Hypertension affects the majority of patients with chronic kidney disease (CKD) and increases the risk of cardiovascular disease, end-stage renal disease and mortality. Previously, many hypertension guidelines have suggested blood pressure targets in patients with CKD. Recently, the American College of Cardiology/American Heart Association 2017 Guideline for Hypertension suggests a new definition for hypertension and therapeutic targets, which were equally applicated to patients with CKD. These changes reflect the results of the Systolic Blood Pressure Intervention Trial (SPRINT) study, but the renal outcome of intensive blood pressure control was not good. Furthermore, the majority of hypertension guidelines including those of the Korean Society of Hypertension and the European Society of Hypertension have retained the traditional definition. Herein, we intend to analyze in detail the effect of intensive blood pressure control on kidney through the post-hoc analyses of the SPRINT study.
Blood Pressure ; Cardiovascular Diseases ; Diagnosis ; Heart ; Humans ; Hypertension ; Kidney ; Kidney Failure, Chronic ; Mortality ; Renal Insufficiency, Chronic

Echocardiographic parameters can predict cardiovascular events in several clinical settings. However, which echocardiographic parameter is most predictive of each cardiovascular or non-cardiovascular event in patients starting hemodialysis remains unresolved. Echocardiography was used in 189 patients at the time of starting hemodialysis. We established primary outcomes as follows: cardiovascular events (ischemic heart disease, cerebrovascular disease, peripheral artery disease, and acute heart failure), fatal non-cardiovascular events, all-cause mortality, and all combined events. The most predictable echocardiographic parameter was determined in the Cox hazard ratio model with a backward selection after the adjustment of multiple covariates. Among several echocardiographic parameters, the E/e' ratio and the left ventricular end-diastolic volume (LVEDV) were the strongest predictors of cardiovascular and non-cardiovascular events, respectively. After the adjustment of clinical and biochemical covariates, the predictability of E/e' remained consistent, but LVEDV did not. When clinical events were further analyzed, the significant echocardiographic parameters were as follows: s' for ischemic heart disease and peripheral artery disease, LVEDV and E/e' for acute heart failure, and E/e' for all-cause mortality and all combined events. However, no echocardiographic parameter independently predicted cerebrovascular disease or non-cardiovascular events. In conclusion, E/e', s', and LVEDV have independent predictive values for several cardiovascular and mortality events.
*Echocardiography ; Female ; Heart Failure/*diagnosis/mortality ; Humans ; Kidney Failure, Chronic/mortality/*therapy ; Male ; Middle Aged ; Predictive Value of Tests ; Prognosis ; *Renal Dialysis ; Risk Factors ; Ventricular Function, Left/*physiology

Diabetes is a rapidly increasing heath care problem all over the world due to increased prevalence during past decade. Diabetic nephropathy develops in 25-30% of patients with type 1 diabetes and is the leading cause of end stage renal disease. Diabetic nephropathy is characterized by persistent proteinuria, decline in renal function, hypertension and increased cardiovascular morbidity and mortality. Early detection of diabetic nephropathy risk is an important goal because early diagnosis and treatment prevent advanced renal damage and other diabetic complications. Increased urinary albumin excretion rate is widely accepted as the first clinical sign of diabetic nephropathy. However, reduced glomerular filtration or hypertension could be the first manifestation in some diabetic patients. We need improved markers and predictors of diabetic nephropathy risk. We report a case of diabetic nephropathy and decreased glomerular filtration rate (GFR) without microalbuminuria occcured in type 1 diabetic patient.
Diabetes Complications ; Diabetic Nephropathies* ; Early Diagnosis ; Filtration ; Glomerular Filtration Rate ; Humans ; Hypertension ; Kidney Failure, Chronic ; Mortality ; Prevalence ; Proteinuria

