Sepsis-associated acute kidney injury: recent advances in enrichment strategies, sub-phenotyping and clinical trials

Acute kidney injury (AKI) often complicates sepsis and is associated with high morbidity and mortality. In recent years, several important clinical trials have improved our understanding of sepsis-associated AKI (SA-AKI) and impacted clinical care. Advances in sub-phenotyping of sepsis and AKI and clinical trial design offer unprecedented opportunities to fill gaps in knowledge and generate better evidence for improving the outcome of critically ill patients with SA-AKI. In this manuscript, we review the recent literature of clinical trials in sepsis with focus on studies that explore SA-AKI as a primary or secondary outcome. We discuss lessons learned and potential opportunities to improve the design of clinical trials and generate actionable evidence in future research. We specifically discuss the role of enrichment strategies to target populations that are most likely to derive benefit and the importance of patient-centered clinical trial endpoints and appropriate trial designs with the aim to provide guidance in designing future trials.

Evaluation of the effect of sodium zirconium cyclosilicate on arrhythmia-related cardiovascular outcomes in patients receiving chronic haemodialysis with hyperkalaemia: protocol for the multicentre, randomised, controlled DIALIZE-Outcomes study

INTRODUCTION

Patients with kidney failure receiving chronic haemodialysis have elevated risk of arrhythmias potentially increasing the likelihood of sudden cardiac death, stroke and hospitalisation. The DIALIZE study (NCT03303521) demonstrated that sodium zirconium cyclosilicate (SZC) was an efficacious and well-tolerated treatment for predialysis hyperkalaemia in patients undergoing haemodialysis. The DIALIZE-Outcomes study evaluates the effect of SZC on sudden cardiac death and arrhythmia-related cardiovascular outcomes in patients receiving chronic haemodialysis with recurrent hyperkalaemia.

METHODS AND ANALYSIS

International, multicentre, randomised, double-blind, placebo-controlled study conducted at 357 study sites across 25 countries. Adults (≥18 years) receiving chronic haemodialysis three times per week with recurrent predialysis serum potassium (K+) ≥5.5 mmol/L post long interdialytic interval (LIDI) are eligible. Patients (~2800) will be randomised 1:1 to SZC or placebo, starting at 5 g orally once daily on non-dialysis days and titrated weekly in 5 g increments (maximum 15 g) to target predialysis serum K+ 4.0-5.0 mmol/L post LIDI. The primary objective is to evaluate efficacy of SZC versus placebo in reducing occurrence of the primary composite endpoint of sudden cardiac death, stroke or arrhythmia-related hospitalisation, intervention or emergency department visit. Secondary endpoints include efficacy of SZC versus placebo in maintaining normokalaemia (serum K+ 4.0-5.5 mmol/L post LIDI) at the 12-month visit, preventing severe hyperkalaemia (serum K+ ≥6.5 mmol/L post LIDI) at the 12-month visit and reducing the incidence of individual cardiovascular outcomes. Safety of SZC will be evaluated. The study is event driven, with participants remaining in the study until 770 primary endpoint events have occurred. Average time in the study is expected to be ~25 months.

ETHICS AND DISSEMINATION

Approval was obtained from the relevant institutional review board/independent ethics committee from each participating site (approving bodies in supplementary information). The results will be submitted to a peer-reviewed journal.

TRIAL REGISTRATION NUMBERS

EudraCT 2020-005561-14 and clinicaltrials.gov identifier NCT04847232.

Cultivating Innovative Pragmatic Cluster-Randomized Registry Trials Embedded in Hemodialysis Care: Workshop Proceedings From 2018

Hemodialysis is a life-sustaining treatment for persons with kidney failure. However, those on hemodialysis still face a poor quality of life and a short life expectancy. High-quality research evidence from large randomized controlled trials is needed to identify interventions that improve the experiences, outcomes, and health care of persons receiving hemodialysis. With the support of the Canadian Institutes of Health Research and its Strategy for Patient-Oriented Research, the Innovative Clinical Trials in Hemodialysis Centers initiative brought together Canadian and international kidney researchers, patients, health care providers, and health administrators to participate in a workshop held in Toronto, Canada, on June 2 and 3, 2018. The workshop served to increase knowledge and awareness about the conduct of innovative, pragmatic, cluster-randomized registry trials embedded into routine hemodialysis care and provided an opportunity to discuss and build support for new trial ideas. The workshop content included structured presentations, facilitated group discussions, and expert panel feedback. Partnerships and promising trial ideas borne out of the workshop will continue to be developed to support the implementation of future large-scale trials.

