Effect of Intensive Blood Pressure Control on Kidney Outcomes: Long-Term Electronic Health Record-Based Post-Trial Follow-Up of SPRINT

BACKGROUND

Intensive BP lowering in the Systolic Blood Pressure Intervention Trial (SPRINT) produced acute decreases in kidney function and higher risk for AKI. We evaluated the effect of intensive BP lowering on long-term changes in kidney function using trial and outpatient electronic health record (EHR) creatinine values.

METHODS

SPRINT data were linked with EHR data from 49 (of 102) study sites. The primary outcome was the total slope of decline in eGFR for the intervention phase and the post-trial slope of decline during the observation phase using trial and outpatient EHR values. Secondary outcomes included a ≥30% decline in eGFR to <60 ml/min per 1.73 m 2 and a ≥50% decline in eGFR or kidney failure among participants with baseline eGFR ≥60 and <60 ml/min per 1.73 m 2 , respectively.

RESULTS

EHR creatinine values were available for a median of 8.3 years for 3041 participants. The total slope of decline in eGFR during the intervention phase was -0.67 ml/min per 1.73 m 2 per year (95% confidence interval [CI], -0.79 to -0.56) in the standard treatment group and -0.96 ml/min per 1.73 m 2 per year (95% CI, -1.08 to -0.85) in the intensive treatment group ( P < 0.001). The slopes were not significantly different during the observation phase: -1.02 ml/min per 1.73 m 2 per year (95% CI, -1.24 to -0.81) in the standard group and -0.85 ml/min per 1.73 m 2 per year (95% CI, -1.07 to -0.64) in the intensive group. Among participants without CKD at baseline, intensive treatment was associated with higher risk of a ≥30% decline in eGFR during the intervention (hazard ratio, 3.27; 95% CI, 2.43 to 4.40), but not during the postintervention observation phase. In those with CKD at baseline, intensive treatment was associated with a higher hazard of eGFR decline only during the intervention phase (hazard ratio, 1.95; 95% CI, 1.03 to 3.70).

CONCLUSIONS

Intensive BP lowering was associated with a steeper total slope of decline in eGFR and higher risk for kidney events during the intervention phase of the trial, but not during the postintervention observation phase.

Fluid Intake Management in Maintenance Hemodialysis Using a Smartphone-Based Application: A Pilot Study

Rationale & Objective

Increased interdialytic weight gain (IDWG) has been associated with increased morbidity and mortality. We evaluated the usefulness and safety of a mobile application (app) that allows patients receiving maintenance hemodialysis to self-monitor their daily fluid intake.

Study Design

Within group comparison before or during intervention.

Setting & Participants

Patients receiving maintenance hemodialysis with mean IDWG of <4%.

Exposure

Participants were trained to use a smartphone-based app, FiApp that allowed them to record fluid intake and compare with individual targeted daily fluid intake determined by the nephrologist.

Outcomes

The primary study outcome was the association between IDWG and fluid intake recorded in the FiApp. Secondary outcomes included FiApp safety and usage. Patient interviews were performed at weeks 1 and 4 to collect information regarding FiApp usability and recommendations for app improvements.

Analytical Approach

Mean, median, and standard deviation.

Results

Eighteen of 25 patients completed the full 4-week study, provided all app data, and completed 2 patient interviews. The mean 4-week IDWG during app use was similar to the baseline mean 4-week IDWG before app use; however, 61% of the participants had a decrease in IDWG when using the app compared with IDWG at baseline. Of the 18 participants who completed the study, only 1 had a mean 4-week IDWG that was 20% higher than that at baseline. The app was used on ≥80% of the days by 13 (72%) of 18 participants, and was used every day in 7 (39%) of 18 participants. The mean relationship between fluid reported in the app and fluid consumed was 40%.

Limitations

This safety study recruited patients who had IDWG of <4%.

Conclusions

A smartphone-based app can be safely used to help patients receiving maintenance hemodialysis track and control fluid intake. Motivated patients were able to decrease IDWG despite baseline IDWG being <4% of the body weight.

Trial Registration

NCT03759847.

Plain-Language Summary

Patients receiving maintenance hemodialysis struggle to limit fluid intake. Excess fluid intake can lead to adverse cardiovascular events. We developed a smartphone app to help patients receiving dialysis self-monitor their fluid intake. In this safety study in patients receiving dialysis with an interdialytic weight gain of <4% of the body weight, more than half of the patients were able to decrease their interdialytic fluid intake while using the app, and only 1 patient had an increase in interdialytic weight gain of >20% while using the app. Information gleaned from structured patient interviews will be used to refine this app.

Concordance between clinical outcomes in the Systolic Blood Pressure Intervention Trial and in the electronic health record

BACKGROUND

Randomized trials are the gold standard for generating clinical practice evidence, but follow-up and outcome ascertainment are resource-intensive. Electronic health record (EHR) data from routine care can be a cost-effective means of follow-up, but concordance with trial-ascertained outcomes is less well-studied.

METHODS

We linked EHR and trial data for participants of the Systolic Blood Pressure Intervention Trial (SPRINT), a randomized trial comparing intensive and standard blood pressure targets. Among participants with available EHR data concurrent to trial-ascertained outcomes, we calculated sensitivity, specificity, positive predictive value, and negative predictive value for EHR-recorded cardiovascular disease (CVD) events, using the gold standard of SPRINT-adjudicated outcomes (myocardial infarction (MI)/acute coronary syndrome (ACS), heart failure, stroke, and composite CVD events). We additionally compared the incidence of non-CVD adverse events (hyponatremia, hypernatremia, hypokalemia, hyperkalemia, bradycardia, and hypotension) in trial versus EHR data.

RESULTS

2468 SPRINT participants were included (mean age 68 (SD 9) years; 26% female). EHR data demonstrated ≥80% sensitivity and specificity, and ≥ 99% negative predictive value for MI/ACS, heart failure, stroke, and composite CVD events. Positive predictive value ranged from 26% (95% CI; 16%, 38%) for heart failure to 52% (95% CI; 37%, 67%) for MI/ACS. EHR data uniformly identified more non-CVD adverse events and higher incidence rates compared with trial ascertainment.

CONCLUSIONS

These results support a role for EHR data collection in clinical trials, particularly for capturing laboratory-based adverse events. EHR data may be an efficient source for CVD outcome ascertainment, though there is clear benefit from adjudication to avoid false positives.

A National Registry for People With All Stages of Kidney Disease: The National Kidney Foundation (NKF) Patient Network

RATIONALE & OBJECTIVE

The National Kidney Foundation (NKF) launched the first national US kidney disease patient registry, the NKF Patient Network, that is open to patients throughout the continuum of chronic kidney disease (CKD). The Network provides individualized education and will facilitate patient-centered research, clinical care, and health policy decisions. Here, we present the overall design and the results of a feasibility study that was conducted July through December 2020.

STUDY DESIGN

Longitudinal observational cohort study of patient-entered data with or without electronic health care record (EHR) linkage in collaboration with health systems.

SETTING & PARTICIPANTS

People with CKD, age≥18 years, are invited through their provider, NKF communications, or national outreach campaign. People self-enroll and share their data through a secure portal that offers individualized education and support. The first health system partner is Geisinger.

EXPOSURE

Any cause and stage of CKD, including dialysis and kidney transplant recipients.

OUTCOME

Feasibility of the EHR data transfer, participants' characteristics, and their perspectives on usability and content.

ANALYTICAL APPROACH

Data were collected and analyzed through the registry portal powered by the Pulse Infoframe healthie 2.0 platform.

RESULTS

During the feasibility study, 80 participants completed their profile, and 42 completed a satisfaction survey. Mean age was 57.5 years, 51% were women, 83% were White, and 89% were non-Hispanic or Latino. Of the participants, 60% were not aware of their level of estimated glomerular filtration rate and 91% of their urinary albumin-creatinine ratio.

LIMITATIONS

Challenges for the Network are lack of awareness of kidney disease for many with CKD, difficulty in recruiting vulnerable populations or those with low digital readiness, and loss to follow-up, all leading to selection bias.

CONCLUSIONS

The Network is positioned to become a national and international platform for real-world data that can inform the development of patient-centered research, care, and treatments.

Longer-Term All-Cause and Cardiovascular Mortality With Intensive Blood Pressure Control: A Secondary Analysis of a Randomized Clinical Trial

Importance

The Systolic Blood Pressure Intervention Trial (SPRINT) showed that intensive blood pressure control reduced cardiovascular morbidity and mortality. However, the legacy effect of intensive treatment is unknown.

Objective

To evaluate the long-term effects of randomization to intensive treatment with the incidence of cardiovascular and all-cause mortality approximately 4.5 years after the trial ended.

Design, Setting, and Participants

In this secondary analysis of a multicenter randomized clinical trial, randomization began on November 8, 2010, the trial intervention ended on August 20, 2015, and trial close-out visits occurred through July 2016. Patients 50 years and older with hypertension and increased cardiovascular risk but without diabetes or history of stroke were included from 102 clinic sites in the US and Puerto Rico. Analyses were conducted between October 2021 and February 2022.

