Nephrology Community Research Articles

An IQ Industry Perspective on Informing Dosing Recommendations in Patients With Renal Impairment.

The IQ CPLG Organ Impairment WG conducted a survey to understand how various IQ member companies develop dosing recommendations for patients with renal impairment. Eighteen IQ member companies participated in the survey. The survey results were summarized by the working group in light of the regulatory renal impairment guidance documents as well as recent publications from the pharmaceutical industry and nephrology community. There were two important learnings from the survey: (i) pharmaceutical companies do not use a consistent methodology to assess renal function in their drug development programs. (ii) there has been significant improvement in predicting how kidney function affects drug pharmacokinetics (PK) and thus dose recommendations. Applying model-based methods such as population PK, physiologically-based PK (PBPK), and virtual controls has enabled earlier prediction of how kidney function influences PK, leading to the participation of more patients with impaired kidney function in Phase 2 and 3 trials.

Antimalarials in Lupus Nephritis: How Strong is the Evidence?

Systemic lupus erythematosus is a chronic multisystem autoimmune disease that affects the kidneys in approximately 50% of patients, with prevalence rising to as high as 70% in certain populations, such as African Americans and Asians. Antimalarials -and particularly hydroxychloroquine- are currently considered a mainstay of therapy, together with immunosuppressants. Over the last decades, several studies have extensively investigated the mechanisms of action of antimalarial agents, and their potential beneficial properties in patients with SLE in general. However, the evidence for the therapeutic benefit of hydroxychloroquine in patients with lupus nephritis (LN) derives mainly from observational studies, conducted in an era prior to the refinement of induction and maintenance protocols for immunosuppressive therapy. Despite the paucity of high-quality evidence on its efficacy in LN, the nephrology community widely supports the universal use of hydroxychloroquine in LN patients, and recommendations for its use are firmly entrenched in various clinical practice guidelines. Nonetheless, the use of antimalarials may also carry inherent risks, underscoring the importance of personalized approaches in these patients. Herein, we comprehensively review the available literature on antimalarials in LN aiming to update the current evidence, limitations, and future perspectives for the use of antimalarials in adults.

Proceedings of a membrane update symposium: advancements, scientific insights, and future trends for dialysis membranes for enhanced clinical outcomes in end stage kidney disease patients.

From September 6 - 8 2022, the Life/2022 Membrane Symposium was held in Frankfurt, Germany, and transmitted live to a worldwide internet audience. The event was part of the Life/Nephrology Campus initiative, a continuous educational platform for the nephrology community to expand knowledge and share expertise on contemporary topics in chronic kidney disease. We describe recent questions and advances in the field, and we underline challenges in the care of dialysis patients and opportunities for integration of new findings into clinical practice to improve patient outcomes in end stage kidney disease patients. Most patients with kidney failure are on maintenance hemodialysis (MHD). The scientific program of the symposium was developed around topics about the role, functional determinants, technical aspects, limitations, and clinical implications of membranes presently in use. International experts with clinical or technical expertise as well as scientific recognition within the nephrology community were asked to prepare their presentations based on their own experiences, perceptions, opinions, and sources of information. The symposium devoted a major portion to discussing novel approaches for improving membranes and treatment quality, including updates on innovative concepts that may could potentially transform the landscape of kidney replacement therapy for chronic kidney disease patients in the future. The intent was to provide insights into current attention points for healthcare professionals new to the field of MHD, and to test a unique forum for continuing medical education integrating physician and patient experiences to promote changes in clinical practice. Furthermore, the symposium premiered a specifically developed mixed reality holographic 3D model to demonstrate recent dialyzer innovation diminishing protein fouling on membrane surfaces. As a continuous online educational platform for scientific exchange, this Life/2022 event provided online learning opportunities with on-demand content, with all symposium lectures freely available on nephrologycampus.com.

Early Versus Late Initiation of Dialysis in CKD Stage 5: Time for a Consensus

Chronic kidney disease (CKD), a major global public health problem, emerged as one of the leading causes of death, affecting over 800 million individuals worldwide, with significant burden to patients and their caregivers, and may lead to end-stage kidney disease (ESKD). The decision on optimal initiation of chronic dialysis is a common problem faced by nephrologists, patients and caregivers due to lack of adequate data. Determining the ideal time to initiate maintenance dialysis for individuals struggling with ESKD has remained a puzzle.Currently, there is no consensus among guidelines as to the best time to initiate dialysis. Discrepancies in guidelines stem from lack of adequate data, necessitating larger randomized controlled trials to fill this major gap and come to a universal acceptance by the nephrology community about the optimal time to initiate dialysis for patients with advanced CKD. The fact that there has been only one randomized controlled trial that addressed early vs. late dialysis initiation is inadequate to convincingly answer such as critical clinical decision making.In this review, we will analyze the available literature and try to come with recommendations for further studies to guide nephrologist to the best time to initiate dialysis for patient approaching ESKD.

