Advanced Chronic Kidney Disease Research Articles

The safety of indocyanine green in patients with advanced chronic kidney disease or kidney transplantation – a scoping review

Near-infrared fluorescence imaging with indocyanine green (ICG) is increasingly being used in the field of image-guided surgery. Although ICG is considered non-nephrotoxic in current literature, caution is advised for the use of ICG in patients with advanced chronic kidney disease (CKD), including kidney transplant recipients. Therefore, a scoping review was performed to assess the safety of ICG in patients with advanced CKD or a renal allograft. This scoping review was guided by the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-analyses extension for Scoping Reviews). Web of Science, PubMed, and Embase were searched for articles and abstracts in which ICG was administered in patients with CKD or a renal allograft. The extracted data included the incidence of adverse events, kidney function after injection of ICG, preservation of transplant function, and type of other possible complications. The initial search resulted in 635 records of which nineteen studies were found eligible for the review. ICG was used for multiple purposes but never specifically as an objective to investigate possible nephrotoxicity. No adverse events were reported in the transplant group (n=250) or the CKD group (n= 74). Despite ICG-injection, preservation of transplant function after transplantation surgery was 94% in 198 patients, and no increase in possible ICG-related other complications was reported. This scoping review found no evidence that ICG increases the risk of adverse events in patients with CKD, including kidney transplant recipients. Therefore, the administration of ICG should not be withheld from these patients.

Impact of arteriovenous fistula formation on trajectory of kidney function decline: a target trial emulation

Abstract Background Prior nonrandomised studies have suggested nephroprotective effects of arteriovenous fistula (AVF) formation, but these are plausibly susceptible to immortal time and selection biases. Methods We studied patients attending nephrology clinics in the West of Scotland during 2010-2022 with an eGFR ≤15mL/min/1.73m2 and no prior AVF. Using target trial emulation and a sequential trial design, we simulated a hypothetical trial that would randomise patients to either undergo AVF formation immediately or not to undergo AVF formation. The primary outcome was the difference in eGFR slope for the first six months of follow-up, estimated using a mixed-effects model. The secondary outcomes were 5-year absolute risks of dialysis and death, estimated using the Aalen-Johansen and Kaplan-Meier estimators respectively. Results 1,364 unique patients (mean age 51.1, 55.7% male) contributed 3,125 person-trials, with 561 in the AVF and 2,564 in the no AVF group. Mean eGFR was 12.6mL/min/1.73m2 and the median number of eGFR measurements per person-trial was 7 (IQR 4 – 12). Slope of eGFR decline did not differ significantly between the AVF and no AVF groups (between group difference -0.67mL/min/1.73m2/year, 95%CI -1.43, 0.10). The 5-year absolute risk of dialysis was 87% (95%CI 84, 91) in the AVF group and 75% (95%CI 73, 77) in the no AVF group and the 5-year survival probability was 77% (95%CI 70, 83) in the AVF group and 67% (95%CI 64, 69) in the no AVF group. Conclusions In this study of patients with advanced CKD, there was no evidence of a nephroprotective effect of AVF formation.

Depletion by Hemodialysis of the Antioxidant Ergothioneine

Background: Hemodialysis may excessively remove valuable solutes. Untargeted metabolomics data from a prior study suggested that ergothioneine was depleted in the plasma of hemodialysis subjects. Ergothioneine is a dietary-derived solute with antioxidant properties. The presence of a highly specific ergothioneine uptake transporter suggests that it is valuable. Ergothioneine levels are high in tissues susceptible to oxidative stress, particularly erythrocytes. We compared erythrocyte and plasma ergothioneine levels in subjects receiving hemodialysis to those in subjects with advanced chronic kidney disease (CKD) and subjects without known kidney disease (controls). We further examined the extent to which indiscriminate removal by hemodialysis could contribute to ergothioneine depletion. Methods: Liquid chromatography tandem mass spectrometry with stable isotope dilution was used to measure the erythrocyte and plasma levels of ergothioneine in 12 control, 12 CKD, and 11 hemodialysis subjects. We also measured the urinary excretion of ergothioneine in control and CKD subjects, and the dialytic removal of ergothioneine in hemodialysis subjects. Results: Erythrocyte ergothioneine levels were markedly reduced in CKD and hemodialysis subjects. Erythrocyte levels in CKD subjects were on average 24% of the levels in control subjects and were even lower in hemodialysis subjects, averaging 8% of control subjects. Plasma ergothioneine levels were also reduced in CKD and hemodialysis subjects but to a lesser extent than the erythrocyte levels. Kidney tubular reabsorption of ergothioneine was avid. In contrast, hemodialysis cleared ergothioneine at a rate of 146±36 ml/min so that removal of ergothioneine by hemodialysis greatly exceeded the amount excreted in the urine in both CKD and control subjects. Conclusions: Ergothioneine, a potentially valuable antioxidant, is severely depleted in people maintained on hemodialysis. Future studies are required to assess the consequences of ergothioneine depletion.