Interventions

Randomization to systolic blood pressure (SBP) goal of less than 120 mm Hg (intensive treatment group; n = 4678) vs less than 140 mm Hg (standard treatment group; n = 4683).

Main Outcomes and Measures

Extended observational follow-up for mortality via the US National Death Index from 2016 through 2020. In a subset of 2944 trial participants, outpatient SBP from electronic health records during and after the trial were examined.

Results

Among 9361 randomized participants, the mean (SD) age was 67.9 (9.4) years, and 3332 (35.6%) were women. Over a median (IQR) intervention period of 3.3 (2.9-3.9) years, intensive treatment was beneficial for both cardiovascular mortality (hazard ratio [HR], 0.66; 95% CI, 0.49-0.89) and all-cause mortality (HR, 0.83; 95% CI, 0.68-1.01). However, at the median (IQR) total follow-up of 8.8 (8.3-9.3) years, there was no longer evidence of benefit for cardiovascular mortality (HR, 1.02; 95% CI, 0.84-1.24) or all-cause mortality (HR, 1.08; 95% CI, 0.94-1.23). In a subgroup of participants, the estimated mean outpatient SBP among participants randomized to intensive treatment increased from 132.8 mm Hg (95% CI, 132.0-133.7) at 5 years to 140.4 mm Hg (95% CI, 137.8-143.0) at 10 years following randomization.

Conclusions and Relevance

The beneficial effect of intensive treatment on cardiovascular and all-cause mortality did not persist after the trial. Given increasing outpatient SBP levels in participants randomized to intensive treatment following the trial, these results highlight the importance of consistent long-term management of hypertension.

Trial Registration

ClinicalTrials.gov Identifier: NCT01206062.

Effect of Intensive versus Standard BP Control on AKI and Subsequent Cardiovascular Outcomes and Mortality: Findings from the SPRINT EHR Study

Background

Adjudication of inpatient AKI in the Systolic Blood Pressure Intervention Trial (SPRINT) was based on billing codes and admission and discharge notes. The purpose of this study was to evaluate the effect of intensive versus standard BP control on creatinine-based inpatient and outpatient AKI, and whether AKI was associated with cardiovascular disease (CVD) and mortality.

Methods

We linked electronic health record (EHR) data from 47 clinic sites with trial data to enable creatinine-based adjudication of AKI. Cox regression was used to evaluate the effect of intensive BP control on the incidence of AKI, and the relationship between incident AKI and CVD and all-cause mortality.

Results

A total of 3644 participants had linked EHR data. A greater number of inpatient AKI events were identified using EHR data (187 on intensive versus 155 on standard treatment) as compared with serious adverse event (SAE) adjudication in the trial (95 on intensive versus 61 on standard treatment). Intensive treatment increased risk for SPRINT-adjudicated inpatient AKI (HR, 1.51; 95% CI, 1.09 to 2.08) and for creatinine-based outpatient AKI (HR, 1.40; 95% CI, 1.15 to 1.70), but not for creatinine-based inpatient AKI (HR, 1.20; 95% CI, 0.97 to 1.48). Irrespective of the definition (SAE or creatinine based), AKI was associated with increased risk for all-cause mortality, but only creatinine-based inpatient AKI was associated with increased risk for CVD.

Conclusions

Creatinine-based ascertainment of AKI, enabled by EHR data, may be more sensitive and less biased than traditional SAE adjudication. Identifying ways to prevent AKI may reduce mortality further in the setting of intensive BP control.

Is Medication Adherence Predictive of Cardiovascular Outcomes and Blood Pressure Control? The Systolic Blood Pressure Intervention Trial (SPRINT)

BACKGROUND

Adherence to study medications is crucial to evaluating treatment effects in clinical trials. To assess whether in the SPRINT trial, adherence and cardiovascular outcomes are associated regardless of intervention assignment.

METHODS

This study included 9,361 participants aged ≥50 years, recruited from 102 clinics. Participants were randomized to a Standard Treatment Group (targeted systolic blood pressure [SBP] <140 mm Hg) or an Intensive Treatment Group (targeted SBP <120 mm Hg) and followed for incident cardiovascular events until the study was halted early for benefit. The 8-item Morisky Medication Adherence Scale (MMAS-8) was administered at baseline, and at the 12- and 48-month (or close out) visit.

RESULTS

Adjusting for covariates, there was no association between the baseline 8-item MMAS-8 and the likelihood of the primary composite endpoint, any of the secondary endpoints, or blood pressure (BP) control. Low adherence was associated with a higher body mass index, SBP, diastolic BP, and Patient Health Questionnaire, and high adherence was associated with a higher Montreal Cognitive Assessment. There was no difference in the MMAS-8 over time by treatment arm assignment. For the primary outcome (a composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes), baseline odds ratios (95% confidence intervals) for the Low vs. Medium and vs. High; and, for Medium vs. High MMAS-8 were 1.02 (0.82-1.28), 1.07 (0.85-1.34), and 1.05 (0.88-1.250).

CONCLUSIONS

In SPRINT, medication adherence as measured using the MMAS-8 was not associated with outcomes or BP control.

Impact of DBP on all-cause and cardiovascular mortality: results from the National Health and Nutrition Examination survey, 1999-2014

INTRODUCTION

Hypertension is common and has a significant effect on cardiovascular morbidity and death. However, despite the development of several guidelines to manage SBP, there is little research or guidance on the evaluation and management of DBP or isolated diastolic hypertension (IDH).

METHOD

To determine the association of DBP with all-cause and cardiovascular mortality, we used NHANES data from 1999 to 2014 and included adults aged at least 18 years. The relationship between DBP, IDH and all-cause, cardiovascular mortality was evaluated.

RESULTS

Of the 35 109 participants, all-cause death occurred in 10.6%, and cardiovascular death occurred in 2.1% over a median follow-up of 7.2 years. Multivariate Cox regression analysis revealed that the risk of all-cause mortality was significantly higher in the lowest (≤56.9 mmHg) DBP groups than in the reference group (DBP 74-76.9 mmHg). However, the risk of cardiovascular mortality was significantly higher in the lowest and highest (≥83 mmHg) DBP group than in the reference group. The risk of all-cause mortality was higher for most groups with SBP at least 140 mmHg than for the reference group with DBP 74-76.9 mmHg and SBP 100-139.9 mmHg. Both the 2018 ESC/NICE and the 2017 AHA/ACC-defined IDH was not significantly associated with all-cause mortality.

CONCLUSION

DBP and all-cause mortality had an inverse relationship, whereas DBP and cardiovascular mortality had a U-shaped relationship, with the DBP reference group having the lowest risk for all-cause and cardiovascular mortality. There was no significant relationship between IDH and death.

SPRINT Revisited: Updated Results and Implications

The SPRINT (Systolic Blood Pressure Intervention Trial) results have influenced clinical practice but have also generated discussion regarding the validity, generalizability, and importance of the findings. Following the SPRINT primary results manuscript in 2015, additional results and analyses of the data have addressed these concerns. The primary objective of this article is to respond to key questions that have been raised.

Incidence and Outcomes of Acute Heart Failure With Preserved Versus Reduced Ejection Fraction in SPRINT

BACKGROUND

In the SPRINT (Systolic Blood Pressure Intervention Trial), intensive BP treatment reduced acute decompensated heart failure (ADHF) events. Here, we report the effect on HF with preserved ejection fraction (HFpEF) and HF with reduced EF (HFrEF) and their subsequent outcomes.

METHODS

Incident ADHF was defined as hospitalization or emergency department visit, confirmed, and formally adjudicated by a blinded events committee using standardized protocols. HFpEF was defined as EF ≥45%, and HFrEF was EF <45%.

RESULTS

Among the 133 participants with incident ADHF who had EF assessment, 69 (52%) had HFpEF and 64 (48%) had HFrEF (P value: 0.73). During average 3.3 years follow-up in those who developed incident ADHF, rates of subsequent all-cause and HF hospital readmission and mortality were high, but there were no significant differences between those who developed HFpEF versus HFrEF. Randomization to the intensive arm had no effect on subsequent mortality or readmissions after the initial ADHF event, irrespective of EF subtype. During follow-up among participants who developed HFpEF, although relatively modest number of events limited statistical power, age was an independent predictor of all-cause mortality, and Black race independently predicted all-cause and HF hospital readmission.

CONCLUSIONS

In SPRINT, intensive BP reduction decreased both acute decompensated HFpEF and HFrEF events. After initial incident ADHF, rates of subsequent hospital admission and mortality were high and were similar for those who developed HFpEF or HFrEF. Randomization to the intensive arm did not alter the risks for subsequent all-cause, or HF events in either HFpEF or HFrEF. Among those who developed HFpEF, age and Black race were independent predictors of clinical outcomes. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01206062.

