Kidney Disease: Improving Global Outcomes Guidelines Research Articles

#2982 Shifts in SGLT2 inhibitor initiation in CKD non-dialysis patients

Abstract Background and Aims KDIGO guidelines have changed since 2020 with the introduction of SGLT2 inhibitors to CKD care. As the agents have become more standard of care in CKD, this research assesses how the treatment of more than 2000 CKD non-dialysis patients in the EU5 aligns with the KDIGO guidelines. Method Data from 1062 patient charts were collected in partnership with 265 EU5 (Germany, United Kingdom, Italy, France, and Spain) nephrologists via an online survey from December 2022-February 2023. Additionally, data from 1282 patient charts were collected from 263 EU5 nephrologists from December 2021-February 2022 via an online survey. Results Nephrologists often report that they strongly rely on the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines when making treatment decisions for their patients. Globally recognized, the KDIGO guidelines are created and periodically updated based on a rigorous scientific process to create an all-encompassing set of clinical practice recommendations. Over the past several years, SGLT2 inhibitors have become a fundamental part of CKD treatment and eGFR management. While the agents are primarily used in CKD patients with diabetic kidney disease (DKD), treatment rates among non-diabetic CKD patients have increased year-over-year. According to 2023 audited patient chart data, approximately one-half of DKD patients in the EU5 are on an SGLT2 inhibitor, while there has been a notable increase in treatment rates among non-diabetic CKD patients, from 11% in 2022 to 23% in 2023. Despite the recent change in the KDIGO guideline, which lowered the recommended eGFR level for SGLT2 inhibitor initiation to 20 mL/min/1.73 m2, 71% of patients who are treated with an SGLT2 inhibitor were initiated on therapy in CKD Stage 3 (eGFR 30-50), indicating that EU5 nephrologists have not yet conformed to the revised guidelines. Notably, participating EU5 nephrologists elicit increased comfort prescribing SGLT2 inhibitors to both their DKD and non-diabetic CKD patients year-over-year. In 2023, nearly all physicians reported that they expect to increase their use of SGLT2 inhibitors in their CKD patients, regardless of their diabetes status, indicating that there is potential for further adoption of the revised KDIGO guidelines into clinical practice. Conclusion As the treatment of CKD patients continues to evolve with SGLT2 inhibitors and newer therapies, KDIGO guidelines will adjust to accommodate evolution. Increased awareness of guideline changes will be paramount in ensuring that patients are receiving top quality care based on treatment recommendations.

#1212 Trends in real-world lipid lowering therapy use among adult patients with chronic kidney disease: 5-year single center experience in the Philippines

Abstract Background and Aims Patients with chronic kidney disease (CKD) carry an extremely high burden for atherosclerotic cardiovascular disease (ASCVD), which worsens as CKD progresses. Several international guidelines, including the 2013 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, have recommended the use of lipid-lowering therapy (LLT) in this high-risk population. To evaluate the implementation of these recommendations in real-world practice, we assessed patterns of dyslipidemia management among patients with CKD. Specific objectives include describing the prevalence and intensity of LLT prescription [stratified by estimated glomerular filtration rate (GFR) and whether requiring renal replacement therapy or not] as well as adherence to guideline recommendations on LLT use. Method We conducted a single-center, cross-sectional study covering the period of January 2019 to December 2023. A review of inpatient and outpatient medical records of the Department of Medicine, University of the Philippine—Philippine General Hospital was done. Eligible patients were at least 18 years of age, and diagnosed with CKD. Exclusion criteria included having a concomitant diagnosis of Acute Kidney Injury, and being pregnant or breastfeeding at any point in the study period. Sociodemographic, clinical, and laboratory data were based off the latest entry in each patient's medical record. No clinical data were collected beyond those that were available on the records. Classification of statin intensity was based on the 2019 American Heart Association/American College of Cardiology Guidelines on the Management of Blood Cholesterol as well as the 2020 Philippine Clinical Practice Guidelines on the Management of Dyslipidemia. All analyses were descriptive and done using STATA 18. Categorical variables were summarized as frequencies and percentages. Continuous variables were reported as measures of central tendency [i.e. mean (SD) or median (IQR), as appropriate]. Results Of the 3845 patients included in the study, 2922 (76%) were prescribed LLT. The most common LLT were statins (92%), followed by statin/ezetimibe combinations (6%), then statin/fibrate combinations (2%). None were prescribed PCKS9 inhibitors, niacin, omega-3 fatty acids, or bile acid sequestrants. Among non-dialytic patients, the distribution of LLT use was as follows: a) eGFR ≥ 60 ml/min/1.73 m2: 40% (173/431) b) eGFR 30-60 ml/min/1.73 m2: 76% (1198/1576) c) eGFR <30 ml/min/1.73 m2: 84% (1551/1838). Among dialytic patients, 68% (601/884) were already on LLT prior to initiation of dialysis while 35% (283/884) were started on LLT after dialysis initiation. Notably, 89% (786/884) of these dialytic patients were still on moderate-to-high-intensity statin doses. Based on recommendations from the 2013 KDIGO guidelines, only 78% (2610/3334) of eligible patients were prescribed on LLT, while 61% (312/511) of ineligible patients were prescribed on LLT. Similar rates of adherence were seen to other international guideline recommendations on the management of dyslipidemia in CKD (e.g. 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol, 2019 European Society of Cardiology/European Atherosclerosis Society guidelines for the management of dyslipidaemias, 2020 Clinical Practice Guidelines for the management of dyslipidemia in the Philippines). Conclusion Real-world LLT use among CKD patients remains high, even at lower eGFRs. More importantly, a large proportion of patients remain under- and over-treated, highlighting significant gaps between guideline recommendations and real-world clinical practice. Further investigation regarding the underlying reasons for these practice variations is necessary to improve quality of care, and safely reduce the burden of dyslipidemia and ASCVD among CKD patients.

