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Tarabeih M, Qaddumi J, Hamdan Z, Bahar A, Sawalmeh O. Worsening of Diabetes Control Measures and Decreased Kidney Function in Pre-Diabetic Kidney Donors Compared to Non-Diabetic Donors Whose BMI Before Kidney Donation was Above 30. Transplant Proc 2024:S0041-1345(24)00362-2. [PMID: 39054221 DOI: 10.1016/j.transproceed.2024.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 05/24/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND The incidence of end-stage renal disease has increased dramatically over the past two decades. Kidney transplantation is the best treatment option for individuals with end-stage renal disease, and living donor kidney transplantation has significant advantages over deceased donor kidney transplantation. Although there are criteria for assessing living kidney donors, different medical centers handle certain medical problems differently. The aim of this study is to investigate how kidney donation affects renal biochemical indicators, blood pressure measurements, and glucose control in healthy young female adults without diabetes compared to a pre-diabetic group. METHODS A prospective cohort study recruited 142 female kidney donors, who were divided into two cohorts based on their diabetic history (pre-diabetic and non-diabetic). The participants were monitored for seven years after kidney donation. Key clinical and biochemical markers were measured before and after donation. RESULTS The pre-diabetic group had higher mean values for blood pressure readings, body mass indices, Oral Glucose Tolerance Test, HbA1c (DCCT) (%), serum creatinine levels, proteinuria, and lower e-GFR compared to those in the non-diabetic group. All these findings were statistically significant. CONCLUSIONS Pre-diabetic donors are at an increased risk for many adverse clinical and biochemical outcomes, including hypertension, glucose tolerance, and worsening kidney function tests and should be advised that their condition may worsen over time and can result in end-organ complications. If the donors decide to proceed, they should be closely and frequently monitored during both the short- and long-term periods.
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Affiliation(s)
- Mahdi Tarabeih
- Nephrology Department, An-Najah National University Hospital, Nablus, State of Palestine.
| | - Jamal Qaddumi
- Public Health Department, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestinian Authority
| | - Zakaria Hamdan
- Nephrology Department, An-Najah National University Hospital, Nablus, State of Palestine.
| | - Anwar Bahar
- Medicine Department, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestinian Authority
| | - Osama Sawalmeh
- Internal Medicine Department, An-Najah National University Hospital, An-Najah National University, Nablus, Palestinian Authority
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Singh AK, Farag YMK, Zheng Z, Bakris GL. Clinical trial designs of emerging therapies for diabetic kidney disease (DKD). Postgrad Med 2024:1-9. [PMID: 39045637 DOI: 10.1080/00325481.2024.2377529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 07/01/2024] [Accepted: 07/04/2024] [Indexed: 07/25/2024]
Abstract
Current evidence for medical therapies for diabetic kidney disease (DKD) is largely based on large-scale clinical trials. These trials, however, often exhibit heterogeneity in participant characteristics and baseline kidney function. These differences may lead to misinterpretation in clinical practice, such that treatment effects from different trials are directly compared and generalized to broader populations beyond the population in which each trial was conducted. This is particularly relevant if comparisons on efficacy and safety are made when the underlying study populations are distinctly different. Indeed, key clinical trials evaluating sodium-glucose transport protein-2 inhibitors (SGLT2i), non-steroidal mineralocorticoid receptor antagonist (nsMRA), and glucagon-like peptide-1 receptor agonist (GLP-1RA) differed in recruitment requirements (inclusion/exclusion criteria), resulting in differences in the severity of the underlying kidney disease as well as risk factor profiles. Moreover, these trials defined their primary and secondary outcomes differently. Collectively, these factors lead to distinct study populations with different baseline risks for DKD progression in the placebo arm in each clinical trial. Consequently, a direct head-to-head comparison of the treatment effect between treatments using relative risk measures from placebo-controlled clinical trials alone is not recommended. In addition, healthcare professionals should be equipped to understand the specific target population of clinical trials to avoid over-generalization when drawing conclusions from these trials.
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Affiliation(s)
- Ajay K Singh
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Denicolò S, Reinstadler V, Keller F, Thöni S, Eder S, Heerspink HJL, Rosivall L, Wiecek A, Mark PB, Perco P, Leierer J, Kronbichler A, Oberacher H, Mayer G. Non-adherence to cardiometabolic medication as assessed by LC-MS/MS in urine and its association with kidney and cardiovascular outcomes in type 2 diabetes mellitus. Diabetologia 2024; 67:1283-1294. [PMID: 38647650 PMCID: PMC11153278 DOI: 10.1007/s00125-024-06149-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 02/23/2024] [Indexed: 04/25/2024]
Abstract
AIMS/HYPOTHESIS Non-adherence to medication is a frequent barrier in the treatment of patients with type 2 diabetes mellitus, potentially limiting the effectiveness of evidence-based treatments. Previous studies have mostly relied on indirect adherence measures to analyse outcomes based on adherence. The aim of this study was to use LC-MS/MS in urine-a non-invasive, direct and objective measure-to assess non-adherence to cardiometabolic drugs and analyse its association with kidney and cardiovascular outcomes. METHODS This cohort study includes 1125 participants from the PROVALID study, which follows patients with type 2 diabetes mellitus at the primary care level. Baseline urine samples were tested for 79 cardiometabolic drugs and metabolites thereof via LC-MS/MS. An individual was classified as totally adherent if markers for all drugs were detected, partially non-adherent when at least one marker for one drug was detected, and totally non-adherent if no markers for any drugs were detected. Non-adherence was then analysed in the context of cardiovascular (composite of myocardial infarction, stroke and cardiovascular death) and kidney (composite of sustained 40% decline in eGFR, sustained progression of albuminuria, kidney replacement therapy and death from kidney failure) outcomes. RESULTS Of the participants, 56.3% were totally adherent, 42.0% were partially non-adherent, and 1.7% were totally non-adherent to screened cardiometabolic drugs. Adherence was highest to antiplatelet and glucose-lowering agents and lowest to lipid-lowering agents. Over a median (IQR) follow-up time of 5.10 (4.12-6.12) years, worse cardiovascular outcomes were observed with non-adherence to antiplatelet drugs (HR 10.13 [95% CI 3.06, 33.56]) and worse kidney outcomes were observed with non-adherence to antihypertensive drugs (HR 1.98 [95% CI 1.37, 2.86]). CONCLUSIONS/INTERPRETATION This analysis shows that non-adherence to cardiometabolic drug regimens is common in type 2 diabetes mellitus and negatively affects kidney and cardiovascular outcomes.
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Affiliation(s)
- Sara Denicolò
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria.
| | - Vera Reinstadler
- Institute of Legal Medicine and Core Facility Metabolomics, Medical University Innsbruck, Innsbruck, Austria
| | - Felix Keller
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Stefanie Thöni
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Susanne Eder
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - László Rosivall
- International Nephrology Research and Training Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - Patrick B Mark
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Paul Perco
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Johannes Leierer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Herbert Oberacher
- Institute of Legal Medicine and Core Facility Metabolomics, Medical University Innsbruck, Innsbruck, Austria
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
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Sosa Mercado I, Putot S, Fertu E, Putot A. Acetazolamide Tolerance in Acute Decompensated Heart Failure: An Observational Study. J Clin Med 2024; 13:3421. [PMID: 38929950 PMCID: PMC11204894 DOI: 10.3390/jcm13123421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Objectives: This real-life study aimed to evaluate the safety of acetazolamide (ACZ), a carbonic anhydrase inhibitor with diuretic effects. ACZ has recently been proven to improve decongestion in the context of patients hospitalized for acute heart failure (HF). However, data in terms of safety are lacking. Methods: We conducted a monocentric observational prospective study from November 2023 to February 2024 in a 12-bed cardiology department, recording adverse events (hypotension, severe metabolic acidosis, severe hypokalemia and renal events) during in-hospital HF treatment. All patients hospitalized for acute HF during the study period treated with ACZ (500 mg IV daily for 3 days) on top of IV furosemide (n = 28, 48.3%) were compared with patients who have been treated with IV furosemide alone (n = 30, 51.7%). Results: The patients treated with ACZ were younger than those without (median age 78 (range 67-86) vs. 85 (79-90) years, respectively, p = 0.01) and had less frequent chronic kidney disease (median estimated glomerular fraction rate (60 (35-65) vs. 38 (26-63) mL/min, p = 0.02). As concerned adverse events during HF treatment, there were no differences in the occurrences of hypotension (three patients [10.7%] in the ACZ group vs. four [13.3%], p = 0.8), renal events (four patients [14.3%] in the ACZ group vs. five [16.7%], p = 1) and severe hypokalemia (two [7.1%] in the ACZ group vs. three [10%], p = 1). No severe metabolic acidosis occurred in either group. Conclusions: Although the clinical characteristics differed at baseline, with younger age and better renal function in patients receiving ACZ, the tolerance profile did not significantly differ from patients receiving furosemide alone. Additional observational data are needed to further assess the safety of ACZ-furosemide combination in the in-hospital management of HF, especially in older, frail populations.
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Affiliation(s)
- Ignacio Sosa Mercado
- Department of Cardiology and Vascular Diseases, Hôpitaux du Pays du Mont Blanc, 74700 Sallanches, France; (I.S.M.); (S.P.); (E.F.)
| | - Sophie Putot
- Department of Cardiology and Vascular Diseases, Hôpitaux du Pays du Mont Blanc, 74700 Sallanches, France; (I.S.M.); (S.P.); (E.F.)
| | - Elena Fertu
- Department of Cardiology and Vascular Diseases, Hôpitaux du Pays du Mont Blanc, 74700 Sallanches, France; (I.S.M.); (S.P.); (E.F.)
| | - Alain Putot
- Department of Internal Medicine and Infectious Diseases, Hôpitaux du Pays du Mont Blanc, 74700 Sallanches, France
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Bidulka P, Lugo-Palacios DG, Carroll O, O'Neill S, Adler AI, Basu A, Silverwood RJ, Bartlett JW, Nitsch D, Charlton P, Briggs AH, Smeeth L, Douglas IJ, Khunti K, Grieve R. Comparative effectiveness of second line oral antidiabetic treatments among people with type 2 diabetes mellitus: emulation of a target trial using routinely collected health data. BMJ 2024; 385:e077097. [PMID: 38719492 PMCID: PMC11077536 DOI: 10.1136/bmj-2023-077097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE To compare the effectiveness of three commonly prescribed oral antidiabetic drugs added to metformin for people with type 2 diabetes mellitus requiring second line treatment in routine clinical practice. DESIGN Cohort study emulating a comparative effectiveness trial (target trial). SETTING Linked primary care, hospital, and death data in England, 2015-21. PARTICIPANTS 75 739 adults with type 2 diabetes mellitus who initiated second line oral antidiabetic treatment with a sulfonylurea, DPP-4 inhibitor, or SGLT-2 inhibitor added to metformin. MAIN OUTCOME MEASURES Primary outcome was absolute change in glycated haemoglobin A1c (HbA1c) between baseline and one year follow-up. Secondary outcomes were change in body mass index (BMI), systolic blood pressure, and estimated glomerular filtration rate (eGFR) at one year and two years, change in HbA1c at two years, and time to ≥40% decline in eGFR, major adverse kidney event, hospital admission for heart failure, major adverse cardiovascular event (MACE), and all cause mortality. Instrumental variable analysis was used to reduce the risk of confounding due to unobserved baseline measures. RESULTS 75 739 people initiated second line oral antidiabetic treatment with sulfonylureas (n=25 693, 33.9%), DPP-4 inhibitors (n=34 464 ,45.5%), or SGLT-2 inhibitors (n=15 582, 20.6%). SGLT-2 inhibitors were more effective than DPP-4 inhibitors or sulfonylureas in reducing mean HbA1c values between baseline and one year. After the instrumental variable analysis, the mean differences in HbA1c change between baseline and one year were -2.5 mmol/mol (95% confidence interval (CI) -3.7 to -1.3) for SGLT-2 inhibitors versus sulfonylureas and -3.2 mmol/mol (-4.6 to -1.8) for SGLT-2 inhibitors versus DPP-4 inhibitors. SGLT-2 inhibitors were more effective than sulfonylureas or DPP-4 inhibitors in reducing BMI and systolic blood pressure. For some secondary endpoints, evidence for SGLT-2 inhibitors being more effective was lacking-the hazard ratio for MACE, for example, was 0.99 (95% CI 0.61 to 1.62) versus sulfonylureas and 0.91 (0.51 to 1.63) versus DPP-4 inhibitors. SGLT-2 inhibitors had reduced hazards of hospital admission for heart failure compared with DPP-4 inhibitors (0.32, 0.12 to 0.90) and sulfonylureas (0.46, 0.20 to 1.05). The hazard ratio for a ≥40% decline in eGFR indicated a protective effect versus sulfonylureas (0.42, 0.22 to 0.82), with high uncertainty in the estimated hazard ratio versus DPP-4 inhibitors (0.64, 0.29 to 1.43). CONCLUSIONS This emulation study of a target trial found that SGLT-2 inhibitors were more effective than sulfonylureas or DPP-4 inhibitors in lowering mean HbA1c, BMI, and systolic blood pressure and in reducing the hazards of hospital admission for heart failure (v DPP-4 inhibitors) and kidney disease progression (v sulfonylureas), with no evidence of differences in other clinical endpoints.
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Affiliation(s)
- Patrick Bidulka
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - David G Lugo-Palacios
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Orlagh Carroll
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen O'Neill
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda I Adler
- Diabetes Trials Unit, The Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Headington, Oxford, UK
| | - Anirban Basu
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle, WA, USA
| | - Richard J Silverwood
- Centre for Longitudinal Studies, UCL Social Research Institute, University College London, London, UK
| | - Jonathan W Bartlett
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Paul Charlton
- Patient author, Patient Research Champion Team, National Institute for Health and Care Research, London, UK
| | - Andrew H Briggs
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Ian J Douglas
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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The efficacy of dapagliflozin in a hierarchical kidney outcome in heart failure. Nat Med 2024; 30:1253-1254. [PMID: 38740999 DOI: 10.1038/s41591-024-02974-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
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Kondo T, Jhund PS, Gasparyan SB, Yang M, Claggett BL, McCausland FR, Tolomeo P, Vadagunathan M, Heerspink HJL, Solomon SD, McMurray JJV. A hierarchical kidney outcome using win statistics in patients with heart failure from the DAPA-HF and DELIVER trials. Nat Med 2024; 30:1432-1439. [PMID: 38710952 PMCID: PMC11108780 DOI: 10.1038/s41591-024-02941-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/21/2024] [Indexed: 05/08/2024]
Abstract
Win statistics offer a new approach to the analysis of outcomes in clinical trials, allowing the combination of time-to-event and longitudinal measurements and taking into account the clinical importance of the components of composite outcomes, as well as their relative timing. We examined this approach in a post hoc analysis of two trials that compared dapagliflozin to placebo in patients with heart failure and reduced ejection fraction (DAPA-HF) and mildly reduced or preserved ejection fraction (DELIVER). The effect of dapagliflozin on a hierarchical composite kidney outcome was assessed, including the following: (1) all-cause mortality; (2) end-stage kidney disease; (3) a decline in estimated glomerular filtration rate (eGFR) of ≥57%; (4) a decline in eGFR of ≥50%; (5) a decline in eGFR of ≥40%; and (6) participant-level eGFR slope. For this outcome, the win ratio was 1.10 (95% confidence interval (CI) = 1.06-1.15) in the combined dataset, 1.08 (95% CI = 1.01-1.16) in the DAPA-HF trial and 1.12 (95% CI = 1.05-1.18) in the DELIVER trial; that is, dapagliflozin was superior to placebo in both trials. The benefits of treatment were consistent in participants with and without baseline kidney disease, and with and without type 2 diabetes. In heart failure trials, win statistics may provide the statistical power to evaluate the effect of treatments on kidney as well as cardiovascular outcomes.
