1
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Docherty NG, Delles C, López-Hernández FJ. Reframing acute kidney injury as a pathophysiological continuum of disrupted renal excretory function. Acta Physiol (Oxf) 2024; 240:e14181. [PMID: 38808913 DOI: 10.1111/apha.14181] [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: 12/04/2023] [Revised: 05/07/2024] [Accepted: 05/15/2024] [Indexed: 05/30/2024]
Abstract
Surrogate measures of glomerular filtration rate (GFR) continue to serve as pivotal determinants of the incidence, severity, and management of acute kidney injury (AKI), as well as the primary reference point underpinning knowledge of its pathophysiology. However, several clinically important deficits in aspects of renal excretory function during AKI other than GFR decline, including acid-base regulation, electrolyte and water balance, and urinary concentrating capacity, can evade detection when diagnostic criteria are built around purely GFR-based assessments. The use of putative markers of tubular injury to detect "sub-clinical" AKI has been proposed to expand the definition and diagnostic criteria for AKI, but their diagnostic performance is curtailed by ambiguity with respect to their biological meaning and context specificity. Efforts to devise new holistic assessments of overall renal functional compromise in AKI would foster the capacity to better personalize patient care by replacing biomarker threshold-based diagnostic criteria with a shift to assessment of compromise along a pathophysiological continuum. The term AKI refers to a syndrome of sudden renal deterioration, the severity of which is classified by precise diagnostic criteria that have unquestionable utility in patient management as well as blatant limitations. Particularly, the absence of an explicit pathophysiological definition of AKI curtails further scientific development and clinical handling, entrapping the field within its present narrow GFR-based view. A refreshed approach based on a more holistic consideration of renal functional impairment in AKI as the basis for a new diagnostic concept that reaches beyond the boundaries imposed by the current GFR threshold-based classification of AKI, capturing broader aspects of pathogenesis, could enhance AKI prevention strategies and improve AKI patient outcome and prognosis.
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Grants
- Instituto de Salud Carlos III
- European Commission
- Consejería de Educación, Junta de Castilla y León
- This study was supported by grants from the Instituto de Salud Carlos III (ISCIII), Spain (PI18/00996, PI21/01226), co-funded by FEDER, Fondo Europeo de Desarrollo Regional "Una manera de hacer Europa", co-funded by the the European Union, Red de Investigación Renal RICORS2040 (Kidney Disease) RD21/0005/0004 funded by the European Union - NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia (MRR), and from the Consejería de Educación, Junta de Castilla y León (IES160P20), Spain, co-funded by FEDER funds from the European Union.
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Affiliation(s)
- Neil G Docherty
- Diabetes Complications Research Centre, Conway Institute of Biomolecular and Biomedical Research, School of Medicine, University College Dublin, Dublin, Ireland
- Disease and Theranostic Modelling (DisMOD) Working Group
| | - Christian Delles
- Disease and Theranostic Modelling (DisMOD) Working Group
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Francisco J López-Hernández
- Disease and Theranostic Modelling (DisMOD) Working Group
- Instituto de Investigación Biomédica de Salamanca (IBSAL) de la Fundación Instituto de Ciencias de la Salud de Castilla y León (ICSCYL); Universidad de Salamanca (USAL), Departamento de Fisiología y Farmacología, Salamanca, Spain
- National Network for Kidney Research RICORS2040 RD21/0005/0004, Instituto de Salud Carlos III, Madrid, Spain
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2
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Xu W, Chen W, Guo J, Zhao L, Ren G, Huang X. Acute kidney injury during autologous stem cell transplantation in light chain amyloidosis with kidney involvement and their impact on prognosis. Bone Marrow Transplant 2024; 59:1076-1083. [PMID: 38658659 DOI: 10.1038/s41409-024-02292-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 04/14/2024] [Accepted: 04/16/2024] [Indexed: 04/26/2024]
Abstract
Acute kidney injury (AKI) is a complication related to important organ dysfunction during autologous stem cell transplantation (ASCT) in light chain (AL) amyloidosis. This study aims to validate the risk factors of AKI during different periods of ASCT and the impact of AKI on long-term outcomes. 302 patients with AL amyloidosis and kidney involvement who underwent ASCT were included. The procedures from stem cell mobilization to 30 days after transplantation were categorized into four periods: Period 0 (stem cell mobilization and harvest), Period 1 (preparation), Period 2 (conditioning and transplantation), and Period 3 (engraftment). The incidence of AKI during ASCT was 27.15% (0.66% in Period 0, 6.62% in Period 1, 15.23% in Period 2, and 6.95% in Period 3). The major causes of AKI were capillary leak syndrome in Period 0, ganciclovir or sulfamethoxazole/trimethoprim in Period 1, high-dose melphalan in Period 2, and engraftment syndrome in Period 3. AKI in different periods had distinct risk factors and predictive models. AKI was a risk factor for both kidney survival and overall survival (OS). Even recovered AKI reduced 10-year kidney survival from 91.7% to 68.4% (p = 0.002) and 10-year OS from 91.1% to 77.7% (p = 0.005).
