Sex differences in chronic kidney disease awareness among US adults, 1999 to 2018

Predictors of chronic kidney disease survival in type 2 diabetes: a 12-year retrospective cohort study utilizing estimated glomerular filtration rate

Predicting the course of kidney disease in individuals with both type 1 and type 2 diabetes mellitus (DM) is a significant clinical and policy challenge. In several regions, DM is now the leading cause of end-stage renal disease. The aim of this study to identify both modifiable and non-modifiable risk factors, along with clinical markers and coexisting conditions, that increase the likelihood of stage 3-5 chronic kidney disease (CKD) development in individuals with type 2 DM in the United Arab Emirates (UAE). This was a single-center retrospective cohort study based on data derived from electronic medical records of UAE patients with DM who were registered at outpatient clinics at Tawam Hospital in Al Ain, UAE, between January 2011 and December 2021. Type 2 DM patients aged ≥ 18 years who had serum HbA1c levels ≥ 6.5% were included in the study. Patients with type 1 DM, who had undergone permanent renal replacement therapy, who had under 1 year of follow-up, or who had missing or incomplete data were excluded from the study. Factors associated with diabetic patients developing stage 3-5 CKD were identified through Cox regression analysis and a fine and gray competing risk model to account for competing events that could potentially hinder the development of CKD. A total of 1003 patients were recruited for the study. The mean age of the study cohort at baseline was 70.6 ± 28.2 years. Several factors were found to increase the risk of developing stage 3-5 CKD: advancing age (HR 1.005, 95% CI 1.002-1.009, p = 0.026), a history of hypertension (HR 1.69, 95% CI 1.032-2.8, p = 0.037), a history of heart disease (HR 1.49, 95% CI 1.16-1.92, p = 0.002), elevated levels of serum creatinine (HR 1.006, 95% CI 1.002-1.010, p = 0.003), decreased levels of estimated glomerular filtration rate (eGFR) (HR 0.943, 95% CI, 0.938-0.947; p < 0.001), and the use of beta-blockers (HR 139, 95% CI 112-173, p = 0.003). Implementing preventative measures, initiating early interventions, and developing personalized care plans tailored to address specific risk factors are imperative for reducing the impact of CKD. Additionally, the unforeseen findings related to eGFR highlight the ongoing need for research to deepen our understanding of the complexities of kidney disease.

Diagnostic Validity of Chronic Kidney Disease in Health Claims Data Over Time: Results from a Cohort of Community-Dwelling Older Adults in Germany

Purpose

The validity of ICD-10 diagnostic codes for chronic kidney disease (CKD) in health claims data has not been sufficiently studied in the general population and over time.

Patients and Methods

We used data from the Berlin Initiative Study (BIS), a prospective longitudinal cohort of community-dwelling individuals aged ≥70 years in Berlin, Germany. With estimated glomerular filtration rate (eGFR) as reference, we assessed the diagnostic validity (sensitivity, specificity, positive [PPV], and negative predictive values [NPV]) of different claims-based ICD-10 codes for CKD stages G3-5 (eGFR <60mL/min/1.73m²: ICD-10 N18.x-N19), G3 (eGFR 30-<60mL/min/1.73m²: N18.3), and G4-5 (eGFR <30mL/min/1.73m²: N18.4-5). We analysed trends over five study visits (2009-2019).

Results

We included data of 2068 participants at baseline (2009-2011) and 870 at follow-up 4 (2018-2019), of whom 784 (38.9%) and 440 (50.6%) had CKD G3-5, respectively. At baseline, sensitivity for CKD in claims data ranged from 0.25 (95%-confidence interval [CI] 0.22-0.28) to 0.51 (95%-CI 0.48-0.55) for G3-5, depending on the included ICD-10 codes, 0.20 (95%-CI 0.18-0.24) for G3, and 0.36 (95%-CI 0.25-0.49) for G4-5. Over the course of 10 years, sensitivity increased by 0.17 to 0.29 in all groups. Specificity, PPVs, and NPVs remained mostly stable over time and ranged from 0.82-0.99, 0.47-0.89, and 0.66-0.98 across all study visits, respectively.

Conclusion

German claims data showed overall agreeable performance in identifying older adults with CKD, while differentiation between stages was limited. Our results suggest increasing sensitivity over time possibly attributable to improved CKD diagnosis and awareness.

Stage 5 Chronic Kidney Disease: Epidemiological Analysis in a NorthEastern District of Italy Focusing on Access to Nephrological Care

BACKGROUND

We conducted a retrospective epidemiological study about the prevalence of stage 5 chronic kidney disease (CKD) in a high-income district, comparing some demographic characteristics and outcomes of those patients who had nephrological consultations and those who had not.

RESULTS

In a district of 400,000 adult subjects in 2020, 925 patients had an estimated glomerular filtration rate (eGFR) under 15 mL/min and CKD. In the same period, 747 (80.4%) patients were assessed by nephrologists, while 178 (19.6%) were not. Age (88 vs. 75, p < 0.0001), female gender (66.3% vs. 47%, p < 0.001), and eGFR (12 vs. 9 mL/min, p < 0.001) were significantly different in the patients assessed by a nephrologist as compared those who did not have nephrological care. Furthermore, unfollowed CKD patients had a significantly higher death rate, 83.1% versus 14.3% (p < 0.0001).

