51
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Evans RDR, Smyth B, Levin A, Jha V, Wheeler DC, Jardine M, Perkovic V, Damster S, Malik C, de Zeeuw D, Hiemstra T. The International Society of Nephrology Advancing Clinical Trials (ISN-ACT) Network: current activities and future goals. Kidney Int 2021; 99:551-554. [PMID: 33309956 DOI: 10.1016/j.kint.2020.10.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/19/2020] [Accepted: 10/26/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Rhys D R Evans
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brendan Smyth
- Innovation and Kidney Research, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vivek Jha
- The George Institute for Global Health, New Delhi, India
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK.
| | - Meg Jardine
- Innovation and Kidney Research, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Vlado Perkovic
- Innovation and Kidney Research, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Charu Malik
- The International Society of Nephrology, Brussels, Belgium
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Thomas Hiemstra
- Cambridge Clinical Trials Unit, University of Cambridge, Cambridge, UK; Department of Medicine, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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52
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Kobayashi K, Toyoda M, Hatori N, Furuki T, Sakai H, Sato K, Miyakawa M, Tamura K, Kanamori A. Sodium-glucose cotransporter 2 inhibitor-induced reduction in the mean arterial pressure improved renal composite outcomes in type 2 diabetes mellitus patients with chronic kidney disease: A propensity score-matched model analysis in Japan. J Diabetes Investig 2021; 12:1408-1416. [PMID: 33377605 PMCID: PMC8354503 DOI: 10.1111/jdi.13491] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/30/2020] [Accepted: 12/27/2020] [Indexed: 12/30/2022] Open
Abstract
Aims/Introduction Large‐scale clinical trials have reported that, in patients with type 2 diabetes mellitus, sodium–glucose cotransporter 2 (SGLT2) inhibitor treatment affords favorable renal outcomes; the underlying mechanisms, however, remain unclear. Thus, this study investigated how SGLT2 inhibitor‐induced changes in the mean arterial pressure (MAP; denoted as ΔMAP) are associated with renal outcomes in type 2 diabetes mellitus patients with chronic kidney disease (CKD). Materials and Methods We retrospectively assessed the data of 624 Japanese type 2 diabetes mellitus patients with CKD who had been using SGLT2 inhibitors for >1 year. For propensity score matching (1:1 nearest neighbor match, with caliper value = 0.053, no replacement), patients were categorized into two groups based on the ΔMAP (>−4 mmHg [n = 329] and ≤−4.0 mmHg [n = 295]). Composite albuminuria progression or a ≥15% annual reduction in the estimated glomerular filtration rate was regarded as the end‐point. Results Per group, 173 propensity‐matched patients were compared. Patients with ΔMAP ≤−4 mmHg had a significantly lower incidence of composite renal outcomes than those with ΔMAP ≥−4 mmHg (5.8% [n = 10] vs 15.6% [n = 27], P = 0.003). Although the between‐group differences in the estimated glomerular filtration rates were non‐significant, patients with a ΔMAP ≤−4 mmHg had significantly larger reductions in the logarithmic urine albumin‐to‐creatinine ratio (P = 0.005). Conclusions The degree of blood pressure reduction after SGLT2 inhibitor treatment influenced renal composite outcomes in Japanese type 2 diabetes mellitus patients with CKD, confirming the importance of blood pressure management in type 2 diabetes mellitus patients with CKD, even when they are under SGLT2 inhibitor treatment.
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Affiliation(s)
- Kazuo Kobayashi
- Committee of Hypertension and Kidney disease, Kanagawa Physicians Association, Yokohama, Japan.,Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masao Toyoda
- Committee of Hypertension and Kidney disease, Kanagawa Physicians Association, Yokohama, Japan.,Department of internal medicine, Division of Nephrology, Endocrinology and Metabolism, Tokai University School of Medicine, lsehara, Japan
| | - Nobuo Hatori
- Committee of Hypertension and Kidney disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Takayuki Furuki
- Committee of Hypertension and Kidney disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Hiroyuki Sakai
- Committee of Hypertension and Kidney disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Kazuyoshi Sato
- Committee of Hypertension and Kidney disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Masaaki Miyakawa
- Committee of Hypertension and Kidney disease, Kanagawa Physicians Association, Yokohama, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akira Kanamori
- Committee of Hypertension and Kidney disease, Kanagawa Physicians Association, Yokohama, Japan
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53
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Natale P, Saglimbene V, Ruospo M, Gonzalez AM, Strippoli GF, Scholes-Robertson N, Guha C, Craig JC, Teixeira-Pinto A, Snelling T, Tong A. Transparency, trust and minimizing burden to increase recruitment and retention in trials: a systematic review. J Clin Epidemiol 2021; 134:35-51. [PMID: 33515656 DOI: 10.1016/j.jclinepi.2021.01.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/08/2021] [Accepted: 01/21/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To describe patient perspectives on recruitment and retention in clinical trials. STUDY DESIGN AND SETTING Systematic review of qualitative studies that reported the perspective of adult patients with any health condition who accepted or declined to participate in clinical trials. RESULTS Sixty-three articles involving 1681 adult patients were included. Six themes were identified. Four themes reflected barriers: ambiguity of context and benefit - patients were unaware of the research question and felt pressured in making decisions; lacking awareness of opportunities - some believed health professionals obscured trials opportunities, or felt confused because of language barriers; wary of added burden - patients were without capacity because of sickness or competing priorities; and skepticism, fear and mistrust - patients feared loss of privacy, were suspicious of doctor's motivation, afraid of being a guinea pig, and disengaged from not knowing outcomes. Two themes captured facilitators: building confidence - patients hoped for better treatment, were supported from family members and trusted medical staff; and social gains and belonging to the community - altruism, a sense of belonging and peer encouragement motivated participation in trials. CONCLUSION Improving the visibility and transparency of trials, supporting informed decision making, minimizing burden, and ensuring confidence and trust may improve patient participation in trials.
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Affiliation(s)
- Patrizia Natale
- Sydney School of Public Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia; Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.
| | - Valeria Saglimbene
- Sydney School of Public Health, University of Sydney, Sydney, Australia; Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Marinella Ruospo
- Sydney School of Public Health, University of Sydney, Sydney, Australia; Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Andrea Matus Gonzalez
- Sydney School of Public Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, University of Sydney, Sydney, Australia; Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Nicole Scholes-Robertson
- Sydney School of Public Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Chandana Guha
- Sydney School of Public Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Tom Snelling
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
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54
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Bacharaki D, Diamandopoulos A. Emperor's syndrome in the COVID-19 era: Time for patient-centered nephrology? World J Nephrol 2021; 10:1-7. [PMID: 33552939 PMCID: PMC7829681 DOI: 10.5527/wjn.v10.i1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/04/2020] [Accepted: 11/11/2020] [Indexed: 02/06/2023] Open
Abstract
The coronavirus disease-19 (COVID-19) pandemic has been a wake-up call in which has forced us to react worldwide. Health policies and practices have attracted particular attention in terms of human and financial cost. Before COVID-19, chronic kidney disease was already considered a risk multiplier in patients with diabetes and hypertension, the two now being the major risk factors for COVID-19 infection and adverse outcome. In contrast to the urgent need for action, the nephrology field is considered to be in a state of stagnation regarding the management of chronic kidney disease patients who still experience unacceptably high morbidity and mortality. Ironically and paradoxically in a field lacking robust clinical trials, clinical practice is driven by guidelines-based medicine on weak evidence. The Emperor's syndrome, referring to Hans Christian Andersen's fairy tale, has been described in medicine as voluntary blindness to an obvious truth, being a weak evidence-based therapeutic intervention or weak health care. A promising positive example of improving heart and kidney outcomes is the emerging treatment with sodium-glucose cotransporter 2 inhibitors. COVID-19 could boost actions for patient-centered care as a positive shift in nephrology care.
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Affiliation(s)
- Dimitra Bacharaki
- Department of Nephrology, Attikon University Hospital, Chaidari 12462, Greece
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55
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Carvalho Silveira F, Martin WP, Maranga G, le Roux CW, Ren-Fielding CJ. The Impact of CKD on Perioperative Risk and Mortality after Bariatric Surgery. KIDNEY360 2020; 2:236-244. [PMID: 35373013 PMCID: PMC8740995 DOI: 10.34067/kid.0004832020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/10/2020] [Indexed: 02/04/2023]
Abstract
Background Twenty percent of patients with CKD in the United States have a body mass index (BMI) ≥35 kg/m2. Bariatric surgery reduces progression of CKD to ESKD, but the risk of perioperative complications remains a concern. Methods The 24-month data spanning 2017-2018 were obtained from the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) database and analyzed. Surgical complications were assessed on the basis of the length of hospital stay, mortality, reoperation, readmission, surgical site infection (SSI), and worsening of kidney function during the first 30 days after surgery. Results The 277,948 patients who had primary bariatric procedures were 44±11.9 (mean ± SD) years old, 79.6% were women, and 71.2% were White. Mean BMI was 45.7±7.6 kg/m2. Compared with patients with an eGFR≥90 ml/min per BSA, those with stage 5 CKD/ESKD were 1.91 times more likely to be readmitted within 30 days of a bariatric procedure (95% CI, 1.37 to 2.67; P<0.001). Similarly, length of hospital stay beyond 2 days was 2.05-fold (95% CI, 1.64 to 2.56; P<0.001) higher and risk of deep incisional SSI was 6.92-fold (95% CI, 1.62 to 29.52; P=0.009) higher for those with stage 5 CKD/ESKD. Risk of early postoperative mortality increased with declining preoperative eGFR, such that patients with stage 3b CKD were 3.27 (95% CI, 1.82 to 5.89; P<0.001) times more likely to die compared with those with normal kidney function. However, absolute mortality rates remained relatively low at 0.53% in those with stage 3b CKD. Furthermore, absolute mortality rates were <0.5% in those with stages 4 and 5 CKD, and these advanced CKD stages were not independently associated with an increased risk of early postoperative mortality. Conclusions Increased severity of kidney disease was associated with increased complications after bariatric surgery. However, even for the population with advanced CKD, the absolute rates of postoperative complications were low. The mounting evidence for bariatric surgery as a renoprotective intervention in people with and without established kidney disease suggests that bariatric surgery should be considered a safe and effective option for patients with CKD.
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Affiliation(s)
| | - William P. Martin
- Diabetes Complications Research Centre, School of Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
| | - Gabrielle Maranga
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Carel W. le Roux
- Diabetes Complications Research Centre, School of Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland
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56
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Abstract
People with end-stage kidney disease (ESKD) who require chronic dialysis are often reliant on complicated medication regimens to manage their health conditions. Due to the complexities of the advanced kidney disease, underlying comorbidities, and special instructions, medication regimens for patients on dialysis put patients at high risk for medication therapy problems related to safety, effectiveness, appropriateness, and adherence. This article explores the factors that affect optimal medication use for people on dialysis, including the broader drug use system, and offers recommendations around medication reconciliation, medication review, deprescribing, and considering social determinants of health to improve medication management among patients with ESKD.
