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Li D, Hsu FC, Palmer ND, Liu L, Choi YA, Murea M, Parks JS, Bowden DW, Freedman BI, Ma L. Multi-omics Analyses Identify AKR1A1 as a Biomarker for Diabetic Kidney Disease. Diabetes 2024:db230540. [PMID: 38394643 DOI: 10.2337/db23-0540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
Diabetic kidney disease (DKD) is the leading cause of end-stage kidney disease. As many genes associate with DKD, multi-omics approaches were employed to narrow the list of functional genes, gene products and related pathways providing insights into the pathophysiological mechanisms of DKD. The Kidney Precision Medicine Project human kidney single-cell RNA-sequencing (scRNAseq) dataset and Mendeley Data on human kidney cortex biopsy proteomics were utilized. R package Seurat was used to analyze scRNAseq and subset proximal tubule cells. PathfindR was applied for pathway analysis in cell type-specific differentially expressed genes and R limma package was used to analyze differential protein expression in kidney cortex. A total of 790 differentially expressed genes were identified in proximal tubule cells, including 530 upregulated and 260 downregulated transcripts. Compared with differentially expressed proteins, 24 genes/proteins were in common. An integrated analysis combining protein quantitative trait loci (pQTL), GWAS hits (estimated glomerular filtration rate) and a plasma metabolomics analysis was performed using baseline metabolites predictive of DKD progression in our longitudinal Diabetes Heart Study samples. Aldo-keto reductase family 1 member A1 gene (AKR1A1) was revealed as a potential molecular hub for DKD cellular dysfunction in several cross-linked pathways featured by deficiency of this enzyme.
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Affiliation(s)
- DengFeng Li
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Fang-Chi Hsu
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Nicholette D Palmer
- Department of Biochemistry, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Liang Liu
- Bioinformatics Shared Resource, Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Young A Choi
- Department of Internal Medicine - Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Mariana Murea
- Department of Internal Medicine - Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - John S Parks
- Department of Molecular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Donald W Bowden
- Department of Biochemistry, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Barry I Freedman
- Department of Internal Medicine - Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Lijun Ma
- Department of Internal Medicine - Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC
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Casino DFG, Murea M, Floege MJ, Zoccali C. Incremental dialysis: two complementary views. Clin Kidney J 2024; 17:sfae020. [PMID: 38404364 PMCID: PMC10894032 DOI: 10.1093/ckj/sfae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Indexed: 02/27/2024] Open
Abstract
Franco Casino and Mariana Murea discuss today's knowledge about the 'incremental dialysis' concept. Franco Casino frames the problem by saying that, in the presence of substantial residual kidney function, kidney replacement therapy can begin with low doses and/or frequencies, to be gradually increased to compensate for any subsequent losses of residual kidney function, keeping the total clearance above the minimum levels of adequacy. He remarks that studies so far have documented that this approach is safe. He recognizes that adequate randomized controlled trials (RCTs) are necessary to confirm the safety and simplify and standardize the practical aspects of this approach. Mariana Murea objects that most of the evidence gathered so far primarily derives from retrospective and observational studies, which can be influenced by socioeconomic constraints. She argues for the need for RCTs to provide compelling empirical evidence on the efficacy of incremental dialysis. Nephrologists are still reluctant to adopt this approach for various reasons, including unfamiliarity with the method, lack of practical guidance and financial disincentives. Several countries have ongoing or planned RCTs comparing incremental dialysis with conventional dialysis. These trials can shift the haemodialysis paradigm if they validate the safety and effectiveness of this approach. The moderators believe that the results of ongoing trials must be carefully interpreted, and further validation may be needed across different patient populations or healthcare settings. The ultimate goal is to gather robust evidence that could lead to widespread adoption of incremental haemodialysis, optimizing treatment, reducing overtreatment, preserving resources and improving patients' quality of life.
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Affiliation(s)
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | - Carmine Zoccali
- Renal Research Institute NY, USA
- BIOGEM, Ariano Irpino, Italy
- IPNET, Reggio Cal, Italy
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Murea M, Allon M. The reasons for comparative effectiveness clinical trials of arteriovenous fistula versus graft strategy in older adults on hemodialysis with a catheter. Clin Nephrol 2023; 100:243-248. [PMID: 37877300 PMCID: PMC10795491 DOI: 10.5414/cn111227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/09/2023] [Indexed: 10/26/2023] Open
Abstract
Clinicians and patients are guided by observational studies to make one of the most consequential decisions for patients with advanced kidney disease: the selection of the "right" hemodialysis vascular access. More than a decade ago, a call for randomized clinical trials was made to equitably compare clinical outcomes between arteriovenous (AV) fistulas (AVFs) and AV grafts (AVGs). Mounting evidence suggests that trade-offs between AVF- and AVGrelated outcomes are context dependent. In this article, we summarize four streams of evidence that collectively underpin the burden of equipoise between the two types of AV access in older adults with comorbidities who are on hemodialysis with a central venous catheter.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, and
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Murea M, Sirich TL. The Hemodialysis Prescription: Past, Present, and Future. Kidney360 2023; 4:990-993. [PMID: 37257086 PMCID: PMC10371267 DOI: 10.34067/kid.0000000000000164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/04/2023] [Indexed: 06/02/2023]
Affiliation(s)
- Mariana Murea
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Tammy L. Sirich
- Department of Medicine, Stanford University, Palo Alto, California
- Department of Medicine, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
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Murea M, Lin E, Torreggiani M. On the path to individualizing care with incremental-start hemodialysis. J Nephrol 2023:10.1007/s40620-023-01689-7. [PMID: 37289367 DOI: 10.1007/s40620-023-01689-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1053, USA.
| | - Eugene Lin
- Department of Medicine, Division of Nephrology, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - Massimo Torreggiani
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037, Le Mans, France.
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Li D, Liu L, Murea M, Freedman BI, Ma L. Bioinformatics Analysis Reveals a Shared Pathway for Common Forms of Adult Nephrotic Syndrome. Kidney360 2023; 4:e515-e524. [PMID: 36763793 PMCID: PMC10278839 DOI: 10.34067/kid.0000000000000074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/20/2023] [Indexed: 02/12/2023]
Abstract
Key Points Dysregulation of the focal adhesion pathway is present in the three most common forms of glomerular disease, that is, Focal segmental glomerulosclerosis, membranous nephropathy, and minimal change disease. Zyxin is seen to be upregulated in the glomerular compartment of patients with the three most common forms of glomerular disease. Background Focal segmental glomerulosclerosis, membranous nephropathy, and minimal change disease are common causes of nephrotic syndrome. Although triggers for these diseases differ, disease progression may share common molecular mechanisms. The aim of this study was to investigate the presence of molecular pathways that are dysregulated across these glomerular diseases. Methods The gene expression dataset GSE200828 from the Nephrotic Syndrome Study Network study was obtained from the Gene Expression Omnibus database. R and Python packages, Cytoscape software, and online tools (DAVID and STRING) were used to identify core genes and topologically relevant nodes and molecular pathways. Single-cell RNA sequencing analysis was applied to identify the expression patterns of core genes across kidney cell types in glomerular compartments. Results A total of 1087 differentially expressed genes were identified, including 691 upregulated genes and 396 downregulated genes, which are common in all three forms of nephrotic syndrome compared with kidney donor controls (FDR P <0.01). A multiapproach bioinformatics analysis narrowed down to 28 similarly dysregulated genes across the three proteinuric glomerulopathies. The most topologically relevant nodes belonged to the adherens junction, focal adhesion, and cytoskeleton pathways, where zyxin covers all of those gene ontology terms. Conclusions We report that dysregulation of cell adhesion complexes was present in the three most common forms of glomerular disease. Zyxin could be a biomarker in all three common forms of nephrotic syndrome. If further functional studies confirm its role in their development, zyxin could be a potential therapeutic target.
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Affiliation(s)
- DengFeng Li
- Informatics and Analytics, The University of North Carolina at Greensboro, Greensboro, North Carolina
| | - Liang Liu
- Bioinformatics Shared Resource, Department of Cancer Biology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Mariana Murea
- Department of Internal Medicine—Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Barry I. Freedman
- Department of Internal Medicine—Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Lijun Ma
- Department of Internal Medicine—Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Murea M, Gardezi AI, Goldman MP, Hicks CW, Lee T, Middleton JP, Shingarev R, Vachharajani TJ, Woo K, Abdelnour LM, Bennett KM, Geetha D, Kirksey L, Southerland KW, Young CJ, Brown WM, Bahnson J, Chen H, Allon M. Study protocol of a randomized controlled trial of fistula vs. graft arteriovenous vascular access in older adults with end-stage kidney disease on hemodialysis: the AV access trial. BMC Nephrol 2023; 24:43. [PMID: 36829135 PMCID: PMC9960188 DOI: 10.1186/s12882-023-03086-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/13/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Treatment of end-stage kidney disease (ESKD) with hemodialysis requires surgical creation of an arteriovenous (AV) vascular access-fistula (AVF) or graft (AVG)-to avoid (or limit) the use of a central venous catheter (CVC). AVFs have long been considered the first-line vascular access option, with AVGs as second best. Recent studies have suggested that, in older adults, AVGs may be a better strategy than AVFs. Lacking evidence from well-powered randomized clinical trials, integration of these results into clinical decision making is challenging. The main objective of the AV Access Study is to compare, between the two types of AV access, clinical outcomes that are important to patients, physicians, and policy makers. METHODS This is a prospective, multicenter, randomized controlled trial in adults ≥ 60 years old receiving chronic hemodialysis via a CVC. Eligible participants must have co-existing cardiovascular disease, peripheral arterial disease, and/or diabetes mellitus; and vascular anatomy suitable for placement of either type of AV access. Participants are randomized, in a 1:1 ratio, to a strategy of AVG or AVF creation. An estimated 262 participants will be recruited across 7 healthcare systems, with average follow-up of 2 years. Questionnaires will be administered at baseline and semi-annually. The primary outcome is the rate of CVC-free days per 100 patient-days. The primary safety outcome is the cumulative incidence of vascular access (CVC or AV access)-related severe infections-defined as access infections that lead to hospitalization or death. Secondary outcomes include access-related healthcare costs and patients' experiences with vascular access care between the two treatment groups. DISCUSSION In the absence of studies using robust and unbiased research methodology to address vascular access care for hemodialysis patients, clinical decisions are limited to inferences from observational studies. The goal of the AV Access Study is to generate evidence to optimize vascular access care, based on objective, age-specific criteria, while incorporating goals of care and patient preference for vascular access type in clinical decision-making. TRIAL REGISTRATION This study is being conducted in accordance with the tenets of the Helsinki Declaration, and has been approved by the central institutional review board (IRB) of Wake Forest University Health Sciences (approval number: 00069593) and local IRB of each participating clinical center; and was registered on Nov 27, 2020, at ClinicalTrials.gov (NCT04646226).