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in end- stage renal disease (ESRD) patients. The early diagnosis and treatment of CVD could improve survival in dialysis patients. The plasma level of B-type Natriuretic Peptide (BNP) correlates with the severity of LV dysfunction and increases following myocardial ischemia. We investigated the ability of BNP as a predictor of CVD in new ESRD patients whose volume overload status were not corrected. METHODS: CVD was defined as an LV ejection fraction <45% or a positive myocardial SPECT. We measured plasma levels of BNP in 79 new ESRD patients requiring hemodialysis (HD) and investigated the relationships between BNP levels and echocardiography and myocardial SPECT. RESULTS: Median concentrations of BNP were higher in 16 patients with heart failure than those in 63 patients without heart failure (1, 748.5 vs. 127.0 pg/mL, p<0.001) and higher in 12 patients with positive myocardial SPECT than those in 67 patients with negative SPECT (1, 160.5 vs. 129.0 pg/mL, p< 0.001). BNP levels were higher in 23 patients with CVD than those in 56 patients without CVD (1, 234.0 vs. 119.0 pg/mL, p<0.001). There was an inverse correlation between BNP and LV ejection fraction (r=-0.65, p<0.001). The present study demonstrated a significant 34.9% increment of cardiac mortality by the every increase of 100 pg/mL of BNP. The negative predictive value of BNP for excluding CVD was 89.3% (cut-off value, 500 pg/mL). CONCLUSION: Our findings suggest that BNP could be an effective screening test for the evaluation of the presence of CVD in ESRD patients starting maintenance HD.
Cardiovascular Diseases* ; Dialysis ; Early Diagnosis ; Echocardiography ; Heart Failure ; Humans ; Kidney Failure, Chronic* ; Mass Screening ; Mortality ; Myocardial Ischemia ; Natriuretic Peptide, Brain* ; Plasma ; Renal Dialysis* ; Tomography, Emission-Computed, Single-Photon

BACKGROUND: Patients with pulmonary embolism are at high risk of death because of right ventricular dysfunction (RVD) and mortality rate increases with worsening right ventricular dysfuction. The utility of N-terminal probrain natriuretic peptide (NT-proBNP) testing in the emergency department for diagnosing right ventricular dysfunction with pulmonary embolism and optimal cut-off points for its uses are not well established. METHODS: Forty-nine consecutive patients with confirmed pulmonary embolism, who visited our emergency medical center from March 2005 to September 2006, were recruited. Patients with congestive heart failure and chronic renal failure were excluded from study enrollment. The diagnosis of right ventricular dysfunction was based on echocardiographic evidence of right ventricular dysfunction. RESULTS: The mean age was 68+/-11 yr, and 71% of the patients were women. The median NT-proBNP level among 29 patients (59%) who had RVD was 1296 versus 250 pg/ml for those 20 patients (41%) who did not have RVD (p=0.01). The area under the receiver operating characteristic curve was 0.94 (95% CI of 0.89~0.98). At a cutoff of 400 pg/ml, NT-proBNP had a sensitivity of 97%, a specificity of 75%, and an overall accuracy of 88% for RVD (p=0.01). An NT-proBNP level <400 pg/ml was optimal for ruling out RVD, which was a negative predictive value of 94%. Increased NT- proBNP was the strong independent predictor of RVD (odds ratio 13, 95% CI 4.3-39.0, p=0.01). CONCLUSIONS: NT-proBNP levels are frequently increased in patients with pulmonary embolism who have RVD than who did not have RVD. In acute pulmonary embolism, NT-proBNP elevation is highly predictive of RVD.
Diagnosis* ; Echocardiography ; Emergencies ; Emergency Service, Hospital ; Female ; Heart Failure ; Humans ; Kidney Failure, Chronic ; Mortality ; Pulmonary Embolism* ; ROC Curve ; Sensitivity and Specificity ; Ventricular Dysfunction, Right*

Diabetic kidney disease is a microvascular complication of diabetes mellitus and the leading cause of end-stage renal disease resulting in renal replacement therapy. Approximately 30% to 40% of diabetic patients have diabetic kidney disease, which contributes to a significant increase in morbidity and mortality. Microalbuminuria is considered the gold standard for diabetic kidney disease diagnosis; however, its predictive value is restricted. Although blood glucose control, blood pressure control, and angiotensin converting enzyme inhibitors have been the primary treatment strategies, there are no definitive treatment modalities capable of inhibiting the progression of kidney dysfunction in these patients. This study was undertaken to answer seven questions regarding the various aspects of diabetic kidney disease. Why does it develop? what kind of factors affect its development? How is it diagnosed? What are its possible biomarkers? When is a kidney biopsy necessary? What are the preventive and therapeutic options? And what are the novel treatments?
Angiotensin-Converting Enzyme Inhibitors ; Biomarkers ; Biopsy ; Blood Glucose ; Blood Pressure ; Diabetes Mellitus ; Diabetic Nephropathies ; Diagnosis ; Humans ; Kidney ; Kidney Failure, Chronic ; Mortality ; Renal Replacement Therapy

