Toshikazu Wada

Histological predictors for renal prognosis in diabetic nephropathy in diabetes mellitus type 2 patients with overt proteinuria.

Aim:  Although several clinical risk factors for end‐stage renal disease in diabetic nephropathy are known, the pathological findings that may help predict renal prognosis have not yet been defined.

Prognostic significance of home blood pressure control on renal and cardiovascular outcomes in elderly patients with chronic kidney disease

The influence of home blood pressure (HBP) control on renal and cardiovascular outcomes is not fully defined, and the optimal blood pressure (BP) target in elderly patients with chronic kidney disease (CKD) remains unknown. To clarify the influence of HBP on the progression of CKD and the occurrence of cardiovascular events in elderly CKD patients, we recruited 104 patients with stage 3 to 5 CKD, who were ⩾70 years of age. The mean follow-up duration was 39±15 months. HBP was measured every morning and evening for 7 consecutive days. HBP data were obtained every 6 months for 79 of these patients. There were significant correlations observed between morning systolic BP (SBP), evening SBP and the change in estimated glomerular filtration rate (eGFR) during the follow-up period (baseline/follow-up; morning r=−0.55/−0.51, evening r=−0.48/−0.38, all P<0.0001, baseline: baseline values, follow-up: mean values obtained every 6 months during the follow-up period). Stepwise multivariate regression analysis identified morning SBP and urinary protein excretion as independent predictors of a change in eGFR during the follow-up period. Cox proportional hazards analysis showed that baseline morning SBP, baseline evening SBP and follow-up morning SBP were significantly associated with an increased risk of renal events (hazard ratios; 1.04 (95% CI, 1.01–1.07), 1.06 (1.02–1.09) and 1.10 (1.04–1.17), respectively). However, Cox proportional hazards analyses showed that there was no significant association between BP and the risk of cardiovascular events. In conclusion, even among elderly CKD patients, HBP is a significant predictor of decline in renal function and the development of end-stage renal disease. In addition, the optimal target BP for elderly CKD patients needs to be clarified.

Clinical significance of microscopic haematuria in diabetic nephropathy in type 2 diabetes patients with overt proteinuria.

Although some patients with diabetic nephropathy with overt proteinuria have microscopic haematuria, the pathological characteristics and clinical significance related to microscopic haematuria have not yet been clarified. The aim of the present study was to clarify the pathological characteristics and clinical significance of microscopic haematuria.

Phosphate handling by end-stage kidneys and benefits of residual renal function on phosphate removal in patients on haemodialysis.

We investigated the handling of phosphate by end‐stage kidneys and the contribution of residual renal function (RRF) to phosphate homeostasis in haemodialysis patients.

Clinical evaluation of chronic nephrotoxicity of long-term cyclosporine A treatment in adult patients with steroid-dependent nephrotic syndrome

Aim:  Chronic nephrotoxicity of long‐term cyclosporine A (CsA) treatment is a matter of concern in patients with steroid‐dependent nephrotic syndrome (SDNS).

Benefits of first-half intensive haemodiafiltration for the removal of uraemic solutes

Aim:  Haemodiafiltration (HDF) is the most efficient blood purification method and can remove a wide spectrum of solutes of different molecular weights (MW). The purpose of this study was to investigate whether the removed amounts of solutes, especially the larger molecules, could be increased by changing the HDF filtration procedure.

Association between visit-to-visit clinic blood pressure variability and home blood pressure variability in patients with chronic kidney disease

Abstract Although both clinic blood pressure (BP) variability and home BP variability are associated with the risk of cardiovascular disease, the relationship between both BP variabilities remain unclear. We evaluated the association between visit-to-visit variability of clinic BP (VVV) and day-by-day home BP variability (HBPV) in patients with chronic kidney disease (CKD). We recruited 143 CKD patients in whom we performed HBP measurements every morning and evening over seven consecutive days. We obtained clinic BP data during 9.6 ± 1.0 consecutive visits within 24 months. The associations between the variables of VVV and HPBV were examined. The CV values of clinic systolic BP (CSBP) was significantly correlated with the mean values of morning systolic BP (MSBP) and those of evening systolic BP (ESBP) (r = 0.23, 0.20; p = 0.007, 0.02, respectively). The CV values of CSBP was significantly correlated with the CV values of MSBP and those of ESBP (r = 0.19, 0.31; p = 0.02, <0.001, respectively). On the multivariate regression analysis, the CV values of CSBP was significantly correlated with the CV values of MSBP and those of ESBP [standardized regression coefficient (β) = 0.19, 0.34; p = 0.03, <0.001, respectively]. In conclusion, VVV showed a weak but significant association with HBPV, especially the CV values of ESBP in CKD patients. Further studies are necessary to clarify whether these different BPV elements will be alternative marker of BPV.

