US Renal Data System 2021 Annual Data Report: Epidemiology of Kidney Disease in the United States

Machine learning algorithms for diabetic kidney disease risk predictive model of Chinese patients with type 2 diabetes mellitus

BACKGROUND

Diabetic kidney disease (DKD) is a common and serious complication of diabetic mellitus (DM). More sensitive methods for early DKD prediction are urgently needed. This study aimed to set up DKD risk prediction models based on machine learning algorithms (MLAs) in patients with type 2 DM (T2DM).

METHODS

The electronic health records of 12,190 T2DM patients with 3-year follow-ups were extracted, and the dataset was divided into a training and testing dataset in a 4:1 ratio. The risk variables for DKD development were ranked and selected to establish forecasting models. The performance of models was further evaluated by the indexes of sensitivity, specificity, positive predictive value, negative predictive value, accuracy, as well as F1 score, using the testing dataset. The value of accuracy was used to select the optimal model.

RESULTS

Using the importance ranking in the random forest package, the variables of age, urinary albumin-to-creatinine ratio, serum cystatin C, estimated glomerular filtration rate, and neutrophil percentage were selected as the predictors for DKD onset. Among the seven forecasting models constructed by MLAs, the accuracy of the Light Gradient Boosting Machine (LightGBM) model was the highest, indicated that the LightGBM algorithms might perform the best for predicting 3-year risk of DKD onset.

CONCLUSIONS

Our study could provide powerful tools for early DKD risk prediction, which might help optimize intervention strategies and improve the renal prognosis in T2DM patients.

The Use of B. Braun Hemodialysis Machine to Provide Home Hemodialysis

BACKGROUND

Home hemodialysis (home HD) continues to be an underutilized dialysis modality despite its potential advantages when compared to peritoneal dialysis (PD) and in-center hemodialysis (HD).

METHODS

We conducted a retrospective study to evaluate the feasibility of using the B. Braun Dialog+ HD machine to provide home HD with the necessary requirements and modifications at home to be able to provide such treatments. In this retrospective study, we compared data obtained from patients who received home HD using the B. Braun Dialog+ HD machine since we started utilizing it for home HD (n = 27 patients) to data obtained from eligible patients who received home HD using the NxStage System One machine around the same period (n = 36 patients).

RESULTS

Our results showed that the B. Braun group had a better single treatment single-pool Kt/V (spKt/V) (1.48 ± 0.27 for B. Braun vs. 1.14 ± 0.32 for NxStage, p < 0.001), better standard weekly Kt/V (4.44 ± 0.82 for B. Braun vs. 2.65 ± 0.57 for NxStage, p < 0.001), and better urea reduction rate (URR) (71.4 ± 6.2 for B. Braun vs. 59.2 ± 9.1 for NxStage, p < 0.001). The duration for the HD treatments among the B. Braun group patients was significantly shorter than that of the NxStage group patients (3.48 ± 0.32 vs. 4.58 ± 1.52, p < 0.001) while the ultrafiltration rate for the B. Braun group patients was significantly larger than that of the NxStage group patients (1.83 ± 0.64 vs. 1.18 ± 0.66, p < 0.001). The average laboratory data for both groups showed that there was only a significant difference between the two groups in bicarbonate level, with B. Braun having a lower level (23.5 ± 2.0 for B. Braun vs. 24.9 ± 2.8 for NxStage, p = 0.021). There were no significant differences between the two groups in the average albumin, BUN, calcium, creatinine, hemoglobin, phosphorus, platelets, potassium, WBC, or PTH.

CONCLUSION

B. Braun HD machine is another HD device that can be considered to provide home HD. Our study has shown that B. Braun machine had higher spKt/V in addition to standard weekly Kt/V and URR when compared to the NxStage machine. Larger, well-designed, and well-powered studies are needed to confirm these results.

Impact of Intradialytic Weight Gain on Left Ventricular Function and Characteristics in Hemodialysis Patients

BACKGROUND

Pulmonary circulation is particularly overloaded in hemodialysis patients with high interdialytic weight gain (IDWG), as evidenced by deterioration in right ventricular function indices. This study aimed to evaluate the impact of the degree of fluid accumulation on left ventricular (LV) systolic and diastolic function and sizing characteristics.

METHODS

This is a post hoc analysis of a cross-over study in 41 hemodialysis patients. Study participants were stratified using the recommended threshold IDWG% into a higher (> 4.5%) and a lower (< 4.5%) IDWG% group. All participants underwent 4 echocardiographic assessments at the start and the end of the 2-day and the 3-day interdialytic interval.

RESULTS

Over the 2-day interval, stroke volume and cardiac output increments were more prominent in the higher IDWG% group (> 4.5% 22.97 ± 18.45 vs. < 4.5% 0.95 ± 29.1 mmHg, p = 0.006; > 4.5% 1.32 ± 1.39 vs. < 4.5% -0.36 ± 2.08 L/m2, p = 0.004, respectively). Over the 3-day interval, significant increments in stroke volume were observed for both groups. With regard to diastolic function, a significant increase in E wave, E/A, and E/E'm lateral ratios was observed over the 3-day interval, and significant between-group differences in interdialytic changes were detected for the E/A ratio (IDWG > 4.5% 0.35 ± 0.29 vs. < 4.5% 0.06 ± 0.44, p = 0.035) and the E wave (IDWG > 4.5% 0.31 ± 0.24 vs. < 4.5% 0.10 ± 0.19, p = 0.02). Left atrial dimensions and LV mass were enlarged to a similar extent in both study groups during both intervals.

CONCLUSIONS

Patients exceeding the recommended IDWG threshold experience more pronounced changes in indices of LV function and significant deterioration of preload-dependent indexes of LV diastolic function.

Serum Metabolomic Markers of Dietary Potassium and Risk of CKD

Key Points

We identified metabolomic markers of dietary potassium and diet-related metabolites that were associated with incident CKD in US adults. These metabolites may be prioritized for elucidating mechanisms that could be modified by dietary strategies to prevent CKD.

Background

Discovering metabolomic markers of dietary potassium may help improve dietary assessment of potassium and trace the effect of dietary potassium on CKD development.

Methods

We included adults from the Atherosclerosis Risk in Communities study without CKD at visit 1 (N =3812). Cross-sectional associations between dietary potassium and serum metabolites were assessed using multivariable linear regression models. Cox regression models estimated hazard ratios for potassium-related metabolites and incident CKD. Incident CKD was defined as eGFR (<60 ml/min per 1.73 m2 and ≥25% decline), CKD-related hospitalization or death, or KRT identified using the United States Renal Data System registry from visit 1 (1987–1989) through December 31, 2020.

Results

There were 33 significant associations between dietary potassium and serum metabolites, including pyridoxate, N -methylproline, stachydrine, pantothenate, and scyllo-inositol. During more than two decades of follow-up (median: 23 years, 25th–75th percentile: 14–30), 1616 (42%) of participants developed incident CKD. Ten of the 33 potassium-related metabolites were significantly associated with incident CKD. Metabolites involved in phenylalanine and tyrosine metabolism—3-(4-hydroxyphenyl)lactate and 3-phenylpropionate—were significantly associated with dietary potassium and CKD. In addition, glycerate, involved in glucose metabolism, was positively associated with dietary potassium (β =0.09, P = 4.01×10−17) and inversely associated with CKD (hazard ratio, 0.77; 95% confidence interval, 0.69 to 0.85; P = 8.57×10−7). There was a significant trend for CKD risk across quartiles of 3-(4-hydroxyphenyl)lactate, 3-phenylpropionate, and glycerate.

Conclusions

Dietary potassium was associated with 33 serum metabolites. 3-(4-hydroxyphenyl)lactate 3-phenylpropionate and glycerate are candidate markers of dietary potassium's effect on CKD.

Proteinuria as an End Point in Clinical Trials of Focal Segmental Glomerulosclerosis

Focal segmental glomerulosclerosis (FSGS) is a characteristic histopathological lesion that is indicative of underlying glomerular dysfunction. It is not a single disease entity but rather a heterogeneous disorder that is an important cause of nephrotic syndrome and kidney failure in children and adults. The aim of this Kidney Health Initiative project was to evaluate potential end points for clinical trials in FSGS. Our focus is on the data supporting proteinuria as a surrogate end point. Available data support the use of complete remission of proteinuria in patients with heavy proteinuria as a surrogate end point for progression to kidney failure. Substantial treatment effects on proteinuria that are short of a complete remission may also predict the effect of a treatment on progression to kidney failure, but further work is needed to determine how such an end point should be defined. Fortunately, efforts are underway to bring together patient-level data from randomized controlled trials, observational studies, and registries to address this issue.

The prevalence and contributing factors of NSAIDs prescription among chronic kidney disease patients in primary care: a mixed methods study from Kingdom of Bahrain

BACKGROUND

The prevalence of Non-steroidal Anti-Inflammatory Drugs (NSAIDs) prescription and its contributory factors among chronic kidney disease (CKD) patients are unknown in the Kingdom of Bahrain - though NSAIDs are known to cause significant renal impairment. This study will determine the prevalence of NSAIDs prescription among CKD patients and the contributory factors to this behavior from the perspective of primary care physicians in Bahrain.

METHODOLOGY

A sequential mixed-method design study comprising of a retrospective cross-sectional survey drawn from patients' electronic medical records (EMR) and qualitative in-depth interviews with primary care physicians (PCPs) was conducted between December 2022 and January 2023 - with an EMR data lookback from 1 st June 2021 to 1 st June 2022 Quantitative descriptive analysis was conducted to estimate the prevalence of NSAIDs and their associations with sociodemographic and service delivery indicators. An Ishikawa diagram was used to describe contributory factors to NSAID prescription among CKD patients drawing from the literature and was used to guide a deductive thematic analysis of the qualitative data.

RESULT

Of the enrolled CKD patient population (4,380 patients), 17.4% had at least one inappropriate NSAID prescription. 80% of these patients had moderate renal impairment, while 19.3% had severe impairment. Most of the prescriptions were in 24-h health centers (48.5%). A Bivariate relationship between the prescription and the sociodemographic factors showed a significant P value regarding age (P-value 0.008*) and the severity of the renal impairment (P-value < 0.001*). The contributory factors were divided into five themes: patient factors, physician factors, health team factors, I SEHA factors and system factors. Of these themes, patients and PCPs were identified by the primary care physicians as some of the most important reasons for NSAIDs prescription among CKD patients.