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Affiliation(s)
- Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Samvel B Gasparyan
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Mingming Yang
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Finnian R McCausland
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paolo Tolomeo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Muthiah Vadagunathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
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Takayama A, Fukasawa T, Takeuchi M, Kawakami K. Timing of Initiation of Xanthine Oxidase Inhibitors Based on Serum Uric Acid Level Does Not Predict Renoprognosis in Patients with Preserved Kidney Function. Metab Syndr Relat Disord 2024; 22:222-231. [PMID: 38170182 DOI: 10.1089/met.2023.0238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024] Open
Abstract
Background: Despite recent evidence of remaining possibility that early initiation of xanthine oxidase inhibitors (XOIs) is beneficial in renoprognosis for patients with stage 2 or less chronic kidney disease (CKD), no evidence is available regarding the difference in renoprognosis based on serum uric acid (sUA) levels at the initiation of XOIs among patients with preserved kidney function. Methods: New XOI initiators were divided into quartiles based on baseline sUA. Primary outcome was the composite incidence of a significant estimated glomerular filtration rate (eGFR) decline (≥40% decline in eGFR from baseline or development of eGFR <30 mL/1.73 m2/min) or all-cause death within 5 years. Results: After excluding inapplicable patients, 1170 XOI initiators were analyzed (mean ± standard deviation age: 68 ± 14.3 years; sUA: 10.6 ± 1.15 mg/dL). On overall median [interquartile range (IQR)] follow-up of 824 (342, 1576) days, incidence rate of the primary outcome was 287 per 1000 person-years for 5 years. Although the nonadjusted model showed a dose-response association between baseline sUA level and the outcome, the adjusted model showed no significant association. Adjusted hazard ratios (95% confidence interval) of the second, third, and fourth quartiles of baseline sUA with the composite outcome within 5 years compared to the first quartile were 1.00 (0.78, 1.29), 1.00 (0.80, 1.30), and 1.02 (0.80, 1.32), respectively. Conclusions: Early initiation of XOIs did not predict a significant benefit on renoprognosis even among the population with preserved kidney function. The validity of initiating XOIs with the aim of improving renoprognosis based on sUA is questionable.
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Affiliation(s)
- Atsushi Takayama
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Toshiki Fukasawa
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
- Department of Digital Health and Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Masato Takeuchi
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
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Atiquzzaman M, Er L, Djurdjev O, Bevilacqua M, Elliott M, Birks PC, Wong MM, Yi TW, Singh A, Tangri N, Levin A. Implications of Implementing the 2021 CKD-EPI Equation Without Race on Managing Patients With Kidney Disease in British Columbia, Canada. Kidney Int Rep 2024; 9:830-842. [PMID: 38765563 PMCID: PMC11101769 DOI: 10.1016/j.ekir.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/15/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction We investigated the implications of implementing race-free Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2021 equation among real-world patients with chronic kidney disease (CKD) from British Columbia (BC), Canada. Methods This study included nondialysis-dependent patients with CKD aged ≥19 years who were registered in the Patient Records and Outcome Management Information System (PROMIS) as of March 31, 2016 (index date) with ≥1 serum creatinine measurement within 1 year before the index date. Patients with a history of kidney transplantation before the index date were excluded. CKD-EPI 2021 versus 2009 equation was the exposure variable. Difference in mean estimated glomerular filtration rate (eGFR) and number (%) of patients reclassified to a different eGFR category were estimated. We used Fine and Gray subdistribution hazard model to investigate the association between change in eGFR category and progression to kidney failure (incident maintenance dialysis or kidney transplantation) within 2 years. Results A total of 11,604 patients (median age 73 years, 52% male) were included. Compared to the 2009 equation, eGFR from 2021 equation was on average 2.7 ml/min per 1.73 m2 higher. Variation was higher among males. Overall, ∼17% of the study sample were reclassified to a category with higher eGFR by 2021 equation (switchers). The highest proportion (28%) of patients were reclassified from G5 to G4. The risk of progressing to kidney failure was 22% less among switchers compared to nonswitchers; adjusted subdistribution hazard ratio (HR) (95% confidence interval [CI]) is 0.78 (0.65, 0.94). Conclusion CKD-EPI 2021 equation appeared to provide higher eGFR compared to 2009 equation. This higher eGFR values appeared to be concordant with subsequent real-world CKD progression outcomes. Higher eGFR from the 2021 equation may have substantial clinical implications in both diagnosis as well as long-term care of patients with CKD.
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Affiliation(s)
- Mohammad Atiquzzaman
- BC Renal, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lee Er
- BC Renal, Vancouver, British Columbia, Canada
| | - Ognjenka Djurdjev
- BC Renal, Vancouver, British Columbia, Canada
- Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Micheli Bevilacqua
- BC Renal, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark Elliott
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter C. Birks
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michelle M.Y. Wong
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tae Won Yi
- BC Renal, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anurag Singh
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Navdeep Tangri
- Section of Nephrology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Adeera Levin
- BC Renal, Vancouver, British Columbia, Canada
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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Liu M, Di YM, Zhang L, Yang L, Zhang L, Chen J, Wang R, Xie X, Lan F, Xie L, Huang J, Zhang AL, Xue CC, Liu X. Oral Chinese Herbal Medicine plus usual care for diabetic kidney disease: study protocol for a randomized, double-blind, placebo-controlled pilot trial. Front Endocrinol (Lausanne) 2024; 15:1334609. [PMID: 38390199 PMCID: PMC10881862 DOI: 10.3389/fendo.2024.1334609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Background Diabetic kidney disease (DKD) has become the leading cause of kidney failure, causing a significant socioeconomic burden worldwide. The usual care for DKD fails to achieve satisfactory effects in delaying the persistent loss of renal function. A Chinese herbal medicine, Tangshen Qushi Formula (TQF), showed preliminary clinical benefits with a sound safety profile for people with stage 2-4 DKD. We present the protocol of an ongoing clinical trial investigating the feasibility, efficacy, and safety of TQF compared to placebo in delaying the progressive decline of renal function for people with stage 2-4 DKD. Methods A mixed methods research design will be used in this study. A randomized, double-blind, placebo-controlled pilot trial will evaluate the feasibility, efficacy, and safety of TQF compared to placebo on kidney function for people with stage 2-4 DKD. An embedded semi-structured interview will explore the acceptability of TQF granules and trial procedures from the participant's perspective. Sixty eligible participants with stage 2-4 DKD will be randomly allocated to the treatment group (TQF plus usual care) or the control group (TQF placebo plus usual care) at a 1:1 ratio for 48-week treatment and 12-week follow-up. Participants will be assessed every 12 weeks. The feasibility will be assessed as the primary outcome. The changes in the estimated glomerular filtration rate, urinary protein/albumin, renal function, glycemic and lipid markers, renal composite endpoint events, and dampness syndrome of Chinese medicine will be assessed as the efficacy outcomes. Safety outcomes such as liver function, serum potassium, and adverse events will also be evaluated. The data and safety monitoring board will be responsible for the participants' benefits, the data's credibility, and the results' validity. The intent-to-treat and per-protocol analysis will be performed as the primary statistical strategy. Discussion Conducting a rigorously designed pilot trial will be a significant step toward establishing the feasibility and acceptability of TQF and trial design. The study will also provide critical information for future full-scale trial design to further generate new evidence supporting clinical practice for people with stage 2-4 DKD. Trial registration number https://www.chictr.org.cn/, identifier ChiCTR2200062786.
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Affiliation(s)
- Meifang Liu
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuan Ming Di
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Lei Zhang
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lihong Yang
- Evidence-Based Medicine and Clinical Research Service Group, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - La Zhang
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Junhui Chen
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ruobing Wang
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaoning Xie
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fang Lan
- Department of Nephrology, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Liping Xie
- Department of Nephrology, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Juan Huang
- Pharmaceutical Research Team for New Drug Development and Authentication of Chinese Medicines, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Anthony Lin Zhang
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Charlie Changli Xue
- The China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Xusheng Liu
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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11
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Rovin BH, Furie RA, Ross Terres JA, Giang S, Schindler T, Turchetta A, Garg JP, Pendergraft WF, Malvar A. Kidney Outcomes and Preservation of Kidney Function With Obinutuzumab in Patients With Lupus Nephritis: A Post Hoc Analysis of the NOBILITY Trial. Arthritis Rheumatol 2024; 76:247-254. [PMID: 37947366 DOI: 10.1002/art.42734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To determine whether adding obinutuzumab to standard-of-care lupus nephritis (LN) therapy could improve the likelihood of long-term preservation of kidney function and do so with less glucocorticoids. METHODS Post hoc analyses of the phase II NOBILITY trial were performed. Time to unfavorable kidney outcome (a composite of treatment failure, doubling of serum creatinine, or death), LN flare, first 30% and 40% declines in estimated glomerular filtration rate (eGFR) from baseline, and chronic eGFR slope during the trial were compared between patients with active LN who were randomized to take obinutuzumab (n = 63) or placebo (n = 62) in combination with mycophenolate mofetil and glucocorticoids. The number of patients who achieved complete renal response (CRR) on 7.5 mg or less per day of prednisone was also determined. RESULTS Obinutuzumab reduced the risk of developing the composite kidney outcome by 60%, LN flare by 57%, and first eGFR decline of 30% or 40% by 80% and 91%, respectively. Patients receiving obinutuzumab had a significantly slower decline in eGFR than patients receiving placebo, with an annualized eGFR slope advantage of 4.1 ml/min/1.73 m2 /year (95% confidence interval 0.14-8.08). Overall, 38% of patients receiving obinutuzumab compared with 16% of patients receiving placebo achieved CRR at week 76 while receiving 7.5 mg or less per day of prednisone (P < 0.01); at week 104, the difference did not achieve significance (38% vs 22%; P = 0.06). CONCLUSION Post hoc analyses of NOBILITY demonstrated that compared with standard-of-care therapy, obinutuzumab treatment resulted in superior preservation of kidney function and prevention of LN flares. More patients achieved CRR at week 76 with less glucocorticoid use in the obinutuzumab group.
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Affiliation(s)
- Brad H Rovin
- The Ohio State University Wexner Medical Center, Columbus
| | | | | | | | | | | | - Jay P Garg
- Genentech, Inc, South San Francisco, California
| | | | - Ana Malvar
- Hospital Fernandez, Buenos Aires, Argentina
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12
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Tang L, Li S, Guo X, Lai J, Liu P, Fang J, Liu X. Combinative predictive effect of left ventricular mass index, ratio of HDL and CRP for progression of chronic kidney disease in non-dialysis patient. Int Urol Nephrol 2024; 56:205-215. [PMID: 37204678 DOI: 10.1007/s11255-023-03624-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 05/02/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE This current study scrutinized the association among left ventricular mass index (LVMI), ratio of high-density lipoprotein (HDL) and C-reactive protein (CRP), and renal function. Furthermore, we examined the predictive effects of left ventricular mass index and HDL/CRP on progression of non-dialysis chronic kidney disease. METHODS We enrolled adult patients with chronic kidney disease (CKD) who were not receiving dialysis and obtained follow-up data on them. We extracted and compared data between different groups. To investigate the relationship between left ventricular mass index (LVMI), high-density lipoprotein (HDL)/C-reactive protein (CRP) levels, and CKD, we employed linear regression analysis, Kaplan-Meier analysis, and Cox proportional hazards regression analysis. RESULTS Our study enrolled a total of 2351 patients. Compared with those in the non-progression group, subjects in the CKD progression group had lower ln(HDL/CRP) levels (- 1.56 ± 1.78 vs. - 1.14 ± 1.77, P < 0.001) but higher left ventricular mass index (LVMI) values (115.45 ± 29.8 vs. 102.8 ± 26.31 g/m2, P < 0.001). Moreover, after adjusting for demographic factors, ln(HDL/CRP) was found to be positively associated with estimated glomerular filtration rate (eGFR) (B = 1.18, P < 0.001), while LVMI was negatively associated with eGFR (B = - 0.15, P < 0.001). In the end, we found that both LVH (HR = 1.53, 95% CI 1.15 to 2.05, P = 0.004) and lower ln(HDL/CRP) (HR = 1.46, 95% CI 1.08 to 1.96, P = 0.013) independently predicted CKD progression. Notably, the combined predictive power of these variables was stronger than either variable alone (HR = 1.98, 95% CI 1.5 to 2.62, P < 0.001). CONCLUSION Our study findings indicate that in pre-dialysis patients, both HDL/CRP and LVMI are associated with basic renal function and are independently correlated with CKD progression. These variables may serve as predictors for CKD progression, and their combined predictive power is stronger than that of either variable alone.
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Affiliation(s)
- Leile Tang
- Department of Cardiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Shaomin Li
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Xinghua Guo
- Department of Rheumatology, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jiahui Lai
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Peijia Liu
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Jia Fang
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Xun Liu
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China.
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13
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Chen CH, Wu MJ, Tsai SF. Validating the association of Oxford classification and renal function deterioration among Taiwanese individuals with Immunoglobulin A nephropathy. Sci Rep 2023; 13:21904. [PMID: 38082065 PMCID: PMC10713632 DOI: 10.1038/s41598-023-49331-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/07/2023] [Indexed: 12/18/2023] Open
Abstract
Validation of the Oxford classification (MEST and MEST-C) for Immunoglobulin A nephropathy (IgAN) in the Taiwanese population is lacking. Our study aimed to validate this classification and assess individual lesion impact. We conducted a retrospective cohort study at Taichung Veterans General Hospital, Taiwan (Jan 2011-Jul 2023). Composite renal outcomes were evaluated using clinical conditions and estimated glomerular filtration rate (eGFR). We used Kaplan-Meier, univariable/multivariable logistic regression and ROC curves. Subgroup analysis considered eGFR < or ≥ 30.0 ml/min/1.73 m2. In 366 renal biopsies, serum creatinine was 1.34 mg/dl, eGFR 53.8 ml/min/1.73 m2, urine protein-creatinine ratio 1159 mg/g. T1/T2 lesions had lowest baseline eGFR (39.6/11.5 ml/min/1.73 m2), correlating with poorest renal survival (median survival 54.7/34.4 months). Univariable analysis linked all individual variables to worse renal outcomes. Multivariable analysis (MEST/MEST-C) showed only T1/T2 linked to worse outcomes. T score had highest predictive power (AUC 0.728, sensitivity 60.2%, specificity 83.6%), with MEST having high AUC (0.758). No extra predictive power was seen transitioning MEST to MEST-C. Subgroup analysis (eGFR < 30.0 ml/min/1.73 m2) associated C1 with improved renal outcomes (odds ratio 0.14, 95% CI 0.03-0.65). T lesion correlated with worse outcomes across subgroups. The T lesion consistently correlated with worse renal outcomes across all groups and baseline statuses. Integrating the C lesion into the transition from MEST to MEST-C did not enhance predictive power. Importantly, the C1 lesion was linked to improved renal outcomes in the eGFR < 30.0 ml/min/1.73 m2 subgroup, likely due to treatment effects.
