The Implication of Dropping Race from the MDRD Equation to Estimate GFR in an African American-Only Cohort

The widely used Modification of Diet in Renal Disease (MDRD) formula adapts a 1.212 multiplier for individuals who are identified as African Americans (AAs) or Blacks, which leads to a higher GFR estimation. As it stands, AAs have a lower prevalence of chronic kidney disease (CKD) but higher incidence of end-stage renal disease (ESRD) compared with Whites. Many hypotheses have been postulated to explain this paradox, but the imprecision of the GFR estimation with race-adaptation could be contributory. We performed a single-center, longitudinal, retrospective study on a cohort of outpatient AA patients using the MDRD and MDRDrace removed and CKD-EPI and CKD-EPIrace removed and their progression to CKD G5 (eGFR <15 ml/min/1.73 m2). 327 patients were analyzed. Median follow-up was 88.1 months (interquartile range, 34.4–129.1). When race was removed from MDRD, 39.9% of patients in CKD G1/2 were reclassified to CKD G3a, 72.6% of patients in CKD G3a would be reclassified to CKD G3b, and 54.1% and 36.4% of patients would be reclassified from CKD 3b to CKD G4 and CKD G4 to CKD G5, respectively p < 0.0001 . Comparing the CKD-EPI formula against the MDRD in our cohort, we found that 8.2%, 18.8%, and 11.4% of patients were reclassified from CKD G1/2 to CKD G3a, CKD G3a to G3b, and CKD G3b to CKD G4 respectively. Overall median time to progression to CKD G5 was 137.4 (131.9–142.8) months in patients who were not reclassified and 133.6 (127.6–139.6) months for patients who were reclassified by MDRDrace removed p < 0.288 . Concerns of inequitable access to healthcare have elicited calls to review race-corrected eGFR equations. A substantial number of individuals would have their CKD stage reclassified should have the MDRDrace removed equation be adopted en masse on an AA-only population. The discrepancy is highest at the 45–59 and >60 ml/min/1.72 min2 ranges. This will have tremendous impact on our center’s approach to pharmacological dosing, referral system, best practices, and outcome surveillance. Comprehensive review of the current “race-corrected” eGFR will require a multifaceted approach and adjunctive use of noncreatinine-based approach.

Groundwater in New Valley and kidney disease

Background This study was performed to assess the possible association between groundwater and kidney disease in new valley governorate . Methods This hospital-based cross-sectional observational study was conducted at the Department of Nephrology, Ain Shams University, Cairo, Egypt, during the period from August 2018 to January 2019. After obtaining verbal consent from all participants; the general information of each participant was recorded, full history taken and general examination was done for each participant, then urine samples and serum blood samples taken for urine analysis, serum urea and serum creatinine, then estimated glomulurar filtratin rate (eGFR) was calculated for healthy subjects groups using MDRD Equation; after that three different groundwater samples and Nile water sample collected and analyzed for different solutes and heavy metals contents. Result Our data suggests that rural community as in Eldakhla; which depends on groundwater supply may affected by more risk of CKD than urban community as in Cairo city, which depends on Nile water supply. Conclusion there are increased prevalence of CKD in New Valley governorate and this may be due to groundwater consumption .

Prospective Comparison of 24-Hour Urine Creatinine Clearance with Estimated Glomerular Filtration Rates in Chronic Renal Disease Patients of African Descent

Background: The 24-hour (24-h) creatinine clearance (CrCl) is the most common method for measuring GFR in clinical laboratories. However, the limitations of CrCl have resulted in the widespread acceptance of mathematically derived estimated glomerular filtration rate (eGFR) using Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations in predicting eGFR. The aim of the study was to compare 24-h CrCl with eGFR derived from these formulae and to identify which could be the best alternative. Method: A prospective study was conducted involving 140 CKD patients. Creatinine and cystatin C concentrations were determined using the cobas 6000 analyzer. The eGFR was calculated using the CG formula, 4-variable MDRD and CKD-EPI equations, and Bland-Alman plots bias was determined. Results: The CG and MDRD formulas had mean eGFR values similar to CrCl and correlation coefficients (r) were highest for CG (0.906) and lowest for MDRD (0.799). The CG equation was in agreement with 24-h CrCl in all but stage V CKD while the MDRD equation compared well in all except Stage IV CKD. The CG equation was positively biased (0.9857) while the MDRD had a negative bias (−0.05). Conclusion: The Cockcroft-Gault formula provides a more accurate assessment of GFR than 24-h CrCl and would be recommended as a substitute to provide the best estimate of GFR in our population.

