Blood pressure lowering for kidney transplant recipients: systematic review with network meta-analysis

OBJECTIVE

Hypertension affects 50-90% of kidney transplant recipients and is associated with cardiovascular disease and graft loss. We aimed to evaluate the comparative benefits and harms of blood pressure lowering agents in people with a functioning kidney transplant.

METHODS

We conducted a systematic review with network meta-analysis of randomized controlled trials (RCTs). We searched MEDLINE, Embase, and CENTRAL through to October 2023. RCTs evaluating blood pressure lowering agents administered for at least 2 weeks in people with a functioning kidney transplant with and without preexisting hypertension were eligible. Two reviewers independently extracted data. The primary outcome was graft loss. Treatment effects were estimated using random effects network meta-analysis, with treatment effects expressed as an odds ratio (OR) for binary outcomes and mean difference (MD) for continuous outcomes together with their 95% confidence interval (CI). Confidence in the evidence was assessed using GRADE for network meta-analysis.

RESULTS

Ninety-four studies (7547 adults) were included. Two studies were conducted in children. No blood pressure-lowering agent reduced the risk of graft loss, withdrawal because of adverse events, death, cardiovascular or kidney outcomes compared with placebo/other drug class. Angiotensin-converting enzyme inhibitors and angiotensin receptor blocker therapy may incur greater odds of hyperkalemia compared with calcium channel blockers [odds ratio (OR) 5.48, 95% confidence interval (CI) 2.47-12.16; and OR 8.67, 95% CI 2.65-28.36; low certainty evidence, respectively).

CONCLUSION

The evidentiary basis for the comparative benefits and safety of blood pressure lowering agents in people with a functioning kidney transplant is limited to guide treatment decision-making.

Oral manifestations after vaccinations: A systematic review of observational studies

OBJECTIVE

This study aimed to assess the prevalence and types of oral adverse events following immunization (AEFIs) in people who received at least one dose of any type of vaccine.

MATERIALS AND METHODS

We conducted a bibliographic search about oral AEFIs in MEDLINE, Embase, PubMed, and Ovid from database inception to November 07, 2022. Risk of bias was assessed using the MURAD or the Quality In Prognosis Studies tools. Random-effects proportional meta-analysis was applied.

RESULTS

A total of 119 studies involving 343 people were eligible. These reported AEFIs occurred following administration of the coronavirus disease 2019 vaccine, anti-influenza vaccine, hepatitis B vaccine, and anti-smallpox vaccine. The most common to be affected in vaccinated people were buccal mucosa (63.1%; 95% confidence interval (CI) 33.4-88.2) and lips (55.7%; 95% CI, 41.1-69.8). The most prevalent oral AEFIs were ulceration (55.2%; 95% CI 24.4-84.0), swelling (65.2%; 95% CI 34.9-89.8), and burning sensation (18.3%; 95% CI 7.9-31.8).

CONCLUSIONS

The mechanisms underlying oral AEFIs should be further investigated to promptly recognize oral manifestations and provide optimal management for people undergoing vaccination.

Actioning the findings of hard endpoint clinical trials as they emerge in the realm of chronic kidney disease care: a review and a call to action

Fewer than half of patients treated with hemodialysis survive 5 years. Multiple therapeutics are used to address the complications of advanced chronic kidney disease but most have not been found to improve clinical outcomes. Clinical trials of treatment innovations for chronic kidney diseases and dialysis care have been suboptimal in number and quality. Recent trials are changing this trend. Practice and policy change when new evidence emerges remains frequently impeded by resource and organizational constraints and accordingly, clinical practice guidelines are updated years or decades after definitive evidence is produced. Ultimately, practice change in health systems is slow, leading to impaired uptake of effective medical interventions and lower value healthcare, although innovations in rapid guideline production are emerging. What can be done to ensure that conclusive evidence is taken up in practice, policy and healthcare funding? We use the example of the recently published hard endpoint study "Comparison of high-dose HDF with high-flux HD" (CONVINCE) (hemodiafiltration versus hemodialysis), to explain how a new trial can impact on medical knowledge and change in practices. We (i) assess how the trial can be placed in the context of the totality of the evidence, (ii) define whether or not further trials of convective dialysis therapies are still needed and (iii) examine whether the evidence for convective therapies is now ready to inform practice, policy and funding change. When looking at CONVINCE in the context of the totality of evidence, we show that it addresses dialysis quality improvement priorities and is consistent with other trials evaluating convective dialysis therapies, and that the evidence for convective dialysis therapies is now definitive. Once updated evidence for cost-effectiveness in specific healthcare settings and patient-reported outcomes become available, we should therefore determine whether or not clinical practice guidelines should recommend uptake of convective dialysis therapies routinely, and move on to evaluating other treatments.

Vitamin D Therapy in Adults With CKD: A Systematic Review and Meta-analysis

RATIONALE & OBJECTIVE

Vitamin D is widely used to manage chronic kidney disease-mineral and bone disorder (CKD-MBD). We evaluated the effects of vitamin D therapy on mortality, cardiovascular, bone, and kidney outcomes in adults with CKD.

STUDY DESIGN

Systematic review of randomized controlled trials (RCT) with highly sensitive searching of MEDLINE, Embase, and CENTRAL, through February 25, 2023.

SETTING & STUDY POPULATIONS

Adults with stage 3, 4, or 5 CKD, including kidney failure treated with dialysis. Recipients of a kidney transplant were excluded.

SELECTION CRITERIA FOR STUDIES

RCTs with≥3 months of follow-up evaluating a vitamin D compound.

DATA EXTRACTION

Data were extracted independently by three investigators.

ANALYTICAL APPROACH

Treatment estimates were summarized using random effects meta-analysis. Primary review endpoints were all-cause death, cardiovascular death, and fracture. Secondary outcomes were major adverse cardiovascular events, hospitalization, bone mineral density, parathyroidectomy, progression to kidney failure, proteinuria, estimated glomerular filtration rate, hypercalcemia, hyperphosphatemia, biochemical markers of CKD-MBD, and various intermediate outcome measures of cardiovascular disease. Risk of bias was assessed using the Cochrane Risk of Bias (RoB) 2 tool. Evidence certainty was adjudicated using GRADE.

RESULTS

Overall, 128 studies involving 11,270 participants were included. Compared with placebo, vitamin D therapy probably had no effect on all-cause death (relative risk [RR], 1.04; 95% CI, 0.84-1.24); and uncertain effects on fracture (RR, 0.68; 95% CI, 0.37-1.23) and cardiovascular death (RR, 0.73; 95% CI, 0.31-1.71). Compared with placebo, vitamin D therapy lowered serum parathyroid hormone and alkaline phosphatase, but increased serum calcium.

LIMITATIONS

Data were limited by trials with short-term follow-up periods, small sample size, and the suboptimal quality.

CONCLUSIONS

Vitamin D therapy did not reduce the risk of all-cause death in people with CKD. Effects on fracture and cardiovascular and kidney outcomes were uncertain.

TRIAL REGISTRATION

Registered at PROSPERO with study number CRD42017057691.

PLAIN-LANGUAGE SUMMARY

Chronic kidney disease (CKD) is associated with increased risk of death, cardiovascular disease, and fractures. This excess risk is thought to be related to changes in bone and mineral metabolism, leading to the development of CKD-mineral and bone disorder (CKD-MBD) which is characterized by vascular calcification and reduced bone quality. Vitamin D is commonly used in the treatment of this condition. We reviewed randomized controlled trials examining the effect of vitamin D therapy in CKD. We found that vitamin D therapy affects serum biomarkers, including an increase in serum calcium. However, it probably has no effect on risk of all-cause death in CKD, and the effects on other clinical bone, cardiovascular, and kidney outcomes are uncertain.

Effect of Hemodiafiltration or Hemodialysis on Mortality in Kidney Failure

BACKGROUND

Several studies have suggested that patients with kidney failure may benefit from high-dose hemodiafiltration as compared with standard hemodialysis. However, given the limitations of the various published studies, additional data are needed.

METHODS

We conducted a pragmatic, multinational, randomized, controlled trial involving patients with kidney failure who had received high-flux hemodialysis for at least 3 months. All the patients were deemed to be candidates for a convection volume of at least 23 liters per session (as required for high-dose hemodiafiltration) and were able to complete patient-reported outcome assessments. The patients were assigned to receive high-dose hemodiafiltration or continuation of conventional high-flux hemodialysis. The primary outcome was death from any cause. Key secondary outcomes were cause-specific death, a composite of fatal or nonfatal cardiovascular events, kidney transplantation, and recurrent all-cause or infection-related hospitalizations.

RESULTS

A total of 1360 patients underwent randomization: 683 to receive high-dose hemodiafiltration and 677 to receive high-flux hemodialysis. The median follow-up was 30 months (interquartile range, 27 to 38). The mean convection volume during the trial in the hemodiafiltration group was 25.3 liters per session. Death from any cause occurred in 118 patients (17.3%) in the hemodiafiltration group and in 148 patients (21.9%) in the hemodialysis group (hazard ratio, 0.77; 95% confidence interval, 0.65 to 0.93).

CONCLUSIONS

In patients with kidney failure resulting in kidney-replacement therapy, the use of high-dose hemodiafiltration resulted in a lower risk of death from any cause than conventional high-flux hemodialysis. (Funded by the European Commission Research and Innovation; CONVINCE Dutch Trial Register number, NTR7138.).

Physical performance tasks were linked to the PROMIS physical function metric in patients undergoing hemodialysis

OBJECTIVES

To investigate whether a multi-item performance outcome measure, the physical performance test (PPT), can be calibrated to a common scale with patient-reported outcome measures, using the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) metric.

STUDY DESIGN AND SETTING

We analyzed baseline data (N = 1,113) from the CONVINCE study, an international trial in end-stage kidney disease patients comparing high-dose hemodiafiltration with high-flux hemodialysis. Assumptions of item response theory (IRT) modelling were investigated for the combined set of the nine-item PPT and a four-item PROMIS PF short form (PROMIS-PF4a). We applied unidimensional IRT linking for calibrating the PPT to the PROMIS PF metric.

