Predicting hospitalizations for patients with chronic kidney disease

OBJECTIVES

Patients with chronic kidney disease (CKD) are at higher risk of being admitted to the hospital than the general population. Hospitalizations in patients with CKD are associated with higher medical costs and increased morbidity and mortality. Identification of patients with CKD who are at greatest risk of hospitalization may hold promise to improve clinical outcomes and enable judicious allocation of health care resources.

STUDY DESIGN

Retrospective, observational cohort study.

METHODS

Medicare Part A and Part B claims from calendar years 2017 and 2018 from 50,000 unique patients with a diagnosis of stage 3 to 5 CKD were used for this study. Data were split into training (n = 40,000) and test (n = 10,000) sets. A variety of model types were built to predict all-cause hospitalization within 90 days.

RESULTS

The final model was a gradient-boosting machine with 399 input terms. The model demonstrated good ability to discriminate (area under the curve [AUC] for the receiver operating characteristic curve = 0.73), which was stable when tested in the test set (AUC = 0.73). The positive predictive value in the test set was 0.306, 0.240, and 0.216 at the 10%, 20%, and 30% thresholds, respectively. The sensitivity in the test set was 0.288, 0.453, and 0.609 at the 10%, 20%, and 30% thresholds, respectively.

CONCLUSIONS

We developed an algorithm that uses medical claims to identify Medicare patients with CKD stages 3 to 5 who are at highest risk of being hospitalized in the near term. This algorithm could be used as a decision support tool for clinical programs focusing on management of patient populations with CKD.

Comparative Effectiveness of mRNA-Based BNT162b2 Vaccine versus Adenovirus Vector-Based Ad26.COV2.S Vaccine for Prevention of COVID-19 among Dialysis Patients

Background Studies have demonstrated that mRNA-based SARS-CoV-2 vaccines are highly effective among dialysis patients. Because individual vaccines may be differentially available or acceptable to patients, it is important to understand comparative effectiveness relative to other vaccines, such those based on adenovirus technologies.

Methods In this retrospective study, we compared the clinical effectiveness of adenovirus vector-based Ad26.COV2.S (Janssen/Johnson & Johnson) to mRNA-based BNT162b2 (Pfizer/BioNTech) in a contemporary cohort of dialysis patients. Patients who received a first BNT162b2 dose were matched 1:1 to Ad26.COV2.S recipients based on date of first vaccine receipt, US state of residence, site of dialysis care (in-center versus home), prior history of COVID-19, and propensity score. The primary outcome was the comparative rate of COVID-19 diagnoses starting in the seventh week postvaccination. In a subset of consented Ad26.COV2.S patients, blood samples were collected ≥28 days after vaccination and anti-SARS-Cov-2 immunoglobulin G antibodies were measured

Results A total of 2572 matched pairs of patients qualified for analysis. Cumulative incidence rates of COVID-19 did not differ for BNT162b2 versus Ad26.COV2.S. No differences were observed in peri-COVID-19 hospitalizations and deaths among patients receiving BNT162b2 versus Ad26.COV2.S who were diagnosed with COVID-19 during follow-up. Results were similar when excluding patients with prior history of COVID-19, in subgroup analyses restricted to patients who completed the two-dose BNT162b2 regimen, and in patients receiving in-center hemodialysis. SARS-CoV-2 antibodies were detected in 59.4% of 244 patients who received Ad26.COV2.S.

Conclusions In a large real-world cohort of dialysis patients, no difference was detected in clinical effectiveness of BNT162b2 and Ad26.COV2.S over the first 6 months postvaccination, despite an inconsistent antibody response to the latter.

Real-World Effectiveness and Immunogenicity of BNT162b2 and mRNA-1273 SARS-CoV-2 Vaccines in Patients on Hemodialysis

BACKGROUND

Patients on hemodialysis have an elevated risk for COVID-19 but were not included in efficacy trials of SARS-CoV-2 vaccines.

