Advances in Renal Replacement Therapy

Hyperphosphatemia and dyslipidemia are common clinically significant conditions in end-stage renal disease (ESRD). Hyperphosphatemia management is essential; however, use of calcium-based phosphate binder has been associated with elevated risk of cardiac calcification in ESRD, increasing risks for cardiovascular disease and death. An alternative to calcium-based phosphate binders is sevelamer hydrochloride, a calcium-free, metal-free, nonabsorbed polymer that binds phosphate effectively. We conducted a meta-analysis on the effects of sevelamer hydrochloride on parameters of mineral metabolism (serum phosphorous, calcium, Ca x P, and iPTH) and the lipid profile (total, LDL, HDL, and non-HDL cholesterol, and triglycerides) in dialysis patients. After application of inclusion/exclusion criteria, 17 core studies were statistically analyzed to determine the sevelamer treatment effect on the study parameters as demonstrated by simple, n-weighted, and inverse variance-weighted mean changes. Analysis of inverse variance-weighted mean changes indicated that sevelamer treatment was associated with a 2.14 mg/dL drop in serum phosphorus (P <.001), no significant overall effect on calcium (0.09 mg/dL, P =.364), significant decline in Ca x P product (15.91 mg(2)/dL(2), P <.001), 35.99 pg/mL reduction in iPTH (P =.026), significant reduction in total cholesterol (30.58 mg/dL, P <.001), 31.38 mg/dL drop in LDL cholesterol (P <.001), significant increase in HDL cholesterol (4.09 mg/dL, P =.008), and a significant reduction in triglycerides (22.04 mg/dL, P x.001). This meta-analysis suggests that sevelamer offers a dual therapeutic benefit in dialysis patients-a population at high risk for cardiovascular disease-by improving phosphorus control and the lipid profile, without altering serum calcium.

Steven K. Burke

Maureen A. Dillon

Douglas E. Hemken

Margit S. Rezabek

James M. Balwit

Meta-analysis of the effect of sevelamer on phosphorus, calcium, PTH, and serum lipids in dialysis patients

透析患者中司维拉姆对磷、钙、PTH及血清脂质影响的Meta分析

This article gives a technical summary over the development of our dialysis water preparation site covering more than a decade of common effort to improve and secure water quality. We invite the reader to follow us through the experience of 3 major conception changes determined by available localities and resources, operational difficulties, and maintenance as well as progressive technologies and standards. Critical analysis aims to provide information to promote development in this area including details of preventable errors and misconceptions. The findings show that it is possible to achieve higher water quality on regular bases at affordable cost through technical changes, often minor; preventive maintenance; and continual monitoring of all components. © 2003 by the National Kidney Foundation, Inc.

Katja Martin

Erick Laydet

Bernard Canaud

Design and technical adjustment of a water treatment system: 15 years of experience

