Uptake of SGLT2i and Outcomes in Patients with Diabetes and Heart Failure: A Population-Based Cohort and a Specialized Clinic Cohort

BACKGROUND

Sodium/glucose cotransporter 2 inhibitors (SGLT2i) are effective in adults with diabetes mellitus (DM) and heart failure (HF) based on randomized clinical trials. We compared SGLT2i uptake and outcomes in two cohorts: a population-based cohort of all adults with DM and HF in Alberta, Canada and a specialized heart failure clinic (HFC) cohort.

METHODS

The population-based cohort was derived from linked provincial healthcare datasets. The specialized clinic cohort was created by chart review of consecutive patients prospectively enrolled in the HFC between February 2018 and August 2022. We examined the association between SGLT2i use (modeled as a time-varying covariate) and all-cause mortality or deaths/cardiovascular hospitalizations.

RESULTS

Of the 4,885 individuals from the population-based cohort, 64.2% met the eligibility criteria of the trials proving the effectiveness of SGLT2i. Utilization of SGLT2i increased from 1.2% in 2017 to 26.4% by January 2022. In comparison, of the 530 patients followed in the HFC, SGLT2i use increased from 9.8% in 2019 to 49.1 % by March 2022. SGLT2i use in the population-based cohort was associated with fewer all-cause mortality (aHR 0.51, 95% CI 0.41-0.63) and deaths/cardiovascular hospitalizations (aHR 0.65, 95% CI 0.54-0.77). However, SGLT2i usage rates were far lower in HF patients without DM (3.5% by March 2022 in the HFC cohort).

CONCLUSIONS

Despite robust randomized trial evidence of clinical benefit, the uptake of SGLT2i in patients with HF and DM remains low, even in the specialized HFC. Clinical care strategies are needed to enhance the use of SGLT2i and improve implementation.

Chronic thrombotic microangiopathy presenting as acute nephrotic syndrome in a patient with renal cancer receiving tyrosine kinase inhibitor therapy

Thrombotic microangiopathy (TMA) is a rare but serious side effect of tyrosine kinase inhibitor (TKI) therapy. Previous case reports of renal TMA have usually occurred in the first few months of TKI initiation with only very few cases occurring within 2-3 years. We report a case of a patient who was referred to the Nephrology service for nephrotic syndrome and worsening renal function after 8 years of sunitinib therapy for metastatic clear cell carcinoma of the kidney. Renal biopsy showed chronic TMA without another secondary aetiology identified. With discontinuation of sunitinib and pharmacological optimisation of his hypertension, his renal function and proteinuria both significantly improved. No relapse or recurrence of disease activity was noted after a year of follow-up. This case highlights the importance of remaining vigilant for the development of renal TMA even after an extended duration of TKI therapy.

Implementing a Formalized Risk-Based Approach to Determine Candidacy for Multidisciplinary CKD Care: A Descriptive Cohort Study

Background

The kidney failure risk equation (KFRE) can be used to predict progression to end-stage kidney disease in a clinical setting.

Objective

Evaluate implementation of a formalized risk-based approach in nephrologists' outpatient clinics and multidisciplinary chronic kidney disease (CKD) clinics to determine candidacy for multidisciplinary care, and the impact of CKD care selection on clinical outcomes.

Design

Population-based descriptive cohort study.

Setting

Alberta Kidney Care South.

Patients

Adults attending or considered for a multidisciplinary CKD clinic between April 1, 2017, and March 31, 2019.

Measurements

Exposure-The course of CKD care assigned by the nephrologist: management at multidisciplinary CKD clinic; management by a nephrologist or primary care physician. Primary Outcome-CKD progression, defined as commencement of kidney replacement therapy (KRT). Secondary Outcomes-Death, emergency department visits, and hospitalizations.

Methods

We linked operational data from the clinics (available until March 31, 2019) with administrative health and laboratory data (available until March 31, 2020). Comparisons among patient groups, courses of care, and clinical settings with negative binomial regression count models and calculated unadjusted and fully adjusted incidence rate ratios. For the all-cause death outcome, we used Cox survival models to calculate unadjusted and fully adjusted hazard ratios.

Results

Of the 1748 patients for whom a KFRE was completed, 1347 (77%) remained in or were admitted to a multidisciplinary CKD clinic, 310 (18%) were managed by a nephrologist only, and 91 (5%) were referred back for management by their primary care physician. There was a much higher kidney failure risk among patients who remained at or were admitted to a multidisciplinary CKD clinic (median 2-year risk of 34.7% compared with 3.6% and 0.8% who remained with a nephrologist or primary care physician, respectively). None of the people managed by their primary care physician alone commenced KRT, while only 2 (0.6%) managed by a nephrologist without multidisciplinary CKD care commenced KRT. The rates of emergency department visits, hospitalizations, and death were lower in those assigned to management outside the multidisciplinary CKD clinics when compared with those managed in the multidisciplinary care setting.

Limitations

The follow-up period may not have been long enough to determine outcomes, and potentially limited generalizability given variability of care in multidisciplinary clinics.

Conclusions

Our findings indicate that a portion of patients can be directed to less resource-intensive care without a higher risk of adverse events.

Trial registration

Not applicable.

PATTERN OF RENAL DISEASES AMONG CHILDREN ATTENDING PAEDIATRIC NEPHROLOGY CLINIC, FEDERAL TEACHING HOSPITAL, GOMBE

Introduction

Children present with a spectrum of renal diseases depending on age, sex, and geographic location among other factors. With the absence of a paediatric renal registry in Nigeria, this will provide part of the regional data necessary for the Nigerian renal registry.

Methodology

A retrospective study where cases of renal diseases that presented in a nephrology clinic over a 2-year period were retrieved from the nurses' and doctors' records and analysed.

Results

A total of 147 children were reviewed, male and female were 101 and 46 respectively with M: F being 2.2: 1. Mean age was 9.59 ± 4.58 years, age distribution were <5 years (23.0; 15.6%), 5-9 years (52; 35.4%) and ≥ 10 years (72.0; 49.0%). The majority (77.0; 52.4%) had low socioeconomic status. Majority (145; 98.6%) were acquired renal diseases while ectopic kidney (2.0; 1.4%) was the only CAKUT. Acute glomerulonephritis (49; 33.3%), urinary tract infections (37; 25.2%) and nephrotic syndrome (30.0; 20.4%) were the major acquired renal diseases. Acute kidney injury (AKI) and chronic kidney disease (CKD) were seen in 9 (6.1%) and 13 (8.8%) respectively. Urolithiasis, sickle cell nephropathy, and primary enuresis were seen in 5(3.4%) and 1 (0.7%) respectively. The mean age of children with CAKUT and acquired renal diseases were13.00 ±1.41 and 9.54±4.59 years (P=0.290) while that of AKI and CKD were 10.89±5.21 and 14.15±3.24 years respectively (P= 0.084).

Conclusion

Childhood renal diseases increase with age and are more common among adolescents, especially the chronic forms. Regular screening and aggressive treatment are recommended in adolescents.

OBSTRUCTIVE UROPATHY FROM BILATERAL URETERIC CALCULI IN AN INFANT WITH DIARRHOEA DISEASE

Introduction

Urolithiasis is the presence of mineral deposits in the urinary tract. It is rare in under-5 children and in Sub-Saharan Africa. Although metabolic abnormality is implicated in 50% of cases, infection, decreased urine volume and flow (dehydration state) have been implicated. We report a case of bilateral ureteric calculi in an infant with diarrhoea disease and dehydration.

Case Report

A.S, is an 8-month-old male with prolonged loose, large-volume stool, large-volume vomiting, high-grade fever, body weakness, and peri-orbital swelling that progressed to generalized body swelling and absent urine for 2 days. He was conscious, afebrile (36.90C), pale with anasarca. Had distended abdomen with ascites. Dyspnea, coarse crepitation, and hypoxemia. Tachycardia (PR -180/min) Hypertensive (BP - 125/79mmHg). PCV - 20%, WBC - 24,000/l, platelet - 110,000/l. Creatinine (1030 umol/l), Urea - 30mmol/l, Multi drug resistant E.Coli. Bilateral Grade II nephritis, hydro-uretero-nephrosis, right pelvi-ureteric and left vesico-ureteric junction calculi. Managed for Diarrhoea disease complicated with Bilateral Obstructive uropathy secondary to Bilateral Ureteric Calculi. Had bilateral open ureteric exploration, ureterolithotomy, Stenting, intraoperative transfusion, antibiotics, analgesics, and IVF. 24-hr post-surgery: urine output (3.26ml/kg/hr): right stent (210ml), left stent (423ml) while urethral catheter (150ml), 742umol/l, Urea: 26mmol/l 48-hr post-surgery: Urine output 5.1ml/kg/hr (1224ml/24hr); Cr: 424umol/l, Urea: 16mmo/l 5 days post-surgery: Urine output 3.1ml/kg/hr (725ml/24hr); Cr: 47umol/l, Urea: 4.6 mmo/l, Patient was discharged home and currently on follow-up in paediatric nephrology and urology clinics.

Conclusion

A high index of suspicion of obstructive uropathy in children with diarrhoea disease, and dehydration, who have developed acute kidney injury is recommended.

CASE FATALITY RATE OF CHILDHOOD TUBERCULOSIS: EXPERIENCE FROM FEDERAL TEACHING HOSPITAL GOMBE: A TWO DECADE REVIEW

Introduction

Tuberculosis (TB) was the leading cause of death from an infectious agent worldwide, until the Coronavirus (COVID-19) pandemic, ranking above HIV/AIDS. Nigeria ranks 6th among the 30 TB high-burden countries (TB, TB/HIV, DRTB) and 1st in Africa. The estimated case fatality rate (CFR) of TB in Sub-Sahara Africa (SSA) is 15%.

Objective

To review the Tuberculosis case fatality rate (TCFR) in children diagnosed with TB from 2000-2019 in Federal Teaching Hospital Gombe.

Methodology

All cases of Tuberculosis (TB) diagnosed in children using ICD 10 classification were retrieved and analyzed. These included deaths from TB. The mainstay of TB diagnosis was clinical using TB Score (81%), Gene Xpert was 7%, and AFB was 10%.

