Hibiki Shinjo

Effect of an educational program on the predialysis period for patients with chronic renal failure

BackgroundThe purpose of the treatment and management of chronic renal failure during the predialysis period is mainly to retard the progression of the deterioration of renal function. Optimal dialysis initiation is important to improve the patients outcome after therapy. We investigated whether providing information through an original educational program could facilitate dialysis initiation, with the patient in a better condition, and therefore greater cost-effectiveness.MethodsOne hundred and seventy-six patients who underwent dialysis initiation for chronic renal failure in our hospital between April 2002 and March 2005 were divided into two groups according to their participation or nonparticipation in an educational program. Participation in the education program was of their own free will. The instructors consisted of nephrologists, nursing staff, clinical engineering technologists, national registered dietitians, and medical social workers. We investigated whether the education program facilitated trouble-free dialysis initiation by comparing findings of blood tests at the start, the existence of heart-failure symptoms, type of blood access, percentage of scheduled initiation, and the number of days and cost of hospitalization as indices between participating and nonparticipating groups.ResultsThe number of patients using a double-lumen dialysis catheter, and the duration and cost of hospitalization in training the participating group, were significantly less than those in the nonparticipating group. Although there was no significant difference in renal function at the initiation of renal replacement therapy (RRT) between the two groups, serum albumin, hemoglobin, and hematocrit in the participating group were significantly higher than those of the nonparticipating group.ConclusionsThis study suggests that providing sufficient information before dialysis initiation may be effective in both physical condition at dialysis initiation, and medical economic benefits through the understanding of the dialysis.

KDIGO (Kidney Disease: Improving Global Outcomes) Criteria Could Be a Useful Outcome Predictor of Cisplatin-Induced Acute Kidney Injury

Objectives: The purpose of this study was to investigate if KDIGO (Kidney Disease: Improving Global Outcomes) criteria could be a useful outcome predictor of cisplatin-induced acute kidney injury (CIA). Methods: In the period between January 2006 and December 2011, we identified Japanese patients who had been diagnosed with cancer and treated with cisplatin as a first-line chemotherapy at Nagoya University Hospital. The serum creatinine was used to define CIA and determine the KDIGO criteria of each patient after chemotherapy within 7 days. Results: Eighty-nine patients (5.4%) were classified as having acute kidney injury (AKI) going by the KDIGO criteria, and the numbers of patients classified into AKI stages 1, 2 and 3 were 65 (3.9%), 18 (1.1%) and 6 (0.4%), respectively. Overall survival times were significantly shorter in AKI stages 2 and 3 than in stage 1. The area under the receiver operating characteristic curve with all patients was 0.68, and that of patients who were diagnosed with cancer stage 4 was 0.80. Conclusion: These results suggest that KDIGO criteria can be a predictor of CIA mortality in patients with different primary cancers.

Relationship between renal function at the time of percutaneous coronary intervention and prognosis in ischemic heart disease patients

BackgroundAs hypertension and diabetes mellitus increase, the number of patients developing complications of cardiovascular disease (CVD) associated with conventional risk factors is increasing. In addition to these risk factors for CVD, chronic kidney disease (CKD) has also been reported to play an important role. We investigated the association of representative ischemic heart disease and CKD.MethodsBetween July 1, 2000, and June 30, 2005, a total of 790 patients who underwent percutaneous coronary intervention (PCI) for angina pectoris or myocardial infarction in our division of cardiovascular disease were reviewed. Serum markers at the implementation of PCI were compared in patients classified according to renal function. For prognosis, in-hospital mortality, 1-year survival rate, overall mortality, and CVD death were investigated. Changes in renal function were also monitored during the follow-up period. The glomerular filtration rate (GFR) was calculated by the Modification of Diet in Renal Disease Study Group (MDRD) formula.ResultsThe mean estimated GFR (eGFR) at PCI implementation was 66.2 ± 21.0 ml/min/1.73 m2. Stage 2 CKD was shown in 51.5% of all the patients. During the overall follow-up period, 126 patients died. With the progression of CKD stage, all-cause, CVD, and in-hospital mortality increased, and the 1-year survival rate decreased. It was proved that a medical history of hypertension, hyperlipidemia, and diabetes, multiple vessel lesions, hypoalbuminemia, C-reactive protein (CRP), and estimated GFR were independent risk factors for all-cause death. In CVD death, in addition to the above risk factors, anemia and total cholesterol were also an independent risk factor. Renal function deteriorated significantly during the follow-up period.ConclusionsPatients with ischemic heart disease requiring PCI often develop renal dysfunction, which may considerably affect prognosis.