RESULTS

Although some evidence for multidimensionality was found, classical test statistics (Cronbach's Alpha = 0.93), Mokken (Loevinger's H = 0.50), and bifactor analysis (explained common variance = 0.65) indicated that PPT and PROMIS-PF4a items can be used to assess a common PF construct. On the group level, the agreement between PROMIS-PF4a and linked PPT scores was stable across several subsamples. On the individual level, scores differed considerably.

CONCLUSION

We found preliminary evidence that the PPT can be linked to the PROMIS PF metric in hemodialysis patients, enabling group comparisons across patient-reported outcome and performance outcome measures. Alternative linking methods should be applied in future studies using a more comprehensive PROMIS PF item set.

Clinical outcomes associated with drugs for obesity and overweight: A systematic review and network meta-analysis of randomized controlled trials

AIM

To compare the benefits and harms of drugs approved for weight management in adults with obesity or overweight.

MATERIALS AND METHODS

We performed a systematic review of drugs approved for treating obesity and overweight. We searched MEDLINE, Embase and CENTRAL through 26 February 2023. Random-effects network meta-analysis was applied.

RESULTS

A total of 168 trials (97 938 patients) were included. There was no evidence that drugs approved for weight management had different associations with cardiovascular death (69 trials, 59 037 participants). Naltrexone/bupropion was associated with lower cardiovascular mortality than placebo (odds ratio [OR], 0.62 [95% CI: 0.39, 0.99]; low certainty evidence). All drugs were associated with greater weight loss at 12 months than placebo (33 trials, 37 616 participants), mainly semaglutide (mean difference [MD], -9.02 kg [95% CI: -10.42, -7.63]; moderate certainty) and phentermine/topiramate (MD, -8.10 kg [95% CI: -10.14, -6.05]; high certainty); and with greater waist circumference reduction at 12 months than placebo (24 trials, 35 733 participants), mainly semaglutide (MD, -7.84 cm [95% CI: -9.34, -6.34]; moderate certainty) and phentermine/topiramate (MD, -6.20 cm [95% CI: -7.46, -4.94]; high certainty). Semaglutide and phentermine/topiramate were associated with lower or no difference in the odds of treatment withdrawal compared with all other drugs (87 trials, 70 860 participants).

CONCLUSIONS

Among adults with obesity or overweight, semaglutide and phentermine/topiramate were associated with greater body weight loss and waist circumference reduction at 12 months than all other drugs, and lower or no significant difference in risks of withdrawal. There was no evidence that drugs approved for weight management had different associations with cardiovascular death.

Residual Renal Phosphate Clearance in Patients Receiving Hemodialysis or Hemodiafiltration

OBJECTIVES

Substantial levels of residual renal clearance and urine output may occur in patients treated with hemodialysis or hemodiafiltration. However, the relationships among residual renal urea, creatinine, and phosphate clearances, respectively, and between clearances and urine volume have not been well described.

METHODS

We performed a prospective, cross-sectional study which enrolled hemodialysis and hemodiafiltration patients with a urine volume of >100 mL/day, in whom at least 2 residual renal clearances were obtained over a 6-month observation period. Urine was collected for 24 hours prior to the midweek treatment session and concentrations of urea, creatinine, and phosphate were measured.

RESULTS

Thirty-eight patients (24 men, 14 women) with a mean age of 70.4 ± 12.4 (SD) years were included in this analysis. All patients were dialyzed 3 times per week with mean treatment duration of 243 ± 7.89 minutes. Twenty patients were undergoing hemodiafiltration and 18 patients high-flux hemodialysis. In total, 102 dialysis sessions, of which 52 were hemodiafiltration, and urine collections were analyzed. Mean urine volume was 457 ± 254 mL per 24 hours. Residual renal clearance rates of urea (Kr Urea), creatinine (Kr Cr), and phosphate (Kr Phos) were 1.60 ± 0.979, 4.69 ± 3.79, and 1.98 ± 1.36 mL/minute, respectively. Mean ratios of Kr Cr/Kr Urea, Kr Phos/Kr Urea, and Kr Phos/Kr Cr were 2.83 ± 1.21, 1.23 ± 0.387, and 0.477 ± 0.185, respectively. There was a modest correlation between Kr Phos and daily urine volume (r = 0.605, P = .001).

CONCLUSIONS

In maintenance hemodialysis and hemodiafiltration patients, residual renal phosphate clearance is approximately 23% higher than residual renal urea clearance. Urine volume is a modestly accurate surrogate for estimating residual renal phosphate clearance, but only when urine volume is <300 mL/day.

Perspectives and experiences of self-monitoring of blood pressure among patients with hypertension: a systematic review of qualitative studies

BACKGROUND

Self-monitoring of blood pressure is a key strategy in managing hypertension but may be challenging and burdensome for patients. The aim of the study was to describe the perspectives and experiences of self-monitoring of blood pressure in patients with hypertension.

METHODS

MEDLINE, Embase, PsycINFO, CINAHL were searched from database inception to March 2022. We used thematic synthesis to analyze the data.

RESULTS

Thirty-five studies involving 872 patients aged 18-95 years were included. Four themes were identified: enabling autonomy and empowerment of own health (allowing access to comprehensive and accurate data, bolstering motivation for lifestyle changes, encouraging diligence in medication taking, gaining interest in self-management, and increasing awareness of health status); providing reassurance and convenience (instilling a sense of security, readiness for troubleshooting, and reducing the frequency of clinical appointments); triggering confusion and stress (anxiety and panic over "bad" numbers, constant reminder of illness identity, disregarded by clinicians, lack of confidence in interpreting and responding to results, redundancy of continuous monitoring, and uncertainties around targets and frequency of measures, concerns of unreliability); financial and operational burden of device (vulnerability preventing use, or unsustainable cost).

CONCLUSIONS

Inadequate knowledge about the benefits of lowering blood pressure, home blood pressure monitoring, blood pressure goals, and interpretation of blood pressure values, limited access to home blood pressure monitoring devices, and psychological burden with home blood pressure monitoring limit home blood pressure monitoring.

Immunosuppression therapy for idiopathic membranous nephropathy: systematic review with network meta-analysis

BACKGROUND

Idiopathic membranous nephropathy is a common cause of nephrotic syndrome in adults. The Kidney Disease Improving Global Outcomes guidelines recommend rituximab or cyclophosphamide and steroids, or calcineurin inhibitor-based therapy. However, there have been few or no head-to-head comparisons of the relative efficacy and safety of different immunosuppression regimens. We conducted a network meta-analysis to evaluate the comparative efficacy and safety of available immunosuppression strategies compared to cyclophosphamide in adults with idiopathic membranous nephropathy.

METHODS

We performed a systematic search of MEDLINE, Embase and CENTRAL for randomized controlled trials in the treatment of adults with idiopathic membranous nephropathy. The primary outcome was complete remission. Secondary outcomes were kidney failure, partial remission, estimated glomerular filtration rate, doubling of serum creatinine, proteinuria, serious adverse events, discontinuation of treatment, serious infection and bone marrow suppression.

RESULTS

Cyclophosphamide had uncertain effects on inducing complete remission when compared to rituximab (OR 0.35, CI 0.10-1.24, low certainty evidence), mycophenolate mofetil (OR 1.81, CI 0.69-4.71, low certainty), calcineurin inhibitor (OR 1.26, CI 0.61-2.63, low certainty) or steroid monotherapy (OR 2.31, CI 0.62-8.52, low certainty). Cyclophosphamide had a higher probability of inducing complete remission when compared to calcineurin inhibitor plus rituximab (OR 4.45, CI 1.04-19.10, low certainty). Compared to other immunosuppression strategies, there was limited evidence that cyclophosphamide had different effects on other pre-specified outcomes.

CONCLUSIONS

The comparative effectiveness and safety of immunosuppression strategies compared to cyclophosphamide is uncertain in adults with idiopathic membranous nephropathy.

CONVINCE in the context of existing evidence on haemodiafiltration

Haemodiafiltration (HDF) provides a greater removal of larger solutes and protein-bound compounds than conventional high-flux haemodialysis (HD). There are indications that the patients receiving the highest convection volumes of HDF result in an improved survival compared with HD. However, the comparative efficacy of HDF vs HD remains unproven. Here we provide a comparative account of the methodology and aims of ‘the comparison of high-dose HDF with high-flux HD’ (CONVINCE) study in the context of the totality of evidence and how this study will contribute to reaching a higher level of certainty regarding the comparative efficacy of HDF vs HD in people with end-stage kidney disease (ESKD).

Perspectives of patients, family members, health professionals and the public on the impact of COVID-19 on mental health

BACKGROUND

The coronavirus (COVID-19) pandemic has seen a global surge in anxiety, depression, post-traumatic stress disorder (PTSD), and stress.

AIMS

This study aimed to describe the perspectives of patients with COVID-19, their family, health professionals, and the general public on the impact of COVID-19 on mental health.

METHODS

A secondary thematic analysis was conducted using data from the COVID-19 COS project. We extracted data on the perceived causes and impact of COVID-19 on mental health from an international survey and seven online consensus workshops.

RESULTS

We identified four themes (with subthemes in parenthesis): anxiety amidst uncertainty (always on high alert, ebb and flow of recovery); anguish of a threatened future (intense frustration of a changed normality, facing loss of livelihood, trauma of ventilation, a troubling prognosis, confronting death); bearing responsibility for transmission (fear of spreading COVID-19 in public; overwhelming guilt of infecting a loved one); and suffering in isolation (severe solitude of quarantine, sick and alone, separation exacerbating grief).

CONCLUSION

We found that the unpredictability of COVID-19, the fear of long-term health consequences, burden of guilt, and suffering in isolation profoundly impacted mental health. Clinical and public health interventions are needed to manage the psychological consequences arising from this pandemic.

Healthy Lifestyle and Mortality Among Adults Receiving Hemodialysis: The DIET-HD Study

RATIONALE & OBJECTIVE

A healthy lifestyle promotes cardiovascular health and reduces cardiac-related mortality in the general population but its benefits for people receiving maintenance hemodialysis are uncertain.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

5,483 of 9,757 consecutive adults receiving maintenance hemodialysis (January 2014 to June 2017, median dialysis vintage: 3.6 yrs) in a multinational private dialysis network and with complete lifestyle data.

EXPOSURES

Based on the American Heart Association's recommendations for cardiovascular prevention, a modified healthy lifestyle score was the sum of four components addressing use of smoking tobacco, physical activity, diet, and control of systolic blood pressure.

