Nomenclature for kidney function and disease: report of a Kidney Disease: Improving Global Outcomes (KDIGO) Consensus Conference

Chronic Kidney Failure Provokes the Enrichment of Terminally Differentiated CD8+ T Cells, Impairing Cytotoxic Mechanisms After Kidney Transplantation

Chronic kidney failure (KF) provokes the development of immune senescent CD8⁺ cytotoxic T cells, affecting the occurrence of graft rejection, viral infections, and malignancies after kidney transplantation. In this study, we analyzed the impact of KF, subsequent dialysis treatment, and kidney transplantation on the differentiation of CD8⁺CD31⁺CD45RA⁺CCR7⁺ recent thymic emigrant (CCR7⁺ RTE) Tregs/Tresps into CD8⁺CD31^-CD45RA^- memory (CD31^- memory) Tregs/Tresps and its effect on the release of cytokines, Fas receptor, Fas ligand as well as cytotoxic mediators by naïve, central memory (CM), effector memory (EM), and terminally differentiated effector memory (TEMRA) Tresps. We found that normal age-dependent differentiation of CD8⁺ Tregs/Tresps generally differs in the way that TEMRA cells only arise in Tresps. Compared to healthy controls, KF patients revealed an age-independently decreased frequency of CCR7⁺ RTE Tregs/Tresps, but increased frequencies of CCR7⁺ MN Tregs/Tresps and CD31^- memory Tregs/Tresps, suggesting an increased differentiation via CD31⁺CD45RA^- memory (CD31⁺ memory) Tregs/Tresps into CD31^- memory Tregs/Tresps. Intensified differentiation via CD31⁺ memory Tresps increased the emergence of apoptosis-resistant CM Tresps with strong Fas ligand-mediated cytotoxicity. CCR7⁺ RTE Tresp proliferation generated TEMRA Tresps, secreting high levels of cytotoxic mediators. In dialysis and transplant patients, CD31⁺ TEMRA Tregs/Tresps accumulated, proposing an impaired CCR7⁺ RTE Treg/Tresp differentiation via CD31⁺ memory Tregs/Tresps into CD31^- memory Tregs/Tresps. Increased percentages of CD31^- TEMRA Tresps, but not of CD31^- TEMRA Tregs, were observed in all patient groups, indicating impaired proliferation of CCR7⁺ RTE Tresps, but not of CCR7⁺ RTE Tregs, into CD31^- memory Tregs/Tresps. In transplant patients, CCR7⁺ RTE Tregs accumulated, while frequencies of CCR7⁺ RTE Tresps were decreased, suggesting that the immunosuppressive therapy only prevented excessive CCR7⁺ RTE Treg differentiation but not that of CCR7⁺ RTE Tresps. Presumably, this caused the accumulation of TEMRA Tresps with decreased release of cytotoxic mediators, such as perforin. In conclusion, we propose that chronic KF affects both the differentiation of CD8⁺ Tregs and CD8⁺ Tresps. However, the immunosuppressive therapy after transplantation may successfully prevent excessive Treg differentiation, but not as suffciently that of Tresps. Therefore, the risk for graft rejection may be reduced, while the susceptibility for infections and malignancies may be increased in these patients.

Immune globulin therapy and kidney disease: Overview and screening, monitoring, and management recommendations

Purpose

This report calls attention to the potential risks of diminished kidney function when administering immune globulin (IG). The goal is to increase awareness of chronic kidney disease (CKD) and kidney function impairment in patients receiving IG and provide recommendations for screening, monitoring, and management to promote risk prevention and mitigation.

Summary

Human IG preparations for intravenous (IVIG) or subcutaneous (SCIG) administration are the mainstay of treatment in patients with primary immunodeficiency diseases. Increasingly, IVIG at high doses (1,000 to 2,400 mg/kg) is also used as a treatment for a variety of autoimmune and inflammatory conditions. Although some autoinflammatory disorders respond to a single course of IVIG therapy, the majority of patients require long-term, regular infusions, thereby increasing the overall risks. Often, both patients and physicians treating adults with IG are unaware of underlying CKD or kidney function impairment. This lack of awareness constitutes a major risk factor for potential worsening, particularly when using high doses of IVIG. Therefore, screening of all patients for CKD and kidney function impairment before the use of IG is essential. Identification of the cause of kidney impairment is strongly encouraged, as IG therapy may need to be modified.

Conclusion

As detailed here, there are potential risks to patients with impaired kidney function with administration of IG, particularly at high doses. Product selection, volume, route of administration, and rate of infusion may impact those with compromised kidney function. Therefore, screening of all patients for CKD and kidney function impairment before the use of IVIG and SCIG, as well as ongoing monitoring and management, is critical. As with all potential adverse drug reactions, the best approach is to prevent them.

Injúria renal aguda e métodos de suporte: padronização da nomenclatura

Resumo O Departamento de Injúria Renal Aguda (IRA) da Sociedade Brasileira de Nefrologia elaborou o presente documento para fins de padronização da terminologia em IRA e modalidades dialíticas na língua portuguesa para o Brasil. Diversos termos com significados semelhantes têm sido empregados em IRA e suas modalidades dialíticas, causando confusão e disparidades entre pacientes, nefrologistas, instituições de saúde, empresas privadas de assistência, seguradoras e entidades governamentais. Essas disparidades podem impactar a assistência médica, a organização e o atendimento hospitalares, assim como o financiamento e reembolso dos procedimentos relacionados com a IRA. Assim, nomenclatura e definições consensuais foram elaboradas, incluindo-se as definições de IRA, doença renal aguda (DRA) e doença renal crônica (DRC). Adicionalmente, todas as modalidades dialíticas e os procedimentos extracorpóreos relacionados a IRA, atualmente aprovados e disponíveis no país, foram abordados. A Sociedade Brasileira de Nefrologia espera que este Consenso possa padronizar a nomenclatura e prover suporte técnico para todos os atores envolvidos na assistência à IRA no Brasil.

Outcomes of Prophylactic Enoxaparin Against Venous Thromboembolism in Hospitalized Children

OBJECTIVES

To assess the biochemical and clinical outcomes of hospitalized children who received prophylactic enoxaparin.

METHODS

We conducted a retrospective observational study of hospitalized children aged <18 years who received prophylactic enoxaparin against hospital-acquired venous thromboembolism (HA-VTE). Weight-based enoxaparin dosing was administered using a pharmacy-driven protocol, which later included a low molecular weight, anti-Xa level directed-dose adjustment strategy. Primary biochemical and clinical outcomes were achievement of goal anti-Xa range of 0.2 to 0.5 IU/mL and development of HA-VTE, respectively. Secondary clinical outcome was development of clinically relevant bleed.

RESULTS

We analyzed 194 children with 13 (6.7%) infants aged <1 year and 181 (93.3%) older children aged ≥1 year. After the initial dose, only 1 (11.1%) infant, but 62 (57.9%) older children, achieved goal. Median number of anti-Xa levels until goal was 2 (interquartile range: 2-3) in infants and 1 (interquartile range: 1-2) in older children (P = .01). HA-VTE developed in 2 (15.4%) infants and 9 (5.0%) older children. Among children with anti-Xa level, HA-VTE developed less frequently in children who achieved (2.1%) than in those who did not achieve (13.6%) goal (P = .046). A total of 4 (2.1%) older children and no infants developed clinically relevant bleed. Among children with anti-Xa level, frequency of bleeding was comparable between children who did (3.2%) and did not achieve (0%) goal (P >.99).

CONCLUSIONS

Our findings suggest the effectiveness and safety of an anti-Xa level directed strategy of prophylactic enoxaparin. However, this strategy should be investigated in prospective controlled studies.

Psychosocial factors in patients with kidney failure and role for social worker: A secondary data audit

BACKGROUND

People with kidney failure face a multitude of psychosocial stressors that affect disease trajectory and health outcomes.