Has the CONVINCE trial convinced the nephrology and dialysis community?

Has the CONVINCE trial convinced the nephrology and dialysis community?

Interventional nephrology in peritoneal dialysis: Best practice report of the Peritoneal Dialysis Project Group of the Italian Society of Nephrology.

The procedure of peritoneal dialysis (PD) catheter placement is of utmost importance for a good outcome of peritoneal dialysis. Currently, catheters are mainly placed by surgeons and interventional nephrologists. Still, there is a lack of trained personnel in many dialysis units, which can impair the efficiency of PD units and reduce the patients' possibility to enter a PD programme. The Italian Society of Nephrology has endorsed a practical core curriculum for interventional nephrology in PD available on the Society website, which is here reported for the wider nephrology community. The topics addressed are the hernias of the abdominal wall, catheter placement with standard surgical open technique, basic video-laparoscopy, advanced video-laparoscopy, video-laparoscopic cholecystectomy and catheter placement, cuff-shaving and video-laparoscopy in catheter malfunction.

TikTok and pediatric nephrology: content quality assessment of videos related to pediatric kidney disease and kidney transplant.

Social media platforms such as TikTok™ are key sources of health information for young patients and caregivers. Misinformation is prevalent on TikTok™ across healthcare fields, which can perpetuate false beliefs about medical care. Limited data exists on the reliability of pediatric nephrology TikTok™ content. This study aimed to describe the quality of medical content of TikTok™ Videos (TTVs), related to pediatric kidney disease and transplant. TTVs were selected using specific search terms and categorized into pediatric kidney disease and kidney transplant, excluding duplicate and adult-related content. The top 100 TTVs in each category, based on views, were analyzed. TTV characteristics were stratified by account type (physician, non-physician healthcare professional (HCP), non-HCP) and video aim (personal story, education, entertainment). DISCERN scoring, a validated questionnaire evaluating health information reliability, was conducted by 4 independent raters. Inter-rater reliability was assessed using a 2-way random effects model, and differences between content creator types were evaluated using one-way ANOVA and post-Hoc Tukey test. TTVs had a total of 12.5 million likes and 113.1 million views. Over 70% of videos were created by non-HCPs (n = 147/200). DISCERN scoring revealed low reliability of medical information across content creator types. TTVs created by physicians and non-physician HCPs about kidney disease had significantly higher mean DISCERN scores compared to those created by non-HCPs (2.85, p < 0.001 and 2.48, p = 0.005, respectively). Educators within the pediatric nephrology community must keep in mind the lack of reliability of medical information available on TikTok™ and coordinate collective efforts to consider utilizing TikTok™ for patient education.

Multidisciplinary approach to advance care planning and directives in patients with end-stage renal disease: a point of view on patient-centered decision-making.

Implementing Advance Care Planning (ACP) for patients with End-Stage Kidney Disease (ESKD), particularly in the context of hemodialysis, presents significant challenges. Despite existing legal frameworks, disparities in advance care planning practices are evident across Europe. The present perspective introduces a multidisciplinary model, initiated in 2019. This model incorporates a specialized team comprising a nephrologist, a psychologist, a palliative care specialist, and an anesthesiologist/intensivist. Through this collaborative approach, we aimed to comprehensively address the intricate medical, emotional, and psychological dimensions in advance care planning. In this point of view, we discuss the strengths of our model, its potential for European Nephrology, and advocate for guidelines to enhance advance care planning implementation within the nephrology community.

Banff 2022 Kidney Commentary: Reflections and Future Directions.

