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

Challenges in predictive modelling of chronic kidney disease: A narrative review

The exponential rise in the burden of chronic kidney disease (CKD) worldwide has put enormous pressure on the economy. Predictive modeling of CKD can ease this burden by predicting the future disease occurrence ahead of its onset. There are various regression methods for predictive modeling based on the distribution of the outcome variable. However, the accuracy of the predictive model depends on how well the model is developed by taking into account the goodness of fit, choice of covariates, handling of covariates measured on a continuous scale, handling of categorical covariates, and number of outcome events per predictor parameter or sample size. Optimal performance of a predictive model on an independent cohort is desired. However, there are several challenges in the predictive modeling of CKD. Disease-specific methodological challenges hinder the development of a predictive model that is cost-effective and universally applicable to predict CKD onset. In this review, we discuss the advantages and challenges of various regression models available for predictive modeling and highlight those best for future CKD prediction.

Clinical profile and complications seen in the patients in the later stages of chronic kidney disease presenting to the Emergency Department in a tertiary care center in Nepal: a cross-sectional study

Introduction

Chronic kidney disease (CKD) has an estimated prevalence of 6% in Nepal, which has resulted in a huge public health and socioeconomic burden for the country. People with different stages of CKD come to the Emergency Department (ED) with various clinical features and complications, which if detected and managed early can result in a decreased need for renal replacement therapy and thus decreased medical cost.

Methods

The authors conducted a cross-sectional analysis taking nonprobability convenience sampling in the ED of a tertiary-level hospital of Nepal, after getting approval from the Institutional Review Committee and obtaining informed consent from the patient. Kruskal-Wallis test and χ 2 test of homogeneity were conducted to determine if there were differences in the continuous variables and categorical variables of three stages of CKD. Pairwise comparisons with a Bonferroni correction was done for both variables.

Result

Among 291 patients of CKD, 25 were in stage 3, 15 in stage 4, and 251 in stage 5. Significant differences between groups were found in continuous variables of SBP, pulse, temp, TLC, platelet, sodium, potassium, urea, and creatinine. Similarly, a significant difference was found for the categorical variables of hyperkalemia, hyponatremia, thrombocytopenia, leukocytosis, and high creatinine levels.

Conclusion

Patients with CKD commonly present to the ED due to electrolyte imbalances, uremia, shortness of breath, and high SBP. Hyperkalemia, thrombocytopenia are more frequently observed in stage 5 CKD, whereas the incidence of hypertension significantly increase from stage 4 onwards. Hyponatremia, on the other hand, is more prevalent in stage 3 than in the later stages.

Prevalence of undetected chronic kidney disease in high-risk middle-aged patients in primary care: a cross-sectional study

Introduction

The global health burden of chronic kidney disease (CKD) results from both the disease itself and the numerous health problems associated with it. The aim of this study was to estimate the prevalence of previously undetected CKD in middle-aged patients with risk factors for CKD. Identified patients were included in the Styrian nephrology awareness program "kidney.care 2.0" and data on their demographics, risk factors and kidney function were described.

Methods

Cross-sectional analysis of baseline data derived from the "kidney.care 2.0" study of 40-65 year old patients with at least one risk factor for CKD (hypertension, diabetes, cardiovascular disease, obesity or family history of end-stage kidney disease). Participants were considered to have previously undetected CKD if their estimated glomular filtration rate (eGFR) was less than 60 ml/min/1.73 m2 and/or albumin creatinine ratio (ACR) ≥ 30 mg/g. We calculated the prevalence of previously undetected CKD and performed multivariate analyses.

Results

A total of 749 participants were included in this analysis. The prevalence of previously undetected CKD in an at-risk population was estimated at 20.1% (95%CI: 17.1-23.6). Multivariable analysis showed age (OR 1.06, 95%CI: 1.02-1.09), diabetes mellitus (OR 1.65, 95%CI: 1.12-2.30) and obesity (OR: 1.55, 95%CI: 1.04-2.30) to be independent predictors of CKD. The majority of patients with previously undetected CKD had category A2-A3 albuminuria (121 out of 150). Most patients with previously undetected eGFR < 60 ml/min/1.73 m2 were in stage G3 (36 out of 39 patients).