Communicating health risk in chronic kidney disease: a scoping review.

Communicating risk is a key component of shared decision-making and is vital for the management of advanced chronic kidney disease (CKD). Despite this, there is little evidence to suggest how best to communicate health risk information to people living with CKD. The aim of this review was to identify and understand the nature of evidence-based risk communication strategies for people living with CKD. We searched MEDLINE, CINAHL and Scopus databases for articles which described or evaluated the use of risk communication strategies within the renal population. Similar risk communication strategies were collated and summarised narratively. A total of 3700 sources were retrieved from the search, of which 19 were included in the review. Eleven studies reported primary research, and eight reported either narrative or systematic reviews. Seven main risk communication strategies were identified: framing, absolute versus relative risk, natural frequencies versus percentages, personalised risk estimates, qualitative risk communication, best-case/worst-case framework and use of graphs and graphics. There was a paucity of risk communication strategies specific to the CKD population. Evidence-based strategies to improve health risk communication for patients living with CKD are lacking. There is a need to establish the informational and communication preferences for patients living with CKD to better understand how to best communicate health risk information to individuals in this population.

Glycemic control and risk factors of mortality in patients with diabetes mellitus and COVID-19: A single center experience from Pakistan.

Objective: To highlight the effect of COVID-19 and DM on each other by studying glycemic control and risk factors for mortality. Study Design: Retrospective Observational Review. Setting: Sindh Institute of Urology and Transplantation Karachi Pakistan. Period: March 2020 till March 2021. Methods: Covid-19 diagnosed patients admitted were enrolled. They were divided into DM and non-DM. Demographics, clinical variables and outcome were compared. Glycemic control during hospitalization was noted. Fasting glucose level >120 mg/dl, and random >200 mg/dl were considered as poor glycemic control. Survivors and non- survivors among DM patients were compared. Results: A total of 366 patients were included, 113(30.87%) DM and 253(69.12%) non-DM. Mean age was higher in DM group (58yrs vs 49.6yrs p <0.001). Significantly more patients with hypertension (p <0.001) and ischemic heart disease (p=0.001) developed Covid-19 in DM group. There was no difference in mortality (p = 0.295). In DM patients, the significant risk factors for mortality were age >60years, hypertension and chronic kidney disease. The mean high fasting and pre-dinner blood glucose levels at admission and day 5 were significantly associated with mortality. Conclusion: Diabetic patients with advanced age, hypertension and chronic kidney disease were associated with increased risk of death. More attention should be focused on dynamic monitoring and strict glycemic control as uncontrolled diabetes is associated with severe infection and mortality.

Physical activity and renal outcome in diabetic and non-diabetic patients with chronic kidney disease stage G3b to G5

The association of physical activity with renal outcome and mortality in advanced chronic kidney disease (CKD; i.e., estimated glomerular filtration rate [eGFR] < 45 ml/min/1.73m2) is poorly studied. We examined this association in patients with advanced CKD in Japan. We used the Rapid Assessment of Physical Activity to assess baseline physical activity and classify patients as active or inactive. CKD progression was defined as 40% decline in eGFR, eGFR < 10, or requiring dialysis or transplantation. Among the 1,808 eligible patients, after adjusting for possible confounders, hazard ratios (HRs) for poor renal outcome in the active group were 0.68 (95% CI, 0.44–1.04), 1.09 (0.86–1.38), and 1.01 (0.82–1.25) in CKD stage G3b, G4, and G5, respectively, suggesting a renal benefit of exercise in CKD stage G3b. Adjusted HRs for death were 0.79 (0.40–1.57), 0.55 (0.38–0.80), and 0.75 (0.44–1.26) in stage G3b, G4, and G5, respectively. While the adjusted HRs of death were 0.84 (0.52–1.38) and 0.60 (0.43–0.83) in diabetic and non-diabetic patients, suggesting that exercise may reduce mortality in non-diabetic patients. Our study suggests that exercise is associated with better survival in non-diabetic patients with CKD stage G3b-5, and better renal outcome in diabetic and non-diabetic CKD stage G3b.

Premature mortality and disparities in kidney healthcare for people with chronic kidney disease and severe mental health difficulties.

