US Renal Data System 2015 Annual Data Report: Epidemiology of Kidney Disease in the United States

Machine learning model and nomogram to predict the risk of heart failure hospitalization in peritoneal dialysis patients

INTRODUCTION

The study presented here aimed to establish a predictive model for heart failure (HF) and all-cause mortality in peritoneal dialysis (PD) patients with machine learning (ML) algorithm.

METHODS

We retrospectively included 1006 patients who initiated PD from 2010 to 2016. XGBoost, random forest (RF), and AdaBoost were used to train models for assessing risk for 1-year and 5-year HF hospitalization and mortality. The performance was validated using fivefold cross-validation. The optimal ML algorithm was used to construct the models to predictive the risk of the HF and all-cause mortality. The prediction performance of ML methods and Cox regression was compared.

RESULTS

Over a median follow-up of 49 months. Two hundred and ninety-eight patients developed HF required hospitalization; 199 patients died during the follow-up. The RF model (AUC = 0.853) was the best performing model for predicting HF, and the XGBoost model (AUC = 0.871) was the best model for predicting mortality. Baseline moderate or severe renal disease, systolic blood pressure (SBP), body mass index (BMI), age, Charlson Comorbidity Index (CCI) score were strongly associated with HF hospitalization, whereas age, CCI score, creatinine, age, high-density lipoprotein cholesterol (HDL-C), total cholesterol, baseline estimated glomerular filtration rate (eGFR) were the most significant predictors of mortality. For all the above endpoints, the ML models demonstrated better discrimination than Cox regression.

CONCLUSIONS

We developed and validated a novel method to predict the risk factors of HF and all-cause mortality that integrates readily available clinical, laboratory, and electrocardiographic variables to predict the risk of HF among PD patients.

Proneurotensin/Neuromedin N and Risk of Incident CKD and Other Kidney Outcomes in Community-Living Individuals: The REGARDS Study

Rationale & Objective

Plasma proneurotensin/neuromedin N (pro-NT/NMN) is a precursor of neurotensin, a tridecapeptide linked with type 2 diabetes mellitus and other comorbid conditions associated with kidney disease. Whether pro-NT/NMN is directly associated with incident chronic kidney disease (CKD), and whether that association differs by race, is uncertain. We evaluated whether pro-NT/NMN levels were associated with increased risk of kidney outcomes.

Study Design

Prospective cohort.

Setting & Participants

Participants in Biomarker Mediators of Racial Disparities in Risk Factors, a nested cohort from the REasons for Geographic And Racial Differences in Stroke study, with available stored serum and urine samples from baseline and second visits for biomarker measurement.

Exposure

Baseline log-transformed pro-NT/NMN.

Outcomes

Incident CKD, progressive estimated glomerular filtration rate (eGFR) decline, incident albuminuria, and incident kidney failure within median follow-up time of 9.4 years.

Analytical Approach

Logistic regression.

Results

Among 3,914 participants, the mean ± SD age was 64 ± 8 (SD) years, 48% were women, and 51% were Black. Median baseline eGFR was 90 (IQR, 77-102) mL/min/1.73 m2. Each SD higher of pro-NT/NMN was associated with 9% higher odds of progressive eGFR decline (OR, 1.09; 95% CI, 1.00-1.20). There was no association observed with incident CKD (OR, 1.10; 95% CI, 0.96-1.27), incident albuminuria (OR, 1.08; 95% CI, 0.96-1.22), or incident kidney failure (OR, 1.10; 95% CI, 0.83-1.46). There were no differences in results by race or sex.

Limitations

Single measurement of pro-NT/NMN and limited generalizability.

Conclusions

Higher pro-NT/NMN was associated with progressive eGFR decline but no other manifestations of kidney disease incidence.

Cardioprotective effect of intradialytic exercise on left atrial mechanics

Left atrial (LA) function plays a pivotal role in cardiac performance by modulating left ventricular (LV) function. Impairments in LV function are commonly reported during hemodialysis (HD), but available data describing changes in LA function are limited. There is growing evidence of the cardioprotective effect of intradialytic exercise (IDE) on LV function, but studies analyzing its effect on LA function are scarce. Our aim was to evaluate whether IDE can limit the severity of HD-induced impairment in LA myocardial function. In this prospective, open-label, two-center randomized crossover trial, 56 stable individuals receiving HD participated in 2 HD sessions in random order: standard HD and a session incorporating 30 min of aerobic exercise. LA and LV global longitudinal strains (GLSs) were obtained before and at peak stress of HD (i.e., 30 min before the HD ending). IDE totally eradicated the decline in LA reservoir strain observed during HD (estimated difference: 3.1%, 95% confidence interval: 0.4/5.8, P = 0.02), whereas it did not affect the other components of LA mechanics. A similar result favoring IDE intervention was also demonstrated on GLS changes over the HD procedure (P < 0.001). Between-session differences of changes in GLS and LA reservoir strain were correlated (r = -0.32, P = 0.03). The cardioprotective effect of IDE disappeared in patients with LA enlargement (i.e., LA volume index >34 mL/m2). In conclusion, even a short duration of IDE at moderate intensity is effective in preventing HD-associated decline in LA reservoir function. Further research is needed to explore the long-term benefits of IDE on LA function.NEW & NOTEWORTHY A single bout of intradialytic exercise (IDE) at moderate intensity can prevent the hemodialysis-associated decline in left atrial (LA) function. This was partially explained by the relative preservation of left ventricular systolic function with IDE. Benefits of IDE on LA function were lost in patients with LA dilation. Further studies are needed to explore the mechanisms behind IDE-induced cardioprotection and evaluate the clinical impacts of the repetitive cardioprotective effects of IDE on LA function.

A clustering approach to improve our understanding of the genetic and phenotypic complexity of chronic kidney disease

Chronic kidney disease (CKD) is a complex disorder that causes a gradual loss of kidney function, affecting approximately 9.1% of the world's population. Here, we use a soft-clustering algorithm to deconstruct its genetic heterogeneity. First, we selected 322 CKD-associated independent genetic variants from published genome-wide association studies (GWAS) and added association results for 229 traits from the GWAS catalog. We then applied nonnegative matrix factorization (NMF) to discover overlapping clusters of related traits and variants. We computed cluster-specific polygenic scores and validated each cluster with a phenome-wide association study (PheWAS) on the BioMe biobank (n = 31,701). NMF identified nine clusters that reflect different aspects of CKD, with the top-weighted traits signifying areas such as kidney function, type 2 diabetes (T2D), and body weight. For most clusters, the top-weighted traits were confirmed in the PheWAS analysis. Results were found to be more significant in the cross-ancestry analysis, although significant ancestry-specific associations were also identified. While all alleles were associated with a decreased kidney function, associations with CKD-related diseases (e.g., T2D) were found only for a smaller subset of variants and differed across genetic ancestry groups. Our findings leverage genetics to gain insights into the underlying biology of CKD and investigate population-specific associations.

Beta-blocker efficacy for intra- and interdialytic hypertension patients: a systematic review and meta-analysis

PURPOSE

Intradialytic hypertension affects 5-15% of hemodialysis patients, yet relevant studies are relatively scarce. It is also associated with higher interdialytic blood pressure. Beta-blockers can be preferred as antihypertensive drugs due to their superior blood pressure control, decreased risk of cardiovascular events, improved endothelial cell function, and decreased noradrenaline levels. Through this study, beta-blocker antihypertensive effects in intra- and interdialytic hypertension were analyzed.

METHODS

Systematic review and meta-analysis were performed following PRISMA guidelines. We registered our PROSPERO protocol (Registration ID: CRD42023446184) and included relevant full-text clinical trials or RCTs from 2008 to 2023 with predetermined keywords and criteria from multiple databases including PUBMED, COCHRANE, SCOPUS, and citation searching. Seven eligible articles were included in this review study.

RESULTS

Four studies with 82 participants for intradialytic hypertension evaluation were included. Meta-analysis showed a decrease in SBP in intradialytic hypertensive patients after beta-blocker intervention, with a significant estimated mean difference of - 15.19 mmHg (P < 0.00001; 95% CI - 19.47 to - 10.91). Supporting previous data, SBP remains constant between pre- and post-dialysis with beta-blocker therapy, with an insignificant estimated mean difference of - 2.72 mmHg (P = 0.29; 95% CI - 7.80 to 2.36). Whereas five studies with 142 participants were included for interdialytic hypertension evaluation. Meta-analysis shows a significant decrease in SBP before to after therapy, with an estimated mean difference of - 10.92 (P < 0.0001; 95% CI - 16.33 to - 5.51).

CONCLUSION

Beta-blocker treatment resulted in significant reductions in post-hemodialysis systolic blood pressure among intra- and interdialytic hypertensive patients.

Show Me CKDintercept Initiative: A Collective Impact Approach to Improve Population Health in Missouri

Ninety percent of people with chronic kidney disease (CKD) remain undiagnosed, most people at risk do not receive guideline-concordant testing, and disparities of care and outcomes exist across all stages of the disease. To improve CKD diagnosis and management across primary care, the National Kidney Foundation launched a collective impact (CI) initiative known as Show Me CKDintercept. The initiative was implemented in Missouri, USA from January 2021 to June 2022, using a data strategy, stakeholder engagement and relationship mapping, learning in action working groups (LAWG), and a virtual leadership summit. The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was used to evaluate success. The initiative united 159 stakeholders from 81 organizations (Reach) to create an urgency for change and engage new CKD champions (Effectiveness). The adoption resulted in 53% of participants committed to advancing the roadmap (Adoption). Short-term results reported success in laying a foundation for CI across Missouri. The long-term success of the CI initiative in addressing the public health burden of kidney disease remains to be determined. The project reported the potential use of a CI initiative to build leadership consensus to drive measurable public health improvements nationwide.

