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Background: The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is most accurate for estimating glomerular filtration rate (GFR) but requires an adjustment for African-American patients. Estimation equations are also improved with the use of serum cystatin C combined with standardized creatinine. Combination equations have been derived by the CKD-EPI and Chinese investigators. We investigated whether these cystatin C-based equations improve estimation adequately, so that adjustments for ethnicity are not required in a multiethnic Asian population with chronic kidney disease (CKD)., Methods: This was a cross-sectional study of 232 stable CKD patients who underwent GFR measurements using 3-sample plasma clearances of (99m)Tc-DTPA, and for whom serum cystatin C and creatinine were quantified., Results: For all patients, the median biases with cystatin C equations were generally greater than with the CKD-EPI equation, and precision and root mean square error (RMSE) were not significantly better. However, the combination serum creatinine and cystatin C equation improved the precision, RMSE, and percentage of estimated GFR to within 15% and 30% of the measured GFR (57.3% vs 50.0%, 88.4% vs 82.8%, respectively). The derived ethnicity coefficients for the combination equation were all >1 (1.009-1.082) but small, suggesting that coefficients are not required. The Chinese-specific equations were more biased and performed more poorly than the CKD-EPI equation., Conclusions: The use of a cystatin C and creatinine combination equation for estimating GFR in a multiethnic Asian population with CKD does not require ethnicity coefficients because the derived coefficients are very close to each other.

Background: Clinical practice guidelines recommend using equations for estimating glomerular filtration rate (GFR) in chronic kidney disease (CKD) management and research. The MDRD (Modification of Diet in Renal Disease) Study and CKD-EPI (CKD Epidemiology Collaboration) equations originally were derived from a North American population and had an ethnic coefficient adjustment for African Americans. A Chinese coefficient for the MDRD Study equation subsequently was determined, but this has not been externally validated. We compared the accuracy of the equations, evaluated the ethnic coefficients, and assessed the equations for disease staging in a multiethnic Asian population with CKD., Study Design: A diagnostic test study comparing the Asian coefficient (and subgroups)-modified MDRD Study and CKD-EPI equations and a cross-sectional study assessing disease staging., Setting & Participants: 232 outpatients (52% men; 40.5% Chinese, 32% Malay, and 27.5% Indian/other) with stable CKD., Index Test: Asian and ethnicity-based modifications of the MDRD Study and CKD-EPI equations., Reference Test: Measured GFR using 3-sample plasma clearance of technetium-99m diethylenetriaminepentaacetic acid ((99m)Tc-DTPA), calculated using the slope-intercept method, with body surface area normalization (du Bois) and Brochner-Mortensen correction., Results: Overall, the CKD-EPI equation is more accurate than the MDRD Study equation throughout the GFR range, with improved bias (median difference of estimated GFR - measured GFR) and root mean square error (P <0.001). CKD-EPI versus MDRD Study equation: bias, 1.1 ± 13.8 vs -1.0 ± 15.2 mL/min/1.73 m(2); precision, 12.1 vs 12.2 mL/min/1.73 m(2). Ethnic coefficients did not improve estimates of GFR significantly. The correctness of staging was improved using the CKD-EPI equation., Limitations: All participants had CKD, but few were of European descent. The reference GFR technique was different from the original studies., Conclusions: The CKD-EPI is more accurate than the MDRD Study equation, particularly at higher GFRs. Therefore, we recommend adopting the CKD-EPI equation without ethnic adjustment for estimating GFR in multiethnic Asian patients with CKD., (Copyright © 2011 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: For patients on dialysis with poor quality of life and prognosis, dialysis withdrawal and subsequent transition to palliative care is recommended. This study aims to understand multi-stakeholder perspectives regarding dialysis withdrawal and identify their information needs and support for decision-making regarding withdrawing from dialysis and end-of-life care. Methods: Participants were recruited through purposive sampling from eight dialysis centers and two public hospitals in Singapore. Semi-structured in-depth interviews were conducted with 10 patients on dialysis, 8 family caregivers, and 16 renal healthcare providers. They were held in-person at dialysis clinics with patients and caregivers, and virtually via video-conferencing with healthcare providers. Interviews were audio-recorded, transcribed, and thematically analyzed. The Ottawa Decision Support Framework's decisional-needs manual was used as a guide for data collection and analysis, with two independent team members coding the data. Results: Four themes reflecting perceptions and support for decision-making were identified: a) poor knowledge and fatalistic perceptions; b) inadequate resources and support for decision-making; c) complexity of decision-making, unclear timing, and unpreparedness; and d) internal emotions of decisional conflict and regret. Participants displayed limited awareness of dialysis withdrawal and palliative care, often perceiving dialysis withdrawal as medical abandonment. Patient preferences regarding decision-making ranged from autonomous control to physician or family-delegated choices. Cultural factors contributed to hesitancy and reluctance to discuss end-of-life matters, resulting in a lack of conversations between patients and providers, as well as between patients and their caregivers. Conclusions: Decision-making for dialysis withdrawal is complicated, exacerbated by a lack of awareness and conversations on end-of-life care among patients, caregivers, and providers. These findings emphasize the need for a culturally-sensitive tool that informs and prepares patients and their caregivers to navigate decisions about dialysis withdrawal and the transition to palliative care. Such a tool could bridge information gaps and stimulate meaningful conversations, fostering informed and culturally aligned decisions during this critical juncture of care. [ABSTRACT FROM AUTHOR]

