Chronic Kidney Disease Guidelines Research Articles

Australian and New Zealand Living Guideline cholesterol-lowering therapy for people with chronic kidney disease (CARI Guidelines): Reducing the evidence-practice gap.

People with chronic kidney disease experience high rates of cardiovascular disease. Cholesterol-lowering therapy is a mainstay in the management but there is uncertainty in the treatment effects on patient-important outcomes, such as fatigue and rhabdomyolysis. Here, we summarise the updated CARI Australian and New Zealand Living Guidelines on cholesterol-lowering therapy in chronic kidney disease. We updated a Cochrane review and monitored newly published studies weekly to inform guideline development according to international standards. The Working Group included expertise from nephrology, cardiology, Indigenous Health, guideline development and people with lived experience of chronic kidney disease. The guideline recommends people with chronic kidney disease (eGFR ≥15 mL/min/1.73 m2) and an absolute cardiovascular risk of 10% or higher should receive statin therapy (with or without ezetimibe) to reduce the risk of cardiovascular events and death (strong recommendation, moderate certainty evidence). The guidelines also recommends a lower absolute cardiovascular risk threshold (≥5%) for Aboriginal and Torres Strait Islander Peoples and Māori with chronic kidney disease to receive statin therapy (with or without ezetimibe) (strong recommendation, low certainty evidence). The evidence was actively surveyed from 2020-2023 and updated as required. No changes to guideline recommendations were made, with no new data on the balance and benefits of harms. The development of living guidelines was feasible and provided the opportunity to update recommendations to improve clinical decision-making in real-time. Living guidelines provide the opportunity to transform chronic kidney disease guidelines.

Consumer involvement in the development and dissemination of chronic kidney disease guidelines: a summary of a meaningful and sustainable approach developed by Caring for Australians and New ZealandeRs with kidney Impairment guidelines

ObjectivesThe involvement of consumers (people with lived experience of disease) in guidelines is widely advocated to improve their relevance and uptake. However, the approaches to consumer involvement in guidelines vary and are not well documented. We describe the consumer involvement framework of Caring for Australians and New ZealandeRs with kidney Impairment Guidelines. Study Design and SettingWe used a descriptive document analysis to collate all relevant policies, documents, e-mails, and presentations on consumer involvement in our organizations. We performed a narrative synthesis of collated data to summarize our evolving consumer involvement approach in guidelines. ResultsWe involve consumers at all levels of Caring for Australians and New ZealandeRs with kidney Impairment guideline development and dissemination according to their capacity, from conducting consumer workshops to inform the scope of guidelines, to including consumers as members of the guideline Working Groups and overseeing operations and governance as members of the Steering Committee and staff. Our approach has resulted in tangible outcomes including high-priority topics on patient education, psychosocial care, and clinical care pathways, and focusing the literature reviews to assess patient-important outcomes. The ongoing partnership with consumers led to the generation of consumer version guidelines to improve guideline dissemination and translation to support shared decision-making. ConclusionMeaningful consumer involvement can be achieved through a comprehensive approach across the entire lifecycle of guidelines. However, it must be individualized by ensuring that the involvement of consumers is timely and flexible. Future work is needed to assess the impact of consumer involvement in guideline development.

Integrating Retrieval-Augmented Generation with Large Language Models in Nephrology: Advancing Practical Applications.

The integration of large language models (LLMs) into healthcare, particularly in nephrology, represents a significant advancement in applying advanced technology to patient care, medical research, and education. These advanced models have progressed from simple text processors to tools capable of deep language understanding, offering innovative ways to handle health-related data, thus improving medical practice efficiency and effectiveness. A significant challenge in medical applications of LLMs is their imperfect accuracy and/or tendency to produce hallucinations-outputs that are factually incorrect or irrelevant. This issue is particularly critical in healthcare, where precision is essential, as inaccuracies can undermine the reliability of these models in crucial decision-making processes. To overcome these challenges, various strategies have been developed. One such strategy is prompt engineering, like the chain-of-thought approach, which directs LLMs towards more accurate responses by breaking down the problem into intermediate steps or reasoning sequences. Another one is the retrieval-augmented generation (RAG) strategy, which helps address hallucinations by integrating external data, enhancing output accuracy and relevance. Hence, RAG is favored for tasks requiring up-to-date, comprehensive information, such as in clinical decision making or educational applications. In this article, we showcase the creation of a specialized ChatGPT model integrated with a RAG system, tailored to align with the KDIGO 2023 guidelines for chronic kidney disease. This example demonstrates its potential in providing specialized, accurate medical advice, marking a step towards more reliable and efficient nephrology practices.

#4441 KIDNEY DISEASE OUTCOMES WITH SEMAGLUTIDE VERSUS PLACEBO ACROSS BASELINE KDIGO RISK CATEGORIES: A POST HOC ANALYSIS OF SUSTAIN 6

Abstract Background and Aims The Kidney Disease: Improving Global Outcomes (KDIGO) risk categories classify risk of progression of chronic kidney disease (CKD) and cardiovascular (CV) complications based on estimated glomerular filtration rate (eGFR) and urinary albumin:creatinine ratio (UACR). Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are recommended by the KDIGO 2022 Clinical Practice Guidelines for Diabetes and CKD in patients with type 2 diabetes (T2D) and CKD who need better glycaemic control or CV risk reduction. In patients with T2D, once-weekly (OW) semaglutide, a GLP-1RA, reduces albuminuria and may preserve eGFR compared with placebo, irrespective of baseline eGFR or UACR. The aim of this analysis was to assess the treatment effects on kidney outcomes of OW semaglutide by KDIGO risk category at baseline compared with placebo. Method In a post hoc analysis from the SUSTAIN 6 trial (NCT01720446), randomised patients with T2D (N = 3,297) treated with OW semaglutide (0.5 and 1.0 mg) or placebo were stratified by baseline KDIGO risk category (low, moderate, high, and very high). The median follow-up time was 2.1 years. The treatment effect on the adjudicated endpoint of time to first new or worsening nephropathy (a composite of macroalbuminuria onset, doubling of serum creatinine and eGFR <45 mL/min/1.73 m2, need for kidney replacement therapy, or death due to kidney disease) across KDIGO categories was analysed using Cox regression. Analyses of treatment for eGFR slope and change in UACR (log-transformed) across KDIGO categories were performed using random slope modelling and mixed models adjusted for baseline UACR and assessed at 104 weeks. Results Participants with baseline eGFR and UACR values (N = 3,238) were stratified in to the low (n = 1,596 [49%]; 60% male; mean 64 years), moderate (n = 831 [26%]; 62% male; mean 65 years), high (n = 445 [14%]; 62% male; mean 66 years) and very high (n = 366 [11%]; 59% male; mean 67 years) KDIGO risk categories. Regardless of treatment group, participants in the moderate-, high- and very high-risk groups were more likely to experience the new or worsening nephropathy endpoint vs participants in the low-risk group at end of trial (hazard ratios [95% confidence intervals] 15.7 [8.0;35.7], 15.7 [7.7;36.6] and 23.9 [11.5;55.9], respectively). The treatment effect of OW semaglutide vs placebo was comparable in the low-, moderate-, high- and very high-risk categories (n = 785, 433, 227 and 171 for semaglutide and n = 811, 398, 218 and 195 for placebo, respectively) for new or worsening nephropathy (pinteraction = 0.28), eGFR slope (pinteraction = 0.44) and change in UACR (pinteraction = 0.84; Figure). Conclusion Participants in the higher risk groups had substantially greater hazards of adverse kidney outcomes compared with participants in the low-risk group, as predicted by KDIGO risk category classification. The treatment effect of OW semaglutide vs placebo on risk of new or worsening nephropathy, eGFR slope and change in UACR was consistent across KDIGO risk categories. The ongoing FLOW kidney outcomes trial has a population with T2D and CKD that corresponds to the high- and very high-risk KDIGO categories, and it will provide primary outcome data on potential kidney-protective effects of OW semaglutide; results are anticipated in 2024.

Comprehensive review of current management guidelines of chronic kidney disease.

Chronic kidney disease (CKD) is a prevalent and progressive condition affecting millions worldwide. It is a long-term condition characterized by gradual loss of kidney function over time. The management of CKD is complex and requires a multidisciplinary approach. This review aims to outline the current management guidelines for CKD. The study included a comprehensive search of various PubMed, Embase, and the Cochrane Library databases for articles published between 2010 and 2023. The search terms used were "chronic kidney disease," "management," and "guidelines." The inclusion criteria were articles that provided management guidelines for patients with CKD. A total of 23 articles were included in the review. Most articles were based on the Kidney Disease Improving Global Outcomes guidelines, the most widely recognized and used guidelines for managing CKD. The study found that the guidelines emphasize the importance of early detection and management of CKD and the need for an approach that involves multiple disciplines in its management. The guidelines recommend several interventions to slow the progression of CKD, including blood pressure control, glycemic control in diabetic patients, and reduce proteinuria. Other interventions include lifestyle modifications such as dietary changes, physical activity, and smoking cessation. The guidelines also recommend regular monitoring of kidney function and referral to a nephrologist for patients with advanced CKD or other complications. Overall, the current management guidelines for CKD emphasize the importance of early detection and a multidisciplinary approach to its management.

Rapid identification of chronic kidney disease in electronic health record database using computable phenotype combining a common data model.

