Practical Approach to Detection and Management of Chronic Kidney Disease for the Primary Care Clinician

Fabrication of bio-mimic nanozyme based on Mxene@AuNPs and molecular imprinted poly(thionine) films for creatinine detection

Creatinine (Ctn) is a biomarker for chronic kidney disease (CKD). In this study, a highly sensitive and specific detection method for Ctn based on a molecularly imprinted polymer (MIP) based electrochemical biosensor was developed. Mxene (Mx), which has high absorption properties, was modified using carbon screen-printed electrodes (SPCE). Subsequently, gold nanoparticles (AuNPs) were electrochemically deposited on the Mx/SPCE surface, followed by thionine as a redox-active functional monomer. Ctn served as a template molecule, resulting in poly(thionine) (PTH) on the AuNPs coated Mx surface (Mx@Au/PTH/MIP), providing the biosensor with high selectivity. The surface morphology, electrochemical measurements, and analytical performance of the developed Mx@Au/PTH/MIP nanozyme were evaluated using field-emission scanning electron microscopy, and other electroanalytical techniques. Nanozyme pact demonstrated high dynamic linear concentrations from 0.4 to 5000 μg/L with a detection limit of 0.03 μg/L and superior selectivity in the presence of possible interferences. To assist in accessible clinical analysis, a fabricated Mx@Au/PTH/MIP nanozyme exhibited outstanding consistency and high accessibility for sensing rat serum (adenine diet-induced kidney fibrosis model) samples without pretreatment. The developed biomimic nanozymes will not only assist in clinical analysis but also improve patient care.

Predicting Time in Range Without Hypoglycaemia Using a Risk Calculator for Intermittently Scanned CGM in Type 1 Diabetes

PURPOSE

To investigate the impact of clinical and socio-economic factors on glycaemic control and construct statistical models to predict optimal glycaemic control (OGC) after implementing intermittently scanned continuous glucose monitoring (isCGM) systems.

METHODS

This retrospective study included 1072 type 1 diabetes patients (49.0% female) from three centres using isCGM systems. Clinical data and net income from the census tract were collected for each individual. OGC was defined as time in range > 70%, with time below 70 mg/dL < 4%. The sample was randomly split in two equal parts. Logistic regression models to predict OGC were developed in one of the samples, and the best model was selected using the Akaike information criterion and adjusted for Pearson's and Hosmer-Lemeshow's statistics. Model reliability was assessed via external validation in the second sample and internal validation using bootstrap resampling.

RESULTS

Out of 2314 models explored, the most effective predictor model included annual net income per person, sex, age, diabetes duration, pre-isCGM HbA1c, insulin dose/kg, and the interaction between sex and HbA1c. When applied to the validation cohort, this model demonstrated 72.6% specificity, 67.3% sensitivity, and an area under the curve (AUC) of 0.736. The AUC through bootstrap resampling was 0.756. Overall, the model's validity in the external cohort was 80.4%.

CONCLUSIONS

Clinical and socio-economic factors significantly influence OGC in type 1 diabetes. The application of statistical models offers a reliable means of predicting the likelihood of achieving OGC following isCGM system implementation.

11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

2024 Latin American Society of Hypertension guidelines on the management of arterial hypertension and related comorbidities in Latin America

Hypertension is responsible for more than two million deaths due to cardiovascular disease annually in Latin America (LATAM), of which one million occurs before 70 years of age. Hypertension is the main risk factor for cardiovascular morbidity and mortality, affecting between 20 and 40% of LATAM adults. Since the publication of the 2017 LASH hypertension guidelines, reports from different LATAM countries have confirmed the burden of hypertension on cardiovascular disease events and mortality in the region. Many studies in the region have reported and emphasized the dramatically insufficient blood pressure control. The extremely low rates of awareness, treatment, and control of hypertension, particularly in patients with metabolic disorders, is a recognized severe problem in LATAM. Earlier implementation of antihypertensive interventions and management of all cardiovascular risk factors is the recognized best strategy to improve the natural history of cardiovascular disease in LATAM. The 2024 LASH guidelines have been developed by a large group of experts from internal medicine, cardiology, nephrology, endocrinology, general medicine, geriatrics, pharmacology, and epidemiology of different countries of LATAM and Europe. A careful search for novel studies on hypertension and related diseases in LATAM, together with the new evidence that emerged since the 2017 LASH guidelines, support all statements and recommendations. This update aims to provide clear, concise, accessible, and useful recommendations for health professionals to improve awareness, treatment, and control of hypertension and associated cardiovascular risk factors in the region.

Assessing the quality of CKD care using process quality indicators: A scoping review

INTRODUCTION

Assessing the quality of chronic kidney disease (CKD) management is crucial for optimal care and identifying care gaps. It is largely unknown which quality indicators have been widely used and the potential variations in the quality of CKD care. We sought to summarize process quality indicators for CKD and assess the quality of CKD care.

METHODS

We searched databases including Medline (Ovid), PubMed, Cochrane Library, Web of Science, CINAHL, and Scopus from inception to June 20, 2024. Two reviewers screened the identified records, extracted relevant data, and classified categories and themes of quality indicators.

RESULTS

We included 24 studies, extracted 30 quality indicators, and classified them into three categories with nine themes. The three categories included laboratory measures and monitoring of CKD progression and/or complications (monitoring of kidney markers, CKD mineral and bone disorder, anemia and malnutrition, electrolytes, and volume), use of guideline-recommended therapeutic agents (use of medications), and attainment of therapeutic targets (blood pressure, glycemia, and lipids). Among the frequently reported quality indicators (in five or more studies), the following have a median proportion of study participants achieving that quality indicator exceeding 50%: monitoring of kidney markers (Scr/eGFR), use of medications (ACEIs/ARBs, avoiding non-steroidal anti-inflammatory drugs (NSAIDs)), management of blood pressure (with a target of ≤140/90, or without specific targets), and monitoring for glycated hemoglobin A1c (HbA1c)). The presence of diabetes, hypertension, cardiovascular disease, or proteinuria was associated with higher achievement in indicators of monitoring of kidney markers, use of recommended medications, and management of blood pressure and glycemia.

CONCLUSION

The quality of CKD management varies with quality indicators. A more consistent and complete reporting of key quality indicators is needed for future studies assessing CKD care quality.

Immune Microenvironment Alterations and Identification of Key Diagnostic Biomarkers in Chronic Kidney Disease Using Integrated Bioinformatics and Machine Learning

Background

Chronic kidney disease (CKD) involves complex immune dysregulation and altered gene expression profiles. This study investigates immune cell infiltration, differential gene expression, and pathway enrichment in CKD patients to identify key diagnostic biomarkers through machine learning methods.

Methods

We assessed immune cell infiltration and immune microenvironment scores using the xCell algorithm. Differentially expressed genes (DEGs) were identified using the limma package. Gene Set Enrichment Analysis (GSEA) and Gene Set Variation Analysis (GSVA) were performed to evaluate pathway enrichment. Machine learning techniques (LASSO and Random Forest) pinpointed diagnostic genes. A nomogram model was constructed and validated for diagnostic prediction. Spearman correlation explored associations between key genes and immune cell recruitment.

Results

The CKD group exhibited significantly altered immune cell infiltration and increased immune microenvironment scores compared to the normal group. We identified 2335 DEGs, including 124 differentially expressed immune-related genes. GSEA highlighted significant enrichment of inflammatory and immune pathways in the high immune score (HIS) subgroup, while GSVA indicated upregulation of immune responses and metabolic processes in HIS. Machine learning identified four key diagnostic genes: RGS1, IL4I1, NR4A3, and SOCS3. Validation in an independent dataset (GSE96804) and clinical samples confirmed their diagnostic potential. The nomogram model integrating these genes demonstrated high predictive accuracy. Spearman correlation revealed positive associations between the key genes and various immune cells, indicating their roles in immune modulation and CKD pathogenesis.

Conclusion

This study provides a comprehensive analysis of immune alterations and gene expression profiles in CKD. The identified diagnostic genes and the constructed nomogram model offer potent tools for CKD diagnosis. The immunomodulatory roles of RGS1, IL4I1, NR4A3, and SOCS3 warrant further investigation as potential therapeutic targets in CKD.

