The Oxford Classification of IgA nephropathy (IgAN) includes the following four histologic components: mesangial (M) and endocapillary (E) hypercellularity, segmental sclerosis (S) and interstitial fibrosis/tubular atrophy (T). These combine to form the MEST score and are independently associated with renal outcome. Current prediction and risk stratification in IgAN requires clinical data over 2 years of follow-up. Using modern prediction tools, we examined whether combining MEST with cross-sectional clinical data at biopsy provides earlier risk prediction in IgAN than current best methods that use 2 years of follow-up data. We used a cohort of 901 adults with IgAN from the Oxford derivation and North American validation studies and the VALIGA study followed for a median of 5.6 years to analyze the primary outcome (50% decrease in eGFR or ESRD) using Cox regression models. Covariates of clinical data at biopsy (eGFR, proteinuria, MAP) with or without MEST, and then 2-year clinical data alone (2-year average of proteinuria/MAP, eGFR at biopsy) were considered. There was significant improvement in prediction by adding MEST to clinical data at biopsy. The combination predicted the outcome as well as the 2-year clinical data alone, with comparable calibration curves. This effect did not change in subgroups treated or not with RAS blockade or immunosuppression. Thus, combining the MEST score with cross-sectional clinical data at biopsy provides earlier risk prediction in IgAN than our current best methods.
The pathophysiology of hypertension in patients on renal replacement therapy is not yet clear, and the role of extracellular fluid overload is still a matter of debate. The main problem is the lack of techniques to determine the fluid state. Recently new noninvasive techniques have become available which make it possible to accurately determine the hydration state in these patients. We have studied the influence of the hydration state on interdialytic blood pressure in 45 patients: 21 (46.6%) using antihypertensive medication and 24 (53.4%) without antihypertensive medication. Total body water (TBW) was determined by bioelectrical impedance analysis performed just before a hemodialysis session. The TBW was then related to the fat-free mass calculated by the anthropometric method (aFFM) of Durnin. The hydration state was defined using the following formula: TBW/aFFM·100. Furthermore, for each patient the ideal TBW was calculated according to the Watson formula. The difference between TBW and ideal TBW was considered a further index of the hydration state. Ambulatory blood pressure monitoring was performed by using a Takeda 2420 recorder according to the Korotkoff method during the 24 h before the midweek hemodialysis session. Blood pressure monitoring showed a significant correlation with the hydration state of these patients. In conclusion, the hydration state seems to play a major role in interdialytic blood pressure control.
In summary, the present study shows that the PDC(TM) program is a robust, accurate method to describe the peritoneal membrane transport characteristics. Analysis of PDC(TM) data of large groups of patients, especially if followed up over time, can give interesting information on the physiology of the peritoneal membrane and the impact of different parameters on it.
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