CONCLUSION

The prevalence of NSAIDs prescription among CKD patients is relatively high in the kingdom of Bahrain - largely due to patient and physician factors as identified by primary care physicians. Possible solutions for addressing these factors include raising awareness among patients, PCPs, and other healthcare workers and activating the Swiss Cheese Model that involves patients, PCPs, and other health team members to ensure appropriate medication practice and patients' safety.

The integrin repertoire drives YAP-dependent epithelial:stromal interactions during injury of the kidney glomerulus

The kidney glomerulus is a filtration barrier in which capillary loop architecture depends on epithelial-stromal interactions between podocytes and mesangial cells. Podocytes are terminally differentiated cells within the glomerulus that express YAP and TAZ. Here we test the hypotheses that YAP and TAZ are required in podocytes to maintain capillary loop architecture and that shifts in the integrin repertoire during podocyte injury affect transcriptional activity of YAP and TAZ. Loss of YAP in podocytes of adult mice renders them more sensitive to injury, whereas loss of both YAP and TAZ in podocytes rapidly compromises the filtration barrier. α3β1 and αvβ5 are two prominent integrins on murine podocytes. Podocyte injury or loss of α3β1 leads to increased abundance of αvβ5 and nuclear localization of YAP. In vitro, blockade of αvβ5 decreases nuclear YAP. Increased αv integrins are found in human kidney disease. Thus, our studies demonstrate the crucial regulatory interplay between cell adhesion and transcriptional regulation as an important determinant of human disease.

Regional high iron deposition on brain quantitative susceptibility mapping correlates with cognitive decline in chronic kidney disease patients

This study aimed to evaluate changes in gray matter nuclei iron deposition in chronic kidney disease (CKD) patients using the quantitative susceptibility mapping (QSM) threshold method, and analyze the relationship between brain iron levels and cognitive function. A total of fifty-three CKD patients were prospectively recruited, comprising 35 hemodialysis (HD, 57.54 ± 10.42 years, 21 males) and 18 non-hemodialysis (NHD, 55.06 ± 11.47 years, 10 males ), and were compared to 43 healthy controls (HC, 55.67 ± 7.79 years, 18 males). All participants underwent clinical assessments, neuropsychological tests, and QSM scans. The mean magnetic susceptibility value (MSV) and volume of the whole nuclei (MSVM, VM) and high iron region (MSVRII, VRII) were measured. Correlations between QSM data, neuropsychological scores, and clinical variables in HD group were analyzed. Linear regression analysis was performed to explore the effect of iron deposition on cognition and emotional well-being in HD group. A statistically significant P-value was set at 0.05. HD patients exhibited higher MSVM in the right red nucleus (RN) compared to HCs (P = 0.006). Additionally, significant differences in the MSVRII were observed in the left caudate nucleus (CN), bilateral putamen (Put), and right RN among the three groups (all P = 0.027, FDR-corrected). MSVRII of the left Put was positively correlated with creatinine and uric acid levels, while the MSVRII of the right Put was negatively correlated with mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration. Regression analysis revealed that iron deposition in left CN was independently associated with depression, while iron deposition in left Put and right RN were independently positively associated with delayed recall performance. Conversely, iron deposition in bilateral Put and right RN were negatively associated with orientation ability, after controlling for age, sex, years of education and duration of dialysis. Brain iron deposition is often excessive and uneven in CKD patients, particularly those undergoing hemodialysis. Assessing regional high-iron deposition can provide valuable insights into the distribution of iron, which is associated with cognitive dysfunction and emotional disorders.

Targeting Kidney Inflammation After Brain Death and Cold Storage: Investigating the Potential of an NLRP3 Inflammasome Inhibitor (MCC950) for Preconditioning Donor Kidneys

BACKGROUND

Brain death (BD) and cold storage (CS) are critical factors that induce inflammation in donor kidneys, compromising organ quality. We investigated whether treating kidneys from BD rats with an inflammasome Nod-like receptor family pyrin domain containing 3 (NLRP3) inhibitor (MCC950) followed by CS could reduce kidney inflammation.

METHODS

BD rats were assigned to MCC950-treated or nontreated (NT) groups. Kidneys were evaluated immediately before CS (T0) and after 12 h (T12) and 24 h (T24) of CS. Mean arterial pressure, serum creatinine, gene/protein expression, and histology were evaluated.

RESULTS

At T0, MCC950 treatment did not affect mean arterial pressure but tended to reduce serum creatinine and ameliorated the histological score of acute tubular necrosis. However, MCC950 reduced NLRP3 , caspase-1 , interleukin (IL)-1β , IL-6 , Kim-1 , nuclear factor kappa B , tumor necrosis factor alpha , and caspase-3 gene expression while increasing IL-10 cytokine gene expression. After 12 h of CS, only the expression of the NLRP3 and caspase-1 genes decreased, and after 24 h of CS, no further changes in the gene expression profile were observed. The levels of the inflammasome proteins NLRP3, caspase-1, and IL-1β consistently decreased across all time points (T0, T12, and T24).

CONCLUSIONS

These findings suggest that MCC950 treatment holds promise for mitigating the proinflammatory state observed in kidneys after BD and CS.

Population Health Management for Improving Kidney Health Outcomes

Chronic kidney disease (CKD) is globally prevalent, a leading cause of mortality, and is associated with poor patient outcomes and high healthcare costs. Gaps in guideline-concordant care are common across the continuum of CKD. These gaps lead to CKD progression, hospitalizations, and mortality, and are potentiated by existing racial and socioeconomic disparities. A thoughtfully designed population health management approach, that leverages electronic health record, can modernize CKD care delivery and improve outcomes. Such an approach can potentially provide timely, equitable, resource- and cost-efficient care across health systems in a way that is scalable and data driven. Herein, we share our experiences with the implementation of nephrology population health initiatives at the University of Pittsburgh Medical Center across the CKD spectrum, which include ongoing and planned programs in the primary care, kidney-palliative care, kidney transplantation, and transitions of care settings. Further, we discuss the challenges of population health management and future directions that can move healthcare toward personalized medicine.

One-year Survival of End-Stage Kidney Disease Patients Undergoing Hemodialysis in Indonesia

Background

Chronic Kidney Disease (CKD) represents a significant global health challenge, with Indonesia experiencing the highest surge in End-Stage Kidney Disease (ESKD) prevalence over the past decade. Kidney registries are essential for reporting health outcomes, evaluating healthcare services, advocating for policy change, and informing health infrastructure development. Survival rates in ESKD patients undergoing hemodialysis (HD) are a critical outcome measure. However, there is a lack of survival analysis data for ESKD patients receiving HD in Indonesia.

Objective

This study aims to assess the one-year survival rate of ESKD patients undergoing HD in Indonesia, while examining risk factors associated with survival, including age, gender, CKD etiology, and dialysis adequacy.

Methods

This analytical observational study employed a retrospective cohort design, utilizing patient data from Indonesia Renal Registry between 2016 and 2019. Kaplan-Meier survival curves were generated, and Log rank test was applied to assess the significance of survival differences across subgroups based on age, gender, CKD etiology, and dialysis adequacy.

Results

A total of 122,449 ESKD patients on HD were analyzed, with a mean age of 52 years; majority (55.5%) were male, and hypertensive kidney disease was the leading cause of CKD (43.7%). The overall one-year survival rate was 91.5% (95% CI: 91.3-91.6). Survival decreased significantly with advancing age (p < 0.01), and female patients exhibited lower survival rates compared to males (p < 0.01). Patients with diabetic nephropathy had the lowest survival rate among CKD etiologies (p < 0.01). Dialysis adequacy, assessed in 11,633 patients, revealed that 69.2% had a Kt/V below 1.8. Those with inadequate dialysis had significantly lower survival rates (p=0.00015).

Conclusion

The one-year survival rate for ESKD patients undergoing HD in Indonesia is 91.5%. Increased age, female, diabetic nephropathy as the underlying CKD etiology, and inadequate dialysis adequacy are associated with reduced survival rates.

Evaluating the effectiveness of systemic heparin during arteriovenous fistula creation by emulating a target trial

Most of the 800 000 people living with end-stage kidney disease in the United States rely on a functioning vascular access to provide life-sustaining hemodialysis, yet one-third of arteriovenous fistulas experience early failures. Determining the safety and effectiveness of systemic heparin during fistula creation could improve the quality and quantity of life for these vulnerable patients. In this article, a pragmatic randomized trial was emulated to assess the effect of systemic heparin administration (vs none) during radiocephalic arteriovenous fistula creation on early bleeding and thrombosis, using data from 2 international, multicenter, randomized trials performed between 2014 and 2019. Marginal risks were estimated using inverse probability weighted parametric survival analysis and CIs were generated with bootstrapping. A total of 914 patients were enrolled and 61% received systemic heparin; their median (IQR) age was 58 (49, 67) years and 45% were on hemodialysis at enrollment. No difference in the risk of bleeding events was observed, with a risk difference (95% CI) at 14 days of -0.1% (-1.6 to 1.4). The risk of access thrombosis was lower in the heparin group, with a risk of 3.7% (2.6-4.8) after heparin and 5.3% (3.4-7.4) without heparin at 14 days (risk ratio = 0.72; 95% CI, 0.50-0.98). Trial registration: ClinicalTrials.gov. Identifiers: NCT02110901 and NCT02414841.

