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The Effect of Cadmium on GFR Is Clarified by Normalization of Excretion Rates to Creatinine Clearance. Int J Mol Sci 2021; 22:ijms22041762. [PMID: 33578883 PMCID: PMC7916559 DOI: 10.3390/ijms22041762] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/02/2021] [Accepted: 02/06/2021] [Indexed: 01/13/2023] Open
Abstract
Erroneous conclusions may result from normalization of urine cadmium and N-acetyl-β-D-glucosaminidase concentrations ([Cd]u and [NAG]u) to the urine creatinine concentration ([cr]u). In theory, the sources of these errors are nullified by normalization of excretion rates (ECd and ENAG) to creatinine clearance (Ccr). We hypothesized that this alternate approach would clarify the contribution of Cd-induced tubular injury to nephron loss. We studied 931 Thai subjects with a wide range of environmental Cd exposure. For x = Cd or NAG, Ex/Ecr and Ex/Ccr were calculated as [x]u/[cr]u and [x]u[cr]p/[cr]u, respectively. Glomerular filtration rate (GFR) was estimated according to the Chronic Kidney Disease (CKD) Epidemiology Collaboration (eGFR), and CKD was defined as eGFR < 60 mL/min/1.73m2. In multivariable logistic regression analyses, prevalence odds ratios (PORs) for CKD were higher for log(ECd/Ccr) and log(ENAG/Ccr) than for log(ECd/Ecr) and log(ENAG/Ecr). Doubling of ECd/Ccr and ENAG/Ccr increased POR by 132% and 168%; doubling of ECd/Ecr and ENAG/Ecr increased POR by 64% and 54%. As log(ECd/Ccr) rose, associations of eGFR with log(ECd/Ccr) and log(ENAG/Ccr) became stronger, while associations of eGFR with log(ECd/Ecr) and log(ENAG/Ecr) became insignificant. In univariate regressions of eGFR on each of these logarithmic variables, R2 was consistently higher with normalization to Ccr. Our tabular and graphic analyses uniformly indicate that normalization to Ccr clarified relationships of ECd and ENAG to eGFR.
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Bang JB, Oh CK. Mathematical model for early functional recovery pattern of kidney transplant recipients using serum creatinine. KOREAN JOURNAL OF TRANSPLANTATION 2020; 34:167-177. [PMID: 35769063 PMCID: PMC9186847 DOI: 10.4285/kjt.2020.34.3.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/24/2022] Open
Abstract
Background Commonly used equations for calculating estimated glomerular filtration rate (eGFR) are not applicable when serum creatinine (Scr) is rapidly changing like the post-transplant period. A new mathematical model applicable to the post-transplant period is required. Methods All 623 patients who underwent kidney transplantation from January 2008 to June 2018 at a single institute were included to validate the Scr mathematical equations, and 14,360 Scr laboratory results from the time of re-perfusion to 30 days post-transplantation were analyzed. Results In the validation of model equations, linear regression analysis yielded adjusted R2 values of 0.972 and 0.925 for equation 5 (applicable when renal function is changing) and equation 1 (applicable when renal function is unchanged), respectively. In selected cases, the population comprised individuals who presented an adjusted R2 value >0.95 with equation 5. Linear regression analysis showed that adjusted R2 values and Pearson's correlation coefficients for equation 5 and equation 1 were 0.994 and 0.997 (P<0.001) and 0.956 and 0.978 (P<0.001), respectively. Most of the eGFR formulas are mathematically applicable only if the creatinine input rate equals the creatinine output rate when comparing between commonly used eGFRs and creatinine clearance using the modeled equation. Conclusions The proposed equations can provide a new perspective for calculating renal function during the early phase of kidney transplantation. A study of a correlation between the equations and long-term graft outcomes is required.
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Affiliation(s)
- Jun Bae Bang
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Kwon Oh
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
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Yeh HC, Lo YC, Ting IW, Chu PL, Chang SN, Chiang HY, Kuo CC. 24-hour Serum Creatinine Variation Associates with Short- and Long-Term All-Cause Mortality: A Real-World Insight into Early Detection of Acute Kidney Injury. Sci Rep 2020; 10:6552. [PMID: 32300213 PMCID: PMC7162857 DOI: 10.1038/s41598-020-63315-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 02/28/2020] [Indexed: 11/26/2022] Open
Abstract
Real-world evidence describing the variation in serum creatinine (S-Cre) within 24 hours and its prognostic value is unknown. We enrolled 14 912 adults who received two S-Cre measurements within 24 hours at a tertiary hospital between 2003 and 2016. The study population was divided into four groups according to the hospital service settings where the baseline and second S-Cre were measured: Group 1, Outpatient-to-Outpatient; Group 2, Outpatient-to-ED (emergency department) or Inpatient; Group 3, ED-to-ED or Inpatient; and Group 4, Inpatient-to-Inpatient. The main predictors were the difference between the two S-Cre measurements (ΔS-Cre) and the percent change (ΔS-Cre%). The main outcomes were 30-day, 1-year, or 3-year all-cause mortality. A total of 6753 and 8159 patients with an increase and a decrease within-day ΔS-Cre, respectively. Among 6753 patients who had deteriorating ΔS-Cre or ΔS-Cre%, the adjusted hazard ratio (aHR) for 1-year all-cause mortality for each 0.1 mg/dL or 5% change in S-Cre was 1.09 (95% confidence interval [CI]: 1.07, 1.11) and 1.03 (95% CI: 1.03, 1.04). In 8159 patients with improving ΔS-Cre%, the aHR was 0.97 (95% CI: 0.94, 1.00). Groups 3 and 4 had statistically significant positive linear relationships between deteriorating ΔS-Cre% and 30-day and 3-year mortality. The optimal cut-offs for deteriorating ΔS-Cre% for predicting 30-day mortality were approximately 22% for Group 3 and 20% for Group 4. Inpatient within-day deteriorating ΔS-Cre or ΔS-Cre% above 0.2 mg/dL or 20%, respectively, is associated with all-cause mortality. Monitoring 24-hour S-Cre variation identifies acute kidney injury earlier than the conventional criteria.
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Affiliation(s)
- Hung-Chieh Yeh
- AKI-CARE (Clinical Advancement, Research and Education) Center, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Yen-Chun Lo
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - I-Wen Ting
- AKI-CARE (Clinical Advancement, Research and Education) Center, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Pei-Lun Chu
- Division of Nephrology, Department of Internal Medicine, Fu Jen Catholic University Hospital, and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Shih-Ni Chang
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Hsiu-Yin Chiang
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Chin-Chi Kuo
- AKI-CARE (Clinical Advancement, Research and Education) Center, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan.
- Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan.
- Big Data Center, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan.
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Szeto CC, Kong J, Wu AK, Wong TY, Wang AY, Li PK. The Role of Lean Body Mass as a Nutritional Index in Chinese Peritoneal Dialysis Patients—Comparison of Creatinine Kinetics Method and Anthropometric Method. Perit Dial Int 2020. [DOI: 10.1177/089686080002000622] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To compare, in Chinese continuous ambulatory peritoneal dialysis (CAPD) patients, the creatinine kinetics method (LBM-CK) and the anthropometric method (LBM-AM) for determining lean body mass (LBM). Design Single-center cross-sectional study. Patients and Methods We studied 151 unselected CAPD patients (78 males, 73 females). We calculated LBM-CK and LBM-AM using standard formulas. The results of the two methods were then compared by the Bland and Altman method. Dialysis adequacy and other nutritional indices, including total Kt/V, weekly creatinine clearance (CCr), residual glomerular filtration rate (GFR), protein nitrogen appearance (PNA), subjective global assessment (SGA), and serum albumin, were measured simultaneously. Results The mean age of the patients was 55.6 ± 12.2 years, and the mean duration of dialysis was 33.6 ± 28.5 months. The mean body mass index (BMI) was 22.7 ± 3.7. The average LBM-AM was 43.6 ± 8.0 kg; the average LBM-CK was 33.0 ± 9.3 kg. The difference between the calculated LBM-AM and LBM-CK was 10.7 kg, with LBM-AM always giving a higher value; the limits of agreement were –5.8 kg and 27.1 kg. The difference between the two measures correlated with residual GFR (Pearson r = 0.629, p < 0.001). After normalizing for desired body weight, LBM-AM was only modestly correlated with serum albumin level. No correlations were found between overall SGA score or normalized protein nitrogen appearance (nPNA) and LBM-AM or LBM-CK. Conclusions In Chinese patients at least, a substantial discrepancy exists between LBM-AM and LBM-CK. The difference is especially marked in patients with significant residual renal function. The optimal method for determining LBM remains obscure in Chinese CAPD patients. Moreover, LBM correlated poorly with other nutritional indices. Multiple parameters should be taken into consideration in an assessment of nutritional status of CAPD patients.
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Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Johnathan Kong
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Alan K.L. Wu
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Teresa Y.H. Wong
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Angela Y.M. Wang
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Philip K.T. Li
- Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Burkart JM, Bleyer AJ, Jordan JR, Zeigler NC. An Elevated Ratio of Measured to Predicted Creatinine Production in Capd Patients is Not a Sensitive Predictor of Noncompliance with the Dialysis Prescription. Perit Dial Int 2020. [DOI: 10.1177/089686089601600210] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To determine the effect a period of “intentional noncompliance” in stable continuous ambulatory peritoneal dialysis (CAPD) patients has on the ratio of measured to predicted creatinine generation. Design Prospective study that compares baseline to noncompliant periods in individual CAPD patients. Patients Nine chronic, stable CAPD patients. Study Design At baseline, measured creatinine production and adequacy parameters (KT/V, creatinine clearance, lean body mass, and protein equivalent of nitrogen appearance) were calculated from 24-hour collections of dialysate and urine while patients were performing their routine dialysis prescriptions. After three days of intentional noncompliance (one less exchange/day) the patients repeated their 24-hour collections, again performing their routine number of exchanges. Measured creatinine production and adequacy parameters were again calculated. Predicted creatinine production for each patient was calculated from standard equations. All parameters at baseline were compared to corresponding parameters after intentional noncompliance. Results In all patients, except one where there was no change, there was a statistically significant increase in not only the ratio of measured to predicted creatinine production but also all other parameters. Conclusion As suspected by previous investigators, this study suggests that one cause of an elevated ratio of measured to predicted creatinine production may be a recent period of noncompliance with the patient's dialysis prescription. However, these data suggest that an isolated ratio of measured to predicted creatinine generation is not a sensitive predictor of noncompliance with the peritoneal dialysis prescription.