In September 2022, in Banff, Alberta, Canada, the XVIth Banff meeting, corresponding to the 30th anniversary of the Banff classification, was held, leading to 2 recent publications. Discussions at the Banff meeting focused on proposing improvements to the Banff process as a whole. In line with this, a unique opportunity was offered to a selected group of 16 representatives from the pathology and transplant nephrology community, experts in the field of kidney transplantation, to review these 2 Banff manuscripts. The aim was to provide an insightful commentary, to gauge any prospective influence the proposed changes may have, and to identify any potential areas for future enhancement within the Banff classification. The group expressed its satisfaction with the incorporation of 2 new entities, namely "microvascular inflammation/injury donor-specific antibodies-negative and C4d negative" and "probable antibody-mediated rejection," into category 2. These changes expand the classification, facilitating the capture of more biopsies and providing an opportunity to explore the clinical implications of these lesions further. However, we found that the Banff classification remains complex, potentially hindering its widespread utilization, even if a degree of complexity may be unavoidable given the intricate pathophysiology of kidney allograft pathology. Addressing the histomorphologic diagnosis of chronic active T cell-mediated rejection (CA TCMR), potentially reconsidering a diagnostic-agnostic approach, as for category 2, to inflammation in interstitial fibrosis and tubular atrophy and chronic active T cell-mediated rejection was also an important objective. Furthermore, we felt a need for more evidence before molecular diagnostics could be routinely integrated and emphasized the need for clinical and histologic context determination and the substantiation of its clinical impact through rigorous clinical trials. Finally, our discussions stressed the ongoing necessity for multidisciplinary decision-making regarding patient care.

#341 Dialysis modality patterns across six continents in Apollo Dial DB

Abstract Background and Aims Data is often collected during kidney dialysis treatments, providing data on a large scale and at a constant flow. As multinational datasets are scarce, Apollo Dial DB was created by a global provider that contains longitudinal observational data across six continents. This database is fully anonymised and can be used to better understand modality practice of global patients from a variety of healthcare systems for quality improvement and research efforts. Our aim was to detail patterns of dialysis modalities used among patients treated in 40 countries across six continents represented in the first version of the global database. Method Apollo Dial DB, a global anonymised dialysis database, contains demographics, diagnoses, laboratories, medications, treatments, quality of life, and outcomes from six continents and 40 countries. Data was harmonised from different electronic systems and anonymised based on logic established in a re-identification risk assessment. Data is consolidated and stored in a central cloud environment. The initial version of the dataset contains data on more than 360 variables from January 2018 to March 2021 and will be updated periodically. Results The first version of the Apollo Dial DB includes data on 543,169 patients, with 4.6% from Asia-Pacific (AP), 13.9% from Europe, Middle East, and Africa (EMEA), 7.0% from Latin America (LA), and 74.5% from North America (NA) countries. Most of the patients included in the database are between 45-64 years old at the initiation of dialysis. Overall, Apollo Dial DB contains information on 140,016,249 dialysis treatment observations. Depending on the region, different treatment patterns could be observed (Table 1 and Fig. 1). In EMEA a higher proportion of patients received hemodiafiltration with post-dilution, especially in Northern and Southern Europe as well as in South Africa. Peritoneal dialysis was more frequently used in LA and NA than in other regions. CCPD was mainly used in NA, whereas CAPD was common in LA and EMEA. For a more detailed look across the six continents Fig. 1 illustrates incentre hemodialysis modality patterns on a minor world region level. For incentre hemodialysis treatments, the majority of treatments from the minor regions in AP, LA, and NA had HD treatments. However, the majority treatments from EMEA minor regions are receiving incentre HDF treatments. Conclusion In a descriptive analysis, we defined modality treatment patterns in major world regions. These findings act as benchmarks for the nephrology community and expand upon scarce point prevalent information on modality practice patterns used throughout the world [1]. Apollo Dial DB offers opportunities for investigators to conduct global analytics and advance the state of the art.

#1166 ACTION3 pivotal Phase 3 &amp; open-label extension study assessing DMX-200 in adult &amp; paediatric patients with focal segmental glomerulosclerosis (FSGS)

