Mineral disorders in pediatric pre-emptive kidney transplantation.

BACKGROUND: Pre-emptive kidney transplantation (PEKT) is beneficial for patients, improves graft survival and minimizes the complications associated with chronic kidney disease. Reports on pediatric PEKT, however, are limited, and little is known about the parathyroid hormone (PTH) abnormalities and calcium-phosphorus disorders (CPD) in this condition. This study was the first to report on mineral disorders in pediatric PEKT patients during a 1 year period. METHODS: We conducted a comparative examination of the abnormalities in calcium, phosphorus, calcium-phosphorus products and PTH before and 1 year after living donor kidney transplantation in PEKT and non-PEKT patients. RESULTS: Thirty-one patients were included. The patients were divided into two groups: PEKT (n = 11; 5 months in CKD stage 4-5) and non-PEKT (n = 20; 31.5 months in dialysis). Mean age at transplantation was 9.4 ± 5.0 years. Hypercalcemia and hyperphosphatemia were observed before and after transplantation in the PEKT and non-PEKT groups, and >15% of patients in each group had bone disorder and ectopic calcification associated with mineral disorder. Mineral disorder was present for approximately 3 months after transplantation in both treatment groups. CONCLUSIONS: No significant differences in PTH or CPD were noted between PEKT and non-PEKT groups; moreover, normalization of abnormal values did not differ between the PEKT and non-PEKT groups. Compared with non-PEKT, PEKT did not improve the course of mineral metabolism disorders. Mineral and bone disorder treatment was likely insufficiently provided to pediatric PEKT patients. To obtain the maximum advantage of PEKT, calcium and phosphorus levels should be strictly controlled before kidney transplantation.

Results of a multicenter prospective clinical study in Japan for evaluating efficacy and safety of desensitization protocol based on rituximab in ABO-incompatible kidney transplantation.

BACKGROUND: Deceased organ donations are rare in Japan, with most kidney transplants performed from a limited number of living donors. Researchers have thus developed highly successful ABO-incompatible transplantation procedures, emphasizing preoperative desensitization and postoperative immunosuppression. A recent open-label, single-arm, multicenter clinical study prospectively examined the efficacy and safety of rituximab/mycophenolate mofetil desensitization in ABO-incompatible kidney transplantation without splenectomy. METHODS: Mycophenolate mofetil and low dose steroid were started 28 days pretransplant, followed by two doses of rituximab 375 mg/m2 at day -14 and day -1, and postoperative immunosuppression with tacrolimus or ciclosporin and basiliximab. The primary endpoint was the non-occurrence rate of acute antibody-mediated rejection. Patient survival and graft survival were monitored for 1 year posttransplant. RESULTS: Eighteen patients received rituximab and underwent ABO-incompatible kidney transplantation. CD19-positive peripheral B cell count decreased rapidly after the first rituximab infusion and recovered gradually after week 36. The desensitization protocol was tolerable, and most rituximab-related infusion reactions were mild. No anti-A/B antibody-mediated rejection occurred with this series. One patient developed anti-HLA antibody-mediated rejection (Banff 07 type II) on day 2, which was successfully managed. Patient and graft survival were both 100 % after 1 year. CONCLUSION: Our desensitization protocol was confirmed to be clinically effective and with acceptable toxicities for ABO-I-KTx (University Hospital Medical Information Network Registration Number: UMIN000006635).

Successful third renal transplantation in a child with an occluded inferior vena cava: A novel technique to use the venous interposition between the transplant renal vein and the infrahepatic inferior vena cava.

A girl aged 11 years and 3 months with occlusion of the inferior vena cava had experienced two renal transplant graft failures since birth. The third renal transplant from a live donor was carried out. Preoperative evaluation showed that the arteries from the right common to the right external iliac artery were absent, and the ilio-caval vein was occluded below the level of the renal vein. The donor's renal artery was anastomosed to the aorta. The donor's ovarian and large saphenous veins were used to extend the transplant renal vein to the recipient's patent inferior vena cava. The present report concludes that the extension of a short donor renal vein using other donor veins is a viable therapeutic option for pediatric patients with vascular occlusions.