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA. .,Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Ali I Gardezi
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mathew P Goldman
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston- Salem, NC, USA
| | - Caitlin W Hicks
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, 600 N Wolfe St, Halsted 668, Baltimore, MD, USA
| | - Timmy Lee
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Nephrology, Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - John P Middleton
- Division of Nephrology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Roman Shingarev
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Tushar J Vachharajani
- Department of Kidney Medicine, Glickman Urological & Kidney Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Karen Woo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Lama M Abdelnour
- Department of Medicine, Division of Nephrology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kyla M Bennett
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Kevin W Southerland
- Division of Vascular & Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Carlton J Young
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - William M Brown
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Judy Bahnson
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Haiying Chen
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael Allon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA. .,Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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8
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Murea M, Kalantar-Zadeh K. Starting chronic hemodialysis twice weekly: when less is more. Nephrol Dial Transplant 2022; 37:2297-2299. [PMID: 36083981 DOI: 10.1093/ndt/gfac261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Indexed: 12/31/2022] Open
Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, CA, USA.,Long Beach Veterans Affairs Healthcare System, Long Beach, CA, USA.,Dept Epidemiology, UCLA Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA.,The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
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Brastauskas IM, Patel N, German Z, Davis RP, Stafford JM, Edwards M, Murea M, Goldman MP. A Single-Center Experience with Forearm Arteriovenous Loop Grafts for Hemodialysis. Ann Vasc Surg 2022; 87:286-294. [PMID: 35817384 DOI: 10.1016/j.avsg.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/15/2022] [Accepted: 06/23/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Autogenous arteriovenous fistula (AVF) remains the standard of hemodialysis (HD) access; however, it cannot be reasonably obtained in all patients. For patients with contraindications to AVFs, prosthetic arteriovenous graft (AVG) remains an alternative. AVGs are plagued by high failure rates; however, there is a paucity of literature examining this. This study aims to examine a single-center review of outcomes of forearm loop AVGs in patients requiring HD access. METHODS A single institution, retrospective chart review was completed from 2012 to 2019, including demographics, end-stage renal disease etiology, brachial vessel diameters, and comorbidities. Logistic regression and Cox proportional hazard models were evaluated. Outcomes were defined as primary patency (time elapsed from graft creation until it was utilized as the patient's primary access), primary-assisted patency (time from primary access to intervention to maintain patency), and functional patency (time from graft placement until graft failure). Additionally, multinomial regression models were used to evaluate associations with categorical number of required interventions. RESULTS Ninety-eight patients [mean age 61.8 (13.9) years, 42.9% female] were identified as having brachial artery to brachial vein AVG creation during the study period, of which 75% achieved primary patency. Primary-assisted patency was 0.36 [standard error (SE) 0.07] at 6 months and 0.12 (SE 0.05) at 1 year. Functional patency was 0.75 (SE 0.07) at 6 months and 0.43 (SE 0.09) at 1 year. No association between preoperative vessel diameters and primary-assisted or functional patency was observed. Interestingly, there was a significant negative association between previous ipsilateral access and achievement of primary patency with a 60% decrease in odds of achieving primary patency in patients with previous ipsilateral access [odds ratio 0.4, 95% confidence interval (CI) 0.1-0.9, P = 0.03]. There was also noted to be a significant association between the presence of an ipsilateral catheter and increased risk of subsequent abandonment of the AVG (hazard ratio 2.6, 95% CI 1.1-5.8, P = 0.02). CONCLUSIONS Prosthetic forearm loop AVGs remain hindered in their utility as they show high rates of graft failure within a year of creation. A significant patient-specific factor leading to this was not clearly demonstrated. As guidelines change regarding the nature of dialysis access for patients on HD, these results draw into question the utility of prosthetic forearm loop grafts in patients requiring long-term HD access.
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Affiliation(s)
- Ian M Brastauskas
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC.
| | - Nimesh Patel
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Zachary German
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Ross P Davis
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Jeanette M Stafford
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Matthew Edwards
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Mariana Murea
- Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
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Murea M, Highland BR, Yang W, Dressler E, Russell GB. Patient-reported outcomes in a pilot clinical trial of twice-weekly hemodialysis start with adjuvant pharmacotherapy and transition to thrice-weekly hemodialysis vs conventional hemodialysis. BMC Nephrol 2022; 23:322. [PMID: 36167537 PMCID: PMC9513956 DOI: 10.1186/s12882-022-02946-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 09/13/2022] [Indexed: 11/24/2022] Open
Abstract
Background Physical and emotional symptoms are prevalent in patients with kidney-dysfunction requiring dialysis (KDRD) and the rigors of thrice-weekly hemodialysis (HD) may contribute to deteriorated health-related quality of life. Less intensive HD schedules might be associated with lower symptom and/or emotional burden. Methods The TWOPLUS Pilot study was an individually-randomized trial conducted at 14 dialysis units, with the primary goal to assess feasibility and safety. Patients with incident KDRD and residual kidney function were assigned to incremental HD start (twice-weekly HD for 6 weeks followed by thrice-weekly HD) vs conventional HD (thrice-weekly HD). In exploratory analyses, we compared the two treatment groups with respect to three patient-reported outcomes measures. We analyzed the change from baseline in the score on Dialysis Symptom Index (DSI, range 0–150), Generalized Anxiety Disorder-7 (GAD-7, range 0–21), and Patient Health Questionnaire-9 (PHQ-9, range 0–27) at 6 (n = 20 in each treatment group) and 12 weeks (n = 21); with lower scores denoting lower symptom burden. Analyses were adjusted for age, race, gender, baseline urine volume, diabetes mellitus, and malignancy. Participants’ views on the intervention were sought using a Patient Feedback Questionnaire (n = 14 in incremental and n = 15 in conventional group). Results The change from baseline to week 6 in estimated mean score (standard error; P value) in the incremental and conventional group was − 9.7 (4.8; P = 0.05) and − 13.8 (5.0; P = 0.009) for DSI; − 1.9 (1.0; P = 0.07) and − 1.5 (1.4; P = 0.31) for GAD-7; and − 2.5 (1.1; P = 0.03) and − 3.5 (1.5; P = 0.02) for PHQ-9, respectively. Corresponding changes from week 6 to week 12 were − 3.1 (3.2; P = 0.34) and − 2.4 (5.5; P = 0.67) in DSI score; 0.5 (0.6; P = 0.46) and 0.1 (0.6; P = 0.87) in GAD-7 score; and − 0.3 (0.6; P = 0.70) and − 0.5 (0.6; P = 0.47) in PHQ-9 score, respectively. Majority of respondents felt their healthcare was not jeopardized and expressed their motivation for study participation was to help advance the care of patients with KDRD. Conclusions This study suggests a possible mitigating effect of twice-weekly HD start on symptoms of anxiety and depression at transition from pre-dialysis to KDRD. Larger clinical trials are required to rigorously test clinically-matched incrementally-prescribed HD across diverse organizations and patient populations. Trial registration Registered at ClinicalTrials.gov with study identifier NCT03740048, registration date 14/11/2018. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02946-w.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1053, USA.
| | - Benjamin R Highland
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Wesley Yang
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Emily Dressler
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Gregory B Russell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
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11
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Murea M, Patel A, Highland BR, Yang W, Fletcher AJ, Kalantar-Zadeh K, Dressler E, Russell GB. Twice-Weekly Hemodialysis With Adjuvant Pharmacotherapy and Transition to Thrice-Weekly Hemodialysis: A Pilot Study. Am J Kidney Dis 2022; 80:227-240.e1. [PMID: 34933066 DOI: 10.1053/j.ajkd.2021.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/04/2021] [Indexed: 01/27/2023]
Abstract
RATIONALE & OBJECTIVE Thrice-weekly hemodialysis (HD) is the most common treatment modality for kidney failure in the United States. We conducted a pilot study to assess the feasibility and safety of incremental-start HD in patients beginning maintenance HD. STUDY DESIGN Pilot study. SETTING & PARTICIPANTS Adults with estimated glomerular filtration rate (eGFR) ≥5 mL/min/1.73 m2 and urine volume ≥500 mL/d beginning maintenance HD at 14 outpatient dialysis units. EXPOSURE Randomized allocation (1:1 ratio) to twice-weekly HD and adjuvant pharmacologic therapy for 6 weeks followed by thrice-weekly HD (incremental HD group) or thrice-weekly HD (conventional HD group). OUTCOME The primary outcome was feasibility. Secondary outcomes included changes in urine volume and solute clearance. RESULTS Of 77 patients invited to participate, 51 consented to do so, representing 66% of eligible patients. We randomized 23 patients to the incremental HD group and 25 patients to the conventional HD group. Protocol-based loop diuretics, sodium bicarbonate, and patiromer were prescribed to 100%, 39%, and 17% of patients on twice-weekly HD, respectively. At a mean follow-up of 281.9 days, participant adherence was 96% to the HD schedule (22 of 23 and 24 of 25 in the incremental and conventional groups, respectively) and 100% in both groups to serial timed urine collection. The incidence rate ratio for all-cause hospitalization was 0.31 (95% CI, 0.08-1.17); and 7 deaths were recorded (1 in the incremental and 6 in the conventional group). At week 24, the incremental HD group had lower declines in urine volume (a difference of 51.0 [95% CI, -0.7 to 102.8] percentage points) and in the averaged urea and creatinine clearances (a difference of 57.9 [95% CI, -22.6 to 138.4] percentage points). LIMITATIONS Small sample size, time-limited twice-weekly HD. CONCLUSIONS It is feasible to enroll patients beginning maintenance HD into a randomized study of incremental-start HD with adjuvant pharmacotherapy who adhere to the study protocol during follow-up. Larger multicenter clinical trials are indicated to determine the efficacy and safety of incremental HD with longer twice-weekly HD periods. FUNDING Funding was provided by Vifor Inc. TRIAL REGISTRATION Registered at ClinicalTrials.gov, identifier NCT03740048.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
| | - Ashish Patel
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Benjamin R Highland
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Wesley Yang
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Alison J Fletcher
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology Hypertension, and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California-Irvine, Orange, California; Long Beach Veterans Affairs Healthcare System, Long Beach, California
| | - Emily Dressler
- Department of Biostatistics and Data Science, Division of Public Health Sciences, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Gregory B Russell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
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12
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Rhee CM, Edwards D, Ahdoot RS, Burton JO, Conway PT, Fishbane S, Gallego D, Gallieni M, Gedney N, Hayashida G, Ingelfinger J, Kataoka-Yahiro M, Knight R, Kopple JD, Kumarsawami L, Lockwood MB, Murea M, Page V, Sanchez JE, Szepietowski JC, Lui SF, Kalantar-Zadeh K. Living Well With Kidney Disease and Effective Symptom Management: Consensus Conference Proceedings. Kidney Int Rep 2022; 7:1951-1963. [PMID: 36090498 PMCID: PMC9459054 DOI: 10.1016/j.ekir.2022.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/08/2022] [Accepted: 06/20/2022] [Indexed: 11/23/2022] Open
Abstract
Chronic kidney disease (CKD) confers a high burden of uremic symptoms that may be underrecognized, underdiagnosed, and undertreated. Unpleasant symptoms, such as CKD-associated pruritus and emotional/psychological distress, often occur within symptom clusters, and treating 1 symptom may potentially alleviate other symptoms in that cluster. The Living Well with Kidney Disease and Effective Symptom Management Consensus Conference convened health experts and leaders of kidney advocacy groups and kidney networks worldwide to discuss the effects of unpleasant symptoms related to CKD on the health and well-being of those affected, and to consider strategies for optimal symptom management. Optimizing symptom management is a cornerstone of conservative and preservative management which aim to prevent or delay dialysis initiation. In persons with kidney dysfunction requiring dialysis (KDRD), incremental transition to dialysis and home dialysis modalities offer personalized approaches. KDRD is proposed as the preferred term given the negative connotations of "failure" as a kidney descriptor, and the success stories in CKD journeys. Engaging persons with CKD to identify and prioritize their personal values and individual needs must be central to ensure their active participation in CKD management, including KDRD. Person-centered communication and care are required to ensure diversity, equity, and inclusion; education/awareness that considers the health literacy of persons with CKD; and shared decision-making among the person with CKD, care partners, and providers. By putting the needs of people with CKD, including effective symptom management, at the center of their treatment, CKD can be optimally treated in a way that aligns with their goals.
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Affiliation(s)
- Connie M. Rhee
- Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
| | - Dawn Edwards
- Forum of ESRD Networks Kidney Patient Advisory Council, New York, New York, USA
| | - Rebecca S. Ahdoot
- Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA
| | | | - Paul T. Conway
- American Association of Kidney Patients, Washington, USA
| | - Steven Fishbane
- Donald and Barbara Zucker School of Medicine at Hofstra / Northwell Health, Great Neck, New York, New York, USA
| | | | - Maurizio Gallieni
- Department of Biomedical and Clinical Sciences, Università di Milano, Milan, Italy
| | | | - Glen Hayashida
- National Kidney Foundation of Hawaii, Honolulu, Hawaii, USA
| | | | - Merle Kataoka-Yahiro
- University of Hawaii at Manoa, Nancy Atmospera-Walch School of Nursing, Honolulu, Hawaii, USA
| | - Richard Knight
- American Association of Kidney Patients, Washington, USA
| | | | | | - Mark B. Lockwood
- Department of Biobehavioral Nursing Science, University of Illinois at Chicago, College of Nursing, Chicago, Illinois, USA
| | - Mariana Murea
- Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Victoria Page
- National Kidney Foundation of Hawaii, Honolulu, Hawaii, USA
| | | | - Jacek C. Szepietowski
- Department of Dermatology, Venereology and Allergology, Medical University, Wroclaw, Poland
| | - Siu-Fai Lui
- Hong Kong Kidney Foundation, Hong Kong, China
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology Hypertension and Kidney Transplantation, University of California Irvine, Orange, California, USA,Tibor Rubin Veterans Affairs Long Beach Health Care Center, Long Beach, California, USA,Correspondence: Kamyar Kalantar-Zadeh, Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine School of Medicine, 333 City Boulevard West. Orange, California 92868, USA.