Results

26,716 children were admitted; 383 had TB out of which 208(54.3%) were males and 175 (45.7%) females. TB constituted 1.4% of Paediatric admissions. Children 0 -5 years constituted 46.7% (179/383) of cases and 11 - 18 years were 31.3% (120/383). Fulani, Hausa, and Tangale constituted 43.6% (167), 21.1% (81), and 6.8% (26) of TB cases respectively. TB admissions were highest between 2015 and 2019 (31.8%). TB adenitis was the most common extrapulmonary TB. Tuberculosis/HIV co-infection accounted for 103(27%), out of which 74% (44) died. Overall TCFR was 15.6%; TCFR was 16.3% in males and 14.8% in females. The TCFR was 46.7% in 0-5yrs; 15% in 6-9yrs and 38.3% in 10-18yrs.Fulani had the highest CFR (11.9%). Tuberculosis CFR was highest between 2010-2014 (30.0%) and lowest in 2005-2009 (21.6%).

Conclusion

The Tuberculosis CFR is comparable to SSA CFR.

Evaluating a novel consensus bacterial 6-phytase variant on growth performance of broilers fed U.S. commercial diets deficient in nutrients and energy through 63 days of age

An experiment was conducted to evaluate the efficacy of a novel consensus bacterial 6-phytase variant expressed in Trichoderma reesei (PhyG) in broilers fed corn-soybean meal-based diets with application of dose-specific full nutrient and energy matrix values. Ross 708, straight-run broilers (n = 2,016) were assigned to one of 7 dietary treatments, with 12 replicate pens/diet and 24 birds/pen. Diets were a nutrient adequate control (PC), nutrient reduced negative controls 1, 2, and 3 (NC1, NC2, and NC3) with reductions in available phosphorus (avP) by 0.15%, 0.18%, and 0.19%, calcium (Ca) by 0.17%, 0.20%, and 0.21%, dig amino acids (AA) by 0.02%-0.05%, sodium (Na) by 0.03%-0.05%, and metabolizable energy (ME) by 62.8, 68.8, and 69.5 kcal/kg, respectively. Other diets were the NC1, NC2, and NC3 respectively supplemented with 500 (PhyG500), 1,000 (PhyG1000), and 2,000 (PhyG2000) FTU/kg. Over the 63-day feeding period, decreasing nutrient specifications lowered body weights (P < 0.05) in broilers from 4,518 g in PC to 4,256 g and 4,191 g and increased body weight-corrected feed conversion ratio (FCR, P < 0.05) from 1.92 in PC to 2.06 and 2.08 in the NC2 and NC3, respectively. Compared with PC, PhyG maintained (P > 0.05) BW in broilers fed PhyG500 (4,474 g), PhyG1000 (4,417 g), and PhyG2000 (4,449 g). Moreover, PhyG at all dose-levels maintained (P > 0.05) overall FCR vs. PC. The NC1, NC2, and NC3 diets decreased (P < 0.05) tibia ash vs. PC, and each PhyG500, PhyG1000, and PhyG2000 completely restored tibia ash to the similar levels (P > 0.05) as the PC. Carcass yield was decreased (P < 0.05) by NC1 (80.63%), NC2 (80.51%), and NC3 (80.31%) vs. PC (81.96%) with complete alleviation by PhyG500 (82.11%), PhyG1000 (81.80%), and PhyG2000 (81.54%). In conclusion, the novel consensus phytase variant completely compensated for the reduction in dietary avP, Ca, dig AA, and ME at each dose-level and maintained growth performance, bone quality, carcass characteristics, and nutrient digestibility in a typical corn-soybean mean based diet fed to broilers through 63 days of age.

Conflicts of interest in electrophysiology and devices presentations

AIMS

Industry collaboration with arrhythmia and devices research is common. However, this results in conflicts of interest (CoI) for researchers that should be disclosed. This study aimed to examine the quality of CoI disclosures in arrhythmia and devices presentations.

METHODS

Recorded presentations from the Arrhythmia & Devices section of the ESC Annual Congress 2016-2020 were assessed. The number of words, conflicts, and time displayed was documented for CoI declarations. Meta-data including sponsorship by an industry partner, presenter sex, and institution were obtained.

RESULTS

Of 1153 presentations assessed, 999 were suitable for inclusion. CoI statements were missing from 7.2% of presentations, and 58% reported ≥1 conflict. Those with conflicts spent less time-per-word on their disclosures (median 150 ms, interquartile range [IQR] 83-273 ms) compared with those without conflicts (median 250 ms, IQR 125-375 ms). One-in-eight presentations were sponsored (12.8%, n = 128). CoI statements were more likely to be missing in sponsored presentations (14.8%, n = 19) compared with non-sponsored presentations (6.1%, n = 53), P = 0.0003. Sponsored presentations contained a greater median number of CoIs (10, IQR 6-18) compared with non-sponsored sessions (1, IQR 0-5), P < 0.0001. Time-per-word spent on COI disclosures was 50% lower in sponsored sessions (125 ms, IQR 75-231 ms) compared with non-sponsored sessions (250 ms, IQR 125-375 ms), P < 0.0001.

CONCLUSION

The majority of those presenting arrhythmia and devices research have CoIs to declare. Declarations were often missing or displayed for short periods of time. Presenters in sponsored sessions, while being more conflicted, had a lower standard of declaration suggesting a higher risk of potential bias which viewers had insufficient opportunity to assess.

A roadmap for kidney care in Africa: An analysis of International Society of Nephrology–Global Kidney Health Atlas Africa data describing current gaps and opportunities

Delivery of kidney care in Africa is significantly constrained by various factors. In this review, we used International Society of Nephrology–Global Kidney Health Atlas (ISN–GKHA) data for Africa to address sub-regional differences in care delivery in the continent with focus on infrastructure, workforce, and the economic aspects of kidney care. Forty two African countries participated in the survey conducted in 2018. North Africa had the highest proportions of nephrologists [12.53 per million population (pmp)], nephrology trainees (2.19 pmp) and haemodialysis (HD) centres (8.58 pmp); whereas southern Africa had the highest proportions of peritoneal dialysis (PD) centres (0.89 pmp) and kidney transplant (KT) centres (0.29 pmp); West Africa had the greatest nephrology workforce shortages. The annual median costs of HD (US$22,731 [interquartile range (IQR): US$1,560–43,902]) and PD (US$34,165 [US$34,165–34,165]) were highest in Central Africa and only Algeria, Egypt and South Africa reported zero co-payment for all modalities of kidney replacement therapy in the public sector. Policies on chronic kidney disease and non-communicable diseases were scarcely available across all African sub-regions. The ISN–GKHA African data highlight a stark difference in kidney care measures between North and sub-Saharan Africa and also suggest the need for a more cohesive approach to policy formulations that support and protect patients with kidney disease in the continent, especially from the excessive costs associated with care. Using the World Health Organization (WHO) Global Action Plan for noncommunicable diseases, this paper proposes an African roadmap for optimal kidney care.

Use of Google Analytics to Explore Dissemination Activities for an Online CKD Clinical Pathway: A Retrospective Study

Background:

Data on dissemination strategies that generate awareness of clinical pathways for kidney care are limited.

Objective:

This study reports the application of Google Analytics to describe the reach and use of the Chronic Kidney Disease Pathway (CKD-P) using a multi-faceted dissemination strategy.

Design:

The design of this study is a retrospective descriptive study.

Setting:

This study was conducted in Alberta, Canada.

Patients:

Individuals who accessed the CKD-P Web site between November 5, 2014, and May 31, 2019.

Measurements:

Dissemination activities included print, electronic, in-person meetings, and a laboratory prompt. We used Google Analytics over a 5-year period to evaluate the following CKD-P Web site user metrics: number of sessions, pageviews, visit duration, user path, and bounce rate (when an individual visits a single page of the Web site and leaves the Web site without interacting with additional pages).

Methods:

We plotted dissemination activities alongside Web site metrics using control charts and described the data using means and percentages. We performed chi-square test for trends to evaluate year-over-year usage.

Results:

There were 83 294 users, 90 805 sessions, and 231 684 pageviews. The overall bounce rate was 45.7%. Each user had an average of 1.5 sessions and a session duration of 2 minutes and 8 seconds. There was a significant positive trend for total annual users (P = .008), new users (P = .009), number of sessions (P = .006), and pageviews per day (P = .016).

Limitations:

We were unable to confirm if users were primary care providers and if word-of-mouth dissemination among providers/researchers drove people to use the CKD-P.

Conclusions:

Google Analytics was a useful and accessible tool for evaluating CKD-P reach and use trends. It was challenging to identify how individual dissemination activities contributed to CKD-P reach; however, repeated dissemination appeared to play a role in increasing CKD-P use.

Trial registration:

Not applicable—observational study design.

Update on Existing Care Models for Chronic Kidney Disease in Low- and Middle-Income Countries: A Systematic Review

Background:

Approximately 78% of chronic kidney disease (CKD) cases reside in low- and middle-income countries (LMICs). However, little is known about the care models for CKD in LMICs.

Objective:

Our objective was to update a prior systematic review on CKD care models in LMICs and summarize information on multidisciplinary care and management of CKD complications.

Design:

We searched MEDLINE, EMBASE, and Global Health databases in September 2020, for papers published between January 1, 2017, and September 14, 2020. We used a combination of search terms, which were different iterations of CKD, care models, and LMICs. The World Bank definition (2019) was used to identify LMICs.

Setting:

Our review included studies published in LMICs across 4 continents: Africa, Asia, North America (Mexico), and Europe (Ukraine). The study settings included tertiary hospitals (n = 6), multidisciplinary clinics (n = 1), primary health centers (n = 2), referral centers (n = 2), district hospitals (n = 1), teaching hospitals (n = 1), regional hospital (n = 1), and an urban medical center (n = 1).

Patients:

Eighteen studies met inclusion criteria, and encompassed 4679 patients, of which 4665 were adults. Only 9 studies reported mean eGFR which ranged from 7 to 45.90 ml/min/1.73 m².

Measurements:

We retrieved the following details about CKD care: funding, urban or rural location, types of health care staff, and type of care provided, as defined by Kidney Disease Improving Global Outcomes (KDIGO) guidelines for CKD care.

