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Nangaku M, Herrington WG, Goto S, Maruyama S, Kashihara N, Ueki K, Wada J, Watada H, Nakashima E, Lee R, Massey D, Mayne KJ, Tomita A, Haynes R, Hauske SJ, Kadowaki T. Effects of empagliflozin in patients with chronic kidney disease from Japan: exploratory analyses from EMPA-KIDNEY. Clin Exp Nephrol 2024; 28:588-595. [PMID: 38643286 PMCID: PMC11116192 DOI: 10.1007/s10157-024-02489-4] [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: 09/21/2023] [Accepted: 03/18/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND EMPA-KIDNEY assessed the effects of empagliflozin 10 mg once daily vs. placebo in 6609 patients with chronic kidney disease (CKD) at risk of progression, including 612 participants from Japan. METHODS Eligibility required an estimated glomerular filtration rate (eGFR) of ≥ 20 < 45; or ≥ 45 < 90 ml/min/1.73m2 with a urinary albumin-to-creatinine ratio (uACR) of ≥ 200 mg/g. The primary outcome was a composite of kidney disease progression (end-stage kidney disease, a sustained eGFR decline to < 10 ml/min/1.73m2 or ≥ 40% from randomization, or renal death) or cardiovascular death. In post-hoc analyses, we explored the effects of empagliflozin in participants from Japan vs. non-Japan regions, including additional models assessing whether differences in treatment effects between these regions could result from differences in baseline characteristics. RESULTS Japanese participants had higher levels of albuminuria and eGFR than those from non-Japan regions. During a median of 2.0 year follow-up, a primary outcome occurred in 432 patients (13.1%) in the empagliflozin group and in 558 patients (16.9%) in the placebo group (hazard ratio [HR], 0.72, 95% confidence interval [95%CI] 0.64-0.82; P < 0.0001). Among the participants from non-Japan regions, there were 399 vs. 494 primary outcomes (0.75, 0.66-0.86), and 33 vs. 64 (0.49, 0.32-0.75; heterogeneity p = 0.06) in Japan. Results were similar when models explicitly considered treatment interactions with diabetes status, categories of eGFR/uACR, and recruitment in Japan (heterogeneity p = 0.08). Safety outcomes were broadly comparable between the two groups, and by Japanese status. CONCLUSIONS Empagliflozin safely reduced the risk of "kidney disease progression or cardiovascular death" in patients with CKD, with consistent effects in participants from Japan.
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Affiliation(s)
- Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo School of Medicine, Tokyo, 113-8655, Japan.
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Shinya Goto
- Tokai University School of Medicine, Isehara, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Kohjiro Ueki
- Diabetes Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Hirotaka Watada
- Department of Metabolism &Endocrinology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Eitaro Nakashima
- Department of Diabetes and Endocrinology, Chubu Rosai Hospital, Nagoya, Japan
| | - Ryonfa Lee
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Dan Massey
- Elderbrook Solutions GmbH On Behalf of Boehringer Ingelheim Pharma GmbH & Co.KG, Biberach, Germany
| | - Kaitlin J Mayne
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Aiko Tomita
- Tokai University School of Medicine, Isehara, Japan
| | - Richard Haynes
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sibylle J Hauske
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Vth Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Takashi Kadowaki
- The University of Tokyo School of Medicine/Toranomon Hospital, Tokyo, Japan
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Zhu D, Judge PK, Haynes R. Improvements in Kidney Outcomes Over the Years: Reason for Optimism but a Challenge for Trialists. Am J Kidney Dis 2024; 83:427-428. [PMID: 38260929 DOI: 10.1053/j.ajkd.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 01/24/2024]
Affiliation(s)
- Doreen Zhu
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Parminder K Judge
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Richard Haynes
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
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Dellepiane S, Marengo M, D'Arezzo M, Donati G, Fabbrini P, Lacquaniti A, Ronco C, Cantaluppi V. The Next Evolution of HemoDialysis eXpanded: From a Delphi Questionnaire-Based Approach to the Real Life of Italian Dialysis Units. Blood Purif 2022; 51:943-952. [PMID: 35231902 PMCID: PMC9808684 DOI: 10.1159/000522038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/17/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Impact assessment of new technologies in chronic hemodialysis (HD) is challenging due to HD patient frailty, the complexity of HD clinical trials and practice variability among countries. Among the most recent HD innovations, medium cut-off (MCO) dialyzers present an optimized membrane geometry that provides enhanced clearances for middle and large molecular weight uremic toxins (UT). These toxins are poorly cleared by available HD techniques and largely contribute to patient morbidity and mortality. The aim of this paper is to assess the available clinical evidence about MCO membranes and to identify the next steps needed to generate conclusive data on their use in HD. METHODS With this purpose, we first reviewed and compared the current HD technologies aimed to improve the clearance of middle and large UT; subsequently, we used a Delphi questionnaire to identify and discuss the consensus about MCO efficacy within a large sample of the Italian Nephrology community. RESULTS AND CONCLUSIONS Our investigation gathered a significant degree of consensus on the beneficial role of MCO membrane and expanded HD. Finally, we used our results to propose future trial designs and clinical investigations aimed to improve evidence quality about the use of these membranes in the present clinical scenario of dialysis units.
