Kidney Disease Outcomes Quality Initiative Research Articles

The challenging surgical vascular access creation.

With the increasing life expectancy of patients with end-stage kidney disease, the creation and maintenance of hemodialysis vascular access are becoming more challenging. A comprehensive patient evaluation including a complete history, physical examination, and ultrasonographic vessel assessment is the foundation of the clinical evaluation. A patient-centered approach acknowledges the myriad of factors that impact the selection of optimal access for the distinct clinical and social circumstance of each patient. An interdisciplinary team approach involving various healthcare providers in all stages of hemodialysis access creation is important and associated with better outcomes. While patency is considered the most important parameter in most vascular reconstructive scenarios, the ultimate determinant of success in vascular access for hemodialysis is a circuit that allows consistent and uninterrupted delivery of the prescribed hemodialysis. The best conduit is one that is superficial, easily identified, straight, and of a large caliber. Individual patient factors and skill level of the cannulating technician also play a crucial role in the initial success and maintenance of vascular access. Special attention should be considered in dealing with more challenging groups such as the elderly population where the newest vascular access guidance from The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative will be transformative. The current guidelines recommend monitoring the vascular access by regular physical and clinical assessments, however, inadequate evidence is available to support routine ultrasonographic surveillance for improving access patency.

A decision-making algorithm proposal for PICCs and midlines insertion in patients with advanced kidney disease: A pilot study.

Kidney Disease Outcomes Quality Initiative clinical practice guidelines recommend avoiding placement of peripherally inserted vascular access devices in patients with an estimated glomerular filtration rate (eGFR) <45 ml/min. On the other hand, many patients with severe chronic kidney disease (CKD) have poor prognosis.This study carried out a global assessment of mortality at 2 years through Charlson Comorbidity Index (CCI) and Beclap score in patients with PICCs or Midlines, assuming that in those with an estimated high mortality rate at 2 years, it could be acceptable to implant a peripheral vascular access device (PVAD) despite the presence of CKD. We analyzed data on patients with PICCs or Midlines inserted from October 2018 to November 2019. CCI, Beclap score, and eGFR were calculated for each patient at the time of the catheter insertion. We then followed patients for 2 years to assess 2-year mortality for each. One hundred and thirty-one patients were enrolled, 49 (37.4%) had eGFR<45 ml. The 2-year mortality rate was 57.3%. The cut off derived from ROC curve analysis of 15 for Beclap score and 5 for CCI, showed good sensitivity and specificity in predicting mortality of the total population, patients without an oncological disease and patients with eGFR<45 ml/min. CCI and Beclap score are good predictors of mortality at 2 years.Physicians and nurses can use these tools in the evaluation of patients at risk for future dialysis, instead of relying exclusively on renal function to decide whether implanting PICCs, Midlines, or other vascular access devices.

Placing an appropriate tunneled dialysis catheter in an appropriate patient including the nonconventional sites.

Hemodialysis remains the most frequently chosen kidney replacement modality across the world. A well-functioning dialysis vascular access is critical to providing successful dialysis therapy. Despite its drawbacks, central venous catheter is commonly used as a vascular access to initiate hemodialysis therapy in acute and chronic settings. The growing recognition of providing patient centric care and per recommendations from the recently published Kidney Disease Outcome Quality Initiative (KDOQI) Vascular Access Guidelines, selecting the appropriate patient population for a central venous catheter placement involves implementing the End Stage Kidney Disease (ESKD) Life-Plan strategy. The current review examines the circumstances and challenges that increasingly lead to the hemodialysis catheter being the default and the only available choice for patients. The current review outlines the clinical scenarios for selecting an appropriate patient for hemodialysis catheter use for short-term or long-term needs. The review further discusses clinical pointers to assist with the decision-making process on estimation on prospective catheter length selection, particularly in the intensive care unit setting without the aid of conventional fluoroscopic guidance. A hierarchy of conventional and non-conventional access sites is proposed based on KDOQI guidance and multi-disciplinary author experience. Non-conventional sites are reviewed, including complications and technical guidance, for trans-lumbar IVC, trans-hepatic, trans-renal, and other exotic sites.

Alignment Among Patient, Caregiver, and Health Care Provider Perspectives on Hemodialysis Vascular Access Decision-Making: A Qualitative Study.