Kidney Biopsy and Immuno-Rheumatological Diseases: A Retrospective and Observational Study

Renal involvement is a common occurrence in patients with immuno-rheumatological diseases (IRDs). Several instances of glomerulonephritis (GN) occur in the setting of IRD and complicate the clinical course of an underlying condition. The aim of this study was to observe the spectrum of nephropathies according to age, kidney function, history of IRD at the time of biopsy, and histopathological kidney diagnosis. We evaluated data relating to 699 consecutive kidney native biopsies (female 52.1%) with a median age of 48 years (IQR 34-62) performed in adult patients collected over 15 years. The study population was divided into three groups: patients with kidney histological findings correlated to underlying IRD (Group 1), patients with kidney histological findings not correlated to underlying IRD (Group 2), and patients with kidney histological findings compatible with "de novo" IRD (absent in personal medical history) (Group 3). Kidney involvement related to IRD was found in 25.2% of patients. Group 1 was mostly represented by lupus nephritis (76.6%), with a younger age than Group 3 (p < 0.001) and by a higher percentage of females than other groups (p < 0.001). Group 3 was the most represented by microscopic polyangiitis (50.8%) when compared with the other two groups (p < 0.001). Acute nephritic syndrome (p < 0.001), acute kidney injury (AKI), and abnormal urinalysis (p < 0.001) were more represented in Group 3 than the other groups. In conclusion, IRDs are characterized by different clinical presentations and heterogeneous histological findings. Kidney biopsy remains fundamental to achieving the correct diagnosis and starting targeted therapy.

Complex central venous catheter for dialysis: interventional radiology experience in insertion and management of their complications

BACKGROUND

CVCs are defined 'complex' when they are inserted through non-conventional accesses or positioned in non-usual sites or substituted by IR endovascular procedures. We report our experience in using diagnostic and interventional radiology techniques for complex CVC insertion and management; we recommend some precautions and techniques that could lead to long-term availability of central venous access and to avoid non-conventional sites CVC insertion.

METHODS

We retrospectively evaluated 617 patients, between January 2010 and December 2019, (mean age 71 ± 13; male 448/617), treated in our department for insertion of tunnelled CVC for haemodialysis.

RESULTS

Among 617 patients, 241 cases (39%) are considered 'complex' because they required either a PTA with or without stenting to restore/maintain venous access or had an unusual positioning site or required unconventional access. A direct correlation between CT angiography and PTA (r = 0.95; p-value <0.001) and an inverse correlation between CT angiography and unconventional 'rescue' access (r = -0.92; p-value <0.001) were found.

CONCLUSIONS

Precise pre-operative planning of treatment in a multidisciplinary setting and diagnostic and interventional radiology procedures knowledge allows reducing complex catheterisms in haemodialysis patient.

Comparative analysis of hospitalizations among patients treated with hemodialysis and peritoneal dialysis in European pediatric nephrology centers: results from a prospective EPDWG/ESPN Dialysis Working Group study

Background and hypothesis

Hospital admissions in pediatric dialysis patients need to be better studied, and most existing studies are retrospective and based on registry data. This study aimed to analyse and compare hospital admission rates, causes, length of stay (LOS), and outcomes in children treated with peritoneal dialysis (PD) and hemodialysis (HD).

Methods

Data from 236 maintenance PD and 138 HD patients across 16 European dialysis centers were collected between 1 July 2017 and 30 June 2018. A total of 178 hospitalized patients (103 PD, 75 HD) were included for further analyses.

Results

There were 465 hospitalization events (268 PD, 197 HD) with a rate of 0.39 admissions per 100 patient-days at risk (PDAR) and 2.4 hospital days per 100 PDAR. The admission rates were not significantly different between HD and PD patients. The most common causes of hospitalization were access-related infections (ARI) (17%), non-infectious complications of access (NIAC) (14%), and infections unrelated to access (12%). ARI was the leading cause in PD patients (24%), while NIAC was more common in HD patients (19%). PD patients had more ARIs, diagnostic procedures, and treatment adjustments (P < .05), while HD patients had more NIACs, infections unrelated to access, access placement procedures, and interventional/surgical procedures (P < .001). LOS was longer with acute admissions than non-acute admissions (P < .001). Overall LOS and LOS in the intensive care unit were similar between HD and PD patients. High serum uric acid and low albumin levels were significant predictors of longer LOS (P = .022 and P = .045, respectively). Young age, more significant height deficit, and older age at the start of dialysis were predictors of longer cumulative hospital days (P = .002, P = .001, and P = .031, respectively).

Conclusion

Access-related complications are the main drivers of hospitalization in pediatric dialysis patients, and growth and nutrition parameters are significant predictors of more extended hospital stays.

MAPK1 Mediates MAM Disruption and Mitochondrial Dysfunction in Diabetic Kidney Disease via the PACS-2-Dependent Mechanism

Diabetic kidney disease (DKD) is a leading cause of end-stage renal disease (ESRD). Mitochondrial dysfunction in renal tubules, occurring early in the disease, is linked to the development of DKD, although the underlying pathways remain unclear. Here, we examine diabetic human and mouse kidneys, and HK-2 cells exposed to high glucose, to show that high glucose disrupts mitochondria-associated endoplasmic reticulum membrane (MAM) and causes mitochondrial fragmentation. We find that high glucose conditions increase mitogen-activated protein kinase 1(MAPK1), a member of the MAP kinase signal transduction pathway, which in turn lowers the level of phosphofurin acidic cluster sorting protein 2 (PACS-2), a key component of MAM that tethers mitochondria to the ER. MAPK1-induced disruption of MAM leads to mitochondrial fragmentation but this can be rescued in HK-2 cells by increasing PACS-2 levels. Functional studies in diabetic mice show that inhibition of MAPK1 increases PACS-2 and protects against the loss of MAM and the mitochondrial fragmentation. Taken together, these results identify the MAPK1-PACS-2 axis as a key pathway to therapeutically target as well as provide new insights into the pathogenesis of DKD.

Association of oral iron replacement therapy with kidney failure and mortality in CKD patients

Background

Oral iron is the predominant route of iron replacement (IRT) but its benefits and safety are unclear in patients with chronic kidney disease (CKD).

Methods

We examined the association of oral IRT vs no IRT with end-stage kidney disease (ESKD) and mortality in a national cohort of US Veterans. We identified 17 413 incident new users of oral IRT with estimated glomerular filtration rates <60 mL/min/1.73 m2 and 32 530 controls who did not receive any IRT during 2004-18. We used propensity score-overlap weighting to account for differences in key baseline characteristics associated with the use of oral IRT. We examined associations using competing risk regression and Cox models.

Results

In the cohort of 49 943 patients, 1616 (3.2%) patients experienced ESKD and 28 711 (57%) patients died during a median follow-up of 1.9 years. Oral IRT was not associated with ESKD [subhazard ratio (HR) (95% confidence interval, CI) 1.00 (0.84-1.19), P = .9] and was associated with higher risk of all-cause mortality [HR (95% CI) 1.06 (1.01-1.11), P = .01]. There was significant heterogeneity of treatment effect for mortality, with oral IRT associated with higher mortality in the subgroups of patients without congestive heart failure (CHF), anemia or iron deficiency. In patient with blood hemoglobin <10 g/dL oral IRT was associated with significantly lower mortality.

Conclusion

Oral IRT was associated with lower mortality only in patients with anemia. In patients without anemia, iron deficiency or CHF, the risk-benefit ratio of oral IRT should be further examined.

Comparison of focal segmental glomerulosclerosis and other primary glomerulonephrites in terms of parameters of hepatic steatosis and metabolic syndrome

PURPOSE

The increasing frequency of coexistence of focal segmental glomerulosclerosis (FSGS) and obesity-associated glomerulopathy and the relationship between metabolic syndrome components and chronic kidney disease have been demonstrated in studies. Based on this information, in this study, we aimed to compare FSGS and other primary glomerulonephritis diagnoses in terms of parameters of metabolic syndrome and hepatic steatosis.

MATERIALS AND METHODS

In our study, the data of 44 patients who were diagnosed FSGS through kidney biopsy and 38 patients with any other primary glomerulonephritis diagnoses in our nephrology clinic were retrospectively analyzed. Patients were divided into two groups: FSGS and other primary glomerulonephritis diagnoses, and they were examined in terms of their demographic data, laboratory parameters, body composition measurements, and the presence of hepatic steatosis, as shown using liver ultrasonography.

RESULTS

In the comparative analysis of patients with FSGS and other primary glomerulonephritis diagnoses, with the increase in age increased the risk of FSGS by 1.12 times, the increase in BMI ​​increased the risk of FSGS by 1.67 times, while with the decrease in waist circumference decreased the risk of FSGS by ​​0.88 times, the decrease in HbA1c decreased the risk of FSGS by ​​0.12 times, and the presence of hepatic steatosis increased the risk of FSGS by 20.24 times.

CONCLUSION

The presence of hepatic steatosis, an increase in waist circumference and BMI values, which are body components favoring obesity, and an increase in HbA1c, which is a marker for hyperglycemia and insulin resistance, are greater risk factors for the development of FSGS compared with other primary glomerulonephritis diagnoses.

Diagnosis of Kidney Diseases of Unknown Etiology Through Biopsy-Genetic Analysis

Introduction

Previous studies have suggested that genetic kidney diseases in adults are often overlooked, representing up to 10% of all cases of chronic kidney disease (CKD). We present data obtained from exome sequencing (ES) analysis of patients with biopsy-proven undetermined kidney disease (UKD).

Methods

ES was proposed during routine clinical care in patients with UKD from January 2020 to December 2021. We used in silico custom kidney genes panel analysis to detect pathological variations using American College of Medical Genetics guidelines in 52 patients with biopsy-proven UKD with histological finding reassessment.

Results

We detected 12 monogenic renal disorders in 21 (40.4%) patients. The most common diagnoses were collagenopathies (8/21,38.1%), COL4A3 and COL4A4 accounting for 80% of these diagnoses, and ciliopathies (5/21, 23.8%). The diagnostic yield of ES was higher in female patients and patients with a family history of kidney disease (57.1% and 71%, respectively). Clinical nephropathy categories matched with the final genetic diagnoses in 72.7% of cases, whereas histological renal lesions matched with the final diagnoses in 92.3% of cases. The genetics diagnoses and histopathological findings were in complete agreement for both glomerular and tubulointerstitial cases. Interstitial inflammation without tubulitis was only observed in tubulopathies or ciliopathies. Isolated CKD, CKD with proteinuria or hematuria, and isolated proteinuria or hematuria yielded the highest diagnostic yields (54.6%, 52.6%, and 42.9%, respectively).

Conclusion

ES done in patients with biopsy-proven UKD should be considered as a first-line tool for CKD patients with a family history of kidney disease. Combination of ES and kidney biopsy may have major impacts on kidney disease ontology.

Assessment of dysfunctional tunneled hemodialysis catheters and outcome of endovascular salvage techniques: a simple solution to a complex problem

Objective

The aim of this study was to evaluate the causes of the dysfunctional tunneled cuffed catheters (TCCs) using multi-spiral computed tomography venography (MSCTV), and to analyze the outcomes of endovascular salvage techniques.

