Chronic kidney disease and cardiovascular risk in six regions of the world (ISN-KDDC): a cross-sectional study

Prevalence and Risk Factors of Chronic Kidney Disease in Patients With Type 2 Diabetes in China: Cross-Sectional Study

BACKGROUND

Chronic kidney disease (CKD) is a significant long-term complication of diabetes and is a primary contributor to end-stage kidney disease.

OBJECTIVE

This study aimed to report comprehensive nationwide data on the prevalence, screening, and awareness rates of CKD in Chinese patients with type 2 diabetes, along with associated risk factors.

METHODS

Baseline data analysis of the ongoing prospective, observational IMPROVE study was conducted. The study cohort comprised patients who had been diagnosed with type 2 diabetes more than 12 months prior, received at least 1 hypoglycemic medication, and were aged ≥18 years. The participants completed questionnaires and underwent laboratory assessments, including blood and urine samples. The data encompassed patient demographics, medical history, concurrent medications, and comorbidities. Comprehensive evaluations involved physical examinations, urinary albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), glycated hemoglobin (HbA1c), fasting blood glucose, 2-hour postprandial blood glucose, fasting blood lipid profile, and urinalysis. Descriptive statistics were applied for data interpretation, and logistic regression analyses were used to identify the CKD-associated risk factors in patients with type 2 diabetes.

RESULTS

A national study from December 2021 to September 2022 enlisted 9672 participants with type 2 diabetes from 45 hospitals that had endocrinology departments. The enrollees were from diverse regions in China, as follows: central (n=1221), east (n=3269), south (n=1474), north (n=2219), and west (n=1489). The prevalence, screening, and awareness rates of CKD among patients with type 2 diabetes were 31% (2997/9672), 27% (810/2997), and 54.8% (5295/9672), respectively. Multivariate binary regression analysis revealed that the CKD risk factors were screening, awareness, smoking, age, diabetes duration, concurrent antihypertensive and microcirculation medications, diabetic complications (foot, retinopathy, and neuropathy), hypertension, elevated low-density lipoprotein (LDL) cholesterol, and suboptimal glycemic control. Subgroup analysis highlighted an increased CKD prevalence among older individuals, those with prolonged diabetes durations, and residents of fourth-tier cities. Residents of urban areas that had robust educational and economic development exhibited relatively high awareness and screening rates. Notably, 24.2% (1717/7107) of patients with an eGFR ≥90 mL/min/1.73 m2 had proteinuria, whereas 3.4% (234/6909) who had a UACR <30 mg/g presented with an eGFR <60 mL/min/1.73 m2. Compared with patients who were cognizant of CKD, those who were unaware of CKD had increased rates of HbA1c ≥7%, total cholesterol >5.18 μmol/L, LDL cholesterol >3.37 μmol/L, BMI ≥30 kg/m2, and hypertension.

CONCLUSIONS

In a Chinese population of adults with type 2 diabetes, the CKD prevalence was notable, at 31%, coupled with low screening and awareness rates. Multiple risk factors for CKD have been identified.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05047471; https://clinicaltrials.gov/study/NCT05047471.

Beyond Numbers: How Biochemical Parameters Can Predict Outcomes in Chronic Kidney Disease Patients on Maintenance Hemodialysis

Introduction The treatment and management of patients undergoing maintenance hemodialysis (MHD) requires constant evaluation through the assessment of biochemical markers. This is necessary for treatment, to prevent progression to complications such as mineral bone disease, and to improve quality of life. We aimed to study the biochemical profile of patients with chronic kidney disease (CKD) grades 4 and 5 on MHD, identify markers altered due to different etiologies, duration of illness, and duration of hemodialysis, and create a panel of markers that can be useful in planning better management. Methods All consecutive patients attending the dialysis unit of ESIC Super Speciality Hospital with CKD grade 4 or grade 5 on MHD between 2019 and 2020 were recruited. A detailed clinical history and demographic profile were taken, and blood samples were collected from the patients during follow-up visits in plain and EDTA (ethylenediamine tetraacetic acid) tubes for analysis. Results A total of 312 patients (22.1% females and 77.9% males.) with a mean age of 49.74 ± 11.49 years were recruited. In the study population, diabetic nephropathy (DN) (17%) and hypertensive nephropathy (48.7%) were the two most prevalent causes of CKD. The majority (64%) of the patients were on MHD three times a week. The range of estimated glomerular filtration rate (eGFR) (ml/min/1.73 m2) at the time of initiation of MHD was 2.9-26.8 according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. The mean duration of MHD was 51.58 months, with a mortality rate of 5.9% during the follow-up period (3-108 months). Conclusion Optimal selection and combination of biochemical tests will help in ascertaining the adequacy of management, progress of disease, or complications in MHD patients. This in turn will help guide the clinicians in effectively using these markers in their day-to-day practice.

Overview of global healthcare policies for patients with chronic kidney disease: an integrative literature review

INTRODUCTION

Chronic kidney disease is a progressive and irreversible loss of kidney function and considerably affects the lives of patients and their families. Its high incidence necessitates efficient public policies for prevention and treatment. However, policies for chronic kidney disease education and awareness are scarce.

OBJECTIVE

To evaluate global public policies for the prevention and treatment of chronic kidney disease adopted in various regions, aiming to comprehend the differences between various models.

METHODS

This integrative review followed PRISMA recommendations and included papers published between 2016 and 2021 across several databases.

RESULTS

The 44 selected articles were categorized into three themes: structural and financial aspects of the organization of renal healthcare, access to renal healthcare or management of chronic kidney disease, and coping strategies for chronic kidney disease or kidney health. Critical analysis of the papers revealed global neglect of kidney disease in political agendas. Considerable policy variations exist between different countries and regions of the same country. Our research highlighted that free and universal health coverage, especially for the most vulnerable patients, is crucial for accessing treatment owing to the prohibitively high treatment costs.

CONCLUSION

Social, economic, and ethnic inequalities strongly correlate with disease occurrence, primarily affecting minority groups who lack health support, especially for the prevention and treatment of chronic kidney disease.

Mind the gap in kidney care: translating what we know into what we do

Historically, it takes an average of 17 years for new treatments to move from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. Now is the time to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions are diagnosed worldwide, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because it is often silent in the early stages. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from the patient to the clinician to the health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

De-indexed estimated glomerular filtration rates for the dosing of oral antidiabetic drugs in patients with chronic kidney disease

Introduction: Adjusting drug dose levels based on equations that standardize the estimated glomerular filtration rate (eGFR) to a body surface area (BSA) of 1.73 m2 can pose challenges, especially for patients with extremely high or low body mass index (BMI). The objective of the present study of patients with CKD and diabetes was to assess the impact of deindexing creatinine-based equations on estimates of kidney function and on the frequency of inappropriate prescriptions of oral antidiabetic drugs (OADs). Methods: The prospective CKD-REIN cohort is comprised of patients with eGFR <60 mL/min/1.73 m2. The inclusion criteria for this study were the use of OADs and the availability of data on weight, height and serum creatinine. We compared data for three BMI subgroups (group 1 <30 kg/m2; group 2 30-34.9 kg/m2; group 3 ≥35 kg/m2). Inappropriate prescriptions (contraindicated or over-dosed drugs) were assessed with regard to the summary of product characteristics and the patient's kidney function estimated with the 2009 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, the 2021 CKD-EPI equation, the Modification of Diet in Renal Disease (MDRD) equation, the European Kidney Function Consortium (EKFC) equation, their deindexed estimates, and the Cockcroft-Gault (CG) formula. The impact of deindexing the equations was evaluated by assessing 1) the difference between the indexed and deindexed eGFRs, and 2) the difference in the proportion of patients with at least one inappropriate OAD prescription between the indexed and deindexed estimates. Results: At baseline, 694 patients were receiving OADs. The median BMI was 30.7 kg/m2, the mean BSA was 1.98 m2, and 90% of patients had a BSA >1.73 m2. Deindexing the kidney function estimates led to higher eGFRs, especially in BMI group 3. The proportion of patients with at least one inappropriate prescription differed greatly when comparing indexed and deindexed estimates. The magnitude of the difference increased with the BMI: when comparing BMI group 1 with BMI group 3, the difference was respectively -4% and -10% between deindexed 2021 CKD-EPI and indexed CKD-EPI. Metformin and sitagliptin were the most frequent inappropriately prescribed OADs. Conclusion: We highlight significant differences between the BSA-indexed and deindexed versions of equations used to estimate kidney function, emphasizing the importance of using deindexed estimates to adjust drug dose levels - especially in patients with an extreme BMI.

