Rate Of Chronic Kidney Disease Progression Research Articles

Optimizing kidney and cardiovascular protection in an era of multiple effective treatments.

After decades of relying on the control of hypertension and treatment with renin angiotensin system inhibitors as the only evidence-based interventions to slow the progression of chronic kidney disease (CKD), we have entered an era when multiple effective treatment options are available. This review considers the mechanisms and benefits of these novel treatments as well as the challenges associated with achieving optimal combination therapy. Over the past 5 years, large clinical trials have provided robust evidence that, when added to renin angiotensin system inhibitors, treatment with sodium glucose cotransporter 2 inhibitors reduces the rate of CKD progression and the risk of cardiovascular events in people with CKD with or without diabetes and with or without albuminuria; nonsteroidal mineralocorticoid antagonists and glucagon-like peptide-1 receptor agonists afford similar benefits in people with type 2 diabetes and CKD. The mechanisms of actions of these novel therapies suggest that combination therapy will produce additive benefits, though specific evidence is sparse. Further trials are warranted to investigate the benefits of combination therapy with novel treatments in people with CKD. Clinical implementation of optimal combination therapy will require reorganization of services to ensure that patients receive adequate education, support and monitoring.

Assessing Functional Outcomes of Partial Versus Radical Nephrectomy for T1b-T2 Renal Masses: Results from a Multi-institutional Collaboration.

Deterioration of renal function is associated with increased all-cause mortality. In renal masses larger than 4 cm, whether partial versus radical nephrectomy (PN vs. RN) might affect long-term functional outcomes is unknown. This study tested the association between PN versus RN and postoperative acute kidney injury (AKI), recovery of at least 90% of the preoperative estimated glomerular filtration rate (eGFR) at 1 year, upstaging of chronic kidney disease (CKD) one stage or more at 1 year, and eGFR decline of 45 ml/min/1.73 m2 or less at 1 year. Data from 23 high-volume institutions were used. The study included only surgically treated patients with single, unilateral, localized, clinical T1b-2 renal masses. Multivariable logistic regression analyses were performed. Overall, 968 PN patients and 325 RN patients were identified. The rate of AKI was lower in the PN versus the RN patients (17% vs. 58%; p < 0.001). At 1 year after surgery, for the PN versus the RN patients, the rate for recovery of at least 90% of baseline eGFR was 51% versus 16%, the rate of CKD progression of ≥ 1 stage was 38% versus 65%, and the rate of eGFR decline of 45 ml/min/1.73 m2 or less was 10% versus 23% (all p < 0.001). Radical nephrectomy independently predicted AKI (odds ratio [OR], 7.61), 1-year ≥ 90% eGFR recovery (OR, 0.30), 1-year CKD upstaging (OR, 1.78), and 1-year eGFR decline of 45 ml/min/1.73 m2 or less (OR, 2.36) (all p ≤ 0.002). For cT1b-2 masses, RN portends worse immediate and 1-year functional outcomes. When technically feasible and oncologically safe, efforts should be made to spare the kidney in case of large renal masses to avoid the hazard of glomerular function loss-related mortality.

Cost-effectiveness of screening for chronic kidney disease using a cumulative eGFR-based statistic.