Material and methods

This retrospective review data from 27 patients who experienced TCC dysfunction between July 1, 2016 and January 31, 2021 was conducted. Patients' demographic data, clinical signs and symptoms, and imaging data were collected from interventional radiology database.

Results

MSCTV showed a range of abnormalities in the hemodialysis (HD) patients, including central venous occlusion (n = 4), fibrin sheath formation (n = 3), malposition of the catheter tips (n = 4), central venous perforation (n = 1), thrombus formation (n = 12), regular catheter exchange without determined lesions (n = 3). Interventional catheter salvage procedures were performed, such as catheter exchange, balloon disruption of a fibrin sheath, angioplasty for central vein stenosis, and stent deployment. The technical success rate for catheter insertions was 100%, and no procedure-related severe complications were observed. The 30-day catheter patency for all assessable catheters was 85.2%.

Conclusion

The use of MSCTV showed abnormal findings in almost 88.9% of cases concerning dysfunctional TCC. In this study, the examined appropriate endovascular techniques were found to be safe and technically successful, with a low incidence of procedure-related complications.

Renal, but not platelet or skin, extracellular vesicles decrease oxidative stress, enhance nascent peptide synthesis, and protect from ischemic renal injury

Acute kidney injury (AKI) is deadly and expensive, and specific, effective therapy remains a large unmet need. We have demonstrated the beneficial effects of transplanted adult tubular cells and extracellular vesicles (EVs; exosomes) derived from those renal cells on experimental ischemic AKI, even when administered after renal failure is established. To further examine the mechanisms of benefit with renal EVs, we tested the hypothesis that EVs from other epithelia or platelets (a rich source of EVs) might be protective, using a well-characterized ischemia-reperfusion model. When given after renal failure was present, renal EVs, but not those from skin or platelets, markedly improved renal function and histology. The differential effects allowed us to examine the mechanisms of benefit with renal EVs. We found significant decreases in oxidative stress postischemia in the renal EV-treated group with preservation of renal superoxide dismutase and catalase as well as increases in anti-inflammatory interleukin-10. In addition, we propose a novel mechanism of benefit: renal EVs enhanced nascent peptide synthesis following hypoxia in cells and in postischemic kidneys. Although EVs have been used therapeutically, these results serve as "proof of principle" to examine the mechanisms of injury and protection.NEW & NOTEWORTHY Acute kidney injury is common and deadly, yet the only approved treatment is dialysis. Thus, a better understanding of injury mechanisms and potential therapies is needed. We found that organ-specific, but not extrarenal, extracellular vesicles improved renal function and structure postischemia when given after renal failure occurred. Oxidative stress was decreased and anti-inflammatory interleukin-10 increased with renal, but not skin or platelet, exosomes. We also propose enhanced nascent peptide synthesis as a novel protective mechanism.

Electronic Phenotype for Advanced Chronic Kidney Disease in a Veteran Health Care System Clinical Database: Systems-Based Strategy for Model Development and Evaluation

BACKGROUND

Identifying advanced (stages 4 and 5) chronic kidney disease (CKD) cohorts in clinical databases is complicated and often unreliable. Accurately identifying these patients can allow targeting this population for their specialized clinical and research needs.

OBJECTIVE

This study was conducted as a system-based strategy to identify all prevalent Veterans with advanced CKD for subsequent enrollment in a clinical trial. We aimed to examine the prevalence and accuracy of conventionally used diagnosis codes and estimated glomerular filtration rate (eGFR)-based phenotypes for advanced CKD in an electronic health record (EHR) database. We sought to develop a pragmatic EHR phenotype capable of improving the real-time identification of advanced CKD cohorts in a regional Veterans health care system.

METHODS

Using the Veterans Affairs Informatics and Computing Infrastructure services, we extracted the source cohort of Veterans with advanced CKD based on a combination of the latest eGFR value ≤30 ml·min-1·1.73 m-2 or existing International Classification of Diseases (ICD)-10 diagnosis codes for advanced CKD (N18.4 and N18.5) in the last 12 months. We estimated the prevalence of advanced CKD using various prior published EHR phenotypes (ie, advanced CKD diagnosis codes, using the latest single eGFR <30 ml·min-1·1.73 m-2, utilizing two eGFR values) and our operational EHR phenotypes of a high-, intermediate-, and low-risk advanced CKD cohort. We evaluated the accuracy of these phenotypes by examining the likelihood of a sustained reduction of eGFR <30 ml·min-1·1.73 m-2 over a 6-month follow-up period.

RESULTS

Of the 133,756 active Veteran enrollees at North Florida/South Georgia Veterans Health System (NF/SG VHS), we identified a source cohort of 1759 Veterans with advanced nondialysis CKD. Among these, 1102 (62.9%) Veterans had diagnosis codes for advanced CKD; 1391(79.1%) had the index eGFR <30 ml·min-1·1.73 m-2; and 928 (52.7%), 480 (27.2%), and 315 (17.9%) Veterans had high-, intermediate-, and low-risk advanced CKD, respectively. The prevalence of advanced CKD among Veterans at NF/SG VHS varied between 1% and 1.5% depending on the EHR phenotype. At the 6-month follow-up, the probability of Veterans remaining in the advanced CKD stage was 65.3% in the group defined by the ICD-10 codes and 90% in the groups defined by eGFR values. Based on our phenotype, 94.2% of high-risk, 71% of intermediate-risk, and 16.1% of low-risk groups remained in the advanced CKD category.

CONCLUSIONS

While the prevalence of advanced CKD has limited variation between different EHR phenotypes, the accuracy can be improved by utilizing two eGFR values in a stratified manner. We report the development of a pragmatic EHR-based model to identify advanced CKD within a regional Veterans health care system in real time with a tiered approach that allows targeting the needs of the groups at risk of progression to end-stage kidney disease.

Role of the CD40-CD40 Ligand Pathway in Cardiovascular Events, Neurological Alterations, and Other Clinical Complications of Chronic Hemodialysis Patients: Protective Role of Adsorptive Membranes

Despite the recent advances in dialysis technology, mortality rate of chronic uremic patients still remains excessively high: of note, in comparison to age- and sex-matched healthy controls, this frail population shows a higher incidence of infections, cancer, cognitive decline, and, in particular, major adverse cardiovascular events (MACE) that represent nowadays the first cause of mortality. Several traditional and nontraditional factors contribute to this increased risk for MACE and accelerated cellular senescence: among these, inflammation has been shown to play a key role. The costimulatory pathway CD40-CD40 Ligand (CD40L) is harmfully activated during inflammation and uremia-associated clinical complications: in particular, the soluble form of CD40L (sCD40L) can bind to the CD40 receptor triggering a cascade of detrimental pathways in immune and nonimmune cells. In this narrative review, we summarize the current concepts of the biological role of the CD40-CD40L pathway in uremia-associated organ dysfunction, focusing on the above-described main causes of mortality. Moreover, we discuss the interaction of the CD40-CD40L pathway with extracellular vesicles, microparticles recently identified as new uremic toxins. The biological effects of sCD40L in MACE, cognitive decline, infections, and cancer will be also briefly commented. Last, based on recent studies and ongoing clinical trials, we herein describe the modulatory activity of adsorptive dialysis membranes in polymethylmethacrylate on CD40-CD40L detrimental activation.

Association of Intradialytic Hypertension with Future Cardiovascular Events and Mortality in Hemodialysis Patients: Effects of Ambulatory Blood Pressure

INTRODUCTION

Intradialytic hypertension (IDHTN) is associated with increased risk of adverse outcomes. Patients with IDHTN have higher 44-h blood pressure (BP) than patients without this condition. Whether the excess risk in these patients is due to the BP rise during dialysis per se or on elevated 44-h BP or other comorbid conditions is uncertain. This study evaluated the association of IDHTN with cardiovascular events and mortality and the influence of ambulatory BP and other cardiovascular risk factors on these associations.

METHODS

242 hemodialysis patients with valid 48-h ABPM (Mobil-O-Graph-NG) were followed for a median of 45.7 months. IDHTN was defined as: systolic BP (SBP) rise ≥10 mm Hg from pre- to post-dialysis and post-dialysis SBP ≥150 mm Hg. The primary endpoint was all-cause mortality; the secondary endpoint was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, resuscitation after cardiac arrest, heart failure hospitalization, coronary or peripheral revascularization.

RESULTS

Cumulative freedom from both the primary and secondary endpoint was significantly lower for IDHTN patients (logrank-p = 0.048 and 0.022, respectively), corresponding to higher risks for all-cause mortality (hazard ratio (HR) = 1.566; 95% confidence interval (CI) [1.001, 2.450]) and the composite cardiovascular outcome (HR = 1.675; 95% CI [1.071, 2.620]) in these individuals. However, the observed associations lost statistical significance after adjustment for 44-h SBP (HR = 1.529; 95% CI [0.952, 2.457] and HR = 1.388; 95% CI [0.866, 2.225], respectively). In the final model after additional adjustment for 44-h SBP, interdialytic weight gain, age, history of coronary artery disease, heart failure, diabetes, and 44-h pulse wave velocity, the association of IDHTN with the outcomes was also not significant and the respective HRs were 1.377 (95% CI [0.836, 2.268]) and 1.451 (95% CI [0.891, 2.364]).

CONCLUSIONS

IDHTN patients had higher risk for mortality and cardiovascular outcomes but this risk is at least partly confounded by the elevated BP levels during the interdialytic period.

Current and Novel Biomarkers of Progression Risk in Children with Chronic Kidney Disease

BACKGROUND

Due to the complexity of chronic kidney disease (CKD) pathophysiology, biomarkers representing different mechanistic pathways have been targeted for the study and development of novel biomarkers. The discovery of clinically useful CKD biomarkers would allow for the identification of those children at the highest risk of kidney function decline for timely interventions and enrollment in clinical trials.

SUMMARY

Glomerular filtration rate and proteinuria are traditional biomarkers to classify and prognosticate CKD progression in clinical practice but have several limitations. Over the recent decades, novel biomarkers have been identified from blood or urine with metabolomic screening studies, proteomic screening studies, and an improved knowledge of CKD pathophysiology. This review highlights promising biomarkers associated with the progression of CKD that could potentially serve as future prognostic markers in children with CKD.

KEY MESSAGES

Further studies are needed in children with CKD to validate putative biomarkers, particularly candidate proteins and metabolites, for improving clinical management.

