National Kidney Foundation Kidney Disease Outcomes Quality Initiative Research Articles

Epidemiological Characteristics of Chronic Renal Failure Patients of Hodeidah, Yemen in 2023

Chronic renal failure (CRF) is an emergent worldwide public health problem. The increasing incidence of CRF warrants a need for an epidemiological approach to better understand the disease and its prevention. Therefore, the study aims to describe the epidemiological characteristics of chronic renal failure patients in Hodeidah, Yemen. The study included 560 patients with CRF in retrospective study (a case series based on medical files) in Center of Dialysis and Renal Diseases of Hodeidah, Yemen from 1st January 2023 to 31st December 2023. The patients were diagnosed based on evidence – based clinical practice guideline of all stages of CRF that was extracted from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKFKDOQI). Epidemiological data were reported with ethical approval consideration, data obtained were analyzed. 560 cases were diagnosed with renal failure, 555 patients (99.107 %) of them were diagnosed with CRF and 5 patients (0.89 %) were diagnosed with acute renal failure (ARF). CRF patients was founded 61.81 % in the males while 38.11 % in the females. However, this difference was statistically significant (X2= 30.921; p < 0.00001). The age range of patients was from 5 to 95 years, where 54.64% of cases occurred more than 50 years then 39.28 % between 18 to 49 years and the lower frequency was in children less than 18 years (5.22%) with different significant ( X2= 226.314 ; p < 0.00001). In addition, 81.98 % of patients in rural and 18.02 % in urban. The maximum cases were reported in summer session namely 13.21 % in July and 11.25 % in August. On the other hand , the major causes were chronic diseases 406 case (73.14 %) that diagnosed and recorded , 161 case (29 %) of hypertension ,132 case (23.78 %) of diabetes , 113 (20.36 %) of inflammation nephrolithiasis obstructive uropathy , 8 cases (1.44 %) of genetic polycystic renal disease , and 4 cases ( 0.72 % ) of sedative narcotic addiction and 137 case (24.68%) of unknown causes with different significant ( X2= 119.00 ; p < 0.00001). The chronic diseases namely diabetes and hypertension were the major causes reported to develop the CRF, therefore, to prevent the development of CRF based on center for control diseases and control (CDC), managing risk factors.

Biomedical Evaluation of Early Chronic Kidney Disease in the Air Force: Building a Predictive Model from the Taiwan Military Health Service.

Chronic kidney disease (CKD) is one of the most common diseases worldwide. The increasing prevalence and incidence of CKD have contributed to the critical problem of high medical costs. Due to stressful environments, aircrew members may have a high risk of renal dysfunction. A better strategy to prevent CKD progression in Air Force personnel would be to diagnosis CKD at an early stage. Since few studies have been conducted in Taiwan to examine the long-term trends in early CKD in Air Force aircrew members, this study is highly important. We investigated the prevalence of CKD and established a predictive model of disease variation among aircrew members. In this retrospective study, we included all subjects who had received physical examinations at a military hospital from 2004 to 2010 and who could be tracked for four years. The Abbreviated Modification of Diet in Renal Disease Formula (aMDRD) was used to estimate the glomerular filtration rate (GFR) and was combined with the National Kidney Foundation/ Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) to identify CKD patients. A total of 212 aircrew members were assessed. The results showed that the prevalence of CKD was 3.8%, 9.4%, 9.0%, and 9.4% in each of the four years. According to the logistic regression analysis, abnormal urobilinogen levels, ketones, and white blood cell (WBC) counts in urine and a positive urine occult blood test increased the risk of CKD. A positive urine occult blood test can be used to predict the future risk of CKD. Moreover, the generalized estimating equation (GEE) model showed that a greater risk of CKD with increased examination time, age and seniority had a negative effect. In conclusion, abnormal urobilinogen levels, ketones, and urine WBC counts in urine as well as a positive urine occult blood test might serve as independent predictors for CKD. In the future, we can focus not only on annual physical examinations but also on simple and accurate examinations, such as urine occult blood testing, to determine the risk of CKD and prevent its progression in our aircrew members.