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Affiliation(s)
- Sergio Dellepiane
- Department of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Mario D'Arezzo
- Nephrology, Dialysis and Kidney Transplant Unit, Ospedali Riuniti − Ancona University Hospital, Ancona, Italy
| | - Gabriele Donati
- Nephrology Dialysis and Renal Transplantation Unit, St. Orsola University Hospital, Bologna, Italy
| | - Paolo Fabbrini
- Nephrology and Dialysis Unit, San Gerardo Hospital and Milano Bicocca University, Monza, Italy
| | | | - Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy,Division of Nephrology, Dialysis and Kidney Transplantation Unit, International Renal Research Institute Vicenza (IRRIV), “San Bortolo” Hospital, Vicenza, Italy
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale (UPO), “Maggiore della Carità” University Hospital, Novara, Italy,*Vincenzo Cantaluppi,
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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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Hofherr A, Williams J, Gan LM, Söderberg M, Hansen PBL, Woollard KJ. Targeting inflammation for the treatment of Diabetic Kidney Disease: a five-compartment mechanistic model. BMC Nephrol 2022; 23:208. [PMID: 35698028 PMCID: PMC9190142 DOI: 10.1186/s12882-022-02794-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 04/20/2022] [Indexed: 12/25/2022] Open
Abstract
Diabetic kidney disease (DKD) is the leading cause of kidney failure worldwide. Mortality and morbidity associated with DKD are increasing with the global prevalence of type 2 diabetes. Chronic, sub-clinical, non-resolving inflammation contributes to the pathophysiology of renal and cardiovascular disease associated with diabetes. Inflammatory biomarkers correlate with poor renal outcomes and mortality in patients with DKD. Targeting chronic inflammation may therefore offer a route to novel therapeutics for DKD. However, the DKD patient population is highly heterogeneous, with varying etiology, presentation and disease progression. This heterogeneity is a challenge for clinical trials of novel anti-inflammatory therapies. Here, we present a conceptual model of how chronic inflammation affects kidney function in five compartments: immune cell recruitment and activation; filtration; resorption and secretion; extracellular matrix regulation; and perfusion. We believe that the rigorous alignment of pathophysiological insights, appropriate animal models and pathology-specific biomarkers may facilitate a mechanism-based shift from recruiting ‘all comers’ with DKD to stratification of patients based on the principal compartments of inflammatory disease activity.
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Affiliation(s)
- Alexis Hofherr
- Research and Early Clinical Development, Cardiovascular, Renal and Metabolism, AstraZeneca, BioPharmaceuticals R&D, Gothenburg, Sweden. .,Renal Division, Department of Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Julie Williams
- Bioscience Renal, Research and Early Development, Cardiovascular, Renal and Metabolic, AstraZeneca, BioPharmaceuticals R&D, Gothenburg, UK
| | - Li-Ming Gan
- Research and Early Clinical Development, Cardiovascular, Renal and Metabolism, AstraZeneca, BioPharmaceuticals R&D, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Department of Cardiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Söderberg
- Cardiovascular, Renal and Metabolic Safety, Clinical Pharmacology and Safety Sciences, AstraZeneca, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Pernille B L Hansen
- Bioscience Renal, Research and Early Development, Cardiovascular, Renal and Metabolic, AstraZeneca, BioPharmaceuticals R&D, Gothenburg, UK.,Wallenberg Center for Molecular and Translational Medicine, Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kevin J Woollard
- Bioscience Renal, Research and Early Development, Cardiovascular, Renal and Metabolic, AstraZeneca, BioPharmaceuticals R&D, Gothenburg, UK. .,Centre for Inflammatory Disease, Imperial College London, London, UK.