Updates to the Kidney Disease Outcomes Quality Initiative Clinical Practice Guideline for Vascular Access emphasize the "right access, in the right patient, at the right time, for the right reasons." Although this implies a collaborative approach, little is known about how patients, their caregivers, and health care providers engage in vascular access (VA) decision-making. To explore how the perspectives of patients receiving hemodialysis, their caregivers, and hemodialysis care team align and diverge in relation to VA selection. Qualitative descriptive study. Five outpatient hemodialysis centers in Calgary, Alberta. Our purposive sample included 19 patients receiving maintenance hemodialysis, 2 caregivers, and 21 health care providers (7 hemodialysis nurses, 6 VA nurses, and 8 nephrologists). We conducted semi-structured interviews with consenting participants. Using an inductive thematic analysis approach, we coded transcripts in duplicate and characterized themes addressing our research objective. While participants across roles shared some perspectives related to VA decision-making, we identified areas where views diverged. Areas of alignment included (1) optimizing patient preparedness-acknowledging decisional readiness and timing, and (2) value placed on trusting relationships with the kidney care team-respecting decisional autonomy with guidance. Perspectives diverged in the following aspects: (1) differing VA priorities and preferences-patients' emphasis on minimizing disruptions to normalcy contrasted with providers' preferences for fistulas and optimizing biomedical parameters of dialysis; (2) influence of personal and peer experience-patients preferred pragmatic, experiential knowledge, whereas providers emphasized informational credibility; and (3) endpoints for VA review-reassessment of VA decisions was prompted by access dissatisfaction for patients and a medical imperative to achieve a functioning access for health care providers. Participation was limited to individuals comfortable communicating in English and from urban, in-center hemodialysis units. Few informal caregivers of people receiving hemodialysis and younger patients participated in this study. Although patients, caregivers, and healthcare providers share perspectives on important aspects of VA decisions, conflicting priorities and preferences may impact the decisional outcome. Findings highlight opportunities to bridge knowledge and readiness gaps and integrate shared decision-making in the VA selection process.

Significance of arteriovenous ratio index on predicting the primary functional maturation of autogenous arteriovenous fistula

Background The incidence of end-stage renal disease is progressively increasing, with more than a fifth of cases progressing to dialysis yearly. According to the newest The Kidney Disease Outcome Quality Initiative (KDOQI) and The National Kidney Foundation (NFK), they consider autologous arteriovenous fistulas (AVFs) as a primary method of choice in hemodialysis patients. To this date, different studies have evaluated the impact of several different variables on the primary functional maturation (FM) of AVFs. One of the preoperative investigations used is ultrasound mapping on vessels. Even so, the vessels meet the minimal threshold diameter for surgical AVF creation, but still, there is high rate of AVF maturation failure. This suggests a need to reassess the preoperative ultrasound criteria used to optimize AVF maturation. Aim The aim of this study is to demonstrate that the suggested measurement technique of arteriovenous ratio (AVR) index obtained from inflow (arterial diameter) to that of outflow (venous diameter) is an independent predictor of primary FM of AVFs. This study implies that minimal diameter difference between inflow and outflow remains crucial for optimal hemodynamics of AVFs irrespective of other variables. Patients and methods This a prospective observational cohort study that was conducted at Ain Shams University hospitals on 120 patients presented with end-stage renal failure between November 2020 and March 2022, which were submitted for AVF. Results This study shows that the AVR index has significant importance in FM of AVF. As shown, AVR index of 1.01–1.06 and 1.06–1.14 has maturation rate of 100%. While as the AVR index increases or decreases away from AVR index subgroups of 1.01–1.06 and 1.06–1.14, the rate of FM decreases subsequently reaching to only 57.9% in AVR index 0–0.79 and 55.6% in AVR index 1.51–2.63. Conclusion The outcome of this study demonstrates that the suggested novel measurement technique (AVR index) is an independent predictor of FM in AVFs. This study implies that minimal diameter (i.e. inflow artery diameter to outflow cephalic vein diameter) mismatch, irrespective of other variables, remains crucial for optimal hemodynamics of AVFs and their primary FM.