Management of concomitant central venous disease

Symptomatic central venous disease (CVD) is a significant common problem in patients with end-stage renal disease given its adverse impact on hemodialysis (HD) vascular access (VA). The current mainstay management is percutaneous transluminal angioplasty (PTA) with or without stenting which is typically reserved for unsatisfactory angioplasty or more challenging lesions. Despite factors such as target vein diameters and lengths and vessel tortuosity that may determine the choice of bare-metal versus covered stents (CS), current scientific literature is pointing out the superiority of the latter one. Alternative management options such as hemodialysis reliable outflow (HeRO) graft showed favorable results in terms of high patency rates and fewer infections, however, complications such as a steal syndrome and, to a lesser extent, graft migration and separation are major concerns. The surgical reconstruction approaches such as bypass, patch venoplasty, or chest wall arteriovenous graft with or without endovascular interventions as a hybrid procedure are still viable options and may be considered. However, further long-term investigations are needed to highlight the comparative outcomes of these approaches. Open surgery might be an alternative before proceeding to more unfavorable approaches such as lower extremity vascular access (LEVA). The appropriate therapy should be selected based upon a patient-centered interdisciplinary discussion utilizing the locally available expertise in the area of VA creation and maintenance.

Does anybody really know what (the kidney median waiting) time is?

The median waiting time (MWT) to deceased donor kidney transplant is of interest to patients, clinicians, and the media but remains elusive due to both methodological and philosophical challenges. We used Organ Procurement and Transplantation Network data from January 2003 to March 2022 to estimate MWTs using various methods and timescales, applied overall, by era, and by candidate demographics. After rising for a decade, the overall MWT fell to 5.19 years between 2015 and 2018 and declined again to 4.05 years (April 2021 to March 2022), based on the Kaplan-Meier method applied to period-prevalent cohorts. MWTs differed markedly by blood type, donor service area, and pediatric vs adult status, but to a lesser degree by race/ethnicity. Choice of methodology affected the magnitude of these differences. Instead of waiting years for an answer, reliable kidney MWT estimates can be obtained shortly after a policy is implemented using the period-prevalent Kaplan-Meier approach, a theoretical but useful construct for which we found no evidence of bias compared with using incident cohorts. We recommend this method be used complementary to the competing risks approach, under which MWT is often inestimable, to fill the present information void concerning the seemingly simple question of how long it takes to get a kidney transplant in the United States.

Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges

There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.

Prevalence and incidence of chronic kidney disease stage 3-5 - results from KidDiCo

BACKGROUND

Chronic kidney disease (CKD) is a global challenge. CKD prevalence estimation is central to management strategies and prevention. It is necessary to predict end stage kidney disease (ESKD) and, subsequently, the burden for healthcare systems. In this study we characterize CKD stage 3-5 prevalence and incidence in a cohort covering the majority of the Region of Southern Denmark and investigate individuals' demographic, socioeconomic, and comorbidity status.

METHODS

We used data from the Kidney Disease Cohort (KidDiCo) combining laboratory data from Southern Denmark with Danish national databases. Chronic kidney disease was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.

RESULTS

The prevalence varied between 4.83 and 4.98% and incidence rate of CKD was 0.49%/year. The median age was 76.4 years. The proportion of individuals with CKD stage 3-5 in the entire population increased consistently with age. The percentage of women in the CKD 3-5 group was higher than in the background population. Diabetes mellitus, hypertension and cardiovascular disease were more prominent in patients with CKD. CKD stage 5 and ESKD were more frequent as incident CKD stages in the 18-49 year olds when compared to older individuals. CKD patients tended to have a lower socioeconomic status.

CONCLUSION

Chronic kidney disease stage 3-5 is common, especially in the elderly. Patients with CKD stage 3-5 are predominantly female. The KidDiCo data suggests an association between lower socioeconomic status and prevalence of CKD.

Hedgehog interacting protein activates sodium-glucose cotransporter 2 expression and promotes renal tubular epithelial cell senescence in a mouse model of type 1 diabetes

AIMS/HYPOTHESIS

Senescent renal tubular cells may be linked to diabetic kidney disease (DKD)-related tubulopathy. We studied mice with or without diabetes in which hedgehog interacting protein (HHIP) was present or specifically knocked out in renal tubules (Hhip^RT-KO), hypothesising that local deficiency of HHIP in the renal tubules would attenuate tubular cell senescence, thereby preventing DKD tubulopathy.

METHODS

Low-dose streptozotocin was employed to induce diabetes in both Hhip^RT-KO and control (Hhip^fl/fl) mice. Transgenic mice overexpressing Hhip in renal proximal tubular cells (RPTC) (Hhip^RPTC-Tg) were used for validation, and primary RPTCs and human RPTCs (HK2) were used for in vitro studies. Kidney morphology/function, tubular senescence and the relevant molecular measurements were assessed.

RESULTS

Compared with Hhip^fl/fl mice with diabetes, Hhip^RT-KO mice with diabetes displayed lower blood glucose levels, normalised GFR, ameliorated urinary albumin/creatinine ratio and less severe DKD, including tubulopathy. Sodium-glucose cotransporter 2 (SGLT2) expression was attenuated in RPTCs of Hhip^RT-KO mice with diabetes compared with Hhip^fl/fl mice with diabetes. In parallel, an increased tubular senescence-associated secretory phenotype involving release of inflammatory cytokines (IL-1β, IL-6 and monocyte chemoattractant protein-1) and activation of senescence markers (p16, p21, p53) in Hhip^fl/fl mice with diabetes was attenuated in Hhip^RT-KO mice with diabetes. In contrast, Hhip^RPTC-Tg mice had increased tubular senescence, which was inhibited by canagliflozin in primary RPTCs. In HK2 cells, HHIP overexpression or recombinant HHIP increased SGLT2 protein expression and promoted cellular senescence by targeting both ataxia-telangiectasia mutated and ataxia-telangiectasia and Rad3-related-mediated cell arrest.

CONCLUSIONS/INTERPRETATION

Tubular HHIP deficiency prevented DKD-related tubulopathy, possibly via the inhibition of SGLT2 expression and cellular senescence.

Utility of ultrasonography for predicting indications for tolvaptan in patients with autosomal dominant polycystic kidney disease

PURPOSE

Tolvaptan is the first approved treatment for autosomal dominant polycystic kidney disease (ADPKD) that targets a mechanism directly contributing to the development and growth of renal cysts. We investigated the ability of ultrasonography to predict total kidney volume (TKV) of 750 mL or more, which is an indication for tolvaptan therapy in patients with ADPKD.

METHODS

A total of 46 patients with ADPKD were evaluated. The most statistically appropriate measurement based on ultrasonography for predicting TKV determined by computed tomography (CT) was assessed.

RESULTS

TKV determined by CT was 796.8 (508.8-1,560.3) mL. The median length, anteroposterior distance, and mediolateral distance determined using ultrasonography were 15.7 cm, 7.6 cm, and 7.6 cm in the left kidney, and 13.4 cm, 6.9 cm, and 7.2 cm in the right kidney, respectively. Multivariate regression analysis showed that total kidney length (left and right) [variance inflation factor (VIF), 9.349] and total mediolateral distance (left and right) (VIF, 3.988) were independently associated with TKV. The correlation (r) between the logarithm of TKV determined by CT and total mediolateral distance determined using ultrasonography was 0.915 (p < 0.001). The linear regression equation was log (total kidney volume) = 1.833 + 0.075 × total mediolateral distance (left and right) based on ultrasonography. The area under the receiver operating characteristic curve for total mediolateral distance determined using ultrasonography to predict TKV of 750 mL or more was 0.989. Using the total mediolateral distance cut-off value of 14.2 cm, the sensitivity and specificity were 96.0% and 100.0%, respectively.

CONCLUSION

Total mediolateral distance determined using ultrasonography can predict TKV in patients with ADPKD.

Prostate Cancer in Renal Transplant Recipients: Results from a Large Contemporary Cohort

Objectives: The aim of this study was to assess the natural history of prostate cancer (PCa) in renal transplant recipients (RTRs) and to clarify the controversy over whether RTRs have a higher risk of PCa and poorer outcomes than non-RTRs, due to factors such as immunosuppression. Patients and Methods: We performed a retrospective multicenter study of RTRs diagnosed with cM0 PCa between 2001 and 2019. Primary outcomes were overall (OS) and cancer-specific survival (CSS). Secondary outcomes included biochemical recurrence and/or progression after active surveillance (AS) and evaluation of variables possibly influencing PCa aggressiveness and outcomes. Management modalities included surgery, radiation, cryotherapy, HIFU, AS, and watchful waiting. Results: We included 166 men from nine institutions. Median age and eGFR at diagnosis were 67 (IQR 60−73) and 45.9 mL/min (IQR 31.5−63.4). ASA score was >2 in 58.4% of cases. Median time from transplant to PCa diagnosis was 117 months (IQR 48−191.5), and median PSA at diagnosis was 6.5 ng/mL (IQR 5.02−10). The biopsy Gleason score was ≥8 in 12.8%; 11.6% and 6.1% patients had suspicion of ≥cT3 > cT2 and cN+ disease. The most frequent management method was radical prostatectomy (65.6%), followed by radiation therapy (16.9%) and AS (10.2%). At a median follow-up of 60.5 months (IQR 31−106) 22.9% of men (n = 38) died, with only n = 4 (2.4%) deaths due to PCa. Local and systemic progression rates were 4.2% and 3.0%. On univariable analysis, no major influence of immunosuppression type was noted, with the exception of a protective effect of antiproliferative agents (HR 0.39, 95% CI 0.16−0.97, p = 0.04) associated with a decreased risk of biochemical recurrence (BCR) or progression after AS. Conclusion: PCa diagnosed in RTRs is mainly of low to intermediate risk and organ-confined at diagnosis, with good cancer control and low PCa death at intermediate follow-up. RTRs have a non-negligible risk of death from causes other than PCa. Aggressive upfront management of the majority of RTRs with PCa may, therefore, be avoided.

Optimal Frequency of Urinary Albumin Screening in Type 1 Diabetes

OBJECTIVE

Kidney disease screening recommendations include annual urine testing for albuminuria after 5 years' duration of type 1 diabetes. We aimed to determine a simple, risk factor-based screening schedule that optimizes early detection and testing frequency.

RESEARCH DESIGN AND METHODS

Urinary albumin excretion measurements from 1,343 participants in the Diabetes Control and Complications Trial and its long-term follow-up were used to create piecewise-exponential incidence models assuming 6-month constant hazards. Likelihood of the onset of moderately or severely elevated albuminuria (confirmed albumin excretion rate AER ≥30 or ≥300 mg/24 h, respectively) and its risk factors were used to identify individualized screening schedules. Time with undetected albuminuria and number of tests were compared with annual screening.

