Major adverse kidney events in multidisciplinary chronic kidney disease care compared with usual outpatient care: a propensity score matched analysis.

BACKGROUND: Chronic kidney disease (CKD) is a public health problem worldwide. Multidisciplinary care has been recommended in clinical practice to delay disease progression and minimize complications. However, the effectiveness of multidisciplinary care on major adverse kidney events in CKD patients is still inconclusive. METHODS: We conducted a cohort study in patients with CKD stages G3b to 4 who were followed up at Bhumibol Adulyadej Hospital from 2014 to 2020. Propensity score matching by age, sex, CKD staging, Diabetes Mellitus (DM), blood pressure and rate of estimated Glomerular Filtration Rate (eGFR) decline before inclusion between patients in multidisciplinary CKD care (MDC) and usual outpatient care (UOC) was performed. The primary outcome was a composite of cardiovascular or renal mortality, 40% eGFR decline and initiation of long-term kidney replacement therapy. RESULTS: After 1:1 propensity score matching, 822 patients were included. Mean age was 70.9 years, 64% had diabetes. During the mean follow-up of 3.3 years, rate of reaching the primary endpoint was lower in the multidisciplinary CKD care group than in the usual outpatient care group (24.1% vs. 38.9%; hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.52-0.86; P = 0.002). The multidisciplinary CKD care group benefited more than the usual outpatient care group with regard to 40% eGFR decline (21.7% vs. 35.0%; HR, 0.67; 95%CI 0.52-0.88; P = 0.004), all-cause mortality (8.5% vs. 19.5%; HR, 0.60; 95%CI 0.40-0.90; P = 0.014), non-cardiovascular death (6.1% vs. 15.1%; HR, 0.56; 95%CI 0.35-0.90; P = 0.015) and hospitalizations per year (1.0 ± 1.5 vs. 1.6 ± 2.0; P < 0.001). According to subgroup analysis, diabetes mellitus patients benefited the most from multidisciplinary CKD care. CONCLUSIONS: In a tertiary care hospital, multidisciplinary CKD care showed benefits over usual outpatient care on kidney outcomes in patients with CKD stages G3b and 4. The benefit was enhanced in DM patients.

Safety and efficacy of proactive versus reactive administration of desmopressin in severe symptomatic hyponatremia: a randomized controlled trial.

This randomized controlled trial aimed to evaluate the safety and efficacy of proactive versus reactive desmopressin (DDAVP) strategies in treating severe symptomatic hyponatremia. Conducted from June 20, 2022, to February 20, 2023, it involved 49 patients with serum sodium levels below 125 mmol/L. Patients were assigned to either the proactive group, receiving DDAVP immediately upon diagnosis, or the reactive group, receiving DDAVP only if the serum sodium level tended to be overcorrected. The primary outcome was the incidence of overcorrection. The study revealed no significant difference in the overcorrection incidence between the proactive (16.7%) and reactive (28%) groups (p = 0.54). The change in serum sodium levels at 1, 6, 12, and 24 h were not different, however, at 48 h, the proactive group exhibited a higher but still safe change in serum sodium levels compared to the reactive group (10.3 ± 3.6 mmol/L vs. 7.7 ± 3.6 mmol/L, p = 0.013). Other parameters including time to symptom improvement, total intravenous fluid administered, DDAVP dose, urine volume, hospital stay duration, osmotic demyelination syndrome incidence, and 28-day mortality did not significantly differ between the groups. In conclusion, our findings suggest that there was no significant disparity in overcorrection rates between proactive and reactive DDAVP strategies for treating severe symptomatic hyponatremia. However, further large-scale studies are warranted to validate these results.

The hidden financial catastrophe of chronic kidney disease under universal coverage and Thai "Peritoneal Dialysis First Policy".