Routine screening for chronic kidney disease (CKD) could enable timely interventions to slow down disease progression, but currently there are no clinical guidelines for screening. We aim to evaluate the cost-effectiveness of screening for CKD using a novel analytical tool based on a cumulative sum statistic of estimated glomerular filtration rate (CUSUMGFR). We developed a microsimulation model that captured CKD disease progression, major complications, patients' awareness, and treatment adherence for a nationally representative synthetic cohort of age ≥ 30 years in the United States. In addition to the status quo with no screening, we considered four CUSUMGFR-based universal screening policies by frequency (annual or biennial) and starting age (30 or 60 years), and two targeted annual screening policies for patients with hypertension and diabetes, respectively. For each policy, we evaluated the total discounted disability-adjusted life years (DALYs) and direct health costs over a lifetime horizon and estimated the incremental cost-effectiveness ratio (ICER). We further performed one-way and probabilistic sensitivity analyses to assess the impact of parameter uncertainty. Compared with the status quo, all the CUSUMGFR-based screening policies were cost-effective under the willingness-to-pay (WTP) range of $50,000 -$100,000, with the estimated incremental cost-effectiveness ratios (ICERs) ranging from $15,614/DALYs averted to $54,373/DALYs averted. Universal annual screening with starting age of 30 was the non-dominated policy on the cost-effectiveness frontier under the WTP of approximately $25,000. Adding more recent treatment option of sodium-glucose cotransporter-2 (SGLT2) inhibitors to the treatment regimen was found to be cost-saving. Among the most influential model parameters, variation in the CKD progression rate, adherence, and testing cost resulted in the highest variability in model outcomes. CUSUMGFR-based screening policies for CKD are highly cost-effective in identifying patients at risk of end stage kidney disease in early stages of CKD. Given its simple requirement of a basic blood test, the CUSUMGFR-based screening can be easily incorporated into clinical workflow for disease monitoring and prevention.

Preoperative hydronephrosis is an independent protective factor of renal function decline after nephroureterectomy for upper tract urothelial carcinoma.

To evaluate the predictive role of pre-nephroureterectomy (NU) hydronephrosis on post-NU renal function (RF) change and preserved eligibility rate for adjuvant therapy in patients with upper tract urothelial carcinoma (UTUC). This retrospective study collected data of 1018 patients from the Taiwan UTUC Collaboration Group registry of 26 institutions. The patients were divided into two groups based on the absence or presence of pre-NU hydronephrosis. Estimated glomerular filtration rate (eGFR) was calculated pre- and post-NU respectively. The one month post-NU RF change, chronic kidney disease (CKD) progression, and the preserved eligibility rate for adjuvant therapy were compared for each CKD stage. 404 (39.2%) patients without and 614 (60.8%) patients with pre-NU hydronephrosis were enrolled. The median post-NU change in the eGFR was significantly lower in the hydronephrosis group (-3.84 versus -12.88, p<0.001). Pre-NU hydronephrosis was associated with a lower post-NU CKD progression rate (33.1% versus 50.7%, p< 0.001) and was an independent protective factor for RF decline after covariate adjustment (OR=0.46, p<0.001). Patients with pre-NU hydronephrosis had a higher preserved eligibility rate for either adjuvant cisplatin-based chemotherapy (OR=3.09, 95%CI 1.95-4.69) or immune-oncology therapy (OR=2.31, 95%CI 1.23-4.34). Pre-NU hydronephrosis is an independent protective predictor for post-NU RF decline, CKD progression, and eligibility for adjuvant therapy. With cautious selection for those unfavorably prognostic, non-metastatic UTUC patients with preoperative hydronephrosis, adjuvant rather than neoadjuvant therapy could be considered due to higher chance of preserving eligibility.

Sex-specific differences in the epidemiology, progression, and outcomes of chronic kidney disease

Higher prevalence of chronic kidney disease (CKD) in women than in men was reported all over the world. This difference could be partly explained by longer life expectancy and slower CKD progression rate in women. Potential factors associated with sex differences in CKD progression are as follows: difference in glomerular hemodynamic and the response to angiotensin II; sex hormones ? estrogen has protective and testosterone deleterious effects on CKD progression; lifestyle. In most countries, the percentage of men is higher than that of women among incident and prevalent patients on hemodialysis (HD). In HD patients, the Kt/V index overestimates HD adequacy, secondary hyperparathyroidism is more common in women, and women require higher doses of erythropoiesis-stimulating agents for achieving and maintaining the hemoglobin target level. The survival of HD patients is equal for both sexes. In earlier years, an equal percentage of women and men started peritoneal dialysis, but in recent years, a higher percentage of women, especially at younger ages, start peritoneal dialysis. Initial peritoneal transport properties differ between men and women. A smaller percentage of women than men receive deceased donor kidneys, but women are more likely to be living kidney donors. Kidney allograft outcome depends on the sex and age of both the recipient and the donor. Cardiovascular diseases are the most common cause of death for renal replacement therapy patients of both sexes. Although sex-specific differences have been described in CKD patients, the inequality of patients in access to medical care has not been found in most regions of the world.