Epidemiology of Diabetic Kidney Disease among US Veterans.

With a large number of patients and high mortality, diabetic kidney disease (DKD) imposes a significant burden on US health care. Although diabetes is the leading cause of chronic kidney disease and complications, the epidemiology of DKD in the contemporary US veteran population is generally unknown. We aimed to estimate the rate of DKD progression and to measure the general epidemiology of DKD in the United States veteran population. We performed a retrospective observational research using electronic health-care records and administrative databases. The DKD patient cohort was abstracted from the Veterans Health Administration health-record data from January 2016 to March 2022. We defined DKD patients using the laboratory test data based on Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines. Summary statistics include the five-year cumulative incidence of progression to an advanced stage from the DKD stage at the cohort entry date and prevalence at a series of single time points. A total of 685,288 patients (male [96%], mean age 62 years, Caucasian [64%], non-Hispanic [87%]) met our eligibility criteria. The 5-year cumulative incidence of progression to an advanced DKD stage or all-cause death from DKD stages G1 A2/A3, G2 A2/A3, G3a, and G3b were 52.0%, 47.4%, 50.5%, and 60.9%, respectively. In sum, 594,082 patients were classified as moderate or high risk as per KDIGO guidelines in 2021, and stages G3a and G3b accounted for 51.2% and 25.3%, respectively, of cases. More than half of DKD patients underwent a stage progression or death within 5 years. A substantial number of DKD patients at an earlier stage might be left undetermined. The study findings warrant a revision of DKD patient identification and management in US veterans.

Risk factors for chronic kidney disease in middle eastern patients with type 2 diabetes mellitus: A cross-sectional study using the KDIGO classification

AimsChronic kidney disease (CKD) is prevalent in patients with type 2 diabetes mellitus (T2DM). This study aimed to investigate risk factors for CKD progression across the kidney disease-Improving Global Outcomes (KDIGO)categories in a Middle Eastern population beyond hyperglycemia as emphasized by KDIGO guidelines which classifying CKD by cause and severity. MethodsThis cross-sectional study targeted 1603 patients with T2DM. Risk factors for CKD progression were determined using odds ratios (ORs) and 95 % confidence intervals (CIs). ResultsOverall, 35.5 %, 31.7 %, and 32.8 % of patients were classified as low-risk, moderate-risk, and high-/very high-/highest-risk, respectively. Several factors were associated with high/very high/highest risk categorization, including being aged >45 years (OR: 1.85, 95 % CI: 1.36–2.49; P < 0.001), male gender (OR: 1.87, 95 % CI: 1.38–2.54; P < 0.001), hypertension (OR: 3.66, 95 % CI: 2.32–5.78; P < 0.001), and T2DM duration of ≥15 years (OR: 3.2, 95 % CI: 2.27–4.5; P < 0.001). Patients with more concurrent risk factors were notably represented in the high/very high/highest risk category. ConclusionsMale patients, older patients, and those with comorbid hypertension, longstanding T2DM, and additional concurrent risk factors have a significantly higher risk of advanced CKD. Such findings should be considered when planning management approaches for patients with CKD.

