Lifestyle interventions for preventing and ameliorating CKD in primary and secondary care

Are Digital Health Technologies and Models of Nutrition Care the Future of Chronic Kidney Disease Management?

People living with chronic kidney disease (CKD) require long-term support at varying levels of individualization, intensity, and frequency. Mobile and digital models of nutrition care can facilitate long-term behavior change, address nutrition issues proactively, reduce travel burden, and reach people without access to health care more easily. However, while traditional health delivery continues to be digitally disrupted, there are many barriers to address before mobile and digitally supported models of nutrition care can become business as usual in nephrology and nutrition care practice. This paper overviews the current evidence base concerning the past and present mobile and digital health programs to improve nutrition in CKD and highlights the novel future trends in this field. The way nutrition and dietetic care can be feasible, safe, and potentially effective when delivered using various digital and virtual technologies, including consultations, assessments, establishment of diagnoses, formulation of plans, and monitoring/reviewing clinical progress is discussed. Of the available evidence to date, these modalities appear to improve dietary sodium intake and diet quality, self-efficacy, interdialytic weight gain, and body weight. Many barriers exist to sustaining the continued and widespread adoption of digital and mobile health-supported nutrition care in CKD. These include patient-, clinician-, and health system-specific and are discussed in detail. Mobile and digital-supported models of nutrition care present an exciting opportunity to assist kidney dietitians deliver patient-centred nutrition care in CKD.

Animal Protein Intake and Possible Cardiovascular Risk in People With Chronic Kidney Disease: Mechanisms and Evidence

Individuals with chronic kidney disease (CKD) have an increased risk of cardiovascular disease (CVD), and the kidney function is a critical determinant of this risk. CKD is also a major cause of complications and disease progression in patients with CVD. Practice guidelines suggest that CVD risk in CKD patients can be managed through healthy lifestyle and dietary behaviors. Assessing the impact of diet on heart and kidney health is complex because numerous bioactive compounds from diet may contribute to or prevent CVD or CKD via a myriad of pathways and mechanisms. The objective of this review was to provide a discussion of the mechanisms and evidence linking protein-rich foods and CVD risk in people with CKD. This review highlights the current evidence-based strategies for primary CKD prevention that incorporate a healthy dietary pattern, while tertiary prevention strategies focus on avoiding excess protein and reducing dietary acid load. The effect of protein restriction for improving CVD and CKD outcomes is conflicting; however, these approaches show no negative effects on kidney health. Low-protein and very low-protein diets are promising interventions for reducing the progression of CKD and CVD. Animal-sourced protein may be more detrimental to kidney health than plant-sourced protein due to specific acid load, amino acid composition, generation of uremic toxins, accompanying saturated fat content, low fiber composition, and higher generation of advanced glycation end-products. There are no one-size fits all nutrition prescriptions. Personalized nutrition interventions that target the unique risk factors for CVD associated with reduced kidney function are required to improve the health of people living with CKD.

Expectation of clinical decision support systems: a survey study among nephrologist end-users

BACKGROUND

Chronic kidney disease (CKD), a major public health problem with differing disease etiologies, leads to complications, comorbidities, polypharmacy, and mortality. Monitoring disease progression and personalized treatment efforts are crucial for long-term patient outcomes. Physicians need to integrate different data levels, e.g., clinical parameters, biomarkers, and drug information, with medical knowledge. Clinical decision support systems (CDSS) can tackle these issues and improve patient management. Knowledge about the awareness and implementation of CDSS in Germany within the field of nephrology is scarce.

PURPOSE

Nephrologists' attitude towards any CDSS and potential CDSS features of interest, like adverse event prediction algorithms, is important for a successful implementation. This survey investigates nephrologists' experiences with and expectations towards a useful CDSS for daily medical routine in the outpatient setting.

METHODS

The 38-item questionnaire survey was conducted either by telephone or as a do-it-yourself online interview amongst nephrologists across all of Germany. Answers were collected and analysed using the Electronic Data Capture System REDCap, as well as Stata SE 15.1, and Excel. The survey consisted of four modules: experiences with CDSS (M1), expectations towards a helpful CDSS (M2), evaluation of adverse event prediction algorithms (M3), and ethical aspects of CDSS (M4). Descriptive statistical analyses of all questions were conducted.

RESULTS

The study population comprised 54 physicians, with a response rate of about 80-100% per question. Most participants were aged between 51-60 years (45.1%), 64% were male, and most participants had been working in nephrology out-patient clinics for a median of 10.5 years. Overall, CDSS use was poor (81.2%), often due to lack of knowledge about existing CDSS. Most participants (79%) believed CDSS to be helpful in the management of CKD patients with a high willingness to try out a CDSS. Of all adverse event prediction algorithms, prediction of CKD progression (97.8%) and in-silico simulations of disease progression when changing, e. g., lifestyle or medication (97.7%) were rated most important. The spectrum of answers on ethical aspects of CDSS was diverse.

