CKD Clinic Research Articles

A Collaborative Approach: Pharmacist-Led CKD Clinic in the Primary Care Setting

A Collaborative Approach: Pharmacist-Led CKD Clinic in the Primary Care Setting

Can Functional Motor Capacity Influence Mortality in Advanced Chronic Kidney Disease Patients?

Alterations in the body's nutritional status or composition may be observed as the kidney disease advances, which could influence the kidney's functional capacity and, consequently, could increase the risk of mortality. The aim of the study is to determine the influence of functional capacity on mortality assessed by different functional tests in patients with advanced chronic kidney disease (ACKD). A prospective observational study was designed, which included 225 patients followed for 8 years in a CKD clinic. The study assessed functional capacity by using a range of tests, which included the Short Physical Performance Battery, the 6 minutes walking gait test, the timed up and go, and the four versions of the sit-to-stand test. Additionally, body composition and nutritional conditions were considered, taking into consideration various biochemical indicators such as albumin, prealbumin, c-reactive protein (CRP), lymphocytes, and transferrin, muscle strength, comorbidity, and frailty. The relationship between functionality and all-cause mortality was investigated using a Cox proportional hazard model. A total of fifty patients died during the duration of the study. Patients who performed worse on the function and muscle strength tests showed a worse body composition and nutritional status, and exhibited a reduced life expectancy. Inflammation (CRP) was associated with an increased risk of mortality (model 1: hazard ratio (HR) = 1.246; 95% confidence interval (95% CI = 1.014-1.531; model 2: HR = 1.333; 95% CI = 1.104-1.610). Good functional capacity as determined by the SPPB test decreased the risk of mortality (model 1: HR = 0.764; 95% CI = 0.683-0.855; model 2 HR = 0.778; 95% CI = 0.695-0.872). Cut-off points of maximum sensitivity and specificity for mortality were obtained with different tests. The study demonstrated that functional capacity influences mortality in patients with ACKD, being higher in those patients with impaired functionality regardless of the test used, although the SPPB allows a larger number of patients to be assessed. Therefore, it is essential to incorporate the assessment of functionality into the comprehensive care of patients with CKD.

#1470 Study of limitations for the implementation of an assisted peritoneal dialysis program in Spain

Abstract Background and Aims Assisted peritoneal dialysis (APD), whether partial or total, is a home-based technique for patients who have lost their independence due to age or comorbidities, requiring some assistance to manage their treatment. It is also a viable option for patients ineligible for Peritoneal Dialysis (PD) due to social, cognitive, or physical barriers or those approaching the end of life. Moreover, APD has demonstrated lower hospitalization and mortality rates, lower costs, and similar quality of life compared to in center Hemodialysis (HD). To understand the usual clinical practice in PD and the limitations for the implementation of an APD program in Spain. Method Cross-sectional observational study conducted through a survey with closed-ended questions distributed by email to the PD working group of the Spanish Society of Nephrology. Participation was voluntary and anonymous. The survey included four questions about the center's structure, six about usual practices, and six about potential barriers to the implementation of APD. Results A total of 74 responses from 59 centers were analyzed. Average PD programs were 40 ± 26 [2-100]. The median number of patients undergoing APD is 5 [3-10] per program. Among the respondents, 73% believe that APD should include support in organizing and preparing materials at home, connecting and disconnecting in APD/CAPD, and documenting the treatment. Regarding the offering of APD, 48% of respondents answered it should be provided to patients who have initiated PD and need assistance to continue the technique, 47% in cases of family surrender, 39% to all patients wishing to undergo PD despite physical or mental impairment, 38% at any time if the patient requires it, and 22% during information sessions on techniques in CKD clinic. Regarding who should perform APD, 73% responded with a caregiver, 63% with external nursing/assistant personnel not affiliated with the PD unit, 52% with a family member, and 48% with nursing/assistant personnel from the PD unit itself. Perceived limitations by the respondents include lack of funding (80%), lack of experience in PD units (15%), lack of motivation in PD units (11%), lack of trained personnel (5%), and none of the above (7%). Eighty percent of the respondents believe that implementing APD would increase the number of PD patients in their program. Conclusion Seventy-three percent considers that APD should include support in material preparation at home, connection-disconnection, and treatment documentation. There is no consensus on who should be offered APD or who should perform the treatment at the patient's home. The primary perceived limitations are program funding and a lack of training and motivation among the teams.

