Burden, access and disparities in kidney disease

Global trends in chronic kidney disease mortality and disability-adjusted life years attributable to low physical activity (1990-2021): a growing public health challenge

BACKGROUND

Low physical activity (LPA) is a major contributor to the global burden of chronic kidney disease (CKD). Our goal was to assess the spatiotemporal trends in the CKD burden attributable to LPA from 1990 to 2021, with a focus on the globe, China, five SDI regions, and four continents.

METHODS

We analysed CKD-related deaths, DALYs, the ASMR, the ASDR, and the EAPC attributable to low physical activity (LPA). This study focused on trends from 1990 to 2021 across the globe, China, five SDI regions, and four continents. Decomposition analysis, frontier analysis, and forecasting models were employed to explore changes in these indicators and their influencing factors.

RESULTS

In 2021, CKD attributable to low physical activity (LPA) resulted in 913,070 [95% UI: 348,170-1,619,770] DALYs and 40,920 [95% UI: 16,170-72,560] deaths globally, both of which were higher than those reported in 1990. The AOSD increased from 9.63 (95% UI: 3.73-17.02) to 10.81 (95% UI: 4.14-19.18) per 100,000, with an EAPC of 0.42 (95% CI: 0.35-0.48). The ASMR increased from 0.42 (95% UI: 0.17-0.74) to 0.50 (95% UI: 0.20-0.90) per 100,000, with an EAPC of 0.65 (95% CI: 0.57-0.73). The burden was greater among females, with more rapid increases in the ASDR and ASMR. The Americas and high-SDI regions presented the greatest growth in DALY and mortality rates.

CONCLUSIONS

The burden of CKD attributable to low physical activity (LPA) has increased significantly, particularly in low-SDI regions, women, and elderly individuals. The findings highlight the importance of promoting physical activity and implementing early interventions to inform public health policies.

CLINICAL TRIAL NUMBER

Not applicable.

Associations of cardiovascular-kidney-metabolic syndrome stages with premature mortality and the role of social determinants of health

OBJECTIVES

The American Heart Association defined cardiovascular-kidney-metabolic (CKM) syndrome as a novel multi-stage disorder. We examined the associations of CKM stages with premature mortality and the role of social determinants of health (SDOHs).

DESIGN

A prospective cohort study.

SETTING AND PARTICIPANTS

A nationally representative sample of US adults from NHANES 1999-2018.

MEASUREMENTS

CKM included 5 stages (stages 0-4), reflecting progressive pathophysiology. Premature mortality (deaths before 75 years) were ascertained via linkage to the National Death Index with follow-up until 2019. Cox proportional-hazards models adjusted for age, sex, race/ethnicity, medical history, and other confounding factors were used to calculate the hazard ratios (HR) and 95% CIs for CKM-mortality associations.

RESULTS

Among 27,909 participants (mean age 49.7 years, 49.0% females), 1762 premature deaths occurred over a median follow-up of 8.3 years. Compared with stage 0, the adjusted HRs for all-cause premature mortality at CKM stages 1-4 were 0.88 (95% CI 0.66-1.17), 1.31 (0.99-1.73), 1.94 (1.31-2.87), and 2.19 (1.61-2.98), respectively. For CVD premature mortality, the adjusted HRs for CKM stages 1-4 were 1.12 (0.46-2.72), 1.74 (0.71-4.28), 3.93 (1.53-10.12), and 6.48 (2.95-14.20), respectively. Among adults at CKM stages 3-4, unfavorable SDOHs, particularly not living with a partner, low family income, lack of private health insurance, unemployment, or ≥2 cumulative SDOHs (4.16, 95% CI 3.35-5.18) were associated with increased all-cause premature mortality. Among those at CKM stages 0-2, unfavorable SDOHs were also related to increased premature mortality.

CONCLUSION

CKM stages 3-4, but not stages 1-2, were associated with increased risks of premature mortality compared with stage 0. The risks were increased by unfavorable SDOHs across CKM stages.