CONCLUSION

This survey provides insights into experience with and expectations of out-patient nephrologists on CDSS. Despite the current lack of knowledge on CDSS, the willingness to integrate CDSS into daily patient care, and the need for adverse event prediction algorithms was high.

Adherence to Life's Essential 8 and incident chronic kidney disease: a prospective study of 147,988 UK Biobank participants

BACKGROUND

The American Heart Association recently updated Life's Essential 8 (LE8) score. This amalgamation of health factors, recognized for their individual associations with chronic kidney disease (CKD) risk, provides a robust tool to assess overall cardiovascular health (CVH), which could potentially be extrapolated to predict CKD risk.

OBJECTIVES

This study aimed to investigate the association between levels of CVH, as measured by the LE8 score, and risk of CKD in the UK Biobank.

METHODS

A total of 147,988 participants free of CKD and cardiovascular disease from the UK Biobank were included in this prospective study. CVH levels were categorized as low (0-49), moderate (50-79), and high (80-100) using LE8 score. An adjusted Cox proportional hazard model was used to investigate the association between LE8 and CKD. The population attributable-risk (PAR) was also calculated.

RESULTS

During a median follow-up of 10 y, 1936 CKD cases were documented. A higher LE8 score was associated with a significant lower risk of CKD (P < 0.001), and a linear dose-response relationship was observed. Similar patterns were also found in the associations of the LE8 behavior and biological subscale scores with CKD. Compared with participants with a low CVH category, participants with a moderate CVH were associated with a 39% lower risk of developing CKD (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.52, 0.72); and those with a high CVH had a 57% lower risk of CKD incidence (HR: 0.43; 95% CI: 0.35, 0.53) after adjustment for covariates. Among 8 distinct metrics of LE8 score, the BMI metric had the highest PAR (24.6%; 95% CI: 18.8, 30.2). Of the total CKD risk, 3.2% (95% CI: 1.4, 5.0) was attributable to inadequate or excessive sleep duration.

CONCLUSIONS

High CVH, defined by LE8, is significantly associated with a lower risk of CKD. These results suggest that promoting optimal cardiovascular health may lower the burden of CKD.

Association of Nighttime Masked Uncontrolled Hypertension With Left Ventricular Hypertrophy and Kidney Function Among Patients with Chronic Kidney Disease Not Receiving Dialysis

IMPORTANCE

Nighttime hypertension is prevalent and associated with adverse outcomes in patients with chronic kidney disease (CKD), but nighttime hypertension, a subtype of masked uncontrolled hypertension (MUCH), is often undetected among patients with controlled office blood pressure. Little attention has been paid to patients with CKD and nighttime MUCH.

OBJECTIVE

To investigate the prevalence of nighttime MUCH and its associations with cardiovascular and kidney outcomes in patients with CKD who were not receiving dialysis.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients with nondialysis CKD and hypertension, enrolled in Shanghai, China, from July 2012 through November 2020 and followed up for a median of 39 months.

EXPOSURES

Participants were classified as having controlled hypertension, sustained hypertension, and MUCH, which was further divided into isolated nighttime MUCH and day-night MUCH, assessed by office and ambulatory blood pressure monitoring.

MAIN OUTCOMES AND MEASURES

Left ventricular hypertrophy (LVH) was determined by echocardiography. The composite kidney outcome consisted of end-stage kidney diseases (ESKD) and a reduction of estimated glomerular filtration rate (eGFR) by 50% or more. Logistic and Cox regression assessed the associations of hypertension subtypes with LVH and kidney outcomes.

RESULTS

The 675 patients (425 [63.0%] men; mean [SD] age, 50.8 [15.9] years; mean [SD] eGFR, 61.6 [29.4] mL/min/1.73 m2) included 125 (19.3%) with controlled hypertension, 244 (37.6%) with MUCH, and 280 (43.1%) sustained hypertension. Among patients with MUCH, 2 (0.8%) had isolated daytime MUCH, 154 (63.1%) had isolated nighttime MUCH, and 88 (36.1%) had day-night MUCH. During a median (IQR) follow-up of 39 (19-64) months, 130 composite kidney events, including 97 ESKD events, occurred. Compared with controlled hypertension, MUCH and sustained hypertension were associated with LVH (eg, MUCH: odds ratio [OR], 2.94; 95% CI, 1.18-7.34; P = .02) and the composite kidney outcome (eg, MUCH: hazard ratio [HR], 4.12; 95% CI, 1.75-9.73; P = .001) after adjustment for age, sex, proteinuria, eGFR, and other baseline risk factors. Multivariate-adjusted associations were also significant between day-night MUCH and LVH (OR, 3.26; 95% CI, 1.15-9.25) and between isolated nighttime MUCH and the composite kidney outcome (HR, 4.27; 95% CI, 1.69-10.77).

