Kidney Disease Outcomes Quality Initiative Research Articles

Prediction of cardiovascular complications and progression of renal failure in pediatric patients with chronic kidney disease according to NKF-K/DOQI (2002) and KDIGO (2012) classifications

Chronic kidney disease in pediatric and adult patients is an overarching global problem. Stratification of chronic kidney disease C1–5 severity by classifications of the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) (2002) and Kidney Disease: Improving Global Outcomes (KDIGO) (2012) carried out in pediatric patients over the age of 2 years old, taking into account the low glomerular filtration rate at the age of 0 to 2 years. Differences were found in the prognosis of cardiovascular complications and the progression of renal failure in adult patients with chronic kidney disease at stages С3а and C3b according to KDIGO (2012). The literature data demonstrate different risks of cardiovascular complications and progression of renal functions by stages of chronic kidney disease in accordance with the NKF-K/DOQI (2002) and KDIGO (2012) classifications in pediatric patients. The results indicate that children with chronic kidney disease in the pre-dialysis stages C2–4 form a high-risk group, while those on C4–5 dialysis form a group of very high risk of cardiovascular complications.

Serum leptin level and incidence of CKD: a longitudinal study of adult enrolled in the Korean genome and epidemiology study(KoGES)

BackgroundChronic kidney disease(CKD) is a major public health issue and is highly prevalent in the general population. Leptin is an adipose tissue-derived endocrine factor that has been associated with several metabolic factors involved in cardiovascular diseases. Several studies have investigated the association between leptin and renal diseases so far. But the results are conflicting between the studies. The objective of our study was to verify the direct association of serum leptin level with CKD development.MethodsThis prospective cohort study included 2646 adult aged 40–70 without CKD in the Korean Genome and Epidemiology Study(KoGES) across South Korea from November 2005 to February 2012. The primary outcome was the development of CKD as defined by National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI). Multivariate stepwise logistic regression analysis was done to assess the independent associations, for with the incident of CKD as the dependent variable, in tertiles of leptin values.ResultsAmong 1100 men and 1546 women with 2.8 mean years of follow-up, incidence of CKD was 18(1.63%) for men and 50(3.23%) for women. In the multivariate logistic regression models, individuals in the highest serum leptin tertile showed significant associations with risk of CKD after adjustment compared to the lowest tertiles in the population. The crude odds ratio for trend was 2.95(p = 0.004) for men. After adjusting for age, baseline eGFR variables showed correlation with statistical significance (OR for trend = 2.25, p = 0.037) for men. The same trends were also seen observed in all population and women also, but no statistical significance was found.ConclusionsHigher plasma leptin levels are associated with the incidence of CKD, independent of traditional factors such as age, baseline eGFR. Our results suggest that leptin may partly explain part of the reported association between obesity and kidney disease.

0719 The Risk Of Progression Of Chronic Kidney Failure In Patients With Obstructive Sleep Apnea

Abstract Introduction To describe the risks of chronic kidney disease (CKD) progression in patients with obstructive sleep apnea (OSA) Methods In this retrospective case control study; patients with CKD and OSA compared to patients with CKD without OSA who followed up at Creighton University Hospital Clinic. Data retrieved from Electronic Medical Records: demographics, time of diagnosis severity of OSA , apnea hypopnea index, severity of chronic kidney disease using serum creatinine and CKD -EPI equation for glomerular filtration rate cut offs. Patient’s kidney function was followed up for 10 years from their diagnosis of OSA. Worsening kidney function is defined on the basis of laboratory values including estimaed GFR( eGFR) and serum creatinine as well as Kidney Diseases Outcome Quality Initiative (KDOQI) 2002 definition and staging. We calculated the mean and SD when appropriate. P values less than 0.05 were considered statistically significant. Results 269 patients without OSA included in the study. 416 patients with mild OSA, 343 with moderate OSA and 225 with severe OSA mean (SD) age 46.6 (16.3), 52.9(13.5), 56.9(14.1) and 55.3(15.1) years respectively; 59.1, 56.5, 39.1 and 35.6% were females respectively. CKD stage 1 42.8, 26.9, 26.5 and 28.9% respectively. Stage 246.5, 56.3, 54.2 and 46.7% respectively. Stage 3 10.7, 16.9, 19.2 and 24.3% respectivelyPatient’s renal functions who had CKD stage 2 or 3 with mild., moderate and severe OSA got worse in 21.2,31.5 and 26.7% respectively. compared to 13.1% with no sleep apnea.(p <.001)) ,There was no significant difference on progression of CKD in late stages( CKD IV/V) Conclusion Patients with OSA and CKD are more likely to have worsening renal function compared to patients without OSA and this association may depend on severity of both CKD and OSA. Support (If Any)

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

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

MO765: Should We have to Create A Proximal Fistula in First Instance for Patients ≥75 Years Old?