Objective: Universal health coverage can decrease the magnitude of the individual patient's financial burden of chronic kidney disease (CKD), but the residual financial hardship from the patients' perspective has not been well-studied in low and middle-income countries (LMICs). This study aimed to evaluate the residual financial burden in patients with CKD stage 3 to dialysis in the "PD First Policy" under Universal Coverage Scheme (UCS) in Thailand. Methods: This multicenter nationwide cross-sectional study in Thailand enrolled 1,224 patients with pre-dialysis CKD, hemodialysis (HD), and peritoneal dialysis (PD) covered by UCS and other health schemes for employees and civil servants. We interviewed patients to estimate the proportion with catastrophic health expenditure (CHE) and medical impoverishment. The risk factors associated with CHE were analyzed by multivariable logistic regression. Results: Under UCS, the total out-of-pocket expenditure in HD was over two times higher than PD and nearly six times higher than CKD stages 3-4. HD suffered significantly more CHE and medical impoverishment than PD and pre-dialysis CKD [CHE: 8.5, 9.3, 19.5, 50.0% (p < 0.001) and medical impoverishment: 8.0, 3.1, 11.5, 31.6% (p < 0.001) for CKD Stages 3-4, Stage 5, PD, and HD, respectively]. In the poorest quintile of UCS, medical impoverishment was present in all HD and two-thirds of PD patients. Travel cost was the main driver of CHE in HD. In UCS, the adjusted risk of CHE increased in PD and HD (OR: 3.5 and 16.3, respectively) compared to CKD stage 3. Conclusions: Despite universal coverage, the residual financial burden remained high in patients with kidney failure. CHE was considerably lower in PD than HD, although the rates remained alarmingly high in the poor. The "PD First' program" could serve as a model for other LMICs. However, strategies to minimize financial distress should be further developed, especially for the poor.

Diagnostic accuracy of fibroblast growth factor 23 for predicting acute kidney injury in patients with acute decompensated heart failure.

BACKGROUND: Elevated plasma levels of fibroblast growth factor 23 (FGF23) have emerged as a predictor for the development of acute kidney injury (AKI) in patients undergoing cardiac surgery and those with critical illnesses. However, accurate data in cases involving acute decompensated heart failure (ADHF) remains limited. METHODS: Single centre cohort study was performed in patients admitted for ADHF. Plasma c-terminal FGF23 (c-FGF23) was measured at baseline and 24 hours after being diagnosed with ADHF. AKI was defined by KDIGO 2012 criteria. RESULTS: The study enrolled 62 patients diagnosed with ADHF. The incidence of AKI was 45% and significantly increased the risk of death. Patients developing AKI had significantly higher levels of plasma c-FGF23 at baseline in comparison with those not developing AKI [median value 1258.5 (57.2, 15 850) vs 230.2 (68.515 850) RU/mL, P = .005]. During the first 24 hours, plasma c-FGF23 levels decreased in both groups, and the levels of c-FGF23 at 24 hours were consistent with the baseline [861.8 (75.7, 15 850) vs 226.3 (56, 5450.8) RU/mL, P = .006]. Receiver operating characteristic analysis of both first time and second time for plasma c-FGF23 collection yielded an area under curve of 0.71 for the prediction of AKI incidence. With the cut-off point at 450 RU/mL, the sensitivity and specificity of plasma c-FGF23 at the baseline for predicting AKI were 71.4% and 61.8% respectively. CONCLUSION: Plasma c-FGF23 may serve as a novel biomarker for development of AKI in patients with ADHF. These results should be revalidated in larger-scale, cohort studies.

Prevalence of and Predictive Factor for Abdominal Aortic Calcification in Thai Chronic Kidney Disease Patients.