Renal complications in 6p duplication syndrome: microarray-based investigation of the candidate gene(s) for the development of congenital anomalies of the kidney and urinary tract (CAKUT) and focal segmental glomerular sclerosis (FSGS).

6p duplication syndrome is a rare chromosomal disorder that frequently manifests renal complications, including proteinuria, hypoplastic kidney, and hydronephrosis. We report a girl with the syndrome, manifesting left hydronephrosis, proteinuria/hematuria, and focal segmental glomerular sclerosis (FSGS) resulting in chronic end-stage renal failure, successfully treated with renal transplantation. Microarray comparative genomic hybridization showed the derivative chromosome 6 to have a 6.4-Mb duplication at 6p25.3-p25.1 with 32 protein-coding genes and a 220-Kb deletion at 6p25.3 with two genes of no possible relation to the renal pathology. Review of the literature shows that variation of renal complications in the syndrome is compatible with congenital anomalies of the kidney and urinary tract (CAKUT). FSGS, observed in another patient with 6p duplication syndrome, could be a non-coincidental complication. FOXC1, located within the 6.4-Mb duplicated region at 6p25.3-p25.2, could be a candidate gene for CAKUT, but its single gene duplication effect would not be sufficient. FSGS would be a primary defect associated with duplicated gene(s) albeit no candidate could be proposed, or might occur in association with CAKUT.

Comparing the efficacy of continuous erythropoietin receptor activator and darbepoetin Alfa treatments in Japanese patients with chronic kidney disease during the predialysis period: A propensity-matched analysis.

AIM: Erythropoiesis-stimulating agent (ESA) treatment during the predialysis period can be a strategy to reduce cardiac mortality soon after initiation of dialysis. In this study, we compared the efficacy of continuous erythropoietin receptor activator (CERA) and darbepoetin alfa (DA) in patients with chronic kidney disease (CKD) over 6 months prior to initiation of dialysis. METHODS: This study was a retrospective propensity score-matched study conducted at a single center in Japan that analyzed the effects of CERA and DA therapy on haemoglobin (Hb) changes, ESA resistance index (ERI) changes, and interval of ESA administration during a 6-month observation period prior to initiation of dialysis. Propensity scores were used for matching the patients included in the CERA and DA groups. RESULTS: Among 680 screened, 74 pairs of patients (one in each group) were included in the present analysis after propensity score matching. Mean Hb significantly decreased over 6 months in the DA group compared to that in the CERA group (-0.70 ± 0.23 vs. -0.33 ± 0.22). In the DA group, mean ERI was significantly increased at 4, 3, 2, and 1 month before dialysis and initiation of dialysis, while in the CERA group, mean ERI was significantly increased only at 1 month before dialysis and initiation of dialysis. Moreover, patients administered CERA were required to visit the hospital significantly less frequently for ESA administration than those administered DA. CONCLUSION: Our study showed that CERA may be more effective than DA for management of anaemia during the predialysis period in CKD patients.

Evaluation of blood group antibodies in ABO-incompatible living-donor kidney transplantation.

