Kidney Disease: Improving Global Outcomes Guidelines Research Articles

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 <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 <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 <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.

Early acute kidney injury is associated with in-hospital adverse outcomes in critically ill burn patients: an observational study.

There are no studies in large series of burn patients on the relationship between acute kidney injury (AKI) and adverse outcomes using the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. We retrospectively analysed data from a cohort of burn patients admitted to the intensive care unit (ICU) with the diagnosis of burn injury. The diagnosis of AKI over the first 7days after injury was made according to the KDIGO guidelines. The primary outcome was ICU mortality. We used estimative models using univariable and multivariable logistic regression analyses. A total of 960 patients were studied and AKI was diagnosed in 50.5%. In multivariable analysis, AKI was associated, as compared with patients without AKI, with ICU mortality {adjusted odds ratio [aOR] 2.135 [95% confidence interval (CI) 1.384-3.293]} and secondary outcomes [kidney replacement therapy, aOR 4.030 (95% CI 1.838-8.835); infection, aOR 1.437 (95% CI 1.107-1.866); hospital mortality, aOR 1.652 (95% CI 1.139-2.697)]. AKI stage 1 was associated with a higher ICU [aOR 1.869 (95% CI 1.183-2.954)] and hospital mortality [aOR 1.552 (95% CI 1.050-2.296)] and infection [aOR 1.383 (95% CI 1.049-1.823)]. AKI meeting the urine output (UO) criterion alone was not associated with increased mortality. Ignoring the UO criterion would have missed 50 (10.3%) cases with AKI. The KDIGO guidelines are useful to diagnose AKI in burn patients. Even the mild form of AKI is independently associated with increased mortality. Considering the UO criterion is important to more accurately assess the incidence of AKI, but AKI meeting the UO criterion alone is not associated with increased mortality.

Risk factors of chronic kidney disease among type 2 diabetic patients with longer duration of diabetes.

Chronic kidney disease (CKD) in patients with type 2 diabetes mellitus (T2DM) is the major cause of end stage renal disease, characterized by proteinuria with a subsequent decline in glomerular filtration rate. Although hyperglycemia is the major risk factor for the development and progression of kidney disease among diabetic patients, many other risk factors also contribute to structural and functional changes in the kidneys. As recommended by Kidney Disease Improving Global Outcomes (KDIGO), CKD classification based on cause and severity, links to risk of adverse outcomes including mortality and kidney outcomes. The aim of this study is to investigate the involvement of risk factors associated with the severity of CKD among participants with longer duration of diabetes. This study also aims to find whether number of risk factors vary among risk of CKD progression categories based on KDIGO classification. This cross-sectional study retrospectively selected 424 participants from type 2 diabetic cohort and categorized them based on the classifications for the diagnosis of kidney diseases in patients with diabetes, according to the KDIGO guidelines. Odds ratios and 95% CI of each risk factors according to severity of renal disease were determined. Based on KDIGO classification, participants with type 2 diabetes (T2D) were categorized in to low risk (n=174); moderately increased risk (n=98); and high/very high risk (n=152). Type 2 diabetic participants with risk factors such as, hyperlipidemia, hypertension, DM duration ≥15 years and diabetic retinopathy showed a high/very high risk of CKD progression when compared with low-risk category. While T2D participants with risk factors such as, lack of exercise, hypertension, and diabetic retinopathy showed a moderately increased risk of CKD progression. In addition, participants with highest number of risk factors were significantly distributed among high/very high risk of CKD progression category. This study findings conclude that patients with T2DM and duration of ≥15 years, hyperlipidemia, hypertension and diabetic retinopathy have an increased prevalence of advanced CKD. In addition to this, increased number of risk factors could be an indicator of the severity of CKD in T2D.

Machine Learning Predicts Acute Kidney Injury in Hospitalized Patients with Sickle Cell Disease