Effectiveness of a systematic home-based albuminuria screening programme to detect chronic kidney disease in high-risk individuals in primary care (SALINE): a cross-sectional screening study

Background

Although guidelines recommend opportunistic screening for chronic kidney disease (CKD) in individuals with established risk factors, such as diabetes, hypertension, or cardiovascular disease, screening for CKD in these individuals remains suboptimal. This study aimed to evaluate the effectiveness of a systematic home-based albuminuria screening program in primary care patients at risk for CKD.

Methods

A cross-sectional screening study was performed in ten general practices and five pharmacies in the Netherlands from November 2021 to May 2024. A random selection of patients aged 45-80 years at risk for CKD based on risk factors registered in their electronic medical record was invited for home-based albuminuria screening using a urine collection device for measurement of the urinary albumin-to-creatinine ratio (ACR). In those patients with confirmed increased albuminuria (ACR ≥3 mg/mmol), an elaborate screening to assess the presence of CKD and cardiovascular risk factors was performed, followed by a referral to their general practitioner (GP) for evaluation of the findings. The primary outcome was the yield of the home-based albuminuria screening and elaborate screening to detect increased albuminuria in the GP and the pharmacy setting. SALINE is registered with ClinicalTrials.gov, NCT05321095.

Findings

In total, 6380 patients (3802 via ten GPs and 2578 via five pharmacies) were invited for home-based albuminuria screening. The participation rate was 40·1% among patients invited via their GP (1524/3802), compared to 21·8% (562/2578) among those invited via their pharmacy (P < 0·001). In total, 8·7% of the GP participants had confirmed increased albuminuria (133/1524), compared to 6·0% of the pharmacy participants (34/562). Of the 115 GP participants with detected increased albuminuria who completed the elaborate screening, 102 (88·7%) were identified with one or more newly diagnosed CKD or cardiovascular risk factor(s) (n = 46, 40·0%), or with a known risk factor that was outside the target range for treatment (n = 75, 65·2%). Of the pharmacy participants with detected increased albuminuria completing the home-based screening, 26 completed the elaborate screening. Of those, 22 (84·6%) were identified with one or more newly diagnosed CKD or cardiovascular risk factor(s) (n = 6, 2·3%), or with a known risk factor that was outside the target range for treatment (n = 21, 80·8%).

Interpretation

Systematic albuminuria screening of patients at risk for CKD in primary care, when performed in addition to regular opportunistic screening, has an acceptable participation rate and yield when performed via GPs, whereas it is less effective when performed via pharmacies. Such a screening program identifies patients with yet unknown albuminuria who may benefit from starting or optimizing kidney and cardioprotective treatment. The introduction of such systematic albuminuria screening programs via GPs merits further study to optimize the participation and yield.

Funding

This study is funded by AstraZeneca Netherlands.

Community Point of Care Testing in Diagnosing and Managing Chronic Kidney Disease

Chronic kidney disease (CKD) poses a significant global health challenge with increasing prevalence and associated morbidity. Point-of-care testing (POCT) provides an opportunity to improve CKD management and outcomes through early detection and targeted interventions, particularly in underserved communities. This review evaluates the roles of POCT in CKD, focusing on utility (through screening programs, monitoring of kidney function, and assessing participants on renally excreted medications), accuracy, and acceptability. Screening programs employing POCT have demonstrated promising outcomes, with improved rates of CKD diagnosis in groups with disparate health outcomes, offering a vital avenue for early intervention in high-risk populations. These have been conducted in rural and urban community or pharmacy settings, highlighting convenience and accessibility as important facilitators for participants. In addition, POCT holds significant promise in the monitoring of CKD, particularly in groups requiring frequent testing, such as kidney transplant recipients and patients on renin-angiotensin-aldosterone inhibitors. The consideration of the variable analytical performance of different devices remains crucial in assessing the utility of a POCT intervention for CKD. While the convenience and improved accessibility of home self-testing versus healthcare professional management is important, it must be balanced with acceptable levels of accuracy and precision to maintain patient and clinical confidence. Despite challenges including variability in accuracy and the user-friendliness of devices, patient feedback has generally remained positive, with studies reporting increased patient satisfaction and engagement. However, challenges regarding wider uptake are limited by healthcare professional confidence (in test reliability), the potential for increased workload, and early prohibitive costs. In conclusion, POCT represents a growing and valuable tool in enhancing CKD care, particularly in resource-limited settings, but careful consideration of device selection and implementation strategies is essential to achieve desired outcomes.

