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Fishbane S, El-Shahawy MA, Pecoits-Filho R, Van BP, Houser MT, Frison L, Little DJ, Guzman NJ, Pergola PE. Roxadustat for Treating Anemia in Patients with CKD Not on Dialysis: Results from a Randomized Phase 3 Study. J Am Soc Nephrol 2021; 32:737-755. [PMID: 33568383 PMCID: PMC7920165 DOI: 10.1681/asn.2020081150] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 12/01/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Current anemia therapies for patients with non-dialysis-dependent CKD may require injection and medical visits. Roxadustat, an oral hypoxia-inducible factor prolyl hydroxylase inhibitor, stimulates erythropoiesis and improves iron homeostasis. METHODS In this double-blind phase 3 study, we randomized patients with non-dialysis-dependent CKD stages 3-5 and hemoglobin <10.0 g/dl (1:1) to thrice-weekly 70-mg oral roxadustat or placebo. Doses were titrated throughout the study based on hemoglobin levels. The primary efficacy end point was mean change from baseline in hemoglobin averaged over weeks 28-52 versus placebo, irrespective of rescue therapy use. We assessed patients for adverse events. RESULTS The study included 2781 patients, 1393 who received roxadustat and 1388 who received placebo. Mean baseline hemoglobin was 9.1 g/dl for both groups. The mean change in hemoglobin from baseline was 1.75 g/dl (95% confidence interval [95% CI], 1.68 to 1.81) with roxadustat versus 0.40 g/dl (95% CI, 0.33 to 0.47) with placebo, (P<0.001). Among 411 patients with baseline elevated high-sensitivity C-reactive protein, mean change in hemoglobin from baseline was 1.75 g/dl (95% CI, 1.58 to 1.92) with roxadustat versus 0.62 g/dl (95% CI, 0.44 to 0.80) with placebo, (P<0.001). Roxadustat reduced the risk of red blood cell transfusion by 63% (hazard ratio, 0.37; 95% CI, 0.30 to 0.44). The most common adverse events with roxadustat and placebo, respectively, were ESKD (21.0% versus 20.5%), urinary tract infection (12.8% versus 8.0%), pneumonia (11.9% versus 9.4%), and hypertension (11.5% versus 9.1%). CONCLUSIONS Roxadustat effectively increased hemoglobin in patients with non-dialysis-dependent CKD and reduced the need for red blood cell transfusion, with an adverse event profile comparable to that of placebo. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Safety and Efficacy Study of Roxadustat to Treat Anemia in Patients With CKD, Not on Dialysis, NCT02174627.
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Guedes M, Muenz D, Zee J, Lopes MB, Waechter S, Stengel B, Massy ZA, Speyer E, Ayav C, Finkelstein F, Sesso R, Pisoni RL, Robinson BM, Pecoits-Filho R. Serum biomarkers of iron stores are associated with worse physical health-related quality of life (HRQoL) in non-dialysis dependent chronic kidney disease (NDD-CKD) patients with or without anemia. Nephrol Dial Transplant 2021; 36:1694-1703. [PMID: 33624825 PMCID: PMC8396397 DOI: 10.1093/ndt/gfab050] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Indexed: 12/28/2022] Open
Abstract
Background Iron deficiency (ID) is a common condition in nondialysis-dependent chronic kidney disease (NDD-CKD) patients that is associated with poorer clinical outcomes. However, the effect of ID on health-related quality of life (HRQoL) in this population is unknown. We analyzed data from a multinational cohort of NDD-CKD Stages 3–5 patients to test the association between transferrin saturation (TSAT) index and ferritin with HRQoL. Methods Patients from Brazil (n = 205), France (n = 2015) and the USA (n = 293) in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps, 2013–2019) were included. We evaluated the association of TSAT and ferritin (and functional and absolute ID, defined as TSAT ≤20% and ferritin ≥300 or <50 ng/mL) on pre-specified HRQoL measures, including the 36-item Kidney Disease Quality of Life physical component summary (PCS) and mental component summary (MCS) as the primary outcomes. Models were adjusted for confounders including hemoglobin (Hb). Results TSAT ≤15% and ferritin <50 ng/mL and ≥300 ng/mL were associated with worse PCS scores, but not with MCS. Patients with composite TSAT ≤20% and ferritin <50 or ≥300 ng/mL had lower functional status and worse PCS scores than those with a TSAT of 20–30% and ferritin 50–299 ng/mL. Patients with a lower TSAT were less likely to perform intense physical activity. Adjustment for Hb only slightly attenuated the observed effects. Conclusions Low TSAT levels, as well as both low TSAT with low ferritin and low TSAT with high ferritin, are associated with worse physical HRQoL in NDD-CKD patients, even after accounting for Hb level. Interventional studies of iron therapy on HRQoL among NDD-CKD individuals are needed to confirm these findings.
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Weissheimer R, Bucharles SGE, Truyts CAM, Jorgetti V, Figueiredo AE, Barrett P, Olandoski M, Pecoits-Filho R, Moraes TPD. High prevalence of biochemical disturbances of chronic kidney disease - mineral and bone disorders (CKD-MBD) in a nation-wide peritoneal dialysis cohort: are guideline goals too hard to achieve? J Bras Nefrol 2021; 43:173-181. [PMID: 33538758 PMCID: PMC8257285 DOI: 10.1590/2175-8239-jbn-2020-0147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/15/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Chronic kidney disease - mineral and bone disorders (CKD-MBD) are common in dialysis patients. Definition of targets for calcium (Ca), phosphorus (P), parathormone (iPTH), and alkaline phosphatase (ALP) and their treatment recommendations, are provided by international guidelines. There are few studies analyzing CKD-MBD in peritoneal dialysis (PD) patients and the impact of guidelines on mineral metabolism control. The aim of our study was to describe the prevalence of biomarkers for CKD-MBD in a large cohort of PD patients in Brazil. METHODS Data from the nation-wide prospective observational cohort BRAZPD II was used. Incident patients were followed between December 2004 and January 2011. According to KDOQI recommendations, reference ranges for total Ca were 8.4 to 9.5 mg/dL, for P, 3.5 to 5.5 mg/dL, for iPTH, 150-300 pg/mL, and for ALP, 120 U/L. RESULTS Mean age was 59.8 ± 16 years, 48% were male, and 43% had diabetes. In the beginning, Ca was 8.9 ± 0.9 mg/dL, and 48.3% were on the KODQI target. After 1 year, Ca increased to 9.1 ± 0.9 mg/dL and 50.4% were in the KDOQI preferred range. P at baseline was 5.2 ± 1.6 mg/dL, with 52.8% on target, declining to 4.9 ± 1.5 mg/dL after one year, when 54.7% were on target. Median iPTH at baseline was 238 (P25% 110 - P75% 426 pg/mL) and it remained stable throughout the first year; patients within target ranged from 26 to 28.5%. At the end of the study, 80% was in 3.5 meq/L Ca dialysate concentration, 66.9% of patients was taking any phosphate binder, and 25% was taking activated vitamin D. CONCLUSIONS We observed a significant prevalence of biochemical disorders related to CKD-MBD in this dialysis population.