Protein crotonylation: Basic research and clinical diseases

Crotonylation is an importantly conserved post-translational modification, which is completely different from acetylation. In recent years, it has been confirmed that crotonylation occurs on histone and non-histone. Crotonylated Histone primarily affects gene expression through transcriptional regulation, while non-histone Crotonylation mainly regulates protein functions including protein activity, localization, and stability, as well as protein-protein interactions. The change in protein expression and function will affect the physiological process of cells and even cause disease. Reviewing previous studies, this article summarizes the mechanisms of histone and non-histone crotonylation in regulating diseases and cellular physiological processes to explore the possibility of precise regulation of crotonylation sites as potential targets for disease treatment.

High prevalence of albuminuria among adult males living with HIV in Botswana

Chronic HIV disease is associated with a fivefold increase in albuminuria outside of sub-Saharan Africa. However, very little is known about albuminuria risk among people living with HIV (PLWH) in sub-Saharan Africa. Therefore, we conducted a cross-sectional observational HIV clinic-based study of albuminuria among 1533 adults aged 21 years or older between January 2020 and January 2021 in Gaborone, Botswana. Clinical albuminuria was defined using a sex-based albumin‒creatinine ratio (ACR) of 25-355 mg/g for females and 17-250 mg/g for males. The study population mean age was 48.5 (SD 10.3) years, and 764/1533 (49.7%) were female. The overall prevalence of albuminuria was 20.7% (95% CI 18.7%, 22.8%). A higher proportion of males were more likely to be categorized as having albuminuria than females, 25% (95% CI 22.0, 28.2) versus 16.4% (95% CI 13.8,19.2), P value < 0.001. In the final multivariate models, predictors of albuminuria differed by sex group. Larger longitudinal studies are required to evaluate the impact of albuminuria among PLWH with particular emphasis on the effect of sex on the risk of albuminuria.

Mind the Gap in Kidney Care: Translating What We Know into What We Do

Historically, it takes an average of 17 years to move new treatments from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. The time is now to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions worldwide are diagnosed, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because in the early stages it is often silent. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from patient to clinician to health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

Mind the gap in kidney care: Translating what we know into what we do

Historically, it takes an average of 17 years to move new treatments from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. The time is now to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions worldwide are diagnosed, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because in the early stages it is often silent. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from patient to clinician to health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

Glomerular crescents are associated with the risk of type 2 diabetic kidney disease progression: a retrospective cohort study

BACKGROUND

Diabetic kidney disease (DKD) stands as the predominant cause of chronic kidney disease and end-stage kidney disease. Its diverse range of manifestations complicates the treatment approach for patients. Although kidney biopsy is considered the gold standard for diagnosis, it lacks precision in predicting the progression of kidney dysfunction. Herein, we addressed whether the presence of glomerular crescents is linked to the outcomes in patients with biopsy-confirmed type 2 DKD.

METHODS

We performed a retrospective evaluation, involving 327 patients diagnosed with biopsy-confirmed DKD in the context of type 2 diabetes, excluding cases with other glomerular diseases, from nine tertiary hospitals. Hazard ratios (HRs) were calculated using a Cox regression model to assess the risk of kidney disease progression, defined as either ≥ 50% decrease in estimated glomerular filtration rates or the development of end-stage kidney disease, based on the presence of glomerular crescents.

RESULTS

Out of the 327 patients selected, ten patients had glomerular crescents observed in their biopsied tissues. Over the follow-up period (median of 19 months, with a maximum of 18 years), the crescent group exhibited a higher risk of kidney disease progression than the no crescent group, with an adjusted HR of 2.82 (1.32-6.06) (P = 0.008). The presence of heavy proteinuria was associated with an increased risk of developing glomerular crescents.

CONCLUSION

The presence of glomerular crescents is indeed linked to the progression of type 2 DKD. Therefore, it is important to determine whether there is an additional immune-mediated glomerulonephritis requiring immunomodulation, and it may be prudent to monitor the histology and repeat a biopsy.

Mind the Gap in Kidney Care: Translating What We Know Into What We do

Historically, it takes an average of 17 years to move new treatments from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. The time is now to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions worldwide are diagnosed, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because in the early stages, it is often silent. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary-care level. Many systematic barriers exist, ranging from patient to clinician to health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

Higher prevalence of kidney function impairment among older people living with HIV in Uganda

Background

People living with HIV (PLWH) are at risk of kidney function impairment due to HIV-related inflammation, antiretroviral therapy (ART), diabetes mellitus, and hypertension. Older persons may experience a higher burden of chronic kidney disease (CKD) as kidney function declines with increasing age. There is a paucity of data comparing the prevalence of kidney function impairment in older PLWH to that in HIV-uninfected people in sub-Saharan Africa.

Methods

We conducted a cross-sectional study among people aged ≥ 60 years living with and without HIV in Kampala, Uganda who were matched 1:1 by community location. We collected data on sociodemographics, comorbidities, and HIV-related clinical characteristics. We defined kidney function impairment as an estimated glomerular filtration rate(eGFR) < 60mls/min/1.73m2 with or without proteinuria. We constructed multivariable logistic regression models to study associations between participant characteristics and kidney function impairment.

Results

We enrolled 278 people (median age 66 years); 50% were PLWH, and 51.8% were female. Overall, the prevalence of kidney function impairment was 23.0% (95% CI:18.4%-28.4%); 33.1% (95% CI: 25.7%-41.4%) versus 12.9% (95% CI: 8.3%-19.7%) among people living with and without HIV (p-value < 0.01). The prevalence of proteinuria among PLWH versus people without HIV was 43.9% (95% CI:35.8%-52.3%) versus 19.4% (95% CI:13.6%-26.9%) p-value < 0.01. Living with HIV (OR = 3.89(95% CI: 2.04-7.41), p-value < 0.01), older age (OR = 1.13, (95% CI:1.07-1.20), p-value < 0.01), female sex (OR = 1.95, (95% CI:1.06-3.62), p-value = 0.03) and a prior diagnosis of hypertension (OR = 2.19(95% CI:1.02-4.67), p-value = 0.04) were significantly associated with kidney function impairment.

Conclusions

HIV infection is strongly associated with kidney function impairment among older PLWH. Prioritizing routine measurements of kidney function and proteinuria in older PLWH will enable early detection and institution of measures to reduce the progression of kidney disease.

Laboratory-based surveillance of chronic kidney disease in people with private health coverage in Brazil

BACKGROUND

Although approximately 25% of Brazilians have private health coverage (PHC), studies on the surveillance of chronic kidney disease (CKD) in this population are scarce. The objective of this study was to estimate the prevalence of CKD in individuals under two PHC regimes in Brazil, who total 8,335,724 beneficiaries.

METHODS

Outpatient serum creatinine and proteinuria results of individuals from all five regions of Brazil, ≥ 18 years of age, and performed between 10/01/2021 and 10/31/2022, were analyzed through the own laboratory network database. People with serum creatinine measurements were evaluated for the prevalence and staging of CKD, and those with simultaneous measurements of serum creatinine and proteinuria were evaluated for the risk category of the disease. CKD was classified according to current guidelines and was defined as a glomerular filtration rate (GFR) < 60 ml/min/1.73 m² estimated by the 2021 CKD-EPI equation.

RESULTS

The number of adults with serum creatinine results was 1,508,766 (age 44.0 [IQR, 33.9-56.8] years, 62.3% female). The estimated prevalence of CKD was 3.8% (2.6%, 0.8%, 0.2% and 0.2% in CKD stages 3a, 3b, 4 and 5, respectively), and it was higher in males than females (4.0% vs. 3.7%, p < 0.001, respectively) and in older age groups (0.2% among 18-29-year-olds, 0.5% among 30-44-year-olds, 2.0% among 45-59-year-olds, 9.4% among 60-74-year-olds, and 32.4% among ≥ 75-year-olds, p < 0.001) Adults with simultaneous results of creatinine and proteinuria were 64,178 (age 57.0 [IQR, 44.8-67.3] years, 58.1% female). After adjusting for age and gender, 70.1% were in the low-risk category of CKD, 20.0% were in the moderate-risk category, 5.8% were in the high-risk category, and 4.1% were in the very high-risk category.

CONCLUSION

The estimated prevalence of CKD was 3.8%, and approximately 10% of the participants were in the categories of high or very high-risk of the disease. While almost 20% of beneficiaries with PHC had serum creatinine data, fewer than 1% underwent tests for proteinuria. This study was one of the largest ever conducted in Brazil and the first one to use the 2021 CKD-EPI equation to estimate the prevalence of CKD.