TrajVis: a visual clinical decision support system to translate artificial intelligence trajectory models in the precision management of chronic kidney disease

OBJECTIVE

Our objective is to develop and validate TrajVis, an interactive tool that assists clinicians in using artificial intelligence (AI) models to leverage patients' longitudinal electronic medical records (EMRs) for personalized precision management of chronic disease progression.

MATERIALS AND METHODS

We first perform requirement analysis with clinicians and data scientists to determine the visual analytics tasks of the TrajVis system as well as its design and functionalities. A graph AI model for chronic kidney disease (CKD) trajectory inference named DisEase PrOgression Trajectory (DEPOT) is used for system development and demonstration. TrajVis is implemented as a full-stack web application with synthetic EMR data derived from the Atrium Health Wake Forest Baptist Translational Data Warehouse and the Indiana Network for Patient Care research database. A case study with a nephrologist and a user experience survey of clinicians and data scientists are conducted to evaluate the TrajVis system.

RESULTS

The TrajVis clinical information system is composed of 4 panels: the Patient View for demographic and clinical information, the Trajectory View to visualize the DEPOT-derived CKD trajectories in latent space, the Clinical Indicator View to elucidate longitudinal patterns of clinical features and interpret DEPOT predictions, and the Analysis View to demonstrate personal CKD progression trajectories. System evaluations suggest that TrajVis supports clinicians in summarizing clinical data, identifying individualized risk predictors, and visualizing patient disease progression trajectories, overcoming the barriers of AI implementation in healthcare.

DISCUSSION

The TrajVis system provides a novel visualization solution which is complimentary to other risk estimators such as the Kidney Failure Risk Equations.

CONCLUSION

TrajVis bridges the gap between the fast-growing AI/ML modeling and the clinical use of such models for personalized and precision management of chronic diseases.

Proteinuria Assessment and Therapeutic Implementation in Chronic Kidney Disease Patients-A Clinical Audit on KDIGO ("Kidney Disease: Improving Global Outcomes") Guidelines

Background/Objectives: Chronic kidney disease (CKD) is a major health problem with a rising prevalence due to comorbidities like diabetes and hypertension. The aim of this research was to audit the assessment and therapeutic management of proteinuria in CKD patients at the Cantonal Hospital Baselland (KSBL) in Switzerland and determine associations between patient comorbidities, rehospitalisation, death, and the quality of therapeutic management. Methods: We analysed data from 427 adults with CKD (eGFR < 45 mL/min/1.73 m2) hospitalised on the internal medicine ward in 2022. Results: The mean age was 85 years (range: 79-89), 45.9% were female, and the median eGFR was 32.8 mL/min/1.73 m2 (range: 25-40). Proteinuria assessment was performed in 120 (28.1%) patients (the ProtU group), and a corresponding treatment was prescribed in 59%. The ProtU group had a higher quota of patients with diabetes (44.1% vs. 33%, p = 0.048) and obesity (21.2% vs. 12.5%, p = 0.039) when compared to the group without proteinuria assessment (the Ustix group). Twelve-month survival was not significantly different between the groups (HR: 0.75; 95% CI: 0.488-1.154; p-value = 0.191). However, survival was significantly better in patients who received an antiproteinuric treatment compared to those who did not (HR: 0.30; 95% CI: 0.121-0.0761; p = 0.011). Conclusions: Improvements need to be made in managing CKD at the KSBL in accordance with the guidelines.

Emerging therapeutic landscape: Incretin agonists in chronic kidney disease management

The increasing incidence of chronic kidney disease (CKD) poses a significant public health concern, prompting heightened attention to its treatment. Incretins, including glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide, are intestinal peptides released after nutrient intake, known for their hypoglycemic effects in diabetes management. Recent advancements highlight the promising outcomes of GLP-1 receptor agonists in reducing CKD risk factors and improving renal outcomes. The multifaceted functions of GLP-1, such as its anti-obesity, anti-hypertensive, anti-hyperglycemic, anti-lipid, anti-inflammatory, and endothelial function protective properties, contribute to its potential as a therapeutic agent for CKD. Although experiments suggest the potential benefits of incretin in CKD, a comprehensive understanding of its specific mechanisms is still lacking. This review aims to provide a detailed examination of current evidence and potential future directions, emphasizing the promising yet evolving landscape of incretin agonists in the context of CKD.

Time above range and no coefficient of variation is associated with diabetic retinopathy in individuals with type 1 diabetes and glycated hemoglobin within target

AIMS

This study aimed to investigate the association between glucose metrics and diabetic retinopathy in type 1 diabetes (T1D) patients using flash continuous glucose monitoring (FGM) systems, including those maintaining glycated hemoglobin (HbA1c) within the target range.

METHODS

We conducted a cross-sectional study involving 1070 T1D patients utilizing FGM systems. Data on clinical, anthropometric, and socioeconomic characteristics were collected and retinopathy was classified based on international standards.

RESULTS

Patients' mean age was 47.6 ± 15.0 years, with 49.4% of them being females. Within the cohort, 24.8% of patients presented some form of retinopathy. In the analysis involving the entire sample of subjects, male gender (OR = 1.51, p = 0.027), Time Above Range (TAR) > 250 mg/dL (OR = 1.07, p = 0.025), duration of diabetes (OR = 1.09, p < 0.001), smoking (OR = 2.30, p < 0.001), and history of ischemic stroke (OR = 5.59, p = 0.025) were associated with diabetic retinopathy. No association was observed between the coefficient of variation and diabetic retinopathy (p = 0.934). In patients with HbA1c < 7%, the highest quartile of TAR > 250 was independently linked to diabetic retinopathy (OR = 8.32, p = 0.040), in addition to smoking (OR = 2.90, p = 0.031), duration of diabetes (OR = 1.09, p < 0.001), and hypertension (OR = 2.35, p = 0.040).

CONCLUSION

TAR > 250 mg/dL significantly emerges as a modifiable factor associated with diabetic retinopathy, even among those patients maintaining recommended HbA1c levels. Understanding glucose metrics is crucial for tailoring treatment strategies for T1D patients.

Electronic Health Record-Oriented Knowledge Graph System for Collaborative Clinical Decision Support Using Multicenter Fragmented Medical Data: Design and Application Study

BACKGROUND

The medical knowledge graph provides explainable decision support, helping clinicians with prompt diagnosis and treatment suggestions. However, in real-world clinical practice, patients visit different hospitals seeking various medical services, resulting in fragmented patient data across hospitals. With data security issues, data fragmentation limits the application of knowledge graphs because single-hospital data cannot provide complete evidence for generating precise decision support and comprehensive explanations. It is important to study new methods for knowledge graph systems to integrate into multicenter, information-sensitive medical environments, using fragmented patient records for decision support while maintaining data privacy and security.

OBJECTIVE

This study aims to propose an electronic health record (EHR)-oriented knowledge graph system for collaborative reasoning with multicenter fragmented patient medical data, all the while preserving data privacy.

METHODS

The study introduced an EHR knowledge graph framework and a novel collaborative reasoning process for utilizing multicenter fragmented information. The system was deployed in each hospital and used a unified semantic structure and Observational Medical Outcomes Partnership (OMOP) vocabulary to standardize the local EHR data set. The system transforms local EHR data into semantic formats and performs semantic reasoning to generate intermediate reasoning findings. The generated intermediate findings used hypernym concepts to isolate original medical data. The intermediate findings and hash-encrypted patient identities were synchronized through a blockchain network. The multicenter intermediate findings were collaborated for final reasoning and clinical decision support without gathering original EHR data.

RESULTS

The system underwent evaluation through an application study involving the utilization of multicenter fragmented EHR data to alert non-nephrology clinicians about overlooked patients with chronic kidney disease (CKD). The study covered 1185 patients in nonnephrology departments from 3 hospitals. The patients visited at least two of the hospitals. Of these, 124 patients were identified as meeting CKD diagnosis criteria through collaborative reasoning using multicenter EHR data, whereas the data from individual hospitals alone could not facilitate the identification of CKD in these patients. The assessment by clinicians indicated that 78/91 (86%) patients were CKD positive.

CONCLUSIONS

The proposed system was able to effectively utilize multicenter fragmented EHR data for clinical application. The application study showed the clinical benefits of the system with prompt and comprehensive decision support.

