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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_373"
                     title="Protein in Urine Presages More Severe Problems (CME/CE)"
                     score="0.012"
                     href="http://www.medpagetoday.com/Nephrology/ESRD/tb/18265?impressionId=1265788569853"
                     
      &lt;p&gt;The three-year risk of death, heart attack, and kidney failure was markedly increased in patients with baseline proteinuria, regardless of their estimated glomerular filtration rate (eGFR), researchers said.&lt;/p&gt;
&lt;p&gt;In a population-based study of nearly 1 million people, mortality was approximately doubled with heavy proteinuria among individuals stratified according to their eGFR, reported Brenda R. Hemmelgarn, MD, PhD, of the University of Calgary in Canada, and colleagues.&lt;/p&gt;
&lt;p&gt;Rates of myocardial infarction were increased by about 50% with heavy proteinuria, and end-stage renal disease and doubled levels of serum creatinine were as much as 30 times more common, the researchers reported in the Feb. 3 issue of the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;Prognosis associated with a given level of eGFR varies substantially based on the presence and severity of proteinuria,&quot; Hemmelgarn and colleagues concluded.&lt;/p&gt;
&lt;p&gt;&quot;In fact, patients with heavy proteinuria but without overtly abnormal eGFR appeared to have worse clinical outcomes than those with moderately reduced eGFR but without proteinuria.&quot;&lt;/p&gt;
&lt;p&gt;They added that the findings were important because current recommendations for managing chronic kidney disease rely on eGFR for staging purposes without consideration of proteinuria.&lt;/p&gt;
&lt;p&gt;&quot;Future revisions of the classification system for chronic kidney disease should incorporate information from proteinuria,&quot; the researchers urged.&lt;/p&gt;
&lt;p&gt;The results emerged from a laboratory registry covering some 921,000 adults in the province of Alberta who had had measurements of eGFR, serum creatinine, and urinary protein from 2002 to 2007.&lt;/p&gt;
&lt;p&gt;Proteinuria was measured with a urine dipstick or the albumin-creatinine ratio. Dipstick readings of at least 2 points were considered heavy proteinuria. Readings showing at least trace protein but less than 2 points were classed as mild; negative readings were considered normal.&lt;/p&gt;
&lt;p&gt;The stratifications of albumun-creatinine ratio were greater than 300 mg/g, 30 to 300 mg/g, and less than 30 mg/g for heavy, mild, and normal, respectively.&lt;/p&gt;
&lt;p&gt;Other registry data for the province provided outcomes in these individuals, with median follow-up of 35 months.&lt;/p&gt;
&lt;p&gt;Among individuals with eGFR rates of at least 60 mL/min/1.73 m&lt;sup&gt;2&lt;/sup&gt;, death rates were 7.2 per 1,000 for those with dipstick-measured heavy proteinuria (95% CI 6.6 to 7.8) and 5.8 per 1,000 for mild proteinuria (95% CI 5.5 to 6.0) compared with 2.7 per 1,000 for those with normal urine protein (95% CI 2.6 to 2.8).&lt;/p&gt;
&lt;p&gt;At the other end of the eGFR spectrum  --  those with levels of 15 to 29.9 mL/min/1.73 m&lt;sup&gt;2&lt;/sup&gt;  --  proteinuria remained an independent predictor of death: Mortality rates were 10.4 per 1,000 with heavy proteinuria (95% CI 9.3 to 11.6) and 9.1 per 1,000 with mild proteinuria (95% CI 8.2 to 10.0) versus 6.7 per 1,000 with normal urine protein (95% CI 6.2 to 7.3).&lt;/p&gt;
&lt;p&gt;These death rates reflected adjustments for a host of potential confounding factors and comorbidities, including age, sex, diabetes, hypertension, liver disease, and cardiovascular conditions.&lt;/p&gt;
&lt;p&gt;Proteinuria also predicted myocardial infarction in patients stratified by eGFR, but not as strongly. In the group with eGFR above 60 mL/min/1.73 m&lt;sup&gt;2&lt;/sup&gt;, rates of MI were 1.6 per 1,000 (95% CI 1.3 to 2.0) and 0.9 (95% CI 0.9 to 1.0) for heavy and normal urinary protein, respectively, as measured by dipstick.&lt;/p&gt;