OBJECTIVES

To investigate psychosocial factors affecting people with kidney failure before or at start of kidney replacement therapy (KRT) and kidney supportive and palliative care (KSPC) phases of illness and to explore role of social worker during the illness trajectory.

METHODS

We conducted a secondary data audit of patients either before or at start of KRT (Phase 1) and at the KSPC (Phase 2) of illness and had psychosocial assessments between March 2012 and March 2020 in an Australian setting.

RESULTS

Seventy-nine individuals, aged 70 ± 12 years, had at least two psychosocial assessments, one in each of the two phases of illness. The median time between social worker evaluations in Phase 1 and Phase 2 was 522 (116-943) days. Adjustment to illness and treatment (90%) was the most prevalent psychosocial issue identified in Phase 1, which declined to 39% in Phase 2. Need for aged care assistance (7.6%-63%; p < 0.001) and carer support (7.6%-42%; p < 0.001) increased significantly from Phase 1 to Phase 2. There was a significant increase in psychosocial interventions by the social worker in Phase 2, including supportive counselling (53%-73%; p < 0.05), provision of education and information (43%-65%; p < 0.01), and referrals (28%-62%; p < 0.01).

CONCLUSION

Adults nearing or at the start of KRT experience immense psychosocial burden and adaptive demands that recognisably change during the course of illness. The positive role played by the nephrology social worker warrants further investigation.

The prevalence of Fabry disease in a statewide chronic kidney disease cohort - Outcomes of the aCQuiRE (Ckd.Qld fabRy Epidemiology) study

Background

Prevalence of Fabry disease amongst Chronic Kidney Disease (CKD) patients on haemodialysis has been shown to be approximately 0.2%.

Methods

We undertook a cross-sectional study employing a cascade screening strategy for Fabry Disease amongst 3000 adult, male and female patients affected by CKD stage 1-5D/T at public, specialty renal practices within participating Queensland Hospital and Health Services from October 2017 to August 2019. A multi-tiered FD screening strategy, utilising a combination of dried blood spot (DBS) enzymatic testing, and if low, then lyso-GB3 testing and DNA sequencing, was used.

Results

Mean (SD) age was 64.0 (15.8) years (n = 2992), and 57.9% were male. Eight participants withrew out of the 3000 who consented. Of 2992 screened, 6 (0.20%) received a diagnosis of FD, 2902 (96.99%) did not have FD, and 84 (2.81%) received inconclusive results. Of the patients diagnosed with FD, mean age was 48.5 years; 5 were male (0.29%) and 1 was female (0.08%); 4 were on kidney replacement therapy (2 dialysis and 2 transplant); 3 were new diagnoses.

Conclusions

Estimated overall FD prevalence was 0.20%. Screening of the broader CKD population may be beneficial in identifying cases of FD.

Trial registration

The aCQuiRE Study has been prospectively registered with the Queensland Health Database of Research Activity (DORA, https://dora.health.qld.gov.au) as pj09946 (Registered 3rd July 2017).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02805-8.

Information and consensus document for the detection and management of chronic kidney disease

Chronic kidney disease (CKD) is a major public health problem worldwide that affects more than 10% of the Spanish population. CKD is associated with high comorbidity rates, poor prognosis and major consumption of health system resources. Since the publication of the last consensus document on CKD seven years ago, little evidence has emerged and few clinical trials on new diagnostic and treatment strategies in CKD have been conducted, apart from new trials in diabetic kidney disease. Therefore, CKD international guidelines have not been recently updated. The rigidity and conservative attitude of the guidelines should not prevent the publication of updates in knowledge about certain matters that may be key in detecting CKD and managing patients with this disease. This document, also prepared by 10 scientific associations, provides an update on concepts, clarifications, diagnostic criteria, remission strategies and new treatment options. The evidence and the main studies published on these aspects of CKD have been reviewed. This should be considered more as an information document on CKD. It includes an update on CKD detection, risk factors and screening; a definition of renal progression; an update of remission criteria with new suggestions in the older population; CKD monitoring and prevention strategies; management of associated comorbidities, particularly in diabetes mellitus; roles of the Primary Care physician in CKD management; and what not to do in Nephrology. The aim of the document is to serve as an aid in the multidisciplinary management of the patient with CKD based on current recommendations and knowledge.

Polymyxin B-Associated Nephrotoxicity and Its Predictors: A Retrospective Study in Carbapenem-Resistant Gram-Negative Bacterial Infections

Polymyxin B (PMB), a kind of polymyxin, was widely used in carbapenem-resistant Gram-negative bacterial (CR-GNB) infections. However, adverse reactions such as nephrotoxicity and neurotoxicity limit its use in clinical practice. The aim of this study was to explore PMB associated with nephrotoxicity and its predictors. Patients who received PMB intravenous drip for more than 72 h were eligible for the study. Characteristics of patients, concomitant nephrotoxic agents, underlying disease, and antimicrobial susceptibility were submitted for descriptive analysis. Univariate analysis and binary logistic regression were used to assess the factors leading to acute kidney injury (AKI). AKI was assessed with serum creatinine variations according to the classification of risk (stage R), injury (stage I), failure (stage F), loss, and end-stage of kidney disease. Among 234 patients with CR-GNB infections who used PMB in our study, 67 (28.63%) patients developed AKI, including 31 (14.25%) patients in stage R, 15 (6.41%) patients in stage I, and 21 (8.97%) patients in stage F. The incident rate of PMB-related nephrotoxicity in patients with normal renal function was 32.82% (43/131). The higher risk factors of AKI include males [odds ratio (OR) = 3.237; 95% confidence interval (95%CI) = 1.426–7.350], digestive system diseases [OR = 2.481 (1.127–5.463)], using furosemide (&gt;20 mg/day) [OR = 2.473 (1.102–5.551)], and baseline serum creatinine [OR = 0.994 (0.990–0.999)]. Nonparametric tests of K-independent samples showed that baseline serum creatinine and the PMB maintenance dose were associated with the severity of nephrotoxicity (both p &lt; 0.05). Male, digestive system diseases, using furosemide (&gt;20 mg/day), and high baseline serum creatinine were the independent risk factors of PMB-associated AKI development. The maintenance dose of PMB may be related to the severity of AKI. These risk factors should be taken into consideration when initiating PMB-based therapy. The serum creatinine value should be closely monitored when using PMB.

Association between Use of Nutrition Labels and Risk of Chronic Kidney Disease: The Korean National Health and Nutrition Examination Survey (KNHANES) 2008-2019

Nutrition labeling on food packages is increasingly found to promote healthier food choices associated with lower risk of chronic kidney disease (CKD). To examine associations between nutrition labels use and CKD risk, we conducted a nationally representative cross-sectional study of 32,080 adults from the 2008−2019 Korean National Health and Nutrition Examination Survey. Nutrition labels use was collected via self-reported questionnaires. Ascertainment and severity of CKD was determined by estimated glomerular filtration rate or proteinuria. In multivariable-adjusted (MV) logistic regression models, increasing awareness and use of nutrition labels was significantly associated with lower CKD risk (MV-adjusted OR “nutrition labels aware and use” group vs. “nutrition labels unaware” group [95% CIs]: 0.75 [0.59−0.95], Ptrend:0.03). This inverse association varied with CKD’s risk of progression, with 21% and 42% reduced risk observed for CKD subtypes with “moderate” and “high” risk of progression, respectively (all Ptrend ≤ 0.04). Furthermore, the nutrition labels use and CKD risk association significantly differed by age, with 35% reduced risk observed in the older group aged 49 years or older, but not in the younger group (Pinteraction < 0.001). Our results suggest increasing perception and use of nutrition labels may contribute to CKD prevention and its early asymptomatic progression, especially in older adults.