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13
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Murea M, Flythe JE, Anjay R, Emaad ARM, Gupta N, Kovach C, Vachharajani TJ, Kalantar-Zadeh K, Casino FG, Basile C. Kidney dysfunction requiring dialysis is a heterogeneous syndrome: we should treat it like one. Curr Opin Nephrol Hypertens 2022; 31:92-99. [PMID: 34846314 DOI: 10.1097/mnh.0000000000000754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Advanced kidney failure requiring dialysis, commonly labeled end-stage kidney disease or chronic kidney disease stage 5D, is a heterogeneous syndrome -a key reason that may explain why: treating advanced kidney dysfunction is challenging and many clinical trials involving patients on dialysis have failed, thus far. Treatment with dialytic techniques - of which maintenance thrice-weekly hemodialysis is most commonly used - is broadly named kidney 'replacement' therapy, a term that casts the perception of a priori abandonment of intrinsic kidney function and subsumes patients into a single, homogeneous group. RECENT FINDINGS Patients with advanced kidney failure necessitating dialytic therapy may have ongoing endogenous kidney function, and differ in their clinical manifestations and needs. Different terminology, for example, kidney dysfunction requiring dialysis (KDRD) with stages of progressive severity could better capture the range of phenotypes of patients who require kidney 'assistance' therapy. SUMMARY Classifying patients with KDRD based on objective, quantitative levels of endogenous kidney function, as well as patient-reported symptoms and quality of life, would facilitate hemodialysis prescriptions tailored to level of kidney dysfunction, clinical needs, and personal priorities. Such classification would encourage clinicians to move toward personalized, physiological, and adaptive approach to hemodialysis therapy.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem
| | - Jennifer E Flythe
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
| | - Rastogi Anjay
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Abdel-Rahman M Emaad
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
| | - Nupur Gupta
- Indiana University Health, Indianapolis, Indiana
| | - Cassandra Kovach
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Tushar J Vachharajani
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Francesco G Casino
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti
- Dialysis Centre SM2, Policoro, Italy
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14
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Murea M, Deira J, Kalantar-Zadeh K, Casino FG, Basile C. The spectrum of kidney dysfunction requiring chronic dialysis therapy: Implications for clinical practice and future clinical trials. Semin Dial 2021; 35:107-116. [PMID: 34643003 DOI: 10.1111/sdi.13027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/11/2021] [Accepted: 09/22/2021] [Indexed: 12/13/2022]
Abstract
Staging to capture kidney function and pathophysiologic processes according to severity is widely used in chronic kidney disease or acute kidney injury not requiring dialysis. Yet the diagnosis of "end-stage kidney disease" (ESKD) considers patients as a single homogeneous group, with negligible kidney function, in need of kidney replacement therapy. Herein, we review the evidence behind the heterogeneous nature of ESKD and discuss potential benefits of recasting the terminology used to describe advanced kidney dysfunction from a monolithic entity to a disease with stages of ascending severity. We consider kidney assistance therapy in lieu of kidney replacement therapy to better reconcile all available types of therapy for advanced kidney failure including dietary intervention, kidney transplantation, and dialysis therapy at varied schedules. The lexicon "kidney dysfunction requiring dialysis" (KDRD) with stages of ascending severity based on levels of residual kidney function (RKF)-that is, renal urea clearance-and manifestations related to uremia, fluid status, and other abnormalities is discussed. Subtyping KDRD by levels of RKF could advance dialysis therapy as a form of kidney assistance therapy adjusted based on RKF and clinical symptoms. We focus on intermittent hemodialysis and underscore the need to personalize dialysis treatments and improve characterization of patients included in clinical trials.
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Affiliation(s)
- Mariana Murea
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California Irvine, Orange, California, USA
| | - Francesco G Casino
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy.,Dialysis Centre SM2, Policoro, Italy
| | - Carlo Basile
- Clinical Research Branch, Division of Nephrology, Miulli General Hospital, Acquaviva delle Fonti, Italy
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15
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Abstract
Shared decision-making (SDM) is a process of collaborative deliberation in the dyadic patient-physician interaction whereby physicians inform the patients about the pros and cons of all available treatment options and reach an agreement with the patients on their preferred treatment plan. In hemodialysis vascular access practice, SDM advocates a deliberative approach based on the existence of reasonable alternatives-that is, arteriovenous fistula, arteriovenous graft, and central venous catheter-so that patients are able to form and share preferences about access options. In spite of its ethical imperative, SDM is not broadly applied in hemodialysis vascular access planning. Physicians and surgeons commonly deliver prescriptive fistula-centered recommendations concerning the approach to vascular access care. This paternalistic approach has been shaped by directions from long-held clinical practice guidelines and is reinforced by financial payment models linked with the prevalence of arteriovenous fistula in patients on hemodialysis. Awareness is growing that what may have initially seemed a medically and surgically appropriate approach might not always be focused on each individual's goals of care. Clinician's recommendations for vascular access often do not sufficiently consider the uncertainty surrounding the potential benefits of the decision or the cumulative impact of the decision on patient's quality of life. In the evolving health care landscape, it is time for the practice of hemodialysis vascular access to shift from a hierarchical doctor-patient approach to patient-centered care. In this article we review the current state of vascular access practice, present arguments why SDM is necessary in vascular access planning, review barriers and potential solutions to SDM implementation, and discuss future research contingent on an effective system of physician-patient participative decision-making in hemodialysis vascular access practice.
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Affiliation(s)
- Mariana Murea
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
| | - Carl R Grey
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Charmaine E Lok
- Department of Medicine, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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16
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Murea M, Woo K. New Frontiers in Vascular Access Practice: From Standardized to Patient-tailored Care and Shared Decision Making. Kidney360 2021; 2:1380-1389. [PMID: 35369664 PMCID: PMC8676387 DOI: 10.34067/kid.0002882021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/07/2021] [Indexed: 02/04/2023]
Abstract
Vascular access planning is critical in the management of patients with advanced kidney disease who elect for hemodialysis for RRT. Policies put in place more than two decades ago attempted to standardize vascular access care around the model of optimal, namely arteriovenous fistula, and least preferred, namely central venous catheter, type of access. This homogenized approach to vascular access care emerged ineffective in the increasingly heterogeneous and complex dialysis population. The most recent vascular access guidelines acknowledge the limitations of standardized care and encourage tailoring vascular access care on the basis of patient and disease characteristics. In this article, we discuss available literature in support of patient-tailored access care on the basis of differences in vascular access outcomes by biologic and social factors-age, sex, and race. Further, we draw attention to the overlooked dimension of patient-reported preferences and shared decision making in the practice of vascular access planning. We discuss milestones to overcome as requisite steps to implement effective shared decision making in vascular access care. Finally, we take into consideration local practice cofactors as major players in vascular access fate. We conclude that a personalized approach to hemodialysis vascular access will require dynamic care specifically relevant to the individual on the basis of biologic factors, fluctuating clinical needs, values, and preferences.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Karen Woo
- Department of Surgery, University of California Los Angeles, Los Angeles, California
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17
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Murea M, Moossavi S, Fletcher AJ, Jones DN, Sheikh HI, Russell G, Kalantar-Zadeh K. Renal replacement treatment initiation with twice-weekly versus thrice-weekly haemodialysis in patients with incident dialysis-dependent kidney disease: rationale and design of the TWOPLUS pilot clinical trial. BMJ Open 2021; 11:e047596. [PMID: 34031117 PMCID: PMC8149445 DOI: 10.1136/bmjopen-2020-047596] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/23/2021] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The optimal haemodialysis (HD) prescription-frequency and dose-for patients with incident dialysis-dependent kidney disease (DDKD) and substantial residual kidney function (RKF)-that is, renal urea clearance ≥2 mL/min/1.73 m2 and urine volume ≥500 mL/day-is not known. The aim of the present study is to test the feasibility and safety of a simple, reliable prescription of incremental HD in patients with incident DDKD and RKF. METHODS AND ANALYSIS This parallel-group, open-label randomised pilot trial will enrol 50 patients from 14 outpatient dialysis units. Participants will be randomised (1:1) to receive twice-weekly HD with adjuvant pharmacological therapy for 6 weeks followed by thrice-weekly HD (incremental HD group) or outright thrice-weekly HD (standard HD group). Age ≥18 years, chronic kidney disease progressing to DDKD and urine output ≥500 mL/day are key inclusion criteria; patients with left ventricular ejection fraction <30% and acute kidney injury requiring dialysis will be excluded. Adjuvant pharmacological therapy (ie, effective diuretic regimen, patiromer and sodium bicarbonate) will complement twice-weekly HD. The primary feasibility end points are recruitment rate, adherence to the assigned HD regimen, adherence to serial timed urine collections and treatment contamination. Incidence rate of clinically significant volume overload and metabolic imbalances in the first 3 months after randomisation will be used to assess intervention safety. ETHICS AND DISSEMINATION The study has been reviewed and approved by the Institutional Review Board of Wake Forest School of Medicine in North Carolina, USA. Patient recruitment began on 14 June 2019, was paused between 13 March 2020 and 31 May 2020 due to COVID-19 pandemic, resumed on 01 June 2020 and will last until the required sample size has been attained. Participants will be followed in usual care fashion for a minimum of 6 months from last individual enrolled. All regulations and measures of ethics and confidentiality are handled in accordance with the Declaration of Helsinki. TRIAL REGISTRATION NUMBER NCT03740048; Pre-results.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Shahriar Moossavi
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alison J Fletcher
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Deanna N Jones
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Hiba I Sheikh
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Gregory Russell
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, University of California Irvine School of Medicine, Irvine, California, USA
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18
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Robinson T, Geary RL, Davis RP, Hurie JB, Williams TK, Velazquez-Ramirez G, Moossavi S, Chen H, Murea M. Arteriovenous Fistula Versus Graft Access Strategy in Older Adults Receiving Hemodialysis: A Pilot Randomized Trial. Kidney Med 2021; 3:248-256.e1. [PMID: 33851120 PMCID: PMC8039401 DOI: 10.1016/j.xkme.2020.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background It is unclear whether surgical placement of an arteriovenous (AV) fistula (AVF) confers substantial clinical benefits over an AV graft (AVG) in older adults with end-stage kidney disease (ESKD). We report vascular access outcomes of a pilot clinical trial. Study Design Pilot randomized parallel-group open-label trial. Setting & Participants Patients 65 years and older with ESKD and no prior AV access receiving maintenance hemodialysis through a tunneled central venous catheter referred for AV access placement by their treating nephrologist. Intervention Participants were randomly assigned in a 1:1 ratio to surgical placement of an AVG or AVF. Outcomes Index AV access primary failure, successful cannulation, adjuvant interventions and infections. Results Of 122 older adults receiving hemodialysis and no prior AV access surgery, 24% died before (n = 18) or were too sick for (n = 11) referral for a permanent AV access. Of 46 eligible patients, 36 (78%) consented and were randomly assigned to AVG (n = 18) and AVF (n = 18) placement, of whom 13 (72%) and 16 (89%) underwent index AV access surgical placement, respectively. At a median follow-up of 321.0 days, primary AV access failure was noted in 31% in each group. The proportion of patients with successful cannulation was 62% (8 of 13) in the AVG and 50% (8 of 16) in the AVF group; median times to successful cannulation were 75.0 and 113.5 days, respectively. Endovascular procedures were recorded in 38% and 44%, and surgical reinterventions, in 23% and 25%, respectively. AV access infection was seen in 3 (23%) and 2 (13%) patients, respectively. Limitations Small sample size precludes statistical inference. Conclusions Almost one-quarter of older adults with incident ESKD and a central venous catheter as primary access were not referred for AV access placement due to medical reasons. Based on these limited results, there is little reason to favor either an AVF or AVG in this population until results from a larger randomized clinical trial become available. Funding Government funding to an author (Dr Murea is supported by National Institutes of Health∖National Institute on Aging grant 1R03 AG060178-01). Trial Registration NCT03545113.