Presence and severity of cardiovascular calcifications strongly predict cardiovascular morbidity and mortality in patients with CKD. This multicenter, cross-sectional study primarily aimed to determine prevalence of abdominal aortic calcification (AAC) detected by plain lateral abdominal radiograph, and secondarily aimed to assess predictive factors for AAC. Patients (N = 1500), aged 18-70 years, with CKD stages 3-5D for ≥3 months prior to evaluation, were enrolled at 24 study centers in Thailand; 54.3% were non-dialysis patients. The prevalence of AAC was 70.6% and 70.8% in non-dialysis and dialysis patients, respectively. Patient's advanced age and widening pulse pressure were identified as predictive factors for AAC ≥ 5 in non-dialysis patients, while patient's age, history of coronary heart disease or diabetes, longer dialysis vintage, and increasing corrected serum calcium or high-sensitivity C-reactive protein were identified as such in dialysis patients. With additional regression having covariates in binary, corrected serum calcium ≥9.5 mg/dL gave an OR 1.974 (95% CI: 1.324-2.943) for AAC ≥ 5 among the dialysis patients. AAC in diabetes subgroup (N = 692) was additionally evaluated and found that it was prevalent at 84.7% with increased phosphorus as predictive factor (OR, 1.178; 95% CI: 1.032-1.344) and 1,25 (OH)2 vitamin D as protective factor (OR, 0.983; 95% CI, 0.970-0.996). The prevalence of AAC in the Thai CKD population is lower than that reported in the literature, and yet the burden is prominent in patients coexisting with diabetes. Variable relationships identified in this study may guide preventive measures against cardiovascular complications in CKD patients.

Efficacy of low-dose cinacalcet on alternate days for the treatment of secondary hyperparathyroidism in hemodialysis patients: a single-center study.

INTRODUCTION: Cinacalcet is effective in reducing serum parathyroid hormone (PTH) in patients with secondary hyperparathyroidism (HPT). This study focused on testing whether a prescription of low-dose cinacalcet on alternate days could be an option for treatment of secondary HPT. MATERIALS AND METHODS: A retrospective clinical study was conducted on chronic maintenance hemodialysis patients. Patients with secondary HPT who received cinacalcet at a starting dose of 25 mg on alternate days were reviewed (low-dose group). Patients who were being treated with a standard dose of cinacalcet in the same period of time were selected as the control group. The primary outcome was difference in the percentage of patients achieving >30% reduction of intact parathyroid hormone (iPTH) levels at 16 weeks. The changes of serum iPTH and other biochemical data were also tested. RESULTS: A total of 30 patients (16 low doses and 14 controls) took part in the study. Baseline iPTH levels in the low-dose and control group were 1,065.9±477.7 and 1,214.1±497.6 pg/mL, respectively (p=0.413). The analysis showed that the percentage of patients who achieved the primary outcome showed little or no difference (33.3% in the low-dose group compared with 38.5% in the control group, p=1.0). Serum iPTH reduction during 16 weeks of study period in the low-dose and control group was 253.5±316.1 and 243.4±561.3 pg/mL, respectively (p=0.957). There was no difference in the adverse events between both groups. CONCLUSION: Among patients with secondary HPT, initial treatment with cinacalcet 25 mg on alternate days can decrease serum PTH levels. The role of low-dose cinacalcet in secondary HPT should be further determined in large-scale, randomized controlled trials.

Metabolic Syndrome in Thai Renal Transplant Recipients: A Multicenter Study.

BACKGROUND Many renal transplant recipients develop complications such as obesity, posttransplantation diabetes mellitus, and dyslipidemia. There have been few studies of metabolic syndrome (MS) in Asian renal transplant recipients. MATERIAL AND METHODS This cross-sectional study was performed in 303 patients in 5 transplant centers in Bangkok, Thailand. The diagnosis of MS was based on the criteria of the modified NCEP-ATPIII, and chronic allograft dysfunction was defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m^2. RESULTS Of 303 recipients, MS was diagnosed in 94 cases (31.0%) and the prevalence of MS in the first 3 years and after 3 years posttransplantation were 21.4% and 34.7% (P=0.042), respectively. There was an association between advanced age and chronic allograft dysfunction and higher prevalence of MS. Regarding non-anti-hypertensive and non-hypoglycemic medications, m-TOR inhibitor (odds ratio [OR], 2.14; 95% CI, 1.02-4.5) was associated with the prevalence of MS. Multivariate analysis revealed MS was associated with the use of beta-blockers (OR, 3.17; 95% CI, 1.88-5.32). Patients with no MS components had 26.9% prevalence of chronic allograft dysfunction and patients with higher numbers of MS components had 87.5% prevalence of chronic allograft dysfunction, which was significantly different (P=0.022). CONCLUSIONS Our study revealed that the prevalence of MS was higher in patients with higher numbers of MS components, especially after 3 years posttransplantation. Presence of more components of MS was associated with worse renal function in renal transplant recipients.