Validity of Estimated Glomerular Filtration Rate Equation and Assessment of Bio-Impedance Analysis in Advanced Chronic Kidney Disease Patients

Introduction: This cross-sectional study was conducted to validate estimated glomerular filtration rate (eGFR) equation and assess body composition in chronic kidney disease (CKD) stage 5 non-dialysis (ND) participants.Methods: A total of 111 samples of Thai CKD stage 5 ND participants with eGFR below 15 mL/min/1.73 m2, calculated by using the CKD Epidemiology Collaboration (CKD-EPI) equation, were enrolled into the study. The 99mTc-DTPA plasma clearance was used as the reference GFR. Body composition analysis was measured by bio-impedance analysis (BIA) to assess volume as well as body composition.Results: The mean isotope for GFR was 17.39±6.83 mL/min/1.73m2. The mean bias values between isotope GFR and re-expressed MDRD equation, CKD-EPI equation, Thai equation, and cystatin C-based equation were 8.89±6.35, 9.47±6.13, 2.05±6.80, and 5.50±6.40 mL/min/1.73m2, respectively. The accuracy (root-mean-square error) values were 13.05, 13.68, 8.73, and 10.58 mL/min, respectively. Using BIA, the low muscle mass was 33.66%, excessive fat was 55.00 %, and the presence of edema was 48.5%. Participants with low muscle mass, excessive fat, and subclinical edema had higher bias of GFR measurement for all equations. The bias values for eGFR in participants with low muscle mass, excessive fat, and subclinical edema by re-expressed MDRD equation were 10.23, 9.61, 10.88 mL/min/1.73m2; by CKD-EPI equation: 8.49, 10.25, 11.63 mL/min/1.73m2; by the Thai eGFR equation: 3.16, 2.73, 4.77 mL/min/1.73m2; and by the cystatin C-based equation: 6.32, 6.6, 7.99 mL/min/1.73m2, respectively.Conclusions: The Thai equation was the most accurate and precise method to determine the renal function of Thai CKD stage 5 ND participants who had a high prevalence of low muscle mass, excessive fat, and subclinical edema. The result suggested that ethnic-specific eGFR equation should be recommended in advanced CKD patients. Alteration of the body composition in advanced CKD patients is of concern because it can affect the performance of all of the eGFR equations.

MO111PATTERN OF CARDIAC AND RENAL RISK FACTORS PREVAILING IN HYPERTENSIVE SUBJECTS OF RURAL COMMUNITY: PRIMARY RESULTS FROM AN ONGOING SYSTEMATIC SURVEY IN BANGLADESH

