Chronic kidney disease

Chronic kidney disease impacts outcomes after abdominal aortic aneurysm repair

OBJECTIVE

Chronic kidney disease (CKD) and end-stage renal disease are traditionally associated with worse outcomes after endovascular and open repair of abdominal aortic aneurysm (AAA). This study stratifies outcomes of AAA repair by approach, CKD severity, and dialysis dependence.

METHODS

All patients undergoing elective infrarenal open aneurysm repair (OAR) and endovascular aortic repair (EVAR) with preoperative renal function data captured by the Vascular Quality Initiative between January 2003 and September 2020 were analyzed. Patients were stratified by CKD class as follows: CKD stages 1 and 2, CKD stage 3a, CKD stage 3b, CKD stages 4 and 5, and dialysis. Primary outcomes were perioperative and 1-year mortality. Predictors of survival were identified by Cox multivariate regression models.

RESULTS

In total, 53,867 elective AAA repairs were identified: 5396 (10%) OARs and 48,471 (90%) EVARs. Most patients were White (90%) and male (81%), with a mean age of 73 ± 9 years. Patients who underwent EVAR were older and had more comorbidities. The use of elective EVAR for AAA increased from 52% in 2003 to 91% in 2020 (P < .001). The OAR cohort had more perioperative complications and short-term mortality. The CKD 1 and 2 group had the highest 1-year survival compared with the other groups after both OAR and EVAR. On Cox regression analysis, after EVAR, compared with CKD 1 and 2, worsening CKD stage (CKD 3a: hazard ratio [HR], 1.25; 95% confidence interval [CI], 0.93-1.68; P = .13; CKD 3b: HR, 1.74; 95% CI, 1.23-2.45; P < .050; CKD 4-5: HR, 3.23; 95% CI, 2.13-4.88; P < .001), and dialysis (HR, 4.48; 95% CI, 1.90-10.6; P < .001) were independently associated with worse 1-year survival rates. After OAR, compared with CKD 1 and 2, worsening CKD stage (CKD 3a: HR, 1.08; 95% CI, 0.96-1.20; P = .20; CKD 3b: HR, 1.60; 95% CI, 1.41-1.81; P < .001; CKD 4-5: HR, 2.85; 95% CI, 2.39-3.41; P < .001), and dialysis (HR, 3.79; 95% CI, 3.01-4.76; P < .001) were independently associated with worse 1-year survival rates.

CONCLUSIONS

Regardless of the treatment approach, CKD severity is an important predictor of perioperative and 1-year mortality rates after infrarenal AAA repair and may reflect the natural history of CKD. Open repair is associated with high perioperative mortality risk in patients with CKD stages 4 and 5, as well as end-stage renal disease. Individualization of patient decision-making is especially important in patients with a glomerular filtration rate of less than 45 and perhaps consideration should be given to raising the threshold for elective AAA repair in these patients. Further studies focusing on appropriate size threshold for repair in these patients may be warranted.

Value of SGLT-2 inhibitors in the treatment of chronic kidney disease : Clinical and practical implications

Chronic kidney disease (CKD) drastically increases the risk for cardiovascular morbidity and mortality and its worldwide prevalence is still rising. Effective treatment slows CKD progression, prevents development of end-stage kidney disease and cardiovascular disease thereby prolonging survival of patients. Recently, several large-scale studies with sodium-glucose cotransport‑2 inhibitors (SGLT-2i) have demonstrated profound nephroprotective and cardioprotective properties in patients with type 2 diabetes mellitus with both CKD and heart failure. Recently, the dapagliflozin and prevention of adverse outcomes in chronic kidney disease (DAPA-CKD) trial demonstrated that the selective SGLT-2i dapagliflozin reduced the hazard ratio for a composite renal and cardiovascular death endpoint in patients with CKD with or without type 2 diabetes. Furthermore, dapagliflozin exerted strong nephroprotection in CKD patients with diverse etiologies like IgA nephropathy. Furthermore, other promising CKD trials such as with empagliflozin are underway. Hence, individualized treatment with SGLT2i represents a promising therapeutic option for patients with both diabetic and non-diabetic CKD. Here we summarize the current knowledge on the treatment with SGLT-2i in CKD patients underscoring a strong rationale for SGLT2 inhibition to be incorporated into standard of care for most CKD patients also with non-diabetic kidney disease. Finally, we aim to translate the current evidence into recommendations for the clinical practice in the management of patients with CKD.

Integrative phosphatidylcholine metabolism through phospholipase A2 in rats with chronic kidney disease

Dysregulation in lipid metabolism is the leading cause of chronic kidney disease (CKD) and also the important risk factors for high morbidity and mortality. Although lipid abnormalities were identified in CKD, integral metabolic pathways for specific individual lipid species remain to be clarified. We conducted ultra-high-performance liquid chromatography-high-definition mass spectrometry-based lipidomics and identified plasma lipid species and therapeutic effects of Rheum officinale in CKD rats. Adenine-induced CKD rats were administered Rheum officinale. Urine, blood and kidney tissues were collected for analyses. We showed that exogenous adenine consumption led to declining kidney function in rats. Compared with control rats, a panel of differential plasma lipid species in CKD rats was identified in both positive and negative ion modes. Among the 50 lipid species, phosphatidylcholine (PC), lysophosphatidylcholine (LysoPC) and lysophosphatidic acid (LysoPA) accounted for the largest number of identified metabolites. We revealed that six PCs had integral metabolic pathways, in which PC was hydrolysed into LysoPC, and then converted to LysoPA, which was associated with increased cytosolic phospholipase A2 protein expression in CKD rats. The lower levels of six PCs and their corresponding metabolites could discriminate CKD rats from control rats. Receiver operating characteristic curves showed that each individual lipid species had high values of area under curve, sensitivity and specificity. Administration of Rheum officinale significantly improved impaired kidney function and aberrant PC metabolism in CKD rats. Taken together, this study demonstrates that CKD leads to PC metabolism disorders and that the dysregulation of PC metabolism is involved in CKD pathology.

Role of FXR in Renal Physiology and Kidney Diseases

Farnesoid X receptor, also known as the bile acid receptor, belongs to the nuclear receptor (NR) superfamily of ligand-regulated transcription factors, which performs its functions by regulating the transcription of target genes. FXR is highly expressed in the liver, small intestine, kidney and adrenal gland, maintaining homeostasis of bile acid, glucose and lipids by regulating a diverse array of target genes. It also participates in several pathophysiological processes, such as inflammation, immune responses and fibrosis. The kidney is a key organ that manages water and solute homeostasis for the whole body, and kidney injury or dysfunction is associated with high morbidity and mortality. In the kidney, FXR plays an important role in renal water reabsorption and is thought to perform protective functions in acute kidney disease and chronic kidney disease, especially diabetic kidney disease. In this review, we summarize the recent advances in the understanding of the physiological and pathophysiological function of FXR in the kidney.

Frailty score and outcomes of patients undergoing vascular surgery and amputation: A systematic review and meta-analysis

Introduction

Frailty is associated with adverse postoperative health outcomes, including increased mortality, longer length of stay, higher rehospitalization, and other complications. There are many frailty assessment tools are to assess the level of frailty in vascular surgery patients. The aim of this study was to perform a systematic review and meta-analysis to assess the association between the frailty levels described by different frailty scores and adverse postoperative health outcomes among hospitalized vascular surgery patients and patients undergoing amputation.

Methods

Studies utilizing frailty scores and similar frailty assessment tools to describe frailty and investigate the association between frailty and health outcomes were searched. The primary outcomes of this study were in-hospital mortality, postdischarge mortality, length of hospital stay, rehospitalization, and discharge location. Additional outcomes included postoperative myocardial infarction, postoperative renal failure, cerebrovascular accident and stroke, comorbidities, and estimated glomerular filtration rate (eGFR) levels. Joanna Briggs Institute (JBI) Critical Appraisal Tools were used for quality assessment.

Results

In total, 24 studies with 1,886,611 participants were included in the final analysis. The overall results found that higher in-hospital mortality and postdischarge mortality were significantly associated with frailty. Frailty was also found to be significantly associated with a longer length of hospital stay, higher rehospitalization, and higher likelihood of non-home discharge. In addition, the results also showed that frailty was significantly associated with all kinds of comorbidities investigated, except chronic kidney disease. However, lower eGFR levels were significantly associated with frailty.

Conclusion

Among patients who underwent all types of vascular surgery and those who underwent amputations, assessment of frailty was significantly associated with adverse postoperative outcomes and multiple comorbidities.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=336374, identifier CRD42022336374.

Long-term effectiveness of a primary care practice facilitation program for chronic kidney disease management: an extended follow-up of a cluster-randomized FROM-J study

BACKGROUND

Practice facilitation program by multidisciplinary care for primary care physicians (PCPs) is expected to improve chronic kidney disease (CKD) outcomes, but there is no clear evidence of its long-term effectiveness. We have previously performed a cluster-randomized controlled trial for 3.5 years (the Frontier of Renal Outcome Modifications in Japan (FROM-J) study) with two arms-group A without the program and group B with the program. We aimed to assess the long-term effectiveness of the practice facilitation program on CKD outcomes via an extended 10-year follow-up of the FROM-J study.

METHODS

We enrolled patients who were in the FROM-J study. The primary composite endpoint comprised cardiovascular disease (CVD), renal replacement therapy initiation and a 50% decrease in the estimated glomerular filtration rate (eGFR). The secondary endpoints were survival rate, eGFR decline rate and collaboration rate between PCPs and nephrologists.