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Affiliation(s)
- Katie E Cardone
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA.,Department of Population Health Sciences, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Wendy M Parker
- Department of Population Health Sciences, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
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57
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Carswell C, Reid J, Walsh I, Johnston W, McAneney H, Mullan R, Lee JB, Nelson H, Matthews M, Weatherup E, Spencer A, Michelo J, Quail A, Kielty G, Mackenzie A, Elliott J, Arbuckle N, Wilson A, Noble H. A mixed-methods feasibility study of an arts-based intervention for patients receiving maintenance haemodialysis. BMC Nephrol 2020; 21:497. [PMID: 33213413 PMCID: PMC7678271 DOI: 10.1186/s12882-020-02162-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/10/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Haemodialysis can negatively impact quality of life and mental health. Arts-based interventions used successfully in other settings to improve health and well-being, could help address the impact of haemodialysis. This study aimed to evaluate the feasibility and acceptability of conducting a randomised controlled trial (RCT) of an arts-based intervention for patients receiving haemodialysis. METHODS A parallel convergent mixed-methods design was used, including a pilot cluster RCT and qualitative process evaluation. Phase 1 evaluated recruitment and retention rates through a pilot cluster RCT at a single haemodialysis unit in Northern Ireland. Participants included patients who received haemodialysis for ESKD, were over the age of 18 and had the capacity to consent. These participants were randomised to the intervention or control group according to their haemodialysis shift. The intervention involved six one-hour, one-to-one facilitated arts sessions during haemodialysis. Phase 2 explored intervention and trial acceptability through a qualitative process evaluation using semi-structured interviews based on the RE-AIM framework. Participants included 13 patients who participated in phase 1 of the study, including 9 participants from the experimental group and four participants from the control group, and nine healthcare professionals who were present on the unit during implementation. RESULTS Out of 122 outpatient haemodialysis patients, 94 were assessed as eligible for participation. Twenty-four participants were randomised, meaning 80% of the target sample size was recruited and the attrition rate at 3 months was 12.5% (n = 3). Participants viewed the arts as more accessible and enjoyable than anticipated following implementation. All participants who started the intervention (n = 11) completed the full six sessions. Qualitative benefits of the intervention suggest improvements in mental well-being. Patient choice and facilitation were important factors for successful implementation. CONCLUSION An arts-based intervention for patients receiving haemodialysis is acceptable for both patients and healthcare professionals, and a definitive trial is feasible. The intervention may help improve mental-wellbeing in patients receiving haemodialysis, but this requires further investigation in a definitive trial. TRIAL REGISTRATION The trial was prospectively registered on clinicaltrials.gov on 14/8/2018, registration number NCT03629496 .
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Affiliation(s)
- Claire Carswell
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK.
| | - Joanne Reid
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Ian Walsh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | | | - Helen McAneney
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Robert Mullan
- Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, UK
| | - Jenny B Lee
- College of the Arts, Center for Arts in Medicine, University of Florida, Gainesville, USA
| | - Hugh Nelson
- Northern Health and Social Care Trust, Antrim, UK
| | - Michael Matthews
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK
| | | | | | - Jean Michelo
- Northern Ireland Kidney Patient Association, Belfast, UK
| | | | | | | | | | | | - Anna Wilson
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Helen Noble
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland, UK
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Eddy S, Mariani LH, Kretzler M. Integrated multi-omics approaches to improve classification of chronic kidney disease. Nat Rev Nephrol 2020; 16:657-668. [PMID: 32424281 DOI: 10.1038/s41581-020-0286-5] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2020] [Indexed: 12/11/2022]
Abstract
Chronic kidney diseases (CKDs) are currently classified according to their clinical features, associated comorbidities and pattern of injury on biopsy. Even within a given classification, considerable variation exists in disease presentation, progression and response to therapy, highlighting heterogeneity in the underlying biological mechanisms. As a result, patients and clinicians experience uncertainty when considering optimal treatment approaches and risk projection. Technological advances now enable large-scale datasets, including DNA and RNA sequence data, proteomics and metabolomics data, to be captured from individuals and groups of patients along the genotype-phenotype continuum of CKD. The ability to combine these high-dimensional datasets, in which the number of variables exceeds the number of clinical outcome observations, using computational approaches such as machine learning, provides an opportunity to re-classify patients into molecularly defined subgroups that better reflect underlying disease mechanisms. Patients with CKD are uniquely poised to benefit from these integrative, multi-omics approaches since the kidney biopsy, blood and urine samples used to generate these different types of molecular data are frequently obtained during routine clinical care. The ultimate goal of developing an integrated molecular classification is to improve diagnostic classification, risk stratification and assignment of molecular, disease-specific therapies to improve the care of patients with CKD.
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Affiliation(s)
- Sean Eddy
- Division of Nephrology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Laura H Mariani
- Division of Nephrology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Matthias Kretzler
- Division of Nephrology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA.
- Department of Computational Medicine and Bioinformatics, Michigan Medicine, Ann Arbor, MI, USA.
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Groopman EE, Povysil G, Goldstein DB, Gharavi AG. Rare genetic causes of complex kidney and urological diseases. Nat Rev Nephrol 2020; 16:641-656. [PMID: 32807983 PMCID: PMC7772719 DOI: 10.1038/s41581-020-0325-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2020] [Indexed: 02/08/2023]
Abstract
Although often considered a single-entity, chronic kidney disease (CKD) comprises many pathophysiologically distinct disorders that result in persistently abnormal kidney structure and/or function, and encompass both monogenic and polygenic aetiologies. Rare inherited forms of CKD frequently span diverse phenotypes, reflecting genetic phenomena including pleiotropy, incomplete penetrance and variable expressivity. Use of chromosomal microarray and massively parallel sequencing technologies has revealed that genomic disorders and monogenic aetiologies contribute meaningfully to seemingly complex forms of CKD across different clinically defined subgroups and are characterized by high genetic and phenotypic heterogeneity. Investigations of prevalent genomic disorders in CKD have integrated genetic, bioinformatic and functional studies to pinpoint the genetic drivers underlying their renal and extra-renal manifestations, revealing both monogenic and polygenic mechanisms. Similarly, massively parallel sequencing-based analyses have identified gene- and allele-level variation that contribute to the clinically diverse phenotypes observed for many monogenic forms of nephropathy. Genome-wide sequencing studies suggest that dual genetic diagnoses are found in at least 5% of patients in whom a genetic cause of disease is identified, highlighting the fact that complex phenotypes can also arise from multilocus variation. A multifaceted approach that incorporates genetic and phenotypic data from large, diverse cohorts will help to elucidate the complex relationships between genotype and phenotype for different forms of CKD, supporting personalized medicine for individuals with kidney disease.
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Affiliation(s)
- Emily E Groopman
- Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Gundula Povysil
- Institute for Genomic Medicine, Columbia University, New York, NY, USA
| | - David B Goldstein
- Institute for Genomic Medicine, Columbia University, New York, NY, USA
| | - Ali G Gharavi
- Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, NY, USA.
- Institute for Genomic Medicine, Columbia University, New York, NY, USA.
- Center for Precision Medicine and Genomics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.
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Levin A, Sapir D, Steele A, Cherney D, Hellstrom IC, Lanktree MB, Moist L, Suri RS. Proceedings From a Canadian Nephrology Forum: Nephrology Is Back. Can J Kidney Health Dis 2020; 7:2054358120965001. [PMID: 33117551 PMCID: PMC7573708 DOI: 10.1177/2054358120965001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/31/2020] [Indexed: 01/21/2023] Open
Abstract
PURPOSE OF CONFERENCE On January 18, 2020, the Nephrology is Back learning day forum was held in Toronto, ON, Canada. The objectives of the meeting were to describe recent advances in nephrology for community and academic nephrologists and patients, and to define challenges and opportunities for integration of new data into clinical practice. The intent was to test a unique forum for continuing medical education integrating physician and patient experiences with the goal of encouraging change in practice. SOURCES OF INFORMATION Program content was based on current literature and clinical experience. Additional information was provided by patient partners who attended the meeting to provide their perspective on current issues in nephrology. METHODS A steering committee (A.L., A.S., and D.S.) developed goals and an outline for the content to be covered over the course of the meeting and led the recruitment of speakers. Speakers were asked to develop their presentations independently following direction by the committee, based on primary sources, including their own experiences. Presentations were followed by discussion including both physicians and patients, and participants had an opportunity to evaluate the conference and its outcomes. KEY FINDINGS We present a unique approach to providing continuing medical education by including both physicians and patients in the learning process. Patient perspectives accompanying presentations around data and other clinical topics provided a much different environment from other knowledge translation exercises. We believe this represents an innovative approach for knowledge translation that allows physicians to address clinical topics in a novel manner, including the integration of new findings into practice and the need to cascade this education to their peers. LIMITATIONS Because the conference was a one-time event, it has been difficult to assess the actual clinical impact of the knowledge translation exercise and whether physician behaviors have changed as a result of the activity. The conference could also have included broader representation from across Canada. IMPLICATIONS The success of this test forum among both physicians and patient partners suggests that the inclusion of patient partners in learning could have an important role in future educational initiatives.
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Affiliation(s)
- Adeera Levin
- Division of Nephrology, The University of British Columbia, Vancouver, Canada,Adeera Levin, Division of Nephrology, The University of British Columbia, 1081 Burrard Street, Room 6010A, Vancouver, BC, Canada V6Z 1Y6.
| | - Daniel Sapir
- Halton Healthcare Services, Oakville, ON, Canada
| | - Andrew Steele
- Lakeridge Health, Oshawa, ON, Canada,Queen’s University, Kingston, ON, Canada
| | - David Cherney
- University Health Network, University of Toronto, ON, Canada
| | | | - Matthew B. Lanktree
- Division of Nephrology, Department of Medicine, St. Joseph’s Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | - Louise Moist
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Rita S. Suri
- Division of Nephrology, McGill University, Montreal, QC, Canada
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61
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International consensus definitions of clinical trial outcomes for kidney failure: 2020. Kidney Int 2020; 98:849-859. [DOI: 10.1016/j.kint.2020.07.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 01/30/2023]
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Carter SA, Lightstone L, Cattran D, Bagga A, Barbour SJ, Barratt J, Boletis J, Caster D, Coppo R, Fervenza FC, Floege J, Hladunewich M, Hogan JJ, Kitching AR, Lafayette R, Malvar A, Radhakrishnan J, Rovin BH, Zhang H, Gutman T, Howell M, Logeman C, Shen JI, Teixeira-Pinto A, Alexander SI, Cho Y, Craig JC, Harris D, Johnson DW, Kerr PG, Ryan J, Viecelli AK, Wang AYM, Wilkie M, Scholes-Robertson N, Tong A. Standardized Outcomes in Nephrology-Glomerular Disease (SONG-GD): establishing a core outcome set for trials in patients with glomerular disease. Kidney Int 2020; 95:1280-1283. [PMID: 31122702 DOI: 10.1016/j.kint.2019.01.047] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/27/2019] [Accepted: 01/29/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Simon A Carter
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia.