People with severe mental health difficulties, including schizophrenia, bipolar disorder and psychosis, have higher risk of chronic kidney disease (CKD). Little was known regarding clinical outcomes and utilisation of kidney care for people with CKD and severe mental health difficulties. We conducted a retrospective cohort analysis of individuals with CKD attending a tertiary renal unit in London, between 2006 and 2019. Individuals with severe mental health difficulty diagnoses were identified, and differences between those with and without severe mental health difficulties were analysed. Of the 5105 individuals with CKD, 112 (2.2%) had a recorded severe mental health difficulty diagnosis. The mean lifespan of those with severe mental health difficulties was 13.1 years shorter than those without severe mental health difficulties, t(1269) = 5.752, p < 0.001. People with severe mental health difficulties had more advanced CKD at their first nephrology appointment. There were no statistically significant differences between groups in the rates of kidney failure, age at onset of kidney failure, or time elapsed between first appointment and death/kidney failure. The number of inpatient admissions was similar between groups, but those with severe mental health difficulties had higher rates of emergency and ICU admissions. Among individuals on renal replacement therapy (RRT), those with severe mental health difficulties were less likely to receive a kidney transplant and peritoneal dialysis. For patients receiving haemodialysis, those with severe mental health difficulties had a higher proportion of shortened sessions, greater mean weight loss during sessions, and a higher proportion of serum potassium and phosphate levels outside normal ranges. Findings illustratea number of disparities in kidney healthcare betweenpeople with and without severe mental health difficulties, underscoring the need for interventions which prevent premature mortality and improve kidney care for this population.

Exercise and physical activity for people with chronic kidney disease: A national survey of nephrologist practice patterns in Saudi Arabia.

A variety of health benefits are associated with physical activity (PA) in individuals with chronic kidney disease (CKD). The aim of this study was to examine nephrologist practice patterns concerning exercise and PA in CKD patients. This is an online cross-sectional survey study that was conducted between June 2023 and May 2024 in Saudi Arabia. Nephrology fellow, specialists, and consultants in Saudi Arabia formed the study population. A total of 96 physicians participated in this study. Only 9.4% of renal units have exercise programs available to patients. These programs are available mainly for advanced CKD (pre-dialysis) and in-center hemodialysis patients. The major barriers for initiating or expanding exercise programs at their centers are a lack of motivation/interest from front-line staff (55.2%), lack of interest from management (48.3%), and no funding (47.1). Around 56.2% of respondents ask patients about their level of PA. Additionally, 64.6% give patients specific advice on how to increase their level of PA. For the types of exercise most beneficial for people with CKD, 90.6% recommend walking. Around 34.4% of respondents believe that physiotherapists should take ownership in providing exercise counseling and resources to people with CKD. The majority agreed or strongly agreed to recommend exercise in patients with CKD (76.0%). The mean attitude score for the study participants was 32.1 (standard deviation: 3.9) out of 40 (equal to 80.3%); which demonstrates positive attitude towards recommending exercise for CKD patients. Binary logistic regression analysis identified that there is no statistically significant difference between physicians in term of their attitude towards recommending exercise for CKD patients (P > .05). This study highlights a critical gap in the availability of exercise programs for CKD patients. Key barriers include lack of interest by staff and management and funding issues. In spite of these barriers, a majority of physicians acknowledge the role of exercise in CKD patients and advice regarding PA on a frequent basis. It suggests recommendations in order to expand the programs, including increasing staff motivation, securing management support, and getting funding for exercise programs and identifying the role of physiotherapists in exercise counseling for CKD patients.

Mediterranean Diet Pattern: Potential Impact on the Different Altered Pathways Related to Cardiovascular Risk in Advanced Chronic Kidney Disease.

Cardiovascular disease (CVD) remains the most common cause of mortality in chronic kidney disease (CKD) patients. Several studies suggest that the Mediterranean diet reduces the risk of CVD due to its influence on endothelial function, inflammation, lipid profile, and blood pressure. Integrating metabolomic and proteomic analyses of CKD could provide insights into the pathways involved in uremia-induced CVD and those pathways modifiable by the Mediterranean diet. We performed metabolomic and proteomic analyses on serum samples from 19 patients with advanced CKD (aCKD) and 27 healthy volunteers. The metabolites were quantified using four different approaches, based on their properties. Proteomic analysis was performed after depletion of seven abundant serum proteins (Albumin, IgG, antitrypsin, IgA, transferrin, haptoglobin, and fibrinogen). Integrative analysis was performed using MetaboAnalyst 4.0 and STRING 11.0 software to identify the dysregulated pathways and biomarkers. A total of 135 metabolites and 75 proteins were differentially expressed in aCKD patients, compared to the controls. Pathway enrichment analysis showed significant alterations in the innate immune system pathways, including complement, coagulation, and neutrophil degranulation, along with disrupted linoleic acid and cholesterol metabolism. Additionally, certain key metabolites and proteins were altered in aCKD patients, such as glutathione peroxidase 3, carnitine, homocitrulline, 3-methylhistidine, and several amino acids and derivatives. Our findings reveal significant dysregulation of the serum metabolome and proteome in aCKD, particularly in those pathways associated with endothelial dysfunction and CVD. These results suggest that CVD prevention in CKD may benefit from a multifaceted approach, including dietary interventions such as the Mediterranean diet.