Protective effect of orientin on diabetic nephropathy in rat models of high-fat diet and streptozotocin-induced diabetes

Diabetic nephropathy (DN) represents the primary cause of chronic kidney disease (CKD) worldwide. Orientin is a natural bioactive flavonoid with profound immunomodulatory, anti-inflammatory, and antioxidative effects. This study aimed to investigate the nephroprotective effect of orientin on rat prototypes of high-fat diet (HFD) and streptozotocin (STZ)-induced DN. 75 male rats were divided into 5 groups of 15 rats each. Rats were fed a HFD for 4 weeks, injected with a single dose of STZ 30 mg/kg, and continued on HFD for 15 weeks. Orientin was administered daily at 40 mg/kg for 15 weeks. The diabetic group reported substantially greater fasting blood glucose, HbA1c, and renal function measures than normal controls, as well as notable kidney histological abnormalities such as interstitial inflammation, glomerular shrinkage, and tubular necrosis. Additionally, the diabetic group showed dramatically greater amounts of IL-1β, IL-6, TNF-α, TGF-β1, MDA, and a much lower level of GSH than the control group. However, orientin had no effect on the glycaemic parameters, but it dramatically reduced blood creatinine levels, prevented the development of histopathological irregularities, and minimized the renal concentrations of inflammatory and oxidative markers. Orientin may be a promising natural medication for improving diabetic nephropathy thanks to its robust anti-inflammatory and anti-proliferative properties.

Patient Education for CKD and Decision Support in Primary Care: Findings From the EPIK Pilot Study

RATIONALE & OBJECTIVE

Chronic kidney disease (CKD) affects millions of people in the United States, yet effective interventions to address gaps in patient knowledge and engagement are not well-established. We developed and pilot tested a brief educational decision aid for patients with CKD who are being treated in primary care settings.

STUDY DESIGN

Pilot quality improvement (QI) study of a decision aid intervention.

SETTING & PARTICIPANTS

The decision aid was introduced and used in 1 of 2 general internal medicine primary care clinics for adult patients with CKD.

EXPOSURE

An electronic medical record-based patient educational decision aid called the Encounter Decision Intervention (EDI) developed using QI methods and with input from patients and clinicians for use during primary care visits to address a CKD diagnosis and engage patients in their clinical management.

OUTCOME

Perceived and objective CKD knowledge, CKD-specific stress, and patient satisfaction measured in both primary care clinics as assessed using validated surveys.

ANALYTICAL APPROACH

Fisher exact tests, t tests, and Kruskal-Wallis tests were used to detect univariable associations of outcomes with use of the EDI across primary care clinics.

RESULTS

Seventy-four patients completed the study (37 in each clinic). There were no statistically significant differences in patient characteristics between the clinics. The group treated in the clinic that used the EDI had statistically significantly higher satisfaction with their clinicians, with clinician communication, and with their overall care. The patients reported high satisfaction with the EDI, and the clinicians reported favorable usability.

LIMITATIONS

A nonrandomized comparison, small sample size, and possible differences across practice settings.

CONCLUSIONS

A new integrated educational decision aid was successfully implemented in a primary care setting. Pilot testing suggested that the EDI was associated with higher patient satisfaction with their primary care provider, with their clinician's communication, and with their overall care.

PLAIN-LANGUAGE SUMMARY

Most patients who have chronic kidney disease (CKD) are not aware of their illness. Few studies have explored whether patient education can increase patients' knowledge about CKD or influence patients' satisfaction with the care or communication they receive from their physicians. This study tested whether a short CKD education intervention implemented by the patient's physician was associated with patients' greater awareness of their CKD as well as their satisfaction with care and communication. This pilot study found that a decision aid for patients with CKD was implementable in a primary care setting. Patients who received CKD education felt more satisfied with their care and communication with their physicians compared with patients who did not receive the education.

Reviewing the Impacts of Natural and Technological Disasters on the End-Stage Kidney Disease Community

The impact and severity of natural disasters and hazards have been increasing in the United States and throughout the world. With our mounting reliance and dependence on technology in our industrialized society, technological disasters also have become more commonplace. Although disasters may occur with little to no warning, these risks are felt to be acceptable despite their ability to impact large populations. Natural and technological disasters disproportionately affect vulnerable populations, including those with end-stage kidney disease (ESKD). The impact of natural and technological disasters on the ESKD community has been closely examined via numerous case studies and through the lens of particular disasters, but there is a paucity of data exploring the impacts of natural and technological disasters on the ESKD community by disaster type. A comprehensive literature search was performed using PubMed and Google Scholar, and relevant articles pertaining to the impacts of natural and technological disasters on the ESKD community were reviewed. More than 50 studies were reviewed in total. This review aimed to identify common patterns and trends observed in the impacts of different disaster types on the ESKD community to better prepare patients and their providers before the next disaster strikes.

Use of artificial intelligence with retinal imaging in screening for diabetes-associated complications: systematic review

Background

Artificial Intelligence (AI) has been used to automate detection of retinal diseases from retinal images with great success, in particular for screening for diabetic retinopathy, a major complication of diabetes. Since persons with diabetes routinely receive retinal imaging to evaluate their diabetic retinopathy status, AI-based retinal imaging may have potential to be used as an opportunistic comprehensive screening for multiple systemic micro- and macro-vascular complications of diabetes.

Methods

We conducted a qualitative systematic review on published literature using AI on retina images to detect systemic diabetes complications. We searched three main databases: PubMed, Google Scholar, and Web of Science (January 1, 2000, to October 1, 2024). Research that used AI to evaluate the associations between retinal images and diabetes-associated complications, or research involving diabetes patients with retinal imaging and AI systems were included. Our primary focus was on articles related to AI, retinal images, and diabetes-associated complications. We evaluated each study for the robustness of the studies by development of the AI algorithm, size and quality of the training dataset, internal validation and external testing, and the performance. Quality assessments were employed to ensure the inclusion of high-quality studies, and data extraction was conducted systematically to gather pertinent information for analysis. This study has been registered on PROSPERO under the registration ID CRD42023493512.

Findings

From a total of 337 abstracts, 38 studies were included. These studies covered a range of topics related to prediction of diabetes from pre-diabetes or non-diabeticindividuals (n = 4), diabetes related systemic risk factors (n = 10), detection of microvascular complications (n = 8) and detection of macrovascular complications (n = 17). Most studies (n = 32) utilized color fundus photographs (CFP) as retinal image modality, while others employed optical coherence tomography (OCT) (n = 6). The performance of the AI systems varied, with an AUC ranging from 0.676 to 0.971 in prediction or identification of different complications. Study designs included cross-sectional and cohort studies with sample sizes ranging from 100 to over 100,000 participants. Risk of bias was evaluated by using the Newcastle-Ottawa Scale and AXIS, with most studies scoring as low to moderate risk.

Interpretation

Our review highlights the potential for the use of AI algorithms applied to retina images, particularly CFP, to screen, predict, or diagnose the various microvascular and macrovascular complications of diabetes. However, we identified few studies with longitudinal data and a paucity of randomized control trials, reflecting a gap between the development of AI algorithms and real-world implementation and translational studies.

Funding

Dr. Gavin Siew Wei TAN is supported by: 1. DYNAMO: Diabetes studY on Nephropathy And other Microvascular cOmplications II supported by National Medical Research Council (MOH-001327-03): data collection, analysis, trial design 2. Prognositc significance of novel multimodal imaging markers for diabetic retinopathy: towards improving the staging for diabetic retinopathy supported by NMRC Clinician Scientist Award (CSA)-Investigator (INV) (MOH-001047-00).

Forearm Versus Upper Arm Location of Arteriovenous Access Used at Hemodialysis Initiation: Temporal Trends and Racial Disparities

RATIONALE & OBJECTIVE

Race and ethnicity differences exist in the type of arteriovenous access (AVA, including fistulas and grafts) used at hemodialysis (HD) initiation. The preferred anatomic location for the creation of an initial HD AVA is typically in the forearm We evaluated race and ethnicity differences in the use of an AVA in the forearm location at HD initiation.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Using records from DaVita Kidney Care linked to the US Renal Data System (USRDS), we evaluated patients aged≥16 years who initiated in-center HD with an AVA between 2006 and 2019.

PREDICTOR

Race and ethnicity, categorized as non-Hispanic White, non-Hispanic Black, Hispanic, or Other.

OUTCOME

Forearm versus upper arm AVA location.

ANALYTICAL APPROACH

Multivariable modified Poisson regression to estimate adjusted trends in AVA location over time and race and ethnicity differences in AVA location. Nested models helped assess the relative confounding by groups of variables on estimates of race and ethnicity differences.

RESULTS

Among 70,147 patients (51.7% White, 28.8% Black, 12.6% Hispanic, 6.9% Other), White patients were older and more likely to have peripheral vascular disease but less likely to have diabetes compared with the other groups. The proportion initiating HD using a forearm AVA decreased from 49% in 2006 to 29% in 2019 and by 3.6% (95% CI, 3.3%-3.9%) annually, with no difference in this trend among groups (race and ethnicity by calendar year interaction P=0.32). Black patients were 13% (95% CI, 10%-15%) less likely and Hispanic patients were 5% (95% CI, 1%-9%) less likely than White patients to initiate HD with a forearm AVA.

LIMITATIONS

Findings may not apply to home HD.

CONCLUSIONS

Use of a forearm AVA for HD initiation has declined and racial differences have persisted, with Black and Hispanic patients being less likely than White patients to have an AVA in the forearm location. Research toward understanding the causes and consequences of these trends and disparities is warranted.

The Need for Culturally Tailored CKD Education in Older Latino Patients and Their Families

Older Latino adults (aged 65+years) comprise the fastest growing minoritized group among the older population in the United States and experience a disproportionate burden of kidney failure as well as disparities in kidney care compared with non-Hispanic White individuals. Despite significant need and barriers uniquely faced by this population, few educational resources or decision aids are available to meet the language and cultural needs of Latino patients. Decision aids are designed to improve knowledge and empower individuals to engage in shared decision making and have been shown to improve decisional quality and goal-concordant care among older patients with chronic kidney disease (CKD). In this commentary, we examine the barriers faced by older Latino people with CKD who must make dialysis initiation decisions. We conclude that there is a need for culturally concordant decision aids tailored for older Latino patients with CKD to overcome barriers in access to care and improve patient-centered care for older Latino CKD patients.

The Impact of Glomerular Disease on Dyslipidemia in Pediatric Patients Treated with Dialysis

BACKGROUND/OBJECTIVES

Children on dialysis have a 10-fold increase in cardiovascular disease (CVD)-related mortality when compared to the general population. The development of CVD in dialysis patients is attributed to Chronic Kidney Disease-Mineral Bone Disorder (CKD-MBD) and dyslipidemia. While the prevalence of dyslipidemia in adult dialysis patients has been described, there are limited data on prevalence, severity, and risk factors for pediatric dyslipidemia.