Severe acute kidney disease is associated with worse kidney outcome among acute kidney injury patients

Acute kidney disease (AKD) comprises acute kidney injury (AKI). However, whether the AKD staging system has prognostic values among AKI patients with different baseline estimated glomerular filtration (eGFR) remains a controversial issue. Algorithm-based approach was applied to identify AKI occurrence and to define different AKD stages. Risk ratio for major adverse kidney events (MAKE), including (1) eGFR decline > 35% from baseline, (2) initiation of dialysis, (3) in-hospital mortality of different AKD subgroups were identified by multivariable logistic regression. Among the 4741 AKI patients identified from January 2015 to December 2018, AKD stages 1–3 after AKI was common (53% in the lower baseline eGFR group and 51% in the higher baseline eGFR group). In the logistic regression model adjusted for demographics and comorbidities at 1-year follow-up, AKD stages 1/2/3 (AKD stage 0 as reference group) were associated with higher risks of MAKE (AKD stage: odds ratio, 95% confidence interval [95% CI], AKD 1: 1.85, 1.56–2.19; AKD 2: 3.43, 2.85–4.12; AKD 3: 10.41, 8.68–12.49). Regardless of baseline eGFR, staging criteria for AKD identified AKI patients who were at higher risk of kidney function decline, dialysis and mortality. Post-AKI AKD patients with severer stage need intensified care and timely intervention.

Uremic Toxins and Cardiovascular Risk in Chronic Kidney Disease: What Have We Learned Recently beyond the Past Findings?

Patients with chronic kidney disease (CKD) have an elevated prevalence of atheromatous (ATH) and/or non-atheromatous (non-ATH) cardiovascular disease (CVD) due to an array of CKD-related risk factors, such as uremic toxins (UTs). Indeed, UTs have a major role in the emergence of a spectrum of CVDs, which constitute the leading cause of death in patients with end-stage renal disease. The European Uremic Toxin Work Group has identified over 100 UTs, more than 25 of which are dietary or gut-derived. Even though relationships between UTs and CVDs have been described in the literature, there are few reviews on the involvement of the most toxic compounds and the corresponding physiopathologic mechanisms. Here, we review the scientific literature on the dietary and gut-derived UTs with the greatest toxicity in vitro and in vivo. A better understanding of these toxins' roles in the elevated prevalence of CVDs among CKD patients might facilitate the development of targeted treatments. Hence, we review (i) ATH and non-ATH CVDs and the respective levels of risk in patients with CKD and (ii) the mechanisms that underlie the influence of dietary and gut-derived UTs on CVDs.

Machine Learning Improves Upon Clinicians' Prediction of End Stage Kidney Disease

Background and Objectives

Chronic kidney disease progression to ESKD is associated with a marked increase in mortality and morbidity. Its progression is highly variable and difficult to predict.

Methods

This is an observational, retrospective, single-centre study. The cohort was patients attending hospital and nephrology clinic at The Canberra Hospital from September 1996 to March 2018. Demographic data, vital signs, kidney function test, proteinuria, and serum glucose were extracted. The model was trained on the featurised time series data with XGBoost. Its performance was compared against six nephrologists and the Kidney Failure Risk Equation (KFRE).

Results

A total of 12,371 patients were included, with 2,388 were found to have an adequate density (three eGFR data points in the first 2 years) for subsequent analysis. Patients were divided into 80%/20% ratio for training and testing datasets.

ML model had superior performance than nephrologist in predicting ESKD within 2 years with 93.9% accuracy, 60% sensitivity, 97.7% specificity, 75% positive predictive value. The ML model was superior in all performance metrics to the KFRE 4- and 8-variable models.

eGFR and glucose were found to be highly contributing to the ESKD prediction performance.

Conclusions

The computational predictions had higher accuracy, specificity and positive predictive value, which indicates the potential integration into clinical workflows for decision support.

Prognosis of hospitalized patients with cirrhosis and acute kidney disease

BACKGROUND

The prognosis of acute kidney disease (AKD), defined as a glomerular filtration rate of <60 ml/min/1.73 m2 or a rise in serum creatinine (sCr) of <50% for <3 months, is not clearly known.

AIM

To study the prevalence, predictive factors and clinical outcomes in hospitalized cirrhotic patients with AKD.

METHODS

The North American Consortium for the Study of End-Stage Liver Disease prospectively enrolled hospitalized decompensated cirrhotic patients. Patients were separated into those with normal renal function (controls or C), AKD or stage 1 AKI as their worst renal dysfunction per International Club of Ascites definition and compared. Parameters assessed included demographics, laboratory data, haemodynamics, renal and patient outcomes.

RESULTS

1244 patients with cirrhosis and ascites (C: 704 or 57%; AKD: 176 or 14%; stage 1 AKI: 364 or 29%) with similar demographics were enrolled. AKD patients had similar baseline sCr but higher hospital admission in the previous 6 months, and higher peak sCr, compared to controls, with their peak sCr being lower than that in stage 1 AKI patients (all P < .0001). The in-hospital and 30-day survival for AKD patients were intermediary between that for controls and stage 1 AKI patients (96% vs 91% vs 86%, P < .0001). The strongest predictors for AKD development while in hospital were the presence of a second infection (OR: 2.44) and diabetes (OR: 1.53).

CONCLUSIONS

Patients with AKD had intermediate outcomes between stage 1 AKI and controls. AKD patients, especially those with diabetes and a second infection, need careful monitoring and prompt treatment for AKD to prevent negative outcomes.

APOL1 Risk Variants, Acute Kidney Injury, and Death in Participants With African Ancestry Hospitalized With COVID-19 From the Million Veteran Program

IMPORTANCE

Coronavirus disease 2019 (COVID-19) confers significant risk of acute kidney injury (AKI). Patients with COVID-19 with AKI have high mortality rates.

OBJECTIVE

Individuals with African ancestry with 2 copies of apolipoprotein L1 (APOL1) variants G1 or G2 (high-risk group) have significantly increased rates of kidney disease. We tested the hypothesis that the APOL1 high-risk group is associated with a higher-risk of COVID-19-associated AKI and death.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included 990 participants with African ancestry enrolled in the Million Veteran Program who were hospitalized with COVID-19 between March 2020 and January 2021 with available genetic information.

EXPOSURES

The primary exposure was having 2 APOL1 risk variants (RV) (APOL1 high-risk group), compared with having 1 or 0 risk variants (APOL1 low-risk group).

MAIN OUTCOMES AND MEASURES

The primary outcome was AKI. The secondary outcomes were stages of AKI severity and death. Multivariable logistic regression analyses adjusted for preexisting comorbidities, medications, and inpatient AKI risk factors; 10 principal components of ancestry were performed to study these associations. We performed a subgroup analysis in individuals with normal kidney function prior to hospitalization (estimated glomerular filtration rate ≥60 mL/min/1.73 m2).

RESULTS

Of the 990 participants with African ancestry, 905 (91.4%) were male with a median (IQR) age of 68 (60-73) years. Overall, 392 (39.6%) patients developed AKI, 141 (14%) developed stages 2 or 3 AKI, 28 (3%) required dialysis, and 122 (12.3%) died. One hundred twenty-five (12.6%) of the participants were in the APOL1 high-risk group. Patients categorized as APOL1 high-risk group had significantly higher odds of AKI (adjusted odds ratio [OR], 1.95; 95% CI, 1.27-3.02; P = .002), higher AKI severity stages (OR, 2.03; 95% CI, 1.37-2.99; P < .001), and death (OR, 2.15; 95% CI, 1.22-3.72; P = .007). The association with AKI persisted in the subgroup with normal kidney function (OR, 1.93; 95% CI, 1.15-3.26; P = .01). Data analysis was conducted between February 2021 and April 2021.