Acyclovir-Induced Nephrotoxicity in Adults with Viral Encephalitis.

To determine the frequency of parenteral Acyclovir-induced Acute Kidney Injury (AKI) in patients with viral encephalitis. Descriptive study. Place and Duration of the Study: Department of Neurology, Liaquat National Hospital, Karachi, from January to December 2021. A total of 89 suspected and proven cases of encephalitis receiving IV Acyclovir were collated. All had extensive medical histories and underwent CSF studies with +/- brain imaging. CSF routine and viral PCR were done. Acyclovir-induced AKI was defined as a rise in serum creatinine of >0.3 mg/dl in 48 h or by ≥1.5 times the baseline value, and its severity was staged into 1 (risk), 2 (injury), and 3 (failure) according to the KDIGO guidelines (Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group, 2012). Patients' variables, including age, gender, presenting features, comorbid conditions, and CSF findings, were divided into two groups, i.e. with and without AKI. This research included 89 patients with a mean age of 48 years. AKI occurred in 34 patients (38.2%). The frequency of AKI with Stage 1 was 24%, Stage 2 was 44%, and Stage 3 was 32%; approximately two-thirds of cases were in Stage 2 and 3 (p >0.05). Five patients (5.6%) from Stage 3, required dialysis. AKI is an important adverse effect of parenteral acyclovir, which necessitates its early identification and timely management. Renal function monitoring is essential for patients on Acyclovir treatment as they are at risk for AKI. Acyclovir, Acute kidney injury, Viral encephalitis, Creatinine, Kidney Disease Improving Global Outcomes.

Lipid Management in Kidney Transplant Recipients Per KDIGO and American Heart Association Guidelines: A Single-Center Experience.

The 2013 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommends statin treatment for all adult kidney transplant recipients (KTRs), except those aged <30 years of age and without prior cardiovascular risk factors (CVRF), but does not specify on-treatment low-density lipoprotein cholesterol (LDL) target levels. The 2018 American Heart Association (AHA) guidelines addressed the management of hyperlipidemia in the general population based on an individualized approach of the CVRF with a specific on-treatment LDL target. To analyze dyslipidemia management according to the recommendations of the KDIGO and AHA guidelines. This retrospective study included all KTRs who underwent transplantation between January 2017 and May 2020 at King Abdulaziz Medical Center, Riyadh, Saudi Arabia. The rate of statins prescription in general, rate of statins prescription among KTRs per their CVRF, and rate of achieving the proposed LDL goals, as defined by the AHA, were analyzed. A total of 287 KTRs were included. Of the 214 (74.6%) patients aged ≥30 years, 80% received a statin. Statins were prescribed in 93% and 96% of KTRs with diabetes or coronary artery disease, respectively. In patients aged ≥30 years, LDL targets, per AHA guidelines, were achieved in 62% with a target of 2.6 mmol/l, and in 19% with a target of 1.8 mmol/l. Statin therapy resulted in non-significant changes in the mean LDL values from baseline to 12 months after transplantation (P = 0.607), even when only patients prescribed statin after transplantation were included (P = 0.34). By applying the KDIGO guidelines, a high rate of statin prescriptions was achieved among KTRs with multiple CVRF and KTRs in general. However, a significant proportion of these KTRs did not achieve the LDL targets proposed by the AHA guidelines, suggesting that higher-intensity statins would be required to achieve these targets.