OBJECTIVE: To assess changes in anti-blood type antibody titers and postoperative outcomes (graft survival and rejection rates) at our center with the use of the immunosuppressant, rituximab, in ABO-incompatible kidney transplants from living donors. Confirming anti-donor blood group antibodies is important for avoiding humoral rejection in ABO-incompatible kidney transplants. Splenectomy has been carried out in our hospital according to Alexandre's policy in order to suppress the production of anti-donor blood group antibodies. However, splenectomy has recently been avoided due to the administration of the immunosuppressant rituximab, which gives satisfactory outcomes. Thus, pre- and postoperative anti-donor blood group antibodies were measured, and the outcomes achieved with rituximab were examined. METHODS: A total of 134 cases of ABO-incompatible kidney transplants were carried out at Toho University Omori Medical Center between March 1989 and February 2013. These cases were classified as follows: azathioprine group (n = 62 patients); mycophenolate mofetil group (n = 33 patients); rituximab group (n = 39 patients). The anti-donor blood group antibodies levels (immunoglobulin G and immunoglobulin M) were measured in all groups before antibody removal, immediately before surgery, and 1, 2, 4 weeks and 3 months after surgery, and then compared. RESULTS: Rates of antibody-mediated rejection, including hyperacute rejection, in the azathioprine, mycophenolate mofetil, and rituximab groups were 32.2%, 18.1% and 7.6%, respectively. Graft survival rates were higher in the mycophenolate mofetil and rituximab groups than in the azathioprine group, but were lower in patients with higher preoperative antibody titers (≥128-fold higher immunoglobulin G) than in those with lower titers (<128-fold higher immunoglobulin G). In addition, postoperative anti-blood type antibody titers were significantly suppressed in the rituximab group. CONCLUSIONS: Administration of rituximab results in better antibody control than previous protocols including splenectomy, even in the postoperative period during which humoral rejection often occurs. This protocol eliminates the physical invasiveness of pre-transplant splenectomy, and is expected to provide better outcomes in chronic renal failure patients who undergo kidney transplants.

Urinary reconstruction in vertebral, anorectal, cardiac, trachea-esophageal, renal abnormalities and limb defects association with chronic renal failure and penile duplication.

Various urological complications in VATER association require careful management. A 15-year-old boy with VATER association, including a hypoplastic lower urinary tract and diphallia, presented with chronic kidney disease and incontinence after a right loop ureterostomy. In order to acquire urinary continence without renal function impairment, an ileocecal reservoir with umbilical catheterizable stoma was created as a urinary reconstruction. The ectopic posterior penis was resected for cosmetic reasons, and the stump of the hypoplastic urethra was opened at the perineal skin. Clean intermittent self-catheterization through the umbilicus using disabled bilateral limbs was then achieved. This report describes the management of VATER association in a patient with complicated urological anomalies.

[Test-retest reliability of the Implicit Association Test for measuring shyness: Inclusion of malleability of implicit shyness].

The Implicit Association Test of Shyness (Shyness IAT: Aikawa & Fujii, 2011) provides an indirect assessment of shyness by measuring associations of self (vs. other) with shyness-related (vs sociability-related) words. In this study we examined the test-retest reliability of the Shyness IAT. Thirty-five participants responded twice to the Shyness IAT with a time lag of one month. The correlation coefficient between the two time points was .54 (p = .001), confirming an adequate level of test-retest reliability. Indeed, changes in explicit and implicit shyness between the two time points were not related to sociable behavior during the one month period. Implications of the results for the assessment of personalities using IATs as well as relevant future directions are discussed.

Association between ratio of measured extracellular volume to expected body fluid volume and renal outcomes in patients with chronic kidney disease: a retrospective single-center cohort study.

BACKGROUND: Excess extracellular volume is a major clinical problem in patients with chronic kidney disease (CKD). However, whether the extracellular volume status is associated with disease progression is unclear. We investigated the association between the extracellular volume status and renal outcomes. METHODS: We performed a retrospective cohort study of 149 patients with CKD who underwent bioelectrical impedance analysis (BIA) from 2005 to 2009. Patients were categorized according to tertiles of extracellular volume status. The extracellular volume status was assessed by examining the ratio of extracellular water measured by BIA (ECWBIA) to the total body water calculated using the Watson formula (TBWWatson). The main outcomes were adverse renal outcomes as defined by a decline of ≥50% from the baseline glomerular filtration rate or initiation of renal replacement therapy. RESULTS: A higher %ECWBIA/TBWWatson ratio tended to be associated with older age, male sex, diabetes mellitus, resistant hypertension, lower renal function, lower serum albumin levels, higher proteinuria levels, and a higher frequency of furosemide use. In the multivariate analysis, proteinuria remained independently associated with the %ECWBIA/TBWWatson ratio. Both the intracellular and extracellular water volumes decreased with age (correlation between ICW and age, r=-0.30, P<0.001; correlation between ECW and age, r=-0.17, P=0.03). Consequently, the %ECWBIA in the body fluid composition increased with age. During a median follow-up of 4.9 years, patients in the highest tertile of the %ECWBIA/TBWWatson ratio were at greater risk of adverse renal outcomes (16.6 per 100.0 patient years) than were those in the lowest tertile (8.1 per 100.0 patient years) or second tertile (5.6 per 100.0 patient years) (log-rank P=0.005). After adjustment for covariates, the %ECWBIA/TBWWatson ratio was significantly associated with adverse renal outcomes (hazard ratio, 1.21; 95 % confidence interval, 1.10-1.34; P<0.001). CONCLUSIONS: The ECWBIA/TBWWatson ratio was independently associated with adverse renal outcomes. Proteinuria was independently associated with the extracellular volume status. The balance between ICW and ECW changes with age in that the percentage of ECW content in the body fluid composition increases. Elderly patients with CKD may thus be susceptible to volume overload.