OUTCOMES

Cardiovascular and all-cause mortality.

ANALYTICAL APPROACH

Adjusted proportional hazards (aHRs) regression analyses with country as a random effect to estimate the associations between lifestyle score (low [0-2 points] as the referent, medium [3-5], and high [6-8]) and mortality. Associations were expressed as aHRs with 95% confidence intervals (CIs).

RESULTS

During a median of 3.8 years (17,451 person-years in total), there were 2,163 deaths, of which 826 were related to cardiovascular disease. Compared to patients with a low lifestyle score, the aHRs (95% CIs) for all-cause mortality among those with medium and high lifestyle scores were 0.75 (0.65-0.85) and 0.64 (0.54-0.76), respectively. Compared to patients with a low lifestyle score, the aHRs (95% CIs) for cardiovascular mortality among those with medium and high lifestyle scores were 0.73 (0.59-0.91) and 0.65 (0.49-0.85), respectively.

LIMITATIONS

Self-reported lifestyle, data-driven approach.

CONCLUSIONS

A healthier lifestyle is associated with lower all-cause and cardiovascular mortality among patients receiving maintenance hemodialysis.

Establishing a core outcome measure for pain in patients with autosomal dominant polycystic kidney disease: a consensus workshop report

Background

Pain is the highest prioritized patient-reported outcome in people with autosomal dominant polycystic kidney disease (ADPKD) but remains infrequently and inconsistently measured in clinical trials and poorly managed in clinical settings. A recently completed systematic review of pain in ADPKD identified 26 different outcome measures. None of these measures were considered appropriate as a core outcome measure due to the lack of patient-important dimensions, inadequate content, relatively long duration of completion time and limited evidence to support psychometric robustness.

Methods

We convened an international Standardized Outcomes in Nephrology–Polycystic Kidney Disease consensus workshop involving 21 patients/caregivers and 40 health professionals (clinicians, nurses, researchers, policy makers and industry representatives) from 18 countries to discuss the identification or development of a core outcome measure for pain.

Results

Four themes were identified highlighting fundamental issues for the measurement of pain in ADPKD: distressing and disrupting life participation; variability and ambiguity in defining pain; stigma, frustration and adaptation to pain; and ensuring validity and feasibility of pain measures.

Conclusions

Existing measures were found to be insufficient in capturing pain as a core outcome and there was consensus on the need for a new validated measure that is simple, succinct and addresses the impact of pain on life participation. This measure will facilitate the appropriate prioritization of pain in all trials and guide clinical decision making in people with ADPKD.

Patient-reported outcome measures for pain in autosomal dominant polycystic kidney disease: A systematic review

Pain is a common symptom in people with autosomal dominant polycystic kidney disease (ADPKD), but it is assessed and reported inconsistently in research, and the validity of the measures remain uncertain. The aim of this study was to identify the characteristics, content, and psychometric properties of measures for pain used in ADPKD. We conducted a systematic review including all trials and observational studies that reported pain in people with ADPKD. Items from all measures were categorized into content and measurement dimensions of pain. We assessed the general characteristics and psychometric properties of all measures. 118 studies, we identified 26 measures: 12 (46%) measures were developed for a non-ADPKD population, 1 (4%) for chronic kidney disease, 2 (8%) for polycystic liver disease and 11 (42%) specifically for ADPKD. Ten anatomical sites were included, with the lower back the most common (10 measures [39%]), four measurement dimensions (intensity (23 [88%]), frequency (3 [12%]), temporality (2 [8%]), and sensory (21 [81%]), two pain types, nociceptive including visceral (15 [58%]) and somatic (5 [20%]), and neuropathic (2 [8%]), and twelve impact dimensions, where the most frequent was work (5 [31%]). The validation data for the measures were variable and only the ADPKD Impact Scale reported all psychometric domains. The measures for pain in ADPKD varied in terms of content and length, and most had not been validated in ADPKD. A standardized psychometrically robust measure that captures patient-important dimensions of pain is needed to evaluate and manage this debilitating complication of ADPKD.

Dietary intake in adults on hemodialysis compared with guideline recommendations

Background

Clinical practice guidelines of dietary management are designed to promote a balanced diet and maintain health in patients undergoing haemodialysis but they may not reflect patients’ preferences. We aimed to investigate the consistency between the dietary intake of patients on maintenance haemodialysis and guideline recommendations.

Methods

Cross-sectional analysis of the DIET-HD study, which included 6,906 adults undergoing haemodialysis in 10 European countries. Dietary intake was determined using the Global Allergy and Asthma European Network (GA²LEN) Food Frequency Questionnaire (FFQ), and compared with the European Best Practice Guidelines. Consistency with guidelines was defined as achieving the minimum daily recommended intake for energy (≥ 30 kcal/kg) and protein (≥ 1.1 g/kg), and not exceeding the maximum recommended daily intake for phosphate (≤ 1000 mg), potassium (≤ 2730 mg), sodium (≤ 2300 mg) and calcium (≤ 800 mg).

Results

Overall, patients’ dietary intakes of phosphate and potassium were infrequently consistent with guidelines (consistent in 25% and 25% of patients, respectively). Almost half of the patients reported that energy (45%) and calcium intake (53%) was consistent with the guidelines, while the recommended intake of sodium and protein was consistent in 85% and 67% of patients, respectively. Results were similar across all participating countries. Intake was consistent with all six guideline recommendations in only 1% of patients.

Conclusion

Patients on maintenance haemodialysis usually have a dietary intake which is inconsistent with current recommendations, especially for phosphate and potassium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40620-020-00962-3.

Sodium-glucose cotransporter protein-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists for type 2 diabetes: systematic review and network meta-analysis of randomised controlled trials

OBJECTIVE

To evaluate sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists in patients with type 2 diabetes at varying cardiovascular and renal risk.

DESIGN

Network meta-analysis.

DATA SOURCES

Medline, Embase, and Cochrane CENTRAL up to 11 August 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials comparing SGLT-2 inhibitors or GLP-1 receptor agonists with placebo, standard care, or other glucose lowering treatment in adults with type 2 diabetes with follow up of 24 weeks or longer. Studies were screened independently by two reviewers for eligibility, extracted data, and assessed risk of bias.

MAIN OUTCOME MEASURES

Frequentist random effects network meta-analysis was carried out and GRADE (grading of recommendations assessment, development, and evaluation) used to assess evidence certainty. Results included estimated absolute effects of treatment per 1000 patients treated for five years for patients at very low risk (no cardiovascular risk factors), low risk (three or more cardiovascular risk factors), moderate risk (cardiovascular disease), high risk (chronic kidney disease), and very high risk (cardiovascular disease and kidney disease). A guideline panel provided oversight of the systematic review.

RESULTS

764 trials including 421 346 patients proved eligible. All results refer to the addition of SGLT-2 inhibitors and GLP-1 receptor agonists to existing diabetes treatment. Both classes of drugs lowered all cause mortality, cardiovascular mortality, non-fatal myocardial infarction, and kidney failure (high certainty evidence). Notable differences were found between the two agents: SGLT-2 inhibitors reduced admission to hospital for heart failure more than GLP-1 receptor agonists, and GLP-1 receptor agonists reduced non-fatal stroke more than SGLT-2 inhibitors (which appeared to have no effect). SGLT-2 inhibitors caused genital infection (high certainty), whereas GLP-1 receptor agonists might cause severe gastrointestinal events (low certainty). Low certainty evidence suggested that SGLT-2 inhibitors and GLP-1 receptor agonists might lower body weight. Little or no evidence was found for the effect of SGLT-2 inhibitors or GLP-1 receptor agonists on limb amputation, blindness, eye disease, neuropathic pain, or health related quality of life. The absolute benefits of these drugs vary substantially across patients from low to very high risk of cardiovascular and renal outcomes (eg, SGLT-2 inhibitors resulted in 3 to 40 fewer deaths in 1000 patients over five years; see interactive decision support tool (https://magicevidence.org/match-it/200820dist/#!/) for all outcomes.

CONCLUSIONS

In patients with type 2 diabetes, SGLT-2 inhibitors and GLP-1 receptor agonists reduced cardiovascular and renal outcomes, with some differences in benefits and harms. Absolute benefits are determined by individual risk profiles of patients, with clear implications for clinical practice, as reflected in the BMJ Rapid Recommendations directly informed by this systematic review.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019153180.

Recruitment and retention in clinical trials in chronic kidney disease: report from national workshops with patients, caregivers and health professionals

BACKGROUND

Slow recruitment and poor retention jeopardize the reliability and statistical power of clinical trials, delaying access to effective interventions and increasing costs, as commonly observed in nephrology trials. Involving patients in trial design, recruitment and retention is infrequent but potentially transformational.

METHODS

We conducted three workshops involving 105 patients/caregivers and 43 health professionals discussing patient recruitment and retention in clinical trials in chronic kidney disease.

RESULTS

We identified four themes. 'Navigating the unknown'-patients described being unaware of the research question, confused by technical terms, sceptical about findings and feared the risk of harm. 'Wary of added burden'-patients voiced reluctance to attend additional appointments, were unsure of the commitment required or at times felt too unwell and without capacity to participate. 'Disillusioned and disconnected'-some patients felt they were taken for granted, particularly if they did not receive trial results. Participants believed there was no culture of trial participation in kidney disease and an overall lack of awareness about opportunities to participate. To improve recruitment and retention, participants addressed 'Building motivation and interest'.

CONCLUSIONS

Investigators should establish research consciousness from the time of diagnosis, consider optimal timing for approaching patients, provide comprehensive information in an accessible manner, emphasize current and future relevance to them and their illness, involve trusted clinicians in recruitment and minimize the burden of trial participation. Participation in clinical trials was seen as an opportunity for people to give back to the health system and for future people in their predicament.

International Survey to Establish Prioritized Outcomes for Trials in People With Coronavirus Disease 2019

OBJECTIVES

There are over 4,000 trials conducted in people with coronavirus disease 2019. However, the variability of outcomes and the omission of patient-centered outcomes may diminish the impact of these trials on decision-making. The aim of this study was to generate a consensus-based, prioritized list of outcomes for coronavirus disease 2019 trials.