Influence of erythropoietin-stimulating agent treatment on glycated hemoglobin values in diabetic patients with chronic kidney disease

Glycated hemoglobin (HbA1c) is used to assess glycemic control in diabetic patients. Erythropoietin-stimulating agent (ESA) treatment decreases HbA1c values in dialysis patients [1, 2]. However it is not clear whether ESA influences HbA1c values in non-dialyzed chronic kidney disease (CKD) patients. Recently, Ng et al. [3] showed a significant decrease in HbA1c values after starting ESA in non-dialyzed CKD patients. We simultaneously examined the change in HbA1c values and glycated albumin (GA) values, which are alternative markers unaffected by erythrocyte turnover, after starting ESA treatment in 42 patients with CKD stage 3 to 5 (diabetic nephropathy/non-diabetic renal diseases with/without diabetes: 36/3/3). Glycemic treatment was not changed during the study. Twenty-nine patients were men. Age, serum creatinine, and body weight at starting ESA were 68.3 ± 8.9 years, 3.47 ± 1.60 mg/dl, and 63.2 ± 11.2 kg, respectively. Twenty-two patients received insulin, and 11 patients received oral hypoglycemic agents. Epoetin-alfa or epoetin-beta was administered once or twice a month. Monthly doses ranged from 6,000 to 24,000 units. No patients received iron supplements during the study. As shown in Table 1, HbA1c values tended to decrease slightly after starting ESA; however, there was no statistically significant change compared with baseline values. GA significantly increased after 12 months compared with baseline values. GA/HbA1c ratios significantly increased after 6 and 12 months compared with baseline values. There were no significant correlations among the change in HbA1c values from baseline, the ESA doses, and the change in hemoglobin levels in any period. In our study, GA/HbA1c ratios significantly increased after starting ESA. Both or either a decrease in HbA1c values and an increase in GA values would result in an increase in GA/HbA1c ratios. HbA1c values tended to decrease slightly after starting ESA. Thus, we could not exclude the possibility of the influence of ESA on HbA1c values. In addition, the decline in renal function might influence HbA1c values, independent of the effect of ESA therapy. Erythrocyte survival decreases as renal failure progresses [4]. Furthermore, it is possible that there is an interindividual variability of erythrocyte survival in CKD patients as well as dialysis patients [5], and this might influence HbA1c values differently among the patients. Finally, although it is not clear whether proteinuria influences GA values in patients without nephrotic syndrome, the significant increase in GA values after 12 months might be related to a decrease in urinary protein excretion, independent of glycemic state. We speculate that the greater decrease in HbA1c values in Ng’s study was due to the greater efficacy of ESA and the greater increase in hemoglobin levels compared with our study. GA provides additional information on glycemic state. It is not clear whether GA is more beneficial than HbA1c in the assessment of glycemic control in diabetic CKD patients. We need to pay attention to the change in HbA1c values in the individual CKD patients receiving ESA, and further studies are needed to clarify the factors affecting the glycemic markers in diabetic CKD patients. T. Okada (&) T. Nakao H. Matsumoto Y. Nagaoka T. Wada Department of Nephrology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan e-mail: t-okada@tokyo-med.ac.jp

Clinical Practice of Two Measurements of Home Blood Pressure on Each Occasion in Patients with Chronic Kidney Disease.

Background/Aims: Although several guidelines propose two or three measurements of home blood pressure (HBP) on each occasion, the actual status of multiple measurements is not clear in the practical management of hypertension. We surveyed the details regarding two measurements of HBP in patients with chronic kidney disease (CKD). Methods: HBP was measured twice every morning and evening over 7 consecutive days in 175 CKD patients. The distribution of the differences between two BP values (2nd - 1st BP) and their association with BP parameters were evaluated. Results: The 2nd - 1st morning systolic BP (SBP) and diastolic BP (DBP) differences were -2.3 ± 4.1 and -0.4 ± 2.6 mm Hg, respectively. The proportion of 2nd - 1st morning SBP differences >0 mm Hg was 31.7% in a total of 1,195 measurements. Eighty patients (45.7%) had days with a difference ≤-5 mm Hg and days with a difference ≥5 mm Hg in morning SBP during 7 days. The multivariate regression analysis of the SD values of 2nd - 1st morning SBP as a dependent variable showed that the SD value of the 1st morning SBP (β = 0.65, p < 0.001) was a significant determinant. Conclusion: Although the 2nd SBP was 2-3 mm Hg lower than the 1st SBP in the population as a whole, various differences were found for each subject during 7 days. 2nd - 1st BP variability might be associated with day-by-day 1st BP variability.

Benefits of Staple Food Restriction for Japanese Obese Patients With Chronic Kidney Disease: A Pilot Study

OBJECTIVE We conducted a pilot study to assess the effects of dietary intervention on metabolic risk factors and renal parameters in obese patients with chronic kidney disease (CKD). METHODS We studied 19 obese patients with CKD at our outpatient clinic. The diet selected for this study restricted only their staple food intake, with no change in the side dish component of their meals. We studied neither the lifestyles of the patients nor the activities that they were involved in. We examined changes in clinical and laboratory parameters at baseline and after consumption of the diet. RESULTS After 2 and 6 months of staple food restriction, changes in body weight were found to be -3.6% ± 3.9% and -3.4% ± 4.7%, respectively. Of the 19 patients, the body weights of 9 decreased by >3% (range: 3.4% to 17.1%) from baseline to follow-up at 6 months. After 6 months of following the diet, these 9 patients showed marked reductions in blood pressure, homeostasis model assessment insulin resistance, and triglycerides, when compared with the remaining 10 patients with stable body weights; however, for proteinuria and estimated glomerular filtration rate they reported having values similar to the 10 patients with stable body weights. CONCLUSIONS Weight reduction associated with a lowered insulin resistance was reported in obese patients with CKD after 6 months of staple food restriction; however, further studies need to be conducted to confirm the presence of other possible renal benefits.