Strategic plan for integrated care of patients with kidney failure.

There is a huge gap between the number of patients worldwide requiring versus those actually receiving safe, sustainable, and equitable care for kidney failure. To address this, the International Society of Nephrology coordinated the development of a Strategic Plan for Integrated Care of Patients with Kidney Failure. Implementation of the plan will require engagement of the whole kidney community over the next 5-10 years.

Socioeconomic Status: The Missing Link Between Obesity and Diabetes Mellitus?

BACKGROUND: Currently, there is an epidemic expansion of obesity rates worldwide. The increasing number of obese individuals associated with the aging of population leads to increasing number of individuals with type 2 diabetes mellitus (T2DM) at the same rate. The traditional factors that link obesity to T2DM are related to genetics, hypercaloric diet, sedentary lifestyle, and stress. Individuals from lower Socioeconomic Status (SES) have restricted autonomy and opportunities that could lead to more stress and consequently increase in stress hormones, such as cortisol, catecholamines, glucagon, and growth hormone, which might ultimately change fat deposition, increasing visceral fat and increasing the risk of T2DM development. METHODS: We conducted a review of the literature on the effects of low SES and the risk of developing T2DM in obese persons. RESULTS: 191 studies were found. The obesity of lower SES individuals is more central than that for individuals from higher socioeconomic position. It is also proposed that the quality of food seems to be lower, with more intake of fat and simple carbohydrates and less of fruits, vegetables and whole wheat bread, in the more disadvantaged social classes. The lower income neighborhoods, without exercise facilities and unsafety are also associated with higher indices of physical inactivity. Cross sectional and prospective studies confirm the relationship between lower socioeconomic status and obesity and diabetes. The lower SES is associated to metabolic implications that are linked to insulin resistance and possibly may also interfere with the ability of beta cell to secrete insulin and change the gut microbiota, increasing even more the future risk of developing diabetes.

Neck Circumference and its Correlation to Other Anthropometric Parameters and Finnish Diabetes Risk Score (FINDRISC).

BACKGROUND: The Neck Circumference (NC) is an anthropometric measure to evaluate obesity. The FINDRISC predicts the risk of developing type 2 diabetes mellitus. Our aims were to identify the mean value of NC in individuals with higher (≥15 points) and lower FINDRISC and to establish cutoff values that indicate individuals with higher FINDRISC. METHODS: It is a population-based, cross-sectional study representative of the city of Curitiba, Brazil. We studied individuals (>18 years), without diabetes mellitus, between August 2013 and August 2014. We evaluated anthropometric parameters, glycaemia, socioeconomic situation, chronic conditions, and their risk factors. In a sex-specific analysis, data are presented as mean and standard deviation. We performed Pearson's and Spearman's correlation between NC and the waist circumference, body mass index and FINDRISC. Receiver Operating Characteristic curves were estimated for NC and higher FINDRISC. Logistic regression models were built to analyze the association between higher FINDRISC and 1-SD increase in NC. RESULTS: We studied 950 individuals (621 women) with a mean age of 47.4 ± 17.6 years and body mass index of 26.2 ± 5.6 kg/m2. The mean NCs were 34.1 ± 3.1 cm in women and 38.2 ± 3.5 cm in men. Mean NC was lower in women (33.7 ± 2.9 cm vs. 35.8 ± 3.2 cm) and men (37.7 ± 3.4 cm vs. 41 ± 3.6 cm) with lower FINDRISC (p <0.001). All the correlations with NC were significant (p ≤ 0.001). The area under the curve for NC and the higher FINDRISC was 0.702 (95% CI 0.653 - 0.752) for women and 0.762 for men (95% CI 0.679 - 0.845), determining the best cutoff value of 34.5 cm for women and 39.5 cm for men to discriminate individuals with higher FINDRISC. Fully adjusted odds ratios for higher FINDRISC per 1-SD increase in NC in women and men were, respectively 1.89 (95% CI 1.53 - 2.33) and 2.86 (95% CI 1.91 - 4.29). CONCLUSION: NC is positively correlated to the body mass index, waist circumference, glycaemia, and FINDRISC scores in a population-based sample of adults. We identified the mean values of NC in higher and lower FINDRISC and established cutoff values for NC and higher FINDRISC.