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Liabeuf S, Lambert O, Metzger M, Hamroun A, Laville M, Laville SM, Frimat L, Pecoits-Filho R, Fouque D, Massy ZA, Jacquelinet C, Stengel B. Adverse outcomes of proton pump inhibitors in patients with chronic kidney disease: The CKD-REIN cohort study. Br J Clin Pharmacol 2021; 87:2967-2976. [PMID: 33368448 DOI: 10.1111/bcp.14713] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 12/02/2020] [Accepted: 12/05/2020] [Indexed: 12/18/2022] Open
Abstract
AIMS Long-term use of proton pump inhibitors (PPIs) has been associated with adverse kidney events in the general population, but their impact among chronic kidney disease (CKD) patients is unclear. We studied the prevalence and incidence (new users) of PPI prescriptions and their relation to kidney outcomes and mortality in CKD patients. METHODS We collected drug prescriptions prospectively in a cohort of 3023 nephrology outpatients with CKD stages 2-5 at inclusion. Hazard ratios (HR, 95% confidence intervals [95% CI]) for acute kidney injury (AKI), end-stage kidney disease (ESKD), and mortality associated with new PPI prescriptions as a time-dependent variable were estimated with cause-specific Cox models in 1940 non-users with eGFR ≥ 15 mL/min/1.73 m2 at baseline, adjusted for comorbidities, laboratory data and drugs. RESULTS There were 981/3023 (32%) prevalent users (67 ± 13 years, 65% men) at baseline, and 366/3023 (12%) were prescribed PPI (new users) over a median follow-up of 3.9 years (interquartile range, 3-4.2). Among these new users, their median cumulative duration of prescription was 1 year (interquartile range: 0.4-2.3). During follow-up, 354 patients developed ESKD and 216 died before ESKD. The adjusted HRs associated with PPI prescription were 1.74 (95% CI, 1.26-2.40) for ESKD and 2.42 (95% CI, 1.73-3.39) for all-cause mortality. Over the first 3 years of follow-up, 211 AKI events had occurred. The adjusted HR for AKI associated with PPI prescription was 2.89 (95% CI, 1.91-4.38). CONCLUSIONS Long-term PPI prescription was common in CKD patients. Our results call attention to its potential risks of both acute and chronic kidney failure.
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Lopes MB, Karaboyas A, Bieber B, Pisoni RL, Walpen S, Fukagawa M, Christensson A, Evenepoel P, Pegoraro M, Robinson BM, Pecoits-Filho R. Impact of longer term phosphorus control on cardiovascular mortality in hemodialysis patients using an area under the curve approach: results from the DOPPS. Nephrol Dial Transplant 2021; 35:1794-1801. [PMID: 32594171 PMCID: PMC7538234 DOI: 10.1093/ndt/gfaa054] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 02/12/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Serial assessment of phosphorus is currently recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, but its additional value versus a single measurement is uncertain. METHODS We studied data from 17 414 HD patients in the Dialysis Outcomes and Practice Patterns Study, a prospective cohort study, and calculated the area under the curve (AUC) by multiplying the time spent with serum phosphorus >4.5 mg/dL over a 6-month run-in period by the extent to which this threshold was exceeded. We estimated the association between the monthly average AUC and cardiovascular (CV) mortality using Cox regression. We formally assessed whether AUC was a better predictor of CV mortality than other measures of phosphorus control according to the Akaike information criterion. RESULTS Compared with the reference group of AUC = 0, the adjusted hazard ratio (HR) of CV mortality was 1.12 [95% confidence interval (CI) 0.90-1.40] for AUC > 0-0.5, 1.26 (95% CI 0.99-1.62) for AUC > 0.5-1, 1.44 (95% CI 1.11-1.86) for AUC > 1-2 and 2.03 (95% CI 1.53-2.69) for AUC > 2. The AUC was predictive of CV mortality within strata of the most recent phosphorus level and had a better model fit than other serial measures of phosphorus control (mean phosphorus, months out of target). CONCLUSIONS We conclude that worse phosphorus control over a 6-month period was strongly associated with CV mortality. The more phosphorus values do not exceed 4.5 mg/dL the better is survival. Phosphorus AUC is a better predictor of CV death than the single most recent phosphorus level, supporting with real-world data KDIGO's recommendation of serial assessment of phosphorus to guide clinical decisions.