A new era in the science and care of kidney diseases

Notable progress in basic, translational and clinical nephrology research has been made over the past five decades. Nonetheless, many challenges remain, including obstacles to the early detection of kidney disease, disparities in access to care and variability in responses to existing and emerging therapies. Innovations in drug development, research technologies, tissue engineering and regenerative medicine have the potential to improve patient outcomes. Exciting prospects include the availability of new drugs to slow or halt the progression of chronic kidney disease, the development of bioartificial kidneys that mimic healthy kidney functions, and tissue engineering techniques that could enable transplantable kidneys to be created from the cells of the recipient, removing the risk of rejection. Cell and gene therapies have the potential to be applied for kidney tissue regeneration and repair. In addition, about 30% of kidney disease cases are monogenic and could potentially be treated using these genetic medicine approaches. Systemic diseases that involve the kidney, such as diabetes mellitus and hypertension, might also be amenable to these treatments. Continued investment, communication, collaboration and translation of innovations are crucial to realize their full potential. In addition, increasing sophistication in exploring large datasets, implementation science, and qualitative methodologies will improve the ability to deliver transformational kidney health strategies.

Leonotis ocymifolia (Burm.f.) Iwarsson aerial parts aqueous extract mitigates cisplatin-induced nephrotoxicity via attenuation of inflammation, and DNA damage

Herein, we explored the protective effect of Leonotis ocymifolia (Burm.f.) Iwarsson aerial parts extract (LO) against cisplatin (CP)-induced nephrotoxicity in rats and profiled their phytocontents. A total of 31 compounds belonging to organic and phenolic acids and their glycosides as well as flavonoids and their O- and C-glycosides were identified through LC-MS/MS. The DPPH and FRAP assays revealed that the extract had powerful antioxidant properties. The in vivo results demonstrated that administering LO extract for 30 days (40 and 80 mg/kg b. w.) significantly improved the altered renal injury markers via reducing creatinine (high dose only) and uric acid levels compared to the Cp-group. The deleterious action of cisplatin on renal oxidative stress markers (GSH, MDA, SOD, and CAT) were also mitigated by LO-pretreatment. The reduction of the inflammatory marker (IL-6), and inhibition of DNA fragmentation, highlighted the prophylactic action of LO in kidney tissue. Molecular docking followed by a 100 ns molecular dynamic simulation analyses revealed that, amongst the 31 identified compounds in LO, chlorogenic and caffeoylmalic acids had the most stable binding to IL-6. The nephroprotective effects were further confirmed by histopathological observations, which showed improvement in ultrastructural changes induced by cisplatin. The observed findings reinforce the conclusion that L. ocymifolia extract exerts nephroprotective properties, which could be related to its antioxidant and anti-inflammatory activities. Further studies are required to determine the therapeutic doses and the proper administration time.