CONCLUSIONS AND RELEVANCE

In this cohort study of veterans with African ancestry hospitalized with COVID-19 infection, APOL1 kidney risk variants were associated with higher odds of AKI, AKI severity, and death, even among individuals with prior normal kidney function.

Radiomics-Based Image Phenotyping of Kidney Apparent Diffusion Coefficient Maps: Preliminary Feasibility & Efficacy

Given the central role of interstitial fibrosis in disease progression in chronic kidney disease (CKD), a role for diffusion-weighted MRI has been pursued. We evaluated the feasibility and preliminary efficacy of using radiomic features to phenotype apparent diffusion coefficient (ADC) maps and hence to the clinical classification(s) of the participants. The study involved 40 individuals (10 healthy and 30 with CKD (eGFR < 60 mL/min/1.73 m2)). Machine learning methods, such as hierarchical clustering and logistic regression, were used. Clustering resulted in the identification of two clusters, one including all individuals with CKD (n = 17), while the second one included all the healthy volunteers (n = 10) and the remaining individuals with CKD (n = 13), resulting in 100% specificity. Logistic regression identified five radiomic features to classify participants as with CKD vs. healthy volunteers, with a sensitivity and specificity of 93% and 70%, respectively, and an AUC of 0.95. Similarly, four radiomic features were able to classify participants as rapid vs. non-rapid CKD progressors among the 30 individuals with CKD, with a sensitivity and specificity of 71% and 43%, respectively, and an AUC of 0.75. These promising preliminary data should support future studies with larger numbers of participants with varied disease severity and etiologies to improve performance.

Diabetic kidney disease and risk of incident stroke among adults with type 2 diabetes

BACKGROUND

Data on the relations between kidney function abnormalities and stroke in type 2 diabetes are limited. We evaluated the associations of kidney function abnormalities and chronic kidney disease (CKD) stages with incident stroke in a large sample of adults with type 2 diabetes.

METHODS

Participants with type 2 diabetes from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study without history of stroke at baseline were included. Urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) were assessed at baseline. CKD categories were defined according to the KDIGO (Kidney Disease: Improving Global Outcomes) guidelines. Cox proportional hazards regression models were used to compute hazard ratios (HR) and 95% confidence intervals (CI) for stroke in relation to measures of kidney function and CKD categories.

RESULTS

A total of 9170 participants (mean age 62.8 [SD: 6.6] years, 38.2% women, 62.9% white) were included. Over a median follow-up of 4.9 years (interquartile range: 4.0-5.7), 156 participants developed a stroke (incidence rate 3.6/1000 person-years [95% CI 3.0-4.2]). After adjusting for relevant confounders, higher UACR and lower eGFR were each associated with increased risk of stroke. Compared to UACR < 30 mg/g, moderate albuminuria and severe albuminuria were associated with increasing hazards for stroke (HR 1.61 [95% CI 1.12-2.32] and 2.29 [95% CI 1.39-3.80], respectively). Compared to eGFR of ≥ 60 mL/min/1.73 m², decreased eGFR (eGFR < 60 mL/min/1.73 m²) was associated with higher risk of stroke (HR 1.50, 95% CI 0.98-2.29). Compared to no CKD, worsening CKD stage was associated with an increasing risk of stroke (HRs of 1.76 [95% CI 1.10-2.83] for CKD G1, 1.77 [95% CI 1.13-2.75] for CKD G2, and 2.03 [95% CI 1.27-3.24] for CKD G3).

CONCLUSIONS

In a large sample of adults with type 2 diabetes, increasing albuminuria and worsening stages of early CKD were independently associated with higher risk of incident stroke.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT00000620 .

How to Prolong Filter Life During Continuous Renal Replacement Therapy?

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .

Consistency of the estimated target weights and ECW/TBW using BIA after hemodialysis in patients between standing and lying-down positions

Background

As hemodialysis is administered with the patient lying down, the distribution of body fluid is stable in the lying position, which is why this position is recommended for bioimpedance analysis (BIA). Although the InBody S10 is widely used for hemodialysis patients in the lying position, clinicians must make the measurements in person. In contrast, patients can use the InBody 770 to obtain measurements by themselves in the standing position, which may be more convenient. Therefore, this study compared the measurements of hemodialysis patients’ estimated target weight and ECW/TBW obtained lying down using the S10 to those obtained in the standing position using the 770.

Methods

This study was conducted among maintenance hemodialysis patients at Chuncheon Sacred Heart Hospital in October 2020. Measurements from 56 patients before and after hemodialysis were obtained using the 2 machines. Each (S10 or 770) estimated target weight, both pre- and post-hemodialysis, was considered ideal when the ECW/TBW ratio was 0.380. R² was calculated and the Bland-Altman test was performed.

Results

The patients’ median age was 64 years old, and 51% were men. The actual ultrafiltration was 2 kg, and the mean TBW change measured using the InBody devices was 1.5 L (R² = 0.718) for the S10 and 1.7 L (R² = 0.616) for the 770. The estimated target weight at pre- and post-hemodialysis showed a remarkably high correlation with the patients’ actual pre- and post-hemodialysis weight (R² > 0.095). The correlation between these measurements (lying vs. standing) before and after hemodialysis was also very close (R² = 1.0000). In addition, ECW/TBW had a good correlation (R2 ≥ 0.970) The Bland-Altman test of dry weight and ECW/TBW yielded similar results.

Conclusions

This study showed that patients’ estimated target weights in the lying position using the InBody S10 device and in the standing position using the InBody 770 device were consistent in both pre- and post-hemodialysis states.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02737-3.

Outcomes of COVID-19 Critically Ill Extremely Elderly Patients: Analysis of a Large, National, Observational Cohort

BACKGROUND

During the COVID-19 pandemic, resource allocation became a major problem in globally overwhelmed ICUs. The main goal of this study was to describe the clinical characteristics of the very elderly patients (aged ≥ 80 years) with COVID-19 admitted in Romanian ICUs. The study objectives were to evaluate and determine the factors associated with ICU mortality.

METHODS

We designed a national, multicentric, observational platform with prospective enrolment. This study included patients aged ≥ 80 years admitted in Romanian ICUs with SARS-CoV-2 infection from March 2020 to December 2021.

RESULTS

We included 1666 patients with a median age of 83 years and 78% ICU mortality. Male sex, dyspnoea, lower Glasgow Coma Scale and lower SpO2 at ICU admission, the need for mechanical ventilation (MV), and corticosteroid use were independently associated with mortality. A total of 886/1666 (53%) elderly patients underwent invasive mechanical ventilation, with a mortality of 97%. The age impact on mortality was confirmed by a 1:1 propensity matching with less elderly ICU patients.

CONCLUSION

In extremely elderly patients with COVID-19 admitted in the ICU, mortality is high, particularly when requiring MV. Therapy should be directed towards the optimization of less invasive ventilatory methods and the use of MV and corticosteroids only in highly selected patients.

Adolescent Blood Pressure and the Risk for Early Kidney Damage in Young Adulthood

BACKGROUND

Recent guidelines classified blood pressure above 130/80 mm Hg as hypertension. However, outcome data were lacking.

OBJECTIVE

To determine the association between blood pressure in adolescence and the risk for early kidney damage in young adulthood.

METHODS

In this nationwide cohort study, we included 629 168 adolescents aged 16 to 20 who underwent medical examinations before mandatory military service in Israel. We excluded 30 466 adolescents with kidney pathology, hypertension, or missing blood pressure or anthropometric data at study entry. Blood pressure measurements at study entry were categorized according to the Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents: group A (<120/<80 mm Hg; Reference group), group B (120/<80-129/<80 mm Hg), group C (130/80-139/89 mm Hg), and group D (≥140/90 mm Hg). Early kidney damage in young adulthood was defined as albuminuria of ≥30 mg/g with an estimated glomerular filtration rate of 60 mL/(min·1.73 m²) or over.