To the Editor: Chronic kidney disease (CKD) is a global burden of the public health. The global prevalence of CKD exceeded 10% while the awareness was around 10%.[1] In the era of big data, improving the identification of CKD using informatic tools is important. Computable phenotype is proven as an efficient tool to facilitate the process of patient identification using electronic health record (EHR) data. It is an automatic algorithm identifying the target population through objective criteria with logic statements. Effective implementation of a computable phenotype depends on valid mapping of raw data to a standard set of data and definitions. Previous studies developed computable phenotypes for CKD identification in English by using the Logical Observation Identifiers Names and Codes (LOINC) and the International Classification of Diseases (ICD) codes.[2,3] With the limited utilization of these codes and the language barrier, implementing these computable phenotypes in non-English circumstances and/or in the absence of identical coding system is difficult. Common data model (CDM) was reported as a solution for data standardization and the localization of computable phenotypes.[4] The core of CDM is the extraction of key elements, transforming into a standard terminology and loading into a standard schema extraction, transformation, loading (ETL). Currently, various CDMs with different original aims, such as the Observational Medical Outcomes Partnership CDM, Sentinel CDM, and the Patient-Centered Outcomes Research Network CDM, had been widely used and successfully facilitated the standardization of EHR data. Sentinel previously posted coding trend analyses on kidney disease, and only ICD-9 codes and ICD-10 codes were included. The CDM for CKD characterization was still lacking. The confirmation of CKD takes at least 3 months. This condition hinders the timely diagnosis and increases the missed diagnosis of CKD in clinical practice, especially for patients seeking health care in different institutes.[5] EHR database collects healthcare data continuously across institutes and updates those in real time. Monitoring and identifying the patients with CKD by using an informatic tool based on this database are promising. Collectively, speculating that a computable phenotype combining a CDM might facilitate the CKD-related data extraction and CKD identification using EHR data is reasonable. Yinzhou is a district with a population of 1.6 million people located in Ningbo Zhejiang province, China. The Regional Health Information System (RHIS) in Yinzhou collected EHRs of residents and updated the database in real time. Using this database, a unique identity code (PERSONKEY) was generated by using personal ID, sex, date of birth, and name and was adopted to recognize the identical person, link the health profiles in different sub-databases, and generate the complete EHRs. The EHRs of 976,409 adults with medical records were extracted as the raw data for the following analyses [Supplementary Figure 1, https://links.lww.com/CM9/B73]. This study was approved by the ethics committee of Peking University First Hospital. The CDM for CKD characterization was designed in accordance with the principles described in The Book of OHDSI: Observational Health Data Sciences and Informatics. In accordance with the Kidney Disease: Improving Global Outcomes (KDIGO) clinical guidelines for CKD (2012), the key elements for CKD identification were defined as age, sex, kidney function, and urine abnormality.[6] Hence, Data Domain of CDM for CKD identification was designed as demographics, laboratory tests, and diagnosis. Standard terminology of data domains was defined in accordance with the KDIGO-CKD clinical guidelines and ICD-10 codes in English and in Chinese. Forms containing demographics (age, sex), laboratory tests (kidney function, albuminuria, proteinuria, hematuria), and diagnosis (ICD-10 codes and texts) in the EHR database were integrated by PERSONKEY. Altogether, 10,981,723 medical records of 976,409 individuals in the EHR database were prepared for the extraction of original vocabularies [Supplementary Figure 1, https://links.lww.com/CM9/B73]. The mapping rules between original vocabularies and the standard terminology were established through manual annotation and format conversion. Two nephrologists independently conducted the annotation and one informaticist performed the mapping [Figure 1].Figure 1: Process of the development of CDM for CKD characterization and computable phenotype for CKD identification. CDM: Common data model; CKD: Chronic kidney disease; eGFR: Estimated glomerular filtration rate; EHR: Electronic health record; ICD: International Classification of Diseases.The algorithm of the computable phenotype for CKD identification was designed in accordance with KDIGO clinical guidelines for CKD[6] [Figure 1]. On the basis of the standard terminology of CDM, patients showing at least one of the following manifestations lasting for >3 months were defined as having CKD: (1) reduced kidney function: estimated glomerular filtration rate (eGFR) <60 mL·min−1 · 1.73 m−2); (2) albuminuria: urine albumin-to-creatinine ratio ≥30 mg/g or urine albumin concentration ≥20 mg/L; (3) proteinuria: urine protein-to-creatinine ratio ≥150 mg/g, or 24 h proteinuria ≥150 mg/24 h, or urinalysis protein ≥+1; (4) hematuria without non-CKD related causes including urologic neoplasms, urinary tract infection and injury. Criteria for hematuria: urine red blood cell ≥3 cells/HPF (or >28 cells/μL) or urine occult blood ≥+2; (5) CKD-related diagnosis including primary, secondary or congenital kidney disease, renal vascular disease, maintenance dialysis and recipient/donor of kidney transplantation [Supplementary Table 1, https://links.lww.com/CM9/B73]. Patients who received re-tests over a period of 3 months and were confirmed with the absence of the abovementioned manifestations were defined as normal cases. Patients who presented these manifestations for ≤3 months or did not receive any re-test were defined as cases to be addressed and will be processed in the next iteration of CKD identification. [Figure 1]. In accordance with the number of individuals with EHRs and considering the diversity of EHR infrastructures and data sources, seven institutes were selected from 42 healthcare institutes in Yinzhou to implement the computable phenotype based on the CDM. In total, three tertiary general hospitals, two specialty hospitals (a maternity and children's hospital and an orthopedic hospital), one secondary general hospital, and one community health center were selected. The performance of the computable phenotype was validated through manual review. Cases identified as with/without CKD were randomly selected, and their original records of demographics, diagnosis, and laboratory tests were manually reviewed by two nephrologists. For those without CKD, all diagnosis and CKD-related laboratory tests in the database were extracted and manually reviewed. For those with CKD, all diagnosis and laboratory tests from the date of presentation of CKD to the endpoint of the database were extracted and manually reviewed. Panel discussion was held when they have different opinions. Review by nephrologists was defined as the gold standard for CKD identification. The data processing and computation in the RHIS were based on the Hadoop framework. The computing engine was Spark, and the data warehouse was Hive as the support for structured query language (SQL) (The Apache Software Foundation, Wakefield, United Kingdom). The ETL process of CDM and the implementation of the computable phenotype were conducted using SQL statements. The demographic and clinical characteristics of CKD-identified patients were analyzed. The stages of CKD-identified patients were evaluated in terms of the levels of eGFR and presented in G1–G5. Continuous and categorical variables were presented as mean ± standard deviation and frequency, respectively. The performance of the computable phenotype was evaluated in terms of sensitivity, specificity, and accuracy and analyzed using MedCalc 15.8 (MedCalc Software Ltd., Ostend, Belgium). The standard terminology for CKD characterization is shown in Figure 1. The bilingual terminology is presented in Supplementary Table 2, https://links.lww.com/CM9/B73. A total of 617 original vocabularies for laboratory tests were found and standardized by processing 10,981,723 medical records of 976,409 individuals from 42 medical institutes. The formats of date, categorical data, and unit of test were converted. By manual annotation, 111 types of diagnosis (corresponding to 171 types of ICD-10 codes in English and Chinese versions) including primary, secondary and congenital kidney disease, renal vascular disease, and uremia-related diagnosis were reorganized as CKD-related diagnosis. [Supplementary Table 1, https://links.lww.com/CM9/B73] By scanning 21,474,008 records of laboratory tests and diagnoses of 557,719 individuals in seven medical institutes, 64,036 (11.5%) patients with CKD were identified by the computable phenotype. In China, patients commonly seek health care across different institutes. Thus, the EHRs of more than half of residents in the whole database were extracted from the seven representative institutes. Among them, 55,682 (87.0%) patients received serum creatinine tests. The majority of patients were in early stages (G1: 33,315 cases [59.8%]; G2: 12,980 cases [23.3%]). Patients in G1 were the youngest (53.7 ± 14.0 years), whereas patients in G4 were the oldest (82.3 ± 14.6 years). The highest proportion of hematuria and albuminuria/proteinuria was observed in G1 (17,187 cases [51.6%]) and G5 (417 cases [51.3%]), respectively. The frequency of patients labeled with CKD-related ICD-10 code increased from G1 (16,795 cases[50.4%]) to G5 (737 cases [90.7%]) [Supplementary Table 3, https://links.lww.com/CM9/B73]. In total, the EHRs of 50 CKD-identified cases and 50 cases without CKD were randomly sampled and reviewed by two nephrologists. Fifty CKD-identified cases were confirmed as disease present and three cases without CKD were defined as mis-classified because they did not meet the criterion of re-testing over 3 months. The sensitivity, specificity, and accuracy of the computable phenotype for CKD identification were 94.3%, 100.0%, and 97.0%, respectively [Supplementary Table 4, https://links.lww.com/CM9/B73]. Compared with the previous models, the present computable phenotype particularly considered the utilization of existing non-uniform data and its capacity of localization across databases with different settings. Nadkarni et al[3] developed a computable phenotype to identify patients with CKD in the population with diabetes and/or hypertension based on eMERGE network. Their algorithm mainly relied on ICD-9 codes. Hence, the performance of their computable phenotype was influenced by the missing rate of diagnosis records and/or the awareness. Norton et al[2] developed an NKDEP e-phenotype for CKD identification using laboratory tests, which were extracted through LOINC. Obviously, National Kidney Disease Education Program (NKDEP) e-phenotype avoided the influence of diagnosis rate effectively, but its dependence of LOINC limited the localization in a database without LOINC. The algorithm of the present computable phenotype combined CKD-related diagnostic records and laboratory tests to improve the data utilization and the identification rate. The terminology of the CDM preferred standard description rather than a coding system, so as to reserve the potential for further expansion in foreign databases in the absence of the identical coding system. In accordance with the present results of implementation, the EHR data in different levels of healthcare institutes were scanned successfully and the prevalence of CKD and the characteristics of identified-CKD patients were consistent with previous nationally representative study.[7] This condition demonstrated the effectiveness of the design embedding a CDM into the computable phenotype. The present study established a reproducible paradigm for the design and construction of CDM and computable phenotype in other fields and databases. First, slightly expanding the criteria for disease identification based on the standard definition of the disease is allowable to balance the utilization of data and the rate of identification. Second, embedding a CDM into the computable phenotype can improve the efficiency of its implementation across different databases. Third, a CDM containing non-monotonic terminology will increase the potentiality for the localization. Finally, the correspondence between the English and Chinese terminologies can be the interface to link the data in Chinese and the existing resources and techniques in English. This strategy may be feasible to promote the data extraction and information exchange in other languages. The present study is the first research to establish a computable phenotype for CKD identification based on the CDM with a bilingual terminology for CKD characterization. This study develops an efficient tool for CKD identification based on a real-world EHR database and provides a potential interface, the CDM, for the generalization of the computable phenotype across English and Chinese settings of database. Funding This study was supported by grants from the National Natural Science Foundation of China (Nos. 82100741, 82003529, 91846101, 81771938, 81900665, 82090021), Beijing Municipal Science and Technology Commission (Grant No. 7212201), the University of Michigan Health System-Peking University Health Science Center Joint Institute for Translational and Clinical Research (Nos. BMU2020JI011, BMU2019JI005, BMU2018JI012), Beijing Nova Programme Interdisciplinary Cooperation Project (No. Z191100001119008), National Key R&D Program of the Ministry of Science and Technology of China (No. 2019YFC2005000), the National Key Research and Development Program of China (No. 2018AAA0102100), PKU-Baidu Fund (Nos. 2020BD005, 2019BD017), and CAMS Innovation Fund for Medical Sciences (No. 2019-I2M-5-046). Conflicts of interest None.

