Disease Outcomes Quality Initiative Guidelines Research Articles

Twice Weekly versus Thrice Weekly Hemodialysis-A Pilot Cross-Over Equivalence Trial.

The 2015 Update of the Kidney Disease Outcomes Quality Initiative (KDOQI) Guideline for Hemodialysis Adequacy increased the contribution of residual kidney function in calculating standard Kt/Vurea (stdKt/Vurea). However, no study has assessed the effect of prescribing twice weekly hemodialysis according to this guideline on patients' quality of life or uremic solute levels. Twenty six hemodialysis patients with average residual urea clearance (Kru) 4.7±1.8 ml/min and hemodialysis vintage of 12±15 months (range two months to 4.9 years) underwent a cross-over trial comparing four weeks of twice weekly hemodialysis and four weeks of thrice weekly hemodialysis. Twice weekly hemodialysis was prescribed to achieve stdKt/Vurea 2.2 incorporating Kru using the 2015 KDOQI Guideline. Thrice weekly hemodialysis was prescribed to achieve spKt/Vurea 1.3 regardless of Kru. Quality of life and plasma levels of secreted uremic solutes and β2 microglobulin (β2m) were assessed at the end of each period. Equivalence testing between twice and thrice weekly hemodialysis based on the Kidney Disease Quality of Life instrument (primary analysis) was inconclusive. Symptoms as assessed by the secondary outcomes Dialysis Symptom Index and post-dialysis recovery time were not worse with twice weekly hemodialysis. StdKt/Vurea was adequate during twice weekly HD (2.7±0.5), and ultrafiltration rate and plasma potassium were controlled with minimally longer treatment times (twice weekly: 195±20 vs. thrice weekly: 191±17 minutes). Plasma levels of the secreted solutes and β2m were not higher with twice weekly than thrice weekly hemodialysis. Twice weekly hemodialysis can be prescribed using the higher contribution assigned to Kru by the 2015 KDOQI Guideline. With twice weekly hemodialysis, quality of life was unchanged, and the continuous function of the residual kidneys controlled fluid gain and plasma levels of potassium and uremic solutes without substantially longer treatment times.

The relationship between hypomagnesemia and albuminuria in patients with type 2 diabetes mellitus.

Diabetic nephropathy is a prevalent cause of chronic kidney disease worldwide. Magnesium plays a critical role in insulin resistance, and insulin, in turn, regulates magnesium levels. We aimed to investigate the association between hypomagnesemia and albuminuria in patients with type 2 diabetes mellitus (T2DM). This retrospective single-centre study encompassed 1178 patients aged 18 and above with T2DM, who attended our outpatient clinic between January 2019 and August 2020. Albuminuria levels were categorised according to Kidney Disease Outcomes Quality Initiative guidelines. In the literature, when examining cut-off values for hypomagnesemia, it is observed that studies typically use hospital normal level as a reference point. Hypomagnesemia, defined as magnesium levels below 1.6 mg/dL, was compared to normomagnesemia (magnesium between 1.6 and 2.4 mg/dL). The primary objective was to explore the impact of magnesium levels on albuminuria, while the secondary objective was to determine the prevalence of hypomagnesemia. The multivariate logistic regression analyses were performed according to age, gender (male), HbA1c, and presence of hypomagnesemia. The mean age of the participants was 58.7 ± 12.2 years, with 44% being male. Hypomagnesemia was identified in 5.3% of the patients. Advanced age and female gender were more common among patients with hypomagnesemia (p = .001). Magnesium levels exhibited a negative correlation with HbA1c and fasting blood glucose, and a positive correlation with creatinine levels (r = -.117, r = -.131, r = .117, p < .001 for all three variables). Hypomagnesemia was significantly more prevalent in patients with albuminuria (15.9% vs. 4.7%, p < .001). Moreover, participants with the presence of hypomagnesemia were independently associated with a higher risk of albuminuria (odds ratio 3,64 1.76-7.52, p = .001). Albuminuria is more frequently observed in patients with hypomagnesemia.

The influence of near-infrared therapy on arteriovenous fistula patency in haemodialysis patients: A multicentre, randomised, controlled clinical trial.

