Anaemia, diabetes and chronic kidney disease: where are we now?

Anaemia is a common finding in people with diabetes and chronic kidney disease and failure of the kidney to produce erythro-poietin in response to a falling haemoglobin concentration is a key component, correlating with the degree of albuminuria, renal dysfunction and iron deficiency. Anaemia in diabetes is associated with a number of adverse outcomes, including increased risk of all cause and cardiovascular mortality. Whether or not anaemia is a marker or mediator of adverse outcome still remains to be completely resolved. Treatment of anaemia in diabetes has quality of life benefits and reduces transfusion requirements. Correction of anaemia to normal haemoglobin concentrations is associated with significant adverse cardiovascular outcomes and is not recommended, escalating doses of erythropoiesis-stimulating agents should be avoided. The treatment of anaemia in people with diabetes and chronic kidney disease should begin with optimisation of iron stores. An aspirational haemoglobin concentration range of 10-12 g/dl with anaemia management, balances proven benefits of anaemia treatment with potential cardiovascular risk.

Estimating glomerular filtration rate: comparison of the CKD-EPI and MDRD equations in a large UK cohort with particular emphasis on the effect of age.

BACKGROUND: The chronic kidney disease (CKD)-Epidemiology Collaboration (CKD-EPI) equation was developed to address the underestimation of measured glomerular filtration rate (GFR) by the Modification of Diet in Renal Disease (MDRD) equation at levels >60 mL/min/1.73 m(2). AIM: To assess the impact of the CKD-EPI equation on the estimation of GFR in a large adult UK population (n = 561,400), particularly looking at the effect of age. DESIGN: Serum creatinine results (ID-MS-aligned enzymatic assay) were extracted from the pathology database during 1 year on adult (≥ 18 years) patients from primary care. METHODS: The first available creatinine result from 174,448 people was used to estimate GFR using both equations and agreement assessed. RESULTS: Median CKD-EPI GFR was significantly higher than median MDRD GFR (82 vs. 76 mL/min/1.73 m(2), P < 0.0001). Overall mean bias between CKD-EPI and MDRD GFR was 5.0%, ranging from 13.0% in the 18-29 years age group down to -7.5% in those aged ≥ 90 years. Although statistically significant at all age groups the difference diminished with age and the agreement in GFR category assignment increased. Age-adjusted population prevalence of CKD Stages 3-5 was lower by CKD-EPI than by MDRD (4.4% vs. 4.9%). CONCLUSION: CKD-EPI produces higher GFR and lower CKD estimates, particularly among 18-59 year age groups with MDRD estimated GFRs of 45-59 mL/min/1.73 m(2) (Stage 3A). However, at ages >70 years there is very little difference between the equations, and among the very elderly CKD-EPI may actually increase CKD prevalence estimates.

Characteristics, cardiovascular comorbidity and medicines management in patients with type 2 diabetes and CKD: results of the IRIDIEM study.

BACKGROUND: Type 2 diabetes is a leading cause of chronic kidney disease (CKD). The purpose of the Individual Risk-Profiling and Treatment in Diabetes Management (IRIDIEM) study was to evaluate the characteristics of CKD and associated comorbidities in patients with type 2 diabetes and CKD. METHODS: IRIDIEM was conducted as a cross-sectional survey in 109 centres in 11 countries and included 1,205 patients aged >or=50 years with type 2 diabetes for >or=5 years and CKD stage 2-4. RESULTS: 50% of patients were in CKD stage 4; 42% had CKD stage 3, and 4% were in CKD stage 2. Concomitant risk factors for cardiovascular disease and/or progression of CKD included hypertension (92% of patients), proteinuria (74%), hypercholesterolaemia (65%), and hypertriglyceridaemia (44%). Only 64% of patients with hypertension had received antihypertensive medication. Anaemia was present in 34% of patients and increased markedly with advanced CKD stages. Of patients with documented anaemia, only 19% had received epoetin and only 7% had received iron treatment. CONCLUSION: IRIDIEM documents the need to improve adherence to current best practice guidelines for management of cardiorenal risk factors including earlier initiation of antihypertensive treatment, lipid and anaemia management in this high-risk patient population.

Blind Pew sends a black spot: the current haemoglobin controversy.

Two randomised controlled trials of anaemia management published in the last year have fuelled the current haemoglobin controversy and led the United States Food and Drug Administration to issue a public health advisory warning concerning the use of erythropoiesis-stimulating agents and target haemoglobin levels. There is much more to the haemoglobin controversy than purely target haemoglobin levels. This article seeks to outline some of the current issues involved.