Presence of Atrial Fibrillation at the Time of Dialysis Initiation Is Associated with Mortality and Cardiovascular Events

Background: Death in dialysis patients results mainly from cardiovascular and cerebrovascular diseases. To our knowledge, no prospective study has compared the rates of mortality or cardiovascular events between patients with and without atrial fibrillation (AF) at the time of dialysis initiation. Methods: This study included 1,516 patients who were initiated into dialysis between October 2011 and August 2013. Rates of mortality and cardiovascular events were compared between patients with and without AF, and between AF patients with and without warfarin (WF) treatment. Results: The study comprised 1,025 men and 491 women with a mean age of 67.5 ± 13.1. Of these patients, 93 had AF, while 1,423 did not; 22.6% of the former group and 9.7% of the latter group died by March 2014 (p < 0.01). Cardiovascular events occurred in 34.4% of patients with AF and 15.1% of patients without (p < 0.01). Even after adjustments for various factors, AF remained an independent risk factor for mortality (hazard ratio (HR) 1.873, 95% CI 1.168-3.002, p < 0.01). It was also an independent risk factor for cardiovascular events (HR 1.872, 95% CI 1.262-2.778, p < 0.01). No difference in any parameter was noted between the groups that did and did not receive WF treatment. Conclusion: Patients with AF at the time of dialysis initiation show a poor prognosis and are at high risk of cardiovascular events. Therefore, AF should be taken into consideration in dialysis patients.

Relationship Between Mortality and Cancer-Bearing Status at Time of Dialysis Initiation: Cancer-Bearing at Time of Dialysis Initiation

Patients with malignancy are reported to have poorer prognosis than those without malignancy. When patients with malignancy develop end‐stage kidney disease, clinicians must determine treatment with consideration of prognosis. Furthermore, malignancy is sometimes found at time of dialysis initiation. However, prognosis of patients with malignancy at time of dialysis initiation has not been investigated. A total of 1524 patients with chronic kidney disease who initiated dialysis at 17 centers participating in the Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis were included. Patients initiated dialysis between October 2011 and September 2013. Mortality rates were compared between patients with and without malignancy. Types of malignancy and respective prognoses also were assessed. The study included 1030 men and 492 women with a mean age of 67.5 ± 13.1 years. Of these, 92 had malignancy and 1430 did not; 45.7% of the former group and 16.0% of the latter group died by March 2015 (P < 0.01). Even after adjusting for various factors, presence of malignancy remained an independent risk factor for mortality (P < 0.01). Patients with performance status (PS) of 0 had significantly lower mortality (P < 0.01). Patients with malignancy at time of dialysis initiation had poor prognosis. Therefore, presence of malignancy should be taken into consideration when patients initiate dialysis. In patients with malignancy, better PS was associated with better prognosis.

Ferrokinetics is associated with the left ventricular mass index in patients with chronic kidney disease

Abstract Background Patients with chronic kidney disease (CKD) often have the complication of anaemia. Usage of an erythropoietin-stimulating agent accelerates iron deficiency because it promotes iron utilization. Recently, iron administration was reported to be effective for patients with cardiac failure. We examined the association between ferrokinetics and cardiac function in patients with CKD. Methods In this cross-sectional study, we examined 558 patients (424 men and 134 women; mean age, 68.9 ± 13.1 years) with CKD who were admitted to our hospital. We assessed cardiac function by ultrasonography and ferrokinetics through transferrin saturation (TSAT) and ferritin levels. Results The primary diseases of CKD were nephrosclerosis (n = 247), diabetic nephropathy (n = 154), chronic glomerulonephritis (n = 73), and others. The mean estimated glomerular filtration rate was 16.9 ± 9.3 mL/min/1.7 m2, and the haemoglobin (Hb) level was 11.0 ± 1.7 g/dL. The median of TSAT was 28.05%, and patients were divided into two groups: below (L-Ts) and above (H-Ts) the median. The median of ferritin was 122 ng/mL, and patients were divided into two groups: below (L-f) and above (H-f) the median. We categorized four groups as H-Ts + H-F, H-Ts + L-F, L-Ts + H-F, and L-Ts + L-F. The Hb levels were 11.1 ± 1.8, 11.3 ± 1.4, 10.9 ± 1.6, and 10.8 ± 1.5 g/dL, respectively, and there was no difference between groups. However, the left ventricular mass indices (LVMIs) were 122.6 ± 46.6, 110.8 ± 32.0, 118.3 ± 36.0, 126.7 ± 46.9, respectively (P = 0.0291). This tendency was stronger in patients without cardiovascular events. Conclusion In patients with CKD, there is an association between ferrokinetics and LVMI. We have to be mindful not only of anaemia but also of ferrokinetics.

Predialysis Vitamin D Receptor Activator Treatment and Cardiovascular Events after Dialysis Initiation: A Multicenter Observational Study

Background: Vitamin D receptor activator (VDRA) administration has been linked with a reduced incidence of cardiovascular disease (CVD). However, it is unclear whether VDRA administration during the predialysis stage is associated with CVD incidence after dialysis initiation in patients with chronic kidney disease. Therefore, we examined the association between VDRA use and CVD events. Methods: This multicenter observational study included 1,516 patients; they were divided into 2 groups: those who did and did not receive oral VDRA for at least 3 months before dialysis initiation. The CVD incidence was compared between these groups. Factors that impacted CVD incidence were extracted through a multivariate analysis. Subgroups were created based on prior CVD history and serum CRP levels. Results: The incidence of CVD was significantly lower in the VDRA group (log-rank test, p = 0.014). Stepwise multivariate analyses identified age, gender, diabetes, CVD history, calcium-channel blockers, beta-blockers, loop diuretics, anti-platelet agents, phosphate binders, VDRA, erythropoiesis stimulating agents, and cardiothoracic ratio as factors affecting CVD incidence. In the group with no CVD history, VDRA use was associated with a low incidence of CVD (HR 0.35). In the group with serum CRP levels <1.0 mg/dl, VDRA use was associated with a low incidence of CVD (HR 0.47). Conclusion: Administration of VDRA during predialysis was associated with a low incidence of CVD onset after dialysis initiation.

