Identification of Patients with CKD in Medical Databases: A Comparison of Different Algorithms

Development of a quick guide for assessment of the most frequently used renal risk medication in Danish hospitals and primary care

Due to changes in pharmacokinetics and pharmacodynamics, patients with impaired renal function suffer an increased risk of suboptimal and potentially harmful medication treatment. This necessitates careful consideration of medications affected by impaired renal function when performing medication reviews. The aim of this study was to develop a quick guide (a list of recommendations) for assessing renal risk medications in medication reviews led by hospital pharmacists. The list was based on the 100 most frequently used medications in Danish hospitals and primary care. After combining the 200 records, 29 duplicates were excluded resulting in a pool of 171 medications. Assessment by two clinical pharmacists led to the exclusion of 121 medications. Of the remaining 50 medications, seven were discussed among the two pharmacists, and two of these were also in the research group to reach a consensus. The renal risk quick guide comprised 50 medications. The most prevalent medications on the list were from Anatomical Therapeutic Chemical Classification System (ATC)-group N, C and L. Recommendations from two databases were included in the quick guide in order to provide clinical pharmacists with existing, updated evidence on medication use in impaired renal function. The next step is to test the feasibility of the quick guide in daily practice when performing medication reviews.

Acute Myocardial Infarction and Chronic Kidney Disease: A Nationwide Cohort Study on Management and Outcomes from 2010 to 2022

Key Points

Retrospective study of guideline-directed management of myocardial infarction in patients with and without CKD from 2010 to 2022. CKD was associated with lower rate of guideline-directed management and worse prognosis. Uptake of guideline-directed management increased and prognosis improved in both groups during the study period.

Background

CKD is present in >30% of patients with acute myocardial infarction (MI) and has been associated with lower rates of guideline-directed management and worse prognosis. We investigated the use of guideline-directed management and mortality risk in patients with and without CKD.

Methods

A nationwide cohort study based on health care registers encompassing all patients ≥18 years hospitalized with first-time MI in Denmark from 2010 to 2022 was conducted. CKD was defined as an eGFR <60 ml/min per 1.73 m2. Probability of guideline-directed management and risk of all-cause mortality in patients with and without CKD were calculated from adjusted multivariable logistic and Cox regression models with probabilities and risks standardized to the distribution of confounders in the population.

Results

In total, we identified 21,009 patients who met eligibility criteria. The median age was 72 years, and 61% of patients were male; the median eGFR was 82 ml/min per 1.73 m2, and 21% of patients had CKD. The 30-day probabilities of coronary angiography and revascularization were 71% (95% confidence interval [CI], 69% to 72%) and 78% (95% CI, 77% to 79%), P < 0.001 and 52% (95% CI, 50% to 54%) and 58% (95% CI, 58% to 59%), P < 0.001, in patients with and without CKD, respectively. Probabilities increased during the study period (P for trend 0.05, 0.03, 0.02, and 0.03, respectively). In patients with and without CKD, the probability of dual antiplatelet therapy was 67% (95% CI, 65% to 68%) and 70% (95% CI, 69% to 71%), P = 0.001, whereas the probability of lipid-lowering treatment was 76% (95% CI, 75% to 78%) and 82% (95% CI, 81% to 83%), P < 0.001, respectively. The associated 1-year mortality was 21% (95% CI, 20% to 22%) and 16.4% (95% CI, 16% to 17%) in patients with and without CKD, respectively. with decreasing mortality rates in both groups during the study period (P for trend 0.03 and 0.01).

Conclusions

Although survival after MI improved for all patients, CKD continued to be associated with lower use of guideline-directed management and higher mortality.

Cohort profile: the PRIMETIME 1 (PRecIsion MEdicine based on kidney TIssue Molecular interrogation in diabetic nEphropathy) cohort - a longitudinal Danish nationwide study of individuals with diabetes and a performed kidney biopsy

PURPOSE

Individuals with diabetes and chronic kidney disease are at high risk of kidney failure, cardiovascular events and premature mortality and more research is warranted to further improve the prevention and management of complications. The PRecIsion MEdicine based on kidney TIssue Molecular interrogation in diabetic nEphropathy (PRIMETIME) 1 cohort is designed to study clinical characteristics, diagnostic accuracy and prognostic markers in a population with diabetes and kidney disease classified by biopsy.

PARTICIPANTS

This retrospective Danish nationwide cohort includes 2586 individuals with diabetes who have undergone a kidney biopsy between the 1980s and 2022.

FINDINGS TO DATE

By combining multiple registries and medical databases, we comprehensively describe the cohort with data on demographics, socioeconomic status, lifestyle, laboratory measurements, medication use and comorbidity at the time of diagnosis of diabetes and at the time of kidney biopsy within types of kidney disease. In individuals with type 1 diabetes, 132 cases of diabetic nephropathy were identified, with 70.5% of them being men, with a median (IQR) age of 50 (41-59) years at biopsy, and a median (IQR) estimated glomerular filtration rate (eGFR) 37 (23-5X) mL/min/1.73 m2. Among individuals with type 2 diabetes and diabetic nephropathy (n=599), 76.8% were male aged 61.9 (55-99) years at biopsy and with an eGFR 40 (24-6X) mL/min/1.73 m2.

FUTURE PLANS

The national population registries in Denmark provide a long follow-up period and a distinct opportunity to use superior registry data. This cohort offers a unique opportunity to study the prognostic value of findings in kidney biopsies, the impact of comorbidity and the effect of therapy at the time of kidney biopsy, with a follow-up period increasing over time with running updates.