Prevalence trend of renal replacement therapy in Thailand: impact of health economics policy.

OBJECTIVE: The national health insurance fund in Thailand initiated by the national health security act in November, 2002. In October 2007, the national health insurance fund launched the first renal replacement therapy (RRT) reimbursement plan by the "Peritoneal Dialysis-First" (PD First) policy. The rationale of the PD First Policy resulted from the perspective that PD for end stage renal disease (ESRD) treatment offers the most economic and efficient outcome. The present study was conducted to determine whether the increase of RRT penetration by national health policy could impact the national RRT prevalence. MATERIAL AND METHOD: The Thailand Renal Replacement Therapy (TRT) database in 2007, 2008, and 2009 were retrieved and analyzed. RESULTS: By TRT registry data, the total yearly prevalence of RRT increased by an average of 14.8% after the implementation of national health insurance and the "PD First" policy from 2007 to 2009. The total yearly prevalence of hemodialaysis (HD) modestly increased (14.7%) while the total yearly prevalence of PD remarkably expanded by 107.3%. The yearly incidence of all RRT modalities increased by an average of 34.8% in 2007 to 2009. The yearly incidence of HD modestly increased (8.1%) while the total yearly incidence of PD remarkably elevated by 157.8%. Civil Servants Medical Benefit Compensation (CSMBS) was the major funding source of RRT cases (34.5%) while national health insurance funding was the second major funding source (26.0%). From 2007-2009, the CSMBS funding was the majority of HD while national health insurance funding was the majority of PD. The sharing of PD by national health insurance increased from 33.9% in 2007, 58.6% in 2208, and 77.2% in 2009. CONCLUSION: The coverage ofESRD patients by national health insurance fund by the "PD First" policy impacted the RRT prevalence and incidence both the total prevalence and total incidence due to the universal penetration to RRT treatment of Thai population. Also, the policy altered the RRT modality predisposition. PD modality willfinally be the majority ofThaiRRT modalities if the policy can be managed successfully.

The changing profile of PD-related peritonitis in Thailand: a single centers experience.

OBJECTIVE: The percentage of utilizing peritoneal dialysis (PD) in Thailand was increased dramatically since the implementation of PD-First policy in 2008. However, peritonitis remains a major obstacle to achieve success of this modality. The aim of the present study, was to assess the clinical characteristics of PD peritonitis in the PD-first policy era. MATERIAL AND METHOD: The PD peritonitis patients in Bhumibol Adulyadej Hospital between October 2008 and December 2010 were reviewed. Microbiological diagnosis, treatment responses, technique, and patient survival were analyzed. RESULTS: Since October 2008, 93 peritoneal dialysis patients were followed-up in Bhumibol Adulyadej Hospital including 75 new cases. During the present study period of 1,560 patient-months, 51 episodes of peritonitis from 33 cases were recorded and analyzed. The mean age of the peritonitis patients was 57.9 +/- 16.1 years and 63.6% were females. The most common isolates were gram negative organisms (33.3%) followed by gram positive (17.6%) and fungi (5.9%). Nocardiosis was diagnosed in 1 patient. However, 43.1% of episodes were culture-negative peritonitis. Treatment of peritonitis resulted in a complete cure in 74.5% of patients while 7.8% of patients required catheter removal, and 17.6% died. Event-free survival was better in gram positive organisms (43.3 months) compared with those infected with gram negative (26.8 months) and culture negative peritonitis (16.1 months). CONCLUSION: The proportions of peritonitis due to gram negative organisms were increased and associated with less favorable outcome. These findings suggest that it is necessary to prepare the appropriate protocol for prevention and treatment of PD peritonitis under national PD-First policy scheme.

A simplified clinical prediction score of chronic kidney disease: a cross-sectional-survey study.