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Affiliation(s)
- John M. Burkart
- Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - Anthony J. Bleyer
- Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - Jean R. Jordan
- Piedmont Dialysis Center, Inc., Winston-Salem, North Carolina, U.S.A
| | - Nancy C. Zeigler
- Piedmont Dialysis Center, Inc., Winston-Salem, North Carolina, U.S.A
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Tzamaloukas AH, Murata GH. A Population-Specific Formula Predicting Creatinine Excretion in Continuous Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686080202200111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective The Cockroft–Gault formula was shown to systematically overestimate the decline in creatinine excretion with age in continuous peritoneal dialysis (CPD) patients and is, therefore, not suitable for studying creatinine excretion. The purpose of the present study was to develop and test a population-specific formula predicting average creatinine excretion in CPD. Methods Creatinine excretion in urine plus dialysate was measured in 925 CPD patients. Forty patients were excluded because of evidence of noncompliance. The remaining 885 subjects were randomly grouped into a derivation group ( n = 432) and a validation group ( n = 453). Stepwise multiple linear regression models were used to predict creatinine excretion in the derivation group. The candidate variables, chosen because they were previously shown to be predictors of creatinine excretion in CPD, included weight (W), age (A), gender (G), diabetes (D), and interaction terms between these four variables. Estimates of creatinine excretion from the best-fit regression formula (CrExcr1) and from the Cockroft–Gault formula (CrExcr2) were compared to creatinine excretion (CrExcr) in the validation group. Results The best-fit regression model in the derivation group included all four candidate variables (W, A, G, D), but no interaction terms. This model was as follows: CrExcr1 = 302.150 – 4.380A + 171.234G – 39.041D + 11.730W ( r 2 = 0.477, p < 0.001). In the validation set, CrExcr = –15.795 + 0.988CrExcr1 ( r2 = 0.447, p < 0.001), and CrExcr = –303.823 + 0.732CrExcr2 ( r2 = 0.340, p < 0.001). When the differences between measured and predicted creatinine excretion did not take into account the sign of each individual difference, CrExcr – CrExcr1 = 201 ± 156 mg/24 hours, and CrExcr – CrExcr2 = 235 ± 174 mg/24 hr ( p < 0.001) in the validation group. When the sign of the difference was taken into account, CrExcr – CrExcr1 = –28 ± 149 mg/24 hr, and CrExcr – CrExcr2 = 63 ± 295 mg/24 hr ( p < 0.001). Conclusions A population-specific formula predicting creatinine excretion in CPD was derived. This formula has greater accuracy than the Cockroft–Gault formula and can be used in studies of creatinine excretion in CPD.
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Affiliation(s)
| | - Glen H. Murata
- New Mexico Veterans Affairs Health Care System, and University of New Mexico School of Medicine, Albuquerque, New Mexico, U.S.A
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Nolph KD, Twardowski ZJ, Khanna R, Moore HL, Prowant BF. Predicted and Measured Daily Creatinine Production in CAPD: Identifying Noncompliance. Perit Dial Int 2020. [DOI: 10.1177/089686089501500105] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Objective To evaluate the ratio of measured creatinine (Cr) production to predicted creatinine production as an index of noncompliance in patients on continuous ambulatory peritoneal dialysis (CAPD). Design A cross-sectional analysis. Patients One hundred and twenty-one patients on CAPD. Measurements We have calculated Cr production from measured Cr outputs in 24-hour collections of urine and dialysate. Predicted Cr productions were calculated from standard tables. Weekly KTN urea and weekly Cr clearances were determined from the same 24-hour urine and dialysate collections. Lean body mass (LBM) was calculated from the Cr production. Serum albumin concentration was measured. Results The ratio of measured/predicted Cr production correlated positively and significantly with weekly KTN urea, the protein equivalent of nitrogen appearance (PNA), weekly Cr clearance, and LBM. There was a decline in serum albumin concentration at ratios greater than 1.24, supporting the opinions of previous authors who have suggested that ratios greater than 1.24 are highly suggestive of noncompliance with the dialysis prescription. Defining noncompliance as a ratio greater than 1.24 implied that at least 5% of the female and 17% of the male patients were noncompliant. Conclusions Declining serum albumin concentrations at higher ratios of measured/predicted Cr production support the opinion that this is an index of noncompliance. However, not all noncompliant patients necessarily have a ratio greater than 1.24. Weekly KTN urea, weekly Ccr and LBM are all artifactually increased by “washout effects” if all exchanges are done only or mainly on the collection day.
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Affiliation(s)
- Karl D. Nolph
- Division of Nephrology, University of Missouri Health Sciences Center, Dalton Cardiovascular Research Center, Dialysis Clinics Inc., Columbia, Missouri, U.S.A
| | - Zbylut J. Twardowski
- Division of Nephrology, University of Missouri Health Sciences Center, Dalton Cardiovascular Research Center, Dialysis Clinics Inc., Columbia, Missouri, U.S.A
| | - Ramesh Khanna
- Division of Nephrology, University of Missouri Health Sciences Center, Dalton Cardiovascular Research Center, Dialysis Clinics Inc., Columbia, Missouri, U.S.A
| | - Harold L. Moore
- Division of Nephrology, University of Missouri Health Sciences Center, Dalton Cardiovascular Research Center, Dialysis Clinics Inc., Columbia, Missouri, U.S.A
| | - Barbara F. Prowant
- Division of Nephrology, University of Missouri Health Sciences Center, Dalton Cardiovascular Research Center, Dialysis Clinics Inc., Columbia, Missouri, U.S.A
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Jansen MA, Korevaar JC, Dekker FW, Jager KJ, Boeschoten EW, Krediet RT. The Relationship between Kt/VUrea and Npna in Anuric Peritoneal Dialysis Patients: A Comparison with Predialysis Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080102100513] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective It is unknown whether a given level of urea clearance by the native kidneys provides better or similar control of uremia than the same level of urea clearance by continuous peritoneal dialysis (PD). More insight into possible differences between renal and peritoneal urea clearances is warranted. Therefore, we investigated the relationship between Kt/Vurea and protein equivalent of total nitrogen appearance normalized to body weight (nPNA), the relationship between urea clearance and creatinine appearance, and other nutritional parameters in PD patients without residual renal function, and in predialysis end-stage renal disease patients. Patients All patients participated in the Netherlands Cooperative Study on the Adequacy of Dialysis. This is a prospective cohort study of incident dialysis patients, in whom regular assessments of renal function are done. A group of 75 PD patients was identified at the first follow-up assessment in which their urine production was less than 100 mL/day. These patients were considered the anuric group. This group was compared with a control group of 97 predialysis patients studied 0 – 4 weeks before the start of dialysis treatment. Results Linear relationships were present between Kt/Vurea and nPNA, in both the predialysis patients and the anuric PD patients. A significant difference was present between the slopes of the two regression lines (0.40 vs 0.18, p = 0.007). When Kt/Vurea exceeded 1.3/week, a given level of Kt/Vurea was associated with a higher nPNA in predialysis than in anuric PD patients. Similar relationships were found between Kturea and PNA. Kturea was also significantly related to urine or dialysate creatinine appearance. A significant difference existed between the slopes of the regression lines in the two groups of patients ( p < 0.001). A weekly Kturea of 70 L was associated with a urine creatinine appearance of 11.0 mmol/day and a dialysate creatinine appearance of 8.4 mmol/day. Nutritional status measured with creatinine appearance and Subjective Global Assessment was better in the predialysis population, despite much lower values for Kt/Vurea in these patients. Conclusions The relationship between Kt/Vurea and nPNA in anuric PD patients is different from that in a predialysis population. It follows from our results that, when Kt/Vurea is above 1.3/week, a given level of Kt/Vurea is associated with a higher nPNA in predialysis than in anuric PD patients. This challenges the concept of equivalency between renal and peritoneal Kt/Vurea with respect to control of uremic morbidity.
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Affiliation(s)
| | - Maarten A.M. Jansen
- Division of Nephrology, Department of Medicine, Academic Medical Center, University of Amsterdam
- NECOSAD Foundation; Academic Medical Center, University of Amsterdam, Amsterdam
| | - Johanna C. Korevaar
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, Amsterdam
| | - Friedo W. Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kitty J. Jager
- Division of Nephrology, Department of Medicine, Academic Medical Center, University of Amsterdam
- NECOSAD Foundation; Academic Medical Center, University of Amsterdam, Amsterdam
| | - Elisabeth W. Boeschoten
- Division of Nephrology, Department of Medicine, Academic Medical Center, University of Amsterdam
| | - Raymond T. Krediet
- Division of Nephrology, Department of Medicine, Academic Medical Center, University of Amsterdam
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Chung SH, Lindholm B, Lee HB. Influence of Initial Nutritional Status on Continuous Ambulatory Peritoneal Dialysis Patient Survival. Perit Dial Int 2020. [DOI: 10.1177/089686080002000105] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives To evaluate the influence of initial nutritional status on continuous ambulatory peritoneal dialysis (CAPD) patient survival and to identify factors determining initial nutritional status and patient mortality. Design Prospective single-center study. Setting Kidney Center, Soon Chun Hyang University Hospital. Patients A total of 91 consecutive CAPD patients, who underwent initial nutritional assessment at Soon Chun Hyang University Hospital, Seoul, Korea, between September 1994 and January 1999, was included in this study. All patients were assessed at a mean of 7 days after beginning CAPD (range 3 – 24 days). Forty-eight patients were male, 50 were diabetics, and their mean age was 53.9 years (range 22 – 76 years). Methods Nutritional status was assessed by subjective global assessment (SGA), biochemical and anthropometric measurements, fat-free edema-free (FFEF) body mass by creatinine kinetics, urea kinetic studies, and calculation of the normalized protein equivalent of total nitrogen appearance (nPNA). Results By SGA, 55% were classified as having normal nutrition while 45% had signs of malnutrition; 61% of female and 31% of male patients, and 54% of diabetics and 34% of nondiabetics were classified as malnourished. Initial FFEF body mass, blood urea nitrogen (BUN), serum albumin (sAlb), residual renal function (RRF), and weekly total creatinine clearance were significantly lower in the malnourished patients than in the patients with normal nutrition. On multiple regression analysis, only FFEF body mass was an independent determinant of SGA score. On 31 January 1999, 41 patients were still on CAPD, 15 patients had died, and 27 patients had been transferred to hemodialysis. Those who died during observation were older and had lower initial FFEF body mass, % lean body mass, BUN, sAlb, RRF, and SGA score. The 2-year patient survival rate was significantly lower in the malnourished than in normal patients (67.1% vs 91.7%, p = 0.02). On Cox proportional hazards analysis, initial age, malnutrition assessed by SGA, and FFEF body mass were identified as factors determining death. Conclusion Malnutrition was present in 45% of patients commencing CAPD when assessed by SGA. Initial FFEF body mass was a determinant of SGA score and predicted death. Malnutrition as assessed by SGA was also an independent predictor of death. Initial nutritional status, therefore, appears to exert a powerful influence on CAPD patient survival.