#3281 SAFETY AND EFFICACY OF VIRTUAL OUTPATIENT NEPHROLOGY CONSULTATION IN THE NORTHERN ALBERTA RENAL PROGRAM

Abstract Background and Aims There is a growing awareness among Canadian health care providers of the need to incorporate virtual consultations safely and effectively post pandemic. With the onset of the Covid-19 pandemic in March 2020, outpatient consultation in Northern Alberta Renal Program (NARP) was rapidly transitioned to virtual delivery (telephone or videoconferencing) in place of face-to-face visits. To scale up and sustain virtual consultation in kidney care programs, its safety and effectiveness in improving processes of care (reduced wait time and access to care) and patient-related outcomes must be established. Data establishing safety and effectiveness of virtual consultation in kidney care has been limited. We therefore aimed to evaluate the safety and effectiveness of virtual consultation in patients with advanced CKD or peritoneal dialysis (PD) being cared for in NARP. Method The study was conducted in NARP (one of the largest kidney care programs in Canada). The study populations comprised two categories of patients with kidney disease: 1) CKD (non-dialytic) being followed in the ambulatory care clinics and 2) chronic PD patients being followed up in a dedicated home dialysis clinic at 3-monthly intervals. Data were collected over two-time points, pre and post implementation of virtual kidney following the COVID-19 pandemic: March 2019-February 2020 (pre-implementation), and March 2020- February 2021 (post implementation). We were only allowed to collate data on the processes of care outcomes for CKD (clinic cancellations or no-shows, wait times to see a nephrologist from the point of referral and number of visits), and adverse clinical outcomes (peritonitis rates, all-cause hospitalizations, technique failure, defined as PD failure with transition to hemodialysis) for the patients on PD. Summary statistics and tests of associations applied as appropriate. Interrupted time series analyses were used to evaluate trends. All analyses were conducted using (STATA 15 software (Stata Corporation, 2017). The study was approved by the University of Alberta Research Ethics Board. Results In patients on PD, the studied outcome measures were not significantly impacted (no changes in the trend) pre and post virtual care implementation (Figs 1a-c). The absolute number of clinic visits in patients on PD did not change (data not shown). In the patients with CKD, there were significant reductions in the rate of clinic cancellations/no-show rates (Fig. 2a), and a reduction in wait time (by a median of two weeks) following virtual care implementation (Fig. 2b). The rates of clinic visits pre and post implementation did not change (Fig. 2c) Conclusion The implementation of virtual consultation with the onset of COVID-19 pandemic (and the attendant reduction in face-to-face contacts with patients) did not negatively impact the care of patients on PD regarding risk for adverse clinical outcomes (peritonitis rates, all-cause hospitalizations, and technique failure). In patients with CKD, implementation of virtual care has led to significant improvements in the processes of care (reduction in wait times and enhanced access to care). These findings have implications in the design of sustainable virtual care programs for delivery of specialized kidney care in both dialysis and non-dialytic CKD in Canada and beyond.

#6018 SODIUM-GLUCOSE CO-TRANSPORTER-2 INHIBITOR USE IN THE MANAGEMENT OF PATIENTS WITH CHRONIC KIDNEY DISEASE AND TYPE 2 DIABETES MELLITUS

Abstract Background and Aims Sodium-glucose co-transporter-2 (SGLT-2) inhibitors were initially developed for the management of type 2 diabetes mellitus (T2DM). Results from large placebo-controlled clinical outcome trials have now highlighted efficacy of SGLT-2 inhibitors in reducing the risk of CKD progression [1,2]. NICE CKD guidelines now recommend use of SGLT-2 inhibitors alongside standard of care in those patients with T2DM [3]. This has subsequently extended SGLT-2 inhibitor licensing highlighting the importance of wider multi-disciplinary team practise awareness. The aim of this audit was to assess the level of implementation of updated NICE guidelines in patients under a specialist CKD clinic in Birmingham. Method A database of renal diabetics under a specialist CKD clinic in May 2022 was generated via the trust electronic patient record system. Patients with a recorded diagnosis of T2DM and estimated glomerular filtration rate (eGFR) >25ml/min (current UK regulatory licensing for SGLT-2 inhibitor use) were included. Parameters of renal function (urine albumin: creatinine ratio (uACR) and eGFR) as well as medication histories were retrospectively collected for 158 patients and analysed using descriptive statistics. Results Results demonstrated 19% (n = 43) of 143 patients with an accessible drug history were prescribed an SGLT-2 inhibitor. Less than half (44%) of those prescribed standard of care (ACEI/ARB) with a uACR >30 mg/mmol (n = 34) were prescribed an SGLT-2 inhibitor as per NICE recommendations. The prescribing of SGLT-2 inhibitors in patients at different stages of CKD was noted except in those with eGFR <30 ml/min. Conclusion Results suggest a number of patients with T2DM are not prescribed an SGLT-2 inhibitor as per NICE recommendations for CKD management. Whilst considering sample size limitation as well as possible contraindications relevant to SGLT-2 inhibitor treatment, these findings may reflect the recent update to NICE guidelines and delayed dissemination of information between multi-disciplinary teams around extended SGLT-2 inhibitor licensing. Glycaemic control is less effective in later stages of CKD however, trials have demonstrated the independent role of SGLT-2 inhibitors in reducing the risk of CKD progression irrespective of their attenuated ability to lower glucose in reduced kidney function [1,2]. It is imperative patients not currently prescribed an SGLT-2 inhibitor are reviewed for treatment eligibility and any contraindications. Results of this study were fed back to the local renal and diabetes team with the recommendation for development of clear guidelines for use of SGLT-2 inhibitors in all eligible patients in order to achieve maximum healthcare benefits. In addition, there are ongoing discussions with primary care regarding review of their use of SGLT-2 inhibitors.