Methods:

We included studies which met the following criteria: (1) population was largely adults, defined as age 18 years and older; (2) most of the study population had CKD, and not end-stage kidney disease (ESKD); (3) population resided in an LMIC as defined by the World Bank; (4) manuscript described in some detail a clinical care model for CKD; (5) manuscript was in either English or French. Animal studies, case reports, comments, and editorials were excluded.

Results:

Eighteen studies (24 care models with 4665 patients) met inclusion criteria. Out of 24 care models, 20 involved interdisciplinary health care teams. Twenty models incorporated international guidelines for CKD management. However, conservative kidney management (management of kidney failure without dialysis or renal transplant) was in a minority of models (11 of 24). Although there were similarities between all the clinical care models, there was variation in services provided and in funding arrangement; the latter ranged from comprehensive government funding (eg, Sri Lanka, Thailand), to out-of-pocket payments (eg, Benin, Togo).

Limitations:

These include (1) lack of detail on CKD care in many of the studies, (2) small number of included studies, (3) using a different definition of care model from the original Stanifer et al paper, and (4) using the KDIGO Guidelines as the standard for defining a CKD care model.

Conclusions:

Most of the CKD models of care include the key elements of CKD care. However, access to such care depends on the funding mechanism available. In addition, few models included conservative kidney management, which should be a priority for future investment.

Trial registration:

Not applicable.

A novel consensus bacterial 6-phytase variant added to phytate-rich diets totally replaced inorganic phosphate in broilers

The capacity of a novel bacterial 6-phytase variant (PhyG) to totally replace dietary supplemental inorganic phosphate (Pi) in broilers aged one day old was evaluated using a phased dosing strategy and reduction in dietary phytate. A total of 1,248 one-day-old Ross 308 broilers were assigned to 24 pens (52 birds/pen, 12 pens/diet, six each males and females) in a complete randomised block design with a 2×2 factorial arrangement (two diets, two genders). Diets comprised: (1) a positive control (PC) based on maize, wheat and soybean meal, containing Pi from monocalcium phosphate and 2,000 XU/kg xylanase, and; (2) an inorganic phosphate-free (IPF) diet equivalent to PC but with reduced Ca (-2.0 g/kg) and supplemented with PhyG at 3,000, 2,000 and 1000 FTU/kg from d 0 to 11 (3.4 g/kg phytate-P (PP)), d 11 to 22 (3.3 g/kg PP) and d 22 to 42 (2.8 to 2.9 g/kg PP), respectively. A negative control was not included for animal welfare reasons. Tibias were collected on d 11, 22 and 42 from two birds/pen. Treatment IPF maintained or improved average daily gain (ADG), average daily feed intake and feed conversion ratio (FCR) vs PC during all phases; Body weight was higher in the IPF treatment than the PC at d 42 (+3.97%, P<0.01) and ADG during d 0 to 42 (+4.10%, P<0.01). Overall (d 0 to 42), treatment IPF improved FCR in males (-5 points vs PC, P<0.05) but not females. Tibia ash was equivalent in IPF and PC throughout, with no gender differences. In conclusion, when applied as a phased dosing strategy to diets with graded reduction in PP content, PhyG totally replaced supplemental Pi during all growth phases in males and females.

Modeling improvements in ileal digestible amino acids by a novel consensus bacterial 6-phytase variant in broilers

Data from 13 datasets from 4 trials on the effect of a novel consensus bacterial 6-phytase variant (PhyG) on the apparent ileal digestibility (AID) of amino acids (AA) in broilers were used to model AID AA responses. The datasets were obtained from 3 trial locations (New Zealand, Australia and United States) and collectively incorporated variations in diet composition (feedstuff composition, phytate-P (PP) level, limestone solubility), feed form (mash or pellet), bird genetics (strain), and age at sampling (11-35 d of age). In total, 384 observations were analyzed. First, the relationships between AID of AA (as coefficients) and increasing phytase dose level from 0 to 4,000 FTU/kg were evaluated across all datasets using exponential curve fitting. Second, the percentage unit change in AID of AA at each phytase dose level from baseline (basal diet [BD] without phytase) was calculated separately for each dataset and the data then modeled together using exponential curve fitting. The model-predicted mean coefficient of AID of total AA in basal diets was 0.76 (range 0.56 [Cys] to 0.83 [Glu]), which was increased by PhyG to 0.80 and 0.81 at 2,000 and 4,000 FTU/kg, respectively. Exponential increases in the percentage unit improvement in AID of 18 individual and of total AA with increasing phytase dose level were evident (P < 0.05). Improvements (vs. BD) at 2,000 FTU/kg and 4,000 FTU/kg, respectively, were greatest for Cys (+9.2 and +11.0% units), Met (after deduction of synthetic Met, +8.4 and +9.0% units), and Thr (after deduction of synthetic Thr, +6.2 and +7.3% units). The data demonstrated consistent improvements in the AID of AA by the phytase. The modeling results generated from data gathered from birds sampled at different ages and from different dietary settings with correction of synthetic AA for Lys, Met, Thr, and Trp, enabled a more accurate prediction of the digestible AA contribution from the diet by this novel phytase. This will allow diet-specific AA matrix recommendations to be made in commercial feed formulations.

Effects of a novel consensus bacterial 6-phytase variant on the apparent ileal digestibility of amino acids, total tract phosphorus retention and tibia ash in young broilers

The effect of a novel consensus bacterial 6-phytase variant (PhyG) on apparent ileal digestibility (AID) of amino acids (AA) and phosphorus (P) utilization in young broilers when added to diets with high phytate-P (PP) content without added inorganic phosphate (Pi) and deficient in digestible (dig) AA and metabolizable energy (ME) was investigated. A total of 256 Ross 308 male broilers were assigned to 4 treatments (8 birds/cage, 8 cages/treatment) in a completely randomized design. Treatments comprised a positive control (PC, 2,975 kcal/kg ME, 3.7 g/kg dig P, 2.83 g/kg PP, 8.4 g/kg Ca, 10.6 g/kg dig lysine), a negative control (NC) without added Pi (ME −68 kcal/kg, crude protein −10 g/kg, dig AA −0.1 to −0.4 g/kg, Ca −2.0 g/kg, dig P −2.2 g/kg, Na −0.4 g/kg vs. PC), and NC plus 500 or 1,000 FTU/kg of PhyG. Test diets were corn/soy/rapeseed-meal/rice-bran-based and fed from 5 to 15 d of age. Ileal digesta and tibias were collected on day 15. Excreta was collected during days 12 to 15 to determine P retention. The NC (vs. PC) reduced (P < 0.05) P retention (−10.4% units), tibia ash (−14.3% units), weight gain (−109 g), feed intake (−82 g) and increased FCR (from 1.199 to 1.504), confirming that the NC was extremely deficient in nutrients and energy. Phytase addition to the NC linearly (P < 0.001) improved performance, but did not fully recover it to the level of the PC due to the severe nutrients/energy reduction in NC. Phytase linearly increased P retention (P < 0.001), tibia ash (P < 0.001), AID of dry matter (P < 0.05), nitrogen (P < 0.01), gross energy (P < 0.05), and all 17 individual AA (P < 0.01). At 1,000 FTU/kg, phytase increased (P < 0.05) P retention vs. PC and NC (+14.5 and +24.9% units, respectively) and increased tibia ash vs. NC (+13.8% units), equivalent to PC. The NC decreased AID of Cys, Gly, Thr, and Met vs. PC (P < 0.05). At 1,000 FTU/kg, phytase increased AID of all 17 AA vs. NC (P < 0.01), equivalent to PC. At 1,000 FTU/kg, AID AA responses (above NC) ranged from +4.5% (Met) to +15.0% (Cys), being maximal for essential Thr (+10.4%) and Val (+8.2%) and non-essential Cys (+15.0%) and Gly (+10.4%). The results highlight the efficacy of PhyG at a dose level of 500 to 1,000 FTU/kg in young broilers for improving the ileal digestibility of nitrogen, AA, and energy alongside P retention and tibia ash. The performance data emphasize the need to consider digestible nutrient intake as a response variable in exogenous enzyme studies.

Microbial phytase is widely used in commercial broiler diets to improve digestion of phosphorus (P) and reduce its excretion into the environment. Phytase improves the digestion of phosphorus and other nutrients including amino acids (AA). This study evaluated the effect of a novel consensus bacterial 6-phytase variant (PhyG) added to a nutrient-reduced diet without any added inorganic P on the digestibility of nutrients including P and AA in the ileum of young broilers. Effects on P retention and bone mineralization were also assessed. Compared to an unsupplemented negative control diet, PhyG improved growth performance, P retention, bone mineralization (tibia ash), digestibility of dry matter, nitrogen, gross energy, and all 17 individual AA during 5 to 15 d post-hatch, in a dose-dependent manner (dose range 0 to 1,000 phytase units [FTU] per kilogram of feed). For some AA, the increases in digestibility with PhyG at 1,000 FTU/kg were substantial (cysteine: +15.0%, threonine:+10.4%), and for all AA were equivalent to the responses produced by a nutritionally adequate positive control (unsupplemented) diet. The results demonstrate the efficacy of PhyG to improve AA digestibility alongside growth performance, P retention, and bone mineralization in young broilers.

Inter- and intradialytic fluid volume changes and vascular stiffness parameters in patients on hemodialysis

Background

Whether fluid overload is associated with vascular stiffness parameters in hemodialysis (HD) patients has not been fully elucidated. We hypothesized that interdialytic fluid accumulation increases vascular stiffness parameters, which improves with intradialytic ultrafiltration.

Methods

Fluid overload and vascular stiffness parameters were assessed in 39 HD patients (20 with and 19 without fluid overload) and compared to 26 healthy controls. Fluid status was assessed 15 minutes before the mid-week HD session by bio-impedance spectroscopy. Following this, ambulatory pulse wave velocity (PWV) and augmentation index (AIx) were measured for 24 hours before another mid-week HD session and then for 5 hours starting 30 minutes before and ending 30 minutes after the session.