| | - Liz Lightstone
- Faculty of Medicine, Centre for Inflammatory Disease, Imperial College London, London, UK
| | - Daniel Cattran
- Faculty of Medicine, University of Toronto, Toronto, Canada; Toronto General Research Institute, Toronto, Canada
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sean J Barbour
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Jonathan Barratt
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK; John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - John Boletis
- Nephrology Department and Renal Transplantation Unit, Laiko Hospital, Athens, Greece
| | - Dawn Caster
- Division of Nephrology, University of Louisville, Louisville, Kentucky, USA
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Fernando C Fervenza
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, RWTH University Hospital, Aachen, Germany
| | - Michelle Hladunewich
- Faculty of Medicine, University of Toronto, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jonathan J Hogan
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - A Richard Kitching
- Department of Nephrology, Monash Health, Victoria, Australia; Centre for Inflammatory Diseases, Monash University Department of Medicine, Victoria, Australia
| | - Richard Lafayette
- Stanford University Medical Center, Stanford, California, USA; Department of Medicine, Division of Nephrology, Stanford University, Stanford, California, USA
| | - Ana Malvar
- Nephrology Department, Hospital Fernández, Buenos Aires, Argentina
| | - Jai Radhakrishnan
- Columbia University Medical Center, New York, New York, USA; Division of Nephrology, New York Presbyterian Hospital, New York, New York, USA
| | - Brad H Rovin
- Department of Internal Medicine, Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hong Zhang
- Renal Division of Peking University First Hospital, Beijing, China
| | - Talia Gutman
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Charlotte Logeman
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Jenny I Shen
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Stephen I Alexander
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - David Harris
- Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia; Sydney Medical School, The University of Sydney, Sydney, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Health, Victoria, Australia; Centre for Inflammatory Diseases, Monash University Department of Medicine, Victoria, Australia
| | - Jessica Ryan
- Department of Nephrology, Monash Health, Victoria, Australia; Department of Medicine, Monash University, Victoria, Australia
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Martin Wilkie
- Department of Nephrology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
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Shikida Y, Mizobuchi M, Yoshitake O, Kato T, Ogata H, Koiwa F, Honda H. Lower soluble Klotho levels in the pretransplant period are associated with an increased risk of renal function decline in renal transplant patients. Ther Apher Dial 2020; 25:331-340. [PMID: 33405323 DOI: 10.1111/1744-9987.13578] [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: 04/02/2020] [Revised: 07/15/2020] [Accepted: 08/14/2020] [Indexed: 11/28/2022]
Abstract
Serum soluble Klotho levels are associated with renal function in predialysis patients with chronic kidney disease. However, few reports exist regarding the association between soluble Klotho levels and renal function in kidney transplant (KTx) recipients. This was a retrospective observational study of 41 living KTx recipients. The serum soluble Klotho levels were classed as "high" (>456 pg/mL [i.e., high-Klotho group]) or "low" (≤456 pg/mL [i.e., low-Klotho group]). Renal function decline was defined as a decrease in the estimated glomerular filtration rate (eGFR) of 30% or more from the baseline value within 3 months after KTx. A multivariable time-to-event analysis between the groups was conducted. Among the KTx recipients, the incidence of a 30% decrease in the eGFR was significantly higher in the low-Klotho group than in the high-Klotho group (P = .036). After adjusting for donor age, donor sex, the presence of rejection, and the number of cytomegalovirus infections, multivariable Cox models revealed that low soluble Klotho levels remained associated with a higher risk of a 30% decrease in the eGFR (hazard ratio, 2.38; 95% confidence interval, 1.02-6.41). These findings suggested that lower soluble Klotho levels in the pre-KTx period are associated with an increased risk of renal function decline in KTx recipients.
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Affiliation(s)
- Yasuto Shikida
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Masahide Mizobuchi
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Osamu Yoshitake
- Division of Gastroenterological and General Surgery, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tadashi Kato
- Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Hiroaki Ogata
- Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Fumihiko Koiwa
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Hirokazu Honda
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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64
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Ying T, Shi B, Kelly PJ, Pilmore H, Clayton PA, Chadban SJ. Death after Kidney Transplantation: An Analysis by Era and Time Post-Transplant. J Am Soc Nephrol 2020; 31:2887-2899. [PMID: 32908001 DOI: 10.1681/asn.2020050566] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/25/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Mortality risk after kidney transplantation can vary significantly during the post-transplant course. A contemporary assessment of trends in all-cause and cause-specific mortality at different periods post-transplant is required to better inform patients, clinicians, researchers, and policy makers. METHODS We included all first kidney-only transplant recipients from 1980 through 2018 from the Australia and New Zealand Dialysis and Transplant Registry. We compared adjusted death rates per 5-year intervals, using a piecewise exponential survival model, stratified by time post-transplant or time post-graft failure. RESULTS Of 23,210 recipients, 4765 died with a functioning graft. Risk of death declined over successive eras, at all periods post-transplant. Reductions in early deaths were most marked; however, recipients ≥10 years post-transplant were 20% less likely to die in the current era compared with preceding eras (2015-2018 versus 2005-2009, adjusted hazard ratio, 0.80; 95% confidence interval, 0.69 to 0.90). In 2015-2018, cardiovascular disease was the most common cause of death, particularly in months 0-3 post-transplant (1.18 per 100 patient-years). Cancer deaths were rare early post-transplant, but frequent at later time points (0.93 per 100 patient-years ≥10 years post-transplant). Among 3657 patients with first graft loss, 2472 died and were not retransplanted. Death was common in the first year after graft failure, and the cause was most commonly cardiovascular (50%). CONCLUSIONS Reductions in death early and late post-transplant over the past 40 years represent a major achievement. Reductions in cause-specific mortality at all time points post-transplant are also apparent. However, relatively greater reductions in cardiovascular death have increased the prominence of late cancer deaths.
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Affiliation(s)
- Tracey Ying
- Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Camperdown, Australia .,Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Bree Shi
- Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Camperdown, Australia .,Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Patrick J Kelly
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Helen Pilmore
- Renal Department, Auckland City Hospital, Auckland, New Zealand
| | - Philip A Clayton
- Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Camperdown, Australia.,Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia.,Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Steven J Chadban
- Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Camperdown, Australia.,Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, Australia.,Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, Adelaide, Australia
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65
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Major R, Selvaskandan H, Makkeyah YM, Hull K, Kuverji A, Graham-Brown M. The Exclusion of Patients with CKD in Prospectively Registered Interventional Trials for COVID-19-a Rapid Review of International Registry Data. J Am Soc Nephrol 2020; 31:2250-2252. [PMID: 32900842 DOI: 10.1681/asn.2020060877] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Rupert Major
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom .,John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, United Kingdom
| | - Haresh Selvaskandan
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, United Kingdom.,Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Yahya Mostafa Makkeyah
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, United Kingdom.,Internal Medicine and Nephrology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Katherine Hull
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, United Kingdom.,Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Apexa Kuverji
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, United Kingdom
| | - Matthew Graham-Brown
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, United Kingdom.,Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
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66
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Judge C, Murphy RP, Cormican S, Smyth A, O'Halloran M, O'Donnell M. Adaptive design methods in dialysis clinical trials: a systematic review protocol. BMJ Open 2020; 10:e036755. [PMID: 32859663 PMCID: PMC7454175 DOI: 10.1136/bmjopen-2019-036755] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/25/2020] [Accepted: 07/18/2020] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Adaptive design methods are a potential solution to improve efficiency of clinical trials but their uptake in dialysis is unknown. We aim to investigate the use of adaptive design methods in dialysis clinical trials and to cultivate further adoption of adaptive design methods by the nephrology community. METHODS AND ANALYSIS We will adhere to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines and the Cochrane Collaboration Handbook. We will perform a literature search through MEDLINE (PubMed), EMBASE and CENTRAL, a detailed data extraction of trial characteristics and a narrative synthesis of the data. There will be no language restrictions. We will estimate the percentage of adaptive clinical trials per year in dialysis. Subgroup analysis will be performed by dialysis modality, funder and geographical location. ETHICS AND DISSEMINATION Ethical approval will not be required for this study as data will be obtained from publicly available clinical trials. We will disseminate our results in a peer-reviewed publication. PROSPERO REGISTRATION NUMBER.
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Affiliation(s)
- Conor Judge
- HRB-Clinical Research Facility, National University of Ireland, Galway, Co. Galway, Ireland
- Translational Medical Device Lab, National University of Ireland Galway, Galway, Co. Galway, Ireland
- Wellcome Trust - HRB, Irish Clinical Academic Training, National University of Ireland Galway, Galway, Ireland
- Deparrtment of Nephrology, Galway University Hospital, Galway, Ireland
| | - Robert P Murphy
- HRB-Clinical Research Facility, National University of Ireland, Galway, Co. Galway, Ireland
| | - Sarah Cormican
- Wellcome Trust - HRB, Irish Clinical Academic Training, National University of Ireland Galway, Galway, Ireland
- Deparrtment of Nephrology, Galway University Hospital, Galway, Ireland
| | - Andrew Smyth
- HRB-Clinical Research Facility, National University of Ireland, Galway, Co. Galway, Ireland
- Deparrtment of Nephrology, Galway University Hospital, Galway, Ireland
| | - Martin O'Halloran
- Translational Medical Device Lab, National University of Ireland Galway, Galway, Co. Galway, Ireland
| | - Martin O'Donnell
- HRB-Clinical Research Facility, National University of Ireland, Galway, Co. Galway, Ireland
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67
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Dose-Response Mixed Models for Repeated Measures – a New Method for Assessment of Dose-Response. Pharm Res 2020; 37:157. [PMID: 32737604 PMCID: PMC7651607 DOI: 10.1007/s11095-020-02882-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/14/2020] [Indexed: 11/27/2022]
Abstract
Purpose In this paper we investigated a new method for dose-response analysis of longitudinal data in terms of precision and accuracy using simulations. Methods The new method, called Dose-Response Mixed Models for Repeated Measures (DR-MMRM), combines conventional Mixed Models for Repeated Measures (MMRM) and dose-response modeling. Conventional MMRM can be applied for highly variable repeated measure data and is a way to estimate the drug effect at each visit and dose, however without any assumptions regarding the dose-response shape. Dose-response modeling, on the other hand, utilizes information across dose arms and describes the drug effect as a function of dose. Drug development in chronic kidney disease (CKD) is complicated by many factors, primarily by the slow progression of the disease and lack of predictive biomarkers. Recently, new approaches and biomarkers are being explored to improve efficiency in CKD drug development. Proteinuria, i.e. urinary albumin-to-creatinine ratio (UACR) is increasingly used in dose finding trials in patients with CKD. We use proteinuria to illustrate the benefits of DR-MMRM. Results The DR-MMRM had higher precision than conventional MMRM and less bias than a dose-response model on UACR change from baseline to end-of-study (DR-EOS). Conclusions DR-MMRM is a promising method for dose-response analysis. Electronic supplementary material The online version of this article (10.1007/s11095-020-02882-0) contains supplementary material, which is available to authorized users.