CONCLUSIONS

About 20% of ESKD patients did not receive a nephrologist consultation. Older people and women were more likely not to be referred to nephrology clinics. Unfollowed patients with stage 5 CKD had a significantly higher death rate.

Resting heart rate is associated with the prevalence of chronic kidney disease in Korean adult: the Korean National Health and Nutrition Survey

BACKGROUND

Chronic kidney disease (CKD) poses a significant health challenge, yet early detection remains difficult. Resting heart rate (RHR) has been shown to be a reliable indicator of type 2 diabetes, prompting interest in its potential as an independent predictor of CKD. This study aimed to investigate the association between RHR and CKD prevalence, as well as explore potential interactions between RHR and other risk factors for CKD in a sample of 25,246 adults.

METHODS

Data from the Korean National Health and Nutrition Examination Survey (2011-2014) were utilized for this study, with 19,210 participants included after screening. Logistic regression analysis was employed to examine the relationship between RHR and CKD prevalence. Stratified analyses were conducted based on known risk factors for CKD.

RESULTS

Participants with an RHR ≥ 90 bpm exhibited a 2.07-fold [95% confidence interval (CI): 1.28-3.34] and 2.22-fold (95% CI: 1.42-3.48) higher prevalence of CKD in men and women, respectively, compared to those with an RHR < 60 bpm. The association between RHR and CKD prevalence was particularly pronounced in younger participants (40-59 years vs. ≥ 60 years), individuals with diabetes (yes vs. no), and those with a longer duration of diabetes (≥ 7 years vs. < 7 years).

CONCLUSION

Elevated RHR was found to be significantly associated with a higher prevalence of CKD in both men and women, independent of demographic, lifestyle, and medical factors. These findings suggest that RHR could serve as a valuable predictor for undiagnosed CKD.

Differences in the epidemiology, management and outcomes of kidney disease in men and women

Improved understanding of differences in kidney disease epidemiology, management and outcomes in men and women could help nephrologists to better meet the needs of their patients from a sex- and gender-specific perspective. Evidence of sex differences in the risk and outcomes of acute kidney injury is mixed and dependent on aetiology. Women have a higher prevalence of chronic kidney disease (CKD) stages 3-5 than men, whereas men have a higher prevalence of albuminuria and hence CKD stages 1-2. Men show a faster decline in kidney function, progress more frequently to kidney failure and have higher mortality and risk of cardiovascular disease than women. However, the protective effect of female sex is reduced with CKD progression. Women are less likely than men to be aware of, screened for and diagnosed with CKD, started on antiproteinuric medication and referred to nephrologist care. They also consistently report a poorer health-related quality of life and a higher symptom burden than men. Women experience greater barriers than men to access the waiting list for kidney transplantation, particularly with respect to older age and obesity. However, women also have longer survival than men after transplantation, which may partly explain the comparable prevalence of transplantation between the sexes.

Sex Differences in Mouse Cardiac Electrophysiology Revealed by Simultaneous Imaging of Excitation-Contraction Coupling

Males and females differ in the basic anatomy and physiology of the heart. Sex differences are evident in cardiac repolarization in humans; women have longer corrected QT and JT intervals. However, the molecular mechanisms that lead to these differences are incompletely understood. Here, we present that, like in humans, sex differences in QT and JT intervals exist in mouse models; female mice had longer corrected QT and JT intervals compared with age-matched males. To further understand the molecular underpinning of these sex differences, we developed a novel technology using fluorescent confocal microscopy that allows the simultaneous visualization of action potential, Ca2+ transients, and contractions in isolated cardiomyocytes at a high temporal resolution. From this approach, we uncovered that females at baseline have increased action potential duration, decreased Ca2+ release and reuptake rates, and decreased contraction and relaxation velocities compared with males. Additionally, males had a shorter overall time from action potential onset to peak contraction. In aggregate, our studies uncovered male and female differences in excitation-contraction coupling that account for differences observed in the EKG. Overall, a better understanding of sex differences in electrophysiology is essential for equitably treating cardiac disease.

Sex-specific differences in the association between steps per day and all-cause mortality among a cohort of adult patients from the United States with congestive heart failure

BACKGROUND

There is a lack of understanding of how daily step counts differentially affect the risk of all-cause mortality in adult with congestive heart failure (CHF) by sex in the United States (US).

OBJECTIVES

To explore the relationship between daily step counts and all-cause mortality in patients with CHF by sex.

METHODS

This is a cohort analysis from the National Health and Nutrition Examination Survey from 2005 to 2006. Multiple Cox hazard regression was performed to explore the association of step counts and all-cause mortality in patients with CHF by sex.