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Wheeler DC, Stefansson BV, Batiushin M, Bilchenko O, Cherney DZI, Chertow GM, Douthat W, Dwyer JP, Escudero E, Pecoits-Filho R, Furuland H, Górriz JL, Greene T, Haller H, Hou FF, Kang SW, Isidto R, Khullar D, Mark PB, McMurray JJV, Kashihara N, Nowicki M, Persson F, Correa-Rotter R, Rossing P, Toto RD, Umanath K, Van Bui P, Wittmann I, Lindberg M, Sjöström CD, Langkilde AM, Heerspink HJL. The dapagliflozin and prevention of adverse outcomes in chronic kidney disease (DAPA-CKD) trial: baseline characteristics. Nephrol Dial Transplant 2020; 35:1700-1711. [PMID: 32862232 PMCID: PMC7538235 DOI: 10.1093/ndt/gfaa234] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 12/22/2022] Open
Abstract
Background The Dapagliflozin and Prevention of Adverse outcomes in Chronic Kidney Disease (DAPA-CKD; NCT03036150) trial was designed to assess the effect of the sodium–glucose co-transporter 2 (SGLT2) inhibitor dapagliflozin on kidney and cardiovascular events in participants with CKD with and without type 2 diabetes (T2D). This analysis reports the baseline characteristics of those recruited, comparing them with those enrolled in other trials. Methods In DAPA-CKD, 4304 participants with a urinary albumin:creatinine ratio (UACR) ≥200 mg/g and estimated glomerular filtration rate (eGFR) between 25 and 75 mL/min/1.73 m2 were randomized to dapagliflozin 10 mg once daily or placebo. Mean eGFR was 43.1 mL/min/1.73 m2 and median UACR was 949 mg/g (108 mg/mmol). Results Overall, 2906 participants (68%) had a diagnosis of T2D and of these, 396 had CKD ascribed to a cause other than diabetes. The most common causes of CKD after diabetes (n = 2510) were ischaemic/hypertensive nephropathy (n = 687) and chronic glomerulonephritis (n = 695), of which immunoglobulin A nephropathy (n = 270) was the most common. A total of 4174 participants (97%) were receiving an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, 1882 (43.7%) diuretics, 229 (5.3%) mineralocorticoid receptor antagonists and 122 (2.8%) glucagon-like peptide 1 receptor agonists. In contrast to the Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE), the DAPA-CKD trial enrolled participants with CKD due to diabetes and to causes other than diabetes. The mean eGFR of participants in the DAPA-CKD trial was 13.1 mL/min/1.73 m2 lower than in CREDENCE, similar to that in the Finerenone in Reducing Kidney Failure and Disease Progression in DKD (FIDELIO-DKD) trial and the Study Of diabetic Nephropathy with AtRasentan (SONAR). Conclusions Participants with a wide range of underlying kidney diseases receiving renin–angiotensin system blocking therapy have been enrolled in the DAPA-CKD trial. The trial will examine the efficacy and safety of dapagliflozin in participants with CKD Stages 2–4 and increased albuminuria, with and without T2D.
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Loesch G, Cruz JAW, Pecoits-Filho R, Figueiredo AE, Barretti P, de Moraes TP. Public health investments and mortality risk in Brazilian peritoneal dialysis patients. Clin Kidney J 2020; 13:1012-1016. [PMID: 33391744 PMCID: PMC7769512 DOI: 10.1093/ckj/sfaa118] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 05/25/2020] [Indexed: 12/02/2022] Open
Abstract
Background End-stage kidney disease (ESKD) treatment is very costly and accounts for a significant percentage of public healthcare expenditures. Beyond direct costs, dialysis patients use other healthcare levels, but the impact of public investment on each of these levels is unclear. This study aimed to investigate the association between direct financing at different healthcare levels and overall mortality in peritoneal dialysis (PD) patients. Methods We included all adult incident PD patients from a Brazilian prospective, nationwide PD cohort. Overall mortality was the primary outcome of interest. We used a three-level multilevel survival analysis to investigate whether mortality was associated with the investments destined to different levels of healthcare complexity: (i) primary, (ii) medium and high and (iii) professional healthcare training and community awareness. Results We evaluated 5707 incident PD patients from 78 Brazilian cities, which were divided into four quartiles for each healthcare level (Groups I–IV). After taking the highest quartile (Group IV) as a reference, investment in the primary health level was not associated with patient survival. Otherwise, medium and high complexity levels were associated with higher mortality risk. Also, investment in healthcare manager training and community awareness had an impact on patient survival. Conclusions Investments in different levels of the healthcare system have distinct impacts on PD patient survival. Investment in healthcare manager training and community awareness seems to be a promising strategy on which to focus, given the relatively low cost and positive impact on outcome.
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Hödlmoser S, Winkelmayer WC, Zee J, Pecoits-Filho R, Pisoni RL, Port FK, Robinson BM, Ristl R, Krenn S, Kurnikowski A, Lewandowski M, Ton A, Carrero JJ, Schernhammer ES, Hecking M. Sex differences in chronic kidney disease awareness among US adults, 1999 to 2018. PLoS One 2020; 15:e0243431. [PMID: 33338051 PMCID: PMC7748269 DOI: 10.1371/journal.pone.0243431] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/22/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is less prevalent among men than women, but more men than women initiate kidney replacement therapy. Differences in CKD awareness may contribute to this gender gap, which may further vary by race/ethnicity. We aimed to investigate trends in CKD awareness and the association between individual characteristics and CKD awareness among US men versus women. METHODS AND FINDINGS We conducted a serial, cross-sectional analysis of 10 cycles (1999-2018) from the National Health and Nutrition Examination Survey (NHANES). Adult participants with CKD stages G3-G5 (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73m2) were included, unless they were on dialysis or medical information was missing. Serum creatinine was measured during NHANES medical exams. CKD stage was classified by eGFR, based on the CKD-EPI formula. CKD awareness was assessed with the question: "Have you ever been told by a health care professional you had weak or failing kidneys", asked in standardized NHANES questionnaires on each survey. Using logistic regression models, we evaluated the association between sex and CKD awareness, adjusting for potential confounders including age, race/ethnicity and comorbidities. We stratified CKD awareness by 5 pre-defined calendar-year periods and conducted all analyses for the complete study population as well as the Caucasian and African American subpopulations. We found that among 101871 US persons participating in NHANES, 4411 (2232 women) had CKD in stages G3-G5. These participants were, on average, 73±10 years old, 25.3% reported diabetes, 78.0% reported hypertension or had elevated blood pressure during medical examinations and 39.8% were obese (percentages were survey-weighted). CKD awareness was more prevalent among those with higher CKD stage, younger age, diabetes, hypertension and higher body mass index. CKD awareness was generally low (<22.5%), though it increased throughout the study period, remaining consistently higher among men compared to women, with a decreasing gender gap over time (adjusted odds ratio [men-to-women] for CKD awareness = 2.71 [1.31-5.64] in period 1; = 1.32 [0.82-2.12] in period 5). The sex difference in CKD awareness was smaller in African American participants, in whom CKD awareness was generally higher. Using serum creatinine rather than eGFR as the CKD-defining exposure, CKD awareness increased with rising serum creatinine, in a close to identical fashion among both sexes during 1999-2008, while during 2009-2018, CKD awareness among women increased earlier than among men (i.e. with lower serum creatinine levels). CONCLUSIONS CKD awareness is lower among US women than men. The narrowing gap between the sexes in more recent years and the results on CKD awareness by serum creatinine indicate that health care professionals have previously been relying on serum creatinine to inform patients about their condition, but in more recent years have been using eGFR, which accounts for women's lower serum creatinine levels due to their lower muscle mass. Additional efforts should be made to increase CKD awareness among both sexes.