RESULTS

The occurrence of the primary composite endpoint tended to be lower in group B (group A: 27.1% versus group B: 22.1%, P = 0.051). Furthermore, CVD incidence was remarkably lower in group B (group A: 10.5% versus group B: 6.4%, P = 0.001). Although both mortality and the rate of eGFR decline were identical between both groups, the eGFR decline rate was significantly better in group B than in group A only in patients with stage G3a at enrollment (group A: 2.35 ± 3.87 mL/min/1.73 m2/year versus group B: 1.68 ± 2.98 mL/min/1.73 m2/year, P = 0.02). The collaboration rate was higher in group B.

CONCLUSIONS

The CKD practice facilitation program for PCPs reliably decreases CVD events and may reduce the progression of cases to end-stage kidney disease.

Cadmium-Induced Proteinuria: Mechanistic Insights from Dose-Effect Analyses

Cadmium (Cd) is a toxic metal that accumulates in kidneys, especially in the proximal tubular epithelial cells, where virtually all proteins in the glomerular ultrafiltrate are reabsorbed. Here, we analyzed archived data on the estimated glomerular filtration rate (eGFR) and excretion rates of Cd (E_Cd), total protein (E_Prot), albumin (E_alb), β₂-microglobulin (E_β2M), and α1-microglobulin (E_α1M), which were recorded for residents of a Cd contamination area and a low-exposure control area of Thailand. Excretion of Cd and all proteins were normalized to creatinine clearance (C_cr) as E_Cd/C_cr and E_Prot/C_cr to correct for differences among subjects in the number of surviving nephrons. Low eGFR was defined as eGFR ≤ 60 mL/min/1.73 m², while proteinuria was indicted by E_Pro/C_cr ≥ 20 mg/L of filtrate. E_Prot/C_cr varied directly with E_Cd/C_cr (β = 0.263, p < 0.001) and age (β = 0.252, p < 0.001). In contrast, eGFR values were inversely associated with E_Cd/C_cr (β = -0.266, p < 0.001) and age (β = -0.558, p < 0.001). At E_Cd/C_cr > 8.28 ng/L of filtrate, the prevalence odds ratios for proteinuria and low eGFR were increased 4.6- and 5.1-fold, respectively (p < 0.001 for both parameters). Thus, the eGFR and tubular protein retrieval were both simultaneously diminished by Cd exposure. Of interest, E_Cd/C_cr was more closely correlated with E_Prot/C_cr (r = 0.507), E_β2M (r = 0.430), and E_α1M/C_cr (r = 0.364) than with E_Alb/C_cr (r = 0.152). These data suggest that Cd may differentially reduce the ability of tubular epithelial cells to reclaim proteins, resulting in preferential reabsorption of albumin.

The Bidirectional Relationship between Chronic Kidney Disease and Hyperuricemia: Evidence from a Population-Based Prospective Cohort Study

BACKGROUND

Although several studies have examined the association between chronic kidney disease (CKD) and hyperuricemia (HUA), the direction of the association remains unclear. We aimed to investigate whether there was a bidirectional association between them.

METHODS

The present study was conducted in three analyses. Analysis I included 25,433 participants free of HUA at baseline to evaluate the associations between CKD and estimated glomerular filtration rate (eGFR) with incident HUA. Analysis II had 28,422 participants free of CKD at baseline to analyze the relationships between HUA and serum uric acid (sUA) with new-onset CKD. Cox proportional hazards regression models were applied to evaluate the association involved in Analysis I and II. Analysis III included 31,028 participants with complete data and further dissected the bidirectional association between sUA and eGFR using cross-lag models.

RESULTS

New-onset HUA and CKD were observed in the first round of the follow-up study among 1597 and 1212 participants, respectively. A significantly higher risk of HUA was observed in individuals with CKD compared to individuals without CKD (HR = 1.58, 95% CI: 1.28-1.95). The adjusted HRs (95% CIs) of HUA were 3.56 (2.50-5.05) for the participants in the group of eGFR less than 60 mL·min^-1·1.73 m^-2, 1.61 (1.42-1.83) for those in the group of eGFR between 60 and 90 mL·min^-1·1.73 m^-2, and 1.74 (1.42-2.14) for those in the group of eGFR more than 120 mL·min^-1·1.73 m^-2, compared with the group of eGFR between 90 and 120 mL·min^-1·1.73 m^-2. A higher risk of CKD was also observed in individuals with HUA compared to individuals without HUA (HR = 1.28, 95% CI: 1.12-1.47). Compared with the first quintile of sUA, the adjusted HR (95% CI) of CKD was 1.24 (1.01-1.51) for the participants in the fourth quantile. There was a bidirectional relationship between sUA and eGFR, with the path coefficients (ρ₁ = -0.024, p < 0.001) from baseline eGFR to follow-up sUA and the path coefficients (ρ₂ = -0.015, p = 0.002) from baseline sUA to follow-up eGFR.

CONCLUSIONS

The present study indicated that CKD and HUA were closely associated, and there was a bidirectional relationship between sUA and eGFR.

Mixed heavy metals exposure affects the renal function mediated by 8-OHG: A cross-sectional study in rural residents of China

Heavy metals are important risk factors for kidney, but their co-exposure effect on kidney and related mechanism remain unclear. This study evaluated the relationship between heavy metals and renal function, and the feasible mediation effect of oxidative stress. Based on the Dongdagou-Xinglong cohort, participants were recruited and their information were collected through questionnaires and physical examinations. The urine concentration of heavy metals like Cobalt, Nickel, Molybdenum, Cadmium, Antimony, Copper, Zinc, Mercury, Lead, Manganese, and renal injury biomarkers like β2-microglobulin, β-N-Acetylglucosaminidase, retinol-binding protein, 8-hydroxyguanine (8-OHG) were measured and corrected by creatinine. Linear regression was conducted to analyze the relationship between metals and renal biomarkers. Bayesian kernel machine regression, weighted quantile sum and quantile-based g-computation were applied to analyze the association between metal mixtures and renal biomarkers. Finally, the mediating effect of 8-OHG was analyzed through the mediation model. We found that these metals were positively related with renal biomarkers, where copper showed the strongest relationship. The co-exposure models showed that renal biomarkers increased with the concentration of mixtures, particularly for cadmium, copper, mercury, manganese. In addition, the proportion of 8-OHG in mediating effect of metals on renal function ranged from 2.6% to 86.9%. Accordingly, the renal function damage is positively associated with metals, and 8-OHG may play an important mediating role.

Microgreens-A Comprehensive Review of Bioactive Molecules and Health Benefits

Microgreens, a hypothesized term used for the emerging food product that is developed from various commercial food crops, such as vegetables, grains, and herbs, consist of developed cotyledons along with partially expanded true leaves. These immature plants are harvested between 7-21 days (depending on variety). They are treasured for their densely packed nutrients, concentrated flavors, immaculate and tender texture as well as for their vibrant colors. In recent years, microgreens are on demand from high-end restaurant chefs and nutritional researchers due to their potent flavors, appealing sensory qualities, functionality, abundance in vitamins, minerals, and other bioactive compounds, such as ascorbic acid, tocopherol, carotenoids, folate, tocotrienols, phylloquinones, anthocyanins, glucosinolates, etc. These qualities attracted research attention for use in the field of human health and nutrition. Increasing public concern regarding health has prompted humans to turn to microgreens which show potential in the prevention of malnutrition, inflammation, and other chronic ailments. This article focuses on the applications of microgreens in the prevention of the non-communicable diseases that prevails in the current generation, which emerged due to sedentary lifestyles, thus laying a theoretical foundation for the people creating awareness to switch to the recently introduced category of vegetable and providing great value for the development of health-promoting diets with microgreens.

Causal Effects of Specific Gut Microbiota on Chronic Kidney Diseases and Renal Function-A Two-Sample Mendelian Randomization Study

BACKGROUND

Targeting the gut microbiota may become a new therapeutic to prevent and delay the progression of chronic kidney disease (CKD). Nonetheless, the causal relationship between specific intestinal flora and CKD is still unclear.

MATERIALS AND METHOD

To identify genetically predicted microbiota, we used summary data from genome-wide association studies on gut microbiota in 18340 participants from 24 cohorts. Furthermore, we genetically predicted the causal relationship between 211 gut microbiotas and six phenotypes (outcomes) (CKD, estimated glomerular filtration rate (eGFR), urine albumin to creatinine ratio (UACR), dialysis, rapid progress to CKD, and rapid decline of eGFR). Four Mendelian randomization (MR) methods, including inverse variance weighted (IVW), MR-Egger, weighted median, and weighted mode were used to investigate the casual relationship between gut microbiotas and various outcomes. The result of IVW was deemed as the primary result. Then, Cochrane's Q test, MR-Egger, and MR-PRESSO Global test were used to detect heterogeneity and pleiotropy. The leave-one method was used for testing the stability of MR results and Bonferroni-corrected was used to test the strength of the causal relationship between exposure and outcome.

RESULTS

Through the MR analysis of 211 microbiotas and six clinical phenotypes, a total of 36 intestinal microflora were found to be associated with various outcomes. Among them, Class Bacteroidia (=-0.005, 95% CI: -0.001 to -0.008, p = 0.002) has a strong causality with lower eGFR after the Bonferroni-corrected test, whereas phylum Actinobacteria (OR = 1.0009, 95%CI: 1.0003-1.0015, p = 0.0024) has a strong causal relationship with dialysis. The Cochrane's Q test reveals that there is no significant heterogeneity between various single nucleotide polymorphisms. In addition, no significant level of pleiotropy was found according to MR-Egger and MR-PRESSO Global tests.

