Management Of Chronic Kidney Disease Research Articles

Association of urinary volatile organic compounds and chronic kidney disease in patients with diabetes: real-world evidence from the NHANES.

Chronic kidney disease (CKD) is common in patients with diabetes mellitus (DM). Volatile organic compounds (VOCs) are widespread pollutants that may impact DM development. This study aims to explore the association between urinary VOC metabolites and CKD in patients with DM. Adult National Health and Nutrition Examination Survey (NHANES) 2011 to 2018 participants with DM were included in this study. CKD was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 or urine albumin-to-creatinine ratio (UACR) ≥ 30 mg/g. Multivariable regression models were used to analyze the associations between urinary VOC metabolites and CKD. A total of 1,295 participants with DM and a mean age of 59 years were included. After adjustment for demographic and clinical characteristics, elevated levels of N-acetyl-S-(2-carbamoylethyl)-L-cysteine (AAMA) (tertile 2: adjusted odds ratio (aOR) = 1.81, 95% confidence interval (CI): 1.15-2.85, p = 0.012), N-acetyl-S-(N-methylcarbamoyl)-L-cysteine (AMCC) (tertile 2: aOR = 1.84, 95% CI: 1.10-3.08, p = 0.021), DHBMA (tertile 3: aOR = 1.93, 95% CI: 1.12-3.35, p = 0.020), and phenylglyoxylic acid (PGA) (tertile 3: aOR = 1.71, 95% CI: 1.11-2.63, p = 0.017) were significantly associated with increased likelihood of CKD. Specific urinary VOC metabolite levels are positively associated with an increased risk of CKD in patients with DM. These findings suggest that monitoring urinary VOC metabolites could be important for the prevention and management of CKD in this population. Future longitudinal studies should focus on establishing causality and elucidating the underlying mechanisms of these associations.

Population Health Management and Guideline-Concordant Care in CKD: A Secondary Analysis of K-CHAMP.

Gaps in guideline-concordant care for chronic kidney disease (CKD) lead to poor outcomes. The Kidney Coordinated HeAlth Management Partnership (K-CHAMP) cluster randomized trial tested the effect of a population health management intervention versus usual care on CKD progression and evidence-based care delivery in the primary care setting. K-CHAMP included adults aged 18-85 years with eGFR <60 mL/min/1.73m2 and moderate-high risk of CKD progression who were not seeing a nephrologist. The multi-faceted intervention included nephrology e-consult, pharmacist-led medication management, and patient education. In this post-hoc analysis, we evaluate the effectiveness of K-CHAMP on guideline-concordant care processes (blood pressure and glycemic control, annual albuminuria testing), and medication exposure days (ACEi/ARB, moderate-high intensity statin, SGLT-2i, GLP-1RA). Given multiplicity of outcomes, Benjamini-Hochberg method was used to control false discovery rate (FDR). All 1,596 (754 intervention, 842 usual care) enrolled patients (mean age 74±9 years, eGFR 37±8 mL/min/1.73m2, 928 (58%) female, 127 (8%) Black) were analyzed. After a median 17-month follow-up, intervention arm patients had significantly higher exposure days per year to SGLT-2i (56 vs 32 days, relative benefit 1.72, 95% CI 1.14-2.30) and GLP-1RA (78 vs 29 days, relative benefit 2.65, 95% CI 1.59-3.71) compared to usual care in adjusted analysis. At study initiation in 2019, similar proportion of patients were prescribed SGLT-2i and/or GLP-1RA in intervention and control arm (8% vs 6% respectively, rate ratio 1.23, 95% CI 0-2.99), but by 2022, prescription of these medications was significantly higher in intervention arm (44% vs 27% respectively, rate ratio 1.63, 95% CI 1.32-1.94). There was no significant difference in any process measures or exposure days to ACEi/ARB in patients with albuminuria or moderate-high intensity statin. K-CHAMP was effective in accelerating implementation of SGLT-2i and GLP-1RA but did not increase ACEi/ARB in patients with albuminuria or moderate-high intensity statin use, or improve blood pressure control, glycemic control, or albuminuria testing in individuals with CKD in the primary care setting.

