Effect of renin-angiotensin-aldosterone system blockade in adults with diabetes mellitus and advanced chronic kidney disease not on dialysis: a systematic review and meta-analysis.

The presumed superiority of renin-angiotensin-aldosterone system (RAAS)-blocking agents over other antihypertensive agents in patients with diabetes to delay development of end-stage kidney disease (ESKD) has recently been challenged. In addition, there is ongoing uncertainty whether RAAS-blocking agents reduce mortality and/or delay ESKD in patients with diabetes and chronic kidney disease (CKD) stages 3-5. In this subgroup, there might be an expedited need for renal replacement therapy (RRT) when RAAS-blocking agents are used. We conducted a meta-analysis of randomized controlled trials (RCTs) of at least 6-months duration in adult patients with diabetes who also have non-dialysis CKD stages 3-5. RCTs comparing single RAAS-blocking agents to placebo or alternative antihypertensive agents were included. Outcomes of interest were all-cause mortality, cardiovascular morbidity, progression of renal function, ESKD and adverse events. A total of nine trials (n = 9797 participants with CKD stages 3-5) fit our inclusion criteria. There was no difference between the RAAS group and control group regarding all-cause mortality {relative risk [RR] = 0.97 [95% confidence interval (CI) 0.85-1.10]}, cardiovascular mortality [RR = 1.03 (95% CI 0.75-1.41)] and adverse events [RR = 1.05 (95% CI 0.89-1.25)]. There was a trend for a favourable effect for non-fatal cardiovascular events [RR = 0.90 (95% CI 0.81-1.00)] and a lower risk of the composite endpoint need for RRT/doubling of serum creatinine [RR = 0.81 (95% CI 0.70-0.92)] in the RAAS-blocking agents group versus the control group. We found evidence that in patients with diabetes mellitus and CKD stages 3-5, treatment with RAAS-blocking agents did not result in a clear survival advantage. The effect on renal outcomes did depend on the selected outcome measure. However, we did not find evidence that the use of RAAS-blocking agents expedited the need for RRT in patients with CKD stages 3-5.

The impact of periodontal disease on physical and psychological domains in long-term hemodialysis patients: a cross-sectional study.

PURPOSE: Periodontal disease is a chronic infectious disease. Individuals with end-stage kidney disease (ESKD) experience impaired quality of life (QoL) and low oral health. This is the first comprehensive study which aimed to explore the link between periodontal disease and quality of life, assessed with the Short Form 36-Item Health Survey in hemodialysis patients. METHODS: In total, 101 patients (57 females) with ESKD were recruited from two Romanian dialysis centers. Periodontal disease assessment included the measurement of periodontal disease index, with its three components: the gingival and periodontal index (GP), the bacterial plaque index (PI) and the calculus index (CI). For assessing QoL, we used the Short Form 36-Item Health Survey (SF-36), with its two components: physical component (PCS) and mental component (MCS). RESULTS: The mean age was 52.5 ± 14.3 years. The dialysis vintage was 6.7 ± 5.6 years. According to periodontal status, the mean value of GP was 4.0 ± 1.3, mean PI was 1.8 ± 0.9, and mean CI was 1.3 ± 0.7. Regarding the QoL, the means for PCS and MCS were 38.0 ± 17.3 and 45.0 ± 16.3, respectively. In univariate analysis, the physical and mental components of QoL were significantly associated with the gingival and periodontal index, the bacterial plaque index and the calculus index. In the multivariable linear regression, only the gingival and periodontal index remained significantly associated with physical component (ß = -3.26, p = 0.04, 95% CI -6.39 to -0.13) and mental component (ß = -5.57, p = 0.001, 95% CI -8.74 to -2.41) of QoL. CONCLUSION: Our study shows a high prevalence and severity of periodontal disease. The gingival and periodontal index was associated with low QoL, both on physical and on mental components.

Serum Uric Acid and Risk for Acute Kidney Injury Following Contrast.