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

Periodontal disease as a predictor of chronic kidney disease (CKD) stage in older adults.

ObjectiveThe aim of this study was to evaluate periodontal disease as a predictor of chronic kidney disease (CKD) stage in older adults.MethodsA total of 1159 adults aged 65 to 80 years and diagnosed with periodontal disease and CKD (stages 1, 2, and 3) were randomly selected for a cross-sectional study. Periodontal status was assessed using the Community Periodontal Index of Treatment Needs (CPITN) and CKD was staged using the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines.ResultsIn patients with stage 1 CKD, the odds ratios (ORs) (95% confidence intervals [CIs]) for CPITN-1, CPITN-2, CPITN-3, and CPITN-4 were 1.13 (0.83–1.55), 1.47 (1.13–1.81), 1, and 1, respectively. In patients with stage 2 CKD, the ORs (95% CIs) for CPITN-1, CPITN-2, CPITN-3, and CPITN-4 were 1.49 (1.14–1.93), 1.37 (1.02–1.78), 3.07 (2.81–3.25), and 3.65 (3.49–3.71), respectively. In patients with stage 3 CKD, the ORs (95% CIs) for CPITN-1, CPITN-2, CPITN-3, and CPITN-4 were 1, 1, 4.61 (4.47–5.21), and 5.23 (5.14–5.47), respectively.ConclusionThe highest CPITN values (CPITN-3 and CPITN-4) were associated with CKD stages 2 and 3. Thus, periodontal disease may be associated with progression of CKD.

KDOQI US Commentary on the 2018 KDIGO Clinical Practice Guideline for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C

The first KDIGO (Kidney Disease: Improving Global Outcomes) guideline for the prevention, diagnosis, evaluation, and treatment of hepatitis C virus (HCV) infection was published in 2008. The ensuing decade bore witness to remarkable advances in the treatment of HCV infection following the approval of direct-acting antiviral (DAA) agents that deliver cure rates routinely >95%. In this context, the KDIGO organization correctly recognized the need for an updated HCV guideline that would be relevant to the treatment of HCV-infected patients with kidney disease in the DAA era. The current NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) commentary provides an in-depth review and perspective on the 2018 KDIGO guideline. Of note, the KDIGO work group made significant updates to guideline chapters 2 and 4 as a direct result of the availability of DAAs. The intent of this commentary is to provide useful interpretation for nephrologists and other practitioners caring for HCV-infected patients with chronic kidney disease, including dialysis patients and kidney transplant recipients. The availability of DAA agents that are safe and highly effective has created new opportunities, such as the transplantation of kidneys from HCV-infected kidney donors. The ability to treat HCV infection in patients with kidney disease will have a significant impact on the care of our patients and should favorably influence long-term outcomes as well.

Sucroferric Oxyhydroxide as Part of Combination Phosphate Binder Therapy among Hemodialysis Patients.

Combination therapy with multiple phosphate binders is prescribed to reduce elevated serum phosphorus (sP) concentrations among patients on maintenance hemodialysis. Sucroferric oxyhydroxide (SO), an iron-based phosphate binder, has demonstrated efficacy at reducing sP while also being associated with a low pill burden. Whereas the effects of SO monotherapy have been well characterized in clinical trials and observational cohorts, little is known about the effects of SO-containing combination therapy. Patients on hemodialysis (N=234) at Fresenius Kidney Care (FKC) who received ≥120 days of uninterrupted phosphate binder combination therapy with SO were included in this retrospective study. Patient data were censored after SO discontinuation, end of care at FKC, or completion of 12 months of follow-up. Quarterly (Q) changes in phosphate binder pill burden, mean sP, and proportion of patients achieving National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI)-recommended sP levels (≤5.5 mg/dl) were compared between baseline (-Q1) and follow-up (Q1-Q4). Phosphate binder combination therapy with SO was associated with significant increase in the proportion of patients with sP ≤5.5 mg/dl (from 19% at baseline to up to 40% at follow-up; P<0.001) and reduction in sP at all postbaseline time points (from 6.7 mg/dl to 6.2-6.3 mg/dl; P<0.001). Patients on calcium acetate (N=54) and sevelamer (N=94) who added SO therapy at follow-up resulted in a ≥250% increase in patients achieving sP ≤5.5 mg/dl (all P<0.001). Whereas mean phosphate binder pill burden increased with initiation of phosphate binder combination therapy with SO (15.8 pills/d at Q1 versus 12.3 pills/d at -Q1), continued use of SO was associated with down-titration of non-SO phosphate binders such that, by Q4, mean total PB pill burden reduced to 12.3 pills/d. For patients on hemodialysis with uncontrolled hyperphosphatemia, combination therapy with SO may allow for sustained improvements in sP control without adversely affecting phosphate binder pill burden.