Abstract BACKGROUND In France, the Network Epidemiology and Information in Nephrology evaluated the incidence of cases of chronic end-stage renal disease (ESRD), treated by dialysis, of patients aged ≥75 years at 39.8% (2015). Timely placement and development of functional fistulas for haemodialysis remain difficult logistical problems along with their high failure rate. Cardiovascular (CV) morbidity-mortality increases when patients initiate catheter-based treatment. The recommendations call for a glomerular filtration rate (GFR) between 15 and 30 mL/min/1.73m² (EBPG 2007 and Canadian 2006) to implement a fistula. The older the patients, the more the quality of the venous network deteriorates. In this population, clinicians face a simple problem: creating a too early fistula and preparing patients for an adequate supply. The surgery of vascular approaches tries to avoid two pitfalls: ‘too much to preserve’ the vascular capital, ‘too much to privilege’ the permeability of the first by creating proximal approaches (Barrou B.). The guidelines [Kidney Disease Outcomes Quality Initiative (K/DOQI) 2006] recommend the most distal vascular approach possible. Since 2016, CKD patients aged ≥75 years, have been implanted with arteriovenous fistula (native or prosthetic), localized in the first line of the humero-cephalic vein, huméro-basilique, or humero-axillary. Our primary objective is to assess primary permeability in a population of patients aged ≥75 years with stage IV/V chronic kidney disease (CKD) after the first-line proximal fistula. METHOD All patients aged ≥75 years for which a first-line proximal VA was created between 1 January 2016 and 31 December 2019 have been retrospectively reviewed in an observational study. They were followed for 12 months. A quarterly compilation of data has been produced. RESULTS A total of 31 patients (74% of men) benefit from the creation of a native fistula (90.3%) or prosthetic. During follow-up, 8 patients were excluded. 29% of patients had started catheter haemodialysis treatment prior to the creation of their first fistula. A total of 7 changed fistula from initial surgery during the study, of which 2 after the first use. At the creation of the vascular access, the median age of patients is 81 years, of which 35.5% have vascular nephropathy and 19.4% have diabetic nephropathy. The location of the anastomosis is as follows: 84% FAV brachiocephalic, 10% FAV brachiobasilic and 6% FAV axillary. At 12 months, 16 patients were still under observation. A total of 5 patients had thrombosis of their VA (80% of native fistulas). The average interval between the creation of the first, and the thrombosis is 2.18 months. Patients dialyzed with VA were 68%. On a scale from 0 (no difficulty) to 10 (puncture not performed), the average difficulty score of the first puncture is 2.2. The average time in the day between the first puncture and first ‘effective’ dialysis on the first 13.9 days and the average weekly duration of dialysis at the first effective puncture is 11.29 hours. There are 28 hospitalizations, 21% of which are related to VA, 37 ultrasound, 9 angiography and 4 surgical repairs were performed on VA. Only one ischaemia of the hand is observed, treated medically. Estimates of the risk of thrombosis associated with diabetes are confirmed [P = 0.02; 95% confidence interval (95%CI); hazard ratio (HR): 0.054–0.332]. At 12 months, 94% of the surroundings are permeable without any thrombosis. CONCLUSION This study confirms the interest in a proximal vascular approach in people aged ≥75. We have voluntarily included patients from the creation of their VA and for the majority before the time of starting haemodialysis. The average age is high in a high-risk epidemiological context (HTA, diabetes) and the number of early deaths (16%). The quality of the surroundings is confirmed by the percentage of native fistula at nearly 90% in accordance with the guidelines. The surgical team is motivated and sensitized in this collaborative project. A total of 52% of patients remained in observation at M12 and 94% had a permeable first with satisfactory dialysis quality. These results are encouraging and require a broader multicentre prospective and comparative study like other problems in managing vascular access for haemodialysis.