Evaluating a multicomponent intervention for managing kidney outcomes among patients with moderate or advanced chronic kidney disease (CKD): protocol for the Strategies for Kidney Outcomes Prevention and Evaluation (SKOPE) randomized controlled trial

BackgroundChronic kidney disease (CKD) poses a global health challenge with high morbidity and mortality rates. Early detection and prompt intervention are critical in preventing progression to end-stage kidney disease (ESKD) and cardiovascular complications. Effective CKD management requires comprehensive care packages that integrate both pharmacological and non-pharmacological interventions within collaborative, team-based models, aiming to enhance patient outcomes and overall quality of life. The goal of the Strategies for Kidney Outcomes Prevention and Evaluation (SKOPE) study is to establish effective multicomponent intervention (MCI) strategies for evaluating and preventing kidney outcomes in patients with moderate to advanced CKD within primary care settings in Singapore.MethodsThis study is a 3-year randomized controlled trial among 896 participants aged between 40 and 80 years with moderate or advanced CKD in five government-subsidized polyclinics in Singapore. The components of the MCI are (1) nurses/service coordinators trained as health coaches for motivational conversation and CKD-specific lifestyle counseling on diet and exercise, using a hybrid follow-up approach of in-person, telephone, and secure video meetings; (2) training physicians in algorithm-based standardized management of CKD; (3) subsidy on SGLT2i medications for CKD; and (4) regular CKD case review meetings. The primary outcome is the estimated glomerular filtration rate (eGFR) total slope from randomization to final follow-up at 36 months.DiscussionIf shown to be effective, cost-effective, and acceptable, SKOPE should be considered for scaling country-wide and in similar regional healthcare systems.Trial registrationClinicalTrials.gov NCT05295368. Registered on March 25, 2022.

Medications for community pharmacists to dose adjust or avoid to enhance prescribing safety in individuals with advanced chronic kidney disease: a scoping review and modified Delphi

BackgroundCommunity pharmacists commonly see individuals with chronic kidney disease (CKD) and are in an ideal position to mitigate harm from inappropriate prescribing. We sought to develop a relevant medication list for community pharmacists to dose adjust or avoid in individuals with an estimated glomerular filtration rate (eGFR) below 30 mL/min informed through a scoping review and modified Delphi panel of nephrology, geriatric and primary care pharmacists.MethodsA scoping review was undertaken to identify higher risk medications common to community pharmacy practice, which require a dose adaptation in individuals with advanced CKD. A 3-round modified Delphi was conducted, informed by the medications identified in our scoping review, to establish consensus on which medications community pharmacists should adjust or avoid in individuals with stage 4 and 5 CKD (non-dialysis).ResultsNinety-two articles and 88 medications were identified from our scoping review. Of which, 64 were deemed relevant to community pharmacy practice and presented for consideration to 27 panel experts. The panel consisted of Canadian pharmacists practicing in nephrology (66.7%), geriatrics (18.5%) and primary care (14.8%). All participants completed rounds 1 and 2 and 96% completed round 3. At the end of round 3, the top 40 medications to adjust or avoid were identified. All round 3 participants selected metformin, gabapentin, pregabalin, non-steroidal anti-inflammatory drugs, nitrofurantoin, ciprofloxacin and rivaroxaban as the top ranked medications.ConclusionMedications eliminated by the kidneys may accumulate and cause harm in individuals with advanced chronic kidney disease. This study provides an expert consensus of the top 40 medications that community pharmacists should collaboratively adjust or avoid to enhance medication safety and prescribing for individuals with an eGFR below 30 mL/min.

Heart failure and advanced chronic kidney disease: differences in characteristics, treatment and outcomes in patients with glomerular filtration rate greater or less than 30 ml/minute/m2

