Kidney Disease: Improving Global Outcomes Guidelines Research Articles

Abstract 4138714: Implementation of the KDIGO Guidelines to Prevent Cardiac Surgery Associated Acute Kidney Injury in Patients with Heart Failure With Preserved Ejection Fraction Undergoing Coronary Artery Bypass Grafting

Backgrounds: The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommended the initiation of multiple supportive measures in patients at high risk for cardiac surgery associated acute kidney injury (CSA-AKI). Heart failure with preserved ejection fraction (HFpEF) was known as a critical risk factor for CSA-AKI. Purpose: Our study was designed to assess the effectiveness of KDIGO guidelines and the risk of CSA-AKI following coronary artery bypass grafting (CABG) among patients with HFpEF. Methods: This retrospective cohort study included 7420 patients undergoing CABG from 2019 to 2022, including 1960 patients with pre-operative HFpEF and 5460 patients without pre-operative HF as comparison. Implementation of the KDIGO guidelines consists of 6 measures in the first 72 hours after surgery, including avoidance of nephrotoxic agents, discontinuation of ACEi and ARB, implementation of advanced hemodynamic monitoring, avoidance of hyperglycemia, optimization of hemodynamics, and intensified monitoring of renal function. The primary outcome was in-hospital postoperative AKI according to the KDIGO criteria. Results: Among the included patients with HFpEF, 125 (6.4%) patients were classified as fully implementing the KDIGO guidelines. For the primary outcome, implementation of guidelines was associated with a significantly decreased risk of CSA-AKI (46.4% vs. 62.0%; OR, 0.591 [95% CI, 0.407-0.857]; p = 0.006). Meanwhile, implementation of guidelines had a greater preventive effect on CSA-AKI for HFpEF patients compared with non-HF patients (OR, 0.921 [95% CI, 0.759-1.118]; p = 0.405). Noticeably, we found that avoidance of hyperglycemia (OR, 0.737 [95% CI, 0.591-0.920]; p = 0.007) and optimization of hemodynamics (OR, 0.638 [95% CI, 0.508-0.802]; p < 0.001) were associated with lower incidence of CSA-AKI. Conclusions: Despite a lack of adherence to the KDIGO guidelines in patients undergoing CABG, implementation of the guidelines was found to be associated with a significantly lower risk of CSA-AKI for patients with HFpEF. Among the measures in the guidelines, avoidance of hyperglycemia and optimization of hemodynamics had stronger preventive effects for CSA-AKI.

Abstract 4136654: Urine Output Response to a Furosemide Infusion is Associated with Acute Kidney Injury in Infants Following Cardiac Surgery

Background: Acute kidney injury (AKI) following cardiac surgery in infants is common and associated with longer mechanical ventilation times and length of stay. Prior studies have shown that a lack of responsiveness to bolus dose furosemide has been associated with increased incidence of AKI. However, these studies have excluded patients on continuous furosemide infusions who are often younger, more hemodynamically unstable, and at higher risk for AKI. Hypothesis: Decreased urine output after initiation of a furosemide infusion predicts development of AKI. Methods: A retrospective cohort study of infants (<1 year of age) was conducted who underwent cardiac surgery requiring cardiopulmonary bypass from 2020-2023 and were on a furosemide infusion post-operatively. The primary outcome was post-operative AKI as defined using KDIGO (Kidney Disease: Improving Global Outcomes) guidelines. A furosemide response score (FRS) was calculated using the total urine output divided by the total dose of furosemide administered over a given time. Univariate and multivariate analyses were performed, and receiver operating characteristic curves used to determine the discriminatory ability of the FRS with regards to the primary outcome. Results: A total of 155 infants (median age at surgery 9 days) were included. Overall, 77% of infants met definition for the primary outcome of AKI; 32% stage 1, 30% stage 2, and 15% stage 3. Lower FRS at 4, 10, and 24 hours after infusion initiation were associated with AKI development (p<0.0001). Younger age, smaller weight at surgery, lack of pre-operative feedings, pre-operative inotropic use and higher surgical complexity were also associated with a higher risk of AKI. An FRS (mL/mg/kg) cutoff of <11.3 at 4 hours, <25.5 at 10 hours, and <55.3 at 24 hours had good discriminatory ability (area under the curve 0.7-0.75) in predicting AKI stage 2 or 3 (p<0.001). Controlling for the significant univariate variables listed above, the FRS cutoffs remained an independent risk factor for the development of AKI stage 2 or 3, (p<0.01) and were significantly associated with longer mechanical ventilation days and length of stay. Conclusion: Lack of responsiveness to a furosemide infusion (as measured by urine output corrected for dose of furosemide) is associated with the development of AKI in a high-risk cohort of infants. These novel findings may be helpful to predict those at risk and allow for further investigations for modifiable risk factors.