Discussion

Pragmatic, targeted, risk-based screening for CKD in primary care successfully identified a significant number of middle-aged patients with previously undetected CKD and addressed the problem of these patients being overlooked for future optimized care. The intervention may slow progression to kidney failure and prevent related cardiovascular events.

The Future of Kidney Care in Low- and Middle-Income Countries: Challenges, Triumphs, and Opportunities

CKD affects about 850 million people worldwide and is projected to be the fifth leading cause of death by 2040. Individuals from low- and middle-income countries (LMICs) bear the bulk of CKD. They face challenges including lack of awareness among the general population, as well as health care providers, unique risk factors such as genetic predispositions, infectious diseases, and environmental toxins, limited availability and affordability of diagnostic tests and medications, and limited access to KRTs. The inadequate health system infrastructure, human resources, and financing mechanisms to support comprehensive and integrated kidney care worsen the situation. Overcoming these challenges needs concerted efforts toward early detection, intervention, and multidisciplinary follow-up, policy, collaboration, advocacy, and financing. To achieve this, there is need for individual governments to include kidney health among the key health priorities and build capacity toward resilient health care systems. Integrating kidney care using the roadmaps of well-established management systems for other chronic diseases, such as HIV, has the potential to expedite the widespread adoption of kidney health. The aim of this article is to provide an overview of the current state and future prospects of kidney care in LMICs, highlighting the main challenges, ongoing efforts, and opportunities for improvement. We present case studies of exemplary efforts from three continents of the world with the highest densities of LMICs and propose potential strategies for a sustainable solution.

The Renoprotective Mechanisms of Sodium-Glucose Cotransporter-2 Inhibitors (SGLT2i)-A Narrative Review

Chronic kidney disease (CKD) is a noncommunicable condition that has become a major healthcare burden across the globe, often underdiagnosed and associated with low awareness. The main cause that leads to the development of renal impairment is diabetes mellitus and, in contrast to other chronic complications such as retinopathy or neuropathy, it has been suggested that intensive glycemic control is not sufficient in preventing the development of diabetic kidney disease. Nevertheless, a novel class of antidiabetic agents, the sodium-glucose cotransporter-2 inhibitors (SGLT2i), have shown multiple renoprotective properties that range from metabolic and hemodynamic to direct renal effects, with a major impact on reducing the risk of occurrence and progression of CKD. Thus, this review aims to summarize current knowledge regarding the renoprotective mechanisms of SGLT2i and to offer a new perspective on this innovative class of antihyperglycemic drugs with proven pleiotropic beneficial effects that, after decades of no significant progress in the prevention and in delaying the decline of renal function, start a new era in the management of patients with CKD.

Cardiometabolic comorbidities and complications of obesity and chronic kidney disease (CKD)

Obesity and chronic kidney disease are two ongoing progressive clinical pandemics of major public health and clinical care significance. Because of their growing prevalence, chronic indolent course and consequent complications both these conditions place significant burden on the health care delivery system especially in developed countries like the United States. Beyond the chance coexistence of both of these conditions in the same patient based on high prevalence it is now apparent that obesity is associated with and likely has a direct causal role in the onset, progression and severity of chronic kidney disease. The causes and underlying pathophysiology of this are myriad, complicated and multi-faceted. In this review, continuing the theme of this special edition of the journal on " The Cross roads between Endocrinology and Nephrology" we review the epidemiology of obesity related chronic kidney disease (ORCKD), and its various underlying causes and pathophysiology. In addition, we delve into the consequent comorbidities and complications associated with ORCKD with particular emphasis on the cardio metabolic consequences and then review the current body of evidence for available strategies for chronic kidney disease modulation in ORCKD as well as the potential unique role of weight reduction and management strategies in its improvement and risk reduction.

Preferences of people with chronic kidney disease regarding digital health interventions that promote healthy lifestyle: qualitative systematic review with meta-ethnography

OBJECTIVES

Diet and physical activity are crucial for people with chronic kidney disease (CKD) to maintain good health. Digital health interventions can increase access to lifestyle services. However, consumers' perspectives are unclear, which may reduce the capacity to develop interventions that align with specific needs and preferences. Therefore, this review aims to synthesise the preferences of people with CKD regarding digital health interventions that promote healthy lifestyle.