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Abstract
BACKGROUND Glomerulosclerosis represents the final stage of glomerular injury during the course of kidney disease and can result from a primary disturbance in disorders like focal segmental glomerulosclerosis or a secondary response to tubulointerstitial disease. Overall, primary focal glomerulosclerosis (FSGS), the focus of this review, accounts for 10-20% of patients of all ages who progress to end stage kidney disease. There are no FDA approved therapeutic options that effectively prevent or delay the onset of kidney failure. AREAS COVERED Current immunosuppressive therapy and conservative management including inhibitors of the renin-angiotensin-aldosterone axis and sodium-glucose cotransporter are reviewed. FSGS is now recognized to represent a heterogeneous entity with multiple underlying disease mechanisms. Therefore, novel approaches targeting the podocyte cytoskeleton, immunological, inflammatory, hemodynamic and metabolic pathways are highlighted. EXPERT OPINION A number of factors are driving the development of drugs to treat focal segmental glomerulosclerosis in particular and glomerulosclerosis in general including growing awareness of the burden of chronic kidney disease, improved scientific understanding of the mechanism of injury, and the development of noninvasive profiles to identify subgroups of patients with discrete mechanisms of glomerular injury.
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Affiliation(s)
- Howard Trachtman
- Department of Pediatrics, Division of Nephrology, NYU Langone Health , New York, NY, USA
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69
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Kumar S, Lim E, Covic A, Verhamme P, Gale CP, Camm AJ, Goldsmith D. Anticoagulation in Concomitant Chronic Kidney Disease and Atrial Fibrillation: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 74:2204-2215. [PMID: 31648714 DOI: 10.1016/j.jacc.2019.08.1031] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/22/2019] [Accepted: 08/27/2019] [Indexed: 01/22/2023]
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist as they share multiple risk factors, including hypertension, diabetes mellitus, and coronary artery disease. Although there is irrefutable evidence supporting anticoagulation in AF in the general population, these data may not be transferable to the setting of advanced CKD, where the decision to commence anticoagulation poses a conundrum. In this cohort, there is a progressively increased risk of both ischemic stroke and hemorrhage as renal function declines, complicating the decision to initiate anticoagulation. No definitive clinical guidelines derived from randomized controlled trials exist to aid clinical decision-making, and the findings from observational studies are conflicting. In this review, the authors outline the pathophysiological mechanisms at play and summarize the limited existing data related to anticoagulation in those with concomitant CKD and AF. Finally, the authors suggest how to approach the decision of whether and how to use oral anticoagulation in these patients.
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Affiliation(s)
- Shankar Kumar
- Centre for Medical Imaging, University College London, London, United Kingdom; Imaging Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Emma Lim
- Imaging Department, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Adrian Covic
- Department of Nephrology, University of Medicine and Pharmacy "Gr. T. Popa," Iasi, Romania
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - A John Camm
- Molecular and Clinical Sciences Research Institute, St. George's University of London, London, United Kingdom
| | - David Goldsmith
- Department of Nephrology, University of Medicine and Pharmacy "Gr. T. Popa," Iasi, Romania; Molecular and Clinical Sciences Research Institute, St. George's University of London, London, United Kingdom; Renal and Transplantation Department, Guys and St. Thomas' Hospitals NHS Foundation Trust, Great Maze Pond, London, United Kingdom.
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70
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Carter SA, Gutman T, Logeman C, Cattran D, Lightstone L, Bagga A, Barbour SJ, Barratt J, Boletis J, Caster D, Coppo R, Fervenza FC, Floege J, Hladunewich M, Hogan JJ, Kitching AR, Lafayette RA, Malvar A, Radhakrishnan J, Rovin BH, Scholes-Robertson N, Trimarchi H, Zhang H, Azukaitis K, Cho Y, Viecelli AK, Dunn L, Harris D, Johnson DW, Kerr PG, Laboi P, Ryan J, Shen JI, Ruiz L, Wang AYM, Lee AHK, Fung S, Tong MKH, Teixeira-Pinto A, Wilkie M, Alexander SI, Craig JC, Tong A. Identifying Outcomes Important to Patients with Glomerular Disease and Their Caregivers. Clin J Am Soc Nephrol 2020; 15:673-684. [PMID: 32354728 PMCID: PMC7269216 DOI: 10.2215/cjn.13101019] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/26/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Shared decision making in patients with glomerular disease remains challenging because outcomes important to patients remain largely unknown. We aimed to identify and prioritize outcomes important to patients and caregivers and to describe reasons for their choices. DESIGN , setting, participants, & measurementsWe purposively sampled adult patients with glomerular disease and their caregivers from Australia, Hong Kong, the United Kingdom, and the United States. Participants identified, discussed, and ranked outcomes in focus groups using the nominal group technique; a relative importance score (between zero and one) was calculated. Qualitative data were analyzed thematically. RESULTS Across 16 focus groups, 134 participants (range, 19-85 years old; 51% women), including 101 patients and 33 caregivers, identified 58 outcomes. The ten highest-ranked outcomes were kidney function (importance score of 0.42), mortality (0.29), need for dialysis or transplant (0.22), life participation (0.18), fatigue (0.17), anxiety (0.13), family impact (0.12), infection and immunity (0.12), ability to work (0.11), and BP (0.11). Three themes explained the reasons for these rankings: constraining day-to-day experience, impaired agency and control over health, and threats to future health and family. CONCLUSIONS Patients with glomerular disease and their caregivers highly prioritize kidney health and survival, but they also prioritize life participation, fatigue, anxiety, and family impact.
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Affiliation(s)
- Simon A Carter
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia .,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Talia Gutman
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Charlotte Logeman
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Dan Cattran
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Toronto General Research Institute, Toronto, Ontario, Canada
| | - Liz Lightstone
- Centre for Inflammatory Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sean J Barbour
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathan Barratt
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, United Kingdom.,John Walls Renal Unit, Leicester General Hospital, Leicester, United Kingdom
| | - John Boletis
- Nephrology Department and Renal Transplantation Unit, Medical School, University of Athens, Laiko Hospital, Athens, Greece
| | - Dawn Caster
- Division of Nephrology, University of Louisville, Kentucky, Louisville
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule University Hospital, Aachen, Germany
| | - Michelle Hladunewich
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jonathan J Hogan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - A Richard Kitching
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia.,Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Richard A Lafayette
- Stanford University Medical Center, Stanford, California.,Division of Nephrology, Department of Medicine, Stanford University, Stanford, California
| | - Ana Malvar
- Nephrology, Hospital Fernández, Buenos Aires, Argentina
| | | | - Brad H Rovin
- Division of Nephrology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nicole Scholes-Robertson
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Hérnan Trimarchi
- Nephrology Service and Kidney Transplantation Unit, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Beijing, China
| | - Karolis Azukaitis
- Clinic of Pediatrics, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
| | - Louese Dunn
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - David Harris
- Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia
| | - Peter G Kerr
- Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Paul Laboi
- Department of Nephrology, York Hospital, York, United Kingdom
| | - Jessica Ryan
- Department of Nephrology, Monash Health, Clayton, Victoria, Australia.,Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Jenny I Shen
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Lorena Ruiz
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | | | - Samuel Fung
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | | | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Martin Wilkie
- Department of Nephrology, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Stephen I Alexander
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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71
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Zoccali C, Blankestijn PJ, Bruchfeld A, Capasso G, Fliser D, Fouque D, Goumenos D, Ketteler M, Massy Z, Rychlık I, Jose Soler M, Stevens K, Spasovski G, Wanner C. Children of a lesser god: exclusion of chronic kidney disease patients from clinical trials. Nephrol Dial Transplant 2020; 34:1112-1114. [PMID: 30815678 DOI: 10.1093/ndt/gfz023] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Indexed: 01/28/2023] Open
Abstract
The exclusion of chronic kidney disease (CKD) patients from clinical trials-particularly cardiovascular trials-remains a long-standing, unsolved problem, which prevents the optimization of clinical care in these patients. The situation recalls the insufficient recruitment of women in cardiovascular trials until the 1980s, a problem that was only resolved following regulatory interventions. Regulatory agencies are in a unique position to promote recruitment of CKD patients in clinical trials. The main stakeholders, namely patients' associations and scientific societies, should make major lobbying efforts to persuade these agencies that the issue is an absolute public health priority.
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Affiliation(s)
| | - Peter J Blankestijn
- Department of Nephrology, University Medical Center, Utrecht, The Netherlands
| | - Annette Bruchfeld
- Department of Renal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | | | - Danilo Fliser
- Internal Medicine IV, Renal and Hypertensive Disease, University Medical Center, Homburg/Saar, Germany
| | - Denis Fouque
- Department of Nephrology, Dialysis, Nutrition, Centre Hospitalier Lyon Sud, Pierre Bénite Cedex, France
| | - Dimitrios Goumenos
- Department of Nephrology and Renal Transplantation, Patras University Hospital, Patras, Greece
| | | | - Ziad Massy
- Division of Nephrology, Ambroise Paré Hospital, Paris Ile de France West University (UVSQ), Villejuif, France
| | - Ivan Rychlık
- First Department of Internal Medicine, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Maria Jose Soler
- Department of Nephrology, Hospital Universitari Vall d'Hebron, Nephrology Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Kate Stevens
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Goce Spasovski
- Department of Nephrology, Medical Faculty, University of Skopje, Skopje, Former Yugoslav Republic of Macedonia
| | - Christoph Wanner
- Division of Nephrology, University of Würzburg, Würzburg, Germany
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72
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Kimura T, Hesaka A, Isaka Y. D-Amino acids and kidney diseases. Clin Exp Nephrol 2020; 24:404-410. [PMID: 32112266 PMCID: PMC7174270 DOI: 10.1007/s10157-020-01862-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/13/2020] [Indexed: 11/16/2022]
Abstract
d-Amino acids are the recently detected enantiomers of l-amino acids. Accumulating evidence points their potential in solving the long-standing critical problems associated with the management of both chronic and acute kidney diseases. This includes estimating kidney function, early diagnosis and prognosis of chronic kidney disease, and disease monitoring. Among the d-amino acids, d-serine levels in the blood are strongly correlated with the glomerular filtration rate and are useful for estimating the function of the kidney. Urinary d-serine also reflects other conditions. The kidney proximal tubule reabsorbs serine with chiral-selectivity, with d-serine being reabsorbed much less efficiently than l-serine, and urinary excretion of d-serine is sensitive to the presence of kidney diseases. Therefore, assessing the intra-body dynamics of d-serine by measuring its level in blood and urinary excretion can be used to detect kidney diseases and assess pathophysiology. This new concept, the intra-body dynamics of d-serine, can be useful in the comprehensive management of kidney disease.
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Affiliation(s)
- Tomonori Kimura
- KAGAMI Project, National Institute of Biomedical Innovation, Health and Nutrition (NIBIOHN), Osaka, Japan. .,Reverse Translational Research Project, Center for Rare Disease Research, National Institute of Biomedical Innovation, Health and Nutrition (NIBIOHN), Osaka, Japan. .,Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Atsushi Hesaka
- KAGAMI Project, National Institute of Biomedical Innovation, Health and Nutrition (NIBIOHN), Osaka, Japan.,Reverse Translational Research Project, Center for Rare Disease Research, National Institute of Biomedical Innovation, Health and Nutrition (NIBIOHN), Osaka, Japan.,Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
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73
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Schaub JA, Hamidi H, Subramanian L, Kretzler M. Systems Biology and Kidney Disease. Clin J Am Soc Nephrol 2020; 15:695-703. [PMID: 31992571 PMCID: PMC7269226 DOI: 10.2215/cjn.09990819] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The kidney is a complex organ responsible for maintaining multiple aspects of homeostasis in the human body. The combination of distinct, yet interrelated, molecular functions across different cell types make the delineation of factors associated with loss or decline in kidney function challenging. Consequently, there has been a paucity of new diagnostic markers and treatment options becoming available to clinicians and patients in managing kidney diseases. A systems biology approach to understanding the kidney leverages recent advances in computational technology and methods to integrate diverse sets of data. It has the potential to unravel the interplay of multiple genes, proteins, and molecular mechanisms that drive key functions in kidney health and disease. The emergence of large, detailed, multilevel biologic and clinical data from national databases, cohort studies, and trials now provide the critical pieces needed for meaningful application of systems biology approaches in nephrology. The purpose of this review is to provide an overview of the current state in the evolution of the field. Recent successes of systems biology to identify targeted therapies linked to mechanistic biomarkers in the kidney are described to emphasize the relevance to clinical care and the outlook for improving outcomes for patients with kidney diseases.
