The majority of patients (96%) with renal insufficiency at the time of dialysis initiation (compared to those with normal renal function) receive ACEI or ARB at the time of dialysis initiation. ACEI or ARB is the primary agent for improving survival and preventing progression of chronic kidney disease in both renal insufficiency groups. ARBs may be more effective than ACEI in patients with renal insufficiency (and advanced chronic kidney disease) in preventing progression of chronic kidney disease at the initial time of dialysis initiation. We postulate that this difference in benefit may result from higher plasma concentrations of ARB, possibly attributable to poor absorption.
Patients with the most severe type of CKD have decreased survival. They are older and have more comorbid conditions and more advanced dialysis dependence and comorbidities when they enter the kidney replacement program. Better understanding of the underlying mechanisms and therapies are warranted to provide the optimal treatment for these patients and their families.
The number of people with declining renal function continues to be increasing, although current trends seem to be slowing. The cause of this slowing trend is not clear and warrants further study.
The common denominator underlying chronic kidney disease is an increase in glomerular filtration rate. The causes of this increase can vary from simple ageing to more complex metabolic disease that include a range of risk factors, such as hypertension, diabetes and excess weight. This in turn, predisposes to albuminuria, proteinuria or diabetic nephropathy. Over time the damage that affects other organs of chronic kidney disease causes the kidney to become a target organ by itself, as illustrated by the development of kidney cancer.
We found signs of deterioration of renal function in our study. The severity of renal dysfunction was similar to that of the general population. It can be associated with multiple causes (e.g., proteinuria, glomerular filtration impairment, high urinary albumin excretion or metabolic syndrome). More work is needed to establish a standard definition of renal impairment.
When renal function is seriously impaired, dialysis or hemodialysis can only slow the decline of renal function and improve the patient's quality of life. However, some patients with worsening renal function may benefit from aggressive interventions in the form of peritoneal dialysis or renal transplantation.
The kidney is a key organ involved in protein metabolism and plays a vital role in maintaining blood pressure. The kidney deteriorates from a chronic or sudden loss of proteins. Once the kidney stops working, it can become a life-threatening condition. Kidney failure can occur in both acute or chronic kidney diseases. Dialysis and kidney transplant are the two treatment options available to patients with end-stages of kidney failure. In the United States, one out of three patients have end-stages of kidney failure, [over a lifetime] with women being more likely to develop end-stage kidney failure in comparison to men. Women were also three times as likely to need to initiate hemodialysis in comparison to men.
This subgroup of patients had worse health-related quality of life before tolebrutinib therapy, but there was no worsening after either time points tested. Treatment with tolebrutinib was tolerated by most patients who experienced progressive renal function decline.
Given that the field of renal disease has been dominated by nephrologists, there are few clinicians with significant experience in treating this disease. Furthermore, most of the current treatment strategies require a combination of more than one therapeutic approach to treat worsening renal function. Current research is focused mostly on individual therapies such as ACE inhibition, glucocorticoids, and the immunosuppressive agents. Clinical trials are underway for individual therapies to determine their efficacy. But, more research and clinical trials will be needed to develop a treatment strategy for treating progressing renal function.
The primary cause of declining renal function was diabetic nephropathy. In a recent study, findings illustrates the value of a comprehensive evaluation of patient's co-morbidities in the initial management when nephropathy develops in non-insulin dependent diabetes.
TBR treatment was associated with a high-density decline in glomerular turnover at baseline, suggestive of acute glomerular injury, despite the absence of any changes in kidney histologic abnormalities by follow-up that correlated with an associated rise in serum creatinine level. The high prevalence of renal dysfunction at this dose warrants caution when considering a broad-spectrum kinase inhibitor in the treatment setting for patients with chronic kidney disease.
There was a marked improvement in patient reported symptoms and UPCR, with tolebrutinib. This promising trial is the first to demonstrate a beneficial effect of tolebrutinib on these parameters in a patient with CLL.