Management of chronic kidney disease: The current novel and forgotten therapies

Chronic kidney disease (CKD) is a progressive and incurable condition that imposes a significant burden on an aging society. Although the exact prevalence of this disease is unknown, it is estimated to affect at least 800 million people worldwide. Patients with diabetes or hypertension are at a higher risk of developing chronic kidney damage. As the kidneys play a crucial role in vital physiological processes, damage to these organs can disrupt the balance of water and electrolytes, regulation of blood pressure, elimination of toxins, and metabolism of vitamin D. Early diagnosis is paramount to prevent potential complications. Treatment options such as dietary modifications and medications can help slow disease progression. In our narrative review, we have summarized the available therapeutic options to slow the progression of chronic kidney disease. Many new drug treatments have recently become available, offering a beacon of hope and optimism in CKD management. Nonetheless, disease prevention remains the most critical step in disease management. Given the significant impact of CKD on public health, there is a pressing need for further research. With the development of new technologies and advancements in medical knowledge, we hope to find more effective diagnostic tools and treatments for CKD patients.

Vitamin D Status and Cardiovascular Risk Factors in Patients with Type 2 Diabetes Mellitus: A Cross-Sectional Study in a Tertiary-Level Hospital in Antananarivo, Madagascar

Background

Diabetes mellitus is already a major cardiovascular risk factor (CRF). Hypovitaminosis D is common in patients with type 2 diabetes mellitus (T2DM). It also increases the cardiovascular risk of these subjects.

Objective

To determine the vitamin D status of Malagasy with T2DM seen at the Soavinandriana Hospital Center, and the association between hypovitaminosis D and CRF.

Methods

This was a cross-sectional study, carried out over a period of 2 years. Assayed by the chemiluminescence technique, vitamin D was "normal", "insufficient" and "deficient" if the 25-hydroxyvitamin D plasma was ≥30 ng/mL, 20-29 ng/mL and ≤19 ng/mL, respectively. Hypovitaminosis D was the set of vitamin D insufficiency and deficiency.

Results

Among the 318 T2DM, the prevalence of hypovitaminosis D was 66.0% (45.2% insufficiency and 20.8% deficiency). Their factors associated were age ≥70 years (OR = 2.15 [1.26-3.66]), glycated haemoglobin ≥7% (4.97 [2.97-8.39]), and retinopathy (OR = 4.15 [1.85-9.32]). After adjustment for age, Hb A1c ≥7% and retinopathy, hypovitaminosis D was associated with hypertension (OR = 8.77 [4.76-16.2]), dyslipidaemia (OR = 8.05 [3.98-14.5]), ex-smoking (OR = 6.07 [2.78-13.3]), microalbuminuria (OR = 2.95 [1.25-6.97]) and carotid atherosclerosis (OR = 2.96 [1.83-4.35]).

Conclusion

Hypovitaminosis D was common in T2DM. Its treatment is primarily preventive. It is also important to control associated CRF, diabetes and its complications.

Gut microbiota associations with chronic kidney disease: insights into nutritional and inflammatory parameters

Introduction

The gut barrier, comprising gut microbiota, plays a pivotal role in chronic kidney disease (CKD) progression and nutritional status. This study aimed to explore gut barrier alterations in hemodialyzed (HD) patients, non-HD (NHD) CKD patients, and healthy volunteers.

Methods

Our cross-sectional study enrolled 22 HD patients, 11 NHD patients, and 11 healthy volunteers. We evaluated fecal microbiota composition (assessed via bacterial 16S rRNA gene sequencing), fecal IgA levels, surrogate markers of gut permeability, serum cytokines, appetite mediators, nutritional status, physical activity, and quality of life.

Results

HD patients exhibited significant alterations in fecal microbiota composition compared to healthy volunteers, with observed shifts in taxa known to be associated with dietary patterns or producing metabolites acting on human host. In comparison to healthy volunteers, individuals with HD patients exhibited elevated levels of inflammatory markers (CRP, IL-6 and TNF-α), glucagon-like peptide-2, and potential anorexigenic markers (including leptin and peptide YY). NHD patients had increased levels of CRP and peptide YY. Overall fecal microbiota composition was associated with height, soft lean mass, resting energy expenditure, handgrip strength, bone mineral content and plasma albumin and TNF-α.

Discussion

Compared to healthy volunteers, HD patients have an altered fecal microbiota composition, a higher systemic inflammation, and a modification in plasma levels of appetite mediators. While some differences align with previous findings, heterogeneity exists likely due to various factors including lifestyle and comorbidities. Despite limitations such as sample size, our study underscores the multifaceted interplay between gut microbiota, physiological markers, and kidney function, warranting further investigation in larger cohorts.

Kidney function in healthcare clients in Khayelitsha, South Africa: Routine laboratory testing and results reflect distinct healthcare experiences by age for healthcare clients with and without HIV

In South Africa, PLHIV are eligible for free ART and kidney function screening. Serum creatinine (SCr) laboratory test data from the National Health Laboratory Service are collated at the Provincial Health Data Centre and linked with other routine health data. We analysed SCr and estimated glomerular filtration rate (eGFR) results for PLHIV and HIV-negative healthcare clients aged 18-80 years accessing healthcare in Khayelitsha, South Africa and comorbidity profiles at SCr and eGFR testing. 45 640 individuals aged 18-80 years with at least one renal test accessed Khayelitsha public health facilities in 2016/2017. 22 961 (50.3%) were PLHIV. Median age at first SCr and eGFR test for PLHIV was 33yrs (IQR: 27,41) to 36yrs (IQR: 30,43) compared to 49yrs (IQR: 37,57) and 52yrs (IQR: 44,59) for those without HIV. PLHIV first median SCr results were 66 (IQR: 55,78) μmol/l compared to 69 (IQR: 58,82) μmol/l for HIV-negative individuals. Hypertension, diabetes, and CKD at testing were more common in HIV-negative people than PLHIV. HIV, diabetes and tuberculosis (TB) are associated with higher eGFR results; whilst hypertension, being male and older are associated with lower eGFR results. These data reflect testing practices in the Western Cape: younger people without HIV have generally worse kidney function test results; younger PLHIV have generally good test results, and older people with/without HIV have generally similar test results, reflecting regular screening for kidney function in asymptomatic PLHIV whereas young HIV-negative people are tested only when presenting with renal symptoms. Our analysis suggests we cannot infer the future healthcare requirements of younger PLHIV based on the current ageing population, due to changing ART availability for different generations of PLHIV. Instead, routine health data may be used in an agile way to assess ongoing healthcare requirements of ageing PLHIV, and to reflect implementation of treatment guidelines.

Frail hypertensive older adults with prediabetes and chronic kidney disease: insights on organ damage and cognitive performance - preliminary results from the CARYATID study

BACKGROUND

Hypertension and chronic kidney disease (CKD) pose significant public health challenges, sharing intertwined pathophysiological mechanisms. Prediabetes is recognized as a precursor to diabetes and is often accompanied by cardiovascular comorbidities such as hypertension, elevating the risk of pre-frailty and frailty. Albuminuria is a hallmark of organ damage in hypertension amplifying the risk of pre-frailty, frailty, and cognitive decline in older adults. We explored the association between albuminuria and cognitive impairment in frail older adults with prediabetes and CKD, assessing cognitive levels based on estimated glomerular filtration rate (eGFR).

METHODS

We conducted a study involving consecutive frail older patients with hypertension recruited from March 2021 to March 2023 at the ASL (local health unit of the Italian Ministry of Health) of Avellino, Italy, followed up after three months. Inclusion criteria comprised age over 65 years, prior diagnosis of hypertension without secondary causes, prediabetes, frailty status, Montreal Cognitive Assessment (MoCA) score < 26, and CKD with eGFR > 15 ml/min.

RESULTS

237 patients completed the study. We examined the association between albuminuria and MoCA Score, revealing a significant inverse correlation (r: 0.8846; p < 0.0001). Subsequently, we compared MoCA Score based on eGFR, observing a significant difference (p < 0.0001). These findings were further supported by a multivariable regression analysis, with albuminuria as the dependent variable.

CONCLUSIONS

Our study represents the pioneering effort to establish a significant correlation between albuminuria and eGFR with cognitive function in frail hypertensive older adults afflicted with prediabetes and CKD.

Investigational new drugs for the treatment of chronic renal failure: an overview of the literature

INTRODUCTION

Chronic kidney disease (CKD) is widespread throughout the world, with a high social and health impact. It is considered a 'silent killer' for its sudden onset without symptoms in the early stages of the disease. The main goal of nephrologists is to slow the progression of kidney disease and treat the associated symptoms with a range of new medications.