Arteriovenous fistula (AVF) is the preferred vascular access for patients undergoing haemodialysis (HD). AVF malfunction remains a major clinical problem and is a significant independent risk factor for death. Although far-infrared (FIR) therapy has been shown to reduce complications and improve the patency rate of AVFs in various studies, it has been cautiously recommended by the Kidney Disease Outcome Quality Initiative (KDOQI) guidelines for AVF care due to insufficient evidence. Therefore, it is necessary to identify more effective methods for preventing AVF dysfunction. Many in vitro studies and few clinical studies have examined the effects of near-infrared (NIR) therapy on the vasculature. This study will examine the effects of NIR therapy on AVF. A randomised, controlled, open-label, multicentre trial will compare the effect of NIR on AVF patency after 1 year of therapy with that of a control group of patients with existing AVF. One group of patients received NIR treatment above their AVFs, whereas the control group received regular care. The primary outcome is the primary fistula patency rate within 12 months. In addition, acute changes in inflammatory, vasodilatory and haemodynamic parameters after a single treatment in the first 40 participants will be examined. This study was registered in the Clinical Trials Registry (ChiCTR2300071305) at https://register.clinicaltrials.gov/. This study will explore the long-term and acute effects of NIR on AVFs. The study findings will provide information that can be used to develop new technical support for the prevention of AVF dysfunction in patients undergoing haemodialysis.

Prevalence and risk factors of erythropoiesis stimulating agents hyporesponsiveness in chronic hemodialysis patients attending nephrology center of Benghazi

Background: Anemia is quite prevalent in end stage renal disease patients. Despite availability of different forms of erythropoiesis stimulating agents, many end stage renal disease patients are anemic according to National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative guidelines. Patient and methods: we conduct a cross sectional study between May 2022 and July 2022, targeting adult chronic hemodialysis patients, to investigate the prevalence of erythropoiesis stimulating agents hyporesponsiveness, to assess if patients are receiving the appropriate weight-based dosing of these agents, and to identify additional risk factors behind inadequate response to therapy.390 end stage renal disease patients are receiving chronic hemodialysis at nephrology center of Benghazi. Incident hemodialysis patients, patients with other hematological disease or with malignancy are excluded. Finally, 150 patients met the inclusion criteria and enrolled in the study. Results: 100 (66.7%) are male, and 50 (33.3%) are females. Age is 50.6 ±13.2 years. Erythropoiesis stimulating agents hyporesponsiveness is prevalent in chronic hemodialysis patients, 130 (86.7%) patients are anemic as their Hb levels were &lt;11 g/dl, while only 20 (13.3%) patients have Hb levels of &gt;/=11g/dl. There is a significant relationship between gender and ESA response, as hyporesponsiveness is more observed in male patients (P &lt; .005). We find that 105 (70%) patients are receiving an appropriate weight-based dose, while only 45 (30%) patients were giving an inappropriate dose. When the relationship between ESA dosing and patients' response to ESA is examined, we find, that despite receiving the appropriate dose, 90 (60%) patients are ESA hyporesponsive, while only 15 (10%) are responsive to the appropriate weight-based dose. However, no statistical association is found between ESA hyporesponsiveness and age or weekly hours of dialysis. Conclusion: despite receiving an appropriate dosage of ESA, our study population shows high prevalence of ESA hyporesponsive anemic state. New strategies should be applied to detect risk factors and adopt therapeutic measures to reduce its high prevalence in hemodialysis population.

Predicting recurrent interventions after radiocephalic arteriovenous fistula creation with machine learning and the PREDICT-AVF web app.

Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines discourage ongoing access salvage attempts after two interventions prior to successful use or more than three interventions per year overall. The goal was to develop a tool for prediction of radiocephalic arteriovenous fistula (AVF) intervention requirements to help guide shared decision-making about access appropriateness. Prospective cohort study of 914 adult patients in the United States and Canada undergoing radiocephalic AVF creation at one of the 39 centers participating in the PATENCY-1 or -2 trials. Clinical data, including demographics, comorbidities, access history, anatomic features, and post-operative ultrasound measurements at 4-6 and 12 weeks were used to predict recurrent interventions required at 1 year postoperatively. Cox proportional hazards, random survival forest, pooled logistic, and elastic net recurrent event survival prediction models were built using a combination of baseline characteristics and post-operative ultrasound measurements. A web application was created, which generates patient-specific predictions contextualized with the KDOQI guidelines. Patients underwent an estimated 1.04 (95% CI 0.94-1.13) interventions in the first year. Mean (SD) age was 57 (13) years; 22% were female. Radiocephalic AVFs were created at the snuffbox (2%), wrist (74%), or proximal forearm (24%). Using baseline characteristics, the random survival forest model performed best, with an area under the receiver operating characteristic curve (AUROC) of 0.75 (95% CI 0.67-0.82) at 1 year. The addition of ultrasound information to baseline characteristics did not substantially improve performance; however, Cox models using either 4-6- or 12-week post-operative ultrasound information alone had the best discrimination performance, with AUROCs of 0.77 (0.70-0.85) and 0.76 (0.70-0.83) at 1 year. The interactive web application is deployed at https://predict-avf.com. The PREDICT-AVF web application can guide patient counseling and guideline-concordant shared decision-making as part of a patient-centered end-stage kidney disease life plan.