Abstract Introduction Heart failure (HF) is a serious health problem and continues to have a high mortality and incidence of decompensation, despite advances in its management. Chronic kidney disease (CKD) is very prevalent in patients with HF, hinders their treatment and worsens their prognosis, especially when it is advanced CKD (glomerular filtration rate-GFR &amp;lt;30 ml(min/m2). It is important to know the differential characteristics of these patients to improve their management. Purpose To analyze in a contemporary registry of HF patients followed in specialized HF units in Spain the differences in clinical characteristics and treatment between patients with HF and advanced CKD. Methods We analyzed data from the registry of the SEC-Excelente-IC quality accreditation program of the Spanish Society of Cardiology, with 1716 patients with HF included between 2019 and 2021 by 45 specialized HF units accredited by the SEC. Patients were included consecutively in two 1-month cutoffs (March and October) in that period. The clinical and demographic characteristics and comorbidities of the patients were compared according to GFR &amp;lt; or &amp;gt; 30ml/min/m2. Results Of the 1,716 patients, 11.1% had a GFR&amp;lt;30 and 88.9% &amp;gt;30 mL/min/m2. Figure 1 shows the main clinical characteristics and comorbidities of the 2 groups. Median LVEF was similar in both groups: 42 (30-58) vs 38% (29-54). The group with advanced CKD was older (77±9.6 vs 70.5±12.6 years; p&amp;lt;0.001), had greater HF severity (more admissions for HF in the last year, worse NYHA functional class and longer evolution time), and a higher prevalence of coronary heart disease, hypertension, diabetes mellitus, cognitive impairment, anemia, iron deficiency and hyponatremia. There were no differences in sex, BMI, serum potassium or other comorbidities (Figure 1). Figure 2 shows the treatment received in each group. Patients with GFR &amp;lt;30 received in a significantly lower proportion all drugs for HF (p&amp;lt;0.001), except diuretics and potassium binders (ACEI/ARA, sacubitril-valsartan, MRA, beta-blockers, digoxin and SLGT2 inhibitors), and less cardiac rehabilitation (5.2 vs 10.4%; p=0.029). Incidence of one-year mortality was significantly higher in patients with GFR&amp;lt;30 ml/min/m2 (37.2 vs 14.4 per 100 persons-year, p&amp;lt;0.001), as were HF hospitalizations (61.3 vs 33.0; p&amp;lt;0.001) and HF decompensations without hospitalization (24.1 vs 11; p&amp;lt;0.001). Conclusions In our contemporary cohort of real-life HF patients, the prevalence of advanced CKD was 11.1%. These patients had a higher severity of HF, despite which, the utilization of HF drugs, including SGLT2 inhibitors was much lower than in those with GFR &amp;gt;30 ml/min/m2. One-year mortality, HF hospitalization and HF decompensations were almost 3-times higher. This treatment trend needs to be modified to improve the prognosis of these patients.

Differences in the optimization of pharmacological treatment in patients with heart failure and reduced ejection fraction and advanced chronic kidney disease

Abstract Introduction Chronic kidney disease is very prevalent in patients with HF, makes their treatment difficult and worsens their prognosis, especially when it is advanced CKD (glomerular filtration rate &amp;lt;30 mL/min/m2). Renal insufficiency increases the risk of drug intolerance and an increase in serious side effects, which can lead to underuse, with consequent negative effects on patient prognosis. Purpose To analyze in a contemporary registry of HF patients followed in specialized HF units in Spain the achievement of dose targets for the most used drugs in HF with reduced ejection fraction (HFrEF) and the impact of advanced CKD. Methods We analyzed 914 patients with HFrEF consecutively included between 2019 and 2021 in the registry of the SEC-Excelente-IC quality accreditation program of the Spanish Society of Cardiology in 45 centers. We evaluated the proportion of patients treated with ACEI, ARA, ARNI, MRA, beta-blockers and SGLT2 inhibitors at the registry inclusion visit, the causes of non-prescription, and the achievement of the maximum dose recommended in the ESC clinical practice guidelines or the maximum tolerated dose in these patients, comparing the GFR groups, greater or less than 30 ml/min/m2. Results Of the 914 patients, 8.9% had a GFR&amp;lt;30 mL/min/m2. Their age was 76.9±9.7 years, 39.7% women, mean LVEF 32.8±9-6%. Patients with GFR&amp;lt;30 received in a significantly lower proportion all HF drugs except diuretics, ARBs and potassium chelators: sacubitril-valsartan 30.5% vs 59.2%; MRAs 31.7 vs 77.8%; SGLT2 inhibitors 34.1 vs 52.9% (p&amp;lt;0.001; Figure 1). The main reason for non-use was intolerance/contraindication for beta-blockers and "other" for the rest of the drugs (Figure 1). The proportion of patients in whom the maximum recommended, or maximum tolerated dose was reached was low in both groups, less than 40-50% for all drugs except MRA. There were no significant differences between the two groups in relation to the degree of renal dysfunction, although there was a tendency for the recommended doses to be obtained more frequently in the group with lower GFR (Figure 2). Conclusions In our contemporary cohort of real-life patients with HFrEF and advanced CKD, the use of recommended drugs for HF was significantly lower than in those patients with better renal function. However, where they were used, maximum recommended or tolerated doses were achieved in a higher proportion of patients. This indicates that with adequate selection it is possible to achieve the objectives proposed by the clinical practice guidelines in this complex group of patients.