Patients, healthcare providers, and general population preferences for hemodialysis vascular access: a discrete choice experiment

Background

A patient-centered dialysis treatment option requires an understanding of patient preferences for alternative vascular accesses and nephrologists often face difficulties when recommending vascular access to end-stage kidney disease (ESKD) patients. We aimed to quantify the relative importance of various vascular access characteristics to patients, healthcare providers and general population, and how they affect acceptability for patients and healthcare providers.

Methods

In a discrete choice experiment, patients with maintenance hemodialysis (MHD), healthcare providers, and individuals from the general population were invited to respond to a series of hypothetical vascular access scenarios that differed in five attributes: cumulative patency, infection rate, thrombosis rate, cost, and time to maturation. We estimated the respondents' preference heterogeneity and relative importance of the attributes with a mixed logit model (MXL) and predicted the willingness to pay (WTP) of respondents via a multinomial logit model (MNL).

Results

Healthcare providers (n = 316) and the general population (n = 268) exhibited a favorable inclination toward longer cumulative patency, lower access infection rate and lower access thrombosis rate. In contrast, the patients (n = 253) showed a preference for a 3-year cumulative patency, 8% access infection rate, 35% access thrombosis rate and 1.5 access maturity time, with only the 3-year cumulative patency reaching statistical significance. Among the three respondent groups, the general population found cumulative patency less important than healthcare providers and patients did. Patients demonstrated the highest WTP for cumulative patency, indicating a willingness to pay an extra RMB$24,720(US$3,708) for each additional year of patency time.

Conclusion

Patients and healthcare providers had a strong preference for vascular access with superior patency. While the general population preferred vascular access with lower thrombosis rates. These results indicate that most patients prefer autogenous arteriovenous fistula (AVF) as an appropriate choice for vascular access due to its superior patency and lower complications than other vascular access types.

Mind the gap in kidney care: Translating what we know into what we do

Historically, it takes an average of 17 years to move new treatments from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. The time is now to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions worldwide are diagnosed, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition because in the early stages, it is often silent. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from patient to clinician to health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

A novel enzyme-based functional correlation algorithm for multi-omics reveals the potential mechanisms of traditional Chinese medicines: Taking Jian-Pi-Yi-Shen formula as an example

The integrated analysis of host metabolome and intestinal microbiome is an opportunity to explore the complex therapeutic mechanisms of traditional Chinese medicines. Currently, researchers mainly employ various statistical correlation analytical methods to investigate metabolome-microbiome correlations. However, these conventional correlation techniques often focus on statistical correlations and their biological meanings are always ignored, especially the functional relevance between them. Here, we developed a novel enzyme-based functional correlation (EBFC) algorithm to further improve the interpretability and the identified scope of microbe-metabolite correlations based on the conventional Spearman's analysis. The proposed EBFC algorithm is successfully utilized to reveal the therapeutic mechanisms of Jian-Pi-Yi-Shen (JPYS) formula on the treatment of adenine-induced chronic kidney disease (CKD) rats. JPYS, a TCM formula for treating CKD, has beneficial clinical effects. We tentatively revealed the potential mechanism of JPYS for treating CKD rats from the perspective of the serum metabolome, gut microbiome, and their interactions. Specifically, 11 metabolites and 19 bacterial genera in the CKD rats were significantly regulated to approaching normal status after JPYS treatment, suggesting that JPYS could ameliorate the pathological symptoms of CKD rats by reshaping the disturbed metabolome and gut microbiota. Further correlation analysis between the significantly perturbed metabolites, microbiota, and the related enzymes provided more strong evidence for the study of host metabolism-microbiota interactions and the therapeutic mechanism of JPYS on CKD rats. In conclusion, these findings will help us to deeply understand the pathogenesis of CKD and provide new insights into the therapeutic mechanism of JPYS.

Role of Synbiotics (Prebiotics and Probiotics) as Dietary Supplements in Type 2 Diabetes Mellitus Induced Health Complications

Diabetes is a metabolic disorder whose prevalence has become a worrying condition in recent decades. Chronic diabetes can result in serious health conditions such as impaired kidney function, stroke, blindness, and myocardial infarction. Despite a variety of currently available treatments, cases of diabetes and its complications are on the rise. This review article provides a comprehensive account of the ameliorative effect of prebiotics and probiotics individually or in combination i.e. synbiotics on health complications induced by Type 2 Diabetes Mellitus (T2DM). Recent advances in the field underscore encouraging outcomes suggesting the consumption of synbiotics leads to favorable changes in the gut microbiota. These changes result in the production of bioactive metabolites such as short-chain fatty acids (crucial for lowering blood sugar levels), reducing inflammation, preventing insulin resistance, and encouraging the release of glucagon-like peptide-1 in the host. Notably, novel strategies supplementing synbiotics to support gut microbiota are gaining attraction as pivotal interventions in mitigating T2DM-induced health complications. Thus, by nurturing a symbiotic relationship between prebiotics and probiotics i.e. synbiotics, these interventions hold promise in reshaping the microbial landscape of the gut thereby offering a multifaceted approach to managing T2DM and its associated morbidities. Supporting the potential of synbiotics underscores a paradigm shift toward holistic and targeted interventions in diabetes management, offering prospects for improved outcomes and enhanced quality of life for affected individuals. Nevertheless, more research needs to be done to better understand the single and multispecies pre/pro and synbiotics in the prevention and management of T2DM-induced health complications.

New-onset atrial fibrillation following arteriovenous fistula increases adverse clinical events in dialysis patients with end-stage renal disease

Background

End-stage renal disease (ESRD) patients have a high potential cardiovascular burden, and cardiovascular disease (CVD) is the leading cause of death in maintenance haemodialysis (MHD) patients. Arteriovenous fistula (AVF) is the preferred vascular access for MHD patients, but AVF significantly affects the haemodynamics of the cardiovascular system, leading to or exacerbating CVD, including atrial fibrillation (AF). This study aimed to evaluate the impact of AVF on cardiac function, especially of the left atrium (LA), in patients with ESRD and to further explore the relationship between AVF establishment and the occurrence of AF.

Methods

We selected 1,107 ESRD patients on haemodialysis using AVF and 550 patients with tunneled-cuffed catheters (TCC) admitted between January 2016 and December 2022 for follow-up to compare the rate of AF between the two groups. A total of 153 patients in the AVF group with complete information (clinical data, echocardiographic and biochemical indices, and other data) were enrolled and retrospectively analysed for risk factors for the development of AF and were followed up for adverse clinical outcomes (including all-cause death, cardiac death, readmission due to heart failure, and stroke).

Results

The incidence of new-onset AF was higher in the AVF group than the TCC group after dialysis access was established (16.30% vs. 5.08%, P < 0.001). Echocardiography showed that the LA anteroposterior diameter increased (P < 0.001) and the incidence of AF increased from 11.76% to 26.14% (P = 0.001) after AVF establishment. Multivariate logistic regression analysis showed that age and LA enlargement were independent risk factors for new-onset AF after AVF establishment (P < 0.05). Adverse clinical outcomes were more common in patients with AF than in patients without AF (P < 0.001). Multivariate Cox risk regression analysis suggested that new-onset AF (HR = 4.08, 95% CI: 2.00-8.34, P < 0.001) and left ventricular systolic dysfunction (HR = 2.42, 95% CI: 1.20-4.88, P = 0.01) after AVF establishment were independent risk factors for adverse clinical outcomes.

Conclusion

LA enlargement after AVF establishment is associated with a significant increase in the incidence of AF, in addition, AF which is as an important influential factor in patients with MHD combined other systemic diseases might increase adverse clinical events.

Clinical Trial Registration

(NCT06199609).

Dapagliflozin and Blood Pressure in Patients with Chronic Kidney Disease and Albuminuria

BACKGROUND AND AIMS

Sodium-glucose cotransporter 2 inhibitors decrease blood pressure in patients with type 2 diabetes, but the consistency and magnitude of blood pressure lowering with dapagliflozin in patients with chronic kidney disease (CKD) is unknown. We conducted a prespecified analysis of the DAPA-CKD trial to investigate the effect of dapagliflozin on systolic blood pressure (SBP) in patients with CKD, with and without type 2 diabetes.

METHODS

A total of 4304 adults with baseline estimated glomerular filtration rate (eGFR) 25-75 mL/min/1.73m2 and urinary albumin-to-creatinine ratio (UACR) 200-5000 mg/g were randomized to either dapagliflozin 10 mg or placebo once daily; median follow-up was 2.4 years. The primary endpoint was a composite of sustained ≥50% eGFR decline, end-stage kidney disease, or death from a kidney or cardiovascular cause. Change in SBP was a prespecified outcome.