&lt;p&gt;MI rates were also increased with proteinuria in participants with eGFR below 30 mL/min/1.73 m&lt;sup&gt;2&lt;/sup&gt;, the researchers reported.&lt;/p&gt;
&lt;p&gt;End-stage renal disease was enormously more common with dipstick-measured heavy proteinuria, independent of baseline eGFR.&lt;/p&gt;
&lt;p&gt;Individuals with eGFR above 60 mL/min/1.73 m&lt;sup&gt;2&lt;/sup&gt; were diagnosed with the condition at a rate of 1.0 per 1,000 (95% CI 0.7 to 1.4) if they had heavy proteinuria, compared with 0.03 per 1,000 (95% CI 0.02 to 0.09) among those with normal urine protein.&lt;/p&gt;
&lt;p&gt;A five-fold difference in rates of end-stage renal disease was still apparent among those with eGFR below 30 mL/min/1.73 m&lt;sup&gt;2&lt;/sup&gt;: 65.9 (95% CI 52.3 to 82.9) versus 12.7 per 1,000 (95% CI 9.3 to 17.3) for heavy versus normal protein, respectively.&lt;/p&gt;
&lt;p&gt;These results were confirmed when cross-checked against the more accurate albumin-creatinine ratio, Hemmelgarn and colleagues indicated.&lt;/p&gt;
&lt;p&gt;Each 10-fold increase in albumin-creatinine ratio was associated with the following relative rates of the major study outcomes, after adjusting for eGFR:&lt;ul&gt; &lt;li&gt;Death: 1.22 (95% CI 1.21 to 1.24)&lt;/li&gt; &lt;li&gt;MI: 1.18 (95% CI 1.14 to 1.21)&lt;/li&gt; &lt;li&gt;Doubling of serum creatinine: 1.76 (95% CI 1.70 to 1.82)&lt;/li&gt; &lt;li&gt;End-stage renal disease: 1.92 (95% CI 1.81 to 2.04)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Hemmelgarn and colleagues noted several limitations to the study including the fact that the sample was restricted to outpatients undergoing laboratory evaluations for kidney function and urinary protein, and the data were based on single measurements. Missing were data on alcohol, tobacco, and antihypertensive drug use, which might have affected the findings.&lt;/p&gt;
&lt;p&gt;The researchers also indicated that the follow-up period may have been too short to fully evaluate risks of progression to kidney failure.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Support for the study came from the Alberta Heritage Foundation for Medical Research, the Canadian Institutes of Health Research, Alberta Health and Wellness, and internal funds.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_325"
                     title="MRI Reveals Risk for Kidney Failure in Diabetic Patients (CME/CE)"
                     score="0.006"
                     href="http://www.medpagetoday.com/Nephrology/Diabetes/tb/18195?impressionId=1265788569853"
                     
      So-called silent strokes, visible on cerebral MRI scans, predict kidney failure in patients with type 2 diabetes, Japanese researchers said.&lt;br&gt;
&lt;br&gt;After an average follow-up of 7.5 years, diabetic patients with evidence of small cerebral infarctions at baseline later suffered death or kidney failure at more than twice the rate seen in patients who had not had silent strokes, reported Takashi Uzu, MD, of Shiga University of Medical Sciences in Shiga, Japan, and colleagues.&lt;br&gt;
&lt;br&gt;Silent strokes are a consequence of cerebral microvascular disease and thus may logically accompany the development of similar abnormalities in renal blood vessels, ultimately leading to kidney failure, the researchers explained online in the &lt;em&gt;Journal of the American Society of Nephrology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;It is important to identify individuals who are at risk of progression of diabetic renal disease,&quot; Uzu and colleagues wrote.&lt;/p&gt;
&lt;p&gt;The current standard prognostic test is the albumin-creatinine ratio, but it is not entirely adequate for the purpose, they suggested: &quot;Recent clinical studies have shown that renal insufficiency can occur in the absence of microalbuminuria in patients with type 2 diabetes.&quot;&lt;/p&gt;
&lt;p&gt;But they acknowledged that brain MRI scans would be too expensive and inconvenient for routine prognostic testing.&lt;/p&gt;
&lt;p&gt;&quot;New strategies are needed to determine the presence of renal and/or extrarenal microvascular diseases,&quot; Uzu and colleagues wrote.&lt;/p&gt;