New mechanisms for the kidney-protective effect of alkali in chronic kidney disease.

Worldwide, more than one in ten adults are estimated to have chronic kidney disease (CKD). As CKD progresses, both the cost of treatment and associated risk of morbidity and mortality increase exponentially. As such, there is a great need for therapies that effectively slow CKD progression. Evidence from several small clinical trials indicates that alkali therapy may slow the rate of CKD progression. The biological mechanisms underlying this protective effect, however, remain unknown. In their recently published manuscript, Pastor Arroyo et al. (Clin Sci (Lond) (2022) 136(8): https://doi.org/10.1042/CS20220095) demonstrate that the alkali sodium bicarbonate protects against loss of renal function in a crystal nephropathy model in mice. Using unbiased approaches in both mice and human tissue, the authors go on to identify two novel mechanisms that may underly this protection. The first pathway is through promoting pathways of cell metabolism, which they speculate helps the remaining functional nephrons adapt to the greater metabolic needs required to maintain kidney filtration. The second pathway is by restoration of α-Klotho levels, which may limit the expression of adhesion molecules in the injured kidney. This, the authors speculate, may prevent inflammation from driving the functional decline of the kidney. Identifying these novel pathways represents an important step forward harnessing the potential benefits of alkali therapy in CKD.

Effect of Adopting the New Race-Free 2021 Chronic Kidney Disease Epidemiology Collaboration Estimated Glomerular Filtration Rate Creatinine Equation on Racial Differences in Kidney Disease Progression Among People With Human Immunodeficiency Virus: An Observational Study.

The impact of adopting a race-free estimated glomerular filtration rate (eGFR) creatinine (eGFRcr) equation on racial differences in chronic kidney disease (CKD) progression among people with human immunodeficiency virus (PWH) is unknown. We defined eGFR stages using the original race-adjusted Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) eGFRcr equation and the new race-free CKD-EPI eGFRcr equation. We then estimated 5-year probabilities of transitioning from baseline kidney function to more advanced eGFR stages and examined the association of race (black vs white) with rates of CKD progression using Markov models. With the race-adjusted eGFRcr equation, black participants (n = 31 298) had a lower risk of progressing from eGFR stage 1 to 2 (hazard ratio [HR], 0.77; 95% confidence interval [CI], .73-.82), an equal risk of progressing from stage 2 to 3 (1.00; .92-.07) and a 3-fold risk of progressing from stage 3 to 4 or 5 (3.06; 2.60-3.62), compared with white participants (n = 27 542). When we used the race-free eGFRcr equation, 16% of black participants were reclassified into a more severe eGFR stage at baseline. The reclassified black individuals had a higher prevalence of CKD risk factors than black PWH who were not reclassified. With the race-free eGFRcr equation, black participants had a higher risk of disease progression across all eGFR stages than white participants. The original eGFRcr equation systematically masked a subgroup of black PWH who are at high-risk of CKD progression. The new race-free eGFRcr equation unmasks these individuals and may allow for earlier detection and management of CKD.

Effectiveness of glycosaminoglycan in patients with glomerulonephritis: A prospective longitudinal cohort study

Abstract. Our study aimed to evaluate the effectiveness of Sulodexide in the treatment of patients with glomerulonephritis(GN).&#x0D; Methods. We conducted a prospective longitudinal cohort study involving 105 patients with CKD, who were hospitalized at the Ivano-Frankivsk Regional Clinical Hospital (Ukraine) from 2021-2022. Only patients with proteinuria of 0.3 g – 3.5 g/day and chronic kidney disease (CKD) stages 1-3 and the diagnosis of GN were included in the study. The clinical diagnosis was determined based on standard examination methods according to the Classification of Kidney Diseases and protocols of management of CKD patients&#x0D; All patients were randomly assigned into 2 groups. Group 1 received basic therapy, and Group 2 received Sulodexide in oral capsules containing 250 lipasemic units (LSU) twice daily in addition to basic therapy. The duration of treatment was 6 months.&#x0D; Results. Our study showed that the additional use of sulodexide for 6 months significantly reduced the level of proteinuria in patients with GN, so in the second group, it was possible to achieve a significantly lower level of proteinuria 567 (356; 745) mg/day, compared to the first group 956 (765; 1233 ) mg/day (р˂0.05).&#x0D; As the glomerular filtration rate remained stable or even increased, proteinuria reduction cannot be explained by alteration of filtration capacity. We also noted a significant decrease in the level of D-dimers in the group of patients who additionally received Sulodexide for 6 months, which may indicate the prevention of thromboembolic and cardiovascular events in this population of patients. However, this hypothesis needs further research.&#x0D; Conclusions. The additional use of Sulodexide in patients with GN statistically significantly reduced proteinuria levels preventing CKD progression rate.