Clinical Outcomes and Vaccine Effectiveness for SARS-CoV-2 Infection in People Attending Advanced CKD Clinics: A Retrospective Provincial Cohort Study.

People with advanced CKD are at high risk of mortality and morbidity from coronavirus disease 2019 (COVID-19). We measured rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe outcomes in a large population attending advanced CKD clinics during the first 21 months of the pandemic. We examined risk factors for infection and case fatality, and we assessed vaccine effectiveness in this population. In this retrospective cohort study, we analyzed data on demographics, diagnosed SARS-CoV-2 infection rates, outcomes, and associated risk factors, including vaccine effectiveness, for people attending a province-wide network of advanced CKD clinics during the first four waves of the pandemic in Ontario, Canada. In a population of 20,235 patients with advanced CKD, 607 were diagnosed with SARS-CoV-2 infection over 21 months. The case fatality rate at 30 days was 19% overall but declined from 29% in the first wave to 14% in the fourth. Hospitalization and intensive care unit (ICU) admission rates were 41% and 12%, respectively, and 4% started long-term dialysis within 90 days. Significant risk factors for diagnosed infection on multivariable analysis included lower eGFR, higher Charlson Comorbidity Index, attending advanced CKD clinics for more than 2 years, non-White ethnicity, lower income, living in the Greater Toronto Area, and long-term care home residency. Being doubly vaccinated was associated with lower 30-day case fatality rate (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.03 to 0.52). Older age (OR, 1.06 per year; 95% CI, 1.04 to 1.08) and higher Charlson Comorbidity Index (OR, 1.11 per unit; 95% CI, 1.01 to 1.23) were associated with higher 30-day case fatality rate. People attending advanced CKD clinics and diagnosed with SARS-CoV-2 infection in the first 21 months of the pandemic had high case fatality and hospitalization rates. Fatality rates were significantly lower in those who were doubly vaccinated. This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_04_10_CJN10560922.mp3.

Understanding Care Gaps in the CKD Clinic

Understanding Care Gaps in the CKD Clinic

Generalizability of DAPA-CKD trial to the real-world setting of outpatient CKD clinics in Italy.

Generalizability of DAPA-CKD trial to the real-world setting of outpatient CKD clinics in Italy.

Multifaceted Intervention to Increase the Use of Home Dialysis: A Cluster Randomized Controlled Trial.

Home dialysis therapies (peritoneal and home hemodialysis) are less expensive and provide similar outcomes to in-center hemodialysis, but they are underutilized in most health systems. Given this, we designed a multifaceted intervention to increase the use of home dialysis. In this study, our objective was to evaluate the effect of this intervention on home dialysis use in CKD clinics across Canada. We conducted a cluster randomized controlled trial in 55 CKD clinic clusters in nine provinces in Canada between October 2014 and November 2015. Participants included all adult patients who initiated dialysis in the year following the intervention. We evaluated the implementation of a four-component intervention, which included phone surveys from a knowledge translation broker, a 1-year center-specific audit/feedback on home dialysis use, delivery of an educational package (including tools aimed at both providers and patients), and an academic detailing visit. The primary outcome was the proportion of patients using home dialysis at 180 days after dialysis initiation. A total of 55 clinics were randomized (27 in the intervention and 28 in the control), with 5312 patients initiating dialysis in the 1-year follow-up period. In the primary analysis, there was no difference in the use of home dialysis at 180 days in the intervention and control clusters (absolute risk difference, 4%; 95% confidence interval, -2% to 10%). Using a difference-in-difference comparison, the use of home dialysis at 180 days was similar before and after implementation of the intervention (difference of 0% in intervention clinics; 95% confidence interval, -2% to 3%; difference of 0.8% in control clinics; 95% confidence interval, -1% to 3%; P=0.84). A multifaceted intervention did not increase the use of home dialysis in adults initiating dialysis. A Cluster Randomized Trial to Assess the Impact of Patient and Provider Education on Use of Home Dialysis, NCT02202018.