RESULTS

Of 598 702 adolescents (54% men), 2004 (0.3%) developed early kidney damage during a mean follow-up of 15.1 (7.2) years. The adjusted hazard ratios for early kidney damage in blood pressure group C were 1.17 (1.03-1.32) and 1.51 (1.22-1.86) among adolescents with lean (body mass index <85th percentile) and high body mass index (body mass index ≥85th percentile), respectively. Corresponding hazard ratios for kidney disease in group D were 1.49 (1.15-1.93) and 1.79 (1.35-2.38) among adolescents with lean and high body mass index, respectively.

CONCLUSIONS

Blood pressure of ≥130/80 mm Hg was associated with early kidney damage in young adulthood, especially in adolescents with overweight and obesity.

Spiritual Well-Being and Its Relationship with Patient Characteristics and Other Patient-Reported Outcomes in Peritoneal Dialysis Patients: Findings from the PDOPPS

BACKGROUND

Spiritual well-being (SWB), an individual's understanding of the meaning and purpose of life, may help patients with chronic or terminal illnesses cope with their disease. This study aimed to assess SWB in patients on peritoneal dialysis (PD), as well as its relationship with patient characteristics and patient-reported outcomes (PRO).

METHODS

The data were obtained from questionnaires that formed part of the PD Outcomes and Practice Patterns Study (PDOPPS). Measures used in this study were SWB scores derived from the WHO Quality of Life, Spirituality, Religiousness, and Personal Beliefs (WHOQOL-SRPB) tool including 32 items from 8 facets; physical (PCS) and mental component summary (MCS) scores of the 12-Item Short-Form Health Survey (SF-12), Center of Epidemiologic Studies Depression Scale-10 (CES-D-10) scores, burden of kidney disease scores, and functional status scores.

RESULTS

Overall, 529 out of 848 participants (62%) completely responded to the questionnaires and were included in the analysis. Over two-thirds of PD patients (70%) had moderate or higher SWB scores. The SWB scores were significantly lower in patients with age > 65 years and unemployed status. SWB scores positively correlated with higher PCS, MCS, burden of kidney disease scores, and functional status scores, while negatively correlated with depression scores by CES-D-10 scale. Patients who reported significant depressive symptoms (CES-D-10 score ≥ 10) had significantly lower SWB scores.

CONCLUSION

Better SWB was significantly associated with better health-related QOL (HRQOL) and the absence of depressive symptoms. SWB may be an essential consideration in the delivery of high-quality PD.

MicroRNAs and their delivery in diabetic fibrosis

The global prevalence of diabetes mellitus was estimated to be 463 million people in 2019 and is predicted to rise to 700 million by 2045. The associated financial and societal costs of this burgeoning epidemic demand an understanding of the pathology of this disease, and its complications, that will inform treatment to enable improved patient outcomes. Nearly two decades after the sequencing of the human genome, the significance of noncoding RNA expression is still being assessed. The family of functional noncoding RNAs known as microRNAs regulates the expression of most genes encoded by the human genome. Altered microRNA expression profiles have been observed both in diabetes and in diabetic complications. These transcripts therefore have significant potential and novelty as targets for therapy, therapeutic agents and biomarkers.

KDOQI US Commentary on the 2021 KDIGO Clinical Practice Guideline for the Management of Blood Pressure in CKD

The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the 2021 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for the management of blood pressure in chronic kidney disease (CKD). This commentary is the product of that work group and presents the recommendations and practice points from the KDIGO guideline in the context of US clinical practice. A critical addition to the KDIGO guideline is the recommendation for accurate assessment of blood pressure using standardized office blood pressure measurement. In the general adult population with CKD, KDIGO recommends a goal systolic blood pressure less than 120 mm Hg on the basis of results from the Systolic Blood Pressure Intervention Trial (SPRINT) and secondary analyses of the Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial. The KDOQI work group agreed with most of the recommendations while highlighting the weak evidence base especially for patients with diabetes and advanced CKD.

Serum metabolomic signatures of plant-based diets and incident chronic kidney disease

BACKGROUND

Greater adherence to plant-based diets is associated with a lower risk of incident chronic kidney disease (CKD). Metabolomics can help identify blood biomarkers of plant-based diets and enhance understanding of underlying mechanisms.

OBJECTIVES

Using untargeted metabolomics, we aimed to identify metabolites associated with 4 plant-based diet indices (PDIs) (overall PDI, provegetarian diet, healthful PDI, and unhealthful PDI) and incident CKD in 2 subgroups within the Atherosclerosis Risk in Communities study.

METHODS

We calculated 4 PDIs based on participants' responses on an FFQ. We used multivariable linear regression to examine the association between 4 PDIs and 374 individual metabolites, adjusting for confounders. We used Cox proportional hazards regression to evaluate associations between PDI-related metabolites and incident CKD. Estimates were meta-analyzed across 2 subgroups (n1 = 1762; n2 = 1960). We calculated C-statistics to assess whether metabolites improved the prediction of those in the highest quintile compared to the lower 4 quintiles of PDIs, and whether PDI- and CKD-related metabolites predicted incident CKD beyond the CKD prediction model.

RESULTS

We identified 82 significant PDI-metabolite associations (overall PDI = 27; provegetarian = 17; healthful PDI = 20; unhealthful PDI = 18); 11 metabolites overlapped across the overall PDI, provegetarian diet, and healthful PDI. The addition of metabolites improved prediction of those in the highest quintile as opposed to the lower 4 quintiles of PDIs compared with participant characteristics alone (range of differences in C-statistics = 0.026-0.104; P value ≤ 0.001 for all tests). Six PDI-related metabolites (glycerate, 1,5-anhydroglucitol, γ-glutamylalanine, γ-glutamylglutamate, γ-glutamylleucine, γ-glutamylvaline), involved in glycolysis, gluconeogenesis, pyruvate metabolism, and γ-glutamyl peptide metabolism, were significantly associated with incident CKD and improved prediction of incident CKD beyond the CKD prediction model (difference in C-statistics for 6 metabolites = 0.005; P value = 0.006).

CONCLUSIONS

In a community-based study of US adults, we identified metabolites that were related to plant-based diets and predicted incident CKD. These metabolites highlight pathways through which plant-based diets are associated with incident CKD.

Effects of Expanded Hemodialysis with Medium Cut-Off Membranes on Maintenance Hemodialysis Patients: A Review

Kidney failure is associated with high morbidity and mortality. Hemodialysis, the most prevalent modality of renal replacement therapy, uses the principle of semipermeable membranes to remove solutes and water in the plasma of patients with kidney failure. With the evolution of hemodialysis technology over the last half century, the clearance of small water-soluble molecules in such patients is adequate. However, middle molecules uremic toxins are still retained in the plasma and cause cardiovascular events, anemia, and malnutrition, which significantly contribute to poor quality of life and high mortality in maintenance hemodialysis patients. A new class of membrane, defined as a medium cut-off (MCO) membrane, has emerged in recent years. Expanded hemodialysis with MCO membranes is now recognized as the artificial kidney model closest to natural kidney physiology. This review summarizes the unique morphological characteristics and internal filtration–backfiltration mechanism of MCO membranes, and describes their effects on removing uremic toxins, alleviating inflammation and cardiovascular risk, and improving quality of life in maintenance hemodialysis patients.