Background and Aims Hypertension is the leading entity of non communicable diseases (NCD). Some 15-30% adult population is identified suffering from hypertension at any given time worldwide. Complications of hypertension cause severe functional deficit and a major decline in quality of life for the patient and family. This study was carried out to identify the presence and pattern of cardiac and renal risk factors influencing major morbidity and mortality in hypertensive subject by performing relevant clinical and laboratory evaluations. Method In this survey adult subjects were selected randomly from a defined rural area. Their demographic, anthropometric and clinical information was recorded by WHO STEP wise approach surveillance-Instrument v.3.1. Information on prevailing NCDs and related risk factor were collected on a short questionnaire by face-to-face interview. Blood Pressure (BP) was measured by digital blood pressure monitor (Omron) with standard sized cuff after 10-15 minutes of rest in sitting posture by taking mean of two readings. Systolic BP ≥140 and/or diastolic BP ≥90mmHg or subjects taking antihypertensive medications were considered for hypertension. Early morning urine and fasting blood sample was collected for glycemic profile, lipid profile, serum creatinine, eGFR (MDRD equation) and urine ACR estimations for identifying diabetes, dyslipidemia and nephropathy. Results from an early group are presented here. Results From surveyed population consequative 300 hypertensive subjects with 100 normotensive subjects were analyzed. Male/female distribution was 66% and 34%. Age in 75% was between 25-55 years and BMI overweight to obese in 45%. Etiology wise in 81% it was essential hypertension followed by diabetes 18% and nephropathies in rest. Mean systolic BP was 147±16 and diastolic BP 71±9 mmHg. Comparison of hypertensive vs. normotensives showed FBS 6.7±3 vs. 5.8±1.0 mmol/l, (p&lt;0.001). Lipids as cardiac markers were TG 170±107 vs. 130±76 g/dl, (p&lt;0.001); Cholesterol 195±50 vs. 180±49 g/dl, (p&lt;0.001); LDL 170±107 vs. 130±76 g/dl, (p&lt;0.04); and HDL 42±7 vs. 46±8 g/dl, (p&lt;0.001). Renal parameters like eGFR was 88±22 vs. 98±26 ml/min, (p&lt;0.001); and ACR 99±556 vs. 30±87 mg/g, (p&lt;0.04). These comparisons showed fasting hyperglycemia with most of the lipids higher and HDL lower in hypertensives. Renal parameters like eGFR was lower and albuminuria was significantly higher with similar urinary Na and K excretion in hypertensives. Other cardio renal markers like Uric Acid and hCRP was similar in both groups. Pearson’s correlations showed a positive correlation of systolic and diastolic BP with major components of cardiac, renal and metabolic risk factors. Conclusion It is found that hypertension is essential in nature among 81% of rural subjects. Nearly half of the study subjects are overweight. Dyslipidemia, albuminuria and low GFR is more pronounced in hypertensives in comparison to the normotensive counterparts. So, hypertension is mostly associated with adverse cardio-renal risk markers.

Renal function in a cohort of HIV-infected patients initiating antiretroviral therapy in an outpatient setting in Ethiopia

Aim To evaluate the prevalence and associated factors of abnormal renal function among Ethiopian HIV-infected patients at baseline prior to initiation of antiretroviral therapy (ART) and during follow-up. Methods We conducted a retrospective observational cohort study of HIV infected patients who initiated ART at the outpatient ART clinic of Mehal Meda Hospital of North Shewa, Ethiopia from January 2012 to August 2018. Demographic and clinical data were abstracted from the medical records of patients. Renal function was assessed by estimated glomerular filtration rate (eGFR) calculated using the Modification of Diet in Renal Disease (MDRD) equation. Univariate and multivariate analysis were conducted to determine the factors associated with abnormal renal function at baseline and during follow-up. Results Among 353 patients, 70 (19.8%) had baseline eGFR <60 ml/min/1.73m2 and 102 (28.9%) had eGFR = 60–89.9 ml/min/1.73m2. Factors associated with baseline renal impairment (eGFR <60 ml/min/1.73m2) included female sex (AOR = 3.52, CI 1.75–7.09), CD4 count < 200 cells/mm3 (AOR = 2.75, CI 1.40–5.42), BMI < 25 Kg/m2 (AOR = 3.04, CI 1.15–8.92), low hemoglobin (AOR = 2.19, CI 1.16–4.09) and high total cholesterol (AOR = 3.15, CI 1.68–5.92). After a median of 3.0 years of ART, the mean eGFR declined from 112.9 ± 81.2 ml/min/1.73m2 at baseline to 93.9 ± 60.6 ml/min/1.73m2 (P < 0.001). The prevalence of renal impairment increased from 19.8% at baseline to 22.1% during follow-up. Of 181 patients with baseline normal renal function, 49.7% experienced some degree of renal impairment. Older age (AOR = 3.85, 95% CI 2.03–7.31), female sex (AOR = 4.18, 95% CI 2.08–8.40), low baseline CD4 (AOR = 2.41, 95% CI 1.24–4.69), low current CD4 count (AOR = 2.32, 95% CI 1.15–4.68), high BMI (AOR = 2.91, 95% CI 1.49–5.71), and low hemoglobin (AOR = 3.38, 95% CI 2.00–7.46) were the factors associated with renal impairment during follow-up. Conclusion Impaired renal function was common in HIV-infected patients initiating ART in an outpatient setting in Ethiopia, and there appears to be a high prevalence of renal impairment after a median ART follow-up of 3 years. There is a need for assessment of renal function at baseline before ART initiation and regular monitoring of renal function for patients with HIV during follow-up.