Complications and Mortality After Surgery in Patients with Chronic Kidney Disease: A Retrospective Cohort Study Based on a Multicenter Clinical Database

Objective

To evaluate the postoperative complications and mortality among patients with chronic kidney disease.

Methods

Biochemical measurements, diagnosis codes for CKD and comorbid conditions for surgical patients aged ≥20 years were obtained from electronic medical records of three large hospitals in Taiwan in 2009-2017. We conducted this retrospective cohort study by using propensity score-matching methods to balance the baseline characteristics between CKD and non-CKD groups. The multiple logistic regression analysis was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of risks of primary outcome (included postoperative mortality) and secondary outcome (included postoperative infectious complications and non-infectious complications) associated with CKD.

Results

Among 31950 eligible surgical patients, the adjusted OR of in-hospital mortality in patients with CKD was 5.49 (95% CI 3.42-8.81) compared with that in non-CKD controls. The adjusted ORs of postoperative septicemia, pneumonia and cellulitis in patients with CKD were 5.90 (95% CI 2.12-16.5), 5.39 (95% CI 1.37-21.16), and 4.42 (95% CI 1.57-12.4), respectively, when compared with the non-CKD patients. CKD was also associated with postoperative stroke (OR 2.21, 95% CI 1.47-3.31).

Conclusion

Patients with CKD are at increased risk of postoperative stroke, infectious complications, and mortality. Our study implicated that it is crucial to improve the levels of hemoglobin and K+ in patients with CKD before surgery. Preventive strategies should be developed to improve clinical outcomes in these populations.

Coronary angiography in patients with kidney dysfunction and myocardial injury: A retrospective cohort study on management of myocardial injury in hospitalized patients with kidney disease

BACKGROUND

Although kidney insufficiency has been shown to be associated with increased risk of myocardial injury, benefit of coronary angiography (CAG) and revascularization remains uncertain, with implications on management strategies and outcomes. We aimed to compare rates of CAG and revascularization and subsequent risk of cardiovascular and kidney outcomes in hospitalized patients with myocardial injury and kidney dysfunction.

METHODS

Retrospective cohort study encompassing hospitalized patients with myocardial injury i.e. elevated troponin I or T and an eGFR ≤60 ml/min/1.73 m2 identified between 2011 and 2021 in Danish national registers. 30-day odds for CAG were computed across granular eGFR-categories based on multiple logistic regression. Standardized one-year risks of cardiovascular and kidney outcomes including mortality were determined based on hazards obtained in multiple Cox regression.

RESULTS

A total of 52,798 patients with myocardial injury were identified. CAG was performed in 14.3 % (n = 7549). 30-day odds ratios for CAG were 0.64 [0.60-0.68], 0.38 [0.34-0.42], 0.18 [0.14-0.22], and 0.35 [0.30-0.40] in patients with eGFR 31-45 ml/min/1.73 m2, eGFR 15-30 ml/min/1.73 m2 for eGFR<15 ml/min/1.73 m2 and chronic dialysis, respectively (eGFR 46-60 ml/min/1.73 m2 as reference). Median follow-up was 4.1 years. One-year mortality risk differences associated with CAG and revascularization (no CAG as reference) were -7.8 [-7.0; -8.7] and -9.1 [-8.4; -9.9] for eGFR 46-60 ml/min/1.73 m2; -7.0 [-5.7;-8-3] and -8.0 [-6.6; -9.5] for eGFR 31-45 ml/min/1.73 m2; -5.4 [-3.0; -7.2] and -5.2 [-2.2; -8.3] for eGFR 15-30 ml/min/1.73 m2; -8.8 [-3.1; -13.7] and -5.4 [3.1; -13.4] for eGFR<15 ml/min/1.73 m2; and -4.9 [-0.1; -9.7] and -4.2 [1.5; -9.2] for chronic dialysis, respectively.

CONCLUSION

Probability of CAG following myocardial injury declined with progressive kidney dysfunction. Overall, CAG was associated with lower mortality irrespective of kidney function and subsequent revascularization.

Variations in Incidence and Prognosis of Stage 4 CKD Among Adults Identified Using Different Algorithms: A Population-Based Cohort Study

RATIONALE & OBJECTIVE

Clinical guidelines define chronic kidney disease (CKD) as abnormalities of kidney structure or function for>3 months. Assessment of the duration criterion may be implemented in different ways, potentially impacting estimates of disease incidence or prevalence in the population, individual diagnosis, and treatment decisions, especially for more severe cases. We investigated differences in incidence and prognosis of CKD stage G4 identified by 1 of 4 algorithms.

STUDY DESIGN

Population-based cohort study in Alberta, Canada.

SETTING & PARTICIPANTS

Residents>18 years old with incident CKD stage G4 (eGFR 15-29mL/min/1.73m2) diagnosed between April 1, 2015, and March 31, 2018, based on administrative and laboratory data.

EXPOSURE

Four outpatient eGFR-based algorithms, increasing in stringency, for defining cohorts with CKD G4 were evaluated: (1) a single test, (2) first eGFR<30mL/min/1.73m2 and a second eGFR 15-29mL/min/1.73m2 measured>90 days apart (2 tests), (3) ≥2 eGFR measurements of<30mL/min/1.73m2 sustained for>90 days (qualifying period) and the last eGFR in the qualifying period of 15-29mL/min/1.73m2 (relaxed sustained), and (4) ≥2 consecutive measurements of 15-29mL/min/1.73m2 for>90 days (rigorous sustained).

OUTCOME

Time to the earliest of death, eGFR improvement (a sustained increase in eGFR to≥30mL/min/1.73m2 for>90 days and>25% increase from the index eGFR), or kidney failure.