Acute Kidney Injury: Biomarker-Guided Diagnosis and Management

Acute kidney injury (AKI) is a common clinical syndrome that is characterized by abnormal renal function and structure. The Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference in 2019 reviewed the stages of AKI and the definitions of AKI-related terminologies, and discussed the advances in the last decade. Along with serum creatinine level and urine output, more accurate novel biomarkers for predicting AKI are being applied for the early detection of renal dysfunction. A literature search was conducted in PubMed, Scopus, Medline, and ClinicalTrials.gov using the terms AKI and biomarker, combined with diagnosis, management, or prognosis. Because of the large volume of data (160 articles) published between 2005 and 2022, representative literature was chosen. A number of studies have demonstrated that new biomarkers are more sensitive in detecting AKI in certain populations than serum creatinine and urine output according to the recommendations from the Acute Disease Quality Initiative Consensus Conference. To be specific, there is a persistently unresolved need for earlier detection of patients with AKI before AKI progresses to a need for renal replacement therapy. Biomarker-guided management may help to identify a high-risk group of patients in progression to severe AKI, and decide the initiation time to renal replacement therapy and optimal follow-up period. However, limitations such as biased data to certain studied populations and absence of cutoff values need to be solved for worldwide clinical use of biomarkers in the future. Here, we provide a comprehensive review of biomarker-based AKI diagnosis and management and highlight recent developments.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Epidemiology of haemodialysis outcomes

Haemodialysis (HD) is the commonest form of kidney replacement therapy in the world, accounting for approximately 69% of all kidney replacement therapy and 89% of all dialysis. Over the last six decades since the inception of HD, dialysis technology and patient access to the therapy have advanced considerably, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes vary widely across the world and, overall, the rates of impaired quality of life, morbidity and mortality are high. Cardiovascular disease affects more than two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality. In addition, patients on HD have high symptom loads and are often under considerable financial strain. Despite the many advances in HD technology and delivery systems that have been achieved since the treatment was first developed, poor outcomes among patients receiving HD remain a major public health concern. Understanding the epidemiology of HD outcomes, why they might vary across different populations and how they might be improved is therefore crucial, although this goal is hampered by the considerable heterogeneity in the monitoring and reporting of these outcomes across settings.

This Review examines the epidemiology of haemodialysis outcomes — clinical, patient-reported and surrogate outcomes — across world regions and populations, including vulnerable individuals. The authors also discuss the current status of monitoring and reporting of haemodialysis outcomes and potential strategies for improvement.

Nearly 4 million people in the world are living on kidney replacement therapy (KRT), and haemodialysis (HD) remains the commonest form of KRT, accounting for approximately 69% of all KRT and 89% of all dialysis.

Dialysis technology and patient access to KRT have advanced substantially since the 1960s, particularly in high-income countries. However, HD availability, accessibility, cost and outcomes continue to vary widely across countries, particularly among disadvantaged populations (including Indigenous peoples, women and people at the extremes of age).

Cardiovascular disease affects over two-thirds of people receiving HD, is the major cause of morbidity and accounts for almost 50% of mortality; mortality among patients on HD is significantly higher than that of their counterparts in the general population, and treated kidney failure has a higher mortality than many types of cancer. Patients on HD also experience high burdens of symptoms, poor quality of life and financial difficulties.

Careful monitoring of the outcomes of patients on HD is essential to develop effective strategies for risk reduction. Outcome measures are highly variable across regions, countries, centres and segments of the population. Establishing kidney registries that collect a variety of clinical and patient-reported outcomes using harmonized definitions is therefore crucial.

Evaluation of HD outcomes should include the impact on family and friends, and personal finances, and should examine inequities in disadvantaged populations, who comprise a large proportion of the HD population.

Energy conservation education intervention for people with end-stage kidney disease receiving haemodialysis (EVEREST): protocol for a cluster randomised control trial

INTRODUCTION

Multiple symptoms occur in people with kidney failure receiving haemodialysis (HD) and these symptoms have a negative impact on health-related quality of life (HRQoL). Fatigue, the most common symptom, is debilitating and difficult to manage. Educational interventions involving energy conservation strategies are helpful in reducing fatigue, however the effectiveness of energy conservation has not been previously studied in those receiving HD. The aim of this study is to evaluate the effectiveness of an energy conservation education intervention for people with end-stage kidney disease receiving HD (EVEREST trial).

METHODS AND ANALYSIS

A pragmatic cluster randomised control trial with repeated measure will be used. One hundred and twenty-six participants from tertiary level dialysis centre will be cluster randomised to the intervention and control group according to HD treatment day. The intervention group will receive usual care along with a structured energy conservation education programme over 12 weeks comprising three individual face-to-face educational intervention sessions, one booster session and a booklet. The control group will receive usual care from their healthcare providers and a booklet at the end of the study. The primary outcome is fatigue, and the secondary outcomes are other Chronic Kidney Disease (CKD) symptoms, occupational performance and HRQoL. Intention-to-treat analysis will occur and will include a change in primary and secondary outcomes.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Human Research Committee of the Griffith University and Nepal Health Research Council. The results of this research will be published and presented in a variety of forums.

TRIAL REGISTRATION NUMBER

NCT04360408.

Kidney Failure in Bardet-Biedl Syndrome

The aim of this study was to explore kidney failure (KF) in Bardet–Biedl syndrome (BBS), focusing on high‐risk gene variants, demographics, and morbidity. We employed the Clinical Registry Investigating BBS (CRIBBS) to identify 44 (7.2%) individuals with KF out of 607 subjects. Molecularly confirmed BBS was identified in 37 KF subjects and 364 CRIBBS registrants. KF was concomitant with recessive causal variants in 12 genes, with BBS10 the most predominant causal gene (26.6%), while disease penetrance was highest in SDCCAG8 (100%). Two truncating variants were present in 67.6% of KF cases. KF incidence was increased in genes not belonging to the BBSome or chaperonin‐like genes (p < 0.001), including TTC21B, a new candidate BBS gene. Median age of KF was 12.5 years, with the vast majority of KF occurring by 30 years (86.3%). Females were disproportionately affected (77.3%). Diverse uropathies were identified, but were not more common in the KF group (p = 0.672). Kidney failure was evident in 11 of 15 (73.3%) deaths outside infancy. We conclude that KF poses a significant risk for premature morbidity in BBS. Risk factors for KF include female sex, truncating variants, and genes other than BBSome/chaperonin‐like genes highlighting the value of comprehensive genetic investigation.

Compliance with the DPP-4 inhibitors dose adjustment recommendations based on renal function in a population database

OBJECTIVE

To examine the prescription pattern of the different dipeptidyl peptidase-4 inhibitors (DPP4is), depending on the estimated glomerular filtration rate (eGFR) under real-world clinical practice conditions.

METHOD

This was a descriptive, observational study using a population database (SIDIAP Catalonia). Subjects diagnosed with T2DM with kidney function assessed and on active treatment with DPP4is were enrolled. Patients were included at the time of the measurement of eGFR (CKD-epi) and were monitored for 6 months after enrolment. For each subject, the prescribed daily dose (PDD) of DPP4i, the theoretical dose according to the degree of renal failure established by the recommendations in the summary of product characteristics (DDD-adj), and the PDR ratio (PDD/DDD-adj) were estimated. A subject was considered overtreated if his/her RDR was greater than 1.2 (>20%).

RESULTS

The study sample consisted of 72,135 subjects with a mean age of 69.7 (±11.6) years and 55.9% males. The proportion of patients overtreated varied depending on the type of DPP4i and the renal function stage. Overall, overdosage was recorded in 7.15% of all DPP4i treatments. In advanced stages (IIIb, IV, and V), overdosage was much higher (36.8% for all DPP4is, and 58.7% if linagliptin is excluded).

DISCUSSION

Under real-world clinical practice conditions, more than one third of T2DM patients with advanced renal failure were overdosed with DPP4is because the doses were not adequately adjusted to the glomerular filtration rate of each patient.

Kidney disease profile and encountered problems during follow-up in Syrian refugee children: a multicenter retrospective study

BACKGROUND

Children are one of the most vulnerable groups in conflict zones, especially those with chronic diseases. This study aimed to investigate kidney disease profiles and problems during follow-up in a population of Syrian refugee children residing in Turkey.