CONCLUSIONS

Through the two-sample MR analysis, we identified the specific intestinal flora that has a causal relationship with the incidence and progression of CKD at the level of gene prediction, which may provide helpful biomarkers for early disease diagnosis and potential therapeutic targets for CKD.

Perturbed gut microbiome and fecal and serum metabolomes are associated with chronic kidney disease severity

BACKGROUND

Chronic kidney disease (CKD) is a severe public health problem associated with a disordered gut microbiome. However, the functional alterations of microbiota and their cross talk with metabolism pathways based on disease severity remain unclear.

RESULTS

We performed metagenomics and untargeted metabolomics in a cohort of 68 patients with CKD of differing severities and 20 healthy controls to characterize the complex interplay between the gut microbiome and fecal and serum metabolites during CKD progression. We identified 26 microbial species that significantly changed in patients with CKD; 18 species changed as the disease progressed, and eight species changed only in a specific CKD group. These distinct changes in gut microbiota were accompanied by functional alterations in arginine and proline, arachidonic acid, and glutathione metabolism and ubiquinone and other terpenoid-quinone biosynthesis pathways during CKD progression. Further metabolomic analyses revealed that the distributions of toxic and pro-oxidant metabolites from these four essential metabolic pathways varied in the feces and serum as CKD progressed. Furthermore, we observed a complex co-occurrence between CKD severity-related bacteria and the characterized metabolites from the four essential metabolic pathways. Notably, Ruminococcus bromii, fecal hydroquinone, and serum creatinine were identified as the main contributors to the integrated network, indicating their key roles in CKD progression. Moreover, a noninvasive model including R. bromii and fecal hydroquinone, L-cystine, and 12-keto-tetrahydro-LTB4 levels classified the CKD severity (area under the curve [AUC]: > 0.9) and had better performance than the serum creatinine level for mild CKD (AUC: 0.972 vs. 0.896).

CONCLUSIONS

Perturbed CKD severity-related gut microbiota may contribute to unbalanced toxic and pro-oxidant metabolism in the gut and host, accelerating CKD progression, which may be an early diagnostic and therapeutic target for CKD. Video Abstract.

Catalpol Attenuates Oxidative Stress and Inflammation via Mechanisms Involving Sirtuin-1 Activation and NF-κB Inhibition in Experimentally-Induced Chronic Kidney Disease

Chronic kidney disease (CKD) is a stealthy disease, and its development is linked to mechanisms including inflammation and oxidative stress. Catalpol (CAT), an iridoid glucoside from the root of Rehmannia glutinosa, is reported to manifest anti-inflammatory, antioxidant, antiapoptotic and antifibrotic properties. Hence, we studied the possible nephroprotective effects of CAT and its mechanisms in an adenine-induced (0.2% w/w in feed for 4 weeks) murine model of CKD by administering 5 mg/kg CAT to BALB/c mice for the duration of 4 weeks except during weekends. Upon sacrifice, the kidney, plasma and urine were collected and various physiological, biochemical and histological endpoints were assessed. CAT significantly ameliorated the adenine-induced altered body and kidney weight, water intake, urine volume, and concentrations of urea and creatinine in plasma, as well as the creatinine clearance and the albumin and creatinine ratio. Moreover, CAT significantly ameliorated the effect of adenine-induced kidney injury by reducing the kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, cystatin C and adiponectin. Similarly, the augmented concentrations of markers of inflammation and oxidative stress in the adenine-treated group were markedly reduced with CAT pretreatment. Furthermore, CAT prevented adenine-induced deoxyribonucleic acid damage and apoptotic activity in the kidneys. Histologically, CAT significantly reduced the formation of tubular necrosis and dilation, as well as interstitial fibrosis in the kidney. In addition to that, CAT significantly decreased the adenine-induced increase in the phosphorylated NF-κB and reversed the reduced expression of sirtuin-1 in the kidney. In conclusion, CAT exhibits salutary effects against adenine-induced CKD in mice by mitigating inflammation, oxidative stress and fibrosis via mechanisms involving sirtuin-1 activation and NF-κB inhibition. Confirmatory studies are warranted in order to consider CAT as a potent nephroprotective agent against CKD.

Calponin 2 harnesses metabolic reprogramming to determine kidney fibrosis

In the fibrotic kidneys, the extent of a formed deleterious microenvironment is determined by cellular mechanical forces. This process requires metabolism for energy; however, how cellular mechanics and metabolism are connected remains unclear. Our proteomics revealed that actin filament binding and cell metabolism are the two most dysregulated events in the fibrotic kidneys. As a prominent actin stabilizer, Calponin 2 (CNN2) is predominantly expressed in fibroblasts and pericytes. CNN2 knockdown preserves kidney function and alleviates fibrosis. Global proteomics profiled that CNN2 knockdown enhanced the activities of the key rate-limiting enzymes and regulators of fatty acid oxidation (FAO) in diseased kidneys. Inhibiting carnitine palmitoyltransferase 1α in the FAO pathway results in lipid accumulation and extracellular matrix deposition in the fibrotic kidneys, which were restored after CNN2 knockdown. In patients, increased serum CNN2 levels are correlated with lipid content. Bioinformatics and chromatin immunoprecipitation showed that CNN2 interactor, estrogen receptor 2 (ESR2) binds peroxisome proliferator-activated receptor-α (PPARα) to transcriptionally regulate FAO downstream target genes expression amid kidney fibrosis. In vitro , ESR2 knockdown repressed the mRNA levels of PPARα and the key genes in the FAO pathway. Conversely, activation of PPARα reduced CNN2-induced matrix inductions. Our results suggest that balancing cell mechanics and metabolism is crucial to develop therapeutic strategies to halt kidney fibrosis.

Kidney transplant-related knowledge and influencing factors in Chinese kidney transplant candidates and recipients: A cross-sectional study

Objective

To investigate the kidney transplantation knowledge of kidney transplant (KT) candidates and recipients, and to explore the related influencing factors.

Methods

From March to July 2022, a total of 170 KT candidates and 270 KT recipients were investigated in two tertiary and Grade A hospitals in Hunan Province, China, using demographic questionnaires and the Kidney Transplant Understanding Tool (K-TUT). Multiple linear regression was used to explore the influencing factors of related knowledge of kidney transplantation.

Results

The scores of kidney transplantation knowledge of the two groups were 50.67 (Ranged: 0-63) and 52.79 (Ranged: 0-62), indicating a middle level of knowledge. Education level and whether they have received health education were significantly associated with the knowledge level of kidney transplantation in both KT candidates and recipients. In addition, age and fertility status were only significantly associated with the knowledge level of kidney transplantation in KT recipients.

Conclusion

Our finding shows that the knowledge level of KT candidates and recipients is not optimistic, which suggests that healthcare providers should pay more attention to the health education of this population. In addition, future health education interventions should consider the education level, age, and fertility status factors affecting kidney transplantation knowledge in KT candidates and recipients.

Alterations of gut microbes and their correlation with clinical features in middle and end-stages chronic kidney disease

Gut microecosystem has been shown to play an important role in human health. In recent years, the concept of the gut-kidney axis has been proposed to explain the potential association between gut microbiota and chronic kidney disease (CKD). Here, a cohort of fecal samples collected from patients with CKD (n = 13) were involved. The composition of gut microbial communities and clinical features in CKD and end-stage renal disease (ESRD) were characterized. Our study focused on the changes in gut microbiome and the correlation with clinical features in patients with CKD and ESRD by analyzing high-throughput sequencing results of collected feces. We elucidated the alterations of gut microbiota in CKD patients at different stages of disease and initially identified the gut microbiota associated with CKD progression. We also combined correlation analysis to identify clinical features closely related to the gut microbiome. Our results offered the possibility of using non-invasive gut microbiome in the early diagnosis of course from CKD to ESRD and provide new insights into the association between clinical features and gut microbiota in CKD.

Practicing health equity in involuntary discharges to overcome disparities in dialysis and kidney patient care

PURPOSE OF REVIEW

Potential causes and consequences of involuntary discharge (IVD) of patients from dialysis facilities are widely unknown. So, also are the extent of racial disparities in IVDs and their impact on health equity.

RECENT FINDINGS

Under the current End-Stage Renal Disease (ESRD) programConditions for Coverage (CFC), there are limited justifications for IVDs. The ESRD Networks oversee dialysis quality and safety including IVDs in US dialysis facilities, with support from the Agency for Healthcare Quality and Research (AHRQ) and other stakeholders. Whereas black Americans constitute a third of US dialysis patients, they are even more overrepresented in the planned and executed IVDs. Cultural gaps between patients and dialysis staff, psychosocial and regional factors, structural racism in kidney care, antiquated ESRD policies, unintended consequences of quality incentive programs, other perverse incentives, and failed patient-provider communications are among potential contributors to IVDs.

SUMMARY

Practicing health equity in kidney care may be negatively impacted by IVDs. Accurate analyses of patterns and trends of involuntary discharges, along with insights from well designed AHRQ surveys and qualitative research with mixed method approaches are urgently needed. Pilot and feasibility programs should be designed and tested, to address the root causes of IVDs and related racial disparities.