KDOQI Commentary on the KDIGO 2022 Update to the Clinical Practice Guideline for Diabetes Management in CKD

The Kidney Disease: Improving Global Outcomes (KDIGO) guideline for diabetes management in chronic kidney disease (CKD) was updated in 2022, just 2 years after the previous update. The need for this rapid update is reflective of the recent and unprecedented positive results of numerous clinical trials aimed at reducing kidney and cardiovascular morbidity and mortality in people with diabetes. The Kidney Disease Outcomes Quality Initiative (KDOQI) work group for diabetes in CKD, convened by the National Kidney Foundation, provides herein a commentary on these changes, particularly the implications for health care in the United States. Changes to the KDIGO guideline mirror the evolution of sodium/glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists from purely antihyperglycemic agents to cardiorenal-metabolic therapeutics, and the lower estimated glomerular filtration rate of≥20mL/min/1.73m2 for SGLT2 inhibitor initiation. New data have also brought the addition of the first-in-class, Federal Drug Administration-approved nonsteroidal mineralocorticoid receptor antagonist finerenone as an agent to reduce cardiorenal end points. While there has been significant progress in innovation, there remain serious challenges to implementation, particularly in the United States where inequities in insurance coverage and high costs limit their use, particularly in vulnerable populations, ultimately widening health care disparities.

Introducing the general management of glomerular disease from a pediatric perspective based on the updated KDIGO guidelines

In 2021, a new chapter on the general management of glomerulonephritis (GN) was added to the Kidney Disease: Improving Global Outcomes (KDIGO). It emphasizes the importance of early general management of GN for improving long-term kidney outcomes and prognosis. The chapter introduces the management of glomerular diseases in 18 subchapters. Here, kidney biopsy for the diagnosis and evaluation of kidney function and the management of complications, such as hypertension, infection, and thrombosis, are presented. Moreover, the adverse effects of glucocorticoids and immunosuppressive therapy, which are commonly used drugs for glomerular disease, are mentioned, and a guideline for drug selection is presented. Each subtheme focused on items reflecting the interpretation of the “practice points” of the expert working group are introduced. In this review of the general treatment for GN in the KDIGO guidelines, excluding pregnancy and reproductive health, we focused on and compared various references pertaining to pediatric GN management.

KDIGO 2021 Blood Pressure Target Update and Chronic Kidney Disease Progression

In 2021, Kidney Disease: Improving Global Outcomes (KDIGO) published revised guidelines, including updated recommendations for the management of chronic renal disease and the control of blood pressure. The 2021 KDIGO Guidelines utilize current research and comprehensive scientific evidence to provide the most favorable blood pressure goals for those suffering from chronic kidney disease. The primary objective is to decelerate the advancement of renal impairment, mitigate problems linked to chronic kidney disease, and enhance the patient's quality of life. The 2021 KDIGO guidelines ground the blood pressure target recommendations for patients with chronic kidney disease (CKD) in a thorough evaluation of the extent of kidney damage, cardiovascular risk, and individual patient characteristics. The 2021 KDIGO guidelines recommend tailoring blood pressure control in patients with CKD to each individual rather than following a standardized method.

Abstract 14823: Assessment of the Appropriateness and Prognostic Significance of the Current Universal Diagnostic Definition for Acute Kidney Injury in Patients After Cardiac Surgery and Exploration of Tailored Criteria

Background: Cardiac surgery-associated AKI (CSA-AKI) is prevalent and its diagnosis currently adheres to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, commonly used criteria developed for general populations. Limited evidence exists on their appropriateness and prognostic value for CSA-AKI, which exhibits unique mechanisms and clinical courses. Aims: We aimed to assess the prognostic value of the KDIGO diagnostic criteria for CSA-AKI and explore potentially more prognostically relevant criteria for cardiac surgery. Methods: Patients undergoing coronary artery bypass grafting surgery at a single institution were included and categorized into four groups: no AKI, AKI stage-1, AKI stage-2, and AKI stage-3, based on KDIGO guidelines. Patients of AKI-1 were further divided based on specific criteria met: absolute criteria (0.3mg/dL serum creatinine (SCr) increase over 48-hour intervals), ratio criteria (1.5-1.9 times baseline SCr), and dual criteria (meeting both criteria) AKI-1. The primary outcome was 30-day all-cause mortality. Results: Among 20626 patients, the overall incidence of CSA-AKI was 47.4%, with rates of 44.2% for AKI-1, 2.2% for AKI-2, and 0.9% for AKI-3. The overall 30-day mortality was 0.6%. Among AKI-1, 72.4%, 3.2%, and 24.2% met the absolute criteria, ratio criteria, and dual criteria, respectively. After multivariate adjustment, AKI-2 and AKI-3 were significantly associated with increased 30-day mortality. However, neither AKI-1 nor its subcategories showed prognostic significance. Subsequent restricted cubic spline analysis identified more prognostically relevant cut-off values for AKI-1 criteria as &gt;0.7 mg/dL SCr increase over 48-hour intervals and &gt;1.3 times baseline SCr, respectively. Conclusions: The current universal KDIGO diagnostic criteria may not be suitable for CSA-AKI, especially regarding cut-off values for AKI stage-1, highlighting the necessity of tailored criteria for cardiac surgery.