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Affiliation(s)
- Weiwei Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Wencui Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Jinzhou Guo
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Liang Zhao
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Guisheng Ren
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xianghua Huang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.
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3
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Legrand M, McCoy IE, Tallarico RT. Decision-making in Perioperative Oliguria: Reply. Anesthesiology 2024:141756. [PMID: 39008510 DOI: 10.1097/aln.0000000000005062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Affiliation(s)
- Matthieu Legrand
- University of California San Francisco, San Francisco, California (M.L.).
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4
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McCoy IE, Chertow GM. The Use of Kidney Disease Improving Global Outcomes AKI Definitions in AKI Research: PRO. KIDNEY360 2024; 5:941-943. [PMID: 38833308 PMCID: PMC11296524 DOI: 10.34067/kid.0000000000000486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 05/31/2024] [Indexed: 06/06/2024]
Affiliation(s)
- Ian E. McCoy
- Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Glenn M. Chertow
- Departments of Medicine, Epidemiology and Population Health, and Health Policy, Stanford University School of Medicine, Stanford, California
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5
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Srivastava A, Schmidt IM, Palsson R. Combined Angiotensin Inhibition for CKD: The Truth Is Rarely Pure and Never Simple. Am J Kidney Dis 2024; 83:130-132. [PMID: 38069999 DOI: 10.1053/j.ajkd.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/22/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Anand Srivastava
- Division of Nephrology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Insa M Schmidt
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts; Hamburg Center for Kidney Health, University Medical Center Hamburg, Hamburg, Germany
| | - Ragnar Palsson
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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6
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Barreto EF, Cerda J, Freshly B, Gewin L, Kwong YD, McCoy IE, Neyra JA, Ng JH, Silver SA, Vijayan A, Abdel-Rahman EM. Optimum Care of AKI Survivors Not Requiring Dialysis after Discharge: An AKINow Recovery Workgroup Report. KIDNEY360 2024; 5:124-132. [PMID: 37986185 PMCID: PMC10833609 DOI: 10.34067/kid.0000000000000309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 11/08/2023] [Indexed: 11/22/2023]
Abstract
AKI survivors experience gaps in care that contribute to worse outcomes, experience, and cost.Challenges to optimal care include issues with information transfer, education, collaborative care, and use of digital health tools.Research is needed to study these challenges and inform optimal use of diagnostic and therapeutic interventions to promote recovery AKI affects one in five hospitalized patients and is associated with poor short-term and long-term clinical and patient-centered outcomes. Among those who survive to discharge, significant gaps in documentation, education, communication, and follow-up have been observed. The American Society of Nephrology established the AKINow taskforce to address these gaps and improve AKI care. The AKINow Recovery workgroup convened two focus groups, one each focused on dialysis-independent and dialysis-requiring AKI, to summarize the key considerations, challenges, and opportunities in the care of AKI survivors. This article highlights the discussion surrounding care of AKI survivors discharged without the need for dialysis. On May 3, 2022, 48 patients and multidisciplinary clinicians from diverse settings were gathered virtually. The agenda included a patient testimonial, plenary sessions, facilitated small group discussions, and debriefing. Core challenges and opportunities for AKI care identified were in the domains of transitions of care, education, collaborative care delivery, diagnostic and therapeutic interventions, and digital health applications. Integrated multispecialty care delivery was identified as one of the greatest challenges to AKI survivor care. Adequate templates for communication and documentation; education of patients, care partners, and clinicians about AKI; and a well-coordinated multidisciplinary posthospital follow-up plan form the basis for a successful care transition at hospital discharge. The AKINow Recovery workgroup concluded that advancements in evidence-based, patient-centered care of AKI survivors are needed to improve health outcomes, care quality, and patient and provider experience. Tools are being developed by the AKINow Recovery workgroup for use at the hospital discharge to facilitate care continuity.
