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    1st Posting (Epidemiology and Diagnostic Parameters)

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    Post  D1 (R.Pe on Sat 20 Jun 2009, 12:04 am


    [b]Glomerular Filtration Rate, Urinary Albumin May Help Predict End-Stage Renal Disease

    Laurie Barclay

    April 19, 2009 — Glomerular filtration rate (GFR) and urinary albumin levels may help determine which patients with chronic kidney disease (CKD) will go on to have end-stage renal disease (ESRD), according to the results of a population-based study reported in the April 8 Online First issue of the Journal of the American Society of Nephrology.

    "Despite the high prevalence of...CKD, relatively few individuals with CKD progress to ESRD," write Dr. Stein I. Hallan, from the Norwegian University of Science and Technology and St. Olav University Hospital in Trondheim, Norway, and colleagues. "A better understanding of the risk factors for progression could improve the classification system of CKD and strategies for screening."

    The study sample consisted of 65,589 adults enrolled in the Nord-Trøndelag Health (HUNT 2) Study from 1995 to 1997. After 10.3 years of follow-up, 124 patients had progressed to ESRD.

    Estimated GFR (eGFR) and albuminuria were independently and strongly associated with progression to ESRD, based on multivariable survival analysis. Hazard ratios (HRs) for eGFR 45 to 59 mL/minute/1.73 m2, 30 to 44 mL/minute/1.73 m2, and 15 to 29 mL/minute/1.73 m2 were 6.7, 18.8, and 65.7, respectively (P < .001 for all). For microalbuminuria and macroalbuminuria, HRs were 13.0 and 47.2, respectively (P < .001 for both). No additional predictive information was added by hypertension, diabetes, male sex, smoking status, depression, obesity, cardiovascular disease, dyslipidemia, physical activity level, or educational achievement.

    Considering both the urinary albumin/creatinine ratio and eGFR markedly improved diagnostic accuracy, based on time-dependent receiver operating characteristic analyses.

    Using the current criteria for stages III to IV CKD (eGFR, 15 - 59 mL/minute/1.73 m2) would correctly identify 69.4% of all individuals who progressed to ESRD, but it would also include 4.7% of the general population. Using the classification system developed in this study would include only 1.4% of the general population without losing significant predictive power because it would identify 65.6% of those expected to progress to ESRD.

    "We provide clear evidence...that reduced eGFR should always be complemented by information on urine-albumin to yield optimal prediction of the risk of progression to ESRD," Dr. Hallan said in a news release.

    Limitations of this study include issues concerning the validity of ESRD as a primary outcome; homogeneous study population, decreasing the generalizability of the results; selection bias; and observational design.

    "All levels of reduced eGFR should be complemented by quantification of urinary albumin to predict optimally progression to ESRD," the study authors conclude. "Future risk scores and classification systems based on these two variables will be a simple and powerful tool for improving our ability to efficiently handle the large group of patients with CKD."

    The HUNT Study is a collaboration among the HUNT Research Center, Faculty of Medicine, Norwegian University of Science and Technology; The Norwegian Institute of Public Health; Nord-Trøndelag County Council; and Central Norway Regional Health Authority. The study authors have disclosed no relevant financial relationships.

    J Am Soc Nephrol. Published online April 8, 2009

    Reminders: We are not able to attach the original study on this thread due to its memory requirements. To view the whole study in PDF format, visit this website and download the file:


    End Stage Renal Disease (ESRD) is the term used in the medical field wherein function of the person’ kidneys is not sufficient to maintain life(Black and Hawk, 2005). The Kidney Disease Outcomes Quality Initiative (K/DOQI) of the National Kidney Foundation (NKF) defines kidney failure or ESRD or Stage 5 Chronic Kidney Disease as having a glomerular filtration rate(GFR) of less than 15 mL/min/1.73 m2 (cited at Arora, 2009). Globally, the number of cases of individuals with ESRD is continuously growing. As indicated in the study made by Dr. Rashad Barsoum (2006), the prevalence of ESRD in various developing countries is as follows: (1) Japan has 2000 per million population, (2) United States has 1500 per million population, (3)European Union has about 800 per million population, (Sub-Saharan Africa and India has less than 100 per million population, (5)Latin America has 400 per million population, and (6) Saudi Arabia has more than 600 per million population.