Diet as a treatment for chronic kidney disease

The management of chronic kidney disease (CKD) includes nutritional interventions aimed at slowing disease progression and mitigating complications. This review examines various dietary approaches for CKD treatment, focusing on carbohydrate intake modulation, ketogenic diets, and plant-based diets. Standard guidelines recommend carbohydrate intake within 45% to 65% of total calories, but there is growing interest in reducing carbohydrate consumption to preserve kidney function. Low-carbohydrate diets (&lt;25% of total calories) have shown benefits in glycemic control and weight reduction but may pose long-term adherence challenges. High-protein, low-carbohydrate diets are discouraged due to associations with hyperfiltration and CKD progression. Limiting fructose intake has been linked to reductions in blood pressure and uric acid levels. Intermittent fasting and ketogenic diets, which promote ketone body production and reduce inflammation, have shown promise in animal models and some human studies, particularly in autosomal dominant polycystic kidney disease, though more research is needed. Plantbased diets, such as the Mediterranean and DASH (Dietary Approaches to Stop Hypertension) diets, offer cardiovascular benefits and may reduce CKD risk but require careful management of potassium intake. Overall, dietary interventions should be individualized, considering potential risks like hyperkalemia and ensuring nutritional adequacy.

Evaluating a multicomponent intervention for managing kidney outcomes among patients with moderate or advanced chronic kidney disease (CKD): protocol for the Strategies for Kidney Outcomes Prevention and Evaluation (SKOPE) randomized controlled trial

BackgroundChronic kidney disease (CKD) poses a global health challenge with high morbidity and mortality rates. Early detection and prompt intervention are critical in preventing progression to end-stage kidney disease (ESKD) and cardiovascular complications. Effective CKD management requires comprehensive care packages that integrate both pharmacological and non-pharmacological interventions within collaborative, team-based models, aiming to enhance patient outcomes and overall quality of life. The goal of the Strategies for Kidney Outcomes Prevention and Evaluation (SKOPE) study is to establish effective multicomponent intervention (MCI) strategies for evaluating and preventing kidney outcomes in patients with moderate to advanced CKD within primary care settings in Singapore.MethodsThis study is a 3-year randomized controlled trial among 896 participants aged between 40 and 80 years with moderate or advanced CKD in five government-subsidized polyclinics in Singapore. The components of the MCI are (1) nurses/service coordinators trained as health coaches for motivational conversation and CKD-specific lifestyle counseling on diet and exercise, using a hybrid follow-up approach of in-person, telephone, and secure video meetings; (2) training physicians in algorithm-based standardized management of CKD; (3) subsidy on SGLT2i medications for CKD; and (4) regular CKD case review meetings. The primary outcome is the estimated glomerular filtration rate (eGFR) total slope from randomization to final follow-up at 36 months.DiscussionIf shown to be effective, cost-effective, and acceptable, SKOPE should be considered for scaling country-wide and in similar regional healthcare systems.Trial registrationClinicalTrials.gov NCT05295368. Registered on March 25, 2022.

Cost minimization analysis of chronic kidney disease management: Evaluating economic strategies for early intervention and treatment optimization

Chronic kidney disease is a common global health condition characterized by progressive loss of kidney function and significant cost burden on the healthcare system worldwide. The disease often coexists with conditions such as diabetes and hypertension, further complicates its management and increasing associated costs. Effective economic management, particularly in the early stages of CKD, is crucial for reducing long-term healthcare expenses and improving patient outcomes. This review examines the utility of cost minimization analysis (CMA) as a strategic tool for evaluating economic options in CKD management. CMA is an economic evaluation method that compares the costs of different therapeutic interventions that have demonstrated equivalent clinical effectiveness, thereby aiding healthcare providers and policymakers in identifying the most cost-efficient options to optimize resource utilization. This review highlights the economic impact of CKD, focusing on the increasing costs linked to advanced disease management and the essential role of early diagnosis and intervention in reducing these costs and explores various cost-effective strategies for CKD management, including pharmacological treatments, lifestyle modifications, and patient education, to identify approaches that are both clinically and economically advantageous. Additionally, the broader implications of cost minimization for healthcare policy, clinical decision-making, and resource allocation are discussed for their significance in a resource-limited healthcare setting. Evidence indicates that prioritizing cost-effective CKD management through early intervention and preventive care can significantly lower healthcare expenditures, slow the disease progression, and enhance patient’s quality of life. By adopting such strategies, healthcare systems can achieve better clinical outcomes and ensure financial sustainability.

Awareness and perceptions of cardiologists towards systemic inflammation in atherosclerotic cardiovascular disease: A multi-national survey across 5 geographical regional sub-groups