Higher Prevalence of Chronic Kidney Disease in Myelodysplastic Syndromes Patients Compared to Age- Adjusted General Population - Results from the Polish Adult Leukemia Group (PALG) Registry

Introduction Chronic comorbidities that are common in the elderly population can have a significant impact on the clinical course, the choice of treatment, and survival of myelodysplastic syndromes (MDS) patients. No studies have focused on the coexistence of two diseases that are common in the elderly population, chronic kidney disease (CKD) and MDS, so the epidemiological data and clinical implications of both diseases occurring together are unknown. Aims Primary objective: to assess the prevalence of CKD in patients with MDS in comparison to the age-adjusted general population. Secondary objective: to evaluate the impact of CKD on clinical course in MDS patients. Methods This was a prospective analysis using clinical and laboratory data from MDS patients who were registered in the Polish Adult Leukemia Group (PALG) Registry from 2010 to 2023. Data have been provided by 28 hematologic centers. CKD was defined as an eGFR &amp;lt; 60 mL/min/1.73m², disregarding albuminuria since urinalysis results were not recorded in the database. The stages of CKD were classified based on eGFR according to the NKF KDOQI National Kidney Foundation Kidney Disease Outcome Quality Initiative guidelines, and eGFR was calculated using CKD-EPI equation. For comparison of the prevalence of CKD in MDS subjects aged ≥60 years to the general population, we used data from the PolSenior 2 study (covering the years 2018-2019). Data were age and sex standardized using demographic tables from Statistics Poland (https:// demografia.stat.gov.pl/bazademografia/Tables.aspx). Median survival time was calculated using Kaplan-Meier estimator. Multivariate analysis was performed using Cox regression. Results Overall, data (including eGFR) were available for 1813 MDS patients. Median age at diagnosis was 71 years [IQR 64 - 78]. and 55.3% patients were male. Sixty percent of the patients were diagnosed as IPPS lower risk. At the time of MDS diagnosis, CKD was detected in 479 patients (26.4%). Among patients aged ≥ 60, the crude rate of CKD was 30.3%. The standardized rate of CKD in the general population aged ≥ 60 years was significantly lower than in the similarly aged MDS group, with rates of 13.2% [CI 12.3-14.1] and 25.5% [CI 22.9-28.4]; p&amp;lt;0.001, respectively. (Figure 1) Patients with CKD were significantly older (median 78 yo) than those without CKD (median 68 yo; p&amp;lt;0.001), and more likely to have diabetes (33.2% vs 19.7%; p&amp;lt;0.001), and to have coincidence of another malignancy (21.6%) than those without CKD (14.9%; p=0.001). Median hemoglobin concentration was significantly lower in the CKD group (8.9 g/dL) than in the non-CKD group (9.4 g/dL; p &amp;lt; 0.05). Subjects with decreased eGFR were more likely to be dependent on RBC transfusion (56.5%) than subjects with eGFR ≥ 60 ml/min per 1.73m 2 (48.9%; p=0.0008). Median survival of patients with eGFR ≥ 60 ml/min per 1.73m 2 was 2.5 y [CI 1.0-6.1] vs 1.4 y [CI 0.6-4.2] for CKD. In multivariate analysis we found that CKD stage, age ≥ 65, higher IPSS score, high-risk IPSS cytogenetics and ECOG &amp;gt;1 were independent predictors of shorter survival. (Figure 2). Conclusions Myelodysplastic syndrome (MDS) subjects are more likely to have chronic kidney disease (CKD) than the general population. The presence of CKD in MDS patients is associated with worse overall survival and higher RBC transfusion requirement.

Examining the Relationship between Dietary Intake, Socioeconomic Status, and Systolic Blood Pressure of Adults on Hemodialysis in Quito, Ecuador