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6
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Sprangers B, Perazella MA, Lichtman SM, Rosner MH, Jhaveri KD. Improving Cancer Care for Patients With CKD: The Need for Changes in Clinical Trials. Kidney Int Rep 2022; 7:1939-1950. [PMID: 36090489 PMCID: PMC9458993 DOI: 10.1016/j.ekir.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/10/2022] [Accepted: 06/06/2022] [Indexed: 11/06/2022] Open
Abstract
Chemotherapeutic agents used to treat cancer generally have narrow therapeutic indices along with potentially serious adverse toxicities. Many cancer drugs are at least partially excreted through the kidney and, thus, the availability of accurate data on safe and effective dosing of these drugs in patients with chronic kidney disease (CKD) is essential to guide treatment decisions. Typically, during drug development, initial clinical studies only include patients with normal or only mildly impaired kidney function. In subsequent preregistration studies, a limited number of patients with more severe kidney dysfunction are included. Data obtained from patients with either severe kidney dysfunction (here defined as an estimated glomerular filtration rate [eGFR] < 30 ml/min or stage 4G CKD) or end-stage kidney disease (ESKD) requiring kidney replacement treatment are particularly limited before drug registration and only a minority of new drug applications to the US Food and Drug Administration (FDA) include data from this population. Unfortunately, limited data and/or other safety concerns may result in a manufacturer statement that the drug is contraindicated in patients with advanced kidney disease, which hinders access to potentially beneficial drugs for these patients. This systemic exclusion of patients with CKD from cancer drug trials remains an unsolved problem, which prevents provision of optimal clinical care for these patients, raises questions of inclusion, diversity, and equity. In addition, with the aging of the population, there are increasing numbers of patients with CKD and cancer who face these issues. In this review, we evaluate the scientific basis to exclude patients with CKD from cancer trials and propose a comprehensive strategy to address this problem.
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Abstract
A huge array of data in nephrology is collected through patient registries, large epidemiological studies, electronic health records, administrative claims, clinical trial repositories, mobile health devices and molecular databases. Application of these big data, particularly using machine-learning algorithms, provides a unique opportunity to obtain novel insights into kidney diseases, facilitate personalized medicine and improve patient care. Efforts to make large volumes of data freely accessible to the scientific community, increased awareness of the importance of data sharing and the availability of advanced computing algorithms will facilitate the use of big data in nephrology. However, challenges exist in accessing, harmonizing and integrating datasets in different formats from disparate sources, improving data quality and ensuring that data are secure and the rights and privacy of patients and research participants are protected. In addition, the optimism for data-driven breakthroughs in medicine is tempered by scepticism about the accuracy of calibration and prediction from in silico techniques. Machine-learning algorithms designed to study kidney health and diseases must be able to handle the nuances of this specialty, must adapt as medical practice continually evolves, and must have global and prospective applicability for external and future datasets.
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Bomback AS, Appel GB, Gipson DS, Hladunewich MA, Lafayette R, Nester CM, Parikh SV, Smith RJH, Trachtman H, Heeger PS, Ram S, Rovin BH, Ali S, Arceneaux N, Ashoor I, Bailey-Wickins L, Barratt J, Beck L, Cattran DC, Cravedi P, Erkan E, Fervenza F, Frazer-Abel AA, Fremeaux-Bacchi V, Fuller L, Gbadegesin R, Hogan JJ, Kiryluk K, le Quintrec-Donnette M, Licht C, Mahan JD, Pickering MC, Quigg R, Rheault M, Ronco P, Sarwal MM, Sethna C, Spino C, Stegall M, Vivarelli M, Feldman DL, Thurman JM. Improving Clinical Trials for Anticomplement Therapies in Complement-Mediated Glomerulopathies: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis 2021; 79:570-581. [PMID: 34571062 DOI: 10.1053/j.ajkd.2021.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/13/2021] [Indexed: 12/25/2022]
Abstract
Blocking the complement system as a therapeutic strategy has been proposed for numerous glomerular diseases but presents myriad questions and challenges, not the least of which is demonstrating efficacy and safety. In light of these potential issues and because there are an increasing number of anticomplement therapy trials either planned or under way, the National Kidney Foundation facilitated an all-virtual scientific workshop entitled "Improving Clinical Trials for Anti-Complement Therapies in Complement-Mediated Glomerulopathies." Attended by patient representatives and experts in glomerular diseases, complement physiology, and clinical trial design, the aim of this workshop was to develop standards applicable for designing and conducting clinical trials for anticomplement therapies across a wide spectrum of complement-mediated glomerulopathies. Discussions focused on study design, participant risk assessment and mitigation, laboratory measurements and biomarkers to support these studies, and identification of optimal outcome measures to detect benefit, specifically for trials in complement-mediated diseases. This report summarizes the discussions from this workshop and outlines consensus recommendations.