Chronic kidney disease in patients with heart failure in German primary care practices: the InspeCKD study

Abstract Background Chronic kidney disease (CKD) is, alongside type 2 diabetes mellitus, the most common comorbidity in patients with heart failure (HF), with a prevalence of 40-50%. HF patients should therefore be screened, monitored, and treated according to international Kidney Disease Improving Global Outcomes (KDIGO) conclusions for early identification and intervention of CKD, with annual determination of eGFR to monitor kidney function and annual urine albumin-to-creatinine ratio (UACR) testing as appropriate. Early diagnosis is important as therapeutic options can be offered to slow the progression of CKD and reduce the risk of cardiovascular complications and mortality. Purpose Currently, there are only limited data available regarding screening, diagnosis and treatment of CKD for HF patients in German primary care physician (PCP) practices. Therefore, this analysis of the InspeCKD study was designed to examine the frequency of use of CKD-specific laboratory diagnostics in HF patients in routine PCP care. Methods In the current data analysis, fully anonymized patient data from German PCP practices were evaluated. In accordance with the screening recommendation of the KDIGO guideline, adult patients with diabetes, hypertension and/or cardiovascular disease, including HF, with at least one year of observation period were included in the analysis. Results The overall patient cohort comprised 448.837 patients from 1.244 German PCP practices. Of the 7.9% HF patients, 6.1% participated in a disease management program (DMP) for coronary heart disease. The average age of HF patients was 74 years. The prevalence of diagnosed CKD in HF patients during the observational period (mean: 1.7 years) was 26.8%. Within the subgroup of patients with HF, serum creatinine to estimate GFR was measured at least once in 48.5% of patients. Urine dipstick testing for albuminuria was performed in 7.4% of patients and UACR was measured at least once in 0.3% of patients. In patients with at least one documented measurement, eGFR and UACR were checked 2.2 and 0.9 times, respectively, per patient and year. Of the HF patients with laboratory-confirmed CKD according to KDIGO criteria, 81.8% were not diagnosed with CKD. Conclusion The analysis shows that, given the high prevalence of CKD in HF patients and the current KDIGO recommendations for early identification and intervention of CKD, a substantial proportion of HF patients in German PCP practices did not receive adequate laboratory diagnostics for early diagnosis of CKD. In addition, the majority of patients with laboratory-confirmed CKD were not diagnosed. Early detection of CKD and the use of evidence-based therapeutic options can significantly reduce the risk of CKD progression. In conclusion, there is an urgent need to raise awareness among PCPs about secondary and tertiary prevention of CKD in patients with HF and to include coordinated CKD screening recommendations in HF guidelines.

Preoperative risk factors for ileostomy-associated kidney injury in colorectal tumor surgery following ileostomy formation