RESULTS

In this study, 363 unweighted samples were enrolled from NHANES 2005-2006, representing about 8.4 million of the US population. Further, 46.28% were women, and the average age was 46 years. Patients with CHF in the more than 5581 steps/day group (HR, 0.31 [95% CI, 0.16-0.58]) had a significantly reduced risk of all-cause mortality compared with the patients in the less 5581 steps/day group after accounting for all covariates. In men, after accounting for all the covariates, there was a significant difference in more than 5581 steps/day group (HR, 0.33 [95% CI, 0.14-0.76]) on all-cause mortality in men with CHF compared with men in the less than 5581 steps/day group.

CONCLUSIONS

Step count is associated with all-cause mortality in patients with CHF. Taking 5581 daily steps was associated with a decreased risk of all-cause mortality in patients with CHF.

Factors associated with chronic kidney disease in patients with diabetes in French Guiana

Introduction

With over half of the population living under the poverty threshold, the social and health context in French Guiana is more difficult than in mainland France. The prevalence of diabetes is twice as great and end-stage renal failure is 45% higher than in mainland France.

Objective

Our objective was to describe the profile of diabetic patients with chronic kidney disease in French Guiana and search for possible risk factors.

Method

We conducted a multicenter cross-sectional observational study based on the CODIAM cohort (Cohort of Diabetes in French Amazonia). We analyzed 1,287 patients followed up between May 2019 and June 2021 at Cayenne Hospital, Saint Laurent Hospital, and delocalized health centers.

Results

In our cohort, chronic kidney disease was present after an average of 12 years of diabetes. Compared with the French population, 41% of diabetic patients had chronic kidney disease (i.e., 12% more), and had an average age of 56 years (i.e., 10 years younger). Forty-eight per cent of these patients were obese (i.e., 7% more). Seventy-four per cent of patients were precarious and 45% were foreigners but neither was associated with chronic kidney disease, contrary to countries where the health system is not universal.

Conclusion

Screening of patients with chronic kidney disease among diabetics in French Guiana remains a real challenge. Patients were younger and more obese than in other French territories. In this cohort, precariousness and immigration were not associated with the presence of chronic kidney disease. However, particular attention should be paid to hypertensive patients and those over 65 years of age, which are, with diabetes itself, the two most obvious risk factors for developing chronic kidney disease among diabetic patients in our territory.

Chronic kidney disease awareness and its determinants in middle-aged and older Japanese adults: Observations from a 5-year follow-up of the Uonuma cohort study

AIM

Despite global efforts in public health campaigns concerning chronic kidney disease (CKD), awareness of the condition remains low. We evaluated CKD awareness and related factors to identify an effective way to raise awareness.

METHODS

This study assessed laboratory-confirmed CKD and self-reported CKD using a population-based cohort (baseline from 2012 to 2014, age ≥40 years) in Niigata, Japan. Self-reported CKD was obtained at a 5-year follow-up survey and laboratory-confirmed CKD was diagnosed when an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 or dipstick urinary protein ≥1+ was observed in at least two health check-ups during the 5-year period. CKD awareness was defined as a match between laboratory-confirmed and self-reported CKD. The association between characteristics and CKD awareness was tested by multivariable logistic regression analysis with adjustment for eGFR and other potential confounders.

RESULTS

The analytic population comprised 7472 individuals (mean age, 65.6 years old, 51.2% women) and 19.4% with laboratory-confirmed CKD. The sensitivity and specificity of the survey question concerning self-reported CKD were 12.4% and 98.2%, respectively. Among the participants with laboratory-confirmed CKD, significant factors associated with CKD awareness were male sex (adjusted odds ratio [95% confidence interval], 1.81 [1.27, 2.59]), a history of urinary tract stone (1.86 [1.06, 3.26]), age (0.97 [0.95, 0.99]), and married status (0.66 [0.44, 0.99]).

CONCLUSION

Our findings suggest that known lifestyle-related diseases that could cause CKD are not associated with CKD awareness independently of kidney function and that a sex-dependent approach may help to raise CKD awareness in community-dwelling Japanese adults.

Black Patients Equally Benefit From Renal Genetics Evaluation but Substantial Barriers in Access Exist

Introduction

Genetic testing is increasingly accessible to patients with kidney diseases. Racial disparities in renal genetics evaluations have not been investigated.

Methods

A cohort of patients evaluated by the Cleveland Clinic Renal Genetics Clinic (RGC) from January 2019 to March 2022 was analyzed.

Results

Forty-eight Black patients, including 27 (56.3%) males, median age 34 (22-49) years and 232 White patients, including 76 (32.8%) males, median age 35 (21-53) years, were evaluated. Black patients were more likely to have end-stage kidney disease (ESKD) at the time of referral compared with White patients (23% vs. 7.3%, P = 0.004), more likely to be covered by Medicaid (46% vs. 15%, P < 0.001), and less likely to be covered by private insurance (35% vs. 66%, P < 0.001). Black patients were more likely to "no show" to scheduled appointment(s) or not submit specimens for genetic testing compared with White patients (24.1% vs. 6.7%, P = 0.0005). Genetic testing was completed in 35 Black patients. Of these, 37% had a positive result with 9 unique monogenic disorders and 1 chromosomal disorder diagnosed. Sixty-nine percent of Black patients with positive results received a new diagnosis or a change in diagnosis. Of these, 44% received a significant change in disease management. No differences in diagnostic yield and implications of management were noted between Black and White patients.