Abstract Background Despite improvement in the management of atherosclerotic cardiovascular disease and chronic kidney disease (ASCVD+CKD), cardiovascular (CV) mortality remains unacceptably high. Evidence suggests that systemic inflammation (SI) is one of the key drivers for disease progression, yet clinical perceptions towards SI amongst cardiologists is poorly understood. Purpose FLAME-ASCVD (systemic inFLAMmation and rolE of hsCRP as a biomarker in AtheroSclerotic CardioVascular Disease) survey assessed cardiologist’s perceptions and awareness towards the role of SI and high sensitivity C-reactive protein (hsCRP) in patients (pts.) with ASCVD+CKD. Overall results were reported earlier1 and here we present results by sub-groups across 5 geographical regions. Methods This was a multinational, cross-sectional, online survey-based study conducted during March-May 2023. Eligible participants were cardiologists (interventional and general) who treated ≥15 ASCVD+CKD pts./month and practiced for ≥3 years. To minimize selection bias, specific study objective was not disclosed until eligibility criteria was met. An online questionnaire was used. Analysis included 5 sub-groups: Europe (EU: France, Germany, Italy, UK), Asia Pacific (AP: Australia, India), East Asia (EA: China, Japan), LatAm (LA: Brazil), Middle East (ME: Saudi Arabia). Descriptive statistics were used. Results Of the 1755 respondents, 602 eligible cardiologists (~60/country) completed the survey across the EU (n=241), AP (n=121), EA (n=120), LA (n=60), and ME (n=60). Hypertension, hyperlipidaemia, and lifestyle (diet/exercise) were consistently amongst the top 3-5 CV risk factors discussed with pts, across all regions. SI as a CV risk factor was discussed consistently less across regions (overall 10th at 43%, ³9th across regions, EU: 30%) (Table 1). Across regions, &amp;gt;70% of cardiologists acknowledged an intention to consider testing for SI, with the lowest being in the EU at 46%. Of those in the EU who did not consider testing, 53% (n=129) cited lack of medication as the reason. Across all regions, SI was consistently perceived as a risk factor for recurrent CV events (³65%) and residual inflammatory risk (47-85%), yet a noticeable proportion (52-92%) cardiologists acknowledged a need to learn more about SI in ASCVD+CKD (highest in ME, 92%). While overall (aided: 47% [n= 571]; unaided: 24%) considered hsCRP test for SI, few variations were observed (EA/AP/EU, aided: 55/52/33 and unaided: 22/24/03) (Table 2). Proven efficacy of hsCRP test, availability of medication for SI, and guideline recommendation were acknowledged as unmet needs to inform clinical care in ASCVD+CKD. Conclusion In this survey across regional sub-groups, discussion of SI as a CV risk factor was consistently low. Barring few noticeable variations in testing patterns in EU, perceptions towards SI were generally consistent. There is a need for better understanding and guidance on SI and hsCRP testing in practice.

Automated digital counselling promotes therapeutic change in mental health in patients with chronic heart failure or chronic kidney disease: ODYSSEE-vCHAT study

Abstract Background The efficacy of digital programs to improve the management of chronic heart failure (CHF) and chronic kidney disease (CKD) is not established. Building on related studies in digital health, behavioural counselling, and social support, we evaluated whether an automated digital counselling program with social network support (ODYSSEE-vCHAT) could improve mental health and health-related quality of life in patients with CHF or CKD. Purpose The primary objective was to examine whether engagement with ODYSSEE-vCHAT was associated with a minimal clinically important difference for improvement in the Mental Component Summary (MCS) of the SF-36 at end-of-study. Secondary outcomes included: ENRICHD Social Support Index (ESSI), Patient Health Questionnaire for Depression (PHQ-9) Godin-Shephard Leisure Time Physical Activity Scale (GSLTPAQ), and an index of the frequency to which patients engaged in goal-directed activities for living well (EUROIA). Methods ODYSSEE-vCHAT was a multi-centre, single group, open label study with assessments at baseline and end-of-study (approximately 11 months). Inclusion criteria were: ≥18 years of age, diagnosis of CHF (reduced ejection fraction (EF) ≤ 40%, mid-range EF, 41-49%, or preserved EF ≥ 50%); or CKD diagnosis (&amp;gt;10% risk for dialysis using the 4-variable, 2-year Kidney Failure Risk Equation, or on dialysis). Exclusion was based on inability to participate due to co-morbidities. The digital counselling protocol taught self-care skills to improve mental health, quality of life, and adherence to medications, exercise, diet, and smoke-free living (Figure 1). Patient engagement with ODYSSEE-vCHAT was defined as Not Engaged (0 logon minutes) vs. Engaged (&amp;gt; 0 logon minutes). The primary outcome was a minimal clinically important difference for MCS change: ΔMCS ≥ 3.8 or MCS ≥ 65 at baseline and study endpoint. It was assessed using multivariable binary logistic regression, controlling for exposure to COVID-19 and health literacy. Secondary outcomes were assessed using multivariable linear regression analyses with the same covariates. Results 215 patients were enrolled. There were 7 deaths and 34 withdrew. In our sample of 174 patients, mean age = 54.4 years (95% Confidence Interval, CI, 25, 81), gender identity as women, n = 68 (39%), ethno-racial group other than White, n = 83, (48%), primary diagnosis, CHF, n = 68 (39%), and CKD, n = 106 (61%). Duration of enrolment to end-of-study: median = 352 days, (95% CI, 159, 496). Engagement with ODYSSEE was associated with therapeutic change on the MCS (for both CHF and CKD patients, and CHF patients alone), GSLTPAQ, and EUROIA, but not the PHQ9 or ESSI (Figure 2). Conclusions Automated digital counselling with social network support promotes improvement in indices of mental health for patients with CHF and CKD. These findings support a follow-up randomized controlled trial.Figure 1.ODYSSEE-vCHAT Study ProtocolFiFigure 2.ODYSSEE-vCHAT Study Outcomes

