The burden of comorbidity in people with chronic kidney disease stage 3: a cohort study

Optimizing kidney and cardiovascular protection in an era of multiple effective treatments

PURPOSE OF REVIEW

After decades of relying on the control of hypertension and treatment with renin angiotensin system inhibitors as the only evidence-based interventions to slow the progression of chronic kidney disease (CKD), we have entered an era when multiple effective treatment options are available. This review considers the mechanisms and benefits of these novel treatments as well as the challenges associated with achieving optimal combination therapy.

RECENT FINDINGS

Over the past 5 years, large clinical trials have provided robust evidence that, when added to renin angiotensin system inhibitors, treatment with sodium glucose cotransporter 2 inhibitors reduces the rate of CKD progression and the risk of cardiovascular events in people with CKD with or without diabetes and with or without albuminuria; nonsteroidal mineralocorticoid antagonists and glucagon-like peptide-1 receptor agonists afford similar benefits in people with type 2 diabetes and CKD. The mechanisms of actions of these novel therapies suggest that combination therapy will produce additive benefits, though specific evidence is sparse.

SUMMARY

Further trials are warranted to investigate the benefits of combination therapy with novel treatments in people with CKD. Clinical implementation of optimal combination therapy will require reorganization of services to ensure that patients receive adequate education, support and monitoring.

Efficacy of CHA2DS2-VASc scores in predicting chronic kidney disease risk in patients treated in cardiac intensive care units

The CHA2DS2 -VASc score is a vital clinical tool for evaluating thromboembolic risk in patients with atrial fibrillation (AF). This study investigated the efficacy of the CHA2DS2 -VASc score in a cohort of 737 heterogeneous patients (mean age: 63 years) receiving care in cardiac intensive care units (CICUs), with a creatinine-based estimated glomerular filtration rate (eGFR) of ≥60 mL/min/1.73 m2 upon admission and discharge. Incident chronic kidney disease (CKD) was defined as the emergence of a new-onset eGFR<60 mL/min/1.73 m2, accompanied by a decline of >5 mL/min/1.73 m2 compared to that at discharge. The primary endpoint was the incidence of CKD, and the secondary endpoints included all-cause mortality, cardiovascular events, and progression to end-stage kidney disease. In this cohort, 210 (28 %) patients developed CKD. Multivariate analyses revealed that CHA2DS2 -VASc score was a significant independent predictor of incident CKD, regardless of the presence of AF. Integration of CHA2DS2 -VASc scores with eGFR enhanced the predictive accuracy of incident CKD, as evidenced by the improved C-index, net reclassification improvement, and integrated discrimination improvement values (all p < 0.05). Over the 12-month follow-up period, a composite endpoint was observed in 61 patients (8.3 %), with elevated CHA2DS2 -VASc scores being independently associated with this endpoint. In conclusion, CHA2DS2-VASc scores have emerged as robust predictors of both CKD incidence and adverse outcomes. Their inclusion substantially refined the 12-month risk stratification of patients with preserved renal function hospitalized in the CICUs.

Hyperkalemia Burden and Treatment Pathways in Patients with CKD: Findings From the DISCOVER CKD Retrospective Cohort

Key Points

Hyperkalemia (HK) is associated with increased comorbidity burden in patients with CKD. Reducing serum potassium levels after HK episodes helps continuation of renin-angiotensin-aldosterone system inhibitor treatment. In Japan, HK treatment pathways are more heterogeneous and potassium binders are more commonly prescribed compared with the United Kingdom.

Background

This analysis used retrospective data from the DISCOVER CKD observational study (NCT04034992 ) to describe the burden of and treatment pathways for hyperkalemia (HK) in patients with CKD.

Methods

Data were extracted from the following databases: UK Clinical Practice Research Datalink (2008–2019) and Japan Medical Data Vision (2008–2017). Patients with CKD (two eGFR measures <75 ml/min per 1.73 m2 recorded ≥90 days apart) and HK (at least two serum potassium [sK+] measures >5.0 mmol/L) were compared with patients without HK (sK+ <5.0 mmol/L); HK index event was the second sK+ measurement. Outcomes included baseline characteristics and treatment pathways for key medications (renin-angiotensin-aldosterone system inhibitors [RAASi], diuretics and potassium [K+] binders).

Results

In the UK Clinical Practice Research Datalink, 37,713 patients with HK and 142,703 patients without HK were included for analysis (HK prevalence 20.9%). In the Japan Medical Data Vision, 5924 patients with HK and 74,272 patients without HK were included for analysis (HK prevalence 7.4%). In both databases, median eGFR was lower and comorbidities such as hypertension, heart failure, type 2 diabetes, and AKI were more prevalent among patients with versus without HK, and most patients were taking RAASi at the time of HK index. Treatment pathways were more heterogeneous in Japan; <0.2% of patients with CKD and HK in the United Kingdom initiated K+ binders within 3 months of HK index versus 18.7% in Japan. The proportions of patients with CKD and HK who stopped treatment with diuretics, K+ binders, and RAASi during follow-up were 48.7%, 76.5%, and 50.6%, respectively, in the United Kingdom, and 22.9%, 53.6%, and 29.2%, respectively, in Japan.

Conclusions

HK was associated with increased comorbidity burden in patients with CKD. Variations in treatment pathways between the United Kingdom and Japan reflect the previous lack of a standardized approach to HK management in CKD.

Telemedicine in Advanced Kidney Disease and Kidney Transplant: A Qualitative Meta-Analysis of Studies of Patient Perspectives

Rationale & Objective

While the use of telemedicine has increased dramatically across disciplines, patient perspectives on telemedicine related to chronic kidney disease are not well understood. We systematically reviewed qualitative studies on patients with chronic kidney disease as well as those with kidney transplant to better understand these patients' perspectives related to telemedicine.

Study Design

Qualitative meta-analysis.

Setting & Participants

Pre-dialysis chronic kidney disease and kidney transplant patients that used telemedicine.

Selection Criteria for Studies

English language studies published in the year 2000 and beyond that investigated patient perspectives in a qualitative manner. Works that were not qualitative or did not focus on provider-patient interactive modes of telemedicine were excluded.

Data Extraction

375 articles were pulled from PubMed, Embase, and Academic Science Premier. After filtering, 8 final articles were selected. These articles were critically appraised for quality and were used in the final analysis.

Analytical Approach

We used a grounded theory approach to develop a codebook to systematically review each of the selected articles through a qualitative meta-analysis of the included literature.

Results

Telemedicine was seen by patients to have notable strengths as well as weaknesses. These characteristics can be organized into 4 primary themes (autonomy, logistics, privacy/confidentiality, and trust). Within each primary theme, we identified subthemes. Universally, all articles included the subtheme "fewer trips to the health care facility" as a beneficial factor of telemedicine within the primary theme "logistics." A majority (6 of 8) of the articles included positive patient perspectives on the primary theme "autonomy" in terms of telemedicine promoting the subtheme of "engagement." Patients' views on telemedicine were mixed regarding the primary themes of "privacy/confidentiality" and "trust" related to telemedicine.

Limitations

Lack of provider perspectives, non-English studies, and studies published before the year 2000. Articles published after the start of data extraction were also not included.

Conclusions

Telemedicine should continue to be offered to patients with chronic kidney disease and kidney transplant patients to facilitate access. Additional research should focus on ways to decrease negative factors experienced by some patients such as difficulty using the technology.

A Multinational, Multicenter Study Mapping Models of Kidney Supportive Care Practice

Introduction

Kidney supportive care (KSC) integrates kidney and palliative care to improve quality of life for people with chronic kidney disease (CKD). Despite increasing interest and global advocacy to integrate KSC into kidney care, evidence to guide optimal care delivery is limited.

Methods

This observational cross-sectional study used an online survey to describe current KSC models in Australia, Aotearoa-New Zealand, and the UK.

Results

Between April and December 2022, 114 nephrology units responded (response rate 67%), with 66% having a dedicated KSC service (UK, 74%; Australia, 58%; and New Zealand, 67%). Many different health care professionals worked in KSC services with diversity in clinical resources and activities between units and across countries. Overall, funding for KSC services was low, with a median full time equivalent (FTE) per unit (standardized per 100 people receiving hemodialysis [HD]) of 0.51 (interquartile range [IQR], 0.17-1.05) and 4 units provided a service without allocated funding. The scope of KSC service was wide-ranging and prioritized activities included symptom management, psychological support, complex future treatment planning and discussion, and care coordination. There were no significant differences between countries in terms of location of care provision, frequency of review, referral patterns or discharge rates; however, there was variation described within countries.

Conclusion

Models of KSC vary markedly across kidney units and between countries. Despite this variation, there was consistency in terms of clinical priorities which were person-centered and focused on physical and psychosocial well-being. Further research is required to evaluate the effectiveness of KSC provision, alongside improved funding methods to ensure sustainable and equitable KSC delivery.

Polypharmacy in Patients with CKD: A Systematic Review and Meta-Analysis

Key Points

The prevalence of polypharmacy in patients with CKD was over 80%. Polypharmacy was highest in patients with a kidney transplant and those receiving dialysis. Polypharmacy is associated with worse clinical outcomes, lower quality of life, and medication-related problems in patients with CKD.

Background

Despite the high prevalence of polypharmacy in patients with CKD, the extent of polypharmacy across patients with (different stages of) CKD, as well as the association with clinical outcomes remains unknown. This systematic review aimed to evaluate the prevalence of polypharmacy in (different subgroups of) patients with CKD and assess the association between polypharmacy and patient-important outcomes.

Methods

MEDLINE, Embase, and the Cochrane Library were searched from inception until July 2022. Studies that reported the prevalence of polypharmacy, medication use, or pill burden in patients with CKD (including patients receiving dialysis and kidney transplant recipients) and their association with patient-important outcomes (i.e ., mortality, kidney failure, quality of life [QoL], and medication nonadherence) were included. Two reviewers independently screened title and abstract and full texts, extracted data, and assessed risk of bias. Data were pooled in a random-effects single-arm meta-analysis.