Abstract 13183: The Burden of Uncontrolled Hypertension (HTN) in Chronic Kidney Disease (CKD). Impact of the Revised KDIGO Guidelines

Introduction: The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease for patients not receiving dialysis highlights the increasing awareness of controlling HTN in CKD patients. Goals/Aims: To identify the number of persons in the US with HTN and advanced CKD. Research Question: Determine the current number of persons with advanced CKD and HTN based on various blood pressure thresholds and to project the increase in the number of patients over the next 10 years. Methods: The analysis is based on multiple years of the US National Health and Nutrition Examination Survey (NHANES). Results: We examined and projected the prevalence, awareness and treated number of HTN patients as well as the number of patients with uncontrolled HTN. Uncontrolled HTN was defined as taking at least 2 or more anti-hypertensive medications and the analysis focused on advanced CKD patients not requiring dialysis (stage 3b/4). Lowering the systolic/diastolic blood pressure threshold (mm Hg) from &gt;140/90 to &gt;130/80 or &gt; 120/70 shows significant current numbers of patients with uncontrolled HTN and advanced kidney disease of 1.5 MM, 2.0 MM, and 2.7 MM, respectively. The number of patients is expected to increase 20% in the next 10 years highlighting the need for effective management of HTN in CKD.

Kidney function monitoring and trajectories in patients with atrial fibrillation.

Atrial fibrillation (AF) and chronic kidney disease (CKD) frequently co-exist. The frequency of kidney monitoring and range of kidney function in patients with AF in clinical practice are uncertain. All adult Albertans with AF between 2008 and 2017 were identified using ICD-9 and -10 codes 427.3 and I48. Kidney Disease Improving Global Outcomes (KDIGO) risk categories were defined using eGFR by the Chronic Kidney Disease Epidemiology Collaborative equation and albuminuria results within 6months of eGFR measurement. eGFR trajectories were compared from baseline to maximum value within the following year. Among 105,946 patients with AF, 16.0% were KDIGO category G1 (eGFR ≥ 90), 49.0% G2 (60-89.9), 19.8% G3a (45-59.9), 11.4% G3b (30-44.9), and G4 3.8% (15-29.9). Albuminuria was normal/mild 83.4%, moderate 11.7%, and severe 4.9%. Kidney monitoring was more common among people with lower eGFR and worse albuminuria, from approximately twice annually for G1-2/A1-2 to 8 times annually in stage G4A3. Approximately 60-80% of patients received guideline-recommended monitoring, consistent across KDIGO stages. With lower baseline eGFR, annual change in eGFR decreased while the relative proportion of patients who worsened compared to improved increased: for baseline eGFR 60-89.9, 16.7% worsened vs 6.7% improved, but for eGFR 30-44.9, 8.8% worsened but only 1.0% improved. The frequency of kidney function monitoring in patients with AF increased with worsening KDIGO risk category and adhered to KDIGO guidelines in approximately three quarters of patients. A minority of patients had moderate to severe eGFR impairment, of whom most remained stable over 1year.

The 2021 KDIGO blood pressure target and the progression of chronic kidney disease: Findings from KNOW-CKD.