ANALYTICAL APPROACH

For each of the 4 cohorts, incidence rates and event-specific cumulative incidence functions at 1 year from cohort entry were estimated.

RESULTS

The incidence rates of CKD G4 decreased as algorithms became more stringent, from 190.7 (single test) to 79.9 (rigorous sustained) per 100,000 person-years. The 2 cohorts based on sustained reductions in eGFR were of comparable size and 1-year event-specific probabilities. The 2 cohorts based on a single test and a 2-test sequence were larger and experienced higher probabilities of eGFR improvement.

LIMITATIONS

A short follow-up period of 1 year and a predominantly White population.

CONCLUSIONS

The use of more stringent algorithms for defining CKD G4 results in substantially lower estimates of disease incidence, the identification of a group with a lower probability of eGFR improvement, and a higher risk of kidney failure. These findings can inform implementation decisions of disease definitions in clinical reporting systems and research studies.

PLAIN-LANGUAGE SUMMARY

Although guidelines recommend>3 months to define chronic kidney disease (CKD), the methods for defining specific stages, particularly G4 (eGFR 15-29mL/min/1.73m2) when referral to nephrology services is recommended, have been implemented differently across studies and surveillance programs. We studied differences in incidence and prognosis of CKD G4 cohorts identified by 4 algorithms using administrative and outpatient laboratory databases in Alberta, Canada. We found that, compared with a single-test definition, more stringent definitions resulted in a lower disease incidence and identified a group with worse short-term kidney outcomes. These findings highlight the impact of the choice of algorithm used to define CKD G4 on disease burden estimates at the population level, on individual prognosis, and on treatment/referral decisions.

Recovery of kidney function after acute kidney disease-a multi-cohort analysis

BACKGROUND

There are no consensus definitions for evaluating kidney function recovery after acute kidney injury (AKI) and acute kidney disease (AKD), nor is it clear how recovery varies across populations and clinical subsets. We present a federated analysis of four population-based cohorts from Canada, Denmark and Scotland, 2011-18.

METHODS

We identified incident AKD defined by serum creatinine changes within 48 h, 7 days and 90 days based on KDIGO AKI and AKD criteria. Separately, we applied changes up to 365 days to address widely used e-alert implementations that extend beyond the KDIGO AKI and AKD timeframes. Kidney recovery was based on resolution of AKD and a subsequent creatinine measurement below 1.2× baseline. We evaluated transitions between non-recovery, recovery and death up to 1 year; within age, sex and comorbidity subgroups; between subset AKD definitions; and across cohorts.

RESULTS

There were 464 868 incident cases, median age 67-75 years. At 1 year, results were consistent across cohorts, with pooled mortalities for creatinine changes within 48 h, 7 days, 90 days and 365 days (and 95% confidence interval) of 40% (34%-45%), 40% (34%-46%), 37% (31%-42%) and 22% (16%-29%) respectively, and non-recovery of kidney function of 19% (15%-23%), 30% (24%-35%), 25% (21%-29%) and 37% (30%-43%), respectively. Recovery by 14 and 90 days was frequently not sustained at 1 year. Older males and those with heart failure or cancer were more likely to die than to experience sustained non-recovery, whereas the converse was true for younger females and those with diabetes.

CONCLUSION

Consistently across multiple cohorts, based on 1-year mortality and non-recovery, KDIGO AKD (up to 90 days) is at least prognostically similar to KDIGO AKI (7 days), and covers more people. Outcomes associated with AKD vary by age, sex and comorbidities such that older males are more likely to die, and younger females are less likely to recover.

Natural compounds efficacy in complicated diabetes: A new twist impacting ferroptosis

Ferroptosis, as a way of cell death, participates in the body's normal physiological and pathological regulation. Recent studies have shown that ferroptosis may damage glucose-stimulated islets β Insulin secretion and programmed cell death of T2DM target organs are involved in the pathogenesis of T2DM and its complications. Targeting suppression of ferroptosis with specific inhibitors may provide new therapeutic opportunities for previously untreated T2DM and its target organs. Current studies suggest that natural bioactive compounds, which are abundantly available in drugs, foods, and medicinal plants for the treatment of T2DM and its target organs, have recently received significant attention for their various biological activities and minimal toxicity, and that many natural compounds appear to have a significant role in the regulation of ferroptosis in T2DM and its target organs. Therefore, this review summarized the potential treatment strategies of natural compounds as ferroptosis inhibitors to treat T2DM and its complications, providing potential lead compounds and natural phytochemical molecular nuclei for future drug research and development to intervene in ferroptosis in T2DM.

Increased Cancer Risk in Patients with Kidney Disease and Venous Thromboembolism: A Population-Based Cohort Study

BACKGROUND

 Venous thromboembolism (VTE) may be a harbinger of cancer in the general population. Patients with kidney disease have an a priori increased VTE risk. However, it remains unknown how a VTE affects subsequent cancer risk in these patients.

OBJECTIVES

 To examine the cancer risk in patients with kidney disease following a VTE.

METHODS

 We conducted a nationwide population-based cohort study in Denmark (1996-2017), including all VTE patients with a diagnosis of kidney disease. We calculated absolute risks of cancer (accounting for competing risk of death) and age-, sex-, and calendar-period standardized incidence ratios (SIRs) comparing the observed cancer incidence with national cancer incidence rates and cancer incidence rates of VTE patients without kidney disease.