PurposeDiverting ileostomy is related to postoperative high-output stoma (HOS) leading to kidney injury. The purpose of our study was to clarify the risk factors for ileostomy-associated kidney injury, which is kidney injury starting after the first operation to ileostomy closure after colorectal tumor surgery with diverting ileostomy.MethodsBetween January 2013 and December 2020, 442 patients who underwent colorectal tumor surgery (cancer, neuroendocrine tumor, and leiomyosarcoma) following diverting ileostomy formation were included. We used the KDIGO (Kidney Disease Improving Global Outcomes) guidelines, which defines the acute kidney injury (AKI) to classify patients with ileostomy-associated kidney injury. The definition of AKI was (i) serum creatinine (sCr) ≥ 0.3 mg/dL or (ii) sCr ≥1.5-fold the preoperative level. Multivariate analyses were performed to identify the independent risk factors for kidney injury.ResultsKidney injury developed in 99/442 eligible patients (22.4%). Patients in the kidney injury group were older age, male sex, high American Society of Anesthesiologists Physical Status Classification System (ASA-PS) score, hypertension, cardiovascular diseases, diabetes. The preoperative hemoglobin, albumin, prognostic nutritional index (PNI), and creatinine clearance (CCr) were lower, and the maximum wound length was more extended than the non-kidney injury group. The median highest daily stoma output was significantly higher in the kidney injury group. The postoperative white blood cell (WBC) and C-reactive protein (CRP) levels were also high in the kidney injury group. The univariate analysis showed older age, male sex, high ASA-PS score, hypertension, cardiovascular diseases, and diabetes were the risk factors for kidney injury. The multivariate analysis revealed that age 70 or older, ASA-PS III/IV, hypertension, and HOS ≥2000 ml/day were independent risk factors for kidney injury.ConclusionsSurgeons should consider diverting colostomy creation for patients with risk factors such as age 70 or older, ASA-PS III/IV, and hypertension.

Proteinuria Assessment and Therapeutic Implementation in Chronic Kidney Disease Patients-A Clinical Audit on KDIGO ("Kidney Disease: Improving Global Outcomes") Guidelines.

Background/Objectives: Chronic kidney disease (CKD) is a major health problem with a rising prevalence due to comorbidities like diabetes and hypertension. The aim of this research was to audit the assessment and therapeutic management of proteinuria in CKD patients at the Cantonal Hospital Baselland (KSBL) in Switzerland and determine associations between patient comorbidities, rehospitalisation, death, and the quality of therapeutic management. Methods: We analysed data from 427 adults with CKD (eGFR < 45 mL/min/1.73 m2) hospitalised on the internal medicine ward in 2022. Results: The mean age was 85 years (range: 79-89), 45.9% were female, and the median eGFR was 32.8 mL/min/1.73 m2 (range: 25-40). Proteinuria assessment was performed in 120 (28.1%) patients (the ProtU group), and a corresponding treatment was prescribed in 59%. The ProtU group had a higher quota of patients with diabetes (44.1% vs. 33%, p = 0.048) and obesity (21.2% vs. 12.5%, p = 0.039) when compared to the group without proteinuria assessment (the Ustix group). Twelve-month survival was not significantly different between the groups (HR: 0.75; 95% CI: 0.488-1.154; p-value = 0.191). However, survival was significantly better in patients who received an antiproteinuric treatment compared to those who did not (HR: 0.30; 95% CI: 0.121-0.0761; p = 0.011). Conclusions: Improvements need to be made in managing CKD at the KSBL in accordance with the guidelines.

Leveraging Quantitative Systems Pharmacology and Artificial Intelligence to advance treatment of Chronic Kidney Disease Mineral Bone Disorder.

Chronic kidney disease mineral bone disorder (CKD-MBD) is a complex clinical syndrome responsible for the accelerated cardiovascular mortality seen in individuals afflicted with CKD. Current approaches to therapy have failed to improve clinical outcomes adequately, likely due to targeting surrogate biochemical parameters as articulated by the guideline developer, KDIGO (Kidney Disease: Improving Global Outcomes). We hypothesized that using a Systems Biology Approach combining machine learning with mathematical modeling, we could test a novel approach to therapy targeting the abnormal movement of mineral out of bone and into soft tissue that is characteristic of CKD-MBD. The mathematical model describes the movement of calcium and phosphate between body compartments in response to standard therapeutic agents. The machine learning technique we applied is Reinforcement Learning (RL). We compared calcium, phosphate, PTH, and mineral movement out of bone and into soft tissue under four scenarios: standard approach (KDIGO), achievement of KDIGO guidelines using RL (RLKDIGO), targeting abnormal mineral flux (RLFLUX), and combining achievement of KDIGO guidelines with minimization of abnormal mineral flux (RLKDIGOFLUX). We demonstrate through simulations that explicitly targeting abnormal mineral flux significantly decreases abnormal mineral movement compared to standard approach while achieving acceptable biochemical outcomes. These investigations highlight the limitations of current therapeutic targets, primarily secondary hyperparathyroidism, and emphasize the central role of deranged phosphate homeostasis in the genesis of the CKD-MBD syndrome.