Contrast-induced acute kidney injury (CI-AKI) is a common cause of hospital-acquired acute kidney injury (AKI). We evaluated the evidence that uric acid (UA) plays a pathogenic role in CI-AKI. Ten studies were eligible for inclusion for meta-analysis. Hyperuricemia predicted risk for cases with AKI in prospective cohort studies. Higher levels of serum UA (SUA), as defined by the authors, were associated with a 2-fold increased risk to develop AKI (pooled odds ratio 2.03; 95% confidence interval [CI] 1.48-2.78). Significant heterogeneity was found in cohort studies ( P = .001, I2 = 85.7%). In 2 clinical trials, lowering of SUA with saline hydration was significantly associated with reduced risk for AKI compared with saline hydration alone or saline hydration with N-acetyl cysteine. An analysis of 2 randomized controlled trials found that allopurinol with saline hydration had a significant protective effect on renal function (assessed by serum creatinine values) compared with hydration alone (mean difference: -0.52 mg/dL; 95% CI: -0.81 to -0.22). Hyperuricemia independently predicts CI-AKI. Two clinical trials suggest lowering SUA may prevent CI-AKI. The mechanism by which UA induces CI-AKI is likely related to acute uricosuria.

The Survival of Roma Minority Patients on Chronic Hemodialysis Therapy - A Romanian Multicenter Survey.

OBJECTIVE: The Roma minority represents the largest ethnic group in Central and South-East European countries. Data regarding the mortality in Roma hemodialysis subjects are limited. We evaluated the 3 year mortality of ESRD Roma patients treated with hemodialysis (HD). STUDY DESIGN AND SETTING: Our prospective cohort study included 600 ESRD patients on HD therapy recruited from 7 HD centers, from the main geographical regions of Romania. The median age of the patients was 56 (19) years, 332 (55.3%) being males, 51 (8.5%) having Roma ethnicity. RESULTS: Roma ESRD patients initiate dialysis at a younger age, 47.8 years vs. 52.3 years (P = 0.017), present higher serum albumin (P = 0.013) and higher serum phosphate levels (P = 0.021). In the Roma group, the overall 3 year mortality was higher when compared to Caucasians (33.3% vs. 24.8%). The multivariate survival analysis revealed that being of Roma ethnicity is an independent risk factor for mortality (HR = 1.74; 95% CI = 1.04-2.91; P = 0.035). CONCLUSIONS: Roma patients with ESRD initiate HD therapy at a younger age as compared to Caucasians. They have a higher 3 year mortality rate and are dying at a younger age. Roma ethnicity represents an independent risk factor for mortality in our cohort.

Increased arterial stiffness predicts cognitive impairment in hemodialysis patients.

Introduction Cognitive impairment is a major, but underdiagnosed, risk factor for negative outcomes in patients with chronic kidney disease (CKD). The main goal of this study was to evaluate, for the first time, the relationship between arterial stiffness and cognitive impairment in a cohort of hemodialysis patients. Methods We prospectively analyzed the cognitive function and pulse wave velocity (PWV) of 72 hemodialysis patients, mean age 56.54 ± 13.96 y, from two Romanian dialysis centers. We administered to all patients the Mini Mental State Examination (MMSE), Trail Making Test Part-A (TMTA) and Part-B (TMTB), and Mini-Cog Test. Radial arterial waveforms during 40 cardiac cycles were recorded in each patient. Findings Mean MMSE score was 25.13 ± 3.47, mean MiniCog score was 3.51 ± 1.18, mean TMTA (sec) was 103.77 ± 53.13 and mean TMTB (sec) was 214.93 ± 112.25. In linear unadjusted regression, PWV values were associated with worse MMSE scores (ß = -0.36, P = 0.001, 95% CI: -0.68 to -0.17), and MiniCog scores (ß = -0.26, P = 0.02, 95% CI: -0.19 to -0.01). Also, PWV value was significant associated with TMTA test, but not with TMTB. After further adjustments, PWV remained a strong predictor for cognitive impairment measured by MMSE, TMTA, MiniCog, but not for TMTB. Discussion Cognitive impairment was associated with higher PWV values in our cohort. Further evidence is needed in order to support arterial stiffness as a long-term predictor for cognitive decline in ESRD patients.

