Decline in estimated glomerular filtration rate is associated with risk of end-stage renal disease in type 2 diabetes with macroalbuminuria: an observational study from JDNCS.

BACKGROUND: There is increased interest in surrogate endpoints for clinical trials of chronic kidney disease. METHODS: In this nationwide observational study of 456 patients with type 2 diabetes and clinically suspected diabetic nephropathy followed for a median of 4.2 years, we evaluated the association between estimated glomerular filtration rate (eGFR) and albuminuria at baseline or during follow-up and risk of ESRD. RESULTS: Low eGFR (<60 mL/min/1.73 m2) and macroalbuminuria at enrollment were independently associated with risk of ESRD. In patients with macroalbuminuria, both ≤-50% change and -50 to -30% change in eGFR over 1 and 2 years were predictive of ESRD. The higher cut point (≥50% decline in eGFR) was more strongly predictive but less common. Remission of macroalbuminuria to normo-/microalbuminuria at 1 and 2 years was associated with a lower incidence of ESRD than no remission; however, it was not a determinant for ESRD independently of initial eGFR and initial protein-to-creatinine ratio. CONCLUSION: These results suggest that a ≥30% decline in eGFR over 1 or 2 years adds prognostic information about risk for ESRD in patients with type 2 diabetes and macroalbuminuria, supporting the consideration of percentage decline in eGFR as a surrogate endpoint among macroalbuminuric cases in type 2 diabetes. On the other hand, our study suggests that additional analyses on the relationship between remission of macroalbuminuria and risk of ESRD are needed in type 2 diabetes.

[Current status of and regional differences in CKD management and medical cooperation in Japan: from the results of a nationwide questionnaire survey for primary care physicians].

OBJECTIVE: The goal of this study was to figure out the current status of and regional differences in CKD management and medical cooperation in Japan. METHODS: We conducted a nationwide questionnaire survey on CKD management for primary care physicians (PCPs) from December 2012 to March 2013. The questionnaire included 36 items about CKD management and medical cooperation. In order to compare the current status of CKD care and cooperation, we divided the country into 11 areas; Hokkaido, Tohoku, Kanto, Koshin-etsu, Hokuriku, Chubu-Tokai, Kinki, Chugoku, Shikoku, Kyushu and Okinawa. RESULTS: 28,200 sets of questionnaires were delivered to PCPs throughout Japan, and 2,287 (8.1%) doctors responded. Doctors at clinics accounted for 86.5%, and 90.9% were non-nephrologists. Regional differences were evident in the following items regarding CKD management; urinalysis at the first examination, measurement of urinary protein/albumin excretion, frequency of blood testing, counselling with eGFR, prescription of erythropoiesis stimulating agents (ESA). Urinalysis at the first examination was relatively rare in Koshin-etsu and Kanto (p < 0.01), and counseling with eGFR was relatively rare in Tohoku, Shikoku and Koshin-etsu (p = 0.05). Regional differences regarding medical cooperation were evident in the following items; functional level of cooperation, critical path, presence of consulting nephrologist, personal relationship, satisfaction with the nephrologists' reaction to referral, CKD involvement in Specific Medical Checkup/Specific Medical Guidance. Functional level of cooperation was higher in Chugoku, Okinawa, Chubu-Tokai and Hokuriku, and lower in Shikoku, Koshin-etsu and Kinki (p < 0.05). Serum creatinine measurement in the Specific Medical Checkup was involved more frequently in Okinawa, Shikoku, Kanto, Chubu-Tokai, Kyushu and Hokuriku, and less frequently in Tohoku, Chugoku and Kinki (p < 0.01). CONCLUSION: We elucidated the current status of CKD management by PCPs and medical cooperation in Japan. Effective actions to improve CKD care must be proposed on the basis of these data, especially the existing regional differences.

[Influence of physicians' subspecialty and training history on CKD management and medical cooperation: from the results of a nationwide questionnaire survey for primary care physicians].

OBJECTIVE: The goal of this study was to elucidate how the subspecialty and training history of primary care physicians(PCPs) influence CKD management and medical cooperation in Japan. METHODS: We conducted a nationwide questionnaire survey on CKD management for PCPs from December 2012 to March 2013. The questionnaire included 32 items about CKD management and medical cooperation. PCPs' subspecialties were categorized as follows: general internal medicine, nephrology, cardiology, diabetology/endocrinology, gastroenterology, pulmonology, neurology, neurosurgery, hematology, collagen disease/rheumatology, allergology. The PCPs' training history of nephrology was classified into three categories: none, experienced, active-nephrologist. Response distributions for each question were compared between the PCPs' subspecialties and the three categories of training history. RESULTS: 2,287 out of 28,200 PCPs (8.1%) of all 47 prefectures responded. The majority (86.5%) of responders were PCPs at clinics, and 90.9% were non-nephrologists. The PCPs' subspecialty influenced the response distributions in the following questions: utilization of the CKD guidebook, urinalysis at the first and follow-up examinations, frequency of blood testing, counselling with eGFR, self-monitoring of blood pressure, prescription and cessation of renin-angiotensin system (RAS) inhibitors, anemia treatment with erythropoiesis stimulating agents (ESA). The PCPs' training history of nephrology had a strong impact on various aspects of CKD management. The PCPs' subspecialties also influenced the responses regarding medical cooperation of CKD: relationship with nephrologists, utilization of critical path, criterion of patient referral, requests for nephrologists, discontent with the nephrologists' response. CONCLUSION: We elucidated that the PCPs' subspecialty and training history of nephrology substantially influenced CKD management and medical cooperation in Japan. Effective promotion activities to improve CKD management and medical cooperation should be proposed on the basis of these data.

[Seven cases of remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome].

Among the elderly patients with seronegative polyarthritis, McCarty et al. (1985) proposed a disease entity of "remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome", but only a few cases have been reported in Japan. Here we report 7 cases suspicious of RS3PE syndrome, 2 men and 5 women with an average age of 75.9 years, ranging from 67-82 years. Their common findings were (1) relatively acute onset, (2) polyarthritis, (3) pitting edema of the dorsum of both hands and both feet, and (4) negative rheumatoid factor and antinuclear antibody. McCarty et al. found that RS3 PE syndrome was more prevalent in men; however, in our experience, the opposite was observed. The clinical courses of all patients were good, and they were effectively treated either by small dosages of oral prednisolone, nonsteroidal antiinflammatory drugs, or Chinese herbal (Kampo) medicines. Since this syndrome might not be rare in Japan, it seems necessary to evaluate elderly patients with seronegative polyarthritis with pitting edema as RS3PE syndrome in their routine medical examinations.