The mediating role of the left ventricular mass index on the relationship between the fluid balance and left ventricular diastolic function in patients with chronic kidney disease

Background The pathophysiological mechanism of cardiovascular disease in patients with chronic kidney disease (CKD) is complicated. Mediation analysis is an important statistical tool for gaining insight into the complex mechanisms of exposure-outcome effects. We investigated the potential mediating role of the left ventricular mass index (LVMI) on the association between fluid balance (overhydration/extracellular water, OH/ECW) and left ventricular diastolic function (E/e´ ratio) in patients with CKD not yet on dialysis. Methods Bioimpedance spectroscopy, echocardiography, and laboratory evaluations were performed on 425 consecutive patients on the same day. The patients were classified into two groups according to the estimated glomerular filtration rate corresponding to CKD stages 3 and 5. Mediation analysis was performed using the PROCESS macro and bootstrapping methods. Results OH/ECW and LVMI were positively correlated with the E/e´ ratio in both the CKD stages 3 and five groups. In CKD stage 5, there was a statistically significant association between OH/ECW and LVMI, whereas no correlation was observed in CKD stage 3. In the mediation analysis, LVMI positively mediated the relationship between OH/ECW and E/e´ ratio when controlling for confounders in patients with CKD stage 5 (B = 2.602; Boot 95% confidence interval, 1.313–4.076). Conclusion In our analysis, the indirect effect of mediators was significant in patients with advanced CKD. Therefore, our study suggests that further research on several other risk factors may be needed to determine the underlying mechanisms of association between the associated factors in all CKD stages

Control of fluid balance guided by body composition monitoring in patients on peritoneal dialysis (COMPASS): study protocol for a randomized controlled trial

Background: The clinical benefits of bioimpedance spectroscopy (BIS)-guided fluid management in patients on hemodialysis have been widely demonstrated. However, no previous reports have evaluated the effect of regular and serial BIS-guided fluid management on the residual renal function (RRF) in patients on peritoneal dialysis (PD). Therefore, we will evaluate the clinical efficacy of BIS-guided fluid management for preserving RRF and protecting cardiovascular events in patients on PD. Methods/design: This is a multicenter, prospective, randomized controlled trial. A total of 138 participants on PD will be enrolled and randomly assigned to receive either BIS-guided fluid management or fluid management based only on the clinical information for 1 year. The primary outcome is the change in the glomerular filtration rate (GFR) between months 0 and 12 after starting treatment. The secondary outcomes will include GFR at month 12, time to the anuric state (urine volume <100 ml/day), and fatal and nonfatal cardiovascular events during treatment. Discussion: This is the first clinical trial to investigate the effect of BIS-guided fluid management on RRF and for protecting against cardiovascular events in patients on PD.Peer Reviewe

Relationship between volume status and possibility of pulmonary hypertension in dialysis naive CKD5 patients.

BACKGROUND:Chronic fluid overload is common in patients with chronic kidney disease (CKD) and can with time lead to poor prognosis regarding to the cardiovascular events. Serum NT-proBNP and OH/ECW might reflect fluid status of the patients, and the maximal tricuspid regurgitation velocity (TRVmax) could reflect systolic pulmonary artery pressure (SPAP). We investigated the relationship between markers of volume status and marker of pulmonary hypertension (PH) in non-dialysis CKD5 (CKD5-ND) patients. METHODS:Bioimpedance spectroscopy (BIS), echocardiography, and measurement of serum NT-proBNP were performed in 137 consecutive patients on the same day. TRVmax greater than or equal to 2.9 m/s, corresponding to SPAP of approximately 36 mmHg, was used as a definition of the possibility of PH in the absence of left heart disease and chronic respiratory disease (PH group). RESULTS:Patients with possibility of PH (TRVmax ≥ 2.9 m/s) was found in 27 (19.70%) patients. Among the values obtained from BIS, those reflecting the fluid balance (OH, OH/ECW, and E/I ratio) were significantly higher in the PH group. The OH/ECW in patients with PH were significantly higher than those patients without (26.76 ± 15.07 vs. 13.09 ± 15.05, P < 0.001). NT-proBNP was also significantly higher in PH group compared to the non-PH group (median = 10,112 pg/ml, IQR = 30,847 pg/ml vs. median = 1,973 pg/ml, IQR = 7,093 pg/ml, P < 0.001). OH/ECW was positively associated with TRVmax (r = 0.235, P = 0.006). Multivariate logistic regression revealed that increased OH/ECW and serum NT-proBNP were significantly associated with an increased risk of PH. CONCLUSIONS:A significant number of patients showed increased TRVmax, which was closely related to volume status in CKD5-ND patients. Echocardiography and BIS could be important players in a high possibility of PH detection and treatment in asymptomatic CKD patients. Therefore, these measures could be helpful to improve the cardiac outcomes after initiating renal replacement therapy. Further research may be needed to validate the consistency of this association across other stages of CKD