The effects of home-based progressive resistance training in chronic kidney disease patients

INTRODUCTION

Faced with lockdowns, it was mandatory the development of supervised home-based RT protocols to keep patients with chronic kidney disease engaged in programs. Nonetheless, there is a lack of scientific literature regarding its effects on patients.

PURPOSE

To investigate the effects of a supervised home-based progressive resistance training program on functional performance, bone mineral density, renal function, endothelial health, inflammation, glycemic homeostasis, metabolism, redox balance, and the modulation of exerkines in patients with CKD in stage 2.

METHODS

Patients (n = 31) were randomized and allocated into the control group (CTL; n = 15; 58.07 ± 5.22 yrs) or resistance training group (RT; n = 16; 57.94 ± 2.74 yrs). RT group performed 22 weeks of supervised progressive home-based resistance exercises. Bone mineral density, anthropometric measurements, and functional performance were assessed. Venous blood samples were collected at baseline and after the intervention for the analysis of markers of renal function, endothelial health, inflammation, glycemic homeostasis, metabolism, and redox balance.

RESULTS

Twenty-two weeks of home-based RT were effective in improving (P < 0.05) functional performance, bone mineral density, uremic profile, ADMA, inflammatory markers, the Klotho-FGF23 axis, glycemic homeostasis markers, and exerkines. These improvements were accompanied by higher concentrations of exerkines and anti-inflammatory cytokines. RT group displayed a decrease in cases of osteopenia after the intervention (RT: 50 % vs. CTL: 86.7 %; X² = 4.763; P = 0.029).

CONCLUSION

Results provide new evidence that supervised home-based progressive RT may be a relevant intervention to attenuate the progression of CKD and improve functional capacity, bone mineral density, and the immunometabolic profile. These improvements are associated with positive modulation of several exerkines.

Integration of artificial intelligence and multi-omics in kidney diseases

Kidney disease is a leading cause of death worldwide. Currently, the diagnosis of kidney diseases and the grading of their severity are mainly based on clinical features, which do not reveal the underlying molecular pathways. More recent surge of ∼omics studies has greatly catalyzed disease research. The advent of artificial intelligence (AI) has opened the avenue for the efficient integration and interpretation of big datasets for discovering clinically actionable knowledge. This review discusses how AI and multi-omics can be applied and integrated, to offer opportunities to develop novel diagnostic and therapeutic means in kidney diseases. The combination of new technology and novel analysis pipelines can lead to breakthroughs in expanding our understanding of disease pathogenesis, shedding new light on biomarkers and disease classification, as well as providing possibilities of precise treatment.

The effect of pharmacist-led interventions on the management and outcomes in chronic kidney disease (CKD): A systematic review and meta-analysis protocol

Background and Aims

Chronic kidney disease (CKD) is a progressive condition that results in a decline in kidney function over time. There are several conditions that increase the likelihood of developing CKD, particularly diabetes and hypertension. CKD increases the risk of mortality and has a detrimental impact on quality of life (QoL). Strategies for managing CKD include controlling cardiovascular risk factors and treating complications of CKD. There is an ever-increasing role of pharmacists in managing CKD, from the optimization of risk factors to patient education. However, currently, there is a lack of data on the effect pharmacist-led interventions have on the clinical, economic, and humanistic outcomes.

Methods

This protocol, in adherence to PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) standards, describes a prospective systematic review and meta-analysis of randomized controlled trials, where any intervention led by a pharmacist in CKD is used. Comparison groups will consist of usual care or non-pharmacist-led interventions. Literature searches will be conducted in the following databases: MEDLINE, Scopus, and Web of Science. Data pertaining to clinical (e.g., mortality), economic (e.g., healthcare-associated costs), and humanistic (e.g., QoL) outcomes will be extracted. Risk of bias will be assessed using the United States National Heart Lung and Blood Institute quality assessment tool for controlled intervention studies. A meta-analysis will be conducted to synthesize appropriate comparable outcomes.

Results

The findings of this review will be published in a peer-reviewed journal, where the results will be presented in lay language with appropriate infographics online and via social media.

Conclusion

The findings of this review can identify gaps in the literature concerning optimizing pharmacist-led interventions in improving outcomes. In addition, this review will establish the importance of pharmacists in managing CKD patients, and whether this may result in their increased incorporation in multidisciplinary teams.

The Association of Sarcopenia and Central Obesity with Mortality Risk in Patients with Chronic Kidney Disease - a 2-Year Observational Study

Background

Patients with chronic kidney disease (CKD) face numerous challenges regarding their nutritional status, including undernutrition, wasting, overweight, and obesity. However, there is a gap in the knowledge on the importance of nutritional status on the survival of CKD in patients along the spectrum of progression of CKD.

Objectives

This study aimed to investigate the association of several nutritional measures with all-cause mortality. The hypothesis was that indicators of nutritional status exceeding BMI are associated with increased mortality risk.

Methods

One-hundred seventy adult patients with predialysis CKD (n = 82), receiving hemodialysis (n = 42) or kidney transplantation (n = 46) were recruited from 2014 to 2019. At baseline, nutritional status was assessed by anthropometry, body composition, and muscle function by handgrip strength. Patient survival was assessed after a 2-y follow-up by Cox regression models adjusted for age, sex, and renal function and generalized additive models.

Results

Thirty-one patients (18%) died during the 2-y follow-up. Sarcopenia (n = 30) was associated with an increased risk of death (HR: 2.92; 95% CI: 1.24, 6.89), whereas central obesity (n = 82) was not associated with mortality (1.05; 0.51, 2.15) in the Cox regression analyses. An association between BMI and mortality risk per unit increase (0.97; 0.90, 1.05) was not observed. Other markers of nutritional status were inversely associated with mortality risk, including handgrip strength (0.89; 0.83, 0.95), mid-upper arm circumference (0.86; 0.78, 0.95), and phase angle (per 0.1 degree increase 0.86; 0.81, 0.92). In the generalized additive models, U-shaped relationships were observed between mortality risk and waist circumference and mid-upper arm muscle circumference, while BMI < 22 kg/m2 was associated with increased mortality risk.

Conclusions

Sarcopenia, but not central obesity was associated with total mortality in patients with CKD. The inclusion of muscle strength and mass measures in clinical practice should be considered.

Causal associations between polyunsaturated fatty acids and kidney function: A bidirectional Mendelian randomization study

BACKGROUND

PUFAs were suggested to be beneficial for kidney function in observational studies. However, whether these associations are causal remains unclear.

OBJECTIVES

This study explores the causality between PUFAs and chronic kidney disease (CKD) or estimated glomerular filtration rate (eGFR) using bidirectional 2-sample Mendelian randomization (MR).

METHODS

Single nucleotide polymorphisms associated with PUFAs and kidney function were obtained from the largest and most recent genome-wide association studies with sample sizes of 13,544, 13,506, 13,499, 13,527, and 13,549 for omega-3 fatty acids, omega-6 fatty acids, DHA, LA, and other PUFAs than 18:2 (otPUFA), and 480,698 and 1,201,909 for CKD and eGFR, respectively. MR inverse-variance weighted (IVW) and pleiotropy residual sum and outlier test (MR-PRESSO) were used for data analysis, supplemented with a weighted median estimator, MR-Egger regression, and multivariable MR, giving β or OR and their 95% CIs.

RESULTS

There was suggestive evidence that higher omega-6 fatty acids were associated with increased eGFR using MR-PRESSO [β: 0.005 log(mL/min/1.73 m²) per SD increase in omega-6 fatty acids; 95% CI: 0.002, 0.008; P = 0.008]. Higher LA level was also associated with higher eGFR [β: 0.005 log(mL/min/1.73 m²) per SD increase in LA; 95% CI: 0.003, 0.007; P = 0.0007] using MR-PRESSO. Neither association of the other PUFAs, i.e., omega-3 fatty acids, DHA, and otPUFA, with CKD or eGFR nor the association of CKD and eGFR with PUFAs was found. Similar results were found in sensitivity analyses.

CONCLUSIONS

Our results suggest that higher omega-6 fatty acids and LA may increase eGFR levels. Although the estimated effects were relatively small, the results provide public health and research relevance, indicating the need for further longitudinal cohorts or randomized controlled trials on omega-6 fatty acids in improving kidney function.

Role of endoplasmic reticulum stress and autophagy in the transition from acute kidney injury to chronic kidney disease

Acute kidney injury (AKI) and chronic kidney disease (CKD) are global health concerns with increasing rates in morbidity and mortality. Transition from AKI-to-CKD is common and requires awareness in the management of AKI survivors. AKI-to-CKD transition is a main risk factor for the development of cardiovascular disease and progression to end-stage kidney disease. The mechanisms driving AKI-to-CKD transition are being explored to identify potential molecular and cellular targets for renoprotective drug interventions. Endoplasmic reticulum (ER) stress and autophagy are involved in the process of AKI-to-CKD transition. Excessive ER stress results in the persistent activation of unfolded protein response, which is an underneath cause of kidney cell death. Moreover, ER stress modulates autophagy and vice-versa. Autophagy is a degradation defensive mechanism protecting cells from malfunction. However, the underlying pathological mechanism involved in this interplay in the context of AKI-to-CKD transition is still unclear. In this review, we discuss the crosstalk between ER stress and autophagy in AKI, AKI-to-CKD transition, and CKD progression. In addition, we explore possible therapeutic targets that can regulate ER stress and autophagy to prevent AKI-to-CKD transition to improve the long-term prognosis of AKI survivors.