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Affiliation(s)
- Cheng-Hsu Chen
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, 160, Sec. 3, Taiwan Boulevard, Taichung, 407, Taiwan
- Department of Life Science, Tunghai University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Ph. D. Program in Tissue Engineering and Regenerative Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Ming-Ju Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, 160, Sec. 3, Taiwan Boulevard, Taichung, 407, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Shang-Feng Tsai
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, 160, Sec. 3, Taiwan Boulevard, Taichung, 407, Taiwan.
- Department of Life Science, Tunghai University, Taichung, Taiwan.
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
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14
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Niihata K, Nishiwaki H, Kinoshita M, Kurosawa K, Sakuramachi Y, Matsunaga S, Okamura S, Tsujii S, Hayashino Y, Kurita N. Association between urinary C-megalin levels and progressive kidney dysfunction: a cohort study based on the diabetes distress and care registry at Tenri (DDCRT 24). Acta Diabetol 2023; 60:1643-1650. [PMID: 37439857 DOI: 10.1007/s00592-023-02144-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/19/2023] [Indexed: 07/14/2023]
Abstract
AIMS The aim of this cohort study was to evaluate the association between urinary levels of C-megalin, a full-length form of megalin, and kidney dysfunction progression and its dependence on the urinary albumin-creatinine ratio (UACR) in individuals with diabetes. METHODS We enrolled 1,547 individuals with diabetes who visited the ambulatory clinic at Tenri Hospital, a regional tertiary-care hospital in Tenri City, Nara Prefecture, Japan, with an estimated glomerular filtration (eGFR) of ≥ 30 mL/min/1.73 m2. The hazard ratio (HR) and 95% confidence interval (CI) were estimated using Cox proportional hazard models to examine the association between urinary C-megalin levels and eGFR decline by ≥ 40% from baseline. RESULTS Urinary C-megalin level was not associated with ≥ 40% eGFR decline in an age-, sex-, eGFR-, systolic blood pressure-, hemoglobin-, and UACR-adjusted model in the 1,547 patients enrolled in the study. However, urinary C-megalin levels were associated with a ≥ 40% decline in eGFR when accounting for the relationship between urinary C-megalin levels and UACR in the model. This association was UACR-dependent. CONCLUSIONS High urinary C-megalin levels were associated with progressive kidney dysfunction in individuals with diabetes, and this association was attenuated by high UACRs.
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Affiliation(s)
- Kakuya Niihata
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima, Fukushima, Japan.
| | - Hiroki Nishiwaki
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima, Fukushima, Japan
- Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
- Showa University Research Administration Center (SURAC), Showa University, Shinagawa, Tokyo, Japan
| | - Maki Kinoshita
- Department of Clinical Laboratory, Tenri Hospital, Nara, Tenri, Japan
| | | | - Yui Sakuramachi
- Department of Endocrinology, Tenri Hospital, Nara, Tenri, Japan
| | | | | | - Satoru Tsujii
- Department of Endocrinology, Tenri Hospital, Nara, Tenri, Japan
| | | | - Noriaki Kurita
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima, Fukushima, Japan
- Department of Innovative Research and Education for Clinicians and Trainees (DiRECT), Fukushima Medical University Hospital, Fukushima, Fukushima, Japan
- Center for Innovative Research for Communities and Clinical Excellence (CIRC2LE), Fukushima Medical University, Fukushima, Japan
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
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15
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Chaemchoi T, Ittiwattanakul W, Ritteeverakul P, Intrarakamhang AL, Thammanatsakul K, Sinphurmsukskul S, Siwamogsatham S, Puwanant S, Ariyachaipanich A. The decline in kidney function after heart transplantation and its impact on survival. Clin Transplant 2023; 37:e15112. [PMID: 37676472 DOI: 10.1111/ctr.15112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Evidence of decline in native renal function after heart transplantation (HTx) in the Asian population is limited. This study determined the incidence and risk factors associated with declining kidney function after HTx and its impact on survival. METHODS A retrospective study of consecutive adult heart transplant patients was conducted in a single center between 2010 and 2020. The decline in kidney function was defined as the presence of one of the following criteria, including a ≥ 40% decline in eGFR, absolute value <15 mL/min/1.73 m2 (calculated by the CKD-EPI method), doubling of serum creatinine, or dialysis. RESULTS A total of 79 patients (77% male, mean age 44.5 ± 11.53 years, with a mean eGFR at discharge from the heart transplant admission of 87.9 ± 25.48 mL/min/1.73 m2 ) were included. During the median follow-up of 42 months, the rate of decline in eGFR was 3.9 mL/min/1.73 m2 per year, with a cumulative probability of decline in kidney function of 22% at 1 year and 43% at 5 years. The need for dialysis was 2.5% at 1 year and 5% at 5 years. The decline in kidney function within 1 year after discharge (hazard ratio (HR), 22.24; p = .007) and pre-HTx diabetes mellitus (DM) (HR, 8.99; p = .034) were independently associated with the need for dialysis. Post-HTx dialysis predicted all-cause mortality (HR, 4.47; p = .017). CONCLUSIONS Approximately 20% of HTx patients developed a decline in kidney function within 1 year after discharge. These individuals and pre-HTx DM patients needed preventive measures to prevent progression to chronic dialysis, which impacted survival. (thaiclinicaltrials.org number, TCTR20230620004).
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Affiliation(s)
- Tasigan Chaemchoi
- Department of Pharmacy, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Wannee Ittiwattanakul
- Department of Pharmacy, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Puangpen Ritteeverakul
- Department of Pharmacy, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Ai-Lada Intrarakamhang
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Kanokwan Thammanatsakul
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Supanee Sinphurmsukskul
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Sarawut Siwamogsatham
- Chula Clinical Research Center, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sarinya Puwanant
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aekarach Ariyachaipanich
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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16
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Agarwal R, Tu W, Farjat AE, Farag YMK, Toto R, Kaul S, Lawatscheck R, Rohwedder K, Ruilope LM, Rossing P, Pitt B, Filippatos G, Anker SD, Bakris GL. Impact of Finerenone-Induced Albuminuria Reduction on Chronic Kidney Disease Outcomes in Type 2 Diabetes : A Mediation Analysis. Ann Intern Med 2023; 176:1606-1616. [PMID: 38048573 DOI: 10.7326/m23-1023] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND In patients with chronic kidney disease (CKD) and type 2 diabetes (T2D), finerenone, a nonsteroidal mineralocorticoid receptor antagonist, reduces cardiovascular and kidney failure outcomes. Finerenone also lowers the urine albumin-to-creatinine ratio (UACR). Whether finerenone-induced change in UACR mediates cardiovascular and kidney failure outcomes is unknown. OBJECTIVE To quantify the proportion of kidney and cardiovascular risk reductions seen over a 4-year period mediated by a change in kidney injury, as measured by the change in log UACR between baseline and month 4. DESIGN Post hoc mediation analysis using pooled data from 2 phase 3, double-blind trials of finerenone. (ClinicalTrials.gov: NCT02540993 and NCT02545049). SETTING Several clinical sites in 48 countries. PATIENTS 12 512 patients with CKD and T2D. INTERVENTION Finerenone and placebo (1:1). MEASUREMENTS Separate mediation analyses were done for the composite kidney (kidney failure, sustained ≥57% decrease in estimated glomerular filtration rate from baseline [approximately a doubling of serum creatinine], or kidney disease death) and cardiovascular (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure) outcomes. RESULTS At baseline, median UACR was 514 mg/g. A 30% or greater reduction in UACR was seen in 3338 (53.2%) patients in the finerenone group and 1684 (27.0%) patients in the placebo group. Reduction in UACR (analyzed as a continuous variable) mediated 84% and 37% of the treatment effect on the kidney and cardiovascular outcomes, respectively. When change in UACR was analyzed as a binary variable (that is, whether the guideline-recommended 30% reduction threshold was met), the proportions mediated for each outcome were 64% and 26%, respectively. LIMITATION The current findings are not readily extendable to other drugs. CONCLUSION In patients with CKD and T2D, early albuminuria reduction accounted for a large proportion of the treatment effect against CKD progression and a modest proportion of the effect against cardiovascular outcomes. PRIMARY FUNDING SOURCE Bayer AG.
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Affiliation(s)
- Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana (R.A.)
| | - Wanzhu Tu
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, Indiana (W.T.)
| | - Alfredo E Farjat
- Data Science and Analytics, Bayer PLC, Reading, United Kingdom (A.E.F.)
| | | | - Robert Toto
- Department of Internal Medicine, University of Texas Southwestern Medicine, Dallas, Texas (R.T.)
| | - Sanjay Kaul
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California (S.K.)
| | - Robert Lawatscheck
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany (R.L.)
| | - Katja Rohwedder
- Cardio-Renal Medical Affairs Department, Bayer AG, Berlin, Germany (K.R.)
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, CIBER-CV, Hospital Universitario 12 de Octubre, and Faculty of Sport Sciences, European University of Madrid, Madrid, Spain (L.M.R.)
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (P.R.)
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan (B.P.)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece (G.F.)
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité, Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany, and Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland (S.D.A.)
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois (G.L.B.)
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17
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Heerspink HJ, Jongs N, Schloemer P, Little DJ, Brinker M, Tasto C, Karpefors M, Wheeler DC, Bakris G, Perkovic V, Nkulikiyinka R, Rossert J, Gasparyan SB. Development and Validation of a New Hierarchical Composite End Point for Clinical Trials of Kidney Disease Progression. J Am Soc Nephrol 2023; 34:2025-2038. [PMID: 37872654 PMCID: PMC10703083 DOI: 10.1681/asn.0000000000000243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/20/2023] [Indexed: 10/25/2023] Open
Abstract
SIGNIFICANCE STATEMENT The established composite kidney end point in clinical trials combines clinical events with sustained large changes in GFR but does not weigh the relative clinical importance of the end point components. By contrast, a hierarchical composite end point (HCE) accounts for the clinical importance of the end point components. The authors developed and validated a kidney HCE that combines clinical kidney outcomes with longitudinal GFR changes (GFR slope). They demonstrate that in seven major placebo-controlled kidney outcome trials with different medications, treatment effect estimates on the HCE were consistently in similar directions and of similar magnitudes compared with treatment effects on the established kidney end point. The HCE's prioritization of clinical outcomes and ability to combine dichotomous outcomes with GFR slope make it an attractive alternative to the established kidney end point. BACKGROUND The established composite kidney end point in clinical trials combines clinical events with sustained large changes in GFR. However, the statistical method does not weigh the relative clinical importance of the end point components. A HCE accounts for the clinical importance of the end point components and enables combining dichotomous outcomes with continuous measures. METHODS We developed and validated a new HCE for kidney disease progression, performing post hoc analyses of seven major Phase 3 placebo-controlled trials that assessed the effects of canagliflozin, dapagliflozin, finerenone, atrasentan, losartan, irbesartan, and aliskiren in patients with CKD. We calculated the win odds (WOs) for treatment effects on a kidney HCE, defined as a hierarchical composite of all-cause mortality; kidney failure; sustained 57%, 50%, and 40% GFR declines from baseline; and GFR slope. The WO describes the odds of a more favorable outcome for receiving the active compared with the control. We compared the WO with the hazard ratio (HR) of the primary kidney outcome of the original trials. RESULTS In all trials, treatment effects calculated with the WO reflected a similar direction and magnitude of the treatment effect compared with the HR. Clinical trials incorporating the HCE would achieve increased statistical power compared with the established composite end point at equivalent sample sizes. CONCLUSIONS In seven major kidney clinical trials, the WO and HR provided similar direction of treatment effect estimates with smaller HRs associated with larger WOs. The prioritization of clinical outcomes and inclusion of broader composite end points makes the HCE an attractive alternative to the established kidney end point.
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Affiliation(s)
- Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Patrick Schloemer
- Pharmaceuticals, Research and Development, Bayer AG, Berlin, Germany
| | - Dustin J. Little
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Meike Brinker
- Pharmaceuticals, Research and Development, Bayer AG, Wuppertal, Germany
| | - Christoph Tasto
- Pharmaceuticals, Research and Development, Bayer AG, Wuppertal, Germany
| | - Martin Karpefors
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - David C. Wheeler
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Renal Medicine, University College London, London, United Kingdom
| | - George Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois
| | - Vlado Perkovic
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Faculty of Medicine & Health, University New South Wales, Sydney, New South Wales, Australia
| | | | - Jerome Rossert
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Samvel B. Gasparyan
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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18
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Tang L, Deng Y, Lai J, Guo X, Liu P, Li S, Liu X. Predictive Effect of System Inflammation Response Index for Progression of Chronic Kidney Disease in Non-Dialyzing Patient. J Inflamm Res 2023; 16:5273-5285. [PMID: 38026247 PMCID: PMC10659112 DOI: 10.2147/jir.s432699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Scant research has been conducted on the interplay between the systemic inflammation response index (SIRI) and chronic kidney disease (CKD). The present study endeavors to meticulously scrutinize the association between SIRI and renal function. Additionally, we aim to assess its efficacy in predicting the progression of CKD in non-dialysis patients. Patients and Methods Adult patients with CKD who were not undergoing dialysis were enrolled, and follow-up data were obtained. Data from distinct groups were extracted and meticulously compared. A comprehensive analytical approach was adopted, including logistic regression analysis, Kaplan-Meier analysis, Cox proportional hazards regression analysis, and subgroup analysis. Results Our study included 1420 patients, with a mean age of 61 ± 17 years, and 63% were male. 244 (17.2%) patients experienced the progression of CKD. As the level of ln(SIRI) increased, patients tended to be older, with a higher proportion of males, and increased prevalence rates of hypertension, stroke, heart failure, and progression of CKD. Additionally, the levels of baseline creatinine and C-reactive protein were elevated, while the levels of estimated glomerular filtration rate and hemoglobin decreased. Upon adjusting for demographic and biochemical variables, logistic regression analysis indicated that ln(SIRI) was independently associated with advanced CKD in pre-dialysis patients (OR=1.59, 95% CI: 1.29-1.95, P<0.001). Moreover, Cox proportional-hazard analysis revealed that ln(SIRI) independently predicted CKD progression (HR: 1.3, 95% CI: 1.07-1.59, P=0.009). Conducting a subgroup analysis, we observed significant interactions between ln(SIRI) levels and gender (p<0.001), age (p=0.046), and hypertension (p=0.028) in relation to the progression of CKD. Conclusion Our study's findings demonstrate a significant association between SIRI and fundamental renal function, and independently establish a correlation between SIRI and the progression of CKD in pre-dialysis patients. These observations suggest that SIRI holds promise as a potential predictor for CKD progression.