METHODS

Data from 1730 pediatric patients ≤ 21 years receiving maintenance hemodialysis or peritoneal dialysis with at least one lipid panel measurement were obtained from USRDS between 2001 and 2016. Disease etiology was classified as being glomerular (n = 1029) or non-glomerular (n = 701). Comparisons were made across etiologies using both linear and logistic regression models to determine the relationship between disease etiology and lipid levels.

RESULTS

The cohort had a mean age of 15.2 years and were 54.5% female. Adjusting for age, sex, race/ethnicity, modality, time with End Stage Kidney Disease (ESKD), and body mass index (BMI) and using non-glomerular etiology as the reference, glomerular disease [mean (95% CI)] was associated with +19% (+14.7%, +23.8%) higher total cholesterol level (183 mg/dL vs. 162 mg/dL), +21% (+14.8%, +26.6%) higher low density lipoprotein cholesterol level (108 mg/dL vs. 87 mg/dL), and +22.3% (+15.5%, +29.5%) higher triglyceride level (169 mg/dL vs. 147 mg/dL). Glomerular disease [OR (95% CI)] was associated with 3.0-fold [2.4, 3.9] higher odds of having an abnormal total cholesterol level, 3.8-fold [2.8, 5.0] higher odds of having an abnormal LDL-C level, and 1.9-fold [1.5, 2.4] higher odds of having an abnormal triglyceride level when compared to non-glomerular disease.

CONCLUSIONS

Pediatric dialysis patients have a high prevalence of dyslipidemia, particularly from elevated triglyceride levels. Specifically, patients with glomerular disease have an even higher risk of dyslipidemia from elevated non-HDL cholesterol and triglyceride levels than patients with non-glomerular disease. The long-term impact of this unfavorable lipid profile requires further investigation.

A novel nomogram for predicting mortality risk in young and middle-aged patients undergoing maintenance hemodialysis: a retrospective study

Objectives

The annual growth in the population of maintenance hemodialysis (MHD) patients is accompanied by a trend towards younger age groups among new cases. Despite the escalating mortality risk observed in MHD patients, there remains a dearth of research focused on young and middle-aged individuals in this cohort, leading to a deficiency in specialized predictive instruments for this demographic. This research seeks to explore the critical determinants impacting mortality risk in young and middle-aged MHD patients and to construct a prediction model accordingly.

Methods

This study involved 127 young and middle-aged patients undergoing MHD in the Blood Purification Center of Chaohu Hospital of Anhui Medical University from January 2019 to January 2022. The follow-up period for each patient ended either at the time of death or on January 31, 2024. Participants were monitored to determine their survival status and categorized into two groups: those who survived (98 patients) and those who deceased (29 patients). Clinical data were gathered for analysis. Logistic regression was utilized to pinpoint independent risk factors for mortality among these patients. Subsequently, a nomogram was established to predict mortality risk. The efficacy of this model was assessed through the area under the receiver operating characteristic curve (AUC-ROC), alongside a calibration curve and the Hosmer-Lemeshow test to examine its fit. Additionally, decision curve analysis (DCA) was conducted to ascertain the clinical relevance of the predictive model.

Results

The study incorporated 127 young and middle-aged patients undergoing MHD, with a mortality rate recorded at 22.83% (29 cases). A logistic regression analysis revealed that age, hemoglobin (HB), serum magnesium (Mg), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-albumin ratio (PAR) were significant independent predictors of mortality among these patients. Utilizing these variables, a nomogram was developed to predict mortality risk, achieving an AUC of 0.899 (95% CI: 0.833-0.966). The model exhibited a specificity of 83.67% and a sensitivity of 82.76%, demonstrating substantial discriminative ability. The model's robustness was confirmed through internal validation with 1,000 bootstrap samples, yielding an AUC of 0.894 (95% CI: 0.806-0.949). The calibration curve closely aligned with the ideal curve, and the Hosmer-Lemeshow goodness-of-fit test yielded a χ 2 value of 6.312 with a p-value of 0.612, verifying the model's high calibration accuracy. Additionally, the DCA indicated that the model provides a net benefit across a wide range of decision thresholds from 0 to 0.99, underscoring its clinical utility.

Conclusion

The nomogram developed from variables including age, HB levels, serum Mg, NLR, and PAR exhibits high levels of discrimination and calibration. This model effectively predicts mortality risk among young and middle-aged patients undergoing MHD, proving its clinical relevance.

An Observational Study of the First 100 Patients Undergoing Nocturnal Every-Other-Day Online Hemodiafiltration: Clinical Outcomes and Patient and Technique Survival

Background: High-volume online hemodiafiltration (OL-HDF) has proven to be the most efficient dialysis modality and to offer better clinical outcomes in patients on hemodialysis. Longer and more frequent dialysis sessions have demonstrated clinical and survival benefits. Methods: A single-center observational study of the first one hundred patients on nocturnal every-other-day OL-HDF was conducted with the aim of reporting the experience with this treatment schedule and evaluating analytical and clinical outcomes as well as the patient and technique survival. Results: Nocturnal OL-HDF on alternate days was highly accepted, with no adverse symptoms, good clinical tolerance, and maintained active work in 62%. Kt, and the convective volume increased from 67.6 ± 12 L to 105.4 ± 11.7 L, and from 27.1 ± 4.6 L to 48.1 ± 6.4 L, respectively, from the baseline to 24 months. An improved calcium-phosphate balance and blood pressure control were observed, as the use of phosphate binders and antihypertensive medications decreased from 76.7% to 3.3% and from 56.7% to 28.3%, respectively. Furthermore, 58.3% of patients required phosphate supplementation in the dialysis fluid to prevent intradialytic hypophosphatemia. Additionally, doses of iron and erythropoiesis-stimulating agents were reduced. The global patient survival was 94% at the end of the follow-up. It was higher in those on the transplant waiting list, with 98.1% survival compared to 84.6% in non-wait-listed patients at 24 months. The main reason for treatment discontinuation was kidney transplantation, accounting for 78.4% of the 88 withdrawals, while death was the leading cause of discontinuation in non-listed patients (41.6%). Conclusions: Nocturnal every-other-day OL-HDF is a well-tolerated dialysis regimen that offers significant clinical benefits, which may positively impact morbidity and mortality. Additionally, it allows patients to integrate the treatment into their social and occupational lives.

Association Between Peritoneal Glucose Absorption, Lipid Metabolism, and Cardiovascular Disease Risk in Nondiabetic Patients on Peritoneal Dialysis

BACKGROUND

Excessive sugar intake increases the energy metabolic burden and the risk of cardiovascular disease (CVD). Patients on peritoneal dialysis absorb much more glucose than the World Health Organization recommends, but the link to CVD is unclear.

OBJECTIVE

To identify the association between peritoneal glucose absorption, lipid metabolism, and CVD.

METHODS

We applied generalized additive mixed effects and mixed effects Cox proportional hazard models to evaluate the impact of peritoneal glucose absorption on lipid profiles and CVD risk. We performed subgroup analyses by using protein intake (normalized protein nitrogen appearance [nPNA] and normalized protein catabolic rate [nPCR] were used to assess protein intake) and high-sensitivity C-reactive protein (hs-CRP).

RESULTS

After multivariable adjustment, peritoneal glucose absorption per 10 g/d increase was associated with an increase in cholesterol of 0.145 (95% confidence interval [CI]: 0.086-0.204) mmol/L. No link with the total risk of CVD was observed; however, protein intake and hs-CRP levels affected the relationship between glucose absorption and CVD risk. Patients with values for nPNA and nPCR <1.0 g/(kg·d) were associated with a lower risk of CVD (hazard ratio [HR] 95% CI: 0.68 (0.46-0.98)) with glucose absorption per 10 g/d increase. While patients with hs-CRP levels ≥3 mg/d or values for nPNA or nPCR ≥1.0 g/(kg·d) were associated with a higher risk of CVD (HR 95% CI: 1.32 (1.07-1.63); 1.31 (1.02-1.68)) for glucose absorption per 10 g/d increase.

CONCLUSIONS

Our study found a positive correlation between peritoneal glucose absorption and lipid profiles. Increased glucose absorption was associated with a lower risk of CVD in lower protein intake patients and a higher risk of CVD in higher hs-CRP or protein intake levels in patients on peritoneal dialysis.

Predicting recurrent interventions after radiocephalic arteriovenous fistula creation with machine learning and the PREDICT-AVF web app

OBJECTIVE

Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines discourage ongoing access salvage attempts after two interventions prior to successful use or more than three interventions per year overall. The goal was to develop a tool for prediction of radiocephalic arteriovenous fistula (AVF) intervention requirements to help guide shared decision-making about access appropriateness.

METHODS

Prospective cohort study of 914 adult patients in the United States and Canada undergoing radiocephalic AVF creation at one of the 39 centers participating in the PATENCY-1 or -2 trials. Clinical data, including demographics, comorbidities, access history, anatomic features, and post-operative ultrasound measurements at 4-6 and 12 weeks were used to predict recurrent interventions required at 1 year postoperatively. Cox proportional hazards, random survival forest, pooled logistic, and elastic net recurrent event survival prediction models were built using a combination of baseline characteristics and post-operative ultrasound measurements. A web application was created, which generates patient-specific predictions contextualized with the KDOQI guidelines.

RESULTS

Patients underwent an estimated 1.04 (95% CI 0.94-1.13) interventions in the first year. Mean (SD) age was 57 (13) years; 22% were female. Radiocephalic AVFs were created at the snuffbox (2%), wrist (74%), or proximal forearm (24%). Using baseline characteristics, the random survival forest model performed best, with an area under the receiver operating characteristic curve (AUROC) of 0.75 (95% CI 0.67-0.82) at 1 year. The addition of ultrasound information to baseline characteristics did not substantially improve performance; however, Cox models using either 4-6- or 12-week post-operative ultrasound information alone had the best discrimination performance, with AUROCs of 0.77 (0.70-0.85) and 0.76 (0.70-0.83) at 1 year. The interactive web application is deployed at https://predict-avf.com.

CONCLUSIONS

The PREDICT-AVF web application can guide patient counseling and guideline-concordant shared decision-making as part of a patient-centered end-stage kidney disease life plan.