DESIGN

In an online survey conducted in English, Chinese, Italian, Portuguese, and Spanish languages, adults with coronavirus disease 2019, their family members, health professionals, and the general public rated the importance of outcomes using a 9-point Likert scale (7-9, critical importance) and completed a Best-Worst Scale to estimate relative importance. Participant comments were analyzed thematically.

SETTING

International.

SUBJECTS

Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public, and health professionals (including clinicians, policy makers, regulators, funders, and researchers).

INTERVENTIONS

None.

MEASUREMENTS

None.

MAIN RESULTS

In total, 9,289 participants from 111 countries (776 people with coronavirus disease 2019 or family members, 4,882 health professionals, and 3,631 members of the public) completed the survey. The four outcomes of highest priority for all three groups were: mortality, respiratory failure, pneumonia, and organ failure. Lung function, lung scarring, sepsis, shortness of breath, and oxygen level in the blood were common to the top 10 outcomes across all three groups (mean > 7.5, median ≥ 8, and > 70% of respondents rated the outcome as critically important). Patients/family members rated fatigue, anxiety, chest pain, muscle pain, gastrointestinal problems, and cardiovascular disease higher than health professionals. Four themes underpinned prioritization: fear of life-threatening, debilitating, and permanent consequences; addressing knowledge gaps; enabling preparedness and planning; and tolerable or infrequent outcomes.

CONCLUSIONS

Life-threatening respiratory and other organ outcomes were consistently highly prioritized by all stakeholder groups. Patients/family members gave higher priority to many patient-reported outcomes compared with health professionals.

Comparative Effectiveness of Calcimimetic Agents for Secondary Hyperparathyroidism in Adults: A Systematic Review and Network Meta-analysis

RATIONALE & OBJECTIVE

Comparative benefits and harms of calcimimetic agents used for the treatment of secondary hyperparathyroidism have not been well characterized. We sought to compare the effectiveness of 3 calcimimetic agents using published data.

STUDY DESIGN

Systematic review of randomized controlled trials and network meta-analysis.

SETTING & STUDY POPULATION

Adults with chronic kidney disease enrolled in a clinical trial of a calcimetic agent.

SEARCH STRATEGY & SOURCES

MEDLINE, EMBASE, CENTRAL (from February 7, 2013, to November 21, 2019), and a published meta-analysis.

DATA EXTRACTION

Two reviewers independently extracted the study data, assessed risk of bias, and rated evidence certainty using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

ANALYTICAL APPROACH

Frequentist network meta-analysis was conducted. The primary review outcomes were achievement of a target reduction in serum parathyroid hormone (PTH) levels and hypocalcemia. Additional outcomes were nausea, vomiting, serious adverse events, all-cause mortality, cardiovascular mortality, heart failure, and fracture.

RESULTS

36 trials (11,247 participants) were included. All except 4 trials involved dialysis patients. Median follow-up was 26 weeks (range, 1 week to 21.2 months). Compared with placebo, calcimimetic agents had higher odds of achieving target PTH levels with high or moderate certainty. Etelcalcetide had the highest odds of achieving a PTH target compared with evocalcet (OR, 4.93; 95% CI, 1.33-18.2) and cinacalcet (OR, 2.78; 95% CI, 1.19-6.67). Etelcalcetide appeared to cause more hypocalcemia than cinacalcet and evocalcet. Cinacalcet and to a lesser extent etelcalcetide appeared to cause more nausea than placebo. Differences in risk for mortality, cardiovascular end points, or fractures across calcimimetic agents could not be discerned with sufficient certainty.

LIMITATIONS

Lack of longer-term data; heterogeneous end point definitions.

CONCLUSIONS

Evidence of the benefits of calcimimetic therapy is limited to short-term assessment of a putative surrogate outcome (serum PTH). Although etelcalcetide was associated with the largest reduction in PTH levels, side-effect profiles differed across the 3 calcimimetic agents, making it not possible to identify 1 preferred agent.

Nephrology consultation and mortality in people with stage 4 chronic kidney disease: a population-based study

BACKGROUND

Guidelines recommend nephrology referral for people with advanced non-dialysis-dependent chronic kidney disease, based mostly on survival benefits seen in retrospective studies of dialysis patients, which may not be generalizable to the broader population with chronic kidney disease. We aimed to examine the association between outpatient nephrology consultation and survival in adults with stage 4 chronic kidney disease.

METHODS

We linked population-based laboratory and administrative data from 2002 to 2014 in Alberta, Canada, on adults with stage 4 chronic kidney disease (sustained estimated glomerular filtration rate ≥ 15 to < 30 mL/min/1.73 m² for > 90 d), who had never had kidney failure and had had no outpatient nephrology encounter in the 2 years preceding study entry. Participants who had never had an outpatient nephrology visit before renal replacement treatment were considered "unexposed." Participants who saw a nephrologist during follow-up were considered "unexposed" before the first outpatient nephrology visit and "exposed" thereafter. The primary outcome was all-cause mortality.

RESULTS

Of the 14 382 study participants (median follow-up 2.7 yr), 64% were aged ≥ 80 years, 35% saw a nephrologist and 66% died during follow-up. Nephrology consultation was associated with lower mortality (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.82-0.93). The association was strongest in people < 70 years (HR 0.78, 95% CI, 0.65-0.92), progressively weaker with increasing age, and absent in people ≥ 90 years (HR 1.05, 95% CI 0.88-1.25).

INTERPRETATION

The survival benefit of nephrology consultation in adults with stage 4 chronic kidney disease may be smaller than expected and appears to attenuate with increasing age. These findings should inform recommendations for nephrology referral considering the advanced age of the patient population meeting current referral criteria.

Healthy Dietary Patterns and Incidence of CKD: A Meta-Analysis of Cohort Studies

BACKGROUND AND OBJECTIVES

Whether a healthy dietary pattern may prevent the incidence of developing CKD is unknown. This study evaluated the associations between dietary patterns and the incidence of CKD in adults and children.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This systematic review and meta-analysis identified potential studies through a systematic search of MEDLINE, Embase and references from eligible studies from database inception to February 2019. Eligible studies were prospective and retrospective cohort studies including adults and children without CKD, where the primary exposure was dietary patterns. To be eligible, studies had to report on the primary outcome, incidence of CKD (eGFR<60 ml/min per 1.73 m²). Two authors independently extracted data, assessed risk of bias and evidence certainty using the Newcastle-Ottawa scale and GRADE.

RESULTS

Eighteen prospective cohort studies involving 630,108 adults (no children) with a mean follow-up of 10.4±7.4 years were eligible for analysis. Included studies had an overall low risk of bias. The evidence certainty was moderate for CKD incidence and low for eGFR decline (percentage drop from baseline or reduced by at least 3 ml/min per 1.73 m² per year) and incident albuminuria. Healthy dietary patterns typically encouraged higher intakes of vegetables, fruit, legumes, nuts, whole grains, fish and low-fat dairy, and lower intakes of red and processed meats, sodium, and sugar-sweetened beverages. A healthy dietary pattern was associated with a lower incidence of CKD (odds ratio [OR] 0.70 (95% confidence interval [95% CI], 0.60 to 0.82); I²=51%; eight studies), and incidence of albuminuria (OR 0.77, [95% CI, 0.59 to 0.99]; I²=37%); four studies). There appeared to be no significant association between healthy dietary patterns and eGFR decline (OR 0.70 [95% CI, 0.49 to 1.01], I²=49%; four studies).

CONCLUSIONS

A healthy dietary pattern may prevent CKD and albuminuria.

Systematic review with network meta-analysis: endoscopic techniques for dysplasia surveillance in inflammatory bowel disease

BACKGROUND

International guidelines recommend dysplasia surveillance in IBD.

AIM

To compare endoscopic techniques for dysplasia surveillance METHODS: We searched MEDLINE, Embase, CENTRAL for randomised trials through May 2019. We estimated odds ratios (ORs) for binary and mean differences (MDs) for continuous outcomes, using frequentist random-effects network meta-analysis. We assessed study risk of bias and appraised evidence certainty using GRADE.

RESULTS

Eighteen trials (2638 participants) were included. Standard definition white-light endoscopy (OR 0.44, 95% CI 0.26-0.73; high certainty) and i-SCAN (OR 0.47, 95% CI 0.25-0.90; moderate certainty) had lower odds of detecting neoplasia than chromoendoscopy. Fujinon intelligent colour enhancement (FICE), standard definition white-light endoscopy and i-SCAN had lower odds for this outcome than full spectrum high definition white-light endoscopy (ORs 0.02 to 0.15; low certainty). Standard definition white-light endoscopy had lower odds of detecting nonpolypoid neoplasia than full spectrum high definition white-light endoscopy, narrow band imaging, chromoendoscopy and high definition white-light endoscopy (ORs 0.01-0.14; moderate certainty). Full spectrum high definition white-light endoscopy ranked as the best technique for both outcomes (moderate certainty). Standard definition white-light endoscopy had lower odds of detecting neoplasia by target biopsy (OR 0.27, 95% CI 0.08-0.91) and had shorter procedure time (MD -14.81 minutes, 95% CI -25.03, -4.06) than chromoendoscopy (moderate certainty).

CONCLUSIONS

Chromoendoscopy, high definition white-light endoscopy, narrow band imaging, autofluorescence, FICE and full spectrum high definition white-light endoscopy may be comparable for dysplasia surveillance. Standard definition white-light endoscopy and i-SCAN probably provide lower yields for neoplasia identification. Full spectrum high definition white-light endoscopy may represent the first-line approach.

Influence of Mortality on Estimating the Risk of Kidney Failure in People with Stage 4 CKD

BACKGROUND

Most kidney failure risk calculators are based on methods that censor for death. Because mortality is high in people with severe, nondialysis-dependent CKD, censoring for death may overestimate their risk of kidney failure.

METHODS

Using 2002-2014 population-based laboratory and administrative data for adults with stage 4 CKD in Alberta, Canada, we analyzed the time to the earliest of kidney failure, death, or censoring, using methods that censor for death and methods that treat death as a competing event factoring in age, sex, diabetes, cardiovascular disease, eGFR, and albuminuria. Stage 4 CKD was defined as a sustained eGFR of 15-30 ml/min per 1.73 m².

