Predialytic treatment of chronic kidney disease

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Chronic kidney disease is a risk factor for cardiovascular disease

Chronic kidney disease (CKD) is common, harmful and treatable. There are no accurate statistics on the prevalence of kidney disease in South Africa but the world prevalence is estimated at approximately 10%. Patients with CKD have cardiovascular (CV) mortality rates as high as 50%. In addition to traditional risk factors, these patients are exposed to other non-traditional CV risk factors. It is important to stress that with the development of early CKD in the form of increasing albuminuria, even from within the normal range (a marker of endothelial dysfunction), the patient is at increased risk of coronary heart disease.“Reverse epidemiology” is the paradox where a high body mass index predicts a better long-term survival in patients with CKD on haemodialysis. Curiously these patients have increased inflammatory markers and atherosclerosis. “Confounding by disease” or “reverse causality” is used to explain why the traditional relationship of increased cholesterol, increased LDL cholesterol and CV risk is not present (except in nephrotics) in CKD.The high phosphate level predisposes to calcium phosphate crystal deposition in the vessels and heart valves. The resultant arteriosclerosis produces the increased pulse wave velocity and systolic hypertension. Rapid valvular calcification, aortic stenosis being a particular difficulty, and early onset coronary artery calcification occur.Arrhythmias are common and the long QT interval syndrome is particularly pertinent. The risk of acquired LQTS is increased by the administration of drugs. Cardiac troponin T is elevated in approximately 25% of asymptomatic patients with CKD.The use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers have been shown to reduce proteinuria and to slow the progressive loss of renal function seen in CKD. These agents also improve cardiac outcomes and reduce the incidence of stroke. Most trials on the management of coronary artery disease have excluded patients with renal disease, and it remains unclear whether the results obtained from these trails can be extrapolated to patients with CKD

Important complications of chronic kidney disease

The complications of chronic kidney disease (CKD) are dyslipidaemia, hyperkalaemia, metabolic acidosis, anaemia, and bone and mineral disorders. Dyslipidaemia may be treated with low-density lipoprotein lowering agents. Statins are ineffective in stages 4 and 5 CKD, but are indicated for preventing the progression of disease in the earlier stages. Chronic acidosis has recently been shown to be a risk factor in the progression of CKD renal dysfunction. Therefore, treatment is mandatory. Practically, this should  consist of 1 - 2 heaped teaspoons of sodium bicarbonate 2 - 3 times per day, which is an inexpensive and safe therapy that does not raise the blood pressure in spite of the increased sodium level. Target levels of haemoglobin, according to international guidelines, are between 10 g/dL and 12 g/dL. The serum phosphate level is raised in stage 4 CKD, and especially in stage 5 CKD, which is associated with coronary carotid and other vascular calcifications and may result in ischaemic heart disease, myocardial infarction and stroke. A raised parathyroid hormone level (secondary hyperparathyroidism) is also a major risk factor for cardiovascular disease and is associated with increased hypertension and resistance to the treatment of CKD-associated anaemia

Movement patterns and athletic performance of leopards in the Okavango Delta

Although leopards are the most widespread of all the big cats and are known for their adaptability, they are elusive and little is known in detail about their movement and hunting energetics. We used high-resolution GPS/IMU (inertial measurement unit) collars to record position, activity and the first high-speed movement data on four male leopards in the Okavango Delta, an area with high habitat diversity and habitat fragmentation. Leopards in this study were generally active and conducted more runs during the night, with peaks in activity and number of runs in the morning and evening twilight. Runs were generally short (less than 100 m) and relatively slow (maximum speed 5.3 m s−1, mean of individual medians) compared to other large predators. Average daily travel distance was 11 km and maximum daily travel distance was 29 km. No direct correlation was found between average daily temperature and travel distance or between season and travel distance. Total daily energy requirements based on locomotor cost and basal metabolic rate varied little between individuals and over time. This study provides novel insights into movement patterns and athletic performance of leopards through quantitative high-resolution measurement of the locomotor, energetic, spatial and temporal movement characteristics. The results are unbiased by methodological and observational limitations characteristic of previous studies and demonstrate the utility of applying new technologies to field studies of elusive nocturnal species

A renal registry for Africa: first steps.

There is a dearth of data on end-stage renal disease (ESRD) in Africa. Several national renal registries have been established but have not been sustainable because of resource limitations. The African Association of Nephrology (AFRAN) and the African Paediatric Nephrology Association (AFPNA) recognize the importance of good registry data and plan to establish an African Renal Registry. This article reviews the elements needed for a successful renal registry and gives an overview of renal registries in developed and developing countries, with the emphasis on Africa. It then discusses the proposed African Renal Registry and the first steps towards its implementation. A registry requires a clear purpose, and agreement on inclusion and exclusion criteria, the dataset and the data dictionary. Ethical issues, data ownership and access, the dissemination of findings and funding must all be considered. Well-documented processes should guide data collection and ensure data quality. The ERA-EDTA Registry is the world's oldest renal registry. In Africa, registry data have been published mainly by North African countries, starting with Egypt and Tunisia in 1975. However, in recent years no African country has regularly reported national registry data. A shared renal registry would provide participating countries with a reliable technology platform and a common data dictionary to facilitate joint analyses and comparisons. In March 2015, AFRAN organized a registry workshop for African nephrologists and then took the decision to establish, for the first time, an African Renal Registry. In conclusion, African nephrologists have decided to establish a continental renal registry. This initiative could make a substantial impact on the practice of nephrology and the provision of services for adults and children with ESRD in many African countries

