Samir S. Patel

The impact of social support on end-stage renal disease.

Social support is a concept recognizing patients exist to varying degrees in networks through which they can receive and give aid, and in which they engage in interactions. Social support can be obtained from family, friends, coworkers, spiritual advisors, health care personnel, or members of ones community or neighborhood. Several studies have demonstrated that social support is associated with improved outcomes and improved survival in several chronic illnesses, including cancer and end‐stage renal disease (ESRD). The mechanism by which social support exerts its salutary effects are unknown, but practical aid in achieving compliance, better access to health care, improved psychosocial and nutritional status and immune function, and decreased levels of stress may all play key roles. Few data exist regarding social support in patients with ESRD and chronic renal insufficiency, but links between social support and depressive affect and quality of life have been established. Interventions that enhance social support in ESRD patients should be evaluated.

Spirituality, Social Support, and Survival in Hemodialysis Patients

BACKGROUND AND OBJECTIVES No studies have evaluated the relationship among spirituality, social support, and survival in patients with ESRD. This study assessed whether spirituality was an independent predictor of survival in dialysis patients with ESRD after controlling for age, diabetes, albumin, and social support. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A total of 166 patients who had ESRD and were treated with hemodialysis completed questionnaires on psychosocial variables, quality of life, and religious and spiritual beliefs. The religious variables were categorized into three scores on a 0 to 20 scale (low to high levels): Spirituality, religious involvement, and religion as coping. Social support was assessed using the Multidimensional Scale for Perceived Social Support. Analyses were also performed including and excluding patients with HIV infection. Religious variables were categorized on the basis of means, medians, and tertiles. RESULTS In analyses that used religious variables, only the responses on the spirituality scale split at the mean were associated with survival. The association of other religious variables with survival did not reach significance. Social support correlated with spirituality, religion as coping, and religious involvement measures. Only social support and age were associated with survival when controlling for diabetes, albumin concentration, HIV infection, and spirituality. CONCLUSIONS These data suggest that the effects of spirituality may be mediated by social support. Larger, multicenter, prospective studies that use well-validated tools to measure religiosity and spirituality are needed to determine whether there is an independent association of spirituality variables with survival in patients with ESRD.

Sleepiness, sleeplessness, and pain in end-stage renal disease: distressing symptoms for patients.

Symptoms are increasingly recognized as problematic for patients with end‐stage renal disease (ESRD) treated with dialysis. Sleep disorders are common in ESRD patients treated with dialysis and are associated with patients’ perceptions of quality of life, assessed by diverse measures, as well as depressive affect. Sleep disorders appear to be equally prevalent in peritoneal dialysis (PD) and hemodialysis (HD) patients. Treatment for sleep disorders in dialysis patients depends on establishing the diagnosis, often in a sleep laboratory, using polysomnography. Reversing coexistent medical and psychological disorders is important. The sleep apnea syndrome (SAS) can be treated with continuous positive airway pressure in dialysis patients, but conventional hemodialytic techniques have little effect on its severity. In contrast, nocturnal HD and transplantation appear to have important beneficial effects on sleep disordered breathing in ESRD patients. Although pain has been appreciated as a problem for ESRD patients for more than 20 years, few studies exist on this subject. Pain appears to be an underappreciated problem for ESRD patients. More research must be performed on the problem of pain in patients with chronic kidney disease (CKD).

PSYCHOSOCIAL FACTORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE: The Impact of Social Support on End‐Stage Renal Disease

Social support is a concept recognizing patients exist to varying degrees in networks through which they can receive and give aid, and in which they engage in interactions. Social support can be obtained from family, friends, coworkers, spiritual advisors, health care personnel, or members of ones community or neighborhood. Several studies have demonstrated that social support is associated with improved outcomes and improved survival in several chronic illnesses, including cancer and end‐stage renal disease (ESRD). The mechanism by which social support exerts its salutary effects are unknown, but practical aid in achieving compliance, better access to health care, improved psychosocial and nutritional status and immune function, and decreased levels of stress may all play key roles. Few data exist regarding social support in patients with ESRD and chronic renal insufficiency, but links between social support and depressive affect and quality of life have been established. Interventions that enhance social support in ESRD patients should be evaluated.