BackgroundIn Ecuador, the number of adults on hemodialysis (HD) continues to rise. Currently, the effect dietary habits and socioeconomic status (SES) have on blood pressure is not known for those on HD. ObjectivesThe objectives of this study focused on adults on HD in Quito, Ecuador to 1) assess the relationship between dietary intake and SES; 2) compare dietary intake to the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines; and 3) explore the relationship between dietary intake and systolic blood pressure. MethodsThis cross-sectional study was conducted at the dialysis center within Eugenio Espejo Specialties Hospital in Quito, Ecuador between May and June 2022 among 50 adults on HD. Three 24-h recalls were used to determine average dietary intake and the 25-item Instituto Nacional de Estadística y Censos-Stratification of SES was used to determine SES. Electrolytes and 2 blood pressure readings were collected. Qualitative narrative data analysis was performed to identify themes using NVivo v12. T-tests of independence, simple, and multiple linear regressions using age and sex as confounders were conducted using R and a P < 0.05 was deemed as statistically significant. ResultsOn an average, 76% of participants consumed <25 kcal/kg body weight energy and 64% consumed <1 g protein/kg body weight. Participants consumed less energy and protein compared with the KDOQI guidelines (P < 0.05). Positive relationships were observed with potassium and blood pressure (β = 0.020, P < 0.05) and SES with energy, protein, and phosphorus (P < 0.05). Themes that were identified as contributing to dietary intake were limited knowledge, lack of consistency with dietary information, and limited appetite. ConclusionsFindings from this study indicate that the focus should be on improving energy and protein intake for this population.

Association between anemia-related biomarkers and the adequacy of peritoneal dialysis in Chinese patients with chronic kidney disease.

Objectives: The study aimed to examine the association of three anemia-related biomarkers with the adequacy of peritoneal dialysis (PD) in patients with chronic kidney disease (CKD). Methods: This study included 127 PD patients. The total Kt/V urea (Kt/V) was calculated according to the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines. All patients were classified into two groups based on Kt/V, viz., adequate (Kt/V ≥1.7) and inadequate (Kt/V <1.7) groups. Effect sizes are expressed as odds ratios (ORs) and 95% confidence interval (CI). Results: After adjusting for age, gender, hypertension, diabetes, and PD duration, 20g/L increment in hemoglobin (Hgb) was observed to significantly reduce the risk of inadequate PD by 19% (OR; 95% CI; P: 0.81; 0.70 to 0.95; 0.009), 5g/L increment in the mean corpuscular hemoglobin concentration (MCHC) by 7% (0.93; 0.88 to 0.98; 0.009), and 5% increment in transferrin saturation (TS) by 23% (0.77; 0.64 to 0.94; 0.012). The gender-specific nomogram model was constructed by incorporating three significant anemia-related biomarkers and convenient influencing factors, and the prediction accuracy was good (concordance index (C-index): 0.686 for men and 0.825 for women). Conclusion: Our findings indicate that the deterioration of three anemia-related biomarkers (Hgb, MCHC, and TS) can precipitate the development of inadequate PD in Chinese patients with CKD.

Screening of Renal Function among a Group of Physicians Working in a Hospital Who are Often Self Neglected

Background: Prevalence of Chronic Kidney Disease (CKD) has been increasing rapidly worldwide and early screening to detect kidney disease, particularly at its early stages is pivotal to stop its further deterioration. Population-based study on detection at early-stage of kidney disease and it’s prevalence are scanty in our country, especially among the medical professional personnel. Hence taking advantage of the observance of World Kidney Day’ 2020, we conducted a screening pro-gram for kidney disease organized at the Chattagram Maa-O-Shishu Hospital (CMOSH) premises among a group of physicians of the hospital.&#x0D; Materials and methods: This was a cross-sectional observational study among 67 physicians of different ranks (Medical Officer to Professor) working at CMOSH in different discipline. Age, body weight, height, Body Mass Index (BMI), blood pressure were documented, and urinary protein and serum creatinine were measured at a single sitting. Kidney function was estimated by calculating the Glomerular Filtration Rate (GFR) using the Modification of Diet in Renal Disease (MDRD) formula. Kidney function was classified according to estimated GFR (eGFR) and Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines.&#x0D; Results: A total of 67 working physicians of the hospital were studied. Majority subjects (30) were in the age group of 20-29 years. Among all 11.9% participants had proteinuria (Trace to 1 plus). The distribution of eGFR was symmetrical, with the majority (70.10%) of subjects in the 60–89 ml/min category, 11.90% had 30-59 ml/min category and only 17.90% of the study population had eGFR &gt; 90 ml/min. An inverse relation between eGFR and age, and a direct relation between eGFR and BMI were observed.&#x0D; Conclusion: Proteinuria low eGFR levels might be related with future decline in renal function among the studied subjects and so regular health check-up is important to abate the potential epidemic of kidney disease among the health professionals.&#x0D; Chatt Maa Shi Hosp Med Coll J; Vol.22 (1); January 2023; Page 14-18

Assessment of Dietary Acid Load in Children with Chronic Kidney Disease: An Observational Study.