Cost-Effectiveness of Empagliflozin (JARDIANCE®) in the Treatment of Patients with Chronic Kidney Disease in France, Based on the EMPA-KIDNEY Clinical Trial.

The efficacy and safety of empagliflozin in the treatment of chronic kidney disease (CKD) were demonstrated in the EMPA-KIDNEY trial, which showed a 28% reduction in combined risks of kidney disease or death from cardiovascular causes (hazard ratio, 0.72; 95% confidence interval, 0.64-0.82; p < 0.001) compared with placebo. Based on these results, the present study aimed to assess the cost-effectiveness of empagliflozin + standard of care (SoC) compared with SoC alone in the treatment of CKD in France. A Markov state microsimulation model was adapted to compare the health and economic outcomes in France, considering a healthcare system perspective, in patients treated with empagliflozin in addition to SoC versus patients treated with SoC alone. The model simulated the intention-to-treat population of the trial, transitioning between 18 mutually exclusive and collectively exhaustive health states defined based on the Kidney Disease: Improving Global Outcomes classification. For each arm, the model estimated (over a 25-year time horizon) the number of events and deaths, and the costs associated with these events, to calculate the incremental cost-effectiveness ratio. The resources used were derived using French authorities reports, literature, and French CKD guidelines. Both economic and health outcomes were discounted at a 2.5% annual rate according to French guidelines. The model predicted that using empagliflozin + SoC to treat patients with CKD would prevent CKD-related complications and deaths associated with a cardiovascular event or all-cause deaths while in kidney replacement therapy, resulting on average in a discounted gain of 1.29 years in overall survival (9.48 years vs. 8.19 with SoC alone). Empagliflozin costs (treatment, events, and disease management) were completely offset by the cost savings from avoided kidney failure events. Overall, empagliflozin + SoC would be more effective and less costly than SoC alone and would therefore be the dominant treatment strategy. The sensitivity analyses conducted support the results' robustness in showing the dominance of empagliflozin + SoC over SoC alone. The base-case results indicate that empagliflozin + SoC is a dominant strategy compared with the current SoC for the management of CKD in France. Empagliflozin + SoC would have a positive impact on patients with CKD by slowing CKD progression and leading to the prevention of kidney failure events on top of all-stages CKD complications.

Propolis Extract Attenuates NF-κB Activation and Chronic Kidney Disease Progression in a Rat Model: Potential Surgical Adjuvant?

Background: Chronic kidney disease (CKD) is a global health concern often complicated by cardiovascular diseases like atherosclerosis. Both conditions share an inflammatory pathogenesis, with nuclear factor kappa B (NF-κB) playing a central role. Propolis, a natural bee product with anti-inflammatory properties, has shown potential in mitigating CKD progression. This study aimed to investigate the effects of propolis extract on NF-κB activation in a rat model of CKD, exploring its potential benefits as a surgical adjuvant. Methods: Male white rats (Rattus norvegicus) were divided into three groups: a control group, a CKD group, and a CKD+Propolis group receiving propolis extract (200 mg/kg body weight) daily for 20 days. CKD was induced using the unilateral ureteral obstruction (UUO) method. NF-κB levels were measured weekly using ELISA. Results: Propolis extract significantly reduced NF-κB levels in the CKD+Propolis group compared to the CKD group (p&lt;0.05). This effect was consistently observed across all time points, indicating a sustained reduction in NF-κB activation with propolis treatment. Conclusion: Propolis extract effectively attenuates NF-κB activation in a rat model of CKD, suggesting its potential as an adjunctive therapy for CKD management, particularly in the context of surgical interventions. Further research is needed to elucidate the underlying mechanisms and evaluate its efficacy in human subjects.