355 Applying Standard AOBP Measurements in a CKD Clinic and its Effect on Nephrologists’ Hypertension Management Inertia

355 Applying Standard AOBP Measurements in a CKD Clinic and its Effect on Nephrologists’ Hypertension Management Inertia

Barriers to pre-dialysis education in hemodialysis patients with end-stage renal disease in Kingdom of Saudi Arabia

Background: Adequate pre-dialysis education was found to help patients select the best modality at the time dialysis is needed. Objectives: To identify the barriers to pre-dialysis education in the nephrology clinics among end-stage renal disease (ESRD) in the Kingdom of Saudi Arabia (KSA). Methods: We did a multi-center, cross-sectional study on 221 patients. A questionnaire was used to collect data about patients’ demographics, the primary cause of renal failure, and barriers to pre-dialysis education in the nephrology clinic. We selected the healthcare providers randomly from the same centers. Results: The leading cause of renal failure was diabetes mellitus (DM) in 24.9% of the Patient participants. About 64.7% were with hemodialysis, and 35.3% had peritoneal dialysis. The distance to the nephrology clinic is more than 50 km, about 63.7%. About 65.2% have followed up in the CKD clinic, and dietitians have seen 64.3% in the clinic. Dialysis educators.s have previously seen 59.7%. About 68.8% of the participants had the chance to understand dialysis modality before the commencement of treatment. The barriers from healthcare participants point out are 43.5 % of participants have no CKD clinic, 74% are without a multidisciplinary team, 61% evaluate more than 15 patients every clinic, and 43.5% assess patients with advanced chronic kidney disease every three months or more. 47.8% found many services in their hospital required to refer patients to another hospital because lack of nephrologists per 74% of participants, and 39% of them indicated no peritoneal dialysis unit. And 47.8% found no sociopsychology services play a role as a barrier. Conclusion: The barriers to pre-dialysis education studied in this paper from patients and healthcare providers points. That included the deficiency of a formal structured multidisciplinary chronic kidney disease clinic, lack of psychosocial support for CKD patients, and patients required to travel between hospitals more than 50 kilometers to get renal services. Key words: barriers, pre-dialysis, education, hemodialysis, ESRD, Saudi Arabia.

Kidney Failure Risk Equation and Cost of Care in Patients with Chronic Kidney Disease.

Patients with CKD exhibit heterogeneity in their rates of progression to kidney failure. The kidney failure risk equation (KFRE) has been shown to accurately estimate progression to kidney failure in adults with CKD. Our objective was to determine health care utilization patterns of patients on the basis of their risk of progression. We conducted a retrospective cohort study of adults with CKD and eGFR of 15-59 ml/min per 1.73 m2 enrolled in multidisciplinary CKD clinics in the province of Saskatchewan, Canada. Data were collected from January 1, 2004 to December 31, 2012 and followed for 5 years (December 31, 2017). We stratified patients by eGFR and risk of progression and compared the number and cost of hospital admissions, physician visits, and prescription drugs. In total, 1003 adults were included in the study. Within the eGFR of 15-29 ml/min per 1.73 m2 group, the costs of hospital admissions, physician visits, and drug dispensations over the 5-year study period comparing high-risk patients with low-risk patients were (Canadian dollars) $89,265 versus $48,374 (P=0.008), $23,423 versus $11,231 (P<0.001), and $21,853 versus $16,757 (P=0.01), respectively. Within the eGFR of 30-59 ml/min per 1.73 m2 group, the costs of hospital admissions, physician visits, and prescription drugs were $55,944 versus $36,740 (P=0.10), $13,414 versus $10,370 (P=0.08), and $20,394 versus $14,902 (P=0.02) in high-risk patients in comparison with low-risk patients, respectively, for progression to kidney failure. In patients with CKD and eGFR of 15-59 ml/min per 1.73 m2 followed in multidisciplinary clinics, the costs of hospital admissions, physician visits, and drugs were higher for patients at higher risk of progression to kidney failure by the KFRE compared with patients in the low-risk category. The high-risk group of patients with CKD and eGFR of 15-29 ml/min per 1.73 m2 had stronger association with hospitalizations costs, physician visits, and drug utilizations.