Purpose: There are limited data on blood pressure variability (BPV) in Singapore. The absence of updated local guidelines might contribute to variations in diagnosis, treatment and control of hypertension and BPV between physicians. This study evaluated BPV awareness, hypertension management and associated training needs in physicians from Singapore.Materials and Methods: Physicians from Singapore were surveyed between September 8, 2016, and October 5, 2016. Those included were in public or private practice for ≥3 years, cared directly for patients ≥70% of the time and treated ≥30 patients for hypertension each month. The questionnaire covered 6 main categories: general blood pressure (BP) management, BPV awareness/diagnosis, home BP monitoring (HBPM), ambulatory BP monitoring (ABPM), BPV management and associated training needs.Results: Responses from 60 physicians (30 general practitioners [GPs], 20 cardiologists, 10 nephrologists) were analyzed (77% male, 85% aged 31-60 years, mean 22 years of practice). Approximately 63% of physicians considered white-coat hypertension as part of BPV. The most common diagnostic tool was HBPM (overall 77%, GPs 63%, cardiologists 65%, nephrologists 70%), but ABPM was rated as the tool most valued by physicians (80% overall), especially specialists (97%). Withdrawn Singapore guidelines were still being used by 73% of GPs. Approximately 48% of physicians surveyed did not adhere to the BP cutoff recommended by most guidelines for diagnosing hypertension using HBPM (>135/85 mmHg). Hypertension treatment practices also varied from available guideline recommendations, although physicians did tend to use a lower BP target for patients with diabetes or kidney disease. There were a number of challenges to estimating BPV, the most common of which was patient refusal of ABPM/HBPM. The majority of physicians (82%) had no training on BPV, but stated that this would be useful.Conclusion: There appear to be gaps in knowledge and guideline adherence relating to the assessment and management of BPV among physicians in Singapore. [ABSTRACT FROM AUTHOR]

Background: Adiponectin and leptin, two of the key cytokines secreted by adipocytes, have been shown to be associated with cardiovascular disease. However, the association of these adipocytokines with chronic kidney disease (CKD) is not clear. We examined the association of serum adiponectin, leptin levels and leptin to adiponectin ratio (LAR) with CKD in a population-based sample of Asian adults. Methods: We conducted a case-control study (450 CKD cases and 920 controls matched for age, sex and ethnicity) involving Chinese and Indian adults aged 40–80 years who participated in the Singapore Epidemiology of Eye Diseases Study (2007–2011). CKD was defined as an estimated glomerular filtration rate <60 mL/min/1.73m2 from serum creatinine. Serum adiponectin and leptin levels were measured using commercially available ELISA. Odds ratio of CKD associated with elevated adiponectin and leptin levels were estimated using logistic regression models adjusted for age, gender, ethnicity, education, smoking, body mass index, diabetes, blood pressure, total and HDL cholesterol. Results: CKD cases had higher levels of leptin (mean [SD] 9.7 [11.5] vs.16.9 [20.2] ng/mL, p<0.0001) and adiponectin (10.4 [7.4] vs. 9.2 [4.2], p = 0.001) compared to controls. In multi-variable models, compared to those in the lowest quartile, the OR (95% confidence interval) of CKD among those in the highest quartile were: 6.46 (3.84, 10.88), 1.94 (1.32–2.85) and 2.88 (1.78–4.64) for leptin, adiponectin and LAR. Similar associations were also observed when adiponectin and leptin were analyzed as continuous variables. This positive association of serum adiponectin, leptin and LAR with CKD was consistently present in subgroups of gender, ethnicity, diabetes, hypertension and overweight status (all P-interaction >0.1). Conclusions: Higher levels of serum adiponectin, leptin and LAR were positively associated with CKD independent of traditional risk factors in this Asian population. [ABSTRACT FROM AUTHOR]