Evaluating national guideline concordance of recurrent interventions after radiocephalic arteriovenous fistula creation

ObjectiveRadiocephalic arteriovenous fistulas have been historically perceived as requiring multiple follow-up procedural interventions to achieve maturation and maintain patency. Recent clinical practice guidelines from the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) emphasize a patient-centered hemodialysis access strategy with new maximum targets for intervention rates, potentially conflicting with concomitant recommendations to prioritize autogenous forearm hemodialysis access creation. The present descriptive study seeks to assess whether radiocephalic fistulas can meet the KDOQI guideline benchmarks for interventions following access creation, and to elucidate clinical and anatomic characteristics associated with the timing and frequency of interventions following radiocephalic arteriovenous fistula creation. MethodsProspective patient-level data from the multicenter PATENCY-1 and PATENCY-2 randomized trials, which enrolled patients undergoing new radiocephalic arteriovenous fistula creation, was analyzed (ClinicalTrials.govNCT02110901 and NCT02414841). The primary outcome was the rate of interventions at 1 year postoperatively. Incidence rates were calculated, and time to surgical or endovascular intervention following fistula creation was modeled using recurrent event extensions of the Cox proportional hazards model. Confidence intervals at the 95% level were calculated using nonparametric bootstrapping. ResultsThe cohort consisted of 914 patients; mean age was 57 years (standard deviation, 13 years), and 22% were female. Median follow-up was 707 days (interquartile range, 447-1066 days). The incidence of interventions per person-year was 1.04 (95% confidence interval [CI], 0.95-1.13) overall; 1.10 (95% CI, 0.98-1.21) before fistula use, and 0.96 (95% CI, 0.82-1.11) after fistula use. The most common interventions overall were balloon angioplasty (54.9% of all interventions), venous side-branch ligation (16.4%), and open revisions (eg, proximalization from snuffbox to wrist, 16.4%). The locations requiring balloon angioplasty included the juxta-anastomotic segment (51.7% of angioplasties), the outflow vein (29.2%), the inflow artery (14.8%), the central veins (3.8%), and the cephalic arch (0.5%). Common indications were to restore or maintain patency (75.6% of all interventions), assist maturation (14.9%), improve depth (4.4%), or improve augmentation (3.0%). In the multivariable regression analysis, female sex (adjusted hazard ratio [HR], 1.21; 95% CI, 1.05-1.45), diabetes (HR, 1.21; 95% CI, 1.01-1.46), and intraoperative vein diameter <3.0 mm (vs ≥4.0 mm: HR, 1.33; 95% CI, 1.02-1.66) were associated with earlier and more frequent interventions. Patients not on hemodialysis at the time of fistula creation underwent less frequent interventions (HR, 0.69; 95% CI, 0.59-0.81). ConclusionsPatients with radiocephalic arteriovenous fistulas can expect to undergo one intervention, on average, in the first year after creation, which aligns with current KDOQI guidelines. Patients already requiring hemodialysis, female patients, patients with diabetes, and patients with intraoperative vein diameters <3.0 mm were at increased risk for repeated intervention. No subgroup exceeded guideline-suggested maximum thresholds for recurrent interventions. Overall, the results demonstrate that creation of radiocephalic arteriovenous fistula remains a guideline-concordant strategy when part of an end-stage kidney disease life-plan in appropriately selected patients.

Impact of personalized nutritional intervention on nutritional status and quality of life of maintenance hemodialysis patients with protein energy wasting

BACKGROUND: Protein energy wasting (PEW) is a common multifactorial problem affecting maintenance hemodialysis (MHD) patients. OBJECTIVES: We aimed to explore the impact of personalized nutritional intervention on nutritional status and quality of life (QOL) in MHD patients. METHODS: Interventional study included 18 MHD patients suffering from PEW. They were subjected to personalized nutritional intervention for 6 months according to Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines (2000). QOL was evaluated by using the Kidney Disease Quality of Life (36 KDQOL-36). Nutritional status and QOL of those patients were re-assessed after 6 months and compared to those at the baseline. RESULTS: Fourteen patients completed six months of the study. Following such intervention, half of these patients became no longer suffering from PEW (responder group). Most of the nutritional and QOL data improved in the responder in contrary to the non-responder group of patients. The baseline level of parathyroid hormone (PTH) was significantly higher but physical health was significantly lower in non-responder than responder groups. CONCLUSIONS: Implementation of an internationally acknowledged nutritional program could improve the nutritional status and QOL of MHD patients with PEW. Moreover, PTH level, and physical health of the studied patients could contribute to the positive response to nutritional intervention.