Role of Balloon Assisted Maturation Technique in the Rate of AVF Maturation in Chronic Renal Failure Patients

Abstract Background the current recommendations from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKFDOQI) favors the use of arteriovenous fistulas (AVF) over grafts and central catheters, in an effort to decrease cost, increase long term patency, reduce interventions and decrease patient morbidity. Purpose this study was designed to determine the rate of AVF maturation using the (BAM) technique; the primary and secondary patency rate and to evaluate the feasibility and safety of the (BAM) technique for the immature or failed AVF. Patients and Methods 30 chronic renal failure patients were selected for the purpose of this study from patients presented to vascular surgery clinic, Ain Shams University Hospital and Nasr City Hospital. Results this study included 30 arteriovenous fistula, belonging to 30 chronic renal failure patient. Their mean age was 57.6 years (±14.6). The demographic characteristics and risk factor distribution are shown below. Conclusion endovascular techniques have an important role to play in helping the dialysis community meet the goals of the Fistula First Initiative. To meet these goals, the previously mentioned techniques need to be used in varying degrees to salvage &amp;gt; 95% of the nearly 60% of AVFs that fail to mature. When prolonged catheter time is taken into account, it is imperative to have a systematic method for salvaging these failing accesses before catheter-related complications are encountered.

Overcoming Barriers for Uptake and Continued Use of Home Dialysis: An NKF-KDOQI Conference Report

Home dialysis modalities are used in a minority of patients with kidney failure in the United States. During the 2018 National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) Home Dialysis Conference, numerous ideas were suggested to help minimize barriers for the uptake and retention of home dialysis therapies. First, educational tools are needed to increase knowledge about home dialysis modalities (eg, continuous ambulatory peritoneal dialysis, continuous cycling peritoneal dialysis, and home hemodialysis). Implementation of a hub and spoke model, pairing smaller and/or newer home dialysis programs with larger more sophisticated programs that offer education and mentoring, may help dialysis programs to grow and prosper. This pairing can be facilitated by traditional conferences and newer modalities such as telemedicine and training applications. Peer support to patients, such as that offered through the NKF Peers Program, and support and respite to care partners can have beneficial effects toward both increasing the number of patients who choose home dialysis as a modality and improving retention in home dialysis programs. Anticipating and understanding both patient and care partner burden is important for the development and implementation of patient- and care partner-centered support programs that can be deployed before a patient ceases home therapy. Finally, aligning Medicare reimbursement to support appropriate increased home dialysis uptake to prioritize both transplantation and home dialysis as the first-line treatments for kidney failure.

KDOQI US Commentary on the 2017 KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors

Living kidney donation is widely practiced throughout the world. During the past 2 decades, various groups have provided guidance about the evaluation and care of living donors. However, during this time, our knowledge in the field has advanced substantially and many agreed on the need for a comprehensive, unifying document. KDIGO (Kidney Disease: Improving Global Outcomes) addressed this issue at an international level with the publication of its clinical practice guideline on the evaluation and care of living kidney donors. The KDIGO work group extensively reviewed the available literature and wrote a series of guideline recommendations using various degrees of evidence when available. As has become recent practice, NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) convened a work group to provide a commentary on the KDIGO guideline, with a focus on how these recommendations apply in the context of the United States. In the United States, the United Network for Organ Sharing (UNOS) guides and regulates the practice of living kidney donation. While the KDIGO guideline for the care of living kidney donors and UNOS policy are similar in most aspects of the care of living kidney donors, several important areas are not consistent or do not align with common practice by US transplantation programs in areas in which UNOS has not set specific policy. For the time being, and recognizing the value of the KDIGO guidelines, US transplantation programs should continue to follow UNOS policy.