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Affiliation(s)
- Sung Hee Chung
- Hyonam Kidney Laboratory, Soon Chun Hyang University Hospital, Seoul, Korea
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
| | - Bengt Lindholm
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
| | - Hi Bahl Lee
- Hyonam Kidney Laboratory, Soon Chun Hyang University Hospital, Seoul, Korea
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10
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Chung SH, Heimbürger O, Stenvinkel P, Wang T, Lindholm B. Influence of Peritoneal Transport Rate, Inflammation, and Fluid Removal on Nutritional Status and Clinical Outcome in Prevalent Peritoneal Dialysis Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080302300214] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the possible associations between peritoneal transport rate (PTR), fluid removal, inflammation, and nutritional status in patients treated with peritoneal dialysis (PD) for more than 6 months, and the impact of these factors on subsequent patient survival. Design and Patients A prospective study of 82 PD patients (48 males) that had been treated with PD more than 6 months. Based on the dialysate-to-plasma creatinine ratio at 4 hours of dwell (D/PCr; mean ± 1 SD), the patients were classified as having a high (H), high-average (HA), low-average (LA), or low (L) PTR. Setting Single PD unit in a university hospital. Main Outcome Measures The PTR, evaluation of adequacy of dialysis and nutritional status, and biochemical analyses were assessed at 10.8 ± 2.8 months after the start of PD. Results Compared to L and LA (L/LA) transporters, H and HA (H/HA) transporters had increased dialysate protein loss, glucose absorption from dialysate, and peritoneal creatinine clearance (CCr), and decreased night ultrafiltration volume and total Kt/V urea. However, nutritional variables, 24-hour total fluid removal (TFR), total CCr, and residual renal function were not significantly different between the two groups. The 24-hour TFR correlated significantly with D/PCr (rho = –0.25), mean arterial pressure (rho = –0.23), serum albumin (rho = 0.25), normalized protein equivalent of total nitrogen appearance (rho = 0.34), lean body mass (LBM) calculated from creatinine kinetics (rho = 0.41), total Kt/V urea (rho = 0.42), and total CCr (rho = 0.30). The group with serum C-reactive protein (sCRP) ⊕ 10 mg/L had a higher proportion of patients with reduced (< 1000 mL) TFR compared to the group with sCRP < 10 mg/(38% vs 16%, p = 0.04). Two-year patient survival rates from the time of the assessment were not different between the different transport groups (78% vs 73% for H/HA and L/LA, p = 0.99). Upon Cox proportional hazards multivariate analysis, age and high sCRP were independent predictors of mortality. Conclusions This study shows that, in a selected group of prevalent PD patients assessed after more than 6 months of PD therapy, ( 1 ) inflammation was an independent predictor for mortality; ( 2 ) reduced TFR was associated with impaired nutritional status, decreased small solute clearance, and inflammation; and ( 3 ) peritoneal transport status was not significantly associated with nutritional status and was not associated with subsequent patient survival. These results indicate that a high peritoneal solute transport rate, as such, should not be regarded as a relative contraindication for PD. Instead, the results suggest that more attention should be given to inflammation and inadequate fluid removal as predictors of mortality in PD patients.
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Affiliation(s)
- Sung Hee Chung
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
- Hyonam Kidney Laboratory, Soon Chun Hyang University, Seoul, Korea
| | - Olof Heimbürger
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
| | - Peter Stenvinkel
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
| | - Tao Wang
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
| | - Bengt Lindholm
- Divisions of Baxter Novum and Renal Medicine, Department of Clinical Science, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
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11
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Blake PG, Spanner E, McMurray S, Lindsay RM, Ferguson E. Comparison of Measured and Predicted Creatinine Excretion is An Unreliable Index of Compliance in Pd Patients. Perit Dial Int 2020. [DOI: 10.1177/089686089601600211] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To evaluate the use of the ratio of measured to predicted creatinine excretion as an index of compliance in peritoneal dialysis (PD) patients. Design A prospective analysis. Setting Academic teaching hospital dialysis unit. Patients Forty-three patients on PD. Measurements Creatinine excretion in daily dialysate and urine collections was measured on one occasion in 10 patients and on two occasions in 33 patients, and, after adding an estimate for extrarenal creatinine degradation, was divided by predicted creatinine excretion to give a creatinine excretion ratio, which has been proposed as an index of compliance with exchanges in PD patients. Values above 1.24 have been suggested to indicate non-compliance. Lean body mass was also estimated from creatinine excretion. Results The mean creatinine excretion ratio was 1.12, and 30% of patients had a value above 1.3. Only one patient admitted noncompliance. Studies on four consecutive days of guaranteed compliance in 7 patients with high ratios showed that creatinine excretion remained constant, suggesting that the patients were high creatinine producers rather than noncompliant. Creatinine excretion was stable when measured at intervals of days, but over months it tended to change markedly in many patients. Lean body mass estimations using creatinine excretion were low in most patients. Conclusion Comparison of measured and predicted creatinine excretion is not a reliable indicator of noncompliance because many compliant patients consistently excrete more creatinine than predicted. The standard formulas were not validated in dialysis patients and underestimate creatinine excretion significantly in many PD patients. Existing estimates in the literature of non-compliance, using this methodology, may not be accurate. Better methods of detecting this problem are required.
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Affiliation(s)
- Peter G. Blake
- Optimal Dialysis Research Unit, Division of Nephrology, Victoria Hospital, and the University of Western Ontario, London, Ontario, Canada
| | - Evelyn Spanner
- Optimal Dialysis Research Unit, Division of Nephrology, Victoria Hospital, and the University of Western Ontario, London, Ontario, Canada
| | - Susan McMurray
- Optimal Dialysis Research Unit, Division of Nephrology, Victoria Hospital, and the University of Western Ontario, London, Ontario, Canada
| | - Robert M. Lindsay
- Optimal Dialysis Research Unit, Division of Nephrology, Victoria Hospital, and the University of Western Ontario, London, Ontario, Canada
| | - Evelyn Ferguson
- Optimal Dialysis Research Unit, Division of Nephrology, Victoria Hospital, and the University of Western Ontario, London, Ontario, Canada
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12
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Affiliation(s)
- Peter G. Blake
- Optimal Dialysis Research Unit London Health Sciences Centre and The University of Western Ontario London, Ontario, Canada
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13
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Abstract
Objective To measure compliance with prescribed exchanges in continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) patients using inventories of home dialysis supplies; to determine the reliability of the ratio of measured to predicted creatinine (MIP) in predicting compliance with prescribed exchanges; to determine the effects of the ingestion of preformed creatine on the excretion of creatinine. Design A prospective analysis. Setting A university dialysis center. Patients Twenty patients on home peritoneal dialysis (PD). Measurements An inventory of supplies during two home visits over a 4 -8 week interval determined the number of PD exchanges performed. This number was divided by the number of exchanges prescribed for the period to determine the percent compliance. Three consecutive days of dialysate and urine were measured with all food consumed recorded during those days. MIP creatinine ratios and dietary protein intake (DPI) for each day were calculated. Results Of the patients tested, 8120 (40%) were found to be noncompliant with the prescribed number of exchanges based on the home visit inventories, performing a mean of 75% of their exchanges. There was no significant difference in the MIP creatinine ratios of compliant and noncompliant patients, nor were the MIP ratios distributed differently for compliant and noncompliant patients. The MIP ratios did not vary significantly over the 3 days. There was no correlation between the measured creatinine on a given day and the DPI for the same day. Conclusion Based on assessment of the patient's inventory, 40% of the patients studied were noncompliant with their prescribed exchanges, indicating this is a serious and common problem in PD patients. The MIP creatinine ratio is not a predictor of compliance in PD. We suggest the use of home visit inventories to assess compliance in PD patients.
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14
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Ilic LM, Davis RB, Brown RS, Lecker SH. The Interdialytic Creatinine Rise is a novel marker of volume overload and mortality risk in hemodialysis patients. BMC Nephrol 2018; 19:202. [PMID: 30115036 PMCID: PMC6097344 DOI: 10.1186/s12882-018-1008-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 08/09/2018] [Indexed: 12/18/2022] Open
Abstract
Background Volume overload poses a major risk in hemodialysis patients but simple detection methods are lacking. We propose a novel marker, the Interdialytic Creatinine Rise (IDCR), readily calculated as the change in serum creatinine over time (in mg/dL/h), to assess volume overload and predict mortality risk in hemodialysis patients. Methods First, we calculated IDCR changes with volume in a prospective cohort of 35 hospitalized hemodialysis patients awaiting hemodialysis and 33 hospitalized patients undergoing hemodialysis every other day. Second, in a prospective cohort of 25 outpatients, IDCR cutoff values associated with hypervolemia were determined between two treatments and compared with simultaneous volume assessments by their nephrologist. Third, IDCR as a mortality predictor was studied using survival analysis in a longitudinal retrospective cohort study of 39 maintenance hemodialysis patients followed from 2012 until death or 2017. Results IDCR decreased by − 0.014 mg/dL/h each day (95%CI − 0.017,− 0.010; p < 0.001) without dialysis due to fluid volume gain and increased by 0.013 mg/dL/h (95%CI 0.008,0.017; p < 0.001) from before to after each successive hemodialysis due to fluid removal. Choosing an IDCR cutoff value of ≤0.1 had sensitivity of 82% and specificity of 79% in diagnosing volume overload with the area under the ROC curve of 0.78 (95%CI 0.59,0.97). The hazard ratio of death for each 0.01 decrease in IDCR was 1.64 (95%CI 1.31,2.07; p < 0.001). If IDCR decreased to less than 0.05 mg/dL/h, the median survival was 32 days and the odds ratio of death within 2 months was 38 (95%CI 8, 131; p < 0.001). Conclusions In this pilot study, IDCR is shown to be a novel metric that decreases with fluid retention and increases after fluid removal. IDCR can assist clinicians in detection or exclusion of volume overload in hemodialysis patients and provide prognostic value in identifying those at high risk for death. Electronic supplementary material The online version of this article (10.1186/s12882-018-1008-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ljubomir M Ilic
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA. .,Department of Medicine - Division of Nephrology and Hypertension, University of Florida College of Medicine - Jacksonville, 655 West 8th Street, Jacksonville, Florida, USA.
| | - Roger B Davis
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Robert S Brown
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stewart H Lecker
- Nephrology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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15
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Daugirdas JT, Depner TA. Creatinine generation from kinetic modeling with or without postdialysis serum creatinine measurement: results from the HEMO study. Nephrol Dial Transplant 2018; 32:1926-1933. [PMID: 28379486 DOI: 10.1093/ndt/gfx038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 02/08/2017] [Indexed: 11/14/2022] Open
Abstract
Background A convenient method to estimate the creatinine generation rate and measures of creatinine clearance in hemodialysis patients using formal kinetic modeling and standard pre- and postdialysis blood samples has not been described. Methods We used data from 366 dialysis sessions characterized during follow-up month 4 of the HEMO study, during which cross-dialyzer clearances for both urea and creatinine were available. Blood samples taken at 1 h into dialysis and 30 min and 60 min after dialysis were used to determine how well a two-pool kinetic model could predict creatinine concentrations and other kinetic parameters, including the creatinine generation rate. An extrarenal creatinine clearance of 0.038 l/kg/24 h was included in the model. Results Diffusive cross-dialyzer clearances of urea [230 (SD 37 mL/min] correlated well (R2 = 0.78) with creatinine clearances [164 (SD 30) mL/min]. When the effective diffusion volume flow rate was set at 0.791 times the blood flow rate for the cross-dialyzer clearance measurements at 1 h into dialysis, the mean calculated volume of creatinine distribution averaged 29.6 (SD 7.2) L], compared with 31.6 (SD 7.0) L for urea (P < 0.01). The modeled creatinine generation rate [1183 (SD 463) mg/day] averaged 100.1 % (SD 29; median 99.3) of that predicted in nondialysis patients by an anthropometric equation. A simplified method for modeling the creatinine generation rate using the urea distribution volume and urea dialyzer clearance without use of the postdialysis serum creatinine measurement gave results for creatinine generation rate [1187 (SD 475) mg/day; that closely matched the value calculated using the formally modeled value, R2 = 0.971]. Conclusions Our analysis confirms previous findings of similar distribution volumes for creatinine and urea. After taking extra-renal clearance into consideration, the creatinine generation rate in dialysis patients is similar to that in nondialysis patients. A simplified method based on urea clearance and urea distribution volume not requiring a postdialysis serum creatinine measurement can be used to yield creatinine generation rates that closely match those determined from standard modeling.