Combination of pulse methylprednisolone infusions with cyclosporine-based immunosuppression is safe and effective to treat recurrent focal segmental glomerulosclerosis after pediatric kidney transplantation.

BACKGROUND: Recurrence of focal segmental glomerulosclerosis (FSGS) in pediatric kidney allografts is associated with poor graft survival. Several therapeutic regimens have been proposed, with conflicting results. METHODS: Ten pediatric patients with recurrent FSGS after kidney transplantation were treated with a protocol of methylprednisolone (MP) infusions in combination with cyclosporine (CsA)-based immunosuppression. The patients received a drug regimen with infusions of 20 mg/kg MP on three consecutive days at week 1, week 3, and week 5, and then monthly until six months after transplantation. If a complete or partial remission (PR) was obtained, MP pulse continued every three months until 24 months after transplantation. The CsA dose was adjusted according to AUC0-4. RESULTS: Seven of 10 patients (70%) achieved complete remission (CR) with stable renal function within 18 months of beginning of treatment. One of two patients with PR entered CR 3.5 yr after transplantation. One patient lost her graft due to recurrence four months after transplantation. After observation for 26-119 months, seven patients maintained remission with normal glomerular filtration rate. Few major side effects were observed in association with the high-dose MP infusion therapy. CONCLUSIONS: MP infusion therapy in combination with CsA-based immunosuppression could be safe and effective in treating recurrent FSGS after kidney transplantation.

Assessment of body composition using dry mass index and ratio of total body water to estimated volume based on bioelectrical impedance analysis in chronic kidney disease patients.

OBJECTIVE: Body mass index (BMI) is commonly used for assessment of nutritional status. However, changes in BMI in chronic kidney disease (CKD) patients are affected not only by muscle and fat but also by fluid volume. The ratio of extracellular water (ECW(BIA)) to total body water (TBW(BIA)) in multifrequency bioelectrical impedance analysis is commonly used for assessing abnormal fluid status. This study reexamines ECW(BIA)/TBW(BIA) and evaluates the reliability of TBW(BIA)/TBW(watson) and dry mass index (DMI) in the assessment of fluid and nutritional status. DESIGN, SETTING, AND SUBJECTS: TBW(BIA), intracellular water (ICW(BIA)), and ECW(BIA) were measured in 45 randomly selected CKD patients. Participants were surveyed for age, gender, BMI, blood pressure, serum albumin, estimated glomerular filtration rate, and proteinuria. DMI was calculated by the formula ([weight--TBW(BIA)]/height(2)) and TBW(BIA)/TBW(watson) using an anthropometric formula (Watson). Fluid and nutritional status were assessed using ECW(BIA)/TBW(BIA), TBW(BIA)/TBW(watson), and DMI. RESULTS: TBW(BIA)/TBW(watson) positively correlated with weight, BMI, and diastolic blood pressure and negatively correlated with age and serum albumin level. In contrast, ECW(BIA)/TBW(BIA) correlated with ICW deficit, aging, and body weight loss. On the basis of DMI and TBW(BIA)/TBW(watson), participants were categorized as follows: 1 obese patient with hypovolemia and 2 with euvolemia; 17 overweight patients with hypovolemia (n = 6), euvolemia (n = 8), or hypervolemia (n = 3); 24 patients of optimal weight with hypovolemia (n = 10), euvolemia (n = 9), or hypervolemia (n = 5); and 1 underweight patient with euvolemia. CONCLUSIONS: A combination of DMI, BMI, and TBW(BIA)/TBW(watson) makes it possible to include assessment of fluid volume to the physique index. In addition, ECW(BIA)/TBW(BIA) is not a reliable marker of edematous state in CKD patients.