RESULTS

 We followed 3,362 VTE patients with kidney disease (45.9% females) for a median follow-up time of 2.4 years (interquartile range: 0.6-5.4). During follow-up, 464 patients were diagnosed with cancer, of whom 169 (36.4%) were diagnosed within the first year. The 1-year absolute risk of any cancer was 5.0% (95% confidence interval [CI]: 4.3-5.8), with a SIR of 2.9 (95% CI: 2.5-3.4) when compared with the general population, and 2.0 (95% CI: 1.8-2.4) when compared with VTE patients without kidney disease. During subsequent years of follow-up, the SIRs declined to 1.5 (95% CI: 1.3-1.6) when compared with the general population, and 1.1 (95% CI: 0.9-1.2) compared with VTE patients without kidney disease.

CONCLUSION

 Patients with hospital-diagnosed kidney disease have increased cancer risk after VTE, especially within the first year following the VTE diagnosis.

Association between incident depression and clinical outcomes in patients with chronic kidney disease

Background

Depression is highly prevalent and related to increased morbidity and mortality in patients on dialysis, but less is known among patients with earlier stages of CKD. This study investigated the associations between depression and clinical outcomes in patients with CKD not receiving dialysis.

Methods

We identified 157 398 adults with CKD stages 3-5 not previously diagnosed with depression from the Stockholm CREAtinine Measurements (SCREAM) project. The primary outcomes included hospitalization, CKD progression (>40% decline in eGFR, initiation of kidney replacement therapy, or death due to CKD), major adverse cardiovascular events (MACE; myocardial infarction, stroke, or cardiovascular death), and all-cause mortality. Survival analyses were used to estimate the associations between incident depression and adverse health outcomes, adjusting for socio-demographics, kidney disease severity, healthcare utilization, comorbidities, and concurrent use of medications.

Results

During a median follow-up of 5.1 (interquartile range: 2.3-8.5) years, 12 712 (8.1%) patients received an incident diagnosis of depression. A total of 634 471 hospitalizations (4 600 935 hospitalized days), 42 866 MACEs, and 66 635 deaths were recorded, and 9795 individuals met the criteria for CKD progression. In the multivariable-adjusted analyses, incident depression was associated with an elevated rate of hospitalized days [rate ratio: 1.77, 95% confidence interval (CI): 1.71-1.83], as well as an increased rate of CKD progression [hazard ratio (HR): 1.38, 95% CI: 1.28-1.48], MACE (HR: 1.22, 95% CI: 1.18-1.27), and all-cause mortality (HR: 1.41, 95% CI: 1.37-1.45). The association with CKD progression was more evident after one year of depression diagnosis (HR: 1.47, 95% CI: 1.36-1.59). Results were robust across a range of sensitivity analyses.

Conclusion

Among patients with nondialysis-dependent CKD stages 3-5, incident depression is associated with poor prognosis, including hospitalization, CKD progression, MACE, and all-cause mortality.

Chronic kidney disease in primary care: risk of cardiovascular events, end stage kidney disease and death

BACKGROUND

The prevalence of chronic kidney disease (CKD) is increasing globally. Early diagnosis in primary care may have a role in ensuring proper intervention. We aimed to determine the prevalence and outcome of CKD in primary care.

METHODS

We performed an observational cohort study in primary care in Copenhagen (2001-2015). Outcomes were stroke, myocardial infarction (MI), heart failure (HF), peripheral artery disease (PAD), all-cause- and cardiovascular mortality. We combined individuals with normal kidney function and CKD stage 2 as reference. We conducted cause-specific Cox proportional regressions to calculate the hazard ratios for outcomes according to CKD group. We explored the associations between kidney function and the outcomes examined using eGFR as a continuous variable modelled with penalised splines. All models were adjusted for age, gender, diabetes, hypertension, existing CVD, heart failure, LDL cholesterol and use of antihypertensive treatment.

RESULTS

We included 171,133 individuals with at least two eGFR measurements of which the majority (n = 157,002) had eGFR > 60 ml/min/1.73m² at index date, and 0.05% were in CKD stage 5. Event rates were low in eGFR > 60 ml/min/1.73m² but increased in those with higher stages of CKD. In adjusted analyses we observed an increase in hazard rates for every outcome with every increment in CKD stage. Compared to the reference group, individuals in CKD stage 4 had double the hazard rate of PAD, MI, cardiovascular and all-cause mortality.

CONCLUSIONS

Our data from a large primary care cohort demonstrate an early increase in the risk of adverse outcomes already at CKD stage 3. This underlines the importance of studying early intervention in primary care.

Cardiovascular mortality in patients with advanced chronic kidney disease with and without diabetes: a nationwide cohort study

BACKGROUND

Cardiovascular mortality and the impact of cardiac risk factors in advanced chronic kidney disease (CKD) remain poorly investigated. We examined the risk of cardiovascular mortality in patients with advanced CKD with and without diabetes as well as the impact of albuminuria, plasma hemoglobin, and plasma low-density lipoprotein (LDL) cholesterol levels.

METHODS

In a Danish nationwide registry-based cohort study, we identified persons aged ≥ 18 years with an estimated glomerular filtration rate < 30 mL/min/1.73m2 between 2002 and 2018. Patients with advanced CKD were age- and sex-matched with four individuals from the general Danish population. Cause-specific Cox regression models were used to estimate the 1-year risk of cardiovascular mortality standardized to the distribution of risk factors in the cohort.