OBJECTIVETo compare the acute kidney injury classification systems of RIFLE,AKIN,KDIGO and conventional criteria for determining prognosis of acute-on-chronic liver failure (ACLF) patients.

METHODSPatients with ACLF admitted to our hospital between July 2008 and March 2014 were enrolled in the study. The incidence, stages, and outcomes of acute kidney injury were determined according to the RIFLE, AKIN,KDIGO and conventional criteria.ROC curves were generated to compare the predictive ability for 30-day mortality of the four systems.Chi-square test and Fisher's exact test were used for statistical analyses, as well.

RESULTSAll four classification systems detected acute kidney injury among the patients in the study population (n =358), but the detection rates were not consistent (expressed as % of total): KDIGO criteria: 45.0%, AKIN: 38.8%, rIFLE: 35.5%, conventional criterion: 20.4%. The KDIGO and AKIN criteria showed higher sensitivity (72%), especially to early kidney injury, but the conventional criterion showed higher specificity (92%). The AUC for 30-day mortality was highest for the conventional criteria (0.75), followed by AKIN (0.72), rIFLE (0.70) and KDIGO (0.69) (all, P less than 0.05). In-hospital mortality increased with severity of AKI in a stepwise manner.

CONCLUSIONAmong the four common evaluation systems for acute kidney injury, the conventional criteria has the highest specificity for predicting short-term prognosis of patients with ACLF, while the AKIN and KDIGO criteria have the highest sensitivity for the presence of acute kidney injury, especially at the early stage.

Acute Kidney Injury ; classification ; diagnosis ; Acute-On-Chronic Liver Failure ; diagnosis ; Hospital Mortality ; Humans ; Incidence ; Prognosis ; ROC Curve ; Retrospective Studies ; Sensitivity and Specificity

BACKGROUND/AIMS: A revised classification system for renal dysfunction in patients with cirrhosis was proposed by the Acute Dialysis Quality Initiative and the International Ascites Club Working Group in 2011. The aim of this study was to determine the prevalence of renal dysfunction according to the criteria in this proposal. METHODS: The medical records of cirrhotic patients who were admitted to Konkuk University Hospital between 2006 and 2010 were reviewed retrospectively. The data obtained at first admission were collected. Acute kidney injury (AKI) and chronic kidney disease (CKD) were defined using the proposed diagnostic criteria of kidney dysfunction in cirrhosis. RESULTS: Six hundred and forty-three patients were admitted, of whom 190 (29.5%), 273 (42.5%), and 180 (28.0%) were Child-Pugh class A, B, and C, respectively. Eighty-three patients (12.9%) were diagnosed with AKI, the most common cause for which was dehydration (30 patients). Three patients had hepatorenal syndrome type 1 and 26 patients had prerenal-type AKI caused by volume deficiency after variceal bleeding. In addition, 22 patients (3.4%) were diagnosed with CKD, 1 patient with hepatorenal syndrome type 2, and 3 patients (0.5%) with AKI on CKD. CONCLUSIONS: Both AKI and CKD are common among hospitalized cirrhotic patients, and often occur simultaneously (16.8%). The most common type of renal dysfunction was AKI (12.9%). Diagnosis of type 2 hepatorenal syndrome remains difficult. A prospective cohort study is warranted to evaluate the clinical course in cirrhotic patients with renal dysfunction.
Acute Kidney Injury/*epidemiology/etiology/mortality ; Adult ; Aged ; Cohort Studies ; Female ; Hospital Mortality ; Humans ; Kidney Failure, Chronic/*epidemiology/etiology/mortality ; Liver Cirrhosis/complications/*diagnosis ; Male ; Middle Aged ; Prevalence ; Prospective Studies ; Severity of Illness Index ; Survival Rate