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Affiliation(s)
- Andrew S Bomback
- Division of Nephrology, Columbia University Irving Medical Center, New York.
| | - Gerald B Appel
- Division of Nephrology, New York University Langone Health, New York
| | - Debbie S Gipson
- Department of Pediatrics, Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | | | | | - Carla M Nester
- Division of Nephrology, University of Iowa, Iowa City, Iowa
| | - Samir V Parikh
- Division of Nephrology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Richard J H Smith
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, Iowa
| | - Howard Trachtman
- Division of Nephrology, New York University Langone Health, New York
| | - Peter S Heeger
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York
| | - Sanjay Ram
- Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University College of Medicine, Columbus, Ohio
| | | | | | - Isa Ashoor
- Division of Nephrology, Louisiana State University Health, New Orleans, Louisiana
| | | | | | - Laurence Beck
- Division of Nephrology, Boston University School of Medicine, Boston, Massachusetts
| | - Daniel C Cattran
- Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - Paolo Cravedi
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York
| | - Elif Erkan
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Ashley A Frazer-Abel
- Division of Nephrology, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | | | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Krzysztof Kiryluk
- Division of Nephrology, Columbia University Irving Medical Center, New York
| | | | - Christoph Licht
- Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - John D Mahan
- Division of Nephrology, The Ohio State University College of Medicine, Columbus, Ohio
| | | | - Richard Quigg
- Division of Nephrology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Michelle Rheault
- Division of Nephrology, University of Minnesota, Minneapolis, Minnesota
| | - Pierre Ronco
- Division of Nephrology, Sorbonne Université, Université Pierre et Marie Curie, Paris
| | - Minnie M Sarwal
- Division of Nephrology, University of California, San Francisco, California
| | - Christine Sethna
- Division of Nephrology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Cathie Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | | | - Marina Vivarelli
- Division of Nephrology, Bambino Gesu Children's Hospital, Rome, Italy
| | | | - Joshua M Thurman
- Division of Nephrology, University of Colorado School of Medicine, Aurora, Colorado
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Neuen BL, Weldegiorgis M, Herrington WG, Ohkuma T, Smith M, Woodward M. Changes in GFR and Albuminuria in Routine Clinical Practice and the Risk of Kidney Disease Progression. Am J Kidney Dis 2021; 78:350-360.e1. [PMID: 33895181 DOI: 10.1053/j.ajkd.2021.02.335] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 02/14/2021] [Indexed: 12/16/2022]
Abstract
RATIONALE & OBJECTIVE Changes in urinary albumin-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) have been used separately as alternative kidney disease outcomes in randomized trials. We tested the hypothesis that combined changes in UACR and eGFR predict advanced kidney disease better than either alone. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 91,319 primary care patients assembled from the Clinical Practice Research Datalink in the United Kingdom between 2000 and 2015. EXPOSURES Changes in UACR and eGFR (categorized as ≥30% increase, stable, or ≥30% decrease), alone and in combination, over a 3-year period. OUTCOMES The primary outcome was advanced CKD (sustained eGFR <30 mL/min/1.73 m2); secondary outcomes included kidney failure, cardiovascular disease, and all-cause mortality. ANALYTICAL APPROACH Multivariable Cox regression with bias from missing values assessed using multiple imputation; discrimination statistics compared across exposure groups. RESULTS 91,319 individuals were studied, with a mean eGFR of 72.6 mL/min/1.73 m2 and median UACR of 9.7 mg/g; 70,957 (77.7%) had diabetes. During a median follow-up of 2.9 years, 2,541 people progressed to advanced CKD. Compared with stable values, hazard ratios for a ≥30% increase in UACR and ≥30% decrease in eGFR were 1.78 (95% CI, 1.59-1.98) and 7.53 (95% CI, 6.70-8.45), respectively, for the outcome of advanced CKD. Compared with stable values of both, the hazard ratio for the combination of an increase in UACR and a decrease in eGFR was 15.15 (95% CI, 12.43-18.46) for the outcome of advanced CKD. The combination of changes in UACR and eGFR predicted kidney outcomes better than either alone. LIMITATIONS Selection bias, relatively small proportion of individuals without diabetes, and very few kidney failure events. CONCLUSIONS In a large-scale general population, the combination of an increase in UACR and a decrease in eGFR was strongly associated with the risk of advanced CKD. Further assessment of combined changes in UACR and eGFR as an alternative outcome for kidney failure in trials of CKD progression is warranted.