AREAS COVERED

The aim of this systematic review is to analyze the new investigational drugs for the treatment of chronic renal failure. Data were obtained from the available scientific literature and from the ClinicalTrials.gov website.

EXPERT OPINION

Among the drugs currently being researched, SGLT2 inhibitors appear to be the most promising drugs for the treatment of CKD, has they have slower progression of CKD and protection of cardiorenal function. An important role in the future of CKD treatment is played by autologous cell-therapy, which appears to be a new frontier in the treatment of CKD. Other therapeutic strategies are currently being investigated and have been shown to slow the progression of CKD. However, further studies are needed to determine whether these approaches may offer benefits in slowing the progression of CKD in the near future.

Association between serum creatinine and 30 days all-cause mortality in critically ill patients with non-traumatic subarachnoid hemorrhage: analysis of the MIMIC-IV database

Background

Serum creatinine is a prognostic marker for various conditions, but its significance of spontaneous subarachnoid hemorrhage is still poorly understood. This study aims to elucidate the correlation between admission serum creatinine (sCr) levels and all-cause mortality within 30 days among individuals affected by non-traumatic subarachnoid hemorrhage (SAH).

Methods

This cohort study included 672 non-traumatic SAH adults. It utilized data from the MIMIC-IV database from 2008 to 2019. The patients' first-time serum creatinine was recorded. Subsequently, an examination of the 30-day all-cause mortality was conducted. Employing a multiple logistic regression model, a nomogram was constructed, while the association between sCr and 30-day all-cause mortality was evaluated using Kaplan-Meier survival curves. The calibration curve was employed to assess the model's performance, while subgroup analysis was employed to examine the impact of additional complications and medication therapy on outcomes.

Results

A total of 672 patients diagnosed with non-traumatic subarachnoid hemorrhage were included in the study. The mortality rate within this timeframe was found to be 24.7%. Multiple logistic regression analysis revealed that sCr served as an independent prognostic indicator for all-cause mortality within 30 days of admission for SAH patients [OR: 2(1.18-3.41); p = 0.01]. A comprehensive model was constructed, incorporating age, sCr, white blood cell count (WBC), glucose, anion gap, and partial thromboplastin time (PTT), resulting in a prediction model with an AUC value of 0.806 (95% CI: 0.768, 0.843), while the AUC for the test set is 0.821 (95% CI: 0.777-0.865).

Conclusion

Creatinine emerges as a significant biomarker, closely associated with heightened in-hospital mortality in individuals suffering from SAH.

A CKD Clinical Decision Support System: A Cluster Randomized Clinical Trial in Primary Care Clinics

Rationale & Objective

The study aimed to develop, implement, and evaluate a clinical decision support (CDS) system for chronic kidney disease (CKD) in a primary care setting, with the goal of improving CKD care in adults.

Study Design

This was a cluster randomized trial.

Setting & Participants

A total of 32 Midwestern primary care clinics were randomly assigned to either receive usual care or CKD-CDS intervention. Between April 2019 and March 2020, we enrolled 6,420 patients aged 18-75 years with laboratory-defined glomerular filtration rate categories of CKD Stage G3 and G4, and 1 or more of 6 CKD care gaps: absence of a CKD diagnosis, suboptimal blood pressure or glycated hemoglobin levels, indication for angiotensin-converting enzyme inhibitor or angiotensin receptor blocker but not prescribed, a nonsteroidal anti-inflammatory agent on the active medication list, or indication for a nephrology referral.

Intervention

The CKD-CDS provided personalized suggestions for CKD care improvement opportunities directed to both patients and clinicians at primary care encounters.

Outcomes

We assessed the proportion of patients meeting each of 6 CKD-CDS quality metrics representing care gap resolution after 18 months.

Results

The adjusted proportions of patients meeting quality metrics in CKD-CDS versus usual care were as follows: CKD diagnosis documented (26.6% vs 21.8%; risk ratio [RR], 1.17; 95% CI, 0.91-1.51); angiotensin-converting enzyme inhibitor or angiotensin receptor blocker prescribed (15.9% vs 16.1%; RR, 0.95; 95% CI, 0.76-1.18); blood pressure control (20.4% vs 20.2%; RR, 0.98; 95% CI, 0.84-1.15); glycated hemoglobin level control (21.4% vs 22.1%; RR, 1.00; 95% CI, 0.80-1.24); nonsteroidal anti-inflammatory agent not on the active medication list (51.5% vs 50.4%; RR, 1.03; 95% CI, 0.90-1.17); and referral or visit to a nephrologist (38.7% vs 36.1%; RR, 1.02; 95% CI, 0.79-1.32).

Limitations

We encountered an overall reduction in expected primary care encounters and obstacles to point-of-care CKD-CDS utilization because of the coronavirus disease 2019 pandemic.

Conclusions

The CKD-CDS intervention did not lead to a significant improvement in CKD quality metrics. The challenges to CDS use during the coronavirus disease 2019 pandemic likely influenced these results.

Funding

National Institute of Diabetes and Digestive and Kidney Diseases (R18DK118463).

Trial Registration

clinicaltrials.gov Identifier: NCT03890588.

Chronic Kidney Disease and Cerebrovascular Pathology: Incidence and Functional Outcomes in Riga East University Hospital

Background and Objectives: The aim of this study was to investigate the incidence of cerebrovascular pathology in patients with chronic kidney disease and its effect on functional outcomes. Materials and Methods: In a retrospective cross-sectional study (2018-2021), the medical records of patients with acute hemorrhagic and ischemic stroke with concomitant chronic kidney disease who received treatment in Riga East University Hospital Stroke Unit were analyzed. Data were analyzed using IBM SPSS 26.0. The Kruskal-Wallis, Mann-Whitney U test, and Spearman's rank correlation coefficient methods were used. Results: The final sample consisted of 305 acute cerebrovascular pathology patients (56.4% females). Overall, 57.3% of stroke patients had second-stage chronic kidney disease with average serum creatinine levels of 104.3 mmol/L (±32.8). The functional outcome of the stroke depended on the stage of chronic kidney disease. There was a statistically significant non-linear correlation between glomerular filtration rate and NIHSS (National Institute of Health Stroke Scale) score on admission (Rho -0.194, p = 0.016), glomerular filtration rate and NIHSS score on discharge (Rho -0.186, p = 0.020), and glomerular filtration rate and modified Rankin score on admission (Rho -0.237, p = 0.003) and discharge (Rho -0.224, p = 0.05). The mean NIHSS score of ischemic stroke patients was 8.3 ± 5.9 on admission and 6.5 ± 5.8 on discharge. In the hemorrhagic stroke patient group, the mean NIHSS score was 9.5 ± 7.3 on admission and 7.1 ± 6.9 on discharge. On average, 34.0% of ischemic stroke patients had an mRS score of 5 on admission, while in the hemorrhagic stroke patient group, this figure was 41%. There was no statistical difference in the glomerular filtration rate between the thrombolyzed versus non-thrombolyzed patient groups (Mann-Whitney U test = 1457, p = 0.794). Conclusions: Chronic kidney disease is an important predictor of the severity and functional outcome of a stroke; furthermore, the early management and prevention of complications should be a top priority in the prophylaxis of this cerebrovascular pathology.

Impact of socioeconomic status on chronic control and complications of type 1 diabetes mellitus in users of glucose flash systems: a follow-up study

BACKGROUND

This study investigates the association between socioeconomic status (SES) and glycemic control in individuals with type 1 diabetes (T1D) using flash glucose monitoring (FGM) devices within a public health system where these technologies are freely available and utilized according to recommended guidelines.

METHODS

A follow-up study of 1060 adults (mean age 47.4 ± 15.0 years, 49.0% women) with T1D, receiving care at three Spanish university hospitals that regularly employ the FGM system. SES was assessed using the Spanish Deprivation Index and the average annual net income per person. Glycemic data were collected over a 14-day follow-up period, including baseline glycated hemoglobin (HbA1c) levels prior to sensor placement, the last available HbA1c levels, and FGM-derived glucose metrics. Individuals with sensor usage time < 70% were excluded. Chronic micro and macrovascular complications related to diabetes were documented. Regression models, adjusted for clinical variables, were employed to determine the impact of SES on optimal sensor control (defined as time in range (TIR) ≥ 70% with time below range < 4%) and disease complications.