Abstract Background and Aims Focal segmental glomerulosclerosis (FSGS) is a major cause of glomerular disease that affects both adults and children. FSGS can rapidly progress to end-stage kidney disease. Lack of safe and effective treatment represents a significant unmet need for patients with FSGS. Development of treatments has been hampered by complexities including the rare nature of the disease, varying drivers of pathogenesis, and the evolving diagnostic and clinical trial designs, necessitating innovative research approaches. DMX-200 (repagermanium) is a C-C motif chemokine receptor 2 (CCR2) pathway inhibitor. Activation of the angiotensin II type 1 receptor (AT1R) and CCR2 have been independently implicated in the pathogenesis and progression of FSGS. These receptors form a functional complex so inhibition of both receptors may provide an efficient approach to FSGS treatment. In vivo data shows co-administration of DMX-200 and the angiotensin receptor blocker (ARB) irbesartan demonstrated a synergistic reduction in proteinuria, macrophage infiltration, and podocyte loss compared with vehicle or either antagonist alone. A subsequent Phase 2a cross-over study (NCT03649152) in N = 8 patients with biopsy-proven primary FSGS showed that the combination of DMX-200 and irbesartan (compared to placebo) was well tolerated with most patients experiencing a reduction in proteinuria. Based on these data, the global Phase 3 study (ACTION3) was initiated to confirm the proteinuria lowering effects of DMX-200 and assess effects on eGFR decline. ACTION3 is a randomised, placebo-controlled, double-blind, long-duration study of FSGS patients and on completion will provide a resource for the wider nephrology community and advocacy groups on the natural history of FSGS patients and the effects of a CCR2-inhibitor on the background of an ARB. Here we present the baseline data from the first 90 patients enrolled in ACTION3 at 12th January 2024. Method The ACTION3 (NCT05183646) study is a pivotal Phase 3, multicentre study of the efficacy and safety of DMX-200, 120 mg twice daily compared with placebo in adult patients with biopsy-proven FSGS receiving maximal tolerated ARB, with persistent proteinuria &amp;gt;1.5g/ day and eGFR &amp;gt;25 ml/min/1.73 m2. The study plans to enroll approximately 286 patients with primary FSGS, genetic FSGS and FSGS of undetermined cause with the primary objective of evaluating the efficacy of DMX-200 in percent change in 24-hour urine PCR and eGFR slope. The initial 104-week randomized period will be extended in a 2-year open label extension study. A futility analysis by an Independent Data Monitoring Committee following the first 72 patients completing 35 weeks of treatment confirm that continuation of the study is non-futile. Results The study is actively recruiting at 71 sites in 11 countries listed in Table 1. Demographic data of randomised patients is listed in Table 2. Patients are predominantly male (65%), with an average age of 46.6 yrs. and mean eGFR 56.3 ± 27.6 (ml/min/1.73 m2). The study is expanding recruitment into additional countries in the Asia Pacific, Europe, and Latin American regions. Further, the study protocol has sought and received regulatory approval to enroll adolescent patients aged 12-18 in Argentina, Mexico, UK and the US. Conclusion DMX-200 (repagermanium) has shown encouraging signs of safety and efficacy in combination with an ARB for the treatment of FSGS. The contributing countries and baseline characteristics of the patients enrolled in ACTION3 are similar to the populations studied in other recent FSGS trials. No clinically significant safety concerns have been observed in patients enrolled to date in the ACTION3 Phase 3 study.

#1157 Body mass and fluid balance in dialysis: global profiles in Apollo Dial DB

Abstract Background and Aims Fluid management is a fundamental component of dialysis care. Achieving euvolemia and avoiding fluid overload can be challenging in dialysis. Apollo Dial DB, an anonymised dialysis database from a global kidney care network, was used to gain deeper insights in patterns of patient body mass and fluid balance during dialysis treatments worldwide. Method Apollo Dial DB, a global anonymised dialysis database, contains real-world data from patients in 40 countries beginning January 2018 throughout March 2021. Parameters include demographics, diagnoses, laboratories, medications, treatments, quality of life, and outcomes. This analysis assessed body mass and fluid status parameters on patients in Asia-Pacific (AP), Europe, Middle East, and Africa (EMEA), Latin America (LA), Northern America (NA). In addition, bioimpedance for body compositions of patients was assessed as it was available in AP, EMEA, and LA. Results The first version of the Apollo Dial DB includes data on 543, 169 patients, with 4.6% from AP, 13.9% from EMEA, 7.0% from LA, and 74.5% from NA countries. EMEA and NA have a higher proportion of patients in the bigger height categories versus the AP and LA regions (Table 1). There is a difference in mean body weight post dialysis of more than 10 kg between regions; the highest weights were observed in EMEA and NA in contrast to the AP and LA regions. Average albumin levels were consistent in all global regions. Intradialytic weight gain is lowest in EMEA at 1.8 kg and highest in NA at 2.2 kg between treatments. While ultrafiltration volume ranged from 2.0 L to 2.4 L, being the highest in AP and NA. Bioimpedance measures defining body compositions were available for the majority of patients in AP (59.3%), EMEA (86.9%), and LA (90.7%). Patient averages in EMEA are slightly higher for ATM, FTM, LTM, TBW than for LA and AP; this is somewhat explained by the differences in body weight between the cohorts (Fig. 1). Conclusion A descriptive analysis of the body mass and fluid status across minor and major regions bring to light key profiles and differences in the characteristics of dialysis patients across the world and fluid management practices in dialysis care. Differences in intradialytic weight gain may deserve further analysis considering the impact of dialysis modality on fluid balance, such as potential influences of convective therapies. These findings act as benchmarks for the nephrology community. Apollo Dial DB offers opportunities for investigators to conduct global analytics and advance kidney disease research.