RESULTS

The 3-year cumulative incidence of elevated albuminuria following normoalbuminuria at any time during the study was 3.2%, which was strongly associated with higher glycated hemoglobin (HbA1c) and AER. Personalized screening in 2 years for those with current AER ≤10 mg/24 h and HbA1c ≤8% (low risk [0.6% three-year cumulative incidence]), in 6 months for those with AER 21-30 mg/24 h or HbA1c ≥9% (high risk [8.9% three-year cumulative incidence]), and in 1 year for all others (average risk [2.4% three-year cumulative incidence]) was associated with 34.9% reduction in time with undetected albuminuria and 20.4% reduction in testing frequency as compared with annual screening. Stratification by categories of HbA1c or AER alone was associated with reductions of lesser magnitude.

CONCLUSIONS

A personalized alternative to annual screening in type 1 diabetes can substantially reduce both the time with undetected kidney disease and the frequency of urine testing.

ARTICLE HIGHLIGHTS

Kidney disease screening recommendations include annual urine testing for albuminuria after 5 years' duration of type 1 diabetes. We investigated simple screening schedules that optimize early detection and testing frequency. Personalized screening in 2 years for those with current AER ≤10 mg/24 h and HbA1c ≤8%, in 6 months for those with AER 21-30 mg/24 h or HbA1c ≥9%, and in 1 year for all others yielded 34.9% reduction in time with undetected albuminuria and 20.4% fewer evaluations compared with annual screening. A personalized alternative to annual screening in type 1 diabetes can substantially reduce both the time with undetected kidney disease and the frequency of urine testing.

Patient-Reported Outcome Dashboards Within the Electronic Health Record to Support Shared Decision-making: Protocol for Co-design and Clinical Evaluation With Patients With Advanced Cancer and Chronic Kidney Disease

BACKGROUND

Patient-reported outcomes-symptoms, treatment side effects, and health-related quality of life-are important to consider in chronic illness care. The increasing availability of health IT to collect patient-reported outcomes and integrate results within the electronic health record provides an unprecedented opportunity to support patients' symptom monitoring, shared decision-making, and effective use of the health care system.

OBJECTIVE

The objectives of this study are to co-design a dashboard that displays patient-reported outcomes along with other clinical data (eg, laboratory tests, medications, and appointments) within an electronic health record and conduct a longitudinal demonstration trial to evaluate whether the dashboard is associated with improved shared decision-making and disease management outcomes.

METHODS

Co-design teams comprising study investigators, patients with advanced cancer or chronic kidney disease, their care partners, and their clinicians will collaborate to develop the dashboard. Investigators will work with clinic staff to implement the co-designed dashboard for clinical testing during a demonstration trial. The primary outcome of the demonstration trial is whether the quality of shared decision-making increases from baseline to the 3-month follow-up. Secondary outcomes include longitudinal changes in satisfaction with care, self-efficacy in managing treatments and symptoms, health-related quality of life, and use of costly and potentially avoidable health care services. Implementation outcomes (ie, fidelity, appropriateness, acceptability, feasibility, reach, adoption, and sustainability) during the co-design process and demonstration trial will also be collected and summarized.

RESULTS

The dashboard co-design process was completed in May 2020, and data collection for the demonstration trial is anticipated to be completed by the end of July 2022. The results will be disseminated in at least one manuscript per study objective.

CONCLUSIONS

This protocol combines stakeholder engagement, health care coproduction frameworks, and health IT to develop a clinically feasible model of person-centered care delivery. The results will inform our current understanding of how best to integrate patient-reported outcome measures into clinical workflows to improve outcomes and reduce the burden of chronic disease on patients and health care systems.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38461.

Accuracy, Reproducibility and User Experience With Standardized Instructions for Measurement of Total Kidney Volume in Autosomal Dominant Polycystic Kidney Disease

PURPOSE

Total kidney volume (TKV) measurement is integral in clinical management of autosomal dominant polycystic kidney disease (ADPKD) but the gold standard of measurement via stereology/manual planimetry is time-consuming and not readily available to clinicians. This study assessed whether standardized measurement instructions based on an ellipsoid equation enhanced TKV assessment on computed tomographic (CT) images of the kidneys as determined by accuracy, reproducibility, efficiency and/or user acceptability.

METHODS

Participating radiologists were randomized to perform TKV measurements with or without standardized instructions. All participants measured the same 3 non-contrast, low-dose CT scans. Accuracy was assessed as variation from TKV measurements obtained by planimetry. Intraclass correlation coefficients and time to complete the measurements were assessed. Surveys assessed prior experience with TKV measurement and user acceptability of the instructions.

RESULTS

49 radiologists participated. There was no difference in accuracy or measurement time between instructed and non-instructed participants. There was a trend towards greater reproducibility with standardized instructions (ICC .8 vs .6). 92% of respondents indicated the instructions were easy to use, 86% agreed the instructions would enhance their comfort with TKV measurement and 75% agreed they would recommend these instructions to colleagues.

CONCLUSIONS

Instructed and non-instructed participants demonstrated similar accuracy and time required for TKV measurement, but instructed participants had a trend towards greater reproducibility. There was high acceptability including enhanced user confidence with the instructions. Standardized instructions may be of value for radiologists seeking to improve their confidence in providing clinicians with TKV measurements necessary to appropriately manage this patient population.

Kidney Retransplantation after Graft Failure: Variables Influencing Long-Term Survival

Background

There is an increasing demand for kidney retransplantation. Most studies report inferior outcomes compared to primary transplantation, consequently feeding an ethical dilemma in the context of chronic organ shortage.

Objective

To assess variables influencing long-term graft survival after kidney retransplantation. Material and Methods. All patients transplanted at our center between 2000 and 2016 were analyzed retrospectively. Survival was estimated with the Kaplan–Meier method, and risk factors were identified using multiple Cox regression.

Results

We performed 1,376 primary kidney transplantations and 222 retransplantations. The rate of retransplantation was 67.8% after the first graft loss, with a comparable 10-year graft survival compared to primary transplantation (67% vs. 64%, p=0.104) but an inferior graft survival thereafter (log-rank p=0.026). Independent risk factors for graft survival in retransplantation were age ≥ 50 years, time on dialysis ≥1 year, previous graft survival <2 years, ≥1 mild comorbidity in the Charlson–Deyo index, active smoking, and life-threatening complications (Clavien–Dindo grade IV) at first transplantation.

Conclusion

Graft survival is comparable for first and second kidney transplantation within the first 10 years. Risk factors for poor outcomes after retransplantation are previous graft survival, dialysis time after graft failure, recipient age, comorbidities, and smoking. Patients with transplant failure should have access to retransplantation as early as possible.

Robotic Radical Prostatectomy for Prostate Cancer in Renal Transplant Recipients: Results from a Multicenter Series

BACKGROUND

Despite an expected increase in prostate cancer (PCa) incidence in the renal transplant recipient (RTR) population in the near future, robot-assisted radical prostatectomy (RARP) in these patients has been poorly detailed. It is not well understood whether results are comparable to RARP in the non-RTR setting.

OBJECTIVE

To describe the surgical technique for RARP in RTR and report results from our multi-institutional experience.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective review of the experience of four referral centers.

SURGICAL PROCEDURE

Transperitoneal RARP with pelvic lymph node dissection in selected patients.

MEASUREMENTS

We measured patient, PCa, and graft baseline features; intraoperative and postoperative parameters; complications, (Clavien classification); and oncological and functional outcomes.

RESULTS AND LIMITATIONS

We included 41 men. The median age, American Society of Anesthesiologists score, preoperative renal function, and prostate-specific antigen were 60 yr (interquartile range [IQR] 57-64), 2 points (IQR 2-3), 45 ml/min (IQR 30-62), and 6.5 ng/ml (IQR 5.2-10.2), respectively. Four men (9.8%) had a biopsy Gleason score >7. The majority of the patients (70.7%) did not undergo lymphadenectomy. The median operating time, hospital stay, and catheterization time were 201 min (IQR 170-250), 4 d (IQR 2-6), and 10 d (IQR 7-13), respectively. At final pathology, 11 men had extraprostatic extension and seven had positive surgical margins. At median follow-up of 42 mo (IQR 24-65), four men had biochemical recurrence, including one case of local PCa persistence and one local recurrence. No metastases were recorded while two patients died from non-PCa-related causes. Continence was preserved in 86.1% (p not applicable) and erections in 64.7% (p = 0.0633) of those who were continent/potent before the procedure. Renal function remained unchanged (p = 0.08). No intraoperative complications and one major (Clavien 3a) complication were recorded.

CONCLUSIONS

RARP in RTR is safe and feasible. Overall, operative, oncological, and functional outcomes are comparable to those described for the non-RTR setting, with graft injury remaining undescribed. Further research is needed to confirm our findings.

PATIENT SUMMARY

Robot-assisted removal of the prostate is safe and feasible in patients who have a kidney transplant. Cancer control, urinary and sexual function results, and surgical complications seem to be similar to those for patients without a transplant, but further research is needed.

Use of Guideline-Based Therapy for Diabetes, Coronary Artery Disease, and Chronic Kidney Disease After Acute Kidney Injury: A Retrospective Observational Study

Background

Survivors of acute kidney injury (AKI) are at a high risk for cardiovascular complications. An underrecognition of this risk may contribute to the low utilization of relevant guideline-based therapies in this population.

Objective

We sought to assess accordance with guideline-based recommendations for survivors of AKI with diabetes, coronary artery disease (CAD), and preexisting chronic kidney disease (CKD) in a post-AKI clinic, and identify factors that may be associated with guideline accordance.

Design

Retrospective cohort study.

Setting

Post-AKI clinics at 2 tertiary care centers in Ontario, Canada.

Patients

We included adult patients seen in both post-AKI clinics between 2013 and 2019 who had at least 2 clinic visits within 24 months of an index AKI hospitalization.

Measurements

We assessed accordance to recommendations from the most recent North American and international guidelines available at the time of study completion for diabetes, CAD, and CKD.

Methods

We compared guideline accordance between visits using the Cochran Mantel Haenszel test. We used multivariable Poisson regression to identify prespecified factors associated with accordance.