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Dias GF, Grobe N, Rogg S, Jörg DJ, Pecoits-Filho R, Moreno-Amaral AN, Kotanko P. The Role of Eryptosis in the Pathogenesis of Renal Anemia: Insights From Basic Research and Mathematical Modeling. Front Cell Dev Biol 2020; 8:598148. [PMID: 33363152 PMCID: PMC7755649 DOI: 10.3389/fcell.2020.598148] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 10/16/2020] [Indexed: 12/17/2022] Open
Abstract
Red blood cells (RBC) are the most abundant cells in the blood. Despite powerful defense systems against chemical and mechanical stressors, their life span is limited to about 120 days in healthy humans and further shortened in patients with kidney failure. Changes in the cell membrane potential and cation permeability trigger a cascade of events that lead to exposure of phosphatidylserine on the outer leaflet of the RBC membrane. The translocation of phosphatidylserine is an important step in a process that eventually results in eryptosis, the programmed death of an RBC. The regulation of eryptosis is complex and involves several cellular pathways, such as the regulation of non-selective cation channels. Increased cytosolic calcium concentration results in scramblase and floppase activation, exposing phosphatidylserine on the cell surface, leading to early clearance of RBCs from the circulation by phagocytic cells. While eryptosis is physiologically meaningful to recycle iron and other RBC constituents in healthy subjects, it is augmented under pathological conditions, such as kidney failure. In chronic kidney disease (CKD) patients, the number of eryptotic RBC is significantly increased, resulting in a shortened RBC life span that further compounds renal anemia. In CKD patients, uremic toxins, oxidative stress, hypoxemia, and inflammation contribute to the increased eryptosis rate. Eryptosis may have an impact on renal anemia, and depending on the degree of shortened RBC life span, the administration of erythropoiesis-stimulating agents is often insufficient to attain desired hemoglobin target levels. The goal of this review is to indicate the importance of eryptosis as a process closely related to life span reduction, aggravating renal anemia.
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Guedes M, Pecoits-Filho R, Leme JEG, Jiao Y, Raimann JG, Wang Y, Kotanko P, de Moraes TP, Thadhani R, Maddux FW, Usvyat LA, Larkin JW. Impacts of dialysis adequacy and intradialytic hypotension on changes in dialysis recovery time. BMC Nephrol 2020; 21:529. [PMID: 33287719 PMCID: PMC7720452 DOI: 10.1186/s12882-020-02187-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 11/25/2020] [Indexed: 11/22/2022] Open
Abstract
Background Dialysis recovery time (DRT) surveys capture the perceived time after HD to return to performing regular activities. Prior studies suggest the majority of HD patients report a DRT > 2 h. However, the profiles of and modifiable dialysis practices associated with changes in DRT relative to the start of dialysis are unknown. We hypothesized hemodialysis (HD) dose and rates of intradialytic hypotension (IDH) would associate with changes in DRT in the first years after initiating dialysis. Methods We analyzed data from adult HD patients who responded to a DRT survey ≤180 days from first date of dialysis (FDD) during 2014 to 2017. DRT survey was administered with annual KDQOL survey. DRT survey asks: “How long does it take you to be able to return to your normal activities after your dialysis treatment?” Answers are: < 0.5, 0.5-to-1, 1-to-2, 2-to-4, or > 4 h. An adjusted logistic regression model computed odds ratio for a change to a longer DRT (increase above DRT > 2 h) in reference to a change to a shorter DRT (decrease below DRT < 2 h, or from DRT > 4 h). Changes in DRT were calculated from incident (≤180 days FDD) to first prevalent (> 365-to- ≤ 545 days FDD) and second prevalent (> 730-to- ≤ 910 days FDD) years. Results Among 98,616 incident HD patients (age 62.6 ± 14.4 years, 57.8% male) who responded to DRT survey, a higher spKt/V in the incident period was associated with 13.5% (OR = 0.865; 95%CI 0.801-to-0.935) lower risk of a change to a longer DRT in the first-prevalent year. A higher number of HD treatments with IDH episodes per month in the incident period was associated with a 0.8% (OR = 1.008; 95%CI 1.001-to-1.015) and 1.6% (OR = 1.016; 95%CI 1.006-to-1.027) higher probability of a change to a longer DRT in the first- and second-prevalent years, respectively. Consistently, an increased in incidence of IDH episodes/months was associated to a change to a longer DRT over time. Conclusions Incident patients who had higher spKt/V and less sessions with IDH episodes had a lower likelihood of changing to a longer DRT in first year of HD. Dose optimization strategies with cardiac stability in fluid removal should be tested. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-020-02187-9.
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Baumgart A, Manera KE, Johnson DW, Craig JC, Shen JI, Ruiz L, Wang AYM, Yip T, Fung SKS, Tong M, Lee A, Cho Y, Viecelli AK, Sautenet B, Teixeira-Pinto A, Brown EA, Brunier G, Dong J, Scholes-Robertson N, Dunning T, Mehrotra R, Naicker S, Pecoits-Filho R, Perl J, Wilkie M, Tong A. Meaning of empowerment in peritoneal dialysis: focus groups with patients and caregivers. Nephrol Dial Transplant 2020; 35:1949-1958. [PMID: 32712672 PMCID: PMC7824999 DOI: 10.1093/ndt/gfaa127] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/21/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND While peritoneal dialysis (PD) can offer patients more independence and flexibility compared with in-center hemodialysis, managing the ongoing and technically demanding regimen can impose a burden on patients and caregivers. Patient empowerment can strengthen capacity for self-management and improve treatment outcomes. We aimed to describe patients' and caregivers' perspectives on the meaning and role of patient empowerment in PD. METHODS Adult patients receiving PD (n = 81) and their caregivers (n = 45), purposively sampled from nine dialysis units in Australia, Hong Kong and the USA, participated in 14 focus groups. Transcripts were thematically analyzed. RESULTS We identified six themes: lacking clarity for self-management (limited understanding of rationale behind necessary restrictions, muddled by conflicting information); PD regimen restricting flexibility and freedom (burden in budgeting time, confined to be close to home); strength with supportive relationships (gaining reassurance with practical assistance, comforted by considerate health professionals, supported by family and friends); defying constraints (reclaiming the day, undeterred by treatment, refusing to be defined by illness); regaining lost vitality (enabling physical functioning, restoring energy for life participation); and personal growth through adjustment (building resilience and enabling positive outlook, accepting the dialysis regimen). CONCLUSIONS Understanding the rationale behind lifestyle restrictions, practical assistance and family support in managing PD promoted patient empowerment, whereas being constrained in time and capacity for life participation outside the home undermined it. Education, counseling and strategies to minimize the disruption and burden of PD may enhance satisfaction and outcomes in patients requiring PD.