Results

HD patients had significant fluid overload compared to healthy controls (2.0±2.4 vs. -0.2±0.6 L; P<0.001) and baseline PWV was higher (10.3±1.7 vs. 8.8±1.4 m/s; P<0.001). There was no significant difference between PWV and AIx in fluid overloaded and non-fluid overloaded HD patients prior to, or during the HD session. AIx of non-fluid overloaded HD patients improved after the HD session (P = 0.04). Average 24-hour AIx was higher in fluid overloaded HD patients (P<0.001).

Conclusions

Inter- and intradialytic changes in fluid volume were only weakly related to vascular stiffness parameters in HD patients. Although there was a modest reduction in AIx in non-fluid overloaded HD patients after the dialysis session, fluid removal did not improve vascular stiffness parameters during the HD session. We speculate that the effect of fluid overload correction on vascular stiffness parameters requires long-term adjustments in the vasculature.

Designing an App for Immunosuppression Adherence and Communication: A Qualitative Approach

Background:

Immunosuppression nonadherence may be the most important factor limiting long-term allograft survival.

Objective:

Following user-centered design, we explored the essential priorities and preferences of kidney transplant recipients and healthcare providers (HCP) to inform development of a smartphone app to improve immunosuppression adherence and communication.

Design:

A qualitative descriptive research design was used.

Setting:

The University of Alberta Hospital adult kidney transplant program in Edmonton, Canada.

Participants:

Participants were recruited by convenience sampling and included 32 kidney transplant recipients and 11 HCPs.

Methods:

Seven focus groups (5 with recipients and 2 with HCPs) were conducted to inform app development. Sessions were recorded, and transcripts were coded to elucidate themes.

Results:

App development to improve adherence was not a priority for HCP. Recipients prioritized choice: that all features be optional. Recipients preferred support while traveling; access to laboratory results; and use by younger or newly transplanted recipients. Both recipients and HCP preferred linkage to pharmacy; and self-management and accountability. For the app to improve communication, HCPs believed the priorities to be addressed included: clarity on scope of app; legal, ethical, and professional obligations; and charting. Both recipients and HCP prioritized HCP workload, and broader medication and health concerns. Healthcare providers preferred tech support; both recipients and HCPs preferred app access for nontransplant HCP.

Limitations:

Limitations include underrepresentation of physicians, recipients with racial/ethnic diversity, and potential selection bias of transplant recipients who perceived themselves to be adhering to immunosuppression medications.

Conclusion:

Future research is needed for the app to become a comprehensive, secure platform for broader communication between recipients and HCP, pharmacies, and nontransplant clinicians while streamlining HCP workload.

Identifying the Clinical and Histological Risk Factors affecting Post-Biopsy Voiding Efficiency: An Observational Closed Cohort Study

BACKGROUND

There is a variability in the reported rate of post-prostate biopsy voiding inefficiency. The burden and potential predictors of this morbidity is not well studied in African patients. This study aimed to evaluate the incidence as well as the clinical and histological factors affecting voiding function in patients undergoing trans-rectal prostate biopsy in an African population.

SUBJECTS, MATERIALS AND METHODS

An observational cohort study was carried out in 68 adult males, 40 years and above, scheduled for trans-rectal prostate biopsy for suspected prostate cancer. Those who could not void spontaneously, had either neurological conditions or were on drugs that could affect voiding, were excluded from the research. Data on demographic characteristics of the patients were collected. Uroflowmetry was done to obtain the peak urine flow rate of the patients at baseline and seven days after the procedure. The prostate volume was determined and the presence of other potential clinical and histological risk factors were recorded. The presence of other bleeding-related biopsy complications was also recorded. Statistical analysis was done using SPSS with a p-value of less than 0.05 reported as significant.

RESULTS

Voiding inefficiency was recorded in 28 (41.2%) of the patients with majority, 21 (75.0%), experiencing a five to nine-point decrease in their seventh day peak flow rate values. Post-biopsy haematuria occurred in 37 (54.4%) of the population. The presence of haematuria with blood clots was associated with a 10.9 times increased risk of voiding inefficiency after the procedure (p = 0.006).

CONCLUSION

About two in five patients developed post-prostate biopsy voiding inefficiency. Blood clot presence was independently. associated with the occurrence of this morbidity.

The influence of the site of drug administration on florfenicol pharmacokinetics in turkeys

Florfenicol is a broad-spectrum antibacterial drug used in the treatment of farm animals, including poultry. This drug is poorly soluble in water, therefore, administration in drinking water may lead to high variability of concentrations in treated individuals. The use of injection preparations, however, requires individual administration and may have a negative effect on the quality of the carcass. In addition, the renal portal system in birds may reduce the bioavailability of the drug administered in the caudofemoral region of the body. The aim of this study was to compare the pharmacokinetics of florfenicol in turkeys after a single intravenous, intramuscular, and subcutaneous administration at a dose of 15 mg/kg body weight. Additionally, to evaluate the effect of renal portal system on drug kinetics, the intramuscular administration was divided into pectoral and caudofemoral administration. The study showed that the area under the concentration-time curve (AUC) was similar regardless of the route of administration. The mean values for clearance and volume of distribution were 0.33 L/kg/h and 0.92 L/kg, respectively. The mean residence time (MRT) was 2.87 h for an intravenous bolus, while for the extravascular administrations it was approx. 5.5 h. The elimination half-life was approx. 4 h regardless of the route of administration. The maximum plasma concentration did not differ statistically between intramuscular (approx. 6.8 mg/L) and subcutaneous (8.2 mg/L) administrations, while the time to appear for this concentration was the longest for caudofemoral administration (1.5 h). The bioavailability was 88.64% for subcutaneous administration, 77.95% for pectoral administration and 85.30% for caudofemoral administration. Overall, all 3 routes of extravascular administration allowed for efficient drug absorption. There was no evidence of an influence of the renal portal system on the kinetic parameters of the drug administered to the lower extremities of the body.

A Research Protocol for Implementation and Evaluation of a Patient-Focused eHealth Intervention for Chronic Kidney Disease

Self-management in chronic kidney disease (CKD) can slow disease progression; however, there are few tools available to support patients with early CKD. My Kidneys My Health is a patient-focused electronic health (eHealth) self-management tool developed by patients and caregivers. This study will investigate the implementation of My Kidneys My Health across primary care and general nephrology clinics. The study aims to: (1) identify and address barriers and facilitators that may impact implementation and sustainability of the website into routine clinical care; (2) evaluate implementation quality to inform spread and scale-up. We will conduct a multi-stage approach using qualitative methods, guided by the Quality Implementation Framework and using a qualitative content analysis approach. First, we will identify perceived barriers and facilitators to implementation and considerations for sustainability through interviews with clinicians, based on the Readiness Thinking Tool and the Long Term Success Tool. Analysis will be guided by the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Appropriate implementation strategies will be identified using the Expert Recommendations for Implementing Change compilation, and implementation plans will be developed based on Proctor's recommendations and the Action, Actor, Context, Target, Time framework. Finally, we will explore implementation quality guided by the RE-AIM framework. There is limited literature describing systematic approaches to implementing and sustaining patient-focused self-management tools into clinical care, in addition to employing tailored implementation strategies to promote adoption and sustainability. We aim to generate insights on how My Kidneys My Health can be integrated into clinical care and how to sustain use of patient-centric eHealth tools in clinical settings on a larger scale.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-022-00038-3.

Development and Preliminary Psychometric Testing of an Adult Chronic Kidney Disease Self-Management (CKD-SM) Questionnaire

Background:

Self-management focused interventions to slow chronic kidney disease (CKD) progression are increasingly common. However, valid self-report instruments to evaluate the effectiveness of self-management interventions in CKD are limited.

Objective:

We sought to develop and conduct preliminary psychometric testing of a patient-informed questionnaire to assess aspects of CKD self-management for patients with CKD categories G2-G5 (not on kidney replacement therapy [KRT]).

Design:

Self-administered electronic questionnaires (multiphase).

Setting:

Online.

Sample:

Canadian adults with CKD categories G2-G5 (not on KRT)

Methods:

The CKD-SM questionnaire was developed and tested in 4 phases. First, we used a content coverage matrix to identify potential questionnaire items based on existing self-efficacy questionnaires, self-management theories, and patient-identified priorities. Second, the draft questionnaire was reviewed by a multidisciplinary expert panel using percent acceptance to finalize the questionnaire. Third, we tested an electronic version of the questionnaire with patients with CKD, evaluating preliminary psychometric properties including internal consistency, face validity, and content validity. Finally, we tested the questionnaire within a CKD self-management intervention study and collected data on internal consistency, test-retest reliability, and pre-post responsiveness.

Results:

We identified 22 potential questionnaire items for the first round of expert panel review. Thirteen items were retained in the first round. Eleven additional items were tested in the second review round and all were retained. Of the 24 items retained following expert review of the questionnaire, 21 had greater than 85% acceptance (content validity index [CVI], 0.75-1.00) and 3 items had 75% acceptance (CVI, 0.5). Thirty patients with CKD from across Canada participated in the pilot testing, and 29 patients participated in the CKD self-management intervention study. In the pilot test, several participants requested inclusion of a question that explicitly addressed mental health; consequently, an additional item relating to mental health was included prior to the intervention study (final questionnaire total was 25 items). Internal consistency (Cronbach α) was high for both the pilot (0.921) and intervention study (0.912). Preintervention test-retest reliability, measured with intraclass correlation coefficient, was acceptable (0.732, 95% confidence interval, 0.686-0.771, P < .001), and paired pre/postintervention comparison, measured with Wilcoxon sign-rank, demonstrated significant increases in self-management (P < .05) despite stable preintervention test-retest responses. Participants were satisfied with the content, wording, and design.

Limitations:

The sample sizes were small for each component of the analysis, and the sampling was consecutive/convenience-based.

Conclusions:

We used self-management theories, patient-identified self-management needs, expert review, and conducted preliminary psychometric testing to finalize a CKD self-management questionnaire for patients with G2-G5 CKD (not on KRT). The finalized questionnaire assesses aspects of self-management for individuals with CKD and may be particularly helpful as a tool to evaluate self-management interventions among patients with CKD.

Knowledge and Practice of Incremental Hemodialysis: A Survey of Canadian Nephrologists

BACKGROUND

Incremental hemodialysis, a strategy to individualize dialysis prescription based on residual kidney function, may be associated with enhanced quality of life and decreased health care costs compared with conventional hemodialysis.