METHODS

We conducted a retrospective, observational study to estimate the real-world effectiveness and immunogenicity of two mRNA SARS-CoV-2 vaccines in a large, representative population of adult hemodialysis patients in the United States. In separate, parallel analyses, patients who began a vaccination series with BNT162b2 or mRNA-1273 in January and February 2021 were matched with unvaccinated patients and risk for outcomes were compared for days 1-21, 22-42, and ≥43 after first dose. In a subset of consented patients, blood samples were collected approximately 28 days after the second dose and anti-SARS-CoV-2 immunoglobulin G was measured.

RESULTS

A total of 12,169 patients received the BNT162b2 vaccine (matched with 44,377 unvaccinated controls); 23,037 patients received the mRNA-1273 vaccine (matched with 63,243 unvaccinated controls). Compared with controls, vaccinated patients' risk of being diagnosed with COVID-19 postvaccination became progressively lower during the study period (hazard ratio and 95% confidence interval for BNT162b2 was 0.21 [0.13, 0.35] and for mRNA-1273 was 0.27 [0.17, 0.42] for days ≥43). After a COVID-19 diagnosis, vaccinated patients were significantly less likely than unvaccinated patients to be hospitalized (for BNT162b2, 28.0% versus 43.4%; for mRNA-1273, 37.2% versus 45.6%) and significantly less likely to die (for BNT162b2, 4.0% versus 12.1%; for mRNA-1273, 5.6% versus 14.5%). Antibodies were detected in 98.1% (309/315) and 96.0% (308/321) of BNT162b2 and mRNA-1273 patients, respectively.

CONCLUSIONS

In patients on hemodialysis, vaccination with BNT162b2 or mRNA-1273 was associated with a lower risk of COVID-19 diagnosis and lower risk of hospitalization or death among those diagnosed with COVID-19. SARS-CoV-2 antibodies were detected in nearly all patients after vaccination. These findings support the use of these vaccines in this population.

Association of Continuation of Loop Diuretics at Hemodialysis Initiation with Clinical Outcomes

BACKGROUND AND OBJECTIVES

Loop diuretics are commonly used to manage nondialysis-dependent CKD. Despite benefits of augmented urine output, loop diuretics are often discontinued after dialysis initiation. Here, we assessed the association of the early decision to continue loop diuretics at hemodialysis start with clinical outcomes during the first year of dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We considered all patients on in-center hemodialysis at a large dialysis organization (2006-2013) with Medicare Part A and D benefits who had an active supply of a loop diuretic at dialysis initiation (n=11,297). Active therapy was determined on the basis of whether loop diuretic prescription was refilled after dialysis initiation and within 30 days of exhaustion of prior supply. Patients were followed under an intention-to-treat paradigm for up to 12 months for rates of death, hospitalization, and intradialytic hypotension and mean monthly values of interdialytic weight gain, serum potassium, predialysis systolic BP, and ultrafiltration rates.

RESULTS

We identified 5219 patients who refilled a loop diuretic and 6078 eligible controls who did not. After adjustments for patient mix and clinical differences, continuation of loop diuretics was associated with lower hospitalization (adjusted incidence rate ratio, 0.93; 95% confidence interval, 0.89 to 0.98) and intradialytic hypotension (adjusted incidence rate ratio, 0.95; 95% confidence interval, 0.92 to 0.99) rates, no difference in death rate (adjusted hazard ratio, 0.92; 95% confidence interval, 0.84 to 1.01), and lower interdialytic weight gain (P=0.03).

CONCLUSIONS

Continuation of loop diuretics after hemodialysis initiation was associated with lower rates of hospitalization and intradialytic hypotension as well as lower interdialytic weight gain, but there was no difference in mortality over the first year of dialysis.

mGlu7 potentiation rescues cognitive, social, and respiratory phenotypes in a mouse model of Rett syndrome

Rett syndrome (RTT) is a neurodevelopmental disorder caused by mutations in the methyl-CpG binding protein 2 (MECP2) gene. The cognitive impairments seen in mouse models of RTT correlate with deficits in long-term potentiation (LTP) at Schaffer collateral (SC)-CA1 synapses in the hippocampus. Metabotropic glutamate receptor 7 (mGlu₇) is the predominant mGlu receptor expressed presynaptically at SC-CA1 synapses in adult mice, and its activation on GABAergic interneurons is necessary for induction of LTP. We demonstrate that pathogenic mutations in MECP2 reduce mGlu₇ protein expression in brain tissue from RTT patients and in MECP2-deficient mouse models. In rodents, this reduction impairs mGlu₇-mediated control of synaptic transmission. We show that positive allosteric modulation of mGlu₇ activity restores LTP and improves contextual fear learning, novel object recognition, and social memory. Furthermore, mGlu₇ positive allosteric modulation decreases apneas in Mecp2^+/- mice, suggesting that mGlu₇ may be a potential therapeutic target for multiple aspects of the RTT phenotype.