RESULTS

The average follow-up was of 2 years. The mean TIR and the percentage of individuals with optimal control were higher in individuals in the highest SES quartile (64.9% ± 17.8% and 27.9%, respectively) compared to those in the lowest SES quartile (57.8 ± 17.4% and 12.1%) (p < 0.001). Regression models showed a higher risk of suboptimal control (OR 2.27, p < 0.001) and ischemic heart disease and/or stroke (OR 3.59, p = 0.005) in the lowest SES quartile. No association was observed between SES and the risk of diabetic nephropathy and retinopathy. FGM system improved HbA1c levels across all SES quartiles. Although individuals in the highest SES quartile still achieved a significantly lower value at the end of the follow-up 55 mmol/mol (7.2%) compared to those in the lowest SES quartile 60 mmol/mol (7.6%) (p < 0.001), the significant disparities in this parameter between the various SES groups were significantly reduced after FGM technology use.

CONCLUSIONS

Socioeconomic status plays a significant role in glycemic control and complications in individuals with T1D, extending beyond access to technology and its proper utilization. The free utilization of FGM technology helps alleviate the impact of social inequalities on glycemic control.

Huaju Xiaoji Formula Regulates ERS-lncMGC/miRNA to Enhance the Renal Function of Hypertensive Diabetic Mice with Nephropathy

Background

Better therapeutic drugs are required for treating hypertensive diabetic nephropathy. In our previous study, the Huaju Xiaoji (HJXJ) formula promoted the renal function of patients with diabetes and hypertensive nephropathy. In this study, we investigated the therapeutic effect and regulation mechanism of HJXJ in hypertensive diabetic mice with nephropathy.

Methods

We constructed a mouse hypertensive diabetic nephropathy (HDN) model by treating mice with streptozotocin (STZ) and nomega-nitro-L-arginine methyl ester (LNAME). We also constructed a human glomerular mesangial cell (HGMC) model that was induced by high doses of sugar (30 mmol/mL) and TGFβ1 (5 ng/mL). Pathological changes were evaluated by hematoxylin and eosin (H&E) staining, periodic acid Schiff (PAS) staining, and Masson staining. The fibrosis-related molecules (TGFβ1, fibronectin, laminin, COL I, COL IV, α-SMA, and p-smad2/3) were detected by enzyme-linked immunosorbent assay (ELISA). The mRNA levels and protein expression of endoplasmic reticulum stress, fibrosis molecules, and their downstream molecules were assessed using qPCR and Western blotting assays.

Results

Administering HJXJ promoted the renal function of HDN mice. HJXJ reduced the expression of ER stress makers (CHOP and GRP78) and lncMGC, miR379, miR494, miR495, miR377, CUGBP2, CPEB4, EDEM3, and ATF3 in HDN mice and model HGMCs. The positive control drugs (dapagliflozin and valsartan) also showed similar effects after treatment with HJXJ. Additionally, in model HGMCs, the overexpression of CHOP or lncMGC decreased the effects of HJXJ-M on the level of fibrosis molecules and downstream target molecules.

Conclusion

In this study, we showed that the HJXJ formula may regulate ERS-lncMGC/miRNA to enhance renal function in hypertensive diabetic mice with nephropathy. This study may act as a reference for further investigating whether combining HJXJ with other drugs can enhance its therapeutic effect. The findings of this study might provide new insights into the clinical treatment of hypertensive diabetic nephropathy with HJXJ.

11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Managing comorbidities in chronic kidney disease reduces utilization and costs

BACKGROUND

Effective management of comorbid diabetes and hypertension in patients with chronic kidney disease (CKD) is important for optimal outcomes. However, little is known about this relationship from a health plan perspective. The objective of this study was to evaluate the association of effective management of comorbid diabetes and/or hypertension with healthcare resource utilization (HCRU) in patients with chronic kidney disease (CKD).

METHODS

This retrospective cohort study used the Humana Research Database to identify patients with CKD Stage ≥ 3a in 2017. Eligible patients were enrolled in a Medicare Advantage Prescription Drug plan for ≥ 12 months before and after the index date (first observed evidence of CKD). Patients with end-stage renal disease, kidney transplant, or hospice election preindex were excluded. Recommended comorbid disease management included hemoglobin A1c monitoring; adherence to glucose-lowering, cardiovascular, and angiotensin-converting enzyme inhibitors/angiotensin receptor blocker medications; and nephrologist/primary care provider (PCP) visits. HCRU was evaluated for 12 months postindex.

RESULTS

The final cohort of 241,628 patients was 55% female and 77% White, with an average age of 75 years. Approximately 90% of patients had Stage 3 CKD. Half had both diabetes and hypertension, and most of the remaining half had hypertension without diabetes. Patients meeting the criteria for good disease management, compared with patients not meeting those criteria, were less likely to experience an inpatient hospitalization, by as much as 40% depending on the criterion and the comorbidities present, or an emergency department visit, by as much as 30%. Total monthly healthcare costs were as much as 17% lower.

CONCLUSIONS

Management of comorbid diabetes and hypertension in patients with CKD was associated with lower HCRU and costs. Care coordination programs targeting patients with CKD must give careful attention to glucose and blood pressure control.

TRIAL REGISTRATION

Not applicable.

Flexible electrochemical sensor for highly sensitive and selective non-enzymatic detection of creatinine via electrodeposited copper over polymelamine formaldehyde

A non-enzymatic electrochemical biosensor was developed for highly sensitive detection of creatinine using copper nanoparticles supported over polymelamine formaldehyde. The synergy between the electrodeposited copper nanoparticles over the highly porous polymer (eCu-PMF) provided a greener platform to boost up the electron transport at the electrode electrolyte interface by eliminating the role of redox species as well as interference of major interferents like glucose, dopamine, and ascorbic acid in physiological media 0.1 M PBS (pH 7.4). The proposed sensor exhibited a wide detection range of 100 fM-60 mM with high sensitivities of 0.320 mA nM-1 cm-2 and 3.8 mA nM-1 cm-2. Moreover, the sensor was applied to real samples of serum creatinine and recoveries of 97 to 114% were found. Additionally, a paper-based flexible screen-printed electrode was fabricated which displayed an excellent activity with the same detection range of 100 fM-60 mM and long-term storage stability of 15 days.

Impact of psychiatric comorbidity on quality of life and activities of daily living among patients suffering from chronic kidney disease undergoing hemodialysis

Introduction

Chronic Kidney Disease (CKD) is a debilitating illness that impairs an individual's physical and social functioning and ultimately affects the quality of life (QOL).

Aim

To determine the impact of psychiatric comorbidity on QOL and activities of daily living in individuals suffering from CKD undergoing hemodialysis.

Materials and Methods

Fifty subjects suffering from CKD undergoing hemodialysis were consequently enrolled in the department of medicine. Institutional ethics committee permission was obtained before the start of the study. The interview was conducted only after the hemodialysis procedure. Consent was obtained and socio-demographic details were noted in the socio-demographic proforma. Schedule for Clinical Assessment in Neuropsychiatry (SCAN) was used to assess psychiatric comorbidity. QOL was assessed on Short Form-36 (SF-36). Katz Index of Independence of Activities of Daily Living scale (KADL) was used to assess the activities of living of such individuals.

Results

46% (n = 23) of subjects suffering from CKD had psychiatric co-morbidity. The most common psychiatric disorder observed was moderate depressive disorder (14%, n = 7) followed by adjustment disorder (12%, n = 6). QOL on SF-36 in all eight domains was low compared to the general population. There was a high statistically significant negative impact of psychiatric comorbidity on QOL on eight domains of SF-36 and activities of daily living. (P = 0.001).

Conclusion

Psychiatric co-morbidity is common in CKD patients on hemodialysis. Quality of life is lower compared to the general population. There is a negative impact of psychiatric co-morbidity on quality of life and activities of daily living.

Association between incident depression and clinical outcomes in patients with chronic kidney disease

Background

Depression is highly prevalent and related to increased morbidity and mortality in patients on dialysis, but less is known among patients with earlier stages of CKD. This study investigated the associations between depression and clinical outcomes in patients with CKD not receiving dialysis.