OBJECTIVE

We surveyed practicing Canadian nephrologists to assess knowledge, perceptions, and practice pattern on the use of incremental hemodialysis.

DESIGN/SETTING

We distributed a cross-sectional, web-based survey. We asked about incremental hemodialysis prescribing practices, including frequency of prescription, clinical factors used to determine suitability for treatment, and barriers to implementation. The survey was conducted from September 21 to October 30, 2020.

PARTICIPANTS

We distributed the survey to practicing Canadian nephrologists identified from a private membership list of the Canadian Society of Nephrology (CSN), as well as to nephrologists named on a publicly available national list of practicing Canadian nephrologists created from provincial College of Physician registries. These were samples of convenience.

METHODS

We conducted descriptive analysis of categorical data including frequencies for nominal variables and measures of central tendency (mean) and dispersion (standard deviation) for ordinal variables. We used chi-square analysis to identify association between participant and practice characteristics and their opinions and attitudes toward incremental dialysis. We used simple thematic analysis on free-text responses on questions regarding the prescription of incremental hemodialysis, focusing on age and baseline management of cardiac and noncardiac comorbidities.

RESULTS

The response rate was 35% (243/691). Most (138/211, 65%) of the participants prescribed incremental hemodialysis using an individualized approach at the nephrologist's discretion. Most participants (200/203, 98%) did not report any policy for implementation. Residual urine output was identified as the most important factor for eligibility (112/172, 65%), followed by electrolyte stability (76/172, 44%) and patient goals of care (69/117, 40%). Most participants agreed that dialysis prescriptions should take residual kidney function into consideration; however, 74% of the participants disagreed with a statement that there was strong evidence supporting incremental hemodialysis. Barriers identified included patient safety, patient acceptance of dose escalation, and logistics of scheduling. Despite these barriers, 82% of participants felt that that incremental hemodialysis is feasible with their current resources and 78% agreed that with specific criteria, it is a safe option.

LIMITATIONS

The generalizability of our study is limited by its response rate of 35%; however, this is comparable with typical response rates seen in electronic surveys. Most participants practice in an academic setting, which may have introduced bias to the results.

CONCLUSIONS

Despite the perception of limited evidence and a lack of guidance on implementation, incremental hemodialysis is frequently practiced by Canadian nephrologists. Barriers to implementation were identified, highlighting the need for research to guide practice.

Evaluation of the responses of broiler chickens to varying concentrations of phytate phosphorus and phytase. Ⅱ. Grower phase (day 12-23 post hatching)

A randomized complete block design study used 768 male broiler chickens to investigate the effects of phytate P (PP) and a novel consensus bacterial phytase variant (PhyG) concentration on growth performance, bone mineralization, apparent ileal digestibility (AID), and total tract retention (TTR) of nutrients in broiler chickens. Treatments were arranged in a 1 + 3 × 5 factorial with a nutrient-adequate positive control diet (PC) with 2.8 g PP/kg, 3 nutrient-reduced negative control diets (NC: PC minus 88 kcal/kg ME, 0.8 g/kg dig. Lys, 2.0 g/kg available P, 2.0 g/kg Ca and 0.5 g/kg Na) with varying PP (g/kg) levels, mainly from rice bran, at 2.3 (NC1), 2.8 (NC2), or 3.3 (NC3) and 5 PhyG doses at 0, 500, 1,000, 2,000, or 4,000 FTU/kg. All treatments had 6 replicate cages with 8 birds/cage. A commercial starter diet was fed from d 0 to 12 and the experimental diets from d 12 to 23 post hatching. Birds fed the NC2 diet without phytase had lower (P < 0.01) BW, BW gain, and feed intake (FI) as compared with birds fed the PC with the same PP level. With increasing phytate, there was a decrease (P < 0.05) in BW, BW gain, and FI. Phytase increased (P < 0.01) BW and feed efficiency of broiler chickens. An interaction (P < 0.05) between PP and phytase concentrations was observed on the AID of Met, Cys, and Thr. Linear decrease (P < 0.01) in the AID and TTR of P and Ca with increasing PP concentrations were observed. Phytase supplementation increased (P ≤ 0.05) the AID of P, Ca, and all AA. The TTR of P, Ca, and Zn was linearly increased (P < 0.01) by 112, 123, and 46%, respectively, when birds fed NC diets with 0 and 4,000 FTU/kg were compared. In conclusion, phytate reduced the growth performance and nutrient utilization of broiler chickens from d 12 to 23 post hatching while phytase ameliorated these negative effects.

Effect of increasing dose level of a novel consensus bacterial 6-phytase variant on phytate degradation in broilers fed diets containing varied phytate levels

1. The effect of increasing the dose level of a novel consensus bacterial 6-phytase variant on apparent ileal digestibility (AID) of phosphorus (P), phytic acid (inositol hexa-phosphate, IP₆) and ileal IP₆ degradation profile was studied in diets containing varying phytate-P (PP) levels.2. Ross 308, one-day-old males (n=1,800) were allocated to cages (20 birds/cage, six cages/treatment) in a completely randomised design employing a 3 × 5 factorial arrangement (three PP levels: 2.45 (low) 2.95 (medium) and 3.45 g/kg (high); five dose levels of phytase (PhyG): 0, 500, 1,000, 2,000 and 4,000 FTU/kg). Phased diets were based on wheat, corn, soybean meal, rapeseed meal and rice bran (d 0 to 10; 2.60 g/kg digestible P, 7.6 g/kg calcium (Ca); d 11 to 21; 2.10 g/kg digestible P, 6.4 g/kg Ca). Ileal digesta was collected on d 21 for determination of P, IP₆ and IP-esters content. Data were analysed by factorial ANOVA; means separation was achieved using Tukey's HSD test.3. Increasing PP reduced AID of IP₆ and sum of IP_3-6 (%) (P<0.05) but absolute P-release (g/kg diet) above NC was increased (P<0.05) at high vs. low PP. Increasing phytase dose exponentially increased (P<0.001) AID IP_6, sum of IP_3-6 (%) and digestible IP_3-6-P g/kg diet (P<0.001). AID P was increased but there was an interaction with PP level (P<0.001). Ileal accumulation of IP_5-3-P was universally low with PhyG at ≥1,000 FTU/kg (<0.06 g/100g DM). At 2,000 and 4,000 FTU/kg, AID IP₆ was 97.2, 92.7, 92.6% and 100, 97.2, 97.1%, respectively, at low, medium and high PP. At 2,000 FTU/kg, phytate-P release estimated as the increase (above NC) in ileal digestible sum of IP_3-6-P in the diet was 2.26, 2.59 and 3.10 g/kg in low, medium and high PP, respectively.4. The data demonstrated that the novel phytase was effective in breaking down phytate to low IP-esters in diets with varied PP content but the optimal dose level for maximising P-release may differ in diets with varying PP content.

Online clinical pathway for chronic kidney disease management in primary care: a retrospective cohort study

BACKGROUND

Clinical pathways aim to improve patient care. We sought to determine whether an online chronic kidney disease (CKD) clinical pathway was associated with improvements in CKD management.

METHODS

We conducted a retrospective pre/post population-based cohort study using linked health data from Alberta, Canada. We included adults 18 years or older with mean estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2. The primary outcome was measurement of an outpatient urine albumin creatinine ratio (ACR) in a 28-day period, among people without a test in the prior year. Secondary outcomes included use of guideline-recommended drug therapies (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statins).

RESULTS

The study period spanned October 2010 to March 2017. There were 84 independent 28-day periods (53 pre, 31 post pathway implementation) including 345,058 adults. The population was predominantly female (56%) with median age 77 years; most had category 3A CKD (67%) and hypertension (82%). In adjusted segmented regression models, the increase in the rate of change of ACR testing was greatest in Calgary zone (adjusted OR 1.19 per year, 95% CI 1.16-1.21), where dissemination of the pathway was strongest; this increase was more pronounced in those without diabetes (adjusted OR 1.25 per year, 95% CI 1.21-1.29). Small improvements in guideline-concordant medication use were also observed.

CONCLUSIONS

Following implementation of an online CKD clinical pathway, improvements in ACR testing were evident in regions where the pathway was most actively used, particularly among individuals without diabetes.

Evaluation of the responses of broiler chickens to varying concentrations of phytate phosphorus and phytase. Ⅰ. Starter phase (day 1-11 post hatching)

Growth performance, tibia ash, apparent ileal digestibility (AID), and total tract retention (TTR) of nutrients responses of broiler chickens fed diets containing varying concentrations of phytate P (PP) and a novel consensus bacterial 6-phytase variant (PhyG) from d 1 to 11 post hatching were evaluated with 1,152 broiler chicks. Diets were a nutrient-adequate positive control diet (PC) with 2.8 g PP/kg or one of 15 nutrient-reduced negative control (NC: PC minus 88 kcal/kg ME, 0.8 g/kg dig. Lys, 2.0 g/kg available P, 1.8 g/kg Ca and 0.5 g/kg Na) diets with 3 PP (g/kg) levels, mainly from rice bran, at 2.3 (NC1), 2.8 (NC2), or 3.3 (NC3) and 5 PhyG supplementation at 0, 500, 1,000, 2,000, or 4,000 FTU/kg in a 1 + 3 × 5 factorial. All treatments had 6 replicate cages with 12 birds per cage. Despite comparable PP levels, birds fed the PC diet had greater (P ≤ 0.01) body weight (BW), feed intake (FI), tibia ash, AID of energy, AA, P, and Ca as compared with birds fed the NC2 without phytase. There was no interaction between PP and phytase for all responses. Increasing PP concentrations linearly decreased (P < 0.01) BW, FI, AID, and TTR of P and Ca. With phytase supplementation, there was a quadratic response (P < 0.05) in BW, FI, tibia ash, and a linear increase (P < 0.05) in the AID of energy, nitrogen, and all the measured AA. Increasing phytase dose from 0 to 4,000 FTU/kg increased (P < 0.01) AID of P and Ca by 88 and 18%, respectively. There was also a quadratic response (P ≤ 0.05) on TTR of P and Ca with increasing phytase dose. In conclusion, increasing levels of PP reduced growth performance and most nutrient utilization responses of broiler chickens while phytase supplementation positively impacted the responses of broiler chickens during d 1 to 11 post hatching.