Identification of shared gene signatures and molecular mechanisms between chronic kidney disease and ulcerative colitis

Background

There is a complex interaction between chronic kidney disease (CKD) and ulcerative colitis (UC), but the pathophysiological mechanisms underlying the coexistence of CKD and UC are unclear. This study aimed to investigate the key molecules and pathways that may mediate the co-occurrence of CKD and UC through quantitative bioinformatics analysis based on a public RNA-sequencing database.

Methods

The discovery datasets of CKD (GSE66494) and UC (GSE4183), as well as validation datasets of CKD (GSE115857) and UC (GSE10616), were downloaded from the Gene Expression Omnibus (GEO) database. After identifying differentially expressed genes (DEGs) with GEO2R online tool, the Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses for the DEGs were performed. Next, protein-protein interaction network was constructed with Search Tool for the Retrieval of Interacting Genes (STRING) and visualized by Cytoscape. Gene modules were identified by the plug-in MCODE and hub genes were screened using the plug-in CytoHubba. Then, correlation between immune cell infiltration and hub genes was analyzed, and the receiver operating characteristic curves were used to assess the predictive value of hub genes. Finally, immunostaining of human specimens was used to validate the relevant findings.

Results

A total of 462 common DEGs were identified and selected for further analyses. GO and KEGG enrichment analyses indicated that these DEGs were primarily enriched in immune- and inflammation-related pathways. Among them, the PI3K-Akt signaling pathway ranked top in both discovery and validation cohorts, and the key signal molecule phosphorylated Akt (p-Akt) was shown to be significantly overexpressed in human CKD kidneys and UC colons, and further elevated in CKD-UC comorbidity specimens. Moreover, nine candidate hub genes, including CXCL8, CCL2, CD44, ICAM1, IL1A, CXCR2, PTPRC, ITGAX, and CSF3, were identified, of which ICAM1 was validated as a common hub gene. Besides, immune infiltration analysis revealed that neutrophils, macrophages, and CD4⁺ T memory cells significantly accumulated in both diseases, and ICAM1 was remarkably associated with neutrophil infiltration. Furthermore, intercellular adhesion molecule1 (ICAM1)-mediated neutrophil infiltration was validated to be upregulated in kidney and colon biopsies of CKD and UC patients, and further increased in patients diagnosed with both CKD and UC. Finally, ICAM1 had shown critical value as a diagnostic marker for the co-occurrence of CKD and UC.

Conclusions

Our study elucidated that immune response, PI3K-Akt signaling pathway, and ICAM1-mediated neutrophil infiltration might be the common pathogenesis of CKD and UC, and identified ICAM1 as a key potential biomarker and therapeutic target for the comorbidity of these two diseases.

Serum leptin levels in patients with chronic kidney disease and hypertensive heart disease: An observational cross-sectional study

Background and Aim

Adipocytes secrete a peptide hormone called leptin, which plays a crucial role in controlling appetite and energy expenditure. Alterations in leptin concentrations are associated with CKD-related cardiovascular problems such as hypertensive heart disease (HHD). Despite the link, data on the precise function of leptin in people with CKD and HHD is scant.

Methods

An observational cross-sectional study involving a total of 108 participants (72 CKD patients with HHD and 36 healthy controls). Their demographic and anthropometric information was collected using a standardized questionnaire. Certain clinical measures such as blood pressure and body mass index (BMI) were assessed. Fasting blood samples were analyzed for levels of plasma glucose (FPG), lipids, creatinine, and leptin. Data were analyzed with SPSS v23.

Results

Leptin, FPG, creatinine and triglyceride levels were all significantly higher in CKD patients with HHD compared to controls (p < 0.01 for all). Furthermore, advanced CKD status (being in stage 5), having a 6-year diagnosis of HHD, being female, having a higher BMI, and elevation in levels of HDL and FPG contributed significantly to the variance in serum leptin levels in the case group (β = 0.37, 0.22, 0.19, 0.18, 0.27, 0.28; p < 0.05 for all). In the control group, the female gender had the biggest unique effect on circulating leptin levels, followed by BMI and eGFR (β = 0.71, 0.34, -0.22; p < 0.01 for all).

Conclusion

Patients with CKD who also had HHD reported considerably higher circulating leptin levels. Significantly higher blood leptin levels were shown to be associated with CKD stage 5 in the case group. These results are consistent with the role of leptin in the metabolic complexity seen in CKD patients. There needs to be more research into treatments that aim to lower leptin levels in CKD patients with HHD.

The effects of mineralocorticoid receptor antagonists on cardiovascular outcomes in patients with end-stage renal disease and heart failure

AIMS

Mineralocorticoid receptor antagonists (MRAs) have been shown to provide survival benefits in patients with heart failure; however, MRA use in patients with chronic kidney disease has been limited by safety concerns. The effects of MRAs on outcomes in patients with end-stage renal disease (ESRD) and heart failure remain unknown. The aim of this study was to evaluate the effects of MRAs on cardiovascular outcomes in patients with heart failure under maintenance dialysis in a real-world setting.

METHODS AND RESULTS

A retrospective cohort study was conducted by collecting data from the Taiwan National Health Insurance Research Database (NHIRD). Patients diagnosed with heart failure and ESRD and who started maintenance dialysis between 1 January 2001 and 31 December 2013 were identified. Patients were grouped according to MRA prescription. The outcomes of interest included cardiovascular (CV) death, hospitalization for heart failure (HHF), all-cause mortality, acute myocardial infarction (AMI), ischaemic stroke, any coronary revascularization procedures, and new-onset hyperkalaemia. Propensity score matching was performed at a 1:3 ratio between MRA users and non-users to minimize selection bias. A total of 50 872 patients who satisfied our inclusion and exclusion criteria were identified. After 1:3 matching, 2176 patients were included in the MRA group, and 6528 patients were included in the non-MRA group. The risk of CV death was significantly lower among patients who received MRAs than those who did not (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.80-0.95), as was the risk of all-cause mortality (HR 0.88, 95% CI 0.83-0.94). Reductions in the risks of CV death and all-cause mortality were more prominent among patients undergoing haemodialysis and those with coronary artery disease.

CONCLUSIONS

In patients undergoing regular dialysis who are diagnosed with heart failure, the use of MRAs is associated with lower risks of all-cause mortality and CV death. The benefits of MRA treatment in heart failure may persist in patients with ESRD. Further investigations through randomized controlled trials are needed to assess the efficacy and safety of MRAs in this high-risk population.

ARIMA model for predicting chronic kidney disease and estimating its economic burden in China

BACKGROUND

Chronic kidney disease (CKD) is an important global public health issue. In China, CKD affects a large number of patients and causes a huge economic burden. This study provided a new way to predict the number of patients with CKD and estimate its economic burden in China based on the autoregressive integrated moving average (ARIMA) model.

METHODS

Data of the number of patients with CKD in China from 2000 to 2019 were obtained from the Global Burden of Disease. The ARIMA model was used to fit and predict the number of patients with CKD. The direct and indirect economic burden of CKD were estimated by the bottom-up approach and the human capital approach respectively.

RESULTS

The results of coefficient of determination (0.99), mean absolute percentage error (0.26%), mean absolute error (343,193.8) and root mean squared error (628,230.3) showed that the ARIMA (1,1,1) model fitted well. Akaike information criterion (543.13) and Bayesian information criterion (546.69) indicated the ARIMA (1,1,1) model was reliable when analyzing our data. The result of relative error of prediction (0.23%) also suggested that the model predicted well. The number of patients with CKD in 2020 to 2025 was predicted to be about 153 million, 155 million, 157 million, 160 million, 163 million and 165 million respectively, accounting for more than 10% of the Chinese population. The total economic burden of CKD from 2019 to 2025 was estimated to be $179 billion, $182 billion, $185 billion, $188 billion, $191 billion, $194 billion and $198 billion respectively.

CONCLUSION

The number of patients with CKD and the economic burden of CKD will continue to rise in China. The number of patients with CKD in China would increase by 2.6 million (1.6%) per year on average from 2020 to 2025. Meanwhile, the total economic burden of CKD in China would increase by an average of $3.1 billion per year. The ARIMA model is applicable to predict the number of patients with CKD. This study provides a new perspective for more comprehensive understanding of the future risk of CKD.

Identification of ferroptosis-related genes and pathways in diabetic kidney disease using bioinformatics analysis

Diabetic kidney disease (DKD) is a major public health issue because of its refractory nature. Ferroptosis is a newly coined programmed cell death characterized by the accumulation of lipid reactive oxygen species (ROS). However, the prognostic and diagnostic value of ferroptosis-related genes (FRGs) and their biological mechanisms in DKD remain elusive. The gene expression profiles GSE96804, GSE30566, GSE99339 and GSE30528 were obtained and analyzed. We constructed a reliable prognostic model for DKD consisting of eight FRGs (SKIL, RASA1, YTHDC2, SON, MRPL11, HSD17B14, DUSP1 and FOS). The receiver operating characteristic (ROC) curves showed that the ferroptosis-related model had predictive power with an area under the curve (AUC) of 0.818. Gene functional enrichment analysis showed significant differences between the DKD and normal groups, and ferroptosis played an important role in DKD. Consensus clustering analysis showed four different ferroptosis types, and the risk score of type four was significantly higher than that of other groups. Immune infiltration analysis indicated that the expression of macrophages M2 increased significantly, while that of neutrophils and mast cells activated decreased significantly in the high-risk group. Our study identified and validated the molecular mechanisms of ferroptosis in DKD. FRGs could serve as credible diagnostic biomarkers and therapeutic targets for DKD.