Current Approaches to Treatment and Protein Intake Management in Pre-Dialysis Chronic Kidney Disease: Impact on Physical Exercise

Chronic kidney disease (CKD) is the 8th most common condition in the modern world. Unfortunately, it becomes more and more frequent and constitutes a significant global health problem, affecting millions of people worldwide. Therefore, its treatment is an important topic among researchers all over the world. It has been the subject of many trials, so it will eventually be as effective, secure, and comfortable for patients as it possibly can be. That is why updating and assembling current knowledge is the key to organizing information. This paper focuses on pharmacological treatment and nutritional guidelines for CKD pre-dialysis patients, as well as physical activity outcomes. It aims to summarize this knowledge, educate, and help doctors in their daily clinical work.

Current management of chronic kidney disease in type-2 diabetes-A tiered approach: An overview of the joint Association of British Clinical Diabetologists and UK Kidney association (ABCD-UKKA) guidelines.

A growing and significant number of people with diabetes develop chronic kidney disease (CKD). Diabetes-related CKD is a leading cause of end-stage kidney disease (ESKD) and people with diabetes and CKD have high morbidity and mortality, predominantly related to cardiovascular disease (CVD). Despite advances in care over the recent decades, most people with CKD and type 2 diabetes are likely to die of CVD before developing ESKD. Hyperglycaemia and hypertension are modifiable risk factors to prevent onset and progression of CKD and related CVD. People with type 2 diabetes often have dyslipidaemia and CKD per se is an independent risk factor for CVD, therefore people with CKD and type 2 diabetes require intensive lipid lowering to reduce burden of CVD. Recent clinical trials of people with type 2 diabetes and CKD have demonstrated a reduction in composite kidney end point events (significant decline in kidney function, need for kidney replacement therapy and kidney death) with sodium-glucose co-transporter-2 (SGLT-2) inhibitors, non-steroidal mineralocorticoid receptor antagonist finerenone and glucagon-like peptide 1 receptor agonists. The Association of British Clinical Diabetologists (ABCD) and UK Kidney Association (UKKA) Diabetic Kidney Disease Clinical Speciality Group have previously undertaken a narrative review and critical appraisal of the available evidence to inform clinical practice guidelines for the management of hyperglycaemia, hyperlipidaemia and hypertension in adults with type 2 diabetes and CKD. This 2024 abbreviatedupdated guidance summarises the recommendations and the implications for clinical practice for healthcare professionals who treat people with diabetes and CKD in primary, community and secondary care settings.

The effect of exercise training in people with pre-dialysis chronic kidney disease: a systematic review with meta-analysis.

Chronic kidney disease (CKD) is a global health issue with high mortality and economic costs. Exercise has potential benefits for pre-dialysis CKD management. This review examines the impact of exercise on CKD patients not on dialysis, focusing on improvement in various health parameters. Findings aim to inform the role of exercise in pre-dialysis CKD care. A systematic search of MEDLINE, EMBASE, the Cochrane Library of Controlled Trials, CINAHL, and SPORTDiscus, up to August 31, 2023, used key terms relating to pre-dialysis CKD and exercise. We pooled randomized controlled trials (RCTs) comparing exercise with usual care and conducted meta-analyses based on a random effects inverse variance model with the effect measure of mean difference. Of 1162 identified studies, 37 RCTs met the inclusion criteria including 1248 participants. Significant improvements were identified for peak VO2, mean difference [MD] (2.66mL/kg/min; 95% confidence interval [CI] 1.48, 3.83; p < 0.00001); the 6-min walk (MD 58.83m; 95% CI 35.26, 82.41; p < 0.00001), timed up and go (standardised mean difference -0.35; 95% CI -0.54, -0.15; p = 0.0006), 2-min step (MD 57.48 steps; 95% CI 27.80, 87.16; p = 0.0001), and sit to stand tests (MD 4.55 repetitions; 95% CI 1.49, 7.60; p = 0.004); short form [SF]-36 general health (MD 4.26; 95% CI 0.04, 8.47; p = 0.05); SF-36 mental component summary (MD 1.84; 95% CI 0.18, 3.51; p = 0.03); estimated glomerular filtration rate (MD 2.19mL/min/1.73 m2; 95% CI 0.97, 3.50; p = 0.001); serum cystatin-C (MD -0.06mg/L; 95% CI -0.11, -0.02; p = 0.004); resting heart rate (MD -1.97 bpm; 95% CI -3.84, -0.11; p = 0.04); triglycerides (MD -12.97mg/dL; 95% CI -17.30, -8.63; p < 0.00001); glycosylated haemoglobin (MD -0.25%; 95% CI -0.50, -0.01; p = 0.04); waist circumference (MD -3.12cm; 95% CI -4.37, -1.86; p < 0.00001); and interleukin-6 (MD -2.24pg/mL; 95% CI -3.87. -0.61; p = 0.007). Analysis revealed improvements in aerobic capacity, functional ability, quality of life, estimated glomerular filtration rate, serum cystatin-C, resting heart rate, waist circumference, triglyceride, glycosylated haemoglobin, and interleukin-6 levels.

