Occult Adrenal Insufficiency in Patients with Chronic Renal Disease

Background: Addison’s disease is a rare disorder of the adrenal cortex that leads to inadequate production of cortisol initially followed by aldosterone and androgens. Its manifestations are usually slow and non-specific with potential for life-threatening adrenal crisis following hypermetabolic demands (infection, trauma, surgery). Patients: Over the past 10 years, 19 CRD-patients were diagnosed with occult PAI in our center. Results: Unprovoked hypotension was the most common manifestations of occult PAI and was the unmasking event in 11 (58%). It was without significant cardiac and/or severe systemic sepsis and was refractory to isotonic saline infusions. Equal number of the remaining patients (n = 2) presented with persistent and inexplicable electrolytes abnormalities viz. 1) hyponatremia despite restricted oral fluid intake, lack of dehydration and massive fluid overload, as well as 2) hyperkalemia despite potassium-restricted diet, hyperkalemic drugs and adequate therapy with Furosemide and low-potassium dialysis-baths. On the other hand, similar proportions presented with unprovoked 3) progressive weight loss, decrease appetite and cachexia as well as 4) frequent hypoglycemic attacks. All patients were treated and were medically stable after 29 (2 - 60) months of follow up. Autoantibodies to 21-hydroxylase enzyme were positive in 16 (90%). At diagnosis, and subsequent follow up, only 7 patients (37%) had multi-endocrine dysfunction of whom 2 with type 1 and 5 with type 2. Conclusion: High index of suspicion should be exerted in diagnosis of PAI in patients with CRD, since its clinical picture is similar to CRD manifestations and complications. In those patients, confirmatory tests and specific management can save their lives. .

Hematological Alterations in an Eastern Sudanese Chronic Kidney Disease Patient Population

Background: Chronic Kidney Disease (CKD), associated with a slow and progressive loss of kidney function over a period of several years, is an important clinical disaster with an increasing rate of morbidity and mortality especially in the least developed countries. Many hematological parameters are thought to alter dramatically during the course of the disease. These include white blood cells, red blood cells, and platelets. Methods: We tried, retrospectively, to evaluate the peripheral blood hematological alterations in a group of patients undergoing hemodialysis in an eastern Sudan dialysis center to add local medical information. Results: Anemia (Low hemoglobin and hematocrit) was detected in 94% of the patients’ group. Mean Erythrocyte count (3.32vs.4.76 (×109/L)), Hemoglobin concentration (9.4vs.13 (g/dl)), Hematocrit (28.7vs.38.7 (L/L)) and platelet count (296 vs. 238 (×109/L)) were significantly lower in the patients’ group than in the control group (P-values Conclusion: Five out of eight studied parameters (Red cell count, hemoglobin, hematocrit, mean cell hemoglobin concentration, and platelets count) have shown a significant alteration in CKD patients. As the complete blood count (CBC) test is the most utilized test in clinical laboratory practice, these alterations may be considered as early indicators for CKD. Furthermore, all patients with CKD must be routinely checked for these alterations.

What is the optimal level of vitamin D in non-dialysis chronic kidney disease population?