Empagliflozin in Adults with Chronic Kidney Disease (CKD): Current Evidence and Place in Therapy.

Chronic kidney disease guidelines and disease modifying therapy have seen a dramatic shift in the last 5 years. The SGLT2 inhibitor class of medications has been catapulted from hyperglycemia management medications, to cardiovascular and kidney disease improvement therapies. Multiple trials looking at dedicated cardiovascular and kidney endpoints have resulted in favorable results. This review will target empagliflozin and the exciting journey that it has taken along this path. Empagliflozin has been studied for hyperglycemia, cardiovascular, and kidney hard outcome endpoints. Both patients with diabetes and without have been rigorously studied and shown surprising results. The major implications for patients on empagliflozin will be shown. Future studies and directions are highly anticipated to add to the growing knowledge of the SGLT2 inhibitor class, as well as discover possibilities for new disease states to benefit from empagliflozin.

Food-Derived Uremic Toxins in Chronic Kidney Disease.

Patients with chronic kidney disease (CKD) have a higher cardiovascular risk compared to the average population, and this is partially due to the plasma accumulation of solutes known as uremic toxins. The binding of some solutes to plasma proteins complicates their removal via conventional therapies, e.g., hemodialysis. Protein-bound uremic toxins originate either from endogenous production, diet, microbial metabolism, or the environment. Although the impact of diet on uremic toxicity in CKD is difficult to quantify, nutrient intake plays an important role. Indeed, most uremic toxins are gut-derived compounds. They include Maillard reaction products, hippurates, indoles, phenols, and polyamines, among others. In this review, we summarize the findings concerning foods and dietary components as sources of uremic toxins or their precursors. We then discuss their endogenous metabolism via human enzyme reactions or gut microbial fermentation. Lastly, we present potential dietary strategies found to be efficacious or promising in lowering uremic toxins plasma levels. Aligned with current nutritional guidelines for CKD, a low-protein diet with increased fiber consumption and limited processed foods seems to be an effective treatment against uremic toxins accumulation.

Development and assessment of a nutrition literacy scale for patients with end-stage kidney disease undergoing dialysis and its correlation with quality of life

Objectives To construct a valid and reliable Nutritional Literacy Scale for patients with end-stage kidney disease (ESKD) receiving dialysis and evaluate associations between nutrition literacy and quality of life. Methods A total of 208 ESKD patients receiving dialysis were selected for this study. Nutrition literacy evaluation items were drafted based on dietary guidelines for chronic kidney disease (CKD), Literature reviews and expert consultation. Scale reliability and validity were then assessed. Factors influencing nutrition literacy and the associations among nutrition literacy, nutritional status, and quality of life were evaluated. Results The scale consists of 28 items with a scale-level content validity index of 0.91 and item-level content validity indices ranging from 0.83 to 1.00. Factor analysis identified 4 common factors (dimensions) named nutrition knowledge, cognitive attitude, behavioral practice, and information acquisition ability that collectively explained 56.31% of literacy score variation. The overall Cronbach’s α coefficient of the scale was 0.83, the dimensional Cronbach’s α coefficients ranged from 0.79 to 0.87, and the retest reliability was r = 0.73 (p < 0.05). Age, education level, residence (urban vs. Rural), occupational status and dialysis modalities were significant factors influencing nutrition literacy. Nutrition literacy score was negatively correlated with SGA score and positively correlated with serum albumin and prealbumin concen- trations, and with SF-36 quality of life score (all p < 0.05). Conclusions This new Nutrition Literacy Scale demonstrates high reliability and validity for Chinese ESKD patients undergoing dialysis. The nutrition literacy is influenced by age, education level, residence, occupational status and dialysis modalities, associated not only with nutritional status but also with quality of life.

First Kidney Transplantation in Child at National Children's Medical Center

Chronic kidney disease, regardless of etiology, have common mechanisms of progression and require certain therapeutic efforts aimed at delaying the onset of the end stage of chronic kidney disease. Once the estimated glomerular filtration rate (GFR) has decreased to less than 30ml/min per 1.73m2 and the child has stage 4 CKD, it is time to begin preparing the child and family for renal replacement therapy. For most patients with end-stage chronic kidney disease, kidney transplantation is the best renal replacement therapy (RRT) option, providing the maximum length and quality of life compared to other treatment options. Chronic kidney disease (CKD) is persistent impairment of kidney function, lasting for 3 months or more, defined as structural and/or changes in the body with varying degrees of decreased clearance function. NKF KDOQI recommendations. National Kidney Foundation; 2002. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Assessment, Classification, and Stratification. Since the first successful kidney transplant in 1954, kidney transplantation has become the best treatment for adult patients with kidney failure. However, early pediatric kidney transplantation complicated by technical and immunological problems, resulting in worse patient and graft survival in children than in adults. Over the past 15 years, a number of advances have significantly improved patient and graft survival in pediatric kidney transplants. Kidney transplantation (KT) is the preferred renal replacement therapy for children with end-stage kidney disease (CKD) because survival and patient quality of life are better in children who receive a transplant compared to those who remain on dialysis. In addition, young children (under six years of age) are more likely to have improved growth after transplantation compared with those undergoing chronic hemodialysis or peritoneal dialysis.

Albuminuria testing and nephrology care among insured US adults with chronic kidney disease: a missed opportunity

BackgroundIn chronic kidney disease (CKD), assessment of both estimated glomerular filtration rate (eGFR) and albuminuria are necessary for stratifying risk and determining the need for nephrology referral. The Kidney Disease: Improving Global Outcomes clinical practice guidelines for CKD recommend nephrology referral for eGFR < 30 ml/min/1.73m2 or for urinary albumin/creatinine ratio ≥ 300 mg/g.MethodsUsing a national claims database of US patients covered by commercial insurance or Medicare Advantage, we identified patients with CKD who were actively followed in primary care. We examined receipt of nephrology care within 1 year among these patients according to their stage of CKD, classified using eGFR and albuminuria categories. Multivariable logistic regression was used to examine odds of receiving nephrology care by CKD category, adjusting for age, sex, race/ethnicity, diabetes, heart failure, and coronary artery disease.ResultsAmong 291,155 patients with CKD, 55% who met guideline-recommended referral criteria had seen a nephrologist. Receipt of guideline-recommended nephrology care was higher among those with eGFR < 30 (64%; 11,330/17738) compared with UACR ≥300 mg/g (51%; 8789/17290). 59% did not have albuminuria testing. Those patients without albuminuria testing had substantially lower adjusted odds of recommended nephrology care (aOR 0.47 [0.43, 0.52] for eGFR < 30 ml/min/1.73m2). Similar patterns were observed in analyses stratified by diabetes status.ConclusionsOnly half of patients meeting laboratory criteria for nephrology referral were seen by a nephrologist. Underutilization of albuminuria testing may be a barrier to identifying primary care patients at elevated kidney failure risk who may warrant nephrology referral.

Clinical implications and guidelines for CKD in type 2 diabetes.

Chronic kidney disease (CKD) is a complication of type 2 diabetes (T2D) with high morbidity and mortality. The prevalence of CKD in T2D is increasing due to rising numbers of persons with T2D. Multiple clinical trials have been conducted testing novel therapies to reduce the progression of CKD, cardiovascular morbidity, in particular hospitalization for heart failure, and mortality. Results of these clinical trials have informed guidelines for the management of CKD in T2D. The epidemiology of CKD in T2D and the process of guideline writing, including data gathering, grading and consensus development, were reviewed. Recent guidelines for the management of CKD in T2D that include recent renal outcome clinical trials are reported, along with supporting evidence. All current guidelines recommend annual screening for CKD, control of blood pressure and glucose, although the target levels and background therapy recommendations vary. Renin-angiotensin system (RAS) inhibition is uniformly recommended. Sodium-glucose cotransporter-2 (SGLT2) inhibition with proven agents is recommended by all guidelines, with minor variations in suggested estimated glomerular filtration rate and albuminuria levels. Finerenone, the first nonsteroidal mineralocorticoid receptor antagonist with renal outcome data, is recommended by the most recent guideline available. Current guidelines continue to recommend screening for CKD, blood pressure control using RAS inhibition as first-line therapy, and glucose control. SGLT2 inhibition and finerenone are recent additions to current guidelines to improve CKD outcomes in T2D, based on robust clinical trial data.

An Endorsement of the Removal of Race From GFR Estimation Equations: A Position Statement From the National Kidney Foundation Kidney Disease Outcomes Quality Initiative