RESULTS

We included 138,583 patients with advanced CKD of whom 32,698 had diabetes. The standardized 1-year risk of cardiovascular mortality was 9.8% (95% CI 9.6-10.0) and 7.4% (95% CI 7.3-7.5) for patients with and without diabetes, respectively, versus 3.1% (95% CI 3.1-3.1) in the matched cohort. 1-year cardiovascular mortality risks were 1.1- to 2.8-fold higher for patients with diabetes compared with those without diabetes across the range of advanced CKD stages and age groups. Albuminuria and anemia were associated with increased cardiovascular mortality risk regardless of diabetes status. LDL-cholesterol was inversely associated with cardiovascular mortality risk in patients without diabetes, while there was no clear association in patients with diabetes.

CONCLUSIONS

Diabetes, albuminuria, and anemia remained important risk factors of cardiovascular mortality whereas our data suggest a limitation of LDL-cholesterol as a predictor of cardiovascular mortality in advanced CKD.

Prevalence, Cardiometabolic Comorbidities and Reporting of Chronic Kidney Disease; A Hungarian Cohort Analysis

Objectives: Chronic kidney disease (CKD) implies increased comorbidity burden, disability, and mortality, becoming a significant public health problem worldwide, however, prevalence data are lacking in Hungary.

Methods: We determined CKD prevalence, stage distribution, comorbidities using estimated glomerular filtration rate (eGFR), albuminuria, and international disease codes in a cohort of healthcare utilizing residents within the catchment area of the University of Pécs, in the County Baranya, Hungary, between 2011 and 2019 by database analysis. The number of laboratory-confirmed and diagnosis-coded CKD patients were compared.

Results: Of the total 296,781 subjects of the region, 31.3% had eGFR tests and 6.4% had albuminuria measurements, of whom we identified 13,596 CKD patients (14.0%) based on laboratory thresholds. Distribution by eGFR was presented (G3a: 70%, G3b: 22%, G4: 6%, G5: 2%). Amongst all CKD patients 70.2% had hypertension, 41.5% diabetes, 20.5% heart failure, 9.4% myocardial infarction, 10.5% stroke. Only 28.6% of laboratory-confirmed cases were diagnosis-coded for CKD in 2011–2019.

Conclusion: CKD prevalence was 14.0% in a Hungarian subpopulation of healthcare-utilizing subjects in 2011–2019, and substantial under-reporting of CKD was also found.

Correlation between perioperative dexmedetomidine administration and postoperative acute kidney injury in hypertensive patients undergoing non-cardiac surgery

Background: Previous studies have suggested that dexmedetomidine may have a protective effect on renal function. However, it is currently unclear whether perioperative dexmedetomidine administration is associated with postoperative acute kidney injury (AKI) incidence risk in hypertensive patients undergoing non-cardiac surgery.

Methods: This investigation was a retrospective cohort study. Hypertensive patients undergoing non-cardiac surgery in Third Xiangya Hospital of Central South University from June 2018 to December 2019 were included. The relevant data were extracted through electronic cases. The univariable analysis identified demographic, preoperative laboratory, and intraoperative factors associated with acute kidney injury. Multivariable stepwise logistic regression was used to assess the association between perioperative dexmedetomidine administration and postoperative acute kidney injury after adjusting for interference factors. In addition, we further performed sensitivity analyses in four subgroups to further validate the robustness of the results.

Results: A total of 5769 patients were included in this study, with a 7.66% incidence of postoperative acute kidney injury. The incidence of postoperative acute kidney injury was lower in the dexmedetomidine-administered group than in the control group (4.12% vs. 8.06%, p &lt; 0.001). In the multivariable stepwise logistic regression analysis, perioperative dexmedetomidine administration significantly reduced the risk of postoperative acute kidney injury after adjusting for interference factors [odds ratio (OR) = 0.56, 95% confidence interval (CI): 0.36–0.87, p = 0.010]. In addition, sensitivity analysis in four subgroups indicated parallel findings: i) eGRF &lt;90 mL/min·1.73/m2 subgroup (OR = 0.40, 95% CI: 0.19–0.84, p = 0.016), ii) intraoperative blood loss &lt;1000 mL subgroup (OR = 0.58, 95% CI: 0.36–0.94, p = 0.025), iii) non-diabetes subgroup (OR = 0.51, 95% CI: 0.29–0.89, p = 0.018), and iv) older subgroup (OR = 0.55, 95% CI: 0.32–0.93, p = 0.027).

Conclusion: In conclusion, our study suggests that perioperative dexmedetomidine administration is associated with lower risk and less severity of postoperative acute kidney injury in hypertensive individuals undergoing non-cardiac surgery. Therefore, future large-scale RCT studies are necessary to validate this benefit.

The Growing Challenge of Chronic Kidney Disease: An Overview of Current Knowledge

Chronic kidney disease (CKD) is becoming one of the world's most prevalent noncommunicable chronic diseases. The World Health Organization projects CKD to become the 5th most common chronic disease in 2040. Causes of CKD are multifactorial and diverse, but early-stage symptoms are often few and silent. Progression rates are highly variable, but patients encounter both an increased risk for end-stage kidney disease (ESKD) as well as increased cardiovascular risk. End-stage kidney disease incidence is generally low, but every single case carries a significant burden of illness and healthcare costs, making prevention by early intervention both desirable and worthwhile. This review focuses on the prevalence, diagnosis, and causes of CKD. In addition, we discuss the developments in the general treatment of CKD, with particular attention to what can be initiated in general practice. With the addition of recent landmark findings and the expansion of the indication for using sodium-glucose cotransporter 2 inhibitors, there are now new effective treatments to add to standard therapy. This will also be relevant for primary care physicians as many patients with CKD have their family physician as their primary health care professional handling kidney function preservation. In the future, more precise and less invasive diagnostic methods may not only improve the determination of the underlying cause of CKD but may also carry information regarding which treatment to use (i.e. personalized medicine). This could lead to a reduced number of preventive treatments per individual, while at the same time improving the prognosis. This review summarizes ongoing efforts in this area.