Introduction Acute kidney injury (AKI) in hospitalized patients is associated with a high morbidity and mortality. Individuals with sickle cell disease (SCD) frequently experience organ dysfunction, including AKI, during hospitalization for episodes of vaso-occlusive crisis (VOC). AKI can lead to progressive kidney disease and chronic kidney disease (CKD), which is associated with further increased morbidity and mortality. Identifying AKI early during hospitalizations can lessen the risk of progressive CKD and renal replacement therapy. Utilizing machine learning techniques, we hypothesized that risk of AKI can be identified in SCD patients before the onset of kidney injury, leading to earlier recognition of AKI. Methods This is a single-site, retrospective IRB-approved study of 6,278 patient encounters with SCD admitted across five regional hospitals in Memphis, TN, from July 2017 to December 2020. Of these, 1,178 patient encounters were selected for analysis by including encounters with continuous minute-by-minute physiological data availability and excluding dialysis-dependent patient encounters. Each patient admission was considered a separate patient encounter if the interval between admissions was at least 1 month. AKI was defined based on the 2012 Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guideline. Physiomarkers, a set of signal processing features, derived from five physiological data streams from bedside monitors, including heart rate, respiratory rate, and blood pressure (systolic, diastolic, and mean), were used, along with clinical laboratory and demographic data. Missing laboratory values and vital sign measurements were first imputed using the last-one carry forward imputation. The remaining missing values were imputed by the global median of the associated variable in the training dataset. Logistic regression, support vector machine, random forest, and eXtream Gradient Boosting (XGBoost) classifiers were used for classification. Case (AKI) and control records were divided into 12 non-overlapping but consecutive 6-hour analysis time-windows (Figure 1). Prediction horizons (the time in advance each model bundle was asked to predict the AKI event) were increased by 6-hour until the beginning of the record. Controls were balanced with cases using a bootstrap method and randomized across each unique iteration to minimize selection bias. Statistical features were derived from the 6-hour analysis window immediately prior to each prediction horizon. Explainability of models generated at each time window was assessed using averaged Shapley Additive Explanations (SHAP) scores. Results A total of 82 (7%) patient encounters were identified as AKI cases based on the 2012 KDIGO guidelines. The other 1096 SCD patient encounters served as controls (Figure 1). Overall, there were more females (64.6%) than males among AKI cases (Table 1). A history of hypertension, pulmonary hypertension, CKD, and pneumonia were higher in AKI cases than in controls (Table 1). The XGBoost model most accurately predicted AKI up to 60 hours before AKI onset, with an average test sensitivity, specificity, and area under the receiver operating characteristics curve of 0.86, 0.72, and 0.80, respectively. Conclusions In this proof-of-concept study, we found that physio/biomarkers derived from continuous bedside monitoring and laboratory data are temporally and differentially expressed in SCD patients with AKI. A minimalistic artificial intelligence model can be developed using this information to predict AKI earlier in hospitalized SCD patients and may enable the development of innovative prevention strategies. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO).

People with diabetes and chronic kidney disease (CKD) are at high risk for kidney failure, atherosclerotic cardiovascular disease, heart failure, and premature mortality. Recent clinical trials support new approaches to treat diabetes and CKD. The 2022 American Diabetes Association (ADA) Standards of Medical Care in Diabetes and the Kidney Disease: Improving Global Outcomes (KDIGO) 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease each provide evidence-based recommendations for management. A joint group of ADA and KDIGO representatives reviewed and developed a series of consensus statements to guide clinical care from the ADA and KDIGO guidelines. The published guidelines are aligned in the areas of CKD screening and diagnosis, glycemia monitoring, lifestyle therapies, treatment goals, and pharmacologic management. Recommendations include comprehensive care in which pharmacotherapy that is proven to improve kidney and cardiovascular outcomes is layered on a foundation of healthy lifestyle. Consensus statements provide specific guidance on use of renin-angiotensin system inhibitors, metformin, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and a nonsteroidal mineralocorticoid receptor antagonist. These areas of consensus provide clear direction for implementation of care to improve clinical outcomes of people with diabetes and CKD.

Nomenclature for kidney function and kidney diseases - Improving assessment and prognosis through precision and comprehensibility

ZusammenfassungNierenkrankheiten stellen ein zunehmendes Gesundheitsproblem dar, dessen Eindämmung eine effektive Kommunikation zwischen den an Erfassung, Diagnostik und Therapie Beteiligten sowie den betroffenen Patientinnen und Patienten erfordert. Die Nomenklatur für Nierenfunktion und Nierenkrankheiten ist jedoch bislang nicht einheitlich. Die internationale, gemeinnützige Organisation Kidney Disease: Improving Global Outcomes (KDIGO) hat deshalb 2019 in einem Konsensus-Prozess ein englischsprachiges Glossar entwickelt, um die Begriffe zur Beschreibung von Nierenfunktion, Nierenstruktur und Nierenkrankheiten zu vereinheitlichen. Leitprinzipien bei der Entwicklung dieser Nomenklatur waren (1) Präzision, (2) Patientenzentrierung und (3) Konsistenz mit bisherigen KDIGO-Leitlinien. Das vorliegende Positionspapier beinhaltet eine deutsche Übersetzung dieses Glossars, die im Auftrag der nephrologischen Fachgesellschaften in Deutschland, Österreich und der Schweiz entwickelt wurde.

