Search

Patients with severely decreased glomerular filtration rate (GFR) (i.e., chronic kidney disease [CKD] G4+) are at increased risk for kidney failure, cardiovascular disease (CVD) events (including heart failure), and death. However, little is known about the variability of outcomes and optimal therapeutic strategies, including initiation of kidney replacement therapy (KRT). Kidney Disease: Improving Global Outcomes (KDIGO) organized a Controversies Conference with an international expert group in December 2016 to address this gap in knowledge. In collaboration with the CKD Prognosis Consortium (CKD-PC) a global meta-analysis of cohort studies (n = 264,515 individuals with CKD G4+) was conducted to better understand the timing of clinical outcomes in patients with CKD G4+ and risk factors for different outcomes. The results confirmed the prognostic value of traditional CVD risk factors in individuals with severely decreased GFR, although the risk estimates vary for kidney and CVD outcomes. A 2- and 4-year model of the probability and timing of kidney failure requiring KRT was also developed. The implications of these findings for patient management were discussed in the context of published evidence under 4 key themes: management of CKD G4+, diagnostic and therapeutic challenges of heart failure, shared decision-making, and optimization of clinical trials in CKD G4+ patients. Participants concluded that variable prognosis of patients with advanced CKD mandates individualized, risk-based management, factoring in competing risks and patient preferences.

Patients with severely decreased glomerular filtration rate (GFR) (i.e., chronic kidney disease [CKD] G4+) are at increased risk for kidney failure, cardiovascular disease (CVD) events (including heart failure), and death. However, little is known about the variability of outcomes and optimal therapeutic strategies, including initiation of kidney replacement therapy (KRT). Kidney Disease: Improving Global Outcomes (KDIGO) organized a Controversies Conference with an international expert group in December 2016 to address this gap in knowledge. In collaboration with the CKD Prognosis Consortium (CKD-PC) a global meta-analysis of cohort studies (n = 264,515 individuals with CKD G4+) was conducted to better understand the timing of clinical outcomes in patients with CKD G4+ and risk factors for different outcomes. The results confirmed the prognostic value of traditional CVD risk factors in individuals with severely decreased GFR, although the risk estimates vary for kidney and CVD outcomes. A 2- and 4-year model of the probability and timing of kidney failure requiring KRT was also developed. The implications of these findings for patient management were discussed in the context of published evidence under 4 key themes: management of CKD G4+, diagnostic and therapeutic challenges of heart failure, shared decision-making, and optimization of clinical trials in CKD G4+ patients. Participants concluded that variable prognosis of patients with advanced CKD mandates individualized, risk-based management, factoring in competing risks and patient preferences.

BackgroundDiabetes mellitus and hypertension are risk factors for acute kidney injury (AKI). Whether estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (ACR) remain risk factors for AKI in the presence and absence of these conditions is uncertain.Study designMeta-analysis of cohort studies.Setting & population8 general-population (1,285,045 participants) and 5 chronic kidney disease (CKD; 79,519 participants) cohorts.Selection criteria for studiesCohorts participating in the CKD Prognosis Consortium.PredictorsDiabetes and hypertension status, eGFR by the 2009 CKD Epidemiology Collaboration creatinine equation, urine ACR, and interactions.OutcomeHospitalization with AKI, using Cox proportional hazards models to estimate HRs of AKI and random-effects meta-analysis to pool results.ResultsDuring a mean follow-up of 4 years, there were 16,480 episodes of AKI in the general-population and 2,087 episodes in the CKD cohorts. Low eGFRs and high ACRs were associated with higher risks of AKI in individuals with or without diabetes and with or without hypertension. When compared to a common reference of eGFR of 80mL/min/1.73m(2) in nondiabetic patients, HRs for AKI were generally higher in diabetic patients at any level of eGFR. The same was true for diabetic patients at all levels of ACR compared with nondiabetic patients. The risk gradient for AKI with lower eGFRs was greater in those without diabetes than with diabetes, but similar with higher ACRs in those without versus with diabetes. Those with hypertension had a higher risk of AKI at eGFRs>60mL/min/1.73m(2) than those without hypertension. However, risk gradients for AKI with both lower eGFRs and higher ACRs were greater for those without than with hypertension.LimitationsAKI identified by diagnostic code.ConclusionsLower eGFRs and higher ACRs are associated with higher risks of AKI among individuals with or without either diabetes or hypertension.