RESULTS

Of the 30,801 participants (106,447 patient-years at risk; mean age 77 years), 18% developed kidney failure and 53% died. The observed risk of the combined end point of death or kidney failure was 64% at 5 years and 87% at 10 years. By comparison, standard risk calculators that censored for death estimated these risks to be 76% at 5 years and >100% at 7.5 years. Censoring for death increasingly overestimated the risk of kidney failure over time from 7% at 5 years to 19% at 10 years, especially in people at higher risk of death. For example, the overestimation of 5-year absolute risk ranged from 1% in a woman without diabetes, cardiovascular disease, or albuminuria and with an eGFR of 25 ml/min per 1.73 m² (9% versus 8%), to 27% in a man with diabetes, cardiovascular disease, albuminuria >300 mg/d, and an eGFR of 20 ml/min per 1.73 m² (78% versus 51%).

CONCLUSIONS

Kidney failure risk calculators should account for death as a competing risk to increase their accuracy and utility for patients and providers.

Validation of the Rainbow Model of Integrated Care Measurement Tools (RMIC-MTs) in renal care for patient and care providers

INTRODUCTION

Integrated service delivery is considered to be an essential condition for improving the management and health outcomes of people with chronic kidney disease (CKD). However, research on the assessment of integrated care by patients and care providers is hindered by the absence of brief, reliable, and valid measurement tools.

OBJECTIVE

The aim of this study was to develop survey instruments for healthcare professionals and patients based on the Rainbow Model of Integrated Care (RMIC), and to evaluate their psychometric properties.

DESIGN

The development process was based on the US Food and Drug Administration guidelines. This included item generation from systematic reviews of existing tools and expert opinion on clarity and content validity, involving renal care providers and chronic kidney patients. A cross-sectional, multi-centre design was used to test for internal consistency and construct validity.

SETTING

Outpatient clinics in a large renal network.

PARTICIPANTS

A sample of 30.788 CKD patients, and 8.914 renal care providers.

METHODS AND ANALYSIS

Both survey instruments were developed using previous qualitative work and published literature. A multidisciplinary expert panel assessed the face and content validity of both instruments and following a pilot study, the psychometric properties of both instruments were explored. Exploratory factor analysis with principal axis factoring and with promax rotation was used to assess the underlying dimensions of both instruments; Cronbach's alpha was used to determine the internal constancy reliability.

RESULTS

17.512 patients (response rate: 56.9%) and 8.849 care providers (response rate: 69.5%) responded to the questionnaires. Factor analysis of the patient questionnaire yielded three internally consistent (Cronbach's alpha > 0.7) factors: person-centeredness, clinical coordination, and professional coordination. Factor analysis of the provider questionnaire produced eight internally consistent (Cronbach's alpha > 0.7) factors: person-centeredness, community centeredness, clinical coordination, professional coordination, organisational coordination, system coordination, technical and cultural competence. As hypothesised, care coordination patient and providers scores significantly correlated with questions about quality of care, treatment involvement, reported health, clinics' organisational readiness, and external care coordination capacity.

CONCLUSION

This study provides evidence for the reliability and validity of the RMIC patient and provider questionnaires as generic tools to assess the experience with or perception of integrated renal care delivery. The instruments are recommended in future applications testing test-retest reliability, convergent and predictive validity, and responsiveness.

Dietary Patterns and Mortality in a Multinational Cohort of Adults Receiving Hemodialysis

RATIONALE & OBJECTIVE

Clinical practice guidelines for dietary intake in hemodialysis focus on individual nutrients. Little is known about associations of dietary patterns with survival. We evaluated the associations of dietary patterns with cardiovascular and all-cause mortality among adults treated by hemodialysis.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

8,110 of 9,757 consecutive adults on hemodialysis (January 2014 to June 2017) treated in a multinational private dialysis network and with analyzable dietary data.

EXPOSURES

Data-driven dietary patterns based on the GA²LEN food frequency questionnaire. Participants received a score for each identified pattern, with higher scores indicating closer resemblance of their diet to the identified pattern. Quartiles of standardized pattern scores were used as primary exposures.

OUTCOMES

Cardiovascular and all-cause mortality.

ANALYTICAL APPROACH

Principal components analysis with varimax rotation to identify common dietary patterns. Adjusted proportional hazards regression analyses with country as a random effect to estimate the associations between dietary pattern scores and mortality. Associations were expressed as adjusted HRs with 95% CIs, using the lowest quartile score as reference.

RESULTS

During a median follow-up of 2.7 years (18,666 person-years), there were 2,087 deaths (958 cardiovascular). 2 dietary patterns, "fruit and vegetable" and "Western," were identified. For the fruit and vegetable dietary pattern score, adjusted HRs, in ascending quartiles, were 0.94 (95% CI, 0.76-1.15), 0.83 (95% CI, 0.66-1.06), and 0.91 (95% CI, 0.69-1.21) for cardiovascular mortality and 0.95 (95% CI, 0.83-1.09), 0.84 (95% CI, 0.71-0.99), and 0.87 (95% CI, 0.72-1.05) for all-cause mortality. For the Western dietary pattern score, the corresponding estimates were 1.10 (95% CI, 0.90-1.35), 1.11 (95% CI, 0.87-1.41), and 1.09 (95% CI, 0.80-1.49) for cardiovascular mortality and 1.01 (95% CI, 0.88-1.16), 1.00 (95% CI, 0.85-1.18), and 1.14 (95% CI, 0.93-1.41) for all-cause mortality.

LIMITATIONS

Self-reported food frequency questionnaire, data-driven approach.

CONCLUSIONS

These findings did not confirm an association between mortality among patients receiving long-term hemodialysis and the extent to which dietary patterns were either high in fruit and vegetables or consistent with a Western diet.

Fruit and Vegetable Intake and Mortality in Adults undergoing Maintenance Hemodialysis

BACKGROUND AND OBJECTIVES

Higher fruit and vegetable intake is associated with lower cardiovascular and all-cause mortality in the general population. It is unclear whether this association occurs in patients on hemodialysis, in whom high fruit and vegetable intake is generally discouraged because of a potential risk of hyperkalemia. We aimed to evaluate the association between fruit and vegetable intake and mortality in hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Fruit and vegetable intake was ascertained by the Global Allergy and Asthma European Network food frequency questionnaire within the Dietary Intake, Death and Hospitalization in Adults with ESKD Treated with Hemodialysis study, a multinational cohort study of 9757 adults on hemodialysis, of whom 8078 (83%) had analyzable dietary data. Adjusted Cox regression analyses clustered by country were conducted to evaluate the association between tertiles of fruit and vegetable intake with all-cause, cardiovascular, and noncardiovascular mortality. Estimates were calculated as hazard ratios with 95% confidence intervals (95% CIs).

RESULTS

During a median follow up of 2.7 years (18,586 person-years), there were 2082 deaths (954 cardiovascular). The median (interquartile range) number of servings of fruit and vegetables was 8 (4-14) per week; only 4% of the study population consumed at least four servings per day as recommended in the general population. Compared with the lowest tertile of servings per week (0-5.5, median 2), the adjusted hazard ratios for the middle (5.6-10, median 8) and highest (>10, median 17) tertiles were 0.90 (95% CI, 0.81 to 1.00) and 0.80 (95% CI, 0.71 to 0.91) for all-cause mortality, 0.88 (95% CI, 0.76 to 1.02) and 0.77 (95% CI, 0.66 to 0.91) for noncardiovascular mortality and 0.95 (95% CI, 0.81 to 1.11) and 0.84 (95% CI, 0.70 to 1.00) for cardiovascular mortality, respectively.

CONCLUSIONS

Fruit and vegetable intake in the hemodialysis population is low and a higher consumption is associated with lower all-cause and noncardiovascular death.

The Long-Term Impact of Renin-Angiotensin System (RAS) Inhibition on Cardiorenal Outcomes (LIRICO): A Randomized, Controlled Trial

BACKGROUND

The comparative effectiveness of treatment with angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or their combination in people with albuminuria and cardiovascular risk factors is unclear.

METHODS

In a multicenter, randomized, open label, blinded end point trial, we evaluated the effectiveness on cardiovascular events of ACE or ARB monotherapy or combination therapy, targeting BP<130/80 in patients with moderate or severe albuminuria and diabetes or other cardiovascular risk factors. End points included a primary composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and hospitalization for cardiovascular causes and a revised end point of all-cause mortality. Additional end points included ESRD, doubling of serum creatinine, albuminuria, eGFR, BP, and adverse events.

RESULTS

Because of slow enrollment, the trial was modified and stopped 41% short of targeted enrollment of 2100 participants, corresponding to 35% power to detect a 25% reduced risk in the primary outcome. Our analysis included 1243 adults, with median follow-up of 2.7 years. Efficacy outcomes were similar between groups (ACE inhibitor versus ARB, ACE inhibitor versus combination, ARB versus combination) as were rates of serious adverse events. The rate of permanent discontinuation for ARB monotherapy (6.3%) was significantly lower than for ACE inhibitor monotherapy (15.7%) or combined therapy (18.3%).

CONCLUSIONS

Patients may tolerate ARB monotherapy better than ACE inhibitor monotherapy. However, data from this trial and similar trials, although as yet inconclusive, show no trend suggesting differences in mortality and renal outcomes with ACE inhibitors or ARBs as dual or monotherapy in patients with albuminuria and diabetes or other cardiovascular risk factors.

The Association of Mediterranean and DASH Diets with Mortality in Adults on Hemodialysis: The DIET-HD Multinational Cohort Study

Background Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets associate with lower cardiovascular and all-cause mortality in the general population, but the benefits for patients on hemodialysis are uncertain.Methods Mediterranean and DASH diet scores were derived from the GA²LEN Food Frequency Questionnaire within the DIET-HD Study, a multinational cohort study of 9757 adults on hemodialysis. We conducted adjusted Cox regression analyses clustered by country to evaluate the association between diet score tertiles and all-cause and cardiovascular mortality (the lowest tertile was the reference category).Results During the median 2.7-year follow-up, 2087 deaths (829 cardiovascular deaths) occurred. The adjusted hazard ratios (95% confidence intervals) for the middle and highest Mediterranean diet score tertiles were 1.20 (1.01 to 1.41) and 1.14 (0.90 to 1.43), respectively, for cardiovascular mortality and 1.10 (0.99 to 1.22) and 1.01 (0.88 to 1.17), respectively, for all-cause mortality. Corresponding estimates for the same DASH diet score tertiles were 1.01 (0.85 to 1.21) and 1.19 (0.99 to 1.43), respectively, for cardiovascular mortality and 1.03 (0.92 to 1.15) and 1.00 (0.89 to 1.12), respectively, for all-cause mortality. The association between DASH diet score and all-cause death was modified by age (P=0.03); adjusted hazard ratios for the middle and highest DASH diet score tertiles were 1.02 (0.81 to 1.29) and 0.70 (0.53 to 0.94), respectively, for younger patients (≤60 years old) and 1.05 (0.93 to 1.19) and 1.08 (0.95 to 1.23), respectively, for older patients.Conclusions Mediterranean and DASH diets did not associate with cardiovascular or total mortality in hemodialysis.