BACKGROUND: Knowing the risk factors of CKD should be able to identify at risk populations. We thus aimed to develop and validate a simplified clinical prediction score capable of indicating those at risk. METHODS: A community-based cross-sectional survey study was conducted. Ten provinces and 20 districts were stratified-cluster randomly selected across four regions in Thailand and Bangkok. The outcome of interest was chronic kidney disease stage I to V versus non-CKD. Logistic regression was applied to assess the risk factors. Scoring was created using odds ratios of significant variables. The ROC curve analysis was used to calibrate the cut-off of the scores. Bootstrap was applied to internally validate the performance of this prediction score. RESULTS: Three-thousand, four-hundred and fifty-nine subjects were included to derive the prediction scores. Four (i.e., age, diabetes, hypertension, and history of kidney stones) were significantly associated with the CKD. Total scores ranged from 4 to 16 and the score discrimination was 77.0%. The scores of 4-5, 6-8, 9-11, and ≥ 12 correspond to low, intermediate-low, intermediate-high, and high probabilities of CKD with the likelihood ratio positive (LR+) of 1, 2.5 (95% CI: 2.2-2.7), 4.9 (95% CI: 3.9 - 6.3), and 7.5 (95% CI: 5.6 - 10.1), respectively. Internal validity was performed using 200 repetitions of a bootstrap technique. Calibration was assessed and the difference between observed and predicted values was 0.045. The concordance C statistic of the derivative and validated models were similar, i.e., 0.770 and 0.741. CONCLUSIONS: A simplified clinical prediction score for estimating risk of having CKD was created. The prediction score may be useful in identifying and classifying at riskpatients. However, further external validation is needed to confirm this.

Prevalence and risk factors of microalbuminuria in Thai nondiabetic hypertensive patients.

PURPOSE: To assess the prevalence and risk factors of microalbuminuria in nondiabetic hypertensive patients in Thailand. PATIENTS AND METHODS: A cross-sectional study was performed during January to December 2007 at outpatients departments of Bhumibol Adulyadej hospital. Nondiabetic hypertensive patients without a history of pre-existing kidney diseases participated in this study. A questionnaire was used for collecting information on demographics, lifestyle, and family history of cardiovascular and kidney disease. Spot morning urine samples were collected for albuminuria estimation. Albuminuria thresholds were evaluated and defined using albumin-creatinine ratio (ACR). RESULTS: A total of 559 hypertensive patients (283 males, 276 females), aged 58.0 +/- 11.6 years were enrolled in this study. Microalbuminuria (ACR 17 to 299 mg/g in males and 25 to 299 mg/g in females) was found in 93 cases (16.6%) [15.0%-18.2%]. The independent determinants of elevated urinary albumin excretion in a multiple logistic regression model were; body mass index > or =30 (odds ratio (OR) = 2.24, 95% confidence intervals (CI): 1.33-3.76) and dihydropyridine calcium channel blockers (DCCB) use (OR = 1.92, 95% CI: 1.22-3.02). CONCLUSION: In Thai nondiabetic hypertensive patients, microalbuminuria was not uncommon. Obesity and use of dihydropyridine calcium channel blocker were found to be the important predictors. Prognostic value of the occurrence of microalbuminuria in this population remains to be determined in prospective cohort studies.

Prevalence and risk factors of chronic kidney disease in the Thai adult population: Thai SEEK study.

