Rates of chronic kidney disease (CKD) progression, end stage kidney disease (ESKD), all-cause mortality, and cardiovascular (CVD) events among individuals with CKD vary widely across countries. Well-characterized demographic, comorbidity, and laboratory markers captured for prospective cohorts may explain, in part, such differences. To investigate whether core characteristics of individuals with CKD explain differences in rates of outcomes, we conducted an individual-level analysis of eight studies that are part of iNET-CKD, an international network of CKD cohort studies. Overall, the rate of CKD progression was 40 events/1000 person-year (95% confidence interval 39-41), 28 (27-29) for ESKD, 41 (40-42) for death, and 29 (28-30) for CVD events. However, standardized rates were highly heterogeneous across studies (over 92.5%). Interactions by study group on the association between baseline characteristics and outcomes were then identified. For example, the adjusted hazard ratio for CKD progression was 0.44 (95% confidence interval 0.35-0.56) for women vs. men among the Japanese (CKD-JAC), while it was 0.66 (0.59-0.75) among the Uruguayan (NRHP). The adjusted hazard ratio for ESKD was 2.02 (95% CI 1.88-2.17) per 10 units lower baseline eGFR among Americans (CRIC), while it was 3.01 (2.57-3.53) among Canadians (CanPREDDICT) (significant interaction for comparisons across all studies). The risks of CKD progression, ESKD, death, and CVD vary across countries even after accounting for the distributions of age, sex, comorbidities, and laboratory markers. Thus, our findings support the need for a better understanding of specific factors in different populations that explain this variation.

IntroductionPatients with chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) <30 ml/min per 1.73 m2 (corresponding to CKD stage G4+) comprise a minority of the overall CKD population but have the highest risk for adverse outcomes. Many CKD G4+ patients are older with multiple comorbidities, which may distort associations between risk factors and clinical outcomes.MethodsWe undertook a meta-analysis of risk factors for kidney failure treated with kidney replacement therapy (KRT), cardiovascular disease (CVD) events, and death in participants with CKD G4+ from 28 cohorts (n = 185,024) across the world who were part of the CKD Prognosis Consortium.ResultsIn the fully adjusted meta-analysis, risk factors associated with KRT were time-varying CVD, male sex, black race, diabetes, lower eGFR, and higher albuminuria and systolic blood pressure. Age was associated with a lower risk of KRT (adjusted hazard ratio: 0.74; 95% confidence interval: 0.69–0.80) overall, and also in the subgroup of individuals younger than 65 years. The risk factors for CVD events included male sex, history of CVD, diabetes, lower eGFR, higher albuminuria, and the onset of KRT. Systolic blood pressure showed a U-shaped association with CVD events. Risk factors for mortality were similar to those for CVD events but also included smoking. Most risk factors had qualitatively consistent associations across cohorts.ConclusionTraditional CVD risk factors are of prognostic value in individuals with an eGFR <30 ml/min per 1.73 m2, although the risk estimates vary for kidney and CVD outcomes. These results should encourage interventional studies on correcting risk factors in this high-risk population.

A rterial hypertension is prevalent in chronic kidney disease (CKD) and contributes to its adverse outcomes. 1 The major benefits of lowering blood pressure (BP) for survival and cardiovascular outcomes are well established, as are those of inhibiting the renin angiotensinaldosterone system (RAAS) to slow CKD progression. 2-8 BP control and RAAS inhibitor use are therefore major goals in the management of patients with CKD, 9 although no consensus exists about the ideal BP level. Current guidelines

By prolonging dialysis time to 21 hours per week, better P serum control and lower Ca x P product were achieved in our patients.

Background: Uruguay has implemented a chronic kidney disease (CKD) prevention program. Aims: The objectives of the study are to assess the results of the National Renal Healthcare Program (NRHP). Methods: This study is a cohort study of nondialysis-registered patients from October 2004 to March 2008. We made a comparison between patients under nephrology care (NC) or the care of a primary care physician (PCP; prereferral). In the outcome analysis, the primary endpoint was end-stage renal disease (ESRD) and the secondary endpoints were progression of CKD, compliance with the therapeutic goals and death. ESRD/mortality predictors were determined by Cox analysis. Results: The study comprised 2,219 patients aged 67.4 ± 13.5 years, of whom 52.5% were male, 42.1% hypertensive, 16.9% had diabetic nephropathy, and 61.3 and 21.4% were in CKD stages III and IV, respectively. At baseline, NC patients showed a better control than patients under the care of a PCP: systolic blood pressure ≧160 mm Hg (22.4 vs. 31.1%); total cholesterol <5.8 mmol/l (56.6 vs. 42.5%); and low-density lipoprotein cholesterol <2.9 mmol/l (41.2 vs. 29.1%). Control improved in patients under the care of a PCP according to years of enrollment. Outcome analysis (1,188 patients) showed a significant improvement in targets, with 56% of the patients stabilizing. CKD stage IV, diabetic nephropathy, proteinuria and hypertension increased the risk of ESRD; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and age <65 years decreased the risk. Conclusions: Our results highlight the best management of CKD patients in both groups and the impact of the NC and renin-angiotensin-aldosterone system blockers.