Similar outcomes of arteriovenous fistulae created under general or regional anesthesia

BACKGROUND

There is growing evidence that type of anesthesia can significantly change vascular access surgery outcomes. Still, there is limited evidence on the impact of regional anesthesia (RA) on patency and failure rates compared to general anesthesia (GA). The aim of this study was to compare the outcomes of RA and GA in patients who underwent vascular access creation at our center.

METHODS

Data collected in our prospectively maintained database of patients with chronic renal dysfunction requiring hemodialysis were analyzed, 464 patients were included. Outcome parameters such as maturation, primary failure, postoperative flow measurements, patency rates, and survival outcomes were compared between RA and GA groups.

RESULTS

In this study 489 vascular access procedures were performed in 464 patients, 318 included in the RA group and 171 in the GA group. Median follow-up time was 29.9 (IQR 37.3) months in the RA group versus 33.0 (IQR 40.7) in the GA group (p = 0.252). Anesthesia type did not significantly affect patient survival (HR, 1.01; CI, 0.70-1.45; p = 0.976). No significant differences were found in vascular access flow volume, primary failure, or time to cannulation between the RA and GA groups for both radiocephalic arteriovenous fistulae and brachiocephalic arteriovenous fistulae. Anesthesia type did not significantly change patency outcomes.

CONCLUSIONS

Based on our results, both RA and GA demonstrate similar results regarding patient survival, maturation, failure, or patency after vascular access creation. Still, patient-specific factors for each type of anesthesia as well as patient preference should be considered.

2024 Latin American Society of Hypertension guidelines on the management of arterial hypertension and related comorbidities in Latin America

Hypertension is responsible for more than two million deaths due to cardiovascular disease annually in Latin America (LATAM), of which one million occurs before 70 years of age. Hypertension is the main risk factor for cardiovascular morbidity and mortality, affecting between 20 and 40% of LATAM adults. Since the publication of the 2017 LASH hypertension guidelines, reports from different LATAM countries have confirmed the burden of hypertension on cardiovascular disease events and mortality in the region. Many studies in the region have reported and emphasized the dramatically insufficient blood pressure control. The extremely low rates of awareness, treatment, and control of hypertension, particularly in patients with metabolic disorders, is a recognized severe problem in LATAM. Earlier implementation of antihypertensive interventions and management of all cardiovascular risk factors is the recognized best strategy to improve the natural history of cardiovascular disease in LATAM. The 2024 LASH guidelines have been developed by a large group of experts from internal medicine, cardiology, nephrology, endocrinology, general medicine, geriatrics, pharmacology, and epidemiology of different countries of LATAM and Europe. A careful search for novel studies on hypertension and related diseases in LATAM, together with the new evidence that emerged since the 2017 LASH guidelines, support all statements and recommendations. This update aims to provide clear, concise, accessible, and useful recommendations for health professionals to improve awareness, treatment, and control of hypertension and associated cardiovascular risk factors in the region.

Contemporary outcomes of distal radial artery ligation for access related hand ischemia

OBJECTIVES

Access related hand ischemia (ARHI) is a rare albeit morbid complication of hemodialysis access creation. Distal radial artery ligation (DRAL) has been described as a strategy to improve perfusion to the hand while maintaining the access. The objective of this study was to report longitudinal outcomes of DRAL for ARHI.

METHODS

Retrospective cohort study (2015-2021) of all patients who underwent DRAL for ARHI at a tertiary care vascular center. Subjects were identified using the Mass General Brigham clinical data warehouse and data collection was supplemented with chart adjudication. Outcomes captured included 30-day complications and improvement in ARHI-related symptoms at 1 year.

RESULTS

Thirty-one patients were included. Mean (SD) age was 59.9 (14.5) and 67.7% were male. Wrist radial-cephalic (74.2%) and proximal radial-cephalic (9.7%) configurations were most common. ARHI severity was: 9.7% stage 1 (retrograde flow without symptoms); 38.7% stage 2 (pain during exercise or dialysis); 41.9% stage 3 (pain at rest); and 9.7% stage 4 (tissue loss). High flow was present in 35.5% of patients at baseline with median (IQR) flow of 1670 ml/min (1478-1954). After DRAL, median (IQR) flow reduction in the high flow group was 953 ml/min (645-993); concurrent precision banding was performed in 29% to reduce flow. The 30-day risk of complication was 3.2% (n = 1 access thrombosis). During follow-up, 82.1% showed improvement in symptoms and 3.6% of patients needed an additional procedure for ARHI. Carpal tunnel surgery was required for improvement in 7.1% of patients and was suspected as the culprit of symptoms in 7.1%.

CONCLUSION

Distal radial artery ligation for ARHI is safe and can improve ischemic symptoms in most patients while salvaging access function. Precision banding can serve as a useful adjunct in high flow accesses. Carpal tunnel syndrome should be considered as part of the differential diagnosis of hand pain in this population.

Predictors of self-care in kidney transplant patients according to preoperative dialysis: A comparative study

Background

Preemptive kidney transplantation (PKT) is associated with reduced dialysis-related morbidity and improved graft survival, which has led to an increase in the prevalence of PKT. The distinct clinical pathways of PKT and non-preemptive kidney transplantation (NPKT) patients may affect their ability to perform self-care, a key factor in post-transplant recovery. However, there is ongoing controversy regarding which group demonstrates better self-care abilities, highlighting the need to explore the factors influencing self-care in each group.

Objectives

This study aims to identify and compare predictors of self-care in PKT and NPKT groups.

Methods

We collected data from 209 KT recipients, consisting of 101 PKT and 108 NPKT patients, using self-administered questionnaires. These questionnaires assessed general and disease-specific characteristics, stress, social support, and self-care behaviors. Data were analyzed using descriptive statistics, t-tests, ANOVA, and multiple regression analysis.

Results

The study identified significant predictors of self-care among both PKT and NPKT patients. For PKT patients, marital status (β = .19, p = .033) and family support (β = .28, p = .006) are key predictors of self-care, with those having spousal support and strong family networks reporting better self-care levels. Conversely, in NPKT patients, significant predictors of self-care included marital status (β = .31, p = .001), employment status (β = .29, p = .007), post-transplantation duration (less than 36 month) (β = -.22, p = .015), post-transplantation duration (36-72 month) (β = -.33, p = .001), and stress levels (β = -.20, p = .028).

Conclusions

The study provides valuable insights into the predictors of self-care based on preoperative dialysis status, illustrating distinct predictors between the growing population of PKT and NPKT patients. These findings emphasize the need for personalized nursing strategies to enhance post-transplant self-care, tailored to individual patient characteristics.

Nationwide trends and outcomes of percutaneous coronary intervention for stable ischemic heart disease in end-stage kidney disease: a longitudinal study

Background

Patients with end-stage kidney disease (ESKD) are at high risk for coronary artery disease. We investigate the trends and outcomes of percutaneous coronary intervention (PCI) for stable ischemic heart disease (SIHD) in patients with ESKD.

Methods

We utilized the United States Renal Data System [2010-2018] to include adult patients with ESKD on dialysis for at least 3 months who underwent PCI for SIHD. Patients with myocardial infarction during index hospitalization, history of coronary artery bypass graft or renal transplantation and without Medicare AB coverage were excluded. Trends and related outcomes, including mortality and revascularization rate, were studied.

Results

The mean age was 65.1 years with 57.5% male and a majority White (64.5%). The dialysis duration was ≤5 years in 83.3% patients. Hypertension (97.6%) and diabetes mellitus (76.8%) were the most common comorbidities. PCI procedures per 1,000 ESKD patients dropped from 6.2 in 2010 to 2.6 in 2018 (P<0.001) while the index hospitalization mortality increased from 0.9% to 3.0% (P<0.001). The 30-day and 1-year mortality also significantly increased from 3.2% to 6.1% and 26.5% to 31.9%, respectively. However, 1-year repeat revascularization rates dropped from 19.8% to 17.0% between 2010-2018 (P<0.001). A significant increase in comorbidity burden was also noted.

Conclusions

We demonstrate a consistent decrease in PCI rates for SIHD in ESKD patients. However, the in-hospital mortality has increased significantly, in part, due to an increasing high-risk profile of these patients. Our results call for individualized clinical decision-making when exploring revascularization options in ESRD patients with SIHD.

Efficacy and safety of intradialytic parenteral nutrition using ENEFLUID® in malnourished patients receiving maintenance hemodialysis: An exploratory, multicenter, randomized, open-label study

The objective of this study was to investigate the efficacy and safety of intradialytic parenteral nutrition (IDPN) using ENEFLUID® (310 kcal, 550 mL) in mild-moderate malnutrition patients receiving maintenance hemodialysis. A total of 40 adult patients with a Nutritional Risk Index-Japanese Hemodialysis (NRI-JH) score of 5-10 were enrolled in this multicenter, randomized, open-label study. Patients in the intervention group received IDPN using ENEFLUID® via the dialysis circuit 3 times a week for 12 weeks; those in the control group did not. The primary endpoint was change in serum transthyretin (TTR). The secondary endpoints were changes in nutritional laboratory tests, nutritional parameters, food intake, plasma amino acids, and blood glucose. For both groups, mean age (72.1±11.4 years) and BMI (20.3±3.0), and median NRI-JH score [7.0 (interquartile range, 6-8)], did not differ. One patient withdrew before intervention, leaving 20 intervention and 19 control patients. Mean (95% confidence interval) change in serum TTR (mg/dL) at 12 weeks did not differ between groups: Intervention, 1.0 (-1.1-3.2); Control, -0.3 (-2.4-1.9); Intragroup difference, 1.3 (-1.7-4.3); P = 0.41. The values reflecting protein intake at 12 weeks compared to those on the study initiation day increased in the intervention group [the changes of blood urea nitrogen, 9.4 (2.6-16.2) mg/dL; P = 0.007, and normalized protein catabolic rate, 0.10 (0.02-0.18) g/kg/day; P = 0.02]. Mean food protein intake (g/kg/day) at 12 weeks increased in the intervention group and decreased in the control group, and differed between groups: Intervention, 0.12 (-0.03-0.28); Control, -0.18 (-0.43-0.08); Inter-group difference, 0.30 (0.00-0.60); P = 0.050. No adverse events occurred. In patients with mild to moderate malnutrition receiving ENEFLUID® for 12 weeks as IDPN, serum TTR was not improved, decreases in protein intake was mitigated, no adverse events occurred. Trial registration Name of the registry: Japan Registry of Clinical Trials Registration number: jRCTs031220296.