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Affiliation(s)
- John T Daugirdas
- Department of Medicine, Division of Nephrology, University of Illinois College of Medicine at Chicago, Chicago, IL 60612, USA
| | - Thomas A Depner
- Department of Medicine, Division of Nephrology, University of California at Davis, Davis, CA, USA
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16
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Tzamaloukas A, Braun M, Malhotra D, Murata G. Estimated versus Predicted Creatinine Generation as an Indicator of Compliance with the Prescribed Dose of Continuous Peritoneal Dialysis. Int J Artif Organs 2018. [DOI: 10.1177/039139889601900303] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The expression (Estimated - Predicted)/Predicted creatinine generation {(E-P)IP} has been proposed as an index of compliance in continuous peritoneal dialysis (CPD). We attempted to define an (E-P)IP value that can be used as a cut-off for non-compliance and to characterize the relation of (E-P)IP to serum albumin. In 324 clearance studies, (E-P)/P had a normal distribution with a mean of +0.094 and an SD of 0.357. In these studies, there was a weak correlation between (E-P)/P and serum albumin (r=0.12, P<0.05), but (E-P)/P was not a predictor of serum albumin by logistic regression. In 34 CPD patients, who had an increase in the dose of CPD resulting in an increase in measured creatinine clearance from 43.8 ± 14.0 to 66.1 ± 17.6 L/1.73 m2 weekly (P<0.001), (E-P)/P increased correspondingly from +0.018 ± 0.284 to +0.153 ± 0.369 (P = 0.018), although all subjects should be in a steady state of creatinine excretion in the second study. The rise in (E-P)/P was statistically significant in the subgroup of 17 subjects who had a decrease in serum albumin, but not in the subgroup of 14 subjects who had an increase in serum albumin from the first to the second clearance study. The (E-P)/P cut-off for a definitive diagnosis of CPD non-compliance may be around +0.400 or +0.500. The findings of this study suggest that non-compliance, as indicated by (E-P)/P, has an adverse effect on serum albumin and that non-compliance increases after a prescribed increase in the dose of CPD.
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Affiliation(s)
- A.H. Tzamaloukas
- Renal Section and Primary Care Section, Albuquerque Veterans Affairs Medical Center and Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico - USA
| | - M. Braun
- Renal Section and Primary Care Section, Albuquerque Veterans Affairs Medical Center and Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico - USA
| | - D. Malhotra
- Renal Section and Primary Care Section, Albuquerque Veterans Affairs Medical Center and Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico - USA
| | - G.H. Murata
- Renal Section and Primary Care Section, Albuquerque Veterans Affairs Medical Center and Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico - USA
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17
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Mindikoglu AL, Opekun AR, Mitch WE, Magder LS, Christenson RH, Dowling TC, Weir MR, Seliger SL, Howell CD, Raufman JP, Rana A, Goss JA, Khaderi SA, Vierling JM. Cystatin C Is a Gender-Neutral Glomerular Filtration Rate Biomarker in Patients with Cirrhosis. Dig Dis Sci 2018; 63:665-675. [PMID: 29392554 PMCID: PMC5994910 DOI: 10.1007/s10620-017-4897-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/21/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Lower serum Cr levels in women as compared to men result in underestimation of renal dysfunction and lower model for end-stage liver disease-sodium scores leading to reduced access to liver transplantation in women compared to men with comparable hepatic dysfunction. AIM The aim of this study was to determine the gender differences in serum Cr, cystatin C, and other endogenous glomerular filtration rate (GFR) biomarkers, measured and estimated GFR, Cr clearance, and Cr production rates. METHODS We measured GFR by iothalamate plasma clearance in 103 patients with cirrhosis and assessed gender differences in GFR, Cr clearance and production rate, serum Cr, cystatin C and other endogenous GFR biomarkers including beta-trace protein, beta-2 microglobulin, and dimethylarginines. RESULTS Comparison of men and women showed significantly lower values for mean serum Cr (0.97 vs. 0.82 mg/dl, P = 0.023), and Cr production rate (13.37 vs. 11.02 mg/kg/day, P = 0.022). In contrast to the serum Cr and Cr production rate, men and women exhibited no significant differences in the means of serum cystatin C and other GFR biomarkers, measured GFR, GFR estimated using Cr-cystatin C GFR equation for cirrhosis, measured and estimated Cr clearances. After controlling for age, race, weight, height, and GFR, female gender remained associated with lower serum Cr levels (P = 0.003). Serum cystatin C levels were not associated with gender, age, race, weight, height, C-reactive protein, and history of hypothyroidism. CONCLUSIONS Our results suggest that cystatin C and endogenous GFR biomarkers other than Cr, measured GFR, GFR estimated by Cr-cystatin C GFR equation for cirrhosis, measured and estimated Cr clearance minimized between-gender biases in accounting for renal function in patients with cirrhosis. Therefore, serum cystatin C should be measured as a complementary test to serum Cr when renal function is assessed in patients with cirrhosis, particularly in women and those with sarcopenia.
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Affiliation(s)
- Ayse L Mindikoglu
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6620 Main Street, Suite 1450, Houston, TX, 77030, USA.
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Antone R Opekun
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - William E Mitch
- Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Laurence S Magder
- Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas C Dowling
- College of Pharmacy, Ferris State University, Grand Rapids, MI, USA
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stephen L Seliger
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Charles D Howell
- Department of Medicine, Howard University College of Medicine, Washington, DC, USA
| | - Jean-Pierre Raufman
- Division of Gastroenterology and Hepatology and VA Maryland Health Care System, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Abbas Rana
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6620 Main Street, Suite 1450, Houston, TX, 77030, USA
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6620 Main Street, Suite 1450, Houston, TX, 77030, USA
| | - Saira A Khaderi
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6620 Main Street, Suite 1450, Houston, TX, 77030, USA
| | - John M Vierling
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6620 Main Street, Suite 1450, Houston, TX, 77030, USA
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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18
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Nagai T, Kimura G, Inoue T, Nakamura S, Inenaga T, Kawano Y, Matsuoka H, Omae T. Quantitative Estimation of Ideal Body Weight in Uremic Patients. Int J Artif Organs 2018. [DOI: 10.1177/039139889501800103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- T. Nagai
- Department of Medicine, National Cardiovascular Center, Osaka - Japan
| | - G. Kimura
- Department of Medicine, National Cardiovascular Center, Osaka - Japan
| | - T. Inoue
- Department of Medicine, National Cardiovascular Center, Osaka - Japan
| | - S. Nakamura
- Department of Medicine, National Cardiovascular Center, Osaka - Japan
| | - T. Inenaga
- Department of Medicine, National Cardiovascular Center, Osaka - Japan
| | - Y. Kawano
- Department of Medicine, National Cardiovascular Center, Osaka - Japan
| | - H. Matsuoka
- Department of Medicine, National Cardiovascular Center, Osaka - Japan
| | - T. Omae
- Department of Medicine, National Cardiovascular Center, Osaka - Japan
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19
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Mindikoglu AL, Pappas SC. New Developments in Hepatorenal Syndrome. Clin Gastroenterol Hepatol 2018; 16:162-177.e1. [PMID: 28602971 PMCID: PMC5831376 DOI: 10.1016/j.cgh.2017.05.041] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/26/2017] [Accepted: 05/28/2017] [Indexed: 02/07/2023]
Abstract
Hepatorenal syndrome (HRS) continues to be one of the major complications of decompensated cirrhosis, leading to death in the absence of liver transplantation. Challenges in precisely evaluating renal function in the patient with cirrhosis remain because of the limitations of serum creatinine (Cr) alone in estimating glomerular filtration rate (GFR); current GFR estimating models appear to underestimate renal dysfunction. Newer models incorporating renal biomarkers, such as the Cr-Cystatin C GFR Equation for Cirrhosis appear to estimate measured GFR more accurately. A major change in the diagnostic criteria for HRS based on dynamic serial changes in serum Cr that regard HRS type 1 as a special form of acute kidney injury promises the possibility of earlier identification of renal dysfunction in patients with cirrhosis. The diagnostic criteria of HRS still include the exclusion of other causes of kidney injury. Renal biomarkers have been disappointing in assisting with the differentiation of HRS from prerenal azotemia and other kidney disorders. Serum metabolomic profiling may be a more powerful tool to assess renal dysfunction, although the practical clinical significance of this remains unclear. As a result of the difficulties of assessing renal function in cirrhosis and the varying HRS diagnostic criteria and the rigor with which they are applied, the precise incidence and prevalence of HRS is unknown, but it is likely that HRS occurs more commonly than expected. The pathophysiology of HRS is rooted firmly in the setting of progressive reduction in renal blood flow as a result of portal hypertension and splanchnic vasodilation. Progressive marked renal cortical ischemia in patients with cirrhosis parallels the evolution of diuretic-sensitive ascites to diuretic-refractory ascites and HRS, a recognized continuum of renal dysfunction in cirrhosis. Alterations in nitrous oxide production, both increased and decreased, may play a major role in the pathophysiology of this evolution. The inflammatory cascade, triggered by bacterial translocation and endotoxemia, increasingly recognized as important in the manifestation of acute-on-chronic liver failure, also may play a significant role in the pathophysiology of HRS. The mainstay of treatment remains vasopressor therapy with albumin in an attempt to reverse splanchnic vasodilation and improve renal blood flow. Several meta-analyses have confirmed the value of vasopressors, chiefly terlipressin and noradrenaline, in improving renal function and reversing HRS type 1. Other interventions such as renal replacement therapy, transjugular intrahepatic portosystemic shunt, and artificial liver support systems have a very limited role in improving outcomes in HRS. Liver transplantation remains the definitive treatment for HRS. The frequency of simultaneous liver-kidney transplantation has increased dramatically in the Model for End-stage Liver Disease era, with changes in organ allocation policies. This has resulted in a more urgent need to predict native kidney recovery from HRS after liver transplantation alone, to avoid unnecessary simultaneous liver-kidney transplantation.
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Affiliation(s)
- Ayse L. Mindikoglu
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation,Baylor College of Medicine, Margaret M. and Albert B. Alkek Department of Medicine, Section of Gastroenterology and Hepatology
| | - Stephen C. Pappas
- Baylor College of Medicine, Margaret M. and Albert B. Alkek Department of Medicine, Section of Gastroenterology and Hepatology
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20
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Mian AN, Schwartz GJ. Measurement and Estimation of Glomerular Filtration Rate in Children. Adv Chronic Kidney Dis 2017; 24:348-356. [PMID: 29229165 DOI: 10.1053/j.ackd.2017.09.011] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Rapid, accurate, and precise measures of kidney function are essential for daily management of patients. While plasma and urinary clearances provide the greatest accuracy for assessing glomerular filtration rate (GFR), these are often impractical particularly for the care of children. Serum creatinine, the most commonly used endogenous marker, is simple, convenient, and practical but less accurate because of the influence of non-GFR determinants such as muscle mass, which increases with age in children. GFR estimating equations have been developed for adults and children to improve the accuracy of endogenous biomarkers, such as creatinine and cystatin C, by accounting for some of the non-GFR determinants, thus enhancing the practitioner's ability to assess GFR. In the steady state, when height is used as a surrogate for growth, there is a strong correlation between height/SCr and GFR. Current national guidelines recommend routine reporting of the estimated GFR alongside the serum creatinine value for adults using the Chronic Kidney Disease Epidemiology Collaboration creatinine-based formula and the updated Schwartz "bedside" formula (CKiD 2009) for children.