Complications of Chronic Kidney Disease: Therapeutic Approaches and What Can Be Done to Halt Disease Progression?

Singapore is one of the most rapidly ageing societies in the world. Currently, Singapore ranks first in the world for the incidence of diabetes-induced end-stage renal disease (ESRD) and seventh for the incidence of kidney failures per million population. It is estimated that nearly one-quarter of Singapore’s population will have chronic kidney disease (CKD) by 2035. Disease management of CKD has been identified as a critical issue due to the rapid increase in cases among the elderly in recent years. Chronic kidney disease is associated with adverse clinical outcomes, and metabolic complications such as anaemia, cardiovascular events, and CKD-associated metabolic bone diseases present treatment management complexities to healthcare professionals. Early detection and management of CKD can avert complications before symptoms occur and prevent the progressive loss of kidney function over time. Angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs) are recommended for hypertension and proteinuria management in CKD patients with and without diabetes. However, neither of these agents alone reduces the risk of all-cause mortality; furthermore, combinational therapy of ACEI plus ARB is associated with renal dysfunction, stroke, and/or hyperkalaemia. Recently, the use of sodium–glucose cotransporter 2 inhibitors (SGLT2i) has been shown to provide favourable effects on the kidney and cardiovascular outcomes in patients with or without type 2 diabetes mellitus. Studies have shown that early initiation of SGLT2i may slow or halt the progression of CKD in patients with the risk of CKD and ESRD. This review discusses the mechanisms underlying the progression of CKD, its associated risk factors and summarises the management strategies as per Kidney Disease Outcomes Quality Initiative clinical practice guideline recommendations. This article also summarises the evidence regarding the use of SGLT2i in slowing the progression of CKD and improvement of health-related quality of life.

Currently Available Handouts for Low Phosphorus Diets in Chronic Kidney Disease Continue to Restrict Plant Proteins and Minimally Processed Dairy Products

The 2020 Kidney Disease Outcome Quality Initiative guidelines recommend adjusting phosphorus intake to achieve and maintain normal serum phosphorus levels for adults living with chronic kidney disease. These guidelines also recommend considering the dietary source of phosphorus as different sources have different bioavailability; however, phosphorus food lists are not provided. Therefore, the aim of this study is to investigate the current teaching materials in Canada regarding low phosphorus diet. Using a geographical approach, websites from each province and territories' government, health, and renal programs (where applicable) were reviewed for resources on dietary phosphorus restriction in chronic kidney disease. All publicly available handouts/booklets/printable webpages were obtained and reviewed for recommendations on how to implement a low phosphorus diet. Sixty-one resources in total met inclusion criteria (52 handouts from health agencies in 6 provinces and 9 handouts from the Kidney Foundation of Canada). Items with minimal nutrition value, such as cola, beer and cocoa, chocolate, and baking powder, were the most commonly restricted with 84% (51/61) resources making this recommendation. Plant proteins and minimally processed dairy were restricted in 80% (49/61) of resources. Processed animal meat was recommended to be restricted in 70% (43/61) of resources and whole grains in 65% (40/61). Sixty-three percent of the handouts (39/61) discuss avoiding phosphorus additives. Many resources restrict items with minimal nutrition value to lower phosphorus intake; however, plant foods, including plant proteins and whole grains, continue to be restricted in the majority of resources, despite having lower bioavailability. The 2020 Kidney Disease Outcome Quality Initiative guidelines recommend considering bioavailability of phosphorus source when implementing low phosphorus diets; current handouts in Canada would likely benefit from review.

IDF21-0084 Role of serum copeptin levels in Type II Diabetes Mellitus patients with progressive stages of diabetic nephropathy