Chronic kidney disease in Kuwait: a multicenter study of two cohorts with different levels of access to public healthcare

IntroductionKuwait has a large expatriate community who experience both restricted access to public health services and lower income than Kuwaiti citizens. Given these conditions, we examined differences in characteristics and management of chronic kidney disease (CKD) between Kuwaitis and expatriates.MethodsClinical and laboratory data for adult CKD Stages 3–5 not on dialysis (CKD 3–5 ND) patients with native kidneys attending nephrology clinics in all Ministry of Health hospitals collected from January 1, 2022, to December 31, 2022. Cohort was then divided into Kuwaiti patients and expatriates patients for comparison.ResultsWe collected data from 2,610 patients (eGFR: 30.8 ml/min/1.73m2; age: 62.6 years; males: 56.7%; Kuwaitis: 62.1%). Kuwaitis were older (63.94 vs. 60.3 years, p < 0.001), with lower mean eGFR (30.4 vs. 31.5 ml/min/1.73m2, p = 0.052) than non-Kuwaitis, however, Kuwaitis had lower mean blood pressure (137.2/76.5 vs. 139.1/78.9 mmHg, p = 0.006), lower HbA1c in diabetics (7.59 vs. 7.82%, p = 0.010), and better lipid profile despite higher body mass indexes (29.6 vs. 28.9 kg/m2, p = 0.002). Both groups had high diabetes mellitus and hypertension rates. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were used in only 22.6% and renin-angiotensin-aldosterone system inhibitors (RAASi) in only 46.2%.ConclusionCKD 3–5 ND is caused by diabetes mellitus in 56.6% of cases, and the majority have hypertension. In our study, non-Kuwaitis had higher eGFR; however, restricted public healthcare access and lower income can lead to an unhealthy diet and suboptimal care, which may cause higher blood pressure, higher HbA1c, and a higher dyslipidemia rate. RAASi and SGLT2i utilization must increase to combat CKD, and antihypertensive selection must improve.

Beyond Dialysis: Reshaping CKD Paradigms in Developing Nations

Dear Sir / Madam, Respected Editor, I am writing to bring attention to the critical need for increased research on conservative kidney management (CKM) in the context of patients with advanced chronic kidney disease (CKD). The recent advancements in developed nations have demonstrated that CKM is a novel and effective approach to caring for CKD patients, particularly those who choose not to pursue maintenance dialysis. Historically, medical care for individuals with CKD has adhered to a paternalistic model, where clinicians make treatment decisions independent of patient preferences. JS Scherer et al observed that a provider's assessment of a patient's frailty and response exerted a more substantial influence on the treatment provided than the patient’s comorbidities, functional status, and stated preferences. 2 Furthermore, another study showed that some individuals exhibited a preference for conservative care after shared-decision making, irrespective of the potential survival benefits offered by dialysis if it entailed frequent hospital visits or travel restrictions. 3 This underscores the significance of patient autonomy, where the pursuit of freedom can sometimes outweigh the emphasis on clinical outcomes. However, contemporary CKD management in the 21st century emphasizes shared decision-making and patient empowerment. While research suggests CKM can improve quality of life, reduce hospitalizations, and minimize invasive procedures, offering a valuable alternative to dialysis, its impact on survival becomes less clear for patients over 80 or those with multiple comorbidities.4 Additionally, the inclusion of patients and their families in collaborative decision-making processes has proven advantageous, supported by specialized decision aids that promote well-informed discussions regarding CKM with healthcare providers.5 Nephrologists face significant challenges in implementing effective conservative kidney management (CKM) due to a lack of clinical guidelines, training, evidence, and system-level infrastructure. This has resulted in limited awareness and discussion of CKM among patients and healthcare providers, hindering its adoption. With the global burden of chronic kidney disease (CKD) increasing significantly over the past three decades, particularly affecting low- and middle-income countries, there is a pressing need for innovative, cost-effective solutions. CKM emerges as a viable alternative where dialysis is often inaccessible or unaffordable, with the potential to significantly impact CKD management, especially in resource-limited settings such as Pakistan. I urge the scientific community and policymakers to recognize the importance of supporting and conducting research on conservative kidney management. ---Continue

Exploring Adiposity and Chronic Kidney Disease: Clinical Implications, Management Strategies, Prognostic Considerations.