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Affiliation(s)
| | - Jorge Cerda
- Division of Nephrology, Department of Medicine, Albany Medical College, Albany, New York
| | | | - Leslie Gewin
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Y. Diana Kwong
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - Ian E. McCoy
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
| | - Javier A. Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jia H. Ng
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York
| | - Samuel A. Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, Ontario, Canada
| | - Anitha Vijayan
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Emaad M. Abdel-Rahman
- Division of Nephrology, Department of Medicine, University of Virginia, Charlottesville, VA
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7
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Sancho-Martínez SM, López-Hernández FJ. Pathophysiology of Acute Kidney Frailty. Physiology (Bethesda) 2023; 38:0. [PMID: 37738019 DOI: 10.1152/physiol.00011.2023] [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: 04/27/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 09/23/2023] Open
Abstract
Acute kidney frailty is a premorbid condition of diminished renal functional reserve that predisposes to acute kidney injury; this condition results from subclinical wear or distortion of renal homeostatic responses that protect the renal excretory function. Knowledge of its pathophysiological basis is critical for the development of diagnostic and therapeutic strategies that allow for prophylactic intervention and disease prevention.
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Affiliation(s)
- Sandra M Sancho-Martínez
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Departamento de Fisiología y Farmacología, Universidad de Salamanca, Salamanca, Spain
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
- National Network for Kidney Research RICORS2040 RD21/0005/0004, Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco J López-Hernández
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Departamento de Fisiología y Farmacología, Universidad de Salamanca, Salamanca, Spain
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
- National Network for Kidney Research RICORS2040 RD21/0005/0004, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Estudios de Ciencias de la Salud de Castilla y León (IECSCYL), Soria, Spain
- Group of Biomedical Research on Critical Care (BioCritic), Valladolid, Spain
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8
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McCoy IE, Hsu JY, Zhang X, Diamantidis CJ, Taliercio J, Go AS, Liu KD, Drawz P, Srivastava A, Horwitz EJ, He J, Chen J, Lash JP, Weir MR, Hsu CY. Probing the Association between Acute Kidney Injury and Cardiovascular Outcomes. Clin J Am Soc Nephrol 2023; 18:850-857. [PMID: 37116457 PMCID: PMC10356151 DOI: 10.2215/cjn.0000000000000163] [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: 01/10/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Patients hospitalized with AKI have higher subsequent risks of heart failure, atherosclerotic cardiovascular events, and mortality than their counterparts without AKI, but these higher risks may be due to differences in prehospitalization patient characteristics, including the baseline level of estimated glomerular filtration rate (eGFR), the rate of prior eGFR decline, and the proteinuria level, rather than AKI itself. METHODS Among 2177 adult participants in the Chronic Renal Insufficiency Cohort study who were hospitalized in 2013-2019, we compared subsequent risks of heart failure, atherosclerotic cardiovascular events, and mortality between those with serum creatinine-based AKI (495 patients) and those without AKI (1682 patients). We report both crude associations and associations sequentially adjusted for prehospitalization characteristics including eGFR, eGFR slope, and urine protein-creatinine ratio (UPCR). RESULTS Compared with patients hospitalized without AKI, those with hospitalized AKI had lower eGFR prehospitalization (42 versus 49 ml/min per 1.73 m 2 ), faster chronic loss of eGFR prehospitalization (-0.84 versus -0.51 ml/min per 1.73 m 2 per year), and more proteinuria prehospitalization (UPCR 0.28 versus 0.16 g/g); they also had higher prehospitalization systolic BP (130 versus 127 mm Hg; P < 0.01 for all comparisons). Adjustment for prehospitalization patient characteristics attenuated associations between AKI and all three outcomes, but AKI remained an independent risk factor. Attenuation of risk was similar after adjustment for absolute eGFR, eGFR slope, or proteinuria, individually or in combination. CONCLUSIONS Prehospitalization variables including eGFR, eGFR slope, and proteinuria confounded associations between AKI and adverse cardiovascular outcomes, but these associations remained significant after adjusting for prehospitalization variables.