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Affiliation(s)
- Jennifer A Schaub
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Habib Hamidi
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Lalita Subramanian
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Matthias Kretzler
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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74
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Manera KE, Johnson DW, Craig JC, Shen JI, Gutman T, Cho Y, Wang AYM, Brown EA, Brunier G, Dong J, Dunning T, Mehrotra R, Naicker S, Pecoits-Filho R, Perl J, Wilkie M, Tong A. Establishing a Core Outcome Set for Peritoneal Dialysis: Report of the SONG-PD (Standardized Outcomes in Nephrology-Peritoneal Dialysis) Consensus Workshop. Am J Kidney Dis 2020; 75:404-412. [PMID: 31955922 DOI: 10.1053/j.ajkd.2019.09.017] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 09/25/2019] [Indexed: 11/11/2022]
Abstract
Outcomes reported in randomized controlled trials in peritoneal dialysis (PD) are diverse, are measured inconsistently, and may not be important to patients, families, and clinicians. The Standardized Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD) initiative aims to establish a core outcome set for trials in PD based on the shared priorities of all stakeholders. We convened an international SONG-PD stakeholder consensus workshop in May 2018 in Vancouver, Canada. Nineteen patients/caregivers and 51 health professionals attended. Participants discussed core outcome domains and implementation in trials in PD. Four themes relating to the formation of core outcome domains were identified: life participation as a main goal of PD, impact of fatigue, empowerment for preparation and planning, and separation of contributing factors from core factors. Considerations for implementation were identified: standardizing patient-reported outcomes, requiring a validated and feasible measure, simplicity of binary outcomes, responsiveness to interventions, and using positive terminology. All stakeholders supported inclusion of PD-related infection, cardiovascular disease, mortality, technique survival, and life participation as the core outcome domains for PD.
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Affiliation(s)
- Karine E Manera
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia.
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Australia; Centre for Kidney Disease Research, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Australia
| | - Jenny I Shen
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | - Talia Gutman
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australasian Kidney Trials Network, School of Medicine, University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Australia
| | | | - Edwina A Brown
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | | | - Jie Dong
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | | | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology/Department of Medicine, University of Washington, Seattle, WA
| | - Saraladevi Naicker
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Roberto Pecoits-Filho
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil; Arbor Research Collaborative for Health, Ann Arbor, MI
| | - Jeffrey Perl
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Martin Wilkie
- Department of Nephrology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
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75
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Neuen BL, Perkovic V. Pilot Trials in Nephrology: Establishing a BASE for Large-Scale Randomized Trials. J Am Soc Nephrol 2020; 31:4-6. [PMID: 31871251 PMCID: PMC6934990 DOI: 10.1681/asn.2019111196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Affiliation(s)
| | - Vlado Perkovic
- The George Institute for Global Health and
- Faculty of Medicine, University of New South Wales, Sydney, Australia
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76
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Lee EJ, Patel A, Acedillo RR, Bachynski JC, Barrett I, Basile E, Battistella M, Benjamin D, Berry D, Blake PG, Chan P, Bohm CJ, Clemens KK, Cook C, Dember L, Dirk JS, Dixon S, Fowler E, Getchell L, Gholami N, Goldstein C, Hahn E, Hogeterp B, Huang S, Hughes M, Jardine MJ, Kalatharan S, Kilburn S, Lacson E, Leonard S, Liberty C, Lindsay C, MacRae JM, Manns BJ, McCallum J, McIntyre CW, Molnar AO, Mustafa RA, Nesrallah GE, Oliver MJ, Pandes M, Pandeya S, Parmar MS, Rabin EZ, Riley J, Silver SA, Sontrop JM, Sood MM, Suri RS, Tangri N, Tascona DJ, Thomas A, Wald R, Walsh M, Weijer C, Weir MA, Vorster H, Zimmerman D, Garg AX. Cultivating Innovative Pragmatic Cluster-Randomized Registry Trials Embedded in Hemodialysis Care: Workshop Proceedings From 2018. Can J Kidney Health Dis 2019; 6:2054358119894394. [PMID: 31903190 PMCID: PMC6933546 DOI: 10.1177/2054358119894394] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Rey R. Acedillo
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
| | | | | | - Erika Basile
- Office of Human Research Ethics, Western
University, London, ON, Canada
| | - Marisa Battistella
- Department of Pharmacy, University
Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy,
University of Toronto, ON, Canada
| | - Derek Benjamin
- Royal Victoria Regional Health Centre,
Barrie, ON, Canada
| | - David Berry
- Algoma Regional Renal Program, Sault
Area Hospital, Sault Ste. Marie, ON, Canada
| | - Peter G. Blake
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
| | - Patricia Chan
- Division of Nephrology, Department of
Medicine, Michael Garron Hospital, Toronto, ON, Canada
| | - Clara J. Bohm
- Department of Internal Medicine, Max
Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Kristin K. Clemens
- ICES, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
- Division of Endocrinology and
Metabolism, Department of Medicine, Western University, London, ON, Canada
- St. Joseph’s Health Care London, ON,
Canada
| | - Charles Cook
- Transplant Ambassador Program, Grand
River Hospital, Kitchener, ON, Canada
| | - Laura Dember
- Renal, Electrolyte and Hypertension
Division, Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Stephanie Dixon
- ICES, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
| | | | | | | | - Cory Goldstein
- Rotman Institute of Philosophy,
Western University, London, ON, Canada
| | | | | | - Susan Huang
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
| | | | - Meg J. Jardine
- Innovation & Kidney Research, The
George Institute for Global Health, UNSW Sydney, Newtown, NSW, Australia
| | | | | | | | | | | | | | - Jennifer M. MacRae
- Division of Nephrology, Department of
Medicine, University of Calgary, AB, Canada
| | - Braden J. Manns
- Department of Medicine, Cumming School
of Medicine, University of Calgary, AB, Canada
| | - Janice McCallum
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
- Renal Services, London Health Sciences
Centre, ON, Canada
| | - Christopher W. McIntyre
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
- Department of Medical Biophysics,
Schulich School of Medicine and Dentistry, Western University, London, ON,
Canada
| | - Amber O. Molnar
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
| | - Reem A. Mustafa
- Division of Nephrology and
Hypertension, Department of Internal Medicine, University of Kansas Medical Center,
Kansas City, USA
| | - Gihad E. Nesrallah
- Division of Nephrology, Department of
Medicine, Humber River Hospital, Toronto, ON, Canada
| | - Matthew J. Oliver
- Division of Nephrology, Department of
Medicine, University of Toronto, ON, Canada
| | | | | | | | | | | | - Samuel A. Silver
- Division of Nephrology, Kingston
Health Sciences Center, Queen’s University, Kingston, ON, Canada
| | - Jessica M. Sontrop
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
| | - Manish M. Sood
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, University of Ottawa, ON, Canada
| | - Rita S. Suri
- Division of Nephrology, Department of
Medicine, McGill University, Montreal, QC, Canada
- Canadian Nephrology Trials Network,
Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Centre,
Winnipeg, MB, Canada
- Department of Internal Medicine,
University of Manitoba, Winnipeg, Canada
| | - Daniel J. Tascona
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
- Orillia Soldiers’ Memorial Hospital,
ON, Canada
| | | | - Ron Wald
- St. Michael’s Hospital, Toronto, ON,
Canada
- Division of Nephrology, Department of
Medicine, University of Toronto, ON, Canada
| | - Michael Walsh
- Division of Nephrology, Department of
Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute,
Hamilton, ON, Canada
| | - Charles Weijer
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
- Rotman Institute of Philosophy,
Western University, London, ON, Canada
| | - Matthew A. Weir
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
| | - Hans Vorster
- Ontario Renal Network, Cancer Care
Ontario, Toronto, Canada
| | - Deborah Zimmerman
- Division of Nephrology, Department of
Medicine, University of Ottawa, ON, Canada
| | - Amit X. Garg
- ICES, ON, Canada
- Division of Nephrology, Department of
Medicine, London Health Sciences Centre, ON, Canada
- Department of Epidemiology and
Biostatistics, Western University, London, ON, Canada
- Kidney Clinical Research Unit, Lawson
Health Research Institute, London, ON, Canada
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78
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Herrington WG, Staplin N, Haynes R. Kidney disease trials for the 21st century: innovations in design and conduct. Nat Rev Nephrol 2019; 16:173-185. [PMID: 31673162 DOI: 10.1038/s41581-019-0212-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2019] [Indexed: 12/11/2022]
Abstract
Compared to other specialties, nephrology has reported relatively few clinical trials, and most of these are too small to detect moderate treatment effects. Consequently, interventions that are commonly used by nephrologists have not been adequately tested and some may be ineffective or harmful. More randomized trials are urgently needed to address important clinical questions in patients with kidney disease. The use of robust surrogate markers may accelerate early-phase drug development. However, scientific innovations in trial conduct developed by other specialties should also be adopted to improve trial quality and enable more, larger trials in kidney disease to be completed in the current era of burdensome regulation and escalating research costs. Examples of such innovations include utilizing routinely collected health-care data and disease-specific registries to identify and invite potential trial participants, and for long-term follow-up; use of prescreening to facilitate rapid recruitment of participants; use of pre-randomization run-in periods to improve participant adherence and assess responses to study interventions prior to randomization; and appropriate use of statistics to monitor studies and analyse their results. Nephrology is well positioned to harness such innovations due to its advanced use of electronic health-care records and the development of disease-specific registries. Adopting a population approach and efficient trial conduct along with challenging unscientific regulation may increase the number of definitive clinical trials in nephrology and improve the care of current and future patients.