&lt;p&gt;Their study involved 608 patients with type 2 diabetes who had no clinical signs of cerebrovascular or cardiovascular disease or overt nephropathy. Their mean age at baseline was about 60 and the average glycated hemoglobin level was about 8.6%.&lt;/p&gt;
&lt;p&gt;Participants underwent cerebral MRI scans at baseline, with 177 showing evidence of silent cerebral infarctions, defined as focal lesions of at least 3 mm in diameter with low signal intensity on T1-weighted images and high intensity with T2 weighting. Dilated perivascular spaces were distinguished from infarcts with proton density scans. Patients with positive findings who had a history of stroke or transient ischemic attack were excluded.&lt;/p&gt;
&lt;p&gt;Those with silent infarctions at baseline differed significantly from other participants according to several parameters. Not surprisingly, patients with cerebral infarcts on average were somewhat older (63 versus 57), had had diabetes for a longer period of time (9.8 years versus 7.6), had higher blood pressure (146.8 mm Hg systolic versus 136.5 ), and were more likely to have a history of smoking (58% versus 46%). All differences were significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.01.&lt;/p&gt;
&lt;p&gt;On the other hand, baseline fasting plasma glucose and glycated hemoglobin levels were both significantly lower in the patients who&apos;d had silent infarctions: mean 163 mg/dL versus 176 for glucose and 8.3% versus 8.7% for HbA1c (&lt;em&gt;P&lt;/em&gt;&amp;#8804;0.01 for both).&lt;/p&gt;
&lt;p&gt;Patients were followed for up to 10 years, with a mean of 7.5. The primary outcome was end-stage renal disease or death, and Uzu and colleagues chose a secondary outcome combining dialysis with doubling of serum creatinine.&lt;/p&gt;
&lt;p&gt;Kaplan-Meier curves for the patients with and without silent infarctions at baseline indicated that the primary outcome occurred at equal rates through the first four years of follow-up, but then the curves diverged abruptly.&lt;/p&gt;
&lt;p&gt;At year eight, approximately 6% of the noninfarcted group had experienced the primary outcome, compared with 21% of those who&apos;d had silent strokes (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001), according to Uzu and colleagues.&lt;/p&gt;
&lt;p&gt;Curves for the secondary outcome began diverging by year three. At year eight, about 6% of the noninfarct participants had gone to dialysis or had serum creatinine levels double, whereas these endpoints occurred in nearly 30% of the infarct group (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001).&lt;/p&gt;
&lt;p&gt;Overall, the hazard ratio associated with baseline silent cerebral infarctions for the primary outcome during follow-up was 2.44 (95% CI 1.36 to 4.38).&lt;/p&gt;
&lt;p&gt;The hazard ratio for death alone was somewhat smaller (1.61, 95% CI 0.71 to 3.62), indicating that most of the risk measured by the primary outcome was actually in end-stage renal disease.&lt;/p&gt;
&lt;p&gt;For the secondary outcome, the hazard ratio was 4.79 (95% CI 2.72 to 8.46).&lt;/p&gt;
&lt;p&gt;All the hazard ratios reflected adjustments for age, sex, duration of diabetes, body mass index, smoking status, HbA1c, blood pressure, serum lipids, and standard lab indices of kidney function at baseline.&lt;/p&gt;
&lt;p&gt;Estimated glomerular filtration rate (eGFR) during follow-up also decreased faster in patients with silent strokes. After five years, mean eGFR had fallen by 8 ml/min/m&lt;sup&gt;2&lt;/sup&gt; in the patients without silent infarcts at baseline compared with 10.5 ml/min/m&lt;sup&gt;2&lt;/sup&gt; in those with cerebral microvascular disease.&lt;/p&gt;
&lt;p&gt;The researchers noted that the study was conducted at two clinical sites, which used somewhat different MRI procedures. But they also indicated that the prevalence of silent infarctions did not differ between the sites.&lt;/p&gt;