Chronic kidney disease management in the United Kingdom: NEOERICA project results.

Early identification of patients with chronic kidney disease (CKD) may allow health-care systems to implement interventions aimed at decreasing disease progression and eventual morbidity and mortality. Primary care in the United Kingdom is computerized suggesting a separate screening program for CKD may not be necessary because identifying data already populates primary care databases. Our study utilized a data set of 163 demographic, laboratory, diagnosis, and prescription variables from 130 226 adults in the regions of Kent, Manchester, and Surrey. The patients were 18 years of age and older in a 5-year study period culminating in November 2003. Estimated glomerular filtration rate was calculated from the four-variable Modification of Diet in Renal Disease equation using calibrated creatinine levels. A valid creatinine value was recorded in almost 30% of this cohort. The age-standardized prevalence of stage 3-5 CKD was 10.6% for females and 5.8% for males. In these patients, the odds ratio for hypertension was 2.1, for diabetes 1.33, and for cardiovascular disease 1.69. Only 20% of the diabetic people with stage 3-5 CKD had a blood pressure less than or equal to 130/80 mm Hg. The proportion of patients with anemia significantly rose as renal function declined. We suggest that stage 3-5 CKD is easily detected in existing computerized records. The associated comorbidity and management is readily available enabling intervention and targeting of specialist resources.

Assessing the prevalence, monitoring and management of chronic kidney disease in patients with diabetes compared with those without diabetes in general practice.

AIMS: To compare rates of chronic kidney disease (CKD) in patients with diabetes and management of risk factors compared with people without diabetes using general practice computer records, and to assess the utility of serum creatinine and albuminuria as markers of impaired renal function. METHODS: The simplified Modification of Diet in Renal Disease (MDRD) equation was used to estimate glomerular filtration rate (eGFR) and stage of CKD. Further data were extracted to assess how effectively impaired renal function was being identified and how well potentially modifiable risk factors were being managed. The setting was 17 practices in Surrey, Kent and Greater Manchester (2003-2004). Participants were all patients with serum creatinine (SCr) recorded. RESULTS: Of the total population of 162 113, 5072 were recorded as having a diagnosis of diabetes, giving a prevalence of 3.1%. Of patients with diabetes, 31% had clinically significant CKD (defined as eGFR < 60 ml/min per 1.73 m(2); CKD stages 3-5) compared with 6.9% of those without diabetes. Only 33% of patients with diabetes at CKD stage 3 had serum creatinine > 120 micromol/l. Of patients with diabetes with eGFR < 60 ml/min per 1.73 m(2), 63% had normoalbuminuria. Considering those with eGFR 30-60 ml/min per 1.73 m(2), 42% of people with diabetes were on an ACE inhibitor compared with 25% of those without diabetes; 32% of patients with diabetes who had any record of micro- or macroalbuminuria at CKD stage 3 were taking an ACE inhibitor. Of people with diabetes and hypertension (BP > 140/80 mmHg), 26% were not prescribed any hypertensive medication, regardless of level of CKD. CONCLUSIONS: CKD is common in people with diabetes living in the community in the UK. The study found a similar rate of stage 3-5 CKD to that found previously in the USA. Currently used measures of renal function fail to identify CKD as effectively as eGFR. Risk factors for CKD and its progression are suboptimally managed.

Severe acute renal failure in adults: place of care, incidence and outcomes.

BACKGROUND: Department of Health guidelines recommend specialist critical care facilities for patients with severe single-organ failure such as acute renal failure (ARF). Prospective studies examining incidence, causes and outcomes of ARF outside of intensive care settings are lacking. AIM: To determine the incidence, causes, place of care and outcomes of severe single-organ ARF. DESIGN: Prospective observational study. METHODS: For 6 weeks in June-July 2003, renal physicians were contacted daily, and ICUs on alternate days, to identify cases of severe single-organ ARF in the Greater Manchester area. All patients with serum creatinine >or=500 micromol/l and not requiring other organ support were included. Patients with end-stage renal disease were excluded. Survivors were followed up at 90 days and 1 year from admission. Two independent consultant nephrologists assessed each case using anonymized summaries. RESULTS: Eighty-five patients had multi-organ ARF and 28 had severe single-organ ARF (380 and 125 pmp/year, respectively). Of those with single-organ ARF, 10 (36%) had known pre-existing chronic kidney disease. Renal replacement therapy (RRT) was required in 15 (54%). Total bed occupancy on ICUs relating to single-organ ARF was 59 days (range per patient 1-21). At 90 days, 18 (64%) were alive, and 17 (94%) had independent renal function. At 1 year, 4/18 had died, none receiving RRT at the time of death. Survivors all had independent renal function. In 13 (46%) cases there was an unacceptable delay in patient transfer and in 7 (25%), delays in assessment or commencement of RRT may have adversely affected patient outcome. DISCUSSION: The incidence of ARF treated with RRT is rising. Delays in transfer to renal services may result in inappropriate ICU bed use, and may adversely affect patient outcomes. There are serious problems regarding the appropriate use of expensive and limited medical resources in the critical care area, and in providing safe and effective treatment of patients with ARF.