Conclusion

Black patients equally benefit from renal genetics evaluation, but barriers to access exist. Steps must be taken to ensure equitable and early access for all patients. Further studies investigating specific interventions to improve access are needed.

Chronic kidney disease promotes cerebral microhemorrhage formation

BACKGROUND

Chronic kidney disease (CKD) is increasingly recognized as a stroke risk factor, but its exact relationship with cerebrovascular disease is not well-understood. We investigated the development of cerebral small vessel disease using in vivo and in vitro models of CKD.

METHODS

CKD was produced in aged C57BL/6J mice using an adenine-induced tubulointerstitial nephritis model. We analyzed brain histology using Prussian blue staining to examine formation of cerebral microhemorrhage (CMH), the hemorrhagic component of small vessel disease and the neuropathological substrate of MRI-demonstrable cerebral microbleeds. In cell culture studies, we examined effects of serum from healthy or CKD patients and gut-derived uremic toxins on brain microvascular endothelial barrier.

RESULTS

CKD was induced in aged C57BL/6J mice with significant increases in both serum creatinine and cystatin C levels (p < 0.0001) without elevation of systolic or diastolic blood pressure. CMH was significantly increased and positively correlated with serum creatinine level (Spearman r = 0.37, p < 0.01). Moreover, CKD significantly increased Iba-1-positive immunoreactivity by 51% (p < 0.001), induced a phenotypic switch from resting to activated microglia, and enhanced fibrinogen extravasation across the blood-brain barrier (BBB) by 34% (p < 0.05). On analysis stratified by sex, the increase in CMH number was more pronounced in male mice and this correlated with greater creatinine elevation in male compared with female mice. Microglial depletion with PLX3397 diet significantly decreased CMH formation in CKD mice without affecting serum creatinine levels. Incubation of CKD serum significantly reduced transendothelial electrical resistance (TEER) (p < 0.01) and increased sodium fluorescein permeability (p < 0.05) across the endothelial monolayer. Uremic toxins (i.e., indoxyl sulfate, p-cresyl sulfate, and trimethylamine-N-oxide) in combination with urea and lipopolysaccharide induced a marked drop in TEER compared with the control group (p < 0.0001).

CONCLUSIONS

CKD promotes the development of CMH in aged mice independent of blood pressure but directly proportional to the degree of renal impairment. These effects of CKD are likely mediated in part by microglia and are associated with BBB impairment. The latter is likely related to gut-derived bacteria-dependent toxins classically associated with CKD. Overall, these findings demonstrate an important role of CKD in the development of cerebral small vessel disease.

Chronic kidney disease is more prevalent among women but more men than women are under nephrological care : Analysis from six outpatient clinics in Austria 2019

BACKGROUND

A discrepancy between sex-specific treatment of kidney failure by dialysis (higher in men) and the prevalence of chronic kidney disease in the general population (higher in women) has been reported internationally, but the prevalence by sex has not been described for Austria. Sex disparity among nephrology outpatients has not been studied.

METHODS

We employed two formulae (2009 CKD-EPI suppressing the race factor, and race-free 2021 CKD-EPI) to estimate the sex distribution of CKD in Austrian primary care, based on creatinine measurements recorded in a medical sample of 39,800 patients from general practitioners' offices (1989-2008). Further, we collected information from all clinic appointments scheduled at nephrology departments of 6 Austrian hospitals (Wien, Linz, Wels, St. Pölten, Villach, Innsbruck) during 2019 and calculated visit frequencies by sex.

RESULTS

Using the 2009 CKD-EPI formula, the prevalence of CKD in stages G3-G5 (estimated glomerular filtration rate < 60 mL/min/1.73 m²) was 16.4% among women and 8.5% among men aged > 18 years who had attended general practitioners' offices in Austria between 1989 and 2008 and had at least one creatinine measurement performed. Using the 2021 CKD-EPI formula, the respective CKD prevalence was 12.3% among women and 6.1% among men. In 2019, 45% of all outpatients at 6 participating nephrology departments were women. The median of nephrology clinic visits in 2019 was two (per year) for both sexes.

CONCLUSION

CKD is more prevalent among Austrian women than men. Men are more prevalent in nephrology outpatient services. Research into causes of this sex disparity is urgently needed.