Chronic Kidney Disease in Patients Undergoing Cardiac Device Placement: Results of a Retrospective Study.

BackgroundCardiovascular issues (especially arrhythmia and sudden cardiac death) are one of the most common causes of mortality in patients with chronic kidney disease (CKD). To minimize cardiac mortality, these patients frequently require various cardiac devices, such as pacemakers, loop recorders, and defibrillators which can compromise their vascular access. In this study, we aim to determine the prevalence of CKD in patients undergoing cardiac device placement and their progression of CKD.MethodsInstitutional review board approval was obtained for this study. A total of 688 patients undergoing cardiac device placement were included in this study over a 3-year period at Jersey Shore University Medical Center. Demographic characteristics, comorbidities, base-line renal functions during the procedure, types of cardiac devices, sites of vascular access and follow-up renal function when available were assessed retrospectively. Patients were categorized into CKD stages 1 - 5 based on the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines. The patients who were already on hemodialysis were excluded in this study.ResultsThe average age of the patient were 73.9 years with male predominance (60%). A total of 227 patients (33%) had estimated glomerular filtration rate (eGFR) < 60 mL/min consistent with the evidence of advanced-stage CKD (stages 3 - 5) at the time of cardiac device placement. The most common types of device placements were new insertion/replacement of atrial and ventricular leads (39.5%), loop recorder implantation (21.1%) and generator changes on an already implanted device (11%). Only 4% (28/688) had a leadless cardiac device placement. The most common access sites were subclavian (47.1%), axillary (32.3%) and femoral (12.2%).ConclusionsThe present study demonstrated that nearly one-third of the patient undergoing cardiac device placement had an advanced degree of renal failure. Because CKD is a progressive disease, many of these patients might require renal replacement therapy in the future. Transvenous devices is not a good choice in this group of patients as they will ultimately require an arteriovenous fistula. Subcutaneous leadless cardiac device insertion might be a better option in patients with advanced CKD.

Use of Renin-Angiotensin System Blockade in Advanced CKD: An NKF-KDOQI Controversies Report

Multiple clinical trials have demonstrated that renin-angiotensin system (RAS) blockade with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers effectively reduces chronic kidney disease (CKD) progression. However, most clinical trials excluded participants with advanced CKD (ie, estimated glomerular filtration rate [eGFR]<30mL/min/1.73m2). It is acknowledged thatinitiation of RAS blockade is often associated with an acute reduction in eGFR, which is thought to be functional, but may result in long-term preservation of kidney function through the reductions inglomerular intracapillary pressure conferred by these agents. In this National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) report, we discuss the controversies regarding use of RAS blockade in patients with advanced kidney disease. We review available published data on this topic and provide perspective on the impact of RAS blockade on changes in eGFRs and potassium levels. We conclude that more research is needed to evaluate the therapeutic index of RAS blockade in patients with advanced CKD.

Effects of fenoldopam on renal blood flow in hypertensive chronic kidney disease.

The synthetic drug fenoldopam mesylate (FM) may have a renoprotective role, and a "renal dose" of 0.1µg/kg/min intravenous (IV) infusion of FM has been reported as able to increase renal blood flow without affecting systemic blood pressure. But conclusive data are still lacking. We aimed to investigate by color-Doppler ultrasonography the effects of IV administration of FM at this dosage in hypertensive chronic kidney disease (CKD) patients, and verify whether it may induce any systemic hemodynamic alteration. In 60 hypertensive CKD patients, we measured by duplex Doppler ultrasonography, at baseline and during infusion of 0.1µg/kg/min of FM, the systolic and diastolic flow velocity (sampled at the renal hilum, intermediate section and origin of both renal arteries) and the intra-parenchymal renal resistive index (RRI) sampled on interlobular arteries of both kidneys. Patients were divided into four subgroups (I-IV) according to classification of National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-DOQI). Infusion of 0.1µg/kg/min FM significantly decreased the RRI (0.73 ± 0.05 vs. 0.65 ± 0.06; p < 0.0001) and increased the systolic and diastolic flow velocities in all renal artery tracts examined. No single episode of systemic hypotension was observed. Very low-dose FM may significantly increase renal blood flow and exert a renal protective effect in hypertensive CKD patients. Infusion of FM at such low dosage appears also to be quite safe, even in CKD and hypertensive patients.