Long-term outcome of dogs recovering from acute kidney injury: 132 cases.

BackgroundInformation regarding long‐term outcome of dogs recovering from acute kidney injury (AKI) is limited.ObjectivesDetermine the long‐term outcome of dogs recovering from AKI and identify predictors for serum creatinine concentration (sCr) normalization and long‐term outcome.AnimalsOne hundred thirty‐two dogs with AKI that survived ≥30 days postdischarge.MethodsRetrospective study. Search of medical records of dogs diagnosed with AKI that survived to discharge. Follow‐up data were retrieved from medical records and by telephone interviews with the owners or primary care veterinarians or both.ResultsEstimated median survival time (MST) was 1322 days (95% confidence interval [CI], 1147‐1626), and 76% of the dogs were alive at last contact. Normalization of sCr was documented in 55% of the dogs at discharge and in additional 20% during the follow‐up period. The proportion of dogs with sCr normalization decreased with increase in AKI grade (P = .02). Long‐term survival was not associated with sCr normalization (P = .63). Etiology was associated with the long‐term outcome (P = .004).Conclusion and Clinical ImportanceLong‐term survival of dogs with AKI is longer than previously described. Normalization of sCr in 99 dogs (75%) occurred, either at discharge or within the follow‐up period. Normalization of sCr was not associated with long‐term survival. Estimated MST of dogs with sCr normalization was not different compared with dogs that developed azotemic chronic kidney disease (CKD), presumably because of slow CKD progression rate. Etiology is an important factor determining sCr normalization and long‐term survival, emphasizing the importance of the reversibility of renal injury rather than its severity.

Features of congenital and infantile nephrotic syndrome in Russian children

Introduction. Nephrotic syndrome (NS) with an onset in the first year of life is one of the actual problems in pediatric nephrology due to the limited therapeutic options, the ineffectiveness of immunosuppressive therapy, and inevitable progression to chronic kidney disease (CKD). The basis of congenital NS (CNS) and infantile NS (INS) is a genetically determined pathology of podocytes. The timely verification of such pathology allows avoiding ineffective therapy and helps to predict outcomes. Aim. To determine CNS and INS’s clinical and molecular genetic characteristics in Russian children. Materials and methods. This study performed molecular genetic testing of 99 children with an early onset of NS. Results. In children with CNS and INS, the genetic cause of the disease was verified in 85%. Causative nucleotide variants prevailed in the NPHS1, NPHS2, WT1 genes. It became possible to identify the significant nucleotide variants for the Russian group of children. Children with NS at an early age turned out to be resistant to therapy with calcineurin inhibitors, which should be considered when choosing therapy tactics. Conclusion. We detected the genetic structure of congenital and infantile NS in the Russian Federation during the study. We analyzed the effectiveness of therapy with calcineurin inhibitors and the rate of CKD progression in this group.

Examining the factors contributing to the association between non-albuminuric CKD and a low rate of kidney function decline in diabetes.

