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| This Month in AJKD | Hypertension Awareness, Treatment, and Control in Adults With CKD
See Muntner et al, pages 441-451; and Becker and Wheeler, pages 415-418.
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In many CKD patients, blood pressure is not controlled to the target of < 130/80 mm Hg as recommended in most clinical practice guidelines. It is believed that a higher level of patient and doctor awareness of the presence of hypertension may lead to better control. In this issue, Muntner et al analyze blood pressure control data among 3,612 patients with CKD in the Chronic Renal Insufficiency Cohort (CRIC) study. The prevalence of hypertension was 85.7%, and 98.9% of CRIC participants were aware of this diagnosis and 98.3% were treated with medications, whereas 67.1% and 46.1% had hypertension controlled to < 140/90 and < 130/80 mm Hg, respectively. An editorial by Becker and Wheeler points out that these results are a strong example of why the upcoming KDIGO blood pressure guidelines relevant to stages 1-5 CKD patients worldwide are sorely needed, and that the guidelines must have rigorous implementation strategies if patients are to benefit fully.
| Cost-Effectiveness of Screening for CKD
See Hoerger et al, pages 452-462 and 463-473; and Abbott and Yuan, pages 419-422.
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In this issue, 2 articles by Hoerger et al provide validated cost-effectiveness models for screening for albuminuria. In the first article, the authors developed a microsimulation model of the incidence, progression, and treatment of CKD, which was validated by comparing its predictions to survey and epidemiological data sources. In the second article, the authors modeled the cost-effectiveness of universal screening for micro- and macroalbuminuria screening at a single time and at 1-, 2-, 5-, and 10-year intervals beginning at age 50, followed by treatment with either an angiotensin-converting enzyme inhibitor and/or an angiotensin receptor blocker. The simulation demonstrated that screening for and treatment of microalbuminuria in patients with diabetes or hypertension is cost-effective versus “usual care” (depending on screening frequency) and that screening was not cost-effective in patients without current diabetes or hypertension. In an editorial, Drs Abbott and Yuan are intrigued by the models used by Hoerger et al, but agree with the authors that the models will require continuous updating as new data emerge on the natural history of CKD progression.
| Determining CKD Prevalence in Remote Populations: 2 Community Studies
See Gutierrez-Padilla et al, pages 474-484; and Torres et al, pages 485-496.
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Decreased kidney function and CKD overwhelm health services in remote populations, making it difficult to determine prevalence of these phenomena. In this issue, 2 studies attempt to determine the prevalence of CKD and decreased kidney function in 2 distinct populations. Gutierrez-Padilla et al examined the diagnostic yield of screening for CKD and cardiovascular disease risk factors using mobile units that traveled to poor communities in Jalisco, Mexico. Of the 3,734 participants studied, 43.5% had a history of diabetes, 11.4% had dipstick positive proteinuria, 62.0% had blood pressure in the hypertensive range, and 15.8% had an estimated GFR compatible with stages 3-5 CKD, and cardiovascular risk factors were detected frequently in those who had no history of cardiovascular disease (99.7%). The authors conclude that trials of targeted screening and intervention are feasible and warranted. In the other study, Torres et al determined prevalences of decreased kidney function in 5 of the most affected villages in northwest Nicaragua. In particular, they found high rates of decreased kidney function among men in villages where mining/subsistence farming and banana/sugarcane production were the main occupations. The authors conclude that the decreased kidney function may be attributable to environmental or occupational reasons.
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Recent studies suggest that the use of erythropoiesis-stimulating agents (ESAs) to treat anemia in CKD may be associated with increased morbidity and mortality, necessitating the need to weigh this potential increased risk against the potential benefit of ESAs in improving health-related quality of life. In this issue are 2 studies that review data concerning quality-of-life domains likely to respond to ESA therapy. Gandra et al examine the impact of ESAs on energy and physical function in 14 RCTs and single-arm studies in nondialysis CKD patients, and suggest a beneficial effect of treatment on both outcomes. In another article, Johansen et al provide a systematic review of effect of treatment on physical function and a meta-analysis of exercise tolerance in 28 studies in dialysis patients, and find a consistent and positive effect. In an editorial, Drs Parfrey and Wish conclude that the evidence to support treatment of moderate anemia (hemoglobin 10-12 g/dL) with ESAs in nondialysis CKD and in dialysis patients is tenuous. On the other hand, evidence to support treatment of severe anemia is stronger because the quality-of-life benefits are greater and high transfusion requirements are substantially reduced.
| Dosing of Renal Replacement Therapy in AKI
See Bouchard et al, pages 570-579.
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Urea kinetic modeling has been the mainstay of dialysis dose quantification in ESRD, but extrapolation of these techniques to critically ill patients with AKI is difficult due to a non-steady state leading to a variable increase in urea generation rate, alterations in total body water and its compartmental distribution, and a changing renal excretory capacity. In this issue, Bouchard et al review the concept of dialysis dose, perform a critical assessment of the most important clinical trials on dialysis dose in AKI, summarize clinical evidence from these trials, and define key research issues that should be addressed in the future. They conclude that to establish a dialysis dose–outcome relationship for AKI, physicians need to standardize a “dose” criterion, select appropriate target parameters that reflect the desired effects of the dialysis procedure and can be measured sequentially, and adapt techniques to best meet the changing needs of the patient.
| Hypertension in the Developing World
See Mittal and Singh, pages 590-598.
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Hypertension is the leading cause of death and disability in developing countries. Modeled projections indicate an increase to 1.15 billion individuals with hypertension by 2025 in developing countries. In this issue, Drs Mittal and Singh review data about the epidemiologic characteristics and risk factors for hypertension in the developing world. They observe variability in the global prevalence of hypertension: ~35% in Latin America, 20%-30% in China and India, and ~14% in Sub-Saharan Africa. The authors attribute this heterogeneity to several factors, including urbanization with its associated changes in lifestyle, racial ethnic differences, nutritional status, and birth weight. Also, a lack of awareness and insufficient treatment complicates this high burden of hypertension. They conclude that the public health response should drive greater promotion of awareness efforts, studies of risk factors for hypertension, and understanding of the impact of lifestyle changes. Also important are efforts to develop multipronged strategies for hypertension management in developing nations.
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| | AJKD News |
Don’t miss the National Kidney Foundation Spring Clinical Meetings, taking place April 13-17 in Orlando. Participants will have the opportunity to learn about new and evolving concepts related to kidney disease through a combination of challenging courses, practical workshops, thought-provoking symposia, well-argued debates, and formal and informal interactions with an internationally renowned faculty. Up-to-date meeting information may be found online www.nkfclinicalmeetings.org.
Put yourself in your patients’ shoes: read this month’s “In a Few Words” feature, and share your own perspective on kidney disease by submitting an essay for consideration (email AJKD@tuftsmedicalcenter.org).
According to the 2008 Journal Citation Reports®, published by Thomson Reuters, the 2008 impact factor for AJKD is 4.822! | NKF | The National Kidney Foundation, Inc., a major voluntary health organization, seeks to prevent kidney and urinary tract diseases, improving the health and well being of individuals and families affected by these diseases, and increase the availability of all organs for transplantation.
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