The Role of mGlu Receptors in Hippocampal Plasticity Deficits in Neurological and Psychiatric Disorders: Implications for Allosteric Modulators as Novel Therapeutic Strategies

Long-term potentiation (LTP) and long-term depression (LTD) are two distinct forms of synaptic plasticity that have been extensively characterized at the Schaffer collateral-CA1 (SCCA1) synapse and the mossy fiber (MF)-CA3 synapse within the hippocampus, and are postulated to be the molecular underpinning for several cognitive functions. Deficits in LTP and LTD have been implicated in the pathophysiology of several neurological and psychiatric disorders. Therefore, there has been a large effort focused on developing an understanding of the mechanisms underlying these forms of plasticity and novel therapeutic strategies that improve or rescue these plasticity deficits. Among many other targets, the metabotropic glutamate (mGlu) receptors show promise as novel therapeutic candidates for the treatment of these disorders. Among the eight distinct mGlu receptor subtypes (mGlu1-8), the mGlu1,2,3,5,7 subtypes are expressed throughout the hippocampus and have been shown to play important roles in the regulation of synaptic plasticity in this brain area. However, development of therapeutic agents that target these mGlu receptors has been hampered by a lack of subtype-selective compounds. Recently, discovery of allosteric modulators of mGlu receptors has provided novel ligands that are highly selective for individual mGlu receptor subtypes. The mGlu receptors modulate the multiple forms of synaptic plasticity at both SC-CA1 and MF synapses and allosteric modulators of mGlu receptors have emerged as potential therapeutic agents that may rescue plasticity deficits and improve cognitive function in patients suffering from multiple neurological and psychiatric disorders.

Identification of positive allosteric modulators VU0155094 (ML397) and VU0422288 (ML396) reveals new insights into the biology of metabotropic glutamate receptor 7

Metabotropic glutamate receptor 7 (mGlu7) is a member of the group III mGlu receptors (mGlus), encompassed by mGlu4, mGlu6, mGlu7, and mGlu8. mGlu7 is highly expressed in the presynaptic active zones of both excitatory and inhibitory synapses, and activation of the receptor regulates the release of both glutamate and GABA. mGlu7 is thought to be a relevant therapeutic target for a number of neurological and psychiatric disorders, and polymorphisms in the GRM7 gene have been linked to autism, depression, ADHD, and schizophrenia. Here we report two new pan-group III mGlu positive allosteric modulators, VU0155094 and VU0422288, which show differential activity at the various group III mGlus. Additionally, both compounds show probe dependence when assessed in the presence of distinct orthosteric agonists. By pairing studies of these nonselective compounds with a synapse in the hippocampus that expresses only mGlu7, we have validated activity of these compounds in a native tissue setting. These studies provide proof-of-concept evidence that mGlu7 activity can be modulated by positive allosteric modulation, paving the way for future therapeutics development.

Targeting glutamate synapses in schizophrenia

Although early clinical observations implicated dopamine dysfunction in the neuropathology of schizophrenia, accumulating evidence suggests that multiple neurotransmitter pathways are dysregulated. The psychotomimetic actions of NMDA receptor antagonists point to an imbalance of glutamatergic signaling. Encouragingly, numerous preclinical and clinical studies have elucidated several potential targets for increasing NMDA receptor function and equilibrating glutamatergic tone, including the metabotropic glutamate receptors 2, 3 and 5, the muscarinic acetylcholine receptors M(1) and M(4), and the glycine transporter GlyT1. Highly specific allosteric and orthosteric ligands have been developed that modify the activity of these novel target proteins, and in this review we summarize both the glutamatergic mechanisms and the novel compounds that are increasing the promise for a multifaceted pharmacological approach to treat schizophrenia.