BackgroundDiabetes mellitus and hypertension are risk factors for acute kidney injury (AKI). Whether estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (ACR) remain risk factors for AKI in the presence and absence of these conditions is uncertain.Study designMeta-analysis of cohort studies.Setting & population8 general-population (1,285,045 participants) and 5 chronic kidney disease (CKD; 79,519 participants) cohorts.Selection criteria for studiesCohorts participating in the CKD Prognosis Consortium.PredictorsDiabetes and hypertension status, eGFR by the 2009 CKD Epidemiology Collaboration creatinine equation, urine ACR, and interactions.OutcomeHospitalization with AKI, using Cox proportional hazards models to estimate HRs of AKI and random-effects meta-analysis to pool results.ResultsDuring a mean follow-up of 4 years, there were 16,480 episodes of AKI in the general-population and 2,087 episodes in the CKD cohorts. Low eGFRs and high ACRs were associated with higher risks of AKI in individuals with or without diabetes and with or without hypertension. When compared to a common reference of eGFR of 80mL/min/1.73m(2) in nondiabetic patients, HRs for AKI were generally higher in diabetic patients at any level of eGFR. The same was true for diabetic patients at all levels of ACR compared with nondiabetic patients. The risk gradient for AKI with lower eGFRs was greater in those without diabetes than with diabetes, but similar with higher ACRs in those without versus with diabetes. Those with hypertension had a higher risk of AKI at eGFRs>60mL/min/1.73m(2) than those without hypertension. However, risk gradients for AKI with both lower eGFRs and higher ACRs were greater for those without than with hypertension.LimitationsAKI identified by diagnostic code.ConclusionsLower eGFRs and higher ACRs are associated with higher risks of AKI among individuals with or without either diabetes or hypertension.

BACKGROUND: Diabetes mellitus and hypertension are risk factors for acute kidney injury (AKI). Whether estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (ACR) remain risk factors for AKI in the presence and absence of these conditions is uncertain. STUDY DESIGN: Meta-analysis of cohort studies. SETTING & POPULATION: 8 general-population (1,285,045 participants) and 5 chronic kidney disease (CKD; 79,519 participants) cohorts. SELECTION CRITERIA FOR STUDIES: Cohorts participating in the CKD Prognosis Consortium. PREDICTORS: Diabetes and hypertension status, eGFR by the 2009 CKD Epidemiology Collaboration creatinine equation, urine ACR, and interactions. OUTCOME: Hospitalization with AKI, using Cox proportional hazards models to estimate HRs of AKI and random-effects meta-analysis to pool results. RESULTS: During a mean follow-up of 4 years, there were 16,480 episodes of AKI in the general-population and 2,087 episodes in the CKD cohorts. Low eGFRs and high ACRs were associated with higher risks of AKI in individuals with or without diabetes and with or without hypertension. When compared to a common reference of eGFR of 80mL/min/1.73m(2) in nondiabetic patients, HRs for AKI were generally higher in diabetic patients at any level of eGFR. The same was true for diabetic patients at all levels of ACR compared with nondiabetic patients. The risk gradient for AKI with lower eGFRs was greater in those without diabetes than with diabetes, but similar with higher ACRs in those without versus with diabetes. Those with hypertension had a higher risk of AKI at eGFRs>60mL/min/1.73m(2) than those without hypertension. However, risk gradients for AKI with both lower eGFRs and higher ACRs were greater for those without than with hypertension. LIMITATIONS: AKI identified by diagnostic code. CONCLUSIONS: Lower eGFRs and higher ACRs are associated with higher risks of AKI among individuals with or without either diabetes or hypertension., Co-authors: Anders Larsson, Uppsala universitet, Institutionen för medicinska vetenskaper, Biokemisk struktur och funktion; Johan Ärnlöv, Uppsala universitet, Institutionen för medicinska vetenskaper, Kardiovaskulär epidemiologi; Lars Lannfelt, Uppsala universitet, Institutionen för folkhälso- och vårdvetenskap, Geriatrik ingår i CKD Prognosis Consortium.