Defining measures of kidney function in observational studies using routine health care data: methodological and reporting considerations

The availability of electronic health records and access to a large number of routine measurements of serum creatinine and urinary albumin enhance the possibilities for epidemiologic research in kidney disease. However, the frequency of health care use and laboratory testing is determined by health status and indication, imposing certain challenges when identifying patients with kidney injury or disease, when using markers of kidney function as covariates, or when evaluating kidney outcomes. Depending on the specific research question, this may influence the interpretation, generalizability, and/or validity of study results. This review illustrates the heterogeneity of working definitions of kidney disease in the scientific literature and discusses advantages and limitations of the most commonly used approaches using 3 examples. We summarize ways to identify and overcome possible biases and conclude by proposing a framework for reporting definitions of exposures and outcomes in studies of kidney disease using routinely collected health care data.

Childhood body mass index trajectories and associations with adult-onset chronic kidney disease in Denmark: A population-based cohort study

BACKGROUND

Although excess adult adiposity is a strong risk factor for chronic kidney disease (CKD), evidence for associations with early life body size is limited. We investigated whether childhood body mass index (BMI) trajectories are associated with adult-onset CKD and end-stage kidney disease (ESKD) using a population-based cohort. Further, we examined the role of adult-onset type 2 diabetes (T2D) in these associations.

METHODS AND FINDINGS

We included 151,506 boys and 148,590 girls from the Copenhagen School Health Records Register, born 1930 to 1987 with information on measured weights and heights at ages 6 to 15 years. Five sex-specific childhood BMI trajectories were analyzed. Information on the main outcomes CKD and ESKD, as well as T2D, came from national health registers. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were estimated using Poisson regression adjusted for year of birth. During a median of 30.8 person-years of follow-up, 5,968 men and 3,903 women developed CKD and 977 men and 543 women developed ESKD. For both sexes, the rates of CKD and ESKD increased significantly with higher child BMI trajectories in comparison with the average BMI trajectory (40% to 43% of individuals) and the below-average BMI trajectory (21% to 23% of individuals) had the lowest rates. When including T2D, most associations were significant and men (IRR = 1.39, 95% CI: 1.13 to 1.72) and women (IRR = 1.54, 95% CI: 1.28 to 1.86) with the obese childhood BMI trajectory (2% of individuals) had significantly higher CKD rates than the average BMI trajectory, whereas for ESKD, the associations were positive, but nonsignificant, for men (IRR = 1.38, 95% CI: 0.83 to 2.31) but significant for women (IRR = 1.97, 95% CI: 1.25 to 3.11) with the obese BMI trajectory. A main study limitation is the use of only hospital-based CKD diagnoses.

CONCLUSIONS

Individuals with childhood BMI trajectories above average had higher rates of CKD and ESKD than those with an average childhood BMI trajectory. When including T2D, most associations were significant, particularly with CKD, emphasizing the potential information that the early appearance of above-average BMI growth patterns provide in relation to adult-onset CKD beyond the information provided by T2D development.

Prevalence, outcomes, and cost of chronic kidney disease in a contemporary population of 2·4 million patients from 11 countries: The CaReMe CKD study

Background

Digital healthcare systems data could provide insights into the global prevalence of chronic kidney disease (CKD). We designed the CaReMe CKD study to estimate the prevalence, key clinical adverse outcomes and costs of CKD across 11 countries.

Methods

Individual-level data of a cohort of 2·4 million contemporaneous CKD patients was obtained from digital healthcare systems in participating countries using a pre-specified common protocol; summarized using random effects meta-analysis. CKD and its stages were defined in accordance with current Kidney Disease: Improving Global Outcomes (KDIGO) criteria. CKD was defined by laboratory values or by a diagnosis code.

Findings

The pooled prevalence of possible CKD was 10·0% (95% confidence interval 8.5‒11.4; mean pooled age 75, 53% women, 38% diabetes, 60% using renin-angiotensin-aldosterone system inhibitors). Two out of three CKD patients identified by laboratory criteria did not have a corresponding CKD-specific diagnostic code. Among CKD patients identified by laboratory values, the majority (42%) were in KDIGO stage 3A; and this fraction was fairly consistent across countries. The share with CKD based on urine albumin-creatinine ratio (UACR) alone (KDIGO stages one and two) was 29%, with a substantial heterogeneity between countries. Adverse events were common; 6·5% were hospitalized for CKD or heart failure, and 6·2% died, annually. Costs for renal events and heart failure were consistently higher than costs for atherosclerotic events in CKD patients across all countries.

Interpretation

We estimate that CKD is present in one out of ten adults. These individuals experience significant adverse outcomes with associated costs. The prevalence of CKD is underestimated when using diagnostic codes alone. There is considerable public health potential in diagnosing CKD and providing treatments to those currently undiagnosed.

Funding

The study was sponsored by AstraZeneca.