American Board of Internal Medicine Nephrology Procedure Requirements for Initial Certification: Time for a Change and Pursuing Consensus in the Nephrology Community

In 1988, the American Board of Internal Medicine (ABIM) defined essential procedural skills in nephrology, and candidates for ABIM certification were required to present evidence of possessing the skills necessary for placement of temporary dialysis vascular access, hemodialysis, peritoneal dialysis, and percutaneous renal biopsy. In 1996, continuous renal replacement therapy was added to the list of nephrology requirements. These procedure requirements have not been modified since 1996 while the practice of nephrology has changed dramatically. In March 2021, the ABIM Nephrology Board embarked on a policy journey to revise the procedure requirements for nephrology certification. With the guidance of nephrology diplomates, training program directors, professional and patient organizations, and other stakeholders, the ABIM Nephrology Board revised the procedure requirements to reflect current practice and national priorities. The approved changes include the Opportunity to Train standard for placement of temporary dialysis catheters, percutaneous kidney biopsies, and home hemodialysis which better reflects the current state of training in most training programs, and the new requirements for home dialysis therapies training will align with the national priority to address the underuse of home dialysis therapies. This perspective details the ABIM process for considering changes to the certification procedure requirements and how ABIM collaborated with the larger nephrology community in considering revisions and additions to these requirements.

Addressing Housing Issues Among People With Kidney Disease: Importance, Challenges, and Recommendations

Kidney disease disproportionately impacts people with low socioeconomic status, and low socioeconomic status is associated with worse outcomes for people with kidney disease. Unstable housing, which includes housing insecurity and homelessness, is increasing due to rising housing costs. There is mounting evidence that unstable housing and other health-related social needs are partially driving worse outcomes for people with low socioeconomic status. In this perspective, we consider the challenges to addressing housing for people with kidney disease, such as difficulty with identification of those with unstable housing, strict eligibility criteria for housing support, inadequate supply of affordable housing, and flaws in communities' prioritization of affordable housing. We discuss ways to tailor management for people experiencing unstable housing with kidney disease, and the importance of addressing safety, trauma, and emotional concerns as a part of care. We identify opportunities for the nephrology community to surmount challenges through increased screening, investment in workforce dedicated to community resource navigation, advocacy for investment in affordable housing, restructuring of communities' prioritization of affordable housing, and conducting needed research. Identifying and addressing housing needs among people with kidney disease is critical to eliminating kidney health disparities.