Obesity poses a significant and growing risk factor for chronic kidney disease (CKD), requiring comprehensive evaluation and management strategies. This review explores the intricate relationship between obesity and CKD, emphasizing the diverse phenotypes of obesity, including sarcopenic obesity and metabolically healthy versus unhealthy obesity, and their differential impact on kidney function. We discuss the epidemiological evidence linking elevated body mass index (BMI) with CKD risk while also addressing the paradoxical survival benefits observed in obese CKD patients. Various measures of obesity, such as BMI, waist circumference, and visceral fat assessment, are evaluated in the context of CKD progression and outcomes. Mechanistic insights into how obesity promotes renal dysfunction through lipid metabolism, inflammation, and altered renal hemodynamics are elucidated, underscoring the role of adipokines and the renin-angiotensin-aldosterone system. Furthermore, the review examines current strategies for assessing kidney function in obese individuals, including the strengths and limitations of filtration markers and predictive equations. The management of obesity and associated comorbidities like arterial hypertension, type 2 diabetes mellitus, and non-alcoholic fatty liver disease in CKD patients is discussed. Finally, gaps in the current literature and future research directions aimed at optimizing the management of obesity-related CKD are highlighted, emphasizing the need for personalized therapeutic approaches to mitigate the growing burden of this intertwined epidemic.

Assessment of pulmonary hypertension in patients diagnosed with chronic kidney disease

BackgroundPulmonary hypertension (PH) represents a condition affecting small arteries of the pulmonary vasculature, inducing progressive blockage that results in increased pulmonary vascular resistance (PVR) as well as pulmonary arterial pressure (PAP), which are defining features of such a disorder. This work was aimed at investigating the PH prevalence among chronic kidney disease (CKD) cases and its linkage to disease severity and the relations between CKD management and PH.MethodsOur prospective observational descriptive cross-sectional study was conducted on 120 CKD patients at the Chest Department, Tanta University Hospitals and Air Forces Specialized Hospitals from December 2020 to December 2022.ResultsThe most frequent diagnosis of PH was Group 1 pulmonary arterial hypertension (36.7%) followed by Group 2 cardiac causes (30%) followed by Group 4 chronic thromboembolic PH (26.7%) and (6.7%) experienced normal pulmonary hemodynamics by RHC. Also, a statistically significant correlation was documented among CKD staging as well as risk assessment of PH (p 0.024). A significant association was documented among treatment as well as risks for developing PH (p 0.034). Patients on medical treatment (60%) showed low risk while (33.3%) of patients depending on dialysis showed high risk.ConclusionsPH was diagnosed in 28 CKD patients confirmed by right (RT) side cardiac catheterization among 120 CKD patients studied for PH assessment representing 23.5%. Right-side cardiac catheterization is more accurate than echocardiography in confirming the diagnosis of PH. The severity of PH showed significant association with the CKD stage.

Identification of serum biomarkers for chronic kidney disease using serum metabolomics

This study aimed to identify biomarkers for chronic kidney disease (CKD) by studying serum metabolomics. Serum samples were collected from 194 non-dialysis CKD patients and 317 healthy controls (HC). Using ultra-high-performance liquid chromatography-tandem mass spectrometry (UPLC-MS), untargeted metabolomics analysis was conducted. A random forest model was developed and validated in separate sets of HC and CKD patients. The serum metabolomic profiles of patients with chronic kidney disease (CKD) exhibited significant differences compared to healthy controls (HC). A total of 314 metabolites were identified as significantly different, with 179 being upregulated and 135 being downregulated in CKD patients. KEGG enrichment analysis revealed several key pathways, including arginine biosynthesis, phenylalanine metabolism, linoleic acid metabolism, and purine metabolism. The diagnostic efficacy of the classifier was high, with an area under the curve of 1 in the training and validation sets and 0.9435 in the cross-validation set. This study provides comprehensive insights into serum metabolism in non-dialysis CKD patients, highlighting the potential involvement of abnormal biological metabolism in CKD pathogenesis. Exploring metabolites may offer new possibilities for the management of CKD.

Sacubitril/valsartan reduces proteinuria depending on blood pressure in patients with stage 4-5 chronic kidney disease.

Blood pressure (BP) control is an important factor in the management of chronic kidney disease (CKD). Several studies have shown that BP in many patients with CKD remained uncontrolled even with multiple medications. Sacubitril/valsartan, an angiotensin receptor neprilysin inhibitor (ARNI), has been newly approved for treating hypertension in Japan. However, the renoprotective effects remain unclear, particularly in patients with advanced CKD. Here, we investigated the effects on proteinuria of this ARNI in patients with stage 4-5 CKD. We retrospectively collected data from outpatients with stage 4-5 CKD who started ARNI from January until December 2023. The primary outcome was the change in urine protein creatinine ratio (UPCR) at 6months after ARNI initiation. Secondary outcomes were systolic and diastolic BP, estimated glomerular filtration rate (eGFR), serum potassium, and serum uric acid (UA). We analyzed factors associated with 50% UPCR reduction by multivariate analysis. In total, 47 patients were analyzed. ARNI reduced UPCR from 2.14g/gCr (interquartile range; 1.09-2.91) to 1.05g/gCr (0.42-1.95; p < 0.001). Systolic BP fell from 150.0mmHg (139.5-160.0) to 134.0mmHg (124.5-140.0; p < 0.001). No significant changes in eGFR, serum potassium, and serum uric acid were observed, except for a slight decrease in eGFR among patients with conversion from a renin-angiotensin system inhibitor to ARNI. In multivariate regression analysis, higher systolic BP (per 10-mmHg increase) was significantly associated with reduced proteinuria (odds ratio 2.51, 95% confidence interval 1.35-4.66; p = 0.004). ARNI reduced proteinuria in patients with stage 4-5 CKD, particularly for those with uncontrolled hypertension.