Kidney disease in the setting of HIV infection: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

HIV-positive individuals are at increased risk for kidney disease, including HIV-associated nephropathy, noncollapsing focal segmental glomerulosclerosis, immune-complex kidney disease, and comorbid kidney disease, as well as kidney injury resulting from prolonged exposure to antiretroviral therapy or from opportunistic infections. Clinical guidelines for kidney disease prevention and treatment in HIV-positive individuals are largely extrapolated from studies in the general population, and do not fully incorporate existing knowledge of the unique HIV-related pathways and genetic factors that contribute to the risk of kidney disease in this population. We convened an international panel of experts in nephrology, renal pathology, and infectious diseases to define the pathology of kidney disease in the setting of HIV infection; describe the role of genetics in the natural history, diagnosis, and treatment of kidney disease in HIV-positive individuals; characterize the renal risk-benefit of antiretroviral therapy for HIV treatment and prevention; and define best practices for the prevention and management of kidney disease in HIV-positive individuals

Understanding kidney care needs and implementation strategies in low- and middle-income countries: conclusions from a "Kidney Disease: Improving Global Outcomes" (KDIGO) Controversies Conference

Evidence-based cinical practice guidelines improve delivery of uniform care to patients with and at risk of developing kidney disease, thereby reducing disease burden and improving outcomes. These guidelines are not well-integrated into care delivery systems in most low- and middle-income countries (LMICs). The KDIGO Controversies Conference on Implementation Strategies in LMIC reviewed the current state of knowledge in order to define a road map to improve the implementation of guideline-based kidney care in LMICs. An international group of multidisciplinary experts in nephrology, epidemiology, health economics, implementation science, health systems, policy, and research identified key issues related to guideline implementation. The issues examined included the current kidney disease burden in the context of health systems in LMIC, arguments for developing policies to implement guideline-based care, innovations to improve kidney care, and the process of guideline adaptation to suit local needs. This executive summary serves as a resource to guide future work, including a pathway for adapting existing guidelines in different geographical regions

Progress towards early detection services for infants with hearing loss in developing countries

BACKGROUND: Early detection of infants with permanent hearing loss through infant hearing screening is recognised and routinely offered as a vital component of early childhood care in developed countries. This article investigates the initiatives and progress towards early detection of infants with hearing loss in developing countries against the backdrop of the dearth of epidemiological data from this region. METHODS: A cross-sectional, descriptive study based on responses to a structured questionnaire eliciting information on the nature and scope of early hearing detection services; strategies for financing services; parental and professional attitudes towards screening; and the performance of screening programmes. Responses were complemented with relevant data from the internet and PubMed/Medline. RESULTS: Pilot projects using objective screening tests are on-going in a growing number of countries. Screening services are provided at public/private hospitals and/or community health centres and at no charge only in a few countries. Attitudes amongst parents and health care workers are typically positive towards such programmes. Screening efficiency, as measured by referral rate at discharge, was generally found to be lower than desired but several programmes achieved other international benchmarks. Coverage is generally above 90% but poor follow-up rates remain a challenge in some countries. The mean age of diagnosis is usually less than six months, even for community-based programmes. CONCLUSION: Lack of adequate resources by many governments may limit rapid nationwide introduction of services for early hearing detection and intervention, but may not deter such services altogether. Parents may be required to pay for services in some settings in line with the existing practice where healthcare services are predominantly financed by out-of-pocket spending rather than public funding. However, governments and their international development partners need to complement current voluntary initiatives through systematic scaling-up of public awareness and requisite manpower development towards sustainable service capacities at all levels of healthcare delivery

Rodent damage to rice crops is not affected by the water‑saving technique, alternate wetting and drying

Rice farmers in Southeast Asia are hesitant to adopt the water-saving technology, alternate wetting and drying (AWD), for fear the practice will lead to increased rodent pest activity, consequently exacerbating yield loss. We examined the effects of AWD on the population dynamics, habitat use and damage levels inflicted on rice crops by the most important rodent pest of rice in Indonesia and the Philippines, Rattus argentiventer and R. tanezumi, respectively. Rice crop damage levels were not affected by the water management scheme employed. Rodent activity in rice fields was not influenced by water level. Both species tended to use the rice paddies over bunds regardless of water level, indicating that something other than water affects their habitat use, and we argue it is likely that the perceived risk of predation is the primary factor driving habitat use. Activity levels and damage inflicted by rodent pests on rice were not correlated. AWD had no effect on breeding and population dynamics of these species. Breeding of R. argentiventer is tied to the growth stages of rice, while available resource dictates breeding by R. tanezumi. Our findings clearly indicate that rice farmers in both Indonesia and the Philippines have no cause to reject AWD based on concerns that AWD would exacerbate crop losses by rodents. Given AWD is being promoted as a climate-smart technology for rice production in Asia and Africa, we strongly recommend its adoption without concerns that it would aggravate rodent pest impacts in lowland irrigated rice cropping systems