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21
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Sharbaf FG, Farhangi H, Assadi F. Prevention of Chemotherapy-Induced Nephrotoxicity in Children with Cancer. Int J Prev Med 2017; 8:76. [PMID: 29114374 PMCID: PMC5651649 DOI: 10.4103/ijpvm.ijpvm_40_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 08/20/2017] [Indexed: 01/14/2023] Open
Abstract
Children with cancer treated with cytotoxic drugs are frequently at risk of developing renal dysfunction. The cytotoxic drugs that are widely used for cancer treatment in children are cisplatin (CPL), ifosfamide (IFO), carboplatin, and methotrexate (MTX). Mechanisms of anticancer drug-induced renal disorders are different and include acute kidney injury (AKI), tubulointerstitial disease, vascular damage, hemolytic uremic syndrome (HUS), and intrarenal obstruction. CPL nephrotoxicity is dose-related and is often demonstrated with hypomagnesemia, hypokalemia, and impaired renal function with rising serum creatinine and blood urea nitrogen levels. CPL, mitomycin C, and gemcitabine treatment cause vascular injury and HUS. High-dose IFO, streptozocin, and azacitidine cause renal tubular dysfunction manifested by Fanconi syndrome, rickets, and osteomalacia. AKI is a common adverse effect of MTX, interferon-alpha, and nitrosourea compound treatment. These strategies to reduce the cytotoxic drug-induced nephrotoxicity should include adequate hydration, forced diuresis, and urinary alkalization. Amifostine, sodium thiosulfate, and diethyldithiocarbamate provide protection against CPL-induced renal toxicity.
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Affiliation(s)
- Fatemeh Ghane Sharbaf
- Department of Pediatric, Division of Nephrology, Dr. Sheikh Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamid Farhangi
- Department of Pediatrics, Division of Hematology and Oncology, Dr. Sheikh Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Farahnak Assadi
- Department of Pediatrics, Division of Nephrology, Rush University Medical Center, Chicago, Illinois, USA
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22
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Alaini A, Malhotra D, Rondon-Berrios H, Argyropoulos CP, Khitan ZJ, Raj DSC, Rohrscheib M, Shapiro JI, Tzamaloukas AH. Establishing the presence or absence of chronic kidney disease: Uses and limitations of formulas estimating the glomerular filtration rate. World J Methodol 2017; 7:73-92. [PMID: 29026688 PMCID: PMC5618145 DOI: 10.5662/wjm.v7.i3.73] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/17/2017] [Accepted: 05/30/2017] [Indexed: 02/06/2023] Open
Abstract
The development of formulas estimating glomerular filtration rate (eGFR) from serum creatinine and cystatin C and accounting for certain variables affecting the production rate of these biomarkers, including ethnicity, gender and age, has led to the current scheme of diagnosing and staging chronic kidney disease (CKD), which is based on eGFR values and albuminuria. This scheme has been applied extensively in various populations and has led to the current estimates of prevalence of CKD. In addition, this scheme is applied in clinical studies evaluating the risks of CKD and the efficacy of various interventions directed towards improving its course. Disagreements between creatinine-based and cystatin-based eGFR values and between eGFR values and measured GFR have been reported in various cohorts. These disagreements are the consequence of variations in the rate of production and in factors, other than GFR, affecting the rate of removal of creatinine and cystatin C. The disagreements create limitations for all eGFR formulas developed so far. The main limitations are low sensitivity in detecting early CKD in several subjects, e.g., those with hyperfiltration, and poor prediction of the course of CKD. Research efforts in CKD are currently directed towards identification of biomarkers that are better indices of GFR than the current biomarkers and, particularly, biomarkers of early renal tissue injury.
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Affiliation(s)
- Ahmed Alaini
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Deepak Malhotra
- Division of Nephrology, Department of Medicine, University of Toledo School of Medicine, Toledo, OH 43614-5809, United States
| | - Helbert Rondon-Berrios
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, United States
| | - Christos P Argyropoulos
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Zeid J Khitan
- Division of Nephrology, Department of Medicine, Joan C. Edwards School of Medicine, Huntington, WV 25701, United States
| | - Dominic S C Raj
- Division of Nephrology, Department of Medicine, George Washington University, Washington, DC 20037, United States
| | - Mark Rohrscheib
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Joseph I Shapiro
- Marshall University Joan C. Edwards School of Medicine, Huntington, WV 25701, United States
| | - Antonios H Tzamaloukas
- Nephrology Section, Medicine Service, Raymond G. Murphy VA Medical Center, Albuquerque, NM 87108, United States
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87108, United States
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23
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Xu Z, Murata GH, Sun Y, Glew RH, Qualls C, Vigil D, Servilla KS, Golper TA, Tzamaloukas AH. Reproducibility of serial creatinine excretion measurements in peritoneal dialysis. World J Nephrol 2017; 6:201-208. [PMID: 28729968 PMCID: PMC5500457 DOI: 10.5527/wjn.v6.i4.201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/21/2017] [Accepted: 05/05/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To test whether muscle mass evaluated by creatinine excretion (EXCr) is maintained in patients with end-stage kidney disease (ESKD) treated by peritoneal dialysis (PD), we evaluated repeated measurements of EXCr in a PD population.
METHODS One hundred and sixty-six PD patients (94 male, 72 female) receiving the same PD dose for the duration of the study (up to approximately 2.5 years) had repeated determinations of total (in urine plus spent dialysate) 24-h EXCr (EXCr T) to assess the adequacy of PD by creatinine clearance. All 166 patients had two EXCr T determinations, 84 of the 166 patients had three EXCr T determinations and 44 of the 166 patients had four EXCr T measurements. EXCr T values were compared using the paired t test in the patients who had two studies and by repeated measures ANOVA in those who were studied three or four times.
RESULTS In patients who were studied twice, with the first and second EXCr T measurements performed at 9.2 ± 15.2 mo and 17.4 ± 15.8 mo after onset of PD, respectively, EXCr T did not differ between the first and second study. In patients studied three times and whose final assessment occurred 24.7 ± 16.3 mo after initiating PD, EXCr T did not differ between the first and second study, but was significantly lower in the third study compared to the first study. In patients who were studied four times and whose fourth measurement was taken 31.9 ± 16.8 mo after onset of PD, EXCr T did not differ between any of the studies. The average EXCr T value did not change significantly, with the exception of the third study in the patients studied thrice. However, repeated determinations of EXCr T in individuals showed substantial variability, with approximately 50% of the repeated determinations being higher or lower than the first determination by 15% or more.
CONCLUSION The average value of EXCr T remains relatively constant for up to 2.5 years of follow-up in PD patients who adhere to the same PD schedule. However, repeated individual EXCr T values vary considerably in a large proportion of the patients. Further studies are needed to evaluate the clinical significance of varying EXCr T values and the stability of EXCr T beyond 2.5 years of PD follow-up.
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Low Urinary Creatinine Excretion Is Associated With Self-Reported Frailty in Patients With Advanced Chronic Kidney Disease. Kidney Int Rep 2017; 2:676-685. [PMID: 29142985 PMCID: PMC5678832 DOI: 10.1016/j.ekir.2017.02.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 02/06/2017] [Accepted: 02/28/2017] [Indexed: 11/21/2022] Open
Abstract
Introduction Frailty and muscle wasting, a component of frailty, are common in advanced stage chronic kidney disease (CKD). Whether frailty is associated with low urinary creatinine excretion (UCrE) as a measure of muscle mass in this population is unknown. Furthermore, reference values of UCrE are lacking. We first defined low UCrE and studied correlates of low UCrE, and subsequently studied cross-sectional associations of frailty with low UCrE in patients with advanced CKD. Methods A total of 2748 healthy individuals of the general population-based PREVEND study were included to define low UCrE (UCrE indexed for height, below the age- and sex-specific 5th percentile of the distribution). Frailty was defined using a modification of the Fried frailty phenotype. In a CKD population that included 320 and 967 participants of the PREPARE-2 and NECOSAD studies, respectively, cross-sectional associations of self-reported frailty, the individual components that define self-reported frailty, and frailty-associated variables with low UCrE were evaluated using multivariate logistic and linear regression models. Results Low UCrE was found in 38% of the CKD patients. A lower glomerular filtration rate was strongly associated with low UCrE. Self-reported frailty (adjusted odds ratio: 2.19; 95% confidence interval: 1.28−3.77) and the individual components were associated with low UCrE, independent of comorbidities. The frailty-associated variables hemoglobin and albumin were inversely associated with low UCrE, and parathyroid hormone was positively associated with low UCrE. Discussion Lower kidney function is a strong correlate of low UCrE and self-reported frailty, and the individual frailty components are associated with low UCrE as well, independent of comorbidities.
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Sun TYT, Lee KE, Kendrick-Jones JC, Marshall MR. Ethnic differences in creatinine kinetics in a New Zealand end-stage kidney disease cohort. Nephrology (Carlton) 2013; 18:222-8. [PMID: 23331989 DOI: 10.1111/nep.12030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent data have suggested that glomerular filtration rate (GFR) is better predicted in New Zealand (NZ) Māori and Pacific People using the equations for Black people that predict higher GFR for any given serum creatinine. We hypothesized that this might be due to a higher rate of creatinine generation in NZ Māori and Pacific People. AIM To compare creatinine kinetics between different ethnic groups in a cohort of NZ peritoneal dialysis patients. METHODS In this retrospective single-centre observational study, creatinine kinetics in 181 patients were determined from timed serum samples, peritoneal dialysate and urine collections between 1 October 2004 and 31 July 2011. Ethnicity was classified as Asian, NZ European, NZ Māori and Pacific People. RESULTS A total of 799 samples from 181 patients were analysed: 194 in Asians, 127 in NZ Europeans, 268 in NZ Māori, 207 in Pacific People. Pacific People had the highest serum creatinine and lean body mass, and the highest creatinine generation rate at 1349 mg/day, compared with 1049 for Asians, 1186 for NZ Europeans and 1094 for NZ Māori (P = 0.0001). After adjustment for confounding factors, Pacific People had a greater creatinine generation by 140 mg/day compared with NZ Europeans (P = 0.047). CONCLUSION Pacific People on peritoneal dialysis in NZ have higher serum creatinine, lean body mass and creatinine generation than other ethnic groups. This is consistent with previous observations that equations for predicting GFR in Black people may have increased accuracy in some Australasian non-White non-Asian populations.