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Guedes M, Dambiski AC, Canhada S, Barra ABL, Poli-de-Figueiredo CE, Cuvello Neto AL, Canziani MEF, Strogoff-de-Matos JP, Raimann JG, Larkin J, Canaud B, Pecoits-Filho R. Achieving high convective volume in hemodiafiltration: Lessons learned after successful implementation in the HDFit trial. Hemodial Int 2020; 25:50-59. [PMID: 33058473 DOI: 10.1111/hdi.12891] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 08/19/2020] [Accepted: 09/17/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES High-volume online hemodiafiltration (OL-HDF) associates with improved outcomes compared to hemodialysis (HD), provided adequate dosing is achieved as estimated from convective volume (CV). Achievement of high CV and its impact on biochemical indicators following a standardized protocol converting HD patients to OL-HDF has not been systematically reported. We assessed the success of implementation of OL-HDF in clinics naïve to the modality. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS We analyzed the results of the implementation of postdilution OL-HDF in patients randomized to the HDF arm of a clinical trial (impact of hemoDiaFIlTration on physical activity and self-reported outcomes: a randomized controlled trial (HDFit) trial [ClinicalTrials.gov:NCT02787161]). The day before randomization of the first patient to OL-HDF at each clinic staff started a 3-day in-person training module on operation of Fresenius 5008 CorDiax machine in HDF mode. Patients were converted from high-flux HD to OL-HDF under oversight of trainers. OL-HDF was performed over a 6-months follow-up with a CV target of 22 L/treatment. We characterized median achieved CV >22 L/treatment record and analyzed the impact of HDF on biochemical variables. RESULTS Ninety-seven patients (mean age 53 ± 16 years, 29% with diabetes, and 11% had a catheter) from 13 clinics randomized to the OL-HDF arm of the trial were converted from HD to HDF. Median CV > 22 L/treatment was achieved in 99% (94/95) of OL-HDF patients throughout follow-up. Monthly mean CV ranged from 27.1 L to 27.5 L. OL-HDF provided an increased single pool Kt/V at 3-months (0.2 [95% CI: 0.1-0.3]) and 6-months (0.2 [95% CI: 0.1-0.4]) compared to baseline, and reduced phosphate at 3-months (-0.4 mg/dL [95% CI: -0.8 to -0.12]) of follow-up. CONCLUSIONS High-volume online hemodiafiltration was successfully implemented with 99% of patients achieving protocol defined CV target. Monthly mean CV was consistently >22 L/treatment during follow-up. Kt/V increased, and phosphate decreased with OL-HDF. Findings resulting from a short training period in several dialysis facilities appear to suggest HDF is an easily implementable technique.
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Kang A, Sukkar L, Hockham C, Jun M, Young T, Scaria A, Foote C, Neuen BL, Cass A, Pollock C, Comino E, Lung T, Pecoits-Filho R, Rogers K, Jardine MJ. Risk Factors for Incident Kidney Disease in Older Adults: an Australian Prospective Population-Based Study. Intern Med J 2020; 52:808-817. [PMID: 33012112 DOI: 10.1111/imj.15074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/23/2020] [Accepted: 09/30/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND We aimed to determine risk factors for incident CKD in a large population-based cohort. METHODS This prospective opt-in population-based cohort study is based on the 45 and Up Study, where New South Wales residents aged ≥45 years were randomly sampled from the Services Australia enrolment database and agreed to complete the 45 and Up Study baseline questionnaire and have their responses linked to their health data in routinely-collected databases. The primary outcome was the development of incident CKD, defined as eGFR<60ml/min/1.73m2 . CKD incidence was calculated using Poisson regression. Risk factors for incident CKD were assessed using Cox regression in multivariable models. RESULTS In 39,574 participants who did not have CKD at enrolment, independent factors associated with developing CKD included: older age, regional residence (HR 1.38 [1.27-1.50] for outer regional versus major city), smoking (1.13 [1.00-1.27] for current smoker versus non-smoker), obesity (1.25 [1.16-1.35] for obese versus normal body mass index), diabetes mellitus (1.41 [1.33-1.50]), hypertension (1.53 [1.44-1.62]), coronary heart disease (1.13 [1.07-1.20]), depression/anxiety (1.16 [1.09-1.24]), and cancer (1.29 [1.20-1.39]). Migrants were less likely to develop CKD compared with people born in Australia (0.88 [0.83-0.94]). Gender, partner status and socioeconomic factors were not independently associated with developing CKD. CONCLUSIONS This large population-based study found multiple modifiable and non-modifiable factors were independently associated with developing CKD. In the Australian setting, the risk of CKD was higher with regional residence. Differences according to socioeconomic status were predominantly explained by age, comorbidities and harmful health-related behaviours This article is protected by copyright. All rights reserved.
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Clase CM, Fu EL, Ashur A, Beale RCL, Clase IA, Dolovich MB, Jardine MJ, Joseph M, Kansiime G, Mann JFE, Pecoits-Filho R, Winkelmayer WC, Carrero JJ. Forgotten Technology in the COVID-19 Pandemic: Filtration Properties of Cloth and Cloth Masks-A Narrative Review. Mayo Clin Proc 2020; 95:2204-2224. [PMID: 33012350 PMCID: PMC7834536 DOI: 10.1016/j.mayocp.2020.07.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022]
Abstract
Management of the global crisis of the coronavirus disease 2019 pandemic requires detailed appraisal of evidence to support clear, actionable, and consistent public health messaging. The use of cloth masks for general public use is being debated, and is in flux. We searched the MEDLINE and EMBASE databases and Google for articles reporting the filtration properties of flat cloth or cloth masks. We reviewed the reference lists of relevant articles to identify further articles and identified articles through social and conventional news media. We found 25 articles. Study of protection for the wearer used healthy volunteers, or used a manikin wearing a mask, with airflow to simulate different breathing rates. Studies of protection of the environment, also known as source control, used convenience samples of healthy volunteers. The design and execution of the studies was generally rigorously described. Many descriptions of cloth lacked the detail required for reproducibility; no study provided all the expected details of material, thread count, weave, and weight. Some of the homemade mask designs were reproducible. Successful masks were made of muslin at 100 threads per inch (TPI) in 3 to 4 layers (4-layer muslin or a muslin-flannel-muslin sandwich), tea towels (also known as dish towels), made using 1 layer (2 layers would be expected to be better), and good-quality cotton T-shirts in 2 layers (with a stitched edge to prevent stretching). In flat-cloth experiments, linen tea towels, 600-TPI cotton in 2 layers, and 600-TPI cotton with 90-TPI flannel performed well but 80-TPI cotton in 2 layers did not. We therefore recommend cotton or flannel at least 100 TPI, at least 2 layers. More layers, 3 or 4, will provide increased filtration but there is a trade-off in that more layers increases the resistance to breathing. Although this is not a systematic review, we included all the articles that we identified in an unbiased way. We did not include gray literature or preprints. A plain language summary of these data and recommendations, as well as information on making, wearing and cleaning cloth masks is available at www.clothmasks.ca.