The Predialysis Serum Sodium Level Modifies the Effect of Hemodialysis Frequency on Left-Ventricular Mass: The Frequent Hemodialysis Network Trials

INTRODUCTION

The Frequent Hemodialysis Network (FHN) Daily and Nocturnal trials aimed to compare the effects of hemodialysis (HD) given 6 versus 3 times per week. More frequent in-center HD significantly reduced left-ventricular mass (LVM), with more pronounced effects in patients with low urine volumes. In this study, we aimed to explore another potential effect modifier: the predialysis serum sodium (SNa) and related proxies of plasma tonicity.

METHODS

Using data from the FHN Daily and Nocturnal Trials, we compared the effects of frequent HD on LVM among patients stratified by SNa, dialysate-to-predialysis serum-sodium gradient (GNa), systolic and diastolic blood pressure, time-integrated sodium-adjusted fluid load (TIFL), and extracellular fluid volume estimated by bioelectrical impedance analysis.

RESULTS

In 197 enrolled subjects in the FHN Daily Trial, the treatment effect of frequent HD on ∆LVM was modified by SNa. When the FHN Daily Trial participants are divided into lower and higher predialysis SNa groups (less and greater than 138 mEq/L), the LVM reduction in the lower group was substantially higher (-28.0 [95% CI -40.5 to -15.4] g) than in the higher predialysis SNa group (-2.0 [95% CI -15.5 to 11.5] g). Accounting for GNa, TIFL also showed more pronounced effects among patients with higher GNa or higher TIFL. Results in the Nocturnal Trial were similar in direction and magnitude but did not reach statistical significance.

DISCUSSION/CONCLUSION

In the FHN Daily Trial, the favorable effects of frequent HD on left-ventricular hypertrophy were more pronounced among patients with lower predialysis SNa and higher GNa and TIFL. Whether these metrics can be used to identify patients most likely to benefit from frequent HD or other dialytic or nondialytic interventions remains to be determined. Prospective, adequately powered studies studying the effect of GNa reduction on mortality and hospitalization are needed.

Final Report of a Trial of Intensive versus Standard Blood-Pressure Control

BACKGROUND

In a previously reported randomized trial of standard and intensive systolic blood-pressure control, data on some outcome events had yet to be adjudicated and post-trial follow-up data had not yet been collected.

METHODS

We randomly assigned 9361 participants who were at increased risk for cardiovascular disease but did not have diabetes or previous stroke to adhere to an intensive treatment target (systolic blood pressure, <120 mm Hg) or a standard treatment target (systolic blood pressure, <140 mm Hg). The primary outcome was a composite of myocardial infarction, other acute coronary syndromes, stroke, acute decompensated heart failure, or death from cardiovascular causes. Additional primary outcome events occurring through the end of the intervention period (August 20, 2015) were adjudicated after data lock for the primary analysis. We also analyzed post-trial observational follow-up data through July 29, 2016.

RESULTS

At a median of 3.33 years of follow-up, the rate of the primary outcome and all-cause mortality during the trial were significantly lower in the intensive-treatment group than in the standard-treatment group (rate of the primary outcome, 1.77% per year vs. 2.40% per year; hazard ratio, 0.73; 95% confidence interval [CI], 0.63 to 0.86; all-cause mortality, 1.06% per year vs. 1.41% per year; hazard ratio, 0.75; 95% CI, 0.61 to 0.92). Serious adverse events of hypotension, electrolyte abnormalities, acute kidney injury or failure, and syncope were significantly more frequent in the intensive-treatment group. When trial and post-trial follow-up data were combined (3.88 years in total), similar patterns were found for treatment benefit and adverse events; however, rates of heart failure no longer differed between the groups.

CONCLUSIONS

Among patients who were at increased cardiovascular risk, targeting a systolic blood pressure of less than 120 mm Hg resulted in lower rates of major adverse cardiovascular events and lower all-cause mortality than targeting a systolic blood pressure of less than 140 mm Hg, both during receipt of the randomly assigned therapy and after the trial. Rates of some adverse events were higher in the intensive-treatment group. (Funded by the National Institutes of Health; SPRINT ClinicalTrials.gov number, NCT01206062.).

Effect of Intensive Blood Pressure Control on Aortic Stiffness in the SPRINT-HEART

[Figure: see text].

Identifying critically important cardiovascular outcomes for trials in hemodialysis: an international survey with patients, caregivers and health professionals

BACKGROUND

Cardiovascular disease (CVD) is a major contributor to morbidity and mortality in people on hemodialysis (HD). Cardiovascular outcomes are reported infrequently and inconsistently across trials in HD. This study aimed to identify the priorities of patients/caregivers and health professionals (HPs) for CVD outcomes to be incorporated into a core outcome set reported in all HD trials.

METHODS

In an international online survey, participants rated the absolute importance of 10 cardiovascular outcomes (derived from a systematic review) on a 9-point Likert scale, with 7-9 being critically important. The relative importance was determined using a best-worst scale. Likert means, medians and proportions and best-worst preference scores were calculated for each outcome. Comments were thematically analyzed.

RESULTS

Participants included 127 (19%) patients/caregivers and 549 (81%) HPs from 53 countries, of whom 530 (78%) completed the survey in English and 146 (22%) in Chinese. All but one cardiovascular outcome ('valve replacement') was rated as critically important (Likert 7-9) by all participants; 'sudden cardiac death', 'heart attack', 'stroke' and 'heart failure' were all rated at the top by patients/caregivers (median Likert score 9). Patients/caregivers ranked the same four outcomes as the most important outcomes with mean preference scores of 6.2 (95% confidence interval 4.8-7.5), 5.9 (4.6-7.2), 5.3 (4.0-6.6) and 4.9 (3.6-6.3), respectively. The same four outcomes were ranked most highly by HPs. We identified five themes underpinning the prioritization of outcomes: 'clinical equipoise and potential for intervention', 'specific or attributable to HD', 'severity or impact on the quality of life', 'strengthen knowledge and education', and 'inextricably linked burden and risk'.

CONCLUSIONS

Patients and HPs believe that all cardiovascular outcomes are of critical importance but consistently identify sudden cardiac death, myocardial infarction, stroke and heart failure as the most important outcomes to be measured in all HD trials.

Recognition and management of community-acquired acute kidney injury in low-resource settings in the ISN 0by25 trial: A multi-country feasibility study

BACKGROUND

Acute kidney injury (AKI) is increasingly encountered in community settings and contributes to morbidity, mortality, and increased resource utilization worldwide. In low-resource settings, lack of awareness of and limited access to diagnostic and therapeutic interventions likely influence patient management. We evaluated the feasibility of the use of point-of-care (POC) serum creatinine and urine dipstick testing with an education and training program to optimize the identification and management of AKI in the community in 3 low-resource countries.

METHODS AND FINDINGS

Patients presenting to healthcare centers (HCCs) from 1 October 2016 to 29 September 2017 in the cities Cochabamba, Bolivia; Dharan, Nepal; and Blantyre, Malawi, were assessed utilizing a symptom-based risk score to identify patients at moderate to high AKI risk. POC testing for serum creatinine and urine dipstick at enrollment were utilized to classify these patients as having chronic kidney disease (CKD), acute kidney disease (AKD), or no kidney disease (NKD). Patients were followed for a maximum of 6 months with repeat POC testing. AKI development was assessed at 7 days, kidney recovery at 1 month, and progression to CKD and mortality at 3 and 6 months. Following an observation phase to establish baseline data, care providers and physicians in the HCCs were trained with a standardized protocol utilizing POC tests to evaluate and manage patients, guided by physicians in referral hospitals connected via mobile digital technology. We evaluated 3,577 patients, and 2,101 were enrolled: 978 in the observation phase and 1,123 in the intervention phase. Due to the high number of patients attending the centers daily, it was not feasible to screen all patients to assess the actual incidence of AKI. Of enrolled patients, 1,825/2,101 (87%) were adults, 1,117/2,101 (53%) were females, 399/2,101 (19%) were from Bolivia, 813/2,101 (39%) were from Malawi, and 889/2,101 (42%) were from Nepal. The age of enrolled patients ranged from 1 month to 96 years, with a mean of 43 years (SD 21) and a median of 43 years (IQR 27-62). Hypertension was the most common comorbidity (418/2,101; 20%). At enrollment, 197/2,101 (9.4%) had CKD, and 1,199/2,101 (57%) had AKD. AKI developed in 30% within 7 days. By 1 month, 268/978 (27%) patients in the observation phase and 203/1,123 (18%) in the intervention phase were lost to follow-up. In the intervention phase, more patients received fluids (observation 714/978 [73%] versus intervention 874/1,123 [78%]; 95% CI 0.63, 0.94; p = 0.012), hospitalization was reduced (observation 578/978 [59%] versus intervention 548/1,123 [49%]; 95% CI 0.55, 0.79; p < 0.001), and admitted patients with severe AKI did not show a significantly lower mortality during follow-up (observation 27/135 [20%] versus intervention 21/178 [11.8%]; 95% CI 0.98, 3.52; p = 0.057). Of 504 patients with kidney function assessed during the 6-month follow-up, de novo CKD arose in 79/484 (16.3%), with no difference between the observation and intervention phase (95% CI 0.91, 2.47; p = 0.101). Overall mortality was 273/2,101 (13%) and was highest in those who had CKD (24/106; 23%), followed by those with AKD (128/760; 17%), AKI (85/628; 14%), and NKD (36/607; 6%). The main limitation of our study was the inability to determine the actual incidence of kidney dysfunction in the health centers as it was not feasible to screen all the patients due to the high numbers seen daily.