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Affiliation(s)
- Tina Y-T Sun
- Department of Renal Medicine, Counties Manukau District Health Board, Auckland, New Zealand
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Mohamed RHA, Zayed HS, Amin A. Renal disease in systemic sclerosis with normal serum creatinine. Clin Rheumatol 2010; 29:729-737. [PMID: 20174989 DOI: 10.1007/s10067-010-1389-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 12/08/2009] [Accepted: 01/13/2010] [Indexed: 02/07/2023]
Abstract
Prognosis of systemic sclerosis largely depends on involvement of internal organs. The aim was to evaluate renal impairment in patients with systemic sclerosis by measuring the Glomerular filteration rate (GFR) and then calculating the GFR using the Cockgroft and Gault formula and the Modification of Diet in Renal Disease Equation (MDRD) formula. Thirty one scleroderma patients were recruited from the Rheumatology and Rehabilitation Department, Cairo University Hospitals, mean age 43.25 +/- 11.28 years, 31 healthy controls were included. Disease severity was done using Medsger score. GFR was measured using classical Gates method TC99mDTPA. The modified Cockcroft and Gault formula and equation 7 from the MDRD were used for calculation of GFR. All patients had within normal serum creatinine levels. A normal GFR (>89ml/min) was found in 45.1%. Gates method showed reduced GFR was reported in 54.9%. Stage II chronic kidney disease (60-89 ml/min) found 32.3%, and stage III (30-59 ml/min) in 22.6%. The formulae used showed reduction of GFR in 35.29% of those affected by the Cockcroft-Gault and in 41.17% of those affected using the MDRD. No correlation to patients' age, disease duration, or severity. A positive correlation was also reported between the presence of renal involvement and pulmonary vascular involvement p = 0.04. Gates method showed reduction of the GFR in 54.9% of the systemic sclerosis patients. The formulae used were not as precise as the measured GFR in diagnosing all cases with subclinical renal involvement. Patients with systemic sclerosis should be screened for renal involvement irrespective of disease severity or duration.
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Affiliation(s)
- Reem H A Mohamed
- Department of Rheumatology and Rehabilitation, Faculty of medicine, Cairo University, Cairo, Egypt.
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Tzamaloukas AH, Murata GH, Piraino B, Raj DSC, VanderJagt DJ, Bernardini J, Servilla KS, Sun Y, Glew RH, Oreopoulos DG. Sources of variation in estimates of lean body mass by creatinine kinetics and by methods based on body water or body mass index in patients on continuous peritoneal dialysis. J Ren Nutr 2009; 20:91-100. [PMID: 19853476 DOI: 10.1053/j.jrn.2009.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE We identified factors that account for differences between lean body mass computed from creatinine kinetics (LBM(cr)) and from either body water (LBM(V)) or body mass index (LBM(BMI)) in patients on continuous peritoneal dialysis (CPD). DESIGN We compared the LBM(cr) and LBM(V) or LBM(BMI) in hypothetical subjects and actual CPD patients. PATIENTS We studied 439 CPD patients in Albuquerque, Pittsburgh, and Toronto, with 925 clearance studies. INTERVENTION Creatinine production was estimated using formulas derived in CPD patients. Body water (V) was estimated from anthropometric formulas. We calculated LBM(BMI) from a formula that estimates body composition based on body mass index. In hypothetical subjects, LBM values were calculated by varying the determinants of body composition (gender, diabetic status, age, weight, and height) one at a time, while the other determinants were kept constant. In actual CPD patients, multiple linear regression and logistic regression were used to identify factors associated with differences in the estimates of LBM (LBM(cr)<LBM(V), or LBM(cr)<LBM(BMI)). MAIN OUTCOME MEASURE We sought predictors of the differences LBM(V) - LBM(cr) and LBM(BMI) - LBM(cr). RESULTS Both LBM(V) (regardless of formula used to estimate V) and LBM(BMI) exceeded LBM(cr) in hypothetical subjects with average body compositions. The sources of differences between LBM estimates in this group involved differences in the coefficients assigned to gender, age, height, weight, presence or absence of diabetes, and serum creatinine concentration. In CPD patients, mean LBM(V) or LBM(BMI) exceeded mean LBM(cr) by 6.2 to 6.9 kg. For example, the LBM(V) obtained from one anthropometric formula was 50.4+/-10.4 kg and the LBM(cr) was 44.1+/-13.6 kg (P < .001), whereas among the 925 clearance studies, only 216 (23.3%) had LBM(cr)>LBM(V). The differences in determinants of body composition between groups with high versus low LBM(cr) were similar in hypothetical and actual CPD patients. Multivariate analysis in actual CPD patients identified serum creatinine, height, age, gender, weight, and body mass index as predictors of the differences LBM(V)-LBM(cr) and LBM(BMI)-LBM(cr). CONCLUSIONS Overhydration is not the sole factor accounting for the differences between LBM(cr) and either LBM(V) or LBM(BMI) in CPD patients. These differences also stem from the coefficients assigned to major determinants of body composition by the formulas estimating LBM.
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Affiliation(s)
- Antonios H Tzamaloukas
- Nephrology Section, Raymond G Murphy Veterans Administration Medical Center and University of New Mexico, Albuquerque, New Mexico 87108, USA
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Schwartz GJ, Work DF. Measurement and estimation of GFR in children and adolescents. Clin J Am Soc Nephrol 2009; 4:1832-43. [PMID: 19820136 DOI: 10.2215/cjn.01640309] [Citation(s) in RCA: 707] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
GFR is the best indicator of renal function in children and adolescents and is critical for diagnosing acute and chronic kidney impairment, intervening early to prevent end-stage renal failure, prescribing nephrotoxic drugs and drugs cleared by a failing kidney, and monitoring for side effects of medications. Renal inulin clearance was the gold standard for GFR but is compromised by lack of availability, difficult assays, and problems of collecting timed urine samples, especially in children with vesicoureteral reflux or bladder dysfunction. Creatinine clearance-based estimates of GFR are often used in pediatrics. The addition of cimetidine to eliminate creatinine secretion permits accurate measurement of GFR in those who can completely empty their bladders to provide timed urine collections. Radioisotopes are used in plasma disappearance GFR determinations; however, these are not ideal for use in children, especially for repeated studies. The plasma disappearance of iohexol serves as a promising alternative GFR marker, because it is safe and not radioactive, easily measured, not metabolized or transported by the kidney, and excreted primarily by glomerular filtration. GFR estimating equations, based on serum concentrations of creatinine or cystatin C, are popular clinically and in research studies. Efforts are ongoing to improve these estimating equations for children and make the results readily available to clinicians obtaining standard chemistry profiles, as is being done for adults. However, at this time, there is no dependable substitute for an accurately determined GFR, and iohexol plasma disappearance offers the best combination of safety, accuracy, and reproducible precision.
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Affiliation(s)
- George J Schwartz
- Department of Pediatrics, Pediatric Nephrology, Box 777, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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Khosla N, Steiner RW. The MDRD equation predicts peritoneal dialysis-delivered creatinine clearances from serum creatinine. Clin J Am Soc Nephrol 2009; 4:798-803. [PMID: 19339415 DOI: 10.2215/cjn.03870808] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES The four- and six-variable Modified Diet in Renal Disease equations (MDRDEs) are empiric expressions that estimate GFR in patients with kidney disease. No method currently exists to directly compare MDRDE estimates of clearance by the failing biologic kidney to the clearances achieved by dialytic modalities. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Because the MDRDEs estimate GFR, which in turn determines much of the small molecule clearance by the biologic kidney, the aim of this study was to determine if the MDRDEs would predict the measured creatinine clearances (including residual renal clearance, if any) from the serum creatinine values alone in 454 peritoneal dialysis patients. RESULTS For the group, the four-variable MDRDE predicted a creatinine clearance of 6.5 +/- 3.7 ml/min/1.73 m(2) when measured clearance was from home collections of dialysate and urine was 6.8 +/- 3.1 ml/min/1.73 m(2). The presence or volume of residual urine had no effect on accuracy. The six-variable MDRDE was similarly accurate. Creatinine appearance rates were similar to those reported in other dialysis populations. CONCLUSIONS Using serum creatinine values in "standard" fashion, MDRDEs can approximate creatinine clearances achieved by peritoneal dialysis with an accuracy similar to that of the MDRDEs in predialysis populations, perhaps because the MRDREs account exponentially for the increasing fractional gut metabolism of daily creatinine production as the serum creatinine increases. "MDRD-like" equations may provide a much needed method of directly comparing dialytic clearances to those achieved by diseased native kidneys and by kidney transplants.
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Affiliation(s)
- Nitin Khosla
- Division of Nephrology and Hypertension, University of California at San Diego, San Diego, California, USA
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Lee EK, Cho YM, Kim JT, Koo BK, Cho HY, Ku YH, Park KS, Jang HC, Kim SY, Lee HK. Derivation of a new equation for estimating creatinine clearance by using fat-free mass and serum creatinine concentration in Korean patients with type 2 diabetes mellitus. Diabetes Res Clin Pract 2009; 83:44-9. [PMID: 19027979 DOI: 10.1016/j.diabres.2008.09.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Revised: 09/29/2008] [Accepted: 09/29/2008] [Indexed: 11/15/2022]
Abstract
AIMS Equations to predict creatinine clearance (Ccr) or glomerular filtration rate have limitations in applying to a wide range of ethnicities with different fat-free mass (FFM). We aimed to determine the serum creatinine (Scr) concentrations that indicate renal insufficiency and formulate a new equation to estimate Ccr by a function of FFM in Korean type 2 diabetic patients. METHODS Ccr was measured in 283 type 2 diabetic patients by 24-h urine collection. Receiver operating characteristic (ROC) curve was used to determine the Scr concentration corresponding to a Ccr of 60 mL min(-1) x 1.73 m(-2). A new equation to predict Ccr was derived by using Scr and FFM. RESULTS The Scr concentration corresponding to a Ccr of 60 mL min(-1) x 1.73 m(-2) was 1.15 mg/dL in men and 0.95 mg/dL in women. The regression equation estimating the Ccr was expressed as (1.72 x FFM-0.23 x age)/Scr, and it showed a good correlation with the measured Ccr (r=0.718, P<0.001). CONCLUSIONS Scr concentrations indicating renal insufficiency in the Korean patients were considerably lower than those in Caucasians. The equation derived in this study would be more useful in Korean or other Asian type 2 diabetic patients.
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Affiliation(s)
- Eun Kyung Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Elevated urine neutrophil gelatinase-associated lipocalin can diagnose acute kidney injury in patients with chronic kidney diseases. Kidney Int 2009; 75:115-6; author reply 116. [DOI: 10.1038/ki.2008.529] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Wang R, Tzamaloukas AH, Agaba EI, Servilla KS, VanderJagt DJ, Gibel LJ, Hartshorne MF, Chang B. Management of extreme azotemia from urinary tract obstruction without dialysis. Clinical correlates and kinetic modeling of the recovery of renal function. Int Urol Nephrol 2007; 39:587-93. [PMID: 17318355 DOI: 10.1007/s11255-006-9035-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2006] [Accepted: 05/05/2006] [Indexed: 11/30/2022]
Abstract
The recovery of renal function following release of urinary tract obstruction with advanced azotemia determines both the need for emergency dialysis in the early post-obstructive period and the long-term planning for chronic kidney disease management. A man with prostatic cancer who presented with 16 days of anuria and a serum creatinine (Scr) of 42.7 mg/dl but had evidence suggesting residual renal function was managed conservatively and reached a steady-state Scr of 1.6 mg/dl within 84 h of urinary bladder catheterization. Modeling of the decrease in Scr taking into account the decline in the body creatinine pool that existed prior to the release of the obstruction and the accumulation in body fluids of creatinine produced after the release of the obstruction suggested that recovery of the value of glomerular filtration rate corresponding to the steady-state Scr occurred at the release of the urinary obstruction. The case illustrates both the clinical factors that may lead to the decision to postpone dialysis in a patient presenting with extreme obstructive azotemia and a novel method of modeling the recovery of renal function after release of the obstruction.
