Longitudinal Progression Trajectory of GFR Among Patients With CKD

Li, Liang; Astor, Brad C.; Lewis, Julia B.; Hu, Bo; Appel, Lawrence J.; Lipkowitz, Michael S.; Toto, Robert D.; Wang, Xuelei; Wright, Jackson T.; Greene, Tom

doi:10.1053/j.ajkd.2011.12.009

Cited by 280 publications

(290 citation statements)

References 13 publications

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“…In addition, cross-sectional studies have shown that increased SBV is associated with increased renal resistive index, a marker of renal arteriosclerosis (6). Despite these potential mechanisms linking SBV with renal disease, SBV was not independently associated with renal events in our study, principally after controlling for proteinuria, which has been demonstrated in hypertensive individuals to be predictive of renal outcomes (15,(29)(30)(31)(32). In our analyses, the HRs for cardiovascular and renal events from highest compared with the lowest tertile of SBV decreased from 2.81 to 1.43 and 1.58 to 1.29, respectively, upon adjusting for log proteinuria.…”

Section: Discussioncontrasting

confidence: 63%

Association of BP Variability with Mortality among African Americans with CKD

McMullan

Bakris

Phillips

et al. 2013

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Increased systolic BP visit-to-visit variability (SBV) may be associated with higher overall mortality and cardiovascular events. However, few studies have examined these associations in patients with CKD, and the relation of SBV with CKD progression and ESRD has not been shown. This study analyzed the association of SBV with overall mortality, cardiovascular mortality, cardiovascular events, and renal events among individuals enrolled in the African American Study of Kidney Disease (AASK) trial.Design, setting, participants, & measurements This was a prospective observational study of 908 participants during the trial phase of the AASK study, with at least 1 year of BP measurements available and followed for 3-6.4 years. SBV was calculated as the SD of the systolic pressure from five visits occurring 3-12 months after randomization. The association of SBV with risk of overall mortality, cardiovascular mortality, a composite of fatal and nonfatal cardiovascular events, and a composite of renal events was assessed using proportional hazards regression and adjusting for multiple potential confounders.Results Greater SBV was associated with higher overall mortality. The adjusted hazard ratio (95% confidence interval) was 2.82 (1.14-6.95) comparing the highest with lowest tertile of SBV. A similar comparison revealed that greater SBV was also associated with cardiovascular mortality (adjusted hazard ratio, 4.91; 1.12-21.50). SBV was associated with both the cardiovascular renal composite endpoints in unadjusted but not adjusted analyses.Conclusions In African Americans with CKD, SBV is strongly and independently associated with overall and cardiovascular mortality.

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Section: Discussioncontrasting

confidence: 63%

Association of BP Variability with Mortality among African Americans with CKD

McMullan

Bakris

Phillips

et al. 2013

Clinical Journal of the American Society of Nephrology

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“…Of note, there was no relationship between total and LDL cholesterol levels and rate of change in GFR in the low proteinuria group (Table 5). This may relate to the overall slow decline in GFR in patients with lower levels of proteinuria with less power to detect an association; in addition, as shown in the African American Study of Kidney Disease and Hypertension study, nonlinear, abrupt declines in GFR are not uncommon in individual patients (29). This may contribute to why an association was seen between LDL and total cholesterol and clinical renal outcomes, but not with rate of decline in GFR.…”

Section: Discussionmentioning

confidence: 97%

Relation of Serum Lipids and Lipoproteins with Progression of CKD

Rahman

Yang

Akkina

et al. 2014

Clinical Journal of the American Society of Nephrology

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Background and objectives Hyperlipidemia is common in patients with CKD. The objective of this study was to evaluate whether measures of plasma lipids and lipoproteins predict progression of kidney disease in patients with CKD.Design, setting, participants, & measurements Prospective cohort study in adults (n=3939) with CKD aged 21-74 years recruited between 2003 and 2008 and followed for a median of 4.1 years. At baseline, total cholesterol, triglycerides, very-low-density lipoprotein cholesterol (VLDL-C), LDL cholesterol (LDL-C), HDL cholesterol (HDL-C), apoA-I , apoB, and lipoprotein(a) [Lp(a)] were measured. The outcomes were composite end point of ESRD or 50% decline in eGFR from baseline (rate of change of GFR).Results Mean age of the study population was 58.2 years, and the mean GFR was 44.9 ml/min per 1.73 m 2 ; 48% of patients had diabetes. None of the lipid or lipoprotein measures was independently associated with risk of the composite end point or rate of change in GFR. However, there were significant (P=0.01) interactions by level of proteinuria. In participants with proteinuria,0.2 g/d, 1-SD higher LDL-C was associated with a 26% lower risk of the renal end point (hazard ratio [HR], 0.74; 95% confidence interval [95% CI], 0.59 to 0.92; P=0.01), and 1-SD higher total cholesterol was associated with a 23% lower risk of the renal end point (HR, 0.77; 95% CI, 0.62 to 0.96; P=0.02). In participants with proteinuria.0.2 g/d, neither LDL-C (HR, 0.98; 95% CI, 0.98 to 1.05) nor total cholesterol levels were associated with renal outcomes. Treatment with statins was reported in 55% of patients and was differential across lipid categories.Conclusions In this large cohort of patients with CKD, total cholesterol, triglycerides, VLDL-C, LDL-C, HDL-C, apoA-I, apoB, and Lp(a) were not independently associated with progression of kidney disease. There was an inverse relationship between LDL-C and total cholesterol levels and kidney disease outcomes in patients with low levels of proteinuria.

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“…Only a minority of units used predicted time to dialysis rather than eGFR to decide when to discuss the CKM option with a patient. Many patients with CKD have a nonlinear eGFR trajectory or a prolonged period of nonprogression in contrast to the traditional notion of steady GFR progression over time (24). This suggests that careful assessment of kidney disease progression is needed to decide when to discuss CKM with patients.…”

Section: Discussionmentioning

confidence: 99%

Conservative Care for ESRD in the United Kingdom

Okamoto

Tonkin‐Crine

Rayner

et al. 2015

Clinical Journal of the American Society of Nephrology

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Background and objectives Conservative kidney management (CKM) has been developed in the United Kingdom (UK) as an alternative to dialysis for older patients with stage 5 CKD (CKD5) and multiple comorbidities. This national survey sought to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development.Design, setting, participants, & measurements A survey on practice patterns of CKM for patients age 75 and older with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013.Results Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although "conservative management" was the most frequently used term (46%). Lack of an agreed-upon definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. Fifty-two percent provided the number of CKM patients age $75 years in 2012; the median was 45 per unit (interquartile range [IQR], 20-83). The median number of symptomatic CKM patients who would otherwise have started dialysis was eight (IQR,. CKM practice patterns varied: 35% had a written guideline, 23% had dedicated CKM clinics, 45% had dedicated staff, and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. Eighty percent identified a need for better evidence comparing outcomes on CKM versus dialysis, and 65% considered it appropriate to enter patients into a randomized trial.Conclusions CKM is provided in almost all UK renal units, but scale and organization vary widely. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support for further research comparing outcomes with conservative care versus dialysis.

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Longitudinal Progression Trajectory of GFR Among Patients With CKD

Cited by 280 publications

References 13 publications

Association of BP Variability with Mortality among African Americans with CKD

Association of BP Variability with Mortality among African Americans with CKD

Relation of Serum Lipids and Lipoproteins with Progression of CKD

Conservative Care for ESRD in the United Kingdom

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