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Lindner G, Burdmann EA, Clase CM, Hemmelgarn BR, Herzog CA, Małyszko J, Nagahama M, Pecoits-Filho R, Rafique Z, Rossignol P, Singer AJ. Acute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference. Eur J Emerg Med 2020; 27:329-337. [PMID: 32852924 PMCID: PMC7448835 DOI: 10.1097/mej.0000000000000691] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/17/2020] [Indexed: 11/30/2022]
Abstract
Hyperkalemia is a common electrolyte disorder observed in the emergency department. It is often associated with underlying predisposing conditions, such as moderate or severe kidney disease, heart failure, diabetes mellitus, or significant tissue trauma. Additionally, medications, such as inhibitors of the renin-angiotensin-aldosterone system, potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs, succinylcholine, and digitalis, are associated with hyperkalemia. To this end, Kidney Disease: Improving Global Outcomes (KDIGO) convened a conference in 2018 to identify evidence and address controversies on potassium management in kidney disease. This review summarizes the deliberations and clinical guidance for the evaluation and management of acute hyperkalemia in this setting. The toxic effects of hyperkalemia on the cardiac conduction system are potentially lethal. The ECG is a mainstay in managing hyperkalemia. Membrane stabilization by calcium salts and potassium-shifting agents, such as insulin and salbutamol, is the cornerstone in the acute management of hyperkalemia. However, only dialysis, potassium-binding agents, and loop diuretics remove potassium from the body. Frequent reevaluation of potassium concentrations is recommended to assess treatment success and to monitor for recurrence of hyperkalemia.
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Clase CM, Fu EL, Joseph M, Beale RCL, Dolovich MB, Jardine M, Mann JFE, Pecoits-Filho R, Winkelmayer WC, Carrero JJ. Cloth Masks May Prevent Transmission of COVID-19: An Evidence-Based, Risk-Based Approach. Ann Intern Med 2020; 173:489-491. [PMID: 32441991 PMCID: PMC7277485 DOI: 10.7326/m20-2567] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
As the COVID-19 pandemic progressed across the world, governments, international agencies, policymakers, and public health officials began recommending widespread use of nonmedical cloth masks to reduce the transmission of SARS-CoV-2. The authors of this article suggest that there is convincing evidence to support this recommendation.
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Hoshino J, Muenz D, Zee J, Sukul N, Speyer E, Guedes M, Lopes AA, Asahi K, van Haalen H, James G, Dhalwani N, Pecoits-Filho R, Bieber B, Robinson BM, Pisoni RL, Lopes A, Pecoits-Filho R, Combe C, Jacquelinet C, Massy Z, Stengel B, Duttlinger J, Fliser D, Lonnemann G, Reichel H, Wada T, Yamagata K, Pisoni R, Robinson B, Calice da Silva V, Sesso R, Speyer E, Asahi K, Hoshino J, Narita I, Perlman R, Port F, Sukul N, Wong M, Young E, Zee J. Associations of Hemoglobin Levels With Health-Related Quality of Life, Physical Activity, and Clinical Outcomes in Persons With Stage 3-5 Nondialysis CKD. J Ren Nutr 2020; 30:404-414. [DOI: 10.1053/j.jrn.2019.11.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 11/04/2019] [Accepted: 11/09/2019] [Indexed: 11/11/2022] Open
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Rigo M, Pecoits-Filho R, Lambie M, Tuon FF, Barretti P, de Moraes TP. Clinical utility of a traditional score system for the evaluation of the peritoneal dialysis exit-site infection in a national multicentric cohort study. Perit Dial Int 2020; 41:292-297. [PMID: 32856533 DOI: 10.1177/0896860820949032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Exit-site infection (ESI) is an important risk factor for peritonitis in patients under chronic peritoneal dialysis (PD). The International Society for Peritoneal Dialysis (ISPD) recommend its diagnosis as the presence of purulent drainage in the exit site (ES) but time-consuming scores using others skin signs are routinely used. OBJECTIVE To investigate the correlation between the diagnosis of ESI with a score based on five clinical signs obtained from ES inspection, and also if there are interaction with patient's race. METHODS Multicenter and prospective cohort. We included adult patients from 122 clinics, incident on PD and with a 12-month stay in therapy. The event of interest was ESI, defined as purulent drainage. The clinical score used was composed of hyperemia, edema, pain, scab, and granuloma. Statistical analysis was performed using multilevel logistic regression model, likelihood test, and Cohen concordance analysis. RESULTS A total of 35,354 ES assessments were performed during the first year of dialysis in 3297 patients. There was a rate of 10.1 (9.1-11.2) episodes of ESI per 1000 patients/month. In patients with ESI, the prevalence of hyperemia was 55.9%, edema 67.3%, pain 31.8%, and scab 23.2%. The agreement with the score was 60.6% and showed differences according to the patient's race, being 53.2% for African Americans descendants and 65.4% for others. The use of scales for the diagnosis of ESI does not add much information in addition to the presence of purulent secretion as currently recommended by the ISPD.