AIM To evaluate thresholds for serum 25(OH)D concentrations in relation to death, kidney progression and hospitalization in non-dialysis chronic kidney disease(CKD) population.METHODS Four hundred and seventy non-dialysis 3-5 stage CKD patients participating in OSERCE-2 study, a prospective, multicenter, cohort study, were prospectively evaluated and categorized into 3 groups according to 25(OH)D levels at enrollment(less than 20 ng/mL, between 20 and 29 ng/mL, and at or above 30 ng/mL), considering 25(OH)D between 20 and 29 ng/mL as reference group. Association between 25(OH)D levels and death(primary outcome), and time to first hospitalization and renal progression(secondary outcomes) over a 3-year followup, were assessed by Kaplan-Meier survival curves and Cox-proportional hazard models. To identify 25(OH)D levels at highest risk for outcomes, receiver operating characteristic(ROC) curves were performed.RESULTS Over 29 ± 12 mo of follow-up, 46(10%) patients dead, 156(33%) showed kidney progression, and 126(27%) were hospitalized. After multivariate adjustment, 25(OH)D < 20 ng/mL was an independent predictor of all-cause mortality(HR = 2.33; 95%CI: 1.10-4.91; P = 0.027) and kidney progression(HR = 2.46; 95%CI: 1.63-3.71; P < 0.001), whereas the group with 25(OH)D at or above 30 ng/mL did not have a different hazard for outcomes from the reference group. Hospitalization outcomes were predicted by 25(OH) levels(HR = 0.98; 95%CI: 0.96-1.00; P = 0.027) in the unadjusted Cox proportional hazards model, but not after multivariate adjusting. ROC curves identified 25(OH)D levels at highest risk for death, kidney progression, and hospitalization, at 17.4 ng/mL [area under the curve(AUC) = 0.60; 95%CI: 0.685-0.69; P = 0.027], 18.6 ng/mL(AUC = 0.65; 95%CI: 0.60-0.71; P < 0.001), and 19.0 ng/m L(AUC = 0.56; 95%CI: 0.50-0.62; P = 0.048), respectively.CONCLUSION25(OH)D < 20 ng/mL was an independent predictor of death and progression in patients with stage 3-5 CKD, with no additional benefits when patients reached the levels at or above 30 ng/m L suggested as optimal by CKD guidelines.

Anemia treatment and left ventricular hypertrophy in non-dialysis chronic kidney disease

To this day, the target hemoglobin level that minimizes cardiovascular risk in chronic kidney disease (CKD) patients remains unclear. When one examines the many randomized trials of epoetin therapy in aggregate, enhanced quality of life provides the most cogent argument for hemoglobin levels above 110 g/L. It remains unclear whether treatment of anemia improves longevity, or even a surrogate marker (such as left ventricular [LV] mass index), especially when applied at earlier phases of CKD.

Morphological and Structural Study of Native Kidneys in Chronic Kidney Disease Patients on Dialysis Compared to Non-Dialysis Patients

Whether on dialysis or not, native kidneys in chronic kidney disease (CKD) patients undergo morphological and structural changes. Objective: To study native kidney morphometric and structural aspects in CKD patients on dialysis and non-dialysis patients. Methods: It was a descriptive, analytical, and cross-sectional study conducted from May to December 2018. The study enrolled CKD patients on dialysis or not followed at CNHU-HKM in Cotonou. Renal ultrasound was performed to locate cysts and uroscanner completed in the presence of atypical cysts. Through logistic regression, associated factors were determined. Results: The sample size was 240 patients, of which 151 (62.9%) were receiving dialysis and 89 (37.1%) non-dialysis patients. Male subjects were predominant (sex ratio = 1.5). The average size of the right kidney, expressed in mm in patients on dialysis was: pole-to-pole length = 78.56;width = 42.06;cortical thickness = 11.80;and the left kidney: pole-to-pole length = 79.76;width = 41.53;cortical thickness = 12.6. For non-dialysis patients, the following size was recorded for the right kidney: pole-to-pole length = 92.35;width = 47.61;cortical thickness = 15.64;and left kidney: length = 92.13;width = 47.82;cortical thickness = 15.43. Predictive factors for the occurrence of acquired renal cysts were: old age (p = 0.0001), dialysis (p < 0.001) and diabetic nephropathy (p = 0.0014). Conclusion: CKD patients on dialysis have small kidneys and are more likely to develop acquired renal cysts. There is a need to carry out an annual ultrasound screening for native kidneys in patients receiving dialysis.