    In another data provided by United States Renal Data System (USRDS, 2008), in the United States of America, the prevalence rate from 1999-2004 that there were about 26 million adults (ages 20 or older) have chronic kidney disease(CKD). But the prevalence rate of (ESRD) or CKD stage 5 in 2006 is about 506,256 U.S. residents being treated for ESRD. If further mentioned that the following primary diseases were the leading cause of ESRD: (1)Diabetes 37% (2)Hypertension 24% (3) Glomerulonephritis 16% (4)Cystic kidney 5% (5)Urologic disease 3% and (6) other causes 15%. The total cost for the ESRD program, in 2006 amounted to a staggering $33.61 billion in public and private spending. Moreover, the study that there were about 93% of the patients with ESRD chose to undergo hemodialysis treatment, while 7% chose peritoneal dialysis. Lastly, it mentioned that the elderly population is the most rapidly growing kidney failure (chronic kidney disease stage 5) population in the United States (Coresh, et al., 2007).

    In the Philippines, kidney disease now ranks as the 10th leading cause of mortality based on the study conducted by the Philippine Renal Disease Registry in cooperation with the Department of Science and Technology (PRDR, 2008). There are about 10,000 Filipinos who needs either dialysis for life or a kidney transplant for survival and roughly 31% of them are afflicted with the advanced stage of the disease. The Department of Health (DOH) also has projected that the number of these patients might double in 2010. Similar to USA studies, today, diabetes mellitus and hypertension are also the top causes for increasing the risk of ESRD which together account for almost 60% of dialysis patients (DOH, 2007).

    Research Appraisal:

    This study is conducted in order to develop a new parameter of diagnosing the severity of CKD which may lead to ESRD. Through this research, classification will be improved,thus helping in the early detection and treatment of ESRD. The participants were taken from a previous research done 10.3 years ago. From the total of 65,589 patients interviewed during the past, only 124 patients progressed to ESRD were included in the study. This research utilized experimental study by assessing the eGFR and proteinuria to small cohorts, and specific populations utilizing laboratory diagnostic procedures. the major strength of the study was the researchers was able to diagnose the clients with ESRD. Some of the limitations that was found out were the validity of methods used to gather urine, accurateness of the computations used, availability of the participants and their being fit within the criteria.

    Research Result

    The study shows that using eGFR and urine albumin are the most powerful predictors of ESRD today. The use of eGFR and Albumin in the identification of ESRD was more effective than the previously used K/DOQI CKD classification system in which albumin is not considered as a predictor for ESRD. the power of this study to predict ESRD was increased from 44%-100% compared to the previous method used

    Reviewers Conclusion
    The significance of the study to the nursing knowledge is that through this research, diagnosis to clients with ESRD will be advance. along with that, interventions which can prevent the progression of the disease may be given earlier. Early detection and prompt treatment will provide clients with ESRD more percentage of improvement and event prolong their lifespan.

    Arora, P. and Verreli, M. Chronic Renal Failure. 2009.

    Barsoum RS. End-stage renal disease in the developing world. Artif Organs 2002;26:737-736. [CrossRef][Medline]

    Black, J. and Hawks, J. Medical-Surgical Nursing: Clinical Management for Positive Outcomes. 7th Ed. Elsvier Inc. 2005. Vol 1, p 766.

    USRDS 2008 Annual Data Report. United States Renal Data System Web site. Accessed October 31, 2008.

    Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. Journal of the American Medical Association. 2007;298(17):2038–2047.