CKD-Associated Pruritus and Clinical Outcomes in Nondialysis CKD

Itching is a frequent symptom experienced by people with chronic kidney disease (CKD). We investigated the associations of CKD-associated pruritus (CKD-aP) with clinical outcomes. This was a longitudinal cohort study. Patients from Brazil, France, and the United States enrolled in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) from 2013 to 2021, an international prospective cohort study of adults with nondialysis dependent CKD, and an estimated glomerular filtration rate (eGFR) of<60 mL/min/1.73 m2 were included. CKD-aP was self-reported by response to the question: "During the past 4 weeks, to what extent were you bothered by itchy skin?" The outcomes were as follows: CKD progression, kidney replacement therapy (KRT) initiation, mortality, hospitalization, cardiovascular events, infection events. Associations with time-to-event outcomes were investigated using Cox proportional hazards models adjusted for potential confounders. There were 4,410 patients from 91 clinics with a median age of 69 years and a median eGFR at patient questionnaire completion of 29 (21-38) mL/min/1.73 m2. The proportion of patients not at all, somewhat, moderately, very much, and extremely bothered by itchy skin was 49%, 27%, 13%, 7%, and 3%, respectively. Patients with more advanced stages of CKD, older age, and greater comorbidities reported to be more likely bothered by itchy skin. Among patients at least moderately bothered, 23% were prescribed at least 1 pharmacotherapy (35% in the United States, 19% in France, 4% in Brazil), including antihistamine (10%), gabapentin (6%), topical corticosteroids (4%), pregabalin (3%), or sedating antihistamine (3%). The HR (95% CI) for patients extremely (vs not at all) bothered was 1.74 (1.11-2.73) for all-cause mortality, 1.56 (1.11-2.18) for all-cause hospitalization, and 1.84 (1.22-2.75) for cardiovascular events. As CKD-aP severity increased, patients also had higher rates of infection events (P= 0.04); CKD-aP severity was not associated with KRT initiation (P= 0.20) or CKD progression (P= 0.87). The limitations were 25% nonresponse rate, recall bias, and residual confounding factors. These results demonstrate a strong association between severe itch and clinical outcomes, providing the nephrology community new insights into the possible adverse consequences of CKD-aP in individuals with nondialysis CKD, and warrant further exploration. Chronic kidney disease-associated pruritus (CKD-aP) is a common disturbing symptom of chronic kidney disease (CKD). This article analyzes longitudinal data from the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) to describe prevalence of CKD-aP in 4,410 individuals with nondialysis CKD, and its association with clinical outcomes. We found that 51% of the surveyed population were bothered by pruritus. CKD-aP was more prevalent in those with more advanced stages of CKD, older age, and with more comorbid conditions. Compared to those not at all bothered by pruritus, those who were extremely bothered had a higher risk of all-cause mortality, hospitalizations, and cardiovascular events. Severity of CKD-aP was not associated with CKD progression or initiation of kidney replacement therapy.

Chronic kidney disease and value-based care: Lessons from innovation, iteration, and ideation in primary care.

Value-based primary care has reduced health care costs, improved the quality of rendered care, and enhanced the patient experience. Value-based care emphasizes prevention, outreach, follow-up, patient engagement, and comprehensive, whole-person health. Primary care Accountable Care Organizations have leveraged technology-enabled workflows, practice transformation, and cutting-edge data and analytics to achieve success. These efforts are increasingly aided by predictive modeling used in the context of patient identification and prioritization algorithms. Value-based kidney care programs can glean salient takeaways from successful value-based primary care methods and models. The kidney care community is experiencing unprecedented transformation as novel payer programs and financial models burgeon. The authors contend these efforts can be accelerated by the adoption of techniques honed in value-based primary care. To optimize value-based kidney care, though, nephrology thought leaders must transcend the archetype of value-based primary care. To do so, the nephrology community must: (1) impel behavioral change among fee-for-service adherents; (2) harness emerging policy, guidelines, and quality measures; (3) adopt innovative tools, technologies, and therapies. In aggregating lessons from value-based primary care-and leveraging novel methodologies and approaches-the kidney care community will be better equipped to achieve the quadruple aim for kidney care.

Epidemiology of acute kidney injury in children: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference

The nephrology and critical care communities have seen an increase in studies exploring acute kidney injury (AKI) epidemiology in children. As a result, we now know that AKI is highly prevalent in critically ill neonates, children, and young adults. Furthermore, children who develop AKI experience greater morbidity and higher mortality. Yet knowledge gaps still exist that suggest a more comprehensive understanding of AKI will form the foundation for future efforts designed to improve outcomes. In particular, the areas of community acquired AKI, AKI in non-critically ill children, and cohorts from low-middle income countries have not been well studied. Longer-term functional outcomes and patient-centric metrics including social determinants of health, quality of life, and healthcare utilization should be the foci of the next phase of scholarship. Current definitions identify AKI-based upon evidence of dysfunction which serves as a proxy for injury; biomarkers capable of identifying injury as it occurs are likely to more accurately define populations with AKI. Despite the strength of the association, the causal and mechanistic relationships between AKI and poorer outcomes remain inadequately examined. A more robust understanding of the relationship represents a potential to identify therapeutic targets. Once established, a more comprehensive understanding of AKI epidemiology in children will allow investigation of preventive, therapeutic, and quality improvement interventions more effectively.