Reduced expression of conditioned fear in the R6/2 mouse model of Huntington's disease is related to abnormal activity in prelimbic cortex

Prefrontal cortex (PFC) dysfunction is common in patients with Huntington's disease (HD), a dominantly inherited neurological disorder, and has been linked to cognitive disruption. We previously reported alterations in neuronal firing patterns recorded from PFC of the R6/2 mouse model of HD. To determine if PFC dysfunction results in behavioral impairments, we evaluated performance of wild-type (WT) and R6/2 mice in a fear conditioning and extinction behavioral task. Fear conditioning and extinction retrieval were similar in both genotypes, but R6/2s exhibited less fear during extinction by freezing less than WTs. A fear reinstatement test after extinction retrieval indicated that faster extinction was not due to poor memory for conditioning. During initial extinction and extinction retrieval training, neuronal activity was recorded from prelimbic (PL) cortex, a subregion of PFC known to be important for fear expression. In WTs, a large number of neurons were activated by the conditioned stimulus during initial extinction and this activation was significantly impaired in R6/2s. Notably, there was no genotype difference in PFC activity during extinction retrieval. Thus, altered extinction is likely a result of reduced fear expression due to impairments in PL activation. Collectively, our results suggest that PFC dysfunction may play a key role in R6/2 cognitive impairments.

Dysregulated Neuronal Activity Patterns Implicate Corticostriatal Circuit Dysfunction in Multiple Rodent Models of Huntington's Disease

Huntington's disease (HD) is an autosomal dominant neurodegenerative disorder that targets the corticostriatal system and results in progressive deterioration of cognitive, emotional, and motor skills. Although cortical and striatal neurons are widely studied in animal models of HD, there is little information on neuronal function during expression of the HD behavioral phenotype. To address this knowledge gap, we used chronically implanted micro-wire bundles to record extracellular spikes and local field potentials (LFPs) in truncated (R6/1 and R6/2) and full-length (knock-in, KI) mouse models as well as in transgenic HD rats (tgHD rats) behaving in an open-field arena. Spike activity was recorded in the striatum of all models and in prefrontal cortex (PFC) of R6/2 and KI mice, and in primary motor cortex (M1) of R6/2 mice. We also recorded LFP activity in R6/2 striatum. All HD models exhibited altered neuronal activity relative to wild-type (WT) controls. Although there was no consistent effect on firing rate across models and brain areas, burst firing was reduced in striatum, PFC, and M1 of R6/2 mice, and in striatum of KI mice. Consistent with a decline in bursting, the inter-spike-interval coefficient of variation was reduced in all regions of all models, except PFC of KI mice and striatum of tgHD rats. Among simultaneously recorded neuron pairs, correlated firing was reduced in all brain regions of all models, while coincident bursting, which measures the temporal overlap between bursting pairs, was reduced in striatum of all models as well as in M1 of R6/2s. Preliminary analysis of striatal LFPs revealed aberrant behavior-related oscillations in the delta to theta range and in gamma activity. Collectively, our results indicate that disrupted corticostriatal processing occurs across multiple HD models despite differences in the severity of the behavioral phenotype. Efforts aimed at normalizing corticostriatal activity may hold the key to developing new HD therapeutics.

Chronic stress alters neural activity in medial prefrontal cortex during retrieval of extinction