Pulmonary hypertension in patients on chronic hemodialysis

Abstract Introduction Pulmonary hypertension (PH) is a common condition in patients with advanced chronic kidney disease and is associated with higher morbidity and mortality. High arteriovenous fistula (AVF) flow is one of known etiological factors, but the association of AVF flow within the acceptable range and PH has not been tested. Moreover, the prevalence of PH differed among various studies. Purpose The aims of this study were: 1. to describe the prevalence of PH in the Czech hemodialysis population; 2. to analyze the relation between dialysis fistula flow and PH; 3. to reveal other etiology of PH in a cross-sectional non-invasive trial. Methods We analyzed index visits of the cohort CZecking HF-CKD study (ISRCTN 18275480). Thus, this is a cross-sectional analysis based on detailed echocardiography with cardiac output (CO) calculation, evaluation of the central venous pressure (CVP) and AVF flow, bio-impedance and basic laboratory tests. All these measurements were done within an hour. The presence of PH was based on the peak systolic pulmonary arterial pressure (PASP) estimation above 35 mmHg. Results We analyzed data of 162 patients. They were 73,2 ± 12,6 years old, dialysis vintage 30 ± 69 months. Pulmonary hypertension was present in 35 % of analyzed patients. Among these patients, mild PH was present in 35 %, moderate in 53 % and severe in 12 %. There was no significant impact of AVF/AVG flow on the presence of PH or PASP value (Table 1.). However patients with PH had higher prevalence of heart failure (HF), which was present in 86 % of patients with PH and only in 46 % without PH (p&amp;lt;0.00001), see Figure 1. This and other differences presented in Table 1. document significant contribution of postcapillary PH. Patients with PH were also more overhydrated when considered by CVP, by overhydration measurement using bioelectrical impedance analysis and had higher N-terminal pro brain natriuretic peptide (NTproBNP) (Table 1.). There was a positive correlation between systemic vascular resistance (SVR) and PASP (R=0,333, p= .001). Conclusions PH is present in approximately one third of the dialysis patients. The presence of heart failure and changes of left heart chambers show for the postcapillary etiology of PH. Neither the prevalence nor the severity of PH were significantly related to arteriovenous access flow.

Cardiovascular mortality with oral potassium-binders in patients with CKD and heart failure

Abstract Introduction Hyperkalemia is an inherent consequence of advancing chronic kidney disease (CKD) as a result of the kidney’s decreased ability to excrete potassium. Heart failure patients with concomitant CKD may not tolerate maximum doses of guideline-directed medical therapies (GDMT) like ACE inhibitors (ACEi), angiotensin receptor blockers (ARB), angiotensin receptor/neprilysin inhibitors (ARNI) and mineralocorticoid receptor antagonists (MRA) due to dose-limiting hyperkalemia. Many randomized controlled trials in heart failure exclude patients with advanced CKD. Two oral therapies exist to manage hyperkalemia - patiromer sorbitex calcium and sodium zirconium cyclosilicate. This study aims to identify the potassium-binder with better outcomes as defined by less readmissions, hyperkalemia episodes, and death. Purpose This project was undertaken to better understand the impact of using potassium-binders in CKD patients with heart failure. Improved management of hyperkalemia will be an avenue for optimization of GDMT in this population. Methods and materials The TriNetX research network was used for this study. Two cohorts of patients were created by using International Classification of Disease 10 (ICD-10) codes and CPT codes. Both cohorts consisted of patients with no prior history of hyperkalemia within 30 days of hospital discharge at which time one cohort was prescribed patiromer and the other received sodium zirconium cyclosilicate. Each cohort was prohibited from exposure to the other medication. The cohorts were balanced by propensity score matching and the greedy nearest neighbor algorithm for age, race, gender, ethnicity. They were also balanced for systolic and diastolic heart failure diagnoses, and for each individual stage of CKD (1 through 5 and end stage). They were also balanced for use of ACEi, ARBs, and MRAs. This resulted in 8,921 patients in each arm. They were then evaluated for the outcomes of hospital readmission, hyperkalemia episodes (&amp;gt;6.1 mmol/L), and death within 12 months. Results Patients treated with patiromer were more likely to be hospitalized over the following twelve months (44% vs 40%, RR 1.11, 95% CI (1.07,1.15), p value &amp;lt;0.0001). They were also more likely to experience hyperkalemia (11.7% vs 9.2%, RR 1.27, 95% CI (1.16,1.38), p value &amp;lt;0.0001). Patiromer was also associated with slightly greater all cause mortality (27% vs 25%, RR 1.08, 95% CI (1.03,1.13), p value 0.0021). Discussion This study demonstrates patiromer has more readmissions and hyperkalemia episodes along with greater mortality. In conclusion, sodium zirconium cyclosilicate was found to have better outcomes compared to that of patiromer. Further studies are necessary to better understand the utility of using sodium zirconium cyclosilicate as maintenance therapy for hyperkalemia in order to maximize GDMT in CKD patients with heart failure.