Abstract 625: Adipose-Associated Mediators Correlate with Anatomic and Physiologic Adaptations Following Fistula Placement: The Hemodialysis Fistula Maturation (HFM) Study

Introduction: Perivascular inflammation stands as an important regulator of vascular remodeling. We hypothesize that the phenotype of adipose tissue adjacent to a hemodialysis arteriovenous fistula (AVF) modulates the anatomy and physiology of maturation.

Methods: During AVF creation, adipose tissue adjacent to the vein was collected from 112 participants in the NIDDK HFM Study, and 9 adipose-associated mediator protein levels were measured. AVF duplex ultrasound was performed post-operatively at Day 1, and Weeks 2 and 6, and prior to 1 st cannulation (Week 10-22) to define the changes in diameter and flow. Associations between biomarker levels and fistula remodeling were evaluated using mixed effects regression analyses.

Results: Fractional changes in vein diameter decrease with increasing IL-6 and MCP-1 levels; changes in AVF flow decrease with increasing leptin ( A ). IL-6 demonstrated a statistically significant relationship with vein adaptations in the early time frame (1D-2W), but not in the later stages of remodeling ( B ). Additional interaction effects between concentration and diameter/flow changes were identified, with elevated inflammatory biomarker levels correlated with reduced early and peri-anastomotic changes in vein diameter and flow ( C ).

Conclusions: Changes in AVF diameter and flow are associated with baseline local adipose phenotype. Impaired vein dilation and reduced capacity for flow augmentation appears related to enhanced inflammation, particularly at early times and in the peri-anastomotic region.

Rate of transmission of human immunodeficiency virus type 1 infection from mother to child and short-term outcome of neonatal infection. Results of a prospective cohort study

In an attempt to determine the rate of transmission of infection from human immunodeficiency virus type 1 (HIV-1) antibody-positive women to their offspring and to describe the short-term outcome of perinatal infection, we enrolled 62 infants in a prospective cohort study during a 30-month period and followed them up for an additional 6 months. The clinical, immunologic, and serologic status of the children was assessed prospectively. Fourteen subjects were symptomatic: 3 had acquired immunodeficiency syndrome, 5 had signs and symptoms that were compatible with HIV-1 infection (Centers for Disease Control, Atlanta, Ga, class P2A), and 6 had ill-defined symptoms that could not be definitely attributed to HIV. Our data indicated that the maximum rate of vertical transmission of HIV-1 infection in New Haven, Conn, was less than 30%, and the rate of HIV-1-associated disease occurring during the first 3 years of life was 16%. The mean and median time to loss of maternal antibody, as detected by Western blot in seroreverters, was approximately 7 months, and the half-life of passive antibody was 38 days. A continued close follow-up of children in the cohort studied, and others like it, is critical to learn the full range of outcomes of HIV infection in the pediatric population.

Differential effects of dopamine agonists on acoustically and electrically elicited startle responses: comparison to effects of strychnine

This study sought to determine where drugs that are known to alter sensorimotor reactivity measured with the acoustic startle reflex ultimately act within the acoustic startle pathway. To do this, startle was elicited either acoustically or electrically within various nuclei believed to comprise the acoustic startle pathway. Direct infusion of serotonin into the subarachnoid space of the lumbar spinal cord increased acoustic startle and startle elicited electrically through the ventral cochlear nucleus (VCN) to a comparable degree. Subconvulsant doses of strychnine increased startle elicited acoustically or electrically through either the VCN or the nucleus reticularis pontis caudalis (RPC), pointing to a spinal locus of action of strychnine after systemic administration. In marked contrast, the dopamine agonists d-amphetamine and apomorphine consistently increased acoustic startle but actually depressed startle elicited electrically through the VCN or the RPC. These later results suggest that dopamine agonists increase sensorimotor reactivity measured with acoustic startle by acting on sensory rather than motor parts of the reflex arc.