Dietary acid load (DAL), which reflects the balance between acid- and alkaline-forming foods, is a modifiable risk factor for metabolic acidosis in CKD. Owing to the paucity of data in the Indian context, we undertook this cross-sectional study to estimate DAL and assess acid and alkaline food consumption in children with CKD2-5D (Chronic kidney disease stage 2 to 5 and 5D-those on hemodialysis). Clinical profile, dietary assessment of energy, protein intake/deficits, and macronutrients were noted and computed using software created by the division of nutrition, St John's research institute based on Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines in clinically stable children with CKD2-5D. DAL was estimated using potential renal acid load (PRAL in mEq/day) = (0.49 × protein intake in g/day) + (0.037 × phosphorus-intake in mg/day) - (0.02 × potassium intake in mg/day) - (0.013 × calcium intake in mg/day) - (0.027 × magnesium intake in mg/day). A positive dietary PRAL (>0) favors acidic content and negative (<0) favors alkaline content. PRAL was stratified into quartiles for analysis. The association of various clinical and dietary parameters were analysed across these quartiles. Eighty-one children [of mean age 122 ± 47 months; 56 (69%) boys, 29 (36%) on dialysis, 62 (77%) non-vegetarians] were studied. Twenty-eight (34%) were on bicarbonate supplements. A positive PRAL (9.97 ± 7.7 mEq/day) was observed in 74/81 (91%) children with comparable proportions in those with CKD2-5 and 5D [47/52 (90%) vs. 27/29 (93%) respectively, P > 0.05]. Protein intake was significantly higher in the highest quartile compared to the lowest quartile of PRAL in CKD2-5 (55 ± 16 g/day vs. 40 ± 14 g/day, P < 0.001) and 5D groups (47 ± 15 g/day vs. 25 ± 11 g/day, P = 0.002). A majority of the participants 60/81 (74%) consumed highly acidic and minimal alkali foods. In children with CKD2-5D, PRAL estimation revealed high DAL in the majority with a high consumption of acidic foods. These findings provide implications for appropriate dietary counseling in children with CKD.

Sex differences in the evaluation of proteinuria using the urine dipstick test.

The urine protein dipstick test is widely used, but false-positive and false-negative results may occur. This study aimed to compare the urine protein dipstick test with a urine protein quantification method. The data were extracted using the Abbott Diagnostic Support System, which analyzes the inspection results using multiple parameters. This study included 41,058 specimens tested using the urine dipstick test and protein creatinine ratio from patients aged ≥18 years. The proteinuria creatinine ratio was classified according to the Kidney Disease Outcomes Quality Initiative guidelines. Urine protein on the dipstick test was negative in 15,548 samples (37.9%), trace in 6,422 samples (15.6%), and ≥1+ in 19,088 samples (46.5%). Among the trace proteinuria samples, A1 (<0.15 g/gCr), A2 (0.15-0.49 g/gCr), and A3 (≥0.5 g/gCr) category proteinuria accounted for 31.2, 44.8, and 24.0% of samples, respectively. All trace proteinuria specimens with a specific gravity of <1.010 were classified as A2 and A3 category proteinuria. In the trace proteinuria cases, women had a lower specific gravity and a higher percentage of A2 or A3 category proteinuria than men. The sensitivity in the "dipstick proteinuria" ≥ trace" group was higher than that in the "dipstick proteinuria ≥ 1+" group within the lower specific gravity group. The sensitivity in the "dipstick proteinuria ≥ 1+" group was higher for men than for women, and the sensitivity in the "dipstick proteinuria ≥ trace" group was higher than that in the "dipstick proteinuria ≥ 1+" group for women. Pathological proteinuria assessment requires caution; this study suggests that evaluating the specific gravity of urine specimens with trace proteinuria is essential. Particularly for women, the sensitivity of the urine dipstick test is low, and caution is needed even with trace specimens.

#2616 DIAGNOSTIC VALUE OF THE HANDGRIP STRENGTH IN DETECTING PROTEIN-ENERGY WASTING AMONG HEMODIALYSIS PATIENTS AT NATIONAL KIDNEY AND TRANSPLANT INSTITUTE