The use of myocardial perfusion scintigraphy to screen for asymptomatic coronary artery disease prior to kidney transplantation

Abstract Background and Objectives Advanced chronic kidney disease (CKD) is associated with an increased risk of cardiovascular disease (CVD), including significant asymptomatic coronary artery disease (CAD) [1], compared to the general general public. Additionally, CVD is the leading cause of mortality in kidney transplant recipients [2]. Given the relative scarcity of available organs, individuals are commonly screened for CAD with non-invasive cardiac testing such as Myocardial Perfusion Scintigraphy (MPS). However, the benefits of screening for asymptomatic CAD are unproven and in the absence of an established screening protocol, investigations vary centre to centre and can result in uncertain interpretation of results and unnecessary delays in transplantation. The objective of this study was to assess the benefits of asymptomatic CVD screening of potential kidney transplant recipients, and its impact on transplantation outcomes. Methods This retrospective analysis included all MPS requested by the transplant team during patients’ assessment process between 2015 and 2023. Any resultant coronary angiograms (CA) were reviewed for evidence of significant CAD. Transplant decisions were reviewed to assess the impact of CVD screening on individuals’ transplant status. Results 689 individuals underwent MPS. Of these, 90% required no further cardiovascular investigations. 6% (42 individuals) had subsequent CA. &amp;lt;1% (5) required percutaneous intervention (PCI) whilst the rest (37) were deemed to have no significant CAD. A further 4% (29) required coronary angiography at a later date (&amp;gt;2 years after their MPS), with similar rates of PCI (1%). All three outcome groups (negative MPS, CA referral, CA in the future) had similar rates of diabetes (40%) and previous diagnoses of CAD (14%). The average wait for CA was 283 days post-MPS. Transplant decisions took a further 286 days after CA, which in combination with the delays associated with CA resulted in average delays of 1.5 years. Conclusions The use of MPS to screen for significant asymptomatic CAD identifies only a small proportion of individuals requiring intervention prior to kidney transplantation and significantly delays transplant decisions. These results suggest transplant centres should review their use of CVD screening prior to listing.

Feasibility and Acceptability of a Palliative Care Intervention Among Older or Adults with Advanced CKD and their Caregivers.

In non-nephrology settings, specialty Palliative Care (PC) improves decision-making, patient's quality of life (QoL), advance care planning (ACP), and certain indicators of the quality of end-of-life (EoL) care. This pilot RCT explored the feasibility and acceptability of a PC intervention, CKD-EDU, for older adults ≥75 years with eGFR ≤25 ml/min and their caregivers. Participants randomized to the control group received standard nephrology care and routine kidney therapy (KT) education, while those randomized to CKD-EDU received a decision aid and met with a PC clinician up to three times to discuss KT decisions and EoL planning. Patients were assessed at baseline, 4-6, 12-14, and 24-26 weeks. Main outcomes included intervention feasibility and acceptability, decision-conflict, and patient QoL. The mediating effects of reduced decision conflict on improved QOL were explored, as were the effects of CKD-EDU on ACP, EoL treatment intensity and 6-month-hospitalization. Statistical analyses encompassed descriptive analyses, adjusted repeated-measure-models, mediation analyses and logistic-regression models. Among the 127 eligible patients screened, 58 (44%) consented: 30 were randomized to CKD-EUD and 28 to the control arm. All patients completed baseline assessments, and 89% completed at least one intervention session (n=26/29), underscoring intervention adherence and feasibility. Similarly, assessments completion rates at 4 (83%, n=45/54) ), 12 (93%, n=42/45), and 24 (95%, n=40/42) weeks were high. The intervention received over 85% acceptability ratings for all questions. Patients exposed to CKD-EDU exhibited significant improvement in decisional conflict scale scores (P = 0.003) at 4-6 weeks and improvements in QoL at 24-26 weeks (P=0.02). Exploratory analyses were not statistically significant in this pilot, but all effect sizes were in the predicted direction. This study demonstrates the feasibility and acceptability of CKD-EDU. A larger scale trial is warranted to assess its effectiveness in improving key outcomes important to patients and families.

Risk of Postoperative Hypermagnesemia in Cardiopulmonary Bypass Assisted Cardiovascular Surgery.