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Affiliation(s)
- Todd Robinson
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Randolph L Geary
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ross P Davis
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Justin B Hurie
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Timothy K Williams
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Shahriar Moossavi
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Haiying Chen
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Mariana Murea
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
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19
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Abstract
PURPOSE OF REVIEW Conventional standardization of haemodialysis for treatment of end-stage kidney disease (ESKD) is predicated upon the fixed construct of one disease stage and one patient category. Increasingly recognized are subgroups of patients for whom less-intensive haemodialysis, such as incremental or decremental haemodialysis, could be employed. RECENT FINDINGS Almost 30% of patients with incident ESKD have clinical and residual kidney function (RFK) parameters that could accommodate less-intensive haemodialysis. In one study, patients with incident ESKD and substantial RKF treated with low-dose haemodialysis had similar mortality rate as those treated with standard-dose haemodialysis, adding to the evidence that endogenous kidney function -- when present -- can complement less-intensive haemodialysis schedules. Hazards related to incremental haemodialysis include insidious development of fluid overload and higher rates of fluid removal. Finally, deintensification of haemodialysis treatment could be employed in patients with ESKD who seek conservative care. SUMMARY A shift in approach to ESKD from a dichotomous frame -- disease presence versus absence -- to stages of dialysis-dependent kidney disease, each stage associated with attuned haemodialysis intensity, has been proposed. Haemodialysis standardization and personalization -- often considered mutually exclusive -- can be combined in incremental haemodialysis. Data from ongoing and future randomized clinical trials, comparing less-intensive with standard haemodialysis schedules, are required to change practice.
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Affiliation(s)
- Mariana Murea
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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20
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Ma L, Palmer ND, Choi YA, Murea M, Snipes JA, Parks JS, Langefeld CD, Freedman BI. APOL1 Risk Variants Impair Multiple Mitochondrial Pathways in a Metabolomics Analysis. Kidney360 2020; 1:1353-1362. [PMID: 35372896 PMCID: PMC8815529 DOI: 10.34067/kid.0003592020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/29/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND Kidney risk variants (KRVs) in the APOL1 gene are associated with mitochondrial dysfunction. However, the molecular spectrum of metabolites affected by the G1 and G2 KRVs, and the downstream mitochondrial pathways they affect, remain unknown. METHODS We performed a metabolomics analysis using HEK293 Tet-on cells conditionally expressing APOL1 G0, G1, and G2 KRVs to determine the patterns of metabolites and pathways potentially involved in nephropathy. The Welch two-sample t test, matched-pairs t test, and two-way repeated measures ANOVA were used to identify differential metabolites. Random forest, a supervised classification algorithm that uses an ensemble of decision trees, and the mean-decrease-accuracy metric were applied to prioritize top metabolites. RESULTS Alterations in the tricarboxylic acid cycle, increased fatty acid oxidation, and compromised redox homeostasis were the major pathways affected by overexpression of APOL1 KRVs. CONCLUSIONS Impairment of mitochondrial membrane respiratory chain complex I appeared to account for critical metabolic consequences of APOL1 KRVs. This finding supports depletion of the mitochondrial membrane potential, as has been reported.
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Affiliation(s)
- Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicholette D. Palmer
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Young A Choi
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James A. Snipes
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - John S. Parks
- Department of Internal Medicine, Section on Molecular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Carl D. Langefeld
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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21
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Affiliation(s)
- Mariana Murea
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine, Orange, California
- Long Beach Veterans Affairs Healthcare System, Long Beach, California
- Department of Epidemiology, University of California Los Angeles Fielding School of Public Health, University of California, Los Angeles, California
- The Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles Medical Center, Torrance, California
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22
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Claudel SE, Miles LA, Murea M. Anticoagulation in hemodialysis: A narrative review. Semin Dial 2020; 34:103-115. [PMID: 33135208 DOI: 10.1111/sdi.12932] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/28/2020] [Accepted: 10/11/2020] [Indexed: 12/18/2022]
Abstract
Systemic anticoagulation in maintenance hemodialysis (HD) has historically been considered necessary to maintain the extracorporeal circuit (ECC) and preserve dialysis efficiency. Unfractionated heparin (UFH) is the most commonly used anticoagulant due to low cost and staff familiarity. Despite widespread use, there is little standardization of heparin dosing protocols in the United States. Although the complication rates with UFH are low for the general population, certain contraindications have led to exploration in alternative anticoagulants in patients with end-stage kidney disease (ESKD). Here we review the current evidence regarding heparin dosing protocols, complications associated with heparin use, and discuss alternatives to UFH including anticoagulant-free routine HD.
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Affiliation(s)
- Sophie E Claudel
- Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Lauren A Miles
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Gabbard J, McLouth CJ, Brenes G, Claudel S, Ongchuan S, Burkart J, Pajewski N, Callahan KE, Williamson JD, Murea M. Rapid Electronic Capturing of Patient-Reported Outcome Measures in Older Adults With End-Stage Renal Disease: A Feasibility Study. Am J Hosp Palliat Care 2020; 38:432-440. [PMID: 32935548 DOI: 10.1177/1049909120954805] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) have a high burden of physical and psychological symptoms. Many remain unrecognized for long periods of time, particularly in older adults. The best strategy to monitor patient-reported outcome measures (PROMs) has not been identified. OBJECTIVE To assess the feasibility of implementing an iPad-based symptom assessment tool in older adults with ESRD on hemodialysis (HD). METHODS We designed an iPad application-delivery system for collecting electronic PROMs (ePROMs). Patient's ≥60 years of age with ESRD on HD were recruited from a single outpatient dialysis unit. Feasibility was evaluated based on recruitment, retention, and the system usability score (SUS). Assessments were completed at baseline, 3 months, and 6 months after enrollment. ANOVA was used to assess longitudinal symptom variability. RESULTS Twenty-two patients (49% recruitment rate) were enrolled, with an 82% retention at 6 months. Mean age was 69.4 years (SD 6.6), 63.6% were female, and 81.8% were African American. Participants reported minimal difficulty in using the app, with an overall SUS score of 77.6. There were no significant relationships between demographic characteristics (age, race, or education) and SUS. Baseline SF-12 physical score and SF-12 mental score were 40.4 (SD 9.1) and 33.9 (SD 6.7), respectively. No significant changes were seen in longitudinal ePROMs of pain, depression, or anxiety; but was seen in the dialysis symptom index. CONCLUSION In older patients with ESRD, collection of iPad-based ePROMs is feasible. This process can overcome inefficiencies associated with paper questionnaires and enable systematic monitoring of symptom burden.
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Affiliation(s)
- Jennifer Gabbard
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA.,Center for Health Care Innovation, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Christopher J McLouth
- Department of Behavioral Science, 12252University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Gretchen Brenes
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Sophie Claudel
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Samantha Ongchuan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - John Burkart
- Section on Nephrology, Department of Internal Medicine, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Nicholas Pajewski
- Center for Health Care Innovation, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA.,Division of Public Health Sciences, Department of Biostatistics and Data Science, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kathryn E Callahan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA.,Center for Health Care Innovation, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jeff D Williamson
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA.,Center for Health Care Innovation, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mariana Murea
- Section on Nephrology, Department of Internal Medicine, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
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Li D, Snipes JA, Murea M, Molina AJA, Divers J, Freedman BI, Ma L, Petrovic S. An Acidic Environment Induces APOL1-Associated Mitochondrial Fragmentation. Am J Nephrol 2020; 51:695-704. [PMID: 32866949 DOI: 10.1159/000509989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Apolipoprotein L1 gene (APOL1) G1 and G2 kidney-risk variants (KRVs) cause CKD in African Americans, inducing mitochondrial dysfunction. Modifying factors are required, because a minority of individuals with APOL1 high-risk genotypes develop nephropathy. Given that APOL1 function is pH-sensitive and the pH of the kidney interstitium is <7, we hypothesized the acidic kidney interstitium may facilitate APOL1 KRV-induced mitochondrial dysfunction. METHODS Human embryonic kidney (HEK293) cells conditionally expressing empty vector (EV), APOL1-reference G0, and G1 or G2 KRVs were incubated in media pH 6.8 or 7.4 for 4, 6, or 8 h. Genotype-specific pH effects on mitochondrial length (µm) were assessed using confocal microscopy in live cells and Fiji derivative of ImageJ software with MiNA plug-in. Lower mitochondrial length indicated fragmentation and early dysfunction. RESULTS After 6 h doxycycline (Dox) induction in pH 6.8 media, G2-expressing cells had shorter mitochondria (6.54 ± 0.40) than cells expressing EV (7.65 ± 0.72, p = 0.02) or G0 (7.46 ± 0.31, p = 0.003). After 8 h Dox induction in pH 6.8 media, both G1- (6.21 ± 0.26) and G2-expressing cells had shorter mitochondria (6.46 ± 0.34) than cells expressing EV (7.13 ± 0.32, p = 0.002 and p = 0.008, respectively) or G0 (7.22 ± 0.45, p = 0.003 and p = 0.01, respectively). Mitochondrial length in cells incubated in pH 7.4 media were comparable after 8 h Dox induction regardless of genotype. APOL1 mRNA expression and cell viability were comparable regardless of pH or genotype after 8 h Dox induction. CONCLUSION Acidic pH facilitates early mitochondrial dysfunction induced by APOL1 G1 and G2 KRVs in HEK293 cells. We propose that the acidic kidney interstitium may play a role in APOL1-mediated mitochondrial pathophysiology and nephropathy.