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Affiliation(s)
- Brendon L Neuen
- George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia.
| | - Misghina Weldegiorgis
- George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia; Department of Epidemiology and Biostatistics, School of Public Health, The George Institute for Global Health, Imperial College London, London
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, United Kingdom
| | - Toshiaki Ohkuma
- George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia; Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Margaret Smith
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Mark Woodward
- George Institute for Global Health, University of New South Wales, Newtown, New South Wales, Australia; Department of Epidemiology and Biostatistics, School of Public Health, The George Institute for Global Health, Imperial College London, London; Department of Epidemiology, John Hopkins University, Baltimore, MD
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10
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Nicholls SG, Carroll K, Goldstein CE, Brehaut JC, Weijer C, Zwarenstein M, Dixon S, Grimshaw JM, Garg AX, Taljaard M. Patient Partner Perspectives Regarding Ethically and Clinically Important Aspects of Trial Design in Pragmatic Cluster Randomized Trials for Hemodialysis. Can J Kidney Health Dis 2021; 8:20543581211032818. [PMID: 34367647 PMCID: PMC8317238 DOI: 10.1177/20543581211032818] [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: 04/14/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cluster randomized trials (CRTs) are trials in which intact groups such as hemodialysis centers or shifts are randomized to treatment or control arms. Pragmatic CRTs have been promoted as a promising trial design for nephrology research yet may also pose ethical challenges. While randomization occurs at the cluster level, the intervention and data collection may vary in a CRT, challenging the identification of research participants. Moreover, when a waiver of patient consent is granted by a research ethics committee, there is an open question as to whether and to what degree patients should be notified about ongoing research or be provided with a debrief regarding the nature and results of the trial upon completion. While empirical and conceptual research exploring ethical issues in pragmatic CRTs has begun to emerge, there has been limited discussion with patients, families, or caregivers of patients undergoing hemodialysis. OBJECTIVE To explore with patients and families with experience of hemodialysis research the challenges raised by different approaches to designing pragmatic CRTs in hemodialysis. Specifically, their perceptions of (1) the use of a waiver of consent, (2) notification processes and information provided to participants, and (3) any other concerns about cluster randomized designs in hemodialysis. DESIGN Focus group and interview discussions of hypothetical clinical trial designs. SETTING Focus groups and interviews were conducted in-person or via videoconference or telephone. PARTICIPANTS Patient partners in hemodialysis research, defined as patients with personal experience of dialysis or a family member who had experience supporting a patient receiving hemodialysis, who have been actively involved in discussions to advise a research team on the design, conduct, or implementation of a hemodialysis trial. METHODS Participants were invited to participate in focus groups or individual discussions that were audio recorded with consent. Recorded interviews were transcribed verbatim prior to analysis. Transcripts were analyzed using a thematic analysis approach. RESULTS Two focus groups, three individual interviews, and one interview involving a patient and family member were conducted with 17 individuals between February 2019 and May 2020. Participants expressed support for approaches that emphasized patient choice. Disclosure of patient-relevant risks and information were key themes. Both consent and notification processes served to generate trust, but bypassing patient choice was perceived as undermining this trust. Participants did not dismiss the option of a waiver of consent. They were, however, more restrictive in their views about when a waiver of consent may be acceptable. Patient partners were skeptical of claims to impracticability based on costs or the time commitments for staff. LIMITATIONS All participants were from Canada and had been involved in the design or conduct of a trial, limiting the degree to which results may be extrapolated. CONCLUSIONS Given the preferences of participants to be afforded the opportunity to decide about trial participation, we argue that investigators should thoroughly investigate approaches that allow participants to make an informed choice regarding trial participation. In keeping with the preference for autonomous choice, there remains a need to further explore how consent approaches can be designed to facilitate clinical trial conduct while meeting their ethical requirements. Finally, further work is needed to define the limited circumstances in which waivers of consent are appropriate.