Exploring kidney biopsy findings in congenital heart diseases:Insights beyond cyanotic nephropathy

BACKGROUND The association between congenital heart disease and chronic kidney disease is well known.Various mechanisms of kidney damage associated with congenital heart disease have been established.The etiology of kidneydisease has commonly been considered to be secondary to focal segmental glomerulosclerosis(FSGS),however,this has only been demonstrated in case reports and not in observational or clinical trials.AIM To identify baseline and clinical characteristics,as well as the findings in kidney biopsies of patients with congenital heart disease in our hospital.METHODS This is a retrospective observational study conducted at the Nephrology Depart-ment of the National Institute of Cardiology“Ignacio Chávez”.All patients over 16 years old who underwent percutaneous kidney biopsy from January 2000 to January 2023 with congenital heart disease were included in the study.RESULTS Ten patients with congenital heart disease and kidney biopsy were found.The average age was 29.00 years±15.87 years with pre-biopsy proteinuria of 6193 mg/24 h±6165 mg/24 h.The most common congenital heart disease was Fallot’s tetralogy with 2 cases(20%)and ventricular septal defect with 2(20%)cases.Among the 10 cases,one case of IgA nephropathy and one case of membranoproliferative glomerulonephritis associated with immune complexes were found,receiving specific treatment after histopathological diagnosis,delaying the initiation of kidney replacement therapy.Among remaining 8 cases(80%),one case of FSGS with perihilar variety was found,while the other 7 cases were non-specific FSGS.CONCLUSION Determining the cause of chronic kidney disease can help in delaying the need for kidney replacement therapy.In 2 out of 10 patients in our study,interventions were performed,and initiation of kidney replacement therapy was delayed.Prospective studies are needed to determine the usefulness of kidney biopsy in patients with congenital heart disease.

Anti-fibrotic and anti-inflammatory effect of mesenchymal stromal cell-derived extracellular vesicles in chronic kidney disease

Renal fibrosis and inflammation are common pathological features of chronic kidney disease(CKD).Since currently available treatments can only delay the progression of CKD,the outcome of patients with CKD is still poor.One therapeutic option for the prevention of CKD-related complications could be the use of mesenchymal stromal cells(MSCs),which have shown beneficial effects in tissue fibrosis and regeneration after damage.However,safety issues,such as cellular rejection and carcinogenicity,limit their clinical application.Among the bioactive factors secreted by MSCs,extracellular vesicles(EVs)have shown the same beneficial effect of MSCs,without any notable side effects.This heterogeneous population of membranous nano-sized particles can deliver genetic material and functional proteins to injured cells,prompting tissue regeneration.Here we describe the anti-fibrotic and antiinflammatory properties of MSC-derived EVs in CKD preclinical models and summarize the potential molecular mechanisms involved in the regulation of renal fibrosis and inflammation.

Complexity and Management of Chronic Kidney Disease

Chronic Kidney Disease (CKD) is ongoing damage of the kidneys, which affects their ability to filter the blood the way they should. Worldwide CKD is considered as the 16th leading cause of death and affects 8% - 16% of the population. CKD often goes unnoticed and is revealed as an incidental finding. Healthcare providers diagnose the condition as CKD based on persistent abnormal kidney function tests revealing kidney damage markers > 3 months, urine albumin creatinine ratio (UACR) > or equal to 30 mg/g per 24 hours, and GFR < 60 mL/min/1.73m2. In this article, we have discussed chronic kidney disease in terms of kidney physiology, chronic kidney disease pathophysiology, etiology, diagnosis, signs and symptoms, and management.

Factors Associated with Non-Compliance among Patients with Chronic Kidney Disease at the Departmental University Hospital of Borgou and Alibori in Parakou (Benin)