Patterns of biopsy-proven renal diseases in geriatric patients: A single medical center experience

The elderly population is expanding rapidly, and that has become a major healthcare burden in terms of chronic kidney disease. The distribution patterns of kidney diseases in these elderly patients remain largely unclear. Here, we compared biopsy-based renal disease patterns between elderly and nonelderly patients. We performed a single-center, retrospective study (1992-2008) on biopsy-proven renal diseases to compare results between geriatric patients (age ≥ 65 years; n = 254) and nongeriatric patients (18 ≤ age < 65 years; n = 2592). Renal pathology was interpreted by pathologists based on light microscopy, immunofluorescence, and electron microscopy. The ages of the geriatric and nongeriatric groups were 71.8 ± 4.5 (65.1-87.3) and 39.7 ± 17.6 (18-64.9) years, respectively, and 74% and 41% of them, respectively, were men. In the geriatric group, the most frequent diagnosis was membranous nephropathy (46.1%), followed by minimal change disease/focal segmental glomerulosclerosis (16.9%), diabetic nephropathy (8.3%), hypertensive nephrosclerosis (7.5%), and IgA nephropathy (5.9%). The geriatric group had more membranous nephropathy and less lupus nephritis and IgA nephropathy than the nongeriatric group. Furthermore, the 5-year survival rate of the geriatric group was significantly low. Our results demonstrated the different distributions of renal biopsy patterns in geriatric patients diagnosed with acute or chronic progressive kidney injury and proteinuria through renal biopsy.

Associations between female birth sex and risk of chronic kidney disease development among people with HIV in the USA: A longitudinal, multicentre, cohort study

Background

Women represent a meaningful proportion of new HIV diagnoses, with Black women comprising 58% of new diagnoses among women. As HIV infection also increases risk of chronic kidney disease (CKD), understanding CKD risk among women with HIV (WWH), particularly Black women, is critical.

Methods

In this longitudinal cohort study of people with HIV (PWH) enrolled in CFAR Network of Integrated Clinical Systems (CNICS), a multicentre study comprised of eight academic medical centres across the United States from Jan 01, 1996 and Nov 01, 2019, adult PWH were excluded if they had ≤2 serum creatinine measurements, developed CKD prior to enrollment, or identified as intersex or transgendered, leaving a final cohort of 33,998 PWH. The outcome was CKD development, defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1·73 m2 calculated using the CKD-EPI equation, for ≥90 days with no intervening higher values.

Findings

Adjusting for demographic and clinical characteristics, WWH were 61% more likely to develop CKD than men (adjusted hazard ratio [aHR]: 1·61, 95% CI: 1·46-1·78, p<0·001). This difference persisted after further adjustment for APOL1 risk variants (aHR female sex: 1·92, 95% CI: 1·63-2·26, p<0·001) and substance abuse (aHR female sex: 1·70, 95% CI: 1·54-1·87, p<0·001).

Interpretation

WWH experienced increased risk of CKD. Given disparities in care among patients with end-stage kidney disease, efforts to engage WWH in nephrology care to improve chronic disease management are critical.

Funding

US National Institutes of Health.

Sex Differences in the Recognition, Monitoring, and Management of CKD in Health Care: An Observational Cohort Study

INTRODUCTION

Reported sex differences in the etiology, population prevalence, progression rates, and health outcomes of people with CKD may be explained by differences in health care.

METHODS

We evaluated sex as the variable of interest in a health care-based study of adults (n=227,847) with at least one outpatient eGFR<60 ml/min per 1.73 m2 measurement denoting probable CKD in Stockholm from 2009 to 2017. We calculated the odds ratios for diagnosis of CKD and provision of RASi and statins at inclusion, and hazard ratios for CKD diagnosis, visiting a nephrologist, or monitoring creatinine and albuminuria during follow-up.

RESULTS

We identified 227,847 subjects, of whom 126,289 were women (55%). At inclusion, women had lower odds of having received a diagnostic code for CKD and were less likely to have received RASi and statins, despite having guideline-recommended indications. In time-to-event analyses, women were less likely to have received a CKD diagnosis (HR, 0.43; 95% CI, 0.42 to 0.45) and visited a nephrologist (HR, 0.46; 95% CI, 0.43 to 0.48) regardless of disease severity, presence of albuminuria, or criteria for referral. Women were also less likely to undergo monitoring of creatinine or albuminuria, including those with diabetes or hypertension. These differences remained after adjustment for comorbidities, albuminuria, and highest educational achievement, and among subjects with confirmed CKD at retesting. Although in absolute terms all nephrology-care indicators gradually improved over time, the observed sex gap persisted.

CONCLUSIONS

There were profound sex differences in the detection, recognition, monitoring, referrals, and management of CKD. The disparity was also observed in people at high risk and among those who had guideline-recommended indications.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/JASN/2022_10_11_JASN2022030373.mp3.

Kidney Complications and Hospitalization in Patients With Chronic Hypoparathyroidism: A Cohort Study in Sweden

CONTEXT

Kidney complications may be considerably higher in patients with chronic hypoparathyroidism (hypoPT) treated with activated vitamin D and calcium supplementation.

OBJECTIVE

We aimed to investigate the risk of chronic kidney disease (CKD), urolithiasis, and hospitalization in patients with chronic hypoPT.