Background:Studies have shown that among people with diabetes, those with non-albuminuric chronic kidney disease (CKD) have a slower rate of reduction in renal function than do those with normal renal function. This suggests the presence of protective factors, the identification of which may open up targets for intervention. The aim of this study was to identify protective clinical factors and nonclinical biomarkers that contribute to the association between non-albuminuric CKD and the low rate of progression of CKD.Methods:We tested for significant associations of several clinical factors and 33 nonclinical biomarkers with (1) normoalbuminuria and (2) a low rate of CKD progression among participants with diabetes and CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study in the United States. Factors significantly associated with both normoalbuminuria and a low rate of CKD progression were assessed in linear regression to estimate their potential contributions to the association between non-albuminuric CKD and rate of CKD progression.Results:Systolic blood pressure (SBP), glycated A1c (HbA1c), estimated glomerular filtration rate (eGFR) and six biomarkers [β-trace protein (BTP), kidney injury molecule (KIM-1), fibrinogen, fractalkine, brain natriuretic peptide (BNP) and high-sensitivity troponin-T (hsTnT)] were associated with both normoalbuminuria and a low rate of eGFR decline. The univariate β-coefficient for normoalbuminuria was 0.93 [95% confidence interval (CI): 0.82, 1.05]. When all associated factors and biomarkers were included, the regression coefficient decreased to 0.54 (95% CI: 0.40, 0.67). The factors that contributed to the association between non-albuminuric CKD and low rate of eGFR were lower levels of SBP, HbA1c, BTP, KIM-1, hsTnT, BNP, fibrinogen and fractalkine.Conclusion:Lower levels of SBP and biomarkers that have pro-inflammatory and vascular modulating features may explain up to 40% of the association between non-albuminuric CKD and low rate of CKD progression. Further investigation of these biomarkers may lead to therapeutic interventions.

Management of asymptomatic hyperuricemia in chronic kidney disease: A proposed stepwise approach

Serum uric acid levels are frequently elevated in patients with chronic kidney disease (CKD). The relatively modest hyperuricaemia in CKD may reflect the reduced efficiency of renal excretion of urate. In the past two decades, basic research has shown that hyperuricaemia plays a causal role in the progression of CKD through direct renal injury. However, clinical studies have reported conflicting results, hence there is much controversy about the scope of treating asymptomatic hyperuricaemia to prevent or reduce the rate of CKD progression. In this review, we highlight the most recent guidelines and clinical trials that tested the use of urate-lowering therapy in the management of asymptomatic hyperuricaemia in CKD patients. Keywords: uric acid, hyperuricaemia, chronic kidney disease

Acute Kidney Injury in COVID-19: Clinical Profile and Outcome.

Introduction:Acute kidney injury (AKI) can be a severe complication of the coronavirus 2019 (COVID-19) infection. Follow-up data of these AKI patients, including the rate of progression to chronic kidney disease (CKD), is limited.Methods:COVID-19 patients with AKI, admitted from June 1, 2020, to August 25, 2020, were enrolled prospectively. Their clinical profile, biochemical investigations, urine analysis, treatment, and outcome in terms of mortality or discharge were analyzed. The discharged patients were followed up 3 months later to determine their renal recovery status.Results:AKI was noted in 146 out of 4,613 COVID-19 patients with an incidence of 3.16%. The outcome was available for 111 patients. According to the KDIGO (Kidney Disease Improving Global Outcomes) AKI criteria, 20 (18%) patients were in Stage 1, 16 (14%) in Stage 2, and 75 (68%) in Stage 3 AKI. Proteinuria and hematuria were present in 66% and 41%, respectively. Renal replacement therapy (RRT) was required in 45 (40.5%) patients. A total of 53 (47.7%) patients turned RT-PCR negative and were discharged. The renal recovery at discharge was complete in 31 of 111 (28%), partial in 20 of 111 (18%), and none in two (2%) patients. At 3 months follow-up of discharged patients, total mortality rate was 55.85%. Twenty three of 53 (43%) recovered their renal functions to baseline and 26 of 53 (49%) had progressed to CKD. Diabetes mellitus, dyspnea, altered sensorium, severe acute respiratory distress syndrome, need for RRT, lymphopenia, high neutrophil–lymphocyte ratio, hyperglycemia, raised inflammatory markers, and hematuria were associated with high mortality rate and reached statistical significance.Conclusion:AKI in COVID-19 patients has a high mortality rate (55.85%) with a high CKD progression rate among survivors (49%).