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Affiliation(s)
- Richard Wang
- Department of Medicine, Renal Section, New Mexico Veterans Affairs Health Care System and University of New Mexico School of Medicine, Albuquerque, NM, USA
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McNiece KL, Ellis EE, Drummond-Webb JJ, Fontenot EE, O'Grady CM, Blaszak RT. Adequacy of peritoneal dialysis in children following cardiopulmonary bypass surgery. Pediatr Nephrol 2005; 20:972-6. [PMID: 15875216 DOI: 10.1007/s00467-005-1894-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2004] [Revised: 01/28/2005] [Accepted: 01/28/2005] [Indexed: 10/25/2022]
Abstract
Acute renal failure requiring renal replacement therapy can complicate cardiopulmonary bypass in children. Peritoneal dialysis has been shown to stabilize electrolytes and improve fluid status in these patients. To assess dialysis adequacy in this setting, we prospectively measured Kt/V and creatinine clearance in five patients (6-839 days of age) requiring renal replacement therapy at our institution. Median dialysis creatinine clearance was 74.25 L/week/1.73m(2) (range 28.28-96.63 L/week/1.73m(2)). Residual renal function provided additional solute clearance as total creatinine clearance was 215.97 L/week/1.73m(2) (range 108.04-323.25 L/week/1.73m(2)). Dialysis Kt/V of >2.1 (median 4.84 [range 2.12-5.59]) was achieved in all patients. No dialysis-associated complications were observed. We conclude that peritoneal dialysis is a safe, simple method of providing adequate clearance in children who develop acute renal failure following exposure to cardiopulmonary bypass.
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Affiliation(s)
- Karen L McNiece
- Department of Pediatrics, Division of Nephrology and Hypertension, University of Texas Health Science Center at Houston, 6431 Fannin Street, Houston, TX 77030-1503, USA
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Traynor JP, McManus SK, Mactier RA. Derived equations are not precise enough to predict the adequacy of creatinine clearance in peritoneal dialysis patients. Am J Kidney Dis 2002; 40:1036-44. [PMID: 12407650 DOI: 10.1053/ajkd.2002.36342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Most renal units assess dialysis adequacy in peritoneal dialysis (PD) patients by formal 24-hour collections of urine and effluent dialysate. We sought a reliable method of predicting dialysis adequacy that allows a decrease in the frequency of these formal and cumbersome measurements. METHODS We created a formula for estimating total creatinine clearances, then assessed the clinical utility of this formula and other published formulae in predicting adequate and inadequate dialysis in PD patients. We collected data over a 6-month period in 2001 from 288 PD patients from 9 centers in Scotland. Four out of every 5 patients were selected at random to create a formula for estimating total creatinine clearance per week, and the fifth patient was used to form a validation group. We plotted creatinine excretion against age, and the resultant linear regression equation was transformed to produce a formula for predicting total creatinine clearance per week, based on patient sex, weight, and serum creatinine. We used the data from the validation subgroup to calculate predictive values for our derived formula and data from all of the patients to calculate predictive values for the Cockcroft and Gault, Jones, and Modification of Diet in Renal Disease Study formulae. RESULTS Neither our derived formula nor the three published formulae were sufficiently powerful to predict accurately either adequate or inadequate PD clearance. Receiver operator characteristic curves showed that no significant improvement in these predictive values could be achieved by altering either the sensitivity or the specificity. CONCLUSION Prediction formulae are not accurate enough to detect underdialysis in PD patients.
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Affiliation(s)
- Jamie P Traynor
- Renal Unit, Glasgow Royal Infirmary and Western Infirmary, Glasgow, Scotland, United Kingdom.
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Tzamaloukas AH, Murata GH. Creatinine excretion in continuous peritoneal dialysis: a systematic error of the Cockroft-Gault formula. Am J Kidney Dis 2001; 38:862-6. [PMID: 11576892 DOI: 10.1053/ajkd.2001.27708] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We investigated the hypothesis that the rate of loss of creatinine excretion with age in peritoneal dialysis (PD) patients differs from the rate predicted from the Cockroft-Gault formula (Cr(Pred)) by analyzing creatinine excretion data obtained from clearance studies of 925 patients on continuous ambulatory PD therapy with an age range of 12 to 91 years. Measured creatinine generation (Cr(Meas)) is the sum of creatinine excretion in urine plus dialysate (Cr(Excr)) plus an estimated metabolic degradation of creatinine. The effect of age on Cr(Excr) and the differences Cr(Excr) - Cr(Pred) and Cr(Meas) - Cr(Pred) were analyzed by linear regression. In 373 women, Cr(Excr) = W(16.9360 - 0.084A), r = -0.342, P < 0.001 (where W is weight in kilograms and A is age in years). The regression slope was one half of the slope in the Cockroft-Gault formula. Cr(Excr) - Cr(Pred) = -413.91 + 4.78A, r = 0.300, P < 0.001. Cr(Meas) - Cr(Pred) = -176.36 + 4.37A, r = 0.278, P < 0.001. In 552 men, Cr(Excr) = W(21.079 - 0.108A), r = -0.338, P < 0.001. The regression slope was approximately one half of the slope in the Cockroft-Gault formula. Cr(Excr) - Cr(Pred) = -493.25 + 6.28A, r = 0.267, P < 0.001. Cr(Meas) - Cr(Pred) = -66.41 + 3.63A, r = 0.143, P = 0.001. The rate of loss of creatinine excretion with age is one half of the rate predicted by the Cockroft-Gault formula in both women and men on PD therapy. Therefore, the difference between excretion (or measured generation) of creatinine and creatinine generation predicted by the Cockroft-Gault formula is not constant, but increases with age. The Cockroft-Gault formula systematically overestimates the effect of age on creatinine excretion in PD patients and is not suitable for predicting creatinine excretion in these subjects.
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Affiliation(s)
- A H Tzamaloukas
- Sections of Nephrology and General Internal Medicine, New Mexico Veterans Administration Health Care System, Albuquerque, NM 87108, USA.
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Jansen MAM, Korevaar JC, Dekker FW, Jager KJ, Boeschoten EW, Krediet RT. Renal function and nutritional status at the start of chronic dialysis treatment. J Am Soc Nephrol 2001; 12:157-163. [PMID: 11134262 DOI: 10.1681/asn.v121157] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Early start of dialysis has been hypothesized to prevent deterioration of nutritional status and to lead to a better clinical outcome. According to the National Kidney Foundation/Dialysis Outcomes Quality Initiative guidelines, dialysis should be started when renal Kt/V(urea) falls below 2.0/wk or the protein equivalent of total nitrogen appearance normalized to body weight (nPNA) falls below 0.8 g/kg per d. The present study was performed 0 to 4 wk before the start of dialysis treatment in 114 incident Dutch patients with chronic renal failure who all had received pre-end-stage renal disease care. The objectives were (1) to analyze the relationship of different levels of residual renal function with parameters of nutritional status and (2) to investigate the relationship of renal Kt/V(urea) and nPNA in this population. The mean GFR at the start of dialysis treatment was 6.2 ml/min per 1.73 m(2), and the Kt/V(urea) was 1.3/wk. Only 10% of the patients fulfilled the Dialysis Outcomes Quality Initiative criterion of Kt/V(urea) > 2.0/wk. In contrast, 69% met the nPNA norm of 0.8 g/kg per d. Seventy-one percent of these patients had a normal nutritional status as scored by subjective global assessment and also other parameters of nutritional status, such as body mass index, and serum albumin fell within the normal range in the majority of the patients. Dutch predialysis patients reached a higher nPNA with the same level of Kt/V(urea) compared with U.S. predialysis patients. Implications of these findings are that guidelines on the initiation of dialysis treatment derived from one population are not necessarily valid in other populations.
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Affiliation(s)
- Maarten A M Jansen
- Division of Nephrology, Department of Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
- NECOSAD Foundation, Amsterdam, the Netherlands
| | | | - Friedo W Dekker
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Kitty J Jager
- Division of Nephrology, Department of Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
- NECOSAD Foundation, Amsterdam, the Netherlands
| | - Elisabeth W Boeschoten
- Division of Nephrology, Department of Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Raymond T Krediet
- Division of Nephrology, Department of Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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Perez RA, Blake PG, Spanner E, Patel M, McMurray S, Heidenheim P, Lindsay RM. High creatinine excretion ratio predicts a good outcome in peritoneal dialysis patients. Am J Kidney Dis 2000; 36:362-7. [PMID: 10922315 DOI: 10.1053/ajkd.2000.8987] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The creatinine excretion (CrEx) ratio was first described as a method for detecting noncompliance in peritoneal dialysis (PD) patients. However, a high CrEx ratio is not specific for noncompliance and may also be found in compliant patients with a relatively greater lean body mass (LBM). A cohort of 44 PD patients was followed up for a mean of 13 +/- 8 months after measurement of baseline CrEx ratio to investigate whether greater values were predictive of good or poor clinical outcomes. During this follow-up, 11 patients died, 12 patients transferred to hemodialysis, 4 patients underwent transplantation, 1 patient recovered renal function, and 16 patients continued on PD. The mean CrEx ratio in all patients was 1.14 +/- 0.32. It did not differ between men and women (1.15 versus 1.13, respectively; P = 0.76) but showed a trend toward being less in patients with diabetes (1.03 versus 1.19; P = 0. 19). The mean weekly Kt/V, weekly creatinine clearance, normalized protein equivalent of nitrogen appearance, and serum albumin values were 2.18 +/- 0.57, 73.57 +/- 33.75 L/1.73 m(2), 0.80 +/- 0.22 g/kg/d, and 3.22 +/- 0.59 g/dL, respectively. Technique failure (P < 0.001) and death (P < 0.05) were significantly more common in patients with a CrEx ratio less than 1 compared with those with a CrEx ratio greater than 1. On Cox regression analysis, the CrEx ratio was the only significant predictor of technique failure and was also an independent predictor of death. High CrEx ratio is a predictor of good, rather than poor, outcome in PD patients, perhaps because it is primarily an index of nutrition. This further weakens the argument that it is a reliable or useful marker of noncompliance.
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Affiliation(s)
- R A Perez
- Optimal Dialysis Research Unit, London Health Sciences Centre, London, Ontario, Canada
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Szeto CC, Lai KN, Wong TY, Law MC, Li PK. Measured-to-predicted creatinine generation ratio increases with time and decline in residual renal function in continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1999; 34:235-41. [PMID: 10430968 DOI: 10.1016/s0272-6386(99)70349-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The expression of measured-to-predicted creatinine generation ratio (M/P) has been proposed as an index of compliance in continuous ambulatory peritoneal dialysis (CAPD) patients. Although M/P may not be sensitive enough for cross-sectional study, serial monitoring has been suggested to identify noncompliance. We attempted to evaluate serial changes of M/P from a nonselected group of CAPD patients. Sixty-three patients, all followed up for 2 years, were reviewed retrospectively. Their M/P ratios at years 0 and 2 were computed and compared. Baseline M/P had a normal distribution with a mean of 0.96 +/- 0.26. There was significant correlation between baseline M/P and residual glomerular filtration rate (GFR; r = -0.81; P < 0.0001). There were weak correlations between M/P and duration of dialysis (r = 0.52; P < 0.0001), body weight (r = -0.52; P < 0.0001), Kt/V (r = 0.31; P < 0.02), weekly creatinine clearance normalized to body surface area (r = 0.53; P < 0.0001), and serum albumin level (r = -0. 28; P < 0.05). After 2 years, M/P increased in 56 of 63 patients (88. 9%). Average M/P increased from 0.96 +/- 0.26 to 1.31 +/- 0.27 (P < 0.0001). Multivariant analysis showed M/P at year 0, which was largely determined by residual GFR, was the only independent factor affecting increase in M/P from year 0 to year 2. The general trend of increasing M/P was still present when only anuric patients were analyzed, although that was not statistically significant (1.21 +/- 0.14 to 1.32 +/- 0.24; P = 0.12). The finding of increasing M/P with time in CAPD patients, particularly those with significant residual renal function, suggests M/P may not be a reliable indicator of noncompliance, even for serial follow-up of the same patient. Better methods for assessment of compliance in CAPD patients are required.