PODOCYTE-SPECIFIC OVEREXPRESSION OF SIRT-1 INCREASES NEPHRIN IN OBESE MICE FED A HIGH-FAT DIET

Obesity can lead to inflammation, hyperlipidemia, diabetes, hypertension, and renal dysfunction, and is also associated with proteinuria. Histopathological changes in the glomeruli in obesity were characterized by glomerulomegaly and focal segmental glomerulosclerosis. This study was designed to investigate the effect of sirtuin 1 (SIRT-1), podocyte-specific overexpressed, on nephrin levels in obese mice induced by high fat diet. SIRT-1 has been proposed as a chemotherapeutic target for type II diabetes mellitus. After establishing the SIRT-1 transgenic mice, experimental groups were divided into following three groups: Normal diet-normal group (ND-NL), high fat diet-normal group (HFD-NL), and high fat diet-SIRT-1 group (HFD-SIRT1). The background of transgenic mice was C57BL/6. High fat diet group were fed with a high calorie diet (60%) for up to 21 weeks to examine a progressive development of obesity. Body weight, 6 hours fasting blood glucose, and HbA1c were regularly measured. Albumin-Creatinine Ratio (ACR) in 24 hours urine was measured 21 weeks after the experiment. The expression levels of SIRT-1 and nephrin in the kidney by using western-blot and RT-PCR were compared. With repeated measures ANOVA test, both high fat diet groups were showing that the body weight was significantly higher than normal diet group (P<0.0001) and showing that 6 hours fasting blood glucose was also significantly different (P<0.05). Although statistically not different, urinary ACR of the HFD-SIRT1 group was lower than the HFD-NL group (P=0.09). The nephrin protein expression in the HFD-SIRT1 group was significantly increased than the HFD-NL (P<0.05). The nephrin mRNA level in the HFD-SIRT1 group showed a tendency to increase compared with the HFD-NL group. Taken together the results, deterioration of the kidney disease caused by obesity and hyperglycemia could be prevented by increasing the level of the nephrin expression through SIRT-1 activation. SIRT-1 may have the ability to protect the podocyte from injuries caused by obesity and hyperglycemia

Clinical Significance of Phase Angle in Non-Dialysis CKD Stage 5 and Peritoneal Dialysis Patients

Background: Fluid overload and protein-energy wasting (PEW) are common in patients with end-stage renal disease (ESRD) and lead to a poor prognosis. We aimed to evaluate the volume and nutritional status of ESRD patients and to determine the clinical significance of phase angle (PhA). Methods: This study was a cross-sectional comparison of bioimpedance spectroscopy (BIS) findings in patients with non-dialysis chronic kidney disease (CKD) stage 5 (CKD5-ND, N = 80) and age/sex-matched peritoneal dialysis patients (PD, N = 80). PEW was defined as a PhA less than 4.5&deg;. Results: The PhA was found to be positively associated with a geriatric nutritional risk index (GNRI, r = 0.561, p &lt; 0.001), lean tissue index (LTI, r = 0.473, p &lt; 0.001), and albumin (r = 0.565, p &lt; 0.001) while OH/ECW (r = &minus;0.824, p &lt; 0.001) showed an inverse correlation. The CKD5-ND group had more overhydration (p = 0.027). The PD group had significantly higher PhA (p = 0.023), GNRI (p = 0.005), hemoglobin (p &lt; 0.001), and albumin (p = 0.003) than the CKD5-ND group. The cut-off values predicting PEW were found to be 3.55 g/dL for albumin, 94.9 for GNRI, and 12.95 kg/m2 for LTI in PD patients. Conclusions: This study demonstrated that PhA could be used as a marker to reflect nutritional status in patients with ESRD. Since BIS can inform both volume and nutritional status, regular monitoring will provide the basis for active correction of fluid overload and nutritional supplementation, which may improve outcomes in patients with ESRD

Decreased Bioimpedance Phase Angle in Patients with Diabetic Chronic Kidney Disease Stage 5

Early detection and regular monitoring of the nutritional status of patients with diabetic chronic kidney disease (DMCKD) with reliable tools are necessary. We aimed to determine the clinical significance of the phase angle (PhA) in patients with DMCKD stage 5 not undergoing dialysis. A total of 219 patients (non-diabetic CKD stage 5 [nDMCKD5], n = 84; diabetic CKD stage 5 [DMCKD5], n = 135) were analyzed. The nDMCKD5 group had a significantly higher PhA (p = 0.001), intracellular water/body weight (p = 0.001), and albumin level (p = 0.010) than the DMCKD5 group. The DMCKD5 group experienced significantly more overhydration (p &lt; 0.001). The PhA was positively associated with the lean tissue index (LTI) (r = 0.332; p &lt; 0.001), hemoglobin level (r = 0.223; p = 0.010), albumin level (r = 0.524; p &lt; 0.001), and estimated glomerular filtration rate (eGFR; r = 0.204; p = 0.018) in the DMCKD5 group. Multivariate logistic regression analysis showed the eGFR (odds ratio [OR]: 0.824, 95% confidence interval [CI]: 0.698&ndash;0.974); p = 0.023), LTI (OR: 0.771, 95% CI: 0.642&ndash;0.926; p = 0.005), and albumin level (OR: 0.131, 95% CI: 0.051&ndash;0.338; p &lt; 0.001) were significantly associated with undernutrition (PhA &lt; 4.17&deg;) in the DMCKD5 group. Our observations suggest that the PhA could be used as a marker to reflect the nutritional status in patients with DMCKD5