Background. The use of spot urine protein to creatinine ratios in estimating 24 hr urine protein excretion rates for diagnosing and managing chronic kidney disease (CKD) predated the standardization of creatinine assays. The comparative predictive performance of spot urine ratios and 24 hr urine collections (of albumin or protein) for the clinical outcomes of CKD progression, end-stage renal disease (ESRD), and mortality in Asians is unclear. We compared 4 methods of assessing urine protein excretion in a multiethnic population of CKD patients. Methods. Patients with CKD (n=232) provided 24 hr urine collections followed by spot urine samples the next morning. We created multiple linear regression models to assess the factors associated with GFR decline (median follow-up: 37 months, IQR 26–41) and constructed Cox proportional-hazards models for predicting the combined outcome of ESRD and death. Results. The linear regression models showed that 24 hr urine protein excretion was most predictive of GFR decline but all other methods were similar. For the combined outcomes of ESRD and death, the proportional hazards models had similar predictive performance. Conclusions. We showed that all methods of assessments were comparable for clinical end-points, and any method can be used in clinical practice or research. [ABSTRACT FROM AUTHOR]

Aim The Chronic Kidney Disease Collaboration - Epidemiology ( CKD-EPI) glomerular filtration rates ( GFR) estimation equation is believed to estimate GFR more accurately in healthy people but this has not been validated in Asians. We studied the distribution of GFR in a multi-ethnic Asian population without CKD, and compared the performance of measures of GFR estimation, including the CKD-EPI equation, Cockroft- Gault equation, and 24-hour urine creatinine clearances. Materials and Methods A total of 103 healthy volunteers without a history of kidney disease, hypertension, or diabetes underwent GFR measurement using 3-sample plasma clearance of 99m Tc- DTPA. Cockroft- Gault estimated GFR and 24-hour urine creatinine clearances were normalized to body surface area. Results The mean measured GFR was 101 ± 15.8 m L/min per 1.73 m2 and was lowest in Indians (93 ± 12.3 m L/min per 1.73 m2; P < 0.001). The CKD-EPI equation appears to be more accurate for healthy participants. Estimated GFR correlated with measured GFR ( r = 0.57, P < 0.001), and the mean difference is 3.72 ± 14.43 m L/min per 1.73 m2 ( P < 0.001). However, estimating GFR using self-directed 24-hour urine creatinine clearances is poorer than using the CKD-EPI equation. Conclusions GFR estimation using self-directed 24-hour urine collection for creatinine clearance is less accurate than using the CKD-EPI equation. A larger study is required to clarify GFR in healthy Asians, and the association of health outcomes of Asian kidney donors with lower GFR thresholds. [ABSTRACT FROM AUTHOR]

Purpose: Accurate assessment of kidney function is critical to evaluate living kidney donors. Direct glomerular filtration rate measurement using isotopes is currently the gold standard but it is complex and costly. We evaluated the performance of surrogate markers of the glomerular filtration rate in living kidney donors by comparing direct measurement of the rate to the creatinine based equation estimated rate, the kidney volume based estimated rate using a newly developed equation and creatinine clearance. Materials and Methods: We first statistically compared direct glomerular filtration rate measurement to the results of the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) creatinine based equations, and to creatinine clearance in 54 potential renal donors from 2006 to 2010. In 32 donors with cross-sectional computerized tomography available we used measured functional renal volume with age, gender, weight and serum creatinine to estimate the rate based on kidney volume according to a previously reported model. Kidney volume based measurement was compared to direct glomerular filtration rate measurement and assessed against the results of the best performing creatinine based equation. Results: In the first group of 54 donors the correlation index of the estimated glomerular filtration rate according to MDRD and CKD-EPI creatinine based equations, and to creatinine clearance was low compared to direct measurement. In the subset of 32 potential donors the kidney volume based estimated rate correlated better with direct measurement than MDRD equation results with higher accuracy (estimated 87.5% and 75.0% within 30% and 10% of direct rate measurement, respectively). Conclusions: To estimate the glomerular filtration rate in healthy individuals a volume based model correlated better than the MDRD equation, which is the best performing creatinine based equation used to estimate the rate. By providing a more robust estimation of the glomerular filtration rate in healthy potential kidney donors, the volume based model adds value to routine preoperative computerized tomography above that of anatomical evaluation. [Copyright &y& Elsevier]

The article discusses a study which examined serum high-sensitivity troponin concentrations in a multi-ethnic Asian population with stable chronic kidney disease. Topics covered include the cardiac effect of elevated troponins in CKD, the use of a high-sensitivity assay in the study, and basic characteristics of the study participants.