    Stein I. Hallan, et.al, Combining GFR and Albuminuria to Classify CKD
    Improves Prediction of ESRD, 2009

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    Post  MS_exec on Sat 20 Jun 2009, 11:24 pm

    The instructions that was given to us by prof. that each posting should contain 3 paragraphs only (full text).

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    Post  rodel_perez_rn on Sun 21 Jun 2009, 12:11 am

    Actually, we have talked to prof. Bondad with regard to this matter. He instructed us to provide separate paragraphs for the epidemiology and the latter 3 paragraphs for the research appraisal of the research article. i think it is better if you consulted our professor first for your clarification before posting. thank you for the comment.

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    Post  gillegarda/joanalynbalino on Sun 21 Jun 2009, 7:48 pm

    Response by:
    Gil Legarda and Joanalyn Balino

    Title: Fibroblast Growth Factor 23 (FGF23) Predicts Progression of Chronic Kidney Disease: The Mild to Moderate Kidney Disease (MMKD) Study
    Danilo Fliser*, Barbara Kollerits{dagger}, Ulrich Neyer{ddagger}, Donna P. Ankerst{dagger},§, Karl Lhotta||, Arno Lingenhel{dagger}, Eberhard Ritz¶, Florian Kronenberg{dagger} for the MMKD Study Group

    Danilo Fliser et. al. studied about Fibroblast Growth Factor 23 (FGF23) as a predictor in a progression of CKD from the Mild to Moderate Kidney Disease. They had studied 227 nondiabetic patients with CKD for their cohort study. Based on the past research they use only calcium-phosphate metabolism as a predictor for CKD and ESRD progression. Patients should have at least 3 months stable renal function to be included in the study. To avoid inter observer differences only one nephrologists is the once recruited the patients these patients were recruited from eight nephrology departments in Germany, south Tyrol and Austria. Immunosuppressive agent, erythropoietin, serum creatinine, with diabetes of any type, malignancy, liver, thyroid infectious disease, nephritic syndrome, organ transplantation pregnancy and allergy were used as an exclusion criteria. This research study points an added a potential consequence, explicitly that serum phosphate level has an effect on renal disease progression. According to what Haunt and Alfrey experimented the renal damage was exasperated by phosphate loads. As what the research tells us the physiologic role of FGF23 in phosphate metabolism this phosphatonin may turn out to be one of the best indicator of cardiovascular risk even in patients without Chronic Kidney disease.


    Danilo Fliser et. al. (2008) Fibroblast Growth Factor 23 (FGF23) Predicts Progression of Chronic Kidney Disease: The Mild to Moderate Kidney Disease (MMKD) Study. Journal of American Society of Nephrology 18: 2600-2608 retrieved June 21, 2009 from

    Block GA, Klassen PS, Lazarus JM, Ofsthun N, Lowrie EG, Chertow GM (2004): Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. Journal American Society Nephrology 15 : 2208 –2218
    Schmitt CP, Odenwald T, Ritz E (2006): Calcium, calcium regulatory hormones, and calcimimetics: Impact on cardiovascular mortality. Journal American Society Nephrololgy 17[Suppl 2] : S78 –S80
    Ritz E, Gross ML, Dikow R (2005): Role of calcium-phosphorous disorders in the progression of renal failure. Kidney International Suppl 99 : S66 –S70
    Berndt TJ, Schiavi S, Kumar R (2005): "Phosphatonins" and the regulation of phosphorus homeostasis. American Journal Physiolgy Renal Physiol 289 : F1170 –F1182

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    Post  alkhaloidz on Sun 21 Jun 2009, 10:54 pm

    Response by: Balajadia/Zaño

    Chronic Kidney Disease Incidence, and Progression to End-Stage Renal Disease, in HIV-Infected Individuals: A Tale of Two Races