Results

In total, 127 studies were included (CKD 3–5 n =39, dialysis: n =38, kidney transplant n =13, different CKD stages n =37). The pooled prevalence of polypharmacy, based on 63 studies with 484,915 patients, across all patients with CKD was 82% (95% confidence interval, 76% to 86%), and the pooled mean number of prescribed medications was 9.7 (95% confidence interval, 8.4 to 11.0). The prevalence of polypharmacy was higher in patients who received dialysis or a kidney transplant compared with patients with CKD 3–5 but did not differ between studies with regards to region or patients' mean age or sex. In patients with CKD, polypharmacy was associated with a higher risk of all-cause mortality, kidney failure, faster eGFR decline, lower QoL, and higher medication nonadherence, adverse drug reactions, and potentially inappropriate medications.

Conclusions

The prevalence of polypharmacy in patients with CKD was over 80%, and highest in patients with a kidney transplant and those receiving dialysis. No causes of heterogeneity were identified, indicating that polypharmacy is an issue for all patients with CKD. Polypharmacy is associated with worse clinical outcomes, lower QoL, and medication-related problems in patients with CKD.

Clinical Trial registry name and registration number:

PROSPERO (CRD42022331941).

Rheumatoid arthritis and the risk of chronic kidney diseases: a Mendelian randomization study

Background

The extra-articular lesions of rheumatoid arthritis (RA) are reported to involve multiple organs and systems throughout the body, including the heart, kidneys, liver, and lungs. This study assessed the potential causal relationship between RA and the risk of chronic kidney diseases (CKDs) using the Mendelian randomization (MR) analysis.

Method

Independent genetic instruments related to RA and CKD or CKD subtypes at the genome-wide significant level were chosen from the publicly shared summary-level data of genome-wide association studies (GWAS). Then, we obtained some single-nucleotide polymorphisms (SNPs) as instrumental variables (IVs), which are associated with RA in individuals of European origin, and had genome-wide statistical significance (p5 × 10-8). The inverse-variance weighted (IVW) method was the main analysis method in MR analysis. The other methods, such as weighted median, MR-Egger, simple mode, and weighted mode were used as supplementary sensitivity analyses. Furthermore, the levels of pleiotropy and heterogeneity were assessed using Cochran's Q test and leave-one-out analysis. Furthermore, the relevant datasets were obtained from the Open GWAS database.

Results

Using the IVW method, the main method in MR analysis, the results showed that genetically determined RA was associated with higher risks of CKD [odds ratio (OR): 1.22, 95% confidence interval (CI) 1.13-1.31; p < 0.001], glomerulonephritis (OR: 1.23, 95% CI 1.15-1.31; p < 0.000), amyloidosis (OR = 1.43, 95% CI 1.10-1.88, p < 0.001), and renal failure (OR = 1.18, 95% CI 1.00-1.38, p < 0.001). Then, using multiple MR methods, it was confirmed that the associations persisted in sensitivity analyses, and no pleiotropy was detected.

Conclusion

The findings revealed a causal relationship between RA and CKD, including glomerulonephritis, amyloidosis, and renal failure. Therefore, RA patients should pay more attention to monitoring their kidney function, thus providing the opportunity for earlier intervention and lower the risk of progression to CKDs.

Chronic kidney disease in America, Africa, and Asia: Overview of treatment cost and options

Chronic kidney disease (CKD) is one of the non-infectious diseases that threaten patients' lives on a daily basis. Its prevalence is high, but under-reported by patients and those living with the disease, as it is silent and asymptomatic in the early stages. Kidney disease increases the risk of heart and vascular disease. These problems can manifest themselves slowly, over a long period of time. Early detection and treatment can often prevent chronic kidney disease from worsening. As kidney disease progresses, it can lead to kidney failure, requiring dialysis or a kidney transplant to stay alive. In this narrative review, we will mainly discuss different treatment option costs in different countries and how much they cost healthcare systems in countries in three different continents.

Cardioprotective effect of intradialytic exercise on left atrial mechanics

Left atrial (LA) function plays a pivotal role in cardiac performance by modulating left ventricular (LV) function. Impairments in LV function are commonly reported during hemodialysis (HD), but available data describing changes in LA function are limited. There is growing evidence of the cardioprotective effect of intradialytic exercise (IDE) on LV function, but studies analyzing its effect on LA function are scarce. Our aim was to evaluate whether IDE can limit the severity of HD-induced impairment in LA myocardial function. In this prospective, open-label, two-center randomized crossover trial, 56 stable individuals receiving HD participated in 2 HD sessions in random order: standard HD and a session incorporating 30 min of aerobic exercise. LA and LV global longitudinal strains (GLSs) were obtained before and at peak stress of HD (i.e., 30 min before the HD ending). IDE totally eradicated the decline in LA reservoir strain observed during HD (estimated difference: 3.1%, 95% confidence interval: 0.4/5.8, P = 0.02), whereas it did not affect the other components of LA mechanics. A similar result favoring IDE intervention was also demonstrated on GLS changes over the HD procedure (P < 0.001). Between-session differences of changes in GLS and LA reservoir strain were correlated (r = -0.32, P = 0.03). The cardioprotective effect of IDE disappeared in patients with LA enlargement (i.e., LA volume index >34 mL/m2). In conclusion, even a short duration of IDE at moderate intensity is effective in preventing HD-associated decline in LA reservoir function. Further research is needed to explore the long-term benefits of IDE on LA function.NEW & NOTEWORTHY A single bout of intradialytic exercise (IDE) at moderate intensity can prevent the hemodialysis-associated decline in left atrial (LA) function. This was partially explained by the relative preservation of left ventricular systolic function with IDE. Benefits of IDE on LA function were lost in patients with LA dilation. Further studies are needed to explore the mechanisms behind IDE-induced cardioprotection and evaluate the clinical impacts of the repetitive cardioprotective effects of IDE on LA function.

Results from a cross-specialty consensus on optimal management of patients with chronic kidney disease (CKD): from screening to complications

BACKGROUND

Chronic kidney disease (CKD) affects around 10% of the global population and has been estimated to affect around 50% of individuals with type 2 diabetes and 50% of those with heart failure. The guideline-recommended approach is to manage with disease-modifying therapies, but real-world data suggest that prescribing rates do not reflect this in practice.

OBJECTIVE

To develop a cross-specialty consensus on optimal management of the patient with CKD using a modified Delphi method.

DESIGN

An international steering group of experts specialising in internal medicine, endocrinology/diabetology, nephrology and primary care medicine developed 42 statements on aspects of CKD management including identification and screening, risk factors, holistic management, guidelines, cross-specialty alignment and education. Consensus was determined by agreement using an online survey.

PARTICIPANTS

The survey was distributed to cardiologists, nephrologists, endocrinologists and primary care physicians across 11 countries.

MAIN OUTCOMES AND MEASURES

The threshold for consensus agreement was established a priori by the steering group at 75%. Stopping criteria were defined as a target of 25 responses from each country (N=275), and a 4-week survey period.

RESULTS

274 responses were received in December 2022, 25 responses from Argentina, Australia, Brazil, Guatemala, Mexico, Singapore, South Korea, Taiwan, Thailand, Turkey and 24 responses from Egypt. 53 responses were received from cardiologists, 52 from nephrologists, 55 from endocrinologists and 114 from primary care physicians. 37 statements attained very high agreement (≥90%) and 5 attained high agreement (≥75% and <90%). Strong alignment between roles was seen across the statements, and different levels of experience (2-5 years or 5+ years), some variation was observed between countries.

CONCLUSIONS

There is a high degree of consensus regarding aspects of CKD management among healthcare professionals from 11 countries. Based on these strong levels of agreement, the steering group derived 12 key recommendations focused on diagnosis and management of CKD.

Health-related Quality of Life in 10 years Long-term Survivors of Chronic Kidney Disease: A From-J Study

OBJECTIVE

The Chronic Kidney Disease (CKD) practice facilitation program in the Frontier of Renal Outcome Modifications in Japan study reduced cardiovascular disease (CVD) events in patients with CKD. 10-year long-term survivors with CKD lived with serious complications, including end-stage kidney disease and CVD. This study aimed to measure health-related quality of life in 10-year long-term CKD survivors and examine the predictors and determinants of clinical indices for measured quality of life (QOL) scores.

METHODS

The EQ-5D-5L, a generic preference-based instrument, was administered to 1,473 CKD survivors enrolled in the Frontier of Renal Outcome Modifications in JapanFrontier of Renal Outcome Modifications in JapanFrontier of Renal Outcome Modifications in Japan study. The 10th-year data collection was performed by either primary care physicians or participants who filled out questionnaires from October 2018 to March 31, 2019.

RESULTS

The response rate was 38.2% (423/1,473). The mean QOL score was 0.893 (95% confidence interval (CI), 0.880-0.906), and the median QOL score was 1.000 (interquartile range (IQR), 0.826-1.000). The mean QOL score in participants with renal replacement therapy was 0.824 (95% CI, 0.767-0.881), and the median was 0.828 (IQR, 0.755-1.000). The mean QOL score in participants with CVD was 0.877 (95% CI, 0.811-0.943), and the median was 1.000 (IQR, 0.723-1.000). The mean QOL score in participants with 50% decline in estimated glomerular filtration was 0.893 (95% CI, 0.860-0.926), and the median was 0.889 (IQR, 0.825-1.000). The decrease in QOL scores with baseline CKD stages was significant according to the Jonckheere-Terpstra test for trend (P = .002). Baseline age, systolic blood pressure, and history of hyperuricemia were significant predictors of 10th-year QOL scores.

CONCLUSION

We suggest that CKD complications negatively affect the QOL scores in 10-year long-term survivors with CKD. CKD guideline-based practices, prevention of end-stage kidney disease/CVD and management of hypertension, diabetes and hyperuricemia, might contribute to future health-related quality of life in patients with CKD.

Roxadustat and Oral Iron Absorption in Chinese Patients with Anemia of Chronic Kidney Disease: A Randomized, Open-Label, Phase 4 Study (ALTAI)

INTRODUCTION

Anemia of chronic kidney disease (CKD) has a high incidence and is associated with many disease conditions. Iron dysmetabolism is an important contributor to anemia in CKD patients.

METHODS

ALTAI, a randomized, active-controlled, phase 4 trial, investigated the efficacy of roxadustat versus recombinant human erythropoietin (rHuEPO) on gastrointestinal iron absorption in patients with anemia of CKD (stage 4/5). The primary endpoint was change from baseline to day 15 in gastrointestinal iron absorption (serum iron area under the concentration-time curve; AUC0-3h) following single-dose oral iron.