As this article reflects the official position of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) and because it was reviewed and approved by NKF-KDOQI, it was not peer reviewed by AJKD. This article was prepared by the KDOQI chairs and led by Dr Holly Kramer. It was reviewed and approved by the NKF Scientific Advisory Board. As this article reflects the official position of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) and because it was reviewed and approved by NKF-KDOQI, it was not peer reviewed by AJKD. This article was prepared by the KDOQI chairs and led by Dr Holly Kramer. It was reviewed and approved by the NKF Scientific Advisory Board. In July 2020, the National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) formed a joint task force to reassess the use of race in the diagnosis of kidney diseases. After multiple sessions with stakeholders, such as clinical laboratory scientists, epidemiologists, and ancestry experts, including open forums for patients and their families and clinicians, the NKF-ASN joint task force released a report in 2021 that made recommendations for an equitable approach for glomerular filtration rate (GFR) estimation and outlined existing gaps in knowledge and research needs.1Delgado C. Baweja M. Crews D.C. et al.A unifying approach for GFR estimation: recommendations of the NKF-ASN Task Force on reassessing the inclusion of race in diagnosing kidney disease.Am J Kidney Dis. 2022; 79: 268-288.e1https://doi.org/10.1053/j.ajkd.2021.08.003Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar The NKF Kidney Disease Outcomes Quality Initiative (KDOQI) strongly supports the joint task force recommendations for the immediate implementation of the 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine-based GFR estimating equation without a race variable; increased use of cystatin C where possible; and the continued examination, identification, and validation of filtration biomarkers than can improve the accuracy of equations for estimated GFR (eGFR). KDOQI also agrees with the task force’s call for more research to identify and implement a consistent and equitable approach to GFR estimation. Removal of the race modifier to estimate GFR is only one small step for equity in kidney disease diagnosis and treatment, and further research and implementation of interventions to reduce chronic kidney disease (CKD) disparities by race and ethnicity are needed, as highlighted by a recent NKF research roundtable.2National Kidney Foundation Research Roundtable Work Group on behalf of the National Kidney FoundationResearch priorities for kidney-related research-an agenda to advance kidney care: a position statement from the National Kidney Foundation.Am J Kidney Dis. 2022; 79: 141-152https://doi.org/10.1053/j.ajkd.2021.08.018Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar This Position Statement discusses the recommendations of the NKF-ASN task force and how it advances the KDOQI goals of improving CKD diagnosis and treatment and eliminating health disparities in kidney disease. Most chronic diseases produce symptoms that incite patients to seek diagnosis and care, but the identification of CKD, which is often asymptomatic, requires laboratory testing. CKD continues to be underdiagnosed and undertreated for several reasons such as gaps in laboratory testing and low clinician recognition and action regarding abnormal test results.2National Kidney Foundation Research Roundtable Work Group on behalf of the National Kidney FoundationResearch priorities for kidney-related research-an agenda to advance kidney care: a position statement from the National Kidney Foundation.Am J Kidney Dis. 2022; 79: 141-152https://doi.org/10.1053/j.ajkd.2021.08.018Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar In the United States, approximately 37 million adults have CKD, but most remain unaware of their condition.3Centers for Disease Control and PreventionChronic Kidney Disease Surveillance System-United States.https://nccd.cdc.gov/ckd/default.aspxGoogle Scholar,4Johansen K.L. Chertow G.M. Foley R.N. et al.US Renal Data System 2020 annual data report: epidemiology of kidney disease in the United States.Am J Kidney Dis. 2021; 77(4)(suppl 1):A7-A8https://doi.org/10.1053/j.ajkd.2021.01.002Abstract Full Text Full Text PDF Scopus (168) Google Scholar Gaps in CKD testing and diagnosis are not uniform across populations, and the delivery of preventive care to avoid CKD or delay its progression and to reduce cardiovascular risk differs by income, insurance status, education level, and race and ethnicity.5Shoham D.A. Vupputuri S. Kshirsagar A.V. Chronic kidney disease and life course socioeconomic status: a review.Adv Chronic Kidney Dis. 2005; 12: 56-63https://doi.org/10.1053/j.ackd.2004.10.007Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 6Jurkovitz C.T. Li S. Norris K.C. et al.Association between lack of health insurance and risk of death and ESRD: results from the Kidney Early Evaluation Program (KEEP).Am J Kidney Dis. 2013; 61(4)(suppl 2):S24-S32https://doi.org/10.1053/j.ajkd.2012.12.015Abstract Full Text Full Text PDF Scopus (41) Google Scholar, 7Thio C.H.L. Vart P. Kieneker L.M. Snieder H. Gansevoort R.T. Bültmann U. Educational level and risk of chronic kidney disease: longitudinal data from the PREVEND study.Nephrol Dial Transplant. 2020; 35: 1211-1218https://doi.org/10.1093/ndt/gfy361Crossref PubMed Scopus (17) Google Scholar, 8Young E.W. Mauger E.A. Jiang K.H. Port F.K. Wolfe R.A. Socioeconomic status and end-stage renal disease in the United States.Kidney Int. 1994; 45: 907-911https://doi.org/10.1038/ki.1994.120Abstract Full Text PDF PubMed Scopus (115) Google Scholar Individuals from underrepresented communities are disproportionately affected by kidney failure,4Johansen K.L. Chertow G.M. Foley R.N. et al.US Renal Data System 2020 annual data report: epidemiology of kidney disease in the United States.Am J Kidney Dis. 2021; 77(4)(suppl 1):A7-A8https://doi.org/10.1053/j.ajkd.2021.01.002Abstract Full Text Full Text PDF Scopus (168) Google Scholar and earlier detection and treatment of kidney disease could delay progression to kidney failure, reduce cardiovascular risk and health disparities, improve survival, and lower health care costs. Due to the asymptomatic nature of kidney disease, however, earlier and wider diagnosis and treatment requires better awareness with public health initiatives, input from multiple health care sectors, and equitable approaches for all individuals at risk for kidney diseases.3Centers for Disease Control and PreventionChronic Kidney Disease Surveillance System-United States.https://nccd.cdc.gov/ckd/default.aspxGoogle Scholar,9Waterman A.D. Browne T. Waterman B.M. Gladstone E.H. Hostetter T. Attitudes and behaviors of African Americans regarding early detection of kidney disease.Am J Kidney Dis. 2008; 51: 554-562https://doi.org/10.1053/j.ajkd.2007.12.020Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar With its clinical practice guidelines and commentaries, KDOQI aims to improve the diagnosis and treatment of kidney disease. Over the past 2 decades, KDOQI guidelines have changed the practices of health care professionals and improved outcomes for people with kidney disease. To address gaps in CKD identification, KDOQI released the very first guideline for CKD diagnosis and classification 20 years ago.10National Kidney FoundationK/DOQI Clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification.Am J Kidney Dis. 2002; 39 (2)(suppl 1):S1-S266Google Scholar This guideline recommended that clinicians utilize an eGFR equation that incorporates serum creatinine and one or more demographic variables (eg, age, sex, race), such as the Modification of Diet in Renal Disease (MDRD) Study equation (Table 1).11Levey A.S. Bosch J.P. Lewis J.B. Greene T. Rogers N. Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group.Ann Intern Med. 1999; 130: 461-470https://doi.org/10.7326/0003-4819-130-6-199903160-00002Crossref PubMed Scopus (13005) Google Scholar The MDRD Study equation was developed using data from 1,431 White and 197 Black study participants.11Levey A.S. Bosch J.P. Lewis J.B. Greene T. Rogers N. Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group.Ann Intern Med. 1999; 130: 461-470https://doi.org/10.7326/0003-4819-130-6-199903160-00002Crossref PubMed Scopus (13005) Google Scholar Because Black race was associated with higher levels of serum creatinine for a given measured GFR, as was younger age and male sex, the MDRD Study equation included a coefficient for Black race, along with coefficients for age and sex. This coefficient for Black race meant that if all other variables (age, sex, serum creatinine) were the same, the expected mean measured GFR would be 21% higher for Black versus Non-Black adults.Table 1Change in Reported eGFR With Black Race by EquationDescriptionFormulaChange in Reported eGFR With Black Race4-Variable MDRD Study equation11Levey A.S. Bosch J.P. Lewis J.B. Greene T. Rogers N. Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group.Ann Intern Med. 1999; 130: 461-470https://doi.org/10.7326/0003-4819-130-6-199903160-00002Crossref PubMed Scopus (13005) Google ScholareGFR = 175 × Scr−1.154 × age−0.203 × 1.212 [if Black] × 0.742 [if female]21% higher2009 CKD-EPI creatinine equation12Levey A.S. Stevens L.A. Schmid C.H. et al.A new equation to estimate glomerular filtration rate.Ann Intern Med. 2009; 150: 604-612https://doi.org/10.7326/0003-4819-150-9-200905050-00006Crossref PubMed Scopus (15951) Google ScholareGFR = 141 × min(Scr/κ, 1)α × max(Scr/κ, 1)−1.209 × 0.993age × 1.018 [if female] × 1.159 [if Black],where κ is 0.7 if female and 0.9 if male, α is −0.329 if female and −0.411 if male, min indicates the minimum of Scr/κ or 1, and max indicates the maximum of Scr/κ or 116% higher2012 CKD-EPI creatinine–cystatin C equation13Inker L.A. Schmid C.H. Tighiouart H. et al.Estimating glomerular filtration rate from serum creatinine and cystatin C.N Engl J Med. 2012; 367: 20-29https://doi.org/10.1056/NEJMoa1114248Crossref PubMed Scopus (2486) Google ScholareGFR = 135 × min(Scr/κ, 1)α × max(Scr/κ, 1)−0.601 × min(Scys/0.8, 1)−0.375 × max(Scys/0.8)−0.711 × 0.9952age × 0.969 [if female] × 1.08 [if Black], where κ = 0.7 if female and 0.9 if male, α = −0.248 if female and −0.207 if male, min indicates the minimum of Scr/κ or 1, and max indicates the maximum of Scr/κ or 18% higher2021 CKD-EPI creatinine equation refit without race variable15Inker L.A. Eneanya N.D. Coresh J. et al.New creatinine- and cystatin C-based equations to estimate GFR without race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (332) Google ScholareGFR = 142 × min(Scr/κ, 1)α × max(Scr/κ, 1)−1.20 × 0.9938age × 1.012 [if female], where κ = 0.7 if female and 0.9 if male, α = −0.241 if female and −0.302 if male, min indicates the minimum of Scr/κ or 1, and max indicates the maximum of Scr/κ or 1No change2021 CKD-EPI creatinine–cystatin C equation refit without race variable15Inker L.A. Eneanya N.D. Coresh J. et al.New creatinine- and cystatin C-based equations to estimate GFR without race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (332) Google ScholareGFR = 135 × min(Scr/κ, 1)α × max(Scr/κ, 1)−0.544 × min(Scys/0.8,1)−0.323 × max(Scys/0.8)−0.778 × 0.9961age × 0.0963 [if female], where κ = 0.7 if female and 0.9 if male, α = −0.219 if female and −0.144 if male, min indicates the minimum of Scr/κ or 1, and max indicates the maximum of Scr/κ or 1No changeThe 2012 CKD-EPI eGFRcys equation did not include a race coefficient and accordingly was not refit in 2021. Abbreviations: CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; eGFR, estimated glomerular filtration rate; MDRD, Modification of Diet in Renal Disease; Scr, serum creatinine; Scys, serum cystatin C. Open table in a new tab The 2012 CKD-EPI eGFRcys equation did not include a race coefficient and accordingly was not refit in 2021. Abbreviations: CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; eGFR, estimated glomerular filtration rate; MDRD, Modification of Diet in Renal Disease; Scr, serum creatinine; Scys, serum cystatin C. More accurate eGFR equations