Klotho, a protective renal factor for platelet lifespan

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

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

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

COMPARISON OF CLINICAL AND BIOCHEMICAL VARIABLES BETWEEN PATIENTS ON TWICE A WEEK DIALYSIS REGIME HAVING DIFFERENT RESIDUAL RENAL FUNCTION – A JACK IN THE BOX

In resource limiting counties, it is a common observation that patients with chronic kidney disease have undergone twice a week dialysis even though they need thrice a week dialysis regime. This not only increases the burden on hospital emergencies but also affects the quality of life of the patients. The current analysis aims to access the quality of life, biochemical variables, and adverse events in patients on twice a week dialysis having renal urea clearance less than 2 mL/min/1.73 m2 (Kr &lt; 2 mL/min/1.73 m2) as compared to those undergoing twice weekly dialysis having Kr &gt; 2 mL/min/1.73 m2. This investigation was carried out at the Services Hospital in Lahore's Department of Nephrology and Hemodialysis Center. The study involved a total of sixty participants. They were then split into two separate groups. Thirty participants in Group A were on dialysis twice a week and had Kr &gt; 2 mL/min/1.73 m2, whereas in Group B, participants with the same age and sex were also on dialysis twice a week but had Kr&lt; 2 mL/min/1.73 m2. According to the 2006 Kidney Disease Outcome Quality Initiative (KDOQI) Clinical Practice Guidelines, individuals with renal urea clearance (Kr) less than 2 mL/min/1.73 m2 should not undergo twice-weekly hemodialysis. Therefore, Group B was not following the advised weekly dialysis schedule. The primary goal of the study was to assess the difference in biochemical variables and the last six-month emergency visit for dialysis and the second goal was to determine the quality of life by using the Sf-12 QoL questionnaire. The trial involved a total of sixty participants receiving twice-weekly dialysis. Males made up 59% of the study's participants. The participants' average age was 42.18 ± 18.10 years. Group A had a mean age of 38.9 ± 17.6 years, while group B had a mean age of 41.2 ± 14.9 years. Systolic blood pressure was considerably higher in group B compared to group A according to the clinical data (p=0.04). The biochemical examination revealed that group B had significantly lower levels of albumin than group A (p=0.001) and significantly higher levels of urea and calcium (p=0.01 and 0.046, respectively) than group A. It was discovered that group B had significantly more hospital visits than group A (p=0.003). Using the SF-12 to measure quality of life, there was no discernible difference between the groups. The patients were on twice a week dialysis despite their renal urea clearance of less than 2 mL/min/1.73 m2 having compromised clinical and biochemical parameters. They also have a poor quality of life and also a greater number of emergency visits.

Surveillance and monitoring of early failing arteriovenous fistula using Doppler assessment in children on regular hemodialysis

BackgroundA well-functioning vascular access is a mainstay to perform an efficient hemodialysis procedure. Limited lifespan of arteriovenous accesses is one of the major challenges of the current long-term hemodialysis therapy. Vascular access-related morbidity accounts for up to 50% of total dialysis patient’s costs. The pediatric vascular access clinical guidelines published by the National Kidney Foundation Kidney Disease Outcome Quality Initiative recommend establishing a surveillance strategy to detect access stenosis and direct patients for early intervention. The aim of this study was to test the role of using the color Doppler ultrasonography (CDU) as a surveillance method for arteriovenous fistulae in children on regular hemodialysis and its value for detecting the early vascular access failure or dysfunction to avoid access loss.ResultsDuring 10-month duration, we prospectively conducted surveillance for 30 patients on regular hemodialysis through arteriovenous fistulae (AVF) as a vascular access, clinical assessment of AVF and radiological examination using CDU of the upper limbs. Their ages were ranging from 2 to 18 years with 1:1 male: female ratio. Doppler indices were measured in the afferent arteries, at the site of anastomosis, and the draining veins. AVF stenosis was the highest among all the detected complications (n = 9, 30%), aneurysm and pseudoaneurysmal formation (n = 8, 26%) anastomoses diameter reduction in 16.6%, and it was correlated with the dialysis adequacy measured through the Kt/v. Other complications were thrombosis (n = 2, 6.7%), central venous stenosis (n = 2, 6.7%), steal syndrome (n = 1, 3.3%) and calcifications in (n = 1, 3.3%). In total, 26% of the patients have more than one malfunction. Only one case has access failure a month after CDU examination.ConclusionIn conclusion, among pediatric patients CDU can detect early stenosis of AVF in children, which can affect the dialysis adequacy.