METHODS

Syrian refugee children aged between 0 and 18 years were included in the study. Demographic data, diagnosis, particular interventions due to nephrological problems, and problems encountered during follow-up were obtained from all participating pediatric nephrology centers.

RESULTS

Data from 633 children from 22 pediatric nephrology centers were included. Mean age of the children was 94.8 ± 61.7 months and 375 were male (59%). 57.7% had parental consanguinity and 23.3% had a close relative(s) with kidney disease. The most common kidney diseases were congenital anomalies of the kidney and urinary tract (CAKUT) (31.0%), glomerular disease (19.9%), chronic kidney disease (CKD) (14.8%), and urolithiasis (10.7%). Frequent reasons for CAKUT were nonobstructive hydronephrosis (23.0%), vesico-ureteral reflux (18.4%), and neurogenic bladder (15.8%). The most common etiology of glomerular diseases was nephrotic syndrome (69%). Ninety-four children had CKD, and 58 children were on chronic dialysis. Six children had kidney transplantation. Surgical intervention was performed on 111 patients. The language barrier, lack of medical records, and frequent disruptions in periodic follow-ups were the main problems noted.

CONCLUSIONS

CAKUT, glomerular disease, and CKD were highly prevalent in Syrian refugee children. Knowing the frequency of chronic diseases and the problems encountered in refugees would facilitate better treatment options and preventive measures.

Factors associated with hospital admission and adverse outcome for COVID-19: role of social factors and medical care

Background

Beyond sex, age, and various comorbidities, geographical origin and socioeconomic deprivation are associated with Coronavirus Disease (COVID-19) morbidity and mortality in the general population. We aimed to assess factors associated with severe forms of COVID-19 after a hospital emergency department visit, focusing on socioeconomic factors.

Methods

Patients with laboratory-confirmed COVID-19 attending the emergency department of Béclère Hospital (France) in March–April 2020 were included. Postal addresses were used to obtain two geographical deprivation indices at the neighborhood level. Factors associated with hospitalization and factors associated with adverse outcomes, i.e. mechanical ventilation or death, were studied using logistic and Cox analyses, respectively.

Results

Among 399 included patients, 321 were hospitalized. Neither geographical origin nor socioeconomic deprivation was associated with any of the outcomes. Being male, older, overweight or obese, diabetic, or having a neuropsychiatric disorder were independent risk factors for hospitalization. Among 296 patients hospitalized at Béclère Hospital, 91 experienced an adverse outcome. Older age, being overweight or obese, desaturation and extent of chest CT scan lesions > 25% at admission (aHR: 2.2 [95% CI: 1.3–3.5]) and higher peak CRP levels and acute kidney failure (aHR: 2.0 [1.2–3.3]) during follow-up were independently associated with adverse outcomes, whereas treatment with hydrocortisone reduced the risk of mechanical ventilation or death by half (aHR: 0.5 [0.3–0.8]).

Conclusion

No association between geographical origin or socioeconomic deprivation and the occurrence of a severe form of COVID-19 was observed in our population after arrival to the emergency department. Empirical corticosteroid use with hydrocortisone had a strong protective impact.

Neuroimmunoendocrine Link Between Chronic Kidney Disease and Olfactory Deficits

Chronic kidney disease (CKD) is a multifactorial pathology that progressively leads to the deterioration of metabolic functions and results from deficient glomerular filtration and electrolyte imbalance. Its economic impact on public health is challenging. Mexico has a high prevalence of CKD that is strongly associated with some of the most common metabolic disorders like diabetes and hypertension. The gradual loss of kidney functions provokes an inflammatory state and endocrine alterations affecting several systems. High serum levels of prolactin have been associated with CKD progression, inflammation, and olfactory function. Also, the nutritional status is altered due to impaired renal function. The decrease in calorie and protein intake is often accompanied by malnutrition, which can be severe at advanced stages of the disease. Nutrition and olfactory functioning are closely interconnected, and CKD patients often complain of olfactory deficits, which ultimately can lead to deficient food intake. CKD patients present a wide range of deficits in olfaction like odor discrimination, identification, and detection threshold. The chronic inflammatory status in CKD damages the olfactory epithelium leading to deficiencies in the chemical detection of odor molecules. Additionally, the decline in cognitive functioning impairs the capacity of odor differentiation. It is not clear whether peritoneal dialysis and hemodialysis improve the olfactory deficits, but renal transplants have a strong positive effect. In the present review, we discuss whether the olfactory deficiencies caused by CKD are the result of the induced inflammatory state, the hyperprolactinemia, or a combination of both.

Predicting Prognosis in Internal Medicine: A Short and Long-Term Mortality Comparison Analysis

Introduction

The marked increase in life expectancy seen in Portugal in the last five decades led to a change in the profile of patients being most commonly admitted in internal medicine wards. In deciding the best care for these patients, prognostication models are needed in order to reduce readmissions, mortality, and adequate care. We aimed to study short and long-term mortality and predictors of all-cause mortality, independently of cause admission, of patients admitted in an internal medicine ward.

Methods

This two-part, single-center study enrolled patients from October 2013 to October 2014 with a follow-up of 60 months.

Results

A total of 681 patients were included; the mean age was 75.86 years with 60.4% females. The most frequent comorbidities were anemia, hypertension, and renal impairment. More than half of the population died in the follow-up period (51.5%). Deaths were significantly higher in the first six months after discharge (53% of all deaths) and then decreased abruptly to 11.6% in the second half-year after discharge. Based on the multivariate logistic regression model, with age over 80 years, anemia and neoplasm were independent predictors of short-term (p<0.001, p=0.001, p<0.001, respectively) and long-term (p<0.001 for the three conditions) mortality. Heart failure (p=0.018) and diabetes (p=0.025) were also predictors of long-term mortality.

Conclusion

High mortality, mainly in the first six months after discharge, elicits strategies targeting transition of care and close follow-up in the first months, which can be the key to improving outcomes. Identification of patients at higher risk may help design realistic models aiming to improve care for this frail population and decrease morbimortality.

The influence of acute kidney disease on the clinical outcomes of patients who received cisplatin, carboplatin, and oxaliplatin

Background and Aims

Cisplatin (CDDP) is used as the first line of treatment for some tumors, but its use may be restricted due to its nephrotoxicity. Carboplatin (CARBO) and oxaliplatin (OXA) are less nephrotoxic alternatives to CDDP. This study has the objective to determine the incidence of acute kidney disease after chemotherapy with CDDP, CARBO, or OXA.

Methods

A clinical study of a retrospective cohort of patients who underwent treatment with CDDP, CARBO, or OXA from January‐December 2016. Acute kidney Disease (AKD) was defined as elevated serum creatinine (sCR) levels before and up to 3 months after chemotherapy. Morbidities, type of tumor, and treatment data were recorded.

Results

A total of 212 patients aged 55.5 ± 14.0 years were evaluated. Among the comorbidities, 30% had arterial hypertension (AH) and 11% had diabetes, and 18% were treated with CDDP, 41% with CARBO, and 41% with OXA. There was no difference in sCR levels before and after chemotherapy regardless of the chemotherapy used. The prevalence of eGFRs <60 mL/min after chemotherapy was higher in patients with AH and cardiovascular disease (CVD). The incidence of post‐chemotherapy AKD was 7.0% (n = 13) and the mortality rate was 38.2%. Survival was lower in patients with AKD (P = .012).

Conclusions

There was a low incidence of AKD among the patients regardless of the chemotherapy used, but the patients with AKD had shorter survival. In addition, the reduction in eGFR after chemotherapy was greater in patients with AH and CVD.