were later introduced such as the 2009 CKD-EPI creatinine equation (eGFRcr equation)12Levey A.S. Stevens L.A. Schmid C.H. et al.A new equation to estimate glomerular filtration rate.Ann Intern Med. 2009; 150: 604-612https://doi.org/10.7326/0003-4819-150-9-200905050-00006Crossref PubMed Scopus (15951) Google Scholar and the 2012 CKD-EPI creatinine–cystatin C and cystatin C equations (eGFRcr-cys and eGFRcys equations)13Inker L.A. Schmid C.H. Tighiouart H. et al.Estimating glomerular filtration rate from serum creatinine and cystatin C.N Engl J Med. 2012; 367: 20-29https://doi.org/10.1056/NEJMoa1114248Crossref PubMed Scopus (2486) Google Scholar (Table 1). The 2009 CKD-EPI eGFRcr and 2012 CKD-EPI eGFRcr-cys equations are not only more accurate than the MDRD Study equation, but unlike their predecessor they are also valid in the eGFR range of 60-90 mL/min/1.73 m2, which can help inform care particularly relevant to earlier diagnosis of CKD.3Centers for Disease Control and PreventionChronic Kidney Disease Surveillance System-United States.https://nccd.cdc.gov/ckd/default.aspxGoogle Scholar,9Waterman A.D. Browne T. Waterman B.M. Gladstone E.H. Hostetter T. Attitudes and behaviors of African Americans regarding early detection of kidney disease.Am J Kidney Dis. 2008; 51: 554-562https://doi.org/10.1053/j.ajkd.2007.12.020Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar The 2009 CKD-EPI eGFRcr and 2012 CKD-EPI eGFRcr-cys equations led to a 16% and 8% higher estimated GFR, respectively, in Black individuals compared to non-Black individuals for the same age, sex, and serum creatinine level (Table 1).12Levey A.S. Stevens L.A. Schmid C.H. et al.A new equation to estimate glomerular filtration rate.Ann Intern Med. 2009; 150: 604-612https://doi.org/10.7326/0003-4819-150-9-200905050-00006Crossref PubMed Scopus (15951) Google Scholar,13Inker L.A. Schmid C.H. Tighiouart H. et al.Estimating glomerular filtration rate from serum creatinine and cystatin C.N Engl J Med. 2012; 367: 20-29https://doi.org/10.1056/NEJMoa1114248Crossref PubMed Scopus (2486) Google Scholar Higher estimated GFR with use of the race modifier has been proposed to account for delays in referrals to a nephrologist or wait-listing for kidney transplantation in Black individuals.14Tsai J.W. Cerdeña J.P. Goedel W.C. et al.Evaluating the impact and rationale of race-specific estimations of kidney function: estimations from U.S. NHANES, 2015-2018.EClinicalMedicine. 2021; 42101197https://doi.org/10.1016/j.eclinm.2021.101197Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Simply removing the race coefficient from existing eGFR equations could lead to over- or underestimation of GFR and errors in CKD diagnosis and staging as well as inappropriate medication use and/or dosing. However, the 2021 CKD-EPI eGFRcr equation refit without a race modifier15Inker L.A. Eneanya N.D. Coresh J. et al.New creatinine- and cystatin C-based equations to estimate GFR without race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (332) Google Scholar will enable the assessment of kidney disease using a consistent eGFR equation for all US racial and ethnic groups, and KDOQI enthusiastically supports the recommendation of the NKF-ASN task force to implement this equation. Implementation of the 2021 CKD-EPI eGFRcr equation could potentially remove barriers for some Black patients for the timely diagnosis of CKD, referral to nephrologist, and access to the kidney transplant waitlist.14Tsai J.W. Cerdeña J.P. Goedel W.C. et al.Evaluating the impact and rationale of race-specific estimations of kidney function: estimations from U.S. NHANES, 2015-2018.EClinicalMedicine. 2021; 42101197https://doi.org/10.1016/j.eclinm.2021.101197Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar However, the overall impact on racial disparities in kidney disease care remains unknown; moreover, racial disparities in kidney failure and treatment existed before the implementation of eGFR equations. Thus, the nephrology community must recognize that the implementation of the 2021 CKD-EPI eGFRcr equation may not substantially impact racial disparities in kidney disease diagnosis and treatment. As recommended by the NKF-ASN task force, more research is urgently needed to identify and implement actionable interventions to reduce racial, ethnic, and socioeconomic disparities in kidney disease diagnosis and treatment. The performance of the 2021 CKD-EPI eGFR equations in Black and Non-Black adults versus measured GFR as reported by Inker et al15Inker L.A. Eneanya N.D. Coresh J. et al.New creatinine- and cystatin C-based equations to estimate GFR without race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (332) Google Scholar is shown in Table 2. The 2021 CKD-EPI eGFRcr equation without the race variable is not as accurate as the 2009 CKD-EPI eGFRcr equation that includes a race variable, but importantly the newer equation shows less systematic difference between Black and non-Black race groups and maintains sufficient accuracy to implement for use in most clinical decisions. However, estimation of GFR continues to rely on serum creatinine. Serum creatinine levels reflect GFR and tubular secretion but also non-GFR factors because creatinine is a by-product of creatine catabolism found in muscle.16Stevens L.A. Levey A.S. Current status and future perspectives for CKD testing.Am J Kidney Dis. 2009; 53(3)(suppl 3):S17-S26https://doi.org/10.1053/j.ajkd.2008.07.047Abstract Full Text Full Text PDF Scopus (49) Google Scholar Cystatin C is filtered but not secreted by the tubules, and serum levels are less strongly influenced by demographic factors.17Ebert N. Shlipak M.G. Cystatin C is ready for clinical use.Curr Opin Nephrol Hypertens. 2020; 29: 591-598https://doi.org/10.1097/MNH.0000000000000638Crossref PubMed Scopus (18) Google Scholar Clinical factors such as obesity, inflammation, and diseases and medications that affect cell turnover have been found to be associated with cystatin C levels, but eGFR equations that utilize cystatin C alone show less bias by race groups compared to equations that utilize creatinine alone.13Inker L.A. Schmid C.H. Tighiouart H. et al.Estimating glomerular filtration rate from serum creatinine and cystatin C.N Engl J Med. 2012; 367: 20-29https://doi.org/10.1056/NEJMoa1114248Crossref PubMed Scopus (2486) Google Scholar,18Hsu C.Y. Yang W. Parikh R.V. et al.Race, genetic ancestry, and estimating kidney function in CKD.N Engl J Med. 2021; 385: 1750-1760https://doi.org/10.1056/NEJMoa2103753Crossref PubMed Scopus (55) Google Scholar Although serum creatinine and cystatin C alone have limitations as GFR biomarkers, use of creatinine in combination with cystatin C to estimate GFR (as in the 2021 CKD-EPI eGFRcr-cys equation) is beneficial because it leads to the most accurate estimates and also reduces the difference in bias in GFR estimates between Black and non-Black individuals (Table 2).15Inker L.A. Eneanya N.D. Coresh J. et al.New creatinine- and cystatin C-based equations to estimate GFR without race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (332) Google ScholarTable 2Performance of the CKD-EPI GFR Estimating Equations Lacking Race Variable by Black Versus Non-Black RaceBlack AdultsNon-Black AdultsBiasP30Correct ClassificationBiasP30Correct Classification2021 CKD-EPI eGFRcr3.687%62%−3.986%67%2012 CKD-EPI eGFRcys−0.185%63%0.789%66%2021 CKD-EPI eGFRcr-cys0.191%68%−2.991%70%Data adapted from Inker et al.15Inker L.A. Eneanya N.D. Coresh J. et al.New creatinine- and cystatin C-based equations to estimate GFR without race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (332) Google Scholar Abbreviations and definitions: CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; eGFR, estimated glomerular filtration rate; eGFRcr, eGFR based on creatinine; eGFRcys, eGFR based on cystatin C; eGFRcr-cys, eGFR based on creatinine and cystatin C; bias, difference between measured and estimated GFR; P30, percentage of eGFR that are < 30 mL/min/1.73 m2 different from measured GFR; correct classification, eGFR in same category (<30, 30-44, 45-59, 60-89, and >90 mL/min/1.73 m2) as measured GFR. Open table in a new tab Data adapted from Inker et al.15Inker L.A. Eneanya N.D. Coresh J. et al.New creatinine- and cystatin C-based equations to estimate GFR without race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (332) Google Scholar Abbreviations and definitions: CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; eGFR, estimated glomerular filtration rate; eGFRcr, eGFR based on creatinine; eGFRcys, eGFR based on cystatin C; eGFRcr-cys, eGFR based on creatinine and cystatin C; bias, difference between measured and estimated GFR; P30, percentage of eGFR that are < 30 mL/min/1.73 m2 different from measured GFR; correct classification, eGFR in same category (<30, 30-44, 45-59, 60-89, and >90 mL/min/1.73 m2) as measured GFR. KDOQI supports the NKF-ASN task force recommendations to increase use of the 2021 CKD-EPI eGFRcr-cys equation to confirm estimated GFR when more accurate estimates of GFR are needed such as with drug initiation and/or dosing changes. This recommendation is congruent with 2012 KDIGO guideline,19Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work GroupKDIGO clinical practice guideline for the evaluation of chronic kidney disease.Kidney Int Suppl. 2013; 3: 1-150https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdfGoogle Scholar which suggested using additional markers such as cystatin C or clearance measurements to confirm GFR when eGFR based on creatinine alone is suspected to be less accurate, such as very low or high muscle mass or when more accurate GFR estimates are needed for clinical decision making (Box 1).Box 1When to Use Cystatin C•When confirmation of CKD is required in adults with eGFR based on serum creatinine of 45-59 mL/min/1.73 m2 alone without markers of kidney damage•When more accurate estimation of GFR is required for drug dosing (due to narrow therapeutic or toxic range) or other clinical decision making•When confirmation or exclusion of CKD is needed in patients with very low or high muscle mass; examples include individuals with spinal cord injury and paraplegia or quadriplegia or severe neuromuscular disease, advanced liver or heart disease (low muscle mass), and body builders and professional athletes (high muscle mass)•When estimation of GFR is required in patients taking medications that inhibit tubular creatinine secretion with eGFR < 60 mL/min/1.73 m2Abbreviations: CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; GFR, glomerular filtration rate. •When confirmation of CKD is required in adults with eGFR based on serum creatinine of 45-59 mL/min/1.73 m2 alone without markers of kidney damage•When more accurate estimation of GFR is required for drug dosing (due to narrow therapeutic or toxic range) or other clinical decision making•When confirmation or exclusion of CKD is needed in patients with very low or high muscle mass; examples include individuals with spinal cord injury and paraplegia or quadriplegia or severe neuromuscular disease, advanced liver or heart disease (low muscle mass), and body builders and professional athletes (high muscle mass)•When estimation of GFR is required in patients taking medications that inhibit tubular creatinine secretion with eGFR < 60 mL/min/1.73 m2 Abbreviations: CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; GFR, glomerular filtration rate. Clearance measurements to confirm eGFR include the urinary clearance of iothalamate and plasma clearance of iohexol, which are available in the United States and correlate highly with inulin clearance.20Stevens L.A. Levey A.S. Measured GFR as a confirmatory test for estimated GFR.J Am Soc Nephrol. 