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Guedes M, Robinson BM, Obrador G, Tong A, Pisoni RL, Pecoits-Filho R. Management of Anemia in Nondialysis Chronic Kidney Disease: Current Recommendations, Real-World Practice, and Patient Perspectives. KIDNEY360 2020; 1:855-862. [PMID: 35372964 DOI: 10.34067/kid.0001442020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/11/2020] [Indexed: 12/19/2022]
Abstract
In nondialysis CKD (ND-CKD), anemia is a multifactorial and complex condition in which several dysfunctions dynamically contribute to a reduction in circulating hemoglobin (Hb) levels in red blood cells. Anemia is common in CKD and represents an important and modifiable risk factor for poor clinical outcomes. Importantly, symptoms related to anemia, including reduced physical functioning and fatigue, have been identified as high priorities by patients with CKD. The current management of anemia in ND-CKD (i.e., parameters to initiate treatment, Hb and iron indexes targets, choice of therapies, and effect of treatment on clinical and patient-reported outcomes) remains controversial. In this review article, we explore the epidemiology of anemia in ND-CKD and revise current recommendations and controversies in its management. Exploring data from real-world clinical practices, particularly from the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps), we highlight the current challenges to translating current recommendations to clinical practice, providing patients' perspectives of anemia and how it affects their quality of life. Finally, we summarize recent advances in the field of anemia that may change the way this condition will be managed in the future.
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Leme J, Guedes M, Larkin J, Han M, Barra ABL, Canziani MEF, Cuvello Neto AL, Poli-de-Figueiredo CE, de Moraes TP, Pecoits-Filho R. Patient perception of vitality and measured physical activity in patients receiving haemodialysis. Nephrology (Carlton) 2020; 25:865-871. [PMID: 32706161 DOI: 10.1111/nep.13758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 11/30/2022]
Abstract
AIM Fatigue in haemodialysis (HD) patients can be captured in quality of life questionnaires and by the dialysis recovery time (DRT) question. The associations between fatigue and measured physical activity has not been explored until the present. We tested our hypothesis that the patient perception of chronic and post dialysis fatigue would be associated with lower physical activity. METHODS This study was a cross sectional evaluation of baseline data from HD patients recruited in the HDFIT trial. Vitality scores from the Kidney Disease Quality of Life (KDQOL-36) and the dialysis recovery time (DRT) question were used as indicators of chronic and post dialysis fatigue, respectively. Granular physical activity was measured by accelerometers as part of the study protocol. RESULTS Among 176 patients, Vitality score was 63 ± 21 and the DRT was ≤30 minutes in 57% of patients. The mean number of steps was 5288 ± 3540 in 24 hours after HD and 953 ± 617 in the 2-hour post-HD period. The multivariable analysis confirmed Vitality scores were associated with physical activity in the 24-hour post-HD period. In contrast, DRT was not associated with physical activity captured by the accelerometer in the period immediately (2 hours) after the HD session. CONCLUSION Chronic fatigue was negatively associated with step counts, while patient perception of post-dialysis fatigue was not associated with physical activity. These patterns indicate limitations in interpretation of DRT. Since physical activity is an important component of a healthy life, our results may partially explain the associations between fatigue and poor outcomes in HD patients.
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Roth-Stefanski CT, Dolenga C, Nakao LS, Pecoits-Filho R, de Moraes TP, Moreno-Amaral AN. Pilot Study of Probiotic Supplementation on Uremic Toxicity and Inflammatory Cytokines in Chronic Kidney Patients. CURRENT NUTRITION & FOOD SCIENCE 2020. [DOI: 10.2174/1573401315666190215111402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Bacterial metabolism contributes to the generation of uremic toxins in patients
with chronic kidney disease (CKD). It has been investigated the use of probiotics in the reduction
of uremic toxins intestinal production.
Objective:
The aim of this pilot study was to evaluate the effect of probiotic supplementation on reducing
the production of uremic toxins and the inflammatory profile of CKD patients.
Methods:
We performed a randomized, blind, placebo-controlled, crossover study on patients with
CKD stages 3 and 4. The intervention was a probiotic formulation composed of Lactobacillus
acidophilus strains given orally three times a day for 3 months. Changes in uremic toxins
(p-Cresylsulfate and Indoxyl Sulfate) and serum inflammatory cytokines were the primary endpoints.
Results:
Of the 44 patients randomized, 25 completed the study (mean age 51 ± 9.34, 64% female,
mean eGFR 36 ± 14.26 mL/min/1.73m², mean BMI 28.5 ± 5.75 kg/m²). At 3 months, there were no
significant changes in any of the studied biomarkers including p-cresylsulfate (p = 0.57), Indoxyl sulfate
(p = 0.08) and interleukin-6 (p = 0.55).
Conclusion:
Lactobacillus acidophilus strains given as probiotic were not able to reduce serum levels
of uremic toxins and biomarkers of inflammation in CKD patients in stage 3 and 4.
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Guedes M, Guetter CR, Erbano LHO, Palone AG, Zee J, Robinson BM, Pisoni R, de Moraes TP, Pecoits-Filho R, Baena CP. Physical health-related quality of life at higher achieved hemoglobin levels among chronic kidney disease patients: a systematic review and meta-analysis. BMC Nephrol 2020; 21:259. [PMID: 32641153 PMCID: PMC7346455 DOI: 10.1186/s12882-020-01912-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 06/26/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The impact of anemia treatment with erythropoietin stimulating agents (ESA) on health-related quality of life (HRQOL) in chronic kidney disease (CKD) patients is controversial, particularly regarding optimal hemoglobin (Hb) target ranges. METHODS We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCT) with ESA to estimate the effect of different achieved Hb values on physical HRQOL and functionality. We searched PubMed, EMBASE, CENTRAL, PEDro, PsycINFO and Web of Science databases, until May 2020. Two authors independently extracted data from studies. We included observational and RCTs that enrolled CKD patients undergoing anemia treatment with ESA with different achieved Hb levels among groups. We excluded studies with achieved Hb < 9 g/dL. For the meta-analysis, we included RCTs with control groups achieving Hb 10-11.5 g/dL and active groups with Hb > 11.5 g/dL. We analyzed the standardized mean difference (SMD) between groups for physical HRQOL. RESULTS Among 8496 studies, fifteen RCTs and five observational studies were included for the systematic review. We performed the meta-analysis in a subset of eleven eligible RCTs. For physical role and physical function, SMDs were 0.0875 [95% CI: - 0.0025 - 0.178] and 0.08 [95% CI: - 0.03 - 0.19], respectively. For fatigue, SMD was 0.16 [95% CI: 0.09-0.24]. Subgroup analysis showed that trials with greater achieved Hb had greater pooled effects sizes - 0.21 [95% CI: 0.07-0.36] for Hb > 13 g/dL vs. 0.09 [95% CI: 0.02-0.16] for Hb 11.5-13 g/dL. Proportion of older and long-term diabetic patients across studies were associated with lower effect sizes. CONCLUSION Achieved hemoglobin higher than currently recommended targets may be associated with small but potentially clinically significant improvement in fatigue, but not in physical role or physical function. Younger and non-diabetic patients may experience more pronounced benefits of higher Hb levels after treatment with ESAs.