Depression and all-cause and cardiovascular mortality in patients on haemodialysis: a multinational cohort study

Background

Depression and early death are both common in adults with Stage 5 chronic kidney disease. Studies have shown an association between depression and total mortality, but the association between depression and cardiovascular death is less certain.

Methods

We conducted a prospective multinational cohort study involving adults who were treated with long-term haemodialysis within a single dialysis network between April and November 2010. Depression was considered present when patients reported a Beck Depression Inventory (BDI) II score ≥14 at baseline. Sensitivity analyses considered a BDI II score ≥20 to identify moderate depression. Multivariable Cox proportional hazards regression was used to assess adjusted hazards for all-cause and cardiovascular mortality at 12 months.

Results

Three thousand and eighty-six participants in the network received the BDI II questionnaire, and 2278 (73%) provided complete responses to the survey questions. Among these, 1047 (46%) reported depression. During a mean follow-up of 11 (standard deviation: 2.5) months (2096 person-years), we recorded 175 deaths, of which 66 were attributable to cardiovascular causes. Depression (BDI score ≥14) was not associated with all-cause mortality [adjusted hazard ratio: 1.26 (95% confidence interval: 0.93–1.71)] or cardiovascular mortality [0.82 (0.50–1.34)]. When a higher BDI score (BDI score ≥20) was used to identify moderate depression, depression was associated with total mortality [1.40 (1.02–1.93)] but not cardiovascular mortality [1.05 (0.63–1.77)].

Conclusions

The association between depression and cardiovascular mortality in adults with kidney failure treated with haemodialysis is uncertain. Depression is a heterogeneous disorder and may only be a risk factor for premature death when at least of moderate severity.

Person-Centered Integrated Care for Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVES

The effectiveness of person-centered integrated care strategies for CKD is uncertain. We conducted a systematic review and meta-analysis of randomized, controlled trials to assess the effect of person-centered integrated care for CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (from inception to April of 2016), and selected randomized, controlled trials of person-centered integrated care interventions with a minimum follow-up of 3 months. Random-effects meta-analysis was used to assess the effect of person-centered integrated care.

RESULTS

We included 14 eligible studies covering 4693 participants with a mean follow-up of 12 months. In moderate quality evidence, person-centered integrated care probably had no effect on all-cause mortality (relative risk [RR], 0.86; 95% confidence interval [95% CI], 0.68 to 1.08) or health-related quality of life (standardized mean difference, 0.02; 95% CI, -0.05 to 0.10). The effects on renal replacement therapy (RRT) (RR, 1.00; 95% CI, 0.65 to 1.55), serum creatinine levels (mean difference, 0.59 mg/dl; 95% CI, -0.38 to 0.36), and eGFR (mean difference, 1.51 ml/min per 1.73 m2; 95% CI, -3.25 to 6.27) were very uncertain. Quantitative analysis suggested that person-centered integrated care interventions may reduce all-cause hospitalization (RR, 0.38; 95% CI, 0.15 to 0.95) and improve BP control (RR, 1.20; 95% CI, 1.00 to 1.44), although the certainty of the evidence was very low.

CONCLUSIONS

Person-centered integrated care may have little effect on mortality or quality of life. The effects on serum creatinine, eGFR, and RRT are uncertain, although person-centered integrated care may lead to fewer hospitalizations and improved BP control.

Mesalazine for People with Diverticular Disease: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Diverticular disease treatment is limited to fibres, antibiotics, and surgery. There is conflicting evidence on mesalazine benefits and harms.

AIM

We systematically reviewed current evidence on benefits and harms of mesalazine versus all other treatments in people with diverticular disease.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, ClinicalTrials.gov for studies published to July 2018. We estimated risk ratios (RR) for dichotomous outcomes (disease remission/recurrence, acute diverticulitis in symptomatic uncomplicated diverticular disease, need for surgery/hospitalization, all-cause/disease-related mortality, adverse events), mean differences (MD) or standardized MD (SMD) for continuous outcomes (quality of life, symptoms score, time to recurrence/remission), and their 95% confidence intervals (CI) using random-effects models. We quantified heterogeneity by Chi² and I² tests. We performed subgroup analyses by disease subtype, comparator, follow-up duration, mesalazine dose, and mode of administration.

RESULTS

We identified 13 randomized trials (n=3028 participants). There was a higher likelihood of disease remission with mesalazine than controls in acute uncomplicated diverticulitis (1 trial, 81 participants, RR=2.67, 95%CI=1.05-6.79), but not in symptomatic uncomplicated diverticular disease (1 trial, 123 participants, RR=1.04, 95%CI=0.81-1.34). There was a lower likelihood of disease recurrence with mesalazine than controls in symptomatic uncomplicated diverticular disease (2 trials, 216 participants, RR=0.52, 95%CI=0.28-0.97), but not in acute uncomplicated diverticulitis (7 trials, 2196 participants, RR=0.90, 95%CI=0.61-1.33). There was no difference in the likelihood of developing acute diverticulitis in symptomatic uncomplicated diverticular disease between the two groups (3 trials, 484 participants, RR=0.26, 95%CI=0.06-1.20). There was a higher global symptoms score reduction with mesalazine than controls in symptomatic uncomplicated diverticular disease (2 trials, 326 participants, SMD=-1.01, 95%CI=-1.51,-0.52) and acute uncomplicated diverticulitis (2 trials, 153 participants, SMD=-0.56, 95%CI=-0.88,-0.24).

CONCLUSIONS

Mesalazine may reduce recurrences in symptomatic uncomplicated diverticular disease. There is uncertainty on the effect of mesalazine in achieving diverticular disease remission. Mesalazine may not prevent acute diverticulitis in symptomatic uncomplicated diverticular disease.

Dietary n-3 polyunsaturated fatty acid intake and all-cause and cardiovascular mortality in adults on hemodialysis: The DIET-HD multinational cohort study

BACKGROUND & AIMS

Patients on hemodialysis suffer from high risk of premature death, which is largely attributed to cardiovascular disease, but interventions targeting traditional cardiovascular risk factors have made little or no difference. Long chain n-3 polyunsaturated fatty acids (n-3 PUFA) are putative candidates to reduce cardiovascular disease. Diets rich in n-3 PUFA are recommended in the general population, although their role in the hemodialysis setting is uncertain. We evaluated the association between the dietary intake of n-3 PUFA and mortality for hemodialysis patients.

METHODS

The DIET-HD study is a prospective cohort study (January 2014-June 2017) in 9757 adults treated with hemodialysis in Europe and South America. Dietary n-3 PUFA intake was measured at baseline using the GA²LEN Food Frequency Questionnaire. Adjusted Cox regression analyses clustered by country were conducted to evaluate the association of dietary n-3 PUFA intake with cardiovascular and all-cause mortality.

RESULTS

During a median follow up of 2.7 years (18,666 person-years), 2087 deaths were recorded, including 829 attributable to cardiovascular causes. One third of the study participants consumed sufficient (at least 1.75 g/week) n-3 PUFA recommended for primary cardiovascular prevention, and less than 10% recommended for secondary prevention (7-14 g/week). Compared to patients with the lowest tertile of dietary n-3 PUFA intake (<0.37 g/week), the adjusted hazard ratios (95% confidence interval) for cardiovascular mortality for patients in the middle (0.37 to <1.8 g/week) and highest (≥1.8 g/week) tertiles of n-3 PUFA were 0.82 (0.69-0.98) and 1.03 (0.84-1.26), respectively. Corresponding adjusted hazard ratios for all-cause mortality were 0.96 (0.86-1.08) and 1.00 (0.88-1.13), respectively.

CONCLUSIONS

Dietary n-3 PUFA intake was not associated with cardiovascular or all-cause mortality in patients on hemodialysis. As dietary n-3 PUFA intake was low, the possibility that n-3 PUFA supplementation might mitigate cardiovascular risk has not been excluded.

Chromoendoscopy for Surveillance in Ulcerative Colitis and Crohn's Disease: A Systematic Review of Randomized Trials

BACKGROUND & AIMS

Key international guideline agencies recommend dysplasia surveillance in inflammatory bowel diseases with chromoendoscopy. We performed a systematic review of randomized trials comparing chromoendoscopy vs other endoscopic techniques for dysplasia surveillance in inflammatory bowel diseases.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for relevant studies published through September 2016. We estimated risk ratios (RRs) for dichotomous outcomes (all-cause/colorectal cancer-related mortality, time to interval cancer, patients with dysplasia, total/subtypes of dysplastic lesions, dysplasia detected by targeted biopsies, adverse events), mean differences for continuous outcomes (procedural time, costs, total/targeted biopsies), and their 95% confidence intervals (CIs) using a random-effects model. Subgroup analyses included technique compared with chromoendoscopy, type of disease, and type of dye. We estimated sensitivity and specificity of the techniques with reference to histology.

RESULTS

We identified 10 randomized trials (n = 1500 participants). There was a higher likelihood of detecting patients with dysplasia with chromoendoscopy compared with other techniques (RR, 1.37; 95% CI, 1.04-1.79). Subgroup analyses confirmed this effect only if chromoendoscopy was compared with standard-definition white-light endoscopy (RR, 2.12; 95% CI, 1.15-3.91). Chromoendoscopy required a significantly longer procedural time compared with other techniques (mean difference, 8.91 min; 95% CI, 1.37-16.45). There was no difference in the likelihood of detecting dysplastic subtypes and dysplasia by targeted biopsies between groups. Test sensitivity and specificity were similar between groups.