Impact of Different KDIGO Criteria on Clinical Outcomes for Early Identification of Acute Kidney Injury after Non-Cardiac Surgery.

The Kidney Disease Improving Global Outcomes (KDIGO) guidelines are currently used in acute kidney injury (AKI) diagnosis and include both serum creatinine (SCR) and urine output (UO) criteria. Currently, many AKI-related studies have inconsistently defined AKI, which possibly affects the comparison of their results. Therefore, we hypothesized that the different criteria in the KDIGO guidelines vary in measuring the incidence of AKI and its association with clinical outcomes. We retrospectively analyzed that data of patients admitted to the intensive care unit after non-cardiac surgery in 2019. Three different criteria used to define AKI were included: UOmean, mean UO < 0.5 mL/kg/h over time; UOcont, hourly UO < 0.5 mL/kg/h over time; or SCR, KDIGO guidelines SCR criteria. A total of 777 patients were included, and the incidence of UOmean-AKI was 33.1%, the incidence of UOcont-AKI was 7.9%, and the incidence of SCR-AKI was 2.0%. There were differences in the length of ICU stay and hospital stay between AKI and non-AKI patients under different criteria. We found differences in the incidence and clinical outcomes of AKI after non-cardiac surgery when using different KDIGO criteria.

Twenty years of real-world data to estimate chronic kidney disease prevalence and staging in an unselected population.

Chronic kidney disease (CKD) represents a global public health burden, but its true prevalence is not fully characterized in the majority of countries. We studied the CKD prevalence in adult users of the primary, secondary and tertiary healthcare units of an integrated health region in northern Portugal (n=136993; representing ∼90% of the region's adult population). Of these, 45983 (33.6%) had at least two estimated glomerular filtration rate (eGFR) assessments and 30534 (22.2%) had at least two urinary albumin:creatinine ratio (UACR) assessments separated by at least 3months. CKD was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines as a persistent decrease in eGFR (<60ml/min/1.73m2) and/or an increase in UACR (≥30mg/g). The estimated overall prevalence of CKD was 9.8% and was higher in females (5.5%) than males (4.2%). From these, it was possible to stratify 4.7% according to KDIGO guidelines. The prevalence of CKD was higher in older patients (especially in patients >70years old) and in patients with comorbidities. This is the first real-world-based study to characterize CKD prevalence in a large, unselected Portuguese population. It probably provides the nearest estimate of the true CKD prevalence and may help healthcare providers to guide CKD-related policies and strategies focused on prevention and on the improvement of cardiovascular disease and other outcomes.

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

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

Association between acute kidney injury and long-term mortality in patients with aneurysmal subarachnoid hemorrhage: A retrospective study

BackgroundThough acute kidney injury (AKI) in the context of aneurysmal subarachnoid hemorrhage (aSAH) worsens short-term outcomes, its impact on long-term survival is unknown.AimWe aimed to evaluate the association between long-term mortality and AKI during hospitalization for aSAH.MethodsThis was a retrospective study of patients who survived >12 months after aSAH. All patients were evaluated at West China Hospital, Sichuan University, between December 2013 and June 2019. The minimum follow-up time was over 1 year. the maximum follow-up time was about 7.3 years. AKI was defined by the KDIGO (The Kidney Disease Improving Global Outcomes) guidelines, which stratifies patients into three stages of severity. The primary outcome was long-term mortality, which was analyzed with Kaplan-Meier curves and Cox proportional hazards models.ResultsDuring this study period, 238 (9.2%) patients had AKI among 2,592 patients with aSAH. We confirmed that AKI during care for aSAH significantly increased long-term mortality (median 4.3 years of follow-up) and that risk increased with the severity of the kidney failure, with an adjusted hazard ratio (HR) of 2.08 (95% CI 1.49–2.89) for stage 1 AKI, 2.15 (95% CI 1.05–4.43) for stage 2 AKI, and 2.66 (95% CI 1.08–6.53) for stage 3 AKI compared with patients without AKI. Among patients with an AKI episode, those with renal recovery still had increased long-term mortality (HR 1.96; 95% CI 1.40–2.74) compared with patients without AKI but had better long-term outcomes than those without renal recovery (HR 0.51, 95% CI 0.27–0.97).ConclusionsAmong 12-month survivors of aSAH, AKI during their initial hospitalization for aSAH was associated with increased long-term mortality, even for patients who had normal renal function at the time of hospital discharge. Longer, multidisciplinary post-discharge follow-up may be warranted for these patients.