RESULTS

Twenty-five patients with a mean age of 55.1 years were randomized 1:1 to roxadustat (n = 13) or rHuEPO (n = 12). Baseline iron profiles were similar between treatment groups. Change from baseline to day 15 in serum iron AUC0-3h was not statistically significantly different between the roxadustat and rHuEPO groups. Mean (SD) change from baseline in serum iron AUC0-3h was 11.3 (28.2) g × 3 h/dl in the roxadustat group and - 0.3 (9.7) g × 3 h/dl in the rHuEPO group. Roxadustat treatment was associated with decreased hepcidin and also increased transferrin, soluble transferrin receptor, and total iron-binding capacity (TIBC), with nominal significance. The proportion of patients experiencing one or more adverse events was 38.5% when treated with roxadustat and 16.7% with rHuEPO.

CONCLUSIONS

The study showed no significant difference between roxadustat and rHuEPO in iron absorption but was underpowered because of recruitment challenges.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT04655027.

Relationship between gout, hyperuricemia, and obesity-does central obesity play a significant role?-a study based on the NHANES database

BACKGROUND

Our objective was to evaluate how various measures of obesity, such as body mass index(BMI), body roundness index(BRI), and weigh adjusted waist index(WWI), influence urate levels, prevalence of gout and to compare the disparities among these obesity indicators.

METHODS

By analyzing the 2001-2018 National Health and Nutrition Examination Survey (NHANES), we assessed the relationship between BMI, WWI, and BRI indices and urate levels, hyperuricemia, and the prevalence of gout. Smoothed curve fitting was used to determine whether there was a nonlinear relationship between BMI,WWI, and BRI indices and urate levels, hyperuricemia, and the prevalence of gout, and threshold effects analysis was used to test this relationship. We also used ROC curves to determine the diagnostic efficacy of BMI, WWI, and BRI on the prevalence of hyperuricemia and gout.

RESULTS

The study incorporated a total of 29,310 participants aged over 20 years, out of which 14,268 were male. Following the adjustment for the pertinent confounding factors, it was observed that higher levels of BMI, WWI, and BRI were significantly associated with a gradual and dose-dependent increase in urate levels. In the sensitivity analysis, each unit increment in BMI, WWI, and BRI levels exhibited an 8%, 72%, and 26% respective elevation in the risk of hyperuricemia, as well as a 5%, 31%, and 15% respective increase in the risk of gout. Dose-response curves provided evidence of a linear positive correlation between BMI, WWI, BRI, and urate levels, as well as the prevalence of hyperuricemia and gout. Based on the response from the ROC curve, overall, the diagnostic efficacy of BRI for hyperuricemia and gout surpasses that of BMI.

CONCLUSION

The central obesity indices WWI and BRI levels are superior to BMI in detecting the prevalence of urate levels, hyperuricemia, and gout, and although a clear causal relationship has not yet been established, it is important to recognize the impact of central obesity on uric acid levels and to give it due attention.

Effect of renal insufficiency on the short- and long-term outcomes of endoscopic submucosal dissection for early gastric cancer: Propensity score-matched analysis

OBJECTIVES

It is unclear whether renal insufficiency (RI) itself is a risk factor for adverse outcomes after gastric endoscopic submucosal dissection (ESD). We aimed to evaluate the safety and efficacy of gastric ESD in patients with and without RI using propensity score-matching analysis.

METHODS

In all, 4775 patients with 4775 early gastric cancer lesions undergoing ESD were analyzed. 1:1 propensity score-matching was performed between patients with and without RI using 12 variables. After matching, logistic regression and survival analyses were performed for short- and long-term outcomes of ESD, respectively.

RESULTS

The matching yielded 188 pairs of patients with and without RI. In both univariable and multivariable analyses, the presence of RI was not significantly associated with postprocedural bleeding (unadjusted odds ratio 1.81, 95% confidence interval 0.74-4.42; adjusted odds ratio 1.86, 95% confidence interval 0.74-4.65, respectively). When RI patients were subclassified into patients with estimated glomerular filtration rate (eGFR) 30-59 mL/min/1.73 m2 and eGFR <30 mL/min/1.73 m2 , no significant differences in bleeding rates were found compared to their matched controls in both groups. Perforation, en bloc resection, en bloc and R0 resection, and curative resection rates of RI patients were 2.1%, 98.4%, 91.0%, and 78.2%, respectively, which were comparable to those of non-RI patients. During a median follow-up of 119 months, there was no difference in gastric cancer-specific survival between patients with and without RI (P = 0.143).

CONCLUSION

The outcomes of ESD were comparable in patients with and without RI. Decreased renal function itself may not be a reason to keep patients with RI from receiving gastric ESD.

Assessment of hepatoprotective, nephroprotective efficacy, and antioxidative potential of Moringa oleifera leaf powder and ethanolic extract against PCOS-induced female albino mice (Mus Musculus)

Moringa oleifera is a medicinal plant that has anti-inflammatory, antihypertensive, antidiabetic, tissue-protective, and antioxidant activities. Here, we evaluated the protective effect of M. oleifera leaf powder (MoLP) and 70% ethanol M. oleifera leaf extract (MoLE) on mitigating polycystic ovary syndrome (PCOS)-induced liver and kidney dysfunction via regulating oxidative stress in female albino mice (Mus musculus). The efficacy of M. oleifera was compared with metformin (standard medicine used to treat infertility in women). PCOS was induced by intramuscular injection of testosterone enanthate at 1.0 mg/100 g BW for 35 days. PCOS-induced mice were treated with MoLP (250 and 500 mg/Kg), MoLE (250 and 500 mg/kg), and metformin (250 mg/kg) orally for 14 days. Renal function test (RFT), liver function test (LFT), and oxidative stress biomarker malondialdehyde (MDA) were quantified in serum at 0, 7, and 14 days of intervention. Mice treated with M. oleifera and metformin showed a significant decrease (p < .001) in alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphate (ALP), total bilirubin, urea, creatinine, and a significant increase (p < .001) in total protein, albumin, globulin, and albumin/globulin (A/G) ratio. Oxidative stress decreased significantly (p = .00) with respect to treatments, exposure days, and their interaction in metformin and all M. oleifera-treated groups. M. oleifera leaf powder and extract reduce oxidative stress and enhance nephron-hepatic activity in PCOS-induced female albino mice.

Comparative analysis of potential drug-drug interactions in a public and private hospital among chronic kidney disease patients in Khyber Pakhtunkhwa: A retrospective cross-sectional study

INTRODUCTION

Chronic kidney disease (CKD) is a significant public health challenge due to its rising incidence, mortality, and morbidity. Patients with kidney diseases often suffer from various comorbid conditions, making them susceptible to potential drug-drug interactions (pDDIs) due to polypharmacy and multiple prescribers. Inappropriate prescriptions for CKD patients and their consequences in the form of pDDIs are a major challenge in Pakistan.

AIM

This study aimed to compare the incidence and associated risk factors of pDDIs among a public and private sector hospital in Khyber Pakhtunkhwa, Pakistan.

METHOD

A retrospective cross-sectional study design was conducted to compare pDDIs among public and private sector hospitals from January 2023 to February 2023. Patients profile data for the full year starting from January 1 2022 to December 302022, was accessed All adult patients aged 18 years and above, of both genders, who currently have or have previously been diagnosed with end-stage renal disease (ESRD) were included. For assessing pDDIs, patient data was retrieved and checked using Lexicomp UpToDate® for severity and documentation of potential drug-drug interactions.

RESULTS

A total of 358 patients' data was retrieved (with n = 179 in each hospital); however, due to incomplete data, n = 4 patients were excluded from the final analysis. The prevalence of pDDIs was found to be significantly higher in private hospitals (84.7%) than in public hospitals (26.6%), with a p-value <0.001. Patients in the age category of 41-60 years (AOR = 6.2; p = 0.008) and those prescribed a higher number of drugs (AOR = 1.2; p = 0.027) were independently associated with pDDIs in private hospitals, while the higher number of prescribed drugs (AOR = 2.9; p = <0.001) was an independent risk factor for pDDIs in public hospitals. The majority of pDDIs (79.0%) were of moderate severity, and a significant number of patients (15.1%) also experienced major pDDIs, with a p-value <0.001. The majority of pDDIs had fair documentation for reliability rating in both public and private hospitals.

CONCLUSION

The prevalence of pDDIs was higher among CKD patients at private hospitals, and most of the pDDIs were of moderate severity. A considerable number of patients also experienced major pDDIs. The risk of experiencing pDDIs was found to be higher in older patients and among those prescribed a higher number of drugs.

Cardioprotective Effect of Acute Intradialytic Exercise: A Comprehensive Speckle-Tracking Echocardiography Analysis

SIGNIFICANCE STATEMENT

Hemodialysis (HD) can lead to acute left ventricular (LV) myocardial wall motion abnormalities (myocardial stunning) due to segmental hypoperfusion. Exercise during dialysis is associated with favorable effects on central hemodynamics and BP stability, factors considered in the etiology of HD-induced myocardial stunning. In a speckle-tracking echocardiography analysis, the authors explored effects of acute intradialytic exercise (IDE) on LV regional myocardial function in 60 patients undergoing HD. They found beneficial effects of IDE on LV longitudinal and circumferential function and on torsional mechanics, not accounted for by cardiac loading conditions or central hemodynamics. These findings support the implementation of IDE in people with ESKD, given that LV transient dysfunction imposed by repetitive HD may contribute to heart failure and increased risk of cardiac events in such patients.

BACKGROUND

Hemodialysis (HD) induces left ventricular (LV) transient myocardial dysfunction. A complex interplay between linear deformations and torsional mechanics underlies LV myocardial performance. Although intradialytic exercise (IDE) induces favorable effects on central hemodynamics, its effect on myocardial mechanics has never been comprehensively documented.

