Showing papers by "Tilman B. Drüeke published in 2018"

Lowering Expectations with Niacin Treatment for CKD-MBD

Abstract: With the progression of CKD, increasingly severe disturbances of mineral and bone metabolism are observed, which are reflected by the term CKD-related mineral and bone disorder. The clinician’s goal is to prevent or correct these complications and many other CKD-associated complications as early

Achievement of Kidney Disease: Improving Global Outcomes mineral and bone targets between 2010 and 2014 in incident dialysis patients in France: the Photo-Graphe3 study.

Abstract: Background Abnormal serum phosphate, calcium and parathyroid hormone (PTH) levels in patients with chronic kidney disease (CKD) undergoing haemodialysis have been associated with poor survival. The French Phosphorus and Calcium Observatory (Photo-Graphe® 3) aimed to estimate the percentage of CKD patients achieving the three Kidney Disease: Improving Global Outcomes (KDIGO) targets about optimal serum phosphate, calcium and PTH over a 3.5-year follow-up period. Methods This was a prospective, multicentre, epidemiological observational study conducted with nephrologists in France, selected using a clustering approach. Eligible patients were adults undergoing intermittent haemodialysis or haemodiafiltration therapy started within the preceding 12 months. Data about clinical events, serum biochemistry and treatment were collected once every 6 months for 2.5 years and 12 months thereafter. Results Overall, 9010 incident patients were included (men, 63%; median age, 71 years) of whom 7515 (83.4%) were treated by haemodialysis and 1495 (16.6%) by haemodiafiltration. None had a history of fracture or revascularization while 89 (1%) patients had a history of parathyroidectomy >6 months. Overall, 874 (10%) patients received a kidney graft, 2183 (24%) died and 1148 (13%) were lost to follow-up. The proportion achieving the three KDIGO targets increased significantly from 11% to 16% (P < 0.0001) until Year 2, but remained stable afterwards. The percentage of incident dialysis patients with normal serum phosphate (P < 0.0001) or normal serum calcium (P < 0.0001) levels increased significantly over time, while no significant change was observed for those with controlled PTH. Conclusion Less than 20% of patients achieved the KDIGO recommendations although their proportion increased slightly over time.

Achievement of 2009 and 2017 Kidney Disease: Improving Global Outcomes mineral and bone targets and survival in a French cohort of chronic kidney disease Stages 4 and 5 non-dialysis patients

Abstract: Background. The aim of the third French Phosphorus and Calcium Observatory (Photo-Graphe (R) 3) was to assess the achievement of international Kidney Disease: Improving Global Outcomes (KDIGO) recommendations on optimal serum phosphate, calcium and parathyroid hormone (PTH) levels and possible associations with mortality in patients with chronic kidney disease (CKD). Methods. This was a prospective, observational study conducted with nephrologists in France who were selected using a clustering approach. Adult patients with non-dialysis Stage 4 or 5 CKD and no kidney graft history were eligible. Data about clinical events, serum biochemistry and treatment were collected every 6 months for 2.5 years and 12 months thereafter. The Kaplan-Meier method was used for survival analysis and Cox proportional hazards model for identification of factors associated with survival. Results. Overall, 566 CKD Stage 4 patients (men, 56%) and 153 CKD Stage 5 patients (men, 62%) were included. In Stage 4, only 14-15% patients achieved the three main 2009 KDIGO targets during the first 2 years and 22% at 2.5 years. In Stage 5 patients, the proportion remained \textless6% throughout. The percentages of patients achieving the three main 2017 KDIGO targets were slightly higher at each time point. Overall, 14% of Stage 4 and 10% of Stage 5 patients died in the observation period. Only age and haemoglobin level were significantly associated with risk of all-cause mortality. Conclusions. Few CKD patients achieved KDIGO mineral targets. Increased mortality risk was linked to older age and lower haemoglobin level, but not to serum calcium, phosphate or PTH targets.

Lessons from clinical trials with erythropoiesis-stimulating agents (ESAs)

Abstract: Initially, the optimal degree of anemia correction in patients with chronic kidney disease by erythropoiesis-stimulating agents (ESAs) relied mainly on the results of observational studies. Many of these studies supported full anemia correction. Subsequently, randomized controlled trials of small sample size examined intermediate outcomes, but only trials with hard outcomes could settle this issue convincingly. In contrast to expectations based on epidemiological studies, the randomized controlled trials of large sample size performed in patients with chronic kidney disease in the last two decades have convincingly shown that full anemia correction, as compared to partial anemia correction, is associated with increased risk of adverse events and mortality and that the increased risk outweighs potential benefit. Although transfusion needs decrease and quality of life increases with actively raised hemoglobin levels in severely anemic patients with chronic kidney disease, any benefit of increasing hemoglobin levels above 11.5 g/dL is at best unclear at present. As some of these patients may experience improvement in physical and mental health and overall well-being above this level, individualization of therapy may be chosen in those who are prepared to accept the associated risks. Future, adequately powered, and blinded randomized controlled trials of anemia treatment using patient-reported outcomes as primary rather than secondary endpoints are needed to answer the question of the optimal hemoglobin target as regards the quality of life.