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

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

Predicting radiocephalic arteriovenous fistula success with machine learning

After creation of a new arteriovenous fistula (AVF), assessment of readiness for use is an important clinical task. Accurate prediction of successful use is challenging, and augmentation of the physical exam with ultrasound has become routine. Herein, we propose a point-of-care tool based on machine learning to enhance prediction of successful unassisted radiocephalic arteriovenous fistula (AVF) use. Our analysis includes pooled patient-level data from 704 patients undergoing new radiocephalic AVF creation, eligible for hemodialysis, and enrolled in the 2014–2019 international multicenter PATENCY-1 or PATENCY-2 randomized controlled trials. The primary outcome being predicted is successful unassisted AVF use within 1-year, defined as 2-needle cannulation for hemodialysis for ≥90 days without preceding intervention. Logistic, penalized logistic (lasso and elastic net), decision tree, random forest, and boosted tree classification models were built with a training, tuning, and testing paradigm using a combination of baseline clinical characteristics and 4–6 week ultrasound parameters. Performance assessment includes receiver operating characteristic curves, precision-recall curves, calibration plots, and decision curves. All modeling approaches except the decision tree have similar discrimination performance and comparable net-benefit (area under the ROC curve 0.78–0.81, accuracy 69.1–73.6%). Model performance is superior to Kidney Disease Outcome Quality Initiative and University of Alabama at Birmingham ultrasound threshold criteria. The lasso model is presented as the final model due to its parsimony, retaining only 3 covariates: larger outflow vein diameter, higher flow volume, and absence of >50% luminal stenosis. A point-of-care online calculator is deployed to facilitate AVF assessment in the clinic.

Dietary Intake Correlated to Waist-To-Hip Ratio in Patients on Maintenance Hemodialysis

ObjectiveIndividuals with end-stage kidney disease (ESKD) receiving maintenance hemodialysis (MHD) are at risk for protein-energy wasting (PEW). Inadequate dietary intake and altered anthropometrics are two criteria of the PEW diagnosis. This study explored whether individuals with ESKD on MHD meet the National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF-KDOQI) 2020 guidelines for nutritional adequacy on a dialysis treatment day (DD) and explored the relationship between dietary energy [DEI] and protein [DPI] intake and anthropometrics. MethodsThis was a secondary analysis of clinical and demographic data for 142 adults from the Rutgers Nutrition and Kidney Disease database. The study assessed the relationships between DEI, DPI, and anthropometrics, including body mass index (BMI), BMI category, waist circumference, and waist-to-hip ratio (WHR) using Pearson’s or Spearman’s correlation and one-way ANOVA. ResultsThe sample had a median age of 55.7 years; 58% were male, 83.8% were Black/African American, with a median dialysis vintage of 42.0 months (e.g., 3.5 years). Seventy-five percent of the data sample were overweight or obese. The WHR was 1.0 ± 0.8 cm for males and 0.9 ± 0.1 for females. DEI and DPI on a DD did not meet the NKF-KDOQI 2020 guidelines. Median DEI was 17.6 ± 8.4 kcal/kg and DPI was 0.7 ± 0.4 g/kg. In the total sample, significant positive correlations were found between DEI (r = 0.74, P = 0.03) and DPI (r = 0.18, P = 0.037) and WHR. In females, a significant positive correlation was identified between DPI and WHR (r = 0.26, P = 0.046). ConclusionsThese findings suggest that the nutritional intake of individuals with ESKD receiving MHD is inadequate to meet NKF-KDOQI 2020 guidelines on a DD. WHR may be a useful tool to assess alterations in anthropometrics related to DEI or DPI in this population, but more research is warranted.

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

A clinical case of surgical treatment of a 10-year-old girl with megaureter of the single kidney