DESIGN

Qualitative systematic review with meta-ethnography.

DATA SOURCES

Databases Scopus, CENTRAL, MEDLINE, CINAHL and SPORTDiscus were searched between 2000 and 2023.

ELIGIBILITY CRITERIA

Primary research papers that used qualitative exploration methods to explore the preferences of adults with CKD (≥18 years) regarding digital health interventions that promoted diet, physical activity or a combination of these health behaviours.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened title, abstract and full text. Discrepancies were resolved by a third reviewer. Consumers' quotes were extracted verbatim and synthesised into higher-order themes and subthemes.

RESULTS

Database search yielded 5761 records. One record was identified following communication with a primary author. 15 papers were included. These papers comprised 197 consumers (mean age 51.0±7.2), including 83 people with CKD 1-5; 61 kidney transplant recipients; 53 people on dialysis. Sex was reported in 182 people, including 53% male. Five themes were generated regarding consumers' preferences for digital lifestyle interventions. These included simple instruction and engaging design; individualised interventions; virtual communities of care; education and action plans; and timely reminders and automated behavioural monitoring.

CONCLUSION

Digital health interventions were considered an important mechanism to access lifestyle services. Consumers' preferences are important to ensure future interventions are tailored to specific needs and goals. Future research may consider applying the conceptual framework of consumers' preferences in this review to develop and evaluate the effect of a digital lifestyle intervention on health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42023411511.

Digital Health Support: Current Status and Future Development for Enhancing Dialysis Patient Care and Empowering Patients

Chronic kidney disease poses a growing global health concern, as an increasing number of patients progress to end-stage kidney disease requiring kidney replacement therapy, presenting various challenges including shortage of care givers and cost-related issues. In this narrative essay, we explore innovative strategies based on in-depth literature analysis that may help healthcare systems face these challenges, with a focus on digital health technologies (DHTs), to enhance removal and ensure better control of broader spectrum of uremic toxins, to optimize resources, improve care and outcomes, and empower patients. Therefore, alternative strategies, such as self-care dialysis, home-based dialysis with the support of teledialysis, need to be developed. Managing ESKD requires an improvement in patient management, emphasizing patient education, caregiver knowledge, and robust digital support systems. The solution involves leveraging DHTs to automate HD, implement automated algorithm-driven controlled HD, remotely monitor patients, provide health education, and enable caregivers with data-driven decision-making. These technologies, including artificial intelligence, aim to enhance care quality, reduce practice variations, and improve treatment outcomes whilst supporting personalized kidney replacement therapy. This narrative essay offers an update on currently available digital health technologies used in the management of HD patients and envisions future technologies that, through digital solutions, potentially empower patients and will more effectively support their HD treatments.

Stage 5 Chronic Kidney Disease: Epidemiological Analysis in a NorthEastern District of Italy Focusing on Access to Nephrological Care

BACKGROUND

We conducted a retrospective epidemiological study about the prevalence of stage 5 chronic kidney disease (CKD) in a high-income district, comparing some demographic characteristics and outcomes of those patients who had nephrological consultations and those who had not.

RESULTS

In a district of 400,000 adult subjects in 2020, 925 patients had an estimated glomerular filtration rate (eGFR) under 15 mL/min and CKD. In the same period, 747 (80.4%) patients were assessed by nephrologists, while 178 (19.6%) were not. Age (88 vs. 75, p < 0.0001), female gender (66.3% vs. 47%, p < 0.001), and eGFR (12 vs. 9 mL/min, p < 0.001) were significantly different in the patients assessed by a nephrologist as compared those who did not have nephrological care. Furthermore, unfollowed CKD patients had a significantly higher death rate, 83.1% versus 14.3% (p < 0.0001).

CONCLUSIONS

About 20% of ESKD patients did not receive a nephrologist consultation. Older people and women were more likely not to be referred to nephrology clinics. Unfollowed patients with stage 5 CKD had a significantly higher death rate.