METHODS

To evaluate the effects of IDE on LV myocardial mechanics, assessed by speckle-tracking echocardiography, we conducted a prospective, open-label, two-center randomized crossover trial. We enrolled 60 individuals with ESKD receiving HD, who were assigned to participate in two sessions performed in a randomized order: standard HD and HD incorporating 30 minutes of aerobic exercise (HDEX). We measured global longitudinal strain (GLS) at baseline (T0), 90 minutes after HD onset (T1), and 30 minutes before ending HD (T2). At T0 and T2, we also measured circumferential strain and twist, calculated as the net difference between apical and basal rotations. Central hemodynamic data (BP, cardiac output) also were collected.

RESULTS

The decline in GLS observed during the HD procedure was attenuated in the HDEX sessions (estimated difference, -1.16%; 95% confidence interval [95% CI], -0.31 to -2.02; P = 0.008). Compared with HD, HDEX also demonstrated greater improvements from T0 to T2 in twist, an important component of LV myocardial function (estimated difference, 2.48°; 95% CI, 0.30 to 4.65; P = 0.02). Differences in changes from T0 to T2 for cardiac loading and intradialytic hemodynamics did not account for the beneficial effects of IDE on LV myocardial mechanics kinetics.

CONCLUSIONS

IDE applied acutely during HD improves regional myocardial mechanics and might warrant consideration in the therapeutic approach for patients on HD.

Incidence, prevalence, and treatment of anemia of non-dialysis-dependent chronic kidney disease: A retrospective database study in France

BACKGROUND

Minimal data are available regarding the prevalence and incidence of anemia among patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) in France.

METHODS

This was a retrospective non-interventional study of patients with a record of NDD-CKD in the Echantillon Généraliste des Bénéficiaires (EGB) database between January 01, 2012, and December 31, 2017. The primary objective was to estimate the annual incidence and prevalence of anemia of NDD-CKD. Secondary objectives included description of the demographics and clinical characteristics of patients with NDD-CKD-related anemia. An exploratory objective was to use machine learning to identify patients from the general population that might have NDD-CKD but without a recorded ICD-10 diagnosis of CKD.

RESULTS

During 2012-2017, 9865 adult patients in the EGB database had confirmed NDD-CKD; of these, 49.1% (4848/9865) had anemia. From 2015 to 2017, estimates of incidence (108.7-114.7 per 1000 population) and prevalence (435.7-449.5 per 1000 population) of NDD-CKD-related anemia were stable. Less than half of patients with anemia of NDD-CKD were treated with oral iron, and approximately 15% were treated with erythropoiesis-stimulating agents. Based on adult French population projections in 2020 and an estimated prevalence rate in 2017 of 42.2 per 1000 population for confirmed plus possible NDD-CKD (as a proportion of the general French population), the estimated number of patients with possible NDD-CKD in France was 2,256,274, approximately five-fold greater than the number identified by diagnostic codes and hospitalizations.

CONCLUSIONS

Anemia of NDD-CKD was shown to be a constant long-term burden in France, and its apparent prevalence may still be significantly underestimated. Given the potential treatment gap, additional initiatives to better identify and treat NDD-CKD anemia may improve patient management and treatment outcomes.

Deprivation and chronic kidney disease-a review of the evidence

The relationship between socioeconomic deprivation and health is inequitable. Chronic kidney disease (CKD) is an archetypal disease of inequality, being more common amongst those living in deprivation. The prevalence of CKD is rising driven by an increase in lifestyle-related conditions. This narrative review describes deprivation and its association with adverse outcomes in adults with non-dialysis-dependent CKD including disease progression, end-stage kidney disease, cardiovascular disease and all-cause mortality. We explore the social determinants of health and individual lifestyle factors to address whether patients with CKD who are socioeconomically deprived have poorer outcomes than those of higher socioeconomic status. We describe whether observed differences in outcomes are associated with income, employment, educational attainment, health literacy, access to healthcare, housing, air pollution, cigarette smoking, alcohol use or aerobic exercise. The impact of socioeconomic deprivation in adults with non-dialysis-dependent CKD is complex, multi-faceted and frequently under-explored within the literature. There is evidence that patients with CKD who are socioeconomically deprived have faster disease progression, higher risk of cardiovascular disease and premature mortality. This appears to be the result of both socioeconomic and individual lifestyle factors. However, there is a paucity of studies and methodological limitations. Extrapolation of findings to different societies and healthcare systems is challenging, however, the disproportionate effect of deprivation in patients with CKD necessitates a call to action. Further empirical study is warranted to establish the true cost of deprivation in CKD to patients and societies.

Prevalence and pattern of multimorbidity among chronic kidney disease patients: a community study in chronic kidney disease hotspot area of Eastern India

Introduction

Chronic kidney disease (CKD) is mostly asymptomatic until reaching an advanced stage. Although conditions such as hypertension and diabetes can cause it, CKD can itself lead to secondary hypertension and cardiovascular disease (CVD). Understanding the types and prevalence of associated chronic conditions among CKD patient could help improve screening for early detection and case management.

Methods

A cross sectional study of 252 CKD patients in Cuttack, Odisha (from the last 4 years CKD data base) was telephonically carried out using a validated Multimorbidity Assessment Questionnaire for Primary Care (MAQ-PC) tool with the help of an android Open Data Kit (ODK). Univariate descriptive analysis was done to determine the socio-demographic distribution of CKD patients. A Cramer's heat map was generated for showing Cramer's coefficient value of association of each diseases.

Results

The mean age of participants was 54.11 (±11.5) years and 83.7% were male. Among the participants, 92.9% had chronic conditions (24.2% with one, 26.2% with two and 42.5% with three or more chronic conditions). Most prevalent chronic conditions were hypertension (48.4%), peptic ulcer disease (29.4%), osteoarthritis (27.8%) and diabetes (13.1%). Hypertension and osteoarthritis were found to be most commonly associated (Cramer's V coefficient = 0.3).

Conclusion

Increased vulnerability to chronic conditions among CKD patients make them at higher risk for mortality and compromised quality of life. Regular screening of CKD patient for other chronic conditions (hypertension, diabetes, peptic ulcer disease, osteoarthritis and heart diseases) would help in detecting them early and undertake prompt management. The existing national program could be leveraged to achieve this.

Rates of adverse clinical events in patients with chronic kidney disease: analysis of electronic health records from the UK clinical practice research datalink linked to hospital data

BACKGROUND

Further understanding of adverse clinical event rates in patients with chronic kidney disease (CKD) is required for improved quality of care. This study described baseline characteristics, adverse clinical event rates, and mortality risk in patients with CKD, accounting for CKD stage and dialysis status.

METHODS

This retrospective, noninterventional cohort study included data from adults (aged ≥ 18 years) with two consecutive estimated glomerular filtration rates of < 60 ml/min/1.73 m², recorded ≥ 3 months apart, from the UK Clinical Practice Research Datalink of electronic health records obtained between January 1, 2004, and December 31, 2017. Select adverse clinical events, associated with CKD and difficult to quantify in randomized trials, were assessed; defined by Read codes and International Classification of Diseases, Tenth Revision codes. Clinical event rates were assessed by dialysis status (dialysis-dependent [DD], incident dialysis-dependent [IDD], or non-dialysis-dependent [NDD]), dialysis modality (hemodialysis [HD] or peritoneal dialysis [PD]), baseline NDD-CKD stage (3a-5), and observation period.

RESULTS

Overall, 310,953 patients with CKD were included. Comorbidities were more common in patients receiving dialysis than in NDD-CKD, and increased with advancing CKD stage. Rates of adverse clinical events, particularly hyperkalemia and infection/sepsis, also increased with advancing CKD stage and were higher in patients on HD versus PD. Mortality risk during follow-up (1-5-year range) was lowest in patients with stage 3a NDD-CKD (2.0-18.5%) and highest in patients with IDD-CKD (26.3-58.4%).

CONCLUSIONS

These findings highlight the need to monitor patients with CKD for comorbidities and complications, as well as signs or symptoms of clinical adverse events.

The Effect of Chronic Kidney Disease or End-stage Kidney Disease on Perioperative Outcomes and Healthcare Utilization in Patients Undergoing Bariatric Surgery

BACKGROUND

As chronic kidney disease (CKD) has a higher prevalence in patients with obesity, there is an increasing need to understand the safety of bariatric surgery for patients with advanced CKD. This study determined if short-term bariatric surgical outcomes and healthcare utilization differ in patients with advanced CKD.

METHODS

A retrospective analysis of the Healthcare Cost and Utilization Project National Inpatient Sample (NIS) was performed. Patients with obesity who underwent bariatric surgery from 2015 to 2019 were included. Patients without CKD, with CKD, and end-stage kidney disease (ESKD) were compared for outcome differences. Univariate and multivariable regression was used to determine the association between perioperative outcomes to CKD status.

RESULTS

The unadjusted analysis found significantly higher mortality and overall complication rate in CKD and ESKD patients, however, after adjustment for confounders, only the ICU admission rate remained significantly higher for patients CKD compared to non-CKD patients (odds ratio 4.21, 95% CI [3.29-5.39]). Length of stay was longer for patients with CKD (mean difference (MD) 0.14 days, 95% CI, [0.04, 0.23]) and patients with ESKD (MD 0.27 days, 95% CI, [0.10, 0.43]) compared to non-CKD patients. Patients with ESKD had higher admission costs compared to non-CKD patients (MD $1982.65).

CONCLUSION

Patients with CKD and ESKD have increased healthcare utilization and higher rates of ICU admission after bariatric surgery compared to non-CKD patients. Otherwise, there is no significant difference in other post-operative complications and mortality. Bariatric surgery may therefore be safely offered to this patient population in hospitals with on-site ICU capacity.

Causal relationship between polycystic ovary syndrome and chronic kidney disease: A Mendelian randomization study

Objective

Polycystic ovary syndrome is one of the most common endocrine disorders among women of childbearing age. The relationship between polycystic ovary syndrome and chronic kidney disease remains unclear and controversial. In this study, we investigated the causal role of polycystic ovary syndrome in the development of chronic kidney disease using the two-sample Mendelian randomization method.

Methods

Public shared summary-level data was acquired from European-ancestry genome wide association studies. We finally obtained 12 single nucleotide polymorphisms as instrumental variables, which were associated with polycystic ovary syndrome in European at genome-wide significance (P < 5 × 10-8). Inverse-variance weighted method was employed in the Mendelian randomization analysis and multiple sensitivity analyses were implemented. Outcome data were obtained from the Open GWAS database.

