Dysglycemia predicts cardiovascular and kidney disease in the Kidney Early Evaluation Program.

The cardiometabolic syndrome has been associated with both chronic kidney disease (CKD) and cardiovascular disease (CVD). Using data from the National Kidney Foundation-Kidney Early Evaluation Program, the authors sought to investigate this association in a targeted CKD cohort. A total of 26,992 patients met eligibility criteria including age 18 years and older, diabetes, hypertension, or family history of CKD, diabetes, or hypertension and excluded those taking renal replacement therapy. Individuals were identified by Third Report of the National Cholesterol Education Program Adult Treatment Panel (NCEP-ATP III) criteria (dysglycemia, hypertension, and dyslipidemia) and World Health Organization criteria (obesity and proteinuria). Univariate and multivariate analyses were used to evaluate increasing components of the cardiometabolic syndrome, CKD, and CVD. On multivariate analysis there was a graded relationship between increasing components with an increased prevalence of CKD and CVD. Additionally, there was a graded trend with the stage of dysglycemia (eg, normoglycemia, prediabetes, and overt diabetes) and increasing CKD. However, there was only an increased prevalence of CVD observed in the clinically diabetic group. This trend was also observed with increasing serum glucose levels and an increasing percent of CVD and CKD up to 160 mg/dL. However, prevalent CVD increased at >140 mg/dL and prevalent CKD at >180 mg/dL. Therefore, data support that increasing metabolic components and dysglycemia are strongly associated with an increased prevalence of CKD and CVD.

A series of unusual complications of the presternal peritoneal dialysis catheter.

An ongoing problem for peritoneal dialysis (PD) patients has been complications associated with an indwelling PD catheter. The indwelling catheter has been through many modifications aimed at reducing complications and providing effective delivery of dialysis solution. In this report, we review four cases of rare complications associated with presternal PD catheters and a brief review of the Tenckhoff, Toronto Western Hospital, and Missouri swan-neck abdominal and presternal PD catheters.

Renin-angiotensin-aldosterone system intervention in the cardiometabolic syndrome and cardio-renal protection.

The metabolic syndrome, also known as the cardiometabolic syndrome (CMS), is a state of metabolic and vascular dysregulation that is associated with activation of the renin-angiotensin-aldosterone system (RAAS). Clinical components of the CMS include central or visceral obesity, hypertension (HTN), dyslipidemia, insulin resistance/hyperinsulinemia, and microalbuminuria that collectively convey increases in oxidative stress, inflammation, and subsequent endothelial dysfunction. The cardio-renal inflammation and oxidative stress enhanced in the CMS increases the risk for cardiovascular disease (CVD) and renal disease end-points such as stroke, congestive heart failure, and chronic kidney disease (CKD). The development of proteinuria is known to herald progressive kidney disease (e.g. CKD) and both are now well accepted as CVD risk factors. Evidence suggests a role for visceral obesity, insulin resistance/hyperinsulinemia, HTN, and other components of the CMS lead to an increased risk for proteinuria and progressive loss of renal function. Intervention with agents that block the RAAS (e.g. ACE inhibitors and Angiotensin type 1 receptor blockers) have been shown to reduce proteinuria, CKD progression, and CVD events. Herein, we will examine the relationship between RAAS intervention and reductions in CKD and CVD events.

Obesity and insulin resistance as risk factors for chronic kidney disease.

The cardiometabolic syndrome is a state of metabolic and vascular dysregulation. The cardiometabolic syndrome is clinically composed of a cluster of metabolic abnormalities including insulin resistance/hyperinsulinemia, central/visceral obesity, dyslipidemia, hypertension, microalbuminuria, fibrinolytic and inflammatory abnormalities, endothelial dysfunction, oxidative stress, and hypercoagulability, which collectively lead to an increased risk of cardiovascular and renal outcomes. The development of microalbuminuria is now accepted as a marker of systemic endothelial dysfunction and, if it progresses to macroalbuminuria (i.e., >200 mg/d albuminuria), then kidney disease is evident. Collectively, visceral obesity, insulin resistance/hyperinsulinemia, and other components of the cardiometabolic syndrome lead to an increased risk of microalbuminuria and progressive loss of renal function. Hence, aggressive management of risk factors for the metabolic syndrome, nonpharmacologic and pharmacologic, is essential to prevent or delay the progressive loss of renal function and chronic kidney disease.

Rates of continuous ambulatory peritoneal dialysis-associated peritonitis at the University of Missouri.

Peritoneal dialysis (PD)-associated peritonitis contributes significantly to morbidity and modalityfailure. The number of patients on PD is declining in Western countries, and peritonitis is a potential deterrent to the therapy. Here, we present a clinically significant decline in the rate of peritonitis at a single center over a 28-year period, with current rates significantly lower than the national average, and we review several factors that have contributed to those outcomes. Peritonitis and duration of follow-up have been recorded for all patients followed in our program since 1977. Introduction of important technological changes into the program were also recorded. All peritonitis rates are expressed as episodes/patient-year or episodes/n patient-months. Data are summarized for each calendar year since 1977. We followed 682 patients for a total follow-up duration of 15,435 patient-months. Glass bottles were changed to plastic bags in 1978. Straight connecting tubes were replaced by Y-sets in 1988. The presternal dialysis catheter was introduced in 1991 and has been the primary PD access since 1995. The peritonitis rate in 1977 was 5.8 episodes/patient-year, and that rate has progressively declined over the past 27 years to 0.35 episodes/patient-year in 2004. Technical improvements that contributed to the decline in overall peritonitis rates have been adopted nationwide. The largest improvement occurred with the switch from glass bottles to plastic bags, and to the closed-system Y-set that incorporated the flush-before-fill principle. Advances in catheter technology have also played a key role. Quality improvement in the program and long years of experience in overall care of PD patients are significant factors that cannot be measured quantitatively. Improvements have been made to exit-site care protocols, to exit-site evaluation and diagnosis, and to treatment strategies. Patient education and training in catheter care remain the important factor in a PD program. Many factors have contributed to the reduction of PD-associated peritonitis rates at our center Improved connectology, catheter care, and patient education play key roles in the reduction of peritonitis.