Editrial comment. The described long-term multi-stage surgical treatment – performed at the child's place of residence was not adequate and was the threat of losing the only kidney. Management of patients with a non-reflexing form of megaureter, especially in the neonatal period, requires the assessment of not only the state of the kidney and ureter, but also the state of the bladder, in order to exclude the bladder-dependent form of megaureter. Proximal ureterocuteniostomy, especially of a single kidney, should not be used without a preliminary, full-fledged urological examination. Children with complex malformations of the urinary system should be promptly consulted in specialized medical institutions. Introduction. Among congenital malformations of the urinary system, one of the most common is megaureter. The recently developed surgical techniques and, namely, minimally invasive ones for megaureter treatment, in some cases prevent or delay surgical intervention. However, if deterioration of the renal function is seen, especially in patients with the only functioning kidney, radical surgery has to be performed in a timely manner, before the formation of irreversible changes in the renal parenchyma leading to nephrosclerosis. Purpose. To illustrate a successful surgical outcome in a patient with megaureter in the only functioning kidney when surgeons had to consider all anatomical features after ineffective previous surgical corrections. Material and methods. The authors present a clinical observation and management of a 10-year-old patient with megaureter in the only kidney after previous ineffective surgical corrections when both open traditional methods and long-term endovesical stentings were performed but without taking into account the anatomical localization of the ureteral junction. The patient also developed a latent course of urinary tract infection and chronic kidney disease stage 3 by classification of the National Kidney Foundation (NKF), and the working group on improving outcomes of kidney diseases, Kidney Disease Outcomes Quality Initiative (KDOQI). Results. Despite the existing problems – deficit in the ureter length caused by previous surgeries, impossible endovideosurgical laparoscopy because of metabolic disorders – the performed treatment was successful. The surgeons formed ureterocystoanastomosis by Cohen technique with extra-bladder mobilization of the ureter. Dynamic follow-up after surgical treatment lasted for 2 years. During the observation period, urodynamics of the upper urinary tract was restored and, one could see the elimination of leukocyturia, improvement of blood flow in the parenchyma of the only functioning kidney as well as stabilization of nitrogen metabolic parameters and glomerular filtration rate. Conclusion. While choosing surgical management, surgeons should consider anatomical features of the ureterovesical junction. Such an approach has promoted good results in the discussed case.

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

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

Obesity-Related Chronic Kidney Disease: Principal Mechanisms and New Approaches in Nutritional Management.

Obesity is the epidemic of our era and its incidence is supposed to increase by more than 30% by 2030. It is commonly defined as a chronic and metabolic disease with an excessive accumulation of body fat in relation to fat-free mass, both in terms of quantity and distribution at specific points on the body. The effects of obesity have an important impact on different clinical areas, particularly endocrinology, cardiology, and nephrology. Indeed, increased rates of obesity have been associated with increased risk of cardiovascular disease (CVD), cancer, type 2 diabetes (T2D), dyslipidemia, hypertension, renal diseases, and neurocognitive impairment. Obesity-related chronic kidney disease (CKD) has been ascribed to intrarenal fat accumulation along the proximal tubule, glomeruli, renal sinus, and around the kidney capsule, and to hemodynamic changes with hyperfiltration, albuminuria, and impaired glomerular filtration rate. In addition, hypertension, dyslipidemia, and diabetes, which arise as a consequence of overweight, contribute to amplifying renal dysfunction in both the native and transplanted kidney. Overall, several mechanisms are closely related to the onset and progression of CKD in the general population, including changes in renal hemodynamics, neurohumoral pathways, renal adiposity, local and systemic inflammation, dysbiosis of microbiota, insulin resistance, and fibrotic process. Unfortunately, there are no clinical practice guidelines for the management of patients with obesity-related CKD. Therefore, dietary management is based on the clinical practice guidelines for the nutritional care of adults with CKD, developed and published by the National Kidney Foundation, Kidney Disease Outcome Quality Initiative and common recommendations for the healthy population. Optimal nutritional management of these patients should follow the guidelines of the Mediterranean diet, which is known to be associated with a lower incidence of CVD and beneficial effects on chronic diseases such as diabetes, obesity, and cognitive health. Mediterranean-style diets are often unsuccessful in promoting efficient weight loss, especially in patients with altered glucose metabolism. For this purpose, this review also discusses the use of non-classical weight loss approaches in CKD, including intermittent fasting and ketogenic diet to contrast the onset and progression of obesity-related CKD.

Knowledge attitude and practice towards prevention and early detection of chronic kidney disease among high risk patients

Background: It is well recognized that chronic kidney disease (CKD), if left, untreated would slowly progress to end-stage renal disease (ESRD)., A targeted approach is to enhance the knowledge of CKD among the public, especially in high risk population, and encourage them to practice a healthy attitude and practice that may help in early detection and thereby better management of CKD. Such a study to assess the baseline data has not been done in India. Aims and Objectives: To inculcate the knowledge attitude and practice towards prevention and early detection of CKD among high risk patients attending a tertiary care centre. This Observational study was carried out on all patients with diabetes and/or hypertension attending General medicine out-patient or in-patient in a given period of time. Patients more than 18 years of age with diabetes and/or hypertension were included while patients with chronic kidney disease were excluded. Methodology: A standard questionnaire obtained from an author of similar study is given to patients fulfilling the inclusion criteria. Is this National Kidney Foundation's Kidney Disease Outcome Quality Initiative (KDOQI)? If so mention it.

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.