METHODS

In this population-based cohort study in Sweden, national registries (Swedish National Patient Register, Swedish Prescribed Drug Register, and Total Population Register, 1997-2018) were used to identify patients with chronic hypoPT and controls matched by sex, age, and county of residence. We determined time to CKD and urolithiasis diagnosis, and incidence rates of hospitalization.

RESULTS

A total of 1562 patients with chronic hypoPT without preexisting CKD and 15 620 controls were included. The risk of developing CKD was higher in patients with chronic hypoPT compared with controls (hazard ratio [HR] 4.45; 95% CI, 3.66-5.41). In people without prior urolithiasis (n = 1810 chronic hypoPT and n = 18 100 controls), the risk of developing urolithiasis was higher in patients with chronic hypoPT (HR 3.55; 95% CI, 2.84-4.44) compared with controls. Patients with chronic hypoPT had higher incidence rates for all-cause hospitalization (49.59; 95% CI, 48.50-50.70, per 100 person-years vs 28.43; 95% CI, 28.15-28.71, respectively) and for CKD (3.46; 95% CI, 3.18-3.76, per 100 person-years vs 0.72; 95% CI, 0.68-0.77, respectively), compared with controls. Men with hypoPT appear to have a higher risk of CKD than women.

CONCLUSION

Patients with chronic hypoPT had an increased risk of CKD, urolithiasis, and hospitalization compared with controls.

Self-report of chronic diseases in old-aged individuals: extent of agreement with general practitioner medical records in the German AugUR study

BACKGROUND

To estimate prevalence and incidence of diseases through self-reports in observational studies, it is important to understand the accuracy of participant reports. We aimed to quantify the agreement of self-reported and general practitioner-reported diseases in an old-aged population and to identify socio-demographic determinants of agreement.

METHODS

This analysis was conducted as part of the AugUR study (n=2449), a prospective population-based cohort study in individuals aged 70-95 years, including 2321 participants with consent to contact physicians. Self-reported chronic diseases of participants were compared with medical data provided by their respective general practitioners (n=589, response rate=25.4%). We derived overall agreement, over-reporting/under-reporting, and Cohen's kappa and used logistic regression to evaluate the dependency of agreement on participants' sociodemographic characteristics.

RESULTS

Among the 589 participants (53.1% women), 96.9% reported at least one of the evaluated chronic diseases. Overall agreement was >80% for hypertension, diabetes, myocardial infarction, stroke, cancer, asthma, bronchitis/chronic obstructive pulmonary disease and rheumatoid arthritis, but lower for heart failure, kidney disease and arthrosis. Cohen's kappa was highest for diabetes and cancer and lowest for heart failure, musculoskeletal, kidney and lung diseases. Sex was the primary determinant of agreement on stroke, kidney disease, cancer and rheumatoid arthritis. Agreement for myocardial infarction and stroke was most compromised by older age and for cancer by lower educational level.

CONCLUSION

Self-reports may be an effective tool to assess diabetes and cancer in observational studies in the old and very old aged. In contrast, self-reports on heart failure, musculoskeletal, kidney or lung diseases may be substantially imprecise.

[High patient unawareness for chronic kidney disease even in later stages - but why is it more frequent in women than in men?]

INTRODUCTION

 Chronic kidney failure (CKD) is as common as diabetes or coronary heart disease in a population aged 40 years and older. Although CKD increases the risk of secondary diseases or premature death, patients with CKD are often unaware of their disease. In a recent analysis of German data, unawareness CKD was higher in women than in men.

METHODS

 Baseline data from 2010 of 3,305 CKD patients from German cohort studies and registries were analyzed. Stage 1-4 CKD was defined by eGFR (estimated glomerular filtration rate) and albumin-creatinine ratio according to the KDIGO-guideline. Patient knowledge of CKD was coded according to self-report. The proportion of patients without knowledge of CKD and the sex-specific proportion difference (each with 95 % confidence interval) were calculated according to CKD stages and additional comorbidities (diabetes, hypertension, anemia, and cardiovascular disease). In addition, the prevalence ratio (PR) for not knowing about CKD was estimated for women compared to men crude and adjusted for age and other risk factors.

RESULTS

 Women were less likely than men to know about their CKD in all subgroups studied by age, CKD stage, and comorbidities. The proportion difference for CKD awareness increased with higher CKD stage and was 21 percentage points (7.6; 34.6) at the expense of women in CKD stage 4. Among patients with CKD stage 3b and concomitant grade 2 hypertension, 61 % of women versus 45 % of men were unaware of their disease. The PR for CKD unawareness in women compared with men in the fully adjusted model increased from 1.08 (1.00; 1.16) in CKD stage 3a to 1.75 (1.14; 2.68) in CKD stage 4.

CONCLUSION

 Despite the presence risk factors that necessitate monitoring of renal function, less than half of patients know they have CKD stage 3b or 4. Women are less likely to be aware of their CKD in all subgroups. Possible causes are gender-related differences in primary health care (gender bias) or in patient-doctor communication.