[The effect of coping and appraisal for coping on mental health and later coping].

This study examined the effect of coping and appraisal for coping on mental health and later coping in two longitudinal studies. In Study 1 (Time 1: n = 342, Time 2: n = 367) investigated the influence of selected coping and coping for appraisal on mental health and assumed coping. In Study 2 (Time 1: n = 161, Time 2: n = 154) investigated the influence of selected coping and coping for appraisal on mental health and later coping. The results indicated that coping and coping for appraisal affected mental health and later coping. However, the influence of the coping for appraisal was more limited than selected coping.

[Verification of the double dissociation model of shyness using the implicit association test].

The "double dissociation model" of shyness proposed by Asendorpf, Banse, and Mtücke (2002) was demonstrated in Japan by Aikawa and Fujii (2011). However, the generalizability of the double dissociation model of shyness was uncertain. The present study examined whether the results reported in Aikawa and Fujii (2011) would be replicated. In Study 1, college students (n = 91) completed explicit self-ratings of shyness and other personality scales. In Study 2, forty-eight participants completed IAT (Implicit Association Test) for shyness, and their friends (n = 141) rated those participants on various personality scales. The results revealed that only the explicit self-concept ratings predicted other-rated low praise-seeking behavior, sociable behavior and high rejection-avoidance behavior (controlled shy behavior). Only the implicit self-concept measured by the shyness IAT predicted other-rated high interpersonal tension (spontaneous shy behavior). The results of this study are similar to the findings of the previous research, which supports generalizability of the double dissociation model of shyness.

Final height in a prospective trial of late steroid withdrawal after pediatric renal transplantation treated with cyclosporine and mizoribine.

A prospective trial of corticosteroid (steroid) withdrawal after pediatric renal transplantation was started in 1990. Fifty-eight recipients with functioning grafts reached their final height. They were transplanted at a mean age of 10.7 yr. Immunosuppressive therapy with CyA, MP, and MZ was started after transplantation. MP was reduced to an alternate-day dose in 49 patients and was withdrawn in 23. Their mean height SDS was -2.4 at the time of transplantation and -2.1 at their final height. Mean final height was 157.9 cm in men and 147.6 cm in women. In 18 patients who had been withdrawn from MP for more than two yr before reaching final height, mean age at transplantation was 8.9 yr. Their mean height SDS of -2.2 at the time of transplantation increased to -1.6 at their final height (p = 0.02), and mean final height was 163.8 cm in men and 147.8 cm in women. The height SDS in all 58 patients was maintained during the immunosuppressive therapy with steroid minimization, and final height SDS increased in recipients older than five yr at transplantation with steroid withdrawal.

Associations of proteinuria, fluid volume imbalance, and body mass index with circadian ambulatory blood pressure in chronic kidney disease patients.