水处理系统的设计与技术调整：15年经验

This special section of Advances in Renal Replacement Therapy, consistent with the first part of this issue, concentrates on malnutrition as exemplified by albumin concentrations in blood, markers of inflammation, and the use of vitamin D analogs. These manuscripts are reprinted from the Journal of Renal Nutrition because of their important viewpoints and findings. Correction of serum albumin concentrations has long been a point of consternation,1Winchester J.F. The albumin dilemma.Am J Kidney Dis. 1992; 20 (editorial): 76-77Google Scholar and the 2 editorials by Kliger and Kaysen and Levin highlight the problems associated with raising serum albumin as a clinical performance measure of a nutritionist’s skill and the fact that there are controllable and uncontrollable factors that determine albumin concentration. Undoubtedly, intradialytic parenteral nutrition can positively influence albumin concentrations, but will this lead to improved survival? The jury is still out. In the study by Hung and associates reported here, physical activity and energy intake were shown to be linked; however, although inflammatory cytokines and malnutrition are correlated, only high levels of tumor necrosis factor-α correlated with energy intake but not with physical activity. This study points out the complexities of the inflammatory process and nutritional indices. The final study in this section also highlights the complex nature of calcium, phosphate, parathyroid hormone, and vitamin D homeostasis. Jernigan and Andress stress the need for a concerted effort of the health care team in regulating bone metabolism in chronic kidney disease patients. This special section of Advances in Renal Replacement Therapy, consistent with the first part of this issue, concentrates on malnutrition as exemplified by albumin concentrations in blood, markers of inflammation, and the use of vitamin D analogs. These manuscripts are reprinted from the Journal of Renal Nutrition because of their important viewpoints and findings. Correction of serum albumin concentrations has long been a point of consternation,1Winchester J.F. The albumin dilemma.Am J Kidney Dis. 1992; 20 (editorial): 76-77Google Scholar and the 2 editorials by Kliger and Kaysen and Levin highlight the problems associated with raising serum albumin as a clinical performance measure of a nutritionist’s skill and the fact that there are controllable and uncontrollable factors that determine albumin concentration. Undoubtedly, intradialytic parenteral nutrition can positively influence albumin concentrations, but will this lead to improved survival? The jury is still out. In the study by Hung and associates reported here, physical activity and energy intake were shown to be linked; however, although inflammatory cytokines and malnutrition are correlated, only high levels of tumor necrosis factor-α correlated with energy intake but not with physical activity. This study points out the complexities of the inflammatory process and nutritional indices. The final study in this section also highlights the complex nature of calcium, phosphate, parathyroid hormone, and vitamin D homeostasis. Jernigan and Andress stress the need for a concerted effort of the health care team in regulating bone metabolism in chronic kidney disease patients.

James F Winchester

Special articles

特稿

A system of regulatory molecules interacts at the cellular level to control and coordinate the many metabolic pathways that constitute normal mineral metabolism. Alterations that occur in uremia profoundly disrupt this intricate system of regulation. A lack of control poses serious consequences for patients with chronic renal disease, and restoring some level of control represents a significant treatment goal. To achieve adequate treatment, it is necessary to correct aberrations in the metabolism of the major regulatory molecules, parathyroid hormone, vitamin D, calcium, and phosphorus. The use of vitamin D hormone replacement therapy is one important part of this strategy, and the availability of newer vitamin D compounds may prove to be especially beneficial. The effective use of these compounds, nevertheless, depends on the coordinated efforts of each member of the health care team to design and implement an integrated treatment protocol that recognizes all aspects of intervention.

Peggy Jernigan

Dennis L Andress

Vitamin D analogs in uremia: integrating medical and nutritional issues

尿毒症中的维生素D类似物：整合医学与营养问题

To determine the associations among dietary intake and inflammatory cytokines with physical activity, function, and performance in maintenance dialysis patients.Cross-sectional analysis of cohort study.University-affiliated dialysis units, general clinical research center.Multiethnic cohort of maintenance hemodialysis patients.Physical activity by accelerometry; physical performance by gait speed, stair climbing, and chair raising; physical functioning by the Medical Outcomes Study Short Form 36-item questionnaire subscale scores; and maximal and adjusted activity scores of human activity profile.Levels of inflammatory cytokines were uniformly high. Tumor necrosis factor-alpha was directly correlated with dietary protein and energy intake; no other cytokines were directly or inversely correlated with intake. Dietary intake was associated with physical activity, as expected, and not significantly associated with performance or function (with the exception of gait speed). There were no significant associations among inflammatory cytokines and physical activity, performance, or function.Although dietary intake and inflammation may independently influence traditional proxies of nutritional status, this analysis provides no evidence for a link between cytokines and physical activity, performance, or function in hemodialysis patients. More research is required to understand the role of cytokines in protein energy malnutrition and the mechanisms of wasting and functional decline in the dialysis population.

Adriana M Hung

Glenn M Chertow

Belinda S Young

Susan Carey

Kirsten L Johansen

Inflammatory markers are unrelated to physical activity, performance, and functioning in hemodialysis