Outcome of Febuxostat treatment in hyperuricemic pre-dialysis chronic kidney disease patients

Introduction: Hyperuricemia is a cause and effect of chronic kidney disease (CKD), accelerates its progression and predisposes to acute kidney injury. Present study aimed to find out the outcome of Febuxostat treatment in hyperuricemic pre-dialysis CKD patients. Method: This was a cross sectional study conducted in Nephrology department, Bir hospital, Nepal, during from February 2019 to January 2020, among pre-dialysis CKD stage 3-5 non dialysis (ND) patients with serum uric acid (SUA) >7 mg/d L who were treated with Febuxostat 40 mg once a day and followed up at one, two and three months. The baseline SUA, creatinine, estimated glomerular filtration rate (eGFR) calculated by the modification of diet in renal disease (MDRD) equation compared with values at follow up and according to CKD stages. The adverse effects and liver enzymes were recorded. Result: There were total 50 patients, mean age 54.2±16.5 years, male 31 (62%).There were significant reductions of SUA from baseline of 8.9±1.4to 7.1±1.2 vs 5.9±0.9 vs 4.7±1.0) at one, two and three month respectively, p=0.000 and increment of eGFR (ml/min/1.73m2) from 29.6±15.0 to 31.6±16.0, 33.6±16.6, 34.1±17.1, p=0.000.And 41 (82%) patients achieved uric acid < 6 mg/dl at three month. Significant reduction of uric acid in all CKD stages and increment of eGFR in CKD stage 3 and 4 were observed. Adverse effects were epigastralgia in 5 (10%) and joint pain in 13 (26%). Conclusion: Febuxostat is an effective serum uric acid lowering drug in pre-dialysis chronic kidney disease patients with improvement of kidney function.