&lt;p&gt;Other limitations included use of an older creatinine assay, inclusion of larger silent infarcts which could reflect macrovascular disease, and more patients in the cerebral infarct group who were taking renin-angiotensin system blocking drugs, which have renal impairment as an adverse effect.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;External funding for the study was not reported.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3193"
                     title="Exercise Improves Survival in Chronic Kidney Disease (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Nephrology/ESRD/tb/16346?impressionId=1265788569853"
                     
      &lt;p&gt;Much like the rest of the population, patients with chronic kidney disease have a decreased risk of death if they exercise regularly, according to an analysis of National Health and Nutrition Examination Survey (NHANES) data.&lt;/p&gt;
&lt;p&gt;Patients who got the recommended amount of weekly exercise were 56% less likely to die through seven years of follow-up than those who did not exercise at all (HR 0.44, 95% CI 0.33 to 0.58), according to Srinivasan Beddhu, MD, of the University of Utah in Salt Lake City, and colleagues.&lt;/p&gt;
&lt;p&gt;Those who exercised, but at less than the recommended level of activity, were still 42% less likely to die during follow-up than sedentary patients (HR 0.58, 95% CI 0.42 to 0.79).&lt;/p&gt;
&lt;p&gt;The findings were reported online in the &lt;em&gt;Clinical Journal of the American Society of Nephrology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Most patients with chronic kidney disease die before developing end-stage renal disease, but the current focus for clinicians is on slowing disease progression rather than reducing mortality, the researchers noted.&lt;/p&gt;
&lt;p&gt;Still, one measure that may be helpful in improving survival in these patients is increasing exercise, they wrote.&lt;/p&gt;
&lt;p&gt;A previous research effort, the Modification of Diet in Renal Disease (MDRD) study, suggested that the mortality benefits of physical activity might not apply to patients with chronic kidney disease.&lt;/p&gt;
&lt;p&gt;To further explore the issue, Beddhu and his colleagues examined data from NHANES III (1988-1994), which included 15,368 participants. Of those, 5.9% had chronic kidney disease (estimated glomerular filtration rate &amp;lt;60 mL/min per 1.73 m&lt;sup&gt;2&lt;/sup&gt;).&lt;/p&gt;
&lt;p&gt;Based on the results of a questionnaire, the participants were divided into three groups: &lt;ul&gt; &lt;li&gt;Active: moderate activity at least five times a week or rigorous activity at least three times a week&lt;/li&gt; &lt;li&gt;Insufficiently active: not inactive, but short of recommended activity levels&lt;/li&gt; &lt;li&gt;Inactive&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Chronic kidney disease patients were significantly more likely to be inactive than the other NHANES III participants (28% versus 13.5%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;After adjusting for potential confounders, participants in either one of the active groups had decreased risks of dying during follow-up, which was an average of seven years for patients with chronic kidney disease and 8.8 years for others.&lt;/p&gt;
&lt;p&gt;The magnitudes of the benefits were similar in patients with chronic kidney disease and the other participants (&lt;em&gt;P&lt;/em&gt;&amp;gt;0.3), &quot;indicating that the associations of physical activity with mortality did not differ by the presence or absence of chronic kidney disease,&quot; the researchers said.&lt;/p&gt;
&lt;p&gt;They said the findings likely differ from those of the MDRD study because of variation in the study designs, including different methods for assessing physical activity, and the occurrence of fewer deaths in the previous study.&lt;/p&gt;
&lt;p&gt;The authors noted limitations of the study, including the inability to establish a causal relationship between exercise and mortality because of the observational design, possible residual confounding, and the use of self-reported information on physical activity.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by a grant from the Dialysis Research Foundation of Utah. Beddhu is the recipient of grants from the National Institute of Diabetes and Digestive and Kidney Diseases.&lt;/p&gt;&lt;p&gt;The authors reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3279"