BACKGROUND/AIMS: This study analyzed the risk factors for technique survival in dialysis patients and compared technique survival rates between hemodialysis (HD) and peritoneal dialysis (PD) in a prospective cohort of Korean patients. METHODS: A total of 1,042 patients undergoing dialysis from September 2008 to June 2011 were analyzed. The dialysis modality was defined as that used 90 days after commencing dialysis. Technique survival was compared between the two dialysis modalities, and the predictive risk factors were evaluated. RESULTS: The dialysis modality was an independent risk factor predictive of technique survival. PD had a higher risk for technique failure than HD (hazard ratio [HR], 10.8; 95% confidence interval [CI], 1.9 to 62.0; p = 0.008) during a median follow-up of 11.0 months. In the PD group, a high body mass index (BMI) was an independent risk factor for technique failure (HR, 1.3; 95% CI, 1.0 to 1.8; p = 0.036). Peritonitis was the most common cause of PD technique failure. The difference in technique survival between PD and HD was more prominent in diabetic patients with a good nutritional status and in non-diabetic patients with a poor nutritional status. CONCLUSIONS: In a prospective cohort of Korean patients with end-stage renal disease, PD was associated with a higher risk of technique failure than HD. Diabetic patients with a good nutritional status and non-diabetic patients with a poor nutritional status, as well as patients with a higher BMI, had an inferior technique survival rate with PD compared to HD.
Adult ; Aged ; Body Mass Index ; Humans ; Kidney Failure, Chronic/diagnosis/mortality/*therapy ; Male ; Middle Aged ; Nutritional Status ; Peritoneal Dialysis/adverse effects/mortality ; Prospective Studies ; *Renal Dialysis/adverse effects/mortality ; Republic of Korea ; Risk Factors ; Time Factors ; Treatment Outcome

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common genetic disorder that accounts for 8-10% of patients receiving renal replacement therapy in Unites States and Europe, and approximately 2% in Korea. ADPKD patients on renal replacement therapy constitute a particular group with typical clinical charateristics and differences from other patients on renal replcement therapy. The objective of this study was to assess clinical features, morbidity, mortality and technical survival in end stage renal disease (ESRD) patients with ADPKD and compare these between each renal replacement therapy. METHODS: We retrospectively analyzed 70 ADPKD patients who received renal replacement therapy in Yonsei university medical center (Jan. 1980-Dec. 2001). RESULTS: Among a total of 70 patients, 41 patients were male and 29 patients were female. Mean age was 45.6+/-10.7 years and average time from diagnosis of ADPKD to start of renal replacement therapy was 5.1+/-5.6 years. As the initial mode of renal replacement therapy, 25 patients started on hemodialysis, 26 patients started on CAPD and 19 patients received renal transplantation. Clinical features and laboratory findings at the initiation of renal replacement therapy had no significant differences between each renal replacement therapy. Cumulative and technical survival in ESRD patients with ADPKD receiving each renal replacement therapy had no significant differences according to Kaplan-Meier. Seven patients died within study period, including 3 hemodialysis patients, 2 CAPD patients and 2 renal transplantation patients. The most common cause of death was infection followed by bleeding and malignancy. Among patients on CAPD, 10 patients had stopped CAPD because of peritonitis, hernia, ultrafiltration failure and CAPD leakage. CONCLUSION: In summary, there were no significant differences of clinical features, cumulative and technical survival between each renal replacement therapy in ADPKD patients. The most frequent reason for cessation of CAPD was peritonitis. The most common cause of death was infection in ESRD patients with ADPKD.
Academic Medical Centers ; Cause of Death ; Diagnosis ; Europe ; Female ; Hemorrhage ; Hernia ; Humans ; Kidney Failure, Chronic* ; Kidney Transplantation ; Korea ; Male ; Mortality ; Peritoneal Dialysis, Continuous Ambulatory ; Peritonitis ; Polycystic Kidney, Autosomal Dominant* ; Renal Dialysis ; Renal Replacement Therapy* ; Retrospective Studies ; Ultrafiltration