Trajectories of Nutritional Parameters Before and After Prescribed Oral Nutritional Supplements: A Longitudinal Cohort Study of Patients With Chronic Kidney Disease Not Requiring Dialysis

Background:The association between oral nutritional supplement use and nutritional parameters among patients with nondialysis chronic kidney disease (CKD-ND) with or at high risk of undernutrition/protein-energy wasting has not been previously studied. The definition of patient subgroups most likely to benefit from oral nutritional supplementation (ONS) is also an area where more research is needed.Objective:To assess nutritional parameter trajectories among patients with CKD-ND prescribed oral nutritional supplements in British Columbia, and to compare trajectories by nutritional phenotype.Design:Longitudinal cohort study, pre-post design.Setting:Multidisciplinary CKD clinics across British Columbia.Patients:A total of 3957 adult patients with CKD-ND, who entered multidisciplinary CKD clinics during 2010 to 2019, met criteria for oral nutritional supplement prescription based on dietitian assessment, and received ≥1 oral nutritional supplement prescription.Measurements:Longitudinal nutritional parameters, including body mass index (BMI), serum albumin, serum bicarbonate, serum phosphate, and neutrophil-to-lymphocyte ratio (NLR).Methods:Using linear mixed models, slopes for nutritional and inflammation parameters were assessed in the 2-year periods before and after the first oral nutritional supplement prescription. Hierarchical cluster analysis was applied to identify nutritional phenotypes using baseline data, and slope analysis was repeated by cluster.Results:In the pre-oral-nutritional-supplement period, declines in BMI (−0.87 kg/m2/year, 95% confidence interval [CI]: −0.99 to −0.75), albumin (−1.11 g/L/year, 95% CI: −1.27 to −0.95), and bicarbonate (−0.49 mmol/L/year; 95% CI: −0.59 to −0.39), and increases in NLR (+0.79/year; 95% CI: 0.60 to 0.98) and phosphate (+0.05 mmol/L/year; 95% CI: 0.04 to 0.06) were observed. Following oral nutritional supplement prescription, there were statistically significant increases in BMI slope (+0.91 kg/m2/year, P < .0001), albumin slope (+0.82 g/L/year, P < .0001), and phosphate slope (+0.02 mmol/L/year, P = .005), as well as a decline in NLR slope of −0.55/year (P < .0001). There was no significant change in bicarbonate slope. Cluster analysis identified 5 distinct phenotypes. The cluster with the highest mean baseline NLR and lowest mean BMI demonstrated the greatest number of improvements in nutritional parameter slopes in the post-oral-nutritional-supplement period.Limitations:Possibility of residual confounding. Data on dietary intake, muscle mass, and nutritional scoring systems were not available in the registry.Conclusions:Among patients with CKD-ND prescribed oral nutritional supplements, there were improvements in nutrition/inflammation parameters over time following the first ONS prescription. The heterogeneity in response to ONS by cluster subgroup suggests an individualized approach to nutritional management may be beneficial.

Nutritional Status, Nutritional Phenotypes, and Oral Nutritional Supplement Prescription Patterns Among Patients With Non-Dialysis Chronic Kidney Disease in British Columbia