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Affiliation(s)
- William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, Oxford, UK.,Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, Oxford, UK
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, Oxford, UK. .,Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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79
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Misra PS, Silva E Silva V, Collister D. Roadblocks and Opportunities to the Implementation of Novel Therapies for Acute Kidney Injury: A Narrative Review. Can J Kidney Health Dis 2019; 6:2054358119880519. [PMID: 31636913 PMCID: PMC6787878 DOI: 10.1177/2054358119880519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/12/2019] [Indexed: 11/29/2022] Open
Abstract
Background: Acute kidney injury (AKI) is a complex and heterogeneous clinical syndrome
with limited effective treatment options. Therefore, a coherent research
structure considering AKI pathophysiology, treatment, translation, and
implementation is critical to advancing patient care in this area. Purpose of review: In this narrative review, we discuss novel therapies for AKI from their
journey from bench to bedside to population and focus on roadblocks and
opportunities to their successful implementation. Sources of information: Peer-reviewed articles, opinion pieces from research leaders and research
funding agencies, and clinical and research expertise. Methods: This narrative review details the challenges of translation of preclinical
studies in AKI and highlights trending research areas and innovative designs
in the field. Key developments in preclinical research, clinical trials, and
knowledge translation are discussed. Furthermore, this article discusses the
current need to involve patients in clinical research and the barriers and
opportunities for effective knowledge translation. Key findings: Preclinical studies have largely been unsuccessful in generating novel
therapies for AKI, due both to the complexity and heterogeneity of the
disease, as well as the limitations of commonly available preclinical models
of AKI. The emergence of kidney organoid technology may be an opportunity to
reverse this trend. However, the roadblocks encountered at the bench have
not precluded researchers from running well-designed and impactful clinical
trials, and the field of renal replacement therapy in AKI is highlighted as
an area that has been particularly active. Meanwhile, knowledge translation
initiatives are bolstered by the presence of large administrative databases
to permit ongoing monitoring of clinical practices and outcomes, with
research output from such evaluations having the potential to directly
impact patient care and inform the generation of meaningful clinical
practice guidelines. Limitations: There are limited objective data examining the process of knowledge creation
and translation in AKI, and as such the opinions and research areas of the
authors are significantly drawn upon in the discussion. Implications: The use of an organized knowledge-to-action framework involving multiple
stakeholders, especially patient partners, is critical to translating basic
research findings to improvements in patient care in AKI, an area where
effective treatment options are lacking.
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Affiliation(s)
- Paraish S Misra
- Kidney Research Scientist Core Education and National Training Program, Canada.,McEwen Stem Cell Institute, Department of Medicine, University of Toronto, ON, Canada
| | - Vanessa Silva E Silva
- Kidney Research Scientist Core Education and National Training Program, Canada.,The Canadian Donation and Transplantation Research Program, Canada.,School of Nursing, Queen's University, Kingston, ON, Canada.,School of Nursing, Federal University of Sao Paulo, Brazil
| | - David Collister
- Kidney Research Scientist Core Education and National Training Program, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
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80
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Levey AS, Gansevoort RT, Coresh J, Inker LA, Heerspink HL, Grams ME, Greene T, Tighiouart H, Matsushita K, Ballew SH, Sang Y, Vonesh E, Ying J, Manley T, de Zeeuw D, Eckardt KU, Levin A, Perkovic V, Zhang L, Willis K. Change in Albuminuria and GFR as End Points for Clinical Trials in Early Stages of CKD: A Scientific Workshop Sponsored by the National Kidney Foundation in Collaboration With the US Food and Drug Administration and European Medicines Agency. Am J Kidney Dis 2019; 75:84-104. [PMID: 31473020 DOI: 10.1053/j.ajkd.2019.06.009] [Citation(s) in RCA: 316] [Impact Index Per Article: 63.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/13/2019] [Indexed: 12/19/2022]
Abstract
The US Food and Drug Administration (FDA) and European Medicines Agency (EMA) are currently willing to consider a 30% to 40% glomerular filtration rate (GFR) decline as a surrogate end point for kidney failure for clinical trials of kidney disease progression under appropriate conditions. However, these end points may not be practical for early stages of kidney disease. In March 2018, the National Kidney Foundation sponsored a scientific workshop in collaboration with the FDA and EMA to evaluate changes in albuminuria or GFR as candidate surrogate end points. Three parallel efforts were presented: meta-analyses of observational studies (cohorts), meta-analyses of clinical trials, and simulations of trial design. In cohorts, after accounting for measurement error, relationships between change in urinary albumin-creatinine ratio (UACR) or estimated GFR (eGFR) slope and the clinical outcome of kidney disease progression were strong and consistent. In trials, the posterior median R2 of treatment effects on the candidate surrogates with the clinical outcome was 0.47 (95% Bayesian credible interval [BCI], 0.02-0.96) for early change in UACR and 0.72 (95% BCI, 0.05-0.99) when restricted to baseline UACR>30mg/g, and 0.97 (95% BCI, 0.78-1.00) for total eGFR slope at 3 years and 0.96 (95% BCI, 0.63-1.00) for chronic eGFR slope (ie, the slope excluding the first 3 months from baseline, when there might be acute changes in eGFR). The magnitude of the relationships of changes in the candidate surrogates with risk for clinical outcome was consistent across cohorts and trials: a UACR reduction of 30% or eGFR slope reduction by 0.5 to 1.0mL/min/1.73m2 per year were associated with an HR of ∼0.7 for the clinical outcome in cohorts and trials. In simulations, using GFR slope as an end point substantially reduced the required sample size and duration of follow-up compared with the clinical end point when baseline eGFR was high, treatment effects were uniform, and there was no acute effect of the treatment. We conclude that both early change in albuminuria and GFR slope fulfill criteria for surrogacy for use as end points in clinical trials for chronic kidney disease progression under certain conditions, with stronger support for change in GFR than albuminuria. Implementation requires understanding conditions under which each surrogate is likely to perform well and restricting its use to those settings.
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Affiliation(s)
- Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA.
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Hiddo L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands
| | - Morgan E Grams
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Hocine Tighiouart
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Edward Vonesh
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University, Chicago, IL
| | - Jian Ying
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Tom Manley
- National Kidney Foundation, New York, NY
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vlado Perkovic
- George Institute for Global Health, UNSW, Sydney, Australia
| | - Luxia Zhang
- Peking University Institute of Nephrology, Beijing, China; Division of Nephrology, Peking University First Hospital, Beijing, China
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81
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Kanda E, Kashihara N, Matsushita K, Usui T, Okada H, Iseki K, Mikami K, Tanaka T, Wada T, Watada H, Ueki K, Nangaku M. Guidelines for clinical evaluation of chronic kidney disease : AMED research on regulatory science of pharmaceuticals and medical devices. Clin Exp Nephrol 2019; 22:1446-1475. [PMID: 30006871 DOI: 10.1007/s10157-018-1615-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Eiichiro Kanda
- Medical Science, Kawasaki Medical School, Okayama, Japan.,Department of Nephrology and Hypertension, Kawasaki Medical School, Okayama, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Okayama, Japan
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Maryland, USA
| | - Tomoko Usui
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Hirokazu Okada
- Department of Nephrology, Saitama Medical University, Saitama, Japan
| | - Kunitoshi Iseki
- Clinical Research Support Center, Tomishiro Central Hospital, Okinawa, Japan
| | - Kenichi Mikami
- Office of New Drug I, Pharmaceuticals and Medical Devices Agency (PMDA), Tokyo, Japan
| | - Tetsuhiro Tanaka
- Division of Nephrology and Endocrinology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Hirotaka Watada
- Department of Metabolism and Endocrinology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Kohjiro Ueki
- Diabetes Research Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
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Hein AM, Scialla JJ, Edmonston D, Cooper LB, DeVore AD, Mentz RJ. Medical Management of Heart Failure With Reduced Ejection Fraction in Patients With Advanced Renal Disease. JACC. HEART FAILURE 2019; 7:371-382. [PMID: 31047016 PMCID: PMC6501813 DOI: 10.1016/j.jchf.2019.02.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 02/20/2019] [Indexed: 02/06/2023]
Abstract
Large randomized clinical trials (RCT) supporting guidelines for the management of heart failure with reduced ejection fraction (HFrEF) have typically excluded patients with advanced chronic kidney disease (CKD). Patients with concomitant advanced CKD and HFrEF experience poor cardiovascular outcomes and mortality relative to either disease in isolation and have been shown to consistently receive lower rates of HFrEF guideline-directed medical therapy (GDMT). This review evaluated recent evidence for the use of GDMT in patients with HFrEF and advanced CKD approaching dialysis from RCTs and observational cohorts. The authors also discuss the limitations and challenges inherent in the evidence for GDMT in this population, and offer guidance to clinicians for proper clinical use and future research directions.
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Affiliation(s)
- Aaron M Hein
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel Edmonston
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Lauren B Cooper
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Adam D DeVore
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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83
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Research imperative. Contemp Clin Trials Commun 2019; 14:100350. [PMID: 31011655 PMCID: PMC6461583 DOI: 10.1016/j.conctc.2019.100350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/12/2019] [Accepted: 03/15/2019] [Indexed: 11/21/2022] Open
Abstract
There is a note of caution expressed when clinical care providers enroll their own patients into investigational trials, a concern expressed in the called dual-role consent. There is concern that this circumstance may create a conflict of interest for the physician-investigator, lead to loss of patient voluntarism, and promote the therapeutic misconceptions. In this opinion paper, I review the circumstances surrounding participation in clinical research and the conduct of standard patient care. I propose that when a patient is eligible for an institutional review board-approved clinical trial, instead of representing a potential ethical lapse, soliciting enrollment by the clinician-researcher may represent optimal care for the patient.
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84
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Polkinghorne KR. ESKD or Cancer: Given the Choice, Which Would You Rather Have? Am J Kidney Dis 2019; 73:753-755. [PMID: 31023501 DOI: 10.1053/j.ajkd.2019.01.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/18/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Kevan R Polkinghorne
- Departments of Nephrology and Medicine, Monash Medical Centre, Clayton; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Prahan, Melbourne, Australia.
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85
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Dember LM, Lacson E, Brunelli SM, Hsu JY, Cheung AK, Daugirdas JT, Greene T, Kovesdy CP, Miskulin DC, Thadhani RI, Winkelmayer WC, Ellenberg SS, Cifelli D, Madigan R, Young A, Angeletti M, Wingard RL, Kahn C, Nissenson AR, Maddux FW, Abbott KC, Landis JR. The TiME Trial: A Fully Embedded, Cluster-Randomized, Pragmatic Trial of Hemodialysis Session Duration. J Am Soc Nephrol 2019; 30:890-903. [PMID: 31000566 DOI: 10.1681/asn.2018090945] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 02/11/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Data from clinical trials to inform practice in maintenance hemodialysis are limited. Incorporating randomized trials into dialysis clinical care delivery should help generate practice-guiding evidence, but the feasibility of this approach has not been established. METHODS To develop approaches for embedding trials into routine delivery of maintenance hemodialysis, we performed a cluster-randomized, pragmatic trial demonstration project, the Time to Reduce Mortality in ESRD (TiME) trial, evaluating effects of session duration on mortality (primary outcome) and hospitalization rate. Dialysis facilities randomized to the intervention adopted a default session duration ≥4.25 hours (255 minutes) for incident patients; those randomized to usual care had no trial-driven approach to session duration. Implementation was highly centralized, with no on-site research personnel and complete reliance on clinically acquired data. We used multiple strategies to engage facility personnel and participating patients. RESULTS The trial enrolled 7035 incident patients from 266 dialysis units. We discontinued the trial at a median follow-up of 1.1 years because of an inadequate between-group difference in session duration. For the primary analysis population (participants with estimated body water ≤42.5 L), mean session duration was 216 minutes for the intervention group and 207 minutes for the usual care group. We found no reduction in mortality or hospitalization rate for the intervention versus usual care. CONCLUSIONS Although a highly pragmatic design allowed efficient enrollment, data acquisition, and monitoring, intervention uptake was insufficient to determine whether longer hemodialysis sessions improve outcomes. More effective strategies for engaging clinical personnel and patients are likely required to evaluate clinical trial interventions that are fully embedded in care delivery.