BACKGROUND/AIMS: Obesity and hypervolemic status are the main causes of hypertension in patients with chronic kidney disease (CKD). However, it is difficult to differentiate between them. We aimed to assess the associations of body mass index (BMI) and total body water (TBW) with ambulatory blood pressure (ABP). METHODS: Body composition by bioelectrical impedance analysis (BIA) and 24-h ABP were measured in 40 patients with CKD. TBW was assessed using corrected TBWBIA adjusted for body surface area (cTBWBIA) and the TBWBIA/TBWWatson ratio obtained using an anthropometric formula (Watson). RESULTS: Elevated ABP (average 24-h BP ≥ 135/85 mmHg) was noted in 23 patients, who were more likely to have a higher cTBWBIA and TBWBIA/TBWWatson ratio than patients without elevated BP. Patients with nocturnal non-dipping (<10% drop in BP during sleep) were more likely to have a higher TBWBIA/TBWWatson ratio. Proteinuria and the TBWBIA/TBWWatson ratio were significant independent factors for 24-h ABP. BMI had a positive correlation with the cTBWBIA, TBWBIA/TBWWatson ratio and furosemide use. CONCLUSION: Hypertension is dependent on proteinuria and fluid volume imbalance. The TBWBIA/TBWWatson ratio can serve as an indicator of fluid volume-dependent hypertension. BMI is affected by TBW, in which case BMI can become less involved with 24-h ABP.

[Development of the coping scale for interpersonal stress events related to the goals of the coping].

This study developed the coping scale for interpersonal stress events, and evaluated its validity. This scale is composed of the following subscales based on the goals of the coping: problem-focused coping, emotion-focused behavioral coping, and emotion-focused cognitive coping. Based on previous research, a pilot study was used to construct scale items, considering the goals of coping to reduce measurement error. In study 1 (N=348), the validity of the scale was examined using several statistical analyses. Study 2 (N=182) and study 3 (N=161) report correlations between the coping scale for interpersonal stress events and several theoretically relevant scales. Based on these results, it was concluded that the scale and subscales are valid for measuring interpersonal stress coping.

Increased ACE and decreased ACE2 expression in kidneys from patients with IgA nephropathy.

BACKGROUND: Angiotensin-converting enzyme (ACE)2 forms angiotensin-1-7 which may protect kidney in a counterregulatory manner to angiotensin II. Recent studies revealed increased ACE and decreased ACE2 expression in kidneys of patients with diabetic nephropathy. However, these changes may not be specific for diabetic nephropathy. We studied ACE and ACE2 expression in patients with IgA nephropathy. METHODS: Renal ACE and ACE2 expression was assessed by immunohistochemistry and in situ hybridization in 30 patients with IgA nephropathy and 21 healthy controls. Correlation between ACE and ACE2 expression and levels of various biochemical parameters was also assessed. Gene expression was also assessed in minimal change nephrotic syndrome (MCNS) and membranous nephropathy (MN) as disease controls. RESULTS: Reduced ACE2 expression (p < 0.01) and increased ACE expression in glomeruli (p < 0.001), and reduced ACE2 expression in tubulointerstitium (p < 0.001) were observed in patients with IgA nephropathy compared to healthy controls, although the changes in ACE2 mRNA were not statistically significant. Reduced renal ACE2 expression was also found in MN but not in MCNS. Correlation between renal ACE and ACE2 expression and proteinuria was not observed in IgA nephropathy. CONCLUSION: IgA nephropathy is associated with increased ACE and decreased ACE2 expression in kidneys, as in diabetic nephropathy.

Risk of macrovascular disease stratified by stage of chronic kidney disease in type 2 diabetic patients: critical level of the estimated glomerular filtration rate and the significance of hyperuricemia.

BACKGROUND: Although a high prevalence of macrovascular disease (MVD) has been reported in patients with stage 3 chronic kidney disease (CKD), few studies have reported its risk with respect to the underlying cause of kidney disease. This study investigated the prevalence of MVD in type 2 diabetic patients with CKD stratified by CKD stage, as defined by estimated glomerular filtration rate (eGFR), as well as the risk factors for MVD. METHODS: 1493 patients with diabetic CKD (1273 males, 220 females) were stratified by CKD stage (stage 1: 39, stage 2: 272, stage 3: 1052, stage 4: 101, stage 5: 29) based on eGFR calculated by the Japanese formula and averaged over 8 months. MVD was defined as one of the following: coronary heart disease (CHD), stroke or arteriosclerosis obliterans (ASO). RESULTS: The prevalence of MVD was 18.6%. A significant increasing trend in MVD prevalence was observed from stage 3 (17.78%) to 4 (52.48%). According to a receiver operating characteristic curve analysis on MVD prevalence in stage 3 patients, an eGFR of 46.4 ml/min/1.73 m(2) was determined to be a critical cut-off level. Proteinuria, eGFR <60 ml/min/1.73 m(2) and hyperuricemia were independent risk factors for MVD. CONCLUSIONS: In patients with diabetic CKD, a significant increase in MVD prevalence was observed from stage 3 to 4. An eGFR of 46.4 ml/min/1.73 m(2) is a critical level that affects MVD prevalence. From the perspective of cardiorenal association, CKD stage 3 should be divided into two substages. As hyperuricemia is related to an increased risk of MVD, uric acid control may be important in reducing MVD risk in diabetic CKD.