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Affiliation(s)
- DengFeng Li
- Department of Biology, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - James A Snipes
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anthony J A Molina
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jasmin Divers
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA,
| | - Snezana Petrovic
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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25
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Murea M, Geary RL, Houston DK, Edwards MS, Robinson TW, Davis RP, Hurie JB, Williams TK, Velazquez-Ramirez G, Bagwell B, Tuttle AB, Moossavi S, Rocco MV, Freedman BI, Williamson JD, Chen H, Divers J. A randomized pilot study to evaluate graft versus fistula vascular access strategy in older patients with advanced kidney disease: results of a feasibility study. Pilot Feasibility Stud 2020; 6:86. [PMID: 32551134 PMCID: PMC7298797 DOI: 10.1186/s40814-020-00619-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/24/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Although older adults encompass almost half of patients with advanced chronic kidney disease, it remains unclear which long-term hemodialysis vascular access type, arteriovenous fistula or arteriovenous graft, is optimal with respect to effectiveness and patient satisfaction. Clinical outcomes based on the initial AV access type have not been evaluated in randomized controlled trials. This pilot study tested the feasibility of randomizing older adults with advanced kidney disease to initial arteriovenous fistula versus graft vascular access surgery. METHODS Patients 65 years or older with pre-dialysis chronic kidney disease or incident end-stage kidney disease and no prior arteriovenous vascular access intervention were randomized in a 1:1 ratio to undergo surgical placement of a fistula or a graft after providing informed consent. Trial feasibility was evaluated as (i) recruitment of ≥ 70% of eligible participants, (ii) ≥ 50 to 70% of participants undergo placement of index arteriovenous access within 90 to 180 days of enrollment, respectively, (iii) ≥ 80% adherence to study-related assessments, and (iv) ≥ 70% of participants who underwent index arteriovenous access placement will have a follow-up duration of ≥ 12 months after index surgery date. RESULTS Between September 2018 and October 2019, 81% (44/54) of eligible participants consented and were enrolled in the study; 11 had pre-dialysis chronic kidney disease, and 33 had incident or prevalent end-stage kidney disease. After randomization, 100% (21/21) assigned to arteriovenous fistula surgery and 78% (18/23) assigned to arteriovenous graft surgery underwent index arteriovenous access placement within a median (1st, 3rd quartile) of 5.0 (1.0, 14.0) days and 13.0 (5.0, 44.3) days, respectively, after referral to vascular surgery. The completion rates for study-specific assessments ranged between 40.0 and 88.6%. At median follow-up of 215.0 days, 5 participants expired, 7 completed 12 months of follow-up, and 29 are actively being followed. Assessments of grip strength, functional independence, and vascular access satisfaction were completed by > 85% of patients who reached pre-specified post-operative assessment time point. CONCLUSIONS Results from this study reveal it is feasible to enroll and randomize older adults with advanced kidney disease to one of two different arteriovenous vascular access placement surgeries. The study can progress with minor protocol adjustments to a multisite clinical trial. TRIAL REGISTRATION Clinical Trials ID, NCT03545113.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1053 USA
| | - Randolph L. Geary
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Denise K. Houston
- Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Matthew S. Edwards
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Todd W. Robinson
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1053 USA
| | - Ross P. Davis
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Justin B. Hurie
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Timothy K. Williams
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC USA
| | | | - Benjamin Bagwell
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1053 USA
| | - Audrey B. Tuttle
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1053 USA
| | - Shahriar Moossavi
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1053 USA
| | - Michael V. Rocco
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1053 USA
| | - Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1053 USA
| | - Jeff D. Williamson
- Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Haiying Chen
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC USA
| | - Jasmin Divers
- Division of Health Services Research, Department of Foundations of Medicine, NYU Long Island School of Medicine, Long Island, NY USA
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Claudel SE, Tucker BM, Kleven DT, Pirkle JL, Murea M. Narrative Review of Hypercoagulability in Small-Vessel Vasculitis. Kidney Int Rep 2020; 5:586-599. [PMID: 32405580 PMCID: PMC7210611 DOI: 10.1016/j.ekir.2019.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/03/2019] [Accepted: 12/31/2019] [Indexed: 01/08/2023] Open
Abstract
Pauci-immune necrotizing and crescentic glomerulonephritis (GN) is the most common etiology of rapidly progressive GN. Clinical presentation in those afflicted is usually related to rapid loss of kidney function. We report the case of a 70-year-old woman who came to medical attention for signs and symptoms related to lower-extremity deep vein thrombosis (DVT). At presentation, the patient had biochemical abnormalities consistent with active GN, which quickly progressed to rapid loss in kidney function requiring renal replacement therapy. Kidney biopsy revealed small-vessel vasculitis with glomerular crescents. Serologic studies were negative for antineutrophil cytoplasmic antibody antibodies and other causes of acute GN. Plasmapheresis, immunosuppressive, and anticoagulant therapies were prescribed. Absence of other apparent end-organ involvement with vasculitis pointed toward renal-limited small-vessel vasculitis, yet presence of unprovoked DVT argues for systemic vascular inflammation. This case illustrates that venous thrombosis can be the presenting manifestation in patients with vasculitis and silent, severe end-organ involvement. The epidemiology and pathophysiology of venous thromboembolism in small-vessel vasculitis are discussed in this report.
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Affiliation(s)
| | - Bryan M. Tucker
- Department of Internal Medicine, Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel T. Kleven
- Department of Pathology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - James L. Pirkle
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
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27
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Ma L, Ainsworth HC, Snipes JA, Murea M, Choi YA, Langefeld CD, Parks JS, Bharadwaj MS, Chou JW, Hemal AK, Petrovic S, Craddock AL, Cheng D, Hawkins GA, Miller LD, Hicks PJ, Saleem MA, Divers J, Molina AJA, Freedman BI. APOL1 Kidney-Risk Variants Induce Mitochondrial Fission. Kidney Int Rep 2020; 5:891-904. [PMID: 32518871 PMCID: PMC7271005 DOI: 10.1016/j.ekir.2020.03.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 02/28/2020] [Accepted: 03/16/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction APOL1 G1 and G2 nephropathy-risk variants cause mitochondrial dysfunction and contribute to kidney disease. Analyses were performed to determine the genetic regulation of APOL1 and elucidate potential mechanisms in APOL1-nephropathy. Methods A global gene expression analysis was performed in human primary renal tubule cell lines derived from 50 African American individuals. Follow-up gene knock out, cell-based rescue, and microscopy experiments were performed. Results APOL1 genotypes did not alter APOL1 expression levels in the global gene expression analysis. Expression quantitative trait locus (eQTL) analysis in polyinosinic-polycytidylic acid (poly IC)–stimulated renal tubule cells revealed that single nucleotide polymorphism (SNP) rs513349 adjacent to BAK1 was a trans eQTL for APOL1 and a cis eQTL for BAK1; APOL1 and BAK1 were co-expressed in cells. BAK1 knockout in a human podocyte cell line resulted in diminished APOL1 protein, supporting a pivotal effect for BAK1 on APOL1 expression. Because BAK1 is involved in mitochondrial dynamics, mitochondrial morphology was examined in primary renal tubule cells and HEK293 Tet-on cells of various APOL1 genotypes. Mitochondria in APOL1 wild-type (G0G0) tubule cells maintained elongated morphology when stimulated by low-dose poly IC, whereas those with G1G1, G2G2, and G1G2 genotypes appeared to fragment. HEK293 Tet-on cells overexpressing APOL1 G0, G1, and G2 were created; G0 cells appeared to promote mitochondrial fusion, whereas G1 and G2 induced mitochondrial fission. The mitochondrial dynamic regulator Mdivi-1 significantly preserved cell viability and mitochondrial cristae structure and reversed mitochondrial fission induced by overexpression of G1 and G2. Conclusion Results suggest the mitochondrial fusion/fission pathway may be a therapeutic target in APOL1-nephropathy.
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Affiliation(s)
- Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Hannah C Ainsworth
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - James A Snipes
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Young A Choi
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Carl D Langefeld
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - John S Parks
- Department of Internal Medicine, Section on Molecular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Manish S Bharadwaj
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jeff W Chou
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Snezana Petrovic
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ann L Craddock
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Dongmei Cheng
- Department of Internal Medicine, Section on Molecular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Gregory A Hawkins
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Lance D Miller
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Pamela J Hicks
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Moin A Saleem
- Children's Renal Unit, Bristol Royal Hospital for Children, University of Bristol, Bristol, United Kingdom
| | - Jasmin Divers
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Anthony J A Molina
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Murea M, Moossavi S, Garneata L, Kalantar-Zadeh K. Narrative Review of Incremental Hemodialysis. Kidney Int Rep 2019; 5:135-148. [PMID: 32043027 PMCID: PMC7000841 DOI: 10.1016/j.ekir.2019.11.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 01/04/2023] Open
Abstract
The prescription of hemodialysis (HD) in patients with incident end-stage kidney disease (ESKD) is fundamentally empirical. The abrupt transition from nondialysis chronic kidney disease (CKD) to thrice-weekly in-center HD of much the same dialysis intensity as in those with prevalent ESKD underappreciates the progressive nature of kidney disease whereby the decline in renal function has been gradual and ongoing-including at the time of HD initiation. Adjuvant pharmacologic treatment (i.e., diuretics, acid buffers, potassium binders), coupled with residual kidney function (RKF), can complement an initial HD regimen of lower intensity. Barriers to less intensive HD in incident ESKD include risk of inadequate clearance of uremic toxins due to variable and unexpected loss of RKF, lack of patient adherence to assessments of RKF or adjustment of HD intensity, increased burden for all stakeholders in the dialysis units, and negative financial repercussions. A stepped dialysis regimen with scheduled transition from time-delineated twice-weekly HD to thrice-weekly HD could represent an effective and safe strategy to standardize incremental HD in patients with CKD transitioning to early-stage ESKD. Patients' adherence and survival as well as other clinical outcomes should be rigorously evaluated in clinical trials before large-scale implementation of different incremental schedules of HD. This review discusses potential benefits of and barriers to alternative dialysis regimens in patients with incident ESKD, with emphasis on twice-weekly HD with pharmacologic therapy, and summarizes in-progress clinical trials of incremental HD schedules.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Shahriar Moossavi
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Liliana Garneata
- Department of Internal Medicine, Section on Nephrology, "Dr Carol Davila" University Hospital of Nephrology, Bucharest, Romania
| | - Kamyar Kalantar-Zadeh
- Department of Internal Medicine, Section on Nephrology, University of California Irvine School of Medicine, Orange, California, USA
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Freedman BI, Kistler AL, Skewes-Cox P, Ganem D, Spainhour M, Turner J, Divers J, Langefeld CD, Murea M, Hicks PJ, Hemal AK, Snipes JA, Zhao L, Abend JR, Lyles DS, Ma L, Skorecki KL. JC polyoma viruria associates with protection from chronic kidney disease independently from apolipoprotein L1 genotype in African Americans. Nephrol Dial Transplant 2019; 33:1960-1967. [PMID: 29420808 DOI: 10.1093/ndt/gfx368] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 12/14/2017] [Indexed: 12/18/2022] Open
Abstract
Background Viral infections can trigger chronic kidney disease (CKD) and the urine virome may inform risk. The Natural History of APOL1-Associated Nephropathy Study (NHAANS) reported that urine JC polyomavirus (JCPyV) associated with a lower risk of APOL1-associated nephropathy in African Americans. Herein, association was assessed between urine JCPyV with CKD in African Americans independent from the APOL1 genotype. Methods Quantitative polymerase chain reaction was performed for urinary detection of JCPyV and BK polyoma virus (BKPyV) in 200 newly recruited nondiabetic African Americans. A combined analysis was performed in these individuals plus 300 NHAANS participants. Results In the 200 new participants, urine JCPyV was present in 8.8% of CKD cases and 45.8% of nonnephropathy controls (P = 3.0 × 10-8). In those with APOL1 renal-risk genotypes, JCPyV was detected in 5.1% of cases and 40.0% of controls (P = 0.0002). In those lacking APOL1 renal-risk genotypes, JCPyV was detected in 12.2% of cases and 48.8% of controls (P = 8.5 × 10-5). BKPyV was detected in 1.3% of cases and 0.8% of controls (P = 0.77). In a combined analysis with 300 NHAANS participants (n = 500), individuals with urine JCPyV had a 63% lower risk of CKD compared with those without urine JCPyV (odds ratio 0.37; P = 4.6 × 10-6). RNA fluorescence in situ hybridization confirmed the presence of JCPyV genomic DNA and JCPyV messenger RNA (mRNA) in nondiseased kidney. Conclusions Inverse relationships exist between JCPyV viruria and non-diabetic CKD. Future studies should determine whether renal inflammation associated with CKD is less permissive for JCPyV reactivation/replication or whether JCPyV is a marker of reduced host immune responsiveness that diminishes immune pathologic contributions to CKD.