Kidney-specific methylation patterns correlate with kidney function and are lost upon kidney disease progression

BACKGROUND

Chronological and biological age correlate with DNA methylation levels at specific sites in the genome. Linear combinations of multiple methylation sites, termed epigenetic clocks, can inform us the chronological age and predict multiple health-related outcomes. However, why some sites correlating with lifespan, healthspan, or specific medical conditions remain poorly understood. Kidney fibrosis is the common pathway for chronic kidney disease, which affects 10% of European and US populations.

RESULTS

Here we identify epigenetic clocks and methylation sites that correlate with kidney function. Moreover, we identify methylation sites that have a unique methylation signature in the kidney. Methylation levels in majority of these sites correlate with kidney state and function. When kidney function deteriorates, all of these sites regress toward the common methylation pattern observed in other tissues. Interestingly, while the majority of sites are less methylated in the kidney and become more methylated with loss of function, a fraction of the sites are highly methylated in the kidney and become less methylated when kidney function declines. These methylation sites are enriched for specific transcription-factor binding sites. In a large subset of sites, changes in methylation patterns are accompanied by changes in gene expression in kidneys of chronic kidney disease patients.

CONCLUSIONS

These results support the information theory of aging, and the hypothesis that the unique tissue identity, as captured by methylation patterns, is lost as tissue function declines. However, this information loss is not random, but guided toward a baseline that is dependent on the genomic loci.

SIGNIFICANCE STATEMENT

DNA methylation at specific sites accurately reflects chronological and biological age. We identify sites that have a unique methylation pattern in the kidney. Methylation levels in the majority of these sites correlate with kidney state and function. Moreover, when kidney function deteriorates, all of these sites regress toward the common methylation pattern observed in other tissues. Thus, the unique methylation signature of the kidney is degraded, and epigenetic information is lost, when kidney disease progresses. These methylation sites are enriched for specific and methylation-sensitive transcription-factor binding sites, and associated genes show disease-dependent changes in expression. These results support the information theory of aging, and the hypothesis that the unique tissue identity, as captured by methylation patterns, is lost as tissue function declines.

Conservative Management in End-Stage Kidney Disease between the Dialysis Myth and Neglected Evidence-Based Medicine

In the last few decades, the aging of the general population has significantly increased the number of elderly patients with end-stage kidney disease (ESKD) who require renal replacement therapy. ESKD elders are often frail and highly comorbid with social issues and seem to not benefit from dialysis in terms of survival and quality of life. Conservative management (CM) could represent a valid treatment option, allowing them to live for months to years with a modest impact on their habits. Despite these possible advantages, CM remains underused due to the myth of dialysis as the only effective treatment option for all ESKD patients regardless of its impact on quality of life and survival. Both CM and dialysis remain valid alternatives in the management of ESKD. However, assessing comorbidities, disabilities, and social context should drive the choice of the best possible treatment for ESKD, while in elderly patients with short life expectancies, referring them to palliative care seems the most reasonable choice.

Pharmacokinetics of Antibacterial Agents in the Elderly: The Body of Evidence

Infections are important factors contributing to the morbidity and mortality among elderly patients. High rates of consumption of antimicrobial agents by the elderly may result in increased risk of toxic reactions, deteriorating functions of various organs and systems and leading to the prolongation of hospital stay, admission to the intensive care unit, disability, and lethal outcome. Both safety and efficacy of antibiotics are determined by the values of their plasma concentrations, widely affected by physiologic and pathologic age-related changes specific for the elderly population. Drug absorption, distribution, metabolism, and excretion are altered in different extents depending on functional and morphological changes in the cardiovascular system, gastrointestinal tract, liver, and kidneys. Water and fat content, skeletal muscle mass, nutritional status, use of concomitant drugs are other determinants of pharmacokinetics changes observed in the elderly. The choice of a proper dosing regimen is essential to provide effective and safe antibiotic therapy in terms of attainment of certain pharmacodynamic targets. The objective of this review is to perform a structure of evidence on the age-related changes contributing to the alteration of pharmacokinetic parameters in the elderly.