Management of protein-energy wasting and undernutrition with oral nutritional supplements (ONS) has not been systematically studied in the non-dialysis chronic kidney disease (CKD-ND) population. We aimed to describe nutritional status, identify phenotypes of patients prescribed ONS, and evaluate ONS prescription patterns among CKD-ND patients in British Columbia. This observational study assessed adult CKD-ND patients who entered multidisciplinary CKD clinics during 2013-2018 in British Columbia. Descriptive statistics were used to describe baseline nutrition and inflammation parameters among patients prescribed ONS versus patients not prescribed ONS within 1year of clinic entry. Hierarchical clustering method with consensus clustering was applied to identify phenotypes of patients prescribed ONS. Multivariable logistic regression was used to assess the associations between ONS prescription and health region/dietitian full-time equivalents per 1,000 CKD patients. Of 15,859 CKD-ND patients, 9% of patients entering CKD clinics were prescribed ONS within 1year of clinic entry, and these patients demonstrated lower baseline estimated glomerular filtration rate, body mass index (BMI), serum albumin, bicarbonate, as well as greater age, serum phosphate, and neutrophil-to-lymphocyte ratio compared with those not receiving ONS. Cluster analysis revealed 5 phenotypes of ONS users: cluster 1 had the highest mean neutrophil-to-lymphocyte ratio; cluster 2 had the lowest mean albumin; cluster 3 had the lowest mean BMI; cluster 4 had the highest mean BMI; and cluster 5 had the lowest mean bicarbonate. There was regional variability in ONS prescription, and an odds ratio for ONS prescription of 1.32 (95% confidence interval 1.16-1.50) for every 1-unit increase in dietitian full-time equivalents per 1,000 patients. Over 3years of follow-up, overall ONS use among CKD-ND patients remained stable. This study demonstrates appropriate prescribing of ONS to patients with suboptimal nutritional status, although regional variation exists. Patients receiving ONS represent a heterogenous group with phenotypes reflecting several clinical and biochemical features of the protein-energy wasting syndrome. These findings will assist with updating ONS policy, planning quality improvement initiatives, and informing dietitian resource allocation.

Preferences for and Experiences of Shared and Informed Decision Making Among Patients Choosing Kidney Replacement Therapies in Nephrology Care

Rationale & ObjectiveChronic kidney disease (CKD) can progress rapidly, and patients are often unprepared to make kidney failure treatment decisions. We aimed to better understand patients’ preferences for and experiences of shared and informed decision making (SDM) regarding kidney replacement therapy before kidney failure.Study DesignCross-sectional study.Setting & ParticipantsAdults receiving nephrology care at CKD clinics in rural Pennsylvania.PredictorsEstimated glomerular filtration rate, 2-year risk for kidney failure, duration and frequency of nephrology care, and preference for SDM.OutcomesOccurrence and extent of kidney replacement therapy discussions and participants’ satisfaction with those discussions.Analytic ApproachMultivariable logistic regression to quantify associations between participants’ characteristics and whether they had discussions.ResultsThe 447 study participants had a median age of 72 (IQR, 64-80) years and mean estimated glomerular filtration rate of 33 (SD, 12) mL/min/1.73 m2. Most (96%) were White, high school educated (67%), and retired (65%). Most (72%) participants preferred a shared approach to kidney treatment decision making, and only 35% discussed dialysis or transplantation with their kidney teams. Participants who had discussions (n = 158) were often completely satisfied (63%) but infrequently discussed potential treatment-related impacts on their lives. In multivariable analyses, those with a high risk for kidney failure within 2 years (OR, 3.24 [95% CI, 1.72-6.11]; P < 0.01), longer-term nephrology care (OR, 1.12 [95% CI, 1.05-1.20] per 1 additional year; P < 0.01), and more nephrology visits in the prior 2 years (OR, 1.34 [95% CI, 1.20-1.51] per 1 additional visit; P < 0.01) had higher odds of having discussed dialysis or transplantation.LimitationsSingle health system study.ConclusionsMost patients preferred sharing CKD treatment decisions with their providers, but treatment discussions were infrequent and often did not address key treatment impacts. Longitudinal nephrology care and frequent visits may help ensure that patients have optimal SDM experiences.

The LIFT trial: study protocol for a double-blind, randomised, placebo-controlled trial of K+-binder Lokelma for maximisation of RAAS inhibition in CKD patients with heart failure

BackgroundCKD is common in heart failure (HF) and associated with morbidity and mortality, yet life-prolonging medications such as renin-angiotensin-aldosterone inhibitors (RAASi) are underused due to risk of hyperkalaemia. Sodium zirconium cyclosilicate (SZC) is a potassium-binding medication that has been shown to reduce incidence of hyperkalaemia in CKD, non-CKD, and HF populations, which we propose will support maximisation of RAASi therapy.MethodsWe propose a 1:1 randomised, double-blind, placebo-controlled trial in which participants will receive either SZC or placebo. We will up-titrate participants’ RAASi therapy while monitoring their serum potassium levels and adjusting their SZC dose if necessary. Participants with CKD and HF will be recruited from CKD and HF clinics at St George’s Hospital. The total study period will be 18 months; 130 participants will be enrolled for approximately two months each following screening. Our primary outcome will be the proportion of participants who achieve maximum RAASi dose while maintaining normokalaemia. Secondary outcomes include participants reaching maximum RAASi dose without severe hyperkalaemia; time from randomisation to hyperkalaemia; time from randomisation to severe hyperkalaemia; number of RAASi dose escalations per participant; final doses of RAASi therapy; changes in quality of life score, eGFR, ACR, serum sodium, troponin T; number and duration of hospital admissions; and within-participant change in serum potassium compared to baseline.DiscussionThis trial will be the first to examine the use of SZC for the maximisation of RAASi dosing in patients with advanced CKD and HF. We will assess the impact of achieving target RAASi dosing on hospital admission rates and duration of stay, with the hope that optimum RAASi treatment will translate into reduced morbidity and improved QoL. If clinical benefit is demonstrated, we hope that the joint multidisciplinary CKD-HF approach will be expanded.Trial registrationEudraCT number 2020–002946-18. Registered on 08 June 2020. Online record pending.