Abstract Background and Aims Protein energy wasting (PEW) is a syndrome of adverse nutritional and catabolic changes common among chronic kidney disease (CKD) patients. Handgrip strength (HGS) was one of the methods of screening PEW mentioned in Kidney Disease Outcomes Quality Initiative guidelines. However, only few studies determined the validity of HGS in detecting PEW among maintenance hemodialysis (MHD) patients. The study aimed to determine the diagnostic validity of HGS in detecting PEW among MHD patients in a tertiary government hospital, with the following specific objectives: to determine the prevalence of PEW among MHD patients, to compare the demographic and clinical profile by PEW status, to identify the optimal cut-off point of HGS pre- and post-HD sessions in detecting PEW by sex, and to determine the following diagnostic value parameters of HGS pre- and post-HD sessions in detecting PEW by sex in terms of discriminative ability, accuracy, sensitivity, specificity, positive predictive value and negative predictive value. Method Participants included in this cross-sectional study are randomly selected patients undergoing MHD in National Kidney and Transplant Institute (NKTI) from September to October, 2022. Diagnosis of PEW was based on the Malnutrition Inflammation Score (MIS) ≥5. HGS was measured using a dynamometer pre- and post-dialysis sessions. Results A total of 143 patients were included in the study, and 53% were diagnosed with PEW. Pre-HD and post-HD HGS have acceptable discriminative ability based on Area Under the Curve &amp;gt;0.70 in detecting PEW regardless of patient sex. In males, a post-hemodialysis cut-off of &amp;lt;17.9 showed 72% sensitivity and 71% specificity in detecting PEW. Meanwhile, a pre-hemodialysis cut-off of &amp;lt;18.6 in females showed 83% sensitivity and 65% specificity in detecting PEW. Conclusion PEW is common among MHD patients in NKTI. The diagnostic performance of HGS in detecting PEW was found to be acceptable in both males and females. While both pre- and post-HD measures can be used in males, only the pre-HD measures are recommended for females. HGS can, therefore, be used as a non-expensive, accurate and objective screening assessment tool in detecting PEW for MHD patients. External validation of the proposed HGS cut-off values is still recommended.

The prognostic value of URR equals that of Kt/V for all-cause mortality in Taiwan after 10-year follow-up

Kt/V and URR (urea reduction ratio) measurements represent dialysis adequacy. Single-pool Kt/V is theoretically a superior method and is recommended by the Kidney Disease Outcomes Quality Initiative guidelines. However, the prognostic value of URR compared with Kt/V for all-cause mortality is unknown. The effect modifiers and cut-off values of the two parameters have not been compared. We investigated 2615 incident hemodialysis patients with URR of 72% and Kt/V (Daugirdas) of 1.6. The average patient age was 59 years, 50.7% were female, and 1113 (40.2%) died within 10 years. URR and Kt/V were both positively associated with nutrition factors and female sex and negatively associated with body weight and heart failure. In Cox regression mod-els for all-cause mortality, the hazard ratios (HRs) of high URR groups (65–70%, 70–75%, and > 75%) and the URR < 65% group were 0.748 (0.623–0.898), 0.693 (0.578–0.829), and 0.640 (0.519–0.788), respectively. The HRs of high Kt/V groups (Kt/V 1.2–1.4, 1.4–1.7, and > 1.7) and the Kt/V < 1.2 group were 0.711 (0.580–0.873), 0.656 (0.540–0.799), and 0.623 (0.498–0.779), respec-tively. In subgroup analysis, Kt/V was not associated with all-cause mortality in women. The prognostic value of URR for all-cause mortality is as great as that of Kt/V. URR > 70% and Kt/V > 1.4 were associated with a higher survival rate. Kt/V may have weaker prognostic value for women.

Predicting Recurrent Interventions After Radiocephalic Arteriovenous Fistula Creation with Machine Learning and the PREDICT-AVF Web App