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Affiliation(s)
- Ian E. McCoy
- Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Jesse Y. Hsu
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xiaoming Zhang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Jonathan Taliercio
- Department of Kidney Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Kathleen D. Liu
- Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Paul Drawz
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota
| | - Anand Srivastava
- Division of Nephrology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Edward J. Horwitz
- Division of Nephrology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jiang He
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
| | - Jing Chen
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
- Division of Nephrology, Tulane University, New Orleans, Louisiana
| | - James P. Lash
- Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, Illinois
| | - Matthew R. Weir
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Chi-yuan Hsu
- Division of Nephrology, University of California San Francisco, San Francisco, California
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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9
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Lazzareschi D, Mehta RL, Dember LM, Bernholz J, Turan A, Sharma A, Kheterpal S, Parikh CR, Ali O, Schulman IH, Ryan A, Feng J, Simon N, Pirracchio R, Rossignol P, Legrand M. Overcoming barriers in the design and implementation of clinical trials for acute kidney injury: a report from the 2020 Kidney Disease Clinical Trialists meeting. Nephrol Dial Transplant 2023; 38:834-844. [PMID: 35022767 PMCID: PMC10064977 DOI: 10.1093/ndt/gfac003] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Indexed: 12/15/2022] Open
Abstract
Acute kidney injury (AKI) is a growing epidemic and is independently associated with increased risk of death, chronic kidney disease (CKD) and cardiovascular events. Randomized-controlled trials (RCTs) in this domain are notoriously challenging and many clinical studies in AKI have yielded inconclusive findings. Underlying this conundrum is the inherent heterogeneity of AKI in its etiology, presentation and course. AKI is best understood as a syndrome and identification of AKI subphenotypes is needed to elucidate the disease's myriad etiologies and to tailor effective prevention and treatment strategies. Conventional RCTs are logistically cumbersome and often feature highly selected patient populations that limit external generalizability and thus alternative trial designs should be considered when appropriate. In this narrative review of recent developments in AKI trials based on the Kidney Disease Clinical Trialists (KDCT) 2020 meeting, we discuss barriers to and strategies for improved design and implementation of clinical trials for AKI patients, including predictive and prognostic enrichment techniques, the use of pragmatic trials and adaptive trials.
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Affiliation(s)
- Daniel Lazzareschi
- Department of Anesthesia & Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Ravindra L Mehta
- Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Laura M Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Pennsylvania, PA, USA
| | | | - Alparslan Turan
- Department of Anesthesiology, Lerner College of Medicine of Case Western University, Cleveland, OH, USA
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | | | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Chirag R Parikh
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Omar Ali
- Verpora Ltd, Nottingham, UK
- University of Portsmouth, UK
| | - Ivonne H Schulman
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Abigail Ryan
- Division of Chronic Care Management, Centers for Medicare & Medicaid Services, Woodlawn, MD, USA
| | - Jean Feng
- Department of Epidemiology and Biostatistics, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Noah Simon
- Department of Biostatistics, University of Washington (UW), Seattle, WA, USA
| | - Romain Pirracchio
- Department of Anesthesia & Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Patrick Rossignol
- INI-CRCT Network, Nancy, France
- University of Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116, Nancy, France
| | - Matthieu Legrand
- Department of Anesthesia & Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
- INI-CRCT Network, Nancy, France
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10
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Qin Z, Li H, Jiao P, Jiang L, Geng J, Yang Q, Liao R, Su B. The value of urinary interleukin-18 in predicting acute kidney injury: a systematic review and meta-analysis. Ren Fail 2022; 44:1717-1731. [PMID: 36259446 PMCID: PMC9586591 DOI: 10.1080/0886022x.2022.2133728] [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] [Indexed: 11/16/2022] Open
Abstract
Aims The aim of this study was to systematically review relevant studies to evaluate the value of urinary interleukin-18 (uIL-18) in predicting acute kidney injury (AKI). Methods A comprehensive search of PubMed, Medline, Embase, and Cochrane Library was conducted for literature published up to 1 August 2022. Quality Assessment Tool for Diagnostic Accuracy Studies-2 (QUADAS-2) was applied to assess the literature quality. Then, relevant data were extracted from each eligible study and a random-effects regression model was utilized to pool sensitivity, specificity, and construct summary receiver operating characteristic (SROC) and area under curve (AUC). Results Twenty-six studies with 7183 patients were enrolled and relevant information was extracted. The estimated sensitivity and specificity of uIL-18 in the diagnosis of AKI were 0.64 (95% confidence interval (CI): 0.54–0.73) and 0.77 (95%CI: 0.71–0.83), respectively. The pooled diagnostic odds ratio (DOR) was 6.08 (95%CI: 3.63–10.18), and the AUC of uIL-18 in predicting AKI was 0.78 (95%CI: 0.74–0.81). Subgroup analysis showed that uIL-18 in pediatric patients was more effective in predicting AKI than in adults (DOR: 7.33 versus 5.75; AUC: 0.81 versus 0.77). Conclusions Urinary IL-18 could be a relatively good biomarker with moderate predictive value for AKI, especially in pediatric patients. However, further research and clinical settings are still needed to validate our findings.