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Affiliation(s)
- Laura M Dember
- Renal, Electrolyte and Hypertension Division, Department of Medicine, .,Department of Biostatistics, Epidemiology, and Informatics
| | - Eduardo Lacson
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | | | - Jesse Y Hsu
- Department of Biostatistics, Epidemiology, and Informatics, and
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah and Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - John T Daugirdas
- Division of Nephrology, Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - Tom Greene
- Departments of Population Health Science and Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Dana C Miskulin
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Ravi I Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts.,Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Denise Cifelli
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rosemary Madigan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amy Young
- DaVita Clinical Research, Minneapolis, Minnesota
| | - Michael Angeletti
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Rebecca L Wingard
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Christina Kahn
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Allen R Nissenson
- DaVita Kidney Care, El Segundo, California.,David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; and
| | - Franklin W Maddux
- Division of Nephrology, Fresenius Medical Care North America, Waltham, Massachusetts
| | - Kevin C Abbott
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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86
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Kosa SD, Monize J, Leenus A, Leenus S, Samra S, Szwiega S, Shi D, Valvasori S, Gafni A, Lok CE, Thabane L. Reporting quality of pilot clinical trials in chronic kidney disease patients on hemodialysis: a methodological survey. Pilot Feasibility Stud 2019; 5:53. [PMID: 30997141 PMCID: PMC6451784 DOI: 10.1186/s40814-019-0436-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/22/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The conduct of high-quality pilot studies can help inform the success of larger clinical trials. Guidelines have been recently developed for the reporting of pilot trials. OBJECTIVE This methodological survey evaluates the completeness of reporting in pilot randomized controlled trials in chronic kidney disease patients on hemodialysis (HD patients) and explores factors associated with better completion of reporting. METHODS The authors searched Pubmed on July 1, 2018, for all pilot trials conducted in HD patients. Reporting quality was assessed against the 40-item Consolidated Standards of Reporting Trials (CONSORT) Extension for Pilot Trials. Study factors including year and country of publication, intervention, number of centers, type of funding, and journal endorsement of CONSORT were also examined. RESULTS The mean number of items reported from the CONSORT extension for pilot trials across all included articles was 18.4 (standard deviation [SD] = 4.4). In the adjusted analysis, studies reported in later years (IRR = 1.026, 95% CI [1.018, 1.034], p < 0.001) and an increase of 20 persons in sample size (adjusted IRR = 1.021, 95% CI [1.010, 1.031], p < 0.001) were associated with a significantly higher number of CONSORT pilot items reported. CONCLUSIONS Current reporting completeness of pilot trials in HD patients is suboptimal. Endorsing the CONSORT extension specific to pilot and feasibility studies and ensuring that pilot trials focus on the feasibility objectives may improve reporting completeness of these trials.
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Affiliation(s)
- Sarah Daisy Kosa
- Kidney CARE Network International, Toronto, Ontario Canada
- Division of Nephrology, Toronto General Hospital, University Health Network, 200 Elizabeth Street 8N844, Toronto, Ontario M5G 2C4 Canada
- Department of Health Research, Evidence, and Impact, McMaster University, Hamilton, Ontario Canada
| | - Jillian Monize
- Kidney CARE Network International, Toronto, Ontario Canada
| | - Alvin Leenus
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario Canada
| | - Selvin Leenus
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario Canada
| | | | - Sylwia Szwiega
- Kidney CARE Network International, Toronto, Ontario Canada
| | - Daniel Shi
- Faculty of Health Sciences, Queen’s University, Kingston, Ontario Canada
| | - Sara Valvasori
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario Canada
| | - Amiram Gafni
- Department of Health Research, Evidence, and Impact, McMaster University, Hamilton, Ontario Canada
| | - Charmaine E. Lok
- Kidney CARE Network International, Toronto, Ontario Canada
- Division of Nephrology, Toronto General Hospital, University Health Network, 200 Elizabeth Street 8N844, Toronto, Ontario M5G 2C4 Canada
- Department of Health Research, Evidence, and Impact, McMaster University, Hamilton, Ontario Canada
| | - Lehana Thabane
- Department of Health Research, Evidence, and Impact, McMaster University, Hamilton, Ontario Canada
- Biostatistics Unit, St Joseph’s Healthcare, Hamilton, Ontario Canada
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87
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Manera KE, Tong A, Craig JC, Shen J, Jesudason S, Cho Y, Sautenet B, Teixeira-Pinto A, Howell M, Wang AYM, Brown EA, Brunier G, Perl J, Dong J, Wilkie M, Mehrotra R, Pecoits-Filho R, Naicker S, Dunning T, Scholes-Robertson N, Johnson DW. An international Delphi survey helped develop consensus-based core outcome domains for trials in peritoneal dialysis. Kidney Int 2019; 96:699-710. [PMID: 31200941 DOI: 10.1016/j.kint.2019.03.015] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/21/2019] [Accepted: 03/14/2019] [Indexed: 12/13/2022]
Abstract
Shared decision-making about clinical care options in end-stage kidney disease is limited by inconsistencies in the reporting of outcomes and the omission of patient-important outcomes in trials. Here we generated a consensus-based prioritized list of outcomes to be reported during trials in peritoneal dialysis (PD). In an international, online, three-round Delphi survey, patients/caregivers and health professionals rated the importance of outcomes using a 9-point Likert scale (with 7-9 indicating critical importance) and provided comments. Using a Best-Worst Scale (BWS), the relative importance of outcomes was estimated. Comments were analyzed thematically. In total, 873 participants (207 patients/caregivers and 666 health professionals) from 68 countries completed round one, 629 completed round two and 530 completed round three. The top outcomes were PD-related infection, membrane function, peritoneal dialysis failure, cardiovascular disease, death, catheter complications, and the ability to do usual activities. Compared with health professionals, patients/caregivers gave higher priority to six outcomes: blood pressure (mean difference, 0.4), fatigue (0.3), membrane function (0.3), impact on family/friends (0.1), peritoneal thickening (0.1) and usual activities (0.1). Four themes were identified that underpinned the reasons for ratings: contributing to treatment longevity, preserving quality of life, escalating morbidity, and irrelevant and futile information and treatment. Patients/caregivers and health professionals gave highest priority to clinical outcomes. In contrast to health professionals, patients/caregivers gave higher priority to lifestyle-related outcomes including the impact on family/friends and usual activities. Thus, prioritization will inform a core outcome set to improve the consistency and relevance of outcomes for trials in PD.
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Affiliation(s)
- Karine E Manera
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Sydney, Australia.
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Sydney, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Jenny Shen
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-University of California Los Angeles Medical Center, Torrance, California, USA
| | - Shilpa Jesudason
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital and University of Adelaide, Adelaide, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Benedicte Sautenet
- University François Rabelais, Tours, France; Department of Nephrology-Hypertension, Dialysis, Kidney Transplantation, Tours Hospital, Tours, France; Methods in Patient-Centered Outcomes & Health Research, Institut National de la Santé et de la Recherche Médicale, U1246, Tours, France
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Sydney, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Sydney, Australia
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Edwina A Brown
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London, United Kingdom
| | - Gillian Brunier
- Sunnybrook Health Sciences Centre (retired), Toronto, Ontario, Canada
| | - Jeffrey Perl
- Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jie Dong
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Martin Wilkie
- Department of Nephrology, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Roberto Pecoits-Filho
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil; Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Saraladevi Naicker
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tony Dunning
- South Bank Technical and Further Education, Brisbane, Australia
| | | | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australian Kidney Trials Network, University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Australia; Centre for Kidney Disease Research, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
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D’Costa M, Pais VM, Rule AD. Leave no stone unturned: defining recurrence in kidney stone formers. Curr Opin Nephrol Hypertens 2019; 28:148-153. [PMID: 30531469 PMCID: PMC6377251 DOI: 10.1097/mnh.0000000000000478] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Established guidelines provide recommendations on the management of kidney stones to prevent recurrence. However, clear and clinically useful terminology for recurrence of kidney stones is needed. This review describes the various manifestations of kidney stone recurrence and the reported rates of kidney stone recurrence in various clinical settings. RECENT FINDINGS Kidney stone recurrence has a wide range of symptomatic and radiographic presentations. Symptomatic recurrence may include characteristic symptoms of stone passage via the ureter (renal colic and gross hematuria). This may be self-managed or result in clinical care, with or without confirmation of an obstructing stone on imaging. Radiographic recurrence has been variably defined as new stone formation, stone growth, or stone disappearance (from passage with or without symptoms). Studies have used inconsistent definitions of recurrence, and recurrence rates vary substantially. Stone free rates and residual stone fragment size after surgical interventions are useful predictors of symptomatic recurrence. SUMMARY The recurrence rate of kidney stones has been assessed in stone formers from sub-specialty clinics, the general community, and clinical trials. The definition of recurrence is quite heterogenous between studies, but the rate of recurrence generally increases as more manifestations are included in the definition.
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Affiliation(s)
- Matthew D’Costa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Vernon M. Pais
- Division of Urology, Geisel School of Medicine at Dartmouth, Hanover NH
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
- Division of Epidemiology, Mayo Clinic, Rochester, MN
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89
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Affiliation(s)
- Rasheeda K Hall
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Julia J Scialla
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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90
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Implementing core outcomes in kidney disease: report of the Standardized Outcomes in Nephrology (SONG) implementation workshop. Kidney Int 2018; 94:1053-1068. [PMID: 30360959 DOI: 10.1016/j.kint.2018.08.018] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 08/22/2018] [Accepted: 08/30/2018] [Indexed: 02/08/2023]
Abstract
There are an estimated 14,000 randomized trials published in chronic kidney disease. The most frequently reported outcomes are biochemical endpoints, rather than clinical and patient-reported outcomes including cardiovascular disease, mortality, and quality of life. While many trials have focused on optimizing kidney health, the heterogeneity and uncertain relevance of outcomes reported across trials may limit their policy and practice impact. The international Standardized Outcomes in Nephrology (SONG) Initiative was formed to identify core outcomes that are critically important to patients and health professionals, to be reported consistently across trials. We convened a SONG Implementation Workshop to discuss the implementation of core outcomes. Eighty-two patients/caregivers and health professionals participated in plenary and breakout discussions. In this report, we summarize the findings of the workshop in two main themes: socializing the concept of core outcomes, and demonstrating feasibility and usability. We outline implementation strategies and pathways to be established through partnership with stakeholders, which may bolster acceptance and reporting of core outcomes in trials, and encourage their use by end-users such as guideline producers and policymakers to help improve patient-important outcomes.