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Affiliation(s)
- Leile Tang
- Department of Cardiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, People’s Republic of China
| | - Ying Deng
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, People’s Republic of China
| | - Jiahui Lai
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, People’s Republic of China
| | - Xinghua Guo
- Department of Rheumatology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People’s Republic of China
| | - Peijia Liu
- Department of Nephrology, Guangzhou Eighth People’s Hospital, Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Shaomin Li
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, People’s Republic of China
| | - Xun Liu
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, People’s Republic of China
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19
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Park CH, Kim HW, Park JT, Chang TI, Yoo TH, Park SK, Kim Y, Jung JY, Jeong JC, Oh KH, Kang SW, Han SH. The 2021 KDIGO blood pressure target and the progression of chronic kidney disease: Findings from KNOW-CKD. J Intern Med 2023; 294:653-664. [PMID: 37538023 DOI: 10.1111/joim.13701] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND The 2021 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) recommends a target systolic BP of <120 mmHg as this target can provide cardiovascular benefits. However, it remains unclear whether implementing the new BP target could improve kidney outcomes. METHODS The association between the 2021 KDIGO BP target and CKD progression was examined and compared with the 2012 KDIGO BP target among 1724 participants included in the KoreaN Cohort Study for Outcomes in Patients With CKD. The main exposure was the BP status categorized according to the 2012 or 2021 KDIGO guideline: (1) controlled within the 2021 target, (2) controlled within the 2012 target only, and (3) above both targets. The primary outcome was a composite kidney outcome of ≥50% decline in the estimated glomerular filtration rate from baseline or the initiation of kidney replacement therapy during the follow-up period. RESULTS Composite kidney outcomes occurred in 650 (37.7%) participants during the 8078 person-years of follow-up (median, 4.9 years). The incidence rates of this outcome were 55, 66.5, and 116.4 per 1000 person-years in BP controlled within the 2021 and 2012 KDIGO targets, and BP above both targets, respectively. In the multivariable cause-specific hazard model, hazard ratios for the composite outcome were 0.76 (95% confidence interval (CI), 0.60-0.95) for BP controlled within the 2021 target and 1.36 (95% CI, 1.13-1.64) for BP above both targets, compared with BP controlled within 2012 target only. CONCLUSION The newly lowered BP target by the 2021 KDIGO guideline was associated with improved kidney outcome compared with BP target by the 2012 KDIGO guideline.
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Affiliation(s)
- Cheol Ho Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Hyung Woo Kim
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Jung Tak Park
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Tae Ik Chang
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyang, Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Sue Kyung Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yaeni Kim
- Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji Yong Jung
- Division of Nephrology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Jong Cheol Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Kidney Research Institute, Seoul, Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Republic of Korea
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20
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Marx N, Federici M, Schütt K, Müller-Wieland D, Ajjan RA, Antunes MJ, Christodorescu RM, Crawford C, Di Angelantonio E, Eliasson B, Espinola-Klein C, Fauchier L, Halle M, Herrington WG, Kautzky-Willer A, Lambrinou E, Lesiak M, Lettino M, McGuire DK, Mullens W, Rocca B, Sattar N. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J 2023; 44:4043-4140. [PMID: 37622663 DOI: 10.1093/eurheartj/ehad192] [Citation(s) in RCA: 210] [Impact Index Per Article: 210.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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21
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Kosinski L, Frey E, Klein A, O'Doherty I, Romero K, Stegall M, Helanterä I, Gaber AO, Fitzsimmons WE, Aggarwal V. Longitudinal estimated glomerular filtration rate (eGFR) modeling in long-term renal function to inform clinical trial design in kidney transplantation. Clin Transl Sci 2023; 16:1680-1690. [PMID: 37350196 PMCID: PMC10499426 DOI: 10.1111/cts.13579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/10/2023] [Indexed: 06/24/2023] Open
Abstract
Kidney transplantation is the preferred treatment for individuals with end-stage kidney disease. From a modeling perspective, our understanding of kidney function trajectories after transplantation remains limited. Current modeling of kidney function post-transplantation is focused on linear slopes or percent decline and often excludes the highly variable early timepoints post-transplantation, where kidney function recovers and then stabilizes. Using estimated glomerular filtration rate (eGFR), a well-known biomarker of kidney function, from an aggregated dataset of 4904 kidney transplant patients including both observational studies and clinical trials, we developed a longitudinal model of kidney function trajectories from time of transplant to 6 years post-transplant. Our model is a nonlinear, mixed-effects model built in NONMEM that captured both the recovery phase after kidney transplantation, where the graft recovers function, and the long-term phase of stabilization and slow decline. Model fit was assessed using diagnostic plots and individual fits. Model performance, assessed via visual predictive checks, suggests accurate model predictions of eGFR at the median and lower 95% quantiles of eGFR, ranges which are of critical clinical importance for assessing loss of kidney function. Various clinically relevant covariates were also explored and found to improve the model. For example, transplant recipients of deceased donors recover function more slowly after transplantation and calcineurin inhibitor use promotes faster long-term decay. Our work provides a generalizable, nonlinear model of kidney allograft function that will be useful for estimating eGFR up to 6 years post-transplant in various clinically relevant populations.
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Affiliation(s)
| | - Eric Frey
- Critical Path InstituteTucsonArizonaUSA
| | | | | | | | - Mark Stegall
- Department of SurgeryMayo ClinicRochesterMinnesotaUSA
| | - Ilkka Helanterä
- Department of Transplantation and Liver SurgeryHelsinki University HospitalHelsinkiFinland
| | - Ahmed Osama Gaber
- Department of Surgery, Houston Methodist HospitalHoustonTexasUSA
- Weill Cornell MedicineNew YorkNew YorkUSA
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22
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Cazzolli R, Sluiter A, Guha C, Huuskes B, Wong G, Craig JC, Jaure A, Scholes-Robertson N. Partnering with patients and caregivers to enrich research and care in kidney disease: values and strategies. Clin Kidney J 2023; 16:i57-i68. [PMID: 37711636 PMCID: PMC10497378 DOI: 10.1093/ckj/sfad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Indexed: 09/16/2023] Open
Abstract
Patient and caregiver involvement broadens the scope of new knowledge generated from research and can enhance the relevance, quality and impact of research on clinical practice and health outcomes. Incorporating the perspectives of people with lived experience of chronic kidney disease (CKD) affords new insights into the design of interventions, study methodology, data analysis and implementation and has value for patients, healthcare professionals and researchers alike. However, patient involvement in CKD research has been limited and data on which to inform best practice is scarce. A number of frameworks have been developed for involving patients and caregivers in research in CKD and in health research more broadly. These frameworks provide an overall conceptual structure to guide the planning and implementation of research partnerships and describe values that are essential and strategies considered best practice when working with diverse stakeholder groups. This article aims to provide a summary of the strategies most widely used to support multistakeholder partnerships, the different ways patients and caregivers can be involved in research and the methods used to amalgamate diverse and at times conflicting points of view.
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Affiliation(s)
- Rosanna Cazzolli
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Amanda Sluiter
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Chandana Guha
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Brooke Huuskes
- Centre for Cardiovascular Biology and Disease Research, School of Agriculture, Biomedicine and Environment, La Trobe University, Melbourne, VIC, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Jonathan C Craig
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Allison Jaure
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Nicole Scholes-Robertson
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
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23
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Herrington WG, Harper C, Staplin N, Haynes R, Emberson JR, Reith C, Hooi LS, Levin A, Wanner C, Baigent C, Landray MJ. Impact of outcome adjudication in kidney disease trials: observations from the Study of Heart and Renal Protection (SHARP). Kidney Int Rep 2023; 8:1489-1495. [PMID: 37538810 PMCID: PMC7614871 DOI: 10.1016/j.ekir.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/08/2023] [Indexed: 08/05/2023] Open
Abstract
Introduction We aimed to assess opportunities for trial streamlining and the scientific impact of adjudication on kidney and cardiovascular outcomes in CKD. Methods We analysed the effects of adjudication of ~2100 maintenance kidney replacement therapy (KRT) and ~1300 major atherosclerotic events (MAEs) recorded in SHARP. We first compared outcome classification before versus after adjudication, and then re-ran randomised comparisons using pre-adjudicated follow-up data. Results For maintenance KRT, adjudication had little impact with only 1% of events being refuted (28/2115). Consequently, randomised comparisons using pre-adjudication reports found almost identical results (pre-adjudication: simvastatin/ezetimibe 1038 vs placebo 1077; risk ratio [RR] 0.95, 95%CI 0.88-1.04; post-adjudicated: 1057 vs 1084; RR=0.97, 95%CI 0.89-1.05). For MAEs, about one-quarter of patient reports were refuted (324/1275 [25%]), and reviewing 3538 other potential vascular events and death reports identified only 194 additional MAEs. Nevertheless, randomised analyses using SHARP's pre-adjudicated data alone found similar results to analyses based on adjudicated outcomes (pre-adjudication: 573 vs 702; RR=0.80, 95%CI 0.72-0.89; adjudicated: 526 vs 619; RR=0.83, 95%CI 0.74- 0.94), and also suggested refuted MAEs were likely to represent atherosclerotic disease (RR for refuted MAEs=0.80, 95%CI 0.65-1.00). Conclusions These analyses provide three key insights. First, they provide a rationale for nephrology trials not to adjudicate maintenance KRT. Secondly, when an event that mimics an atherosclerotic outcome is not expected to be influenced by the treatment under study (e.g. heart failure), the aim of adjudicating atherosclerotic outcomes should be to remove such events. Lastly, restrictive definitions for the remaining suspected atherosclerotic outcomes may reduce statistical power.
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Affiliation(s)
- William G. Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Charlie Harper
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jonathan R. Emberson
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | - Christina Reith
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | | | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Christoph Wanner
- Division of Nephrology, University Clinic of Würzburg, Würzburg, Germany
| | - Colin Baigent
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | - Martin J. Landray
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | - SHARP Collaborative Group7
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Division of Nephrology, University of British Columbia, Vancouver, Canada
- Division of Nephrology, University Clinic of Würzburg, Würzburg, Germany
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24
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Legg A, Roberts MA, Davies J, Cass A, Meagher N, Sud A, Daitch V, Dishon Benattar Y, Yahav D, Paul M, Xinxin C, Ping YH, Lye D, Lee R, Robinson JO, Foo H, Tramontana AR, Bak N, Grenfell A, Rogers B, Li Y, Joshi N, O’Sullivan M, McKew G, Ghosh N, Schneider K, Holmes NE, Dotel R, Chia T, Archuleta S, Smith S, Warner MS, Titin C, Kalimuddin S, Roberts JA, Tong SYC, Davis JS. Longer-term Mortality and Kidney Outcomes of Participants in the Combination Antibiotics for Methicillin-Resistant Staphylococcus aureus (CAMERA2) Trial: A Post Hoc Analysis. Open Forum Infect Dis 2023; 10:ofad337. [PMID: 37496601 PMCID: PMC10368200 DOI: 10.1093/ofid/ofad337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023] Open
Abstract
Background The Combination Antibiotic Therapy for Methicillin-Resistant Staphylococcus aureus (CAMERA2) trial ceased recruitment in July 2018, noting that a higher proportion of patients in the intervention arm (combination therapy) developed acute kidney injury (AKI) compared to the standard therapy (monotherapy) arm. We analyzed the long-term outcomes of participants in CAMERA2 to understand the impact of combination antibiotic therapy and AKI. Methods Trial sites obtained additional follow-up data. The primary outcome was all-cause mortality, censored at death or the date of last known follow-up. Secondary outcomes included kidney failure or a reduction in kidney function (a 40% reduction in estimated glomerular filtration rate to <60 mL/minute/1.73 m2). To determine independent predictors of mortality in this cohort, adjusted hazard ratios were calculated using a Cox proportional hazards regression model. Results This post hoc analysis included extended follow-up data for 260 patients. Overall, 123 of 260 (47%) of participants died, with a median population survival estimate of 3.4 years (235 deaths per 1000 person-years). Fifty-five patients died within 90 days after CAMERA2 trial randomization; another 68 deaths occurred after day 90. Using univariable Cox proportional hazards regression, mortality was not associated with either the assigned treatment arm in CAMERA2 (hazard ratio [HR], 0.84 [95% confidence interval [CI], .59-1.19]; P = .33) or experiencing an AKI (HR at 1 year, 1.04 [95% CI, .64-1.68]; P = .88). Conclusions In this cohort of patients hospitalized with methicillin-resistant S aureus bacteremia, we found no association between either treatment arm of the CAMERA2 trial or AKI (using CAMERA2 trial definition) and longer-term mortality.