                     title="Angiography Okay for Kidney Patients (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Nephrology/KidneyTransplantation/tb/16463?impressionId=1265788569853"
                     
      Using coronary angiography to test whether a patient&apos;s heart is fit enough to undergo kidney transplant is not as dangerous as once thought, researchers found.&lt;br&gt;
&lt;br&gt;Among patients with advanced chronic kidney disease (CKD), mean glomerular filtration rate (GFR) did not change significantly six months before or after angiography, Nicola Kumar, MBChB, of Imperial College London, and colleagues reported online in the &lt;em&gt;Clinical Journal of the American Society of Nephrology&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;&quot;The data suggest coronary angiography screening does not accelerate the decline in renal function for patients with advanced CKD, facilitating a safe preemptive transplant program,&quot; the researchers said. &quot;A transient decline in GFR was demonstrated in the first week following coronary angiography but this was entirely reversible.&quot;&lt;/p&gt;
&lt;p&gt;Physicians have cautioned that the use of dyes and x-rays involved in angiography puts kidney patients at an increased risk of complications from the procedure. There have also been concerns that contrast-induced nephropathy and cholesterol embolization syndrome may precipitate the need for chronic dialysis.&lt;/p&gt;
&lt;p&gt;However, the researchers said, the safety of the procedure has improved.&lt;/p&gt;
&lt;p&gt;So they conducted a retrospective study of 76 patients with late-stage CKD who were potential transplant recipients seen at clinics from 2004 to 2007. Kidney function measurements were recorded 12 months before and 12 months after patients had coronary angiography.&lt;/p&gt;
&lt;p&gt;The researchers found that patients&apos; kidney function was similar before and after the procedure.&lt;/p&gt;
&lt;p&gt;Mean GFR at coronary angiography was about 12.46 ml/min, and that was not significantly different six months before and six months after the procedure, the researchers said.&lt;/p&gt;
&lt;p&gt;Cumulative dialysis-free survival was 89.1% six months after angiography.&lt;/p&gt;
&lt;p&gt;The researchers noted that there was a temporary decline in eGFR following administration of contrast media, but it was only transient.&lt;/p&gt;
&lt;p&gt;The technique detected coronary artery disease in 23 patients (30.3%), making them unsuitable for transplantation until their heart complications were addressed.&lt;/p&gt;
&lt;p&gt;Yet 32.9% of patients were eligible and had transplantation, with 88% of those being performed preemptively.&lt;/p&gt;
&lt;p&gt;A total of 17.1% of patients started dialysis during follow-up, the researchers said.&lt;/p&gt;
&lt;p&gt;None of the patients needed dialysis immediately after contrast administration, and only one started dialysis within three months of angiography, they added.&lt;/p&gt;
&lt;p&gt;The researchers acknowledged that their study may have been limited by the potential for missing data, but concluded that coronary angiography screening doesn&apos;t accelerate the decline in renal function for patients with advanced CKD.&lt;/p&gt;
&lt;p&gt;&quot;If the procedure is performed appropriately with small volumes of contrast, biplane angiography using N-Acetylcysteine and adequate hydration around the time of the procedure,&quot; the researchers said, &quot;then the risk of contrast exposure can be minimized in this population.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The researchers reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_1_243"
                     title="Kidney Failure Another Potential Health Risk of Obesity"
                     score="-0.005"
                     href="