CONCLUSIONS

This multicenter, non-randomized feasibility study in low-resource settings demonstrates that it is feasible to implement a comprehensive program utilizing POC testing and protocol-based management to improve the recognition and management of AKI and AKD in high-risk patients in primary care.

Estimated GFR Variability and Risk of Cardiovascular Events and Mortality in SPRINT (Systolic Blood Pressure Intervention Trial)

RATIONALE AND OBJECTIVE

Although low estimated glomerular filtration rate (eGFR) is associated with cardiovascular disease (CVD) events and mortality, the clinical significance of variability in eGFR over time is uncertain. This study aimed to evaluate the associations between variability in eGFR and the risk of CVD events and all-cause mortality.

STUDY DESIGN

Longitudinal analysis of clinical trial participants.

SETTINGS AND PARTICIPANTS

7,520 Systolic Blood Pressure Intervention Trial (SPRINT) participants ≥50 year of age with 1 or more CVD risk factors.

PREDICTORS

eGFR variability, estimated by the coefficient of variation of eGFR assessments at the 6th, 12th, and 18-month study visits.

OUTCOMES

The SPRINT primary CVD composite outcome (myocardial infarction, acute coronary syndrome, stroke, heart failure, or CVD death) and all-cause mortality from month 18 to the end of follow-up.

ANALYTICAL APPROACH

Cox models were used to evaluate associations between eGFR variability and CVD outcomes and all-cause mortality. Models were adjusted for demographics, randomization arm, CVD risk factors, albuminuria, and eGFR at month 18.

RESULTS

Mean age was 68 ± 9 years; 65% were men; and 58% were White. The mean eGFR was 73 ± 21 (SD) mL/min/1.73 m² at 6 months. There were 370 CVD events and 154 deaths during a median follow-up of 2.4 years. Greater eGFR variability was associated with higher risk for all-cause mortality (hazard ratio [HR] per 1 SD greater variability, 1.29; 95% CI, 1.14-1.45) but not CVD events (HR, 1.05; 95% CI, 0.95-1.16) after adjusting for albuminuria, eGFR, and other CVD risk factors. Associations were similar when stratified by treatment arm and by baseline CKD status, when accounting for concurrent systolic blood pressure changes, use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and diuretic medications during follow up.

LIMITATIONS

Persons with diabetes and proteinuria > 1 g/d were excluded.

CONCLUSIONS

In trial participants at high risk for CVD, greater eGFR variability was independently associated with all-cause mortality but not CVD events.

Effects of Intensive Systolic Blood Pressure Control on All-Cause Hospitalizations

Intensive blood pressure control decreases the rate of cardiovascular events by >25% compared with standard blood pressure control. We sought to determine whether the decrease in cardiovascular events seen with intensive blood pressure control is associated with an increased rate of other causes of hospitalization. This is a post hoc analysis of SPRINT (Systolic Blood Pressure Intervention Trial) in 9361 adult participants with hypertension and elevated cardiovascular risk. Participants were randomly assigned to an intensive or standard systolic blood pressure goal (<120 or <140 mm Hg, respectively). The primary outcome was hospitalization rates per 100 person-years for hospitalizations not associated with SPRINT primary events. After excluding hospitalizations linked to SPRINT primary events, there were 4678 participants with a rate of 19.70 hospitalizations per 100 person-years, compared with 4683 participants with a rate of 19.65 (P=0.37). Equivalence testing shows that these hospitalization rates were statistically equivalent at the P=0.05 level. Of those with hospitalizations, >1 hospitalization was seen in 38.8% of intensive arm participants and 41.9% of standard arm participants (P=0.08). The mean cumulative count of nonprimary event hospitalizations was comparable between the two arms. The most common causes of hospitalization were cardiovascular (23.6%) followed by injuries, including bone and joint therapeutic procedures (15.7%), infections (12.0%), and nervous systems disorders (10.7%). No categories of hospitalization were statistically more common in the intensive arm compared with the standard arm. Thus, the decrease in cardiovascular events seen with intensive blood pressure control is not associated with an increased rate of other causes of hospitalization. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT01206062.

The Difference Between Cystatin C- and Creatinine-Based Estimated GFR and Associations With Frailty and Adverse Outcomes: A Cohort Analysis of the Systolic Blood Pressure Intervention Trial (SPRINT)

RATIONALE & OBJECTIVE

In prior research and in practice, the difference between estimated glomerular filtration rate (eGFR) calculated from cystatin C level and eGFR calculated from creatinine level has not been assessed for clinical significance and relevance. We evaluated whether these differences contain important information about frailty.

STUDY DESIGN

A cohort analysis of the Systolic Blood Pressure Intervention Trial (SPRINT).

SETTING & PARTICIPANTS

9,092 hypertensive SPRINT participants who had baseline measurements of serum creatinine, cystatin C, and frailty.

EXPOSURE

eGFRs calculated using CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equations (eGFR_cys and eGFR_cr), and eGFR_Diff, calculated as eGFR_cys-eGFR_cr.

OUTCOMES

A validated 35-item frailty index that included questionnaire data for general and physical health, limitations of activities, pain, depression, sleep, energy level, self-care, and smoking status, as well as medical history, cognitive assessment, and laboratory data. We defined frailty as frailty index score>0.21 (range, 0-1). The incidence of injurious falls, hospitalizations, cardiovascular events, and mortality was also recorded.

ANALYTICAL APPROACH

We used logistic regression to model the cross-sectional association of baseline eGFR_Diff with frailty among all SPRINT participants. Adjusted proportional hazards regression was used to evaluate the association of eGFR_Diff with adverse outcomes and mortality.

RESULTS

Mean age was 68±9 (SD) years, mean eGFR_cys and eGFR_cr were 73±23 and 72±20mL/min/1.73m², and mean eGFR_Diff was 0.5±15mL/min/1.73m². In adjusted models, each 1-SD higher eGFR_Diff was associated with 24% lower odds of prevalent frailty (OR, 0.76; 95% CI, 0.71-0.81), as well as with lower incidence rate of injurious falls (HR, 0.84; 95% CI, 0.77-0.92), hospitalization (HR, 0.91; 95% CI, 0.88-0.95), cardiovascular events (HR, 0.89; 95% CI, 0.81-0.97), and all-cause mortality (HR, 0.71; 95% CI, 0.63-0.82); P<0.01.

LIMITATIONS

Gold-standard measure of kidney function and assessment of muscle mass were not available.

CONCLUSIONS

The difference between eGFR_cys and eGFR_cr is associated with frailty and health status. Positive eGFR_Diff is strongly associated with lower risks for longitudinal adverse outcomes and mortality, even after adjusting for chronic kidney disease stage and baseline frailty.

Effects of Intensive Blood Pressure Control in Patients with and without Albuminuria: Post Hoc Analyses from SPRINT

BACKGROUND AND OBJECTIVES

It is unclear whether the presence of albuminuria modifies the effects of intensive systolic BP control on risk of eGFR decline, cardiovascular events, or mortality.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Systolic Blood Pressure Intervention Trial randomized nondiabetic adults ≥50 years of age at high cardiovascular risk to a systolic BP target of <120 or <140 mm Hg, measured by automated office BP. We compared the absolute risk differences and hazard ratios of ≥40% eGFR decline, the Systolic Blood Pressure Intervention Trial primary cardiovascular composite outcome, and all-cause death in those with or without baseline albuminuria (urine albumin-creatinine ratio ≥30 mg/g).

RESULTS

Over a median follow-up of 3.1 years, 69 of 1723 (4%) participants with baseline albuminuria developed ≥40% eGFR decline compared with 61 of 7162 (1%) participants without albuminuria. Incidence rates of ≥40% eGFR decline were higher in participants with albuminuria (intensive, 1.74 per 100 person-years; standard, 1.17 per 100 person-years) than in participants without albuminuria (intensive, 0.48 per 100 person-years; standard, 0.11 per 100 person-years). Although effects of intensive BP lowering on ≥40% eGFR decline varied by albuminuria on the relative scale (hazard ratio, 1.48; 95% confidence interval, 0.91 to 2.39 for albumin-creatinine ratio ≥30 mg/g; hazard ratio, 4.55; 95% confidence interval, 2.37 to 8.75 for albumin-creatinine ratio <30 mg/g; P value for interaction <0.001), the absolute increase in ≥40% eGFR decline did not differ by baseline albuminuria (incidence difference, 0.38 events per 100 person-years for albumin-creatinine ratio ≥30 mg/g; incidence difference, 0.58 events per 100 person-years for albumin-creatinine ratio <30 mg/g; P value for interaction =0.60). Albuminuria did not significantly modify the beneficial effects of intensive systolic BP lowering on cardiovascular events or mortality evaluated on relative or absolute scales.

CONCLUSIONS

Albuminuria did not modify the absolute benefits and risks of intensive systolic BP lowering.