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Affiliation(s)
- Amy Legg
- Correspondence: Amy Legg, Bpharm, GradDipClinPharm, Herston Infectious Diseases Institute, Royal Brisbane and Women’s Hospital, Level 8, UQCCR Building, Herston, QLD 4029 Brisbane, Australia (); Joshua S. Davis, MBBS (Hons), DTM&H, FRACP, Grad CertPopHealth, PhD, Infectious Diseases Dept., John Hunter Hospital, Lookout Road, New Lambton, Newcastle, NSW, 2305 ()
| | - Matthew A Roberts
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Jane Davies
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Niamh Meagher
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Archana Sud
- Department of Infectious Diseases, Nepean Hospital and Nepean Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Vered Daitch
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Israel
| | | | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Centre, Ramat-Gan, Israel
| | - Mical Paul
- Infectious Diseases Unit, Sheba Medical Centre, Ramat-Gan, Israel
- Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Chen Xinxin
- National Centre for Infectious Diseases, Singapore
| | - Yeo He Ping
- National Centre for Infectious Diseases, Singapore
| | - David Lye
- National Centre for Infectious Diseases, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Russel Lee
- National Centre for Infectious Diseases, Singapore
| | - J Owen Robinson
- Infectious Disease Department, Royal Perth Hospital and Fiona Stanley Hospital, PathWest Laboratory Medicine,Perth, Western Australia, Australia
- College of Science, Health, Engineering and Education, Discipline of Health, Murdoch University, Perth, Western Australia, Australia
| | - Hong Foo
- Department of Microbiology and Infectious Diseases, NSW Health Pathology, Liverpool, New South Wales, Australia
| | - Adrian R Tramontana
- Infectious Diseases Department, Western Health, Footscray, Victoria, Australia
- Western Clinical School, University of Melbourne, St Albans, Victoria, Australia
| | - Narin Bak
- Infectious Diseases Department, The Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Benjamin Rogers
- Monash Infectious Diseases, Monash Health, Monash University School of Clinical Sciences at Monash Health, Clayton, Victoria, Australia
| | - Ying Li
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Neela Joshi
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Matthew O’Sullivan
- Department of Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales, Australia
- New South Wales Health Pathology, Department of Microbiology, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Genevieve McKew
- Department of Microbiology and Infectious Diseases, Concord Repatriation and General Hospital, New South Wales Health Pathology, Sydney, NSW, Australia
- Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Niladri Ghosh
- Department of Infectious Diseases, Wollongong Public Hospital, Wollongong, New South Wales, Australia
| | - Kellie Schneider
- Immunology and Infectious Diseases Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Natasha E Holmes
- Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Ravindra Dotel
- Department of Infectious Diseases, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Timothy Chia
- Division of Infectious Diseases, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Sophia Archuleta
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Division of Infectious Diseases, Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Simon Smith
- Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
| | - Morgyn S Warner
- Microbiology and Infectious Diseases Directorate, South Australia Pathology, Infectious Diseases Unit, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Christina Titin
- Department of Infectious Diseases, Singapore General Hospital, Singapore
| | - Shirin Kalimuddin
- Department of Infectious Diseases, Singapore General Hospital, Singapore
- Duke–National University of Singapore Medical School, Programme in Emerging Infectious Diseases, Singapore
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
- Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology, Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Joshua S Davis
- Correspondence: Amy Legg, Bpharm, GradDipClinPharm, Herston Infectious Diseases Institute, Royal Brisbane and Women’s Hospital, Level 8, UQCCR Building, Herston, QLD 4029 Brisbane, Australia (); Joshua S. Davis, MBBS (Hons), DTM&H, FRACP, Grad CertPopHealth, PhD, Infectious Diseases Dept., John Hunter Hospital, Lookout Road, New Lambton, Newcastle, NSW, 2305 ()
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25
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Heerspink HJL, Jongs N, Neuen BL, Schloemer P, Vaduganathan M, Inker LA, Fletcher RA, Wheeler DC, Bakris G, Greene T, Chertow GM, Perkovic V. Effects of newer kidney protective agents on kidney endpoints provide implications for future clinical trials. Kidney Int 2023; 104:181-188. [PMID: 37119876 DOI: 10.1016/j.kint.2023.03.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 03/02/2023] [Accepted: 03/24/2023] [Indexed: 05/01/2023]
Abstract
Doubling of serum creatinine (equivalent to a 57% decline in the estimated glomerular filtration rate (eGFR)) is an accepted component of a composite kidney endpoint in clinical trials. Smaller declines in eGFR (40%, 50%) have been applied in several recently conducted clinical trials. Here, we assessed the effects of newer kidney protective agents on endpoints including smaller proportional declines in eGFR to compare relative event rates and the magnitude of observed treatment effects. We performed a post hoc analysis of 4401 patients in the CREDENCE, 4304 in the DAPA-CKD, 5734 in the FIDELIO-DKD, and 3668 in the SONAR trials, which assessed the effects of canagliflozin, dapagliflozin, finerenone and atrasentan in patients with chronic kidney disease. Effects of active therapies versus placebo on alternative composite kidney endpoints incorporating different eGFR decline thresholds (40%, 50%, or 57% eGFR reductions from baseline) with kidney failure or death due to kidney failure were compared. Cox-proportional hazards regression models were used to assess and compare treatment effects. During follow-up, event rates were higher for endpoints incorporating smaller versus larger eGFR decline thresholds. Compared to the treatment effects on kidney failure or death due to kidney failure, the magnitude of relative treatment effects was generally similar when considering composite endpoints incorporating smaller declines in eGFR. Hazard ratios for the four interventions ranged from 0.63 to 0.82 for the endpoint incorporating 40% eGFR decline and 0.59 to 0.76 for the endpoint incorporating 57% eGFR decline. Clinical trials incorporating a 40% eGFR decline in a composite endpoint would require approximately half the number of participants compared to a 57% eGFR decline with equivalent statistical power. Thus, in populations at high risk of CKD progression, the relative effects of newer kidney protective therapies appear generally similar across endpoints based on varying eGFR decline thresholds.
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Affiliation(s)
- Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; The George Institute for Global Health, Sydney, Australia.
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Brendon L Neuen
- The George Institute for Global Health, Sydney, Australia; Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | | | | | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - George Bakris
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Tom Greene
- Division of Biostatistics, Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah, USA
| | - Glenn M Chertow
- Department of Medicine, Epidemiology and Biostatistics, Stanford University School of Medicine, Stanford, California, USA; Department of Health Policy, Stanford University School of Medicine, Stanford, California, USA
| | - Vlado Perkovic
- Faculty of Medicine & Health, University New South Wales, Sydney, Australia
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Odler B, Bruchfeld A, Scott J, Geetha D, Little MA, Jayne DRW, Kronbichler A. Challenges of defining renal response in ANCA-associated vasculitis: call to action? Clin Kidney J 2023; 16:965-975. [PMID: 37261001 PMCID: PMC10229283 DOI: 10.1093/ckj/sfad009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Indexed: 12/06/2023] Open
Abstract
Avoiding end-stage kidney disease in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) has a high therapeutic priority. Although renal response is a crucial measure to capture clinically relevant changes, clinal trials have used various definitions and no well-studied key surrogate markers to predict renal outcome in AAV exist. Differences in clinical features and histopathologic and therapeutic approaches will influence the course of kidney function. Its assessment through traditional surrogates (i.e. serum creatinine, glomerular filtration rate, proteinuria, hematuria and disease activity scores) has limitations. Refinement of these markers and the incorporation of novel approaches such as the assessment of histopathological changes using cutting-edge molecular and machine learning mechanisms or new biomarkers could significantly improve prognostication. The timing is favourable since large datasets of trials conducted in AAV are available and provide a valuable resource to establish renal surrogate markers and, likely, aim to investigate optimized and tailored treatment approaches according to a renal response score. In this review we discuss important points missed in the assessment of kidney function in patients with AAV and point towards the importance of defining renal response and clinically important short- and long-term predictors of renal outcome.
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Affiliation(s)
- Balazs Odler
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Annette Bruchfeld
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine Karolinska Institutet, Stockholm, Sweden
- Department of Health, Medicine and Caring Sciences, Linköpings Universitet, Linköping, Sweden
| | - Jennifer Scott
- Trinity Health Kidney Center, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark A Little
- Trinity Health Kidney Center, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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Pitcher D, Braddon F, Hendry B, Mercer A, Osmaston K, Saleem MA, Steenkamp R, Wong K, Turner AN, Wang K, Gale DP, Barratt J. Long-Term Outcomes in IgA Nephropathy. Clin J Am Soc Nephrol 2023; 18:727-738. [PMID: 37055195 PMCID: PMC10278810 DOI: 10.2215/cjn.0000000000000135] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/06/2023] [Accepted: 03/27/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND IgA nephropathy can progress to kidney failure, and risk assessment soon after diagnosis has advantages both for clinical management and the development of new therapeutics. We present relationships among proteinuria, eGFR slope, and lifetime risks for kidney failure. METHODS The IgA nephropathy cohort (2299 adults and 140 children) of the UK National Registry of Rare Kidney Diseases (RaDaR) was analyzed. Patients enrolled had a biopsy-proven diagnosis of IgA nephropathy plus proteinuria >0.5 g/d or eGFR <60 ml/min per 1.73 m 2 . Incident and prevalent populations and a population representative of a typical phase 3 clinical trial cohort were studied. Analyses of kidney survival were conducted using Kaplan-Meier and Cox regression. eGFR slope was estimated using linear mixed models with random intercept and slope. RESULTS The median (Q1, Q3) follow-up was 5.9 (3.0, 10.5) years; 50% of patients reached kidney failure or died in the study period. The median (95% confidence interval [CI]) kidney survival was 11.4 (10.5 to 12.5) years; the mean age at kidney failure/death was 48 years, and most patients progressed to kidney failure within 10-15 years. On the basis of eGFR and age at diagnosis, almost all patients were at risk of progression to kidney failure within their expected lifetime unless a rate of eGFR loss ≤1 ml/min per 1.73 m 2 per year was maintained. Time-averaged proteinuria was significantly associated with worse kidney survival and more rapid eGFR loss in incident, prevalent, and clinical trial populations. Thirty percent of patients with time-averaged proteinuria of 0.44 to <0.88 g/g and approximately 20% of patients with time-averaged proteinuria <0.44 g/g developed kidney failure within 10 years. In the clinical trial population, each 10% decrease in time-averaged proteinuria from baseline was associated with a hazard ratio (95% CI) for kidney failure/death of 0.89 (0.87 to 0.92). CONCLUSIONS Outcomes in this large IgA nephropathy cohort are generally poor with few patients expected to avoid kidney failure in their lifetime. Significantly, patients traditionally regarded as being low risk, with proteinuria <0.88 g/g (<100 mg/mmol), had high rates of kidney failure within 10 years.
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Affiliation(s)
- David Pitcher
- UK Renal Registry, The UK Kidney Association, Bristol, United Kingdom
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Fiona Braddon
- UK Renal Registry, The UK Kidney Association, Bristol, United Kingdom
| | - Bruce Hendry
- Travere Therapeutics, Inc., San Diego, California
| | | | - Kate Osmaston
- UK Renal Registry, The UK Kidney Association, Bristol, United Kingdom
| | - Moin A. Saleem
- University of Bristol & Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Retha Steenkamp
- UK Renal Registry, The UK Kidney Association, Bristol, United Kingdom
| | - Katie Wong
- UK Renal Registry, The UK Kidney Association, Bristol, United Kingdom
- Department of Renal Medicine, University College London, London, United Kingdom
| | | | - Kaijun Wang
- Travere Therapeutics, Inc., San Diego, California
| | - Daniel P. Gale
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Jonathan Barratt
- University of Leicester & Leicester General Hospital, Leicester, United Kingdom
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Patidar KR, Naved MA, Kabir S, Grama A, Allegretti AS, Cullaro G, Asrani SK, Worden A, Desai AP, Ghabril MS, Nephew LD, Orman ES. Longer time to recovery from acute kidney injury is associated with major adverse kidney events in patients with cirrhosis. Aliment Pharmacol Ther 2023; 57:1397-1406. [PMID: 36883210 PMCID: PMC10441172 DOI: 10.1111/apt.17457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/27/2022] [Accepted: 02/25/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND In patients with cirrhosis and acute kidney injury (AKI), longer time to AKI-recovery may increase the risk of subsequent major-adverse-kidney-events (MAKE). AIMS To examine the association between timing of AKI-recovery and risk of MAKE in patients with cirrhosis. METHODS Hospitalised patients with cirrhosis and AKI (n = 5937) in a nationwide database were assessed for time to AKI-recovery and followed for 180-days. Timing of AKI-recovery (return of serum creatinine <0.3 mg/dL of baseline) from AKI-onset was grouped by Acute-Disease-Quality-Initiative Renal Recovery consensus: 0-2, 3-7, and >7-days. Primary outcome was MAKE at 90-180-days. MAKE is an accepted clinical endpoint in AKI and defined as the composite outcome of ≥25% decline in estimated-glomerular-filtration-rate (eGFR) compared with baseline with the development of de-novo chronic-kidney-disease (CKD) stage ≥3 or CKD progression (≥50% reduction in eGFR compared with baseline) or new haemodialysis or death. Landmark competing-risk multivariable analysis was performed to determine the independent association between timing of AKI-recovery and risk of MAKE. RESULTS 4655 (75%) achieved AKI-recovery: 0-2 (60%), 3-7 (31%), and >7-days (9%). Cumulative-incidence of MAKE was 15%, 20%, and 29% for 0-2, 3-7, >7-days recovery groups, respectively. On adjusted multivariable competing-risk analysis, compared to 0-2-days, recovery at 3-7 and >7-days was independently associated with an increased risk for MAKE: sHR 1.45 (95% CI 1.01-2.09, p = 0.042), sHR 2.33 (95% CI 1.40-3.90, p = 0.001), respectively. CONCLUSION Longer time to recovery is associated with an increased risk of MAKE in patients with cirrhosis and AKI. Further research should examine interventions to shorten AKI-recovery time and its impact on subsequent outcomes.
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Affiliation(s)
- Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mobasshir A. Naved
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - Shaowli Kabir
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Ananth Grama
- Department of Computer Science, Purdue University, West Lafayette, Indiana, USA
| | - Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Giuseppe Cullaro
- Division of Gastroenterology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | | | - Astin Worden
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan S. Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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29
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Goupil R, Nadeau-Fredette AC, Prasad B, Hundemer GL, Suri RS, Beaubien-Souligny W, Agharazii M. CENtral blood pressure Targeting: a pragmatic RAndomized triaL in advanced Chronic Kidney Disease (CENTRAL-CKD): A Clinical Research Protocol. Can J Kidney Health Dis 2023; 10:20543581231172407. [PMID: 37168686 PMCID: PMC10164859 DOI: 10.1177/20543581231172407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/26/2023] [Indexed: 05/13/2023] Open
Abstract
Background Emerging data favor central blood pressure (BP) over brachial cuff BP to predict cardiovascular and kidney events, as central BP more closely relates to the true aortic BP. Considering that patients with advanced chronic kidney disease (CKD) are at high cardiovascular risk and can have unreliable brachial cuff BP measurements (due to high arterial stiffness), this population could benefit the most from hypertension management using central BP measurements. Objective To assess the feasibility and efficacy of targeting central BP as opposed to brachial BP in patients with CKD G4-5. Design Pragmatic multicentre double-blinded randomized controlled pilot trial. Setting Seven large academic advanced kidney care clinics across Canada. Patients A total of 116 adults with CKD G4-5 (estimated glomerular filtration rate [eGFR] < 30 mL/min) and brachial cuff systolic BP between 120 and 160 mm Hg. The key exclusion criteria are 1) ≥ 5 BP drugs, 2) recent acute kidney injury, myocardial infarction, stroke, heart failure or injurious fall, 3) previous kidney replacement therapy. Methods Double-blind randomization to a central or a brachial cuff systolic BP target (both < 130 mm Hg) as measured by a validated central BP device. The study duration is 12 months with follow-up visits every 2 to 4 months, based on local practice. All other aspects of CKD management are at the discretion of the attending nephrologist. Outcomes Primary Feasibility: Feasibility of a large-scale trial based on predefined components. Primary Efficacy: Carotid-femoral pulse wave velocity at 12 months. Others: Efficacy (eGFR decline, albuminuria, BP drugs, and quality of life); Events (major adverse cardiovascular events, CKD progression, hospitalization, mortality); Safety (low BP events and acute kidney injury). Limitations May be challenging to distinguish whether central BP is truly different from brachial BP to the point of significantly influencing treatment decisions. Therapeutic inertia may be a barrier to successfully completing a randomized trial in a population of CKD G4-5. These 2 aspects will be evaluated in the feasibility assessment of the trial. Conclusion This is the first trial to evaluate the feasibility and efficacy of using central BP to manage hypertension in advanced CKD, paving the way to a future large-scale trial. Trial registration clinicaltrials.gov (NCT05163158).
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Affiliation(s)
- Rémi Goupil
- Hopital du Sacré-Coeur de Montréal, Université de Montréal, QC, Canada
| | | | | | - Gregory L. Hundemer
- Division of Nephrology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - Rita S. Suri
- McGill University Health Centre, McGill University, Montréal, QC, Canada
| | | | - Mohsen Agharazii
- Centre Hospitalier Universitaire de Québec, Université Laval, Canada
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30
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Hundemer GL, Sood MM, Canney M. Recent updates in kidney risk prediction modeling: novel approaches and earlier outcomes. Curr Opin Nephrol Hypertens 2023; 32:257-262. [PMID: 36811630 DOI: 10.1097/mnh.0000000000000879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Recent years have witnessed the development of kidney risk prediction models which diverge from traditional model designs to incorporate novel approaches along with a focus on earlier outcomes. This review summarizes these recent advances, evaluates their pros and cons, and discusses their potential implications. RECENT FINDINGS Several kidney risk prediction models have recently been developed utilizing machine learning rather than traditional Cox regression. These models have demonstrated accurate prediction of kidney disease progression, often beyond that of traditional models, in both internal and external validation. On the opposite end of the spectrum, a simplified kidney risk prediction model was recently developed which minimized the need for laboratory data and instead relies primarily on self-reported data. While internal testing showed good overall predictive performance, the generalizability of this model remains uncertain. Finally, there is a growing trend toward prediction of earlier kidney outcomes (e.g., incident chronic kidney disease [CKD]) and away from a sole focus on kidney failure. SUMMARY Newer approaches and outcomes now being incorporated into kidney risk prediction modeling may enhance prediction and benefit a broader patient population. However, future work should address how best to implement these models into practice and assess their long-term clinical effectiveness.