DCRM Multispecialty Recommendations in Patients With Heart Failure

Diabetes mellitus (DM), hypertension, obesity, and atherosclerotic cardiovascular disease (ASCVD) are associated with heart failure (HF). Comorbid metabolic conditions in patients with HF are associated with worse outcomes and may affect the management of HF by limiting treatment options and reducing adherence to therapy. 1 Bozkurt B Aguilar D Deswal A Dunbar SB Francis GS Horwich T et al. Contributory risk and management of comorbidities of hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome in chronic heart failure: a scientific statement from the. American Heart Association. Circulation. 2016; 134: e535-e578 Google Scholar Practice guidelines for these diseases are drafted by the American Diabetes Association (ADA), the Kidney Disease Improving Global Outcomes (KDIGO) or the American College of Cardiology (ACC)/American Heart Association (AHA). These guidelines are drafted in silos, often without cross-collaboration with other cardiorenal/metabolic specialists. As a result, guidelines commonly differ in their recommendations. For example, the KDIGO guidelines and the ACC/AHA HF guidelines recommend different blood pressure goals for the management of hypertension. 2 Kidney disease: improving global outcomes blood pressure work g: KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021; 99: S1-87 Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar ,3 Heidenreich PA Bozkurt B Aguilar D Allen LA Byun JJ Colvin MM et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022; 145: e895-1032 PubMed Google Scholar Comanagement of DM, cardiorenal, and/or metabolic (DCRM) conditions is key to medical optimization. To introduce a more holistic approach to DCRM conditions, a volunteer task force created a multispecialty consensus for the management of complicated comorbid metabolic disease, the DCRM practice recommendations. 4 Handelsman Y Anderson JE Bakris GL Ballantyne CM Beckman JA Bhatt DL et al. DCRM Multispecialty Practice Recommendations for the management of diabetes, cardiorenal, and metabolic diseases. J Diabetes Complicat. 2022; 36108101 Crossref Scopus (4) Google Scholar Herein, we highlight the recommendations of these guidelines for the prevention and management of HF with concurrent DCRM comorbidities.

Warum ist die Nierenbiopsie bei Nierenerkrankungen das zentrale diagnostische Instrument?

A kidney biopsy is the central diagnostic tool in nephrology and according to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines continues to be the gold standard for the evaluation of glomerular diseases. The complication rate is nowadays low; however, the indications for a kidney biopsy must always be determined individually and absolute and relative contraindications should be taken into account. According to the KDIGO guidelines from 2021, a kidney biopsy can be avoided under certain circumstances and in the case of certain diseases but treatment can still be initiated. In this respect, hereditary diseases and diseases defined by specific antibody findings, such as phospholipase A2 receptor (PLA2R) positive membranous glomerulonephritis, antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis and systemic lupus erythematosus are mentioned. In order to correctly classify the findings of a kidney biopsy, however, it is important to have an idea of the specific expectations of the biopsy. In particular, it is helpful if one or more possible suspected diagnoses can be formulated from a clinical point of view, which is useful for the dialogue with the nephropathologist. In order to be able to correctly evaluate the indications for a kidney biopsy and to draw the right conclusions from the biopsy findings, both diagnostically and therapeutically, nephrologists should not only have special nephrological knowledge but also a broad knowledge of the differential diagnostics and a sound competence in the entire field of internal medicine. The present collection of biopsy cases is intended to motivate nephrologists to continue using the kidney biopsy as an indispensable instrument for nephrological diagnostics and to meaningfully implement it in an interdisciplinary context. The cooperation and ongoing dialogue with other specialty disciplines, especially within the field of internal medicine as well as with the diagnosing nephropathologists are indispensable prerequisites for this.