Experience of 5-aminosalicylate nephrotoxicity in the United Kingdom.

AIM: To study 5-aminosalicylate nephrotoxicity in patients with inflammatory bowel disease in the UK. METHODS: A detailed postal questionnaire was sent to all 1298 names in the British Society of Gastroenterology database and 290 consultant members of the Renal Association. The British Society of Gastroenterology reported new cases monthly, the Renal Association 6 monthly. Results were expressed as estimated glomerular filtration rate. RESULTS: Retrospective study: cases--British Society of Gastroenterology:Renal Association 202:87, aged 15-76 years. Median peak (range) creatinine (British Society of Gastroenterology:Renal Association) - 300:301 (78-1200) micromol/L. Prospective study - 59 cases, median age 52 years (M:F ratio: 47:12). Median pre-treatment estimated glomerular filtration rate: 76.9 (123.9-39), at diagnosis 28.4 (80.5-3.6, creatinine range: 92-1361 micromol/L), recovery 46.8 [111.2-end stage renal failure] mL/min/1.73 m2. Recovery of renal function was significantly improved for patients treated for < 12 months [n = 10, median recovery estimated glomerular filtration rate 70.5 (92-26.9) vs. > 12 months 38.4 (111.2-end stage renal failure) mL/min/1.73 m2, P = 0.028]. CONCLUSIONS: Regular monitoring of renal function may allow earlier detection of nephrotoxicity, particularly during the first year of therapy. Based on an inflammatory bowel disease prevalence in the United Kingdom of 412 x 10(5) with about 50% on treatment, we estimate that the incidence of clinical nephrotoxicity in patients taking 5-aminosalicylate therapy is approximately one in 4000 patients/year.

Stability of parathyroid hormone ex vivo in haemodialysis patients.

BACKGROUND: The stability of parathyroid hormone (PTH) in blood ex vivo is a significant practical problem for laboratories and clinicians. Several studies have suggested that PTH is more stable in blood collected into a potassium edetate (EDTA) preservative. METHODS: To confirm that this was applicable to renal dialysis patients using our assay (Nichols chemiluminescence), we examined PTH stability in 13 patients with end-stage renal failure using three different blood collection tubes. RESULTS: PTH remained stable in EDTA plasma for up to 48 h at room temperature. PTH was significantly reduced in serum collected into plain tubes after 2 h, and after 4 h in serum collected into serum separator tubes, at room temperature. CONCLUSION: In the assessment of renal osteodystrophy, the use of EDTA plasma can confer significant benefit, especially in busy laboratories where rapid frozen separation of blood may be hard to achieve.

Midlife women's experiences living with heart disease.

The purpose of this paper is to report results from a qualitative field study of 15 women with heart disease. The study was conducted over a two-year period in a number of clinical settings to document women's subjective experiences after angioplasty or cardiac surgery. The phenomena of interest were participants' perceptions of their health, the impact cardiac illness was having on their lives, lifestyle changes they had engaged in since diagnosis, and how they felt about having heart disease. Qualitative content analysis was applied to field notes and in-depth interviews. The overall sense of living with heart disease for these midlife women was one of paradox. Implications of their contradictory experiences are discussed as they apply to nursing practice.

Non-specialist management of acute renal failure.