PSYCHOSOCIAL FACTORS IN PATIENTS WITH CHRONIC KIDNEY DISEASE: Sleepiness, Sleeplessness, and Pain in End-Stage Renal Disease: Distressing Symptoms for Patients

Symptoms are increasingly recognized as problematic for patients with end‐stage renal disease (ESRD) treated with dialysis. Sleep disorders are common in ESRD patients treated with dialysis and are associated with patients’ perceptions of quality of life, assessed by diverse measures, as well as depressive affect. Sleep disorders appear to be equally prevalent in peritoneal dialysis (PD) and hemodialysis (HD) patients. Treatment for sleep disorders in dialysis patients depends on establishing the diagnosis, often in a sleep laboratory, using polysomnography. Reversing coexistent medical and psychological disorders is important. The sleep apnea syndrome (SAS) can be treated with continuous positive airway pressure in dialysis patients, but conventional hemodialytic techniques have little effect on its severity. In contrast, nocturnal HD and transplantation appear to have important beneficial effects on sleep disordered breathing in ESRD patients. Although pain has been appreciated as a problem for ESRD patients for more than 20 years, few studies exist on this subject. Pain appears to be an underappreciated problem for ESRD patients. More research must be performed on the problem of pain in patients with chronic kidney disease (CKD).

Urinary Sediment Cast Scoring Index for Acute Kidney Injury : A Pilot Study

Background/Aims: Urine microscopy is a useful diagnostic tool; however, the manner in which nephrologists prepare and examine urinary sediment is variable. We developed an acute kidney injury (AKI) cast scoring index (CSI) in order to standardize urinary microscopy. Further, we sought to assess the precision of this scoring system. Methods: Urine from 30 patients with AKI consistent with the syndrome of acute tubular necrosis were collected. Sample preparation was uniform and standardized. A panel of 3 nephrologists blinded to the sample preparation were instructed to grade each slide using the AKI CSI. Subsequently, the AKI CSI was then tested in another 18 patients with AKI to determine if this score could predict nonrenal recovery. Results: The inter-observer agreement index was 99.80%, with a coefficient of variation of 1.24%. Of the 90 paired observations, 98.8% fell within 2 standard deviations of the mean, signifying good agreement. The receiver operator characteristic area under the curve for AKI CSI to predict nonrenal recovery was 0.79. Conclusions: AKI CSI is a simple, novel, reliable scoring system to grade the degree of epithelial cell and granular casts present on urine microscopy. A standardized AKI CSI has the potential to incorporate urinary cast analysis into the advancing field of AKI diagnostics. These preliminary data endorse the notion that the AKI CSI may be useful in predicting renal outcomes.

Mobilizing your medications: an automated medication reminder application for mobile phones and hypertension medication adherence in a high-risk urban population.

Background: Hypertension frequently accompanies diabetes mellitus, worsening prognosis and complicating medical care for patients. Low medication adherence with multiple medications is a major factor in the inadequate achievement of blood pressure treatment goals. Widespread access to mobile phones offers a new opportunity to communicate with patients and enhance disease self-management. Methods: We recruited 50 high-risk urban patients with hypertension, who are using at least two prescription medications for hypertension, into an open-label trial using medication reminder software on a mobile phone. Medication adherence was assessed by review of pharmacy refill rates before, during, and after availability of the medication reminder software (pre-activation, activation, and post-activation phase, respectively). Results: Forty-eight patients completed the study. All subjects were insured by Medicaid, 96% were African-American, and the majority had diabetes mellitus. The proportion of days covered for each study phase was as follows: Pre-activation phase = 0.54, activation phase = 0.58, and post-activation phase = 0.46. A significant difference was found between the activation and post-activation phases (p = .001). The increase in measured adherence between the pre-activation and activation phases approached significance (p = .057). Forty-six patients completed the pre- and post-Morisky medication adherence survey. The median score rose from 2.0 at baseline to 3.0 at study completion (p < .001). Average blood pressure and level of control during study period improved significantly after initiation of the study and remained improved from baseline through the course of the study. The 48 subjects who completed the study reported a high level of satisfaction with the medication reminder application at the final study visit. Conclusions: A mobile-phone-based automated medication reminder system shows promise in improving medication adherence and blood pressure in high-cardiovascular-risk individuals.

