Chronic kidney disease, prevalence of premature cardiovascular disease, and relationship to short-term mortality.

BACKGROUND: Chronic kidney disease (CKD) is recognized as an independent cardiovascular disease (CVD) risk state, particularly in the elderly, and has been defined by levels of estimated glomerular filtration rate (eGFR) and markers of kidney damage. The relationship between CKD and CVD in younger and middle-aged adults has not been fully explored. METHODS: Community volunteers completed surveys regarding past medical events and underwent blood pressure and laboratory testing. Chronic kidney disease was defined as an eGFR <60 mL x min(-1) x 1.73 m(-2) or urine albumin-creatinine ratio (ACR) > or =30 mg/g. Premature CVD was defined as self-reported myocardial infarction or stroke at <55 years of age in men and <65 years of age in women. Mortality was ascertained by linkage to national data systems. RESULTS: Of 31 417 participants, the mean age was 45.1 +/- 11.2 years, 75.5% were female, 36.8% African American, and 21.6% had diabetes. A total of 20.6% were found to have CKD, with the ACR and eGFR being the dominant positive screening tests in the younger and older age deciles, respectively. The prevalences of premature myocardial infarction (MI), stroke, or death, and the composite were 5.3%, 4.7%, 0.8%, 9.2%, and 2.5%, 2.2%, 0.2%, 4.2% for those with and without CKD, respectively (P < .0001 for composite). Multivariable analysis found CKD (OR 1.44, 95% CI 1.27-1.63), age (OR 1.05 [per year], 95% CI 1.04-1.06), hypertension (OR 1.61, 95% CI 1.40-1.84), diabetes (OR 2.03, 95% CI 1.79-2.29), smoking (OR 1.91, 95% CI 1.66-2.21), and less than high school education (OR 1.59, 95% CI 1.37-1.85) as the most significantly associated factors for premature CVD or death (all P < .0001). Survival analysis found those with premature MI or stroke and CKD had the poorest short-term survival over the next 3 years after screening. CONCLUSIONS: Chronic kidney disease is an independent predictor of MI, stroke, and death among men and women younger than age 55 and 65 years, respectively. These data suggest the biologic changes that occur with kidney failure promote CVD at an accelerated rate that cannot be fully explained by conventional risk factors or older age. Screening for CKD by using both the ACR and eGFR can identify younger and middle-aged individuals at high risk for premature CVD and near-term death.

Hypertension awareness, treatment, and control in chronic kidney disease.

BACKGROUND: Hypertension prevalence, awareness, treatment, and blood pressure control rates in the population with chronic kidney disease are limited. The objective of this study was to determine the state of blood pressure control in patients with chronic kidney disease. METHODS: This is a cross-sectional analysis of data of participants with chronic kidney disease from the Kidney Early Evaluation Program. The Kidney Early Evaluation Program is a national-based health screening program for individuals at high risk for kidney disease conducted in 49 states and the District of Columbia. Of 55,220 adults with kidney disease, 10,813 completed information for demographic and medical characteristics used in the analysis. Predictors of blood pressure control were assessed using multiple logistic regression analysis. RESULTS: Hypertension prevalence, awareness, and treatment proportions in the screened cohort were high (86.2%, 80.2%, and 70.0%, respectively), but blood pressure control rates were low (13.2%). These proportions increased with advancing stage of kidney disease. Elevated systolic blood pressure accounted for the majority of inadequate control. Male gender (odds ratio [OR] 0.86; 95% confidence interval [CI], 0.75-0.99), non-Hispanic black race (OR 0.76; 95% CI, 0.65-0.89), and body mass index of 30 kg/m(2) or more (OR 0.83; 95% CI, 0.73-0.94) were inversely related with blood pressure control. Those with stage 3 kidney disease were more likely to have blood pressure at goal than those with stage 1 kidney disease (OR 2.08; 95% CI, 1.55-2.80). CONCLUSION: We conclude that despite increased awareness and treatment of hypertension, control rates in these participants are poor. This poor control rate centers around elevated systolic pressure in people who are obese, non-Hispanic black, or male. These data suggest that those who are aware of their kidney disease are more likely to achieve blood pressure control.

Independent components of chronic kidney disease as a cardiovascular risk state: results from the Kidney Early Evaluation Program (KEEP).