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Affiliation(s)
- Gregory L Hundemer
- Division of Nephrology, Department of Medicine
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Manish M Sood
- Division of Nephrology, Department of Medicine
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Mark Canney
- Division of Nephrology, Department of Medicine
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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31
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Shi Q, Nong K, Vandvik PO, Guyatt GH, Schnell O, Rydén L, Marx N, Brosius FC, Mustafa RA, Agarwal A, Zou X, Mao Y, Asadollahifar A, Chowdhury SR, Zhai C, Gupta S, Gao Y, Lima JP, Numata K, Qiao Z, Fan Q, Yang Q, Jin Y, Ge L, Yang Q, Zhu H, Yang F, Chen Z, Lu X, He S, Chen X, Lyu X, An X, Chen Y, Hao Q, Standl E, Siemieniuk R, Agoritsas T, Tian H, Li S. Benefits and harms of drug treatment for type 2 diabetes: systematic review and network meta-analysis of randomised controlled trials. BMJ 2023; 381:e074068. [PMID: 37024129 PMCID: PMC10077111 DOI: 10.1136/bmj-2022-074068] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To compare the benefits and harms of drug treatments for adults with type 2 diabetes, adding non-steroidal mineralocorticoid receptor antagonists (including finerenone) and tirzepatide (a dual glucose dependent insulinotropic polypeptide (GIP)/glucagon-like peptide-1 (GLP-1) receptor agonist) to previously existing treatment options. DESIGN Systematic review and network meta-analysis. DATA SOURCES Ovid Medline, Embase, and Cochrane Central up to 14 October 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Eligible randomised controlled trials compared drugs of interest in adults with type 2 diabetes. Eligible trials had a follow-up of 24 weeks or longer. Trials systematically comparing combinations of more than one drug treatment class with no drug, subgroup analyses of randomised controlled trials, and non-English language studies were deemed ineligible. Certainty of evidence was assessed following the GRADE (grading of recommendations, assessment, development and evaluation) approach. RESULTS The analysis identified 816 trials with 471 038 patients, together evaluating 13 different drug classes; all subsequent estimates refer to the comparison with standard treatments. Sodium glucose cotransporter-2 (SGLT-2) inhibitors (odds ratio 0.88, 95% confidence interval 0.83 to 0.94; high certainty) and GLP-1 receptor agonists (0.88, 0.82 to 0.93; high certainty) reduce all cause death; non-steroidal mineralocorticoid receptor antagonists, so far tested only with finerenone in patients with chronic kidney disease, probably reduce mortality (0.89, 0.79 to 1.00; moderate certainty); other drugs may not. The study confirmed the benefits of SGLT-2 inhibitors and GLP-1 receptor agonists in reducing cardiovascular death, non-fatal myocardial infarction, admission to hospital for heart failure, and end stage kidney disease. Finerenone probably reduces admissions to hospital for heart failure and end stage kidney disease, and possibly cardiovascular death. Only GLP-1 receptor agonists reduce non-fatal stroke; SGLT-2 inhibitors are superior to other drugs in reducing end stage kidney disease. GLP-1 receptor agonists and probably SGLT-2 inhibitors and tirzepatide improve quality of life. Reported harms were largely specific to drug class (eg, genital infections with SGLT-2 inhibitors, severe gastrointestinal adverse events with tirzepatide and GLP-1 receptor agonists, hyperkalaemia leading to admission to hospital with finerenone). Tirzepatide probably results in the largest reduction in body weight (mean difference -8.57 kg; moderate certainty). Basal insulin (mean difference 2.15 kg; moderate certainty) and thiazolidinediones (mean difference 2.81 kg; moderate certainty) probably result in the largest increases in body weight. Absolute benefits of SGLT-2 inhibitors, GLP-1 receptor agonists, and finerenone vary in people with type 2 diabetes, depending on baseline risks for cardiovascular and kidney outcomes (https://matchit.magicevidence.org/230125dist-diabetes). CONCLUSIONS This network meta-analysis extends knowledge beyond confirming the substantial benefits with the use of SGLT-2 inhibitors and GLP-1 receptor agonists in reducing adverse cardiovascular and kidney outcomes and death by adding information on finerenone and tirzepatide. These findings highlight the need for continuous assessment of scientific progress to introduce cutting edge updates in clinical practice guidelines for people with type 2 diabetes. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022325948.
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Affiliation(s)
- Qingyang Shi
- Department of Endocrinology and Metabolism, Division of Guideline and Rapid Recommendation, Cochrane China Centre, MAGIC China Centre, Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Kailei Nong
- Department of Endocrinology and Metabolism, Division of Guideline and Rapid Recommendation, Cochrane China Centre, MAGIC China Centre, Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Per Olav Vandvik
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, ON, Canada
| | - Oliver Schnell
- Forschergruppe Diabetes eV at the Helmholtz Centre, Munich-Neuherberg, Germany
| | - Lars Rydén
- Department of Medicine K2, Karolinska Institutet, Stockholm, Sweden
| | - Nikolaus Marx
- Clinic for Cardiology, Angiology, and Intensive Care Medicine, RWTH Aachen University, University Hospital Aachen, Aachen, Germany
| | - Frank C Brosius
- Division of Nephrology, University of Arizona College of Medicine Tucson, Tucson, AZ, USA
| | - Reem A Mustafa
- Department of Internal Medicine, Division of Nephrology and Hypertension, University of Kansas, Kansas City, MI, USA
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence and Impact, McMaster University, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Xinyu Zou
- Department of Endocrinology and Metabolism, Division of Guideline and Rapid Recommendation, Cochrane China Centre, MAGIC China Centre, Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Yunhe Mao
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Aminreza Asadollahifar
- Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Chunjuan Zhai
- Department of Cardiology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, China
| | - Sana Gupta
- Department of Health Research Methods, Evidence and Impact, McMaster University, ON, Canada
| | - Ya Gao
- Department of Health Research Methods, Evidence and Impact, McMaster University, ON, Canada
- Evidence-Based Medicine Centre, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - João Pedro Lima
- Department of Health Research Methods, Evidence and Impact, McMaster University, ON, Canada
| | - Kenji Numata
- Department of Emergency Medicine, St Marianna University School of Medicine, Kawasaki, Japan
| | - Zhi Qiao
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Qinlin Fan
- Department of Endocrinology and Metabolism, Division of Guideline and Rapid Recommendation, Cochrane China Centre, MAGIC China Centre, Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Qinbo Yang
- Department of Nephrology, National Clinical Research Centre for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Yinghui Jin
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Long Ge
- Evidence-Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou, China
| | - Qiuyu Yang
- Evidence-Based Nursing Centre, School of Nursing, Lanzhou University, Lanzhou, China
| | - Hongfei Zhu
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China
| | - Fan Yang
- Department of Endocrinology and Metabolism, Chengdu Fifth People's Hospital, Chengdu, China
| | - Zhe Chen
- Evidence-Based Medicine Centre, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xi Lu
- Department of Endocrinology and Metabolism, Division of Guideline and Rapid Recommendation, Cochrane China Centre, MAGIC China Centre, Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Siyu He
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xiangyang Chen
- Department of Endocrinology and Metabolism, First People's Hospital of Shuangliu District, Chengdu, China
| | - Xiafei Lyu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xingxing An
- Department of Endocrinology and Metabolism, Division of Guideline and Rapid Recommendation, Cochrane China Centre, MAGIC China Centre, Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Yaolong Chen
- Evidence-Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou, China
| | - Qiukui Hao
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Eberhard Standl
- Forschergruppe Diabetes eV at the Helmholtz Centre, Munich-Neuherberg, Germany
| | - Reed Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, ON, Canada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, McMaster University, ON, Canada
- Division of General Internal Medicine, Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Haoming Tian
- Department of Endocrinology and Metabolism, Division of Guideline and Rapid Recommendation, Cochrane China Centre, MAGIC China Centre, Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, Division of Guideline and Rapid Recommendation, Cochrane China Centre, MAGIC China Centre, Chinese Evidence-Based Medicine Centre, West China Hospital, Sichuan University, Chengdu, China
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Tawfik YM, Van Tassell BW, Dixon DL, Baker WL, Fanikos J, Buckley LF. Effects of Intensive Systolic Blood Pressure Lowering on End-Stage Kidney Disease and Kidney Function Decline in Adults With Type 2 Diabetes Mellitus and Cardiovascular Risk Factors: A Post Hoc Analysis of ACCORD-BP and SPRINT. Diabetes Care 2023; 46:868-873. [PMID: 36787937 PMCID: PMC10090906 DOI: 10.2337/dc22-2040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/24/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE To determine the effects of intensive systolic blood pressure (SBP) lowering on the risk of major adverse kidney outcomes in people with type 2 diabetes mellitus (T2DM) and/or prediabetes and cardiovascular risk factors. RESEARCH DESIGN AND METHODS This post hoc ACCORD-BP subgroup analysis included participants in the standard glucose-lowering arm with cardiovascular risk factors required for SPRINT eligibility. Cox proportional hazards regression models compared the hazard for the composite of dialysis, kidney transplant, sustained estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2, serum creatinine >3.3 mg/dL, or a sustained eGFR decline ≥57% between the intensive (<120 mmHg) and standard (<140 mmHg) SBP-lowering arms. RESULTS The study cohort included 1,966 SPRINT-eligible ACCORD-BP participants (40% women) with a mean age of 63 years. The mean SBP achieved after randomization was 120 ± 14 and 134 ± 15 mmHg in the intensive and standard arms, respectively. The kidney composite outcome occurred at a rate of 9.5 and 7.2 events per 1,000 person-years in the intensive and standard BP arms (hazard ratio [HR] 1.35 [95% CI 0.85-2.14]; P = 0.20). Intensive SBP lowering did not affect the risk of moderately (HR 0.96 [95% CI 0.76-1.20]) or severely (HR 0.92 [95% CI 0.66-1.28]) increased albuminuria. Including SPRINT participants with prediabetes in the cohort did not change the overall results. CONCLUSIONS This post hoc subgroup analysis suggests that intensive SBP lowering does not increase the risk of major adverse kidney events in individuals with T2DM and cardiovascular risk factors.
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Affiliation(s)
- Yahya M.K. Tawfik
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, MA
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Benjamin W. Van Tassell
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA
| | - Dave L. Dixon
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA
| | - William L. Baker
- Department of Pharmacy Practice, University of Connecticut, Storrs, CT
| | - John Fanikos
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, MA
| | - Leo F. Buckley
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, MA
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Lim LL, Chow E, Chan JCN. Cardiorenal diseases in type 2 diabetes mellitus: clinical trials and real-world practice. Nat Rev Endocrinol 2023; 19:151-163. [PMID: 36446898 DOI: 10.1038/s41574-022-00776-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 11/30/2022]
Abstract
Patients with type 2 diabetes mellitus (T2DM) can have multiple comorbidities and premature mortality due to atherosclerotic cardiovascular disease, hospitalization with heart failure and/or chronic kidney disease. Traditional drugs that lower glucose, such as metformin, or that treat high blood pressure and blood levels of lipids, such as renin-angiotensin-system inhibitors and statins, have organ-protective effects in patients with T2DM. Amongst patients with T2DM treated with these traditional drugs, randomized clinical trials have confirmed the additional cardiorenal benefits of sodium-glucose co-transporter 2 inhibitors (SGLT2i), glucagon-like peptide 1 receptor agonists (GLP1RA) and nonsteroidal mineralocorticoid receptor antagonists. The cardiorenal benefits of SGLT2i extended to patients with heart failure and/or chronic kidney disease without T2DM, whereas incretin-based therapy (such as GLP1RA) reduced cardiovascular events in patients with obesity and T2DM. However, considerable care gaps exist owing to insufficient detection, therapeutic inertia and poor adherence to these life-saving medications. In this Review, we discuss the complex interconnections of cardiorenal-metabolic diseases and strategies to implement evidence-based practice. Furthermore, we consider the need to conduct clinical trials combined with registers in specific patient segments to evaluate existing and emerging therapies to address unmet needs in T2DM.
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Affiliation(s)
- Lee-Ling Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Elaine Chow
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
- Phase 1 Clinical Trial Centre, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Juliana C N Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China.
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China.
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China.
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Wu VC, Chan CK, Chueh JS, Chen YM, Lin YH, Chang CC, Lin PC, Chung SD. Markers of Kidney Tubular Function Deteriorate While Those of Kidney Tubule Health Improve in Primary Aldosteronism After Targeted Treatments. J Am Heart Assoc 2023; 12:e028146. [PMID: 36789834 PMCID: PMC10111488 DOI: 10.1161/jaha.122.028146] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Background Targeted treatment with mineralocorticoid receptor antagonists (MRAs) or adrenalectomy in patients with primary aldosteronism (PA) causes a decline in estimated glomerular filtration rate; however, the associated simultaneous changes in biomarkers of kidney tubule health still remain unclear. Methods and Results We matched 104 patients with newly diagnosed unilateral PA who underwent adrenalectomy with 104 patients with unilateral PA who were treated with MRAs, 104 patients with bilateral PA treated with MRAs, and 104 patients with essential hypertension who served as controls. Functional biomarkers were measured before the targeted treatment and 1 year after treatment, including serum markers of kidney function (cystatin C, creatinine), urinary markers of proximal renal tubular damage (L-FABP [liver-type fatty-acid binding protein], KIM-1 [kidney injury molecule-1]), serum markers of kidney tubular reserve and mineral metabolism (intact parathyroid hormone), and proteinuria. Compared with the patients with essential hypertension, the patients with PA had higher pretreatment serum intact parathyroid hormone and urinary creatinine-corrected parameters, including L-FABP, KIM-1, and albumin. The patients with essential hypertension and with PA had similar cystatin C levels. After treatment with MRAs or adrenalectomy of unilateral PA and MRAs of bilateral PA, the patients with PA had increased serum cystatin C and decreased urinary L-FABP/creatinine, KIM-1/creatinine, creatinine-based estimated glomerular filtration rate, intact parathyroid hormone, and proteinuria (all P<0.05). In multivariable regression models, a higher urinary L-FABP/creatinine ratio and older age were significantly correlated with the occurrence of kidney failure (estimated glomerular filtration rate dip ≥30%) in the patients with PA after targeted treatment. Conclusions Compared with the matched patients with essential hypertension, the incident patients with PA at diagnosis had higher levels of several biomarkers, including markers of kidney damage, tubular reserve/mineral metabolism, and proteinuria. Functional kidney failure in the patients with PA after treatment could be predicted by a higher baseline urinary L-FABP/creatinine ratio and older age. After targeted treatments in the patients with bilateral or unilateral PA, these biomarkers of kidney tubule health were restored, but creatinine-based estimated glomerular filtration rate declined, which may therefore reflect hemodynamic changes rather than intrinsic damage to kidney tubular cells.