Results

A positive causal association was observed between polycystic ovary syndrome and chronic kidney disease (odds ratio [OR]=1.180, 95% confidence interval [CI]: 1.038-1.342; P=0.010). Further analyses clarified that causal relationship exist between polycystic ovary syndrome and some serological indicators of chronic kidney disease (fibroblast growth factor 23: OR= 1.205, 95% CI: 1.031-1.409, P=0.019; creatinine: OR= 1.012, 95% CI: 1.001-1.023, P=0.035; cystatin C: OR= 1.024, 95% CI: 1.006-1.042, P=0.009). However, there was no causal association of polycystic ovary syndrome with other factors in the data sources we employed.

Conclusions

Our results indicate an important role of polycystic ovary syndrome in the development of chronic kidney disease. This study suggests that regular follow-up of renal function in patients with polycystic ovary syndrome is necessary for the early treatment of chronic kidney disease.

Characterising the burden of chronic kidney disease among people with type 2 diabetes in England: a cohort study using the Clinical Practice Research Datalink

OBJECTIVES

To describe prevalence of chronic kidney disease (CKD), demographic and clinical characteristics, treatment patterns and rates of cardiovascular and renal complications for patients with type 2 diabetes (T2D) treated in routine clinical care.

DESIGN

Repeat cross-sectional study (6 monthly cross-sections) and cohort study from 1 January 2017 to 31 December 2019.

SETTING

Primary care data from English practices contributing to the UK Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office for National Statistics mortality data.

PARTICIPANTS

Patients with T2D aged >18 years, at least one year of registration data.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome was prevalence of CKD defined as chronic kidney disease epidemiology collaboration (CKD-EPI) estimated glomerular filtration rate <60 mL/min/1.73 m², and/or urinary albumin creatinine ratio ≥3 mg/mmol in the past 24 months. Secondary outcomes were prescriptions of medications of interest and clinical and demographic characteristics in the past 3 months.In the cohort study rates of renal and cardiovascular complications, all-cause mortality and hospitalisations over the study period were compared among those with and without CKD.

RESULTS

There were 574 190 eligible patients with T2D as of 1 January 2017 and 664 296 as of 31 December 2019. Estimated prevalence of CKD across the study period was stable at approximately 30%. Medication use was stable over time in people with CKD and T2D, with low use of steroidal mineralocorticoid receptor antagonists (approximately 4.5% across all time points) and a low use but steady increase in use of sodium-glucose co-transporter-2 inhibitors (from 2.6% to 6.2%). Rates of all complications were higher in those with CKD at the start of the study period, with increasing rates, with increased severity of CKD, heart failure and albuminuria.

CONCLUSIONS

The burden of CKD in patients with T2D is high and associated with substantially increased rates of complications particularly in those with comorbid heart failure.

Multimorbidity prevalence and patterns in chronic kidney disease: findings from an observational multicentre UK cohort study

PURPOSE

Multimorbidity [defined as two or more long-term conditions (LTCs)] contributes to increased treatment and medication burden, poor health-related quality of life, and worse outcomes. Management strategies need to be patient centred and tailored depending on existing comorbidities; however, little is known about the prevalence and patterns of comorbidities in people with chronic kidney disease (CKD). We investigated the prevalence of multimorbidity and comorbidity patterns across all CKD stages.

METHODS

Multimorbidity was assessed, using a composite of self-report and clinical data, across four CKD groups stratified by eGFR [stage 1-2, stage 3a&b, stage 4-5, and kidney transplant (KTx)]. Principal component analysis using varimax rotation was used to identify comorbidity clusters across each group.

RESULTS

Of the 978 participants (mean 66.3 ± 14 years, 60% male), 96.0% had multimorbidity. In addition to CKD, the mean number of comorbidities was 3.0 ± 1.7. Complex multimorbidity (i.e. ≥ 4 multiple LTCs) was identified in 560 (57.3%) participants. When stratified by CKD stage, the two most prevalent comorbidities across all stages were hypertension (> 55%) and musculoskeletal disorders (> 40%). The next most prevalent comorbidity for CKD stages 1-2 was lung conditions and for CKD stages 3 and 4-5 it was heart problems. CKD stages 1-2 showed different comorbidity patterns and clustering compared to other CKD stages.

CONCLUSION

Most people across the spectrum of CKD have multimorbidity. Different patterns of multimorbidity exist at different stages of CKD, and as such, clinicians should consider patient comorbidities to integrate care and provide effective treatment strategies.

Prevalence and co-incidence of geriatric syndromes according to glomerular filtration rate in older patients

BACKGROUND

Geriatric syndromes are complex clinical manifestations and significant causes of mortality and morbidity. This study was aimed to determine the frequency and co-incidence of geriatric syndromes in older patients with chronic kidney disease (CKD).

METHODS

Older patients were included in this cross-sectional retrospective study. All patients were questioned in terms of geriatric syndromes including dementia, polypharmacy, malnutrition, frailty, probable sarcopenia, urinary incontinence, falls, fear of falling, depression, insomnia, and excessive daytime sleepiness. Geriatric syndromes were evaluated according to Glomerular Filtration Rate (GFR) ≥ 60 ml/min/1.73 m², 30-59 ml/min/1.73 m² and < 30 ml/min/1.73 m².

RESULTS

Of the 1320 patients included, the mean age was 79.6 ± 7.8 and 929 (70%) were female. GFR groups ≥ 60 ml/min/1.73 m², 30-59 ml/min/1.73 m², and < 30 ml/min/1.73 m² comprised of 55%, 38%, and 7% patients, respectively. The rate of ≥ 3 syndromes in the same person was 66.4% in the group with GFR ≥ 60 ml/min/1.73 m^2. After age and sex adjusted; it was observed that frailty was 2.5 times, probable sarcopenia 2.4 times, and malnutrition 2.7 times more in those with GFR 30-59 ml/min/1.73 m² compared to those with GFR ≥ 60 ml/min/1.73 m² (p < 0.05). Dementia 1.4, frailty 1.55, polypharmacy 2.0, and urinary incontinence were 1.6 times more common in those with a GFR < 30 ml/min/1.73 m² (p < 0.05).

CONCLUSIONS

Each of the geriatric syndromes and their co-incidence are high in older CKD patients. Geriatricians and nephrologists should be aware of geriatric syndromes in older CKD patients, and they should cooperate for the management of these patients.

Measuring the burden of comorbidity for ischaemic heart disease and four common non-communicable diseases in Iran, 1990-2017: a modelling study based on global burden of diseases data

OBJECTIVE

This modelling study aimed to estimate the comorbidity burden for four common non-communicable diseases with ischaemic heart diseases (IHD) in Iran during a period of 28 years.

DESIGN

Analysis of the burden of comorbidity with IHD based on data included prevalence rates and the disability weight (DW) average for calculating years lived with disability (YLDs) from the Iran population based on the Global Burden of Disease (GBD) study.

SETTING

Population-based available data in GBD 2017 study of Iran population.

PARTICIPANT

The source of data was the GBD 2017 Study. We evaluated IHD, major depressive disorder (MDD), diabetes mellitus (DM), ischaemic stroke (IS), and osteoarthritis (OA) age-standardised prevalence rates and their DW.

MAIN OUTCOME MEASURES

A new formula that modified the GBD calculator was used to measure the comorbidity YLDs. In the new formula, some multipliers were considered, measuring the departure from independence.

RESULT

The contribution of total comorbidity for each combination of IHD with DM, MDD, IS and OA was 2.5%, 2.0%, 1.6% and 2.9%, respectively. The highest YLD rates were observed for IHD_MDD, 16.5 in 1990 and 17.0 in 2017. This was followed by IHD_DM, from 11.5 to 16.9 per 100 000. The YLD rates for IHD_OA changed slightly (6.5-6.7) per 100 000, whereas there was a gradual reduction in the trends of IHD-IS, from 4.0-4.5 per 100 000.

CONCLUSION

Of the four comorbidities studied, the highest burden was due to the coexistence of MDD with IHD. Our results highlight the importance of addressing the burden of comorbidities when studying the burden of IHD or any other non-communicable disease.

Frailty in kidney transplantation: a review on its evaluation, variation and long-term impact

The problem of frailty in kidney transplantation is an increasingly discussed topic in the transplant field, partially also generated by the multiple comorbidities by which these patients are affected. The criteria currently used to establish the presence and degree of frailty can be rapidly assessed in clinical practice, even in patients with chronic kidney disease (CKD). The main objectives of this work are: (i) to describe the method of evaluation and the impact that frailty has in patients affected by CKD, (ii) to explore how frailty should be studied in the pre-transplant evaluation, (iii) how frailty changes after a transplant and (iv) the impact frailty has over the long term on the survival of renal transplant patients.

Randomized Controlled Trials on Renin Angiotensin Aldosterone System Inhibitors in Chronic Kidney Disease Stages 3–5: Are They Robust? A Fragility Index Analysis

Inhibition of the renin-angiotensin-aldosterone system (RAAS) is broadly recommended in many nephrological guidelines to prevent chronic kidney disease (CKD) progression. This work aimed to analyze the robustness of randomized controlled trials (RCTs) investigating the renal and cardiovascular outcomes in CKD stages 3–5 patients treated with RAAS inhibitors (RAASi). We searched for RCTs in MEDLINE (PubMed), EMBASE databases, and the Cochrane register. Fragility indexes (FIs) for every primary and secondary outcome were calculated according to Walsh et al., who first described this novel metric, suggesting 8 as the cut-off to consider a study robust. Spearman coefficient was calculated to correlate FI to p value and sample size of statistically significant primary and secondary outcomes. Twenty-two studies met the inclusion criteria, including 80,455 patients. Sample size considerably varied among the studies (median: 1693.5, range: 73–17,276). The median follow-up was 38 months (range 24–58). The overall median of both primary and secondary outcomes was 0 (range 0–117 and range 0–55, respectively). The median of FI for primary and secondary outcomes with a p value lower than 0.05 was 6 (range: 1–117) and 7.5 (range: 1–55), respectively. The medians of the FI for primary outcomes with a p value lower than 0.05 in CKD and no CKD patients were 5.5 (range 1–117) and 22 (range 1–80), respectively. Only a few RCTs have been shown to be robust. Our analysis underlined the need for further research with appropriate sample sizes and study design to explore the real potentialities of RAASi in the progression of CKD.