CONCLUSIONS AND RELEVANCE

In this cohort study, nighttime MUCH was common and associated with LVH and poor kidney outcomes among patients with hypertension and nondialysis CKD. These findings suggest that ambulatory blood pressure monitoring was inadequately used in patients with CKD and hypertension, calling for more widespread use, even in patients with controlled office hypertension.

[Long-term physical and psychological consequences of chronic kidney disease]

Aufgrund der verbesserten Behandlungsoptionen können Patient:innen mit chronischen Nierenerkrankungen heute deutlich länger überleben als noch vor 10 Jahren. Das Überleben ist für die Betroffenen jedoch immer mit einem Verlust an Lebensqualität verbunden. In diesem Beitrag wird eine kurze Übersicht über die körperlichen und psychischen Erkrankungsfolgen, Begleiterkrankungen und Therapienebenwirkungen bei chronischen Nierenerkrankungen gegeben. Auf bisher bekannte Auswirkungen der COVID-19-Pandemie wird hingewiesen. Abschließend wird aufgezeigt, wie die Langzeitbehandlung weiterentwickelt werden sollte, um die Lebensqualität der Patient:innen zu erhöhen.

Funktionseinschränkungen der Niere haben aufgrund der Kontamination des Blutes mit harnpflichtigen Substanzen (Urämie) schwere Auswirkungen auf den Gesamtorganismus. Zusätzlich sind die Patient:innen von Nebenwirkungen betroffen, die im Zusammenhang mit der medikamentösen Therapie, Dialyse oder Nierentransplantation auftreten können. Patient:innen und Angehörige sind einer großen psychischen Belastung ausgesetzt. Infektionen mit SARS-CoV‑2 können die Nierenfunktion beeinträchtigen und auch die Prognose einer bereits bestehenden Erkrankung verschlechtern.

Die ganzheitliche Versorgung der Patient:innen mit chronischen Nierenerkrankungen muss neben der medizinischen Versorgung auch die psychologischen und psychosozialen Aspekte berücksichtigen. Nephrologie und Psychonephrologie müssen Hand in Hand weiterentwickelt werden, um die medizinische Versorgung und Lebensqualität der betroffenen Patient:innen zu verbessern.

Risk factors of chronic kidney disease among type 2 diabetic patients with longer duration of diabetes

BACKGROUND

Chronic kidney disease (CKD) in patients with type 2 diabetes mellitus (T2DM) is the major cause of end stage renal disease, characterized by proteinuria with a subsequent decline in glomerular filtration rate. Although hyperglycemia is the major risk factor for the development and progression of kidney disease among diabetic patients, many other risk factors also contribute to structural and functional changes in the kidneys. As recommended by Kidney Disease Improving Global Outcomes (KDIGO), CKD classification based on cause and severity, links to risk of adverse outcomes including mortality and kidney outcomes.

OBJECTIVE

The aim of this study is to investigate the involvement of risk factors associated with the severity of CKD among participants with longer duration of diabetes. This study also aims to find whether number of risk factors vary among risk of CKD progression categories based on KDIGO classification.

MATERIAL AND METHODS

This cross-sectional study retrospectively selected 424 participants from type 2 diabetic cohort and categorized them based on the classifications for the diagnosis of kidney diseases in patients with diabetes, according to the KDIGO guidelines. Odds ratios and 95% CI of each risk factors according to severity of renal disease were determined.

RESULTS

Based on KDIGO classification, participants with type 2 diabetes (T2D) were categorized in to low risk (n=174); moderately increased risk (n=98); and high/very high risk (n=152). Type 2 diabetic participants with risk factors such as, hyperlipidemia, hypertension, DM duration ≥15 years and diabetic retinopathy showed a high/very high risk of CKD progression when compared with low-risk category. While T2D participants with risk factors such as, lack of exercise, hypertension, and diabetic retinopathy showed a moderately increased risk of CKD progression. In addition, participants with highest number of risk factors were significantly distributed among high/very high risk of CKD progression category.

CONCLUSION

This study findings conclude that patients with T2DM and duration of ≥15 years, hyperlipidemia, hypertension and diabetic retinopathy have an increased prevalence of advanced CKD. In addition to this, increased number of risk factors could be an indicator of the severity of CKD in T2D.