Background: The effects of kidney disease on the risk of hospitalization or death from specific noncardiovascular causes, including pneumonia, are unclear. The objective of this study is to determine the associations between estimated glomerular filtration rate (eGFR) and hospitalization or death with pneumonia. Study Design: Retrospective cohort study. Setting & Participants: Community-based study from a Canadian health region of 252,516 participants with 1 or more outpatient serum creatinine measurements from July 1, 2003, to June 30, 2004, who were not receiving dialysis or kidney transplantation. Predictor: eGFR calculated by using the 4-variable Modification of Diet in Renal Disease Study equation. Outcomes: Hospitalization with pneumonia or death within 30 days after pneumonia hospitalization. Measurements: Cox proportional hazards models adjusted for age, sex, socioeconomic status, and comorbidities with censoring at death, initiation of renal replacement therapy, or emigration. Results: Lower eGFR was associated with increased risk of hospitalization with pneumonia, although the magnitude of effect varied with age. The risk associated with decreased eGFR was greatest in participants 18 to 54 years old; compared with participants with an eGFR of 60 to 104 mL/min/1.73 m2, adjusted hazard ratios for hospitalization with pneumonia were 3.23 (95% confidence interval, 2.40 to 4.36) in those with eGFR of 45 to 59 mL/min/1.73 m2, 9.67 (95% confidence interval, 6.36 to 14.69) for eGFR of 30 to 44 mL/min/1.73 m2, and 15.04 (95% confidence interval, 9.64 to 23.47) for eGFR less than 30 mL/min/1.73 m2. Associations became weaker with increasing age, although the graded inverse association between lower eGFR and risk remained for older participants. An age-dependent inverse relationship also was observed between eGFR and risk of death within 30 days of hospitalization with pneumonia. Limitations: Residual confounding cau

Background: Patients with end-stage renal disease requiring dialysis are at high risk for bloodstream infection and infection-related death. Whether patients with chronic kidney disease who are not receiving dialysis are also at increased risk of bloodstream infection is less clear. Methods:Weexamined the association between chronic kidney disease not being treated with dialysis and bloodstream infection in a cohort of patients 66 years or older. All patients required at least 1 outpatient serum creatinine measurement enabling estimation of glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease Study equation. Cox proportional hazards models with censoring at the initiation of renal replacement therapy or death were used to determine associations between eGFR, bloodstream infection, and death within 30 days of community-onset bloodstream infection, adjusting for potential confounders. Results: In 25 675 patients followed up for a median of 3.2 years, 797 developed at least 1 bloodstream infection, of which most (75%) were community-onset infections. Compared with patients with an eGFR of 60 mL/ min/1.73 m2 or higher, adjusted hazard ratios (95% confidence intervals) for bloodstream infection according to eGFR were, respectively, 1.24 (1.01-1.52), 1.59 (1.24-2.04), and 3.54 (2.69-4.69) in those with an eGFR of 45 to 59, 30 to 44, and less than 30 mL/min/1.73 m2. The associations were consistent for both community-onset and nosocomial infections. Compared with patients with an eGFR of 60 mL/min/1.73 m2 or higher, the risk of death within 30 days of community-onset bloodstream infection was significantly greater in those with an eGFR less than 30mL/min/1.73 m2 (hazard ratio, 4.10; 95% confidence interval, 2.06-8.14). Conclusion: Older adults with chronic kidney disease not being treated with dialysis are at increased risk of bloodstream infection and of death following community-onset bloodstream

Over the past 20 years, the United States military has had difficulty gaining access to land while trying to conduct military operations, such as in Operation DESERT STORM and Operation IRAQI FREEDOM (OIF). Events such as these have caused today's military to seek a viable solution to ensure successful operational maneuver from the sea (OMFTS) and over-the-horizon (OTH) actions. In the future, friendly nations possibly could deny U.S. military forces land basing or transit due to their own sovereign interests. The U.S. military sees the solution to this problem as the concept of sea basing. However, despite influential and significant support from military's top officials, sea basing is not currently a viable concept because it creates a large center of gravity, creates an easy target for maritime terrorism, lacks current support requirements, and faces the scrutiny of current budget issues.