Vasopressin receptor antagonists for the treatment of heart failure: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND/OBJECTIVES: Elevated vasopressin may increase systemic vascular resistance and pulmonary capillary wedge pressure, subsequently decrease stroke volume and cardiac output. Vasopressin receptor antagonists may counteract these effects and improve outcomes in heart failure. We aimed to assess benefits and harms of vasopressin receptor antagonists (VRAs) versus placebo in addition to standard care in adults with heart failure (HF). METHODS: We conducted a systematic review of randomized controlled trials with searches of CENTRAL and MEDLINE to January 2014 and reference lists without language restriction. Meta-analysis using a random-effects model was done for all-cause and cardiovascular mortality, hospitalization for heart failure, changes in clinical assessment of HF, serum sodium concentration (Na), kidney function and treatment-specific side effects. RESULTS: We identified 13 trials and 5,525 participants. In 10 trials, participants received standard therapy for HF. In low-quality evidence, VRAs in patients with HF had no effect on all-cause mortality risk ratios (RR 0.98; CI 0.88-1.08), cardiovascular mortality (RR 1.03; CI 0.91-1.16) or change in creatinine mean difference (MD -0.01; CI -0.10 to 0.09 mg/dL), but reduced body weight by 0.8 kg from baseline (MD -0.83; CI -1.10 to -0.55 kg) and increased Na (MD 2.61; 95 % CI 1.88-3.35 mmol/L). Compared with placebo, VRAs increased the risk of adverse events by 14 % (RR 1.14; CI 1.04-1.26). Studies were generally limited to short-term follow-up with limited data available on patient important outcomes. CONCLUSIONS: Vasopressin receptors antagonists may reduce body weight and increase Na but do not improve all-cause mortality, cardiovascular mortality or kidney function. In addition, acceptability of long-term treatment side effects and hospitalization appears problematic.

Erythropoiesis-stimulating agents (ESA) for preventing the progression of chronic kidney disease: a meta-analysis of 19 studies.

BACKGROUND: The effect of anemia correction on kidney function in chronic kidney disease (CKD) patients remains unclear. As 19-40% of patients with CKD receive an erythropoiesis-stimulating agent (ESA), this is a potentially important consideration. SUMMARY: We conducted a systematic review and meta-analysis of randomized trials to January 1, 2014 in adult patients with CKD stages 1 to 4. SELECTION CRITERIA FOR STUDIES: randomized controlled trials of at least 2 months duration. Patients were allocated to ESA versus placebo, no treatment, or different ESA doses with the purpose of achieving a higher versus a lower hemoglobin target. The analyzed outcomes were the need for renal replacement therapy, doubling of serum creatinine, change in GFR (ml/min), mortality and withdrawal of treatment due to adverse events. A total of 19 trials (n = 8,129 participants with CKD stage 1-4) were reviewed. There was no difference in the risk of end-stage kidney disease (RR, 0.97 [CI 0.83-1.20], 17 trials, 8,104 participants), change in GFR (Mean Difference [MD] -0.45 [-2.21, 1.31], 9 trials, 1,848 participants) or withdrawal of treatment due to adverse events (RR, 1.18 [CI 0.77-1.81], 10 trials, n = 1,958 participants) for patients at higher hemoglobin (Hb) targets. Furthermore, no statistically significant differences in mortality (Risk Ratio [RR] 1.10 [CI 0.90-1.35], 16 trials, n = 8,082 participants) were observed. Key Messages: There is no evidence that ESA treatment affects renal function in patients with CKD. Use of these agents should not therefore be influenced by considerations about influencing CKD progression.

A cross-sectional study regarding the impact of end-stage renal disease on quality of life.

UNLABELLED: The number and severity of physical and psychological symptoms reported by chronic hemodialysis (HD) patients are significant and increasing; with a clear need to clarify which symptom intervention is the most needed. Measurements of quality of life (QoL) have shown, for many decades, an impairment of both physical and psychological aspects in both chronic kidney disease (CKD) pre-dialysis and in end stage renal disease (ESRD) patients. This cross-sectional study was conducted assess the quality of life of a Romanian hemodialysis population and the impact of several clinical and biochemical factors. MATERIAL AND METHODS: A total of 102 patients (41 males, 61 females) with a mean age of 52.5 +/- 12.0 years, who were treated with HD three times per week in our dialysis center were included in the study. All subjects completed the Short Form Health Survey Questionnaire (SF-36). Clinical and biochemical parameters were extracted from the EUCLID electronic database. RESULTS: Our measurement showed a deteriorated QoL in our population, all of the included subjects presenting with much lower scores in both physical and mental components than the reference values of SF-36. We did not found any statistic significant correlation between hemoglobin (Hgb) levels or dialysis adequacy and different domains of the SF-36. The only significant association was found between age and the physical component of the SF-36, implying that older patients perceive a more degraded quality of life. CONCLUSION: HD patients experience a great burden from physical and psychological symptoms of the disease, perceiving an important impairment in their quality of life, especially regarding the physical component.