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Affiliation(s)
- Zheng Qin
- Department of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China.,Med-X Center for Materials, Sichuan University, Chengdu, China.,Med + Biomaterial Institute of West China Hospital/West China School of Medicine of Sichuan University, Chengdu, China
| | - Hancong Li
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Pengcheng Jiao
- West China School of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Luojia Jiang
- Department of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China.,Med-X Center for Materials, Sichuan University, Chengdu, China.,Med + Biomaterial Institute of West China Hospital/West China School of Medicine of Sichuan University, Chengdu, China
| | - Jiwen Geng
- Department of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China.,Med-X Center for Materials, Sichuan University, Chengdu, China.,Med + Biomaterial Institute of West China Hospital/West China School of Medicine of Sichuan University, Chengdu, China
| | - Qinbo Yang
- Department of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China.,Med-X Center for Materials, Sichuan University, Chengdu, China.,Med + Biomaterial Institute of West China Hospital/West China School of Medicine of Sichuan University, Chengdu, China
| | - Ruoxi Liao
- Department of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China.,Med-X Center for Materials, Sichuan University, Chengdu, China.,Med + Biomaterial Institute of West China Hospital/West China School of Medicine of Sichuan University, Chengdu, China
| | - Baihai Su
- Department of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, China.,Med-X Center for Materials, Sichuan University, Chengdu, China.,Med + Biomaterial Institute of West China Hospital/West China School of Medicine of Sichuan University, Chengdu, China
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11
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Major adverse kidney events after acute kidney injury in the pediatric intensive care unit: a propensity score-matched cohort study. Pediatr Nephrol 2022; 37:2099-2107. [PMID: 35041037 DOI: 10.1007/s00467-021-05348-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) in patients admitted to the pediatric intensive care unit (PICU) is associated with poor short-term and long-term outcomes. Greater awareness of long-term AKI-associated outcomes is needed to optimally plan follow-up and management after ICU discharge. We used propensity score methods to study associations between pediatric AKI and major adverse kidney outcomes, including mortality. METHODS We included all children 6 months-18 years admitted to PICU at Seattle Children's Hospital from 7/1/2009 to 12/31/2018. Our primary outcome measure was Major Adverse Kidney Events at 30 days (MAKE30): creatinine > 200% of baseline, eGFR < 60 mL/min/1.73 m2, dialysis dependence, or mortality. Propensity scores for AKI development in PICU were generated using demographic, medical history, admission, and PICU hospitalization variables. Patients with AKI were matched to control patients without AKI. Logistic regression was used to test association between AKI status and MAKE30. RESULTS In the unmatched cohort (n = 878), patients with AKI had lower platelet count (160 vs. 222) and higher PRISM III score (11 vs. 3.5). After propensity score matching, those with AKI vs. no AKI had similar PRISM III scores (9 vs. 10) and platelet count (163 vs. 159). AKI was significantly associated with MAKE30 after propensity score matching (OR: 2.97; 95% CI 1.82-4.84). CONCLUSIONS Propensity score matching significantly reduced imbalance in baseline characteristics between those with and without AKI. After matching, AKI remained significantly associated with MAKE30. Patients who developed AKI were more likely to have abnormal kidney function at 30 and 90 days after ICU admission and may be at high risk for developing CKD in the future. A higher resolution version of the Graphical abstract is available as Supplementary information.