BACKGROUND: The relationships of anemia, microalbuminuria, and estimated glomerular filtration rate (eGFR) with cardiovascular disease (CVD) and subsequent death are not fully understood. We hypothesized that each of these chronic kidney disease-related measures would have an independent relationship with CVD. METHODS: A cohort of 37 153 persons screened in the National Kidney Foundation's Kidney Early Evaluation Program were followed up for a median of 16.0 months (range, 0.2-47.5 months). Participants were volunteers who completed surveys regarding past medical events and who underwent blood pressure and laboratory testing. Estimated glomerular filtration rate was computed using a 4-variable equation. Mortality was ascertained by linkage to national data systems. RESULTS: Of 37 153 persons, the mean +/- SD age was 52.9 +/- 15.9 years, and 68.7% were female. A total of 1835 (4.9%) had a self-reported history of myocardial infarction, 1336 (3.6%) had a history of stroke, and 2897 (7.8%) had a history of myocardial infarction or stroke. Multivariate analysis controlling for age demonstrated that the following were independently associated with CVD: male sex (odds ratio [OR], 1.64; P<.001), smoking (OR, 1.73; P<.001), body mass index (OR, 1.01; P = .03), diabetes mellitus (OR, 1.66; P<.001), hypertension (OR, 1.77; P<.001), eGFR of 30 to 59 mL/min per 173 m(3) (OR, 1.37; P = .001), hemoglobin level of 12.8 g/dL or less (OR, 1.45; P<.001), and microalbuminuria of greater than 30 mg/L (OR, 1.28; P = .01). Survival analysis found CVD (OR, 3.02; P = .003), chronic kidney disease (OR, 1.98; P = .05), and the combination (OR, 3.80; P<.001) to be independent predictors of mortality. Persons with a combination of all 3 chronic kidney disease measures (anemia, microalbuminuria, and eGFR of <60 mL/min per 1.73 m(2)) had the lowest survival of about 93% by the end of 30 months. CONCLUSION: Anemia, eGFR, and microalbuminuria were independently associated with CVD, and when all 3 were present, CVD was common and survival was reduced.

Higher prevalence of anemia with diabetes mellitus in moderate kidney insufficiency: The Kidney Early Evaluation Program.

BACKGROUND: The Kidney Early Evaluation Program (KEEP 2.0) cross-sectional, community-based study, targeted individuals at increased risk for kidney disease and measured blood glucose, creatinine, and hemoglobin. METHODS: KEEP 2.0 screening data were used to determine the prevalence of anemia by level of kidney function and diabetes status. Estimated glomerular filtration rate (EGFR) was calculated using serum creatinine values, and categorized as > or =90, 60-89, 30-59 and <30 mL/min/1.73 m(2). Anemia was defined as hemoglobin <12 g/dL in men and in women aged >50 years, and <11 g/dL in women < or =50 years. Diabetes was defined as participant-reported diagnosis, fasting glucose >125 mg/dL, or nonfasting glucose >200 mg/dL. RESULTS: Data were available on 5380 participants screened from August 2000 through December 2001. Diabetes was present in 26.9% of participants, and anemia in 7.7%; 15.9% of participants had at least moderately reduced kidney function (EGFR <60 mL/min/1.73 m(2)). In participants with diabetes, anemia prevalence at the 4 levels of descending EGFR were 8.7%, 7.5%, 22.2%, and 52.4%, compared with 6.9%, 5.0%, 7.9%, and 50.0% in persons without diabetes. In a multivariable model, participants of non-white race/ethnicity, those with diabetes and those with EGFR <30 or 30-59 mL/min/1.73 m(2) had significantly increased odds of anemia. In addition, a significant sex-diabetes interaction was identified; odds of anemia were 4-fold greater in men than women with diabetes relative to sex-matched participants without diabetes. CONCLUSION: Diabetes was independently correlated with anemia, more so in men than women, and may be linked to premature expression of anemia in persons with moderate reductions in kidney function.

Vascular access results from the Dialysis Outcomes and Practice Patterns Study (DOPPS): performance against Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines.

BACKGROUND: The Kidney Disease Outcomes Quality Initiative Guidelines for Vascular Access in hemodialysis patients recommend native arteriovenous (AV) fistulae over AV grafts or catheters for permanent vascular access. They recommend letting fistulae mature > or =1 month before cannulation. METHODS: The Dialysis Outcomes and Practice Patterns Study (DOPPS) provides an unparalleled means to examine vascular access practice patterns and guidelines internationally, with particular attention to associations with mortality risk. RESULTS: Most patients in Europe and Japan dialyze through AV fistulae and very few use AV grafts; in the United States, more patients use grafts than fistulae. Patients who receive nephrologic care for over 30 days before starting dialysis have significantly higher chances of commencing via AV fistula. Medical directors of dialysis facilities in the United States commonly prefer grafts; in Europe and Japan, most prefer fistulae. In the United States, there is a relatively long average time between fistula creation and cannulation but significantly worse fistula survival than that seen in Europe. Tunneled catheters pose a higher mortality risk than permanent accesses and are associated with increased risk of failure of a subsequent fistula. The percentage of prevalent patients in the DOPPS countries using catheters has increased in recent years. DOPPS data suggest that performance in some countries falls short of practices achieved in other countries. AV fistula use is low in the United States but has been improving. The trend of increasing use of catheters in most countries is discouraging. CONCLUSION: The DOPPS will continue to monitor practice trends and explore whether greater application of guidelines will lead to fewer access complications and improved longevity for hemodialysis patients.