Abstract 8874: Diabetes and Chronic Kidney Disease in Heart Failure With Reduced and Preserved

Introduction: Heart Failure (HF) is a major public health burden, but population-based estimates of incidence rates of clinical outcomes by HF category are scarce. We calculated adjusted incidence rates of type 2 diabetes (T2D) and chronic kidney disease (CKD) in patients with HF with preserved (HFpEF) or reduced ejection fraction (HFrEF). Methods: We identified adult patients with a HF diagnosis from 2005-2017 in the electronic medical record of Kaiser Permanent Northwest and calculated age/sex adjusted incidence or progression rates per 1,000 person-years using generalized estimating equations over 15 years of follow-up (2005-2019). Patients with their first diagnosis of T2D or with two eGFR values &lt;60ml/min/1.73m 2 per the CKD-EPI equation recorded after a HF diagnosis were counted as incident cases. Progression of CKD was calculated among those with CKD at baseline defined as deteriorating to a lower eGFR category (category 3a, 45-59 ml/min/1.73m 2 ; 3b, 30-44; 4, 15-29; 5, &lt;15 or ESKD). Progression to insulin was calculated among those with T2D at baseline not already on insulin. Results: Of the 37,773 patients with a HF diagnosis, 36% had no EF available. 46.4% were categorized as HFpEF, 6.7% HFmrEF and 10.9% HFrEF. Compared with HFrEF patients, those with HFpEF were older (72.1 vs. 68.6 years) and more likely to be female (55% vs. 33%). Patients with HFrEF were more likely than HFpEF to develop CKD or have CKD deterioration (Table). However, due to the much larger size of the HFpEF group, HFpEF generated higher absolute numbers of events. Incidence rates and progression of T2D were smaller for both HFrEF and HFpEF. Conclusions: In a large real-world dataset of HF patients, rates of CKD progression were very high in both HFrEF and HFpEF, affecting approximately half of patients with CKD at baseline. Although progression and new incidence of CKD were relatively lower in HFpEF vs. HFrEF, the greater prevalence of HFpEF was driving the majority of heart failure-associated CKD.

Hypoglycemic agents and prognostic outcomes of chronic kidney disease patients with type 2 diabetes

Introduction: Chronic kidney disease (CKD) poses a financial burden on most patients from low/ middle income countries. Glycaemic control with affordable hypoglycemic agents may influence on the prognosis of diabetic nephropathy. Objectives: We aimed to compare the rates of CKD progression and proteinuria in the type 2 diabetic population in response to the use of various hypoglycemic agents. Patients and Methods: A retrospective cross-sectional study of a total of 250 patients of Afro-Caribbean descent at the University hospital of the West Indies between 2018 and 2019 was conducted. The use of hypoglycaemic agents and changes in albuminuria were calculated as odds ratios with a 95% confidence interval (CI). A P value&lt;0.05 was considered statistically significant. Results: Of 250 patients with diabetic nephropathy, the number of rapid CKD progression was highest in patients on insulin (26.3%). In comparison, number of rapid progressions in patients receiving metformin, dipeptidyl peptidase 4 (DPP-4 inhibitors), sulfonylurea and pioglitazone were 19.1%, 22.2%, 21.9% and 20%, respectively. After eliminating confounding factors, comparison within the group analysis on DPP-4 inhibitors (n= 171) demonstrated 62.6% significant improvement in quantitative proteinuria with reduction of mean spot urine albumin creatinine ratio (ACR) from 362.1 ±338.9 mg/g to 303 ±300.1 mg/g (ORs, 0.77; 95% CI 0.41 to 0.97; P = 0.03). Conclusion: Type 2 diabetic patients requiring insulin were found to have progression of CKD than patients on oral hypoglycaemic agents. Among the affordable oral hypoglycaemic agents, DPP-4 inhibitors had an association with reduction in albuminuria.

Multidisciplinary education and lifestyle camps for CKD patients and their closest family members: effects on disease progression, self-management and psychosocial condition-a retrospective cohort study.