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12
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Legrand M, Bagshaw SM, Koyner JL, Schulman IH, Mathis MR, Bernholz J, Coca S, Gallagher M, Gaudry S, Liu KD, Mehta RL, Pirracchio R, Ryan A, Steubl D, Stockbridge N, Erlandsson F, Turan A, Wilson FP, Zarbock A, Bokoch MP, Casey JD, Rossignol P, Harhay MO. Optimizing the Design and Analysis of Future AKI Trials. J Am Soc Nephrol 2022; 33:1459-1470. [PMID: 35831022 PMCID: PMC9342638 DOI: 10.1681/asn.2021121605] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
AKI is a complex clinical syndrome associated with an increased risk of morbidity and mortality, particularly in critically ill and perioperative patient populations. Most AKI clinical trials have been inconclusive, failing to detect clinically important treatment effects at predetermined statistical thresholds. Heterogeneity in the pathobiology, etiology, presentation, and clinical course of AKI remains a key challenge in successfully testing new approaches for AKI prevention and treatment. This article, derived from the "AKI" session of the "Kidney Disease Clinical Trialists" virtual workshop held in October 2021, reviews barriers to and strategies for improving the design and implementation of clinical trials in patients with, or at risk of, developing AKI. The novel approaches to trial design included in this review span adaptive trial designs that increase the knowledge gained from each trial participant; pragmatic trial designs that allow for the efficient enrollment of sufficiently large numbers of patients to detect small, but clinically significant, treatment effects; and platform trial designs that use one trial infrastructure to answer multiple clinical questions simultaneously. This review also covers novel approaches to clinical trial analysis, such as Bayesian analysis and assessing heterogeneity in the response to therapies among trial participants. We also propose a road map and actionable recommendations to facilitate the adoption of the reviewed approaches. We hope that the resulting road map will help guide future clinical trial planning, maximize learning from AKI trials, and reduce the risk of missing important signals of benefit (or harm) from trial interventions.
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco, San Francisco, California
- French Clinical Research Infrastructure Network, Investigation Network Initiative Cardiovascular and Renal Trialists, Nancy, France
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Ivonne H Schulman
- Division of Kidney, Urologic and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Michael R Mathis
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Steven Coca
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Stéphane Gaudry
- French Clinical Research Infrastructure Network, Investigation Network Initiative Cardiovascular and Renal Trialists, Nancy, France
- Département de Réanimation, Medical and surgical intensive care unit, Assistance Publique-Hôpitaux de Paris Hôpital Avicenne, Bobigny, France
- Common and Rare Kidney Diseases, Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), UMR-S 1155, Paris, France
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, California
| | - Ravindra L Mehta
- Department of Medicine, University of California San Diego, San Diego, California
| | - Romain Pirracchio
- Department of Anesthesia and Perioperative Medicine, University of California San Francisco, San Francisco, California
| | - Abigail Ryan
- Division of Chronic Care Management, Chronic Care Policy Group, Center for Medicare, Center for Medicare and Medicaid Services, Baltimore, Maryland
| | - Dominik Steubl
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Norman Stockbridge
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | - Alparslan Turan
- Department of Anesthesiology, Lerner College of Medicine of Case Western University, Cleveland, Ohio
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - F Perry Wilson
- Section of Nephrology and Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Michael P Bokoch
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco, San Francisco, California
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Patrick Rossignol
- French Clinical Research Infrastructure Network, Investigation Network Initiative Cardiovascular and Renal Trialists, Nancy, France
- University of Lorraine, INSERM CIC 1433, Nancy, France
- Nancy CHRU, INSERM U1116, Nancy, French national institute of Health and Medical Research, unit 1116, Nancy, France
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Laboratory, PAIR (Palliative and Advanced Illness Research) Center, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Juan C, Zhu Y, Chen Y, Mao Y, Zhou Y, Zhu W, Wang X, Wang Q. Knocking down ETS Proto-oncogene 1 (ETS1) alleviates the pyroptosis of renal tubular epithelial cells in patients with acute kidney injury by regulating the NLR family pyrin domain containing 3 (NLRP3) transcription. Bioengineered 2022; 13:12927-12940. [PMID: 35611792 PMCID: PMC9275905 DOI: 10.1080/21655979.2022.2079242] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute kidney injury (AKI) has a high mortality rate, but its pathogenesis remains unclear Lipopolysaccharide (LPS)-mediated renal tubular epithelial pyroptosis is involved in the pathogenesis of AKI. NLR family of pyrin domains containing 3 (NLRP3) plays an important role in pyroptosis. To further understand the transcriptional regulation mechanism of NLRP3, the peripheral blood of patients with AKI was analyzed in this study, showing that the levels of NLRP3 and cell pyroptosis in patients with AKI were significantly higher than those in normal controls. Furthermore, elevated levels of NLRP3 and cell pyroptosis were found in renal tubular epithelial cells after LPS treatment. Transcription factor ETS Proto-Oncogene 1 (ETS1) could bind to the upstream promoter transcription site of NLRP3 to transactivate NLRP3 in renal tubular epithelial cells. The cell pyroptosis level also decreased by knocking down ETS1. It is concluded that knocking down of ETS1 may reduce the renal tubular epithelial pyroptosis by regulating the transcription of NLRP3, thus relieving AKI. ETS1 is expected to be a molecular target for the treatment of AKI.