    Little is known about the racial differences in the incidence and progression of HIV-related chronic kidney disease (CKD) that underlie African American–white disparities in HIV-related end-stage renal disease (ESRD). In a cohort in Baltimore, Maryland, we measured CKD incidence, glomerular filtration rate (GFR) slope, and progression to ESRD in 3332 African American and 927 white HIV-infected subjects. A total of 284 subjects developed CKD, 100 (35%) of whom subsequently developed ESRD. African American subjects were at slightly increased risk for incident CKD, compared with white subjects (hazard ratio
    , 1.9 [95% confidence interval {CI}, 1.2–2.8]). However, once CKD had commenced, the African American subjects developed ESRD markedly faster than did the white subjects (HR, 17.7 [95% CI, 2.5–127.0]), and, correspondingly, their GFR decline after diagnosis of CKD was 6-fold more rapid (P < .001). In the subset of African American subjects for whom kidney-biopsy data were available, progression to ESRD was significantly faster than that in white subjects with CKD, irrespective of the presence of HIV-associated nephropathy.

    We therefore conclude that, the results of this study suggest that African American–white discrepancies in HIV-related ESRD are expound predominantly by a more hostile natural disease history in African Americans and less by racial differences in CKD incidence. In summary, the present study found that racial differences in the incidence of CKD in HIV-infected subjects were relatively small, with AIDS status being the strongest risk factor identified as being associated with new onset of CKD; in contrast, once CKD had commenced, its progression was much more rapid in African Americans than in whites, as demonstrated by both a significantly faster decline in GFR and an 18-fold-higher risk of progression to ESRD. The incidence of CKD declined in sequential calendar periods as HIV treatments improved, and ACE-I/ARB was significantly associated with a lower risk of progression to ESRD.

    Reference: Lucas, Gregory et. al. Chronic Kidney Disease Incidence, and Progression to End-Stage Renal Disease, in HIV-Infected Individuals: A Tale of Two Races. PMC. September 25 2008

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    Post  VonDeneb_Vitto on Sun 21 Jun 2009, 11:55 pm

    People of low socioeconomic status (SES) appear to be at increased risk of ESRD (Ward, 2008). The incidence of ESRD was found to be greater in geographic areas with less educated populations and lower household incomes. Associations between SES and risk of ESRD were found in both whites and blacks when race-stratified analyses were performed. Low-SES groups may have a greater prevalence of ESRD because they may be more likely affected by diseases that can cause ESRD. However, SES also was associated with the risk of ESRD caused by specific diseases, such as diabetes mellitus. Previous studies examined populations in selected states or local areas or included only patients in selected age groups or who were white or black or those with a specific primary renal disease.

    Ward’s (2008) study included a national sample of all adults with ESRD and examined whether the association between SES and incidence of ESRD was similar across demographic groups. SES may be associated with risk of ESRD through environmental influences on the biological characteristics of renal disease or through differences in health behaviors in persons of different SES. The researcher hypothesized that one aspect of SES that could contribute to the risk of ESRD was the availability of specific treatments that could prevent or decrease progression to ESRD. Therefore, Ward (2008) specifically contrasted associations among patients with 3 different primary renal diseases that differ in the availability of specific treatments: diabetes mellitus, systemic lupus erythematosus, and autosomal dominant polycystic kidney disease
    (ADPKD). In patients with diabetes mellitus, strict glycemic control can decrease the development of diabetic nephropathy and, by inference, ESRD. Although immunosuppressive therapies are available for patients with lupus nephritis, not all patients respond, and some progress to ESRD despite optimal available treatment. Conversely, there is no specific treatment for patients with ADPKD other than control of hypertension. Differences among patients with ADPKD in rates of progression to ESRD are believed to be related largely to the biological characteristics of this disease. If access to effective treatment was an important mechanism explaining the association of SES and ESRD, one would predict stronger associations between SES and risk of ESRD caused by diabetes mellitus than for ESRD caused by lupus nephritis and little or no association between SES and risk of ESRD caused by ADPKD.