Radiocephalic arteriovenous fistulas (AVFs) are often criticized for requiring numerous recurrent interventions to achieve and maintain hemodialysis access function. Recent Kidney Disease Outcomes Quality Initiative guidelines discourage ongoing access salvage attempts after two interventions prior to successful use or more than three interventions per year overall. This study's goal was to develop a useful prediction tool for preoperative and postoperative assessment of intervention requirements to help guide decision-making about access appropriateness and futility. The data source was patient-level data from the international multicenter PATENCY-1 and PATENCY-2 randomized controlled trials, which enrolled patients undergoing new radiocephalic AVF creation. Routine ultrasounds were performed at 4 to 6 weeks and 12 weeks from AVF creation and interpreted by a core laboratory. The outcome for the prediction models was the number of recurrent surgical or endovascular interventions required at 1 year. Cox, random survival forest, pooled logistic, and penalized pooled logistic (elastic net) recurrent event survival prediction models were built using a combination of baseline characteristics and postoperative ultrasound measurements. Models were trained with 10-fold cross-validation hyperparameter selection within a randomly split training dataset. Discrimination and calibration performance was assessed on a holdout testing dataset. An interactive web application was built, which generates patient-specific predictions at 1 year, draws cumulative hazard curves, and contextualizes the predictions with the Kidney Disease Outcomes Quality Initiative guidelines for recurrent interventions after access creation. The cohort included 914 patients; mean age was 57 ± 13 years and 22% were female. Radiocephalic AVFs were created at the snuffbox (2%), wrist (74%), or proximal forearm (24%). Patients underwent a median of 1.04 (95% confidence interval [CI], 0.95-1.13) interventions in the first year. Using only baseline characteristics, the random survival forest model performed best, with a C-statistic of 0.72 (95% CI, 0.65-0.78) at 1 year (Table). The addition of ultrasound information to baseline characteristics did not substantially improve performance; however, Cox models using either 4- to 6-week or 12-week postoperative ultrasound information alone had the best discrimination performance, with C-statistics of 0.74 (95% CI, 0.67-0.81) and 0.78 (95% CI, 0.72-0.84) at 1 year (Table). The interactive web application is deployed at PREDICT-AVF.com (Figure). When assessing candidates for radiocephalic AVF in the preoperative setting, baseline patient characteristics can predict future interventions with moderate performance. In the postoperative setting, ultrasound findings alone are sufficient to predict future interventions. A free point-of-care web application can guide patient counseling and guideline-concordant surgeon decision-making as part of a patient-centered end-stage kidney disease life plan.TableDiscrimination performance of each model and feature set, measured by the area under the receiver operating characteristic curve (C-statistic) at 1 year postoperativelyFeaturesCoxRandom survival ForestPooled logistic regressionElastic netBaseline0.704 (0.639-0.769)0.715 (0.647-0.783)0.696 (0.631-0.762)0.703 (0.638-0.769)Baseline + 4- to 6-week US0.704 (0.629-0.779)0.737 (0.666-0.808)0.702 (0.627-0.778)0.703 (0.627-0.778)Baseline + 12 week US0.737 (0.670-0.803)0.766 (0.701-0.832)0.730 (0.663-0.797)0.746 (0.680-0.812)4- to 6-Week US0.743 (0.674-0.813)0.696 (0.620-0.773)0.740 (0.670-0.810)0.742 (0.672-0.812)12-Week US0.782 (0.722-0.842)0.721 (0.652-0.791)0.774 (0.712-0.835)0.775 (0.714-0.837)US, Ultrasound.Perfect discrimination corresponds to an area under the receiver operating characteristic curve of 1. Feature sets included baseline (age, sex, race, smoking status, diabetes, heart failure, renal transplant history, anticoagulation use, antiplatelet use, statin use, hemodialysis status at the time of arteriovenous fistula creation, central venous catheter history, number of prior failed accesses, vein and artery diameter, anastomotic suture technique, access location, and access side), baseline with the addition of postoperative ultrasound measurements (flow volume, access diameter, and luminal stenosis), and ultrasound measurements alone. Open table in a new tab

High Alternative Health Eating Index-Taiwan Scores Are Associated With Prevention of Graft Dysfunction in Taiwanese Renal Transplant Recipients

Various dietary quality indices demonstrate that a higher dietary quality score is associated with a reduced risk of several chronic diseases. However, creating an index tailored to the national population is crucial. The study investigated the association between the Alternative Healthy Eating Index-Taiwan (AHEI-Taiwan) and graft dysfunction in Taiwanese renal transplant recipients (RTRs). A prospective cohort study recruited 102 RTRs with a functioning allograft without acute rejection in the last 3 months from September 2016 to June 2018. Laboratory data were obtained from the medical records of patients. Graft dysfunction was indicated by an estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m2 in accordance with the Kidney Disease Outcomes Quality Initiative guideline. The dietary quality index AHEI-Taiwan was adapted from the AHEI based on Taiwanese dietary recommendations. Mean age, renal transplant time, and eGFR were 48.9 ± 12.8 years, 8.5 ± 5.8 years, and 54.9 ± 17.8 mL/min per 1.73 m2, respectively, in 102 RTRs. The RTRs with the highest quartile of AHEI-Taiwan scores were older and had a higher eGFR. Logistic regression analysis adjusted for age, sex, calories, Charlson comorbidity index, transplant time, and dialysis time showed that the highest quartile of the AHEI-Taiwan was associated with an 88% (odds ratio, 0.12; 95% CI, 0.03-0.59, P < .01) lower risk of graft dysfunction. A high AHEI-Taiwan score was associated with a reduced risk of graft dysfunction in Taiwanese RTRs.

Klotho, a protective renal factor for platelet lifespan

Chronic kidney disease (CKD) is a progressive condition characterized by kidney damage or reduced kidney function and is categorized into five stages based on the Kidney Disease Outcomes Quality Initiative guidelines. Owing to the lack of an effective cure and high morbidity and mortality in the general adult population, CKD will become the fifth leading cause of death globally by 2040.1 Usually, CKD is considered a hypercoagulable state associated with a high prevalence of arterial and venous thromboembolisms, which have become the main causes of mortality in these patients.