Background: Type II Diabetes mellitus (DM) is one of the leading metabolic diseases. It has multiple serious complications. Diabetic nephropathy is one of them. Progressive deterioration in renal functions due to DM makes the patient’s life completely handicapped. Thus, patients start depending on dialysis and ultimately develop its complications. Arginine Vasopressin (AVP) maintains glucose hemostasis and therefore, plays an important role in the pathophysiology of DM and its related complications such as diabetic nephropathy. Copeptin is an inactive analogue of AVP and considered as a reliable surrogate biomarker of AVP. Therefore, it is hypothesized that changes in the levels of copeptin can be correlated with diabetic and renal markers and thus may have potential role in predicting progressive stages of DM and diabetic nephropathy. Aim: The aim of the study is to find out the relation of copeptin with different diabetic and renal function biomarkers and to find out a potential role of copeptin as a predictive biomarker in DM and its associated progressive diabetic nephropathy. Method: It was a comparative cross-sectional study. A total number of 120 individuals were recruited into four groups i.e. controls, pre- diabetes, DM without nephropathy and DM with nephropathy as per the criteria of American Diabetes Association (ADA) 2018 and National Kidney Foundation/ Kidney Disease Outcome Quality Initiative (NKF/ KDOQI) 2018 guidelines. All cases were controlled hypertensive. Serum copeptin levels were measured by sandwich ELISA. While, Blood Urea Nitrogen (BUN), creatinine, Glycosylated Hemoglobin (HbA1c), urine micro albumin (UAE) and urinary creatinine were got done using spectrophotometry on Abbott Architect c8000 and electrolytes (Na+, K+ and Cl−) by iso electric method from Dow Diagnostic Research and Reference Laboratory (DDRRL), Dow University of Health Sciences. Statistical analysis was done using Analysis of Variance (ANOVA) and Pearson’s correlation tests on SPSS. Confounders were controlled using univariate linear regression. Results: The average copeptin levels of the study population were 215.096 pg/ml. Copeptin levels were significantly elevated in subjects with positive family history of DM (p = 0.025), levels were also raised in pre diabetes patients (252.85pg/ml) as compared to other groups. Copeptin levels were positively correlated with HbA1c r=0.171 (p=0.101), urea r=0.244 (p=0.007), creatinine r=0.215 (p=0.018), UAE r=0.310 (p=0.001), UACR r=0.375 (p=< 0.001). No significant correlation of copeptin was found with major electrolytes of the body. However, copeptin is found to be significantly associated with progressive stages of albuminuria and declining Glomerular Filtration Rate (GFR). Discussion: The raised levels of copeptin in subjects with positive family history of DM recommends its role in the early prediction of DM. Moreover, significant association of copeptin with progressive stages of albuminuria and declining GFR suggest the contribution of copeptin in the worsening of renal functions in DM and its associated nephropathy.

Chronic kidney disease and associated factors among adult population in Southwest Ethiopia.

In Ethiopia, data on the burden and determinants of chronic kidney disease (CKD) in the general population is limited. This community-based study was conducted to assess the burden and associated factors of CKD among adults in Southwest Ethiopia. The study was conducted from August 23, 2018-October 16, 2018. Study participants were selected using a random sampling method. A structured questionnaire was used to collect relevant data. Blood pressure and anthropometric indices were measured following standard procedures. About 5 ml of urine sample was collected and the dipstick test was performed immediately. A blood sample of 3-5ml was collected for serum creatinine and blood glucose level determination. The three commonest estimators of glomerular filtration rate and the National Kidney Foundation Kidney Disease Outcomes Quality Initiative were used to define and stage CKD. Data were analyzed using SPSS 21. Multivariable logistic regression was employed and p-value <0.05 was used to indicate statistically significant results. A total of 326 participants with a mean age of 39.9(SD±11.2) years were enrolled in the study. The proportions of female participants (59.8%) were relatively higher than male participants (40.2%). The mean eGFR using CKD-EPI, CG and MDRD was 124.34 (SD±23.8) mL/min/1.73m2, 110.67(SD±33.0) mL/min/1.73m2 and 131.29 (SD±32.5) mL/min/1.73m2 respectively. The prevalence of CKD was 7.4% using CKD-EPI & MDRD and 8% using CG. Similar finding using CKD-EPI & MDRD may indicate that either CKD-EPI or MDRD can be used to estimate GFR in this study area. In the age and sex-adjusted logistic regression model, hypertension was significantly associated with CKD using CKD-EPI & MDRD and age ≥40 years old was significantly associated with CKD using CG. Behavioral characteristics and other traditional risk factors were not significantly associated with CKD in the current study. The prevalence of CKD was high in the study area. Only hypertension and age ≥40 years old were significantly associated with CKD. More of the increased prevalence of CKD in the current study remained unexplained and deserves further study.

The dire need for improved management of chronic kidney disease: Associated hypertension in Pakistan.