Voicing Individual Concerns for Engagement in Hemodialysis (VOICE-HD): A Mixed Method, Randomized Pilot Trial of Digital Health in Dialysis Care Delivery

Background:

People receiving in-center hemodialysis (HD) have prioritized the need for more individualized health information and better communication with nephrologists. The most common setting for patient-nephrologist interactions is during the HD treatment, which is a time pressured setting that lacks privacy.

Objective:

To facilitate effective communication in the hemodialysis (HD) unit, we evaluated the usability of a web application (web app) from both the patient and physician perspective. The main aim of the web app was to support patients in prioritizing their dialysis concerns outside of the clinical HD encounter.

Design:

Mixed method, parallel arm, multi-site, pilot randomized controlled trial.

Setting:

Two outpatient Canadian HD centers.

Participants:

Adult patients receiving in-center HD and their attending nephrologists.

Methods:

Patients were randomized to either a web application or an active control (paper form) for logging concerns to be addressed at weekly encounters with the nephrologist over 8 weeks. Topics included: HD treatment, symptoms, modality, and medications. The primary outcome was usability, defined as effectiveness (engagement with the tool, frequency of submitted concerns, whether the concern was satisfactorily addressed) and satisfaction with the tool using a priori thresholds and explored in interviews with patients and nephrologists.

Results:

77 patients (30 women, median age 61, interquartile range [53,67], median 2 years [1,4] on dialysis) and 19 nephrologists (4 women, median age 46 [36,65]) were enrolled. Patient use of a digital device at baseline was low (20%). Engagement with the tool was 70% (web app) and 100% (paper) with a lower proportion of patients in the web app group submitting at least one concern over 8 weeks compared to the paper form group: 56.7% vs 87.9%. Weekly concerns were satisfactorily addressed in both groups and ≥70% of patients would continue to use the tools. For patients, both tools promoted preparation and participation in the encounter; however, only the web app facilitated greater privacy in relaying concerns. For most nephrologists, the tools were disruptive to their workflow and were perceived as unnecessary given existing processes and familiarity with patients. For future versions of the app, patients suggested more features to facilitate self-management and nephrologists suggested integration with health databases and multidisciplinary teams.

Limitations:

Tertiary setting may limit generalizability.

Conclusions:

Both tools promoted fundamental components of self-management; however, patients in the paper form group submitted concerns more often and this tool was easier to remember to use. Although modifications would likely enhance web app usability, successful future adoption is limited by physician acceptance.

Trial registration ClinicalTrials.gov NCT03605875

Effects of the in ovo injection of vitamin D3 and 25-hydroxyvitamin D3 in Ross 708 broilers subsequently challenged with coccidiosis. I. performance, meat yield and intestinal lesion incidence1,2,3

Effects of the in ovo administration of vitamin D₃ (D₃) and 25-hydroxyvitamin D₃ (25OHD₃) on broiler intestinal lesion incidence, performance and breast meat yield after a coccidiosis challenge were investigated. On each of 10 incubator tray levels, 10 Ross 708 broiler hatching eggs were randomly assigned to each of the following 5 in ovo injection treatments administrated at 18 d of incubation (doi): 1) noninjected; 2) diluent; diluent containing either 3) 2.4 μg D₃ (D₃), 4) 2.4 μg 25OHD₃ (25OHD₃), or 5) 2.4 μg D₃ + 2.4 μg 25OHD₃ (D₃+25OHD₃). A 50 μL solution volume was injected into each egg using an Inovoject multi-egg injector. Four male chicks were randomly assigned to each of 80 battery cages in each of 2 rooms. Half of the treatment-replicate cages (8) in each room were challenged with a 20× live coccidial vaccine at 14 d of age (doa). One randomly selected bird from each of 4 treatment-replicate cages was scored for coccidiosis lesions before and 2 wk after challenge. Mean BW, BW gain (BWG), feed intake, and feed conversion ratio were determined for all birds from 0 to 14, 15 to 28, and 29 to 41 doa. Carcass weight, and the absolute and relative (% of carcass weight) weights of carcass parts were determined in 3 birds per treatment-replicate cage at 42 doa. Hatchability of live embryonated injected eggs and hatch residue were not affected by treatment. Across challenge treatment, birds in the 25OHD₃ treatment group experienced an increase in BWG between 29 and 41 doa when compared to the D₃ or diluent-injected birds. Furthermore, pectoralis major muscle percentage tended (P = 0.059) to increase in birds belonging to the 25OHD₃ treatment in comparison to birds in the D₃ or diluent-injected treatments. These results indicate that regardless of challenge treatment, 2.4 μg of 25OHD₃ may increase the BWG and breast meat yield of birds relative to those that only received an injection of commercial diluent.

Workforce capacity for the care of patients with kidney failure across world countries and regions

INTRODUCTION

An effective workforce is essential for optimal care of all forms of chronic diseases. The objective of this study was to assess workforce capacity for kidney failure (KF) care across world countries and regions.

METHODS

Data were collected from published online sources and a survey was administered online to key stakeholders. All country-level data were analysed by International Society of Nephrology region and World Bank income classification.

RESULTS

The general healthcare workforce varies by income level: high-income countries have more healthcare workers per 10 000 population (physicians: 30.3; nursing personnel: 79.2; pharmacists: 7.2; surgeons: 3.5) than low-income countries (physicians: 0.9; nursing personnel: 5.0; pharmacists: 0.1; surgeons: 0.03). A total of 160 countries responded to survey questions pertaining to the workforce for the management of patients with KF. The physicians primarily responsible for providing care to patients with KF are nephrologists in 92% of countries. Global nephrologist density is 10.0 per million population (pmp) and nephrology trainee density is 1.4 pmp. High-income countries reported the highest densities of nephrologists and nephrology trainees (23.2 pmp and 3.8 pmp, respectively), whereas low-income countries reported the lowest densities (0.2 pmp and 0.1 pmp, respectively). Low-income countries were most likely to report shortages of all types of healthcare providers, including nephrologists, surgeons, radiologists and nurses.

CONCLUSIONS

Results from this global survey demonstrate critical shortages in workforce capacity to care for patients with KF across world countries and regions. National and international policies will be required to build a workforce capacity that can effectively address the growing burden of KF and deliver optimal care.

MO754THE INTERRELATIONSHIP BETWEEN FLUID OVERLOAD AND VASCULAR STIFFNESS IN HEMODIALYSIS PATIENTS: A SCOPING REVIEW

Background and Aims

Fluid overload and vascular stiffness are two independent predictors of cardiovascular events in hemodialysis (HD) patients. To date, observational and interventional studies that investigated the effect of inter- and intradialytic fluid overload changes on vascular stiffness in HD patients are very limited. We performed a scoping review to explore existing reports about effects of fluid overload on vascular stiffness in adults receiving HD treatment and to identify knowledge gaps for future research.

Method

We followed the framework originally developed by Arksey and O’Malley. We searched Medline, Embase, CINAHL, and Cochrane Database of systematic reviews from inception to October 29, 2019. References of review papers were screened for relevant studies not identified from the initial search until saturation is achieved.

Results

Of 666 eligible studies, nineteen studies met the inclusion criteria. These included clinical observational studies (n=16) and randomized controlled trials (n=3). In general, most of the identified studies had small sample size and short term of follow up. Studies use different definitions of fluid overload and vascular stiffness. Measures of relative fluid overload like the ratio of extracellular fluid/intracellular fluid, fluid overload/extracellular fluid, and/or extracellular fluid/total body fluid were used as a representative of fluid status. Pulse wave velocity and augmentation index were used interchangeably as vascular stiffness measures. The accumulated findings were inconsistent and inconclusive. There was no consensus whether intradialytic fluid volume changes affected vascular stiffness. In the majority of the observational studies, a decrease in pulse wave velocity or augmentation index correlated with a decrease in blood pressure after fluid correction by HD treatment. The randomized clinical trials used different methods and technologies for the correction of fluid overload, thereby, results were conflicting.

Conclusion

Current literature is insufficient to justify whether fluid overload changes have a direct effect on vascular stiffness in HD patients. The findings were conflicting which limits the comparisons of studies and generalization of findings. These knowledge gaps urge the need for further clinical studies to enhance the understanding and to improve the quality of research in this topic. This includes standardized definitions and methodologies as well as longer term of follow up.

Does industry funding differ between men and women in electrophysiology and devices research?

Funding Acknowledgements

Type of funding sources: None.

Background

A significant gender bias has been identified in cardiology. Industry funding may be important developing electrophysiology (EP) and devices research. Such funding leads to potential conflicts of interest (COI) which must be disclosed on research presentations. There is limited evidence whether the gender bias in cardiology extends to industry funding of research.

Purpose

To assess whether COI disclosures in EP and devices presentations at the ESC Annual Congress differ between men and women.

Methods

Recorded presentations from the Arrhythmia & Devices section of ESC Annual Congresses 2016-2020 were assessed. Presentations were excluded if the original presentation contained no slides, it was a panel discussion, it was a non-scientific presentation, or part of the presentation was missing. Presentations with multiple speakers were also excluded. Chi-squared and Mann-Whitney U tests were used to assess differences between groups for dichotomous and continuous data respectively.

Results

Of 1,153 presentations assessed, 999 were suitable for inclusion. Women made up 22% (n = 221) of presenters. There was no difference in whether COI declaration slides were missing between women (5.9%, n = 13) and men (7.6%, n = 56), p = 0.38. In those with COI disclosure slides (n = 927), women declared significantly lower median number of COIs (0, IQR 0-3) compared with men (2, IQR 0-8), p &lt; 0.0001. In contrast, women spent a greater time-per-word on their COI disclosure slides (250ms, IQR 125-375ms) compared with men (200ms, IQR 118-333ms), p &lt; 0.0001.

Conclusions

Women made up a minority of presenters in EP/devices talks at the ESC annual congress. Women were less likely to have COIs which may suggest that they are less likely to receive industry funding. Despite this, women spent a greater amount of time-per-word on their COI slides. The lower number of declared COIs in women highlights another potential area of gender bias in cardiology that needs further investigation so that it can be addressed.