RESULTS

Baseline mean (SD) SBP was 137.1 mmHg (17.4). By Week 2, dapagliflozin compared to placebo reduced SBP by 3.6 mmHg (95% CI 2.8-4.4 mmHg), an effect maintained over the duration of the trial (2.9 mmHg, 2.3-3.6 mmHg). Time-averaged reductions in SBP were 3.2 mmHg (2.5-4.0 mmHg) in patients with diabetes and 2.3 mmHg (1.2-3.4 mmHg) in patients without diabetes. The time-averaged effect of dapagliflozin on diastolic blood pressure (DBP) was 1.0 mmHg (0.6-1.4 mmHg); 0.8 mmHg (0.4-1.3 mmHg) in patients with diabetes and 1.4 mmHg (0.7-2.1 mmHg) in patients without diabetes. Benefits of dapagliflozin on the primary composite and secondary endpoints were evident across the spectrum of baseline SBP and DBP.

CONCLUSION

In patients with CKD and albuminuria, randomization to dapagliflozin was associated with modest reductions in systolic and diastolic BP.

Ionized and total magnesium levels in patients with chronic kidney disease: associated factors and outcomes

Background

The association between hypo- and/or hypermagnesaemia and cardiovascular (CV) outcomes or mortality has shown conflicting results in chronic kidney disease (CKD) and has been conducted on total magnesium (tMg) levels. Thus, the objectives of the present study were to (i) describe the serum ionized Mg (iMg) concentration in patients at various CKD stages, (ii) measure the correlation between iMg and tMg concentrations, (iii) identify their associated factors and (iv) determine whether serum tMg and/or iMg concentrations are associated with major adverse cardiovascular events (MACE) and mortality before kidney replacement therapy in CKD patients.

Methods

Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) is a prospective cohort of CKD patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Baseline iMg and tMg serum concentrations were centrally measured. Adjusted cause-specific Cox proportional hazard models were used to estimate hazard ratios (HRs) for first MACE and for mortality.

Results

Of the 2419 included patients, median age was 68 years, and the mean eGFR was 34.8 mL/min/1.73 m2. Concentrations of serum iMg and tMg were strongly correlated (r = 0.89, P < .001) and were independently associated with eGFR. The adjusted HR [95% confidence interval (CI)] for MACE associated with the baseline serum tMg level was 1.27 (0.95; 1.69) for patients in Tertile 1 and 1.56 (1.18; 2.06) for patients in Tertile 3, relative to patients in Tertile 2. The HR (95% CI) of death according to serum tMg concentration was increased in Tertile 3 [1.48 (1.11; 1.97)]. The adjusted risk for MACE and mortality (all-cause or CV) associated with the baseline serum iMg level was not significantly different between tertiles.

Conclusions

Our analysis of a large cohort of patients with moderate-to-advanced CKD demonstrated that individuals with higher serum tMg concentrations, although still within the normal range, had a greater likelihood of MACE and mortality. However, serum iMg levels were not associated with these outcomes.

Dietary knowledge-attitude-practice status in hemodialysis patients: a latent profile analysis

BACKGROUND

Hemodialysis patients require a reasonable dietary intake to manage their disease progression effectively. However, there is limited research on these patients' overall dietary knowledge, attitude, and practice (KAP) status. This study aimed to investigate the dietary KAP status and latent profiles in hemodialysis patients and identify sociodemographic and disease-related factors associated with these profiles and dietary practice.

METHODS

A multicenter cross-sectional study involving 425 hemodialysis patients was conducted. A dietary KAP questionnaire in hemodialysis patients was used to evaluate the dietary KAP of the patients. A structural equation model was employed to analyze the correlations between dietary knowledge, attitude, and practice. Multiple linear regression analysis was used to identify factors associated with dietary practice scores. Latent profile analysis was conducted to determine the latent profiles of dietary KAP, and binary logistic regression was used to explore the sociodemographic and disease-related characteristics associated with each KAP profile in hemodialysis patients.

RESULTS

The normalized average scores for dietary knowledge, attitude, and practice in hemodialysis patients were 0.58, 0.82, and 0.58, respectively. The structural equation model revealed significant positive correlations between dietary knowledge and attitude, and attitude and practice. Attitude played an indirect effect between knowledge and practice. Gender, cerebrovascular disease, and dietary attitude scores were identified as independent influencing factors for dietary practice scores. Two dietary KAP profiles were developed: a profile with general knowledge and attitude but low practice (40.2%) and a profile with general knowledge and attitude and high practice (59.8%). Binary logistic regression analysis indicated gender and monthly income per household significantly predicted membership in each KAP profile.

CONCLUSIONS

The dietary practice of hemodialysis patients requires improvement. It is necessary to develop more individualized dietary interventions for these patients. Further exploration is needed to understand the motivation of patients to change their dietary behavior.

R, S Mayya S, Prasad Nagaraju S, S Nayak B. Effectiveness of a Disease Management Program (DMP) in controlling the progression of Chronic Kidney Disease among hypertensives and diabetics

BACKGROUND

The occurrence rate of stage 5 chronic kidney disease (CKD) will be 151 per million population in India in the coming years. Comorbidities like diabetes mellitus and hypertension are the usual triggers of CKD. Hence this study aimed to control the progression of CKD and to note the effectiveness of a structured education program that would help in the prevention of complications related to diabetes and hypertension.

METHODS

This quasi-experimental study was conducted among 88 participants who had hypertension, diabetes mellitus, or both for five or more years. The study objective was to find the effect of a Disease Management Program on delaying progression of CKD in patients with hypertension or diabetes mellitus.The baseline data were obtained from demographic proforma, and the clinical data collected were the blood pressure, serum creatinine, and random blood sugar (RBS) of the participants. The management of hypertension and diabetes mellitus was taught to them. In the fourth and the eighth month, blood pressure and blood sugar were reassessed. At one-year blood pressure, blood sugar, and serum creatinine were tested. Baseline and one-year follow-up blood pressure, blood sugar, and estimated Glomerular Filtration Rate were compared. Descriptive statistics and "Wilcoxon signed-rank test" were used to analyze the data.

RESULTS

In one year, the mean systolic blood pressure reduced by six mm of Hg and mean blood sugar by 24 mg/dl. The prevalence of CKD stage three and above (< 60 ml/min/m2) was nine (10.22%). The median decline in eGFR was 5 ml/min/m2 (Z= 5.925, P< 0.001).

CONCLUSION

The Disease Management Program led to improvements in blood pressure and diabetes control and median progression of CKD was estimated at five ml/min/m2/year.

Mind the gap in kidney care: translating what we know into what we do

Historically, it takes an average of 17 years to move new treatments from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. The time is now to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions worldwide are diagnosed, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because in the early stages it is often silent. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from patient to clinician to health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

Psychological profile of Chinese peritoneal dialysis patients during the Omicron pandemic in 2022

OBJECTIVE

The aim of this study was to determine the psychological status of peritoneal dialysis (PD) patients who were blocked during the 2022 Omic Pandemic in Shanghai.

METHODS

This was an observational and cross-sectional study. We selected 172 PD patients from the peritoneal dialysis center of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, during the quarantine of the Omicron pandemic in Shanghai from April to May 2022. General data and biochemical indices were collected. The Kidney Disease Quality of Life (SF-36) questionnaire was used to evaluate the psychological state of the patients during the quarantine.

RESULTS

According to the assessment of the SF-36 scale, the physiological and psychological health status of PD patients was better than that before quarantine (P < 0.05). According to the comparison of biochemical indices, the high-density lipoprotein, total cholesterol and body mass index (BMI) levels were lower in patients after quarantine than before quarantine, while the blood phosphorus, blood calcium and haemoglobin levels were greater after quarantine (P < 0.05). Logistic regression analysis revealed that health changes were positively correlated with age of penetration (years) (OR = 1.031, 95% CI = 1.005-1.058); however, physiological function was negatively correlated with sex (OR = 0.198, 95% CI = 0.044-0.899). Energy was significantly positively correlated with closed-loop time (OR = 1.063, 95% CI = 1.001-1.128) (P < 0.05). There were no significant differences in biochemical indices or quality of life between APD patients and non-APD patients (P > 0.05). According to the results of the abstract independent sample T test, when comparing the various dimensions of the SF-36 scale, for the dimensions of physiological function, pain and energy, the PD patients were better than the HD patients were (P < 0.05). Similarly, for the dimension of physiological function, the HD patients were better than the PD patients were (P < 0.05). During the quarantine period from April to May in Shanghai, the infection rate of PD patients was lower than usual (P < 0.05).