Acute Kidney Injury in Kidney Transplant Patients in Intensive Care Unit: From Pathogenesis to Clinical Management

Kidney transplantation is the first-choice treatment for end-stage renal disease (ESRD). Kidney transplant recipients (KTRs) are at higher risk of experiencing a life-threatening event requiring intensive care unit (ICU) admission, mainly in the late post-transplant period (more than 6 months after transplantation). Urosepsis and bloodstream infections account for almost half of ICU admissions in this population; in addition, potential side effects related to immunosuppressive treatment should be accounted for cytotoxic and ischemic changes induced by calcineurin inhibitor (CNI), sirolimus/CNI-induced thrombotic microangiopathy and posterior reversible encephalopathy syndrome. Throughout the ICU stay, Acute Kidney Injury (AKI) incidence is common and ranges from 10% to 80%, and up to 40% will require renal replacement therapy. In-hospital mortality can reach 30% and correlates with acute illness severity and admission diagnosis. Graft survival is subordinated to baseline estimated glomerular filtration rate (eGFR), clinical presentation, disease severity and potential drug nephrotoxicity. The present review aims to define the impact of AKI events on short- and long-term outcomes in KTRs, focusing on the epidemiologic data regarding AKI incidence in this subpopulation; the pathophysiological mechanisms underlying AKI development and potential AKI biomarkers in kidney transplantation, graft and patients' outcomes; the current diagnostic work up and management of AKI; and the modulation of immunosuppression in ICU-admitted KTRs.

Motivos referidos pelos indivíduos que não estavam em lista de espera para o transplante renal

RESUMO Objetivo: Descrever os motivos referidos pelos indivíduos em hemodiálise que não estavam cadastrados em lista de espera para o transplante renal. Métodos: Estudo transversal realizado no Rio Grande do Sul, Brasil em seis serviços de terapia de substituição renal com 214 indivíduos em hemodiálise que referiram os motivos de não estarem cadastrados em lista de espera para o transplante renal. A coleta de dados foi realizada por meio de questionário entre março de 2016 e março de 2017. Para a análise estatística descritiva e do teste de independência, utilizou-se o software Stata. Resultados: Os principais motivos referidos pelos 214 indivíduos que não estavam cadastrados em lista de espera para o transplante renal foram: a falta de informação dos indivíduos, não desejar estar em lista, o impedimento por multimorbidade e a idade. Conclusões: A falta de informação apresentou associação com as variáveis baixa escolaridade, sexo masculino, ≤ 5 anos de tempo de diagnóstico e ≤ 5 anos em terapia de substituição renal. O motivo não desejar estar em lista esteve associado com as variáveis não saber ler e idade.

Reasons referred by individuals who were not on kidney transplantation waiting lists

OBJECTIVE

To describe the reasons reported by individuals in hemodialysis that were not registered on kidney transplantation waiting lists.

METHODS

Cross-sectional study conducted in six renal replacement therapy services in Rio Grande do Sul, Brazil with 214 individuals undergoing hemodialysis who reported the reasons for not being registered on kidney transplantation waiting lists. The data collection was carried out through a questionnaire from March 2016 to March 2017. The Stata software was used to the statistical analysis and independence test.

RESULTS

The main reasons reported by the 214 individuals who were not registered on kidney transplantation waiting lists were due to the lack of information of the individuals, not wanting to be on list, due to morbidities and age.

CONCLUSIONS

The lack of information was associated with the variables low education, male, ≤ 5 years of time since diagnosis and ≤ 5 years in renal replacement therapy. The reason for not wanting to be on the list was associated with the variables illiteracy and age.

Physical Activity and Mortality in Patients With Chronic Kidney Disease: A Protocol for Systematic Review and Dose-Response Meta-Analysis

Objective

To examine the dose-response associations between total physical activity, different intensity of physical activity, and all-cause mortality in patients with chronic kidney disease (CKD).

Methods and Analysis

PubMed, Embase, Web of Science, and the Cochrane library will be searched from inception to June 2022. Only cohort studies assessing physical activity associations with all-cause mortality among CKD patients will be considered for inclusion. The quality of included cohort studies will be evaluated according to the Newcastle-Ottawa Scale (NOS). The robust error meta-regression (REMR) model will be used to establish dose-response relationships between physical activity and mortality. Additional statistical analysis including Egger's test, subgroup analysis, sensitivity analysis. The strengths of evidence will be evaluated with the Grading of Recommendation, Assessment, Development, and Evaluation approach.