Current Management of Hyperkalemia in Non-Dialysis CKD: Longitudinal Study of Patients Receiving Stable Nephrology Care.

Background: No study has explored the limitations of current long-term management of hyperkalemia (HK) in outpatient CKD clinics. Methods: We evaluated the association between current therapeutic options and control of serum K (sK) during 12-month follow up in ND-CKD patients stratified in four groups by HK (sK ≥ 5.0 mEq/L) at baseline and month 12: Absent (no-no), Resolving (yes-no), New Onset (no-yes), Persistent (yes-yes). Results: We studied 562 patients (age 66.2 ± 14.5 y; 61% males; eGFR 39.8 ± 21.8 mL/min/1.73 m2, RAASI 76.2%). HK was “absent” in 50.7%, “resolving” in 15.6%, “new onset” in 16.6%, and “persistent” in 17.1%. Twenty-four hour urinary measurements testified adherence to nutritional recommendations in the four groups at either visit. We detected increased prescription from baseline to month 12 of bicarbonate supplements (from 5.0 to 14.1%, p < 0.0001), K-binders (from 2.0 to 7.7%, p < 0.0001), and non-K sparing diuretics (from 34.3 to 41.5%, p < 0.001); these changes were consistent across groups. Similar results were obtained when using higher sK level (≥5.5 mEq/L) to stratify patients. Mixed-effects regression analysis showed that higher sK over time was associated with eGFR < 60, diabetes, lower serum bicarbonate, lower use of non-K sparing diuretics, bicarbonate supplementation, and K-binder use. Treatment-by-time interaction showed that sK decreased in HK patients given bicarbonate (p = 0.003) and K-binders (p = 0.005). Conclusions: This observational study discloses that one-third of ND-CKD patients under nephrology care remain with or develop HK during a 12-month period despite low K intake and increased use of sK-lowering drugs.

Patient Outcomes Following Discharge from a CKD Clinic

Patient Outcomes Following Discharge from a CKD Clinic

Beliefs About Plant-Based Diet in Inner City CKD and Family Medicine Patients and Relationship to Dietary Patterns

Abstract Objectives We compared beliefs about plant-based eating and dietary intake in patients attending inner-City CKD and Family Medicine (FM) clinics. Methods A face-to-face survey was conducted in a random convenience sample of pts in CKD (23) and FM clinics (22). Patients were asked to answer 5 multiple choice questions assessing their beliefs regarding difficulty in finding plant-based foods in restaurants, affordability, ability to get proteins and vitamins, and ability to find good tasting recipes. A mean score was calculated. Lower score indicates more difficulty (PBE-score). Diet analysis was based on 24hr recall and analyzed using ASA-24 software. Comparisons are by t-test unless noted. Results Mean age was 54.3 ± 2.5 yrs. There were 16 (35.6%) males and 22 (62.2%) females with 40 black (89%). 36 (80%) had not completed college. 23 (51%) had an income &amp;lt; $20 K. 16 (35%) were employed. 20 (44%) had diabetes. 22 (49%) received SNAP benefits. Mean BMI was 30.4 ± 1.6 with 41% &amp;gt; 30. There were no differences between clinics. CKD pts had higher creatinine (2.01 ± 0.39 vs 0.85 ± 0.05) and lower albumin (3.92 ± 0.12 vs 4.32 ± 0.09, P = 0.012). CKD pts had more positive attitude towards plant-based eating (PBE-score 2.57 ± 0.1 vs 2.21 ± 0.13, P &amp;lt; 0.05), and ate more cholesterol (411.6 ± 65.2 vs 248.7 ± 30.3, P = 0.031), fatty seafood (1.41 ± 0.54 vs 0.17 ± 0.1, P = 0.034) and eggs (1.05 ± 0.27 vs 0.42 ± 0.16, P = 0.048) and drank more fluid (2499.0 ± 335.6 vs 1367.9 ± 167.1, P = 0.005) than FM pts. Protein, carbohydrate intake and total calories were similar and fruit and vegetable intake was low (1.33 ± 0.3 and 1.34 ± 0.19 respectively). PBE-score did not correlate with dietary intake and serum cholesterol did not differ (184.3 ± 9.4 vs 170.2 ± 8.0, P = NS). Conclusions In our population: 1. Pts with CKD had a more positive attitude towards plant-based eating and were more likely to believe they could eat more plant-based. 2. CKD pts ate more cholesterol with higher intake of eggs and fatty seafood, and drank more fluid. 3.Vegetable intake was poor and there was no difference between the groups. 4. The positive attitude of CKD pts towards plant-based eating and our indigent population as a whole suggests that education could be successful and should be explored further as our population as a whole has a high prevalence of CKD, obesity and diabetes. Funding Sources None.