Gut microbiome in chronic kidney disease

What is the topic of this review? This review addresses the contribution of the altered gut microbiome to uraemic syndrome, with specific reference to gut microbiome‐derived uraemic toxins. It also discusses the potential treatment options to normalize the disturbed microbiome in chronic kidney disease (CKD). What advances does it highlight? This review highlights the importance of the gut–kidney connection and how the altered microbial landscape in the intestine contributes to dysmetabolism and inflammation in CKD. Recent findings linking gut‐derived uraemic toxins to progression of CKD, cardiovascular disease and mortality are also discussed. Finally, we briefly explain targeted therapies that have been studied to restore intestinal symbiosis in CKD.

Association between Inflammation and Cardiac Geometry in Chronic Kidney Disease: Findings from the CRIC Study

Background Left ventricular hypertrophy (LVH) and myocardial contractile dysfunction are independent predictors of mortality in patients with chronic kidney disease (CKD). The association between inflammatory biomarkers and cardiac geometry has not yet been studied in a large cohort of CKD patients with a wide range of kidney function. Methods Plasma levels of interleukin (IL)-1β, IL-1 receptor antagonist (IL-1RA), IL-6, tumor necrosis factor (TNF)-α, transforming growth factor (TGF)-β, high-sensitivity C-Reactive protein (hs-CRP), fibrinogen and serum albumin were measured in 3,939 Chronic Renal Insufficiency Cohort study participants. Echocardiography was performed according to the recommendations of the American Society of Echocardiography and interpreted at a centralized core laboratory. Results LVH, systolic dysfunction and diastolic dysfunction were present in 52.3%, 11.8% and 76.3% of the study subjects, respectively. In logistic regression analysis adjusted for age, sex, race/ethnicity, diabetic status, current smoking status, systolic blood pressure, urinary albumin- creatinine ratio and estimated glomerular filtration rate, hs-CRP (OR 1.26 [95% CI 1.16, 1.37], p<0.001), IL-1RA (1.23 [1.13, 1.34], p<0.0001), IL-6 (1.25 [1.14, 1.36], p<0.001) and TNF-α (1.14 [1.04, 1.25], p = 0.004) were associated with LVH. The odds for systolic dysfunction were greater for subjects with elevated levels of hs-CRP (1.32 [1.18, 1.48], p<0.001) and IL-6 (1.34 [1.21, 1.49], p<0.001). Only hs-CRP was associated with diastolic dysfunction (1.14 [1.04, 1.26], p = 0.005). Conclusion In patients with CKD, elevated plasma levels of hs-CRP and IL-6 are associated with LVH and systolic dysfunction.

Direct Evidence for Calcineurin Binding to the Exon-7 Loop of the Sodium-Bicarbonate Cotransporter NBCn1

The NaHCO3 cotransporter NBCn1 plays a role in neutralizing intracellular acid loads at the basolateral membrane in cells of the medullary thick ascending limb (mTAL). Calcineurin inhibitors (Cn-Is) are known to both downregulate NBCn1 expression in the distal nephron and cause renal tubular acidosis (RTA), a risk factor for nephrocalcinosis and nephrolithiasis. In this report, we provide a new perspective on concurrent studies of NBCn1 in various tissues by using cell-free binding assays to investigate the interaction of NBCn1 with the calcineurin (Cn) isoform PPP3CA. Surface plasmon resonance (SPR) analyses show that the protein domain Exon 7 (translated from cassette II of NBCn1) binds Cn with an equilibrium dissociation constant (KD) of 30 +/- 15 nm. Linked-reaction tests suggest that the binding involves a conformational change. Nested PCR reactions were used to show that NBCn1-Exon 7 splice variants with alternative N-termini regions are expressed in the kidney, as well as other tissues. Additionally, we discuss NBCn1-Exon 7 implication in acid-base balance and calcium crystallization in the kidney.