Oral Anticoagulants to Prevent Stroke in Nonvalvular Atrial Fibrillation in Patients With CKD Stage 5D: An NKF-KDOQI Controversies Report

Stroke risk may be more than 3-fold higher among patients with chronic kidney disease stage 5D (CKD-5D) compared to the general population, with the highest stroke rates noted among those 85 years and older. Atrial fibrillation (AF), a strong risk factor for stroke, is the most common arrhythmia and affects >7% of the population with CKD-5D. Warfarin use is widely acknowledged as an important intervention for stroke prevention with nonvalvular AF in the general population. However, use of oral anticoagulants for stroke prevention in patients with CKD-5D and nonvalvular AF continues to be debated by the nephrology community. In this National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) controversies report, we discuss the existing observational studies that examine warfarin use and associated stroke and bleeding risks in adults with CKD-5D and AF. Non-vitamin K-dependent oral anticoagulants and their potential use for stroke prevention in patients with CKD-5D and nonvalvular AF are also discussed. Data from randomized clinical trials are urgently needed to determine the benefits and risks of oral anticoagulant use for stroke prevention in the setting of AF among patients with CKD-5D.

Ultrafiltration Rate Thresholds in Maintenance Hemodialysis: An NKF-KDOQI Controversies Report.

High hemodialysis ultrafiltration rate (UFR) is increasingly recognized as an important and modifiable risk factor for mortality among patients receiving maintenance hemodialysis. Recently, the Kidney Care Quality Alliance (KCQA) developed a UFR measure to assess dialysis unit care quality. The UFR measure was defined as UFR≥13mL/kg/h for patients with dialysis session length less than 240 minutes and was endorsed by the National Quality Forum as a quality measure in December 2015. Despite this, implementation of a UFR threshold remains controversial. In this NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) Controversies Report, we discuss the concept of the UFR, which is governed by patients' interdialytic weight gain, body weight, and dialysis treatment time. We also examine the potential benefits and pitfalls of adopting a UFR threshold as a clinical performance measure and outline several aspects of UFR thresholds that require further research.

Timing of Dialysis Initiation, Duration and Frequency of Hemodialysis Sessions, and Membrane Flux: A Systematic Review for a KDOQI Clinical Practice Guideline

In 2006, NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) published clinical practice guidelines for hemodialysis adequacy. Recent studies evaluating hemodialysis adequacy as determined by initiation timing, frequency, duration, and membrane type and prompted an update to the guideline. Systematic review and evidence synthesis. Patients with advanced chronic kidney disease receiving hemodialysis. We screened publications from 2000 to March 2014, systematic reviews, and references and consulted the NKF-KDOQI Hemodialysis Adequacy Work Group members. We included randomized or controlled clinical trials in patients undergoing long-term hemodialysis if they reported outcomes of interest. Early versus late dialysis therapy initiation; more frequent (>3 times a week) or longer duration (>4.5 hours) compared to conventional hemodialysis; low- versus high-flux dialyzer membranes. All-cause and cardiovascular mortality, myocardial infarction, stroke, hospitalizations, quality of life, depression or cognitive function scores, blood pressure, number of antihypertensive medications, left ventricular mass, interdialytic weight gain, and harms or complications related to vascular access or the process of dialysis. We included 32 articles reporting on 19 trials. Moderate-quality evidence indicated that earlier dialysis therapy initiation (at estimated creatinine clearance [eClcr] of 10-14mL/min) did not reduce mortality compared to later initiation (eClcr of 5-7mL/min). More than thrice-weekly hemodialysis and extended-length hemodialysis during a short follow-up did not improve clinical outcomes compared to conventional hemodialysis and resulted in a greater number of vascular access procedures (very low-quality evidence). Hemodialysis using high-flux membranes did not reduce all-cause mortality, but reduced cardiovascular mortality compared to hemodialysis using low-flux membranes (moderate-quality evidence). Few studies were adequately powered to evaluate mortality. Heterogeneity of study designs and interventions precluded pooling data for most outcomes. Limited data indicate that earlier dialysis therapy initiation and more frequent and longer hemodialysis did not improve clinical outcomes compared to conventional hemodialysis.