Diabetic Inner- City Kidney Patients Eat Less Sugar and Grains but Also Fewer Healthy Nutrients Than Non-Diabetic Patients

Abstract Objectives We evaluated dietary intake in patients with kidney disease with and without diabetes in inner-city Brooklyn clinics. Methods A face-to-face survey was conducted in a random convenience sample of pts from CKD (23) and transplant (45) clinics. Diet was studied by 24-hour recall using ASA24 software. Healthy Eating Index was calculated using the HEI-15 score and the DASH index as standard. Between group comparison was by t-test unless noted. Results There were 37 males (54%) and 31 (46%) females, 56 (82%) Black, 24/62 (24%) received SNAP benefits. 24 (53%) transplant (TXP) and 13 (57%) CKD pts had diabetes (DIAB). By Chi square, DIAB were more likely to make &amp;lt; $20 K/yr (58% vs 23%, P = 0.015) and be unemployed (89% vs 61%, P = 0.018). DIAB were older (61.8 ± 1.6 vs 50.3 ± 2.25 yrs, P &amp;lt; 0.0001). Creatinine was 1.86 ± 1.09 mg/dl. HbA1c was 11.1 ± 3.1, time with diabetes 206.03 ± 26.9 months. Blood pressure, BMI, albumin, potassium and total cholesterol did not differ but HDL was lower (DIAB 41.8 ± 3.5 vs 55.1 ± 4.3, P = 0.026). DIAB ate fewer calories (1386.5 ± 83.9 vs 1779.9 ± 129.1, P = 0.014), carbohydrates (131.8 ± 10.8 vs 211.8 ± 13.4, P &amp;lt; 0.0001), sugar (41.5 ± 5.2 vs 89.4 ± 9.5, P &amp;lt; 0.0001), added sugar (5.4 ± 0.86 vs 10.15 ± 1.89, P = 0.02) and refined grains (3.01 ± 0.43 vs 4.61 ± 0.59, P = 0.035), less fiber (11.1 ± 1.0 vs 16.1 ± 1.4, p-P = 0.006), vitamin C (49.7 ± 8.9 vs 110.2 ± 23.3, P = 0.014), fruit (0.37 ± 0.1 vs 1.96 ± 0.6, P = 0.009), potassium (1928.3135.8 vs 2578.1 ± 224.9, P = 0.014), magnesium (229.3 ± 16.8 vs 304.4 ± 32.9, P &amp;lt; 0.05) and calcium (548.3 ± 60.1 vs 738.6 ± 67.9, P = 0.04). There was no difference for DASH (3.6 ± 0.15 vs 3.9 ± 0.18) or HEI score (57.8 ± 1.9 vs 59.4 ± 2.3) or dairy, meat, total protein, fat or sodium intake. Conclusions In our population: 1. DIAB pts reported more unemployment and lower income. 2. DIAB pts ate fewer total calories, but similar intake of protein and fat. 3. DIAB pts ate fewer carbohydrates, sugars, added sugars, and refined grains but did not have lower BMI and diabetes control was poor, with lower HDL values. 4. DIAB pts also ate less fresh fruit, potassium, calcium, magnesium, fiber and vitamin C. 5. Education of our pts with kidney disease and diabetes should reinforce positive dietary habits but encourage overall healthy eating that includes fruits and fiber, as patients may be focusing on restricting sugar and carbohydrates to the detriment of other nutrients. Funding Sources None.