Chronic restraint stress produces morphological changes in medial prefrontal cortex and disrupts a prefrontally mediated behavior, retrieval of extinction. To assess potential physiological correlates of these alterations, we compared neural activity in infralimbic and prelimbic cortex of unstressed versus stressed rats during fear conditioning and extinction. After implantation of microwire bundles into infralimbic or prelimbic cortex, rats were either unstressed or stressed via placement in a plastic restrainer (3 h/day for 1 week). Rats then underwent fear conditioning and extinction while activity of neurons in infralimbic or prelimbic cortex was recorded. Percent freezing and neural activity were assessed during all phases of training. Chronic stress enhanced freezing during acquisition of conditioned fear, and altered both prelimbic and infralimbic activity during this phase. Stress did not alter initial extinction or conditioned stimulus (CS)-related activity during this phase. However, stress impaired retrieval of extinction assessed 24 h later, and this was accompanied by alterations in neuronal activity in both prelimbic and infralimbic cortex. In prelimbic cortex, unstressed rats showed decreased activity in response to CS presentation, whereas stressed rats showed no change. In infralimbic cortex, neurons in unstressed rats exhibited increased firing in response to the CS, whereas stressed rats showed no increase in infralimbic firing during the tone. Finally, CS-related firing in infralimbic but not prelimbic cortex was correlated with extinction retrieval. Thus, the stress-induced alteration of neuronal activity in infralimbic cortex may be responsible for the stress-induced deficit in retrieval of extinction.

Dysregulation of coordinated neuronal firing patterns in striatum of freely behaving transgenic rats that model Huntington's disease

Altered neuronal activity in the striatum appears to be a key component of Huntington's disease (HD), a fatal, neurodegenerative condition. To assess this hypothesis in freely behaving transgenic rats that model HD (tgHDs), we used chronically implanted micro-wires to record the spontaneous activity of striatal neurons. We found that relative to wild-type controls, HD rats suffer from population-level deficits in striatal activity characterized by a loss of correlated firing and fewer episodes of coincident spike bursting between simultaneously recorded neuronal pairs. These results are in line with our previous report of marked alterations in the pattern of striatal firing in mouse models of HD that vary in background strain, genetic construct, and symptom severity. Thus, loss of coordinated spike activity in striatum appears to be a common feature of HD pathophysiology, regardless of HD model variability.

Dysregulated information processing by medium spiny neurons in striatum of freely behaving mouse models of Huntington's disease

Huntington's disease (HD) is an autosomal dominant condition that compromises behavioral output. Dysfunction of medium spiny neurons (MSNs), which are the sole output system of the striatum, is thought to underlie HD pathophysiology. What is not known is how HD alters MSN information processing during behavior, which likely drives the HD behavioral phenotype. We recorded from populations of MSNs in two freely behaving and symptomatic HD mouse models: R6/2 transgenics are based on a C57BL/6J*CBA/J background and show robust behavioral symptoms, whereas knock-in (KI) mice have a 129sv background and express relatively mild behavioral signs. At the single-unit level, we found that the MSN firing rate was elevated in R6/2 but not in KI mice compared with their respective wild-type (WT) controls. In contrast, burst activity, which corresponds to periods of high-frequency firing, was altered in both HD models compared with WT. At the population level, we found that correlated firing between pairs of MSNs was a prominent feature in WT that was reduced in both HD models. Similarly, coincident bursts, which are bursts between pairs of neurons that overlap in time and occur more often in pairs of MSNs that exhibit correlated firing, were decreased in HD mice. Our results indicate an important role in both bursting and correlated burst firing for information processing in MSNs. Dysregulation of this processing scheme, moreover, is a key component of HD pathophysiology regardless of the severity of HD symptoms, genetic construct, and background strain of the mouse models.

Methods for the estimation of the number and quality of animal cells immobilized in carbohydrate gels

Rapid and reliable methods for the determination of survival, proliferation, and metabolic activity of immobilized cells in gels are described. The first method is based on an MTT assay that measures qualitatively and quantitatively the metabolic activity of the cells. The second method determines cell number by measuring the amount of DNA available for Feulgen staining. In the third method, two fluorescent dyes are used to differentially stain viable and dead cells. The fourth method involves the use of glutaraldehyde to protect the cells when melting the gel to facilitate hemocytometric count. The presented techniques should help to test the efficiency of the immobilization procedures and to monitor the growth and survival of immobilized cells.

The rapid and sensitive enumeration of antibody-secreting cells using immunogold/silver staining (SIG-blot assay)

A simple and robust method has been developed for the enumeration of antibody-secreting cells. Secretion is assessed on the surface of 96-well microtitre plates using immunogold/silver staining techniques. The method is sufficiently straightforward to allow, for the first time, assessment of secretory cells in the clinical laboratory. This approach has great potential for enumerating cells that secrete other products, such as the interleukins.