A-107 Estimating Glomerular Filtration Rate by the Serum Creatinine and Cystatin C-plus-Creatinine Equations: Concordance and Effect on GFR Categorization

Abstract Background Estimating the glomerular filtration rate (GFR) is essential for evaluating kidney function, which is part of routine medical care. Most clinical laboratories report an estimated glomerular filtration rate (eGFR) based on serum creatinine, but cystatin C is a potential alternative marker. Evidence suggests that using the creatinine-plus-cystatin C (the 2021 CKD-EPI creatinine-cystatin C equation) eGFR gives more accurate results than the eGFR based on creatinine alone. Here we compared two 2021 CKD-EPI equations for estimating GFR—one using standardized creatinine alone (Cre) and the other using cystatin C combined with standardized creatinine (Cre-Cys). We also explored the effect of the equations on the GFR category. Methods: We retrospectively analyzed 777 simultaneous values for eGFR calculated by the two 2021 CKD-EPI equations over a period of nine months, from the time our laboratory initiated the Cre-Cys equation to the present.Cystatin C was measured turbidometrically on the Optilite (Binding Site, Birmingham, UK) and the creatinine was measured by the DxC method (Beckman Coulter, California, USA). We excluded any patient with Cre eGFR &amp;gt;90 mL/min/1.73 m2 because we do not result any value above 90 for that parameter. Results Out of 777 patients (52% female and 48% male), we excluded 82 results with Cre GFR &amp;gt; 90. The mean ± SD for Cre-Cys eGFR and Cre eGFR were 37.3 ± 23.8 and 37.1 ± 23.1, respectively, with a non-statistical difference between both groups using the paired T-Test (t = −0.8249, P-value = 0.4097). The mean difference (Cre-Cys eGFR minus Cre eGFR) was 0.28, with a standard deviation of 9.027. The correlation coefficient between Cre eGFR and Cre-Cys eGFR was r = 0.93. Two hundred and seventy-four (35%) samples had a difference between the numerical value of the two eGFR equations significant enough to change the GFR classification. 128 (34.5%) of the males had different categories when both equations calculated the eGFR vs 146 (36%) females. 36.3% of the white and 34% of the black patients had a discrepancy. The calculations matched for the other 502 patients. Of the 274 samples with discordant category classifications, the Cre-Cys equation gave a lower result and a higher (worse) category in 144 (53%), and a higher result and lower (better) category in 130 (47%). Conclusion The use of Cystatin C is growing and has moved beyond the nephrology community. Furthermore, the 2012 KDIGO guidelines suggest using additional tests (such as cystatin C or a clearance measurement) for confirmatory testing in specific circumstances when eGFR based on serum creatinine is less accurate. Currently, cystatin C testing is only available M-F, 8 AM–4 PM at our institute, but increasing availability and decreasing cost will likely expand Cre-Cys eGFR testing in the future. However, understanding the relationships between eGFR values from the different equations and how they will affect patient management can help clinicians optimize their use for kidney function evaluation.

The Collaborative Nephrology Community: Perspectives and Experience on Data Sharing.

The Collaborative Nephrology Community: Perspectives and Experience on Data Sharing.

Some of the Dilemmas About Creating Arteriovenous Fistulas for Hemodialysis

Abstract The native arteriovenous fistula for haemodialysis has been described as the Achilles heel but also the Cinderella of haemodialysis. Arteriovenous fistula has been the vascular access of choice for haemodialysis, because of lower cost, morbidity and mortality. The significance of a functioning vascular access is that it takes on a major role in determining a positive outcome. Yet, they are a cause of great stress, both for patients and healthcare professionals. About 80% of patients begin dialysis with central venous catheters, 20-70% of fistulas do not reach maturity, and a fifth, of all fistulas, thrombosed before use. A quarter die from poor vascular access. Insufficient number of vascular surgeons and inadequate training to create vascular access often lead to "congestion" of the bed stock in nephrology. Surgeons and radiologists perform all procedures related to vascular approaches, but the dominant role of nephrologists is in the organization of planning and realization of creating a vascular access. Initiation of dialysis in the elderly and diabetics, as a risk population of patients for arteriovenous fistula, is associated with many problems, among which the creation, functioning and maturation of the vascular access dominate. Hyperdynamic conditions, due to arteriovenous communication in patients with arteriovenous fistula, are cited as a possible mechanism for increasing morbidity. However, there is still no agreement within the nephrology community regarding the height of the hemodynamic load and the indication for closing the vascular access. There are many dilemmas associated with creating, care and using an arteriovenous fistulas, and that could be the reason and justification to form a team for vascular access, which would, in addition to nephrologists, include vascular surgeons, interventional radiologists and nurses.