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Affiliation(s)
- Vin-Cent Wu
- Department of Internal Medicine National Taiwan University Hospital and College of Medicine, National Taiwan University Taipei Taiwan.,TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group Taipei Taiwan.,Primary Aldosteronism Center at National Taiwan University Hospital (NTUH-PAC) Taipei Taiwan
| | - Chieh-Kai Chan
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group Taipei Taiwan.,Department of Internal Medicine National Taiwan University Hospital Hsin-Chu Branch Hsin-Chu County Taiwan
| | - Jeff S Chueh
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group Taipei Taiwan.,Department of Urology National Taiwan University Hospital and College of Medicine, National Taiwan University Taipei Taiwan
| | - Yung-Ming Chen
- Department of Internal Medicine National Taiwan University Hospital and College of Medicine, National Taiwan University Taipei Taiwan
| | - Yen-Hung Lin
- Department of Internal Medicine National Taiwan University Hospital and College of Medicine, National Taiwan University Taipei Taiwan.,TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group Taipei Taiwan.,Primary Aldosteronism Center at National Taiwan University Hospital (NTUH-PAC) Taipei Taiwan
| | - Chin-Chen Chang
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group Taipei Taiwan.,Department of Imaging Medicine National Taiwan University Hospital and College of Medicine, National Taiwan University Taipei Taiwan
| | - Po-Chih Lin
- Department of Internal Medicine National Taiwan University Hospital and College of Medicine, National Taiwan University Taipei Taiwan
| | - Shiu-Dong Chung
- Division of Urology, Department of Surgery Far Eastern Memorial Hospital New Taipei City Taiwan.,Department of Nursing College of Healthcare and Management, General Education Center, Asia Eastern University of Science and Technology New Taipei City Taiwan
| | -
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group Taipei Taiwan
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35
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Carrero JJ, Fu EL, Vestergaard SV, Jensen SK, Gasparini A, Mahalingasivam V, Bell S, Birn H, Heide-Jørgensen U, Clase CM, Cleary F, Coresh J, Dekker FW, Gansevoort RT, Hemmelgarn BR, Jager KJ, Jafar TH, Kovesdy CP, Sood MM, Stengel B, Christiansen CF, Iwagami M, Nitsch D. Defining measures of kidney function in observational studies using routine health care data: methodological and reporting considerations. Kidney Int 2023; 103:53-69. [PMID: 36280224 DOI: 10.1016/j.kint.2022.09.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 08/31/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022]
Abstract
The availability of electronic health records and access to a large number of routine measurements of serum creatinine and urinary albumin enhance the possibilities for epidemiologic research in kidney disease. However, the frequency of health care use and laboratory testing is determined by health status and indication, imposing certain challenges when identifying patients with kidney injury or disease, when using markers of kidney function as covariates, or when evaluating kidney outcomes. Depending on the specific research question, this may influence the interpretation, generalizability, and/or validity of study results. This review illustrates the heterogeneity of working definitions of kidney disease in the scientific literature and discusses advantages and limitations of the most commonly used approaches using 3 examples. We summarize ways to identify and overcome possible biases and conclude by proposing a framework for reporting definitions of exposures and outcomes in studies of kidney disease using routinely collected health care data.
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Affiliation(s)
- Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden.
| | - Edouard L Fu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Søren V Vestergaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Simon Kok Jensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Alessandro Gasparini
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Viyaasan Mahalingasivam
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Samira Bell
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
| | - Henrik Birn
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Biomedicine, Aarhus University, Aarhus, Denmark; Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Uffe Heide-Jørgensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Catherine M Clase
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research and Methodology, McMaster University, Hamilton, Ontario, Canada
| | - Faye Cleary
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Kitty J Jager
- ERA Registry, Amsterdam UMC location University of Amsterdam, Medical Informatics, Meibergdreef, Amsterdam, Netherlands; Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, the Netherlands
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Manish M Sood
- Department of Medicine, the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Bénédicte Stengel
- CESP (Center for Research in Epidemiology and Population Health), Clinical Epidemiology Team, University Paris-Saclay, University Versailles-Saint Quentin, Inserm U1018, Villejuif, France
| | - Christian F Christiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Masao Iwagami
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK; Department of Health Services Research, University of Tsukuba, Ibaraki, Japan
| | - Dorothea Nitsch
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK; Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; UK Renal Registry, UK Kidney Association, Bristol, UK.
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36
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Friedman AN, Schauer PR, Beddhu S, Kramer H, le Roux CW, Purnell JQ, Sunwold D, Tuttle KR, Jastreboff AM, Kaplan LM. Obstacles and opportunities in managing coexisting obesity and CKD: Report of a scientific workshop cosponsored by the National Kidney Foundation and The Obesity Society. Obesity (Silver Spring) 2022; 30:2340-2350. [PMID: 36268562 DOI: 10.1002/oby.23599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/19/2022] [Indexed: 01/04/2023]
Abstract
The National Kidney Foundation (NKF) and The Obesity Society (TOS) cosponsored a multispecialty international workshop in April 2021 to advance the understanding and management of obesity in adults with chronic kidney disease (CKD). The underlying rationale for the workshop was the accumulating evidence that obesity is a major contributor to CKD and adverse outcomes in individuals with CKD, and that effective treatment of obesity, including lifestyle intervention, weight loss medications, and metabolic surgery, can have beneficial effects. The attendees included a range of experts in the areas of kidney disease, obesity medicine, endocrinology, diabetes, bariatric/metabolic surgery, endoscopy, transplant surgery, and nutrition, as well as patients with obesity and CKD. The group identified strategies to increase patient and provider engagement in obesity management, outlined a collaborative action plan to engage nephrologists and obesity medicine experts in obesity management, and identified research opportunities to address gaps in knowledge about the interaction between obesity and kidney disease. The workshop's conclusions help lay the groundwork for development of an effective, scientifically based, and multidisciplinary approach to the management of obesity in people with CKD.
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Affiliation(s)
- Allon N Friedman
- Division of Nephrology, School of Medicine, Indiana University Indianapolis, Indiana, USA
| | - Philip R Schauer
- Pennington Biomedical Research Institute, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Srinivasan Beddhu
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Holly Kramer
- Department of Public Health Sciences and Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Carel W le Roux
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin, Ireland
| | - Jonathan Q Purnell
- Division of Cardiovascular Medicine, School of Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - Duane Sunwold
- Culinary Program, Spokane Community College, Spokane, Washington, USA
| | - Katherine R Tuttle
- Providence Health Care and School of Medicine, University of Washington, Spokane, Washington, USA
| | - Ania M Jastreboff
- Endocrinology & Metabolism, Department of Medicine and Pediatric Endocrinology, Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Lee M Kaplan
- Obesity, Metabolism, and Nutrition Institute and Gastroenterology Division, Massachusetts General Hospital, and Medical School, Harvard University, Boston, Massachusetts, USA
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37
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Friedman AN, Schauer PR, Beddhu S, Kramer H, le Roux CW, Purnell JQ, Sunwold D, Tuttle KR, Jastreboff AM, Kaplan LM. Obstacles and Opportunities in Managing Coexisting Obesity and CKD: Report of a Scientific Workshop Cosponsored by the National Kidney Foundation and The Obesity Society. Am J Kidney Dis 2022; 80:783-793. [PMID: 36280397 DOI: 10.1053/j.ajkd.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/14/2022] [Indexed: 11/06/2022]
Abstract
The National Kidney Foundation (NKF) and The Obesity Society (TOS) cosponsored a multispecialty international workshop in April 2021 to advance the understanding and management of obesity in adults with chronic kidney disease (CKD). The underlying rationale for the workshop was the accumulating evidence that obesity is a major contributor to CKD and adverse outcomes in individuals with CKD, and that effective treatment of obesity, including lifestyle intervention, weight loss medications, and metabolic surgery, can have beneficial effects. The attendees included a range of experts in the areas of kidney disease, obesity medicine, endocrinology, diabetes, bariatric/metabolic surgery, endoscopy, transplant surgery, and nutrition, as well as patients with obesity and CKD. The group identified strategies to increase patient and provider engagement in obesity management, outlined a collaborative action plan to engage nephrologists and obesity medicine experts in obesity management, and identified research opportunities to address gaps in knowledge about the interaction between obesity and kidney disease. The workshop's conclusions help lay the groundwork for development of an effective, scientifically based, and multidisciplinary approach to the management of obesity in people with CKD.
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Affiliation(s)
- Allon N Friedman
- Division of Nephrology, School of Medicine, Indiana University, Indianapolis, Indiana.
| | - Philip R Schauer
- Pennington Biomedical Research Institute, Louisiana State University, Baton Rouge, Louisiana
| | - Srinivasan Beddhu
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Holly Kramer
- Department of Public Health Sciences and Medicine, Loyola University Chicago, Maywood, Illinois
| | - Carel W le Roux
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin, Ireland
| | | | - Duane Sunwold
- Culinary Program, Spokane Community College, Spokane, Washington
| | - Katherine R Tuttle
- Providence Health Care and School of Medicine, University of Washington, Spokane and Seattle, Washington
| | - Ania M Jastreboff
- Endocrinology & Metabolism, Department of Medicine and Pediatric Endocrinology, Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut
| | - Lee M Kaplan
- Obesity, Metabolism, and Nutrition Institute and Gastroenterology Division, Massachusetts General Hospital, and Medical School, Harvard University, Boston, Massachusetts
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Baigent C, Emberson J, Haynes R, Herrington WG, Judge P, Landray MJ, Mayne KJ, Ng SY, Preiss D, Roddick AJ, Staplin N, Zhu D, Anker SD, Bhatt DL, Brueckmann M, Butler J, Cherney DZ, Green JB, Hauske SJ, Haynes R, Heerspink HJ, Herrington WG, Inzucchi SE, Jardine MJ, Liu CC, Mahaffey KW, McCausland FR, McGuire DK, McMurray JJ, Neal B, Neuen BL, Packer M, Perkovic V, Sabatine MS, Solomon SD, Vaduganathan M, Wanner C, Wheeler DC, Wiviott SD, Zannad F. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials. Lancet 2022; 400:1788-1801. [PMID: 36351458 PMCID: PMC7613836 DOI: 10.1016/s0140-6736(22)02074-8] [Citation(s) in RCA: 289] [Impact Index Per Article: 144.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Large trials have shown that sodium glucose co-transporter-2 (SGLT2) inhibitors reduce the risk of adverse kidney and cardiovascular outcomes in patients with heart failure or chronic kidney disease, or with type 2 diabetes and high risk of atherosclerotic cardiovascular disease. None of the trials recruiting patients with and without diabetes were designed to assess outcomes separately in patients without diabetes. METHODS We did a systematic review and meta-analysis of SGLT2 inhibitor trials. We searched the MEDLINE and Embase databases for trials published from database inception to Sept 5, 2022. SGLT2 inhibitor trials that were double-blind, placebo-controlled, performed in adults (age ≥18 years), large (≥500 participants per group), and at least 6 months in duration were included. Summary-level data used for analysis were extracted from published reports or provided by trial investigators, and inverse-variance-weighted meta-analyses were conducted to estimate treatment effects. The main efficacy outcomes were kidney disease progression (standardised to a definition of a sustained ≥50% decrease in estimated glomerular filtration rate [eGFR] from randomisation, a sustained low eGFR, end-stage kidney disease, or death from kidney failure), acute kidney injury, and a composite of cardiovascular death or hospitalisation for heart failure. Other outcomes were death from cardiovascular and non-cardiovascular disease considered separately, and the main safety outcomes were ketoacidosis and lower limb amputation. This study is registered with PROSPERO, CRD42022351618. FINDINGS We identified 13 trials involving 90 413 participants. After exclusion of four participants with uncertain diabetes status, we analysed 90 409 participants (74 804 [82·7%] participants with diabetes [>99% with type 2 diabetes] and 15 605 [17·3%] without diabetes; trial-level mean baseline eGFR range 37-85 mL/min per 1·73 m2). Compared with placebo, allocation to an SGLT2 inhibitor reduced the risk of kidney disease progression by 37% (relative risk [RR] 0·63, 95% CI 0·58-0·69) with similar RRs in patients with and without diabetes. In the four chronic kidney disease trials, RRs were similar irrespective of primary kidney diagnosis. SGLT2 inhibitors reduced the risk of acute kidney injury by 23% (0·77, 0·70-0·84) and the risk of cardiovascular death or hospitalisation for heart failure by 23% (0·77, 0·74-0·81), again with similar effects in those with and without diabetes. SGLT2 inhibitors also reduced the risk of cardiovascular death (0·86, 0·81-0·92) but did not significantly reduce the risk of non-cardiovascular death (0·94, 0·88-1·02). For these mortality outcomes, RRs were similar in patients with and without diabetes. For all outcomes, results were broadly similar irrespective of trial mean baseline eGFR. Based on estimates of absolute effects, the absolute benefits of SGLT2 inhibition outweighed any serious hazards of ketoacidosis or amputation. INTERPRETATION In addition to the established cardiovascular benefits of SGLT2 inhibitors, the randomised data support their use for modifying risk of kidney disease progression and acute kidney injury, not only in patients with type 2 diabetes at high cardiovascular risk, but also in patients with chronic kidney disease or heart failure irrespective of diabetes status, primary kidney disease, or kidney function. FUNDING UK Medical Research Council and Kidney Research UK.
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39
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Defining improvement in chronic kidney disease: regression and remission. Curr Opin Nephrol Hypertens 2022; 31:517-521. [PMID: 35894252 DOI: 10.1097/mnh.0000000000000830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW International definitions exist for chronic kidney disease (CKD) progression and kidney failure but despite evidence that kidney function may improve, there are no agreed definitions for regression and remission of CKD. In the light of recent novel kidney protective therapies and the promise of regenerative medicine to reverse kidney damage, it is time to critically examine these neglected aspects of CKD epidemiology. RECENT FINDINGS We propose that CKD regression is viewed as a process of improvement defined as a sustained increase in glomerular filtration rate (GFR) by ≥25% and an improvement in GFR category or increase in GFR of 1≥ml/min/year, whereas remission is considered a category of improvement defined as GFR ≥60 ml/min/1.73m 2 and urine albumin to creatinine ratio <30 mg/g. Several recent studies have reported improvement in kidney function in populations with CKD, even in the absence of specific therapy. Regression and remission of CKD are associated with increased likelihood of sustained improvement in kidney function as well as improved survival. SUMMARY Further research is warranted to validate the proposed definitions and investigate associated mechanisms. We look to a future in which the goal of therapy is not merely to slow CKD progression but to improve kidney function and seek a cure.