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Affiliation(s)
- Stuart G. Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
| | | | - Jamie C. Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
| | - Charles Weijer
- Department of Philosophy, Western University, London, ON, Canada
- Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Western University, London, ON, Canada
- Department of Family Medicine, Western University, London, ON, Canada
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- ICES, Ontario, Canada
| | - Stephanie Dixon
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- ICES, Ontario, Canada
- Lawson Research Institute, London, ON, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
| | - Amit X. Garg
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- ICES, Ontario, Canada
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- Nephrology, London Health Sciences Centre, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
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Vasylchenko VS, Korol LV, Kuchmenko OB, Stepanova NM. The oxidative status in patients with chronic kidney disease. UKRAINIAN BIOCHEMICAL JOURNAL 2020. [DOI: 10.15407/ubj92.05.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Nicholls SG, Carroll K, Weijer C, Goldstein CE, Brehaut J, Sood MM, Al-Jaishi A, Basile E, Grimshaw JM, Garg AX, Taljaard M. Ethical Issues in the Design and Conduct of Pragmatic Cluster Randomized Trials in Hemodialysis Care: An Interview Study With Key Stakeholders. Can J Kidney Health Dis 2020; 7:2054358120964119. [PMID: 33194212 PMCID: PMC7597560 DOI: 10.1177/2054358120964119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pragmatic cluster randomized trials (CRTs) offer an opportunity to improve health care by answering important questions about the comparative effectiveness of treatments using a trial design that can be embedded in routine care. There is a lack of empirical research that addresses ethical issues generated by pragmatic CRTs in hemodialysis. OBJECTIVE To identify stakeholder perceptions of ethical issues in pragmatic CRTs conducted in hemodialysis. DESIGN Qualitative study using semi-structured interviews. SETTING In-person or telephone interviews with an international group of stakeholders. PARTICIPANTS Stakeholders (clinical investigators, methodologists, ethicists and research ethics committee members, and other knowledge users) who had been involved in the design or conduct of a pragmatic individual patient or cluster randomized trial in hemodialysis, or their role would require them to review and evaluate pragmatic CRTs in hemodialysis. METHODS Interviews were conducted in-person or over the telephone and were audio-recorded with consent. Recorded interviews were transcribed verbatim prior to analysis. Transcripts and field notes were analyzed using a thematic analysis approach. RESULTS Sixteen interviews were conducted with 19 individuals. Interviewees were largely drawn from North America (84%) and were predominantly clinical investigators (42%). Six themes were identified in which pragmatic CRTs in hemodialysis raise ethical issues: (1) patients treated with hemodialysis as a vulnerable population, (2) appropriate approaches to informed consent, (3) research burdens, (4) roles and responsibilities of gatekeepers, (5) inequities in access to research, and (6) advocacy for patient-centered research and outcomes. LIMITATIONS Participants were largely from North America and did not include research staff, who may have differing perspectives. CONCLUSIONS The six themes reflect concerns relating to individual rights, but also the need to consider population-level issues. To date, concerns regarding inequity of access to research and the need for patient-centered research have received less coverage than other, well-known, issues such as consent. Pragmatic CRTs offer a potential approach to address equity concerns and we suggest future ethical analyses and guidance for pragmatic CRTs in hemodialysis embed equity considerations within them. We further note the potential for the co-creation of health data infrastructure with patients which would aid care but also facilitate patient-centered research. These present results will inform planned future guidance in relation to the ethical design and conduct of pragmatic CRTs in hemodialysis. TRIAL REGISTRATION Registration is not applicable as this is a qualitative study.
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Affiliation(s)
- Stuart G. Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Charles Weijer
- Department of Philosophy, Western University, London, Canada
- Department of Medicine, Western University, London, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Canada
| | | | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Manish M. Sood
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Jindal Research Chair for the Prevention of Kidney Disease, The Ottawa Hospital, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ontario, Canada
| | - Ahmed Al-Jaishi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Erika Basile
- Research Ethics and Compliance, Western University, London, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Amit X. Garg
- Department of Epidemiology and Biostatistics, Western University, London, Canada
- Institute for Clinical Evaluative Sciences, Ontario, Canada
- Division of Nephrology- Department of Medicine, Western University, London, Canada
- Nephrology, London Health Sciences Centre, London, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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International consensus definitions of clinical trial outcomes for kidney failure: 2020. Kidney Int 2020; 98:849-859. [DOI: 10.1016/j.kint.2020.07.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 01/30/2023]
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Neuen BL, Perkovic V. Pilot Trials in Nephrology: Establishing a BASE for Large-Scale Randomized Trials. J Am Soc Nephrol 2020; 31:4-6. [PMID: 31871251 PMCID: PMC6934990 DOI: 10.1681/asn.2019111196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Affiliation(s)
| | - Vlado Perkovic
- The George Institute for Global Health and
- Faculty of Medicine, University of New South Wales, Sydney, Australia
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