Imbalance in Bone Morphogenic Proteins 2 and 7 Is Associated with Renal and Cardiovascular Damage in Chronic Kidney Disease

Arterial stiffness is a major vascular complication of chronic kidney disease (CKD). The development of renal damage, hypertension, and increased pulse wave velocity (PWV) in CKD might be associated with an imbalance in bone morphogenetic proteins (BMP)-2 and BMP-7. Plasma BMP-2 and BMP-7 were determined by ELISA in CKD patients (stages I-III; n = 95) and Munich Wistar Frömter (MWF) rats. Age-matched Wistar rats were used as a control. The expression of BMP-2, BMP-7, and profibrotic and calcification factors was determined in kidney and perivascular adipose tissues (PVAT). BMP-2 was higher in stage III CKD patients compared to control subjects. BMP-7 was lower at any CKD stage compared to controls, with a significant further reduction in stage III patients. A similar imbalance was observed in MWF rats together with the increase in systolic (SBP) and diastolic blood pressure (DBP), or pulse wave velocity (PWV). MWF exhibited elevated urinary albumin excretion (UAE) and renal expression of BMP-2 or kidney damage markers, Kim-1 and Ngal, whereas renal BMP-7 was significantly lower than in Wistar rats. SBP, DBP, PWV, UAE, and plasma creatinine positively correlated with the plasma BMP-2/BMP-7 ratio. Periaortic and mesenteric PVAT from MWF rats showed an increased expression of BMP-2 and profibrotic and calcification markers compared to Wistar rats, together with a reduced BMP-7 expression. BMP-2 and BMP-7 imbalance in plasma, kidney, and PVATs is associated with vascular damage, suggesting a profibrotic/pro-calcifying propensity associated with progressive CKD. Thus, their combined analysis stratified by CKD stages might be of clinical interest to provide information about the degree of renal and vascular damage in CKD.

Comprehensive single-cell transcriptional profiling defines shared and unique epithelial injury responses during kidney fibrosis

The underlying cellular events driving kidney fibrogenesis and metabolic dysfunction are incompletely understood. Here, we employed single-cell combinatorial indexing RNA sequencing to analyze 24 mouse kidneys from two fibrosis models. We profiled 309,666 cells in one experiment, representing 50 cell types/states encompassing epithelial, endothelial, immune, and stromal populations. Single-cell analysis identified diverse injury states of the proximal tubule, including two distinct early-phase populations with dysregulated lipid and amino acid metabolism, respectively. Lipid metabolism was defective in the chronic phase but was transiently activated in the very early stages of ischemia-induced injury, where we discovered increased lipid deposition and increased fatty acid β-oxidation. Perilipin 2 was identified as a surface marker of intracellular lipid droplets, and its knockdown in vitro disrupted cell energy state maintenance during lipid accumulation. Surveying epithelial cells across nephron segments identified shared and unique injury responses. Stromal cells exhibited high heterogeneity and contributed to fibrogenesis by epithelial-stromal crosstalk.

Association of Retinal Age Gap and Risk of Kidney Failure: A UK Biobank Study

RATIONALE & OBJECTIVE

The incidence of kidney failure is known to increase with age. We have previously developed and validated the use of retinal age based on fundus images as a biomarker of aging. However, the association of retinal age with kidney failure is not clear. We investigated the association of retinal age gap (the difference between retinal age and chronological age) with future risk of kidney failure.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

11,052 UK Biobank study participants without any reported disease for characterizing retinal age in a deep learning algorithm. 35,864 other participants with retinal images and no kidney failure were followed to assess the association between retinal age gap and the risk of kidney failure.

EXPOSURE

Retinal age gap, defined as the difference between model-based retinal age and chronological age.

OUTCOME

Incident kidney failure.

ANALYTICAL APPROACH

A deep learning prediction model used to characterize retinal age based on retinal images and chronological age, and Cox proportional hazards regression models to investigate the association of retinal age gap with incident kidney failure.

RESULTS

After a median follow-up period of 11 (IQR, 10.89-11.14) years, 115 (0.32%) participants were diagnosed with incident kidney failure. Each 1-year greater retinal age gap at baseline was independently associated with a 10% increase in the risk of incident kidney failure (HR, 1.10 [95% CI, 1.03-1.17]; P=0.003). Participants with retinal age gaps in the fourth (highest) quartile had a significantly higher risk of incident kidney failure compared with those in the first quartile (HR, 2.77 [95% CI, 1.29-5.93]; P=0.009).

LIMITATIONS

Limited generalizability related to the composition of participants in the UK Biobank study.

CONCLUSIONS

Retinal age gap was significantly associated with incident kidney failure and may be a promising noninvasive predictive biomarker for incident kidney failure.

Poricoic acid A suppresses renal fibroblast activation and interstitial fibrosis in UUO rats via upregulating Sirt3 and promoting β-catenin K49 deacetylation

Renal interstitial fibrosis is the common pathological process of various chronic kidney diseases to end-stage renal disease. Inhibition of fibroblast activation attenuates renal interstitial fibrosis. Our previous studies show that poricoic acid A (PAA) isolated from Poria cocos is a potent anti-fibrotic agent. In the present study we investigated the effects of PAA on renal fibroblast activation and interstitial fibrosis and the underlying mechanisms. Renal interstitial fibrosis was induced in rats or mice by unilateral ureteral obstruction (UUO). UUO rats were administered PAA (10 mg·kg−1·d−1, i.g.) for 1 or 2 weeks. An in vitro model of renal fibrosis was established in normal renal kidney fibroblasts (NRK-49F cells) treated with TGF-β1. We showed that PAA treatment rescued Sirt3 expression, and significantly attenuated renal fibroblast activation and interstitial fibrosis in both the in vivo and in vitro models. In TGF-β1-treated NRK-49F cells, we demonstrated that Sirt3 deacetylated β-catenin (a key transcription factor of fibroblast activation) and then accelerated its ubiquitin-dependent degradation, thus suppressing the protein expression and promoter activity of pro-fibrotic downstream target genes (twist, snail1, MMP-7 and PAI-1) to alleviate fibroblast activation; the lysine-49 (K49) of β-catenin was responsible for Sirt3-mediated β-catenin deacetylation. In molecular docking analysis, we found the potential interaction of Sirt3 and PAA. In both in vivo and in vitro models, pharmacological activation of Sirt3 by PAA significantly suppressed renal fibroblast activation via facilitating β-catenin K49 deacetylation. In UUO mice and NRK-49F cells, Sirt3 overexpression enhanced the anti-fibrotic effect of PAA, whereas Sirt3 knockdown weakened the effect. Taken together, PAA attenuates renal fibroblast activation and interstitial fibrosis by upregulating Sirt3 and inducing β-catenin K49 deacetylation, highlighting Sirt3 functions as a promising therapeutic target of renal fibroblast activation and interstitial fibrosis.

Associations between plasma metal levels and mild renal impairment in the general population of Southern China

BACKGROUND

Metal exposure were assumed to be closely related with declined renal function, but the conclusions were controversial. We employed diverse statistical models and assessed the association between metal mixture exposure and mild renal impairment.

METHODS

A total of 13 plasma metals were measured in 896 general population from Southern China. Subjects with estimated glomerular filtration rate within 60-89 ml/min/1.73 m² and urinary albumin-creatinine ratio <30 mg/g creatinine were defined as mild renal impairment (MRI).

RESULTS

About 31.47 % participants showed MRI. In the multivariate logistic regression models, compared with the first quartile, high levels of arsenic and molybdenum (the fourth quartile) were both associated with MRI, and the ORs (95 % CI) were 1.68 (1.05, 2.68) and 2.21 (1.40, 3.48), respectively. Their predominant roles were identified by the weighted quantile regression (WQS). Besides, restricted cubic spline analysis verified the relationship between molybdenum level and increased MRI risk in a linear and dose-response manner.

CONCLUSION

High levels of arsenic and molybdenum might be independent risk factors of MRI, and they showed combined effect. Our findings might provide vigorous evidence in preventing mild decline in renal function.

Decoupling dedifferentiation and G2/M arrest in kidney fibrosis

Understanding the cellular mechanisms underlying chronic kidney disease (CKD) progression is required to develop effective therapeutic approaches. In this issue of the JCI, Taguchi, Elias, et al. explore the relationship between cyclin G1 (CG1), an atypical cyclin that induces G2/M proximal tubule cell cycle arrest, and epithelial dedifferentiation during fibrogenesis. While CG1-knockout mice were protected from fibrosis and had reduced G2/M arrest, protection was unexpectedly independent of induction of G2/M arrest. Rather, CG1 drove fibrosis by regulating maladaptive dedifferentiation in a CDK5-dependent mechanism. These findings highlight the importance of maladaptive epithelial dedifferentiation in kidney fibrogenesis and identify CG1/CDK5 signaling as a therapeutic target in CKD progression.

Accelerated Peripapillary Retinal Nerve Fiber Layer Degeneration in Patients With Chronic Kidney Disease: A 2-Year Longitudinal Study

Purpose

To evaluate the longitudinal changes in the peripapillary retinal nerve fiber layer (pRNFL) in patients with chronic kidney disease (CKD).

Methods

In this prospective cohort study, the CKD group consisted of patients with CKD stage ≥ 3. Age-matched healthy controls were enrolled at a 1:4 ratio. Spectral-domain optical coherence tomography was used to measure the pRNFL at baseline, 1 year, and 2 years. Within-group longitudinal changes and between-group comparisons were performed using linear mixed models.