Age-Related Association between Multimorbidity and Mortality in US Veterans with Incident Chronic Kidney Disease

INTRODUCTION

Mortality is an important long-term indicator of the public health impact of chronic kidney disease (CKD). We investigated the role of individual comorbidities and multimorbidity on age-specific mortality risk among US veterans with new-onset CKD.

METHODS

The cohort included 892,005 veterans aged ≥18 years with incident CKD stage 3 between January 2004 and April 2018 in the US Veterans Health Administration (VHA) system and followed until death, December 2018, or up to 10 years. Incident CKD was defined as the first-time estimated glomerular filtration rate (eGFR) was <60 mL/min/1.73 m2 for >3 months. Comorbidities were ascertained using inpatient and outpatient clinical records in the VHA system and Medicare claims. We estimated death rates for any cardiovascular disease (CVD, a composite of 6 CVD conditions) and 15 non-CVD comorbidities, and adjusted risks of death (hazard ratio [HR], 95% confidence interval [CI]) overall and by age group at CKD incidence.

RESULTS

At CKD incidence, the mean age was 72 years, and 97% were male; the mean eGFR was 52 mL/min/1.73 m2, and 95% had ≥2 comorbidities (median, 4) in addition to CKD. During a median follow-up of 4.5 years, among the 16 comorbidities, CVD was associated with the highest relative risk of death in younger veterans (HR 1.96 [95% CI: 1.61-2.37] in ages 18-44 years and HR 1.66 [1.63-1.70] in ages 45-64 years). Dementia was associated with the highest relative risk of death among older veterans (HR 1.71 [1.68-1.74] in ages 65-84 years and HR 1.69 [1.65-1.73] in ages 85-100 years). The additive effect of multimorbidity on risk of death was stronger in younger than older veterans. Compared to having 1 or no comorbidity at CKD onset, the risk of death with ≥5 comorbidities was >7-fold higher among veterans aged 18-44 years and >2-fold higher among veterans aged 85-100 years.

CONCLUSION

The large burden of comorbidities in US veterans with newly identified CKD places them at the risk of premature death. Compared with older veterans, younger veterans with multiple comorbidities, particularly with CVD, at CKD onset are at an even higher relative risk of death.

Twenty years of real-world data to estimate chronic kidney disease prevalence and staging in an unselected population

Chronic kidney disease (CKD) represents a global public health burden, but its true prevalence is not fully characterized in the majority of countries. We studied the CKD prevalence in adult users of the primary, secondary and tertiary healthcare units of an integrated health region in northern Portugal (n = 136 993; representing ∼90% of the region's adult population). Of these, 45 983 (33.6%) had at least two estimated glomerular filtration rate (eGFR) assessments and 30 534 (22.2%) had at least two urinary albumin:creatinine ratio (UACR) assessments separated by at least 3 months. CKD was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines as a persistent decrease in eGFR (<60 ml/min/1.73 m²) and/or an increase in UACR (≥30 mg/g). The estimated overall prevalence of CKD was 9.8% and was higher in females (5.5%) than males (4.2%). From these, it was possible to stratify 4.7% according to KDIGO guidelines. The prevalence of CKD was higher in older patients (especially in patients >70 years old) and in patients with comorbidities. This is the first real-world-based study to characterize CKD prevalence in a large, unselected Portuguese population. It probably provides the nearest estimate of the true CKD prevalence and may help healthcare providers to guide CKD-related policies and strategies focused on prevention and on the improvement of cardiovascular disease and other outcomes.

Patient-related factors associated with medication adherence behavior in patients with end-stage renal disease: A systematic review

Objectives

This systematic review aims to identify influencing factors of medication adherence behavior in patients with end-stage renal disease (ESRD), with a special interest in patient-related factors based on the World Health Organization adherence model.

Materials and Methods

Primary electronic databases comprising PubMed, Scopus, Web of Science, Embase and Cochrane Library, as well as ProQuest (Health and Medical), ProQuest (Psychology), and EBSCOHost (APA PsychARTICLES) were used to search for literature on patient-related factors in medication adherence, from inception till August 31, 2021.

Results

479 articles were identified and six articles meeting eligibility criteria were reviewed and remained in this systematic review. The present review found that despite different tools being used to measure ESRD's perception of medication's necessity and beliefs, there was a profound association between perception and beliefs with medication adherence behavior. There is a positive relationship between knowledge, belief, educational level, ethnicity, female, and medication adherence behavior. Mixed finding was reported between perception, age, and medication adherence behavior. However, there were no studies on patients' attitudes and medication adherence behavior as suggested in the WHO adherence model.

Conclusion

Only a limited number of patient-related factors were available for evaluation in the current systematic review. Additional research is needed to advance the understanding of medication adherence behavior affected by patient-related factors on the medication and illness. However, the findings must be taken with caution because of the limited studies included in this review.

Outcomes Following Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Patients on Hemodialysis

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a potentially debilitating condition, often requiring total hip arthroplasty (THA). Patients on hemodialysis (HD) are at increased risk for complications after THA for osteoarthritis, however there is limited information on outcomes of THA for ONFH in patients on HD. With increasing prevalence of chronic kidney disease (CKD) requiring HD, studies are needed to characterize the risk of complications in these patients. Therefore, the purpose of this study was to evaluate HD as a potential risk factor for complication after THA in patients with ONFH on HD.

METHODS

Patients on HD with ONFH who underwent THA with at least 2 years of follow-up were identified using a combination of ICD-9 and CPT codes in a national insurance database. A 10:1 matched control cohort of patients with ONFH not on HD was created for comparison. A logistic regression analysis was used to evaluate rates of death, hospital readmission, emergency room (ER) visit, infection, revision, and dislocation between cohorts. Differences in hospital charges, reimbursement, and length of stay between the two groups were also assessed.

RESULTS

One thousand one hundred thirty-seven patients on HD who underwent THA for ONFH were compared to a matched control cohort of 11,182 non-HD patients who underwent THA for ONFH. Patients on HD experienced higher rates of death (HD 4.1%, non-HD 0.9%; odds ratio [OR] 3.35, p < 0.01), hospital readmission (HD 16.1%, non-HD 5.9%; OR 2.69, p < 0.01) and ER visit (HD 10.4%, non-HD 7.4% OR 1.5, p < 0.01). Hemodialysis was not associated with higher risk of infection, revision, or dislocation, but was associated with significantly higher charges (p < 0.01), reimbursement (p < 0.01), and hospital length of stay (p < 0.01).

CONCLUSIONS

While patients on HD do not have increased risk of implant-related complications, they are at increased risk of developing medical complications following THA for ONFH and subsequently may require more resources. Orthopedic surgeons and nephrologists should be cognizant of the increased risk in this population to provide appropriate preoperative counseling and enhanced perioperative medical management.

LEVEL OF EVIDENCE

Therapeutic Level III.

Food Insecurity Is Associated with Mental-Physical Comorbidities among U.S. Adults: NHANES 2013 to 2016

The co-occurrence of mental and physical conditions has increased significantly during the last decade. However, research examining the influence of social factors such as food insecurity is limited. The purpose of this study was to examine the association between food insecurity and mental–physical comorbidity status among U.S. adults. Data for this analysis were drawn from the National Health and Nutrition Examination Survey (NHANES) for the years 2013–2016. Respondents ages 18 and older who reported at least one of three chronic conditions (i.e., type 2 diabetes mellitus, hypertension, and hyperlipidemia) and responded to a nine-item depression scale were included in the analytic sample. The prevalence of food insecurity among those with depression and a cardiometabolic condition was 34% compared to 13% among those with a cardiometabolic condition only. Findings from multinomial logistic regression models indicated that food insecurity was associated with higher risk of mental–physical comorbidity (OR: 3.6, 95% CI: 2.26–5.76). Respondents reporting poor diet and poor self-reported health had higher odds of comorbid depression and cardiometabolic conditions. Female respondents had increased odds of comorbid depression and cardiometabolic conditions. Food insecurity is associated with co-occurring depression and cardiometabolic disease and may have implications for disease management.

Multimorbidity prevalence and patterns and their associations with health literacy among chronic kidney disease patients

Background

Health literacy is the ability to deal with information related to one’s health. Patients with low health literacy have poor disease-management skills for chronic diseases, such as chronic kidney disease (CKD). This could influence the number and combination of their diseases.

Methods

We included adult patients with CKD stages 1–5 from the Lifelines Study (n = 2,742). We assessed the association between low health literacy and the number and patterns of comorbidities, considering them globally and stratified by age and sex, using multinomial logistic regression and latent class analysis, respectively.

Results

Low health literacy was associated with a higher number of comorbidities in the crude models, and after adjustment for age, sex, eGFR, smoking, and BMI. In the crude model, the OR for low health literacy increased from 1.71 (1.25–2.33) for two comorbidities to 2.71 (2.00–3.68) for four comorbidities. In the fully-adjusted model, the associations remained significant with a maximum OR of 1.70 (1.16–2.49) for four comorbidities. The patterns of multimorbidity were similar for low and adequate health literacy, overall and by sex, bur tended to be different for patients older than 65. Older patients with low health literacy had higher comorbidity prevalence and a relatively greater share of cardiovascular, psychiatric, and central nervous system diseases.

Conclusions

Among CKD patients, low health literacy is associated with more multimorbidity. Health literacy is not associated with patterns of multimorbidity in younger patients, but a difference was observed in older ones. Improving low health literacy could be an intervention efficient also in decreasing multimorbidity in CKD patients.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40620-021-01229-1.

Polypharmacy and medication use in patients with chronic kidney disease with and without kidney replacement therapy compared to matched controls

Background

This study aims to examine polypharmacy (PP) prevalence in patients with chronic kidney disease (CKD) Stage G4/G5 and patients with kidney replacement therapy (KRT) compared with matched controls from the general population. Furthermore, we examine risk factors for PP and describe the most commonly dispensed medications.

Methods

Dutch health claims data were used to identify three patient groups: CKD Stage G4/G5, dialysis and kidney transplant patients. Each patient was matched to two controls based on age, sex and socio-economic status (SES) score. We differentiated between ‘all medication use’ and ‘chronic medication use’. PP was defined at three levels: use of ≥5 medications (PP), ≥10 medications [excessive PP (EPP)] and ≥15 medications [hyper PP (HPP)].