Introduction: Therapeutic compliance in chronic kidney disease (CKD) represents a major challenge for the prevention of this condition, which is both a non-communicable disease (NCD) and a complication of other NCDs. Non-adherence to treatment (NOT) is a factor in the poor prognosis of CKD in developing countries, particularly in Benin. The aim of this study was to evaluate therapeutic compliance (TC) and determine the factors associated with non-compliance in patients with chronic kidney disease undergoing treatment at the Departmental University Hospital of Borgou and Alibori in Parakou (CHUD/B-A). Patients and Methods: This study was carried out in the Nephrology Department of CHUD/B-A. It was a cross-sectional, descriptive study with analytical aims that ran from December 25, 2022 to March 15, 2023 and covered data from 2017 to 2022. It involved 345 patient records meeting the diagnosis of CKD according to the KDIGO 2012 criteria. NOT was defined by a Girerd score evaluation greater than or equal to 3. Data processing and analysis were performed with R software version 4.3.0. Results: The mean age (SD) of patients was 50 years (±14.9). The prevalence of NOT was 57.1%. Potential predictors of non-adherence were: monthly revenue (p = 0.009), mode of admission (p = 0.001), phytotherapy (p = 0.040), traditional treatment (p = 0.049) and quantity of drugs (p = 0.042). Conclusion: Therapeutic compliance among chronic kidney patients still needs to be improved through awareness-raising sessions.

Evaluation of chronic kidney disease in chronic heart failure: From biomarkers to arterial renal resistances

Chronic kidney disease and its worsening are recurring conditions in chronic heart failure(CHF) which are independently associated with poor patient outcome.The heart and kidney share many pathophysiological mechanisms which can determine dysfunction in each organ. Cardiorenal syndrome is the condition in which these two organs negatively affect each other, therefore an accurate evaluation of renal function in the clinical setting of CHF is essential. This review aims to revise the parameters currently used to evaluate renal dysfunction in CHF with particular reference to the usefulness and the limitations of biomarkers in evaluating glomerular dysfunction and tubular damage. Moreover, it is reported the possible utility of renal arterial resistance index(a parameter associated with abnormalities in renal vascular bed) for a better assesment of kidney disfunction.

Anti-hepatitis C virus therapy in chronic kidney disease patients improves long-term renal and patient survivals

BACKGROUND Hepatitis C virus (HCV) infection is a documented risk factor for chronic kidney disease (CKD) and progression to end-stage renal disease (ESRD). However, to date there are no reports on the long-term hard endpoints (ESRD and death) of anti-HCV therapy [interferon-based therapy (IBT) or new direct-acting antivirals] in CKD patients. Direct-acting antivirals are not available in Taiwan’s singlepayer national health insurance database currently released for research. Therefore, we hypothesized that a retrospective analysis of the long-term outcomes of IBT in CKD patients will serve as a proxy for direct-acting antivirals to increase our understanding of progression to ESRD following HCV infection. AIM To evaluate the long-term outcomes (ESRD and death) of anti-HCV therapy, especially IBT, in HCV-infected patients with stage 1-5 CKD. METHODS We analyzed 93894 Taiwan Residents adults diagnosed with CKD and without HBV infection. Of these, 4.9% were infected with HCV. Of the 4582 HCV-infected CKD patients, 482 (10.5%) received IBT (treated cohort). They were matched 1:4 with 1928 untreated HCV-infected CKD patients (untreated cohort) by propensity scores and year, which further matched 1:2 by propensity scores with 3856 CKD patients without HCV infection (uninfected cohort). All participants were followed until the occurrence of ESRD, death, or the end of 2012. The association between HCV infection, IBT use, and risks of ESRD and death was analyzed using competing risk analysis. RESULTS Taking the uninfected cohort as a reference, the adjusted hazard ratios for ESRD, after adjusting for competing mortality, were 0.34 (0.14-0.84, P = 0.019) and 1.28 (1.03-1.60, P = 0.029) in the treated and untreated cohorts, respectively. The treated cohort had a 29%(0.54-0.92, P = 0.011) decrease in mortality compared to the untreated cohort, in which the mortality was 31%(1.18-1.45, P < 0.001) higher than in the uninfected cohort. The reduced risks of ESRD (0.14, 0.03–0.58, P = 0.007) and death (0.57, 0.41-0.79, P = 0.001) were greatest in HCV-infected CKD patients who received at least 4 mo of IBT, which accounted for 74% of the treated cohort.CONCLUSION Adequate anti-HCV therapy in CKD patients improves long-term renal and patient survival.