Guidelines for the management of hypertension in CKD patients: where do we stand in 2024?

Until recently, major bodies producing guidelines for the management of hypertension in patients with chronic kidney disease (CKD) disagreed in some key issues. In June 2023, the European Society of Hypertension (ESH) published the new 2023 ESH Guidelines for the management of arterial hypertension a document that was endorsed by the European Renal Association. Several novel recommendations relevant to the management of hypertension in patients with CKD appeared in these guidelines, which have been updated to reflect the latest evidence-based practices in managing hypertension in CKD patients. Most of these are in general agreement with the previous 2021 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines-some reflect different emphasis on some topics (i.e. detailed algorithms on antihypertensive agent use) while others reflect evolution of important evidence in recent years. The aim of the present review is to summarize and comment on key points and main areas of focus in patients with CKD, as well as to compare and highlight the main differences with the 2021 KDIGO Guidelines for the management of blood pressure in CKD.

The association of sex differences in ambulatory blood pressure with cardiovascular events and mortality in dialysis patients

Male patients with pre-dialysis chronic kidney disease (CKD) have worse ambulatory blood pressure (BP) control than females; this is associated with higher mortality. Male hemodialysis patients have higher ambulatory BP levels than females. This analysis aimed to investigate the association of sex differences in ambulatory BP with cardiovascular events and mortality in hemodialysis individuals. 129 male and 91 female hemodialysis patients with valid 48-h BP monitoring were followed for 53.4 ± 31.1 months. The primary endpoint was cardiovascular mortality; the secondary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, heart failure-hospitalization, coronary or peripheral revascularization. Cumulative freedom from the primary endpoint was lower for women (logrank-p = 0.032), while cumulative-freedom from the secondary endpoint did not differ significantly between-groups (logrank-p = 0.644). The crude risk for cardiovascular mortality was significantly higher in women (HR = 1.613, 95% CI [1.037, 2.509]). The crude risk for the combined endpoint was not different between the two groups (HR = 0.918, 95% CI [0.638, 1.320]). After adjusting for major risk factors (age, diabetes, dialysis vintage, coronary disease and hemoglobin) no significant differences in the risk for both the primary and the secondary endpoint were observed between women and men (primary: HR = 1.295 (95% CI [0.808, 2.078]), secondary: HR = 0.763 (95% CI [0.521, 1.118])). After additional adjustment for 44-h systolic BP the above relationships did not alter (primary: HR = 1.329 (95% CI [0.826, 2.137]), secondary: HR = 0.808 (95% CI [0.551, 1.184])). In conclusion, female hemodialysis patients have higher crude but similar adjusted cardiovascular mortality rates compared to male counterparts. In contrast to pre-dialysis CKD, the neutral relationship between gender and adverse cardiovascular outcomes in hemodialysis is not further affected by ambulatory BP.

Epidemiological analysis of chronic kidney disease from 1990 to 2019 and predictions to 2030 by Bayesian age-period-cohort analysis

BACKGROUND

Chronic Kidney Disease (CKD) has emerged as a significant global health issue. This study aimed to reveal and predict the epidemiological characteristics of CKD.

METHODS

Data from the Global Burden of Disease Study spanning the years 1990 to 2019 were employed to analyze the incidence, prevalence, death, and disability-adjusted life year (DALY) of CKD. Joinpoint analysis assessed epidemiological trends of CKD from 1990 to 2019. An age-period-cohort model evaluated risk variations. Risk factor analysis uncovered their influences on DALYs and deaths of CKD. Decomposition analysis explored the drivers to CKD. Frontier analysis evaluated the correlations between CKD burden and the sociodemographic index (SDI). A Bayesian Age-Period-Cohort model was employed to predict future incidence and death of CKD.

RESULTS

In 2019, there were 18,986,903 incident cases, 697,294,307 prevalent cases, 1,427,232 deaths, and 41,538,592 DALYs of CKD globally. Joinpoint analysis showed increasing age-standardized rates of CKD incidence, prevalence, mortality, and DALY from 1990 to 2019. High systolic blood pressure significantly contributed to CKD-related deaths and DALYs, particularly in the high SDI region. Decomposition analysis identified population growth as the primary driver of CKD incident cases and DALYs globally. Countries like Nicaragua showed the highest effective differences, indicating room for improvement in CKD management. By 2030, while incident cases of CKD were predicted to rise, the global deaths might decrease.

CONCLUSIONS

The study revealed a concerning upward trend in the global burden of CKD, emphasizing the need for targeted management strategies across different causes, regions, age groups, and genders.

Association between Proenkephalin A and cardiovascular outcomes in ambulatory Veterans

Proenkephalin (PENK) is a novel biomarker of kidney function associated with cardiovascular risk in patients with cardiovascular disease. Its association with cardiovascular outcomes in ambulatory individuals is less described. In an observational study of 199 ambulatory Veterans enrolled from April to September 2010, we assessed PENK's association with major adverse cardiac events (MACE - cardiovascular death, heart failure [HF] hospitalization, myocardial infarction [MI], or stroke) and individual outcomes of all-cause mortality, incident HF, and cardiovascular death using Cox regression. We also assessed the association of PENK with left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDd), and left ventricular mass index (LVMi) with linear regression. The mean age was 66 ± 12 years, 99 % were men, and 76 % were White, with median follow-up of 12.7 years. Each two-fold higher PENK was associated with a 73 % higher risk of MACE in unadjusted analysis (HR 1.73; 95 % CI 1.00, 2.99; p = 0.043), though this association lost significance after adjusting for confounders (HR 1.69; 95 % CI 0.90-3.15; p = 0.098). PENK was not associated with all-cause mortality, incident HF or cardiovascular death, although risk estimates were elevated with wide confidence intervals for incident HF and cardiovascular death. PENK was not associated with LVMi or LVEDd but had a non-linear relationship with LVEF with low and high PENK associated with lower LVEF. In conclusion, PENK may be associated with a higher risk of MACE in ambulatory Veterans with diverse health statuses; however, further studies are needed. Abbreviations: PENK: Proenkephalin A; MACE: Major Adverse Cardiac Events.

Increased indexed proximal aortic diameter is a predictor of poor prognosis in maintenance hemodialysis patients

Background: Recent studies have shown that the baseline values of absolute aortic root diameter (ARD) and indexed diameter are associated with all-cause mortality and cardiovascular events in the general population, even in the absence of aneurysmal aortic disease. However, there is limited available data on the association between ARD and prognosis in end-stage renal disease (ESRD) patients receiving maintenance hemodialysis (MHD). Accordingly, the purpose of this study is to investigate the predictive value of ARD for all-cause mortality and cardiovascular events in this specific population.Methods: ARD was measured by echocardiography at the level of the sinuses of Valsalva at end diastole and indexed to body surface area (BSA). The primary endpoint was all-cause mortality. The secondary endpoint was major adverse cardiovascular events (MACE), including cardiovascular mortality, myocardial infarction and stroke. Cox proportional hazards models were conducted to evaluate the association between baseline ARD/BSA and clinical outcomes.Results: A total of 391 patients were included in this study. The primary endpoint occurred in 95 (24.3%) patients while the secondary endpoint occurred in 71 (18.2%) patients. Multivariate Cox regression analysis showed that ARD/BSA was an independent prognostic factor for all-cause mortality (HR, per 1-SD increase, 1.403; 95% CI, 1.118-1.761; p = 0.003) as well as MACE (HR, per 1-SD increase, 1.356; 95% CI, 1.037-1.772; p = 0.026).Conclusions: Our results show that ARD/BSA is predictive of all-cause mortality and MACE in MHD patients with ESRD and support the view that assessment of ARD/BSA may refine risk stratification and preventive strategies in this population.

Prognosis for Type 1 Diabetes with Diabetic Nephropathy between 2000 and 2020 - Changes in Kidney Function Decline Over Time and Development of Cardiovascular Disease, Kidney Failure, and Mortality

Introduction

Individuals with type 1 diabetes (T1D) and diabetic nephropathy (DN) experience progressive kidney function decline and high risk of cardiovascular disease (CVD) and mortality. This study explored changes in kidney function decline in new-onset DN between 2000 and 2020 and provided an updated prognosis for risk of kidney failure, CVD, and mortality.

Methods

This is a register-based cohort study in T1D with new-onset DN (severely increased albuminuria) between 2000 and 2020 at Steno Diabetes Center Copenhagen, Denmark. Data were derived from electronic health records and national registers. Kidney function development was expressed as trajectories of estimated glomerular filtration rate (eGFR) and measured GFR (mGFR) using mixed-effects models. The prognosis was presented in probabilities of developing complications, stratified by sex, prior CVD, and risk factor control by using simulations based on Poisson regression analysis.

Results

The cohort comprised 591 individuals with median (interquartile range [IQR]) age at DN onset of 53 (39-66) years and 57% were male. In 283 participants, mGFR were available. Plots of eGFR trajectories illustrated tendencies toward higher eGFR in more recent years; however, this was not confirmed in mGFR trajectories. Poor risk factor control, prior CVD, and male sex impacted mortality and morbidity rates negatively. For men and women with fair risk factor control and no prior CVD, the 10-year mortality rate from onset of DN was 28% and 26%, respectively. For men and women with poor risk factor control and CVD prior to DN onset, the 10-year-mortality rate was 62% for each sex.

Conclusion

The results do not support an improved prognosis for T1D and DN, emphasizing the urgent need for new therapeutic approaches.