A report on four new cases of nephrogenic fibrosing dermopathy in chronic hemodialysis patients.

Nephrogenic fibrosing dermopathy (NFD) is a rare clinical entity affecting patients with renal failure, often on chronic dialysis or after transplantation. The patient profile at risk for this debilitating condition is undefined. Lack of awareness of the condition has hampered epidemiologic work in identifying the etiology. We present four chronic hemodialysis (HD) patients who developed this disease. The patients' ages ranged from 26 to 75 years, and they had received HD from between 20 months and 10 years before the diagnosis of NFD. Two patients had a history of renal transplantation. All patients had progressive thickening and woody induration of the skin associated with contractures, leading to difficult ambulation, and permanent disability within weeks of the diagnosis. In one case, the diaphragm, psoas muscle, and pericardium were involved. The latter is likely the first report of pericardial involvement of NFD. In all four patients, the skin findings were restricted to the extremities, sparing the trunk and face. Skin biopsy findings included thickened dermis with particularly thickened collagen bundles, fibroblast proliferation, minimal mucin deposition, and nearly absent inflammation. The pathologic findings were distinct from scleromyxedema and scleroderma. We found no laboratory evidence of autoimmune disease or thyroid dysfunction to account for alternate etiologies. CD34-positive cells were documented in the skin biopsies as well as in the diaphragm, psoas muscle, and pericardial tissue of the concerned case. NFD is a novel fibrosing disorder of progressively debilitating nature which needs further clinical characterization and recognition to guide investigation of its pathogenesis.

Identification of persons at high risk for kidney disease via targeted screening: the NKF Kidney Early Evaluation Program.

BACKGROUND: More than 340,000 individuals were receiving renal replacement therapy in the United States at the end of 1999; this number is projected to double by the year 2010. Almost half had a primary diagnosis of diabetes mellitus particularly type 2, and more than one quarter a primary diagnosis of hypertension. Studies have demonstrated effective maneuvers to prevent or delay the rate of progression of kidney disease, and decrease morbidity and mortality. The objective of early diagnosis is early detection of asymptomatic disease at a time when intervention has a reasonable potential to have a positive impact on outcome. METHODS: In 1997, the National Kidney Foundation launched KEEP trade mark (Kidney Early Evaluation Program), a free community-based screening that targets first order relatives of persons with hypertension, diabetes or kidney disease, and those with a personal history of diabetes or hypertension. RESULTS: Of the 889 individuals screened in the pilot study, 71.4% had at least one abnormality. The program includes an educational component and referral to a physician for follow-up of abnormal values. CONCLUSIONS: Targeted screenings are an effective means of identifying persons at risk for kidney disease, and can identify individuals at risk early enough in the course of their disease to allow for effective intervention.

Longitudinal Study of the National Kidney Foundation's (NKF) Kidney Early Evaluation Program (KEEP).

In 2000, the National Kidney Foundation implemented the Kidney Early Evaluation Program (KEEP 2.0) to increase awareness of kidney disease among those at highest risk, and improve outcomes through early detection and referral for care. The KEEP 2.0 screening program identified significant numbers of persons with reduced kidney function, with previously undetected kidney disease risk factors, and with inadequate risk factor control. These data support the evolution to KEEP 3.0, which will continue to identify individuals at high risk for kidney disease, and will address the educational needs of health care providers and consumers, given that preventing and managing kidney disease requires their joint effort. Consumers need to embrace lifestyle behaviors that reduce risk, and adhere to medical recommendations in managing their existing conditions. At the same time, providers need to ensure that the latest evidence-based guidelines in diagnosis and treatment are being implemented in their clinical practice. KEEP 3.0 participants will be randomly assigned to one of several educational programs that vary on whether they provide individually tailored or nontailored information, with long-term follow-up for evaluation of clinical outcomes. Tailored programs may be more successful in supporting behavioral change as these consider the individuals' "readiness to change." In addition, participant-identified providers will be randomly assigned to one of several educational protocols designed to provide evidence-based recommendations for clinical and pharmaceutical management of kidney disease and risk factors; these programs vary on whether they require active or passive participation of providers. Analytic evaluations will examine changes from baseline in participant kidney disease and risk factor status during follow-up, and estimate the influence of the various educational protocols on both process of care measures and clinical outcomes.