2009; 20: 2305-2313https://doi.org/10.1681/ASN.2009020171Crossref PubMed Scopus (409) Google Scholar However, clearance measurements of iothalamate and iohexol are more expensive and time-consuming than measuring cystatin C. The recommendation for increased use of cystatin C to estimate GFR was further supported by the KDOQI commentary21Inker L.A. Astor B.C. Fox C.H. et al.KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD.Am J Kidney Dis. 2014; 63: 713-735https://doi.org/10.1053/j.ajkd.2014.01.416Abstract Full Text Full Text PDF PubMed Scopus (968) Google Scholar on the 2012 KDIGO CKD guideline. The commentary discussed concerns about incorporating cystatin C–based GFR estimates into clinical practice because most clinical laboratories do not measure cystatin C,17Ebert N. Shlipak M.G. Cystatin C is ready for clinical use.Curr Opin Nephrol Hypertens. 2020; 29: 591-598https://doi.org/10.1097/MNH.0000000000000638Crossref PubMed Scopus (18) Google Scholar precluding its timely use. Cystatin C can be measured on a wide range of instruments, and fully automated tests can be completed with a turbidimeter or nephelometer. Only a minority of clinical laboratories that perform creatinine assays also measure cystatin C, and not all participate in the international assay harmonization efforts, despite availability of a certified reference material.17Ebert N. Shlipak M.G. Cystatin C is ready for clinical use.Curr Opin Nephrol Hypertens. 2020; 29: 591-598https://doi.org/10.1097/MNH.0000000000000638Crossref PubMed Scopus (18) Google Scholar These potential barriers for cystatin C measurement can be avoided via utilization of commercially available assays that participate in international harmonization efforts.17Ebert N. Shlipak M.G. Cystatin C is ready for clinical use.Curr Opin Nephrol Hypertens. 2020; 29: 591-598https://doi.org/10.1097/MNH.0000000000000638Crossref PubMed Scopus (18) Google Scholar Another limitation of cystatin C is cost. The 2021 Medicare laboratory fee schedule is $18.52 for cystatin C (CPT 82610) versus $5.12 for creatinine (CPT 82565) testing,22Centers for Medicare & Medicaid Services Clinical Laboratory Fee Schedule Files. CMS.gov.https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-FilesGoogle Scholar and widespread use for patients without CKD could in aggregate lead to a large increase in health care expenditures.17Ebert N. Shlipak M.G. Cystatin C is ready for clinical use.Curr Opin Nephrol Hypertens. 2020; 29: 591-598https://doi.org/10.1097/MNH.0000000000000638Crossref PubMed Scopus (18) Google Scholar Without a Medicare national coverage determination, there is also concern for cystatin C costs being placed on patients. Higher utilization of cystatin C could potentially lower costs and incentivize more laboratories to perform cystatin C assays. KDOQI agrees with the NKF-ASN task force that national efforts are needed to make cystatin C or other clearance markers routinely and more readily available to clinicians. KDOQI also supports research that addresses new approaches for more accurate and less biased estimates of GFR without the inclusion of race. As stated by the NKF-ASN task force, research funding and support is needed to develop and implement other interventions to eliminate race and ethnic disparities in CKD diagnosis and treatment. KDOQI has consistently advocated for continued research and development of more accurate and less biased equations and for the examination of the performance of eGFR equations in the general population across the full range of age, sex, race, ethnicity, protein intake, and comorbid conditions. An urgent investment in science is needed for newer approaches that generate accurate, unbiased, and precise GFR assessment. The 2021 CKD-EPI eGFRcr-cys equation shows only 68% and 70% agreement with measured GFR for CKD staging in Black and non-Black adults, respectively (Table 2).15Inker L.A. Eneanya N.D. Coresh J. et al.New creatinine- and cystatin C-based equations to estimate GFR without race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (332) Google Scholar Inaccuracies in GFR estimation could lead to errors in clinical decision making such as inappropriate initiation or discontinuation of metformin and sodium/glucose cotransporter 2 inhibitors; incorrect initiation of or under- or overdosing of chemotherapy; poorly timed initiation of other life-saving drugs; and late referral for kidney transplant evaluation and listing, nephrologist care, and dialysis access placement (Table 3). Inaccuracies could also curtail enrollment of Black adults in clinical research studies.23Charytan D.M. Yu J. Jardine M.J. et al.Potential effects of elimination of the Black race coefficient in eGFR calculations in the CREDENCE Trial.Clin J Am Soc Nephrol. 2022; 17: 361-373https://doi.org/10.2215/CJN.08980621Crossref PubMed Scopus (3) Google ScholarTable 3Possible Consequences for CKD Diagnosis and Nephrology Referral With Implementation of the Race-free CKD-EPI Equations in the US Adult PopulationCKD-EPI Equation2021 eGFRcr2012 eGFRcys2021 eGFRcr-cysChange in Black Adult PopulationChange in number of adults with eGFR < 60 mL/min/1.73 m2+0.64 million (+31%)+0.09 million (+4%)+0.09 million (+4%)Increase in number of false CKD diagnosesModerateMinimalMinimalChange in nephrology referralMinimal+0.12 million (+26%)MinimalDrug initiation to slow CKD progressionIncreaseNo changeNo changeInappropriate drug discontinuation and underdosingIncrease or no changeNo changeNo changeChange in Non-Black Adult PopulationChange in number of adults with eGFR < 60 mL/min/1.73 m2−3.14 million (−23%)+4.29 million (+29%)−1.36 million (−9%)Change in nephrology referral−0.29 million (−26%)+1.46 million (+133%)+0.61 million (+55%)Drug initiation to slow CKD progressionDecreaseNo changeNo changeInappropriate drug continuation and overdosingIncreaseNo changeNo changeData adapted from Delgado et al.1Delgado C. Baweja M. Crews D.C. et al.A unifying approach for GFR estimation: recommendations of the NKF-ASN Task Force on reassessing the inclusion of race in diagnosing kidney disease.Am J Kidney Dis. 2022; 79: 268-288.e1https://doi.org/10.1053/j.ajkd.2021.08.003Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar Abbreviations: CKD, chronic kidney disease; CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; eGFRcr, estimated glomerular filtration rate based on creatinine; eGFRcr-cys, eGFR based on creatinine and cystatin C; eGFRcys, eGFR rate based on cystatin C. Open table in a new tab Data adapted from Delgado et al.1Delgado C. Baweja M. Crews D.C. et al.A unifying approach for GFR estimation: recommendations of the NKF-ASN Task Force on reassessing the inclusion of race in diagnosing kidney disease.Am J Kidney Dis. 2022; 79: 268-288.e1https://doi.org/10.1053/j.ajkd.2021.08.003Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar Abbreviations: CKD, chronic kidney disease; CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration; eGFRcr, estimated glomerular filtration rate based on creatinine; eGFRcr-cys, eGFR based on creatinine and cystatin C; eGFRcys, eGFR rate based on cystatin C. The NKF-ASN task force also addressed body surface area (BSA) indexing of GFR. Estimated GFR is indexed for 1.73 m2 BSA, which may lead to errors when an individual’s BSA differs substantially from 1.73. KDOQI supports the NKF-ASN task force recommendation that eGFR reporting by a laboratory be accompanied by a statement that “use of nonindexed eGFR values (mL/min) should be considered for drug dosing decisions”1Delgado C. Baweja M. Crews D.C. et al.A unifying approach for GFR estimation: recommendations of the NKF-ASN Task Force on reassessing the inclusion of race in diagnosing kidney disease.Am J Kidney Dis. 2022; 79: 268-288.e1https://doi.org/10.1053/j.ajkd.2021.08.003Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar because nonindexed GFR correlates better with the clearance of medications that are excreted by the kidneys. The use of nonindexed eGFR may be clinically relevant if the BSA is ≤1.65 m2 or ≥1.9 m2.24Titan S. Miao S. Tighiouart H. et al.Performance of indexed and nonindexed estimated GFR.Am J Kidney Dis. 2020; 76: 446-449https://doi.org/10.1053/j.ajkd.2020.04.010Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar For persons with obesity whose BSA is at least 1.9 m2, Titan et al24Titan S. Miao S. Tighiouart H. et al.Performance of indexed and nonindexed estimated GFR.Am J Kidney Dis. 2020; 76: 446-449https://doi.org/10.1053/j.ajkd.2020.04.010Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar showed that eGFR indexed for 1.73 m2 BSA may underestimate measured GFR by 10 mL/min; the underestimation is 20 mL/min for persons with BSA ≥2.0 m2 with a mean measured GFR of 68 ± 32 mL/min/1.73 m2. For persons with a BSA ≤1.65 m2, eGFR indexed for 1.73 m2 BSA may overestimate the nonindexed eGFR by at least 10 mL/min. To remove BSA indexing, the eGFR is multiplied by the individual’s BSA calculated with height and weight25Du Bois D. Du Bois E.F. A formula to estimate the approximate surface area if height and weight be known.Arch Intern Med. 1916; 17: 863-871Crossref Scopus (4100) Google Scholar and divided by 1.73 m2; that is, nonindexed eGFR in mL/min = eGFR in mL/min/1.73 m2 × patient BSA in m2/1.73 m2. In summary, the NKF-ASN task force recommends the immediate implementation of the 2021 CKD-EPI eGFRcr equation refit without the race modifier because it will provide greater equity in the assessment of kidney disease. KDOQI supports this recommendation and encourages all US laboratories and clinics to implement the 2021 CKD-EPI eGFRcr equation, and incorporate referent-standardized cystatin C into metabolic panels.26Miller W.G. Kaufman H.W. Levey A.S. et al.National Kidney Foundation Laboratory Engagement Working Group Recommendations for Implementing the CKD-EPI 2021 Race-free equations for estimated glomerular filtration rate: practical guidance for clinical laboratories.Clin Chem. 2022; 68: 511-520https://doi.org/10.1093/clinchem/hvab278Crossref PubMed Scopus (9) Google Scholar When more accurate GFR estimates are needed, KDOQI agrees that the 2012 CKD-EPI eGFRcys equation, which has lower bias,13Inker L.A. Schmid C.H. Tighiouart H. et al.Estimating glomerular filtration rate from serum creatinine and cystatin C.N Engl J Med. 2012; 367: 20-29https://doi.org/10.1056/NEJMoa1114248Crossref PubMed Scopus (2486) Google Scholar or the 2021 CKD-EPI eGFRcr-cys equation15Inker L.A. Eneanya N.D. Coresh J. et al.New creatinine- and cystatin C-based equations to estimate GFR without race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (332) Google Scholar should be considered. Changing how we estimate GFR will not eliminate health disparities in kidney disease, and the nephrology community needs to further identify and implement strategies to mitigate factors that contribute to differences in kidney disease diagnosis and treatment as well as kidney disease outcomes by race, ethnicity, income, education, and insurance status. While continued research, evaluation, and validation of filtration biomarkers and eGFR equations are needed to ensure continued advancement of the diagnosis and treatment of kidney diseases for all, we also must actively and vigilantly address how racism, health policies, genetics, access to care, and social and environmental factors influence kidney disease disparities. Holly J. Kramer, MD, MPH, Bernard G. Jaar, MD, MPH, Michael J. Choi, MD, Paul M. Palevsky, MD, Joseph A. Vassalotti, MD, and Michael V. Rocco, MD, MSCE. This work received support from the National Kidney Foundation. Dr Kramer reports serving as a consultant for Astra Zeneca and Bayer Pharmaceuticals and is AJKD Engagement Editor. Dr Choi reports receipt of an honorarium from InMed. Dr Palevsky reports serving as a consultant for Janssen Research & Development and is the current President of the NKF. Dr Vassalotti is chief medical officer of the NKF and serves as a consultant for Renalytix, plc. Drs Jaar and Rocco declare that they have no relevant financial interests. Dr Kramer is KDOQI Vice Chair of Commentaries, is on the editorial boards of the Journal of Renal Nutrition and Advances in Chronic Kidney Disease, and served as NKF immediate past-president. Dr Jaar is KDOQI Vice Chair of Education. Dr Choi is KDOQI Vice Chair of Policy. Dr Rocco is KDOQI Chair. Received August 2, 2022, following review and approval by the NKF Scientific Advisory Board (membership listed at https://www.kidney.org/about/sab). Accepted August 8, 2022, after editorial review by a Deputy Editor.