Multidisciplinary education including psychosocial care (MDE) may alleviate high burden of chronic kidney disease (CKD). Family support also has utmost importance, yet, MDE has rarely been provided jointly for patients and their relatives. We organized intensive, 1-week-long boarding MDE and lifestyle camps for CKD stage III-V patients and their relatives and assessed the rate of CKD progression, proportion of participants' home-based dialysis choice, transplant activity, and improvement of their coping and attitude evaluated by written narratives. Outcome was compared to 40 controls with similarly advanced CKD, under standard of care on our outpatient clinic. In 60 predialysis patients, serum creatinine 12months before participation was 281 [IQR 122] µmol/l, right before MDE 356 [IQR 141] µmol/l, 12months after MDE 388 [IQR 284] µmol/l, eGFR decreased from 18.5 [IQR 10] ml/min to 14.0 [IQR 7] ml/min and 13.0 [IQR 8] ml/min, respectively. Twelve months' changes before and after MDE differed significantly (p = 0.005 for creatinine; p = 0.003 for eGFR). Decreased progression was found in comparison to controls (p = 0.004; 0.016, respectively) as well. During follow-up, MDE patients compared to controls chose PD as dialysis modality more often (p = 0.004), and were more active in renal transplantation (p = 0.026). Based on narratives, MDE enhanced participants' disease-specific knowledge and ability for coping. It also improved sympathy, helpfulness, and the mutual responsibilities of family members. Our unique MDE programme with participation of the closest relatives enhanced the effectiveness of education and strengthened family support, which contributed to favorable CKD outcome, increased activity in home-based dialysis selection and transplant activity.

Precision medicine approaches for diabetic kidney disease: opportunities and challenges.

The prevalence of end-stage kidney disease (ESKD) continuously increases worldwide. The increasing prevalence parallels the growth in the number of people with diabetes, which is the leading cause of ESKD. Early diagnosis of chronic kidney disease (CKD) in patients with diabetes and appropriate intervention is important to delay the progression of kidney function decline and prevent ESKD. Rate of CKD progression and response to treatment varies among patients with diabetes, highlighting the need to tailor individual treatment. In this review, we describe recent advances and areas for future studies with respect to precision medicine in diabetic kidney disease (DKD). DKD is a multi-factorial disease that is subject in part to genetic heritability, but is also influenced by various exogenous mediators, such as environmental or dietary factors. Genetic testing so far has limited utility to facilitate early diagnosis, classify progression or evaluate response to therapy. Various biomarker-based approaches are currently explored to identify patients at high risk of ESKD and to facilitate decision-making for targeted therapy. These studies have led to discovery and validation of a couple of inflammatory proteins such as circulating tumour necrosis factor receptors, which are strong predictors of kidney disease progression. Moreover, risk and drug-response scores based on multiple biomarkers are developed to predict kidney disease progression and long-term drug efficacy. These findings, if implemented in clinical practice, will pave the way to move from a one-size-fits-all to a one-fit-for-everyone approach.

Chronic kidney disease progression in a large prevention program in Colombia: A cohort study

Background: Estimating morbidity outcomes and the rate of progression of chronic kidney disease (CKD) patients is of great importance for the health systems. Objective: The objective of this study is to estimate the incidence of dialysis initiation and the rate of CKD progression in 2 years follow-up and identify factors associated with dialysis starts. Methods: A retrospective cohort study of adult with diagnosed CKD stages-G3, G4 (estimated glomerular filtration rate between 60 and 15 ml/min/1.73 m2) enrolled into a CKD prevention program in Bogota-Colombia, since January 1, 2016, to June 30, 2017, with follow-up until June 30, 2019. Cohort’s outcomes were arrival to dialysis and stage G5, dropout of the program, hospitalization, and mortality. Repeated measurements of the estimation of glomerular filtration rate (eGFR) allowed us to estimate the change over time in 4-month periods using a mixed-effects model. An Extended Cox model was adjusted for the time to start dialysis. Results: One thousand four hundred forty-eight patients were included in the analysis; the incidence rate of dialysis initiation was 2.1 events per 100 patients-year (95% CI: 1.5 2.7). The mean of eGFR variation was +1.1 ml/min/1.73 m2/year; and for diabetics was −1.0 ml/min/m2/year. Being diabetic and having poorly controlled hypertension were significant risk factors for time to dialysis initiation. Conclusion: The incidence rates of dialysis initiation, dropout, and hospitalization are outcomes of significant interest in a CKD prevention program. Being diabetic and poor blood pressure control are risk factors for a more rapid progression to dialysis.