The 2021 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline for the management of blood pressure (BP) in chronic kidney disease (CKD) recommends a target systolic BP of <120mmHg as this target can provide cardiovascular benefits. However, it remains unclear whether implementing the new BP target could improve kidney outcomes. The association between the 2021 KDIGO BP target and CKD progression was examined and compared with the 2012 KDIGO BP target among 1724 participants included in the KoreaN Cohort Study for Outcomes in Patients With CKD. The main exposure was the BP status categorized according to the 2012 or 2021 KDIGO guideline: (1) controlled within the 2021 target, (2) controlled within the 2012 target only, and (3) above both targets. The primary outcome was a composite kidney outcome of ≥50% decline in the estimated glomerular filtration rate from baseline or the initiation of kidney replacement therapy during the follow-up period. Composite kidney outcomes occurred in 650 (37.7%) participants during the 8078 person-years of follow-up (median, 4.9 years). The incidence rates of this outcome were 55, 66.5, and 116.4 per 1000 person-years in BP controlled within the 2021 and 2012 KDIGO targets, and BP above both targets, respectively. In the multivariable cause-specific hazard model, hazard ratios for the composite outcome were 0.76 (95% confidence interval (CI), 0.60-0.95) for BP controlled within the 2021 target and 1.36 (95% CI, 1.13-1.64) for BP above both targets, compared with BP controlled within 2012 target only. The newly lowered BP target by the 2021 KDIGO guideline was associated with improved kidney outcome compared with BP target by the 2012 KDIGO guideline.

Predictive model of acute kidney injury after spontaneous intracerebral hemorrhage: A multicenter retrospective study.

Acute kidney injury is a common comorbidity in patients with intracerebral hemorrhage. Although there are predictive models to determine risk of AKI in patients in critical care or post-surgical scenarios or in general medical floors, there are no models that specifically determine the risk of AKI in patients with ICH. Clinical features and laboratory tests were selected by previous studies and LASSO (least absolute shrinkage and selection operator) regression. We used multivariable logistic regression with a bidirectional stepwise method to construct ICH-AKIM (intracerebral hemorrhage-associated acute kidney injury model). The accuracy of ICH-AKIM was measured by the area under the receiver operating characteristic curve. The outcome was AKI development during hospitalization, defined as KDIGO (Kidney Disease: Improving Global Outcomes) Guidelines. From four independent medical centers, a total of 9649 patients with ICH were available. Overall, five clinical features (sex, systolic blood pressure, diabetes, Glasgow coma scale, mannitol infusion) and four laboratory tests at admission (serum creatinine, albumin, uric acid, neutrophils-to-lymphocyte ratio) were predictive factors and were included in the ICH-AKIM construction. The AUC of ICH-AKIM in the derivation, internal validation, and three external validation cohorts were 0.815, 0.816, 0.776, 0.780, and 0.821, respectively. Compared to the univariate forecast and pre-existing AKI models, ICH-AKIM led to significant improvements in discrimination and reclassification for predicting the incidence of AKI in all cohorts. An online interface of ICH-AKIM is freely available for use. ICH-AKIM exhibited good discriminative capabilities for the prediction of AKI after ICH and outperforms existing predictive models.

#4483 THE 2021 KDIGO BLOOD PRESSURE TARGET AND THE PROGRESSION OF CHRONIC KIDNEY DISEASE: FINDINGS FROM THE KNOW-CKD

Abstract Background and Aims The 2021 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline for management of blood pressure (BP) in chronic kidney disease (CKD) recommends a target systolic BP of &amp;lt;120 mmHg because this lower target can provide cardiovascular benefits. However, whether implementing the new BP target could improve kidney outcome remains unknown. Method We examined the association of the 2021 KDIGO BP target with CKD progression compared with the 2012 KDIGO BP target among 1724 participants from the Korean Cohort Study for Outcomes in Patients With CKD. The main exposure was BP status categorized according to the 2012 or 2021 KDIGO guideline: 1) controlled within 2021 target; 2) controlled within 2012 target only; and 3) above both targets. The primary outcome was a composite kidney outcome of ≥50% decline in estimated glomerular filtration rate from baseline measurement or the initiation of kidney replacement therapy during the follow-up. Results During 8,078 person-years of follow-up (median, 4.9 years), the composite kidney outcome occurred in 650 (37.7%) participants. The incidence rates of this outcome were 55, 66.5, and 116.4 per 1,000 person-years in BP controlled within the 2021 and 2012 KDIGO targets, and BP above both targets, respectively. In the multivariable cause-specific hazard model, hazard ratios for the composite outcome were 0.76 (95% confidence interval, 0.60-0.95) for BP controlled within the 2021 target and 1.36 (95% confidence interval, 1.13-1.64) for BP above both targets, compared with BP controlled within 2012 target only. Conclusion The newly lowered BP target by the 2021 KDIGO guideline was associated with improved kidney outcome compared with BP target by the 2012 KDIGO guideline.