Statin use before and after the KDIGO Lipids in chronic kidney disease guideline: A population-based interrupted time series analysis.

In November 2013, the Kidney Disease: Improving Global Outcomes Clinical Practice Guideline for Lipid Management in Chronic Kidney Disease was published, recommending statins for all individuals 50 years or older with an estimated glomerular filtration rate below 60 ml/min/1.73 m2 to lower the risk of major cardiovascular events. We quantified the prevalence of statin use among the target population before and after the guideline publication in a large Danish cohort of individuals with an estimated glomerular filtration rate below 60 ml/min/1.73 m2 , to investigate the effect of the guideline, but found no difference in the prevalence of statin use prior to and after the guideline publication.

Health Care Quality in CKD Subjects: A Cross-Sectional In-Hospital Evaluation

Methods The study was performed in a retrospective and observational manner. All adult (age 18 years or older) in-hospital subjects treated from January until December 2019 were included. CKD was diagnosed according to the KDIGO 2012 CKD Guideline. The following variables were assessed: CKD stage, quantification/analysis (yes/no) of blood pressure, proteinuria, serum phosphate, serum 25-OH-D3, ferritin and transferrin saturation, and blood gas analysis. In addition, recommendations of the following medicines were analyzed (given/not given): ACE inhibitor or sartan, phosphate binder, vitamin D3 (activated or native), iron, erythropoietin, and bicarbonate. It was also evaluated whether discharge letters contained CKD-related diagnoses or not. Results In total, 581 individuals were included in the study. The majority of aspects related to the monitoring and therapeutic management of CKD were either considered in only a small proportion of affected individuals (e.g., quantification of PTH − 5.5%/25-OH-D3 − 6%/transferrin saturation − 13.6%) or avoided nearly at all (e.g., recommendation of erythropoietin—1%, documentation of CKD-MBD diagnosis—0.3%). A reasonable quality of care was identified concerning the blood pressure monitoring (performed in 100%) and blood gas analysis (55% of the patients received analysis). Serum phosphate was measured in 12.9%, particularly in subjects at higher CKD stages. Conclusions The current investigation revealed poor quality of care in CKD patients treated at the Brandenburg University Hospital over the period of one year. Quality improvement must be achieved, most likely via a standardized educational program for physicians and a directer access to CKD management guidelines.

MO492: ‘The Disease Awareness Innovation Network’ (DANTE) Framework for Chronic Kidney Disease Diagnosis

Abstract BACKGROUND AND AIMS The global burden of chronic kidney disease (CKD) is growing, impacting around 10% of the worldwide population becoming the 5th cause of mortality by 2023, with high cost for the health care system (Glassrock et al. 2017). CKD can be identified using two easy and inexpensive tests (eGFR and ACR). Early stages of CKD are generally asymptomatic, hence challenging clinical recommendations for early detection of CKD. Indeed, a high percentage of patients in primary care are undiagnosed (Zilich et al. 2005). As a result, high-risk individuals, such as those with hypertension, diabetes, a family history of renal disease and cardiovascular disease, require targeted and accessible screening. In a study promoted by the Italian Society of Nephrology (SIN) and the Italian Society of General Practitioners (SIMG), 300 general practitioners (GPs) recruited a cohort of ∼500 thousand patients in the general population, showing that creatinine dosage was requested for only 17% of patients (Minutolo et al. 2008). Of this subgroup, 16% were affected by CKD, but only one out of eight patients was actually identified by the GP as nephropathic, with potential harm to the patient due to possible missed diagnosis. Such study highlighted that, in Italy, a nephrological consultation is usually requested only in 5% of patients with overt nephropathy in the conservative phase (eGFR 30–60), whereas the nephrological referral did not exceed 50% in cases of pre-dialysis disease (eGFR 30–15). With a global lack of CKD specialists, enabling GPs and building successful multidisciplinary teams to play a larger role in early detection and management will assist hospitals and health systems to alleviate the burden. METHOD An observational pilot study was undertaken between 1 May 2021 and 31 October 2021 in the Apulia region, Italy, within a framework called `The Disease Awareness iNnovaTion nEtwork’ (DANTE). We aimed at evaluating the impact of GPs targeted training by specialized nephrologists towards CKD awareness. A first meeting was set up with GPs in which trained nephrologists illustrated to the GPs the KDIGO CKD guidelines. The differences in terms of proportions between the two groups [baseline time (T0) versus time at 6 months (T6)] were evaluated with Pearson's. RESULTS A total of n = 17 854 of patients were enrolled at T0 versus n = 18 661 at T6 from the databases of 17 Apulian GPs who satisfied the entry criterion (having Millewin software installed on their systems). All of the comparisons in terms of percentage patients tested for ACR and eGFR between T0 and T6 resulted in a statistically significant P-value (&amp;lt;.0001) also when stratifying/disease groups (diabetes, hypertension and heart failure, Fig. 1). Patients with eGFR &amp;lt;60 mL/min were found to be 3.8% at T6, hence providing for an increase of detection of + 72.73% after GP CKD training awareness. CONCLUSION The DANTE pilot study was the first of its kind ever planned in Apulia. All of the diagnostic tests undertaken did register an increase of at least + 42.59% at T6, with an overall median increase of + 72.73%. Therefore, we can argue that teaching devoted to GPs by nephrologist it is able to improve GPs CKD awareness and increase its early diagnosis, which can slow down the progression of CKD, plus providing for high savings given the large cost gap between the early and late stages of CKD (Jommi et al. 2018).

Commentary on the 2020 update of the KDOQI clinical practice guideline for nutrition in chronic kidney disease.