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Affiliation(s)
- Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Amy L Kistler
- Infectious Diseases Area, Novartis Institutes for Biomedical Research, Emeryville, CA, USA
| | - Peter Skewes-Cox
- Infectious Diseases Area, Novartis Institutes for Biomedical Research, Emeryville, CA, USA
| | - Don Ganem
- Infectious Diseases Area, Novartis Institutes for Biomedical Research, Emeryville, CA, USA
| | - Mitzie Spainhour
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Jolyn Turner
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Jasmin Divers
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Carl D Langefeld
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Pamela J Hicks
- Department of Biochemistry, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - James A Snipes
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Lihong Zhao
- Infectious Diseases Area, Novartis Institutes for Biomedical Research, Emeryville, CA, USA
| | - Johanna R Abend
- Infectious Diseases Area, Novartis Institutes for Biomedical Research, Emeryville, CA, USA
| | - Douglas S Lyles
- Department of Biochemistry, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Karl L Skorecki
- Department of Genetics and Developmental Biology, Rappaport Faculty of Medicine and Research Institute, Technion-Israel Institute of Technology and Department of Nephrology, Rambam Health Care Campus, Haifa, Israel
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30
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Tucker BM, Hsu FC, Register TC, Xu J, Smith SC, Murea M, Bowden DW, Freedman BI, Lenchik L. Psoas and Paraspinous Muscle Measurements on Computed Tomography Predict Mortality in European Americans with Type 2 Diabetes Mellitus. J Frailty Aging 2019; 8:72-78. [PMID: 30997919 DOI: 10.14283/jfa.2019.5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Appendicular skeletal muscle mass index and muscle attenuation (density) are negatively associated with mortality in European-derived populations. OBJECTIVES The present analyses assessed association between axial skeletal muscle density and muscle index with mortality in European Americans with type 2 diabetes mellitus (T2D). DESIGN Single-center observational study. SETTING Diabetes Heart Study. PARTICIPANTS 839 European Americans with T2D. METHODS Computed tomography-measured psoas and paraspinous muscle mass index (cross sectional area/height2) and radiographic density (Hounsfield Units) were assessed in all participants. A Cox proportional hazards model was computed. The fully-adjusted model included covariates age, sex, body mass index, smoking, alcohol use, diabetes duration, insulin use, hormone replacement therapy (women), prevalent cardiovascular disease (CVD), hypertension, and coronary artery calcified atherosclerotic plaque mass score. Deaths were recorded in the National Death Index data through December 31, 2015. RESULTS Participants included 428 women and 411 men with median (25th, 75th quartile) age 62.8 (56.1, 69.1) years and diabetes duration 8.0 (5.0, 14.0) years. After 11.9 (9.4, 13.3) years of follow-up, 314 (37.4%) of participants were deceased. In the fully-adjusted model, psoas muscle density (hazard ratio [HR] 0.81, p<0.001), psoas muscle index (HR 0.82, p=0.008), and paraspinous muscle density (HR 0.85, p=0.003) were inversely associated with mortality. Paraspinous muscle index was not significantly associated with mortality (HR 0.90, p=0.08). Results did not differ significantly between men and women. CONCLUSIONS In addition to established risk factors for mortality and CVD, higher psoas muscle index, psoas muscle density, and paraspinous muscle density were significantly associated with lower all-cause mortality in European Americans with T2D.
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Affiliation(s)
- B M Tucker
- Barry I. Freedman, MD, Internal Medicine - Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1053, Phone: 336-716-6461, Fax: 336-716-4318,
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Abstract
Vascular access for hemodialysis has a long and rich history. This article highlights major innovations and milestones in the history of angioaccess for hemodialysis. Advances in achievement of lasting hemodialysis access, swift access transition, immediate and sustaining access to vascular space built the momentum at different turning points of access history and shaped the current practice of vascular access strategy. In the present era, absent of large-scale clinical trials to validate practice, the ever-changing demographic and comorbidity makeup of the dialysis population pushes against stereotypical angioaccess goals. The future of hemodialysis vascular access would benefit from proper randomized clinical trials and acclimatization to clinical contexts.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Randolph L Geary
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Ross P Davis
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Shahriar Moossavi
- Department of Internal Medicine, Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Murea M, Ma L, Freedman BI. APOL1 and Mortality in Patients on Dialysis. Cardiorenal Med 2019; 9:261-264. [PMID: 31185465 DOI: 10.1159/000501303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/04/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA,
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Murea M, Geary RL, Edwards MS, Moossavi S, Davis RP, Goldman MP, Hurie J, Williams TK, Velazquez-Ramirez G, Robinson TW, Bagwell B, Tuttle AB, Callahan KE, Rocco MV, Houston DK, Pajewski NM, Divers J, Freedman BI, Williamson JD. A randomized pilot study comparing graft-first to fistula-first strategies in older patients with incident end-stage kidney disease: Clinical rationale and study design. Contemp Clin Trials Commun 2019; 14:100357. [PMID: 31016270 PMCID: PMC6475715 DOI: 10.1016/j.conctc.2019.100357] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/27/2019] [Accepted: 04/05/2019] [Indexed: 11/22/2022] Open
Abstract
Timely placement of an arteriovenous (AV) vascular access (native AV fistula [AVF] or prosthetic AV graft [AVG]) is necessary to limit the use of tunneled central venous catheters (TCVC) in patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD). National guidelines recommend placement of AVF as the AV access of first choice in all patients to improve patient survival. The benefits of AVF over AVG are less certain in the older adults, as age-related biological changes independently modulate patient outcomes. This manuscript describes the rationale, study design and protocol for a randomized controlled pilot study of the feasibility and effects of AVG-first access placement in older adults with no prior AV access surgery. Fifty patients age ≥65 years, with incident ESKD on HD via TCVC or advanced kidney disease facing imminent HD initiation, and suitable upper extremity vasculature for initial placement of an AVF or AVG, will be randomly assigned to receive either an upper extremity AVG-first (intervention) or AVF-first (comparator) access. The study will establish feasibility of randomizing older adults to the two types of AV access surgery, evaluate relationships between measurements of preoperative physical function and vascular access development, compare vascular access outcomes between groups, and gather longitudinal assessments of upper extremity muscle strength, gait speed, performance of activities of daily living, and patient satisfaction with their vascular access and quality of life. Results will assist with the planning of a larger, multicenter trial assessing patient-centered outcomes.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Randolph L. Geary
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Matthew S. Edwards
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Shahriar Moossavi
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ross P. Davis
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Matthew P. Goldman
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Justin Hurie
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Timothy K. Williams
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Todd W. Robinson
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Benjamin Bagwell
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Audrey B. Tuttle
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kathryn E. Callahan
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael V. Rocco
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Denise K. Houston
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Nicholas M. Pajewski
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jasmin Divers
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jeff D. Williamson
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Freedman BI, Spainhour M, Hicks PJ, Turner J, Robertson J, Langefeld CD, Murea M, Divers J. Nephropathy Progression in African Americans With a Family History of ESKD: Implications for Clinical Trials in APOL1-Associated Nephropathy. Am J Kidney Dis 2019; 74:284-286. [PMID: 31076172 DOI: 10.1053/j.ajkd.2019.03.414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 03/04/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC.
| | - Mitzie Spainhour
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC
| | - Pamela J Hicks
- Department of Biochemistry, Wake Forest School of Medicine; Winston-Salem, NC
| | - Jolyn Turner
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC
| | - Julia Robertson
- Division of Public Health Science, Department of Biostatistics and Data Science, Wake Forest School of Medicine; Winston-Salem, NC
| | - Carl D Langefeld
- Division of Public Health Science, Department of Biostatistics and Data Science, Wake Forest School of Medicine; Winston-Salem, NC
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC
| | - Jasmin Divers
- Division of Public Health Science, Department of Biostatistics and Data Science, Wake Forest School of Medicine; Winston-Salem, NC
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Affiliation(s)
- Mark A Cabrera
- Mark A. Cabrera is a nephrologist at Kaiser Permanente Northwest Health Care in Portland, Ore. In Winston-Salem, N.C., Christopher Neil Marshall is a nephrologist at Nephrology Associates, PLLC, Kimberly A. Sadler is a charge RN on the renal unit at Wake Forest Baptist Medical Center, and Mariana Murea is an associate professor of internal medicine and nephrology in the Department of Internal Medicine at Wake Forest University
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Anderson EM, Zhang J, Russell G, Bowline IG, Thyagarajan B, Li D, Ma L, Anderson ER, Murea M. A Single-Center Retrospective Study of Acute Kidney Injury Incidence in Patients With Advanced Malignancies Treated With Antimitochondrial Targeted Drug. Kidney Int Rep 2018; 4:310-320. [PMID: 30775628 PMCID: PMC6365364 DOI: 10.1016/j.ekir.2018.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 10/15/2018] [Accepted: 10/22/2018] [Indexed: 12/18/2022] Open
Abstract
Introduction Mitochondrial dysfunction plays an important role in the pathophysiology of kidney disease. Inhibitors of mitochondrial metabolism are being developed for the treatment of solid organ and hematologic malignancies. We describe the incidence and clinical features of acute kidney injury (AKI) in patients treated with the antimitochondrial drug CPI-613. Methods We identified 33 patients with relapsed or refractory malignancy, previously enrolled in 3 open-label phase II studies, who received single-agent CPI-613 chemotherapy. AKI was defined by the Kidney Disease Improving Global Outcomes serum creatinine criteria. Participants were followed for a median (25th–75th percentile) of 120.0 (74.0–301.0) days. Risk factors for AKI were assessed by proportional hazards regression using univariate and multivariate analyses. Results Participants had baseline mean (SD) age of 63.8 (11.6) years and serum creatinine 0.9 (0.3) mg/dl. AKI developed in 9 (27%) patients; chart review failed to identify a potential cause of AKI other than CPI-613 administration in 5 (15%) patients, of whom 1 had AKI stage 1, 1 had AKI stage 2, and 3 experienced AKI stage 3. Time from initiation of CPI-613 treatment to AKI was 51.0 (16.0–58.0) days. Age, per 5-year increase, was associated with higher risk of AKI (adjusted hazard ratio 2.01, 95% confidence interval 1.06–3.79, P = 0.03). Follow-up serum creatinine was available in 4 participants 174.8 (139.6) days after the episode of AKI; 3 patients had complete recovery in kidney function and 1 had partial recovery. Conclusion AKI is a possible complication during treatment with mitochondria-targeted chemotherapy.
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Affiliation(s)
- Elizabeth M Anderson
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jin Zhang
- Department of Biomedical Research, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Greg Russell
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Isai G Bowline
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Braghadheeswar Thyagarajan
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - DengFeng Li
- Department of Biology, University of North Carolina, Greensboro, North Carolina, USA
| | - Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Erica R Anderson
- Department of Pharmacy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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37
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine; Section on Nephrology; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Bryan M. Tucker
- Department of Internal Medicine; Section on Nephrology; Wake Forest School of Medicine; Winston-Salem NC USA
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38
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Murea M, Lenchik L, Register TC, Russell GB, Xu J, Smith SC, Bowden DW, Divers J, Freedman BI. Psoas and paraspinous muscle index as a predictor of mortality in African American men with type 2 diabetes mellitus. J Diabetes Complications 2018; 32:558-564. [PMID: 29627372 PMCID: PMC5970956 DOI: 10.1016/j.jdiacomp.2018.03.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 02/27/2018] [Accepted: 03/14/2018] [Indexed: 12/25/2022]
Abstract
AIM Recent studies revealed a correlation between skeletal muscle mass index and density with longevity; these studies largely evaluated appendicular skeletal muscles in older Caucasians. This retrospective cohort study assessed the association between axial skeletal muscles size and density with survival in African Americans with type 2 diabetes mellitus. METHODS Psoas and paraspinous muscle mass index (cross sectional area/height2) and radiographic density (in Hounsfield Units) were measured using computed tomography in African American-Diabetes Heart Study participants, 314 women and 256 men, with median (25th, 75th quartile) age 55.0(48.0, 62.0) and 57.0(50.0, 64.0) years, respectively. Covariates in fully-adjusted model included age, sex, BMI, smoking, hormone replacement therapy (women), cardiovascular disease, hypertension, coronary artery calcified plaque mass, carotid artery calcified plaque mass, and African ancestry proportion. RESULTS After median of 7.1(5.9, 8.2) years follow-up, 30(9.6%) of women and 49(19.1%) of men were deceased. In fully-adjusted models, psoas muscle mass index and paraspinous muscle mass index were inversely associated with mortality in men (psoas muscle mass index, hazard ratio [HR] = 0.61, P = 0.004; paraspinous muscle mass index, HR = 0.64, P = 0.004), but not in women. Psoas and paraspinous muscle densities did not associate with all-cause mortality. A penalized Cox regression that involved all covariates and predictors associated with mortality showed that only paraspinous muscle mass index remained a significant predictor of mortality (HR = 0.65, P = 0.02). CONCLUSION Independent from established risk factors for mortality, higher psoas and paraspinous muscle index associate with reduced all-cause mortality in middle-aged African American men with type 2 diabetes mellitus.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Leon Lenchik
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Thomas C Register
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Gregory B Russell
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jianzhao Xu
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - S Carrie Smith
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Donald W Bowden
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jasmin Divers
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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Faig J, Haughton M, Taylor RC, D’Agostino RB, Whelen MJ, Porosnicu Rodriguez KA, Bonomi M, Murea M, Porosnicu M. Retrospective Analysis of Cisplatin Nephrotoxicity in Patients With Head and Neck Cancer Receiving Outpatient Treatment With Concurrent High-dose Cisplatin and Radiotherapy. Am J Clin Oncol 2018; 41:432-440. [PMID: 27281266 PMCID: PMC5145782 DOI: 10.1097/coc.0000000000000301] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Cisplatin remains the pivotal chemotherapy in squamous cell carcinoma of the head and neck (SCCHN), with nephrotoxicity considered the dose-limiting toxicity. The purpose of our study was to propose an outpatient high-dose cisplatin protocol aimed at preventing nephrotoxicity and to analyze the results of its utilization in patients with SCCHN treated with concurrent radiotherapy. MATERIALS AND METHODS We retrospectively evaluated 82 SCCHN patients treated with outpatient high-dose cisplatin concurrent with radiotherapy at our institution. Acute kidney injury (AKI) and chronic kidney disease were defined by Kidney Disease Improving Global Outcomes criteria. Associated factors were identified using analysis of covariance models for categorical variables and adjusted Pearson correlations for continuous variables. RESULTS The incidence of AKI during treatment was 34.2%. With a median follow-up of 25.7 months, the average decrease in estimated glomerular filtration rate was 12.57 mL/min/1.73 m (SD=18.58). At 1 year and at last follow-up, 5.4% and 4.4% of patients had estimated glomerular filtration rate <60 mL/min/1.73 m. Predictors associated with AKI and chronic kidney disease were: lower baseline weight and creatinine, higher baseline creatinine clearance, smoking, female sex, African American race, hypertension, and increased hydration and magnesium replacement requirements. CONCLUSIONS We encountered limited early and late nephrotoxicity. Importantly, nephrotoxicity was not the main dose-limiting toxicity. Our results emphasize the importance of close monitoring and additional replacement of water and electrolytes as needed. A consistent method of measuring and reporting chemotherapy-induced nephrotoxicity would be a valuable contribution to the literature.
