Smoking and Second Hand Smoking in Adolescents with Chronic Kidney Disease: A Report from the Chronic Kidney Disease in Children (CKiD) Cohort Study

The goal of this study was to determine the prevalence of smoking and second hand smoking [SHS] in adolescents with CKD and their relationship to baseline parameters at enrollment in the CKiD, observational cohort study of 600 children (aged 1-16 yrs) with Schwartz estimated GFR of 30-90 ml/min/1.73m2. 239 adolescents had self-report survey data on smoking and SHS exposure: 21 [9%] subjects had “ever” smoked a cigarette. Among them, 4 were current and 17 were former smokers. Hypertension was more prevalent in those that had “ever” smoked a cigarette (42%) compared to non-smokers (9%), p\u3c0.01. Among 218 non-smokers, 130 (59%) were male, 142 (65%) were Caucasian; 60 (28%) reported SHS exposure compared to 158 (72%) with no exposure. Non-smoker adolescents with SHS exposure were compared to those without SHS exposure. There was no racial, age, or gender differences between both groups. Baseline creatinine, diastolic hypertension, C reactive protein, lipid profile, GFR and hemoglobin were not statistically different. Significantly higher protein to creatinine ratio (0.90 vs. 0.53, p\u3c0.01) was observed in those exposed to SHS compared to those not exposed. Exposed adolescents were heavier than non-exposed adolescents (85th percentile vs. 55th percentile for BMI, p\u3c 0.01). Uncontrolled casual systolic hypertension was twice as prevalent among those exposed to SHS (16%) compared to those not exposed to SHS (7%), though the difference was not statistically significant (p= 0.07). Adjusted multivariate regression analysis [OR (95% CI)] showed that increased protein to creatinine ratio [1.34 (1.03, 1.75)] and higher BMI [1.14 (1.02, 1.29)] were independently associated with exposure to SHS among non-smoker adolescents. These results reveal that among adolescents with CKD, cigarette use is low and SHS is highly prevalent. The association of smoking with hypertension and SHS with increased proteinuria suggests a possible role of these factors in CKD progression and cardiovascular outcomes

Bone Mineral Density and Vascular Calcification in Children and Young Adults with Chronic Kidney Disease

Introduction: Older adults with chronic kidney disease (CKD) can have low bone mineral density (BMD) with concurrent vascular calcification. It is not known if mineral accrual by the growing skeleton protects young people with CKD from extraosseous calcification. My hypothesis was that children and young adults with increasing BMD do not develop vascular calcification. Methods: Multicentre longitudinal study in children and young people (5-30 years) with CKD stages 4-5 or on dialysis. Cortical (Cort) and trabecular (Trab) BMD were assessed by peripheral quantitative Computed Tomography and lumbar spine BMD by DXA (Dual Energy X-ray Absorptiometry). Vascular calcification was assessed by cardiac CT for coronary artery calcification (CAC) and ultrasound for carotid intima-media thickness (cIMT). Arterial stiffness was measured by pulse wave velocity (PWV) and carotid distensibility. Results: One hundred participants (median age 13.82 years) were assessed at baseline and 57 followed-up after a median of 1.45 years. The cohort had a significant bone and cardiovascular disease burden. 10% suffered at least one previous atraumatic fracture, and 58% reported bone pain affecting activities of daily living. The majority had evidence of vascular calcification and arterial stiffness with increased cIMT and PWV z-scores. 10% had CAC at baseline. Baseline TrabBMD was independently associated with cIMT (R2=0.10, β=0.34, p=0.001). An annualised increase in TrabBMD was an independent predictor of cIMT increase (R2=0.48, β=0.40, p=0.03), with 6-fold greater odds of an increase in ΔcIMT in those with an increase in ΔTrabBMD [(95%CI 1.88 to 18.35), p=0.003]. Young people that demonstrated statural growth (n=33) had attenuated vascular changes compared to those with static growth. Conclusion: These hypothesis generating studies suggest that children and young adults with CKD or on dialysis may develop vascular calcification even as BMD increases. A presumed buffering capacity of the growing skeleton may offer some protection against extraskeletal calcification

Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life

Malnutrition is becoming a more prominent health problem, with an increasing number of elderly CKD patients being put on dialysis. In addition, the presence of inflammation, sarcopenia/frailty, diabetes, and CVD is a definite and independent risk factor associated with higher mortality in this population. Although the restriction of protein intake has been recommended to protect eGFR decline, hyperphosphatemia, and hyperkalemia in CKD patients, it might accelerate the loss of skeletal muscle and adipose mass, leading to a poor prognosis. Therefore, flexible responses are considered regarding whether protein restriction should be continued or loosened in pre-dialysis CKD patients. In undernourished elderly patients undergoing hemodialysis, sufficient calorie/protein intake is necessary to counteract the development of sarcopenia/frailty. It is expected that the application of new drugs including phosphate binders and potassium chelators may achieve both a high enough intake and balanced levels of phosphate and potassium. Furthermore, the improvement of deficient micronutrients and poor appetite is also necessary. Comprehensive care is essential for the wellbeing of elderly patients undergoing hemodialysis. The topicof this Special Issue is “Extension of Healthy Life Span of Dialysis Patients in the Era of a 100-Year Life”

Determinants of Switching From Peritoneal to Hemodialysis in Preserving Residual Renal Function

There are more than 2 million end stage renal disease (ESRD) patients in the world. ESRD is becoming more manageable with the advent of competent therapies such as peritoneal dialysis (PD) and hemodialysis (HD). While recent evidence suggests that switching from PD to HD may preserve residual renal function longer than either PD or HD alone as an alternative approach, little is known about the optimal timing and the long-term efficacy of switching dialysis modes. The purpose of this quantitative retrospective study, based on the bio-psychosocial model, was to investigate the optimal timing and determinants of the effectiveness of switching dialysis modes from PD to HD. Data were extracted from a national database of ESRD dialysis patients. The Kaplan-Meier survival curve and the log-rank test were used to determine the effect of optimal dialysis time for switching from PD to HD on ESRD patient\u27s survival and mortality. The results showed the optimal duration for switching dialysis modalities was 9 months where patients had a 90% survival rate after switching. ESRD patients taking more than 24 months to switch modes had the highest loss of renal function. Also, patients between 40 and 80 years of age were at a significantly higher hazard of renal function loss than patients younger than 40 years of age. It was concluded that timely switching of dialysis mode from PD to HD increases survival in ESRD patients. Younger patients have better survival rates in peritoneal dialysis modality than older patients. Moreover, females switching from PD to HD have better survival rates than males. The positive social change implications of this study may help raise awareness to the importance of optimal timing when switching dialysis modalities for improved survival and quality of life