Results

The PP prevalence for all medication use was 87, 93 and 95% in CKD Stage G4/G5, dialysis and kidney transplant patients, respectively. For chronic medication use, this was 66, 70 and 75%, respectively. PP and comorbidity prevalence were higher in patients than in controls. EPP was 42 times more common in young CKD Stage G4/G5 patients (ages 20–44 years) than in controls, while this ratio was 3.8 in patients ≥75 years. Older age (64–75 and ≥75 years) was a risk factor for PP in CKD Stage G4/G5 and kidney transplant patients. Dialysis patients ≥75 years of age had a lower risk of PP compared with their younger counterparts. Additional risk factors in all patients were low SES, diabetes mellitus, vascular disease, hospitalization and an emergency room visit. The most commonly dispensed medications were proton pump inhibitors (PPIs) and statins.

Conclusions

CKD Stage G4/G5 patients and patients on KRT have a high medication burden, far beyond that of individuals from the general population, as a result of their kidney disease and a large burden of comorbidities. A critical approach to medication prescription in general, and of specific medications like PPIs and statins (in the dialysis population), could be a first step towards more appropriate medication use.

The effects of extreme temperatures on emergency room visits-a population-based analysis by age, sex, and comorbidity

This study evaluated the effect of extreme temperatures on events requiring emergency room visits (ERVs) for hypertensive disease, ischemic heart disease (IHD), cerebrovascular disease, and chronic kidney disease (CKD) for population stratified by sex and age living in Taiwan's metropolitan city from 2000 to 2014. The distributed lag non-linear model was adopted to examine the association between ambient temperature and area-age-sex-disease-specific ERVs for a population aged 40 years and above. The reference temperature was defined by a percentile value to describe the temperature in each city. Area-age-sex-disease-specific relative risk (RR) and 95% confidence intervals (CI) were estimated in association with extreme high (99th percentile) and low (5th percentile) temperatures. Temperature-related ERV risks varied by area, age, sex, and disease. Patients with CKD tend to have comorbidities with hypertensive disease. All study populations with hypertensive disease have significant risk associations with extreme low temperatures with the highest RR of 2.64 (95% CI: 2.08, 3.36) appearing in New Taipei City. The risk of IHD was significantly associated with extreme high temperature for male subpopulation aged 40-64 years. A less significant association was observed between the risks of cerebrovascular disease with extreme temperature. The risk of CKD was most significantly associated with extreme high temperature especially for a subpopulation aged 40-64 years. All study subpopulations with hypertensive disease have significant risk associations with extreme low temperature. Male subpopulations were more vulnerable to extreme temperatures, especially for those aged 40-64 years.

Association of Polypharmacy with Kidney Disease Progression in Adults with CKD

BACKGROUND AND OBJECTIVE

Polypharmacy is common in patients with CKD and reportedly associated with adverse outcomes. However, its effect on kidney outcomes among patients with CKD has not been adequately elucidated. Hence, this investigation was aimed at exploring the association between polypharmacy and kidney failure requiring KRT.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

We retrospectively examined 1117 participants (median age, 66 years; 56% male; median eGFR, 48 ml/min per 1.73 m²) enrolled in the Fukushima CKD Cohort Study to investigate the association between the number of prescribed medications and adverse outcomes such as kidney failure, all-cause mortality, and cardiovascular events in Japanese patients with nondialysis-dependent CKD. Polypharmacy and hyperpolypharmacy were defined as the regular use of 5-9 and ≥10 medications per day, respectively.

RESULTS

The median number of medications was eight; the prevalence of polypharmacy and hyperpolypharmacy was each 38%. During the observation period (median, 4.8 years), 120 developed kidney failure, 153 developed cardiovascular events, and 109 died. Compared with the use of fewer than five medications, adjusted hazard ratios (95% confidence intervals) associated with polypharmacy and hyperpolypharmacy were 2.28 (1.00 to 5.21) and 2.83 (1.21 to 6.66) for kidney failure, 1.60 (0.85 to 3.04) and 3.02 (1.59 to 5.74) for cardiovascular events, and 1.25 (0.62 to 2.53) and 2.80 (1.41 to 5.54) for all-cause mortality.

CONCLUSIONS

The use of a high number of medications was associated with a high risk of kidney failure, cardiovascular events, and all-cause mortality in Japanese patients with nondialysis-dependent CKD under nephrology care.

Unmet needs for CKD care: from the general population to the CKD clinics-how many patients are we missing?

Introduction

Prevalence of chronic kidney disease (CKD) varies around the world. Little is known about the discrepancy between the general population's needs and nephrology care offered. We aimed to contribute to filling this gap and propose a means to infer the number of patients needing follow-up.

Methods

All patients undergoing at least one nephrology consultation in 2019 were enrolled. We used the ratio between CKD Stages 3 and 4 reported in the literature, and considered that only 25–50% of CKD Stage 3 patients have progressive CKD, to hypothesize different scenarios to estimate the number of CKD Stage 3 patients still needing nephrology follow-up.

Results

The 1992 CKD patients were followed-up in our centre (56.93% males; age 66.71 ± 18.32 years; 16.82% Stage 1; 14.66% Stage 2; 39.46% Stage 3; 19.88% Stage 4; 7.68% Stage 5). The ratio between Stages 3 and 4 in population studies ranged from 7.72 to 51.29, being 1.98 in our centre. Hypothesizing that we followed-up 100, 70 or 50% of CKD Stage 4 patients, 528–2506 CKD Stage 3 patients in our area would need nephrology follow-up [1885–8946 per million population (p.m.p.)]. Three to 17 additional nephrologists p.m.p. would be necessary to fully cover the need for care.

Conclusions

The number of patients with CKD Stage 3 who would benefit from nephrology care is high. Considering that one patient-year of delay of dialysis could cover a nephrologist’s annual salary, interventions aimed to improve the care of advanced CKD may be economically sound.

Hospitalisation events in people with chronic kidney disease as a component of multimorbidity: parallel cohort studies in research and routine care settings

BACKGROUND

Chronic kidney disease (CKD) typically co-exists with multimorbidity (presence of 2 or more long-term conditions: LTCs). The associations between CKD, multimorbidity and hospitalisation rates are not known. The aim of this study was to examine hospitalisation rates in people with multimorbidity with and without CKD. Amongst people with CKD, the aim was to identify risk factors for hospitalisation.

METHODS

Two cohorts were studied in parallel: UK Biobank (a prospective research study: 2006-2020) and Secure Anonymised Information Linkage Databank (SAIL: a routine care database, Wales, UK: 2011-2018). Adults were included if their kidney function was measured at baseline. Nine categories of participants were used: zero LTCs; one, two, three and four or more LTCs excluding CKD; and one, two, three and four or more LTCs including CKD. Emergency hospitalisation events were obtained from linked hospital records.

RESULTS

Amongst 469,339 UK Biobank participants, those without CKD had a median of 1 LTC and those with CKD had a median of 3 LTCs. Amongst 1,620,490 SAIL participants, those without CKD had a median of 1 LTC and those with CKD had a median of 5 LTCs. Compared to those with zero LTCs, participants with four or more LTCs (excluding CKD) had high event rates (rate ratios UK Biobank 4.95 (95% confidence interval 4.82-5.08)/SAIL 3.77 (3.71-3.82)) with higher rates if CKD was one of the LTCs (rate ratios UK Biobank 7.83 (7.42-8.25)/SAIL 9.92 (9.75-10.09)). Amongst people with CKD, risk factors for hospitalisation were advanced CKD, age over 60, multiple cardiometabolic LTCs, combined physical and mental LTCs and complex patterns of multimorbidity (LTCs in three or more body systems).

CONCLUSIONS

People with multimorbidity have high rates of hospitalisation. Importantly, the rates are two to three times higher when CKD is one of the multimorbid conditions. Further research is needed into the mechanism underpinning this to inform strategies to prevent hospitalisation in this very high-risk group.

Management of Drug-Drug Interactions among Critically Ill Patients with Chronic Kidney Disease: Impact of Clinical Pharmacist's Interventions

BACKGROUND AND OBJECTIVES

Drug-drug interactions (DDIs) can create a burden on prescribers to preserve patient safety. This study aimed to identify common DDIs in critically ill patients with chronic kidney disease (CKD) and to evaluate clinical pharmacist's interventions in managing DDIs among these patients.

METHODS

A prospective observational study was conducted from October 2018 to March 2019. The clinical pharmacist performed a medication chart review; DDIs were identified by using Lexicomp® drug interaction. Based on the occurrence of DDIs, patients were divided into group A: patients with DDI (n = 76) and group B: patients without DDI (n = 15). Clinical pharmacist's interventions were classified according to Pharmaceutical Care Network Europe. The National Coordinating Council for Medication Error Reporting and Prevention was used to categorize the severity outcomes of DDIs and the degree of patient harm.

RESULTS

A total of 273 DDIs were identified. The majority of DDIs (63.7%) required close monitoring of the therapeutic outcome to ensure maintaining patient safety. DDIs that needed to be managed by considering therapy modification and avoiding drug combination were accounted for 17.2 and 12.8% of the most common detected interactions, respectively. Seventy-eight percent of DDIs induced no harm to patient. Clinical pharmacist provided different types of recommendations to manage detected interactions, which ranged from therapy outcome monitoring to stop DDIs. A great proportion of pharmacist's interventions (92%) were accepted by prescribers. Compared to patients with stage 3 and 4 CKD, patients with stage 5 had a significantly higher number of DDIs (stage 3 vs 5: p = 0.0019, stage 4 vs 5: p = 0.0456). The number of comorbidities (p = 0.0003) and (p <0.0001) medications were found to be significantly greater in group A.

CONCLUSION

Clinical pharmacist performed important interventions in timely identifying, managing DDIs, and prevention of associated patient harms.

HOW TO CITE THIS ARTICLE

Aghili M, Kasturirangan MN. Management of Drug-Drug Interactions among Critically Ill Patients with Chronic Kidney Disease: Impact of Clinical Pharmacist's Interventions. Indian J Crit Care Med 2021;25(11):1226-1231.