A randomized pilot study to evaluate graft versus fistula vascular access strategy in older patients with advanced kidney disease: results of a feasibility study

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.

Intensive vs Standard Blood Pressure Control in Adults 80 Years or Older: A Secondary Analysis of the Systolic Blood Pressure Intervention Trial

OBJECTIVES

To evaluate the effect of intensive systolic blood pressure (SBP) control in older adults with hypertension, considering cognitive and physical function.

DESIGN

Secondary analysis.

SETTING

Systolic Blood Pressure Intervention Trial (SPRINT) PARTICIPANTS: Adults 80 years or older.

INTERVENTION

Participants with hypertension but without diabetes (N = 1167) were randomized to an SBP target below 120 mm Hg (intensive treatment) vs a target below 140 mm Hg (standard treatment).

MEASUREMENTS

We measured the incidence of cardiovascular disease (CVD), mortality, changes in renal function, mild cognitive impairment (MCI), probable dementia, and serious adverse events. Gait speed was assessed via a 4-m walk test, and the Montreal Cognitive Assessment (MoCA) was used to quantify baseline cognitive function.

RESULTS

Intensive treatment led to significant reductions in cardiovascular events (hazard ratio [HR] = .66; 95% confidence interval [CI] = .49-.90), mortality (HR = .67; 95% CI = .48-.93), and MCI (HR = .70; 95% CI = .51-.96). There was a significant interaction (P < .001) whereby participants with higher baseline scores on the MoCA derived strong benefit from intensive treatment for a composite of CVD and mortality (HR = .40; 95% CI = .28-.57), with no appreciable benefit in participants with lower scores on the MoCA (HR = 1.33 = 95% CI = .87-2.03). There was no evidence of heterogeneity of treatment effects with respect to gait speed. Rates of acute kidney injury and declines of at least 30% in estimated glomerular filtration rate were increased in the intensive treatment group with no between-group differences in the rate of injurious falls.

CONCLUSION

In adults aged 80 years or older, intensive SBP control lowers the risk of major cardiovascular events, MCI, and death, with increased risk of changes to kidney function. The cardiovascular and mortality benefits of intensive SBP control may not extend to older adults with lower baseline cognitive function.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT01206062. J Am Geriatr Soc 68:496-504, 2020.

Urine Markers of Kidney Tubule Cell Injury and Kidney Function Decline in SPRINT Trial Participants with CKD

BACKGROUND AND OBJECTIVES

eGFR and albuminuria primarily reflect glomerular function and injury, whereas tubule cell atrophy and interstitial fibrosis on kidney biopsy are important risk markers for CKD progression. Kidney tubule injury markers have primarily been studied in hospitalized AKI. Here, we examined the association between urinary kidney tubule injury markers at baseline with subsequent loss of kidney function in persons with nondiabetic CKD who participated in the Systolic Blood Pressure Intervention Trial (SPRINT).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Among 2428 SPRINT participants with CKD (eGFR<60 ml/min per 1.73 m²) at baseline, we measured urine markers of tubule injury (IL-18, kidney injury molecule-1 [KIM-1], neutrophil gelatinase-associated lipocalin [NGAL]), inflammation (monocyte chemoattractant protein-1 [MCP-1]), and repair (human cartilage glycoprotein-40 [YKL-40]). Cox proportional hazards models evaluated associations of these markers with the kidney composite outcome of 50% eGFR decline or ESKD requiring dialysis or kidney transplantation, and linear mixed models evaluated annualized change in eGFR.

RESULTS

Mean participant age was 73±9 (SD) years, 60% were men, 66% were white, and mean baseline eGFR was 46±11 ml/min per 1.73 m². There were 87 kidney composite outcome events during a median follow-up of 3.8 years. Relative to the respective lowest quartiles, the highest quartiles of urinary KIM-1 (hazard ratio, 2.84; 95% confidence interval [95% CI], 1.31 to 6.17), MCP-1 (hazard ratio, 2.43; 95% CI, 1.13 to 5.23), and YKL-40 (hazard ratio, 1.95; 95% CI, 1.08 to 3.51) were associated with higher risk of the kidney composite outcome in fully adjusted models including baseline eGFR and urine albumin. In linear analysis, urinary IL-18 was the only marker associated with eGFR decline (-0.91 ml/min per 1.73 m² per year for highest versus lowest quartile; 95% CI, -1.44 to -0.38), a finding that was stronger in the standard arm of SPRINT.

CONCLUSIONS

Urine markers of tubule cell injury provide information about risk of subsequent loss of kidney function, beyond the eGFR and urine albumin.

Nutritional Markers during Peritoneal Dialysis: Data from the 1998 Peritoneal Dialysis Core Indicators Study

Objective

This analysis explores the nutritional status of adult U.S. peritoneal dialysis (PD) patients.

Design

The Peritoneal Dialysis Core Indicators Study is a prospective cross-sectional prevalence survey describing the care provided to a random sample of adult U.S. PD patients.

Methods and Population

Prevalence data were collected from a national random sample of 1381 adult PD patients participating in the United States End Stage Renal Disease (ESRD) program.

Results

The median age of these patients was 55 years, 61% were Caucasian; the leading cause of ESRD was diabetes mellitus. Age, sex, size, peritoneal permeability, dialysis adequacy, and nutritional indices did not differ between patients on continuous ambulatory PD and patients on automated PD. The dialysis prescriptions employed achieved mean weekly Kt/V urea (wKt/V) and creatinine clearance (wCCr) values of 2.22 ± 0.57 and 67.8 ± 22.5 L/1.73 m2/week, respectively. The PD patients were large, with a mean body weight of 77 ± 21 kg and body mass index (BMI) of 27 ± 8.6 kg/m2. The mean serum albumin of these patients was 3.5 ± 0.51 g/dL, and 43% of values fell below the National Kidney Foundation Dialysis Outcomes Quality Initiative's desired range. The PD patients had a normalized protein equivalent of nitrogen appearance (nPNA) of 1.0 ± 0.57 g/kg/day, a normalized creatinine appearance rate (nCAR) of 17 ± 7.3 mg/kg/day, and an estimated lean body mass (%LBM) of 62% ± 18% of body weight. Serum albumin correlated positively with patient size, nCAR, and nPNA, but negatively with age, the presence of diabetes mellitus, female gender, erythropoietin dose, the creatinine dialysate-to-plasma ratio results of peritoneal equilibration testing, and the dialysis portion of the wCCr. The duration of ESRD experience correlated negatively with both serum albumin and patient size, although these relationships were complex.

Conclusion

Peritoneal dialysis patients generally have marginal serum albumin levels, a finding incongruent with alternative measures of nutritional status, such as weight, BMI, and creatinine generation. Serum albumin is reduced in patients with high peritoneal permeability ( i.e., rapid transporters) and, because these patients generally have higher than average wCCr values, serum albumin is inversely correlated with the dialysis component of the wCCr. The presumptive nutritional indicators (BMI, %LBM, nPNA, and serum albumin) provide disparate estimates, varying from 10% to 50% for the prevalence of nutritionally stressed PD patients.

Changes in Peritoneal Transport during the First Month of Peritoneal Dialysis

Objective

To determine if peritoneal transport characteristics change during the initial month of peritoneal dialysis.

Design

Retrospective review of peritoneal equilibration test (PET) results in patients who received their first PET during the first two weeks of peritoneal dialysis (early PET group) versus patients who received their first PET between four and 28 weeks after the initiation of dialysis (late PET group). The initial PET values were compared to subsequent PET results obtained approximately seven months after the initial PET.

Setting

Peritoneal dialysis unit of a tertiary medical center.

Outcome Measures

PET results and calculated mass transfer area coefficient (MT AC) values.

Patients

Thirty-four peritoneal dialysis patients in the early PET group and 17 peritoneal dialysis patients in the late PET group.

Results

In the early PET group, there was a statistically significant increase from the initial to follow-up values for both dialysate-to-plasma (DIP) creatinine and MTAC creatinine (p < 0.01) as well as a significant decrease for four-hour dialysate to initial dialysate ratios (DID) glucose (p = 0.08) and MTAC glucose (p < 0.05). In the late PET group, there was no significant change in any of these parameters with time. However, in the late PET group, there was a significant decrease in DIP urea values with time (p < 0.01), but not with MTAC urea. In addition, there were no differences over time in either group for serum albumin or hematocrit values.

Conclusion

During the first two weeks of peritoneal dialysis, there tends to be a change in peritoneal transport characteristics in some patients. PET data obtained during this time period should be interpreted as preliminary.

Body Surface Area Limitations in Achieving Adequate Therapy in Peritoneal Dialysis Patients

Objective

To estimate the maximal body surface area (BSA) at which an uric chronic peritoneal dialysis patients can achieve adequate peritoneal dialysis using a variety of continuous ambulatory peritoneal dialysis (CAPD) and cycler regimens. Adequate dialysis was defined as a creatinine clearance of either 60 L/week/1.73 m2 or 70 L/ week/1.73 m2.