Effects of the in ovo injection of vitamin D3 and 25-hydroxyvitamin D3 in Ross 708 broilers subsequently fed commercial or calcium and phosphorus-restricted diets. II. Immunity and small intestine morphology1,2,3

Effects of the in ovo injection of vitamin D₃ (D₃) and 25-hydroxyvitamin D₃ (25OHD₃) on the immunity and small intestine morphology of broilers fed calcium and phosphorus-restricted diets were investigated. At 18 d of incubation (doi), live embryonated Ross 708 broiler hatching eggs were in ovo-injected with a 50 μL solution of one of the following treatments using an Inovoject multiegg injector: 1) diluent (control); diluent containing either 2) 2.4 μg D₃; 3) 2.4 μg 25OHD₃; or 4) 2.4 μg D₃ + 2.4 μg 25OHD₃. At hatch, 18 randomly selected male broilers belonging to one of the 4 in ovo injection treatments were placed in each of 12 floor pens and were fed either a commercial diet or a diet restricted by 20% in calcium and available phosphorus (ReCaP) content for the starter, grower and finisher dietary phases. Concentrations of plasma IgG and IgM at 14 d of age (doa) and α-1-acid glycoprotein at 40 doa were determined. Bursa, liver, spleen, duodenum, jejunum, and ileum weights were recorded at 7, 14, and 40 doa and small intestine histology was evaluated at 14 and 40 doa. Blood and organ samples were randomly collected from 1 bird in each of the 6 replicate pens within each of the 8 (4 in ovo x 2 dietary) treatment groups. Plasma IgG levels were higher in 25OHD₃ than in diluent or D₃ in ovo-injected birds. At 14 doa, a higher jejunal villus length (VL) to crypt depth (CD) ratio (RVC) was observed in birds that were in ovo-injected with 25OHD₃ alone as compared to all other in ovo injection treatments. At 40 doa, ileal VL increased and jejunal CD decreased in commercial diet-fed birds compared to ReCaP diet-fed birds. In conclusion, the in ovo injection of 25OHD₃ alone increased the immune response and improved the small intestine morphology and subsequent nutrient uptake of Ross 708 broilers. However, a ReCaP diet was observed to be detrimental to their small intestine morphology.

Effects of the in ovo injection of vitamin D3 and 25-hydroxyvitamin D3 in Ross 708 broilers subsequently fed commercial or calcium and phosphorus-restricted diets. I. Performance, carcass characteristics, and incidence of woody breast myopathy1,2,3

Effects of the in ovo-injection of vitamin D₃ (D₃) and 25-hydroxyvitamin D₃ (25OHD₃) on broiler performance, carcass characteristics, and woody breast myopathy (WBM) incidence were investigated. Live embryonated Ross 708 broiler hatching eggs (2,880) were randomly assigned to one of the following in ovo injection treatments: (1) diluent (50 μL); diluent (50 μL) containing either (2) 2.4 μg D₃; (3) 2.4 μg 25OHD₃; or (4) 2.4 μg D₃ + 2.4 μg 25OHD₃. Eggs were injected at 18 d of incubation (doi) using an Inovoject multiegg injector. At hatch, 18 male chicks were randomly placed in each of 6 replicate pens belonging to each in ovo injection and, dietary treatment combination. Birds were fed either a commercial diet or a diet restricted in calcium and phosphorous (ReCaP) content by 20% for the starter, grower and finisher dietary phases. Broiler performance was determined in each dietary phase and breast muscle yield was also determined at 14 and 40 d of age (doa). At 41 and 46 doa, birds were processed for determination of WBM, carcass weight, and the absolute and relative (% of carcass weight) weights of various carcass parts. Compared to birds fed the commercial diet, birds fed ReCaP diets experienced a reduction in performance from 14 to 40 doa, in breast meat yield at 41 and 46 doa, and in WBM at 41 and 46 doa. At 14 and 40 doa, breast meat yield in birds that received an in ovo injection of 25OHD₃ alone was higher compared to birds that received diluent alone or a combination of D₃ and 25OHD₃. Lower WBM incidence in ReCaP-fed birds was associated with a lower breast weight. An increase in breast meat yield in response to 25OHD₃ alone may be due to improved immunity and small intestine morphology. However, further study is needed to determine the aforementioned effects.

Temporal Associations Among Body Mass Index, Fasting Insulin, and Systemic Inflammation: A Systematic Review and Meta-analysis

IMPORTANCE

Obesity is associated with a number of noncommunicable chronic diseases and is purported to cause premature death.

OBJECTIVE

To summarize evidence on the temporality of the association between higher body mass index (BMI) and 2 potential mediators: chronic inflammation and hyperinsulinemia.

DATA SOURCES

MEDLINE (1946 to August 20, 2019) and Embase (from 1974 to August 19, 2019) were searched, although only studies published in 2018 were included because of a high volume of results. The data analysis was conducted between January 2020 and October 2020.

STUDY SELECTION AND MEASURES

Longitudinal studies and randomized clinical trials that measured fasting insulin level and/or an inflammation marker and BMI with at least 3 commensurate time points were selected.

DATA EXTRACTION AND SYNTHESIS

Slopes of these markers were calculated between time points and standardized. Standardized slopes were meta-regressed in later periods (period 2) with standardized slopes in earlier periods (period 1). Evidence-based items potentially indicating risk of bias were assessed.

RESULTS

Of 1865 records, 60 eligible studies with 112 cohorts of 5603 participants were identified. Most standardized slopes were negative, meaning that participants in most studies experienced decreases in BMI, fasting insulin level, and C-reactive protein level. The association between period 1 fasting insulin level and period 2 BMI was positive and significant (β = 0.26; 95% CI, 0.13-0.38; I2 = 79%): for every unit of SD change in period 1 insulin level, there was an ensuing associated change in 0.26 units of SD in period 2 BMI. The association of period 1 fasting insulin level with period 2 BMI remained significant when period 1 C-reactive protein level was added to the model (β = 0.57; 95% CI, 0.27-0.86). In this bivariable model, period 1 C-reactive protein level was not significantly associated with period 2 BMI (β = -0.07; 95% CI, -0.42 to 0.29; I2 = 81%).

CONCLUSIONS AND RELEVANCE

In this meta-analysis, the finding of temporal sequencing (in which changes in fasting insulin level precede changes in weight) is not consistent with the assertion that obesity causes noncommunicable chronic diseases and premature death by increasing levels of fasting insulin.

A novel consensus bacterial 6-phytase variant completely replaced inorganic phosphate in broiler diets, maintaining growth performance and bone quality: data from two independent trials

Total replacement of dietary inorganic phosphate (Pi) by a novel consensus bacterial 6-phytase variant (PhyG) in phytate-rich diets (>0.3% phytate-P) was investigated in 2 trials using growth performance and bone quality as outcome measures. Both trials utilized a completely randomized design with 5 dietary treatments across 4 phases: starter (0-10 d), grower (10-21 d), finisher 1 (21-35 d), and finisher 2 (35-42 d). Treatments comprised a nutritionally adequate positive control (PC) diet containing monocalcium phosphate and 4 experimental diets (IPF1, IPF2, IPF3, and IPF4), all containing no added Pi and reduced in Ca by 0.2 to 0.3% units vs. PC. IPF1contained PhyG at 1,000 FTU/kg (all phases); IPF2 contained PhyG at 1,000 FTU/kg (all phases) and was additionally reduced in digestible AA, ME, and sodium (-0.2 to -0.4% points, -74 kcal/kg, -0.04% points, respectively, vs. PC); IPF3 contained PhyG at 3,000 FTU/kg in starter, 2,000 FTU/kg in grower, and 1,000 FTU/kg in finisher phases; and IPF4 contained xylanase (2,000 U/kg) and PhyG (2,000 FTU/kg in starter, 1,500 FTU/kg in grower, and 1,000 FTU/kg in finisher phases) and was additionally reduced in ME (-71 kcal/kg vs. PC). Ross 308 broilers were used (trial 1: n = 1,200 mixed sex; 24 birds per pen × 10 replicates; trial 2: n = 1,300 males; 26 birds × 10 replicates). During all phases in both trials, all IPF treatments maintained or improved BW, ADG, ADFI, FCR and BW-corrected FCRc and bone quality parameters vs. PC. vs. PC, treatment IPF3 increased ADG during starter phase (+10.8%) and reduced overall FCRc (-12 points, P < 0.05) in Trial 1, and increased overall ADG (+4.4%), day 35 and day 42 BW (+3.5%, +4.9%), and reduced overall FCRc (-11 points) in Trial 2 (P < 0.05). IPF4 produced equivalent performance to IPF3 (both trials). These are the first data to demonstrate total replacement of Pi by microbial phytase during an entire growth cycle in broiler diets.

Evidence-Based Decision-Making 2: Systematic Reviews and Meta-Analysis

The number of studies published in the biomedical literature has dramatically increased over the last few decades. This massive proliferation of literature makes clinical medicine increasingly complex, and information from multiple studies is often needed to inform a particular clinical decision. However, available studies often vary in their design, methodological quality, and population studied, and may define the research question of interest quite differently. This can make it challenging to synthesize the conclusions of multiple studies. In addition, since even highly cited trials may be challenged over time, clinical decision-making requires ongoing reconciliation of studies which provide different answers to the same question. Because it is often impractical for readers to track down and review all the primary studies, systematic reviews and meta-analyses are an important source of evidence on the diagnosis, prognosis and treatment of any given disease. This chapter summarizes methods for conducting and reading systematic reviews and meta-analyses, as well as describes potential advantages and disadvantages of these publications.

Kidney Transplantation in a Recipient with Positive RT-PCR for SARS-CoV-2

When it is safe to proceed with transplantation after coronavirus disease 2019 (COVID-19) infection is still unknown. We describe the clinical course and management of immunosuppression in a patient with positive real-time polymerase chain reaction (RT-PCR) for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in a nasopharyngeal swab at the time of kidney transplantation, and with positive antibodies for SARS-CoV-2. The patient had no complications and was discharged with a functioning graft.

