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The MERENA Observational Study

The MERENA Observational Study. Source: Martínez-Castelao A, Górriz JL, Portolés JM, et al . Baseline characteristics of patients with chronic kidney disease stage 3 and stage 4 in Spain: the MERENA observational cohort study. BMC Nephrol . 2011;12:53–64. Background:

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The MERENA Observational Study

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  1. The MERENA Observational Study Source: Martínez-Castelao A, Górriz JL, Portolés JM, et al. Baseline characteristics of patients with chronic kidney disease stage 3 and stage 4 in Spain: the MERENA observational cohort study. BMC Nephrol. 2011;12:53–64.

  2. Background: Chronic kidney diseases (CKD) is associated with increased morbidity, mortality, and has an adverse effect on the quality of life and/or progression to end-stage renal disease (ESRD). Decline in the renal function increases the risk of death and cardiovascular (CV) events, requiring renal replacement therapy (RRT), as evident with some studies. In an attempt to obtain information relative to not only CV morbidity but also data relative to hypertension, anemia and mineral metabolism from a large and contemporary Spanish cohort called Morbimortalidad en Enfermedad REnal en pacieNtes diAbéticos y no diabéticos (MERENA), which translates into morbimortality in CKD stage 3–4 in diabetic and non-diabetic.

  3. Aim: To obtain information on CV morbidity, hypertension control, anemia and mineral metabolism based on the analysis of the baseline characteristics of a large cohort of Spanish patients.

  4. Study details: An ongoing prospective, observational, multicenter study of patients with stage 3 and 4 CKD.

  5. Methods: • Multicenter study from the Spanish government hospital-based nephrology outpatient clinics. • 1129 patients with CKD stage 3 (n=434) and 4 (n=695) defined by glomerular filtration rate (GFR) calculated by the Modification of Diet in Renal Disease (MDRD) formula. • Additional analysis was performed with GFR calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Cockcroft–Gault formula.

  6. Results: • Effect of age: In the cohort with higher age (median age=70.9 years), the morbidity from all cardiovascular disease (CVD) was very high (39.1%). • Effect of CKD stage: Patients with CKD stage 4 was higher compared to CKD stage 3 (42.2% vs 35.6%, p<0.024). • CVD increased with declining GFR with the hierarchy (stage 3a < stage 3b < stage 4) [where: stage 3a and 3b comes after sub-dividing the stage 3 into 3a and 3b, and adjusting the age] when calculated by CKD-EPI (31.8%, 35.4%, 42.1%, respectively, p<0.039) and Cockcroft–Gault formula (30.9%, 35.6%, 43.4%, respectively, p<0.010) and MDRD formula (32.5%, 36.2%, 42.2%, respectively) but with the latter, it did not reach statistical significance (p<0.882). • 91.2% patients with stage 3 and 94.1% patients with stage 4 had hypertension, despite the use of more than 3 anti-hypertensive agents including widespread use of RAS blockers. • 60% of patients were observed with proteinuria (>300 mg/day), and there was no significant differences between stages 3 and 4 CKD (1.2±1.8 and 1.3±1.8 g/day, respectively). • Hemoglobin levels greater than 11 g/dL (91.1% and 85.5% in stage 3 and 4 CKD, respectively, p<0.001) was observed, while the use of erythropoiesis-stimulating agents (ESA) was limited to 16% and 34.1% in stage 3 and 4 CKD patients, respectively. • Elevated levels of intact parathyroid hormone (i-PTH) in stage 3 and 4 CKD patients (121±99 and 166±125 pg/mL, respectively, p<0.001) was observed despite good control of calcium–phosphorus levels.

  7. Conclusion: The study stratified the effect of CKD on CV morbidity, hypertension, mineral metabolism and hemoglobin levels. An increase in CV mortality was seen with increasing severity of CKD. Hypertension was found to be an invariable risk in stage 3 and 4 CKD; almost all patients were hypertensive despite effective BP control. Despite calcium–phosphorous homeostasis being near-normal, widespread secondary hyperthyroidism was noted. This gives rise to the idea that vitamin D supplements may be essential in CKD patients.

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