炎症标志物与血液透析中的身体活动、表现和功能无关

Chronic Kidney disease (CKD) has been identified as a public health epidemic, fueled in part by improved outcomes of both diabetic and cardiac patient populations, as well as by the increasing recognition that it is possible to identify CKD at earlier stages. The estimated 8 to 10 million Americans that have CKD, with its concomitant morbidity and mortality, have the potential to overwhelm the current system of specialty practice medicine and health care resources. How can clinicians, clinician scientists, and health care administrators translate research findings into clinical practice in an effective manner to improve the care of this burgeoning patient group? The challenge of translating research into clinical care requires identification of that which we do and do not know, communication of knowledge between those who do and do not know, and efficient collection of information for systematic evaluation. This article will describe the challenges of translating current research findings into clinical practice. There is a need to identify the complexity of CKD disease processes and issues associated with delivery of care and to describe the difficulties in the dissemination of new knowledge to physicians. Because of the propensity of CKD to affect identifiable groups of patients, we will discuss the potential challenges of these strategies given the racial, ethnic, and cultural diversity in North America. A potential solution to these challenges is a new paradigm of “process-based medicine” that integrates clinical and basic science research findings with multidisciplinary and shared care models of health care delivery. In this context, attention to advances in information technology, the cognitive processes that underlie physician learning, and the findings of outcome research may ensure true integration of clinical research and clinical practice.

Lesley Ann Stevens

Adeera Levin

Translating research findings of chronic kidney disease management to clinical practice: challenges and opportunities

将慢性肾脏病管理研究成果转化为临床实践：挑战与机遇

The prevalence of chronic kidney disease (CKD) is on the rise in all ethnic groups. This is because of the increased prevalence of obesity, diabetes mellitus, the metabolic syndrome, and the inadequate control of elevated blood pressure and other cardiovascular-renal risk factors, especially in ethnic minority populations. The implications of the aforementioned trends in risk factor prevalence and control are profound. Moreover, these trends negatively impact patient quality of life and place an enormous financial burden on the health care system for the provision of care to patients with CKD, end-stage renal disease (ESRD), and/or cardiovascular disease (CVD). Thus, it is of utmost importance to devise strategies that prevent kidney disease and delay progressive loss of kidney function in persons with CKD. Proven strategies include pharmacological interventions that lower blood pressure to less than target levels (<130/80 mm Hg), attainment of optimal glycemic control (Hb A1c <7%), and reducing urinary protein excretion. It is also possible, although yet unproven, that correction of anemia and aggressive treatment of dyslipidemia may forestall the loss of kidney function. In general, ethnic minorities are underrepresented in most large trials. Recently, a few outcome clinical trials in blacks have reinforced the lessons of kidney function preservation already learned in nonblack populations. That is, the reversible risk factors for CKD appear to be virtually identical and, at least in nondiabetic CKD, pharmacological targeting of the renin-angiotensin-aldosterone system (RAAS) with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers preserves kidney function better than non-RAAS blood pressure-lowering regimens, especially when significant proteinuria exists. Although more CKD studies in ethnic minorities are needed, until they become available, the best available evidence from the existing clinical trial database should be applied to minorities with CKD-even when specific data are not available for a specific racial or ethnic group. Why this approach? First, there are no known unique risk factors for kidney disease in any ethnic group. Second, poor control of reversible risk factors for CKD is universal, particularly in blacks and other ethnic minorities. Thus, it is logical to predict that more efficient use of strategies proven to forestall loss of kidney function will reduce the excess of CKD and ESRD in ethnic minorities relative to non-minority populations. However, medical-based strategies alone are probably not enough. The global epidemic of obesity will fuel the growing population of persons, especially among ethnic minorities, with diabetes, the main cause of CKD, ESRD, and CVD. The obesity and diabetes epidemics are unlikely to abate without innovative and ultimately effective public health approaches.

Jay Lakkis

Matthew R Weir

Pharmacological strategies for kidney function preservation: are there differences by ethnicity?

肾脏功能保护的药理学策略：种族之间是否存在差异？

Medical nutrition therapy (MNT), nutrition education, and counseling are essential components for effective management of end-stage kidney disease (ESKD). Patients with ESKD have to alter their diets and to implement new eating behaviors, sometimes irrespective of ethnic and cultural food preferences because of their high content of specific nutrients. Ethnic and cultural factors influence dietary adherence. Therefore, assessing cultural issues surrounding food and food preferences may help improve dietary adherence. A large percentage of the ESKD population in the United States is black and Hispanic, with cultural food preferences that are particularly high in potassium, phosphorus, and sodium. This article provides an overview of the role of culture and ethnicity in food habits and dietary adherence, a list of cultural and ethnic foods that should be examined and incorporated in the development of an appropriate renal diet meal plan for black and Hispanic Americans with ESKD, and practical recommendations for cross-cultural nutrition counseling. If MNT is to be effective in the medical management of patients from different cultural and ethnic backgrounds, it must incorporate more traditional and customary foods in the renal diet meal plan.