Chronic Kidney Disease (CKD) refers to various kidney disorders ranging from mild to severe chronic kidney failure. Because of its escalating incidence and mortality rates, CKD is a serious public health concern in Pakistan. According to a study published in 2018, the overall prevalence of CKD among Pakistani adults was 21.2%, the highest in South Asia. (1) Although there are numerous risk factors for CKD, such as diabetes, cardiovascular disease, smoking, obesity, and genetics, hypertension poses the most serious threat, as the global prevalence of CKD-associated hypertension is between 60 – 90%. (2) In most people with CKD, proteinuria is observed in conjunction with hypertension. (3) As per the Kidney Disease Outcomes Quality Initiative (KDOQI) recommendations, ACE inhibitors and Angiotensin II Receptor Blockers (ARBs) are the preferred treatment choices for diabetic kidney disease and non-diabetic kidney disease patients with proteinuria. In 2013, a cross-sectional study conducted in Karachi, Pakistan, revealed that only 46.1% of General Practitioners opted for ACE inhibitors and ARBs as primary treatment for hypertension and proteinuria associated with CKD. (4) A randomized crossover trial conducted in March 2021 compared candesartan’s antihypertensive and antiproteinuric effects and the newest ARB, azilsartan medoxomil. The study results revealed that azilsartan (20 mg daily) treatment significantly decreased proteinuria and blood pressure without a noticeable increase in side effects than candesartan (8 mg daily) in patients with CKD who required antihypertensive drugs. (5) Considering the high prevalence of CKD in Pakistan, doctors must follow KDOQI guidelines and prescribe ARBs as the primary therapeutic agents for hypertensive patients with CKD. Azilsartan, the most recent ARB, has been proven to have the most potent antihypertensive and antiproteinuric benefits with the fewest side effects. (5) Therefore, physicians should encourage CKD patients to use azilsartan instead of candesartan and other classes of ARBs. Furthermore, improved screening techniques for CKD must be introduced and implemented so that doctors can manage the disease more effectively before it progresses into its final stages. Such screening tests would also help to improve blood pressure control among patients recognized to have CKD. Therefore, Pakistan’s public health sector should ensure the implementation of Kidney Disease Improving Global Outcomes (KDIGO) criteria to screen and manage CKD and CKD-associated hypertension and diabetes. Lastly, there is a dire need for awareness programs to educate general health practitioners regarding CKD management and the benefits of timely referral to a nephrologist.

KDOQI US Commentary on the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in CKD

In October 2020, KDIGO (Kidney Disease: Improving Global Outcomes) published its first clinical practice guideline directed specifically to the care of patients with diabetes and chronic kidney disease (CKD). This commentary presents the views of the KDOQI (Kidney Disease Outcomes Quality Initiative) work group for diabetes in CKD, convened by the National Kidney Foundation to provide an independent expert perspective on the new guideline. The KDOQI work group believes that the KDIGO guideline takes a major step forward in clarifying glycemic targets and use of specific antihyperglycemic agents in diabetes and CKD. The purpose of this commentary is to carry forward the conversation regarding optimization of care for patients with diabetes and CKD. Recent developments for prevention of CKD progression and cardiovascular events in people with diabetes and CKD, particularly related to sodium/glucose cotransporter 2 (SGLT2) inhibitors, have filled a longstanding gap in nephrology's approach to the care of persons with diabetes and CKD. The multifaceted benefits of SGLT2 inhibitors have facilitated interactions between nephrology, cardiology, endocrinology, and primary care, underscoring the need for innovative approaches to multidisciplinary care in these patients. We now have more interventions to slow kidney disease progression and prevent or delay kidney failure in patients with diabetes and kidney disease, but methods to streamline their implementation and overcome barriers in access to care, particularly cost, are essential to ensuring all patients may benefit.

Health literacy in chronic kidney disease patients: association with self-reported presence of acquaintance with kidney disease, disease burden and frequent contact with health care provider.