Dietary modification is an important component in the management of Chronic Kidney Disease (CKD).1 An appropriate diet can slow disease progression,2, 3 reduce CKD complications,4 and increase survival.5, 6 The release of new guidance has been eagerly awaited by many clinicians as the previous versions had not been updated since 2000.7 The intent of this commentary is to consider some of the key recommendations in the Australian and New Zealand context and to highlight areas for potential local adaptation. The 2020 update consists of six chapters with 75 recommendations.8 These guidelines cover nutrition assessment, medical nutrition therapy, dietary protein and energy intake, nutritional supplementation and micronutrients. Importantly, the guidelines cover management across stages of CKD as well as specific recommendations for those undertaking maintenance haemodialysis or peritoneal dialysis, and those post-transplant. The guidelines are based on the best available evidence to April 2017 and for those recommendations based on consensus, evidence was reviewed until August 2018. This represents critical review of more than 11 000 individual studies. A summary of the nutrient recommendations for the Australian and New Zealand (ANZ) context is provided in Table S1. Assessment of the methodological rigour and transparency of the guideline using the AGREE II tool9 are shown in Supporting information. The overall score was rated at 69%, with reduced scores due to lack of stakeholder engagement and minimal discussion regarding implementation. The new recommendations for protein intake contain a major departure from previous advice. The recommendations are summarized in Table 1. For adults with CKD stage 3–5 who are metabolically stable, protein should be restricted to 0.55–0.60 g/kg ideal body weight per day. It is slightly higher for those with diabetes (0.6–0.8 g/kg ideal body weight). Reduction of intake to these levels is recommended due to the negative side effects on kidney health (accumulation of urea and other uremic toxins and increased kidney hyperfiltration). Additional benefits to kidney health can be achieved using ketoacid analogue supplements but these are not available readily or registered with the Therapeutic Goods Administration10 in Australia or the Pharmaceutical Management Agency (Pharmac) in New Zealand. HD no diabetes: Evidence level 1C PD no diabetes: OPINION Dialysis with diabetes: OPINION These recommendations are controversial and are in contrast to a 2020 Cochrane review12 which found that, in non-diabetic adults, a low protein intake (0.5–0.6 g/kg) may make little difference to the number of people who reached kidney failure compared to a normal protein intake (≥0.8 g/kg). The 2013 CARI Guidelines for Early CKD recommend 0.75–1.0 g/kg/day with adequate energy13 and the 2020 KDIGO guidelines for diabetes in CKD suggest 0.8 g/kg.14 The challenge for Australasian clinicians is that any changes to protein intake must be carefully managed to meet overall energy needs. Conveying the message to patients to significantly reduce protein intake without attention to adequate calories may result in unintentional weight loss, malnutrition and hyperkalaemia. In accordance with recent Cochrane guidance on low protein diets for those with CKD,12 we suggest consideration also be given to the potentially negative impacts of intensive protein restrictions on patient quality of life. In the absence of high-certainty evidence to support intensive protein restrictions in patients with CKD 3–5 not requiring dialysis and considering the potential harms, we recommend taking an individualized approach to protein restriction taking into account the potential impact on quality of life and nutritional needs. It is now recommended that dietary potassium and phosphorus intake should be individualized in adults with CKD3-5D and post-transplant with hyperkalaemia. This is far less prescriptive than previous dietary guidelines.15 The bioavailability of potassium and phosphorus in fruits, vegetables, wholegrain breads and cereals, legumes and nuts is substantially lower than previously thought,16-18 and these foods need not be restricted as they offer other benefits that are beneficial to people with CKD. Clinicians should actively investigate other factors that contribute to hyperkalaemia before reducing dietary potassium intake. These factors include constipation, inadequate insulin, untreated metabolic acidosis, inadequate dialysis, and medications.19, 20 If hyperkalaemia cannot be reversed, then sensible dietary restriction is encouraged. Regarding phosphorus intake, the new guideline also recommends reducing intake of phosphorus containing additives from processed foods. In the ANZ context, like potassium, phosphorus does not need to be declared on food labels and contributes significantly to overall dietary phosphorus intake.21 Given the increasing popularity of plant-based diets, emphasis on low-bioavailable sources of phosphate, such as those from plant foods, would result in reduced bioavailable phosphate compared to animal-based protein sources. Additional suggested strategies, such as boiling meat prior to eating, can result in an approximate 50% reduction of phosphorus content.22 This practice is common in New Zealand (‘boil ups’) and should be encouraged to support those with CKD. Recommendations for sodium intake remain unchanged, and less than 2300 mg (100 mmol) of sodium per day is advised for all with CKD. The new guideline recommends a Mediterranean diet and high fruit and vegetable diet for those with CKD to improve lipid profile, decrease body weight and blood pressure, and reduce net acid production. Patients will benefit from individualized advice to adopt this dietary pattern and accommodate serum potassium and protein needs. Dietary education resources for patients should be updated to reflect these new recommendations and counter misinformation. The new guidelines recommend nutrition screening occur at least biannually for adults with CKD3-5D or post-transplantation8 to identify risk of Protein Energy Wasting (PEW). However, no gold standard screening tool is available. Clinicians may wish to consider use of the Renal Nutrition Screening Tool (R-NST).23 This tool has good sensitivity (97%) and specificity (74%) to detect risk of undernutrition and was developed in New Zealand. A comprehensive nutrition assessment is also encouraged in adults with CKD3-5D within 90 days of commencing dialysis, annually or when indicated following screening or provider referral. These recommendations will be challenging for many units in ANZ as dietetic staffing is inadequate or absent.24-26 The 7-point Subjective Global Assessment is now recommended as the preferred tool for nutrition assessment due to the robust evidence base, particularly for assessment of body composition in dialysis cohorts.27 The 7-point SGA does not include an extensive list of symptoms that are known to impact patients with CKD at the later stages. As a result, clinicians may still wish to utilize tools, such as the IPOS-renal,28 to establish the degree and severity of symptom burden. There is a notable absence of information for clinicians on the dietary management of patients undertaking conservative management (also referred to as supportive care29). We suggest that health professionals working with these patients refer to important guidance published to assist with diet and symptom management.30-32 To conclude this commentary, the KDOQI nutrition guidelines represent an important discussion of nutrient based guidance as well as food-based recommendations. While input from consumers into these guidelines is lacking, these guidelines are an important step forward and may reduce the challenge and complexity for patients of adhering to the diet for kidney disease.33, 34 Future guidelines are likely to include recommendations regarding plant-based protein35 and eating patterns36, 37 but these studies were published after the guidelines evidence review process. Based on these guidelines, it would be reasonable for ANZ health professionals to encourage all patients with CKD to improve fruit and vegetable intake, focus on plant-based proteins, reduce added salt and processed foods. Based on recent evidence,12 we recommend an individualized, less stringent approach to protein restriction for non-diabetic patients with CKD 3–5. We wish to thank the CARI Guideline group for their support. CARI Guideline Group Investigators: Rathika Krishnasamy, Jane Boag, Helen Coolican, Jonathan Craig, Min Jun, Vincent Lee, Thu Nguyen, Carla Scuderi, Emily See, Rachael Walker, Debbie Fortnum, Vanessa Cullen, Martin Howell, Chandana Guha, David Tunnicliffe, Brydee Johnston, Andrea Viecelli, Kelly Lambert. Open access publishing facilitated by University of Wollongong, as part of the Wiley - University of Wollongong agreement via the Council of Australian University Librarians. Appendix S1: Supporting information. TABLE S1: Summary of nutrient recommendations from the 2020 guidelines on dietary management of Chronic Kidney Disease1 and the level of evidence. If no recommendation is made in the 2020 guidelines then previous recommendations are included in italics, with citation where appropriate. TABLE S2: Guideline assessment according to the Appraisal of Guidelines for Research and Evaluation (Agree II) instrument. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

POS-312 HbA1C AND OUTCOMES IN PATIENTS WITH CKD STAGE 3b AND 4

Currently, there is limited data available to guide glycemic control in patients with CKD stages 3B and 4 as patients with advanced chronic kidney disease (CKD) are mostly excluded from clinical trials. The KDIGO CKD guidelines in 2012 recommend a target HbA1c of about 7.0% to prevent or delay progression of the microvascular complications of diabetes including diabetic kidney disease (DKD). The latest KDIGO 2020 Guidelines recommend an individualized HbA1c target ranging from <6.5% to <8.0% in patients with DM and CKD not on dialysis.

Behaviour modification intervention for patients with chronic kidney disease could provide a mid- to long-term reduction in public health care expenditure: budget impact analysis.

A recent cost-effectiveness analysis (CEA) study evaluated the widespread diffusion of behaviour modification intervention for patients with chronic kidney disease (CKD). Incorporating this behaviour modification intervention, comprising educational sessions on nutrition/lifestyle and support for regular patient visits, to the current CKD guideline-based practice was found to be cost-effective. This study aimed to examine the affordability of this efficient new practice under the hypothesis that the behaviour modification intervention would be initiated by general physicians (GPs). A budget impact analysis was conducted by defining the target population as patients aged 40-74years with stage-3-5 CKD based on the prevalence of definitive CKD in the Japanese general population. Costs expended by social insurers without discount were counted as budgets. We estimated the annual budget impact for 15years by running our CEA model, assuming that it would be good for the span. We estimated the number of patients with end-stage kidney disease (ESKD) to decrease by 4,496 in the fifteenth year of the new practice using our CEA model. Compared to that in the current practice, the budget impact as total additional expenditure of the new practice was estimated to be negative by the tenth year in the base case. The widespread diffusion of behaviour modification intervention would contain public health care expenditure over the mid-to-long term, resulting from a reduction in progression to ESKD. We suggest that providing sufficient economic incentives to GPs and strengthening recommendations in CKD guidelines would realise effective GP-initiated interventions.

Outcome of acute kidney injuries following chronic kidney disease: A systematic review in Nawaz Sharif kidney hospital Swat

 &#x0D; Background: Acute kidney injury may increase the risk for CKD and end-stage renal disease. In an attempt to summarize the literature and provide more compelling evidence, we conducted a systematic review comparing the  risk for CKD (chronic kidney disease), AKI (Acute kidney injury), Acute gastroententeritis, postnatal   AKI, Acute MI (myocardial infarction), AKI  2ndry to chemotherapy, AKI  2ndry to abstractive Nephropathy, AKI 2ndry to sepsis, AKI 2ndry to Drugs (NSAIDS and ARBS), AKI 2ndry to AGN (acute Glomerulonephritis), AKI 2ndry to Rhabdomyolysis, and lest AKI 2ndry to Malaria, death in patients with AKI,HD, CKD (chronic kidney disease). There have been several important developments in the literature recently regarding the association between acute kidney injury (AKI) and chronic kidney disease (CKD). First, when the National Kidney Foundation promulgated their highly influential Kidney Disease Outcomes Quality Initiative CKD guidelines in 2002, six chapters were devoted to the complications associated with decreased glomerular filtration rate (GFR) including hypertension, anemia, nutritional status, bone disease/disorders of calcium, and phosphorus metabolism, neuropathy&#x0D; Objective: To study the outcomecute kidney injury following chronic kidney disease; systematic review. &#x0D; Methods: This was a prospective observational study from January 2018 to December 2020. Patients visiting department of Nephrology Nawaz Sharif Kidney center Swat, number of patients included study 351. All ages and both sexes were considered. Patients treated elsewhere or who has undergone in this study. Complete medical history, detailed examination like age, sex, diagnosis, and outcome, of AKI, examination under microscope and investigations, and necessary blood investigations were carried out.&#x0D; Results: Three fifty one (351) patients were included in this study. The age distribution showed (75%) patients between 40-95 years and 25(25%) between 32-39 years. Mean age was 43 years with Standard Deviation of ± 35.66. Among 351 patients 162 (45%) patients were male and 189 (55%) patients were female. Duration of symptoms in 24(17%) was &lt;4 months and 112(75%) had &gt;4 months, with mean of 4 months and SD ± 2.315. Total 351 participants AKI 45(12%) postnatal AKI 33(9%) Acute MI 18(6%) AKI 2ndry chemotherapy 15(5.72%) AKI 2ndry to abstractive Nephropathy 55 (14%) AKI 2ndry to sepsis 63 (17%) AKI 2ndry to Drugs (NSAIDS and ARBS)   54 (14%) CKD (chronic kidney disease) 48 (15%) AKI 2ndry to Rhabdomylysis 18(6%)&#x0D; Conclusions: The study concludes that the acute kidney injury following CKD systematic reviewing among patients presenting with AKI,CHD ,AKI sepsis, ,AKI Drugs(NSIAD)  in local hospital  settings This can be reduced with proper health education in general public regarding prevention of the disease and hence its complications.&#x0D;