Clinical journal of the American Society of Nephrology : CJASN
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Clin J Am Soc Nephrol · Jan 2010
The HALT polycystic kidney disease trials: design and implementation.
Two HALT PKD trials will investigate interventions that potentially slow kidney disease progression in hypertensive autosomal dominant polycystic kidney disease (ADPKD) patients. Studies were designed in early and later stages of ADPKD to assess the impact of intensive blockade of the renin-angiotensin-aldosterone system and level of BP control on progressive renal disease. Design, settings, participants, and measurements: PKD-HALT trials are multicenter, randomized, double-blind, placebo-controlled trials studying 1018 hypertensive ADPKD patients enrolled over 3 yr with 4 to 8 yr of follow-up. In study A, 548 participants, estimated GFR (eGFR) of >60 ml/min per 1.73 m(2) were randomized to one of four arms in a 2-by-2 design: combination angiotensin converting enzyme inhibitor (ACEi) and angiotensin receptor blocker (ARB) therapy versus ACEi monotherapy at two levels of BP control. In study B, 470 participants, eGFR of 25 to 60 ml/min per 1.73 m2 compared ACEi/ARB therapy versus ACEi monotherapy, with BP control of 120 to 130/70 to 80 mmHg. Primary outcomes of studies A and B are MR-based percent change kidney volume and a composite endpoint of time to 50% reduction of baseline estimated eGFR, ESRD, or death, respectively. ⋯ HALT PKD will evaluate potential benefits of rigorous BP control and inhibition of the renin-angiotensin-aldosterone system on kidney disease progression in ADPKD.
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Clin J Am Soc Nephrol · Jan 2010
Incidence of contrast-induced nephropathy after contrast-enhanced computed tomography in the outpatient setting.
No prospective study has reported the incidence of contrast-induced nephropathy (CIN) or the associated morbidity and mortality after contrast-enhanced computed tomography (CECT) in the outpatient setting. ⋯ CIN occurs in >10% of patients who undergo CECT in the outpatient setting and is associated with a significant risk for severe renal failure and death.
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Clin J Am Soc Nephrol · Dec 2009
Preexisting chronic kidney disease: a potential for improved outcomes from acute kidney injury.
Acute kidney injury (AKI) is associated with adverse outcomes in critically ill patients. The influence of preexisting chronic kidney disease (CKD) on AKI outcomes is unclear. ⋯ Among critically ill patients with AKI, those with prior CKD experience a lower mortality rate but are more likely to be dialysis dependent at hospital discharge. Future studies should determine optimal strategies for managing AKI with and without a prior history of CKD.
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Clin J Am Soc Nephrol · Dec 2009
ReviewThe state of chronic kidney disease, ESRD, and morbidity and mortality in the first year of dialysis.
This review examines trends in the ESRD program, assessing progress in preventive care, hospitalizations, and mortality since 1989, the year of the Dallas Morbidity and Mortality Conference. The number of prevalent dialysis patients nearly tripled, to 366,000 in 2007 from 123,000 in 1989. Prevalent population mortality rates declined in the mid-1980s but did not change overall through the 1990s; rates declined for patients on dialysis for less than 5 yr but increased for patients on dialysis for longer than 5 yr. ⋯ Use of dialysis catheters is high; 82% of patients start dialysis with a catheter. Poor planning for dialysis initiation may contribute to catheter use and the associated high infectious hospitalization rate, limiting potential for improved patient survival during the first year. Public health programs, including the new Medicare chronic kidney disease education benefit, are needed to promote better care of patients who may need dialysis to reduce the high morbidity and mortality in the first year.
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Renal dysfunction is highly prevalent in patients with heart failure. Furthermore, worsening renal function in patients with acute decompensated heart failure (ADHF), the so-called cardiorenal syndrome, impacts short and long-term morbidity and mortality. In recent years, more evidence has surfaced from clinical trials and heart failure registries that a complex cross-talk between the kidney and heart in patients with ADHF exists. ⋯ What is evident from current national statistics; however, are the poor results in treating the congestion of ADHF. In this regard, the role of secondary hyperaldosteronism is discussed in the diuretic section as well as diuretic resistance in ADHF. In conclusion, since renal function is the single most important prognostic factor in the outcome of patients with ADHF, a better understanding of the pathophysiology of the cardiorenal syndrome is needed to target therapy and ultimately improve the mortality of patients with ADHF.