+/-7.8 days after antimicrobial treatment. Abdominal sonography demonstrated focal lesion of ill-defined margin and low echogenicity in 5 of 9 patients(55.6%), while computed tomography revealed nonenhancing low density area in all patients(100%). Three of 9 patients(33.3%) had vesicoureteral reflux, greater than grade III. The initial (99m)Tc-DMSA scan showed one or multiple cortical defects in every patient, and improvements were noted in 2(33.3%) of 6 patients who received follow up scan after 4 months. Intravenous antibiotics was given in every patient under admission. Total febrile period was 11.8+/-6.3 days(pre-admission, 4.0+/-3.0; post-admission, 7.8+/-5.5 days) and the patients needed hospitalization for 17.2+/-8.1 days. CONCLUSION: For the early diagnosis of 'acute focal bacterial nephritis' we should perform renal computed tomography first rather than ultrasonography, when the child has toxic symptoms and severe inflammatory responses in blood and urine.

Pred ictive Efficacy of Radioisotope Voiding Cystography for Renal Outcome / 대한핵의학회잡지

PURPOSE: As vesicoureteral reflux (VUR) could lead to renal functional deterioration when combined with urinary tract infection, we need to decide whether operative anti-reflux treatment should be performed at the time of diagnosis of VUR. Predictive value of radioisotope voiding cystography (RIVCG) for renal outcome was tested. MATERIALS AND METHODS: In 35 children (18 males, 17 females), radiologic voiding cystourethrography (VCU), RIVCG and DMSA scan were performed. Change in renal function was evaluated using the follow-up DMSA scan, ultrasonography, and clinical information. Discriminant analysis was performed using individual or integrated variables such as reflux amount and extent at each phase of voiding on RIVCG, in addition to age, gender and cortical defect on DMSA scan at the time of diagnosis. Discriminant function was composed and its performance was examined. RESULTS: Reflux extent at the filling phase and reflux amount and extent at postvoiding phase had a significant prognostic value. Total reflux amount was a composite variable to predict prognosis. Discriminant function composed of reflux extent at the filling phase and reflux amount and extent at postvoiding phase showed better positive predictive value and specificity than conventional reflux grading. CONCLUSION: RIVCG could predict renal outcome by disclosing characteristic reflux pattern during various voiding phases.