Design

Calculation of daily peritoneal creatinine clearances using standard formulas. For CAPD patients, creatinine clearance was calculated using published values for dialysate-to-plasma ratios for creatinine (DIP cr) measured over a 24-hour period and assuming a daily ultrafiltration rate of 1.5 to 2.0 L/day. For cycler patients, creatinine clearance was calculated for both one and two-hour dwell volumes, using published values for DIP cr from the peritoneal equilibration test and assuming a daily ultrafiltration rate of 2.0 L/day. All clearances were corrected to a normalized body surface area of 1.73 m2.

Results

For CAPD patients, 2– L dwell volumes can provide a weekly creatinine clearance of 60 L/week/1.73 m2 in patients with BSA < 1.45 m2 in the high transporter group and with BSA < 1.2 m2 in the low-average transporter group. Increasing dwell volume from 2.0 to 2.5 L increases these BSA limits in the four transport groups by 0.2 0.3 m2. Cycler therapy is not a viable option for patients in the low transporter group, and this therapy can achieve adequate creatinine clearances in patients in the low-average transport group only with large dwell volumes and in patients with BSA < 1.55 m2. However, in the high-average and high transporter groups, cycler therapy provides for superior creatinine clearances compared to CAPD patients using similar dwell volumes.

Conclusions

Adequate creatinine clearances in anuric patients are most likely to be achieved in patients with BSA > 2.0 m2 if they have high-average or high transport characteristics and are receiving cycler therapy with large dwell volumes and at least one daytime dwell. However, adequate creatinine clearances may be difficult to achieve in an uric patients who have a large BSA an d a low or low-average transport type, regardless of peritoneal dialysis modality. These patients should be considered for either high-dose peritoneal dialysis (multiple daytime and nighttime exchanges) or hemodialysis therapy.

Assessment of Dialysis Dose by Measured Clearance versus Extrapolated Data

Objective

To determine whether estimates of daily dialysis clearance of creatinine and urea, based on data from the 4-hour peritoneal equilibration test, correlate well with daily dialysis clearance measured by 24-hour dialysate collection in chronic ambulatory peritoneal dialysis patients.

Design

Prospective study in which each subject collected all dialysate from a 24-hour period and then immediately thereafter underwent a standard peritoneal equilibration test (PET). Daily clearances of creatinine and urea were calculated from 24-hour dialysate collections by standard methods and then were compared with several estimates of 24-hour clearance based on PET data.

Setting

Single peritoneal dialysis unit of a university teaching hospital.

Patients

Thirty-six stable patients on continuous ambulatory peritoneal dialysis (CAPD).

Main Outcome

The estimated values for daily dialysis clearance both overestimated and underestimated the measured 24-hour clearance. The correlation coefficient between the extrapolations and the actual 24-hour clearances ranged from 0.63–0.68. The range of discordance for daily creatinine clearance was from -2530 mL/dayto +2199 mL/day. For daily urea clearance, the range of discordance was from -21 03 mL/ day to +1940 mL/day. The peritoneal membrane transport characteristics of the individual patient did not predict whether the extrapolation overestimated orunder estimated the measured daily clearance.

Conclusion

Extrapolation of PET data is not a reliable method to estimate the dose of dialysis delivered to the patient. A 24-hour collection of dialysis is necessary for this determination.

1996 Peritoneal Dialysis Core Indicators Study: Report on Nutritional Indicators

Objective

The 1996 Peritoneal Dialysis Core Indicators Study illustrates the conduct of peritoneal dialysis in the United States during 1996.

Design and Patient Population

The survey is a medical records audit of 1317 randomly selected adult U.S.A. Medicare patients using peritoneal dialysis during 1996.

Outcome Measures

Abstracted data included basic demographic characteristics, dialysis prescription, delivered dialysis dose, residual renal function, serum albumin, hematocrit, anemia management, and patient status.

Results

The survey included 785 patients using continuous ambulatory peritoneal dialysis (CAPD) and 423 using automated peritoneal dialysis (APD) primarily in the form of continuous cycling peritoneal dialysis (CCPD). Except for the prescription mechanics and a greater likelihood that African-Americans would use CAPD, the groups did not differ substantially from one another. Evaluation of patient weight (W), body mass index (BMI), residual renal function, average serum albumin, protein equivalent of nitrogen appearance (nPNA), and dialysis efficiency as weekly fractional urea nitrogen removal (wKt/V urea) and weekly creatinine clearance (wCrCI) revealed a picture of reasonable dialysis delivery and marginal protein nutrition. Additionally, there was little evidence that “dialysis efficiency,” over the range assessed, had a major influence on nutritional status. Despite a tendency toward obesity (body weight = 76.6 ± 20.0 kg and BMI = 27 ± 7), 47% of patients had an average serum albumin below “normal” (3.5 g/dL by bromcresol green) and 70% had a nPNA below 1.0 g/kg/day.

Conclusions

Peritoneal dialysis patients appear to have marginal protein reserves despite surfeit energy stores.

Measurement of Continuous Ambulatory Peritoneal Dialysis Prescription Adherence Using a Novel Approach

Objective

The purpose of the study was to test a novel approach to monitoring the adherence of continuous ambulatory peritoneal dialysis (CAPD) patients to their dialysis prescription.

Design

A descriptive observational study was done in which exchange behaviors were monitored over a 2-week period of time.

Setting

Patients were recruited from an outpatient dialysis center.

Participants

A convenience sample of patients undergoing CAPD at Piedmont Dialysis Center in Winston–Salem, North Carolina was recruited for the study. Of 31 CAPD patients, 20 (64.5%) agreed to participate.

Measures

Adherence of CAPD patients to their dialysis prescription was monitored using daily logs and an electronic monitoring device (the Medication Event Monitoring System, or MEMS; APREX, Menlo Park, California, U.S.A.). Patients recorded in their logs their exchange activities during the 2-week observation period. Concurrently, patients were instructed to deposit the pull tab from their dialysate bag into a MEMS bottle immediately after performing each exchange. The MEMS bottle was closed with a cap containing a computer chip that recorded the date and time each time the bottle was opened.

Results

One individual's MEMS device malfunctioned and thus the data presented in this report are based upon the remaining 19 patients. A significant discrepancy was found between log data and MEMS data, with MEMS data indicating a greater number and percentage of missed exchanges. MEMS data indicated that some patients concentrated their exchange activities during the day, with shortened dwell times between exchanges. Three indices were developed for this study: a measure of the average time spent in noncompliance, and indices of consistency in the timing of exchanges within and between days. Patients who were defined as consistent had lower scores on the noncompliance index compared to patients defined as inconsistent ( p = 0.015).

Conclusions

This study describes a methodology that may be useful in assessing adherence to the peritoneal dialysis regimen. Of particular significance is the ability to assess the timing of exchanges over the course of a day. Clinical implications are limited due to issues of data reliability and validity, the short-term nature of the study, the small sample, and the fact that clinical outcomes were not considered in this methodology study. Additional research is needed to further develop this data-collection approach.

Intermediate Outcomes by Race and Ethnicity in Peritoneal Dialysis Patients: Results from the 1997 ESRD Core Indicators Project

Background

Hispanics are the fastest growing minority group in the United States, and approximately 10% of all end-stage renal disease (ESRD) patients are Hispanic. Few data are available, however, regarding dialysis adequacy and anemia management in Hispanic patients receiving peritoneal dialysis in the U.S.

Methods

Data from the Health Care Financing Administration (HCFA) ESRD Core Indicators Project were used to assess racial and ethnic differences in selected intermediate outcomes for peritoneal dialysis patients.

Results

Of the 1219 patients for whom data were available from the 1997 sample, 9% were Hispanic, 24% were non-Hispanic blacks, and 59% were non-Hispanic whites. Hispanics were more likely to have diabetes mellitus as a cause of ESRD compared to blacks or whites, and both Hispanics and blacks were younger than white patients (both p < 0.001). Although whites had higher weekly Kt/V and creatinine clearance values compared to blacks or Hispanics ( p < 0.05), blacks had been dialyzing longer ( p < 0.01) and were more likely to be anuric compared to the other two groups ( p < 0.001). Blacks had significantly lower mean hematocrit values ( p < 0.001) and a greater proportion of patients who had a hematocrit level less than 28% ( p < 0.05) compared to Hispanics or whites, despite receiving significantly larger weekly mean epoetin alfa doses ( p < 0.05) and having significantly higher mean serum ferritin concentrations ( p < 0.01). Multivariate logistic regression analysis revealed significant differences by race/ethnicity for experiencing a weekly Kt/V urea < 2.0 and hypertension, but not for other intermediate outcomes examined (weekly creatinine clearance < 60 L/week/1.73 m2, Hct < 30%, and serum albumin < 3.5/3.2 g/dL).

Conclusion

Hispanics had adequacy values similar to blacks and anemia parameters similar to whites. Additional studies are needed to determine the etiologies of the differences in intermediate outcomes by racial and ethnic groupings in peritoneal dialysis patients.