MO369: A Systematic Review to Evaluate the Drivers of Non-Adherence to Albuminuria Testing Guidelines and the Clinical and Economic Impact of Not Identifying CKD Over the Course of Progressive Kidney Function Loss

Abstract BACKGROUND AND AIMS The Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend regular estimated glomerular filtration rate (eGFR) and albuminuria testing in patients diagnosed with chronic kidney disease (CKD) and those with specific risk factors such as type 2 diabetes (T2D). In addition, the European Society of Cardiology (ESC) guidelines recommend albuminuria testing for cardiovascular (CV) disease risk assessment in CKD patients. An eGFR test can indicate kidney function decline, whereas albuminuria testing gives an indication of kidney damage. When used in combination, an accurate understanding of CKD risk progression can be obtained. Both KDIGO and ESC guidelines are based on evidence that albuminuria testing is critical to prevent CKD and CV events. Evidence from real-world practice suggests that albuminuria, specifically urine albumin-to-creatine ratio (UACR) testing is suboptimal. For example, UACR testing is not regularly undertaken in clinical practice, with low rates reported in the UK1 (67%), The Netherlands2 (57%) and France3 (29%). A systematic literature review (SLR) was undertaken to explore the barriers to regular albuminuria testing in CKD patients in line with the guidelines, and the clinical and economic impact of not identifying these patients over the course of progressive kidney function loss. Our hypothesis was that in the absence of adequate testing, patients are not identified and are more likely to progress to a worse clinical state with an economic impact on healthcare costs. METHOD This SLR searched MEDALL, Embase, Cochrane CENTRAL, and other databases from the date of inception to August 2021 for studies. Title and abstract screening, followed by full-text screening of included papers was undertaken by two independent reviewers. RESULTS Fourteen studies were included. Only one study explored direct physician barriers to UACR testing, with the biggest perceived barrier being that knowing a test would not significantly impact patient management, potentially due to lack of therapeutic options. Twelve studies reported on the clinical and one reported on the economic impact of not identifying CKD patients with or without T2D upon UACR or eGFR testing. All included studies looked at not identifying the patient population because of late referral. These studies showed that patients who were referred late had increased all-cause mortality, increased CV mortality and lower survival rate versus those patients that were referred on time. No studies looked at patients in the early stages of CKD, those that were referred late based on a UACR and eGFR test result, or those that were diagnosed late due to the lack of reporting of diagnostic test results. CONCLUSION A limited number of studies reporting drivers of non-adherence to albuminuria testing were identified. The largest barrier reported was the perception that testing will not impact patient management. Supporting our original hypothesis, individuals referred late with end-stage kidney disease were shown to experience worse clinical outcomes, including higher rates of mortality, than those referred on time. However, there were limited data on the impact of not identifying or diagnosing patients in the early stages of CKD, and a lack of reporting of the tests used, whether eGFR or UACR, to identify these individuals. Funding: Bayer AG PROSPERO: CRD42021275223

Cardiovascular Implications of the 2021 KDIGO Blood Pressure Guideline for Adults With Chronic Kidney Disease

BackgroundThe 2021 Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends a systolic blood pressure (BP) target of <120 mm Hg for nondialysis chronic kidney disease (CKD). ObjectivesWe sought to examine the potential implications of the 2021 KDIGO BP target, compared with the 2012 KDIGO and 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP targets, as related to cardiovascular disease (CVD) outcomes. MethodsFrom the cross-sectional Korea National Health and Nutrition Examination Survey (KNHANES) and longitudinal National Health Insurance Service (NHIS) data, adults with nondialysis CKD were identified and categorized into 4 groups based on concordance/discordance between guidelines: 1) above both targets; 2) above 2021 KDIGO only; 3) above 2012 KDIGO or 2017 ACC/AHA only; and 4) controlled within both targets. We determined the nationally representative proportion and CVD risk of each group. ResultsIn KNHANES (n = 1,939), 50.2% had BP above both 2021 and 2012 KDIGO targets, 15.9% above the 2021 KDIGO target only, 3.5% above the 2012 KDIGO target only, and 30.4% controlled within both targets. In NHIS (n = 412,167; median follow-up: 10.0 years), multivariable-adjusted HRs for CVD events were 1.52 (95% CI: 1.47-1.58) among participants with BP above both targets, 1.28 (95% CI: 1.24-1.32) among those with BP above 2021 KDIGO only, and 1.07 (95% CI: 0.61-1.89) among those with BP above 2012 KDIGO only, compared to those with BP controlled within both targets. Results were similar for comparison between 2021 KDIGO and 2017 ACC/AHA BP targets. ConclusionsNew candidates for BP-lowering treatment per the 2021 KDIGO guideline account for a substantial proportion of the total CKD population and bear significantly high CVD risk.