#5772 ESTIMATING CKD PREVALENCE AND INCIDENCE USING CROSS-SECTIONAL GERMAN CLAIMS DATA IN PERSONS AGED 70+

Abstract Background and Aims Little is known about trends over time and anticipated improvements in CKD diagnosis after the implementation of the Kidney Disease – Improving Global Outcomes (KDIGO) guidelines in 2012. We investigated CKD prevalence and incidence over time using claims data in persons aged 70+. Method We assessed CKD prevalence and incidence biennially in cross-sectional claims data of the German health insurance fund “AOK Nordost” for persons aged 70+ between 2012 and 2018. Data are available for n = 62,200 persons per year and were sampled equally distributed for five age strata (70-74, 75–79, 80–84, 85–89, ≥90) and for sex. CKD prevalence and incidence were estimated in 2012, 2014, 2016, and 2018 using in- and outpatient ICD-10 diagnoses (N18.3, N18.4, N18.5, N18.8, N18.9, N19). Incidence was defined as prevalent cases without a diagnosis in the four quarters preceding their first CKD diagnosis over all persons at risk (i.e., who were not prevalent in the respective previous year). Results are shown in total (standardized by age and sex using nationwide demographic distributions for a respective year) as well as stratified by age and sex. Cochran-Armitage test was applied to test time trends for incidence and prevalence from 2012–2018. Results Claims data-based CKD prevalence showed a significant constant increase from 0.18 in 2012 to 0.26 in 2018 (p &amp;lt;0.001). This time trend in CKD prevalence was consistent among all age and sex strata (Figure 1). Over the same time period, CKD incidence increased from 0.06 to 0.08 (p &amp;lt;0.001), while the percentage of persons at risk decreased from 0.81 to 0.72 between 2012 and 2018 due to increasing prevalence (Table 1). Both prevalence and incidence estimates were higher in males compared to females in all age strata (Figure 1). Conclusion The present cross-sectional analysis in claims data allows novel insights of CKD prevalence and incidence among older adults in Germany. CKD prevalence increased constantly over time after the introduction of the KDIGO guidelines in 2012. For CKD incidence, we detected only a small increase over the observation period. The extent of time trends for CKD incidence might be underestimated due to increasing prevalence.

Real-Life Anemia Management Among Patients with Non-Dialysis-Dependent Chronic Kidney Disease in Three European Countries.

Anemia is prevalent among patients with chronic kidney disease (CKD), yet current evidence indicates that treatment may not adhere to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. We aimed to document the management of patients with non-dialysis-dependent (NDD)-CKD receiving erythropoiesis-stimulating agent (ESA) therapy in Europe. This retrospective, observational study extracted information from medical records in Germany, Spain, and the UK. Eligible patients were adults with NDD-CKD stages 3b-5 who initiated ESA therapy for anemia between January and December 2015. Anemia was defined as hemoglobin (Hb) <13.0 g/dL (males) or <12.0 g/dL (females). Data regarding ESA treatment, treatment response, concomitant iron therapy and blood transfusions were extracted up to 24 months post-ESA initiation, and data on CKD progression until abstraction date. Eight hundred and forty-eight medical records were abstracted. Approximately 40% received no iron therapy prior to ESA initiation. At ESA initiation, mean ± standard deviation Hb level was 9.8 ± 1.0 g/dL. Most patients received darbepoetin alfa, and switching between ESAs was rare (8.5% of patients). Concomitant intravenous and oral iron therapy was prescribed for 36% and 42% of patients, respectively, during initial ESA therapy. Mean Hb levels reached the target level (10-12g/dL) within 3-6 months of ESA initiation. Hb, transferrin saturation, and ferritin levels were infrequently monitored from 3 months post-ESA initiation. Rates of blood transfusion, dialysis, and diagnosis of end-stage renal disease were 16.4%, 19.3%, and 24.6%, respectively. Rates of kidney transplant and death were 4.8% and 8.8%, respectively. Among ESA-treated patients, ESA initiation was in accordance with KDIGO guidelines, but subsequent monitoring of Hb and iron deficiency were suboptimal.

Immunosuppressive Agent Options for Primary Nephrotic Syndrome: A Review of Network Meta-Analyses and Cost-Effectiveness Analysis.