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O'Lone E, Viecelli AK, Craig JC, Tong A, Sautenet B, Herrington WG, Herzog CA, Jafar TH, Jardine M, Krane V, Levin A, Malyszko J, Rocco MV, Strippoli G, Tonelli M, Wang AYM, Wanner C, Zannad F, Winkelmayer WC, Wheeler DC, Craig JC, Tong A, Manns B, Pecoits-Filho R, Harris T, Wheeler DC, Winkelmayer W, Levin A, O'Lone E, Herrington WG, Herzog CA, Rocco MV, Strippoli G, Jardine M, Kleinpeter M, Ju A, Cho Y, Gutman T, Bernier-Jean A, James L, Hamiwka L, Viecelli AK, Jardine A, Bello A, Stengel B, Schiller B, Johnson D, Bavlovlenkov E, Caskey F, Gillespie B, Block G, Phan HA, Heerspink HL, Madero M, Ruospo M, Unruh M, Laville M, Bansal N, Mark P, Blankestijn P, Roy-Chaudhury P, Perlman R, Agarwal R, Mehrotra R, Seliger S, Shafi T, Hiemstra T, Jassal V, Perkovic V, Simplice A, White D, Eilers D, Alexander H, Landry Y, Landry G, Wilkie C. Establishing Core Cardiovascular Outcome Measures for Trials in Hemodialysis: Report of an International Consensus Workshop. Am J Kidney Dis 2020; 76:109-120. [DOI: 10.1053/j.ajkd.2020.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 01/17/2020] [Indexed: 01/08/2023]
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Ferreira Dias G, Bohnen G, Grobe N, Tao X, Pecoits-Filho R, Kotanko P, Moreno-Amaral AN. P0946OXIDATIVE STRESS AND HEME METABOLISM IN RED BLOOD CELLS FROM HEMODIALYSIS PATIENTS. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p0946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Aims
We have previously described that indoxyl sulfate promotes red blood cells (RBC) ROS generation through organic anion transporter 2 as well as NADPH oxidase activity-dependent and GSH-independent mechanisms (Dias et al., 2018). However, there is little information regarding pathways of antioxidant balance to protect RBC from extensive oxidative stress that occurs during hemodialysis (HD). Intracellular free heme is degraded by Heme Oxygenase 1 (HO-1), which is regarded as the major cytoprotective enzyme (Maines, 1988; Gozzelino et al., 2010). In the current study, we assessed HO-1 activity and ROS production in RBC from healthy subjects and hemodialysis (HD) patients before and after HD.
Method
Blood was drawn from 6 healthy individuals (CON-RBC) and 6 HD patients (HD-RBC) before (pre/HD-RBC) and after high flux HD (post/HD-RBC). Isolated RBC were stained with DCFH-DA (Abcam) for ROS measurements. To quantify HO-1, RBC were incubated with anti-HO-1 antibody (Abcam) and m-IgGκ BP-CFL 488 (Santa Cruz Biotechnology) as a secondary antibody. Samples were analyzed by flow cytometry.
Results
Our results show a 4-fold increase in ROS levels in pre/HD-RBC compared to CON-RBC. ROS levels were even further increased by 1.65-fold after HD treatment in post/HD-RBC (Figure 1). Both pre/HD-RBC and post/HD-RBC showed a similarly significant increase of 3.3-fold in HO-1 compared to CON-RBC. (Figure 1).
Conclusion
High levels of HO-1 may represent a defense against oxidative stress that occurs in ESKD and particularly during the HD session. Further research is needed to evaluate whether HO-1 overexpression could accelerate heme degradation and contribute to renal anemia.
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Batalha G, Eugênia Canziani M, Guedes M, Almeida AC, Moreno-Amaral AN, Barra AB, Cuvello A, Poli De Figueiredo CE, Pecoits-Filho R. P0855ASSOCIATIONS BETWEEN A COMPREHENSIVE PANEL OF BIOMARKERS WITH ESA HYPORESPONSIVENESS: ROLE OF IMMUNE DYSFUNCTION IN THE PATHOPHYSIOLOGY OF CKD ANEMIA. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p0855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background and Aims
An inadequate response to the treatment of anemia with erythropoiesis-stimulating agents (ESAs) in patients with chronic kidney disease is a challenging and common clinical condition previously associated with signs of inflammation and episodic clinical events. The associations between different immune response pathways and ESA hyporesponsiveness remain poorly understood. Here we describe the associations between a comprehensive panel of inflammatory biomarkers and ESA resistance in a group of stable HD patients.
Method
This is post-hoc analysis of the baseline evaluation of patients enrolled in the HDFIT, a randomized controlled trial. A panel comprising a more general (CRP), innate (IL-1β and IL-6), adaptive (IFNγ, IFNα2) biomarkers of immune response, and also a specific vascular inflammation (MCP-1) biomarkers were simultaneously measured with the same serum sample through turbidimetry and Milliplex Human Cytokine Magnetic Bead Panel - EMD Milipore Corporation, USA. Multivariable analysis was used to assess the association of their concentrations with the erythropoietin resistance index (ERI), defined as the weekly ESA dose divided by hemoglobin level.
Results
A total of 155 patients were included in this analysis (mean age 52 ± 6; 70% male; 32% with diabetes; mean hemoglobin 11.7 ± 1.5; median ESA dose/week 8000 IU IQR: 4000-12.000). Patients in the highest ERI tercile were mostly female, younger, more diabetic and with slightly higher proportion of iron prescription compared to those in the lowest tercile of ERI. The multivariable models adjusted for age, sex, diabetes and vascular access demonstrated that higher serum levels of IL-1β and IFN-γ were associated with higher ESA resistance, while there were no detectable associations of serum levels of IL-6 or CRP and ERI.
Conclusion
Among the biomarkers included in this comprehensive panel of biomarkers representing the multilevel nature of immune dysfunction in CKD, we observed associations between higher concentrations of innate (IL-1β) and adaptive (IFN) immune response and ESA hyporesponsiveness. Our results support the role of immune dysfunction in the pathophysiology of CKD anemia.
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