Methods

We identified 157 398 adults with CKD stages 3-5 not previously diagnosed with depression from the Stockholm CREAtinine Measurements (SCREAM) project. The primary outcomes included hospitalization, CKD progression (>40% decline in eGFR, initiation of kidney replacement therapy, or death due to CKD), major adverse cardiovascular events (MACE; myocardial infarction, stroke, or cardiovascular death), and all-cause mortality. Survival analyses were used to estimate the associations between incident depression and adverse health outcomes, adjusting for socio-demographics, kidney disease severity, healthcare utilization, comorbidities, and concurrent use of medications.

Results

During a median follow-up of 5.1 (interquartile range: 2.3-8.5) years, 12 712 (8.1%) patients received an incident diagnosis of depression. A total of 634 471 hospitalizations (4 600 935 hospitalized days), 42 866 MACEs, and 66 635 deaths were recorded, and 9795 individuals met the criteria for CKD progression. In the multivariable-adjusted analyses, incident depression was associated with an elevated rate of hospitalized days [rate ratio: 1.77, 95% confidence interval (CI): 1.71-1.83], as well as an increased rate of CKD progression [hazard ratio (HR): 1.38, 95% CI: 1.28-1.48], MACE (HR: 1.22, 95% CI: 1.18-1.27), and all-cause mortality (HR: 1.41, 95% CI: 1.37-1.45). The association with CKD progression was more evident after one year of depression diagnosis (HR: 1.47, 95% CI: 1.36-1.59). Results were robust across a range of sensitivity analyses.

Conclusion

Among patients with nondialysis-dependent CKD stages 3-5, incident depression is associated with poor prognosis, including hospitalization, CKD progression, MACE, and all-cause mortality.

Fulfillment and Validity of the Kidney Health Evaluation Measure for People with Diabetes

Objective

To evaluate the fulfillment and validity of the kidney health evaluation for people with diabetes (KED) Healthcare Effectiveness Data Information Set (HEDIS) measure.

Patients and Methods

Optum Labs Data Warehouse (OLDW) was used to identify the nationally distributed US population aged 18 years and older, with diabetes, between January 1, 2017, and December 31, 2017. The OLDW includes deidentified medical, pharmacy, laboratory, and electronic health record (EHR) data. The KED fulfillment was defined in 2017 as both estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio testing within the measurement year. The KED validity was assessed using bivariate analyses of KED fulfillment with diabetes care measures in 2017 and chronic kidney disease (CKD) diagnosis and evidence-based kidney protective interventions in 2018.

Results

Among eligible 5,635,619 Medicare fee-for-service beneficiaries, 736,875 Medicare advantage (MA) beneficiaries, and 660,987 commercial patients, KED fulfillment was 32.2%, 38.7%, and 37.7%, respectively. Albuminuria testing limited KED fulfillment with urinary albumin-creatinine ratio testing (<40%) and eGFR testing (>90%). The KED fulfillment was positively associated with receipt of diabetes care in 2017, CKD diagnosis in 2018, and evidence-based kidney protective interventions in 2018. The KED fulfillment trended lower for Black race, Medicare-Medicaid dual eligibility status, low neighborhood income, and low education status.

Conclusion

Less than 40% of adults with diabetes received guideline-recommended testing for CKD in 2017. Routine KED was associated with diabetes care and evidence-based CKD interventions. Increasing guideline-recommended testing for CKD among people with diabetes should lead to timely and equitable CKD detection and treatment.

AACC/NKF Guidance Document on Improving Equity in Chronic Kidney Disease Care

BACKGROUND

Kidney disease (KD) is an important health equity issue with Black, Hispanic, and socioeconomically disadvantaged individuals experiencing a disproportionate disease burden. Prior to 2021, the commonly used estimated glomerular filtration rate (eGFR) equations incorporated coefficients for Black race that conferred higher GFR estimates for Black individuals compared to non-Black individuals of the same sex, age, and blood creatinine concentration. With a recognition that race does not delineate distinct biological categories, a joint task force of the National Kidney Foundation and the American Society of Nephrology recommended the adoption of the CKD-EPI 2021 race-agnostic equations.

CONTENT

This document provides guidance on implementation of the CKD-EPI 2021 equations. It describes recommendations for KD biomarker testing, and opportunities for collaboration between clinical laboratories and providers to improve KD detection in high-risk populations. Further, the document provides guidance on the use of cystatin C, and eGFR reporting and interpretation in gender-diverse populations.

SUMMARY

Implementation of the CKD-EPI 2021 eGFR equations represents progress toward health equity in the management of KD. Ongoing efforts by multidisciplinary teams, including clinical laboratorians, should focus on improved disease detection in clinically and socially high-risk populations. Routine use of cystatin C is recommended to improve the accuracy of eGFR, particularly in patients whose blood creatinine concentrations are confounded by processes other than glomerular filtration. When managing gender-diverse individuals, eGFR should be calculated and reported with both male and female coefficients. Gender-diverse individuals can benefit from a more holistic management approach, particularly at important clinical decision points.

Novel Asian-Specific Visceral Adiposity Indices Are Associated with Chronic Kidney Disease in Korean Adults

BACKGROUND

The Chinese visceral adiposity index (CVAI) and new visceral adiposity index (NVAI) are novel indices of visceral adiposity used to predict metabolic and cardiovascular diseases in Asian populations. However, the relationships of CVAI and NVAI with chronic kidney disease (CKD) have not been investigated. We aimed to characterize the relationships of CVAI and NVAI with the prevalence of CKD in Korean adults.

METHODS

A total of 14,068 participants in the 7th Korea National Health and Nutrition Examination Survey (6,182 men and 7,886 women) were included. Receiver operating characteristic (ROC) analyses were employed to compare the associations between indices of adiposity and CKD, and a logistic regression model was used to characterize the relationships of CVAI and NVAI with CKD prevalence.

RESULTS

The areas under the ROC curves for CVAI and NVAI were significantly larger than for the other indices, including the visceral adiposity index and lipid accumulation product, in both men and women (all P<0.001). In addition, high CVAI or NVAI was significantly associated with a high CKD prevalence in both men (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.31 to 3.48 in CVAI and OR, 6.47; 95% CI, 2.91 to 14.38 in NVAI, P<0.05) and women (OR, 4.87; 95% CI, 1.85 to 12.79 in CVAI and OR, 3.03; 95% CI, 1.35 to 6.82 in NVAI, P<0.05); this association remained significant after adjustment for multiple confounding factors in men and women.

CONCLUSION

CVAI and NVAI are positively associated with CKD prevalence in a Korean population. CVAI and NVAI may be useful for the identification of CKD in Asian populations, including in Korea.

Unmet Needs of CKD in Latin America: A Review from Expert Virtual Working Group

Chronic kidney disease (CKD) represents a major challenge for Latin American (LatAm) because of its epidemic proportions. Therefore, the current status and knowledge of CKD in Latin America is not clearly understood. Moreover, there is a paucity of epidemiologic studies that makes the comparison across the countries even more difficult. To address these gaps, a virtual kidney expert opinion meeting of 14 key opinion leaders from Argentina, Chile, Colombia, Costa Rica, Dominican Republic, Ecuador, Guatemala, Mexico, and Panama was held in January 2022 to review and discuss the status of CKD in various LatAm regions. The meeting discussed the following: (i) epidemiology, diagnosis, and treatment of CKD, (ii) detection and prevention programs, (iii) clinical guidelines, (iv) state of public policies about diagnosis and management of chronic kidney disease, and (v) role of innovative therapies in the management of CKD. The expert panel emphasized that efforts should be made to implement timely detection programs and early evaluation of kidney function parameters to prevent the development or progression of CKD. Furthermore, the panel discussed the importance of raising awareness among health care professionals; disseminating knowledge to the authorities, the medical community, and the general population about the kidney and cardiovascular benefits of novel therapies; and the need for timely updating of clinical practice guidelines, regulatory policies, and protocols across the region.

Effectiveness and current status of multidisciplinary care for patients with chronic kidney disease in Japan: a nationwide multicenter cohort study

Background

Multidisciplinary care is well established in clinical practice, but its effectiveness in patients with chronic kidney disease (CKD) remains unclear. The aim of this study was to determine whether multidisciplinary care could help to avoid worsening kidney function in patients with CKD.

Methods

This nationwide study had a multicenter retrospective observational design and included 3015 Japanese patients with CKD stage 3–5 who received multidisciplinary care. We assessed the annual decrease in estimated glomerular filtration rate (ΔeGFR) and urinary protein in the 12 months before and 24 months after the start of multidisciplinary care. All-cause mortality and initiation of renal replacement therapy were investigated according to baseline characteristics.