Hepatitis B Virus Infection Among Patients With Chronic Kidney Disease Who Attended an Educational Program in Japan: HBV in Patients With CKD in Japan

The rate of hepatitis B infection among hemodialysis patients is high. However, it is not clear if this rate reflects the infection rate among patients with chronic kidney disease (CKD). Therefore, we evaluated the rate of hepatitis B infection among patients with CKD. This is an important clinical issue when considering the risk of infection to medical staff when performing invasive procedures in this clinical population. A retrospective, observational study was conducted among stable, non‐dialysis patients with CKD who attended a CKD educational program at our hospital, between August 2012 and October 2017. We collected patients’ background and markers of hepatitis infection (HBsAg, HBcAb and HBsAb, as well as HBV‐DNA when available) from medical records. The data from 496 patients (373 men and 123 women, with a mean age of 69.3 ± 13.0 years and mean level of creatinine of 3.15 ± 1.72 mg/dL, AST of 21.6 ± 10.5 IU/L, and ALT of 17.3 ± 12.5 IU/L), were included in the analysis. The rate of positive testing for hepatitis B virus infection was as follows: HBsAg, 1.6%; HBsAb, 16.5%; and HBcAb, 21.4%. Of the patients with a negative HBsAg test, 20.1% tested positive for HBcAb. Of the 66 patients in whom HBV‐DNA testing was performed, 10.6% tested positive. The rate of hepatitis B virus infection was specifically higher among patients ≥71‐years‐old. In patients with CKD, the rate of HBsAg positivity is high. Rate of HBcAb positivity is higher particularly in older individuals.

Relationship Between Mortality and Cancer-Bearing Status in Patients With Chronic Kidney Disease Who Attended an Educational Program

Patients with malignancy have a poorer prognosis than others do, which must be taken into consideration when treating them for chronic kidney disease (CKD). However, there are few studies investigating their prognosis. This was an observational study of 515 (394 men and 121 women) stable non‐dialysis patients with CKD who attended a CKD educational program. Mean age was 68.8 ± 13.0 years. Median follow‐up was 968.5 days. Mean creatinine was 3.4 ± 1.6 mg/dL. Of these, 63 had malignancy and 452 did not; 20.6% of the former and 11.9% of the latter group died by the end of the study period (P = 0.0548). Malignancy was not associated with all‐cause mortality (HR: 1.3475, 95% CI: 0.7202–2.5214, P = 0.3507) but with malignancy‐associated mortality (HR: 3.9477, 95% CI: 1.6348–9.5331, P = 0.0023). Renal replacement therapy was not associated with mortality. Since malignancy greatly affects the prognosis, it must be taken into consideration when treating these patients.

Deterioration of renal function is associated with increased mortality in patients with cholesterol crystal embolism

Background and Objectives: The importance of arteriosclerotic diseases has increased in recent years owing to population aging. Increased in the incidence of catheter intervention and vascular surgery has also resulted in a corresponding increase of cholesterol crystal embolism (CCE). Patients with chronic kidney disease are often diagnosed with arteriosclerotic disease. Although the severity of CCE varies widely, because it exacerbates renal function, treatment options should be established based on CCE severity. Methods: In this retrospective study, we examined 43 patients (37 men and 6 women; mean age, 74.9 ± 7.2 years) who were admitted to our department from 2002 to 2017 because of deteriorating renal functions. We assessed these patients at admission and followed up 1-year later. Results: The causes of CCE included treatment for ischemic heart disease (41.9%), aortic aneurysm (23.3%), and the administration of warfarin (11.6%). Thirty-one patients (72.1%) were diagnosed pathologically. The mean level of creatinine (Cr) at baseline was 1.84 ± 0.83 mg/dL. The mean level of Cr on admission was 4.90 ± 2.2 mg/dL. Steroid therapy was performed in 27 patients (62.8%) and lipoprotein apheresis was performed in one patient (2.3%). During the observational period, 9 patients (20.9%) died and the increase in Cr rates was significantly higher in these individuals (P = 0.0044). After adjustment for various factors, the Cr increase rate was significantly related to mortality (hazard ratio: 2.9581, 95% confidence interval: 1.1179–7.8271, P = 0.0289). Conclusion: The deterioration rate of renal function is associated with mortality in patients with CCE, which is accompanied by renal manifestation.