Arteriovenous graft configuration in hemodialysis: does it matter?

The current guidelines for arteriovenous graft (AVG) configuration in hemodialysis state the following sequence: forearm loop, upper arm straight or curved and upper arm looped. These recommendations are based upon literature from the 1980s. Modern patient demographics and patient treatment algorithms, i.e., the Fistula First initiative (FFI), have greatly changed the current practice environment. It is not clear if these changes alter the outcomes of AVGs based upon configuration. The most recent National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF/K-DOQI) guidelines for vascular access were reviewed. Articles cited to support recommendations for AVG configuration were evaluated. The following search terms: arteriovenous graft configuration, access configuration, PTFE configuration in hemodialysis and straight, looped, curved graft configuration were used to search PubMed, Ovid, Medline and Google scholar. Articles that included data comparing AVG configuration were included. Citations within those articles were examined for publications overlooked in the initial search. Four articles and one abstract were reviewed and separated into pre- and post-FFI groups. Pre-FFI articles demonstrate superiority of forearm looped AVG over straight forearm grafts. Post-FFI, the literature suggests that primary patency, thrombosis and steal are not affected by configuration and location, although looped configuration may have superior secondary patency. The available literature is mixed regarding the effect of configuration on AVG outcomes. Current studies illustrate the effect may be limited and that larger randomized controlled trials are necessary to draw firm conclusions. Regardless, adequate inflow and an appropriately sized outflow vein are paramount for optimal graft performance.

KDOQI US Commentary on the 2013 KDIGO Clinical Practice Guideline for Lipid Management in CKD

The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guideline for management of dyslipidemia in chronic kidney disease (CKD) was published in 2003. Since then, considerable evidence, including randomized controlled trials of statin therapy in adults with CKD, has helped better define medical treatments for dyslipidemia. In light of the new evidence, KDIGO (Kidney Disease: Improving Global Outcomes) formed a work group for the management of dyslipidemia in patients with CKD. This work group developed a new guideline that contains substantial changes from the prior KDOQI guideline. KDIGO recommends treatment of dyslipidemia in patients with CKD primarily based on risk for coronary heart disease, which is driven in large part by age. The KDIGO guideline does not recommend using low-density lipoprotein cholesterol level as a guide for identifying individuals with CKD to be treated or as treatment targets. Initiation of statin treatment is no longer recommended in dialysis patients. To assist US practitioners in interpreting and applying the KDIGO guideline, NKF-KDOQI convened a work group to write a commentary on this guideline. For the most part, our work group agreed with the recommendations of the KDIGO guideline, although we describe several areas in which we believe the guideline statements are either too strong or need to be more nuanced, areas of uncertainty and inconsistency, as well as additional research recommendations. The target audience for the KDIGO guideline includes nephrologists, primary care practitioners, and non-nephrology specialists such as cardiologists and endocrinologists. As such, we also put the current recommendations into the context of other clinical practice recommendations for cholesterol treatment.

25-Hydroxyvitamin D Testing and Supplementation in CKD: An NKF-KDOQI Controversies Report

The benefits of and thresholds for 25-hydroxyvitamin D administration in individuals with chronic kidney disease (CKD) remain uncertain. In this report, NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) endeavors to provide health care providers with the latest information on a controversial area in the management of CKD, the role for nutritional vitamin D. Although knowledge of the biological mechanisms of vitamin D for bone maintenance in individuals with all stages of CKD has expanded, no consensus currently exists within the medical community regarding methods for 25-hydroxyvitamin D supplementation or optimal 25-hydroxyvitamin D levels in individuals with CKD. Within this report, existing CKD guidelines are summarized and scrutinized and ongoing clinical trials are cited as sources for future guidance on the optimal management of vitamin D in CKD.