Results

Most of the patients had CKD stage 3b or higher and a median eGFR of 23.5 mL/min/1.73 m2. The multidisciplinary care teams consisted of health care professionals from an average of four disciplines. ΔeGFR was significantly smaller at 6, 12, and 24 months after initiation of multidisciplinary care (all P < 0.0001), regardless of the primary cause of CKD and its stage when multidisciplinary intervention was started. Urinary protein level also decreased after initiation of multidisciplinary care. After a median follow-up of 2.9 years, 149 patients had died and 727 had started renal replacement therapy.

Conclusion

Multidisciplinary care may significantly slow the decline in eGFR in patients with CKD and might be effective regardless of the primary disease, including in its earlier stages. Multidisciplinary care is recommended for patients with CKD stage 3–5.

Trial registration

UMIN00004999.

11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Associations between female birth sex and risk of chronic kidney disease development among people with HIV in the USA: A longitudinal, multicentre, cohort study

Background

Women represent a meaningful proportion of new HIV diagnoses, with Black women comprising 58% of new diagnoses among women. As HIV infection also increases risk of chronic kidney disease (CKD), understanding CKD risk among women with HIV (WWH), particularly Black women, is critical.

Methods

In this longitudinal cohort study of people with HIV (PWH) enrolled in CFAR Network of Integrated Clinical Systems (CNICS), a multicentre study comprised of eight academic medical centres across the United States from Jan 01, 1996 and Nov 01, 2019, adult PWH were excluded if they had ≤2 serum creatinine measurements, developed CKD prior to enrollment, or identified as intersex or transgendered, leaving a final cohort of 33,998 PWH. The outcome was CKD development, defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1·73 m2 calculated using the CKD-EPI equation, for ≥90 days with no intervening higher values.

Findings

Adjusting for demographic and clinical characteristics, WWH were 61% more likely to develop CKD than men (adjusted hazard ratio [aHR]: 1·61, 95% CI: 1·46-1·78, p<0·001). This difference persisted after further adjustment for APOL1 risk variants (aHR female sex: 1·92, 95% CI: 1·63-2·26, p<0·001) and substance abuse (aHR female sex: 1·70, 95% CI: 1·54-1·87, p<0·001).

Interpretation

WWH experienced increased risk of CKD. Given disparities in care among patients with end-stage kidney disease, efforts to engage WWH in nephrology care to improve chronic disease management are critical.

Funding

US National Institutes of Health.

Epidemiological-clinical and paraclinical particularities of acute coronary syndrome without persistent ST-segment elevation in type 2 diabetes mellitus: Retrospective comparative study in a Malagasy population

INTRODUCTION

This study aimed at determining the epidemiological-clinical and paraclinical particularities of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in Malagasy with type 2 diabetes mellitus (T2DM).

METHODS

This was a retrospective, descriptive and comparative study between patients with and without T2DM, carried out over a period of 38 months. The diagnosis of NSTE-ACS was retained in front of the association of chest discomfort, electrical abnormalities and elevations beyond fivefold the upper reference limit of high-sensitivity cardiac troponin.

RESULT

With 130 patients included, the overall prevalence of NSTE-ACS was 4.1%, of which 68 patients (52.3%) had T2DM. Compared to without T2DM, NSTE-ACS in T2DM was characterized by young age (p = .0002), high-frequency hypertension (OR 2.92 [1.23-7.25]; p = .0041), overweight/obesity (OR 4.39 [1.72-12.4]; p = .0002) and microalbuminuria (p < .0001), accelerated heart rate (p = .0104), atypical chest discomfort (OR 5.57 [2.21-15.7]; p < .0001), pulmonary crepitations (OR 2.25 [1.02-5.14]; p = .0224), high GRACE score (p = .0016), damage of extensive anterior leads (OR 2.11 [1.02-4.98]; p = .0402) and septal lead (OR 3.64 [1.41-10.3]; p = .0015), significant increase in cardiac troponin (p < .0001), high left ventricular filling pressure (OR 3.39 [1.51-7.90]; p = .001).

CONCLUSION

NSTE-ACS in T2DM is frequent, with an atypical clinical and severe paraclinical presentations. Adequate and multidisciplinary management of cardiovascular risk factors, including T2DM, could thus minimize the occurrence of NSTE-ACS and improve this profile.

Serum Metabolites and Kidney Outcomes: The Atherosclerosis Risk in Communities Study

Rationale & Objective

Novel metabolite biomarkers of kidney failure with replacement therapy (KFRT) may help identify people at high risk for adverse kidney outcomes and implicated pathways may aid in developing targeted therapeutics.

Study Design

Prospective cohort.

Setting & Participants

The cohort included 3,799 Atherosclerosis Risk in Communities study participants with serum samples available for measurement at visit 1 (1987-1989).

Exposure

Baseline serum levels of 318 metabolites.

Outcomes

Incident KFRT, kidney failure (KFRT, estimated glomerular filtration rate <15 mL/min/1.73 m², or death from kidney disease).

Analytical Approach

Because metabolites are often intercorrelated and represent shared pathways, we used a high dimension reduction technique called Netboost to cluster metabolites. Longitudinal associations between clusters of metabolites and KFRT and kidney failure were estimated using a Cox proportional hazards model.

Results

Mean age of study participants was 53 years, 61% were African American, and 13% had diabetes. There were 160 KFRT cases and 357 kidney failure cases over a mean of 23 years. The 314 metabolites were grouped in 43 clusters. Four clusters were significantly associated with risk of KFRT and 6 were associated with kidney failure (including 3 shared clusters). The 3 shared clusters suggested potential pathways perturbed early in kidney disease: cluster 5 (15 metabolites involved in alanine, aspartate, and glutamate metabolism as well as 5-oxoproline and several gamma-glutamyl amino acids), cluster 26 (6 metabolites involved in sugar and inositol phosphate metabolism), and cluster 34 (21 metabolites involved in glycerophospholipid metabolism). Several individual metabolites were also significantly associated with both KFRT and kidney failure, including glucose and mannose, which were associated with higher risk of both outcomes, and 5-oxoproline, gamma-glutamyl amino acids, linoleoylglycerophosphocholine, 1,5-anhydroglucitol, which were associated with lower risk of both outcomes.

Limitations

Inability to determine if the metabolites cause or are a consequence of changes in kidney function.

Conclusions

We identified several clusters of metabolites reproducibly associated with development of KFRT. Future experimental studies are needed to validate our findings as well as continue unraveling metabolic pathways involved in kidney function decline.

Atrial Fibrillation in Chronic Kidney Disease: An Overview

Chronic kidney disease (CKD) is a condition that can be caused due to any etiology leading to structural damage to the kidney, which can be measured by a decrease in estimated glomerular filtration rate (eGFR) and the presence of damage biomarkers for more than three months. This article has discussed the causal relationship between atrial fibrillation (AF) and CKD, a few of them being inflammation, renin-angiotensin-aldosterone system (RAAS) activation, anemia, and uremia associated with CKD. This review mentioned the clinical impact of the presence of AF in CKD patients. The presence of AF in CKD patients aggravates the renal dysfunction, which in turn adds to the generation of AF. This article explores the various pharmacological and interventional treatment modalities, including antiarrhythmics, anticoagulants, and cardiac ablation, and their complications, leading to restricted usage in CKD patients.

Pooled analysis of drug-related interstitial lung disease and/or pneumonitis in nine trastuzumab deruxtecan monotherapy studies

Introduction

This pooled analysis of nine phase I and II trastuzumab deruxtecan (T-DXd) monotherapy studies described drug-related interstitial lung disease (ILD)/pneumonitis in patients treated with T-DXd.

Methods

Patients who received T-DXd across nine studies were included. Investigator-assessed ILD/pneumonitis events were retrospectively reviewed by an independent adjudication committee; events adjudicated as drug-related ILD/pneumonitis are summarized.