Effect of mental state on sleep quality in patients receiving maintenance hemodialysis: A multiple mediation model of hope and family function

The objective of this study was to investigate the current situation of sleep quality in patients receiving maintenance hemodialysis (MHD), and whether hope and family function play a mediating role between negative emotions and sleep quality. The Athens Insomnia Scale, Hospital Anxiety and Depression Scale, Herth Hope Index and Family Adaptation, Partnership, Growth, Affection and Resolve (APGAR) Index were used to investigate 227 MHD patients. The correlations among study variables were analyzed by Pearson correlation analysis. Structural equation model was used to construct and evaluate the mediation model. The sleep quality score of 227 patients receiving MHD was (7.57 ± 4.74), anxiety score was (4.36 ± 4.02), depression score was (5.91 ± 4.37), hope score was (34.64 ± 7.21), family function score was (6.21 ± 2.90). The negative emotions can directly predict sleep quality (β = 0.17, P = .046), positively predict sleep quality through hope (β = 0.12, P = .017), positively predict sleep quality through family function (β = 0.20, P < .001), and positively predict sleep quality through the chain mediating of hope and family function (β = 0.10, P < .001). The total effect size was 71.19%. It is concluded that negative emotions had a direct impact on the sleep quality of patients receiving MHD, and that improving the levels of family function and hope can help them sleep better.

Associations between the Serum Triglyceride Level and Kidney Outcome in Patients with Chronic Kidney Disease: The Fukuoka Kidney disease Registry Study

AIMS

Hypertriglyceridemia is a risk factor for chronic kidney disease (CKD). However, whether or not it predicts the risk of CKD progression is unknown. This study evaluated the association between serum triglyceride (TG) levels and kidney disease progression in patients with non-dialysis-dependent CKD.

METHODS

The Fukuoka Kidney disease Registry (FKR) study was a multicenter, prospective longitudinal cohort study. In total, 4,100 patients with CKD were followed up for 5 years. The primary outcome was the incidence of CKD progression, defined as a ≥ 1.5-fold increase in serum creatinine level or the development of end-stage kidney disease. The patients were divided into quartiles according to baseline serum TG levels under non-fasting conditions: Q1 ＜87 mg/dL; Q2, 87-120 mg/dL; Q3, 121-170 mg/dL, and Q4 ＞170 mg/dL.

RESULTS

During the 5-year observation period, 1,410 patients met the criteria for CKD progression. The multivariable-adjusted Cox proportional hazards model showed a significant association between high serum TG level and the risk of CKD progression in the model without macroalbuminuria as a covariate (multivariable hazard ratio[HR] for Q4 versus Q1, 1.20; 95% CI, 1.03-1.41; P=0.022), but the significance disappeared after adjusting for macroalbuminuria (HR for Q4 versus Q1, 1.06; 95% CI, 0.90-1.24; P=0.507).

CONCLUSIONS

The present findings suggest that individuals with high serum TG levels are more likely to develop CKD progression than those without; however, whether or not higher serum TG levels reflect elevated macroalbuminuria or lead to CKD progression via elevated macroalbuminuria is unclear.

Identifying Major Barriers to Home Dialysis (The IM-HOME Study): Findings From a National Survey of Patients, Care Partners, and Providers

RATIONALE & OBJECTIVE

Developing strategies to improve home dialysis use requires a comprehensive understanding of barriers. We sought to identify the most important barriers to home dialysis use from the perspective of patients, care partners, and providers.

STUDY DESIGN

This is a convergent parallel mixed-methods study.

SETTING & PARTICIPANTS

We convened a 7-member advisory board of patients, care partners, and providers who collectively developed lists of major patient/care partner-perceived barriers and provider-perceived barriers to home dialysis. We used these lists to develop a survey that was distributed to patients, care partners, and providers-through the American Association of Kidney Patients and the National Kidney Foundation. The surveys asked participants to (1) rank their top 3 major barriers (quantitative) and (2) describe barriers to home dialysis (qualitative).

ANALYTICAL APPROACH

We compiled a list of the top 3 patient/care partner-perceived and top 3 provider-perceived barriers (quantitative). We also conducted a directed content analysis of open-ended survey responses (qualitative).

RESULTS

There were 522 complete responses (233 providers; 289 patients/care partners). The top 3 patient/care partner-perceived barriers were fear of performing home dialysis; lack of space; and the need for home-based support. The top 3 provider-perceived barriers were poor patient education; limited mechanisms for home-based support staff, mental health, and education; and lack of experienced staff. We identified 9 themes through qualitative analysis: limited education; financial disincentives; limited resources; high burden of care; built environment/structure of care delivery that favors in-center hemodialysis; fear and isolation; perceptions of inequities in access to home dialysis; provider perspectives about patients; and patient/provider resiliency.

LIMITATIONS

This was an online survey that is subject to nonresponse bias.

CONCLUSIONS

The top 3 barriers to home dialysis for patient/care partners and providers incompletely overlap, suggesting the need for diverse strategies that simultaneously address patient-perceived barriers at home and provider-perceived barriers in the clinic.

PLAIN-LANGUAGE SUMMARY

There are many barriers to home dialysis use in the United States. However, we know little about which barriers are the most important to patients and clinicians. This makes it challenging to develop strategies to increase home dialysis use. In this study, we surveyed patients, care partners, and clinicians across the country to identify the most important barriers to home dialysis, namely (1) patients/care partners identified fear of home dialysis, lack of space, and lack of home-based support; and (2) clinicians identified poor patient education, limited support for staff and patients, and lack of experienced staff. These findings suggest that patients and clinicians perceive different barriers and that both sets of barriers should be addressed to expand home dialysis use.

Extreme Humid-Heat Exposure and Mortality Among Patients Receiving Dialysis

RATIONALE & OBJECTIVE

Exposure to extreme heat events has been linked to increased morbidity and mortality in the general population. Patients receiving maintenance dialysis may be vulnerable to greater risks from these events, but this is not well understood. We characterized the association of extreme heat events and the risk of death among patients receiving dialysis in the United States.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Data from the US Renal Data System were used to identify adults living in US urban settlements prone to extreme heat who initiated maintenance dialysis between 1997 and 2016.

EXPOSURE

An extreme heat event, defined as a time-updated heat index (a humid-heat metric) exceeding 40.6°C for≥2 days or 46.1°C for≥1day.

OUTCOME

Death.

ANALYTICAL APPROACH

Cox proportional hazards regression to estimate the elevation in risk of death during a humid-heat event adjusted for age, sex, year of dialysis initiation, dialysis modality, poverty level, and climate region. Interactions between humid-heat and these same factors were explored.

RESULTS

Among 945,251 adults in 245 urban settlements, the mean age was 63 years, and 44% were female. During a median follow-up period of 3.6 years, 498,049 adults were exposed to at least 1 of 7,154 extreme humid-heat events, and 500,025 deaths occurred. In adjusted models, there was an increased risk of death (hazard ratio 1.18 [95% CI, 1.15-1.20]) during extreme humid-heat exposure. The relative mortality risk was higher among patients living in the Southeast (P<0.001) compared with the Southwest.

LIMITATIONS

Possibility of exposure misclassification, did not account for land use and air pollution co-exposures.

CONCLUSIONS

This study suggests that patients receiving dialysis face an increased risk of death during extreme humid-heat exposure.

PLAIN-LANGUAGE SUMMARY

Patients who receive dialysis are vulnerable to extreme weather events, and rising global temperatures may bring more frequent extreme heat events. We sought to determine whether extreme heat exposure was associated with an increased risk of death in urban-dwelling patients receiving dialysis across the United States. We found that people receiving dialysis were more likely to die during extreme humid-heat events, defined by a heat index exceeding 40.6°C (105°F) for≥2 days or 46.1°C (115°F) for≥1day. These findings inform the nephrology community about the potential importance of protecting patients receiving maintenance dialysis from the risks associated with extreme heat.

Acute Kidney Injury Survivor Remote Patient Monitoring: A Single Center's Experience and an Effectiveness Evaluation

Rationale & Objective

Remote patient monitoring (RPM) could improve the quality and efficiency of acute kidney injury (AKI) survivor care. This study described our experience with AKI RPM and characterized its effectiveness.

Study Design

A cohort study matched 1:3 to historical controls.

Setting & Participants

Patients hospitalized with an episode of AKI who were discharged home and were not treated with dialysis.

Exposure

Participation in an AKI RPM program, which included use of a home vital sign and symptom monitoring technology and weekly in-center laboratory assessments.

Outcomes

Risk of unplanned hospital readmission or emergency department (ED) visit within 6 months.

Analytic Approach

Endpoints were assessed using Cox proportional hazards models.

Results

Forty of the 49 patients enrolled in AKI RPM (82%) participated in the program after hospital discharge. Seventy three percent of patients experienced one AKI RPM alert, most commonly related to fluid status. Among those with stage 3 AKI, the risk of unplanned readmission or ED visit within 6 months of discharge was not different between AKI RPM patients (n = 34) and matched controls (n = 102) (HR 1.33 [95% CI, 0.81-2.18]; P = 0.27). The incidence of an ED visit without hospitalization was significantly higher in the AKI RPM group (HR 1.95, [95% CI, 1.05-3.62]; P = 0.035). The risk of an unplanned readmission or ED visit was higher in those with baseline eGFR < 45 mL/min/1.73 m2 exposed to AKI RPM (HR 2.24 [95% CI, 1.19-4.20]; P = 0.012) when compared with those with baseline eGFR ≥45 mL/min/1.73 m2 (HR 0.69 [95% CI, 0.29-1.67]; P = 0.41) (test of interaction P = 0.04).

Limitations

Small sample size that may have been underpowered for the effectiveness endpoints.

Conclusions

AKI RPM, when used after hospital discharge, led to alerts and interventions directed at optimizing kidney health and AKI complications but did not reduce the risk for rehospitalization.

Cost-Utility of Real-Time Potassium Monitoring in United States Patients Receiving Hemodialysis

Introduction

Patients with kidney failure requiring hemodialysis are at high risk for hyperkalemia between treatments, which is associated with increased cardiovascular morbidity and mortality. Early detection of hyperkalemic events may be useful to prevent adverse outcomes and their associated costs. We performed a cost-utility analysis comparing an intervention where a real-time potassium monitoring device is administered in patients on hemodialysis in comparison to usual care.