Polymorphism of Renalase Gene in Patients of Chronic Kidney Disease

Introduction: Chronic kidney disease (CKD) is an important public health problem. Early detection and treatment is a key factor for prevention of its complications. Hypertensive nephrosclerosis is a subtype of CKD which has a poor correlation between hypertension and development of nephropathy, implying role of genetic factors or epigenetic factors. The knowledge regarding genetic factors is limited. Renalase is a novel hormone with its gene on chromosome 10, which secretes flavin adenine dinucleotide dependent amine oxidase. Renalase metabolizes circulating catecholamines and modulates blood pressure and cardiac function. Recently, two single nucleotide polymorphisms of renalase gene rs2576178 GG and rs2296545 CC have been linked to essential hypertension. The SNPrs2296545 CC is also shown to be associated with cardiac hypertrophy, dysfunction and ischemia. The association of these two single nucleotide polymorphisms with hypertensive nephrosclerosis has not been investigated. Methods: We designed a case-control study to investigate whether the two known renalase gene polymorphisms rs2576178 and rs2296545 are associated with CKD particularly hypertensive nephrosclerosis. We genotyped these two polymorphisms in 287 subjects from North Indian population (106 CKD cases and 181 controls). Results: Comparison shows that subjects with hypertensive nephrosclerosis had higher frequencies of rs2296545 Callele than the healthy controls (0.63 versus 0.47, p 0.02). The odds ratio for rs2296545 CC genotype in hypertensive nephrosclerosis were 2.55 (95% CI, 1.03 to 6.42;p = 0.02) (CC versus GG) and 2.11(95% CI, 1.01 to 4.42;p = 0.03) (CC versus CG + GG) compared to controls. Conclusion: These findings may provide novel insight into the role of additional genomic regions as susceptibility gene in the pathophysiology of hypertensive nephrosclerosis. Further, to account for geoethnic variation, studies on heterogeneous populations involving a larger sample size are required. The correlation between this structural change and actual levels of the enzyme or the activity are required to strengthen this association as well as to be clinically applicable.

Chronic kidney disease after radical nephrectomy for suspected renal cancers

Nephrectomy is the treatment of choice for early stage renal cell carcinoma. However,radical nephrectomy is consistently associated with higher rates of newonset chronic kidney disease(CKD) than the general population,regardless of the method used in measuring renal function. The higher rates of CKD are associated with worsened survival because of increased risk of cardiovascular diseases and mortality. Comorbidities and adjacent non-neoplastic kidney diseases are important risk factors for the development of CKD after nephrectomy. Partial nephrectomy has become the standard of care for patients with stage 1a tumours(diameter < 4 cm) and an attractive option for those with stage 1b(diameter 4-7 cm). Therefore stratifying the risk of postoperative CKD before surgery is important and ongoing monitoring of kidney function after radical nephrectomy is needed in addition to oncological surveillance. More research is needed to better understand the risk of CKD after radical nephrectomy and develop effective strategies to optimize kidney function after such surgery.

Effects of sleep status on renal function in patients with chronic kidney disease: a systematic review