Results

Of 213 eligible patients, 192 (90%) had Kidney Disease Improving Global Outcomes Stage 2-3 AKI, 91 (43%) had diabetes, 76 (36%) had CAD, and 88 (41%) had preexisting CKD. From the first clinic visit to the second, there was an increase in angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE-I/ARB) use across all disease groups-from 33% to 46% (P = .028) in patients with diabetes, from 30% to 57% (P = .002) in patients with CAD, and from 16% to 35% (P < .001) in patients with preexisting CKD. Statin use increased in patients with preexisting CKD from 64% to 71% (P = .034). Every 25 μmol/L rise in the discharge serum creatinine was associated with a 19% (95% confidence interval [CI], 8%-28%) and 12% (95% CI, 2%-21%) lower likelihood of being on an ACE-I/ARB in patients with diabetes and preexisting CKD, respectively.

Limitations

The study lacked a comparison group that received usual care. The small sample and multiple comparisons make false positives possible.

Conclusion

There is room to improve guideline-based cardiovascular risk factor management in survivors of AKI, particularly ACE-I/ARB use in patients with an elevated discharge serum creatinine.

Association of Uric Acid-Lowering Therapy With Incident Chronic Kidney Disease

IMPORTANCE

Uric acid is a waste metabolite produced from the breakdown of purines, and elevated serum uric acid levels are associated with higher risk of hypertension, cardiovascular disease, and mortality and progression of chronic kidney disease (CKD). Treatment of hyperuricemia in patients with preexisting CKD has not been shown to improve kidney outcomes, but the associations of uric acid-lowering therapies with the development of new-onset kidney disease in patients with estimated glomerular filtration rate (eGFR) within reference range and no albuminuria is unclear.

OBJECTIVE

To examine the association of initiating uric acid-lowering therapy with the incidence of CKD.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included patients with eGFR of 60 mL/min/1.73 m2 or greater and no albuminuria treated at US Department of Veterans Affairs health care facilities from 2004 to 2019. Clinical trial emulation methods, including propensity score weighting, were used to minimize confounding. Data were analyzed from 2020 to 2022.

EXPOSURE

Newly started uric acid-lowering therapy.

MAIN OUTCOMES AND MEASURES

The main outcomes were incidences of eGFR less than 60 mL/min/1.73 m2, new-onset albuminuria, and end-stage kidney disease.

RESULTS

A total of 269 651 patients were assessed (mean [SD] age, 57.4 [12.5] years; 252 171 [94%] men). Among these, 29 501 patients (10.9%) started uric acid-lowering therapy, and 240 150 patients (89.1%) did not. Baseline characteristics, including serum uric acid level, were similar among treated and untreated patients after propensity score weighting. In the overall cohort, uric acid-lowering therapy was associated with higher risk of both incident eGFR less than 60 mL/min/1.73 m2 (weighted subhazard ratio [SHR], 1.15 [95% CI, 1.10-1.20; P < .001) and incident albuminuria (SHR, 1.05 [95% CI, 1.01-1.09; P < .001) but was not associated with the risk of end-stage kidney disease (SHR, 0.96 [95% CI, 0.62-1.50]; P = .87). In subgroup analyses, the association of uric acid-lowering therapy with worse kidney outcomes was limited to patients with baseline serum uric acid levels of 8 mg/dL or less.

CONCLUSIONS AND RELEVANCE

These findings suggest that in patients with kidney function within reference range, uric acid-lowering therapy was not associated with beneficial kidney outcomes and may be associated with potential harm in patients with less severely elevated serum uric acid levels.

Correlation between intestinal flora disruption and protein–energy wasting in patients with end-stage renal disease

Background

Different dialysis treatments may affect the composition and structure of the intestinal flora of dialysis-treated chronic kidney disease (CKD) patients. This study aimed to analyze the correlations between the different flora and the nutritional indexes and further explore the potential metabolic pathways in patients with CKD in end-stage renal disease (ESRD).

Methods

Altogether, 102 patients with ESRD were recruited and categorized into the hemodialysis (HD) group (N = 49) and the peritoneal dialysis (PD) group (N = 53). Their biochemical indexes, anthropometric indicators, and inflammatory markers were determined. The total genomic DNA was extracted for 16S ribosomal DNA sequencing. Furthermore, bioinformatics analysis was employed for functional analysis.

Results

Anthropometric indicators, including handgrip strength, mid-upper arm circumference, mid-upper arm muscle circumference, and body mass index, in the HD and PD groups showed a positive correlation with butyric acid-producing bacteria (Rosella and Phascolarctobacterium) and a negative correlation with conditional pathogens (Escherichia spp.). Meanwhile, the inflammatory markers, including high-sensitivity C-reactive protein and interleukin-6, were significantly higher in the PD-protein–energy wasting (PEW) group than in the PD-non-protein–energy wasting (NPEW) group; although they showed an increasing trend in the HD-PEW group, no significant difference was noted. Rosella was considerably scarce in the HD-PEW group than in the HD-NPEW group, whereas Escherichia was substantially more abundant in the PD-PEW group than in the PD-NPEW group. Compared with the HD group, the essential amino acid synthesis pathway, amino acid metabolism-related enzyme pathways, and aminoacyl-transfer RNA biosynthesis pathways were weakened in the PD group. Most carbohydrate metabolic pathways were weakened, although the tricarboxylic acid cycle was slightly enhanced. Concurrently, the fatty acid metabolism was enhanced, whereas fatty acid synthesis was weakened; the metabolic pathways of B vitamins were also weakened. These potential metabolic pathways of the various compounds released by intestinal flora showed a significant correlation with blood biochemical indexes, anthropometric indicators, and inflammatory markers.

Conclusion

In patients with ESRD, different dialysis treatments affected the abundance of butyric acid-producing bacteria (Rosella and Phascolarctobacterium) and conditional pathogens (Escherichia spp.). Butyric acid-producing bacteria showed a positive correlation with PEW and showed a negative correlation with Escherichia. Improving the intestinal diversity and increasing the amount of butyric acid-producing bacteria, such as Blautella, Faecococcus, and Phascolarctobacterium, are potential therapeutic approaches to enhance protein–energy consumption in patients with ESRD.

INFLUENCE OF THE DURATION OF DIABETES AND VIBRATION PERCEPTION THRESHOLD ON THE SEVERITY OF ERECTILE DYSFUNCTION IN PATIENTS WITH TYPE 2 DIABETES MELLITUS

BACKGROUND

Erectile dysfunction(ED) in men is a frequent under-reported complication of diabetes mellitus, which is becoming significant health problem worldwide.

AIMS

The study aims to determine the prevalence and risk factors for development of ED in North Indian patients with type 2 diabetes mellitus.

METHODS

We used international index of erectile function (IIEF-5) for the assessment of ED in 796 patients with type 2 diabetes mellitus. We recorded the age, duration of diabetes, glycemic status, body mass index, diabetes medications, microvascular and macrovascular complications.

RESULTS

The mean age of patients in the study was 49.38 ± 9.52 years. The prevalence of ED in patients with type 2 diabetes mellitus was 79.4%. Logistic regression analysis revealed that age, body mass index, glycemic control, insulin therapy, retinopathy and nephropathy was not significantly associated with erectile dysfunction in patients with type 2 diabetes mellitus. Duration of diabetes (OR = 1.054, 95% CI 1.007 to 1.102, P=0.023) and vibration perception threshold (OR = 1.071, 95% CI 1.042 to 1.102, P=0.000) were identified as key risk factors for development of ED.

CONCLUSION

Duration of diabetes and peripheral neuropathy emerged as significant risk factors for development of severe erectile dysfunction.

Association Between Urinary Protein-to-Creatinine Ratio and Chronic Kidney Disease Progression: A Secondary Analysis of a Prospective Cohort Study

Objective

Studies on the association between urinary protein-to-creatinine ratio (UPCR) and chronic kidney disease (CKD) progression are limited. This study aimed to investigate the relationship between UPCR and CKD progression in a Japanese population.

Methods

The present research was a secondary analysis of a prospective cohort study. Eight hundred and ninety-six subjects from the research of CKD-ROUTE in Japan were included. All the patients were new visitors or first referred to the participating centers of nephrology between October 2010 and December 2011. The target-independent variable was UPCR measured at baseline. The dependent variable was CKD progression and the estimated glomerular filtration rate (eGFR) changes during follow-up. We used Cox proportional hazards regression to investigate the association between UPCR and CKD progression risk. To address UPCR and CKD progression's non-linearity, a multivariate Cox proportional hazards regression analysis with cubic spline functions model and smooth curve fitting (penalized spline method) were conducted. We further used a generalized linear mixed model to explore the relationship between UPCR and the changes of eGFR.

Result

The mean age of the included patients was 67.2 ± 13.4 years old. Two hundred and thirty-four people occurred CKD progression during follow-up. The present study showed that UPCR was independently associated with CKD progression in the multivariate analysis [HR = 1.164, 95% CI (1.116, 1.215)]. The non-linear relationship between UPCR and CKD progression was explored in a dose-dependent manner, with an obvious inflection point of 1.699. Furthermore, our findings indicated that the tendency of the effect sizes on both the left and right sides of the inflection point was not consistent [left HR: 4.377, 95% CI (2.956, 6.483); right HR: 1.100, 95% CI (1.049–1.153)]. Using the linear mixed-effects regression model, we found that UPCR was an independent predictor of the longitudinal changes in eGFR (p < 0.001 for the interaction term with time).

Conclusion

This study demonstrates a nonlinear positive relationship between UPCR and CKD progression in the Japanese population. UPCR is also an independent predictor of the longitudinal changes in eGFR.