Ethics and Dissemination

Ethics approval is not required as no private information from individuals is collected.

PROSPERO Registration Number

CRD 42021283630.

KDOQI US Commentary on the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in CKD

In October 2020, KDIGO (Kidney Disease: Improving Global Outcomes) published its first clinical practice guideline directed specifically to the care of patients with diabetes and chronic kidney disease (CKD). This commentary presents the views of the KDOQI (Kidney Disease Outcomes Quality Initiative) work group for diabetes in CKD, convened by the National Kidney Foundation to provide an independent expert perspective on the new guideline. The KDOQI work group believes that the KDIGO guideline takes a major step forward in clarifying glycemic targets and use of specific antihyperglycemic agents in diabetes and CKD. The purpose of this commentary is to carry forward the conversation regarding optimization of care for patients with diabetes and CKD. Recent developments for prevention of CKD progression and cardiovascular events in people with diabetes and CKD, particularly related to sodium/glucose cotransporter 2 (SGLT2) inhibitors, have filled a longstanding gap in nephrology's approach to the care of persons with diabetes and CKD. The multifaceted benefits of SGLT2 inhibitors have facilitated interactions between nephrology, cardiology, endocrinology, and primary care, underscoring the need for innovative approaches to multidisciplinary care in these patients. We now have more interventions to slow kidney disease progression and prevent or delay kidney failure in patients with diabetes and kidney disease, but methods to streamline their implementation and overcome barriers in access to care, particularly cost, are essential to ensuring all patients may benefit.

Rhubarb Enema Decreases Circulating Trimethylamine N-Oxide Level and Improves Renal Fibrosis Accompanied With Gut Microbiota Change in Chronic Kidney Disease Rats

Objectives: Trimethylamine N-oxide (TMAO), a metabolic product of gut flora, is increased in chronic kidney disease (CKD) subjects and is recognized as one type of uremic toxins which is associated with poor cardiovascular outcomes and kidney function loss. Previous studies have suggested that rhubarb enema could reduce circulating uremic toxins such as urea, creatinine, and indoxyl sulfate and also regulate the intestinal microbiota. However, whether rhubarb enema retards kidney dysfunction by reducing circulating TMAO and its underlying mechanism, are still unclear. The present study aims to investigate the impact of rhubarb enema on TMAO and its precursors, as well as on the intestinal microbiota in 5/6 nephrectomized (5/6Nx) CKD rats.

Design: Rats in the treatment groups were given rhubarb enema after modeling. At the end of the study, blood, feces, and kidney tissues were collected and processed for biochemical analyses, histological and western blot analyses, 16S rRNA sequence and untargeted metabolomic analyses.

Results: Rhubarb enema reduced serum TMAO and trimethylamine (TMA) levels, inhibited the expression of inflammatory markers (interleukin-6, tumor necrosis factor α and Interferon-γ) and alleviated tubular atrophy, monocyte infiltration and interstitial fibrosis in 5/6Nx CKD rats. Moreover, rhubarb enema significantly increased the abundance of some symbiotic bacteria and probiotics, while reduced the abundance of some potential pathogens at the genus level. In addition, Spearman’s correlation analysis revealed that lachnospiraceae and romboutsia were positively correlated with TMAO.

Conclusion: Rhubarb enema decreases circulating TMAO level and improves renal fibrosis in 5/6Nx CKD rats, which may be related to the regulation of intestinal microbial community.

Patient-Reported Measures and Lifestyle Are Associated With Deterioration in Nutritional Status in CKD Stage 4-5: The EQUAL Cohort Study

OBJECTIVE

The aim of this study was to explore the changes in nutritional status before dialysis initiation and to identify modifiable risk factors of nutritional status decline in older adults with advanced renal disease.

