The Role of the Primary Care Physician in Managing Early Stages of Chronic Kidney Disease
Mount Sinai Services, Elmhurst Hospital Center, Elmhurst, NY 11373, USA.Postgraduate Medicine (Impact Factor: 1.7). 09/2011; 123(5):177-85. DOI: 10.3810/pgm.2011.09.2473
Recent increases in obesity, diabetes, and hypertension, along with the aging of the US population, are driving a dramatic rise in the prevalence of chronic kidney disease (CKD). Despite this increase, the majority of Americans with early-stage CKD remain unaware of their disease. Primary care physicians are at the forefront of efforts for early recognition of CKD and management to control its progression. Patients with CKD should be referred to nephrologists no later than the point at which their estimated glomerular filtration rate reaches 30 mL/min. Nephrology evaluation at this point is essential to facilitate timely preparation for care of end-stage renal disease through preemptive transplantation or planned transition to dialysis. In addition to stringent control of underlying hypertension and/or diabetes, mineral metabolic parameters (serum parathyroid hormone, phosphorus, calcium, and bicarbonate) in patients with advancing CKD should be managed closely to avoid adverse effects on the cardiovascular and skeletal systems.
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ABSTRACT: Introduction: To evaluate the role of body mass index (BMI), waist circumference (W-C) and waist/hip ratio (WHR) on arteriovenous fistula (AVF) dysfunction. Methods: We evaluated 84 HD patients with an average follow-up period of 31.3 ± 8.1 months, identifying 8 stenosis (STN) and 17 thrombosis (THR) cases. The association between paired variables was tested with Pearson's coefficient (r) and p-value, whereas the prognostic value on STN and THR was analysed using Cox's regression. The significant independent variables were indentified with an inverse step-wise approach defining the data as hazard ratio (HR). A double-event (Stenosis/Thrombosis) model, function of Body mass index and Waist/hip ratio was used. Arteriovenous fistula survival was assessed with the Kaplan-Meyer curve and the calculations were carried out with Graph-Pad. Results: On univariate analysis, THR showed direct correlation with BMI (r=0.44, p<0.01), W-C (r=0.39, p<0.05) WHR (r=0.37, p<0.01), Hemoglobin (p<0.001), C-Reactive protein (p=0.01), Calcium/Phosforus product (p=0.03), Parathyroid hormone (p=0.03) and inverse with albumin (p<0.001) and systolic blood pressure (p=0.003). On multivariate analysis, BMI variations were not predictive of STN and THR, whereas each unitary WHR and W-C increase was predictive of an increase of risk of events (3.8% and 2.1% respectively). The prognostic power of W-C per STN (HR 1: 1.19; p<0.05) and THR (HR: 1.28; p<0.01) remained significant even after being adjusted to account for traditional risk factors. Conclusions: Abdominal obesity increases the risk of AVF dysfunction. The W-C and WHR parameters, not BMI, emerge as independent STN and THR predictors.
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ABSTRACT: Metabolic diseases such as hyperlipidemia and diabetes attenuate the cardioprotective effect of ischemic preconditioning. In the present study, we examined whether another metabolic disease, prolonged uremia, affects ischemia/reperfusion injury and cardioprotection by ischemic preconditioning. Uremia was induced by partial nephrectomy in male Wistar rats. The development of uremia was verified 29 weeks after surgery. Transthoracic echocardiography was performed to monitor cardiac function. At week 30, hearts of nephrectomized and sham-operated rats were isolated and subjected to a 30-min coronary occlusion followed by 120 min reperfusion with or without preceding preconditioning induced by 3 intermittent cycles of brief ischemia and reperfusion. In nephrectomized rats, plasma uric acid, carbamide and creatinine as well as urine protein levels were increased as compared to sham-operated controls Systolic anterior and septal wall thicknesses were increased in nephrectomized rats suggesting the development of a minimal cardiac hypertrophy. Ejection fraction was decreased and isovolumic relaxation time was shortened in nephrectomized rats demonstrating a mild systolic and diastolic dysfunction. Infarct size was not affected significantly by nephrectomy itself. Ischemic preconditioning significantly decreased infarct size from 24.8±5.2% to 6.6±1.3% in the sham operated group and also in the uremic group from 35.4±9.5% to 11.9±3.1% of the area at risk. Plasma angiotensin II and nitrotyrosine were significantly increased in the uremic rats. We conclude that although prolonged experimental uremia leads to severe metabolic changes and the development of a mild myocardial dysfunction, the cardioprotective effect of ischemic preconditioning is still preserved.
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