Effects of primary kidney disease etiology on renal osteodystrophy in pediatric dialysis patients

Congenital diseases of the kidney and urinary tract (CAKUT) and glomerulonephritis are the main causes of chronic kidney disease (CKD) in children. Although renal osteodystrophy (ROD) and indices of mineral metabolism have been characterized in dialyzed children, the impact of primary kidney disease on ROD is unknown. We performed a cross‐sectional study of bone biopsies performed in 189 pediatric dialysis patients aged 12.6 ± 5.4 years. Patients were classified into three groups according to primary kidney disease: CAKUT (n = 82), hereditary (n = 22), or glomerular disease (n = 85). Serum concentrations of calcium, phosphate, alkaline phosphatase (ALP), parathyroid hormone (PTH), and 25(OH) vitamin D were measured at the time of biopsy. Fibroblast growth factor 23 (FGF23) levels were measured in a subset of 59 patients. Levels of calcium, phosphate, PTH, and 25(OH) vitamin D were similar across groups. CAKUT patients had higher serum ALP and lower C‐terminal FGF23 levels. Bone turnover and bone volume parameters did not differ across groups. However, osteoid volume (OV/BV), osteoid surface (OS/BS), and osteoid maturation time (OMT) were highest in the CAKUT group and lowest in the hereditary group. Multiple regression analysis revealed that calcium, phosphate, ALP, and PTH were independently associated with OV/BV and osteoid thickness (O.Th). PTH was an independent factor affecting bone formation rate. The relationship between CKD etiology and bone histomorphometric variables was abrogated after adjustment for biochemical parameters in the multivariable models. Overall, bone histology differed according to CKD etiology in the unadjusted analysis; however, this association could not be confirmed independently of biochemical parameters. Although CAKUT patients had a greater mineralization defect with elevated serum ALP levels, longitudinal studies will be needed to elucidate mediation pathways that might be involved in the complex interplay of CKD‐mineral bone disease (MBD). © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Causes of Death in End-Stage Kidney Disease: Comparison between the United States Renal Data System and a Large Integrated Health Care System

INTRODUCTION

Using a large diverse population of incident end-stage kidney disease (ESKD) patients from an integrated health system, we sought to evaluate the concordance of causes of death (CODs) between the underlying COD from the United States Renal Data System (USRDS) registry and CODs obtained from Kaiser Permanente Southern California (KPSC).

METHODS

A retrospective cohort study was performed among incident ESKD patients who had mortality records and CODs reported in both KPSC and USRDS databases between January 1, 2007, and December 31, 2016. Underlying CODs reported by the KPSC were compared to the CODs reported by USRDS. Overall and subcategory-specific COD agreements were assessed using Cohen's weighted kappa statistic (95% CI). Proportions of positive and negative agreement were also determined.

RESULTS

Among 4,188 ESKD patient deaths, 4,118 patients had CODs recorded in both KPSC and USRDS. The most common KPSC CODs were circulatory system diseases (35.7%), endocrine/nutritional/metabolic diseases (24.2%), genitourinary diseases (12.9%), and neoplasms (9.6%). Most common USRDS CODs were cardiac disease (46.9%), withdrawal from dialysis (12.6%), and infection (10.1%). Of 2,593 records with causes listed NOT as "Other," 453 (17.4%) had no agreement in CODs between the USRDS and the underlying, secondary, tertiary, or quaternary causes recorded by KPSC. In comparing CODs recorded within KPSC to the USRDS, Cohen's weighted kappa (95% CI) was 0.20 (0.18-0.22) with overall agreement of 36.4%.

CONCLUSION

Among an incident ESKD population with mortality records, we found that there was only fair or slight agreement between CODs reported between the USRDS registry and KPSC, a large integrated health care system.

Predicting 3-month and 1-year mortality for patients initiating dialysis: a population-based cohort study

BACKGROUND

Despite the continual improvements in dialysis treatments, mortality in end-stage kidney disease (ESKD) remains high. Many mortality prediction models are available, but most of them are not precise enough to be used in the clinical practice. We aimed to develop and validate two prediction models for 3-month and 1-year patient mortality after dialysis initiation in our population.

METHODS

Using population-based data of insurance claims in Taiwan, we included more than 210,000 patients who initiated dialysis between January 1, 2006, and June 30, 2015. We developed two prognostic models, which included 9 and 11 variables, respectively (including age, sex, myocardial infarction, peripheral vascular disease, cerebrovascular disease, dementia, chronic pulmonary disease, peptic ulcer disease, malignancy, moderate to severe liver disease, and first dialysis in intensive care unit).

RESULTS

The models showed adequate discrimination (C-statistics were 0.80 and 0.82 for 3-month and 1-year mortality, respectively) and good calibration. In both our models, the first dialysis in the intensive care unit and moderate-to-severe liver disease were the strongest risk factors for mortality.

CONCLUSION

The prediction models developed in our population had good predictive ability for short-term mortality in patients initiating dialysis in Taiwan and could help in decision-making regarding dialysis initiation, at least in our setting, supporting a patient-centered approach to care.

Mortality and Resource Use Among Individuals With Chronic Kidney Disease or Cancer in Alberta, Canada, 2004-2015

IMPORTANCE

Although the public is aware that cancer is associated with excess mortality and adverse outcomes, the clinical consequences of chronic kidney disease (CKD) are not well understood.

OBJECTIVE

To compare the clinical consequences of incident severe CKD and the first diagnosis with a malignant tumor, focusing on the 10 leading causes of cancer in men and women residing in Canada.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study enrolled individuals aged 19 years and older with severe CKD or certain types of cancer between 2004 and 2015 in Alberta, Canada. Data were analyzed in November 2021.

EXPOSURES

Individuals were categorized as having severe CKD (based on estimated glomerular filtration rate <30 mL/min/1.73 m2 or nephrotic albuminuria without dialysis or kidney transplantation) or nonmetastatic or metastatic cancer (defined by a diagnosis of lung, breast, colorectal, prostate, bladder, thyroid, kidney or renal pelvis, uterus, pancreas, or oral cancer).

MAIN OUTCOMES AND MEASURES

All-cause mortality, number of hospitalizations, total number of hospital days, and placement into long-term care were calculated after diagnosis.

RESULTS

Of 200 494 individuals in the cohort (104 559 women [52.2%]; median [IQR] age, 66.8 [55.9-77.7] years), 51 159 (25.5%) had incident severe CKD, 115 504 (57.6%) had nonmetastatic cancer, and 33 831 (16.9%) had metastatic cancer. Kaplan-Meier 1-year survival was 83.3% (95% CI, 83.0%-83.6%) for patients with CKD, 91.2% (95% CI, 91.0%-91.4%) for patients with nonmetastatic cancer, and 52.8% (95% CI, 52.2%-53.3%) for patients with metastatic cancer. Kaplan-Meier 5-year survival was 54.6% (95% CI, 54.2%-55.1%) for patients with CKD, 76.6% (95% CI, 76.3%-76.8%) for patients with nonmetastatic cancer, and 33.9% (95% CI, 33.3%-34.4%) for patients with metastatic cancer. Compared with nonmetastatic cancer, the age-, sex-, and comorbidity-adjusted relative rate of death was similar for CKD (adjusted relative rate, 1.00; 95% CI, 0.97-1.03; P = .92) during the first year of follow-up and was higher for CKD at years 1 to 5 (adjusted relative rate 1.23; 95% CI, 1.19-1.26). During the first year of follow-up, for patients with CKD, adjusted rates of placement in long-term care (adjusted relative rate, 0.88; 95% CI, 0.82-0.94) and hospitalization (adjusted relative rate, 0.65; 95% CI, 0.64-0.66) were lower than rates for patients with nonmetastatic cancer; however, those rates were higher for the CKD group than for the nonmetastatic cancer group during years 1 to 5 (long-term care placement, adjusted relative rate, 1.36; 95% CI, 1.29-1.43; hospitalization, adjusted relative rate, 1.55; 95% CI, 1.52-1.58). As expected, adjusted rates of long-term care placement and hospitalization were higher for patients with metastatic cancer than for the other 2 groups.

CONCLUSIONS AND RELEVANCE

In this study, mortality, hospitalization, and likelihood of placement into long-term care were similar for CKD and nonmetastatic cancer. These data highlight the importance of CKD as a public health problem.

COULD PROTEINURIA PREDICT THE RENAL PROGNOSES OF PATIENTS WITH TYPE 2 DIABETES MELLITUS AND DIABETIC NEPHROPATHY?

AIMS

This study investigated the relationship between proteinuria levels, clinicopathological features, and renal prognoses in Chinese patients with type 2 diabetes mellitus (T2DM) and diabetic nephropathy (DN).

METHODS

Three hundred patients with T2DM and biopsy-proven DN were enrolled. Patients were stratified by 24-h proteinuria levels: Group 1:≤1g/24h); Group 2:1-3g/24h; and Group 3:≥3g/24h. Renal outcomes were defined as having reached end-stage renal disease (ESRD). The proteinuria level's influence on the renal outcomes was evaluated using Cox regression analysis.

RESULTS

Among subgroups stratified by proteinuria levels, systolic blood pressure, serum creatinine, BUN, cholesterol, DR and hypertension incidence, the incidences of patients who progressed to ESRD were the lowest in group 1 (P<0.05). However, eGFR, serum albumin and hemoglobin were highest in group 1. Patients with higher proteinuria levels had much lower five-year renal survival rates. Univariate analyses revealed that higher proteinuria levels were significant clinical predictors of renal prognosis (P<0.05), although they were not independent risk factors for progression to ESRD in the multivariate Cox proportional hazard analysis (P>0.05).

CONCLUSIONS

The higher the level of proteinuria, the lower the 5-year renal survival rate of DN patients, but there was no significant correlation between proteinuria level and 5-year renal survival rate. Other factors in the proteinuria group may have more significant effects on the 5-year renal survival rate, such as lower baseline eGFR, serum albumin, hemoglobin and higher cholesterol, higher incidences of DR and more severe lesions.

Medical nutrition therapy using plant-focused low-protein meal plans for management of chronic kidney disease in diabetes

PURPOSE OF REVIEW

Nearly half of all Americans with chronic kidney disease (CKD) also have type-2-diabetes (T2D). Whereas traditional and emerging pharmacotherapies are increasingly frequently used for the management of CKD in diabetes (CKD/DM), the role of integrated or multimodal interventions including the potentially synergistic and additive effect of diet and lifestyle modifications in addition to pharmacotherapy has not been well examined, in sharp contrast to the well-known integrated approaches to heart disease.

RECENT FINDINGS

Low-carbohydrate low-fat diets are often recommended in T2D, whereas low-protein diets (LPD) are recommended by guidelines for nondiabetic CKD with increasing emphasis on plant-based protein sources. High-protein diets with greater animal protein lead to glomerular hyperfiltration, especially in patients with T2D, and faster decline in renal function. Guidelines provide differing recommendations regarding the amount (low vs high) and source (plant vs animal) of dietary protein intake (DPI) in CKD/DM. Some such as KDIGO recommend 0.8 g/kg/day based on insufficient evidence for DPI restriction in CKD/DM, whereas KDOQI and ISRNM recommend a DPI of 0.6 to <0.8 g/kg/day. A patient-centered plant-focused LPD for the nutritional management of CKD/DM (PLAFOND), a type of PLADO diet comprising DPI of 0.6 to <0.8 g/kg/day with >50% plant-based sources, high dietary fiber, low glycemic index, and 25-35 Cal/kg/day energy, can be implemented by renal dietitians under Medical Nutrition Therapy.