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Affiliation(s)
- Jennifer Faig
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157
| | - Michael Haughton
- Department of Internal Medicine, Section on Hematology and Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157
| | - Richard C. Taylor
- Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157
| | - Ralph B. D’Agostino
- Division of Public Health Sciences, Department of Biostatistical Sciences, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, NC 27157
| | - Megan J. Whelen
- Comprehensive Cancer Center of Wake Forest University, Medical Center Boulevard, Winston-Salem, NC 27157
| | | | - Marcelo Bonomi
- Department of Internal Medicine, Section on Hematology and Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157
| | - Mariana Murea
- Department of Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157
| | - Mercedes Porosnicu
- Department of Internal Medicine, Section on Hematology and Oncology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157
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Murea M, Brown WM, Divers J, Moossavi S, Robinson TW, Bagwell B, Burkart JM, Freedman BI. Vascular Access Placement Order and Outcomes in Hemodialysis Patients: A Longitudinal Study. Am J Nephrol 2017; 46:268-275. [PMID: 28930719 DOI: 10.1159/000481313] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/06/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Arteriovenous accesses (AVA) in patients performing hemodialysis (HD) are labeled "permanent" for AV fistulas (AVF) or grafts (AVG) and "temporary" for tunneled central venous catheters (TCVC). Durability and outcomes of permanent vascular accesses based on the sequence in which they were placed or used receives little attention. This study analyzed longitudinal transitions between TCVC-based and AVA-based HD outcomes according to the order of placement. METHODS All 391 patients initiating chronic HD via a TCVC between 2012 and 2013 at 12 outpatient academic dialysis units were included in this study. Chronological distributions of HD vascular accesses were recorded over a mean (SD) of 2.8 (0.9) years and sequentially grouped into periods for TCVC-delivered and AVA-delivered (AVF or AVG) HD. Primary AVA failure and cumulative access survival were evaluated based on access placement sequence and type, adjusting for age. RESULTS In total, 92.3% (361/391) of patients underwent 497 AVA placement surgeries. Analyzing the initial 3 surgeries, primary AVF failure rates increased with each successive fistula placement (p = 0.008). Among the 82.9% (324/391) of TCVC patients successfully converted to an AVA, 30.9% returned to a TCVC, followed by a 58.0% conversion rate to another AVA. Annual per-patient vascular access transition rates were 2.02 (0.09) HD periods using a TCVC and 0.54 (0.03) HD periods using an AVA. Comparing the first AVA used with the second, cumulative access survivals were 701.0 (370.0) vs. 426.5 (275.0) days, respectively. Excluding those never converting to an AVF or AVG, 169 (52.2%) subsequently converted from a TCVC to a permanent access and received HD via AVA for ≥80% of treatments. CONCLUSIONS HD vascular access outcomes differ based on the sequence of placement. In spite of frequent AVA placements, only half of patients effectively achieved a "permanent" vascular access and used an AVA for the majority of HD treatments.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Murea M, Russell GB, Daeihagh P, Saran AM, Pandya K, Cabrera M, Burkart JM, Freedman BI. Efficacy and safety of low-dose heparin in hemodialysis. Hemodial Int 2017; 22:74-81. [DOI: 10.1111/hdi.12563] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Mariana Murea
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - Gregory B. Russell
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - Pirouz Daeihagh
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - Anita M. Saran
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - Karan Pandya
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - Mark Cabrera
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - John M. Burkart
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
| | - Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology; Wake Forest School of Medicine; Winston-Salem North Carolina USA
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Ma L, Chou JW, Snipes JA, Bharadwaj MS, Craddock AL, Cheng D, Weckerle A, Petrovic S, Hicks PJ, Hemal AK, Hawkins GA, Miller LD, Molina AJA, Langefeld CD, Murea M, Parks JS, Freedman BI. APOL1 Renal-Risk Variants Induce Mitochondrial Dysfunction. J Am Soc Nephrol 2016; 28:1093-1105. [PMID: 27821631 DOI: 10.1681/asn.2016050567] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/12/2016] [Indexed: 11/03/2022] Open
Abstract
APOL1 G1 and G2 variants facilitate kidney disease in blacks. To elucidate the pathways whereby these variants contribute to disease pathogenesis, we established HEK293 cell lines stably expressing doxycycline-inducible (Tet-on) reference APOL1 G0 or the G1 and G2 renal-risk variants, and used Illumina human HT-12 v4 arrays and Affymetrix HTA 2.0 arrays to generate global gene expression data with doxycycline induction. Significantly altered pathways identified through bioinformatics analyses involved mitochondrial function; results from immunoblotting, immunofluorescence, and functional assays validated these findings. Overexpression of APOL1 by doxycycline induction in HEK293 Tet-on G1 and G2 cells led to impaired mitochondrial function, with markedly reduced maximum respiration rate, reserve respiration capacity, and mitochondrial membrane potential. Impaired mitochondrial function occurred before intracellular potassium depletion or reduced cell viability occurred. Analysis of global gene expression profiles in nondiseased primary proximal tubule cells from black patients revealed that the nicotinate phosphoribosyltransferase gene, responsible for NAD biosynthesis, was among the top downregulated transcripts in cells with two APOL1 renal-risk variants compared with those without renal-risk variants; nicotinate phosphoribosyltransferase also displayed gene expression patterns linked to mitochondrial dysfunction in HEK293 Tet-on APOL1 cell pathway analyses. These results suggest a pivotal role for mitochondrial dysfunction in APOL1-associated kidney disease.
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Affiliation(s)
- Lijun Ma
- Department of Internal Medicine, Section on Nephrology, .,Center for Public Health Genomics
| | - Jeff W Chou
- Center for Public Health Genomics.,Division of Public Health Sciences, Department of Biostatistical Sciences
| | | | - Manish S Bharadwaj
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine
| | | | - Dongmei Cheng
- Department of Internal Medicine, Section on Molecular Medicine
| | | | | | | | | | | | | | - Anthony J A Molina
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine
| | - Carl D Langefeld
- Center for Public Health Genomics.,Division of Public Health Sciences, Department of Biostatistical Sciences
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology
| | - John S Parks
- Department of Internal Medicine, Section on Molecular Medicine
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, .,Center for Public Health Genomics.,Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Abstract
Vascular access preparation, a pervasive challenge in hemodialysis (HD), is emerging as a multidimensional subject in geriatric nephrology. Previously published guidelines declared arteriovenous fistulas (AVF) as the preferred vascular access for all patients on HD. In this article, the benefit-risk evidence for using AVF versus an alternative access (arteriovenous graft [AVG] or tunneled central venous catheter [TCVC]) in the elderly is pondered. Compared to their younger counterparts, the elderly have significantly lower survival rates independent of the vascular access used for HD. Recent studies point to comparable dialysis survival rates between AVF and AVG or TCVC in subgroups of elderly patients, as well as lower rates of access-related infections, and lower catheter dependence after AVG compared to AVF construction in these patients. Comprehensive and longitudinal assessments that integrate comorbidities, physical function, cognitive status, and quality of life to estimate prognosis and assist with vascular access selection ought to be employed. In circumstances where patient survival is limited by comorbidities and functional status, AVF is unlikely to confer meaningful benefits compared to AVG or even TCVC in the ill elderly.
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Affiliation(s)
- Mariana Murea
- Department of Internal Medicine-Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Scott Satko
- Department of Internal Medicine-Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Interventional Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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44
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Porosnicu M, Faig J, Taylor R, Rodriguez Porosnicu K, Murea M, Bonomi M, Greven K. Retrospective Analysis of Cisplatin Nephrotoxicity in Patients With Head and Neck Cancer Receiving Outpatient Treatment With Concurrent High-Dose Cisplatin and Radiation Therapy. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2015.12.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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45
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Weckerle A, Snipes JA, Cheng D, Gebre AK, Reisz JA, Murea M, Shelness GS, Hawkins GA, Furdui CM, Freedman BI, Parks JS, Ma L. Characterization of circulating APOL1 protein complexes in African Americans. J Lipid Res 2015; 57:120-30. [PMID: 26586272 DOI: 10.1194/jlr.m063453] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Indexed: 11/20/2022] Open
Abstract
APOL1 gene renal-risk variants are associated with nephropathy and CVD in African Americans; however, little is known about the circulating APOL1 variant proteins which reportedly bind to HDL. We examined whether APOL1 G1 and G2 renal-risk variant serum concentrations or lipoprotein distributions differed from nonrisk G0 APOL1 in African Americans without nephropathy. Serum APOL1 protein concentrations were similar regardless of APOL1 genotype. In addition, serum APOL1 protein was bound to protein complexes in two nonoverlapping peaks, herein referred to as APOL1 complex A (12.2 nm diameter) and complex B (20.0 nm diameter). Neither of these protein complexes associated with HDL or LDL. Proteomic analysis revealed that complex A was composed of APOA1, haptoglobin-related protein (HPR), and complement C3, whereas complex B contained APOA1, HPR, IgM, and fibronectin. Serum HPR was less abundant on complex B in individuals with G1 and G2 renal-risk variant genotypes, relative to G0 (P = 0.0002-0.037). These circulating complexes may play roles in HDL metabolism and susceptibility to CVD.