The Stockholm CREAtinine Measurements (SCREAM) project: Fostering improvements in chronic kidney disease care

SCREAM (Stockholm CREAtinine Measurements project) was initiated in 2010 in collaboration with the healthcare provider of Stockholm County healthcare to quantify potential medication errors, estimate the burden of chronic kidney disease (CKD) and to illustrate the value of incorporating measures of kidney function into the medical decision process. Because most patients are unaware of their CKD and diagnoses are seldom issued, SCREAM took advantage of the commonness of serum/plasma creatinine testing, which can be used to estimate the glomerular filtration rate (eGFR) and classify the stage of CKD severity. SCREAM is periodically updated, and at present contains healthcare information of all residents in Stockholm region during 2006-2019 (about 3 million people), enriched with a broad range of laboratory measurements for those in whom creatinine or albuminuria has been measured (about 1.8 million people). This health information was linked with national administrative and quality registries via the unique personal identification number of each Swedish citizen, conforming the richest characterization in Sweden of the population's journey through health and disease. This review discusses the context of its creation, strengths and weakness, key findings and plans for the future. We summarize our findings related to the burden of CKD in Sweden, its adverse health risks (such as risk of infections, cancer or dementia) and how underlying kidney function alters the risk-benefit ratio of common medications. Results have had clinical impact and demonstrate the importance of population-based research in the spectrum of clinical research to improve health.

The Other Way Around: Living With Chronic Kidney Disease From the Perspective of Men

A wealth of evidence has suggested sex (biological) and gender (sociocultural) differences in the prevalence, progression, and outcomes of persons with chronic kidney disease. Much of this evidence tends to emphasize differences in which women are disadvantaged, and less attention is paid to findings in which women are better off or similar to men. However, gender medicine recognizes that men and women have different disease determinants, presentation, and attitudes, and it pertains to both sexes. In this review, we revisit chronic kidney disease through the perspective of men, and illustrate a population segment at need of stringent preventative and management strategies.

Gender differences in cardiovascular risk factor awareness: Results from the ESC EORP EUROASPIRE V Registry

BACKGROUND

Patient risk factor awareness is essential to decrease the risk of recurrent coronary events. The aim of this study was to provide up-to-date evidence on existing gender differences in the patients' knowledge of risk factors and information provided by healthcare professionals.

METHODS

Analyses were based on the cross-sectional ESC EORP EUROASPIRE V survey, including data on CHD patients across 27 European countries. Consecutive patients (18-80 years), hospitalized for a coronary event or surgical procedure, were retrospectively identified. Information on risk factor awareness was collected from medical records, medical examination, and structured questionnaires during the study visit (six months to two years after hospitalization).

RESULTS

Patient information was available for 8261 patients, of which 25.8% were women. Although women with obesity were significantly less aware about their actual (OR = 0.66, CI = 0.52-0.85) and target weight levels (OR = 0.66, CI = 0.54-0.81), no significant gender differences in risk factor awareness were found in disfavour of women. Remarkably, women with hypertension and women with raised low-density lipoprotein cholesterol (LDL-C) levels were even more aware about their target blood pressure levels (OR = 1.21, CI = 1.01-1.46) and actual cholesterol levels (OR = 1.18, CI = 1.02-1.36), respectively. Moreover, there is some indication that women were more informed by a healthcare professional if they had raised CHD risk factor levels.

CONCLUSIONS

Our study showed only few gender differences in disfavour of women in terms of risk factor awareness and information provided by a healthcare professional. Nevertheless, previous EUROASPIRE V findings demonstrated that women still have a poorer risk factor control in secondary CHD prevention.

Kidney Function, Kidney Replacement Therapy, and Mortality in Men and Women

Introduction

Women are more likely to have chronic kidney disease (CKD), compared with men, yet they are less likely to receive dialysis. Whether this sex disparity, which has predominantly been observed in nephrology-referred or CKD-specific cohorts so far, has a biological root cause remains unclear.

Methods

We extracted general population data from the Stockholm CREAtinine Measurements project (SCREAM) (N = 496,097 participants, 45.5% men, 54.5% women). We used Cox regression to model male-to-female cause-specific hazard ratios (csHRs) for the competing events kidney replacement therapy (KRT, by dialysis or transplantation) and pre-KRT death, adjusted for baseline age, baseline kidney function (assessed via estimated glomerular filtration rate [eGFR] and eGFR slope), and comorbidities. Furthermore, we modeled sex-specific all-cause mortality by eGFR, again adjusted for age, eGFR slope, and comorbidities at baseline.

Results

Compared with women, men were significantly more likely to receive KRT (fully adjusted male-to-female csHR for KRT 1.41 [95% CI 1.13–1.76]) but also more likely to experience pre-KRT death (csHR 1.36 [95% CI 1.33–1.38]). Differences between men and women regarding all-cause mortality by eGFR indicated a higher mortality in men at low eGFR values.

Conclusion

Our data show that sex differences in CKD outcomes persist even after controlling for important comorbidities and kidney function at baseline. While future studies with a wider range of biological factors are warranted, these data suggest that nonbiological factors may be more important in explaining existing sex disparities in CKD progression and therapy.