CONCLUSIONS

During the Omicron pandemic in Shanghai in 2022, PD patients exhibited relatively stable psychological and physiological states and a low infection rate. Compared with HD patients, PD patients had better adaptability. Especially in the context of the COVID-19 pandemic, peritoneal dialysis has more advantages.

Impacts of continuous quality improvement on wound pain in the puncture site of arteriovenous fistula in haemodialysis patient

This study analyses the effects of a continuous quality improvement nursing model on wound pain at the arteriovenous fistula (AVF) puncture site in patients undergoing haemodialysis. Forty haemodialysis patients from the First Affiliated Hospital of Chongqing Medical University, from September 2020 to December 2022, were selected as study subjects. They were randomly divided into an observation group and a control group. The control group received conventional nursing care, while the observation group was treated with a continuous quality improvement nursing model. The study compared the impact of these nursing approaches on pain intensity post-AVF puncture, wound visual analogue scale scores, self-rating anxiety scale, self-rating depression scale, quality of life scores and patient satisfaction with nursing care. In the observation group, the proportion of patients experiencing moderate to severe pain during AVF puncture was lower than that in the control group, whereas the proportion of patients with no pain or mild pain was higher (P = 0.008). After nursing, the observation group exhibited significantly lower wound visual analogue scale scores, self-rating anxiety scale scores, and self-rating depression scale scores compared to the control group (P < 0.001), with a significantly higher quality of life score (P < 0.05). The nursing satisfaction rate was 95.00% in the observation group, significantly higher than the 65.00% in the control group (P = 0.018). The continuous quality improvement nursing model significantly reduces wound pain at the AVF puncture site in haemodialysis patients, alleviates negative emotions, enhances the quality of life, and achieves high patient satisfaction. It is thus a highly recommendable approach in nursing practice.

Exploring patient delay in people with chronic kidney disease: A cross-sectional study

To examine the factors that contribute to patient delays among individuals with chronic kidney disease (CKD) and offer insights to help develop specific risk management strategies. Conducted as a cross-sectional study between September 2021 and April 2022, this study used a convenient sampling technique to select 245 individuals diagnosed with CKD from a Grade 3 Class A hospital located in Shanxi Province. These individuals were chosen as the subjects of the study. The research participants underwent an investigation using several assessment tools, including socio-demographic information questionnaire, medical behavior, the social support rating scale, the simplified coping style questionnaire, and the General Self-efficacy Scale. The study revealed that 35.4% of individuals with CKD experienced patient delay (the interval between the initial onset and the time of seeking medical attention being longer than or equal to 3 months). Through a multifactorial logistic regression analysis, it was determined that various factors independently influenced patient delay in patients with CKD. These factors included the level of knowledge about CKD, educational level, frequency of attending physical examinations, severity of initial symptoms, social support, self-efficacy, positive coping, and negative coping. Numerous factors contribute to the Patient Delay. To effectively enhance awareness and coping abilities regarding CKD in high-risk groups, it is essential to implement focused and continuous interventions throughout the medical seeking process.

Willingness to pay for haemodialysis among patients with chronic kidney disease in Abuja, Nigeria

BACKGROUND

Evidence of willingness to pay for kidney replacement therapy is scarce in low-middle-income countries, including Nigeria's Formal Sector Social Health Insurance Programme. The study, therefore, assessed the willingness to pay for haemodialysis among chronic kidney disease patients in Abuja, Nigeria.

METHODS

The study adopted a cross-sectional survey design. We used the contingent valuation method to estimate the maximum stated willingness to pay (WTP) for haemodialysis among end-stage kidney disease (ESKD) patients. We obtained informed written consent from respondents before data collection. The socio-demographic characteristics and willingness to pay data were summarized using descriptive statistics. We evaluated the mean differences in respondents' WTP using Mann-Whitney and Kruskal-Wallis tests. All variables that had p < 0.25 in the bivariate analysis were included in the Generalized Linear Model (gamma with link function) to determine the predictors of the WTP for one's and another's haemodialysis. The level of significance in the final model was ρ < 0.05.

RESULTS

About 88.3% and 64.8% of ESKD patients were willing to pay for personal and altruistic haemodialysis, correspondingly. The mean annual WTP for haemodialysis for one's and altruistic haemodialysis was USD25,999.06 and USD 1539.89, respectively. Private hospital patients were likelier to pay for their haemodialysis (β = 0.39, 95%CI: 0.21 to 0.57, p < 0.001). Patients attending public-private partnership hospitals were less likely to pay for altruistic haemodialysis than those attending public hospitals (β = -1.65, 95%CI: -2.51 to -0.79, p < 0.001).

CONCLUSIONS

The willingness to pay for haemodialysis for themselves and others was high. The type of facility ESKD patients attended influenced their willingness to pay for haemodialysis. The findings highlight the need for policies to enhance affordable and equitable access to haemodialysis in Nigeria through pre-payment mechanisms and altruistic financing strategies.

Physical and psychosocial burden experienced by women on maintenance hemodialysis

BACKGROUND

The global prevalence of chronic kidney disease is growing at an alarming rate, and the number of patients progressing to kidney failure is increasing. A substantial number of patients are undergoing hemodialysis (HD), which improves health and lengthens life. However, it imposes multiple physical and psychological demands on the patients. With the intensity of symptoms being greater among women, a greater focus is needed to obtain empirical evidence regarding the health problems of females receiving HD.

MATERIALS AND METHODS

A descriptive qualitative design was used to explore the health problems of women undergoing maintenance HD. The sampling technique used was maximum variation purposive sampling. The data were collected through in-depth face-to-face interviews with 12 female patients attending the dialysis unit of a tertiary care hospital in northern Kerala, South India, using a semi-structured interview guide. The interview was audiotaped, and the participant content was later converted verbatim into English. The content was imported to NVivo and coded. Thematic analysis was performed using Braun and Clarke's six-step approach.

RESULT

During data analysis, six major themes and 20 subthemes emerged. The themes include (1) physical suffering, (2) mental agony, (3) restricted life, (4) sexual inactivity, (5) breakdown of social life, and (6) financial hardship.

CONCLUSION

Females undergoing maintenance hemodialysis experience significant health-related issues in all major dimensions of health. They are physically vulnerable, psychologically defeated, and socially detached. The study highlights the need for detailed evaluation and consistently supportive and educational care.

Evaluation of peritoneal dialysis prescriptions in uremic rats

BACKGROUND

Patients with end-stage kidney disease (ESKD) require dialysis or transplantation for their survival. There are few experimental animal models mimicking the human situation in which the animals are dependent on dialysis for their survival. We developed a peritoneal dialysis (PD) system for rats to enable long-term treatment under controlled conditions.

METHOD

Rats were chemically nephrectomised using orellanine to render them uremic. Two studies were performed, the first with highly uremic rats on PD for 5 days, and the other with moderately uremic rats on PD for 21 days. Blood and dialysate samples were collected repeatedly from the first study and solute concentrations analysed. Based on these values, dialysis parameters were calculated together with generation rates allowing for kinetic modelling of the effects of PD. In the second study, the general conditions of the rats were evaluated during a longer dialysis period.

RESULTS

For rats with estimated glomerular filtration rate (GFR) 5-10% of normal (moderately uremic rats), five daily PD cycles kept the rats in good condition for 3 weeks. For highly uremic rats (GFR below 3% of normal), more extensive dialysis is needed to maintain homeostasis and our simulations show that a six daily and four nightly PD cycles should be needed to keep the rats in good condition.

CONCLUSION

In conclusion, the PD system described in this study can be used for long-term studies of PD on uremic dialysis-dependent rats mimicking the human setting. To maintain whole body homeostasis of highly uremic rats, intense PD is needed during both day and night.

Prevalence of multimorbidity and its associated risk factors among population of Mechinagar municipality of Nepal

Background

Multimorbidity is a group of conditions, it has significant impact on the population as a whole, resulting in lower quality of life, higher mortality, frequent use of medical services, and consequently higher healthcare costs. The objective of this study is to document the prevalence of common multimorbidity and its associated risk factors among population of Mechinagar Municipality.

Methods

Community-based cross-sectional study was conducted where selected multimorbidity were assessed in selected areas of Mechinagar municipality of Jhapa District . Systematic random sampling technique was used to select 590 adult participants from three pre-defined pocket areas. Pre-designed semi-structured multimorbidity assessment questionnaire for primary care (MAQ-PC)was used to assess prevalence of multimorbidity. Multiple logistic regression was conducted to identify the strongest determinants of multimorbidity.