Jerrilynn D Burrowes

Incorporating ethnic and cultural food preferences in the renal diet

将民族和文化饮食偏好融入肾病饮食

<h2>Abstract</h2> In the United States, the age-and-gender-adjusted incident rate of end-stage renal disease (ESRD) for blacks has been 4 times higher than that for whites. We analyzed patient information and medical services contained in the Medicare 5% random sample database. White (n = 977,436) and black (n = 77,800) Medicare enrollees who were at least 65 years old on January 1, 1997, were followed from 1999 to 2001. Hierarchical Cox regression models were used to estimate the relative risk of ESRD for blacks (with reference to whites) after adjustment for age and gender, socioeconomic status, special health conditions (anemia, chronic obstructive pulmonary disease, cardiovascular disease), primary causal diseases of ESRD (eg, diabetes, hypertension), diabetes care and preventive care (eg, hemoglobin A1c or lipid testing), and physician visits for primary or specialty care. The relative risk of ESRD for blacks (with reference to whites) was 3.52 (95% confidence interval [CI], 3.25–3.80) after adjustment for age and gender; 2.90 (95% CI, 2.67–3.15) after adjustment for socioeconomic status and special health conditions; and 2.11 (95% CI, 1.94–2.30) after further adjustment for primary causal diseases of ESRD, diabetes care and preventive care, and physician visits. We conclude that a higher prevalence of primary causal diseases of ESRD and lower access to diabetes care, preventive care, and primary physician visits in blacks compared with whites partially accounts for the racial difference in the incidence of ESRD in the elderly Medicare population. Public health policy should focus on improving access to care, which may lower the burden of ESRD in minority and other at-risk populations.

Suying Li

Donna D McAlpine

Jiannong Liu

Shuling Li

Allan J Collins

Differences between blacks and whites in the incidence of end-stage renal disease and associated risk factors

黑人与白人在终末期肾病发病率及相关风险因素上的差异

<h2>Abstract</h2> Idiopathic focal segmental glomerulosclerosis (FSGS) is a common cause of nephrotic syndrome in pediatric and adult patients. Most children with FSGS do not respond to any form of therapy and progress to end-stage renal disease (ESRD). FSGS reoccurs in the transplanted kidney in approximately one third of initial transplants and in a substantially higher percentage of subsequent transplants once FSGS has recurred in an earlier transplant. Thus, FSGS is a disease with substantial morbidity. Over the past several years, the incidence of FSGS in adults and children appears to be increasing, particularly in certain racial groups and ethnic populations. Several recent studies in adult and pediatric patients suggest that the incidence of FSGS is increasing particularly in the black population. In addition, some studies have also demonstrated a more rapid progression of FSGS to ESRD in black patients compared to other ethnic groups. Racial and ethnic background is likely to have a substantial influence on the incidence and progression of FSGS in children and adults. It is likely that specific genes or a combination of genes influence the different clinical manifestations of FSGS in racial and ethnic groups. Genetic mutations in NPHS1 gene, which encodes nephrin, have been found to cause congenital nephrotic syndrome. Genetic mutations in the NPHS2 gene, which encodes podocin, recently have been shown to be strongly associated with a recessive form of steroid-resistant nephrotic syndrome. Mutations in the ACTN4 gene that encodes actinin 4 has also been associated with familial nephrotic syndrome. A role for ACE polymorphisms in the progression of FSGS has been found in some studies. Future investigations to identify polymorphisms that influence the development of FSGS, the progression of FSGS, and the response to therapy will greatly improve understanding of the pathogenesis and management of FSGS.

Sharon P Andreoli

Racial and ethnic differences in the incidence and progression of focal segmental glomerulosclerosis in children

儿童局灶节段性肾小球硬化的发病率和进展的种族和民族差异

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