Closing the gap between evidence and practice in chronic kidney disease.

There are major gaps between our growing knowledge of effective treatments for chronic kidney disease (CKD), and the delivery of evidence-based therapies to populations around the world. Although there remains a need for new, effective therapies, current evidence suggests that many patients with CKD are yet to fully realize the benefits of blood pressure-lowering drugs (with and without reducing proteinuria with renin-angiotensin system blockade), wider use of statins to reduce atherosclerotic cardiovascular disease events, and better glycemic control in both type 1 and type 2 diabetes. There are many barriers to optimizing evidence-based nephrology care around the world, including access to health care, affordability of treatments, consumer attitudes and circumstances, the dissemination of appropriate knowledge, the availability of expertise and structural impediments in the delivery of health care. Further investment in implementation science that addresses the major barriers to effective care in a cost-effective manner could yield both local and global benefits.

Complications of chronic kidney disease: current state, knowledge gaps, and strategy for action.

The International Society of Nephrology has adopted a proactive approach to defining the current state of kidney care and unmet needs through a multifaceted Closing the Gaps initiative. As part of this initiative, the International Society of Nephrology convened a meeting of experts to develop an approach to tackle acute kidney injury and chronic kidney disease (CKD). This manuscript expands on the recently published International Society of Nephrology CKD Roadmap and reports on the discussions of the working group assigned to the task of reviewing the global impact of complication of CKD. The working group defined the following goals: Goal 1: Optimize the management of anemia and endocrine and metabolic abnormalities associated with CKD. The impact of these conditions at a global level is not well understood, particularly in regions where renal replacement therapy is not readily available. Some treatment regimens may be affordable in low- and middle-income countries and if implemented, could have an impact on the burden of suffering associated with CKD. Goal 2: Improve the prevention and management of cardiovascular complications linked to CKD. Most research on cardiovascular complications of CKD has focused on atherosclerotic diseases (myocardial infarction, ischemic stroke, and peripheral gangrene). There has been growing recognition that other forms of cardiovascular diseases, such as heart failure, valvular disease and arrhythmias, have a major impact on patient outcomes. Much less is known about the mechanisms and treatment of these non-atherosclerotic complications. Goal 3: Improve the diagnosis and management of symptoms associated with CKD. Symptom management is one of the greatest challenges in the management of CKD, with limited knowledge about the mechanisms associated with the development of these common problems and how best to characterize them into usable clinical phenotypes. Improved understanding of the complications of CKD may alleviate suffering and prolong life among millions of people worldwide both in developed countries and in regions where renal replacement therapy is not widely available.

A comparison of glomerular filtration rate by creatinine based equations and DTPA-renogram in healthy adult kidney donors.

INTRODUCTION: Accurate determination of donor kidney function has important long-term implications for both donor health and recipient outcome. Many centers use 24 hour urinary creatinine clearance or creatinine-based GFR estimations to assess kidney function but their performance when compared with GFR measurements by isotope clearance remains inconclusive. We assessed the performance of creatinine based equations against DTPA GFR for evaluating Nepalese kidney donors. METHODS: All kidney donors who had undergone both DTPA GFR estimation and 24 hour urine CrCl were included. The performance of the urine-CrCl, CG-CrCl, modified MDRD GFR against DTPA GFR was evaluated by analyzing global bias, precision (R2),Pearson correlation and accuracy percentage within 30% and 15%. The sensitivity and specificity of each predictive equation in selecting donor with GFR of ≥80 mL/min/1.73 m2 was also calculated. RESULTS: Of 51 donors analysed, only 18 (35.29%) were male. The mean measured GFR was 102.752±16.71 mL/min/1.73 m2. Of all prediction equations, urine-CrCL has most precision (R2=0.207) with the highest pearson correlation (0.455) and highest accuracy percentage within 30% and 15%. However, predictive performance was poor for all the equations. The urine CrCl had highest sensitivity of 100% for detecting donor with measured GFR>80 mL/min/1.73 m2 with positive predictive value of 92.1%. CONCLUSIONS: The performance of all equations was disappointing and even the best performing equation urine-CrCl was suboptimal for donor selection. So considering the potential risk of living kidney donation, other more accurate methods of GFR estimation should be used.