DESIGN AND METHODS

The European Quality Study on treatment in advanced chronic kidney disease (EQUAL) is a prospective, observational cohort study involving six European countries. We included 1,103 adults >65 years with incident estimated glomerular filtration rate <20 mL/min/1.73 m² not on dialysis, attending nephrology care. Nutritional status was assessed with the 7-point Subjective Global Assessment tool (7-p SGA), patient-reported outcomes with RAND-36 and the Dialysis Symptom Index. Logistic regression was used to estimate the associations between potential risk factors and SGA decline.

RESULTS

The majority of the patients had a normal nutritional status at baseline, 28% were moderately malnourished (SGA ≤5). Overall, mean SGA decreased by -0.18 points/year, (95% confidence interval -0.21; -0.14). More than one-third of the study participants (34.9%) deteriorated in nutritional status (1 point decline in SGA) and 10.9% had a severe decline in SGA (≥2 points). The proportion of patients with low SGA (≤5) increased every 6 months. Those who dropped in SGA also declined in estimated glomerular filtration rate and mental health score. Every 10 points decrease in physical function score increased the odds of decline in SGA by 23%. Lower physical function score at baseline, gastrointestinal symptoms, and smoking were risk factors for impaired nutritional status. There was an interaction between diabetes and physical function on SGA decline.

CONCLUSIONS

Nutritional status deteriorated in more than one-third of the study participants during the first year of follow-up. Lower patient-reported physical function, more gastrointestinal symptoms, and current smoking were associated with decline in nutritional status.

A simple tourniquet technique for bleeding control after percutaneous hemodialysis fistula and graft interventions

Background

The purse-string suture has been widely used for bleeding control after percutaneous interventions through arteriovenous fistula (AVF) and graft (AVG), and it requires suture removal the next day. This study aimed to introduce a simple method using a tourniquet to facilitate hemostasis following AVF or AVG sheath removal after percutaneous procedures.

Methods

Data were retrospectively collected and included all the consecutive patients who received bleeding control with a tourniquet after percutaneous AVF or AVG interventions. Hemostasis was facilitated using the tourniquet technique after sheath removal.

Results

A total of 1966 patients who received the tourniquet technique for bleeding control after percutaneous AVF or AVG interventions were included. Bleeding control was successfully achieved in all patients. Regarding complications, hematoma, thrombosis, and rebleeding occurred in 57 (2.9%), 11 (0.6%), and 8 (0.4%) patients, respectively. Neither pseudoaneurysm nor infection occurred in the patients. Age, gender, pre-existing diseases (including diabetes and hypertension), procedure count, sheath size, hemodialysis access type, and canalization route were similar between patients with and without complications. The primary patency rates at 6,12, 24, and 36 months were 85.0, 64.6, 53.8, and 41.6%, respectively.

Conclusions

The tourniquet technique is an effective and safe approach for facilitating hemostasis after catheter-based percutaneous interventions of hemodialysis accesses.

Burden, access and disparities in kidney disease: chronic kidney disease hotspots and progress one step at a time

The 2019 International Society of Nephrology World Kidney Day theme is Kidney Health for Everyone Everywhere. It focuses on the uneven burden of acute kidney injury and chronic kidney disease (CKD) in different communities, identifies disparities and challenges in access to care and calls for universal health coverage for prevention and early treatment of kidney disease. This topic is fully in line with the Clinical Kidney Journal (ckj) editorial strategy for improving worldwide kidney care without leaving any community behind. Indeed, the first PubMed-recorded use of the term CKD hotspot was in ckj, where it was defined as 'countries, region[s], communities or ethnicities with higher than average incidence of CKD'. This issue of ckj contains the World Kidney Day editorial as well as contributions that illustrate two concepts: the need to validate biochemical thresholds generated in developed countries in other populations, as exemplified by Kidney Disease: Improving Global Outcomes CKD-mineral and bone disorder parameters in an African population, and the fact that some disease associations characteristic of developing countries may be described initially in developed countries, as exemplified by the association of APOL1 variants with CKD or by minimal change disease secondary to malaria, but have to be validated locally.