CONCLUSIONS

In surveillance of inflammatory bowel diseases, chromoendoscopy identifies more patients with dysplasia only when compared with standard-definition white-light endoscopy. It is associated with longer procedural time with no direct evidence of effect on preventing all-cause/cancer-specific mortality or time to interval cancer.

New approaches to trials in glomerulonephritis

Randomized controlled trials are required to reliably identify interventions to improve the outcomes for people with glomerulonephritis (GN). Unfortunately, although easier, observational studies are inherently unreliable even though the findings of both study designs agree most of the time. Currently there are ∼790 trials in GN, but suboptimal design and reporting, together with small sample sizes, mean that they may not be reliable for decision making. If the history is somewhat bleak, the future looks bright, with recent initiatives to improve the quality, size and relevance of clinical trials in nephrology, including greater patient engagement, trial networks, core outcome sets, registry-based trials and adaptive designs. Given the current state of the evidence informing the care of people with GN, disruptive technologies and pervasive culture change is required to ensure that the potential of trials to improve the health of people with this complex condition is to be realized.

Low versus high dose erythropoiesis-stimulating agents in hemodialysis patients with anemia: A randomized clinical trial

The increased risks of death and adverse events with erythropoiesis-stimulating agent (ESA) therapy targeting a higher hemoglobin level are established. It is uncertain whether the adverse effects of ESA therapy are related to dose and are mitigated when a fixed low ESA dose is used. We conducted a multicenter, prospective randomized open-label, blinded-endpoint (PROBE) trial to evaluate fixed low versus high dose ESA therapy on patient outcomes. We intended to recruit 2104 hemodialysis patients >18 years with anemia or receiving ESA treated at dialysis clinics in Italy. The intervention was fixed low (4000 IU epoetin alfa equivalent weekly) or high (18,000 IU epoetin alfa equivalent weekly) dose ESA for 12 months. Primary outcomes were serum transferrin, ferritin, albumin, C-reactive protein and ESA dose. Secondary outcomes were the composite of death or cardiovascular event, all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, cardiovascular hospitalization, and quality of life. Study recruitment was terminated after inclusion of 656 participants with convergence of ESA dose between groups during follow up. Fixed low dose ESA had uncertain effects on serum ferritin (delta of delta (DD) 3.9 ng/ml, 95% CI -85.0 to 92.8), transferrin (9.2 mg/dl, -6.3 to 24.8), transferrin saturation (3.7%, -5.0 to 12.3), serum albumin (-0.03 g/dl, -0.2 to 0.1), or C-reactive protein (-0.6 mg/l, -3.3 to 2.1). In addition, fixed dose therapy had inconclusive effects on the composite endpoint of mortality and cardiovascular events (hazard ratio [HR] 0.95, 95% CI 0.66 to 1.37), death (0.98, 0.64 to 1.52), nonfatal myocardial infarction (0.52, 0.18 to 1.52), nonfatal stroke (no events), hospital admission for cardiovascular causes (0.93, 0.50 to 1.72) or health-related quality of life. A fixed low ESA dose in hemodialysis patients has uncertain effects on serum parameters, mortality, cardiovascular events, and quality of life. Hemoglobin targets may be so entrenched in nephrology practice that a trial of ESA dose is no longer possible.

Induction and Maintenance Immunosuppression Treatment of Proliferative Lupus Nephritis: A Network Meta-analysis of Randomized Trials

BACKGROUND

Intravenous (IV) cyclophosphamide has been first-line treatment for inducing disease remission in lupus nephritis. The comparative efficacy and toxicity of newer agents such as mycophenolate mofetil (MMF) and calcineurin inhibitors are uncertain.

STUDY DESIGN

Network meta-analysis.

SETTING & POPULATION

Patients with proliferative lupus nephritis.

SELECTION CRITERIA FOR STUDIES

Randomized trials of immunosuppression to induce or maintain disease remission.

INTERVENTIONS

IV cyclophosphamide, oral cyclophosphamide, MMF, calcineurin inhibitor, plasma exchange, rituximab, or azathioprine, alone or in combination.

OUTCOMES

Complete remission, end-stage kidney disease, all-cause mortality, doubling of serum creatinine level, relapse, and adverse events.

RESULTS

53 studies involving 4,222 participants were eligible. Induction and maintenance treatments were administered for 12 (IQR, 6-84) and 25 (IQR, 12-48) months, respectively. There was no evidence of different effects between therapies on all-cause mortality, doubling of serum creatinine level, or end-stage kidney disease. Compared to IV cyclophosphamide, the most effective treatments to induce remission in moderate- to high-quality evidence were combined MMF and calcineurin inhibitor therapy, calcineurin inhibitors, and MMF (ORs were 2.69 [95% CI, 1.74-4.16], 1.86 [95% CI, 1.05-3.30], and 1.54 [95% CI, 1.04-2.30], respectively). MMF was significantly less likely than IV cyclophosphamide to cause alopecia (OR, 0.21; 95% CI, 0.12-0.36), and MMF combined with calcineurin inhibitor therapy was less likely to cause ovarian failure (OR, 0.25; 95% CI, 0.07-0.93). Regimens generally had similar odds of major infection. MMF was the most effective strategy to maintain remission.

LIMITATIONS

Outcome definitions not standardized, short duration of follow-up, and possible confounding by previous or subsequent therapy.

CONCLUSIONS

Evidence for induction therapy for lupus nephritis is inconclusive based on treatment effects on all-cause mortality, doubling of serum creatinine level, and end-stage kidney disease. MMF, calcineurin inhibitors, or their combination were most effective for inducing remission compared to IV cyclophosphamide, while conferring similar or lower treatment toxicity. MMF was the most effective maintenance therapy.

Healthy Dietary Patterns and Risk of Mortality and ESRD in CKD: A Meta-Analysis of Cohort Studies

BACKGROUND AND OBJECTIVES

Patients with CKD are advised to follow dietary recommendations that restrict individual nutrients. Emerging evidence indicates overall eating patterns may better predict clinical outcomes, however, current data on dietary patterns in kidney disease are limited.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This systematic review aimed to evaluate the association between dietary patterns and mortality or ESRD among adults with CKD. Medline, Embase, and reference lists were systematically searched up to November 24, 2015 by two independent review authors. Eligible studies were longitudinal cohort studies reporting the association of dietary patterns with mortality, cardiovascular events, or ESRD.

RESULTS

A total of seven studies involving 15,285 participants were included. Healthy dietary patterns were generally higher in fruit and vegetables, fish, legumes, cereals, whole grains, and fiber, and lower in red meat, salt, and refined sugars. In six studies, healthy dietary patterns were consistently associated with lower mortality (3983 events; adjusted relative risk, 0.73; 95% confidence interval, 0.63 to 0.83; risk difference of 46 fewer (29-63 fewer) events per 1000 people over 5 years). There was no statistically significant association between healthy dietary patterns and risk of ESRD (1027 events; adjusted relative risk, 1.04; 95% confidence interval, 0.68 to 1.40).

CONCLUSIONS

Healthy dietary patterns are associated with lower mortality in people with kidney disease. Interventions to support adherence to increased fruit and vegetable, fish, legume, whole grain, and fiber intake, and reduced red meat, sodium, and refined sugar intake could be effective tools to lower mortality in people with kidney disease.

Prevention of contrast-induced acute kidney injury in patients undergoing cardiovascular procedures-a systematic review and network meta-analysis

Background

Interventional diagnostic and therapeutic procedures requiring intravascular iodinated contrast steadily increase patient exposure to the risks of contrast-induced acute kidney injury (CIAKI), which is associated with death, nonfatal cardiovascular events, and prolonged hospitalization. The aim of this study was to investigate the efficacy of pharmacological and non-pharmacological treatments for CIAKI prevention in patients undergoing cardiovascular invasive procedures with iodinated contrast.

Methods and findings

MEDLINE, Google Scholar, EMBASE and Cochrane databases as well as abstracts and presentations from major cardiovascular and nephrology meetings were searched, up to 22 April 2016. Eligible studies were randomized trials comparing strategies to prevent CIAKI (alone or in combination) when added to saline versus each other, saline, placebo, or no treatment in patients undergoing cardiovascular invasive procedures with administration of iodinated contrast. Two reviewers independently extracted trial-level data including number of patients, duration of follow-up, and outcomes. Eighteen strategies aimed at CIAKI prevention were identified. The primary outcome was the occurrence of CIAKI. Secondary outcomes were mortality, myocardial infarction, dialysis and heart failure. The data were pooled using network meta-analysis. Treatment estimates were calculated as odds ratios (ORs) with 95% credible intervals (CrI). 147 RCTs involving 33,463 patients were eligible. Saline plus N-acetylcysteine (OR 0.72, 95%CrI 0.57–0.88), ascorbic acid (0.59, 0.34–0.95), sodium bicarbonate plus N-acetylcysteine (0.59, 0.36–0.89), probucol (0.42, 0.15–0.91), methylxanthines (0.39, 0.20–0.66), statin (0.36, 0.21–0.59), device-guided matched hydration (0.35, 0.12–0.79), prostaglandins (0.26, 0.08–0.62) and trimetazidine (0.26, 0.09–0.59) were associated with lower odds of CIAKI compared to saline. Methylxanthines (0.12, 0.01–0.94) or left ventricular end-diastolic pressure-guided hydration (0.09, 0.01–0.59) were associated with lower mortality compared to saline.

Conclusions

Currently recommended treatment with saline as the only measure to prevent CIAKI during cardiovascular procedures may not represent the optimal strategy. Vasodilators, when added to saline, may significantly reduce the odds of CIAKI following cardiovascular procedures.

Antihypertensive Agents in Patients With Diabetes

PURPOSE

Management of hypertension in patients with diabetes should address both renal and cardiovascular protection. The use of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) for control of hypertension in patients with diabetic nephropathy is widely advocated by various international guidelines. Use of any agent that provides tight control of blood pressure is indicated in patients with diabetes but without nephropathy.

METHODS

In this article, the authors present a clinical case scenario and review current clinical evidence supporting the use of ACE inhibitors and ARBs in patients with diabetic nephropathy. In addition, the use of ACE and ARBs in patients with diabetes but without nephropathy will be discussed.