The Intake of Ultra-Processed Foods and Prevalence of Chronic Kidney Disease: The Health Examinees Study

Emerging evidence links several health outcomes to the consumption of ultra-processed food (UPF), but few studies have investigated the association between UPF intake and kidney function. This cross-sectional study investigated the prevalence of chronic kidney disease (CKD) in relation to UPF intake in Korea. Data were obtained from the 2004−2013 Health Examinees (HEXA) study. The intake of UPF was assessed using a 106-item food frequency questionnaire and evaluated using the NOVA classification. The prevalence of CKD was defined as an estimated glomerular filtration rate (eGFR) of <60 mL/min/m2. Poisson regression models were used to compute the prevalence ratios (PR) of CKD according to quartiles of the proportion of UPF intake (% food weight). A total of 134,544 (66.4% women) with a mean age of 52.0 years and an eGFR of 92.7 mL/min/m2 were analysed. The median proportion of UPF in the diet was 5.6%. After adjusting for potential confounders, the highest quartile of UPF intake was associated with the highest prevalence of CKD (PR 1.16, 95% CI 1.07−1.25), and every IQR (6.6%) increase in the proportion of UPF in the diet was associated with a 6% higher prevalence of CKD (PR 1.06, 95% CI 1.03−1.09). Furthermore, the highest consumption of UPF was inversely associated with eGFR (Q4 vs. Q1: β −1.07, 95% CI −1.35, −0.79; per IQR increment: (β −0.45, 95% CI −0.58, −0.32). The intake of UPF was associated with a high prevalence of CKD and a reduced eGFR. Longitudinal studies in the Korean population are needed to corroborate existing findings in other populations.

Removing race from the CKD-EPI equation and its impact on prognosis in a predominantly White European population

BACKGROUND

While American nephrology societies recommend using the 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimated glomerular filtration rate (eGFR) equation without a Black race coefficient, it is unknown how this would impact disease distribution, prognosis and kidney failure risk prediction in predominantly White non-US populations.

METHODS

We studied 1.6 million Stockholm adults with serum/plasma creatinine measurements between 2007 and 2019. We calculated changes in eGFR and reclassification across KDIGO GFR categories when changing from the 2009 to 2021 CKD-EPI equation; estimated associations between eGFR and the clinical outcomes kidney failure with replacement therapy (KFRT), (cardiovascular) mortality and major adverse cardiovascular events using Cox regression; and investigated prognostic accuracy (discrimination and calibration) of both equations within the Kidney Failure Risk Equation.

RESULTS

Compared with the 2009 equation, the 2021 equation yielded a higher eGFR by a median [interquartile range (IQR)] of 3.9 (2.9-4.8) mL/min/1.73 m2, which was larger at older age and for men. Consequently, 9.9% of the total population and 36.2% of the population with CKD G3a-G5 was reclassified to a higher eGFR category. Reclassified individuals exhibited a lower risk of KFRT, but higher risks of all-cause/cardiovascular death and major adverse cardiovascular events, compared with non-reclassified participants of similar eGFR. eGFR by both equations strongly predicted study outcomes, with equal discrimination and calibration for the Kidney Failure Risk Equation.

CONCLUSIONS

Implementing the 2021 CKD-EPI equation in predominantly White European populations would raise eGFR by a modest amount (larger at older age and in men) and shift a major proportion of CKD patients to a higher eGFR category. eGFR by both equations strongly predicted outcomes.

Lithium and the risk of chronic kidney disease: A population-based case-control study

The association between lithium use and chronic kidney disease (CKD) needs further evaluation. We aimed to investigate this association using Danish nationwide healthcare registers and routinely collected plasma creatinine measurements from the Funen Laboratory Cohort. We conducted a case–control study nested within the population of Funen, 2001–2015. Incident cases of CKD (estimated glomerular filtration rate <60 ml/min/1.73m²; n = 21 432) were matched with four CKD‐free controls on age, sex and calendar time (n = 85 532). We estimated odds ratios (OR) for the association between lithium exposure and CKD using conditional logistic regression models, adjusted for known risk factors for CKD. Ever‐use of lithium was associated with an increased risk of CKD (adjusted OR [aOR]: 1.57; 95% confidence interval [CI]: 1.33–1.85). A stronger association was seen with current use of lithium (aOR: 1.92; 95%CI: 1.58–2.33) and long‐term use of lithium (>10 years: aOR: 3.02; 95%CI: 2.00–4.56). Furthermore, we found evidence of a dose–response relationship between cumulative dose of lithium and the risk of CKD. In conclusion, the use of lithium, especially long‐term, is associated with an increased risk of CKD, although the extent to which detection bias and confounding by indication contribute to the association is unclear. Monitoring of kidney function in lithium users remains mandatory to identify individuals in which switching to alternative medications should be considered.

Epidemiology of chronic kidney disease: an update 2022

Chronic kidney disease is a progressive condition that affects >10% of the general population worldwide, amounting to >800 million individuals. Chronic kidney disease is more prevalent in older individuals, women, racial minorities, and in people experiencing diabetes mellitus and hypertension. Chronic kidney disease represents an especially large burden in low- and middle-income countries, which are least equipped to deal with its consequences. Chronic kidney disease has emerged as one of the leading causes of mortality worldwide, and it is one of a small number of non-communicable diseases that have shown an increase in associated deaths over the past 2 decades. The high number of affected individuals and the significant adverse impact of chronic kidney disease should prompt enhanced efforts for better prevention and treatment.

OUP accepted manuscript

Background

Methods

Results

Conclusions

Accuracy of identifying diagnosis of moderate to severe chronic kidney disease in administrative claims data

BACKGROUND

Prior validation studies of claims-based definitions of chronic kidney disease (CKD) using ICD-9 codes reported overall low sensitivity, high specificity, and variable but reasonable PPV. No studies to date have evaluated the accuracy of ICD-10 codes to identify a US patient population with CKD.

