This Month in AJKD

Article Outline

• Diabetic Kidney Disease in Siblings of Patients With Diabetic Kidney Disease
• Intrauterine Growth Restriction and Kidney Function: The HUNT 2 Study
• Metabolic Syndrome and CKD in American Indians: The Strong Heart Study
• Circadian Variation of Death in Hemodialysis Patients
• Global Disparities in Health Care

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Diabetic Kidney Disease in Siblings of Patients With Diabetic Kidney Disease 

See Bleyer et al, pages 29-37.

Siblings of patients with treated kidney failure from diabetic kidney disease, who themselves have diabetes, are at a 5-fold increased risk of future kidney failure. Given this risk, prevention, early diagnosis, and appropriate treatment of kidney disease are critical for these siblings. In this issue, Bleyer et al looked at blood pressure, albumin to creatinine ratio, HbA1c, and other measures in 295 diabetic siblings, with a mean diabetes duration of 15 years. Albuminuria was present in 46% of participants. Surprisingly, the authors found that only 35.3% of the siblings had a target systolic blood pressure less than 130 mm Hg, and HbA1c was greater than or equal to 7% in 57.4% of the siblings. In addition, only 58% of the siblings received ACE-inhibitors or angiotensin receptor blockers. Bleyer et al conclude that targeting these high risk individuals for interventions to improve blood pressure and blood glucose control might prevent the development or slow the progression of diabetic kidney disease.

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Intrauterine Growth Restriction and Kidney Function: The HUNT 2 Study 

See Hallan et al, pages 10-20 and Ingelfinger, pages 1-4.

The Nord Trøndelag Health (HUNT 2) Study enrolled 7,457 Norwegian adults aged 20 to 30 years between 1995 and 1997 to test a debated question: whether intrauterine growth restriction is associated with later impairment in kidney function. In this issue, Hallan et al compared estimated kidney function among individuals with birth weight small and very small for gestational age to those with birth weight appropriate for gestational age. Men born small or very small for gestational age had consistently higher odds for low-normal kidney function, whereas women born small or very small for gestational age had a less consistent increase in odds. An editorial by Dr Ingelfinger further examines the HUNT 2 study and compares it with other studies of its kind.

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• Fetal weight percentiles throughout gestation. Reprinted with permission from Peleg D, et al: Intrauterine Growth Restriction: Identification and Management. American Family Physician 58:453-460

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Metabolic Syndrome and CKD in American Indians: The Strong Heart Study 

See Lucove et al, pages 21-28.

While overt diabetes is a major risk factor for kidney function decline, it remains unclear whether early metabolic changes in patients without diabetes, such as those associated with the metabolic syndrome, are also associated with the development of chronic kidney disease (CKD). In this issue, Lucove et al examined the relationship between the metabolic syndrome and CKD in 2,420 nondiabetic American Indian participants in the Strong Heart Study. The adjusted hazard ratio for developing CKD in those with the metabolic syndrome was 1.3 (95% CI, 1.1 to 1.6); the adjusted hazard ratios for developing ACR ≥ 30mg/g and eGFR < 60 mL/min/1.73 m² were 1.4 (95% CI, 1.0 to 1.9) and 1.3 (95% CI, 1.0 to 1.6), respectively. The relationship between the metabolic syndrome and kidney outcomes was stronger among those who developed diabetes during follow-up, suggesting that development of diabetes may mediate the relationship between metabolic syndrome and risk for development of CKD.

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Circadian Variation of Death in Hemodialysis Patients 

See Tislér et al, pages 53-61.

In nondialysis populations, sudden death from cardiovascular events shows a circadian rhythm, with an inordinate number of events occurring in the morning. In this issue, Tislér et al investigated whether this is also true in patients on hemodialysis (HD) by collecting data on time of death for all prevalent (>3 months on HD) and incident (≤3 months on HD) patients of a dialysis network for 18 months. The authors compared the frequency of deaths occurring in the morning hours (4:01-12:00) to what would be expected by chance alone, and found that in the 459 prevalent HD patients, morning deaths occurred approximately 25% more frequently than expected (P<0.001). No similar excess was observed in the 414 incident HD patients (P=0.9), leading Tisléer et al to conclude that prevalent HD patients have an excess of morning deaths, and that its predictors (patient characteristics and circumstances of death) suggest potential avenues for intervention studies.

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Global Disparities in Health Care 

See O’Neil, pages 145-154.

Global disparities in health care overshadow disparities within nations. In this month’s World Kidney Forum, Dr O’Neil, author of Awakening Hippocrates and an emergency staff physician at St. Elizabeth’s Medical Center and Assistant Professor of Emergency Medicine at Tufts University School of Medicine, highlights these global disparities. Dr O’Neil notes the differences among countries in treatment of acute kidney injury from natural disasters, suggesting that these differences reflect disparities in wealth and the burden of illness. Dr O’Neil urges physicians to consider the question “Why should we respond to problems overseas when we have so many problems here?” and answers, “As members of a healing profession, our obligations are to our patients, and there is no nationalistic component to the Hippocratic Oath, or to the unspoken ethic of what we do. Our profession has an honorable heritage that should incite the better angels within us.” Dr O’Neil then urges physicians to become more involved, noting that there are now more than 300 organizations listed in his book, A Practical Guide to Global Health Service, that send health professionals abroad, including nephrologists.

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