Abdominal Hernias in Chronic Peritoneal Dialysis Patients: A Review

Of 1365 patients on continuous ambulatory peritoneal dialysis (CAPD) identified by a literature review, 174 (12.7%) developed one or more abdominal hernias. Twenty-three per cent of these hernias were inguinal, 19.1% developed at the site of catheter insertion, 18.6% were umbilical, 8.3% were ventral, 9.8% were at other incisional sites, 7.4% were at other sites, and 13.7% were unclassified. Twenty-seven (13.2%) of the hernias were strangulated or incarcerated. The incidence of abdominal hernias in 827 CAPD patients was one per 104.2 cathetermonths, with a range among dialysis centers of one hernia per 47.4 to 779.0 catheter-months. Among 436 patients on intermittent peritoneal dialysis, 12 (2.8%) developed an abdominal hernia, four times less frequently than in CAPD patients (P < 0.001).

Risk Factors for Early Mortality in U.S. Peritoneal Dialysis Patients: Impact of Residual Renal Function

Background

Potential risk factors for 1-year mortality, including the peritoneal component of dialysis dose, residual renal function, demographic data, hematocrit, serum albumin, dialysate-to-plasma creatinine ratio, and blood pressure, were examined in a national cohort of peritoneal dialysis patients randomly selected for the Centers for Medicare and Medicaid Services End-Stage Renal Disease (ESRD) Core Indicators Project.

Methods

The study involved retrospective analysis of a cohort of 1219 patients receiving chronic peritoneal dialysis who were alive on December 31, 1996.

Results

During the 1-year follow-up period, 275 patients were censored and 200 non censored patients died. Among the 763 patients who had at least one calculable adequacy measure, the mean [± standard deviation (SD)] weekly Kt/V urea was 2.16 ± 0.61 and the mean weekly creatinine clearance was 66.1 ± 24.4 L/1.73 m2. Excluding the 365 patients who were anuric, the mean (±SD) urinary weekly Kt/V urea was 0.64 ± 0.52 (median: 0.51) and the mean (±SD) urinary weekly creatinine clearance was 31.0 ± 23.3 L/1.73 m2 (median: 26.3 L/1.73 m2). By Cox proportional hazard modeling, lower quartiles of renal Kt/V urea were predictive of 1-year mortality; lower quartiles of renal creatinine clearance were of borderline significance for predicting 1-year mortality. The dialysate component of neither the weekly creatinine clearance nor the weekly Kt/V urea were predictive of 1-year mortality. Other predictors of 1-year mortality ( p < 0.01) included lower serum albumin level, older age, and the presence of diabetes mellitus as the cause of ESRD, and, for the creatinine clearance model only, lower diastolic blood pressure.

Conclusion

Residual renal function is an important predictor of 1-year mortality in chronic peritoneal dialysis patients.

24-Hour Dialysate Collection for Determination of Peritoneal Membrane Transport Characteristics: Longitudinal Follow-Up Data for the Dialysis Adequacy and Transport Test (Datt)

Objective

To determine the ability of the dialysis adequacy and transport test (DATT) to monitor changes in peritoneal transport characteristics over time.

Setting

University-based peritoneal dialysis program.

Patients

One hundred patients on continuous ambulatory peritoneal dialysis who underwent 226 simultaneous DATTs and peritoneal equilibration tests (PET).

Methods

Retrospective analysis of DA TT and PET data.

Results

The mean 24-hour dialysate-to-plasma creatinine (cr) concentration ratio (DIP cr) from the DATT was 0.70±0.10, and the mean four-hour DIP crfrorn the PET was 0.68 ± 0.10. The correlation coefficient between the fourhour and 24-hour DIP cr was 0.81, and the standard error of estimate was 0.065. The mean (±SD) difference between the four-hour and 24-hour DIP cr was 0.023 ± 0.061. Fifty eight patients had two or more sequential DA TTs and PETs. For these 94sets of sequential DATTs and PETs, the mean (±SD) difference between the change in the four-hour DIP cr and the change in the 24-hour DIP cr was 0.020 ± 0.024, and the standard error of estimate was 0.064. In 17 patients a change in dwell volume from 2.0 L to 2.5 L occurred between the first and second measures of peritoneal membrane transport characteristics. The mean (±SD) difference between the change in the four-hour DIP cr and the change in the 24-hour DIP cr was 0.036 ± 0.055, and the standard error of estimate was 0.087.

Conclusion

The DATT can be used to monitor for changes in peritoneal transport over time. It should not be used in patients receiving cycler therapy or in patients whose dwell times and dextrose concentrations vary markedly from day to day.

KDOQI US Commentary on the 2017 KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

Living kidney donation is widely practiced throughout the world. During the past 2 decades, various groups have provided guidance about the evaluation and care of living donors. However, during this time, our knowledge in the field has advanced substantially and many agreed on the need for a comprehensive, unifying document. KDIGO (Kidney Disease: Improving Global Outcomes) addressed this issue at an international level with the publication of its clinical practice guideline on the evaluation and care of living kidney donors. The KDIGO work group extensively reviewed the available literature and wrote a series of guideline recommendations using various degrees of evidence when available. As has become recent practice, NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) convened a work group to provide a commentary on the KDIGO guideline, with a focus on how these recommendations apply in the context of the United States. In the United States, the United Network for Organ Sharing (UNOS) guides and regulates the practice of living kidney donation. While the KDIGO guideline for the care of living kidney donors and UNOS policy are similar in most aspects of the care of living kidney donors, several important areas are not consistent or do not align with common practice by US transplantation programs in areas in which UNOS has not set specific policy. For the time being, and recognizing the value of the KDIGO guidelines, US transplantation programs should continue to follow UNOS policy.

Blood Pressure Measurement: A KDOQI Perspective

The majority of patients with chronic kidney disease (CKD) have elevated blood pressure (BP). In patients with CKD, hypertension is associated with increased risk for cardiovascular disease, progression of CKD, and all-cause mortality. New guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) recommend new thresholds and targets for the diagnosis and treatment of hypertension in patients with and without CKD. A new aspect of the guidelines is the recommendation for measurement of out-of-office BP to confirm the diagnosis of hypertension and guide therapy. In this KDOQI (Kidney Disease Outcomes Quality Initiative) perspective, we review the recommendations for accurate BP measurement in the office, at home, and with ambulatory BP monitoring. Regardless of location, validated devices and appropriate cuff sizes should be used. In the clinic and at home, proper patient preparation and positioning are critical. Patients should receive information about the importance of BP measurement techniques and be encouraged to advocate for adherence to guideline recommendations. Implementing appropriate BP measurement in routine practice is feasible and should be incorporated in system-wide efforts to improve the care of patients with hypertension. Hypertension is the number 1 chronic disease risk factor in the world; BP measurements in the office, at home, and with ambulatory BP monitoring should adhere to recommendations from the AHA.

Cardiovascular Outcomes Reported in Hemodialysis Trials

Patients on long-term hemodialysis are at very high risk for cardiovascular disease but are usually excluded from clinical trials conducted in the general population or in at-risk populations. There are no universally agreed cardiovascular outcomes for trials conducted specifically in the hemodialysis population. In this review, we highlight that trials reporting cardiovascular outcomes in hemodialysis patients are usually of short duration (median 3 to 6 months) and are small (59% of trials have <100 participants). Overall, the cardiovascular outcomes are very heterogeneous and may not reflect outcomes that are meaningful to patients and clinicians in supporting decision making, as they are often surrogates of uncertain clinical importance. Composite outcomes used in different trials rarely share the same components. In a field in which a single trial is often insufficiently powered to fully assess the clinical and economic impact of interventions, differences in outcome reporting across trials make the task of meta-analysis and interpretation of all the available evidence challenging. Core outcome sets are now being established across many specialties in health care to prevent these problems. Through the global Standardized Outcomes in Nephrology-Hemodialysis initiative, cardiovascular disease was identified as a critically important core domain to be reported in all trials in hemodialysis. Informed by the current state of reporting of cardiovascular outcomes, a core outcome measure for cardiovascular disease is currently being established with involvement of patients, caregivers, and health professionals. Consistent reporting of cardiovascular outcomes that are critically important to hemodialysis patients and clinicians will strengthen the evidence base to inform care in this very high-risk population.

Association of Intensive vs Standard Blood Pressure Control With Cerebral White Matter Lesions

Importance

The effect of intensive blood pressure lowering on brain health remains uncertain.

Objective

To evaluate the association of intensive blood pressure treatment with cerebral white matter lesion and brain volumes.

Design, Setting, and Participants

A substudy of a multicenter randomized clinical trial of hypertensive adults 50 years or older without a history of diabetes or stroke at 27 sites in the United States. Randomization began on November 8, 2010. The overall trial was stopped early because of benefit for its primary outcome (a composite of cardiovascular events) and all-cause mortality on August 20, 2015. Brain magnetic resonance imaging (MRI) was performed on a subset of participants at baseline (n = 670) and at 4 years of follow-up (n = 449); final follow-up date was July 1, 2016.

Interventions

Participants were randomized to a systolic blood pressure (SBP) goal of either less than 120 mm Hg (intensive treatment, n = 355) or less than 140 mm Hg (standard treatment, n = 315).