Kidney Disease Management in the Hospital Setting: A Focus on Inappropriate Drug Prescriptions in Older Patients

Aging with multimorbidity and polytherapy are the most significant factors that could led to inappropriate prescribing of contraindicated medications in patients with chronic kidney disease (CKD). The aim of this study was to evaluate the prescriptions of contraindicated drugs in older adults in CKD and to identify their associated factors in a hospital context. An observational retrospective study was carried out considering all patients ≥65 years with at least one serum creatinine value recorded into the REPOSI register into 2010-2016 period. The estimated glomerular filtration rate (eGFR) was applied to identify CKD. A descriptive analysis was performed to compare demographic and clinical characteristics; logistic regression models were used to estimate factors of inappropriate and percentage changes of drug use during hospitalization. A total of 4,713 hospitalized patients were recorded, of which 49.8% had an eGFR <60 ml/min/1.73 m²; the 21.9% were in treatment with at least one inappropriate drug at the time of hospital admission with a decrease of 3.0% at discharge (p = 0.010). The probability of using at least one contraindicated drug was significantly higher in patients treated with more several drugs (OR 1.21, 95% CI 1.16-1.25, p <0.001) and with CKD end-stages (G4: 16.90, 11.38-25.12, p < 0.001; G5: 19.38, 11.51-32.64, p < 0.001). Low-dose acetylsalicylic acid was the contraindicated drug mainly used at the time of admission, reducing 1.2% at discharge. An overall increase in therapeutic appropriateness in hospitalized older patients with CKD was observed, despite a small percentage of therapeutic inappropriateness at discharge that underlines the need for a closer collaboration with the pharmacologist to improve the drug management.

A small-molecule inhibitor of hypoxia-inducible factor prolyl hydroxylase improves obesity, nephropathy and cardiomyopathy in obese ZSF1 rats

Prolyl hydroxylase (PH) enzymes control the degradation of hypoxia-inducible factor (HIF), a transcription factor known to regulate erythropoiesis, angiogenesis, glucose metabolism, cell proliferation, and apoptosis. HIF-PH inhibitors (HIF-PHIs) correct anemia in patients with renal disease and in animal models of anemia and kidney disease. However, the effects of HIF-PHIs on comorbidities associated with kidney disease remain largely unknown. We evaluated the effects of the HIF-PHI FG-2216 in obese ZSF1 (Ob-ZSF1) rats, an established model of kidney failure with metabolic syndrome. Following unilateral nephrectomy (Nx) at 8 weeks of age, rats were treated with 40 mg/kg FG-2216 or vehicle by oral gavage three times per week for up to 18 weeks. FG-2216 corrected blood hemoglobin levels and improved kidney function and histopathology in Nx-Ob-ZSF1 rats by increasing the glomerular filtration rate, decreasing proteinuria, and reducing peritubular fibrosis, tubular damage, glomerulosclerosis and mesangial expansion. FG-2216 increased renal glucose excretion and decreased body weight, fat pad weight, and serum cholesterol in Nx-Ob-ZSF1 rats. Additionally, FG-2216 corrected hypertension, improved diastolic and systolic heart function, and reduced cardiac hypertrophy and fibrosis. In conclusion, the HIF-PHI FG-2216 improved renal and cardiovascular outcomes, and reduced obesity in a rat model of kidney disease with metabolic syndrome. Thus, in addition to correcting anemia, HIF-PHIs may provide renal and cardiac protection to patients suffering from kidney disease with metabolic syndrome.

The association between frailty and chronic kidney disease; cross-sectional analysis of the Nambu Cohort Study

BACKGROUND

Both frailty and chronic kidney disease (CKD) increase with age and share many similarities. Many studies have demonstrated an association between frailty and chronic kidney disease (CKD), but an association with dipstick proteinuria is limited.

METHODS

This is the cross-sectional analysis of the Nambu Cohort Study at the beginning of observation. Frailty was diagnosed using Kihon Checklist. Logistic analysis was used to evaluate the association between frailty and CKD or dipstick proteinuria.

RESULTS

Among a total of 630 outpatients [age, 78 (70-84) years, men, 50%], the prevalence of patients with pre-frailty and frailty was 32% and 40%, respectively. The proportion of patients with pre-frailty and frailty increased with decreasing estimated glomerular filtration rate (eGFR) and increasing dipstick proteinuria levels. The odds ratios (95% confidence intervals) for CKD stage of 60 < eGFR ≤ 45 ml/min/1.73 m², and 45 ml/min/1.73 m² < eGFR for frailty was 0.87 (0.56-1.35) and 2.54 (1.46-4.53), respectively, compared with non-CKD as a reference. Furthermore, the odds ratios for the frailty of dipstick proteinuria with ± and + or over were 1.36 (0.88-2.09) and 1.78 (1.00-3.17), respectively, when dipstick proteinuria-was used as a reference. Moreover, the combination of eGFR and dipstick proteinuria levels increased the odds ratio for pre-frailty and frailty.

CONCLUSION

Elderly patients with CKD had a higher prevalence of pre-frailty and frailty. By adding urinary protein information to eGFR, the link between CKD and frailty becomes even more robust.

Assessing the Delivery of Coordinated Care to Patients with Advanced Chronic Kidney Disease in Ontario, Canada: A Survey of Patients and Healthcare Professionals

Introduction:

Patients with advanced Chronic Kidney Disease (CKD) have complex health needs, and thus require care that is coordinated across professionals and organizations. This study aimed to describe the extent of coordinated care delivery for patients with advanced CKD from the perspectives of both patients and healthcare professionals.

Methods:

The Coordination Scale of the Patient Assessment of Chronic Illness Care (PACIC-26) survey was administered to a random sample of 14,257 patients on maintenance dialysis or receiving care in end-stage kidney disease preparation clinics in Ontario, Canada. A five-item survey was administered to 596 multidisciplinary nephrology professionals.

Results:

Among the 1,925 patient respondents, 67% reported they had been referred to an allied health professional; 19% had been encouraged to attend programs in the community; and 34% had been told how their visits with other types of doctors helped their treatment (% reporting “always” or “most of the time”). Patient responses were significantly different by treatment modality/setting, but not by gender or geographic location of treatment facility. Among the 276 professional respondents, 37% reported their patients’ care was well-coordinated across settings; 56% reported participating in interdisciplinary care planning discussions; and 53% reported they are aware of appropriate home and community services to support their patients (% reporting “always” or “most of the time”).

Conclusion:

The results suggest that care for patients with advanced CKD in Ontario is not consistently coordinated. Healthcare professionals may enhance patient perceptions of coordinated care through explicit communication with patients about how the professionals they see and treatments or services they receive influence their overall health and well-being. At a systems level, there is a need to improve professional awareness of and linkages to home- and community-based services.

Financial Hardship Among Nonelderly Adults With CKD in the United States

RATIONALE & OBJECTIVE

The burden of financial hardship among individuals with chronic kidney disease (CKD) has not been extensively studied. Therefore, we describe the scope and determinants of financial hardship among a nationally representative sample of adults with CKD.

STUDY DESIGN

Cross-sectional.

SETTING & PARTICIPANTS

Nonelderly adults with CKD from the 2014-2018 National Health Interview Survey.

EXPOSURE

Sociodemographic and clinical characteristics.

OUTCOME

Financial hardship based on medical bills and consequences of financial hardship (high financial distress, food insecurity, cost-related medication nonadherence, delayed/forgone care due to cost). Financial hardship was categorized into 3 levels: no financial hardship, financial hardship but able to pay bills, and unable to pay bills at all. Financial hardship was then modeled in 2 different ways: (1) any financial hardship (regardless of ability to pay) versus no financial hardship and (2) inability to pay bills versus no financial hardship and financial hardship but able to pay bills.

ANALYTICAL APPROACH

Nationally representative estimates of financial hardship from medical bills were computed. Multivariable logistic regression models were used to examine the associations of sociodemographic and clinical factors with the outcomes of financial hardship based on medical bills.

RESULTS

A total 1,425 individuals, representing approximately 2.1 million Americans, reported a diagnosis of CKD within the past year, of whom 46.9% (95% CI, 43.7%-50.2%) reported experiencing financial hardship from medical bills; 20.9% (95% CI, 18.5%-23.6%) reported inability to pay medical bills at all. Lack of insurance was the strongest determinant of financial hardship in this population (odds ratio, 4.06 [95% CI, 2.18-7.56]).

LIMITATIONS

Self-reported nature of CKD diagnosis.

CONCLUSIONS

Approximately half the nonelderly US population with CKD experiences financial hardship from medical bills that is associated strongly with lack of insurance. Evidence-based clinical and policy interventions are needed to address these hardships.

A Mediterranean lifestyle is associated with favourable cardiometabolic markers in people with non-dialysis dependent chronic kidney disease

Adherence to a Mediterranean lifestyle may be a useful primary and secondary prevention strategy for chronic kidney disease (CKD). This cross-sectional study aimed to explore adherence to a Mediterranean lifestyle and its association with cardiometabolic markers and kidney function in 99 people aged 73⋅2 ± 10⋅5 years with non-dialysis dependant CKD (stages 3-5) at a single Australian centre. Adherence was assessed using an a priori index, the Mediterranean Lifestyle (MEDLIFE) index. Cardiometabolic markers (total cholesterol, LDL-cholesterol, HbA1c and random blood glucose) and kidney function (estimated GFR) were sourced from medical records and blood pressure measured upon recruitment. Overall, adherence to a Mediterranean lifestyle was moderate to low with an average MEDLIFE index score of 11⋅33 ± 3⋅31. Adherence to a Mediterranean lifestyle was associated with employment (r 0⋅30, P = 0⋅004). Mediterranean dietary habits were associated with cardiometabolic markers, such as limiting sugar in beverages was associated with lower diastolic blood pressure (r 0⋅32, P = 0⋅002), eating in moderation with favourable random blood glucose (r 0⋅21, P = 0⋅043), having more than two snack foods per week with HbA1c (r 0⋅29, P = 0⋅037) and LDL-cholesterol (r 0⋅41, P = 0⋅002). Interestingly, eating in company was associated with a lower frequency of depression (χ2 5⋅975, P = 0⋅015). To conclude, Mediterranean dietary habits were favourably associated with cardiometabolic markers and management of some comorbidities in this group of people with non-dialysis dependent CKD.