Objective:To systematically evaluate the effects of sleep status on renal function in patients with chronic kidney disease (CKD).Methods: To search the relevant literature related to the effects of sleep status on renal function of CKD patients on PubMed database, EMBase database, the Cochrane Library database, CNKI database, Chinese Biomedical Literature Database, VIP and Wanfang database from the initial to June 2018, all literature that met the criteria were included. According to the type of studies, the quality of the literature was evaluated by NOS scale in the cohort study and AHRQ scale in the cross-sectional study, and systematically evaluated the outcome indicators, the main outcome indicators were estimated glomerular filtration rate (eGFR) and endogenous creatinine clearance rate (Ccr), while the secondary indicators were Pittsburgh Sleep Quality Index (PSQI), Sleep Quality (SQ), Serum Creatinine (Scr), Hemoglobin (Hb), Albumin (ALB) and Urine Protein/Creatinine Ratio (UPCR).Results: Four literature and one meeting abstract were included in this study, of which four were cohort studies, three of them the NOS quality evaluations were high, one of them was medium, the remaining one was cross-sectional study, and the AHRQ quality evaluation was medium. This study shows that sleep status has a certain correlation with renal function. Shorter sleep time or poor sleep quality can lead to deterioration of renal function. Among them, the research data of Sabbatinit research team in Italy showed that Ccr gradually decreased with the increased of the PSQI;studies of Cohen research team and the Ricardo research team in the United States showed that eGFR decreased with the increased of the PSQI;the study of Kumar research team in the United States showed that the lower SQ , the worse renal function;the study of Knutson' research team in British showed that the shorter sleep time, the lower eGFR. In addition, studies showed that sleep index also has influence on Hb, ALB, Scr, UPCR and other indicators.Conclusion: Sleep status can affect the renal function of CKD patients in different degrees. Shorter sleep time and poor sleep quality will damage renal function and accelerate the progress of CKD.

Management of patients with hepatitis C infection and renal disease

Hepatitis C virus(HCV) infection in patients with end-stage renal disease(ESRD) is associated with more rapid liver disease progression and reduced renal graft and patients' survival following kidney transplantation. Evaluations and management of HCV in patients with renal disease are challenging. The pharmacokinetics of interferons(IFN), ribavirin(RBV) and some direct acting antiviral(DAA), such as sofosbuvir, are altered in patients with ESRD. With dose adjustment and careful monitoring, treatment of HCV in patients with ESRD can be associated with sustained virological response(SVR) rates nearly comparable to that of patients with normal renal function. DAA-based regimens, especially the IFNfree and RBV-free regimens, are theoretically preferred for patients with ESRD and KT in order to increase SVR rates and to reduce treatment side effects. However, based on the data for pharmacokinetics, dosing safety and efficacy of DAA for patients with severe renal impairment are lacking. This review will be focused on the evaluations, available pharmacologic data, and management of HCV in patients with severe renal impairment, patients who underwent KT, and those who suffered from HCV-related renal disease, according to the available treatment options, including DAA.

Establishing the presence or absence of chronic kidney disease:Uses and limitations of formulas estimating the glomerular filtration rate

The development of formulas estimating glomerular filtration rate(eG FR) from serum creatinine and cystatin C and accounting for certain variables affecting the production rate of these biomarkers, including ethnicity, gender and age, has led to the current scheme of diagnosing and staging chronic kidney disease(CKD),which is based on e GFR values and albuminuria.This scheme has been applied extensively in various populations and has led to the current estimates of prevalence of CKD. In addition, this scheme is applied in clinical studies evaluating the risks of CKD and the efficacy of various interventions directed towards improving its course. Disagreements between creatinine-based and cystatin-based e GFR values and between e GFR values and measured GFR have been reported in various cohorts. These disagreements are the consequence of variations in the rate of production and in factors, other than GFR, affecting the rate of removal of creatinine and cystatin C. The disagreements create limitations for all e GFR formulas developed so far. The main limitations are low sensitivity in detecting early CKD in several subjects, e.g., those with hyperfiltration, and poor prediction of the course of CKD. Research efforts in CKD are currently directed towards identification of biomarkers that are better indices of GFR than the current biomarkers and,particularly, biomarkers of early renal tissue injury.

Treatment of dyslipidemia in chronic kidney disease: Effectiveness and safety of statins