Long-term lithium therapy and risk of chronic kidney disease in bipolar disorder: A historical cohort study.

Long-term lithium therapy (LTLT) has been associated with kidney insufficiency in bipolar disorder (BD). We aimed to investigate the risk factors of chronic kidney disease (CKD) development and progression among BD patients receiving LTLT. We included adult patients with BD on LTLT (≥1year) who were enrolled in the Mayo Clinic Bipolar Biobank, Rochester, Minnesota. We reviewed electronic medical records to extract information related to lithium therapy and kidney-related data to assess changes in the estimated glomerular filtration rate (eGFR). CKD severity was assessed based on eGFR. Among 154 patients who received LTLT, 41 patients (27%) developed CKD, of whom 20 (49%) patients continued lithium (continuers) and 19 (46%) discontinued it (discontinuers). The median time to stage 3 CKD development was 21.7years from the start of Li treatment. Type-2 diabetes mellitus and benzodiazepine use were independent predictors for CKD development in the survival analysis, after controlling for age. The subsequent CKD progression rate did not differ between continuers and discontinuers (mean GFR 48.6 vs. 44.1, p=0.13) at the end of follow-up duration (mean duration: 3.5±4.4years for continuers and 4.9±5.3years for discontinuers). CKD was observed in one fourth of patients with BD receiving LTLT. There was no significant difference in the progression of CKD among Li continuers versus discontinuers, at the mean follow-up duration of 4.2years, after the CKD diagnosis. Progression of CKD could be influenced by existing comorbidities and may not necessarily be due to lithium alone.

P0718HEALTH CARE COSTS IN CHRONIC KIDNEY DISEASE: A LONGITUDINAL STUDY FROM THE PIRP COHORT

Abstract Background and Aims Health care costs in patients with chronic kidney disease (CKD) vary widely according to patients’ severity. In patients followed up in a community-based project, it is of interest to determine cost variations over time, as a result of treatment and CKD progression. The aim of the study was to estimate the costs incurred by the health care system for CKD patients in an Italian region. Method Patients recruited in the Emilia-Romagna (Italy) PIRP project in the years 2007-2014 with CKD stage 3a to 5 were included in the study. Patients were stratified at baseline into 7 groups at different risk of progression according to the CT-PIRP classification (Rucci et al., A clinical stratification tool for chronic kidney disease progression rate based on classification tree analysis, NDT 2014). To calculate the annual medical costs, we multiplied the number of services used by the respective unit cost. Per capita costs were obtained dividing overall costs by person-years. We used DRG tariffs as a proxy of costs for hospital admissions, the regional nomenclator for outpatient visits and lab tests, and cost unit for prescribed drugs. Mixed effects generalized linear models were used to estimate the annual direct costs of CT-PIRP groups, adjusted for calendar year of entry in PIRP and local health authority of residence. Results The study cohort includes 7737 CKD patients, aged 73.2±11.6 years, 64.5% males, mostly in CKD stage 4 (3136, 40.5%) and 3b (2799, 36.2%); 697 patients (9.0%) entered the study at stage 5. The CT-PIRP classification and frequency distribution is shown in Tab.1. After 4 years, 5017 (64.8%) were still alive, 1743 (22.5%) died, 546 (7.2%) were on ESKD and 422 (5.5%) were lost. The overall direct costs of patients while still enrolled in the PIRP project decreased from 36.89 million € in the first year to 32.22 in the fourth year, while the per capita annual median costs were stable around 2200 €. The cost breakdown showed a decrease of hospitalization and drugs costs and an increase in specialty visits costs (Fig.1). The model-estimated average annual costs were significantly higher for proteinuric, low GFR patients of CT-PIRP groups 2 and 3 (7239 € and 8825 € respectively), while non-diabetic, younger patients of group 5 determined a significantly lower burden (3350 €).