Carotid intima-media thickness and carotid plaque represent different adaptive responses to traditional cardiovascular risk factors.

AIM: To assess the effects of each traditional cardiovascular risk factor (hypertension, diabetes mellitus, dyslipidemia, and smoking), including the presence of coronary artery disease (CAD), on carotid intima-media thickness (CIMT) and to assess the degree of carotid plaque occurrence. METHODS: A total of 553 outpatients (216 men and 337 women; mean age 67.06 ± 12.44 years) who underwent a carotid artery ultrasound were screened for carotid plaque and CIMT measurements. RESULTS: The CIMT medians were higher in males (P < .001) and in patients with hypertension (P < .001). A linear increase occurred in mean CIMT of 0.0059 mm for each year of increase in age. The presence of plaque indicated a tendency to correlate with CIMT (P = .067). The presence of hypertension associated with diabetes (P = .0061; estimated difference 0.0494 mm) or dyslipidemia (P = .0016; estimated difference 0.0472 mm) or CAD (P = .0043; estimated difference 0.0527 mm) increased the mean CIMT measurements. The probability of plaque occurrence in carotid arteries is influenced by the age (P < .001) and is higher in patients with dyslipidemia (P = .008) and CAD (P < .001). CONCLUSIONS: Hypertension is the strongest cardiovascular risk factor that increases CIMT, followed by age and male sex. Age and dyslipidemia increase the probability of carotid plaque. Increased CIMT and plaque could be present in the same patient caused by different risk factors and with independent effects on the artery wall and different clinical prognoses.

C.E.R.A. maintains stable hemoglobin in Latin American patients on dialysis.

BACKGROUND: C.E.R.A. is a continuous erythropoietin receptor activator with characteristics that permit a once-monthly schedule of administration for the maintenance treatment for chronic kidney disease (CKD) patients. The main objective of this study was to assess the maintenance of Hb concentration with once-monthly intravenous and/or subcutaneous C.E.R.A. therapy in Latin American dialysis patients with chronic renal anemia previously treated with epoetin alfa s.c or i.v 1-3 times per week. METHODS: This was a single-arm, open-label, multicenter, 32-week study of anemic patients with CKD previously treated with epoetin alfa sc or iv 1-3 times per week. After a 4-week screening period, during which mean Hb levels were maintained between 10.5 and 12.5 g/dL on their previous erythropoiesis stimulating agent, eligible patients entered a 16-week C.E.R.A. dose titration period followed by a 4-week efficacy evaluation period (EEP) and a 28-week safety follow-up. The starting dose of C.E.R.A. was based on the previous dose of epoetin alfa. Doses of C.E.R.A. were then adjusted to maintain Hb levels within ±1.0 g/dL of the reference concentration and between 10.5 and 12.5 g/dL. The Hb reference concentration was defined as the mean of all Hb levels during screening. The primary end point was the proportion of patients maintaining a mean Hb concentration (g/dL) within ±1 g/dL of their reference Hb and between 10.5 and 12.5 g/dL during the EEP. RESULTS: A total of 163 patients from 27 centers in Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, Peru, Uruguay, and Venezuela entered the treatment period and 102 completed the prescribed course of C.E.R.A. Forty-five patients (43.7 %) maintained a mean Hb concentration within ±1 g/dL of their reference Hb value and between 10.5 and 12.5 g/dL during the EEP. The median monthly dose remained constant at 120 µg during the titration period and during the EEP. On the average, there were only 2.3 dose changes per patient in 28 weeks of treatment, covering 7 C.E.R.A. scheduled administrations. 53 % of all dose changes were dose decreases, 47 % increases. A total of 10 AEs and 4 SAEs were considered to be related to the study treatment. CONCLUSIONS: Once-monthly C.E.R.A. treatment effectively maintains stable Hb concentrations in patients with chronic renal anemia undergoing dialysis with a good safety and tolerability profile.