Results

Overall, 152 patients with CKD and 40 controls were included (mean ages, 62.8 ± 9.1 years vs. 63.0 ± 9.3 years; P = 0.931). The CKD group showed faster loss of pRNFL than the control group (-0.87 µm/y vs. -0.26 µm/y; P = 0.004). Subgroup analysis found that the rate of pRNFL change was -0.41 µm/y in stage 3a CKD, -0.74 µm/y in stage 3b, -0.98 µm/y in stage 4/5, and -1.38 µm/y in end-stage renal disease. Multiple linear regression analysis revealed that CKD stage (coefficient = -0.549; 95% confidence interval [CI], -0.966 to -0.131; P = 0.010), hypertension (coefficient = -1.557; 95% CI -3.013 to -0.101; P = 0.036), and rim area (coefficient = -1.505; 95% CI, -2.940 to -0.070; P = 0.040) were factors associated with the pRNFL change over 2 years.

Conclusions

Patients with CKD experienced faster pRNFL loss than healthy controls did. Severity of CKD, hypertension, and rim area were independent factors associated with the loss of pRNFL.

Translational Relevance

This study contributes to our understanding of retinal neurodegeneration in normal aging and in patients with chronic kidney diseases.

Improving the circulation time and renal therapeutic potency of extracellular vesicles using an endogenous ligand binding strategy

Kidney diseases are a serious health issue worldwide, and novel therapeutics are urgently needed. Extracellular vesicles (EVs) have emerged as potent drug delivery systems (DDSs), but their therapeutic potential is limited by short circulation times and insufficient renal retention. Here, we report that endogenous ligand (albumin, ALB) binding is an efficient modification strategy to improve the therapeutic potency of EV-based DDSs for kidney diseases. Surface albumin-binding peptide (ABP)-displayed EVs (ABP-EVs) were produced by transfecting parent cells with the ABP-Lamp2b fusion plasmid. Compared with unmodified EVs (NC-EVs), ABP-EVs showed increased binding to ALB in vitro and elevated circulation time and multiple organ retention in vivo after systemic (iv) injection. Moreover, ABP-EVs had higher renal retention than NC-EVs in mice with acute kidney injury through a complex mechanism involving microvascular injury and megalin-mediated endocytosis. As a result, delivery of small molecule drugs (e.g., curcumin) or proteins (e.g., hepatocyte growth factor) by ABP-EVs had superior therapeutic (e.g., anti-apoptotic, antioxidant, anti-inflammatory) effects in vitro and in vivo. This study highlights that ABP-EVs are versatile DDSs for kidney diseases and provides insights into the new strategies of engineering EVs for drug delivery.

Higher Habitual Dietary Flavonoid Intake Associates With Less Extensive Abdominal Aortic Calcification in a Cohort of Older Women

BACKGROUND

The extent of abdominal aortic calcification (AAC) is a major predictor of vascular disease events. We have previously found regular apple intake, a major source of dietary flavonoids, associates with lower AAC. Whether total dietary flavonoid intake impacts AAC remains unknown. Here, we extend our observations to habitual intakes of total flavonoids, flavonoid subclasses, and specific flavonoid-containing foods, with the odds of extensive AAC.

METHODS

We conducted cross-sectional analyses on 881 females (median [interquartile range] age, 80 [78-82] years; body mass index, 27 [24-30] kg/m²) from the PLSAW (Perth Longitudinal Study of Ageing Women). Flavonoid intake was calculated from food-frequency questionnaires. Calcifications of the abdominal aorta were assessed on lateral lumbar spine images and categorized as less extensive or extensive. Logistic regression was used to investigate associations.

RESULTS

After adjusting for demographic, lifestyle and dietary confounders, participants with higher (Q4), compared with lower (Q1) intakes, of total flavonoids, flavan-3-ols, and flavonols had 36% (odds ratio [95% CI], 0.64 [0.43-0.95]), 39% (0.61 [0.40-0.93]) and 38% (0.62 [0.42-0.92]) lower odds of extensive AAC, respectively. In food-based analyses, higher black tea intake, the main source of total flavonoids (75.9%), associated with significantly lower odds of extensive AAC (2-6 cups/d had 16%-42% lower odds compared with 0 daily intake). In a subset of nonconsumers of black tea, the association of total flavonoid intake with AAC remained (Q4 versus Q1 odds ratio [95% CI], 0.11 [0.02-0.54]).

CONCLUSIONS

In older women, greater habitual dietary flavonoid intake associates with less extensive AAC.

New comprehensive reference values for kidney function indexes across adult and geriatric ages in Chinese popuplation

Background and aims

China has the largest number of chronic kidney disease (CKD) patients. Current CKD definition has been challenged recently. We aim to reassess kidney function in healthy Chinese population, to provide a more appropriate reference range (RIs) for diagnosis, treatment, monitoring (or screening) of kidney disease and related research.

Materials and methods

A total of 49627 apparently healthy people aged 18-94 years old were enrolled. Age and sex effects were explored for the kidney function indicators and RIs were calculated non-parametrically.

Results

Albumin's limits were lower than the national RIs, with 5.7 g/L lower in upper limit (UL) and 0.4 g/L lower in lower limit (LL) [RIs: 39.6-49.3 vs 40-55]. The LL of estimate glomerular filtration rate (eGFR) was 80.4 mL/min/1.73 m² or 63.3 mL/min/1.73 m² at the age of <50 or ≥70 years, respectively. Notably, eGFR showed an approximately 0.7 mL/min/1.73 m² decrease every year. In addition, eGFR increase 0.35 mL/min/1.73 m² per standard deviation increase in blood glucose when uric acid (UA) exceed the RIs.

Conclusion

UA was an important factor affecting eGFR. For healthy elderly in China, albumin's limits were lower than the national RIs, and LLs of eGFR were nearly 60 mL/min/1.73 m². Using national RIs for healthy elderly may be overly stringent.

Health information sharing on social media: quality assessment of short videos about chronic kidney disease

Introduction

Chronic kidney disease (CKD), which affects about 10% of global population, has become a global public health crisis in recent decades. It is well recognized that health information dissemination could change health behaviors, thereby greatly improving the early diagnosis and prevention of diseases. Due to fast dissemination, wide audience, intuitive and vivid, popularization through short videos has rapidly developed into the new main battlefield of health information. The objective of this study was to describe the properties of the CKD-related health information on short video apps.

Methods

Searching on short video apps with high-frequency words in kidney disease as keywords, the basic information of the uploaders was retrieved and extracted short video. Five quality dimensions, awareness, popularity, utility, validity and quality, of each video were assessed with numeric rating scale (NRS) by five volunteers with CKD and three nephrologists.

Results

From the platform of douyin, 65 uploaders and their 3973 short videos of CKD-related health information were investigated in this study. Most information of short videos had relatively high level in awareness, popularity and utility assessment, but some information had relatively low level in validity and quality assessment; 24 (36.9%) uploaders were from governmental hospital (tertiary hospital); 19 uploaders (29.2%) uploaded more than 100 short videos and 49 uploaders (75.4%) updated their videos weekly, and 16 uploaders (24.6%) didn’t update short videos more than one month. There were 4 uploaders (6.2%) have more than 1 million follows, and 39 uploaders (60%) had follows less than 10,000. “Lifestyles”, “Common symptoms of kidney disease” and “Nephritis or kidney disease” were the three main contents of these short videos. The comprehensive data of uploaders with millions of follows in nephrology specialty were much lower than that of orthopedics and other specialty.

Conclusion

The validity and quality of short video is still unsatisfactory, and CKD-related health information also need to be led and improved, although the awareness, popularity, and utility of health information about CKD is acceptable. The public should be selective and cautious in seeking CKD information on social media.

Point-of-Care Urinalysis with One Drop of Sample Using an Aggregation-Induced Emission Luminogen under the Coffee-Ring Effect

Development of a practical point-of-care test for urinalysis is crucial for early diagnosis and treatment of chronic kidney disease (CKD). However, the classical gold standard detection method depends on sophisticated instruments and complicated procedures, impeding them from being utilized in resource-limited settings and daily screening. Herein, we report a rapid point-of-care device for the simultaneous quantification of microalbuminuria and leukocyte using one drop of urine. A luminogen (TTVP) with an aggregation-induced emission property can selectively activate its near-infrared fluorescence in the presence of albumin and leukocyte via hydrophobic or electrostatic interactions. The fluorescence signals from urine albumin and leukocyte could be well-separated combined with the coffee-ring effect. Using a smartphone-based detection device, simultaneous quantification of urine albumin and leukocyte was successfully achieved, which only took 20 min and required one drop of urine. The performance of this system is also verified with 120 clinical samples, which might serve as a simple, low-cost, and rapid tool for CKD screening and disease monitoring at the point of care.