Therapeutic options with immunosuppressive agents for glomerular diseases have widened with refinements to the Kidney Disease Improving Global Outcomes (KDIGO) guidelines from 2012 to 2021. However, international guidelines do not necessarily match the reality in each country. Expensive therapies such as rituximab and calcineurin inhibitors are sometimes inaccessible to patients with refractory nephrotic syndrome due to cost or regulations. Under the Japanese medical insurance system, rituximab is accessible but still limited to steroid-dependent patients who developed idiopathic nephrotic syndrome in childhood. Based on international KDIGO guidelines and other national guidelines, possible applications of immunosuppressive agents for nephrotic syndrome are comprehensively examined in this review. While rituximab has become the mainstay of immunosuppressive therapy for nephrotic syndrome, clinical trials have indicated that options such as cyclophosphamide, calcineurin inhibitors, and mycophenolate mofetil would be preferable. Given the rising number of patients with nephrotic syndrome worldwide, KDIGO guidelines mention the need for further consideration of cost-effectiveness. If the new option of rituximab is to be the first choice in combination with steroids for nephrotic syndrome, its cost-effectiveness should also be verified. Among the few studies examining the cost-effectiveness of treatments for nephrotic syndrome, administration of rituximab to young adults has been shown to be cost-beneficial, at least in Japan. However, further large-scale studies involving multiple facilities are needed to verify such findings. Network meta-analyses have concluded that the efficacy of rituximab remains controversial and confirmation through high-quality studies of large cohorts is needed. To this end, the mechanisms of action underlying immunosuppressive agents, both old and new, need to be understood and experience must be accumulated to evaluate possible effects and side effects.

New guideline on diabetes management in chronic kidney disease

In autumn 2022, an update of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on diabetes management in chronic kidney disease (CKD) was published. This article presents in aclear manner and discusses the new aspects compared to the 2020 guideline. Innovations are seen in the area of general and all-encompassing treatment as well as in relation to blood glucose-lowering and organ-protective treatments with sodium-glucose cotransporter2 inhibitors, non-steroidal mineralocorticoid receptor antagonists, and glucagon-like peptide‑1 receptor agonists. Anew feature is also the top 10 recommendations on diabetes management in CKD for both patients and physicians. The KDIGO guideline on diabetes management in CKD represents the current evidence-based standard of care for patients with diabetes mellitus and CKD. It is now important to implement the guideline in order to provide patients with the benefits of the treatments and thus improve their lives.

Improving awareness of kidney function through electronic urine output monitoring: a comparative study

BackgroundThe current classification for acute kidney injury (AKI) according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria integrates both serum creatinine (SCr) and urine output (UO). Most reports on AKI claim to use KDIGO guidelines but fail to include the UO criterion. It has been shown that patients who had intensive UO monitoring, with or without AKI, had significantly less cumulative fluid volume and fluid overload, reduced vasopressor use, and improved 30-day mortality. We examined whether real-time monitoring of this simple, sensitive, and easy-to-use biomarker in the ICU led to more appropriate intervention by healthcare providers and better outcomes. MethodsRenalSense Clarity RMS Consoles were installed in the General ICU at the Hadassah Medical Center, Israel, from December 2019 to November 2020. The Clarity RMS system continuously and electronically monitors UO in real-time. 100 patients were randomly selected from this period as the study group (UOelec) and compared to a matched control group (UOmanual) from the same period two years earlier. To test whether there was an association between oliguric hours and fluid treatment in each group, the correlation was calculated and analyzed for each of the different UO monitoring methods.ResultsTherapeutic intervention: The correlation of the sum of all oliguric hours on Day 1 and 2 with the sum of any therapeutic intervention (fluid bolus or furosemide) showed a significant correlation for the study group UOelec (P = 0.017). The matched control group UOmanual showed no such correlation (P = 0.932). Length of Stay (LOS): Median LOS [IQR] in the ICU of UOelec versus UOmanual was 69.46 [44.7, 125.9] hours and 116.5 [62.46, 281.3] hours, respectively (P = 0.0002).ConclusionsThe results of our study strongly suggest that ICU patients had more meaningful and better medical intervention, and improved outcomes, with electronic UO monitoring than with manual monitoring.