Nephrology Considerations in the Management of Durable and Temporary Mechanical Circulatory Support

Durable and temporary mechanical circulatory support (MCS) use is growing for a range of cardiovascular indications. Kidney dysfunction is common in people evaluated for or receiving durable or temporary MCS and portends worse outcomes. This kidney dysfunction can be due to preexisting kidney chronic kidney disease (CKD), acute kidney injury (AKI) related to acute cardiovascular disease necessitating MCS, AKI due to cardiac procedures, and acute and chronic MCS effects and complications. Durable MCS, with implantable continuous flow pumps, is used for long-term support in advanced heart failure refractory to guideline-directed medical and device therapy, either permanently or as a bridge to heart transplantation. Temporary MCS-encompassing in this review intra-aortic balloon pumps (IABP), axial flow pumps, centrifugal flow pumps, and venoarterial ECMO-is used for diverse situations: high-risk percutaneous coronary interventions (PCI), acute decompensated heart failure, cardiogenic shock, and resuscitation after cardiac arrest. The wide adoption of MCS makes it imperative to improve understanding of the effects of MCS on kidney health/function and of kidney health/function on MCS outcomes. The complex structure and functions of the kidney, and the complex health states of individuals receiving MCS, makes investigations in this area challenging, and current knowledge is limited. Fortunately, the increasing nephrology toolbox of noninvasive kidney health/function assessments may enable development and testing of individualized management strategies and therapeutics in the future. We review technology, epidemiology, pathophysiology, clinical considerations, and future directions in MCS and nephrology.

Comparison between peritoneal dialysis and hemodialysis on kidney function recovery in incident kidney failure: A nationwide cohort study

BACKGROUND

Patients with kidney failure who start dialysis have a chance of kidney function recovery. Whether the initial dialysis modality affects the possibility of recovery is not fully understood.

METHODS

We included patients diagnosed with kidney failure requiring dialysis during 2001-2013 from the Taiwan National Health Insurance Research Database. We excluded diabetic and elderly patients. Kidney function recovery was defined as not receiving dialysis therapy for longer than 3 months. The primary outcome was kidney function recovery, and the secondary outcome was all-cause mortality during a 3-year follow up.

RESULTS

A total of 12,619 patients was eligible for analysis, with 981 received PD and 11,638 received HD. Total 620 patients had kidney function recovery during a 3-year follow up, which represented 4.9% of the entire cohort. After propensity score matching, the PD groups were more likely to experience kidney function recovery (subdistribution hazard ratio [SHR]: 1.64, 95% confidence interval [CI]: 1.19-2.25). The risk of all-cause mortality between groups did not significantly differ (hazard ratio [HR]: 1.23, 95% CI: 0.89-1.70).

CONCLUSION

The study found that in nonelderly, nondiabetic patients who received inadequate predialysis nephrology care before kidney failure, PD is associated with a higher chance of kidney function recovery.

Protein supplementation versus standard feeds in underweight critically ill children: a pilot dual-centre randomised controlled trial protocol

INTRODUCTION

Protein-energy malnutrition, increased catabolism and inadequate nutritional support leads to loss of lean body mass with muscle wasting and delayed recovery in critical illness. However, there remains clinical equipoise regarding the risks and benefits of protein supplementation. This pilot trial will determine the feasibility of performing a larger multicentre trial to determine if a strategy of protein supplementation in critically ill children with body mass index (BMI) z-score ≤-2 is superior to standard enteral nutrition in reducing the length of stay in the paediatric intensive care unit (PICU).

METHODS AND ANALYSIS

This is a randomised controlled trial of 70 children in two PICUs in Singapore. Children with BMI z-score ≤-2 on PICU admission, who are expected to require invasive mechanical ventilation for more than 48 hours, will be randomised (1:1 allocation) to protein supplementation of ≥1.5 g/kg/day in addition to standard nutrition, or standard nutrition alone for 7 days after enrolment or until PICU discharge, whichever is earlier. Feasibility outcomes for the trial include effective screening, satisfactory enrolment rate, timely protocol implementation (within first 72 hours) and protocol adherence. Secondary outcomes include mortality, PICU length of stay, muscle mass, anthropometric measurements and functional outcomes.

ETHICS AND DISSEMINATION

The trial protocol was approved by the institutional review board of both participating centres (Singhealth Centralised Institutional Review Board and National Healthcare Group Domain Specific Review Board) under the reference number 2020/2742. Findings of the trial will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04565613.

Promoting Plant-Based Therapies for Chronic Kidney Disease

Chronic kidney disease (CKD) is debilitating, increasing in incidence worldwide, and a financial and social burden on health systems. Kidney failure, the final stage of CKD, is life-threatening if untreated with kidney replacement therapies. Current therapies using commercially-available drugs, such as angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and calcium channel blockers, generally only delay the progression of CKD. This review article focuses on effective alternative therapies to improve the prevention and treatment of CKD, using plants or plant extracts. Three mechanistic processes that are well-documented in CKD pathogenesis are inflammation, fibrosis, and oxidative stress. Many plants and their extracts are already known to ameliorate kidney dysfunction through antioxidant action, with subsequent benefits on inflammation and fibrosis. In vitro and in vivo experiments using plant-based therapies for pre-clinical research demonstrate some robust therapeutic benefits. In the CKD clinic, combination treatments of plant extracts with conventional therapies that are seen as relatively successful currently may confer additive or synergistic renoprotective effects. Therefore, the aim of recent research is to identify, rigorously test pre-clinically and clinically, and avoid any toxic outcomes to obtain optimal therapeutic benefit from medicinal plants. This review may prove to be a filtering tool to researchers into complementary and alternative medicines to find out the current trends of using plant-based therapies for the treatment of kidney diseases, including CKD.

Kidney dysfunction requiring dialysis is a heterogeneous syndrome: we should treat it like one

PURPOSE OF REVIEW

Advanced kidney failure requiring dialysis, commonly labeled end-stage kidney disease or chronic kidney disease stage 5D, is a heterogeneous syndrome -a key reason that may explain why: treating advanced kidney dysfunction is challenging and many clinical trials involving patients on dialysis have failed, thus far. Treatment with dialytic techniques - of which maintenance thrice-weekly hemodialysis is most commonly used - is broadly named kidney 'replacement' therapy, a term that casts the perception of a priori abandonment of intrinsic kidney function and subsumes patients into a single, homogeneous group.

RECENT FINDINGS

Patients with advanced kidney failure necessitating dialytic therapy may have ongoing endogenous kidney function, and differ in their clinical manifestations and needs. Different terminology, for example, kidney dysfunction requiring dialysis (KDRD) with stages of progressive severity could better capture the range of phenotypes of patients who require kidney 'assistance' therapy.

SUMMARY

Classifying patients with KDRD based on objective, quantitative levels of endogenous kidney function, as well as patient-reported symptoms and quality of life, would facilitate hemodialysis prescriptions tailored to level of kidney dysfunction, clinical needs, and personal priorities. Such classification would encourage clinicians to move toward personalized, physiological, and adaptive approach to hemodialysis therapy.

Drug Interactions Affecting Kidney Function: Beware of Health Threats from Triple Whammy

Triple whammy (TW) is a potentially dangerous drug combination that can lead to acute kidney injury (AKI). This drug interaction (DI) occurs when angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are used together with diuretics and non-steroidal anti-inflammatory drugs (NSAIDs). One of the most serious consequences of TW DI is an increased risk of developing pre-renal acute kidney injury (pr-AKI). The term TW, in the context of a DI affecting kidney function, is not very widespread. The aim of this article was to gather information on this interaction. Previous knowledge on the mechanism of TW and how to increase patient awareness of this interaction is described. In addition, the specific nature of the acute kidney injury (AKI) caused by triple whammy (AKITW) is presented. On the basis of the current state of knowledge, recommendations on how to manage the TW DI are also demonstrated.