Magnesium administration is a common practice in cardiovascular surgeries utilizing cardiopulmonary bypass (CPB). However, concerns persist regarding the risk of hypermagnesemia, particularly in patients with kidney dysfunction. This study aims to determine the incidence of postoperative hypermagnesemia in CPB-assisted cardiovascular surgeries and identify the associated risk factors. This was a retrospective cohort study conducted at a tertiary medical center. Data from adult patients undergoing open-heart surgery utilizing CPB between 2018 and 2020 were analyzed. Sociodemographic, perioperative, and clinical variables were collected from electronic medical records. Logistic regression was utilized to identify independent risk factors for hypermagnesemia. Of 278 patients analyzed, 53.2% developed postoperative hypermagnesemia (Mg ≥2.5 mg/dL). Mild hypermagnesemia (Mg 2.5-3.9 mg/dL) was most common, with no significant impact on clinical outcomes observed. Patients with hypermagnesemia were older, with higher comorbidity burdens and lower baseline estimated glomerular filtration rate (eGFR). Cardioplegic solutions with higher magnesium content and lower baseline eGFR were independently associated with hypermagnesemia (OR 64.3; 95% CI 12.9-501.1 and OR 1.3; 95% CI, 1.1-1.5 respectively). Notably, ultrafiltration on CPB was associated with low risk of hypermagnesemia (OR 0.4, 95% CI 0.1-1.0, P value 0.048). This study highlights the importance of mindful magnesium supplementation strategies in those with advanced kidney disease. Future large-scale prospective multicenter studies should validate these findings and explore the extended effects of hypermagnesemia on clinical outcomes in patients with advanced CKD undergoing CPB surgeries.

Early Metabolomic Profiling as a Predictor of Renal Function Six Months After Kidney Transplantation

Background: Kidney transplantation is the therapy of choice for patients with advanced chronic kidney disease; however, predicting graft outcomes remains a significant challenge. Early identification of reliable biomarkers could enhance post-transplant management and improve long-term outcomes. This study aimed to identify metabolomic biomarkers within the first week after kidney transplantation that predict renal function at six months. Methods: We conducted a prospective study involving 50 adult patients who received deceased donor kidney transplants. Plasma samples collected one week after transplant were analyzed using liquid chromatography–mass spectrometry in a semi-targeted metabolomic approach. A Partial Least Squares-Discriminant Analysis (PLS-DA) model identified metabolites associated with serum creatinine &gt; 1.5 mg/dL at six months. Metabolites were selected based on a Variable Importance in Projection (VIP) score &gt; 1.5, which was used to optimize model performance. Results: The PLS-DA model demonstrated strong predictive performance with an area under the curve (AUC) of 0.958. The metabolites negatively associated with serum creatinine &gt; 1.5 mg/dL were 3-methylindole, guaiacol, histidine, 3-indolepropionic acid, and α-lipoic acid. Conversely, the metabolites positively associated with worse kidney graft outcomes included homocarnosine, 5-methylcytosine, xanthosine, choline, phenylalanine, kynurenic acid, and L-kynurenine. Conclusions: Early metabolomic profiling after transplantation shows promise in predicting renal function. Identifying metabolites with antioxidant and anti-inflammatory properties, as well as those that are harmful and could be targeted therapeutically, underscores their potential clinical significance. The link between several metabolites and the tryptophan pathway suggests that further specific evaluation of this pathway is warranted. These biomarkers can enhance patient management and graft survival.

Effects of supportive hemodialysis on the management of a pregnant woman with advanced chronic kidney disease: a case report and literature review

BackgroundPregnancy in women with chronic kidney disease (CKD) is associated with an increased risk of adverse maternal and fetal outcomes, including worsening renal function, hypertension, proteinuria, preeclampsia, preterm delivery, stillbirth, and intrauterine growth restriction. Some pregnant women with CKD may require dialysis after conception. Clinical guidelines provide recommendations for optimal hemodialysis prescription in pregnant women undergoing maintenance hemodialysis for end-stage kidney disease. However, the timing of initiation and optimal doses of hemodialysis for pregnant women with non-dialysis advanced CKD remain uncertain.Case presentationWe describe the case of a 29-year-old woman with a history of CKD for at least 2 years. She was referred to our department with a serum creatinine level of 2.48 mg/dL and an estimated glomerular filtration rate of 20 mL/min/1.73 m2. Because she was found to be pregnant at the initial visit, she was referred to the Department of Obstetrics. At 23 weeks’ gestation, she was admitted due to threatened premature delivery and urinary tract infection, which were managed with ritodrine hydrochloride and antibiotics. Owing to maternal weight loss and asymmetrical fetal growth restriction, daily protein intake was increased from 40 g/day to 60–80 g/day. Additionally, supportive hemodialysis (three times per week) was initiated at 26 weeks’ gestation, and the pre-dialysis blood urea nitrogen (BUN) level was consistently maintained < 40 mg/dL. Consequently, the patient’s weight increased, and fetal growth recovered. Because her blood pressure increased particularly during and after dialysis sessions, dialysis was discontinued at 32 weeks’ gestation. Urinary protein increased to a nephrotic level, and blood pressure was poorly controlled by medication, suggesting the onset of preeclampsia. Thus, a cesarean section was performed at 33 weeks’ gestation, and she delivered a male baby weighing 1449 g. Following childbirth, the patient did not require hemodialysis.ConclusionsSupportive hemodialysis during pregnancy in women with advanced CKD can increase maternal protein intake without elevating BUN levels, leading to improved fetal growth.