In a 12-month prospective study of the initial management of patients with acute renal failure (ARF) in East Kent (population 593 000), we evaluated the initial management of ARF and assessed what proportion of ARF may have been preventable. Patients were seen and assessed on a daily basis, and were followed until discharge from hospital or death; survivors were subsequently followed for 3 years. Overall, 288 patients developed ARF (486 per million population/year). Mean age at presentation was 73 years (range 14-96). Initial assessment was often suboptimal, and key features in investigation and initial management were often lacking. In 108 cases, ARF was iatrogenic and/or potentially preventable (53 preventable, 99 iatrogenic, 44 both). Overall survival was 56% at discharge from hospital, 35% at 1-year follow-up, 31% at 2 years, and 28% at 3 years. In discharged patients, recovery of function was complete in 69%. A significant proportion of ARF is preventable. Clear guidelines, easily accessible at the point of care, could aid the diagnostic evaluation of the patient with ARF and indicate where referral for a specialist opinion is appropriate.

Sexuality and safer sex: the issues for lesbians and bisexual women.

UNLABELLED: Nursing interventions to help women reduce their risk of contracting HIV must be designed from an in-depth understanding of the complex sociocultural patterns of sexuality in particular communities and among specific subgroups. OBJECTIVE: In this data collection phase of a community-based HIV prevention project, the objective was to understand HIV risk-taking and HIV risk-reduction activities of lesbians and bisexual women. DESIGN: Qualitative field study. SETTING: Data were collected in women's bars and dance clubs and at selected lesbian/bisexual community events in San Francisco. PARTICIPANTS: Interviews were conducted with 1,189 racially diverse, socially and sexually active lesbians and bisexual women. RESULTS: Inductive content analysis produced two themes: realities of sexual behavior and sexual expressions and their meanings. Realities of sexual behavior included an assumption that women who have sex with other women cannot get HIV, a lack of familiarity with HIV prevention strategies, inconsistent practice of safer sex with men and/or women, and the negative effect of alcohol or drug use on safer sex efforts. Sexual expressions and their meaning included trust in monogamy, a sense that safer sex practices detracted from intimacy and eroticism, the difficulty of negotiating sexual behaviors with men or women, and dealing with partner resistance to safer sex practices. CONCLUSIONS: Specific recommendations for practice are the need for nurses to understand the range and diversity of women's sexual behaviors, to develop skills in conducting inclusive sexual histories, and to develop a comprehensive approach to sexual health.

Inclusion of children in clinical research: lessons learned from mothers of diabetic children.

Nine mothers of diabetic children participated in a qualitative study about the factors that influenced them to consent to have their children involved in clinical research. They were asked to describe how they made decisions about involving their children in research, what motivated them to keep their children in research once they were enrolled, and how they evaluated the clinical studies their children had been in. Results suggest that mothers engage in a personal calculus before making a choice to consent.

A nursing critique of US welfare system reform.

In 1996, the Aid to Families with Dependent Children program was repealed, and the welfare system in the United States was changed. This article critiques, from a nursing perspective, US welfare system reform. It interrogates dominant ideologies about poverty, welfare, and waged labor; examines federal welfare reform legislation of the 1990s and its programmatic implementation at the state level; discusses global health and safety implications of welfare replacement initiatives; and challenges nurses to political and scholarly action.

Assessment of quality of life in a single centre dialysis population using the KDQOL-SF questionnaire.

Health-related quality of life (HRQOL) is a valid marker of outcome for chronic dialysis therapy. A wide range of questionnaires are now available which assess different aspects of an individual's health. Appreciation of those factors that contribute to explaining HRQOL items remains poorly defined. The development of disease-specific questionnaires such as KDQOL-SF, should allow for such questions to be better answered. A cross-sectional analysis of our chronic dialysis population was made using the KDQOL-SF questionnaire. By multiple linear regression analysis demographic, clinical and dialysis-related factors were assessed for their contribution to the HRQOL in this population. The HRQOL of these patients was also compared against a general population sample. From a total of 190 chronic dialysis patients, 146 completed the KDQOL-SF questionnaire. The haemodialysis (HD) and peritoneal dialysis (PD) patients were similar with respect to most demographic, clinical and dialysis variables except for haemoglobin and albumin which were significantly (p < 0.05) greater in the peritoneal and haemodialysis populations respectively. Compared to the general population, the HRQOL of dialysis patients was impaired for all SF-36 subscales. Use of the disease-specific components of KDQOL-SF discriminated between dialysis modality for our dialysis population. Multiple linear regression analysis demonstrated that 27.5 to 42.7% of the variance in the SF-36 subscales could be explained. Satisfactory sleep, dialysis related symptoms, effect of kidney disease on lifestyle and burden of kidney disease were found to be the most important determinants of HRQOL for this population.