Main Outcomes and Measures

The primary outcome was change in total white matter lesion volume from baseline. Change in total brain volume was a secondary outcome.

Results

Among 670 recruited patients who had baseline MRI (mean age, 67.3 [SD, 8.2] years; 40.4% women), 449 (67.0%) completed the follow-up MRI at a median of 3.97 years after randomization, after a median intervention period of 3.40 years. In the intensive treatment group, based on a robust linear mixed model, mean white matter lesion volume increased from 4.57 to 5.49 cm3 (difference, 0.92 cm3 [95% CI, 0.69 to 1.14]) vs an increase from 4.40 to 5.85 cm3 (difference, 1.45 cm3 [95% CI, 1.21 to 1.70]) in the standard treatment group (between-group difference in change, -0.54 cm3 [95% CI, -0.87 to -0.20]). Mean total brain volume decreased from 1134.5 to 1104.0 cm3 (difference, -30.6 cm3 [95% CI, -32.3 to -28.8]) in the intensive treatment group vs a decrease from 1134.0 to 1107.1 cm3 (difference, -26.9 cm3 [95% CI, 24.8 to 28.8]) in the standard treatment group (between-group difference in change, -3.7 cm3 [95% CI, -6.3 to -1.1]).

Conclusions and Relevance

Among hypertensive adults, targeting an SBP of less than 120 mm Hg, compared with less than 140 mm Hg, was significantly associated with a smaller increase in cerebral white matter lesion volume and a greater decrease in total brain volume, although the differences were small.

Trial Registration

ClinicalTrials.gov Identifier: NCT01206062.

Effect of Intensive Blood Pressure Reduction on Left Ventricular Mass, Structure, Function, and Fibrosis in the SPRINT-HEART

In observational studies, left ventricular mass (LVM) and structure are strong predictors of mortality and cardiovascular events. However, the effect of hypertension treatment on LVM reduction and its relation to subsequent outcomes is unclear, particularly at lower blood pressure (BP) targets. In an ancillary study of SPRINT (Systolic Blood Pressure Intervention Trial), where participants were randomly assigned to intensive BP control (target systolic BP target <120 mm Hg) versus standard BP control (<140 mm Hg), cardiac magnetic resonance imaging was performed at baseline and 18-month follow-up to measure: LVM, volumes, ejection fraction, and native T1 mapping for myocardial fibrosis. At baseline, 337 participants were examined (age: 64±9 years, 45% women); 300 completed the 18-month exam (153 intensive control and 147 standard control). In the intensive versus standard BP control group at 18 months, there was no difference in change in LVM (mean±SE =-2.7±0.5 g versus -2.3±0.7 g; P=0.368), ejection fraction, or native T1 (P=0.79), but there was a larger decrease in LVM/end-diastolic volume ratio (-0.04±0.01 versus -0.01±0.01; P=0.002) a measure of concentric LV remodeling. There were fewer cardiovascular events in the intensive control group, but no significant association between the reduced events and change in LVM or any other cardiac magnetic resonance imaging measure. In SPRINT-HEART, contrary to our hypothesis, there were no significant between-group differences in LVM, function, or myocardial T1 at 18-month follow-up. These results suggests that mediators other than these LV measures contribute to the improved cardiovascular outcomes with intensive BP control.

The SPRINT trial suggests that markers of tubule cell function in the urine associate with risk of subsequent acute kidney injury while injury markers elevate after the injury

Urine markers can quantify tubular function including reabsorption (α-1 microglobulin [α1m]) and β-2-microglobulin [β2m]) and protein synthesis (uromodulin). Individuals with tubular dysfunction may be less able to compensate to insults than those without, despite similar estimated glomerular filtration rate (eGFR) and albuminuria. Among Systolic Blood Pressure Intervention Trial (SPRINT) participants with an eGFR under 60 ml/min/1.73m2, we measured urine markers of tubular function and injury (neutrophil gelatinase-associated lipocalin [NGAL], kidney injury molecule-1 [KIM-1], interleukin-18 [IL-18], monocyte chemoattractant protein-1, and chitinase-3-like protein [YKL-40]) at baseline. Cox models evaluated associations with subsequent acute kidney injury (AKI) risk, adjusting for clinical risk factors, baseline eGFR and albuminuria, and the tubular function and injury markers. In a random subset, we remeasured biomarkers after four years, and compared changes in biomarkers in those with and without intervening AKI. Among 2351 participants, 184 experienced AKI during 3.8 years mean follow-up. Lower uromodulin (hazard ratio per two-fold higher (0.68, 95% confidence interval [0.56, 0.83]) and higher α1m (1.20; [1.01, 1.44]) were associated with subsequent AKI, independent of eGFR and albuminuria. None of the five injury markers were associated with eventual AKI. In the random subset of 947 patients with repeated measurements, the 59 patients with intervening AKI versus without had longitudinal increases in urine NGAL, IL-19, and YKL-40 and only 1 marker of tubule function (α1m). Thus, joint evaluation of tubule function and injury provided novel insights to factors predisposing to AKI, and responses to kidney injury.

Implications of Early Decline in eGFR due to Intensive BP Control for Cardiovascular Outcomes in SPRINT

BACKGROUND

The Systolic BP Intervention Trial (SPRINT) found that intensive versus standard systolic BP control (targeting <120 or <140 mm Hg, respectively) reduced the risks of death and major cardiovascular events in persons with elevated cardiovascular disease risk. However, the intensive intervention was associated with an early decline in eGFR, and the clinical implications of this early decline are unclear.

METHODS

In a post hoc analysis of SPRINT, we defined change in eGFR as the percentage change in eGFR at 6 months compared with baseline. We performed causal mediation analyses to separate the overall effects of the randomized systolic BP intervention on the SPRINT primary cardiovascular composite and all-cause mortality into indirect effects (mediated by percentage change in eGFR) and direct effects (mediated through pathways other than percentage change in eGFR).

RESULTS

About 10.3% of the 4270 participants in the intensive group had a ≥20% eGFR decline versus 4.4% of the 4256 participants in the standard arm (P<0.001). After the 6-month visit, there were 591 cardiovascular composite events during 27,849 person-years of follow-up. The hazard ratios for total effect, direct effect, and indirect effect of the intervention on the cardiovascular composite were 0.67 (95% confidence interval [95% CI], 0.56 to 0.78), 0.68 (95% CI, 0.57 to 0.79), and 0.99 (95% CI, 0.95 to 1.03), respectively. All-cause mortality results were similar.

CONCLUSIONS

Although intensive systolic BP lowering resulted in greater early decline in eGFR, there was no evidence that the reduction in eGFR owing to intensive systolic BP lowering attenuated the beneficial effects of this intervention on cardiovascular events or all-cause mortality.

Safe Water Community Project in Jalisco, Mexico

Few studies have assessed kidney function in patients with gastrointestinal infections in low-resource settings. Although dehydration is a frequent complication of acute diarrhea, we do not know the frequency and severity of acute kidney injury (AKI) in this context. A high prevalence of chronic kidney disease (CKD) has been reported among the inhabitants of poor communities in Poncitlan, Mexico. Polluted drinking water has been implicated as a probable cause. These communities report a high mortality associated with gastrointestinal infection. It is possible that a high incidence of waterborne disease and consequent more episodes of AKI might contribute to the high prevalence of CKD in this population. In this study, we aim to determine the association between the use of unsafe water and the incidence of acute diarrhea and AKI, and to determine if the provision of clean water decreases these complications. The study will be conducted in 3 communities of the municipality of Poncitlan. Initially, we will determine the water, sanitation, and hygiene (WASH) characteristics in the population and evaluate the incidence of diarrheal disease. In the observation phase, outcomes will be assessed after families receive training in WASH techniques, but before they are provided with clean water. In the intervention phase, outcomes will be assessed after clean water is provided.

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

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.

KDOQI US Commentary on the 2017 ACC/AHA Hypertension Guideline

Hypertension is a modifiable risk factor for cardiovascular morbidity and mortality and reduction of elevated blood pressure (BP) remains an important intervention for slowing kidney disease progression. Over the past decade, the most appropriate BP target for initiation and titration of BP-lowering medications has been an area of intense research and debate within the clinical community. In 2017, the American College of Cardiology and the American Heart Association (ACC/AHA) in conjunction with several other professional societies released new hypertension guidelines based on data from a systematic review of clinical trials and observational data. While many of the recommendations in the ACC/AHA hypertension guideline are relevant to nephrology practice, BP targets and management strategies for patients receiving dialysis are not discussed. This Kidney Disease Outcomes Quality Initiative (KDOQI) commentary focuses largely on recommendations from the ACC/AHA hypertension guidelines that are pertinent to individuals at risk of chronic kidney disease or with non-dialysis-dependent chronic kidney disease. This KDOQI commentary also includes a brief discussion of the consensus statement regarding hypertension diagnosis and management for adults receiving maintenance dialysis published by the European Renal and Cardiovascular Medicine Working Group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension. Overall, we support the vast majority of the ACC/AHA recommendations and highlight select areas in which best diagnosis and treatment options remain controversial.