The Validity of Benchmark Dose Limit Analysis for Estimating Permissible Accumulation of Cadmium

Cadmium (Cd) is a toxic metal pollutant that accumulates, especially in the proximal tubular epithelial cells of kidneys, where it causes tubular cell injury, cell death and a reduction in glomerular filtration rate (GFR). Diet is the main Cd exposure source in non-occupationally exposed and non-smoking populations. The present study aimed to evaluate the reliability of a tolerable Cd intake of 0.83 μg/kg body weight/day, and its corresponding toxicity threshold level of 5.24 μg/g creatinine. The PROAST software was used to calculate the lower 95% confidence bound of the benchmark dose (BMDL) values of Cd excretion (ECd) associated with injury to kidney tubular cells, a defective tubular reabsorption of filtered proteins, and a reduction in the estimated GFR (eGFR). Data were from 289 males and 445 females, mean age of 48.1 years of which 42.8% were smokers, while 31.7% had hypertension, and 9% had chronic kidney disease (CKD). The BMDL value of ECd associated with kidney tubular cell injury was 0.67 ng/L of filtrate in both men and women. Therefore, an environmental Cd exposure producing ECd of 0.67 ng/L filtrate could be considered as Cd accumulation levels below which renal effects are likely to be negligible. A reduction in eGFR and CKD may follow when ECd rises from 0.67 to 1 ng/L of filtrate. These adverse health effects occur at the body burdens lower than those associated with ECd of 5.24 µg/g creatinine, thereby arguing that current health-guiding values do not provide a sufficient health protection.

Association between triglyceride-glucose index and worsening renal function in the elderly

Background

Triglyceride-glucose (TyG) index is a simple marker of insulin resistance. However, insufficient data is available on whether the TyG index is associated with worsening renal function (WRF) in the elderly. Therefore, this study was designed to explore the association between the TyG index and WRF based on a community elderly cohort.

Methods

In this study, 7,822 elderly (aged ≥ 65 years) adults from southern China were enrolled and divided into four groups according to the TyG index quartiles. The primary endpoint was incident chronic kidney disease (CKD), defined as incident estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m². Additional endpoints included a decline in eGFR of 30% and 40% during the follow-up period.

Results

During the median 2.04 year follow-up period, 1,541 (19.7%) participants developed CKD. After adjusting for confounding factors, multivariable Cox regression models revealed significant associations between TyG index and incident CKD (HR per SD increase, 1.21; 95% CI: 1.14-1.29), a decline in eGFR of 30% (HR per SD increase, 1.38; 95% CI: 1.26-1.50), and decline in eGFR of 40% (HR per SD increase, 1.42; 95% CI: 1.24-1.63). Furthermore, compared with those in Q1, participants in Q4 demonstrated a higher risk of developing CKD (HR, 1.59; 95% CI: 1.35-1.88). These positive associations remained consistent across different subgroup populations.

Conclusion

Our study suggests a positive and independent association between the TyG index and WRF in the elderly.

Sirtuin 7 mitigates renal ferroptosis, fibrosis and injury in hypertensive mice by facilitating the KLF15/Nrf2 signaling

Hypertension is one of the leading causes of chronic kidney disease characterized with renal fibrosis. This study aimed to investigate roles and mechanisms of sirtuin 7 (SIRT7) in hypertensive renal injury. Mini-pumps were implanted to male C57BL/6 mice to deliver angiotensin (Ang) Ⅱ (1.5 mg/kg/d) or saline for 2 weeks. Ang Ⅱ infusion resulted in marked increases in systolic blood pressure levels, renal ferroptosis and interstitial fibrosis in hypertensive mice, concomitantly with downregulated SIRT7 and Krüppel-like factor 15 (KLF15) levels. Notably, administration of recombinant adeno-associated virus-SIRT7 or ferroptosis inhibitor ferrostatin-1 effectively mitigated Ang Ⅱ-triggered renal ferroptosis, epithelial-mesenchymal transition (EMT), interstitial fibrosis, renal functional and structural injury in hypertensive mice by blunting the KIM-1/NOX4 signaling and enforcing the KLF15/Nrf2 and xCT/GPX4 signaling, respectively. In primary cultured mouse renal tubular epithelial cells (TECs), Ang Ⅱ pretreatment led to repressed SIRT7 expression and augmented ferroptosis as well as partial EMT, which were substantially antagonized by rhSIRT7 or ferrostatin-1 administration. Additionally, both Nrf2 inhibitor ML385 and KLF15 siRNA strikingly abolished the rhSIRT7-mediated beneficial roles in mouse renal TECs in response to Ang Ⅱ with reduced expression of Nrf2, xCT and GPX4. More importantly, ML385 administration remarkably amplified Ang Ⅱ-mediated ROS generation, lipid peroxidation and ferroptosis in renal TECs, which were significantly reversed by ferrostatin-1. In conclusion, SIRT7 alleviates renal ferroptosis, lipid peroxidation, and partial EMT under hypertensive status by facilitating the KLF15/Nrf2 signaling, thereby mitigating renal fibrosis, injury and dysfunction. Targeting SIRT7 signaling serves as a promising strategy for hypertension and hypertensive renal injury.

Integrated analysis of comprehensive metabolomics and network pharmacology to reveal the mechanisms of abelmoschus manihot (L.) medik. in the treatment of cisplatin-induced chronic kidney disease

Background: Abelmoschus manihot (L.) Medik (“Huangkui” in Chinese, HK) has been widely used for the treatment of kidney diseases. Nephrotoxicity is the side effect of cisplatin (CDDP), which greatly limits its clinical application. Therefore, CDDP could be used to establish the chronic kidney disease (CKD) model. However, the protective effects of HK on CDDP-induced CKD have not been investigated.

Purpose: To explore the protective effect and underlying mechanisms of HK on multiple low-dose CDDP-induced CKD in rats by the integrated analysis of serum, kidney, and urine metabolomics and network pharmacology.

Methods: The CKD model was induced by multiple low-dose CDDP. Body weight, organ index, serum biochemical, and kidney histology were examined to evaluate the effect of HK. Serum, kidney, and urine were collected and profiled by HILIC/RPLC-Q-TOF/MS-based metabolomics. Potential biomarkers (PBs) were screened according to the criteria of VIP &gt;1, p &lt; 0.01, and FC &gt; 2, and then identified or assigned. The pathway analysis and PBs enrichment were conducted by MetaboAnalyst and ChemRICH. Furthermore, network pharmacology was adopted to dig out the active components and targets. Finally, the results from metabolomics and network pharmacology were integrated to confirm each other.

Results: HK could recover the CDDP-induced abnormal pharmacological and metabolic profile changes. A total of 187 PBs were screened and identified from the serum, kidney, and urine metabolomics. Pathway analysis showed that multiple metabolic pathways, mainly related to amino acid and lipid metabolisms, were involved in the nephroprotective effect of HK, and especially, HK could significantly alleviate the disorder of tryptophan metabolism pathway in serum, kidney, and urine. Meanwhile, network pharmacology analysis revealed that 5 components in HK and 4 key genes could be responsible for the nephroprotection of HK, which also indicated that the metabolism of tryptophan played an important role in HK against CKD.

Conclusion: HK has a nephroprotection on CDDP-induced CKD, mainly by restoring the dysregulation of tryptophan metabolism. Integrated analysis of serum, kidney, and urine metabolomics and network pharmacology was a powerful method for exploring pharmacological mechanisms and screening active components and targets of traditional Chinese medicine.

The Codevelopment of "My Kidneys & Me": A Digital Self-management Program for People With Chronic Kidney Disease

BACKGROUND

Health care self-management is important for people living with nondialysis chronic kidney disease (CKD). However, the few available resources are of variable quality.

OBJECTIVE

This work describes the systematic codevelopment of "My Kidneys & Me" (MK&M), a theory-driven and evidence-based digital self-management resource for people with nondialysis CKD, guided by an established process used for the successful development of the diabetes education program MyDESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed, DESMOND).

METHODS

A multidisciplinary steering group comprising kidney health care professionals and researchers and specialists in the development of complex interventions and digital health provided expertise in the clinical and psychosocial aspects of CKD, self-management, digital health, and behavior change. A patient and public involvement group helped identify the needs and priorities of MK&M and co-design the resource. MK&M was developed in 2 sequential phases. Phase 1 involved the codevelopment process of the MK&M resource (content and materials), using Intervention Mapping (IM) as a framework. The first 4 IM steps guided the development process: needs assessment was conducted to describe the context of the intervention; intervention outcomes, performance objectives, and behavioral determinants were identified; theory- and evidence-based change methods and practical strategies to deliver change methods were selected; and program components were developed and refined. Phase 2 involved the adoption and adaptation of the existing MyDESMOND digital platform to suit the MK&M resource.

RESULTS

The needs assessment identified that individuals with CKD have multiple differing needs and that delivering a self-management program digitally would enable accessible, tailored, and interactive information and support. The intended outcomes of MK&M were to improve and maintain effective self-management behaviors, including physical activity and lifestyle, improve knowledge, promote self-care skills, increase self-efficacy, and enhance well-being. This was achieved through the provision of content and materials designed to increase CKD knowledge and patient activation, reduce health risks, manage symptoms, and improve physical function. Theories and behavior change techniques selected include Self-Management Framework, Capability, Opportunity, Motivation Behavior model components of Behaviour Change Wheel and taxonomy of behavior change techniques, Health Action Process Approach Model, Common Sense Model, and Social Cognitive Theory. The program components developed comprised educational and behavior change sessions, health trackers (eg, monitoring blood pressure, symptoms, and exercise), goal-setting features, and forums for social support. The MyDESMOND digital platform represented an ideal existing platform to host MK&M; thus, the MyDESMOND interface and features were adopted and adapted for MK&M.

CONCLUSIONS

Applying the IM framework enabled the systematic application of theory, empirical evidence, and practical perspectives in the codevelopment of MK&M content and materials. Adopting and adapting a preexisting platform provided a cost- and time-efficient approach for developing our digital intervention. In the next stage of work, the efficacy of MK&M in increasing patient activation will be tested in a randomized controlled trial.