Knowledge and competence of primary healthcare physicians in the management of diabetes-related chronic kidney disease

BACKGROUND: Diabetes mellitus (DM) is a primary cause of chronic kidney disease (CKD), a significant and growing global health issue. Primary healthcare physicians (PHPs) are crucial in detecting, managing, and preventing CKD, but many lack the necessary knowledge and skills to effectively diagnose and manage the disease. This study assessed the knowledge and competence of PHPs in managing diabetes-related CKD. MATERIALS AND METHODS: This cross-sectional study was conducted among all Primary Healthcare Physicians (PHPs) working at Primary Healthcare Center (PHC) in King Abdulaziz Medical City of the National Guard, Jeddah, Saudi Arabia. An online questionnaire was sent to all PHPs and data were collected from January 2024 to February 2024. Data analysis performed utilizing RStudio (version 4.3.1). Categorical variables were expressed as frequencies and percentages, whereas mean and standard deviations were computed for continuous variables. Kruskal–Wallis rank sum test was used to determine differences in confidence scores across various demographic and occupational characteristics. A multivariable linear regression analysis was performed to identify factors related to confidence. RESULTS: Of 141 PHPs, 122 filled online questionnaire yielding a response rate of 86.5%. responded. The majority (90.2%) were 18–45 years of age, 68.0% were qualified as family physicians, 38.0% belonged to the specialized poly clinic, and 54.9% had less than 5 years of experience. PHPs showed a varied levels of confidence and knowledge. While 76.2% were confident about the stages of kidney disease and 65.6% acknowledged the importance of the urine albumin-creatinine ratio (uACR) test, 58.1% were uncertain of interpreting uACR results and CKD diagnostic criteria. More than 60.0% were uncertain of the treatment steps postdiagnosis and prediction of CKD prognosis. Age, qualification, specialization in family medicine, and clinic affiliation were significantly related to confidence levels. CONCLUSION: The study underscores notable gaps in PHPs' knowledge and confidence concerning CKD screening, diagnosis, and management. Continuous education and targeted interventions are essential for the improvement of PHPs' competence and patient outcomes in the management of CKD.

Early Identification and Management of Chronic Kidney Disease: A Narrative Review of the Crucial Role of Primary Care Practitioners.

Early-stage (stage1-3) chronic kidney disease (CKD) has an asymptomatic presentation such that most people with CKD are unaware of their disease status and remain undiagnosed. CKD is associated with multiple long-term conditions (MLTC), or multimorbidity, the most common of these being cardiovascular disease, hypertension, and type2 diabetes. Primary care practitioners (PCPs) are crucial in the early identification and management of patients with CKD. For individuals at high risk of CKD, measurements of estimated glomerular filtration rate, urine albumin-creatinine ratio, and blood pressure should be obtained regularly and recorded in a timely manner. The importance of lifestyle changes in the prevention and management of CKD should also be highlighted. A recent addition to the treatment of CKD in people with and without type2 diabetes has been the recommendation by clinical practice guidelines of a sodium-glucose co-transporter2 (SGLT2) inhibitor alongside a renin-angiotensin-aldosterone system inhibitor as foundational therapy. SGLT2 inhibitors prevent CKD progression and reduce fatal and non-fatal kidney and cardiovascular events, hospitalization for heart failure, and all-cause mortality, and they have a favorable safety and tolerability profile. However, uptake has been slow, particularly in people with CKD without type2 diabetes. A multifaceted approach is required to ensure that people with CKD receive optimal kidney protection. Measures to raise awareness of the importance of early identification and intervention include local/national campaigns via social media and practice-based education; clinical education programs; integration of clinical decision support tools into electronic health records; detection programs built around electronic health records; and good interdisciplinary communication. PCPs at the forefront of multidisciplinary care are best placed to implement the evidence-based clinical practice CKD guidelines for lifestyle modification and guideline-directed medical therapy.