SUMMARY

Potential risks vs benefits of high vs low protein intake in CKD/DM is unknown, for which expert recommendations remain opinion based. Randomized controlled studies are needed to examine safety, acceptability and efficacy of PLAFOND.

Effects of Alpha-lipoic Acid Supplementation on Human Diabetic Nephropathy: A Systematic Review and Meta-analysis

BACKGROUND

Diabetic nephropathy (DN) is kidney dysfunction, which occurs due to elevated urine albumin excretion rate and reduced glomerular filtration rate. Studies on animals have shown that alpha-lipoic acid (ALA) supplementation can reduce the development of DN.

OBJECTIVES

We performed a systematic review and meta-analysis to examine the effects of ALA supplementation on biological indices (albumin, creatinine, etc.) indicative of human DN.

METHODS

The search procedure included PubMed Central, Embase, Cochrane Library (trials), and Web of Science (protocol registration: INPLASY202060095).

RESULTS

We found that ALA supplementation decreased 24h urine albumin excretion rate in patients with diabetes (standardized mean difference=-2.27; confidence interval (CI)=(-4.09)-(-0.45); I²=98%; Z=2.44; p=0.01). A subgroup analysis revealed that the results of studies examining only ALA did not differ from those examined ALA in combination with additional medicines (Chisquared= 0.19; p=0.66; I²=0%), while neither ALA nor ALA plus medication had an effect on 24h urine albumin excretion rate (p>0.05). Also, ALA supplementation decreased urine albumin mg/l (mean difference (MD)=-12.95; CI=(-23.88)-(-2.02); I²=44%; Z=2.32; p=0.02) and urine albumin to creatinine ratio (MD=-26.96; CI=(-35.25)-(-18.67); I²=0%; Z=6.37; p<0.01) in patients with diabetes. When the studies examining ALA plus medication were excluded, it was found that ALA supplementation had no effect on urine albumin mg/l (p>0.05) but did significantly decrease urine albumin to creatinine ratio (MD=-25.88, CI=(34.40-(-17.36), I²=0%, Z=5.95, p<0.00001).

CONCLUSION

The available evidence suggests that ALA supplementation does not improve biological indices that reflect DN in humans. Overall, we identified limited evidence, and therefore, the outcomes should be considered with caution.

Uremic Toxins and Protein-Bound Therapeutics in AKI and CKD: Up-to-Date Evidence

Uremic toxins are defined as harmful metabolites that accumulate in the human body of patients whose renal function declines, especially chronic kidney disease (CKD) patients. Growing evidence demonstrates the deteriorating effect of uremic toxins on CKD progression and CKD-related complications, and removing uremic toxins in CKD has become the conventional treatment in the clinic. However, studies rarely pay attention to uremic toxin clearance in the early stage of acute kidney injury (AKI) to prevent progression to CKD despite increasing reports demonstrating that uremic toxins are correlated with the severity of injury or mortality. This review highlights the current evidence of uremic toxin accumulation in AKI and the therapeutic value to prevent CKD progression specific to protein-bound uremic toxins (PBUTs).

The SGLT-2 Inhibitors in Personalized Therapy of Diabetes Mellitus Patients

Diabetes mellitus (DM) represents a major public health problem, with yearly increasing prevalence. DM is considered a progressive vascular disease that develops macro and microvascular complications, with a great impact on the quality of life of diabetic patients. Over time, DM has become one of the most studied diseases; indeed, finding new pharmacological ways to control it is the main purpose of the research involved in this issue. Sodium–glucose cotransporter 2 inhibitors (SGLT-2i) are a modern drug class of glucose-lowering agents, whose use in DM patients has increased in the past few years. Besides the positive outcomes regarding glycemic control and cardiovascular protection in DM patients, SGLT-2i have also been associated with metabolic benefits, blood pressure reduction, and improved kidney function. The recent perception and understanding of SGLT-2i pathophysiological pathways place this class of drugs towards a particularized patient-centered approach, moving away from the well-known glycemic control strategy. SGLT-2i have been shown not only to reduce death from cardiovascular causes, but also to reduce the risk of stroke and heart failure hospitalization. This article aims to review and highlight the existing literature on the effects of SGLT-2i, emphasizing their role as oral antihyperglycemic agents in type 2 DM, with important cardiovascular and metabolic benefits.

Serum Sortilin Is Associated with Coronary Artery Calcification and Cardiovascular and Cerebrovascular Events in Maintenance Hemodialysis Patients

OBJECTIVE

To analyze the role of serum sortilin in coronary artery calcification (CAC) and cardiovascular and cerebrovascular events (CCE) in maintenance hemodialysis (MHD) patients.

METHODS

One hundred eleven patients with MHD ≥3 months were included in this study. The general data, clinical features, hematological data, and medication history of the patients were recorded. Eighty-five cases were examined by vascular color Doppler ultrasound, cardiac color Doppler ultrasound, lateral lumbar radiography, and coronary artery calcification score. The patients were followed up for a median time of 45 months. The primary endpoint was CCE or death from a vascular event, and the role of sortilin in this process was analyzed.

RESULTS

Among 85 MHD patients, 51 cases (60.00%) had different degrees of CAC. There were significant differences in diabetes, dialysis time, serum phosphorus, calcium-phosphorus product, medical history of phosphate binders, sortilin, and carotid artery plaque between 4 different degrees of calcification groups (p < 0.05). Logistic regression analysis showed that diabetes (OR = 5.475; 95% CI: 1.794-16.71, p = 0.003), calcium-phosphorus product (OR = 2.953; 95% CI: 1.198-7.279, p = 0.019), and sortilin (OR = 1.475 per 100 pg/mL; 95% CI: 1.170-1.858, p = 0.001) were independent risk factors for CAC. During the follow-up, 28 cases of 111 patients (25.23%) suffered from CCE. There were significant differences in CCE between mild, moderate, and severe CAC groups and noncalcification groups (p < 0.05). Cox regression analysis showed that diabetes mellitus (HR 3.424; 95% CI: 1.348-8.701, p = 0.010), CAC (HR 5.210; 95% CI: 1.093-24.83, p = 0.038), and serum sortilin (HR = 8.588; 95% CI: 1.919-38.43, p = 0.005) were independent risk factors for CCE. Besides, we proposed a cutoff value of 418 pg/mL for serum sortilin level, which was able to predict the occurrence of CCE with 75.0% sensitivity and 71.9% specificity. The area under the curve was 0.778 (95% CI: 0.673-0.883).

CONCLUSION

Sortilin is newly found to be independently associated with CAC and CCE in MHD patients.

Endovascular Embolization in Problematic Hemodialysis Arteriovenous Fistulas: A Nonsurgical Technique

Introduction:

In the past, surgical techniques were considered gold standard practice for obliterating the accessory veins, reducing the flow across the high flowing arteriovenous fistulas (AVFs), or for closing the problematic hemodialysis AVFs. However, recently endovascular embolization has emerged as a safe and cost-effective alternative to these surgical techniques. In this study, technical and clinical success, and safety of endovascular embolization have been evaluated for accessory vein obliteration, flow reduction, and fistula closure in problematic AVFs using various embolizing agents.

Methods:

This is a retrospective study of patients with problematic hemodialysis AVFs, who underwent endovascular embolization for accessory vein obliteration, flow reduction, and AVF closure at our center from February 2017 to January 2019 with various embolic agents like vascular plugs (VP), thrombin, coils, and glue. Follow-up was done at 1 week, 3 months, 6 months, and annually thereafter.

Results:

In this study 30 patients with problematic hemodialysis AVFs [Left brachiocephalic fistula (BCF) (n = 22), right BCF (n = 4), and left radiocephalic fistula (RCF) (n = 4)], underwent endovascular embolization for accessory vein obliteration (n = 6), flow reduction (n = 3), and AVF closure (n = 21). Of the 6 patients undergoing embolization for obliteration of accessory collateral, 4 patients had nonmaturing AVFs and 2 patients had symptoms of venous hypertension (VH). Post embolization, all 4 AVFs matured over a month and symptoms of VH completely resolved within a week. Three patients who underwent embolization for flow reduction had patent AVF (on doppler) post procedure and they achieved adequate flow during dialysis with complete resolution of symptoms of VH. Out of 21 patients, who underwent endovascular closure, complete AVF thrombosis was seen in 18 patients only with the use of VP, while 4 patients required additional procedure to achieve complete thrombosis of AVF.

Conclusion:

Endovascular embolization in problematic hemodialysis AVF is a safe and cost-effective alternative to open surgical methods and vascular plug could be embolic agent of choice for AVF closure.

Retinal microvascular function predicts chronic kidney disease in patients with cardiovascular risk factors

BACKGROUND AND AIMS

Endothelial dysfunction is a precursor to atherosclerosis and is implicated in the coexistence between cardiovascular disease (CVD) and chronic kidney disease (CKD). We examined whether retinal microvascular dysfunction is present in subjects with renal impairment and predictive of long-term CKD progression in patients with CVD.

METHODS

In a single centre prospective observational study, 253 subjects with coronary artery disease and CVD risk factors underwent dynamic retinal vessel analysis. Retinal microvascular dysfunction was quantified by measuring retinal arteriolar and venular dilatation in response to flicker light stimulation. Serial renal function assessment was performed over a median period of 9.3 years using estimated GFR (eGFR).

RESULTS

Flicker light-induced retinal arteriolar dilatation (FI-RAD) was attenuated in patients with baseline eGFR <90 mL/min/1.73 m², compared to those with normal renal function (eGFR ≥90 mL/min/1.73 m²) (1.0 [0.4-2.1]% vs. 2.0 [0.8-3.6]%; p < 0.01). In patients with normal renal function, subjects with the lowest FI-RAD responses exhibited the greatest annual decline in eGFR. In uni- and multivariable analysis, among subjects with normal renal function, a 1% decrease in FI-RAD was associated with an accelerated decline in eGFR of 0.10 (0.01, 0.15; p = 0.03) and 0.07 mL/min/1.73 m² per year (0.00, 0.14; p = 0.06), respectively. FI-RAD was not predictive of CKD progression in subjects with baseline eGFR <90 mL/min/1.73 m².

CONCLUSIONS

Retinal arteriolar endothelial dysfunction is present in patients with CVD who have early-stage CKD, and serves as an indicator of long-term CKD progression in those with normal renal function.