Several cardiovascular(CV)risk factors may explain the high rate of CV death among patients with chronic kidney disease(CKD).Among them both traditional and uremia-related risk factors are implicated and,moreover,the presence of kidney disease represents"per se"a multiplier of CV risk.Plasma lipid and lipoprotein profiles are changed in quantitative,but above all in qualitative,structural,and functional ways,and lipoprotein metabolism is influenced by the progressive loss of renal function.Statin therapy significantly reduces cholesterol synthesis and both CV morbidity and mortality either directly,by reducing the lipid profile,or via pleiotropic effects;it is supposed to be able to reduce both the progression of CKD and also proteinuria.These observations derive from a post-hoc analysis of large trials conducted in the general population,but not in CKD patients.However,the recently published SHARP trial,including over 9200 patients,either on dialysis or pre-dialysis,showed that simvastatin plus ezetimibe,compared with placebo,was associated with a significant low-density lipoprotein cholesterol reduction and a 17%reduction in major atherosclerotic events.However,no benefit was observed in overall survival nor in preserving renal function in patients treated.These re-cent data reinforce the conviction among nephrologists to consider their patients at high CV risk and that lipid lowering drugs such as statins may represent an important tool in reducing atheromatous coronary disease which,however,represents only a third of CV deaths in patients with CKD.Therefore,statins have no protective effect among the remaining two-thirds of patients who suffer from sudden cardiac death due to arrhythmia or heart failure,prevalent among CKD patients.The safety of statins is demonstrated in CKD by several trials and recently confirmed by the largest SHARP trial,in terms of no increase in cancer incidence,muscle pain,creatine kinase levels,severe rhabdomyolysis,hepatitis,gallstones and pancreatitis;thus confirming the handiness of statins in CKD patients.Here we will review the latest data available concerning the effectiveness and safety of statin therapy in CKD patients.

Patient selection and preparation strategies for the use of contrast material in patients with chronic kidney disease

The prevalence of chronic kidney disease and peripheral arterial disease is increasing.Thus,it is increasingly problematic to image these patients as the number of patients needing a vascular examination is increasing accordingly.In high-risk patients with impaired kidney function,intravascular administration of iodinated contrast media can result in contrast-induced acute kidney injury and Gadolinium can induce nephrogenic systemic fibrosis(NSF).It is important to identify these highrisk patients by means of se-creatinine/e glomerular filtration rate.The indication for contrast examination should counterbalance the increased risk.One or more alternative examination methods without contrast media,such as CO 2 angiography,Ultrasound/Doppler examination or magnetic resonance angiography without contrast should be considered,but at the same time,allow for a meaningful outcome of the examination.If contrast is deemed essential,the patient should be well hydrated,the amount of contrast should be restricted,the examination should be focused,metformin and diuretics stopped,and renal function monitored.Sodium bicarbonate and N-acetylcysteine are popular but their efficiency is not evidence-based.There is no evidence that dialysis protects patients with impaired renal function from contrast-induced nephropathy or NSF.

Sleep disorders and chronic kidney disease

Sleep disorders have a profound and well-documented impact on overall health and quality of life in the general population. In patients with chronic disease, sleep disorders are more prevalent, with an additional morbidity and mortality burden. The complex and dynamic relationship between sleep disorders and chronic kidney disease(CKD) remain relatively little investigated. This article presents an overview of sleep disorders in patients with CKD, with emphasis on relevant pathophysiologic underpinnings and clinical presentations. Evidence-based interventions will be discussed, in the context of individual sleep disorders, namely sleep apnea, insomnia, restless leg syndrome and excessive daytime sleepiness. Limitations of the current knowledge as well as future research directions will be highlighted, with a final discussion of different conceptual frameworks of the relationship between sleep disorders and CKD.

Cardiovascular disease and renal insufficiency:special considerations with cardiac surgery

Cardiovascular disease is an important cause of mortality in the chronic kidney disease (CKD) population. This review discusses cardiac surgery in the CKD population and considers ostoperative acute renal failure (ARF). CKD patients have worse outcomes following coronary artery bypass grafting (CABG) and cardiac valvular surgery than the general population. However,surgical revascularization is an effective treatment for coronary artery disease (CAD) in this population and may be associated with improved survival over percutaneous intervention (PCI) in advanced CKD. Cardiac surgery in the CKD population requires careful perioperative planning and management. Acute renal failure (ARF) is a serious complication following cardiac surgery, occurring in 1 to 8% of cases. Management of postoperative ARF is largely supportive and emphasis is placed on preoperative risk stratification and prevention.