#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 &amp;lt;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.

#2533 Real-world challenges associated with the use of systemic glucocorticoids in a US IgAN cohort

Abstract Background and Aims Immunoglobulin A nephropathy (IgAN) is the most common primary glomerular disease and up to 50% of patients progress to kidney failure within 10-20 years. Until early 2022, management of IgAN was primarily focused on supportive care. As outlined in the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, patients at high risk of progressive chronic kidney disease despite maximal supportive care can be considered for a 6-month course of systemic glucocorticoids (SGC), although important risks of toxicity and contraindications must be considered. There is currently limited real-world evidence describing the impact of the use of SGC on treatment‑emergent toxicity and healthcare resource utilization (HCRU) in patients with IgAN. We report the incidence of adverse events (AEs) commonly associated with SGC, as well as HCRU rates and costs, in a real-world cohort of IgAN patients, comparing new initiators of SGC with patients who have never initiated SGC. Method This non-interventional, retrospective cohort study was conducted in the TriNetX Dataworks - United States of America Network, a database of de-identified, patient-level electronic medical records (EMR) of approximately 100 million patients. The cohort was selected from a total of 19, 687 patients with IgAN, identified using proxy ICD‑10 codes N02.8 (recurrent and persistent hematuria with other morphologic changes) or N04.1 (nephrotic syndrome) between January 1, 2011, and May 4, 2022. Eligible patients were required to have: an incident diagnosis of IgAN with the same diagnosis within 30-180 days; at least 12 months of EMR history available prior to and after initial IgAN diagnosis; not experienced kidney failure prior to or on the initial date of IgAN diagnosis; and not received SGC prior to the date of diagnosis. Data assessed included demographic and clinical characteristics, IgAN-directed medications, AEs, and HCRU. To promote balance between cohorts, new initiators of SGC (dexamethasone, prednisone, prednisolone, methylprednisolone) were matched with patients who did not receive SGC using a propensity score (PS) approach based on their characteristics at diagnosis. To avoid immortal-time bias, the index date was set as the time of SGC initiation in patients in the SGC cohort; for the non-SGC cohort, a pseudo-index date was assigned using the same lag from diagnosis to index date as their 1:1 PS-matched patient in the SGC cohort. Differences in the cumulative incidence of individual AEs were analyzed using the chi-square test or Fisher's exact test, and differences in HCRU rates and costs were analyzed using the Kruskal-Wallis test. Results After implementing the PS approach, the final analysis included 802 patients (401 PS-matched pairs), with a mean age of 41.2 years and 55% being male. Median duration of follow-up was 3.5 and 3.1 years for the SGC and non-SGC cohorts, respectively. Of AEs that occurred in at least ten of the 802 patients, patients who received SGC experienced a significantly increased incidence of all AEs except for fractures, new onset of diabetes, and reported onset of glaucoma (Table 1). Patients who received SGC had a 12-fold increased incidence of severe infections requiring hospitalization compared with the non-SGC cohort. Annualized mean HCRU rates and costs were significantly greater across all HCRU types for patients who received SGC vs those who did not receive SGC, including an 8-fold increase in inpatient visits, a 4-fold increase in emergency department admissions, and twice as many ambulatory visits (Fig. 1). Results were consistent when the cohort was restricted to patients with IgAN identified using only the ICD-10 code N02.8 (recurrent and persistent hematuria with other morphologic changes). Conclusion The findings of this real-world analysis demonstrate significant side effects and costs for IgAN patients treated with SGC compared with patients not treated with SGC, underscoring the recommendation in the 2021 KDIGO guidelines to carefully consider treatment-emergent toxicity before treating IgAN patients with SGC.

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.