Marty Roberts; The Man Who Brought Sorbent Dialysis to Life.

Marty Roberts; The Man Who Brought Sorbent Dialysis to Life.

The evolving panorama of vascular access in the 21st century.

There are three major types of hemodialysis vascular access: hemodialysis catheters, arteriovenous grafts, and arteriovenous fistulas. Arteriovenous fistulas provide the best access due to their reliability and long-term patency. They are recommended by the current Kidney Disease Outcomes Quality Initiatives (K-DOQI) guidelines; however, not all patients benefit from arteriovenous fistulas due to poor maturation or a lack of adequate vasculature. Currently, hemodialysis is initiated via catheters in the majority of patients. Catheters are associated with high morbidity and mortality due to infection, lower quality of dialysis, and the development of central vein stenosis. The varied responses of patients to the different access types exemplify the need to choose the "right access for the right patient" based on scores that can predict death risk and progression of chronic kidney disease. Additionally, vascular access, often referred to as the "Achilles' heel" of hemodialysis patients, represents a significant percentage of the Medicare budget that continues to increase yearly. The purpose of this paper is to review the current literature on the management of vascular access complications and infection treatment and prevention. The paper also explores emerging research regarding the devices and methods to improve access outcomes such as early cannulation arteriovenous grafts, endovascular arteriovenous fistula creation, and regenerative grafts with resorbable scaffolds, among others. The data were collected through literature searches via PubMed, Athens and web search engines.

Importance of Metabolic Acidosis as a Health Risk in Chronic Kidney Disease.

Human kidneys are well adapted to excrete the daily acid load from diet and metabolism in order to maintain homeostasis. In approximately 30% of patients with more advanced stages of CKD, these homeostatic processes are no longer adequate, resulting in metabolic acidosis. Potential deleterious effects of chronic metabolic acidosis in CKD, including muscle wasting, bone demineralization, hyperkalemia, and more rapid progression of CKD, have been well cataloged. Based primarily upon concerns related to nutrition and bone disease, early Kidney Disease Outcomes Quality Initiative guidelines recommended treating metabolic acidosis with alkali therapy targeting a serum bicarbonate ≥22 mEq/L. More recent guidelines have suggested similar targets based upon potential slowing of CKD progression. However, appropriately powered, long-term, randomized controlled trials to study efficacy and safety of alkali therapy for these outcomes are largely lacking. As a result, practice among physicians varies, underscoring the complexity of treatment of chronic metabolic acidosis in real-world CKD practice. Novel treatment approaches and rigorous phase 3 trials may resolve some of this controversy in the coming years. Metabolic acidosis is an important complication of CKD, and where it "falls" in the priority schema of CKD care will depend upon the generation of strong clinical evidence.

Compliance of NKF KDOQI 2020 nutrition guideline recommendations with other guideline recommendations and protein energy wasting criteria in hemodialysis patients

IntroductionNutrition in hemodialysis patients is important in decreasing complications, improving quality of life, and preventing of malnutrition. Recommendations of the guidelines are taken into consideration while prescribing a nutrition therapy plan for patients. However, the recommendations may differ between the guidelines. It was aimed to compare the newly published National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) guideline with previous reported two guideline recommendations and protein energy wasting criteria in this study. Materials and methodsFifty-five maintenance hemodialysis patients between the ages of 18–65 were included in the study. Daily energy intake and daily protein intake of these patients were evaluated by three different nutrition guidelines; NKF KDOQI-2000, 2020 and European Best Practice Guidelines-2007. In addition, protein energy wasting was determined by using anthropometric measurements, biochemical findings and food intake of the patients. ResultsWhen the inadequacy rate in dietary daily energy intake and daily protein intake of the patients evaluated by NKF KDOQI-2000 recommendations, it was found to be higher than the rates in other two recommendations (P<0.05). Based on criteria, protein energy wasting was detected in 29.1% of the patients. While the NKF KDOQI-2020 daily energy intake recommendation was not consistent with other guideline recommendations, it seems highly compatible with protein energy wasting recommendations such as albumin, body mass index, mid-upper arm circumference, energy, and protein intake. While NKF KDOQI-2020 daily protein intake recommendation complies with European Best Practice Guidelines-2007 recommendations, the level of agreement with protein energy wasting criteria is very low. ConclusionInadequate protein intake is still an ongoing problem in hemodialysis patients. NKF KDOQI-2020 guidelines provide a more suitable and applicable daily energy intake recommendation for patients compared to the previous guidelines.