Limited data suggest that health literacy (HL) is associated with kidney functions and clinical outcomes in patients with non-dialysis chronic kidney disease (CKD). We aimed to identify factors associated with the level of HL in a CKD population that has not been studied previously. Patients with stage I-V (non-dialysis) CKD according to the Kidney Disease Outcomes Quality Initiative classification were enrolled in the study from two tertiary healthcare centers. Data were collected cross-sectionally using the European Health Literacy Survey (HLS-EU). Data of 208 participants were analyzed. HLS-EU scores had the highest correlations with age (r = -0.494, p = 0.0001) and education (r = 0.476, p = 0.0001). Estimated glomerular filtration rate (e-GFR) was significantly correlated with HLS-EU score (r = 0.186, p = 0.01). Presence of a self-reported acquaintance with any kind of kidney disease was associated with higher HL. On the other hand, participants with multiple comorbidities, and therefore with more frequent contact with the health system, had lower HL than those without such frequent contact. Similarly, those with a high disease burden had lower HL than those without. HLS-EU scores were also significantly associated with gender, marital status, occupational status, self-perception of health, restriction of daily activities, participation in social activities, place of residence, blood pressure, body mass index, and serum parathyroid hormone and albumin levels. Low HL is prevalent among CKD patients and is associated with e-GFR. Presence of an acquaintance with any kind of kidney disease is positively associated with HL. Presence of multiple comorbidities might be a limiting factor for the improvement of HL, which might also be expected to improve as a result of frequent contact with healthcare providers.

HeRO Graft: Indications, Technique, Outcomes, and Secondary Intervention.

The Hemodialysis Reliable Outflow (HeRO) graft is a nontraditional, surgical, and endovascularly placed access that offers options in failing arteriovenous fistula/arteriovenous graft or catheter-dependent patients. The HeRO graft provides a unique option and is specifically referred to in the 2019 Kidney Disease Outcomes Quality Initiative (KDOQI) vascular access update. The interventional radiologist has a role and opportunity to work collaboratively with surgeons in assisting with (1) the identification, selection, preparation for, and placement of HeRO grafts and (2) providing post-placement maintenance to ensure long-term patency.

POS-659 THERE ARE NO DIFFERENCES IN PATIENTS QUALITY OF LIFE AND NUTRITION USING INCREMENTAL HEMODIALYSIS ONCE WEEKLY COMPARE TO TWICE WEEKLY

Each year, approximately 100,000 patients transition to hemodialysis as a life-saving therapy for end-stage renal disease (ESRD) in the United States (US). While approximately 132.000 patients in Indonesia undergo hemodialysis. The current paradigm in the US and most developed countries is to initiate “full-dose” thrice-weekly treatment schedules following the current standard practice to achieve an adequate dialysis dose, and the Kidney Disease Outcomes Quality Initiative (KDOQI) guideline recommends thrice-weekly treatment in patients without residual kidney function (RKF).

KDOQI 2019 Vascular Access Guidelines: What Is New.

The new Kidney Disease Outcomes Quality Initiative (KDOQI) Vascular Access Guidelines have a patient focus for comprehensive vascular access management. The patient's unique circumstances and individualized needs are the foundation of their dialysis access strategy, which is interlinked with the patient's End Stage Kidney Disease (ESKD) Life-Plan. The ESKD Life-Plan is an individualized and comprehensive map for dialysis modalities and vascular access for the lifetime of the patient. New targets are introduced that align with this patient-centered approach. They are less detail prescriptive than prior vascular access guidelines, giving opportunity for vascular access management at the clinician's discretion, partly in consideration of constraints of local resources and available expertise; however, the guidelines also emphasize the importance of high-quality standards with defined targets for achieving the guideline's overarching goal for vascular access care. The guidelines made significant changes relevant to the interventionalist, including selective use of vessel mapping in planning for vascular access, choice of vascular access that allows for considering endovascular access creations, and endovascular treatment (e.g., angioplasty, stent graft insertions) based on clinical indicators found on routine clinical monitoring. To that end, preemptive angioplasty of fistulas and grafts with stenosis, not associated with clinical indicators, is not recommended. New content in these guidelines also includes the use of stent grafts and management of central venous stenosis. The new KDOQI Vascular Access Guidelines 2019 represent a rigorous review of the evidence; however, the available evidence to guide vascular access practice remains limited. There is a significant need and opportunity for new and ongoing high-quality research to inform best practice.

Nutrition and quality of life in chronic kidney disease patients: a practical approach for salt restriction.