Sex-Specific Differences in Mortality and Incident Dialysis in the Chronic Kidney Disease Outcomes and Practice Patterns Study

Introduction

More men than women start kidney replacement therapy (KRT) although the prevalence of chronic kidney disease (CKD) is higher in women than men. We therefore aimed at analyzing sex-specific differences in clinical outcomes among 8237 individuals with CKD in stages 3 to 5 from Brazil, France, Germany, and the United States participating in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps).

Methods

Fine and Gray models, evaluating the effect of sex on time to events, were adjusted for age, Black race (model A); plus diabetes, cardiovascular disease, albuminuria (model B); plus estimated glomerular filtration rate (eGFR) slope during the first 12 months after enrollment and first eGFR after enrollment (model C).

Results

There were more men than women at baseline (58% vs. 42%), men were younger than women, and men had higher eGFR (28.9 ± 11.5 vs. 27.0 ± 10.8 ml/min per 1.73 m²). Over a median follow-up of 2.7 and 2.5 years for men and women, respectively, the crude dialysis initiation and pre-emptive transplantation rates were higher in men whereas that of pre-KRT death was more similar. The adjusted subdistribution hazard ratios (SHRs) between men versus women for dialysis were 1.51 (1.27–1.80) (model A), 1.32 (1.10–1.59) (model B), and 1.50 (1.25–1.80) (model C); for pre-KRT death, were 1.25 (1.02–1.54) (model A), 1.14 (0.92–1.40) (model B), and 1.15 (0.93–1.42) (model C); for transplantation, were 1.31 (0.73–2.36) (model A), 1.44 (0.76–2.74) (model B), and 1.53 (0.79–2.94) (model C).

Conclusion

Men had a higher probability of commencing dialysis before death, unexplained by CKD progression alone. Although the causal mechanisms are uncertain, this finding helps interpret the preponderance of men in the dialysis population.

High Unawareness of Chronic Kidney Disease in Germany

Chronic kidney disease (CKD) is associated with an increased risk for cardiovascular events, hospitalizations, end stage renal disease and mortality. Main risk factors for CKD are diabetes, hypertension, and older age. Although CKD prevalence is about 10%, awareness for CKD is generally low in patients and physicians, hindering early diagnosis and treatment. We analyzed baseline data of 3305 participants with CKD Stages 1-4 from German cohorts and registries collected in 2010. Prevalence of CKD unawareness and prevalence ratios (PR) (each with 95%-confidence intervals) were estimated in categories of age, sex, CKD stages, BMI, hypertension, diabetes and other relevant comorbidities. We used a log-binomial regression model to estimate the PR for CKD unawareness for females compared to males adjusting for CKD stage and CKD risk factors. CKD unawareness was high, reaching 71% (68-73%) in CKD 3a, 49% (45-54%) in CKD 3b and still 30% (24-36%) in CKD4. Prevalence of hypertension, diabetes or cardiovascular comorbidities was not associated with lower CKD unawareness. Independent of CKD stage and other risk factors unawareness was higher in female patients (PR = 1.06 (1.01; 1.10)). Even in patients with CKD related comorbidities, CKD unawareness was high. Female sex was strongly associated with CKD unawareness. Guideline oriented treatment of patients at higher risk for CKD could increase CKD awareness. Patient-physician communication about CKD might be amendable.

Nephrologists’ Perspectives on Gender Disparities in CKD and Dialysis

Introduction

Globally, there are more women with chronic kidney disease (CKD), yet they comprise only 40% of patients receiving kidney replacement therapy by dialysis. We aimed to describe the perspectives of nephrologists on gender disparities in access to care and outcomes in CKD and dialysis.

Methods

We conducted semistructured interviews with 51 nephrologists (28, 55% women) from 22 countries from October 2019 to April 2020. Transcripts were analyzed thematically.

Results

We identified 6 themes. Related to women were primary commitment to caregiving (with subthemes of coordinating care, taking charge of health management, deprioritizing own health, centrality of family in decision-making); vigilance and self-reliance (diligence and conscientiousness, stoicism and tolerating symptoms, avoiding burden on family, isolation and coping alone); and stereotyping, stigma, and judgment (body image, dismissed as anxiety, shame and embarrassment, weakness and frailty). Related to men was protecting masculinity (safeguarding the provider role, clinging to control, self-regard, and entitled). Decisional power and ownership included men’s dominance in decision-making and women’s analytical approach in treatment decisions. Inequities compounded by social disadvantage (financial and transport barriers, without social security, limited literacy, entrenched discrimination, vulnerability) were barriers to care for women, particularly in socioeconomically disadvantaged communities.

Conclusion

Nephrologists perceived that women with CKD faced many challenges in accessing care related to social norms and roles of caregiving responsibilities, disempowerment, lack of support, stereotyping by clinicians, and entrenched social and economic disadvantage. Addressing power differences, challenging systemic patriarchy, and managing unconscious bias may help to improve equitable care and outcomes for all people with CKD.