Results

The analysis included 1150 patients (breast cancer, 44.3%; gastric cancer, 25.6%; lung cancer, 17.7%; colorectal cancer, 9.3%; other cancer, 3.0%). Median treatment duration was 5.8 (range, 0.7-56.3) months, with a median of 4 (range, 1-27) prior lines of therapy. The overall incidence of adjudicated drug-related ILD/pneumonitis was 15.4% (grade 5, 2.2%). Most patients with ILD/pneumonitis experienced low-grade events (grade 1 or 2, 77.4%); 87.0% had their first event within 12 months [median, 5.4 (range, <0.1-46.8) months] of their first dose of T-DXd. Based on data review, adjudicated ILD/pneumonitis onset occurred earlier than identified by investigators for 53.2% of events [median difference in onset date, 43 (range, 1-499) days]. Stepwise Cox regression identified several baseline factors potentially associated with increased risk of adjudicated drug-related ILD/pneumonitis: age <65 years, enrollment in Japan, T-DXd dose >6.4 mg/kg, oxygen saturation <95%, moderate/severe renal impairment, presence of lung comorbidities, and time since initial diagnosis >4 years.

Conclusions

In this pooled analysis of heavily treated patients, the incidence of ILD/pneumonitis was 15.4%, with most being low grade and occurring in the first 12 months of treatment. The benefit–risk of T-DXd treatment is positive; however, some patients may be at increased risk of developing ILD/pneumonitis, and further investigation is needed to confirm ILD/pneumonitis risk factors. Close monitoring and proactive management of ILD/pneumonitis are warranted for all.

•

Interstitial lung disease (ILD)/pneumonitis is a significant adverse event related to trastuzumab deruxtecan (T-DXd).

•

This pooled analysis of nine T-DXd monotherapy studies evaluated ILD/pneumonitis risk in 1150 heavily pretreated patients.

•

Overall incidence of adjudicated T-DXd-related ILD/pneumonitis was 15.4% (grade 1 or 2, 77.4%; grade 5, 2.2%).

•

Within 12 months of their first T-DXd dose, 87.0% of patients had their first event [median, 5.4 (range, <0.1-46.8) months].

•

Proactive monitoring and prompt diagnosis and management are important to improving ILD/pneumonitis event outcomes.

Cost-effectiveness of medical migration for chronic kidney disease: a national cross-sectional study in China

Background

The phenomenon of medical migration is common in China. Due to the limited capacity and substantial geographical variation in medical practice, patients with chronic kidney disease (CKD) travel more frequently to seek medical care. We aimed to assess the cost-effectiveness of medical migration for CKD patients in China and provide real-world evidence for the allocation of CKD resources.

Methods

Records of patients with CKD between January 2014 and December 2018 were extracted from a large national database. A patient is defined as a medical migrant if she travelled across the provincial border to a non-residential province to be admitted for inpatient care. The propensity score matching method is used to estimate the effect of medical migration on medical expenditure, length of hospital stay, and in-hospital mortality. The cost-effectiveness is evaluated by comparing the estimated cost per life saved with contemporaneous estimates of the value of a statistical life.

Results

Among 4,392,650 hospitalizations with CKD, medical migrants accounted for 4.9% in 2018. Migrant patients were estimated to incur a 26.35% increase in total medical expenditure, experience a 0.24-percentage-points reduction in in-hospital mortality rates, and a 0.49-days reduction in length of hospital stay compared to non-migrant patients. Overall, medical migration among CKD patients incurred an average of 1 million yuan per life saved, which accounted for 20–40% of contemporaneous estimates of the value of a statistical life. Compared with migrant patients with self-payment and commercial insurance, migrant patients with public health insurance (urban basic medical insurance and new rural co-operative medical care) incurred lower cost per life saved. Cost per life saved for CKD patients was similar between female and male, lower among older population, and varied substantially across regions.

Conclusions

The medical care seeking behaviors of CKD patients was prominent and medical resources of kidney care were unevenly allocated across regions. Medical migration led to a reduction in mortality, but was associated with higher medical expenditure. It is imperative to reduce the regional disparity of medical resources and improve the clinical capacity. Our study shows that it is imperative to prioritize resource allocation toward improving kidney health and regional health care planning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08266-x.

Contribution of phosphate and FGF23 to CKD progression

PURPOSE OF REVIEW

Progressive forms of chronic kidney disease (CKD) exhibit kidney inflammation and fibrosis that drive continued nephron loss; however, factors responsible for the development of these common pathologic features remain poorly defined. Recent investigations suggest pathways involved in maintaining urinary phosphate excretion in CKD may be contributing to kidney function decline. This review provides an update on recent evidence linking altered phosphate homeostasis to CKD progression.

RECENT FINDINGS

High dietary phosphate intake and increased serum concentrations of fibroblast growth factor 23 (FGF23) both increase urinary phosphate excretion and are associated with increased risk of kidney function decline. Recent investigations have discovered high concentrations of tubular phosphate promote phosphate-based nanocrystal formation that drives tubular injury, cyst formation, and fibrosis.

SUMMARY

Studies presented in this review highlight important scientific discoveries that have molded our current understanding of the contribution of altered phosphate homeostasis to CKD progression. The collective observations from these investigations implicate phosphaturia, and the resulting formation of phosphate-based crystals in tubular fluid, as unique risk factors for kidney function decline. Developing a better understanding of the relationship between tubular phosphate handling and kidney pathology could result in innovative strategies for improving kidney outcomes in patients with CKD.

Impact of quality improvement initiatives to improve CKD referral patterns: a systematic review protocol

INTRODUCTION

Chronic kidney disease (CKD) is a global-health problem. A significant proportion of referrals to nephrologists for CKD management are early and guideline-discordant, which may lead to an excess number of referrals and increased wait-times. Various initiatives have been tested to increase the proportion of guideline-concordant referrals and decrease wait times. This paper describes the protocol for a systematic review to study the impacts of quality improvement initiatives aimed at decreasing the number of non-guideline concordant referrals, increasing the number of guideline-concordant referrals and decreasing wait times for patients to access a nephrologist.

METHODS AND ANALYSIS

We developed this protocol by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols (2015). We will search the following empirical electronic databases: MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, PsycINFO and grey literature for studies designed to improve guideline-concordant referrals or to reduce unnecessary referrals of patients with CKD from primary care to nephrology. Our search will include all studies published from database inception to April 2021 with no language restrictions. The studies will be limited to referrals for adult patients to nephrologists. Referrals of patients with CKD from non-nephrology specialists (eg, general internal medicine) will be excluded.

ETHICS AND DISSEMINATION

Ethics approval will not be required, as we will analyse data from studies that have already been published and are publicly accessible. We will share our findings using traditional approaches, including scientific presentations, open access peer-reviewed platforms, and appropriate government and public health agencies.

PROSPERO REGISTRATION NUMBER

CRD42021247756.

A practical approach to chronic kidney disease in primary care

Chronic kidney disease (CKD), a common clinical problem in primary care, can be defined as any abnormality of the kidney structure and/or function that has been present for at least 3 months. Over the past 20 years, the incidence and prevalence of CKD have been increasing in Malaysia in line with the rising number of non-communicable diseases. At present, CKD has no cure. The treatment of CKD is very much dependent on early diagnosis and prevention of CKD progression. In this article, we aim to illustrate a practical approach to CKD in primary care, including diagnosis, evaluation, and management of CKD.

Quality of Life of Hemodialysis Patients during COVID-19 Pandemic in Gatoel Hospital, Mojokerto City

AIM: The purpose of this study was to analyze the quality of life of hemodialysis patients during the COVID-19 pandemic. METHODS: This study used a descriptive design. The sample in this study was hemodialysis patients at the Gatoel Hospital, Mojokerto City, as many as 122 respondents who were determined using simple random sampling technique. The sample criteria in this study were hemodialysis patients at Gatoel Hospital, Mojokerto City, undergoing hemodialysis therapy <2 years, and willing to participate in research activities. The research instrument used was adopted from the WHOQOL-BREF questionnaire. RESULTS: From the results of the study, it was found that more than half of the respondents had poor physical health dimensions as many as 62 respondents (50.8%), more than half of respondents had poor mental health dimensions as many as 68 respondents (55.7%), more than half of respondents had social health dimensions. Bad as many as 62 respondents (50.8%) and most respondents have poor functional health dimensions as many as 74 respondents (60.7%). CONCLUSION: It was found that more than half of the respondents in this study had poor quality of life. More than half of the respondents had physical health dimensions in the poor category, more than half of the respondents had mental health dimensions in the bad category, more than half of the respondents had social health dimensions in the bad category and most of the respondents had functional health dimensions in the bad.