Urinary angiotensin-converting enzyme 2 in patients with CKD.

AIM: Angiotensin-converting enzyme 2 (ACE2) is a type I membrane protein that antagonizes the action of angiotensin II. Because of the need for invasive kidney biopsy, little is known about the role of renal ACE2 in human kidney diseases. The authors studied if urinary ACE2 could provide a novel clue to renal ACE2 in chronic kidney disease (CKD). METHODS: Subjects were 190 patients with CKD including 38 patients with diabetic nephropathy and 36 healthy subjects. Parameters were urinary ACE2 by enzyme-linked immunosorbent assay, blood pressure, casual plasma glucose, proteinuria, microalbuminuria, serum creatinine and estimated glomerular filtration rate. Urine and serum samples were also subjected to western blotting of ACE2. RESULTS: Western blotting confirmed increased urinary ACE2 levels in patients with CKD. Urinary ACE2 was significantly higher in patients with CKD than healthy subjects (median 9.64 (interquartile range, 4.41-16.89) vs 1.50 (0.40-2.33) mg/g·creatinine, P < 0.001) and in patients with diabetic nephropathy than patients without diabetic nephropathy (median 13.16 (interquartile range 6.81-18.70) vs 8.90 (4.19-16.67) mg/g·creatinine, P < 0.05). No significant difference in urinary ACE2 was observed by the use of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker. CONCLUSION: Urinary ACE2 could be used as a non-invasive marker to understand the role of renal ACE2 in CKD.

Reappraisal of proteinuria and estimated GFR to predict progression to ESRD or death for hospitalized chronic kidney disease patients.

BACKGROUND: Despite the high prevalence of chronic kidney disease (CKD) in the general population, few CKD patients progress to end-stage renal disease (ESRD). Adding the criterion of proteinuria to the CKD classification could improve screening and therapeutic strategies. METHOD: We analyzed data from 5122 inpatients who were admitted to our hospital from 2002 to 2003 to survey prevalence of kidney insufficiency, renal survival, mortality, and blood pressure during hospitalization. RESULTS: Among 999 (19.5%) patients with proteinuria of 2+ or more or eGFR under 60 (mL/min/1.73 m(2)), 56 (9.0%; 95% CI, 6.7-11.4) patients progressed to ESRD (false positive (FP) rate: 18.6%; likelihood ratio (LR): 5.28) and 246 (28.4%; 95% CI, 25.3-31.5) patients died at 5 years. Restricting the focus to patients with proteinuria of 2+ or more or eGFR under 30 reduced the optimal participants by 12.0%, identified 48 (12.4%; 95% CI, 9.0-15.8) patients progressing to ESRD with rising predictive power (FP rate: 11.2%; LR: 7.52) and 162 (29.6%; 95% CI, 25.6-33.5) patients died. The predictors for ESRD were the baseline kidney dysfunction with higher levels of proteinuria, hypertension, and older age. The predictors for death were proteinuria, hypotension, older age, and male. The risk for ESRD differed by levels of proteinuria even though eGFR were in the same levels. In the older CKD inpatients with fewer levels of proteinuria, mortality was raised rather than the rate of the progression to ESRD. CONCLUSIONS: Reappraisal by combining proteinuria and eGFR improves prediction of ESRD or death.