Kidney Function

Background: Preeclampsia (the development of proteinuria and hypertension after 20 weeks of gestation) is common; however, there is uncertainty about the natural history of subsequent kidney disease. Our objective is to undertake a systematic review and meta-analysis to determine whether women with a history of preeclampsia are at increased risk of subsequent kidney disease.Study Design: Systematic review and meta-analyses of observational studies.Setting & Population: Studies examining kidney outcomes in women with a history of preeclampsia compared with women with unaffected pregnancies.Selection Criteria: From MEDLINE and EMBASE searches, we included case-control and cohort studies of kidney outcomes at least 6 weeks postpartum in women with and without a history of preeclampsia. 2 independent reviewers determined study eligibility, extracted data, and assessed quality.Study Factor: Preeclampsia.Outcomes: Microalbuminuria, proteinuria, serum creatinine level, and estimated glomerular filtration rate.Results: 7 cohort studies were included, involving 273 patients with preeclampsia and 333 patients with uncomplicated pregnancies. At a weighted mean of 7.1 years postpartum, 31% of women with a history of preeclampsia had microalbuminuria compared with 7% of women with uncomplicated pregnancies, a 4-fold increased risk, whereas women with severe preeclampsia had an 8-fold increase. Serum creatinine level and estimated glomerular filtration rate were not significantly different at follow-up in women with and without preeclampsia, making it unlikely that they would have been different at baseline.Limitations: Limitations of this systematic review include potential confounders that were not explored in most or any of the original studies, the small size of many studies, and possible publication bias (lack of negative studies).Conclusion: Women with a history of preeclampsia have an increased risk of microalbuminuria with a prevalence similar to the published prevalence in patients with type 1 diabetes mellitus. Further research is needed to determine whether the increased risk of microalbuminuria persists after adjustment for a thorough set of confounding factors in larger populations and the mechanisms underlying this association.

Background: Left ventricular hypertrophy (LVH) is common in patients with end-stage renal disease (ESRD) and an independent risk factor for premature cardiovascular death. Left atrial volume (LAV), measured using echocardiography, predicts death in patients with ESRD. Cardiovascular magnetic resonance (CMR) imaging is a volume-independent method of accurately assessing cardiac structure and function in patients with ESRD.Study Design: Single-center prospective observational study to assess the determinants of all-cause mortality, particularly LAV, in a cohort of ESRD patients with LVH, defined using CMR imaging.Setting & Participants: 201 consecutive ESRD patients with LVH (72.1% men; mean age, 51.6 ± 11.7 years) who had undergone pretransplant cardiovascular assessment were identified using CMR imaging between 2002-2008. LVH was defined as left ventricular mass index >84.1 g/m2 (men) or >74.6 g/m2 (women) based on published normal left ventricle dimensions for CMR imaging. Maximal LAV was calculated using the biplane area-length method at the end of left ventricle systole and corrected for body surface area.Predictors: CMR abnormalities, including LAV.Outcome: All-cause mortality.Results: 54 patients died (11 after transplant) during a median follow-up of 3.62 years. Median LAV was 30.4 mL/m2 (interquartile range, 26.2-58.1). Patients were grouped into high (median or higher) or low (less than median) LAV. There were no significant differences in heart rate and mitral valve Doppler early to late atrial peak velocity ratio. Increased LAV was associated with higher mortality. Kaplan-Meier survival analysis showed poorer survival in patients with higher LAV (log rank P = 0.01). High LAV and left ventricular systolic dysfunction conferred similar risk and were independent predictors of death using multivariate analysis.Limitations: Only patients undergoing pretransplant cardiac assessment are included. Limited assessment of left ventricular diastolic function.Conclusions: Higher LAV and left ventricular systolic dysfunction are independent predictors of death in ESRD patients with LVH.

Background: It is controversial whether tighter glycemic control is associated with better clinical outcomes in people with kidney failure. We aim to determine whether worse glycemic control, measured using serum glucose and hemoglobin A1c (HbA1c) levels, is independently associated with higher mortality in patients undergoing maintenance hemodialysis.Study Design: Retrospective cohort study.Setting & Participants: 1,484 patients starting maintenance hemodialysis therapy in Alberta, Canada, between 2001 and 2007.Predictor: Serum glucose and HbA1c levels.Outcome: All-cause mortality.Measurements: Monthly casual glucose levels from specimens drawn immediately before the first dialysis treatment were averaged over 3 months before and after hemodialysis therapy initiation. Similarly, monthly HbA1c values in patients with or at risk of diabetes were averaged.Results: Overall, median age was 66 years, 41% were women, 75% were white, and 55% had diabetes. All-cause mortality during 8 years (median, 1.5 years) was 43%; it was 49% in those with diabetes. There was no relation between average glucose level and mortality in unadjusted analysis (HR, 1.00 per 18 mg/dL [1 mmol/L]; P = 0.4) or after adjustment for confounders (HR, 0.98 per 18 mg/dL; 95% CI, 0.96-1.01; P = 0.2). Higher HbA1c level was not associated with mortality when analyzed in the unadjusted analysis (HR, 1.01 per 1% HbA1c; P = 0.9) or after adjustment for confounders (HR, 0.98 per 1% HbA1c; 95% CI, 0.88-1.08; P = 0.7). Results were similar when HbA1c values were divided into prespecified categories (adjusted P > 0.6 for trend). Markers of malnutrition-inflammation (albumin, hemoglobin, and white blood cell values) or the presence of diabetes did not influence the relation between glycemic control and death (all P for interaction > 0.2).Limitations: Registry data; casual serum glucose measurements; HbA1c values available for only a subset of participants.Conclusions: Higher casual glucose and HbA1c levels were not associated with mortality in maintenance hemodialysis patients with or without diabetes. This may have implications for recommended glycemic targets, quality indicators, and how best to assess glycemic control in this high-risk population.