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Affiliation(s)
- Allison Weckerle
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - James A Snipes
- Nephrology, Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Dongmei Cheng
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Abraham K Gebre
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Julie A Reisz
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Mariana Murea
- Nephrology, Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Gregory S Shelness
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Gregory A Hawkins
- Center for Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Cristina M Furdui
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Barry I Freedman
- Nephrology, Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - John S Parks
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC 27157
| | - Lijun Ma
- Nephrology, Wake Forest School of Medicine, Winston-Salem, NC 27157
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46
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Cheng D, Weckerle A, Yu Y, Ma L, Zhu X, Murea M, Freedman BI, Parks JS, Shelness GS. Biogenesis and cytotoxicity of APOL1 renal risk variant proteins in hepatocytes and hepatoma cells. J Lipid Res 2015; 56:1583-93. [PMID: 26089538 DOI: 10.1194/jlr.m059733] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Indexed: 12/21/2022] Open
Abstract
Two APOL1 gene variants, which likely evolved to protect individuals from African sleeping sickness, are strongly associated with nondiabetic kidney disease in individuals with recent African ancestry. Consistent with its role in trypanosome killing, the pro-death APOL1 protein is toxic to most cells, but its mechanism of cell death is poorly understood and little is known regarding its intracellular trafficking and secretion. Because the liver appears to be the main source of circulating APOL1, we examined its secretory behavior and mechanism of toxicity in hepatoma cells and primary human hepatocytes. APOL1 is poorly secreted in vitro, even in the presence of chemical chaper-ones; however, it is efficiently secreted in wild-type transgenic mice, suggesting that APOL1 secretion has specialized requirements that cultured cells fail to support. In hepatoma cells, inducible expression of APOL1 and its risk variants promoted cell death, with the G1 variant displaying the highest degree of toxicity. To explore the basis for APOL1-mediated cell toxicity, endoplasmic reticulum stress, pyroptosis, autophagy, and apoptosis were examined. Our results suggest that autophagy represents the predominant mechanism of APOL1-mediated cell death. Overall, these results increase our understanding of the basic biology and trafficking behavior of circulating APOL1 from the liver.
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Affiliation(s)
- Dongmei Cheng
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC
| | - Allison Weckerle
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC
| | - Yi Yu
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC
| | - Lijun Ma
- Nephrology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Xuewei Zhu
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC
| | - Mariana Murea
- Nephrology, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - John S Parks
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC
| | - Gregory S Shelness
- Department of Internal Medicine, Sections on Molecular Medicine Wake Forest School of Medicine, Winston-Salem, NC
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Yates JE, Bleyer AJ, Yosipovitch G, Sangueza OP, Murea M. Enigmatic pruritus in a kidney transplant patient. Clin Kidney J 2015; 6:194-8. [PMID: 26019849 PMCID: PMC4432448 DOI: 10.1093/ckj/sft009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 01/16/2013] [Indexed: 11/14/2022] Open
Abstract
Pruritus is a common problem following a kidney transplant and is usually attributable to new medications related to transplantation. We present an unusual case of pruritus that began several months after kidney transplantation. After changing several immunosuppressive medications, numerous clinical visits and consideration by the patient of stopping immunosuppression, scabies was diagnosed as the cause. Treatment with oral ivermectin and topical permethrin resulted in complete resolution of symptoms within 1 week. Transplant physicians should consider common causes of pruritus unrelated to transplantation; diagnostic skin lesions of scabies may be absent.
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Affiliation(s)
- John E Yates
- Department of Internal Medicine , Wake Forest School of Medicine , Winston-Salem, NC , USA
| | - Anthony J Bleyer
- Section on Nephrology , Department of Internal Medicine , Wake Forest School of Medicine , Winston-Salem, NC , USA
| | - Gil Yosipovitch
- Department of Dermatology , Wake Forest School of Medicine , Winston-Salem, NC , USA
| | - Omar P Sangueza
- Department of Pathology , Wake Forest School of Medicine , Winston-Salem, NC , USA
| | - Mariana Murea
- Section on Nephrology , Department of Internal Medicine , Wake Forest School of Medicine , Winston-Salem, NC , USA
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48
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Murea M, Hsu FC, Cox AJ, Hugenschmidt CE, Xu J, Adams JN, Raffield LM, Whitlow CT, Maldjian JA, Bowden DW, Freedman BI. Structural and functional assessment of the brain in European Americans with mild-to-moderate kidney disease: Diabetes Heart Study-MIND. Nephrol Dial Transplant 2015; 30:1322-9. [PMID: 25722384 DOI: 10.1093/ndt/gfv030] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 01/18/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Advanced chronic kidney disease (CKD) is associated with altered cerebral structure and function. Relationships between mild-to-moderate CKD and brain morphology and cognitive performance were evaluated in European Americans (EAs). METHODS A total of 478 EAs with estimated glomerular filtration rate (eGFR) >45 mL/min/1.73 m(2) and urine albumin:creatinine ratio (UACR) < 300 mg/g, most with type 2 diabetes (T2D), were included. Measures of total intracranial volume (TICV), cerebrospinal fluid volume, total white matter volume (TWMV), total gray matter volume (TGMV), total white matter lesion volume (TWMLV), hippocampal white matter volume (HWMV) and hippocampal gray matter volume (HGMV) were obtained with magnetic resonance imaging. Cognitive testing included memory (Rey Auditory Visual Learning Test), global cognition (Modified Mini-Mental State Examination) and executive function (Stroop Task, Semantic Fluency, Digit Symbol Substitution Test). Associations with CKD were assessed using log-transformed eGFR and UACR, adjusted for age, sex, body mass index, smoking, hemoglobin A1c, blood pressure, diabetes duration, cardiovascular disease and education. RESULTS Participants were 55.2% female, 78.2% had T2D; mean ± SD age 67.6 ± 9.0 years, T2D duration 16.4 ± 6.5 years, eGFR 92.0 ± 22.3 mL/min/1.73 m(2) and UACR 23.8 ± 39.6 mg/g. In adjusted models, eGFR was negatively associated with TICV only in participants with T2D [parameter estimate (β): -72.2, P = 0.002]. In non-diabetic participants, inverse relationships were observed between eGFR and HGMV (β: -1.0, P = 0.03) and UACR and normalized TWMLV (β: -0.2, P = 0.03). Kidney function and albuminuria did not correlate with cognitive testing. CONCLUSIONS In EAs with mild CKD enriched for T2D, brain structure and cognitive performance were generally not impacted. Longitudinal studies are necessary to determine when cerebral structural changes and cognitive dysfunction develop with progressive CKD in EAs.
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Affiliation(s)
- Mariana Murea
- Internal Medicine-Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Fang-Chi Hsu
- Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Amanda J Cox
- Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, NC, USA Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Christina E Hugenschmidt
- Internal Medicine-Geriatrics and Gerontology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jianzhao Xu
- Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, NC, USA Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jeremy N Adams
- Molecular Genetics and Genomics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Laura M Raffield
- Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Christopher T Whitlow
- Radiologic Sciences and Advanced NeuroScience Imaging (ANSIR) Laboratory, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Joseph A Maldjian
- Radiologic Sciences and Advanced NeuroScience Imaging (ANSIR) Laboratory, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Donald W Bowden
- Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, NC, USA Biochemistry, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Barry I Freedman
- Internal Medicine-Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA Center for Diabetes Research, Wake Forest School of Medicine, Winston-Salem, NC, USA
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49
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Ma L, Shelness GS, Snipes JA, Murea M, Antinozzi PA, Cheng D, Saleem MA, Satchell SC, Banas B, Mathieson PW, Kretzler M, Hemal AK, Rudel LL, Petrovic S, Weckerle A, Pollak MR, Ross MD, Parks JS, Freedman BI. Localization of APOL1 protein and mRNA in the human kidney: nondiseased tissue, primary cells, and immortalized cell lines. J Am Soc Nephrol 2014; 26:339-48. [PMID: 25012173 DOI: 10.1681/asn.2013091017] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Although APOL1 gene variants are associated with nephropathy in African Americans, little is known about APOL1 protein synthesis, uptake, and localization in kidney cells. To address these questions, we examined APOL1 protein and mRNA localization in human kidney and human kidney-derived cell lines. Indirect immunofluorescence microscopy performed on nondiseased nephrectomy cryosections from persons with normal kidney function revealed that APOL1 protein was markedly enriched in podocytes (colocalized with synaptopodin and Wilms' tumor suppressor) and present in lower abundance in renal tubule cells. Fluorescence in situ hybridization detected APOL1 mRNA in glomeruli (podocytes and endothelial cells) and tubules, consistent with endogenous synthesis in these cell types. When these analyses were extended to renal-derived cell lines, quantitative RT-PCR did not detect APOL1 mRNA in human mesangial cells; however, abundant levels of APOL1 mRNA were observed in proximal tubule cells and glomerular endothelial cells, with lower expression in podocytes. Western blot analysis revealed corresponding levels of APOL1 protein in these cell lines. To explain the apparent discrepancy between the marked abundance of APOL1 protein in kidney podocytes observed in cryosections versus the lesser abundance in podocyte cell lines, we explored APOL1 cellular uptake. APOL1 protein was taken up readily by human podocytes in vitro but was not taken up efficiently by mesangial cells, glomerular endothelial cells, or proximal tubule cells. We hypothesize that the higher levels of APOL1 protein in human cryosectioned podocytes may reflect both endogenous protein synthesis and APOL1 uptake from the circulation or glomerular filtrate.
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Affiliation(s)
| | | | | | | | - Peter A Antinozzi
- Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - Moin A Saleem
- Children's Renal Unit, Bristol Royal Hospital for Children, University of Bristol, Bristol, United Kingdom
| | - Simon C Satchell
- Learning and Research Southmead Hospital Bristol, University of Bristol, Bristol, United Kingdom
| | - Bernhard Banas
- Internal Medicine II-Nephrology/Transplantation, University Medical Center, Regensburg, Germany
| | - Peter W Mathieson
- Children's Renal Unit, Bristol Royal Hospital for Children, University of Bristol, Bristol, United Kingdom
| | - Matthias Kretzler
- Department of Internal Medicine-Nephrology, University of Michigan at Ann Arbor Medical School, Ann Arbor, Michigan
| | | | | | - Snezana Petrovic
- Internal Medicine-Nephrology, Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - Martin R Pollak
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; and
| | - Michael D Ross
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - John S Parks
- Pathology-Lipid Sciences, and Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina
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50
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Murea M, James KM, Russell GB, Byrum GV, Yates JE, Tuttle NS, Bleyer AJ, Burkart JM, Freedman BI. Risk of catheter-related bloodstream infection in elderly patients on hemodialysis. Clin J Am Soc Nephrol 2014; 9:764-70. [PMID: 24651074 DOI: 10.2215/cjn.07710713] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Elderly patients require tunneled central vein dialysis catheters more often than younger patients. Little is known about the risk of catheter-related bloodstream infection in this population. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study identified 464 patients on hemodialysis with tunneled central vein dialysis catheters between 2005 and 2007 and excluded patients who accrued <21 catheter-days during this period. Outpatient and inpatient catheter-related bloodstream infection data were collected. A Cox proportional hazards regression analysis adjusting for sex, ancestry, comorbidites, dialysis vintage, dialysis unit, immunosuppression, initial catheter site, and first antimicrobial catheter lock solution was performed for risk of catheter-related bloodstream infection between nonelderly (18-74 years) and elderly (≥ 75 years) patients. RESULTS In total, 374 nonelderly and 90 elderly patients with mean (SD) ages of 54.8 (12.3) and 81.3 (4.9) years and dialysis vintages of 1.8 (3.3) and 1.5 (2.9) years (P=0.47), respectively, were identified. Mean at-risk catheter-days were 272 (243) in nonelderly and 318 (240) in elderly patients. Between age groups, there were no significant differences in initial catheter site, type of catheter lock solution, or microbiology results. A total of 208 catheter-related bloodstream infection events occurred (190 events in nonelderly and 18 events in elderly patients), with a catheter-related bloodstream infection incidence per 1000 catheter-days of 1.97 (4.6) in nonelderly and 0.55 (1.6) in elderly patients (P<0.001). Relative to nonelderly patients, the hazard ratio for catheter-related bloodstream infection in the elderly was 0.33 (95% confidence interval, 0.20 to 0.55; P<0.001) after multivariate analysis. CONCLUSION Elderly patients on hemodialysis using tunneled central vein dialysis catheters are at lower risk of catheter-related bloodstream infection than their younger counterparts. For some elderly patients, tunneled central vein dialysis catheters may represent a suitable dialysis access option in the setting of nonmaturing arteriovenous fistulae or poorly functioning synthetic grafts.
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Affiliation(s)
- Mariana Murea
- Section on Nephrology and, †Departments of Biostatistical Sciences and, ‡Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, §University of North Carolina, Greensboro, North Carolina
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