The clinical practice guidelines (CPGs) for nutrition in chronic kidney disease (CKD) were updated after 20 years from the previous guidelines by the Kidney Disease Outcomes Quality Initiative (KDOQI). During this period, the severity of CKD was defined by eGFR and albuminuria by the organization Kidney Disease: Improving Global Outcomes (KDIGO). Main risk factors for CKD such as hypertension, hyperlipidemia, obesity, metabolic syndrome, and diabetes mellitus are closely related to lifestyle. Nutritional management is important to prevent and retard the progression of CKD. Members of the International Society of Renal Nutrition and Metabolism (ISRNM) reviewed the KDOQI CPG draft. ISRNM is an international scientific society comprising members of multiple subspecialties. ISRNM proposed the medical term protein-energy wasting (PEW), which is a keyword in renal nutrition. The prevalence of PEW among dialysis patients is high. The success of dietary therapy depends on adherence to the diet. It has to be palatable, otherwise eating habits will not change. To prevent the development and progression of CKD and PEW, regular consultation with an expert dietitian is required, especially regarding salt and protein restriction. Our cluster-randomized trial showed that intervention by a dietician was effective at retarding the progression of stage 3 CKD. In this review, I focus on salt (sodium) restriction and introduce tips for salt restriction and Japanese kidney-friendly recipes. Due to the lack of randomized controlled trials, nutritional management of CKD inevitably relies on expert opinion. In this regard, well-designed observational studies are needed. Too strict salt restriction may decrease quality of life and result in PEW.

KDOQI US Commentary on the 2021 KDIGO Clinical Practice Guideline for the Management of Blood Pressure in CKD

The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the 2021 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for the management of blood pressure in chronic kidney disease (CKD). This commentary is the product of that work group and presents the recommendations and practice points from the KDIGO guideline in the context of US clinical practice. A critical addition to the KDIGO guideline is the recommendation for accurate assessment of blood pressure using standardized office blood pressure measurement. In the general adult population with CKD, KDIGO recommends a goal systolic blood pressureless than 120 mm Hg on the basis of results from the Systolic Blood Pressure Intervention Trial (SPRINT) and secondary analyses of the Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial. The KDOQI work group agreed with most of the recommendations while highlighting the weak evidence base especially for patients with diabetes and advanced CKD.

Outcome of acute kidney injuries following chronic kidney disease: A systematic review in Nawaz Sharif kidney hospital Swat

&#x0D; Background: Acute kidney injury may increase the risk for CKD and end-stage renal disease. In an attempt to summarize the literature and provide more compelling evidence, we conducted a systematic review comparing the risk for CKD (chronic kidney disease), AKI (Acute kidney injury), Acute gastroententeritis, postnatal AKI, Acute MI (myocardial infarction), AKI 2ndry to chemotherapy, AKI 2ndry to abstractive Nephropathy, AKI 2ndry to sepsis, AKI 2ndry to Drugs (NSAIDS and ARBS), AKI 2ndry to AGN (acute Glomerulonephritis), AKI 2ndry to Rhabdomyolysis, and lest AKI 2ndry to Malaria, death in patients with AKI,HD, CKD (chronic kidney disease). There have been several important developments in the literature recently regarding the association between acute kidney injury (AKI) and chronic kidney disease (CKD). First, when the National Kidney Foundation promulgated their highly influential Kidney Disease Outcomes Quality Initiative CKD guidelines in 2002, six chapters were devoted to the complications associated with decreased glomerular filtration rate (GFR) including hypertension, anemia, nutritional status, bone disease/disorders of calcium, and phosphorus metabolism, neuropathy&#x0D; Objective: To study the outcomecute kidney injury following chronic kidney disease; systematic review. &#x0D; Methods: This was a prospective observational study from January 2018 to December 2020. Patients visiting department of Nephrology Nawaz Sharif Kidney center Swat, number of patients included study 351. All ages and both sexes were considered. Patients treated elsewhere or who has undergone in this study. Complete medical history, detailed examination like age, sex, diagnosis, and outcome, of AKI, examination under microscope and investigations, and necessary blood investigations were carried out.&#x0D; Results: Three fifty one (351) patients were included in this study. The age distribution showed (75%) patients between 40-95 years and 25(25%) between 32-39 years. Mean age was 43 years with Standard Deviation of ± 35.66. Among 351 patients 162 (45%) patients were male and 189 (55%) patients were female. Duration of symptoms in 24(17%) was &lt;4 months and 112(75%) had &gt;4 months, with mean of 4 months and SD ± 2.315. Total 351 participants AKI 45(12%) postnatal AKI 33(9%) Acute MI 18(6%) AKI 2ndry chemotherapy 15(5.72%) AKI 2ndry to abstractive Nephropathy 55 (14%) AKI 2ndry to sepsis 63 (17%) AKI 2ndry to Drugs (NSAIDS and ARBS) 54 (14%) CKD (chronic kidney disease) 48 (15%) AKI 2ndry to Rhabdomylysis 18(6%)&#x0D; Conclusions: The study concludes that the acute kidney injury following CKD systematic reviewing among patients presenting with AKI,CHD ,AKI sepsis, ,AKI Drugs(NSIAD) in local hospital settings This can be reduced with proper health education in general public regarding prevention of the disease and hence its complications.&#x0D;