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91
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Vlot MC, den Heijer M, de Jongh RT, Vervloet MG, Lems WF, de Jonge R, Obermayer-Pietsch B, Heijboer AC. Clinical utility of bone markers in various diseases. Bone 2018; 114:215-225. [PMID: 29920402 DOI: 10.1016/j.bone.2018.06.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 06/13/2018] [Accepted: 06/15/2018] [Indexed: 12/13/2022]
Abstract
Measurements of bone markers (BMs) in peripheral blood or urine are a pivotal part of bone research within modern clinical medicine. In recent years the use of BMs increased substantially as they can be useful either to diagnose bone (related) disease and to follow its natural history, but also to monitor the effects of interventions. However, the use of BMs is still complicated mainly due to (pre)analytical variability of these substances, limited accessibility of assays, variable cut-off values in different countries and laboratories and heterogeneous results with regard to clinical implications of measuring BMs in several studies. This review will provide the clinician with a practical guide, based on current evidence, in which circumstances to test which bone markers for optimal diagnostic purposes, in order to improve patient care in different areas of bone diseases including Paget's disease, primary osteoporosis, tumor induced osteomalacia, hypophosphatemic rickets, van Buchem disease, chronic kidney disease, rheumatoid arthritis, neoplasma/multiple myeloma, type 2 diabetes mellitus and primary hyperparathyroidism. The clinician should consider fasting state, recent fractures, aging, menopausal status, concomitant liver and kidney disease when ordering and interpreting BM measurements as these factors might result in misleading BM concentrations. We found that BMs are clearly useful in the current diagnosis of tumor induced osteomalacia, van Buchem disease, Paget's disease and hypophosphatemic rickets. In addition, BMs are useful to monitor disease activity in chronic kidney disease, Paget's disease and are useful to monitor treatment adherence in osteoporosis.
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Affiliation(s)
- M C Vlot
- Department of Clinical Chemistry, Endocrine Laboratory, VU University Medical Center, de Boelelaan 1117, 1081 HV Amsterdam, the Netherlands; Department of Internal Medicine, Endocrinology, VU University Medical Center, de Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - M den Heijer
- Department of Internal Medicine, Endocrinology, VU University Medical Center, de Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - R T de Jongh
- Department of Internal Medicine, Endocrinology, VU University Medical Center, de Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - M G Vervloet
- Department Nephrology, Amsterdam Cardiovascular Sciences (ACS) VU University Medical Center, de Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - W F Lems
- Department of Rheumatology, VU University Medical Center, de Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands
| | - R de Jonge
- Department of Clinical Chemistry, Endocrine Laboratory, VU University Medical Center, de Boelelaan 1117, 1081 HV Amsterdam, the Netherlands
| | - B Obermayer-Pietsch
- Department of Internal Medicine, Endocrinology and Diabetology, Medical University of Graz, Graz 8036, Austria
| | - A C Heijboer
- Department of Clinical Chemistry, Endocrine Laboratory, VU University Medical Center, de Boelelaan 1117, 1081 HV Amsterdam, the Netherlands; Department of Clinical Chemistry, Laboratory of Endocrinology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
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92
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Prischl FC, Wanner C. Renal Outcomes of Antidiabetic Treatment Options for Type 2 Diabetes-A Proposed MARE Definition. Kidney Int Rep 2018; 3:1030-1038. [PMID: 30197969 PMCID: PMC6127417 DOI: 10.1016/j.ekir.2018.04.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/10/2018] [Accepted: 04/16/2018] [Indexed: 02/07/2023] Open
Abstract
One of the most critical long-term complications of type 2 diabetes is nephropathy, currently termed diabetic kidney disease. Although the prevalence is increasing, renal outcomes are heterogeneously defined. Intensive glucose control is effective for the prevention of microvascular complications, including kidney disease. However, the impact of specific drugs on renal outcome measures such as the incidence of kidney disease, albuminuria, progression to end-stage kidney disease, or death of renal cause remains unclear. Comparison of agents or drug classes is impossible, as renal outcomes are inconsistently defined in trials. Recent publications include more stringent criteria, but use only composite endpoints, which can reveal significant results driven by a single surrogate marker but not clinical events of true relevance to patients. This review discusses renal outcomes related to antidiabetic agents for type 2 diabetes, in an attempt to determine the influence of specific drugs on the incidence of diabetic kidney disease and various renal outcomes. There are marked differences among the various agents, but direct comparisons are difficult due to heterogeneous measures. Statements from Kidney Disease Improving Global Outcomes (KDIGO) or European Renal Best Practice (ERBP) highlight that “standardized outcome reporting is key to achieving evidence-based guidance and improving clinical care for patients.” Renal outcome studies including a well-defined, standardized core set of patient-relevant outcomes are needed. Here, we propose to define and establish major adverse renal events (MARE) as the outcome measure for future studies.
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Affiliation(s)
- Friedrich C Prischl
- Department of Nephrology, 4th Department of Internal Medicine, Klinikum Wels-Grieskirchen, Wels, Austria
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93
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Eckardt KU, Bansal N, Coresh J, Evans M, Grams ME, Herzog CA, James MT, Heerspink HJL, Pollock CA, Stevens PE, Tamura MK, Tonelli MA, Wheeler DC, Winkelmayer WC, Cheung M, Hemmelgarn BR. Improving the prognosis of patients with severely decreased glomerular filtration rate (CKD G4+): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2018; 93:1281-1292. [PMID: 29656903 PMCID: PMC5998808 DOI: 10.1016/j.kint.2018.02.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 01/24/2018] [Accepted: 02/05/2018] [Indexed: 12/22/2022]
Abstract
Patients with severely decreased glomerular filtration rate (GFR) (i.e., chronic kidney disease [CKD] G4+) are at increased risk for kidney failure, cardiovascular disease (CVD) events (including heart failure), and death. However, little is known about the variability of outcomes and optimal therapeutic strategies, including initiation of kidney replacement therapy (KRT). Kidney Disease: Improving Global Outcomes (KDIGO) organized a Controversies Conference with an international expert group in December 2016 to address this gap in knowledge. In collaboration with the CKD Prognosis Consortium (CKD-PC) a global meta-analysis of cohort studies (n = 264,515 individuals with CKD G4+) was conducted to better understand the timing of clinical outcomes in patients with CKD G4+ and risk factors for different outcomes. The results confirmed the prognostic value of traditional CVD risk factors in individuals with severely decreased GFR, although the risk estimates vary for kidney and CVD outcomes. A 2- and 4-year model of the probability and timing of kidney failure requiring KRT was also developed. The implications of these findings for patient management were discussed in the context of published evidence under 4 key themes: management of CKD G4+, diagnostic and therapeutic challenges of heart failure, shared decision-making, and optimization of clinical trials in CKD G4+ patients. Participants concluded that variable prognosis of patients with advanced CKD mandates individualized, risk-based management, factoring in competing risks and patient preferences.
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Affiliation(s)
- Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Nisha Bansal
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Marie Evans
- Division of Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden; Swedish Renal Registry, Jönköping, Sweden
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles A Herzog
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA; Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
| | - Matthew T James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carol A Pollock
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia; Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Paul E Stevens
- Kent Kidney Care Centre, East Kent Hospitals, University NHS Foundation Trust, Canterbury, Kent, UK
| | - Manjula Kurella Tamura
- VA Palo Alto Geriatric Research and Education Clinical Center, Palo Alto, California, USA; Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Marcello A Tonelli
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Brenda R Hemmelgarn
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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94
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Rosenstock J, Perkovic V, Alexander JH, Cooper ME, Marx N, Pencina MJ, Toto RD, Wanner C, Zinman B, Baanstra D, Pfarr E, Mattheus M, Broedl UC, Woerle HJ, George JT, von Eynatten M, McGuire DK. Rationale, design, and baseline characteristics of the CArdiovascular safety and Renal Microvascular outcomE study with LINAgliptin (CARMELINA ®): a randomized, double-blind, placebo-controlled clinical trial in patients with type 2 diabetes and high cardio-renal risk. Cardiovasc Diabetol 2018. [PMID: 29540217 PMCID: PMC5870815 DOI: 10.1186/s12933-018-0682-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Cardiovascular (CV) outcome trials in type 2 diabetes (T2D) have underrepresented patients with chronic kidney disease (CKD), leading to uncertainty regarding their kidney efficacy and safety. The CARMELINA® trial aims to evaluate the effects of linagliptin, a DPP-4 inhibitor, on both CV and kidney outcomes in a study population enriched for cardio-renal risk. Methods CARMELINA® is a randomized, double-blind, placebo-controlled clinical trial conducted in 27 countries in T2D patients at high risk of CV and/or kidney events. Participants with evidence of CKD with or without CV disease and HbA1c 6.5–10.0% (48–86 mmol/mol) were randomized 1:1 to receive linagliptin once daily or matching placebo, added to standard of care adjusted according to local guidelines. The primary outcome is time to first occurrence of CV death, non-fatal myocardial infarction, or non-fatal stroke. The key secondary outcome is a composite of time to first sustained occurrence of end-stage kidney disease, ≥ 40% decrease in estimated glomerular filtration rate (eGFR) from baseline, or renal death. CV and kidney events are prospectively adjudicated by independent, blinded clinical event committees. CARMELINA® was designed to continue until at least 611 participants had confirmed primary outcome events. Assuming a hazard ratio of 1.0, this provides 90% power to demonstrate non-inferiority of linagliptin versus placebo within the pre-specified non-inferiority margin of 1.3 at a one-sided α-level of 2.5%. If non-inferiority of linagliptin for the primary outcome is demonstrated, then its superiority for both the primary outcome and the key secondary outcome will be investigated with a sequentially rejective multiple test procedure. Results Between July 2013 and August 2016, 6980 patients were randomized and took ≥ 1 dose of study drug (40.6, 33.1, 16.9, and 9.4% from Europe, South America, North America, and Asia, respectively). At baseline, mean ± SD age was 65.8 ± 9.1 years, HbA1c 7.9 ± 1.0%, BMI 31.3 ± 5.3 kg/m2, and eGFR 55 ± 25 mL/min/1.73 m2. A total of 5148 patients (73.8%) had prevalent kidney disease (defined as eGFR < 60 mL/min/1.73 m2 or macroalbuminuria [albumin-to-creatinine ratio > 300 mg/g]) and 3990 patients (57.2%) had established CV disease with increased albuminuria; these characteristics were not mutually exclusive. Microalbuminuria (n = 2896 [41.5%]) and macroalbuminuria (n = 2691 [38.6%]) were common. Conclusions CARMELINA® will add important information regarding the CV and kidney disease clinical profile of linagliptin by including an understudied, vulnerable cohort of patients with T2D at highest cardio-renal risk. Trial registration ClinicalTrials.gov identifier—NCT01897532; registered July 9, 2013 Electronic supplementary material The online version of this article (10.1186/s12933-018-0682-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, 7777 Forest Lane, Suite C-685, Dallas, TX, 75230, USA.
| | - Vlado Perkovic
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Mark E Cooper
- Head of Diabetes, Monash University, Melbourne, VIC, Australia
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | | | - Robert D Toto
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.,University of Toronto, Toronto, Canada
| | | | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | | | | | | | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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95
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Baigent C, Lennon R. Should We Increase GFR with Bardoxolone in Alport Syndrome? J Am Soc Nephrol 2018; 29:357-359. [PMID: 29371420 DOI: 10.1681/asn.2017101062] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Colin Baigent
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, England;
| | - Rachel Lennon
- Wellcome Trust Centre for Cell-Matrix Research, Department of Paediatric Nephrology, School of Biological Sciences, University of Manchester, Manchester, England; and.,Royal Manchester Children's Hospital, Manchester, England
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