Single-dose pharmacokinetics of BMS-986177/JNJ-70033093 in participants with mild or moderate hepatic impairment compared to healthy participants

Background

According to the scientific evidence accumulated to date (ie, genetic, epidemiological, preclinical, clinical), the modulation of Factor XI (FXI) function may provide a novel mechanism for systemic anticoagulation without increasing the risk of clinically significant bleeding in a variety of conditions predisposing patients to a high risk of thrombotic or bleeding events. BMS-986177/JNJ-70033093 (BMS-177/JNJ-3093) is a small molecule that inhibits the active form of FXI (FXIa) with high affinity and selectivity. Depending on the indication, BMS-177/JNJ-3093 may provide benefit to patients as add-on or potentially replacement therapy to the current standard of care antithrombotic agents. Patients with hepatic impairment may have an increased risk of bleeding when using existing antithrombotic agents and therefore may benefit from drugs with an improved safety profile.

Purpose

To assess the effect of mild or moderate hepatic impairment on the pharmacokinetic (PK) properties of BMS-177/JNJ-3093.

Methods

This was a multicenter, open-label, non-randomized, single-dose study. A single 60-mg oral dose of BMS-177/JNJ-3093 was administered to 9 participants with mild hepatic impairment (Child-Pugh class A), 8 participants with moderate hepatic impairment (Child-Pugh class B), and 9 healthy participants with normal hepatic function. Healthy participants were matched to participants with hepatic impairment in each Child-Pugh class with regard to body weight. To assess the effects of hepatic impairment on BMS-177/JNJ-3093 PK, an analysis of variance was performed on the natural log-transformed Cmax, AUC(INF), and AUC(0-T) with hepatic function group as a fixed effect.

Results

BMS-177/JNJ-3093 was well tolerated when administered as an oral dose of 60 mg in participants with mild or moderate hepatic impairment and healthy participants with normal hepatic function. There were no deaths, serious adverse events (AEs), severe AEs, bleeding AEs, or discontinuations due to an AE reported during the study. The geometric mean ratios (GMRs) (90% CI) comparing mild hepatic impairment to normal hepatic function were 1.180 (0.735, 1.895) and 1.168 (0.725, 1.882) for total BMS-177/JNJ-3093 maximum concentration (Cmax) and area under the curve from time 0 to infinity (AUC(INF)), respectively. The GMRs (90% CI) comparing moderate hepatic impairment to normal hepatic function were 1.140 (0.699, 1.857) and 0.996 (0.609, 1.628) for total BMS-177/JNJ-3093 Cmax and AUC(INF), respectively. Overall, levels of activated partial thromboplastin time (aPTT) increased in an exposure-related manner following single oral doses of 60 mg BMS-177/JNJ-3093 in all groups.

Conclusion

BMS-177/JNJ-3093 was well tolerated in the normal healthy participants and those with mild or moderate hepatic impairment. The observed changes indicate that a dose adjustment in these populations may not be necessary.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This work was sponsored by Bristol-Myers Squibb and Janssen Research & Development, LLC

Current Management Strategies of Chronic Kidney Disease in Resource-Limited Countries

The incidence and prevalence of chronic kidney disease (CKD) and kidney failure continues to increase worldwide, especially in resource-limited countries. Many countries in this category already have a massive burden of communicable diseases, as well as socio-economic and socio-demographic challenges. The rising CKD burden and exorbitant economic cost associated with treatment are mainly responsible for the alarming mortality rate associated with kidney disease in these regions. There is often poor risk factor (diabetes and hypertension) and CKD awareness in these countries and limited availability and affordability of treatment options. Given these observations, early disease detection and preventive measures remain the best options for disease management in resource-limited settings. Primary, secondary and tertiary preventive strategies need to be enhanced and should particularly include measures to increase awareness, regular assessment to detect hypertension, diabetes and albuminuria, options for early referral of identified patients to a nephrologist and options for conservative kidney management where kidney replacement therapies may not be available or indicated. Much is still needed to be done by governments in these regions, especially regarding healthcare funding, improving the primary healthcare systems and enhancing non-communicable disease detection and treatment programs as these will have effects on kidney care in these regions.

Improvement in the performance and inflammatory reaction of Ross 708 broilers in response to the in ovo injection of 25-hydroxyvitamin D3

The effects of the in ovo administration of vitamin D₃ (D₃) and its metabolite, 25-hydroxyvitamin D₃ (25OHD₃)_, on the performance, breast meat yield, and inflammatory responses of broilers fed commercial diets were investigated. Live embryonated Ross 708 broiler hatching eggs were randomly assigned to one of the following 5 in ovo injection treatments at 18 d of incubation: 1) noninjected; 2) diluent; diluent containing 3) 2.4-μg D₃, 4) 2.4-μg 25OHD₃, or 5) 2.4-μg D₃ + 2.4-μg 25OHD₃. A 50-μL solution volume of each prespecified treatment was injected into each egg using an Inovoject multiegg injector. At hatch, 18 male chicks were randomly assigned to each of 30 floor pens. The BW, BW gain, feed intake, and feed conversion ratio of the birds were determined in each dietary phase. At 14, 28, and 39 d of posthatch age (doa), plasma α-1-acid glycoprotein (AGP) levels in 1 bird in each of 6 replicate pens per treatment were determined at 14 and 39 doa. The pectoralis major and minor weights of those same birds were also determined. The remaining birds were processed at 43 doa, and the weights of their processing parts were determined. At 39 doa, the in ovo injection of 25OHD₃ alone decreased plasma AGP concentrations in comparison with the noninjected, diluent, and D₃-alone treatment groups. In addition, birds that received 25OHD₃ alone had a greater BW at 42 doa than birds in the noninjected, diluent, and D₃-alone treatment groups. At 39 and 43 doa, breast meat yield was increased in response to the in ovo injection of 25OHD₃ alone in comparison to all other treatments. These results indicate that the in ovo injection of 2.4 μg of 25OHD₃ resulted in an improvement in the performance and inflammatory responses of broilers. A reduction in the inflammatory response subsequent to the in ovo injection of 2.4 μg of 25OHD₃ may have led to an increase in broiler performance.

Effects of dietary calcium and available phosphorus levels and phytase supplementation on performance, bone mineral density, and serum biochemical bone markers in aged white egg-laying hens

Exogenous phytase supplementation increases P and Ca availability to allow for the dietary reductions without negative consequences on productivity or skeletal health. Effects of a Buttiauxella sp. phytase (BSP) supplemented in available P (avP)-reduced and Ca-reduced diets on performance, BW, eggshell quality, serum biochemical bone markers, and bone densitometry were evaluated in egg-laying hens from 68 to 78 wk of age. One hundred hens were fed 1 of 5 diets (n = 20/treatment), including a positive control (PC) with 0.35% avP and 3.5% Ca, and the PC moderately reduced in avP and Ca levels by 0.187 and 0.159% of the diet (by 53 and 4.5%), respectively, (NC1) or severely reduced by 0.231 and 0.275% of the diet (by 66 and 7.9%), respectively, (NC2). Other diets were the NC1 or NC2 supplemented with BSP at 600 FTU/kg (NC1 + BSP or NC2 + BSP, respectively). Egg production and feed conversion ratio were maintained by NC1 but were 11.9% lower and 12.3% higher, respectively, with the NC2 than the PC, which was alleviated by supplemental BSP. Diet effects on FI and eggshell quality followed a similar pattern. Body weight was 2.9% lower for NC1, and 6.1% for NC2 than the PC; BSP alleviated the decreased BW. Serum pyridinoline (bone resorption marker) was 20 to 27% higher in NC2 hens than in the other groups, with no effects on other bone markers. Total and trabecular space bone mineral density in the proximal metaphysis were 8.4 and 15.2% lower for NC1, respectively, and 12.1 and 26.7% lower for NC2, respectively, than PC. Supplemental BSP completely alleviated the decreased bone densitometry measures in NC1, but only partially in NC2. The NC1 hens maintained performance but had decreased BW and bone quality; phytase supplementation restored productivity, BW, and bone quality. The Ca and avP deficiencies in the NC2 hens relative to other groups were partially alleviated by the 600 FTU/kg BSP.

Effects of source and level of in ovo-injected vitamin D3 on the hatchability and serum 25-hydroxycholecalciferol concentrations of Ross 708 broilers

Effects of the in ovo injection of vitamin D3 (D3) and 25-hydroxycholecalciferol (25OHD3) on broiler embryo serum 25OHD3 concentrations, hatchability, and hatchling somatic characteristics were determined. Eggs from a 35-wk-old commercial Ross 708 broiler breeder flock were set in a single-stage incubator with 11 treatments represented on each of 8 incubator tray levels (blocks). Each treatment group within a flat on each tray level contained 30 eggs. Control treatments were noninjected and diluent injected. Vitamin treatments were commercial diluent containing 0.6 μg D3, 0.6 μg 25OHD3, 0.6 μg D3 + 0.6 μg 25OHD3, 1.2 μg D3, 1.2 μg 25OHD3, 1.2 μg D3 + 1.2 μg 25OHD3, 2.4 μg D3, 2.4 μg 25OHD3, or 2.4 μg D3 + 2.4 μg 25OHD3. At 432 h of incubation (hoi), 50-μL solution volumes were injected. Blood samples were collected at 462 hoi for serum 25OHD3 analysis, and hatchability of injected live embryonated eggs (HI) was determined at 492 and 516 hoi. At 516 hoi, hatchling yolk-free BW and weights of the liver and yolk sac were determined. Percentage of yolk moisture and dry mater was calculated. At 492 and 516 hoi, HI did not differ between treatments. Embryos that received 1.2 μg or more of either vitamin D3 source alone or in combination had higher serum 25OHD3 concentrations than those that were injected with diluent alone or diluent containing 0.6 μg of D3. Hatchlings that received 1.2 or 2.4 μg of 25OHD3 had higher percentage of yolk dry matter or lower percentage of yolk moisture levels than noninjected controls and those that received D3 alone at any level. These results indicate that the in ovo injection of either vitamin D3 source at levels equal to or higher than 1.2 μg resulted in serum 25OHD3 concentrations that were higher than that of noninjected controls. In addition, the in ovo injection of 1.2 μg or higher of either vitamin D3 source did not negatively affect broiler HI or chick quality.