    The incidence of ESRD was greater in patients in the lower SES categories in all sex-race subgroups and decreased progressively with higher SES. These associations tended to be stronger in women than men and were weakest in blacks. This study confirms that the incidence of ESRD is greater in patients of lower SES.

    Ward, M.M. (2008). Socioeconomic Status and the Incidence of ESRD. American Journal of Kidney Diseases. 51 (4). Retrieved June 21, 2009 from http://www.mdconsult.com/das/article/body/144786582-6/jorg=journal&source=MI&sp=20546642&sid=854656887/N/635667/s0272638607016095.pdf?SEQNO=1&issn=0272-6386

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    Post  guomanman on Tue 23 Jun 2009, 10:55 am

    Dyad 6 guomanman and chenya

    Management of early chronic kidney disease in indigenous populations and ethnic minorities. The rate of treated end-stage renal disease (ESRD) continues to increase globally. The disproportionately high rate of ESRD among the many growing indigenous populations and racial/ethnic minorities in the United States highlights the need to reassess present treatment strategies to more appropriately identify and manage chronic kidney disease in diverse communities. Similar projections have been noted worldwide.

    This discrepancy between ESRD rates among racial and ethnic minority groups, and treatment strategies is due to several factors, many of which are modifiable. These include the individual, the health care provider/system, and limited participation in controlled clinical trials.

    Although it is unfortunate that this disparity continues to exist, a thoughtful and compassionate approach to addressing the role of diverse biobehavioral and sociocultural factors might be the key to effective translation of emerging scientific advances into improved clinical outcomes for all patients with chronic kidney disease.

    Last edited by guomanman on Thu 25 Jun 2009, 10:07 pm; edited 1 time in total
    Lucy Yuan

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    Post  Lucy Yuan on Tue 23 Jun 2009, 11:47 pm

    Washington, DC (April 7, 2009) !aMeasuring kidney function by assessing two different factors!
    glomerular filtration rate (GFR) and urinary albumin levels!ahelps determine wich patients with chronic
    kidney disease (CKD) will develop end-stage renal disease (ESRD), according to a study appearing in the
    May 2009 issue of the Journal of the American Society Nephrology (JASN). This combination test could
    help physicians identify patients at high risk of serious kidney trouble and allow them to intervene at an
    early stage.
    While there is a high prevalence of CKD worldwide, relatively few individuals with the disease
    develop ESRD, expected to affect 785,000 people in the U.S. by 2020 (current annual cost: $32 billion).
    Physicians and researchers have looked for ways to identify which patients will progress to ESRD in order
    to target patients most in need of extensive treatment, and help establish clinical guidelines and public
    health plans for treating patients with CKD.
    Stein Hallan, MD, PhD (St. Olav University Hospital, Norway), and his colleagues recently
    conducted a study to see if combining two tests commonly used to measure kidney function might help
    predict ESRD. One test measures an individual!ˉs estimaed glomerular filtration rate (eGFR!aa measure of
    the volume of fluid filtered by the kidneys), while the other measures the amount of albumin (the
    predominant protein in the blood) that is excreted in urine. A high urinary albumin level indicates a rapid
    rate of kidney disease progression, and a low eGFR indicates an advanced stage of disease.
    The researchers analyzed data from 65,589 adults who participated in the population-based Nord-
    Tr0ndelayHealth (HUNT 2) Studyears of follow-up. Combining urinary albumin and eGFRs results identified more than 65% of patients
    who would develop this condition. Other factors such as hypertension, diabetes, smoking, obesity, and
    cardiovascular disease did not provide any additional information that could be used to predict who would
    develop ESRD. y and found 124 individuals who developed ESRD after more than 10years of follow-up. Combining urinary albumin and eGFRs results identified more than 65% of patients
    who would develop this condition. Other factors such as hypertension, diabetes, smoking, obesity, and
    cardiovascular disease did not provide any additional information that could be used to predict who would
    develop ESRD.

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