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Affiliation(s)
- Chenxia Juan
- Department of Nephrology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Ye Zhu
- Department of Nephrology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yan Chen
- Department of Nephrology, Jiangsu Province Geriatric Hospital, Jiangsu Province Official Hospital, Nanjing, Jiangsu, China
| | - Yan Mao
- Department of Pediatrics, the First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yan Zhou
- Department of Nephrology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Weiwei Zhu
- Department of Nephrology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Xufang Wang
- Department of Nephrology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Qian Wang
- Department of Pediatrics, Shanghai General Hospital, Shanghai, Minhang, China
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14
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Rangaswami J, Bhalla V, Chertow GM, Harrington RA, Staruschenko A, Tuttle K, Braunwald E. Changing the Trajectory of Heart Failure and Kidney Disease. Clin J Am Soc Nephrol 2022; 17:742-745. [PMID: 35232819 PMCID: PMC9269572 DOI: 10.2215/cjn.00470122] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Janani Rangaswami
- Division of Nephrology, George Washington University School of Medicine, Washington, DC
| | - Vivek Bhalla
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Robert A. Harrington
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Alexander Staruschenko
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
| | - Katherine Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, Washington
- Division of Nephrology, University of Washington School of Medicine, Seattle, Washington
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
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15
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Kwong YD, Liu KD, Hsu RK. Kidney Dysfunction After Acute Heart Failure: Is Acute Kidney Disease the New Acute Kidney Injury? Kidney Int Rep 2022; 7:378-380. [PMID: 35257051 PMCID: PMC8897667 DOI: 10.1016/j.ekir.2021.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Y. Diana Kwong
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Kathleen D. Liu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Critical Care Medicine, Department of Anesthesia, University of California, San Francisco, San Francisco, California, USA
| | - Raymond K. Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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16
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Wang F, Wang JN, He XY, Suo XG, Li C, Ni WJ, Cai YT, He Y, Fang XY, Dong YH, Xing T, Yang YR, Zhang F, Zhong X, Zang HM, Liu MM, Li J, Meng XM, Jin J. Stratifin promotes renal dysfunction in ischemic and nephrotoxic AKI mouse models via enhancing RIPK3-mediated necroptosis. Acta Pharmacol Sin 2022; 43:330-341. [PMID: 33833407 PMCID: PMC8791945 DOI: 10.1038/s41401-021-00649-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/12/2021] [Indexed: 02/03/2023] Open
Abstract
Stratifin (SFN) is a member of the 14-3-3 family of highly conserved soluble acidic proteins, which regulates a variety of cellular activities such as cell cycle, cell growth and development, cell survival and death, and gene transcription. Acute kidney injury (AKI) is prevalent disorder characterized by inflammatory response, oxidative stress, and programmed cell death in renal tubular epithelial cells, but there is still a lack of effective therapeutic target for AKI. In this study, we investigated the role of SFN in AKI and the underlying mechanisms. We established ischemic and nephrotoxic AKI mouse models caused by ischemia-reperfusion (I/R) and cisplatin, respectively. We conducted proteomic and immunohistochemical analyses and found that SFN expression levels were significantly increased in AKI patients, cisplatin- or I/R-induced AKI mice. In cisplatin- or hypoxia/reoxygenation (H/R)-treated human proximal tubule epithelial cells (HK2), we showed that knockdown of SFN significantly reduced the expression of kidney injury marker Kim-1, attenuated programmed cell death and inflammatory response. Knockdown of SFN also significantly alleviated the decline of renal function and histological damage in cisplatin-caused AKI mice in vivo. We further revealed that SFN bound to RIPK3, a key signaling modulator in necroptosis, to induce necroptosis and the subsequent inflammation in cisplatin- or H/R-treated HK2 cells. Overexpression of SFN increased Kim-1 protein levels in cisplatin-treated MTEC cells, which was suppressed by RIPK3 knockout. Taken together, our results demonstrate that SFN that enhances cisplatin- or I/R-caused programmed cell death and inflammation via interacting with RIPK3 may serve as a promising therapeutic target for AKI treatment.