METHODS

We assessed the accuracy of claims-based algorithms to identify adults with CKD Stages 3-5 compared with laboratory values in a subset (~40%) of a US commercial insurance claims database (Optum's de-identified Clinformatics® Data Mart Database). We calculated the positive predictive value (PPV) of one or two ICD-9 (2012-2014) or ICD-10 (2016-2018) codes for CKD compared with a lab-based estimated glomerular filtration rate (eGFR) occurring within prespecified windows (±90 days, ±180 days, ±365 days) of the ICD-based CKD code(s).

RESULTS

The study population ranged between 104 774 and 161 305 patients (ICD-9 cohorts) and between 285 520 and 373 220 patients (ICD-10 cohorts). The mean age was 74.4 years (ICD-9) and 75.6 years (ICD-10) and the median eGFR was 48 ml/min/1.73 m² . The algorithm of two CKD codes compared with a lab value ±90 days of the first code achieved the highest PPV (PPV 86.36% [ICD-9] and 86.07% [ICD-10]). Overall, ICD-10 based codes had comparable PPVs to ICD-9 based codes and all ICD-10 based algorithms had PPVs >80%. The algorithm of one CKD code compared with laboratory value ±180 days maintained the PPV above 80% but still retained a large number of patients (PPV 80.32% [ICD-9] and 81.56% [ICD-10]).

CONCLUSION

An ICD-10-based definition of CKD identified with sufficient accuracy a patient population with CKD Stages 3-5. Our findings suggest that claims databases could be used for future real-world research studies in patients with CKD Stages 3-5.

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.

Kidney disease and risk of dementia: a Danish nationwide cohort study

OBJECTIVES

It is unclear whether kidney disease is a risk factor for developing dementia. We examined the association between kidney disease and risk of future dementia.

DESIGN AND SETTING

Nationwide historical registry-based cohort study in Denmark based on data from 1 January 1995 until 31 December 2016.

PARTICIPANTS

All patients diagnosed with kidney disease and matched general population cohort without kidney disease (matched 1:5 on age, sex and year of kidney disease diagnosis).

PRIMARY AND SECONDARY OUTCOME MEASURES

All-cause dementia and its subtypes: Alzheimer's disease, vascular dementia and other specified or unspecified dementia. We computed 5-year cumulative incidences (risk) and hazard ratios (HRs) for outcomes using Cox regression analyses.

RESULTS

The study cohort comprised 82 690 patients with kidney disease and 413 405 individuals from the general population. Five-year and ten-year mortality rates were twice as high in patients with kidney disease compared with the general population. The 5-year risk for all-cause dementia was 2.90% (95% confidence interval: 2.78% to 3.08%) in patients with kidney disease and 2.98% (2.92% to 3.04%) in the general population. Compared with the general population, the adjusted HRs for all-cause dementia in patients with kidney disease were 1.06 (1.00 to 1.12) for the 5-year follow-up and 1.08 (1.03 to 1.12) for the entire study period. Risk estimates for dementia subtypes differed substantially and were lower for Alzheimer's disease and higher for vascular dementia.

CONCLUSIONS

Patients diagnosed with kidney disease have a modestly increased rate of dementia, mainly driven by vascular dementia. Moreover, patients with kidney disease may be underdiagnosed with dementia due to high mortality and other comorbidities of higher priority.

Adverse outcomes after partner bereavement in people with reduced kidney function: Parallel cohort studies in England and Denmark

OBJECTIVES

To investigate whether partner bereavement is associated with adverse cardiovascular and kidney-related events in people with reduced kidney function.

DESIGN

Two parallel matched cohort studies using linked routinely collected health data.

SETTING

England (general practices and hospitals using linked Clinical Practice Research Datalink, Hospital Episode Statistics, and Office of National Statistics) and Denmark (hospitals and community pharmacies using the Danish National Patient, Prescription and Education Registries and the Civil Registration System).

PARTICIPANTS

Bereaved people with reduced kidney function (estimated glomerular filtration rate (eGFR) <60mL/min/1.73m2 (England) or hospital-coded chronic kidney disease (Denmark)) and non-bereaved people with reduced kidney function similarly defined, matched on age, sex, general practice (England), and county of residence (Denmark) and followed-up from the bereavement date of the exposed person.

MAIN OUTCOME MEASURES

Cardiovascular disease (CVD) or acute kidney injury (AKI) hospitalization, or death.

RESULTS

In people with reduced kidney function, we identified 19,820 (England) and 5,408 (Denmark) bereaved individuals and matched them with 134,828 (England) and 35,741 (Denmark) non-bereaved individuals. Among the bereaved, the rates of hospitalizations (per 1000 person-years) with CVD were 31.7 (95%-CI: 30.5-32.9) in England and 78.8 (95%-CI: 74.9-82.9) in Denmark; the rates of hospitalizations with AKI were 13.2 (95%-CI: 12.5-14.0) in England and 11.2 (95%-CI: 9.9-12.7) in Denmark; and the rates of death were 70.2 (95%-CI: 68.5-72.0) in England and 126.4 (95%-CI: 121.8-131.1) in Denmark. After adjusting for confounders, we found increased rates of CVD (England, HR 1.06 [95%-CI: 1.01-1.12]; Denmark, HR 1.10 [95%-CI: 1.04-1.17]), of AKI (England, HR 1.20 [95%-CI: 1.10-1.31]; Denmark HR 1.36 [95%-CI: 1.17-1.58]), and of death (England, HR 1.10 [95%-CI: 1.05-1.14]; Denmark HR 1.20 [95%-CI: 1.15-1.25]) in bereaved compared with non-bereaved people.

CONCLUSIONS

Partner bereavement is associated with an increased rate of CVD and AKI hospitalization, and death in people with reduced kidney function. Additional supportive care for this at-risk population may help prevent serious adverse events.