RESULTS

Available trial evidence confirms the survival benefits of patients taking ACE inhibitors with diabetic nephropathy. However, the efficacy of ARB inhibitors on survival is unknown. In patients with diabetes without nephropathy, only ACE inhibitors have been found to reduce the risk of onset of microalbuminuria, while all agents affect survival provided a tight control of blood pressure is monitored.

CONCLUSIONS

Dose of ACE inhibitors should be titrated appropriately to obtain proven benefits. In summary, current evidence supports the use of ACE inhibitors in patients with and without nephropathy because of renal and cardiovascular benefits.

Comparison of Clinical Outcomes and Adverse Events Associated With Glucose-Lowering Drugs in Patients With Type 2 Diabetes: A Meta-analysis

IMPORTANCE

Numerous glucose-lowering drugs are used to treat type 2 diabetes.

OBJECTIVE

To estimate the relative efficacy and safety associated with glucose-lowering drugs including insulin.

DATA SOURCES

Cochrane Library Central Register of Controlled Trials, MEDLINE, and EMBASE databases through March 21, 2016.

STUDY SELECTION

Randomized clinical trials of 24 weeks' or longer duration.

DATA EXTRACTION AND SYNTHESIS

Random-effects network meta-analysis.

MAIN OUTCOMES AND MEASURES

The primary outcome was cardiovascular mortality. Secondary outcomes included all-cause mortality, serious adverse events, myocardial infarction, stroke, hemoglobin A1c (HbA1C) level, treatment failure (rescue treatment or lack of efficacy), hypoglycemia, and body weight.

RESULTS

A total of 301 clinical trials (1,417,367 patient-months) were included; 177 trials (56,598 patients) of drugs given as monotherapy; 109 trials (53,030 patients) of drugs added to metformin (dual therapy); and 29 trials (10,598 patients) of drugs added to metformin and sulfonylurea (triple therapy). There were no significant differences in associations between any drug class as monotherapy, dual therapy, or triple therapy with odds of cardiovascular or all-cause mortality. Compared with metformin, sulfonylurea (standardized mean difference [SMD], 0.18 [95% CI, 0.01 to 0.34]), thiazolidinedione (SMD, 0.16 [95% CI, 0.00 to 0.31]), DPP-4 inhibitor (SMD, 0.33 [95% CI, 0.13 to 0.52]), and α-glucosidase inhibitor (SMD, 0.35 [95% CI, 0.12 to 0.58]) monotherapy were associated with higher HbA1C levels. Sulfonylurea (odds ratio [OR], 3.13 [95% CI, 2.39 to 4.12]; risk difference [RD], 10% [95% CI, 7% to 13%]) and basal insulin (OR, 17.9 [95% CI, 1.97 to 162]; RD, 10% [95% CI, 0.08% to 20%]) were associated with greatest odds of hypoglycemia. When added to metformin, drugs were associated with similar HbA1C levels, while SGLT-2 inhibitors offered the lowest odds of hypoglycemia (OR, 0.12 [95% CI, 0.08 to 0.18]; RD, -22% [-27% to -18%]). When added to metformin and sulfonylurea, GLP-1 receptor agonists were associated with the lowest odds of hypoglycemia (OR, 0.60 [95% CI, 0.39 to 0.94]; RD, -10% [95% CI, -18% to -2%]).

CONCLUSIONS AND RELEVANCE

Among adults with type 2 diabetes, there were no significant differences in the associations between any of 9 available classes of glucose-lowering drugs (alone or in combination) and the risk of cardiovascular or all-cause mortality. Metformin was associated with lower or no significant difference in HbA1C levels compared with any other drug classes. All drugs were estimated to be effective when added to metformin. These findings are consistent with American Diabetes Association recommendations for using metformin monotherapy as initial treatment for patients with type 2 diabetes and selection of additional therapies based on patient-specific considerations.

The Validity of Left Ventricular Mass as a Surrogate End Point for All-Cause and Cardiovascular Mortality Outcomes in People With CKD: A Systematic Review and Meta-analysis

BACKGROUND

Left ventricular mass (LVM) is a widely used surrogate end point in randomized trials involving people with chronic kidney disease (CKD) because treatment-induced LVM reductions are assumed to lower cardiovascular risk. The aim of this study was to assess the validity of LVM as a surrogate end point for all-cause and cardiovascular mortality in CKD.

STUDY DESIGN

Systematic review and meta-analysis.

SETTING & POPULATION

Participants with any stages of CKD.

SELECTION CRITERIA FOR STUDIES

Randomized controlled trials with 3 or more months' follow-up that reported LVM data.

INTERVENTION

Any pharmacologic or nonpharmacologic intervention.

OUTCOMES

The surrogate outcome of interest was LVM change from baseline to last measurement, and clinical outcomes of interest were all-cause and cardiovascular mortality. Standardized mean differences (SMDs) of LVM change and relative risk for mortality were estimated using pairwise random-effects meta-analysis. Correlations between surrogate and clinical outcomes were summarized across all interventions combined using bivariate random-effects Bayesian models, and 95% credible intervals were computed.

RESULTS

73 trials (6,732 participants) covering 25 intervention classes were included in the meta-analysis. Overall, risk of bias was uncertain or high. Only 3 interventions reduced LVM: erythropoiesis-stimulating agents (9 trials; SMD, -0.13; 95% CI, -0.23 to -0.03), renin-angiotensin-aldosterone system inhibitors (13 trials; SMD, -0.28; 95% CI, -0.45 to -0.12), and isosorbide mononitrate (2 trials; SMD, -0.43; 95% CI, -0.72 to -0.14). All interventions had uncertain effects on all-cause and cardiovascular mortality. There were weak and imprecise associations between the effects of interventions on LVM change and all-cause (32 trials; 5,044 participants; correlation coefficient, 0.28; 95% credible interval, -0.13 to 0.59) and cardiovascular mortality (13 trials; 2,327 participants; correlation coefficient, 0.30; 95% credible interval, -0.54 to 0.76).

LIMITATIONS

Limited long-term data, suboptimal quality of included studies.

CONCLUSIONS

There was no clear and consistent association between intervention-induced LVM change and mortality. Evidence for LVM as a valid surrogate end point in CKD is currently lacking.

Cognition in People With End-Stage Kidney Disease Treated With Hemodialysis: A Systematic Review and Meta-analysis

BACKGROUND

Cognitive impairment is associated with poorer quality of life, risk for hospitalization, and mortality. Cognitive impairment is common in people with end-stage kidney disease treated with hemodialysis, yet the severity and specific cognitive deficits are uncertain.

STUDY DESIGN

Systematic review and meta-analysis.

SETTING & POPULATION

Adults receiving hemodialysis compared with the general population, people with non-dialysis-dependent chronic kidney disease (NDD-CKD), people receiving peritoneal dialysis, or people with nondialyzed chronic kidney failure.

SELECTION CRITERIA FOR STUDIES

Randomized controlled trials, cohort or cross-sectional studies without language restriction.

INDEX TESTS

Validated neuropsychological tests of cognition.

OUTCOMES

Cognitive test scores, aggregated by cognitive domain: orientation and attention, perception, memory, language, construction and motor performance, concept formation and reasoning, and executive functions.

RESULTS

42 studies of 3,522 participants. Studies were of high or uncertain risk of bias, assessed by the Newcastle-Ottawa Scale. People treated with hemodialysis had worse cognition than the general population, particularly in attention (n=22; standardized mean difference [SMD], -0.93; 95% CI, -1.18 to -0.68). Hemodialysis patients performed better than nondialyzed patients with chronic kidney failure in attention (n=6; SMD, 0.70; 95% CI, 0.45 to 0.96) and memory (n=6; SMD, 0.36; 95% CI, 0.08 to 0.63), but had poorer memory than the general population (n=16; SMD, -0.41; 95% CI, -0.91 to 0.09) and people with NDD-CKD (n=5; SMD, -0.40; 95% CI, -0.60 to -0.21). There were insufficient data to show other differences among people receiving hemodialysis and those receiving peritoneal dialysis or with NDD-CKD.

LIMITATIONS

Potentially biased studies, not wholly adjusted for education. High heterogeneity, mainly due to the large variety of tests used to assess cognition.

CONCLUSIONS

People treated with hemodialysis have impaired cognitive function compared to the general population, particularly in the domains of orientation and attention and executive function. Cognitive deficits in specific domains should be further explored in this population and should be considered when approaching education and chronic disease management.

Patterns of oral disease in adults with chronic kidney disease treated with hemodialysis

BACKGROUND

Oral disease is a potentially treatable determinant of mortality and quality of life. No comprehensive multinational study to quantify oral disease burden and to identify candidate preventative strategies has been performed in the dialysis setting.

METHODS

The ORAL disease in hemoDialysis (ORALD) study was a prospective study in adults treated with hemodialysis in Europe (France, Hungary, Italy, Poland, Portugal and Spain) and Argentina. Oral disease was assessed using standardized WHO methods. Participants self-reported oral health practices and symptoms. Sociodemographic and clinical factors associated with oral diseases were determined and assessed within nation states.

RESULTS

Of 4726 eligible adults, 4205 (88.9%) participated. Overall, 20.6% were edentulous [95% confidence interval (CI), 19.4-21.8]. Participants had on average 22 (95% CI 21.7-22.2) decayed, missing or filled teeth, while moderate to severe periodontitis affected 40.6% (95% CI 38.9-42.3). Oral disease patterns varied markedly across countries, independent of participant demographics, comorbidity and health practices. Participants in Spain, Poland, Italy and Hungary had the highest mean adjusted odds of edentulousness (2.31, 1.90, 1.90 and 1.54, respectively), while those in Poland, Hungary, Spain and Argentina had the highest odds of ≥14 decayed, missing or filled teeth (23.2, 12.5, 8.14 and 5.23, respectively). Compared with Argentina, adjusted odds ratios for periodontitis were 58.8, 58.3, 27.7, 12.1 and 6.30 for Portugal, Italy, Hungary, France and Poland, respectively. National levels of tobacco consumption, diabetes and child poverty were associated with edentulousness within countries.

CONCLUSIONS

Oral disease in adults on hemodialysis is very common, frequently severe and highly variable among countries, with much of the variability unexplained by participant characteristics or healthcare. Given the national variation and high burden of disease, strategies to improve oral health in hemodialysis patients will require implementation at a country level rather than at the level of individuals.