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40
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Idris I, Zhang R, Mamza JB, Ford M, Morris T, Banerjee A, Khunti K. Significant reduction in chronic kidney disease progression with sodium-glucose cotransporter-2 inhibitors compared to dipeptidyl peptidase-4 inhibitors in adults with type 2 diabetes in a UK clinical setting: An observational outcomes study based on international guidelines for kidney disease. Diabetes Obes Metab 2022; 24:2138-2147. [PMID: 35676798 PMCID: PMC9795968 DOI: 10.1111/dom.14799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 12/30/2022]
Abstract
AIMS To confirm the reno-protective effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors compared with dipeptidyl peptidase-4 (DPP-4) inhibitors on the onset and progression of chronic kidney disease (CKD) in routine clinical practice. MATERIALS AND METHODS We conducted a retrospective cohort study using the Clinical Practice Research Datalink Aurum database linked to Hospital Episode Statistics. The primary outcome was risk of the composite CKD endpoint based on the recent consensus guidelines for kidney disease: >40% decline in estimated glomerular filtration rate (eGFR), kidney death or end-stage kidney disease (ESKD; a composite of kidney transplantation, maintenance of dialysis, sustained low eGFR <15 ml/min/1.73m² or diagnosis of ESKD). Secondary outcomes were components of the composite CKD endpoint, analysed separately. Patients were propensity-score-matched 1:1 for SGLT2 inhibitor versus DPP-4 inhibitor use. RESULTS A total of 131 824 people with type 2 diabetes (T2D) were identified; 79.0% had no known history of CKD. During a median follow-up of 2.1 years, SGLT2 inhibitor initiation was associated with lower risk of progression to composite kidney endpoints than DPP-4 inhibitor initiation (7.48 vs. 11.77 events per 1000 patient-years, respectively). Compared with DPP-4 inhibitor initiation, SGLT2 inhibitor initiation was associated with reductions in the primary composite CKD endpoint (hazard ratio [HR] 0.64, 95% confidence interval [CI] 0.56-0.74), all-cause mortality (HR 0.74, 95% CI 0.64-0.86) and ESKD (HR 0.37, 95% CI 0.25-0.55), reduced the rate of sustained low eGFR (HR 0.33, 95% CI 0.19-0.57), and reduced diagnoses of ESKD in primary care (HR 0.04, 95% CI 0.01-0.18). Results were consistent across subgroup and sensitivity analyses. CONCLUSIONS In adults with T2D, initiation of an SGLT2 inhibitor was associated with a significantly reduced risk of CKD progression and death compared with initiation of a DPP-4 inhibitor.
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Affiliation(s)
- Iskandar Idris
- Division of Medical Sciences and Graduate Entry MedicineSchool of Medicine, University of Nottingham, Royal Derby HospitalDerbyUK
| | - Ruiqi Zhang
- Robertson Centre for BiostatisticsInstitute of Health and Wellbeing, University of GlasgowGlasgowUK
- Medical and Scientific AffairsBioPharmaceuticals Medical, AstraZenecaLondonUK
| | - Jil B. Mamza
- Medical and Scientific AffairsBioPharmaceuticals Medical, AstraZenecaLondonUK
| | - Mike Ford
- Medical and Scientific AffairsBioPharmaceuticals Medical, AstraZenecaLondonUK
| | - Tamsin Morris
- Medical and Scientific AffairsBioPharmaceuticals Medical, AstraZenecaLondonUK
| | - Amitava Banerjee
- Institute of Health Informatics, University College LondonLondonUK
- Department of CardiologyUniversity College London HospitalsLondonUK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of LeicesterLeicesterUK
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Rios P, Sola L, Ferreiro A, Silvariño R, Lamadrid V, Ceretta L, Gadola L. Adherence to multidisciplinary care in a prospective chronic kidney disease cohort is associated with better outcomes. PLoS One 2022; 17:e0266617. [PMID: 36240220 PMCID: PMC9565398 DOI: 10.1371/journal.pone.0266617] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 03/23/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The Renal Healthcare Program Uruguay (NRHP-UY) is a national, multidisciplinary program that provides care to chronic kidney disease (CKD) patients. In this study, we report the global results of CKD patient outcomes and a comparison between those treated at the NRHP-UY Units, with those patients who were initially included in the program but did not adhere to follow up. METHODS A cohort of not-on dialysis CKD patients included prospectively in the NRHP-UY between October 1st 2004 and September 30th 2017 was followed-up until September 30th 2019. Two groups were compared: a) Nephrocare Group: Patients who had at least one clinic visit during the first year on NRHP-UY (n = 11174) and b) Non-adherent Group: Patients who were informed and accepted to be included but had no subsequent data registered after admission (n = 3485). The study was approved by the Ethics Committee and all patients signed an informed consent. Outcomes were studied with Logistic and Cox´s regression analysis, Fine and Gray competitive risk and propensity-score matching tests. RESULTS 14659 patients were analyzed, median age 70 (60-77) years, 56.9% male. The Nephrocare Group showed improved achievement of therapeutic goals, ESKD was more frequent (HR 2.081, CI 95%1.722-2.514) as planned kidney replacement therapy (KRT) start (OR 2.494, CI95% 1.591-3.910), but mortality and the combined event (death and ESKD) were less frequent (HR 0.671, CI95% 0.628-0.717 and 0.777, CI95% 0.731-0.827) (p = 0.000) compared to the Non-adherent group. Results were similar in the propensity-matched group: ESKD (HR 2.041, CI95% 1.643-2.534); planned kidney replacement therapy (KRT) start (OR 2.191, CI95% 1.322-3.631) death (HR 0.692, CI95% 0.637-0.753); combined event (HR 0.801, CI95% 0.742-0.865) (p = 0.000). CONCLUSION Multidisciplinary care within the NRHP-UY is associated with timely initiation of KRT and lower mortality in single outcomes, combined analysis, and propensity-matched analysis.
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Affiliation(s)
- Pablo Rios
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
| | - Laura Sola
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
| | - Alejandro Ferreiro
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
- Departamento de Nefrología, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Ricardo Silvariño
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
- Departamento de Nefrología, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Verónica Lamadrid
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
| | - Laura Ceretta
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
| | - Liliana Gadola
- Comisión Asesora de Programa de Salud Renal, Fondo Nacional de Recursos, Montevideo, Uruguay
- Departamento de Nefrología, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
- * E-mail:
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Inker LA, Grams ME, Guðmundsdóttir H, McEwan P, Friedman R, Thompson A, Weiner DE, Willis K, Heerspink HJL. Clinical Trial Considerations in Developing Treatments for Early Stages of Common, Chronic Kidney Diseases: A Scientific Workshop Cosponsored by the National Kidney Foundation and the US Food and Drug Administration. Am J Kidney Dis 2022; 80:513-526. [PMID: 35970679 DOI: 10.1053/j.ajkd.2022.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 03/14/2022] [Indexed: 02/02/2023]
Abstract
In the past decade, advances in the validation of surrogate end points for chronic kidney disease (CKD) progression have heightened interest in evaluating therapies in early CKD. In December 2020, the National Kidney Foundation sponsored a scientific workshop in collaboration with the US Food and Drug Administration (FDA) to explore patient, provider, and payor perceptions of the value of treating early CKD. The workshop reviewed challenges for trials in early CKD, including trial designs, identification of high-risk populations, and cost-benefit and safety considerations. Over 90 people representing a range of stakeholders including experts in clinical trials, nephrology, cardiology and endocrinology, patient advocacy organizations, patients, payors, health economists, regulators and policy makers attended a virtual meeting. There was consensus among the attendees that there is value to preventing the development and treating the progression of early CKD in people who are at high risk for progression, and that surrogate end points should be used to establish efficacy. Attendees also concluded that cost analyses should be holistic and include aspects beyond direct savings for treatment of kidney failure; and that safety data should be collected outside/beyond the duration of a clinical trial. Successful drug development and implementation of effective therapies will require collaboration across sponsors, patients, patient advocacy organizations, medical community, regulators, and payors.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts.
| | - Morgan E Grams
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Phil McEwan
- Health Economics and Outcomes Research Limited, Cardiff, United Kingdom
| | | | - Aliza Thompson
- Division of Cardiology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | | | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; George Institute for Global Health, Sydney, Australia
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Alencar de Pinho N, Henn L, Raina R, Reichel H, Lopes AA, Combe C, Speyer E, Bieber B, Robinson BM, Stengel B, Pecoits-Filho R. Understanding International Variations in Kidney Failure Incidence and Initiation of Replacement Therapy. Kidney Int Rep 2022; 7:2364-2375. [DOI: 10.1016/j.ekir.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/22/2022] [Indexed: 10/14/2022] Open
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Khan MS, Shahid I, Butler J. Reporting and Definition of Kidney Death in Heart Failure Clinical Trials. Curr Probl Cardiol 2022; 47:101382. [DOI: 10.1016/j.cpcardiol.2022.101382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 11/30/2022]
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Cleary F, Prieto-Merino D, Nitsch D. A systematic review of statistical methodology used to evaluate progression of chronic kidney disease using electronic healthcare records. PLoS One 2022; 17:e0264167. [PMID: 35905096 PMCID: PMC9337679 DOI: 10.1371/journal.pone.0264167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 02/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background Electronic healthcare records (EHRs) are a useful resource to study chronic kidney disease (CKD) progression prior to starting dialysis, but pose methodological challenges as kidney function tests are not done on everybody, nor are tests evenly spaced. We sought to review previous research of CKD progression using renal function tests in EHRs, investigating methodology used and investigators’ recognition of data quality issues. Methods and findings We searched for studies investigating CKD progression using EHRs in 4 databases (Medline, Embase, Global Health and Web of Science) available as of August 2021. Of 80 articles eligible for review, 59 (74%) were published in the last 5.5 years, mostly using EHRs from the UK, USA and East Asian countries. 33 articles (41%) studied rates of change in eGFR, 23 (29%) studied changes in eGFR from baseline and 15 (19%) studied progression to binary eGFR thresholds. Sample completeness data was available in 44 studies (55%) with analysis populations including less than 75% of the target population in 26 studies (33%). Losses to follow-up went unreported in 62 studies (78%) and 11 studies (14%) defined their cohort based on complete data during follow up. Methods capable of handling data quality issues and other methodological challenges were used in a minority of studies. Conclusions Studies based on renal function tests in EHRs may have overstated reliability of findings in the presence of informative missingness. Future renal research requires more explicit statements of data completeness and consideration of i) selection bias and representativeness of sample to the intended target population, ii) ascertainment bias where follow-up depends on risk, and iii) the impact of competing mortality. We recommend that renal progression studies should use statistical methods that take into account variability in renal function, informative censoring and population heterogeneity as appropriate to the study question.
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Affiliation(s)
- Faye Cleary
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - David Prieto-Merino
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Abstract
BACKGROUND The effects of the sodium-glucose co-transporter 2 inhibitor empagliflozin on renal and cardiovascular disease have not been tested in a dedicated population of people with chronic kidney disease (CKD). METHODS The EMPA-KIDNEY trial is an international randomized, double-blind, placebo-controlled trial assessing whether empagliflozin 10 mg daily decreases the risk of kidney disease progression or cardiovascular death in people with CKD. People with or without diabetes mellitus (DM) were eligible provided they had an estimated glomerular filtration rate (eGFR) ≥20 but <45 mL/min/1.73 m2 or an eGFR ≥45 but <90 mL/min/1.73 m2 with a urinary albumin:creatinine ratio (uACR) ≥200 mg/g. The trial design is streamlined, as extra work for collaborating sites is kept to a minimum and only essential information is collected. RESULTS Between 15 May 2019 and 16 April 2021, 6609 people from eight countries in Europe, North America and East Asia were randomized. The mean age at randomization was 63.8 years [standard deviation (SD) 13.9)], 2192 (33%) were female and 3570 (54%) had no prior history of DM. The mean eGFR was 37.5 mL/min/1.73 m2 (SD 14.8), including 5185 (78%) with an eGFR <45 mL/min/1.73 m2. The median uACR was 412 mg/g) (quartile 1-quartile 3 94-1190), with a uACR <300 mg/g in 3194 (48%). The causes of kidney disease included diabetic kidney disease [n = 2057 (31%)], glomerular disease [n = 1669 (25%)], hypertensive/renovascular disease [n = 1445 (22%)], other [n = 808 (12%)] and unknown causes [n = 630 (10%)]. CONCLUSIONS EMPA-KIDNEY will evaluate the efficacy and safety of empagliflozin in a widely generalizable population of people with CKD at risk of kidney disease progression. Results are anticipated in 2022.
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Affiliation(s)
- Andrew S Levey
- From the Division of Nephrology, Tufts Medical Center, Boston (A.S.L., L.A.I.); and the Division of Precision Medicine, Department of Medicine, New York University, New York (M.E.G.)
| | - Morgan E Grams
- From the Division of Nephrology, Tufts Medical Center, Boston (A.S.L., L.A.I.); and the Division of Precision Medicine, Department of Medicine, New York University, New York (M.E.G.)
| | - Lesley A Inker
- From the Division of Nephrology, Tufts Medical Center, Boston (A.S.L., L.A.I.); and the Division of Precision Medicine, Department of Medicine, New York University, New York (M.E.G.)
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Hamid M, Rogers E, Chawla G, Gill J, Macanovic S, Mucsi I. Pretransplant Patient Education in Solid-organ Transplant: A Narrative Review. Transplantation 2022; 106:722-733. [PMID: 34260472 DOI: 10.1097/tp.0000000000003893] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Education for pretransplant, solid-organ recipient candidates aims to improve knowledge and understanding about the transplant process, outcomes, and potential complications to support informed, shared decision-making to reduce fears and anxieties about transplant, inform expectations, and facilitate adjustment to posttransplant life. In this review, we summarize novel pretransplant initiatives and approaches to educate solid-organ transplant recipient candidates. First, we review approaches that may be common to all solid-organ transplants, then we summarize interventions specific to kidney, liver, lung, and heart transplant. We describe evidence that emphasizes the need for multidisciplinary approaches to transplant education. We also summarize initiatives that consider online (eHealth) and mobile (mHealth) solutions. Finally, we highlight education initiatives that support racialized or otherwise marginalized communities to improve equitable access to solid-organ transplant. A considerable amount of work has been done in solid-organ transplant since the early 2000s with promising results. However, many studies on education for pretransplant recipient candidates involve relatively small samples and nonrandomized designs and focus on short-term surrogate outcomes. Overall, many of these studies have a high risk of bias. Frequently, interventions assessed are not well characterized or they are combined with administrative and data-driven initiatives into multifaceted interventions, which makes it difficult to assess the impact of the education component on outcomes. In the future, well-designed studies rigorously assessing well-defined surrogate and clinical outcomes will be needed to evaluate the impact of many promising initiatives.
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Affiliation(s)
- Marzan Hamid
- Multi-Organ Transplant Program and Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
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Neuen BL, Jardine MJ. SGLT2 inhibitors and finerenone: one or the other or both? Nephrol Dial Transplant 2022; 37:1209-1211. [PMID: 35212745 DOI: 10.1093/ndt/gfac046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Indexed: 12/19/2022] Open
Affiliation(s)
- Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
| | - Meg J Jardine
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia.,Concord Repatriation General Hospital, Sydney, Australia
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Chronic kidney disease and vascular risk - what's new? HIPERTENSION Y RIESGO VASCULAR 2022; 39:3-7. [PMID: 35152979 DOI: 10.1016/j.hipert.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/21/2022]
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