BACKGROUND: Previous reports of chronic kidney disease (CKD) prevalence in Thailand varied from 4.3% to 13.8%. However, there were methodological concerns with these reports in terms of generalization and the accuracy of estimation. This study was, therefore, conducted to determine CKD prevalence and its risk factors in Thai adult populations. METHODS: The population-based Thai Screening and Early Evaluation of Kidney Disease (SEEK) study was conducted with cross-sectional stratified-cluster sampling. Serum creatinine was analysed using the modified Jaffe method and then standardized with isotope dilution mass spectrometry. RESULTS: The study included 3,459 subjects were included in the study. The mean age was 45.2 years (SE = 0.8), and 54.5% were female. Six hundred and twenty-six subjects were identified as having CKD, which evidenced an overall CKD prevalence of 17.5% [95% confidence interval (95% CI) = 14.6-20.4%]. The CKD prevalence of Stages I, II, III and IV were 3.3% (95% CI = 2.5%, 4.1%), 5.6% (95% CI = 4.2%, 7.0%), 7.5% (95% CI = 6.2%, 8.8%) and 1.1% (95% CI = 0.7%, 1.5%), respectively. The prevalence of CKD was higher in Bangkok, the Northern and Northeastern regions than in the Central and Southern regions. Seven factors (i.e. age, gender, diabetes, hypertension, hyperuricaemia, history of kidney stones and the use of traditional medicines) were associated with CKD. Only 1.9% of the subjects were aware that they had CKD. CONCLUSIONS: CKD prevalence in the Thai population is much higher than previously known and published. Early stages of CKD seem to be as common as later stages. However, albuminuria measurement was not confirmed and adjusting for persistent positive rates resulted in the prevalence of 14.4%. Furthermore, the awareness of CKD was quite low in the Thai population.

Continuous veno-venous hemofiltration in Bhumibol Adulyadej Hospital.

OBJECTIVE: Continuous veno-venous hemofiltration (CVVH) is a mode of renal replacement therapy in critically ill patients that has gained popularity all over the world. The authors reviewed one-year experience with CVVH in intensive care units (ICUs) of Bhumibol Adulyadej Hospital. The objectives of this study were to describe the characteristics of the patients and demonstrate the association between various factors and outcome. MATERIAL AND METHOD: The medical records of 45 patients who underwent CVVH treatment were analyzed. All patients had been admitted into the ICUs of Bhumibol Adulyadej Hospital between 1 January 2005 and 31 December 2005. RESULTS: Average age of patients was 67.7 +/- 13.3 years (range from 27.0 years to 88.4 years). The male: female ratio was 1.4:1. Twenty-four patients were admitted to the medical ICU, 17 to the coronary care unit (CCU) and 4 to the surgical ICU. All of them needed mechanical ventilator support and 91.1% required vasopressor. Sixty percent of the patients had sepsis. Most of them had comorbidity including, cardiovascular (66.7%), hepatobilliary (35.6%) and neurological comorbidity (13.3%). Half of them had been diagnosed with chronic kidney disease (CKD) with pre-dialysis CKD in 40% and end stage renal disease (ESRD) in 11.1%. The mean number of organ failure was 3.18 +/- 0.1 and 95.6% had more than 2 organ failures. The range of APACHE II score was 15-50 (mean 30.8 +/- 9.5) with a predicted death rate of 21.0-97.8% (mean 66.4 +/- 23.4). The indications for renal replacement were 80% for level of nitrogenous waste product, 75.6% for volume overload, 42.2% for severe metabolic acidosis, 35.6% for hyperkalemia and 2.2% for toxic substance removal. Eighty percent of the patients had 2 or more indications. Mean blood urea nitrogen (BUN) and creatinine (Cr) level before starting CVVH was 78.8 +/- 36.5 mg/dl (10.0 to 187.0) and 5.3 +/- 3.3 mg/dl (2.0 to 20.2) respectively. Duration of CVVH was 1.5 to 251.0 hours (mean 57.8 +/- 58.9) and the average CVVH dose was 36.6 +/- 7.5 ml/kg/hr (24.6 to 55.6). The overall mortality was 80%. The two most frequent causes of death were sepsis (44.4%) and cardiovascular disease (15.6%). The significant difference between the survival and nonsurvival groups were surgical ICU admission (p = 0.021), sepsis (p = 0.019), APACHE II score (p = 0.011), volume indication for CVVH (p = 0.028), number of dialysis indication (p = 0.019), duration of hospitalization (p = 0.004), systolic blood pressure (p = 0.012) and serum albumin level (p = 0.009). By logistic regression analysis, there was only statistical significance for serum albumin level less than 3 g/dl. CONCLUSION: One-year experience of CVVH in Bhumibol Adulyadej Hospital showed high mortality rate but it is comparable to previous publications. The only factor that was associated with death by multivariate analysis was lower serum albumin level at the time of initiating CVVH. Prospective studies are required to explore this issue in the future.