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Affiliation(s)
- C C Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong, China
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De Kimpe J, Cornelis R, Mees L, Vanholder R, Verhoeven G. 74As-arsenate metabolism in Flemish Giant rabbits with renal insufficiency. J Trace Elem Med Biol 1999; 13:7-14. [PMID: 10445212 DOI: 10.1016/s0946-672x(99)80017-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The metabolic management of carrier-free 74As-arsenate (As(V)) by uremic rabbits of the strain Flemish Giant was studied. Renal insufficiency was induced by nephrectomy of respectively 1 kidney (3/6 nephrectomy) and 1 kidney + 2/3 remaining kidney (5/6 nephrectomy). Marginal renal insufficiency developed in the 3/6 nephrectomized group, while animals of the 5/6 group became severely uremic. Renal excretion of 74As was reduced by 90% in 5/6 nephrectomized animals 4 h after intraperitoneal injection (i.p.) of the animals. The associated uremic syndrome caused a strong decrease in methylation capacity of inorganic arsenic (Asi). The second methylation step from monomethylarsonic acid (MMA) to dimethylarsinic acid (DMA) was more strongly affected than the first one, from arsenite (As(III)) to MMA. The increased availability of Asi led to more extensive binding to insoluble tissue constituents after 5/6 nephrectomy. The decreased renal reduction of As(V) led to a decrease in As(III) and an increase of As(V) and the associated As(V)-transferrin binding in plasma. Uptake of 74As-transferrin by the bone marrow might contribute to uremic anemia.
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Affiliation(s)
- J De Kimpe
- Laboratory for Analytical Chemistry, University of Gent, Belgium
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Flanigan MJ, Rocco MV, Frankenfield D, Bailie G, Frederick P, Prowant B, Taylor L. 1997 Peritoneal Dialysis-Core Indicators Study: Dialysis Adequacy and Nutritional Indicators Report. Am J Kidney Dis 1999; 33:e3. [PMID: 10352219 DOI: 10.1016/s0272-6386(99)70170-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The 1997 Peritoneal Dialysis-Core Indicators Study: Dialysis Adequacy and Nutritional Indicators Report documents the current status of peritoneal dialysis within the United States. A national random sample of adult peritoneal dialysis (PD) patients participating in the United States End Stage Renal Disease (ESRD) program was surveyed. PD subjects were large, with a mean body weight of 76 +/- 18.9 kg (mean +/- 1 SD) and a body mass index (BMI) of 27 +/- 6.4. The dialysis prescriptions documented achieved a mean weekly Kt/Vurea (wKt/V) and weekly creatinine clearance (wCrCl) of 2. 45 +/- 2.29 and 65.5 +/- 35.2 L/wk/1.73m2, respectively. The serum albumin of these patients was 3.5 +/- 0.48 g/dL, their normalized protein equivalent of nitrogen appearance (nPNA) 1.0 +/- 0.63 g/kg/d, and their normalized creatinine appearance rate (nCAR) 14 +/- 6.0 mg/kg/d. Serum albumin correlated meagerly but in a positive fashion with BMI, nPNA, and nCAR, and negatively with wCrCl. Among adult US PD patients, serum albumin values appear to correlate poorly with alternative measures of nutritional status and are inversely related to the intensity of renal replacement therapy. The presumptive dietary protein intake (nPNA) and creatinine appearance rate (nCAR) derived for PD patients do correlate in a positive fashion with dialysis delivery, at least up to a wCrCl of 60 to 80 L/wk/1.73 m2 and wKt/V = 2.1, but their values suggest that 30% to 50% of PD patients have marginal nutritional status.
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Affiliation(s)
- M J Flanigan
- Quality Measurement and Health Assessment Group, Wake Forest University School of Medicine, Iowa City, IA, USA.
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NKF-DOQI clinical practice guidelines for peritoneal dialysis adequacy. National Kidney Foundation. Am J Kidney Dis 1997; 30:S67-136. [PMID: 9293258 DOI: 10.1016/s0272-6386(97)70028-3] [Citation(s) in RCA: 159] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Zacur H, Kaufman SC, Smith B, Westhoff C, Helbig D, Lee YJ, Gentile G. Does creatinine adjustment of urinary pregnanediol glucuronide reduce or introduce measurement error? Gynecol Endocrinol 1997; 11:29-33. [PMID: 9086337 DOI: 10.3109/09513599709152314] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Correlation between urinary pregnanediol and serum progesterone measurements and the influence of age, race, smoking and urinary creatinine adjustment was determined during the luteal phase of the menstrual cycle in 175 volunteers. A decline in serum progesterone was observed with increasing age. Mean baseline urinary creatinine declined with increasing age in non-smokers and was not affected by race or baseline weight. An excellent correlation between urinary pregnanediol glucuronide and serum progesterone levels existed except when urinary pregnanediol concentrations were adjusted using creatinine measurements in older individuals. Adjustment of urinary pregnanediol glucuronide concentration using creatinine measurement is therefore discouraged.
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Affiliation(s)
- H Zacur
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abstract
In rats with renal disease, low-protein diets slow the decline in renal function, histologic damage, and mortality. Low-protein (and phosphorus) diets can also ameliorate uremic symptoms, secondary hyperparathyroidism, and metabolic acidosis in patients with chronic renal failure. Albeit controversial, evidence also suggests that dietary protein restriction can slow the rate of progression of renal failure and the time until end-stage renal failure. These dietary regimens appear to be safe and patients with chronic renal failure are able to activate normal compensatory mechanisms designed to conserve lean body mass when dietary protein intake is restricted. When low-protein diets are prescribed, patients should be closely monitored to assess dietary compliance and to ensure nutritional adequacy. Evidence that the spontaneous intake of dietary protein decreases in patients with progressive chronic renal failure who consume unrestricted diets should not be construed as an argument against the use of low-protein diets. Rather, it is a persuasive argument to restrict dietary protein intake in order to minimize complications of renal failure while preserving nutritional status.
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Affiliation(s)
- B J Maroni
- Renal Division, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Walser M, Drew HH, Guldan JL. Prediction of glomerular filtration rate from serum creatinine concentration in advanced chronic renal failure. Kidney Int 1993; 44:1145-8. [PMID: 8264148 DOI: 10.1038/ki.1993.361] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In 85 patients with established chronic renal failure, as manifested by serum creatinine concentration ([Cr]) > 0.177 mM (> 2 mg/dl), urinary clearance of 99mTc-DTPA (GFR) and [Cr] were determined one to four times and averaged. GFR was expressed per 3 m2 of height2 rather than in terms of 1.73 m2 of surface area because weight changes but height does not. GFR in these patients averaged 13 ml/min/3 m2 (range 2 to 37). The following equations were derived for predicting GFR from [Cr]-1 (mM-1), age (years) and weight (kg): males, GFR = 7.57 [Cr]-1 - 0.103 age + 0.096 weight - 6.66; females, GFR = 6.05 [Cr]-1 - 0.08 age + 0.08 weight - 4.81. These equations predict GFR in this series with a root mean square error of 3.0 ml/min and account for 89% of the observed variation in GFR. They are applicable only to patients with [Cr] > 0.177 mM (2 mg/dl). More precise estimates can be obtained by including a value for 24-hour urinary urea N, as a measure of protein intake. Less precise but simpler estimates can be obtained from [Cr]-1 alone: males, GFR = 7.58 [Cr]-1 - 4.29; females, GFR = 6.11 [Cr]-1 - 3.8. Expressing [Cr] in mg/dl, the latter equations become: males, GFR = 86 [Cr]-1 - 4.29; females, GFR = 69 [Cr]-1 - 3.8.
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Affiliation(s)
- M Walser
- Department of Pharmacology and Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Gutierrez A, Alvestrand A, Qureshi GA, Bergström J. Influence of a meat-free diet on the urinary excretion of 3-methylhistidine and creatinine in chronic renal failure. J Intern Med 1992; 232:129-32. [PMID: 1506808 DOI: 10.1111/j.1365-2796.1992.tb00561.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Urinary excretion of 3-methylhistidine has been proposed as an index of internal protein breakdown provided that the intake of exogenous 3-methylhistidine (meat) is excluded. To evaluate the potential use of 3-methylhistidine in the metabolic assessment of patients with advanced renal failure, we studied a group of 11 patients with markedly reduced renal function who were put on a meat-free diet (the protein intake was kept constant). Steady-state plasma concentration and urinary excretion of 3-methylhistidine were not achieved until 14 d after exclusion of meat from the diet. At that time the plasma concentration and urinary excretion of 3-methylhistidine had decreased by 43% and 60%, respectively. We conclude that the delay in reaching steady state makes the clinical use of urinary excretion of 3-methylhistidine in patients with advanced renal failure unpracticable as an index of protein breakdown. The exclusion of meat also resulted in a continuous decrease in the plasma level and urinary excretion of creatinine, with the result that plasma creatinine or its reciprocal become misleading for evaluation of changes in renal function until a new steady state has been reached.
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Affiliation(s)
- A Gutierrez
- Department of Renal Medicine, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden
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Hilbrands LB, Artz MA, Wetzels JF, Koene RA. Cimetidine improves the reliability of creatinine as a marker of glomerular filtration. Kidney Int 1991; 40:1171-6. [PMID: 1762320 DOI: 10.1038/ki.1991.331] [Citation(s) in RCA: 85] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To investigate whether the administration of cimetidine can improve the reliability of creatinine as a marker of GFR, we compared the creatinine clearance (CCr) to the clearance of the true filtration markers 51Cr-EDTA (CEDTA) and inulin (CIn), after oral ingestion of cimetidine in 10 healthy men and 29 patients with varying degrees of renal dysfunction. After administration of cimetidine for three to six days, serum creatinine level rose in all participants, while CEDTA and CIn remained stable in a subgroup of 14 subjects in whom they were measured before as well as after the administration of cimetidine. The mean (+/- SD) ratios of CCr to CEDTA (N = 39) and of CCr to CIn (N = 19) after ingestion of cimetidine were 1.02 +/- 0.13 and 1.01 +/- 0.13, respectively, and did not differ significantly from unity. This high degree of accuracy of the cimetidine-aided CCr was present over the entire range of renal function in the study population. Our results also indicated an improved precision of the cimetidine-aided measurement of CCr, resulting in a variability that did not differ significantly from that of the measurement of CEDTA or CIn. We conclude that after oral administration of cimetidine, the creatinine clearance can be used as a reliable measure of GFR within a broad range of renal function.
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Affiliation(s)
- L B Hilbrands
- Department of Internal Medicine, University Hospital Nijmegen, The Netherlands
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Affiliation(s)
- A S Levey
- New England Medical Center, Boston, Massachusetts
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50
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Affiliation(s)
- M Walser
- Johns Hopkins School of Medicine, Department of Pharmacology, Baltimore, Maryland 21205
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