Immunocytochemical demonstration of glial-neuronal interactions and myelinogenesis in subcultures of rat brain cells

Subcultures have been established from primary rat brain cell cultures and have been characterised with a range of cell-specific immunocytochemical markers. The subcultures are mainly composed of fibrous astrocytes, oligodendrocytes and neurones. The cells do not divide to any great extent giving a system where it is possible to follow culture development at the cellular level for a number of weeks. During this time oligodendrocytes colonise subpopulations of neurones, differentiate further showing the presence of myelin basic protein and elaborate myelin-like membrane; the fibrous astrocytes remain scattered uniformly throughout the cultures. Radially oriented processes emerge from the oligodendrocyte-neurone aggregates which subsequently coalesce to form fascicles that link the clusters of cells together. These fascicles react with antibodies for both neurofilament protein and myelin basic protein. The subcultures provide a straightforward system that is composed of cells derived entirely from the CNS, is free from mitotic inhibitors and yet retains a sufficiently low cell density to allow immunocytochemical identification of the cell types present. The subcultures should be useful for the study of trophic interactions between oligodendrocytes and neurones as well as the early events associated with myelinogenesis.

Immunocytochemical characterisation of cell cultures grown from dissociated 1-2-day post-natal rat cerebral tissue. A developmental study

A range of cell-specific markers have been employed with immunocytochemical methods to characterise and quantitate the cell types present in mixed brain cell cultures derived from dissociated 1-2-day post-natal rat cerebral hemispheres and grown in the presence of FCS. Protoplasmic astrocytes (GFAP+, A2B5-) were the major cell type to develop in culture, a confluent monolayer forming in 5-8 days. A population of smaller round cells of oligodendrocyte-like morphology appeared on this astrocyte layer. Greater than 70% of these smaller cells were GC- and thus were not oligodendrocytes. The GC- cells were A2B5+ and, in early cultures, may therefore be progenitor glial cells. Examination of GFAP and A2B5 co-expression by these smaller cells was difficult due to the dense underlying GFAP+ astrocyte layer. In less dense areas of older cultures these smaller cells with processes were GFAP+ and A2B5+: these are Type 2, fibrous astrocytes. GC+ oligodendrocytes, comprising 5-10% of the total identified cell population, were initially distributed over the astrocyte monolayer; in older cultures (after about 8 days) GC+ cells were observed in clumps over places where NF+ cells were identifiable. Such GC+ cells mostly became MBP+. Neurones accounted for about 6% of the identifiable cells in early cultures but a lower percentage in older cultures. Minor populations of ependymal cells and macrophages were present; cells displaying fibronectin, fibroblasts, were rarely identified. Use of horse serum in place of FCS gave lower yields of GC+ cells in cultures, slowed down astrocyte development, and resulted in the formation of trunks of GFAP+ cells throughout cultures. Other sera gave lower numbers of GC+ cells.

Antenatal diagnosis of urinary tract abnormalities: correlation of ultrasound appearance with postnatal diagnosis

A review was made of the natural history of the urinary tract abnormalities diagnosed antenatally in 18 fetuses in order to correlate the ultrasound appearance with subsequent postnatal diagnosis and prognosis. Unilateral disease, both obstruction and multicystic renal disease, was associated with a good prognosis. Bilateral dysplastic kidneys had a very poor prognosis. The antenatal ultrasound demonstration of bladder distention and/or hydronephrosis, however, does not always signify true obstruction of the urinary tract. This is important in view of the recent introduction of in utero interventions to preserve renal function and prevent pulmonary hypoplasia.

Winteraceous Pollen in the Lower Cretaceous of Israel: Early Evidence of a Magnolialean Angiosperm Family

Pollen of the primitive angiosperm family Winteraceae has been discovered in the Aptian-Albian of Israel, extending the fossil record of this phylogenetically important family of flowering plants from the uppermost Upper Cretaceous back some 40 million years to the upper Lower Cretaceous. This appears to represent the earliest known record of a magnolialean angiosperm family and is convincing evidence for the existence in the Early Cretaceous of an extant family of angiosperms.