Endothelial dysfunction, inflammation and atherosclerosis in chronic kidney disease--a cross-sectional study of predialysis, dialysis and kidney-transplantation patients.

BACKGROUND: Cardiovascular morbidity and mortality are high in chronic kidney disease (CKD) patients compared to the general population. Systemic inflammation may contribute to endothelial dysfunction and accelerated atherosclerosis in CKD patients. We assessed the relationship among, endothelial dysfunction, early atherosclerosis and inflammation in predialysis, dialysis and post kidney-transplantation CKD patients. METHODS AND RESULTS: We studied 76 consecutive CKD patients; 38 predialysis, 18 haemodialysis and 22 kidney-transplant patients. A group of 65 age and gender matched controls were also studied. In both patients and controls, high-sensitivity C-reactive protein (CRP) levels, systemic endothelial function (brachial artery flow mediated dilation, FMD,%) and carotid artery intima-media thickness (IMT, mm) were measured. CKD patients had increased CRP levels (3.7 [1.0-6.0]mg/L vs 1.0 [0.5-2.1]mg/L; p<0.001), reduced FMD (2.2 [1.0-4.0] vs 5.6 [4.4-7.1]; p<0.001) and increased IMT (0.82±0.21 vs 0.67±0.16; p<0.001) values compared to controls. In CKD patients, a significant negative correlation was found between CRP levels and FMD responses (r=-0.51; p<0.001) while a significant positive correlation was found between CRP and IMT values (r=0.50; p<0.001). Increased CRP levels were an independent predictor of both abnormal FMD and IMT after adjusting for age, systolic and diastolic BP and total cholesterol. Compared with predialysis and kidney-transplant patients, haemodialysis subjects had significantly lower FMD and higher CRP and IMT values. CONCLUSIONS: CKD patients taken together have a higher inflammatory status compared to controls. Abnormal FMD responses and IMT values are more commonly found in dialysis patients. Our findings suggest that endothelial dysfunction and atherosclerotic changes correlate with inflammation.

Pulse pressure and inhibition of renin-angiotensin system in chronic kidney disease.

BACKGROUND: Elevated pulse pressure (PP) is an indicator of poor outcome in hypertensives in the general population and on haemodialysis. The prognostic value of PP in pre-dialysis patients with chronic kidney disease (CKD) stages 4/5 and its interaction with renin-angiotensin system (RAS) inhibitors is unknown. METHODS: This retrospective study of 349 patients from the pre-dialysis clinic analysed the effect association of PP and RAS inhibition on adverse outcomes in CKD stages 4/5. Primary endpoints were a composite of death or dialysis. RESULTS: At baseline, 349 patients (63% males, 34% diabetics) were aged 60+/-0.8 years (mean+/-SEM) with systolic blood pressure (SBP) 149+/-1.3 mmHg, diastolic BP (DBP) 83+/-0.7 mmHg, PP 66+/- 1.0 mmHg, creatinine 442+/-16 micromol/l and haemoglobin 10.7+/-0.1 g/dl. Patients were followed up for 297+/-19 days and 93% took one to seven (2.45+/-0.07) antihypertensives. At presentation, the adverse outcome group had higher SBP (151+/-1.5 vs 145+/-2.4 mmHg; P<0.05), proportion of diabetes (39% vs 23%; P<0.05) and creatinine (478+/-22 vs 354+/-11 micromol/l; P<0.05), but lower haemoglobin (10.6+/-0.1 vs 11.2+/-0.2 g/dl; P<0.05). PP increased with age (r(2): 0.4; P<0.0001). PP >80 mmHg was associated with adverse outcome (Kaplan-Meier survival analysis, log-rank test P<0.05). In a model of proportional hazards regression, adjusted for age, baseline creatinine, diabetes and haemoglobin, elevated PP was associated with poorer outcome (hazards ratio: 1.09; 95% confidence interval: 1.01-1.18; P<0.05) and angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker use was beneficial (hazards ratio: 0.73; 95% confidence interval: 0.53-0.99; P<0.05). CONCLUSIONS: The study demonstrates that elevated PP indicates high risk of death or dialysis and the benefit of blockade of the RAS is independent of the baseline PP in patients with CKD stages 4/5.

A training programme for healthcare support workers.

Healthcare support workers (HCSWs) are at the front line of patient care delivery. It is essential that they are appropriately trained and competent in the skills required to deliver the fundamentals of care. There is also a need for HCSWs to have access to continuing professional development that offers a career pathway. The University Hospitals Coventry and Warwickshire NHS Trust has developed a framework for career progression that incorporates three phases of continuing professional development. These are organised and co-ordinated by a dedicated support worker training team comprising four registered nurses plus senior support workers in the role of peripatetic NVQ Care assessors.