<b><i>Introduction:</i></b> Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) reduce proteinuria and slow renal disease progression more effectively than other therapies in patients with chronic kidney disease (CKD). However, differences regarding efficacy and safety between these therapies remain controversial. <b><i>Objectives:</i></b> Aim of this study was to analyze the different treatment effect of ACEI, ARB, and non-ACEI/ARB in CKD progression. The primary outcome was survival to end-stage renal disease (ESRD) and/or death and to ESRD censored by all-cause death, secondary outcomes were proteinuria reduction and hyperkalemia. <b><i>Methods:</i></b> We analyzed data from 1,120 patients extracted from the National Renal Healthcare Program cohort, which included 17,238 CKD nondialysis subjects who were successively monitored between ­September 1, 2004 and August 31, 2016. Inclusion criteria were at least a 1-year follow-up, 3 clinical visits, and no previous treatment with ACEI or ARB. From the baseline visit onward, patients continued with 3 different treatment schemes: no ACEI/ARB, started on ACEI or ARB, but while avoiding both treatments in combination. Chi², <i>t</i> test, binary logistic regression, and multivariate regression models (Cox proportional Hazard model and competing risk Fine and Gray model were used for statistical analysis. <b><i>Results:</i></b> Mean age and follow-up were 67.9 (± 15) and 3.8 (± 2) years, respectively. Estimated glomerular filtration rate averaged 42.1 ± 23 mL/min/1.73 m² and 300 (27%) patients were diabetics. Progression to ESRD was significantly worse in the no ACEI/ARB group (hazard ratio [HR] 4.23, 95% CI 1.28–13.92) versus ACEI (reference group; <i>p</i> = 0.01). The analysis by competing-risks’ regression showed significantly higher risk of ESRD in the no ACEI/ARB group (HR 3.63, 95% CI 1.34–9.85) versus ACEI (<i>p</i> = 0.01). There were no significant differences between ACEI and ARB groups (HR 1.31, 95% CI 0.37–4.66) regarding the risk of progression to ESRD. Survival was similar in all 3 groups (<i>p</i> = 0.051). Statistically significantly more patients experienced reductions in proteinuria/albuminuria in ACEI and ARB groups (together) versus no ACEI/ARB group (<i>p</i> = 0.016, OR 1.82, 95% CI 1.12–2.94). No difference in hyperkalemia frequency was found between them (<i>p</i> = 0.17). <b><i>Conclusions:</i></b> In patients with CKD, treatment with ACEI or ARB had a superior effect than no ACEI or ARB treatment on slowing kidney disease progression and on proteinuria reduction. Efficacy of ACEI and ARB was comparable.

Introduction The Renal Healthcare Program Uruguay (NRHP-UY) is a national, multidisciplinary program that provides care to chronic kidney disease (CKD) patients. In this study, we report the global results of CKD patient outcomes and a comparison between those treated at the NRHP-UY Units, with those patients who were initially included in the program but did not adhere to follow up. Methods A cohort of not-on dialysis CKD patients included prospectively in the NRHP-UY between October 1st 2004 and September 30th 2017 was followed-up until September 30th 2019. Two groups were compared: a) Nephrocare Group: Patients who had at least one clinic visit during the first year on NRHP-UY (n = 11174) and b) Non-adherent Group: Patients who were informed and accepted to be included but had no subsequent data registered after admission (n = 3485). The study was approved by the Ethics Committee and all patients signed an informed consent. Outcomes were studied with Logistic and Cox´s regression analysis, Fine and Gray competitive risk and propensity-score matching tests. Results 14659 patients were analyzed, median age 70 (60–77) years, 56.9% male. The Nephrocare Group showed improved achievement of therapeutic goals, ESKD was more frequent (HR 2.081, CI 95%1.722–2.514) as planned kidney replacement therapy (KRT) start (OR 2.494, CI95% 1.591–3.910), but mortality and the combined event (death and ESKD) were less frequent (HR 0.671, CI95% 0.628–0.717 and 0.777, CI95% 0.731–0.827) (p = 0.000) compared to the Non-adherent group. Results were similar in the propensity-matched group: ESKD (HR 2.041, CI95% 1.643–2.534); planned kidney replacement therapy (KRT) start (OR 2.191, CI95% 1.322–3.631) death (HR 0.692, CI95% 0.637–0.753); combined event (HR 0.801, CI95% 0.742–0.865) (p = 0.000). Conclusion Multidisciplinary care within the NRHP-UY is associated with timely initiation of KRT and lower mortality in single outcomes, combined analysis, and propensity-matched analysis.

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