P0405CURRENT STATUS OF NEPHRITIS IN KOREA: EXPERIENCE OF 18 CENTERS DURING LAST 40 YEARS

Background and Aims Glomerulonephritis (GN) is one of common causes of end-stage renal disease (ESRD) in Korea as well as in the world, however, it is underdiagnosed as a cause of chronic kidney disease. The incidence and prevalence of GNs are different according to periods and countries. We report trends of pathologic diagnosis of nephritis from 18 centers throughout Korea during last 40 years. Method We enrolled 21,617 patients having native kidney biopsy for diagnosis of nephritis between 1979 and 2018, retrospectively. We excluded 191 patients diagnosed as cancer or tumor and analyzed the data of 21,426 patients. We defined the primary GN as IgA nephropathy (IGAN), minimal change disease (MCD), membranous nephropathy (MGN), focal segmental glomerulosclerosis (FSGS), membranoproliferative GN (MPGN), and C3 glomerulopathy (C3G). The estimated glomerular filtration rate (GFR) was calculated by original MDRD equation for adults and by height-independent equation for children. The final outcomes were incidences of end stage renal disease (ESRD) and death. Results There were 22,203 pathologic diagnoses including 777 patients with two kinds of pathologic diagnosis. The age was 42.1 ± 17.7 years at renal biopsy. There were 11565 (54.0 %) men and 976 (4.6 %) children &lt;18 years. The frequencies of hypertension and diabetes mellitus were 53.0 % (10994) and 14.0 % (2833), respectively. Mean levels of serum creatinine, GFR, and urine protein to creatinine ratio were 1.62 ± 1.89 mg/dl, 77.1 ± 60.4 ml/min/1.73 m2, and 3.305 ± 4.164 g/g cr, respectively. The prevalence of GN was 78.45% (17419 diagnoses), followed by tubulointerstitial nephritis (8.84 %), abnormality in glomerular basement membrane (3.43 %), ischemic nephropathies (1.73 %), paraproteinemia related lesions (1.36 %), infection (0.12 %). There were non-specific GN (3.65 %), normal pathology (2.46 %), advanced global sclerosis (1.77 %), inadequate specimen (0.96 %), and miscellaneous lesions (0.12 %), also. The most frequent diagnosis was IGAN (34.17%, 7586 diagnoses), followed by MGN (9.17%), MCD (9.13 %), FSGS (7.65 %), lupus nephritis (LN) (6.30 %), diabetic nephropathy (DMN) (3.99 %), MPGN and C3G (2.79 %), therefore, prevalence of primary GN was 62.90 %. The frequency of IGAN had been increased from 19.9 % at the period of 1979-1989 to 41.4 % at the period of 2005-2009 and then stabilized to 36.0-36.7%. The frequencies of MCD, MGN, and FSGS were not changed since 1990. However, the frequency of MPGN was decreased from 4.7-5.7 % at the period of 1979-1999 to 2.5 % at the period of 2015-2018. The frequency of LN was decreased and that of DMN was increased from 2.5-3.1% during 1990-2009 to 6.3 % during 2015-2018 which might be related to the pathologic classification of DMN, published at 2010 by Tervaert TW et al. The incidences of ESRD and death were 13.3 % (2663/20010 patients) and 2.9 % (608/20884 patients) during follow-up period of 82.6 months (median) for ESRD and 91.5 months (median) for mortality after biopsy. Among patients with primary GN, patients with MCD showed the best prognosis for ESRD, followed by patients with MN, IGAN, FSGS, MPGN, and C3G (p &lt;0.001) by Cox’s hazard proportional model adjusted by risk factors related to ESRD. Prognosis for mortality was not different among patients with MCD, MN, IGAN, and FSGS, but, patients with C3G showed the worst prognosis for mortality (p=0.006). Conclusion IGAN was the most frequent diagnosis followed by MGN and MCD. Compared to Western countries, IGAN and MCD are more prevalent in Korea, while MGN and FSGS are less prevalent. The frequencies of MPGN and LN had been decreased since 2000. The patients with MPGN and C3G showed the worst prognosis.

Recovery of serum metallothionein level after hemodialysis in patients with end stage renal failure

Metallothioneins (MTs) are intracellular metal-protein which not alone have inactivated heavy metals but also have traced elements while improving the antioxidant status. Serum levels of some heavy metals and trace elements showed toxic levels in the end-stage renal failure. This study is aimed to determine the serum level of metallothionein in patients with chronic kidney disease (CKD) and to show the effects of hemodialysis on its level. This cross-sectional study included 125 patients with CKD managed with regular hemodialysis. Estimated glomerular filtration rate (eGFR) was calculated by using the Cockroft and Gault equation adjusted to the body surface area (ml/min/m2), and 4 variable modified diet in renal disease (4-v MDRD) equation (ml/min/1.73m2). The mean ± SD of serum metallothionein was significantly less than the corresponding level of healthy subjects (1113.4±289.5 pg/ml versus 1536.0±341.4 pg/ml). Hemodialysis improves the serum level of metallothionein to attain 1437.6±406.1 pg/ml. There is a non-significant correlation between serum metallothionein with the eGFR and hemodialysis did not produce a significant effect on the correlation between serum metallothionein with eGFR. We conclude that serum metallothionein level is a useful prognostic marker for CKD and hemodialysis plays a role in the recovery of serum metallothionein level.