Predictors of erythropoietin use in patients with cardiorenal anaemia syndrome.

Chronic kidney disease (CKD) and anemia are common in patients with heart failure (HF) - these 3 conditions have been coined the Cardiorenal Anemia Sydrome (CRAS). The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) guidelines do not specifically address patients with CRAS, creating uncertainty in erythropoietin (EPO) prescribing. We sought to determine predictors of EPO use in patients with CRAS. We conducted a retrospective cohort study at the Veteran's Affairs Greater Los Angeles Healthcare System (VAGLAHS), a 300+ bed facility that provides primary and tertiary inpatient, and ambulatory care services, between January 1, 2003 to December 31, 2006. A multiple logistic regression model was constructed to identify predictors of EPO use among CRAS patients. Of 2058 patients with CRAS, 213 (10.3%) were prescribed EPO. There were significant differences in baseline characteristics between the EPO and non-EPO groups. The following predictors were found to be associated with EPO prescription: iron supplementation (odds ratio [OR] 52.70, 95% confidence interval [CI] 11.70-237.46), renal clinic appointment (OR 2.60, 95% CI 1.79-3.76), malignancy (OR 1.52, 95% CI 1.07-2.16) and use of hydralazine/nitrates (OR 1.41, 95% CI 1.03-1.92). There was an inverse association found between EPO prescription and baseline hemoglobin (OR 0.61, 95% CI 0.53-0.70) and eGFR (OR 0.96, 95% CI 0.94-0.97). A small proportion of patients eligible for EPO therapy according to guidelines at the time of the study were prescribed the indicated therapy. Markers of declining renal function or those suggesting need for anemia therapy were identified as EPO predictors.

Biochemical Parameters After Cholecalciferol Repletion in Hemodialysis: Results From the VitaDial Randomized Trial

The 2009 KDIGO (Kidney Disease: Improving Global Outcomes) chronic kidney disease-mineral and bone disorder clinical practice guideline suggests correcting 25-hydroxyvitamin D3 (25[OH]D) levels<30ng/mL in patients treated with maintenance hemodialysis, but does not provide a specific treatment protocol. 2-center, double-blind, randomized, 13-week, controlled trial followed by a 26-week open-label study. 55 adult maintenance hemodialysis patients with 25(OH)D levels<30ng/mL were recruited from June 2008 through October2009. Cholecalciferol, 25,000IU, per week orally versus placebo for 13 weeks, then 26 weeks of individualized cholecalciferol prescription based on NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) guidelines. Primary end point was the percentage of patients with 25(OH)D levels≥30ng/mL at 13 weeks. Secondary outcomes included the percentage of patients with normal calcium, phosphorus, and intact parathyroidhormone (iPTH) blood levels. Safety measures included incidence of hypercalcemia and hypervitaminosis D. Blood calcium and phosphate were measured weekly; iPTH, 25(OH)D, 1,25-dihydroxyvitamin D3 (1,25[OH]2D), and bone turnover markers, trimonthly; fetuin A and fibroblast growth factor 23 (FGF-23) serum levels and aortic calcification scores were determined at weeks 0 and39. The primary end point significantly increased in the treatment group compared with the placebo group (61.5% vs 7.4%; P<0.001), as well as 1,25(OH)2D levels (22.5 [IQR, 15-26] vs 11 [IQR, 10-15]pg/mL; P<0.001) and the proportion of patients achieving the target calcium level (76.9% vs 48.2%; P=0.03). Incidence of hypercalcemia and phosphate and iPTH levels were similar between groups. The second 26-week study phase did not significantly modify the prevalence of 25(OH)D level≥30ng/mL in patients issued from the placebo group. Small size of the study population. Oral weekly administration of 25,000IU of cholecalciferol for 13 weeks is an effective, safe, inexpensive, and manageable way to increase 25(OH)D and 1,25(OH)2D levels in hemodialysis patients. Further evaluation of clinical end points is suggested.