Results

The prevalence of multimorbidity was 22.4%.Hypertension, Diabetes mellitus and COPD was seen in 39.2%, 7.8.% and 4.4% of the participants respectively . Participants with advancing age i. e. 40-49yrs were 12.62 times (AOR) more likely to have multimorbidity compared to their counterparts who were 20-29yrs old( p=<0.01,CI3.01-15.28) after adjusting for occupation, physical activity and family history of kidney disease. Working individuals, Physical inactivity and positive family history of kidney disease were the strongest determinates of multimorbidity.

Conclusions

The study revealed that participants with increasing age, working individuals, physical inactivity and family history of kidney disease were more vulnerable of having multimorbidity. The findings of our study indicate need of intervention strategies and community-based health promotion programs in reducing burden of chronic disease among adult population.

Equity and Quality of Global Chronic Kidney Disease Care: What Are We Waiting for?

BACKGROUND

Chronic kidney disease (CKD) is an important but insufficiently recognized public health problem. Unprecedented advances in delaying progression of CKD and reducing kidney failure and death have been made in recent years, with the addition of the sodium-glucose cotransporter 2 inhibitors and other newer medication to the established standard of care with inhibitors of the renin-angiotensin system. Despite knowledge of these effective therapies, their prescription and use remain suboptimal globally, and more specially in low resource settings. Many challenges contribute to this gap between knowledge and translation into clinical care, which is even wider in lower resource settings across the globe. Implementation of guideline-directed care is hampered by lack of disease awareness, late or missed diagnosis, clinical inertia, poor quality care, cost of therapy, systemic biases, and lack of patient empowerment. All of these are exacerbated by the social determinants of health and global inequities.

SUMMARY

CKD is a highly manageable condition but requires equitable and sustainable access to quality care supported by health policies, health financing, patient and health care worker education, and affordability of medications and diagnostics.

KEY MESSAGES

The gap between the knowledge and tools to treat CKD and the implementation of optimal quality kidney care should no longer be tolerated. Advocacy, research and action are required to improve equitable access to sustainable quality care for CKD everywhere.

Projected impact of population aging on non-communicable disease burden and costs in the Kingdom of Saudi Arabia, 2020-2030

BACKGROUND

The number of people aged greater than 65 years per 100 people aged 20-64 years is expected to almost double in The Kingdom of Saudi Arabia (KSA) between 2020 and 2030. We therefore aimed to quantify the growing non-communicable disease (NCD) burden in KSA between 2020 and 2030, and the impact this will have on the national health budget.

METHODS

Ten priority NCDs were selected: ischemic heart disease, stroke, type 2 diabetes, chronic obstructive pulmonary disease, chronic kidney disease, dementia, depression, osteoarthritis, colorectal cancer, and breast cancer. Age- and sex-specific prevalence was projected for each priority NCD between 2020 and 2030. Treatment coverage rates were applied to the projected prevalence estimates to calculate the number of patients incurring treatment costs for each condition. For each priority NCD, the average cost-of-illness was estimated based on published literature. The impact of changes to our base-case model in terms of assumed disease prevalence, treatment coverage, and costs of care, coming into effect from 2023 onwards, were explored.

RESULTS

The prevalence estimates for colorectal cancer and stroke were estimated to almost double between 2020 and 2030 (97% and 88% increase, respectively). The only priority NCD prevalence projected to increase by less than 60% between 2020 and 2030 was for depression (22% increase). It is estimated that the total cost of managing priority NCDs in KSA will increase from USD 19.8 billion in 2020 to USD 32.4 billion in 2030 (an increase of USD 12.6 billion or 63%). The largest USD value increases were projected for osteoarthritis (USD 4.3 billion), diabetes (USD 2.4 billion), and dementia (USD 1.9 billion). In scenario analyses, our 2030 projection for the total cost of managing priority NCDs varied between USD 29.2 billion - USD 35.7 billion.

CONCLUSIONS

Managing the growing NCD burden in KSA's aging population will require substantial healthcare spending increases over the coming years.

High Rates of Undiagnosed Target Organ Damage Among Adults with Elevated Blood Pressure or Diabetes Mellitus in a Community-Based Survey in Lesotho

INTRODUCTION

Prevalence of elevated blood pressure (BP) and diabetes mellitus (DM) is increasing in sub-Saharan Africa. Data on target organ damage such as retinopathy, left ventricular hypertrophy (LVH), renal impairment and peripheral neuropathy (PN) among persons with elevated BP and/or DM in sub-Saharan Africa remain scarce.

AIM

To determine at community-level the prevalence of retinopathy, LVH, renal impairment, and PN among adults with elevated BP and/or DM, and assess the association of elevated BP and/or DM with target organ damage in Lesotho.

METHODS

During a household-based survey, a sub-sample of adults with elevated BP (≥ 140/90 mmHg) and/or DM (glycosylated hemoglobin ≥ 6.5%), as well as comparators (BP < 140/90 mmHg, HbA1c < 6.5%) were screened for retinopathy, LVH, renal impairment, and PN. We used multivariable logistic regression for inferential analysis.

RESULTS

Out of 6108 participants screened during the survey, 420 with elevated BP only, 80 with DM only, 61 with elevated BP and DM, and 360 comparators were assessed for target organ damage. Among those with elevated BP, and among those with DM with or without elevated BP, prevalence of retinopathy was 34.6% (89/257) and 14.4% (15/104); renal impairment was 45.0% (156/347) and 42.4% (56/132), respectively. Among those with elevated BP, 2.3% (7/300) and 65.7% (224/341) had LVH and left ventricular concentric remodeling, respectively. PN, only assessed among those with DM, was present in 32.6% (42/129). Elevated BP was associated with increased odds of retinopathy (aOR, 19.13; 95% CI, 8.52-42.94; P < 0.001) and renal impairment (aOR, 1.80; 95% CI, 1.27-2.55; P = 0.001). Presence of both elevated BP and DM was associated with an increased odds of retinopathy (aOR, 16.30; 95%CI, 5.69-46.68; P < 0.001), renal impairment (aOR, 2.55; 95% CI, 1.35-4.81; P = 0.004), and PN (aOR, 2.13; 95% CI, 1.04-4.38; P = 0.040).

CONCLUSION

We found a high prevalence of undiagnosed target organ damage among adults with elevated BP and/or DM during community-based screening. These findings emphasize the importance of regular prevention and screening activities in this setting.

Clinical profile and microbiological spectrum of patients with continuous ambulatory peritoneal dialysis-associated peritonitis at a tertiary care center

Background

We present risk factors, clinical profile, and microbiological spectrum of patients with continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis who were managed at our center.

Methods

All consecutive patients with CAPD-associated peritonitis who presented to our center between July 2018 and December 2019 were included in the study. Risk factors, microbiological spectrum, clinical profile, and outcome of patients were studied.

Results

Eighty-five patients with CAPD-associated peritonitis and 50 patients who never had peritonitis during the study period were included. Diabetes Mellitus (OR 0.058, 95% CI0.007-0.493, p < 0.05), residence in rural area (OR 3.376, 95% CI 1.084-10.516, p < 0.05), duration of peritoneal dialysis (OR 0.935, 95% CI 0.886-0.987, p < 0.05), mean serum hemoglobin (OR 1.674, 95% CI 1.119-2.502, p < 0.05) and serum albumin (OR 0.148, 95% CI 0.066-0.333, p < 0.05) were associated with higher risk of peritonitis in CAPD patients. Eight-three patients (98.8%) had turbid CAPD fluid and 52 (61.2%) had fever at the time of presentation to the hospital. The mean CAPD fluid TLC on day 1, 3, and 5 were 2034.3 ± 3330.1 cells/cumm, 1049.0 ± 1210.9 cells/cumm, and 605.2 ± 950.5 cells/cumm, respectively. The organisms isolated were two Escherichia coli (2.4%), one Staphylococcus aureus (1.2%), one Klebsiella (1.2%), two Acinetobacter (2.4%), 10 Fungal organisms (11.7%), and in two (2.4%) cases, Mycobacterium tuberculosis (MTB) was detected by polymerase chain reaction (PCR) of CAPD fluid. Thirty-seven (43.5%) patients had a complete cure and 48 (56.5%) patients were refractory to treatment; hence catheter was removed in them (catheter loss). Six (7.0%) patients died during the study period.

Conclusion

CAPD-associated peritonitis is an important risk factor for technique failure. The majority of episodes are culture-negative, and PCR can help in detecting fungal and tubercular peritonitis early in the course.