Methods

We developed a cost-utility model with microsimulation from the perspective of the United States health care payer. Primary outcomes included the monthly cost-effectiveness threshold cost and break-even cost per patient attributable to the intervention and the incremental cost-effectiveness ratio comparing the intervention to usual care. A 25% reduction in hyperkalemic events was applied as a baseline device effectiveness estimate. Concurrent first and second order microsimulations were performed using 10%, 25%, and 50% effectiveness estimates as sensitivity analyses. Results are presented over a 10-year time horizon in 2022 United States dollars and a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) was considered.

Results

Over 10 years, threshold and break-even analysis yielded maximum monthly costs of $201.10 and $144.15 per patient, respectively. The intervention was associated with reduced mean costs ($6381.21) and increased mean QALYs (0.03) per patient; therefore, was considered dominant. In sensitivity analysis, the intervention was dominant in 99% of simulations performed at all effectiveness rates.

Conclusion

Implementing a real-time potassium monitoring device in patients on hemodialysis has the potential for cost savings and improved outcomes from the perspective of the United States health care payer.

Genetic testing in pediatric kidney transplant recipients to promote informed choice and improve individualized monitoring

BACKGROUND

The growing body of research on kidney disease in children has identified a broad spectrum of genetic etiologies.

METHODS

We conducted a prospective study to evaluate the efficacy of an optimized genetic test and subclinical changes in a real-world context before kidney transplantation. All cases involved recipients under the age of 18 who underwent whole exome sequencing (ES) between 2013 and 2022.

RESULTS

The study population included 244 children, with a median age of 13.1 years at transplantation. ES provided a molecular genetic diagnosis in 114 (46.7%) probands with monogenic variants in 15 known disease-causing genes. ES confirmed the suspected clinical diagnosis in 74/244 (30.3%) cases and revised the pre-exome clinical diagnoses in 40/244 (16.4%) cases. ES also established a specific underlying cause for kidney failure for 19 patients who had previously had an unknown etiology. Genetic diagnosis influenced clinical management in 88 recipients (36.1%), facilitated genetic counseling for 18 families (7.4%), and enabled comprehensive assessment of living donor candidates in 35 cases (14.3%).

CONCLUSIONS

Genetic diagnosis provides critical insights into the pathogenesis of kidney disease, optimizes clinical strategies concerning risk assessment of living donors, and enhances disease surveillance of recipients.

Frailty in the context of kidney transplantation

Frailty, defined as an inappropriate response to stressful situations due to the loss of physiological reserve, was initially described in the elderly population, but is currently being identified in younger populations with chronic diseases, such as chronic kidney disease. It is estimated that about 20% of patients are frail at the time of kidney transplantation (KT), and there is great interest in its potential predictive value for unfavorable outcomes. A significant body of evidence has been generated; however, several areas still remain to be further explored. The pathogenesis is poorly understood and limited to the extrapolation of findings from other populations. Most studies are observational, involving patients on the waiting list or post-KT, and there is a scarcity of data on long-term evolution and possible interventions. We reviewed studies, including those with Brazilian populations, assessing frailty in the pre- and post-KT phases, exploring pathophysiology, associated factors, diagnostic challenges, and associated outcomes, in an attempt to provide a basis for future interventions.

Estimates of eskd risk and timely kidney replacement therapy education

BACKGROUND

Kidney replacement therapy (KRT) needs preparation and its timing is difficult to predict. Nephrologists' predictions of kidney failure risk tend to be more pessimistic than the Kidney Failure Risk Equation (KFRE) predictions. We aimed to explore how physicians' risk estimate related to referral to KRT education, vs. the objective calculated KFRE.

METHODS

Prospective observational study of data collected in chronic kidney disease (CKD) clinics of the Veterans Affairs Medical Center San Diego and the University of California, San Diego. The study included 257 participants who were aged 18 years or older, English speaking, prevalent CKD clinic patients, with estimated glomerular filtration rate (eGFR) < 60 mL/min per 1.73 m2 (MDRD equation). The exposure consisted of end stage kidney disease (ESKD) risk predictions. Nephrologists' kidney failure risk estimations were assessed: "On a scale of 0-100%, without using any estimating equations, give your best estimate of the risk that this patient will need dialysis or a kidney transplant in 2 years." KFRE was calculated using age, sex, eGFR, serum bicarbonate, albumin, calcium, phosphorus, urine albumin/creatinine ratio. The outcomes were the pattern of referral to KRT education (within 90 days of initial visit) and kidney failure evaluated by chart review. The population was divided into groups either by nephrologists' predictions or by KFRE. Referral to KRT education was examined by group and sensitivity and specificity were calculated based on whether participants reached kidney failure at 2 years.

RESULTS

A fifth were referred for education by 90 days of enrollment. Low risk patients by both estimates had low referral rates. In those with nephrologists' predictions ≥ 15% (n = 137), sensitivity was 71% and specificity 76%. In those with KFRE ≥ 15% (n = 55), sensitivity was 85% and specificity 41%.

CONCLUSIONS

Although nephrologists tend to overestimate patients' kidney failure risk, they do not appear to act on this overestimation, as the rates of KRT education referrals are lower than expected when a nephrologist identifies a patient as high risk.

CLINICAL TRIAL NUMBER

Not applicable.

Comparative effectiveness of bovine carotid artery xenograft and polytetrafluoroethylene in hemodialysis access revision

BACKGROUND

When hemodialysis arteriovenous accesses fail, autogenous options are often limited. Non-autogenous conduit choices include bovine carotid artery xenografts (BCAG) and expanded polytetrafluoroethylene (PTFE), yet their comparative effectiveness in hemodialysis access revision remains largely unknown.

METHODS

A cohort study was performed from a prospectively collected institutional database from August 2010 to July 2021. All patients undergoing an arteriovenous access revision with either BCAG or PTFE were followed for up to 3 years from their index access revision. Revision was defined as graft placement to address a specific problem of an existing arteriovenous access while maintaining one or more of the key components of the original access (e.g. inflow, outflow, and cannulation zone). Outcomes were measured starting at the date of the index revision procedure. The primary outcome was loss of secondary patency at 3 years. Secondary outcomes included loss of post-intervention primary patency, rates of recurrent interventions, and 30-day complications. Pooled logistic regression was used to estimate inverse probability weighted marginal structural models for the time-to-event outcomes of interest.

RESULTS

A total of 159 patients were included in the study, and 58% received access revision with BCAG. Common indications for revision included worn out cannulation zones (32%), thrombosis (18%), outflow augmentation (16%), and inflow augmentation (13%). Estimated risk of secondary patency loss at 3 years was lower in the BCAG group (8.6%, 3.9-15.1) compared to the PTFE group (24.8%, 12.4-38.7). Patients receiving BCAG experienced a 60% decreased relative risk of secondary patency loss at 3 years (risk ratio 0.40, 0.14-0.86). Recurrent interventions occurred at similar rates in the BCAG and PTFE groups, with 1.86 (1.31-2.43) and 1.60 (1.07-2.14) interventions at 1 year, respectively (hazard ratio 1.22, 0.74-1.96).

CONCLUSIONS

Under the conditions of this contemporary cohort study, use of BCAG in upper extremity hemodialysis access revision decreased access abandonment when compared to PTFE.

Underrepresentation of black individuals in pivotal trials for novel anticancer drugs: Potential consequence of using estimated creatinine clearance to assess kidney function?

BACKGROUND

Black individuals are historically underrepresented in oncology clinical trials. One potential reason for this is the prevalence of kidney disease in Black individuals, utilization of estimated creatinine clearance as a surrogate for glomerular filtration rate (GFR) in oncology, and GFR-based trial eligibility criteria. We characterized the representation of racial minorities in anticancer agent pivotal trials and examined if GFR-based trial eligibility criteria impact the proportion of Black individuals in trial populations.

METHODS

We constructed a data repository for anticancer drugs FDA-approved from 2015 to 2019 and associated pivotal trials, from which we extracted trial population racial compositions and GFR-based trial eligibility criteria. We calculated the participation-to-incidence ratio (PIR) and participation-to-mortality ratio (PMR) for a variety of cancer sites, where PIR or PMR >1.2 and <0.8 indicate overrepresentation and underrepresentation, respectively. We evaluated the relationship between GFR eligibility cutoffs and the proportion of Black enrollees with Spearman rank correlation coefficient.

RESULTS

We assessed 24,698 patients in 74 trials. Black individuals were underrepresented in all trials (PIR ≤0.48, PMR ≤0.50). For trials with GFR-based eligibility criteria (n = 49), a lower GFR cutoff was modestly associated with a higher proportion of Black enrollees (r = -0.29, p = 0.039). This relationship was strengthened for trials that only used estimated creatinine clearance to estimate GFR (r = -0.43, p = 0.004).

CONCLUSIONS

GFR-related eligibility, and specifically the use of estimated creatinine clearance, may contribute to Black individuals being disproportionately excluded from cancer clinical trials. This highlights the need for implementation of contemporary GFR equations and other interventions to boost racial minority trial enrollment.

Benefits of Living Over Deceased Donor Kidney Transplantation in Elderly Recipients. A Propensity Score Matched Analysis of a Large European Registry Cohort

Although kidney transplantation from living donors (LD) offers better long-term results than from deceased donors (DD), elderly recipients are less likely to receive LD transplants than younger ones. We analyzed renal transplant outcomes from LD versus DD in elderly recipients with a propensity-matched score. This retrospective, observational study included the first single kidney transplants in recipients aged ≥65 years from two European registry cohorts (2013-2020, n = 4,257). Recipients of LD (n = 408), brain death donors (BDD, n = 3,072), and controlled cardiocirculatory death donors (cDCD, n = 777) were matched for donor and recipient age, sex, dialysis time and recipient diabetes. Major graft and patient outcomes were investigated. Unmatched analyses showed that LD recipients were more likely to be transplanted preemptively and had shorter dialysis times than any DD type. The propensity score matched Cox's regression analysis between LD and BDD (387-pairs) and LD and cDCD (259-pairs) revealing a higher hazard ratio for graft failure with BDD (2.19 [95% CI: 1.16-4.15], p = 0.016) and cDCD (3.38 [95% CI: 1.79-6.39], p < 0.001). One-year eGFR was higher in LD transplants than in BDD and cDCD recipients. In elderly recipients, LD transplantation offers superior graft survival and renal function compared to BDD or cDCD. This strategy should be further promoted to improve transplant outcomes.