KONTRIBUSI BIMBINGAN ORANG TUA DAN GURU TERHADAP PERILAKU SOSIAL EMOSIONAL ANAK USIA DINI :Studi Deskriptif Analitik terhadap Perilaku Sosial-Emosional Anak Taman Kanak-Kanak Kelompok B di Kecamatan Sindang Kabupaten Indramayu Tahun ajaran 2008/2009

Penelitian ini bertitik tolak dari permasalahan umum yaitu bagaimana kontribusi bimbingan orang tua dan guru terhadap perilaku sosial-emosional anak usia dini di lembaga pendidikan Taman Kanak-Kanak di-Kecamatan Sindang Kabupaten Indramayu. Adapun batasan masalah dimuat dengan beberapa pertanyaan yaitu bagaimana aktivitas bimbingan orang tua, guru, dan perilaku sosial emosional anak serta kontribusi masing-masing dari variabel-variabel orang tua dan guru terhadap perilaku anak. Metode dalam penelitian ini yaitu menggunakan metode deskriptif analitik dengan teknik survey, metode deskriptif adalah metode yang memusatkan perhatiannya terhadap fenomena yang terjadi pada saat ini dan dalam penelitian ini menggambarkan fenomena yang diselidiki. Adapun pendekatan penelitian ini menggunakan pendekatan kuantitatif korelasional, yaitu pendekatan yang memungkinkan dilakukan pencatatan data hasil penelitian secara nyata dalam bentuk angka sehingga memudahkan proses analisis data dan penafsirannya. Analisis yang dipakai adalah analisis korelasional, regresi dan kontribusi. Menurut Casey (2000) Perkembangan anak usia dini (early child development, ECD) adalah periode perkembangan yang paling cepat pada kehidupan manusia. Pada masa ini, pertumbuhan anak berlangsung dengan cepat. Selain itu kompetisi kognitif, emosi, dan sosial mulai dibentuk dan diperluas. Orang tua adalah guru yang pertama dan utama sekaligus sumber kasih sayang yang paling tulus bagi anak. di sekolah figure guru sebagai kunci. Gurulah panutan utama bagi anak didik, semua sikap dan perilaku guru akan dilihat, didengar dan ditiru oleh anak didik. Anak membutuhkan bimbingan orang dewasa untuk mengetahui apa yang perlu dipelajarinya dan membutuhkan dorongan untuk menguatkan apa yang telah berhasil di pelajarinya. Lingkungan yang kondusip dan dukungan orang tua akan sangat banyak membantu memperlancar rangkaian proses pembelajaran. Dari hasil temuan bahwa bimbingan orang tua, guru dan perilaku sosial emosional anak termasuk dalam kategori baik. Adapun kontribusi yang diberikan, untuk bimbingan orang tua dalam membentuk perilaku sosial emosional anak sebesar 43, guru 31%, dan kalau bersama-sama sebesar 55%. Berdasarkan temuan di atas direkomendasikan baik untuk orang tua atau guru disarankan untuk mempertahankan bimbingan yang telah dilakukan dan untuk mencapai hasil yang lebih baik lagi secara masing-masing harus terus meningkatkan bimbinganya dan juga mengadakan kerja sama antara orang tua dan guru dalam membentuk perilaku sosial emosional anak, sehingga dalam menghadapi persoalan anak dapat diatasi dengan mudah

Secondary Focal Segmental Glomerulosclerosis: From Podocyte Injury to Glomerulosclerosis

Focal segmental glomerulosclerosis (FSGS) is a common cause of proteinuria and nephrotic syndrome leading to end stage renal disease (ESRD). There are two types of FSGS, primary (idiopathic) and secondary forms. Secondary FSGS shows less severe clinical features compared to those of the primary one. However, secondary FSGS has an important clinical significance because a variety of renal diseases progress to ESRD thorough the form of secondary FSGS. The defining feature of FSGS is proteinuria. The key event of FSGS is podocyte injury which is caused by multiple factors. Unanswered questions about how these factors act on podocytes to cause secondary FSGS are various and ill-defined. In this review, we provide brief overview and new insights into FSGS, podocyte injury, and their potential linkage suggesting clues to answer for treatment of the disease