Distribution characteristics of circulating B cell subpopulations in patients with chronic kidney disease

This study compared the levels of circulating B cell subpopulations in patients with different stages of chronic kidney disease (CKD), investigated the effects of haemodialysis (HD) on the B cell-related immune spectrum in patients with end-stage renal disease, and evaluated the link between renal function and immune homeostasis. Overall, 197 patients with CKD (158 non-dialysis patients with CKD stages I-V and 39 end-stage patients undergoing maintenance HD) and 77 healthy controls were included. Compared to healthy controls, patients with CKD stages I-II showed no significant differences except for the proportion of transitional B cells; patients with CKD stage V showed a significant decrease in the proportions of transitional B cells and CD5+ B cells and a significant increase in double-negative (DN) B cells. Compared with early-stage patients with CKD, the absolute count of various B cell subpopulations in advanced-stage patients with CKD showed a significant decrease. The distribution of circulating B cell subpopulations in patients with CKD was significantly altered and was associated with CKD progression. Furthermore, the proportion of DN B cells and CD5+ B cells was inconsistent pre- and post-HD. This in-depth study of the immune status of patients with CKD may have important clinical value.

Cost-effectiveness of population-based screening for microalbuminuria in people with type 2 diabetes mellitus in India

OBJECTIVES

Patients with diabetes have a higher risk of developing chronic kidney disease (CKD). Early detection of CKD through microalbuminuria screening, followed by treatment, delays the progression of CKD. We evaluated the cost-effectiveness of population-based screening of microalbuminuria among normotensive type 2 diabetes mellitus patients aged >40 years compared with no screening scenario using a decision tree combined with the Markov model.

METHODS

We considered two scenarios: Scenario I - dipstick microalbuminuria followed by spot-urine albumin-creatinine ratio (ACR) and serum creatinine in sequence; Scenario II - spot urine ACR plus serum creatinine. A mathematical cohort of the target population was simulated over a lifetime horizon with an annual cycle. Data for the model were obtained from secondary resources. The incremental cost-effectiveness ratios (ICERs) were estimated for screening scenarios compared to nonscreening scenario, along with sensitivity analyses.

RESULTS

The discounted ICER per quality-adjusted life years gained for annual microalbuminuria screening in the normotensive diabetic population in India were ₹ 24,114 (US$ 308) and ₹ 13,790 (US$ 176) for scenarios I and II, respectively. Annual screening by scenarios I and II resulted in a reduction of 180 and 193 end-stage renal disease (ESRD) cases per 100,000 population, respectively, resulting in a cost saving of ₹ 12.3 and 13.3 Crore spent on ESRD management over 10 years. Both scenarios were also cost-effective even at the screening frequencies of 5 and 10 yearly.

CONCLUSION

Microalbuminuria screening was cost-effective at the threshold of one-time GDP per capita in India.

The differences in renal hemodynamic response following high-intensity exercise between younger and older males

BACKGROUND

Renal blood flow (RBF) decreases with exercise, but this change is only temporary, and habitual exercise may be an effective method to improve renal function. The kidney shows structural and functional changes with aging, but it is unclear how aging affects the hemodynamic response of the kidneys to exercise. Therefore, we evaluated the differences in the hemodynamic response of the kidneys to high-intensity exercise between younger and older men.

METHODS

Sixteen men (8 young and 8 older) underwent an incremental exercise test using a cycle ergometer with a 1-min warm up followed by exercise at 10-20 W/min until the discontinuation criteria were met. Renal hemodynamics were assessed before exercise, immediately after exercise, and at 60-min after exercise using ultrasound echo.

RESULTS

High-intensity exercise significantly reduced RBF in both groups (younger: ∆  - 53 ± 16%, p = 0.0005; older: ∆  - 53 ± 19%, p = 0.0004). In the younger group, RBF returned to the pre-exercise level 60-min after exercise (∆  - 0.4 ± 5.7%, p > 0.9999). In contrast, RBF 60-min after exercise was significantly lower than that before exercise in the older group (∆  - 24 ± 19%, p = 0.0006). The older group had significantly lower RBF than younger adults 60-min after exercise (423 ± 32 vs. 301 ± 98 mL/min, p = 0.0283).

CONCLUSIONS

Our findings demonstrate that RBF following high-intensity exercise recovered 60-min after exercise in younger group, whereas RBF recovery was delayed in the older group.

Protocol and Methods: Role of Levothyroxine on the Progression of Chronic Kidney Disease in Subclinical Hypothyroid Populations (LP-CKD) - A Multicenter Randomized Controlled Trial

Introduction

Subclinical hypothyroidism (SCH) is highly prevalent and associated with chronic kidney disease (CKD). However, it is still unanswered whether the restoration of euthyroid status in these patients will be beneficial in retarding a decline in glomerular filtration rate in early CKD patients. We aim to evaluate the efficacy of levothyroxine therapy versus placebo in slowing estimated glomerular filtration rate (eGFR) decline among CKD patients (stage 2-4) with SCH.

Methods

This study will be a multicentric, double-blind, randomized, parallel-group, placebo-controlled study. A total of 500 CKD patients, 250 patients in the treatment group and 250 patients in the placebo group, will be randomized. The randomization between the treatment arm and placebo arm will be performed as per the computer-generated random number table in a 1:1 ratio. The sample size was calculated based on the assumed reduction in eGFR after 1-year follow-up in the treatment and placebo groups of 10% and 25%, respectively, at a minimum two-sided 99% confidence interval and 90% power of the study and considering 20% loss on follow-up. Each patient will be followed every 3 months for at least 1 year after randomization. Individuals completing 1-year follow-up visits will be considered for analysis. The baseline and follow-up data will be compared between the treatment and placebo groups. The study will evaluate the efficacy and safety of levothyroxine therapy versus placebo in slowing eGFR decline among CKD patients (stage 2-4) with SCH. The primary endpoint will be the end of follow-up of the patients, reduction of eGFR by ≥50% from a baseline of that patient, or development of ESKD or death of the patients. The secondary endpoint will be any cardiovascular event or arrhythmia after the institution of the drug.

Urinary peptidome analysis in CKD and IgA nephropathy

Background

Chronic kidney disease (CKD) has emerged as a significant challenge to human health and economic stability in aging societies worldwide. Current clinical practice strategies remain insufficient for the early identification of kidney dysfunction, and the differential diagnosis of immunoglobulin A nephropathy (IgAN) predominantly relies on invasive kidney biopsy procedures.

Methods

First, we assessed a case-control cohort to obtain urine samples from healthy controls and biopsy-confirmed CKD patients. Matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry (MS) was applied to detect urinary peptide and then these urinary peptide profiles were used to construct diagnostic models to distinguish CKD patients from controls and identify IgAN patients from other nephropathy patients. Furthermore, we assessed the robustness of the diagnostic models and their reproducibility by applying different algorithms.

Results

A rapid and accurate working platform for detecting CKD and its IgAN subtype based on urinary peptide pattern detected by MALDI-TOF MS was established. Naturally occurring urinary peptide profiles were used to construct a diagnostic model to distinguish CKD patients from controls and identify IgAN patients from other nephropathy patients. The performance of several algorithms was assessed and demonstrated that the robustness of the diagnostic models as well as their reproducibility were satisfactory.

Conclusions

The present findings suggest that the CKD-related and IgAN-specific urinary peptides discovered facilitate precise identification of CKD and its IgAN subtype, offering a dependable framework for screening conditions linked to renal dysfunction. This will aid in comprehending the pathogenesis of nephropathy and identifying potential protein targets for the clinical management of nephropathy.

Genes, environment, and African ancestry in cardiometabolic disorders

The past two decades have been characterized by a substantial global increase in cardiometabolic diseases, but the prevalence and incidence of these diseases and related traits differ across populations. African ancestry populations are among the most affected yet least included in research. Populations of African descent manifest significant genetic and environmental diversity and this under-representation is a missed opportunity for discovery and could exacerbate existing health disparities and curtail equitable implementation of precision medicine. Here, we discuss cardiometabolic diseases and traits in the context of African descent populations, including both genetic and environmental contributors and emphasizing novel discoveries. We also review new initiatives to include more individuals of African descent in genomics to address current gaps in the field.

Chronic kidney disease awareness and its determinants in middle-aged and older Japanese adults: Observations from a 5-year follow-up of the Uonuma cohort study

AIM

Despite global efforts in public health campaigns concerning chronic kidney disease (CKD), awareness of the condition remains low. We evaluated CKD awareness and related factors to identify an effective way to raise awareness.

METHODS

This study assessed laboratory-confirmed CKD and self-reported CKD using a population-based cohort (baseline from 2012 to 2014, age ≥40 years) in Niigata, Japan. Self-reported CKD was obtained at a 5-year follow-up survey and laboratory-confirmed CKD was diagnosed when an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 or dipstick urinary protein ≥1+ was observed in at least two health check-ups during the 5-year period. CKD awareness was defined as a match between laboratory-confirmed and self-reported CKD. The association between characteristics and CKD awareness was tested by multivariable logistic regression analysis with adjustment for eGFR and other potential confounders.