Pediatric Patients Undergoing a Fontan Operation or with a High RACHS-1 Score Require Monitoring for Chronic Kidney Disease in Early Childhood.

Although the number of pediatric patients with long-term survival following cardiac surgery is increasing, concerns regarding chronic kidney disease (CKD) after surgery are growing. We examined the frequency of and risk factors for pediatric CKD development in patients with congenital heart disease (CHD) at least 2years after cardiac surgery. This was a cross-sectional study of 147 patients who underwent open-heart surgery for CHD at Kagoshima University Hospital from April 2010 to March 2017. Data on demographics, acute kidney injury after cardiac surgery, cyanotic heart disease, Fontan circulation, medications in the perioperative period, and Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) category were recorded. CKD was defined using the current classification system described in the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative and assessed during early childhood within 2-3years of cardiac surgery. Statistical analyses were performed using SPSS Statistics for Windows version 25.0. We consecutively enrolled 147 patients, of whom 22 (15.0%) had CKD, all with stage-2 severity. Among patients with CKD, a higher proportion underwent Fontan surgery (P < 0.001), a higher proportion had cyanotic heart disease (P = 0.009), and the RACHS-1 category was high (P = 0.003). Patients with CKD appeared more frequently than patients without CKD in RACHS-1 categories 3, 5, and 6. It is essential to evaluate renal function longitudinally and monitor for CKD, given that patients who underwent Fontan surgery or complicated surgery in infancy have a high rate of developing postoperative CKD in early childhood.

Under-Dialysis: Determinants and clinical correlates – Findings from a two-centre retrospective study in Nigeria

Background: To deliver an adequate dialysis dose, it is necessary that the dialysis frequency, erythropoietin use, blood pressure control among others, be optimized. This is in addition to treating comorbidities and minimizing complications. Adequate dialysis improves the quality of life (QOL) and reduces the morbidity and mortality rates. Aim: To assess the determinant and correlates of under-dialysis in these two centres. Materials and Methods: We analyzed 5065 prevalent dialysis treatments given to 623 participants with end-stage renal disease from two centres in Nigeria. Participants’ biodata, serum biochemistry, and hematocrit of cohorts with once-, twice-, and thrice-weekly sessions were analyzed. Results: Males had more dialysis treatments than women. Two hundred and twenty-seven (36.4%) cohorts had weekly sessions, 296 (47.5%) had twice-weekly sessions, and 100 (16.1%) had thrice-weekly sessions. The mean age of all participants was 50.5 ± 7.9 years, and was higher in women than men, P = 0.02. The percentage of the elderly in the maintenance dialysis population was 13.8%. Only 19.4% of the participants meet the Kidney Disease Outcomes Quality Initiative recommendation of thrice-weekly erythropoietin, just as only 11.9% had health insurance. The dialysis dose was higher in males (P = 0.07), with health insurance (P < 0.001), frequent dialysis (P < 0.001), frequent erythropoietin (P < 0.001), higher hematocrit (P = 0.03), and bicarbonate (P = 0.001), but was lower in intradialytic hypotension compared to intradialytic hypertension, P = 0.004 versus P = 0.005. Dialysis termination and intradialytic death were negatively correlated with dialysis frequency. Health insurance, frequency of dialysis, and erythropoietin predicted the dialysis dose. Conclusion: Under-dialysis and suboptimal erythropoietin use were prevalent in the dialysis population and it restricted the prescribed dose which eventually gave lower dialysis doses, higher dialysis complications, and poor QOL.