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Affiliation(s)
- Fang Wang
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Jia-nan Wang
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Xiao-yan He
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Xiao-guo Suo
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Chao Li
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Wei-jian Ni
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China ,grid.59053.3a0000000121679639Department of Pharmacy, Anhui Provincial Hospital, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001 China
| | - Yu-ting Cai
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Yuan He
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Xin-yun Fang
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Yu-hang Dong
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Tian Xing
- grid.186775.a0000 0000 9490 772XHospital of Stomatology, Anhui Medical University, Key Laboratory of Oral Diseases Research of Anhui Province, Hefei, 230032 China
| | - Ya-ru Yang
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Feng Zhang
- grid.73113.370000 0004 0369 1660Department of Pharmacy, Changzheng Hospital, Naval Medical University, Shanghai, 200003 China
| | - Xiang Zhong
- grid.54549.390000 0004 0369 4060Department of Nephrology, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072 China
| | - Hong-mei Zang
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Ming-ming Liu
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Jun Li
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Xiao-ming Meng
- grid.186775.a0000 0000 9490 772XInflammation and Immune Mediated Diseases Laboratory of Anhui Province, Anhui Institute of Innovative Drugs, School of Pharmacy, Anhui Medical University, The Key Laboratory of Anti-inflammatory of Immune Medicines, Ministry of Education, Hefei, 230032 China
| | - Juan Jin
- grid.186775.a0000 0000 9490 772XSchool of Basic Medical Sciences, Anhui Medical University, Hefei, 230032 China
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17
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McCoy IE, Han J, Montez-Rath ME, Chertow GM. Barriers to ACEI/ARB Use in Proteinuric Chronic Kidney Disease: An Observational Study. Mayo Clin Proc 2021; 96:2114-2122. [PMID: 33952396 PMCID: PMC8973200 DOI: 10.1016/j.mayocp.2020.12.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/23/2020] [Accepted: 12/23/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To assess present angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) use among patients with proteinuric chronic kidney disease (CKD) and examine barriers limiting this guideline-concordant care. PATIENTS AND METHODS Using a nationwide database containing patient-level claims and integrated clinical information, we examined current ACEI/ARB prescriptions on the index date (April 15, 2017) and prior ACEI/ARB use in 41,743 insured adults with proteinuric CKD. Using multivariable logistic regression, we estimated adjusted associations between current ACEI/ARB use and putative barriers including past acute kidney injury (AKI), hyperkalemia, advanced CKD, and lack of nephrology care. RESULTS Only 49% (n=20,641) of patients had an active ACEI/ARB prescription on the index date, but 87% (n=36,199) had been previously prescribed an ACEI/ARB. Use was lower in patients with past AKI, hyperkalemia, CKD stages 4 or 5, and a lack of nephrology care (adjusted odds ratios were 0.61 [95% CI, 0.58 to 0.64], 0.76 [95% CI, 0.72 to 0.80], 0.48 [95% CI, 0.45 to 0.51], and 0.85 [95% CI, 0.81 to 0.89], respectively). CONCLUSION Discontinuing, rather than never initiating, ACEI/ARB treatment limits guideline-concordant care in proteinuric CKD. Past AKI, hyperkalemia, advanced CKD, and lack of nephrology care were associated with lower use of ACEIs/ARBs, but these putative barriers may in many instances be inappropriate (AKI and advanced CKD) or modifiable (hyperkalemia and lack of nephrology care).
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Affiliation(s)
- Ian E McCoy
- Division of Nephrology, University of California, San Francisco, CA.
| | - Jialin Han
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
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