RESULTS

The analytic population comprised 7472 individuals (mean age, 65.6 years old, 51.2% women) and 19.4% with laboratory-confirmed CKD. The sensitivity and specificity of the survey question concerning self-reported CKD were 12.4% and 98.2%, respectively. Among the participants with laboratory-confirmed CKD, significant factors associated with CKD awareness were male sex (adjusted odds ratio [95% confidence interval], 1.81 [1.27, 2.59]), a history of urinary tract stone (1.86 [1.06, 3.26]), age (0.97 [0.95, 0.99]), and married status (0.66 [0.44, 0.99]).

CONCLUSION

Our findings suggest that known lifestyle-related diseases that could cause CKD are not associated with CKD awareness independently of kidney function and that a sex-dependent approach may help to raise CKD awareness in community-dwelling Japanese adults.

Outcomes Associated with Sodium-Glucose Cotransporter-2 Inhibitor Use in Acute Heart Failure Hospitalizations Complicated by AKI

Key Points

In a multicenter retrospective cohort study of adults hospitalized with acute heart failure, exposure to sodium-glucose cotransporter-2 inhibitor during AKI was associated with lower risk of 30-day mortality. Exposure to sodium-glucose cotransporter-2 inhibitor during acute heart failure–associated AKI was associated with no difference in time to renal recovery. The findings were reproducible in inverse probability-weighted analysis.

Background

Although sodium-glucose cotransporter-2 inhibitor (SGLT2i) use during acute heart failure (AHF) hospitalizations is associated with symptomatic improvement, reduction in rehospitalizations, and mortality, these medications are often withheld during AKI because of concerns about worsening GFR. We aimed to investigate the safety of SGLT2i exposure during AKI among patients hospitalized with AHF. We hypothesized that SGLT2i exposure would not worsen mortality but may prolong return of creatinine to baseline.

Methods

This was a retrospective study of adults hospitalized across five Yale New Haven Health System hospitals between January 2020 and May 2022 with AHF complicated by Kidney Disease Improving Global Outcomes–defined AKI. Patients with stage 5 CKD and those with potential contraindications to SGLT2i were excluded. We tested the association of SGLT2i use with kidney function recovery at 14 days and death at 30 days using time-varying, multivariable Cox-regression analyses.

Results

Of 3305 individuals hospitalized with AHF and AKI, 356 received SGLT2i after AKI diagnosis either as initiation or continuation. The rate of renal recovery was not significantly different among those exposed and unexposed to SGLT2i after AKI (adjusted hazard ratio, 0.94; 95% confidence interval, 0.79 to 1.11; P = 0.46). SGLT2i exposure was associated with lower risk of 30-day mortality (adjusted hazard ratio, 0.45; 95% confidence interval, 0.23 to 0.87; P = 0.02). Sensitivity analyses using an inverse probability-weighted time-varying Cox regression analysis and using alternate definitions of AHF with different NT-proBNP cutoffs yielded similar results. Rates of renal recovery were similar between the exposed and unexposed cohorts regardless of the proximity of SGLT2i exposure to AKI diagnosis.

Conclusion

In adults experiencing AHF-associated AKI, exposure to SGLT2i was associated with decreased mortality and no delay in renal recovery. Prospective studies are needed to elucidate the effect of SGLT2i exposure during AKI, particularly during heart failure hospitalizations.

Risk of rapid progression to dialysis in patients with type 2 diabetes mellitus with and without diabetes-related complications at diagnosis

Many adults with diabetes mellitus are unaware worldwide. The study objectives aimed to evaluate the risk of dialysis within 5 years of diagnosis between patients with newly diagnosed diabetes with and without diabetes-related complications. A retrospective longitudinal nationwide cohort study was conducted. Patients diagnosed with diabetes between 2005 and 2013 were followed up until 2018. They were categorized based on the presence or absence of complications, the number of complications, and the diabetes complications severity index (DCSI) scores. Dialysis outcomes were determined through the Registry of Catastrophic Illness from the National Health Insurance Research Database. Among the analyzed patients, 25.38% had complications at diagnosis. Patients with complications at diagnosis had a significantly higher risk of dialysis within 5 years (adjusted hazard ratio: 9.55, 95% confidence interval CI 9.02-10.11). Increasing DCSI scores and the number of complications were associated with higher dialysis risks. Patients with one complication had a 7.26-times higher risk (95% CI 6.83-7.71), while those with ≥ 3 complications had a 36.12-times higher risk (95% CI 32.28-40.41). In conclusion, newly diagnosed diabetes patients with complications face an increased risk of dialysis within 5 years. The severity and number of complications are directly linked to the risk of dialysis within this timeframe.

Association between blood Loa loa microfilarial density and proteinuria levels in a rural area of the Republic of Congo (the MorLo project): a population-based cross-sectional study

BACKGROUND

Case reports have hypothesised that proteinuria, sometimes with glomerulopathy or nephrotic syndromes, might be associated with loiasis. To our knowledge, no study has been done to assess this association. We aimed to investigate the association between Loa loa microfilariae burden and proteinuria.

METHODS

We did a cross-sectional study between May 16, 2022, and June 11, 2022, to assess the relationship between Loa loa microfilaraemia densities and proteinuria in a rural area of the Republic of Congo. We included all consenting adults living in the target area at study commencement who had L loa microfilarial densities greater than 500 microfilariae per mL during previous screening for a clinical trial in 2019. This study is part of the MorLo project, and used the project's study population of individuals aged 18 years or older who were living near Sibiti. For each microfilaraemic individual, two individuals without L loa microfilarial densities matched on age, sex, and place of residence were included. The association between proteinuria (assessed by dipstick) and L loa microfilarial densities, age, and sex was assessed using an unconstrained ordinal regression model since the parallel-lines assumption was violated for microfilarial densities.

FINDINGS

991 participants were included, of whom 342 (35%) were L loa microfilaraemic. The prevalence of microfilaraemia was 38% (122 of 325) among individuals with trace proteinuria (<300 mg/24 h), 51% (45 of 89) among individuals with light proteinuria (300 mg to 1 g/24 h), and 71% (15 of 21) among individuals with high proteinuria (>1 g/24 h). Individuals with high proteinuria had significantly higher L loa microfilarial densities (p<0·0001): mean microfilariae per mL were 1595 (SD 4960) among individuals with no proteinuria, 2691 (7982) for those with trace proteinuria, 3833 (9878) for those with light proteinuria, and 13 541 (20 118) for those with high proteinuria. Individuals with 5000-14 999 microfilariae per mL and individuals with 15 000 microfilariae per mL or greater were, respectively, 5·39 and 20·49 times more likely to have a high proteinuria than individuals with no microfilaraemia.

INTERPRETATION

The risk of proteinuria increases with L loa microfilaraemia. Further studies are needed to identify renal disorders (eg, tubulopathies, glomerulopathies, or nephrotic syndromes) responsible for loiasis-related proteinuria.

FUNDING

European Research Council, MorLo project.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Biochemical and Sociodemographic Correlates of Major Depressive Disorder in Patients With Chronic Kidney Disease Receiving Hemodialysis

Introduction Chronic kidney disease (CKD) is a chronic disabling illness with multiple physical and psychosocial consequences. A major treatment modality for CKD is renal replacement therapy in the form of hemodialysis. A bidirectional relationship between depression and CKD is proposed, as depressive symptoms lead to poorer outcomes in CKD and vice versa. This study aimed to determine the prevalence of major depressive disorder (MDD) in CKD patients on maintenance hemodialysis and find any sociodemographic, clinical, or biochemical correlates. Material and methods This was a cross-sectional study conducted at a tertiary care teaching hospital in north India. We used clinical interviews for diagnosing MDD according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The severity was quantified using Hamilton Depression Rating Scale (HAM-D) in those diagnosed with MDD.  Results A total of 77 patients were included in the study. The prevalence of MDD in patients with CKD undergoing hemodialysis was 31.17%, much higher than in the general population. Most of those who were depressed had moderate to severe depression. Male gender and lower socioeconomic status were significantly associated with the diagnosis of MDD. Those undergoing dialysis less frequently or having more work days lost due to CKD were more likely to be depressed. Additionally, patients with MDD were found to have significantly lower blood hemoglobin levels, lower serum ionized calcium levels, and a lower urea reduction ratio compared to those who did not have MDD. Conclusion The high prevalence of MDD in patients with CKD undergoing hemodialysis suggests that clinicians should actively evaluate for depressive symptoms in this patient population and refer them to mental health services when required, especially those with the above-identified sociodemographic and biochemical risk factors.