Syndrome of Rapid Onset End-stage Renal Disease reducing the increasing worldwide AKI epidemic in CKD patients.37 This


would have even more far-reaching consequences with reference to reducing the ESRD epidemic if SORO-ESRD is, in fact, shown to be prevalent in the US and worldwide.35


Case I


An 87-year-old Caucasian female patient presented to our unit in early October 2010 with progressive dyspnea, leg swelling, occasional nausea, and poor appetite. She had a history of hypertension, and had been followed in our unit as a CKD referral for many years. Her serum creatinine had progressively increased over the years and her admission serum creatinine was 6.6mg/dl (eGFR of 5ml/min/1.73m2 body surface area [BSA]). She was diagnosed with symptomatic ESRD and she started hemodialysis (HD) via a tunneled dialysis catheter for symptomatic uremia. Her eGFR curve in the last 12 years since 1998 appears in Figure 1.


Case II


A 72-year-old Caucasian diabetic hypertensive male patient, with a history of a previous coronary artery bypass procedure, had been seen in our Nephrology Unit since 1998. He was last seen in our unit in November 2009 with serum creatinine stable at about 2.5–3.0mg/dl in the previous 20 months. He usually traveled to Florida during the winter months. While in Florida, he developed chest pain in February 2010, with electrocardiogram (ECG) changes consistent with an acute coronary event. He therefore urgently underwent a cardiac catheterization, angioplasty, and coronary artery stent placement. Within days of the cardiac procedure, serum creatinine had jumped to 7mg/dl, he was nauseated and vomiting, dropped his urine output, had no appetite, and was retaining fluids. He was started on HD via a tunneled dialysis catheter and has remained on HD ever since. His serum creatinine and eGFR curves in the last 12 years, respectively, appear in Figures 2 and 3.


Patients and Methods


We present here the results of a parallel evaluation of the patterns of CKD to ESRD progression among patients with CKD in our Hypertension Clinic, Midelfort Clinic, Mayo Health System, Eau Claire, Wisconsin, and among a CKD cohort seen by my former colleagues at the Renal Unit of the University of Nigeria Teaching Hospital, Ituku-Ozalla, to ascertain the prevalence of SORO-ESRD in both populations.


Luther Midelfort, Mayo Health System, Eau Claire, Wisconsin


Between September 2002 and March 2005, in a north-western Wisconsin hypertension clinic practice, we prospectively enrolled 100 Caucasian CKD patients exhibiting ≥25% increase in baseline serum creatinine while receiving an angiotensin-converting enzyme inhibitor (ACEI) and/or angiotensin receptor blocker (ARB). RAAS blockade was promptly discontinued. We have continued to prospectively follow and monitor these patients since then. Details of these patients have been variously described in the literature.35–41


Utilizing a network of interconnected and


robust realtime electronic medical record (EMR) systems, together with face-to-face evaluations by the first author, usually every three months, or more frequently as indicated by clinical events, we have been able to continuously and prospectively follow these patients and to monitor clinical events and outcomes such as changes in eGFR, hospitalizations,


US NEPHROLOGY


ESRD and need for RRT, and deaths. Most of their inpatient hospitalizations and major surgical procedures are carried out at the Luther Hospital, Mayo Health System under the close supervision of the first author.35–41


In June 2009 we completed an 82-month prospective and detailed patient-level data analysis of this CKD cohort to determine the pattern of progression to ESRD and the need for RRT. The details of this analysis were recently reported in Renal Failure.35


University of Nigeria Teaching Hospital, Ituku-Ozalla, near Enugu, Nigeria


Working with my former colleagues at the University of Nigeria Teaching Hospital, Ituku-Ozalla, we retrospectively examined the records of 98 CKD patients seen between January 2005 and October 2010 at the Renal Unit of the hospital to determine the pattern of CKD progression to ESRD and the need for RRT.


Results


Luther Midelfort, Mayo Health System, Eau Claire, Wisconsin


One hundred Caucasian CKD patients were enrolled. At enrollment, there were 52 males and 48 females, mean age 71.5 years (25–92). Seventy-five patients (75%) were over 65 years old, 63% over 70 years old, and 23% over 80 years old. Medical diagnoses included hypertension (45), diabetes and hypertension (45), dilated cardiomyopathy (four), diabetes alone (three), kidney transplant (two), vasculitis (two), and immunoglobulin A (IgA) nephropathy (one). Mean enrollment serum creatinine values, in 92 out of 100 patients, were 3.2±2.1 (1.2–18.7) mg/dl (p=0.0000001). Correspondingly, mean enrollment eGFR was 22.1±8.8 (6–45) ml/min/1.73m2 BSA (p<0.001). Mean follow-up was over four years. Seventeen of the patients (17%) had progressed to ESRD during follow-up, requiring RRT. At enrollment these 17 patients had CKD stage III (two), stage IV (11), and stage V (four), respectively. Of the 17 patients who developed ESRD, eight have since died, two had received kidney allografts, six had continued to receive maintenance outpatient HD, and one was lost to follow-up. In the preceding 30 months before July 2009, only two new patients had reached ESRD, and, in both instances, the observed accelerated progression to ESRD followed cardiothoracic surgical procedures.35


One was a 68-year-old female patient who


underwent aortic valve replacement in March 2008. The other patient was a 77-year-old male who underwent coronary artery bypass graft procedure in January 2007. Age did not predict progression to ESRD. Most pertinently, ESRD progression was unpredictable by baseline eGFR. The progression to ESRD was accelerated, unanticipated, and preceded by AKI in 15 out of 17 (88%) of the CKD patients. The causes of AKI in the 15 patients include hypotension or cardiogenic shock (seven), sepsis (two), post-cardiac surgery (two), malignant lymphoma (one), contrast nephropathy (one), obstruction (one), and dementia with failure to thrive (one). These results have been reported earlier in 2010.35


University of Nigeria Teaching Hospital, Ituku-Ozalla, near Enugu, Nigeria


At the University of Nigeria Teaching Hospital, Ituku-Ozalla, between January 2005 and October 2010, the Renal Unit had followed 98 CKD patients, comprising 59 males and 39 females. In 70 of the patients with evaluable data, the causes of CKD were chronic glomerulonephritis in 25 patients (36%), hypertension in 22 patients (31%), diabetes in 10 patients


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