Severe Chronic Kidney Disease Stage Research Articles

Mid- and long-term renal outcomes after metabolic surgery in a multi-center, multi-ethnic Asian cohort with T2DM

ABSTRACT Background Metabolic surgery is recognized for its effectiveness in weight loss and improving outcomes for individuals with type 2 diabetes mellitus (T2DM). However, its impact on renal function, especially in multi-ethnic Asian populations, remains underexplored. This study investigates mid- and long-term renal outcomes following metabolic surgery in Asian patients with T2DM. Methods This retrospective cohort study utilized data from the Asian Diabetes Surgery Study (ADSS), involving T2DM patients aged 20–79 who underwent metabolic surgery from 2008 to 2015. The primary outcome was the change in estimated glomerular filtration rate (eGFR) at 1, 3, and 5 years post-surgery, with adjustments for confounders. Secondary outcomes included changes in chronic kidney disease (CKD) stages and the relationship between weight loss and eGFR changes. Data were analyzed using univariate and multivariable regression analyses, along with the McNemar test. Results The study included 1513 patients with a mean age of 42.7 years. The results revealed that a significant improvement in eGFR was observed at 1-year post-surgery (112.4 ± 32.0 ml/min/1.73 m², P < .001), with a shift toward less severe CKD stages. However, this improvement was not sustained at 3 and 5 years. No significant correlation was found between weight loss and eGFR changes at 1-year follow-up. Conclusion Metabolic surgery significantly improves renal function at 1 year postoperatively in Asian individuals with T2DM, highlighting its potential benefits beyond glycemic control and weight loss. The long-term effects on renal function require further investigation.

Development and validation of a race-agnostic computable phenotype for kidney health in adult hospitalized patients.

Standard race adjustments for estimating glomerular filtration rate (GFR) and reference creatinine can yield a lower acute kidney injury (AKI) and chronic kidney disease (CKD) prevalence among African American patients than non-race adjusted estimates. We developed two race-agnostic computable phenotypes that assess kidney health among 139,152 subjects admitted to the University of Florida Health between 1/2012-8/2019 by removing the race modifier from the estimated GFR and estimated creatinine formula used by the race-adjusted algorithm (race-agnostic algorithm 1) and by utilizing 2021 CKD-EPI refit without race formula (race-agnostic algorithm 2) for calculations of the estimated GFR and estimated creatinine. We compared results using these algorithms to the race-adjusted algorithm in African American patients. Using clinical adjudication, we validated race-agnostic computable phenotypes developed for preadmission CKD and AKI presence on 300 cases. Race adjustment reclassified 2,113 (8%) to no CKD and 7,901 (29%) to a less severe CKD stage compared to race-agnostic algorithm 1 and reclassified 1,208 (5%) to no CKD and 4,606 (18%) to a less severe CKD stage compared to race-agnostic algorithm 2. Of 12,451 AKI encounters based on race-agnostic algorithm 1, race adjustment reclassified 591 to No AKI and 305 to a less severe AKI stage. Of 12,251 AKI encounters based on race-agnostic algorithm 2, race adjustment reclassified 382 to No AKI and 196 (1.6%) to a less severe AKI stage. The phenotyping algorithm based on refit without race formula performed well in identifying patients with CKD and AKI with a sensitivity of 100% (95% confidence interval [CI] 97%-100%) and 99% (95% CI 97%-100%) and a specificity of 88% (95% CI 82%-93%) and 98% (95% CI 93%-100%), respectively. Race-agnostic algorithms identified substantial proportions of additional patients with CKD and AKI compared to race-adjusted algorithm in African American patients. The phenotyping algorithm is promising in identifying patients with kidney disease and improving clinical decision-making.

Prognostic Modeling of Chronic Kidney Disease Progression: Bridging Mild and Severe Stages through a Machine Learning Approach

Background and Aim: Chronic Kidney Disease (CKD) is a condition where the kidneys gradually lose their ability to function properly over time. It is into stages based on the severity of kidney damage and the level of kidney function. The objective of our study is to employ machine learning models for the prediction of Chronic Kidney Disease (CKD) progression. Methods: Our study is centered on the prediction of CKD progression from mild (I, II, III) to advanced stages (IV, V, VI). We utilized logistic regression with a lasso-penalized approach and random forest model for our predictive analysis. We assessed the significance of features using the Gini index derived from the random forest model. The performance of our models was evaluated based on the Area Under Receiver Operating Characteristic (AU-ROC), AU-Precision-Recall (PR) curves, recall, precision and accuracy. Results: Our study showcases remarkable predictive performance of CKD progression from milder (I, II, III) to severe stages (IV, V, VI). Random forest model achieved an accuracy of 85%, a recall rate of 86%, a precision rate of 83%, an AU-ROC score of 92%, and an AU-PR score of 83%. The logistic regression model exhibited an accuracy of 84%, a recall rate of 84%, a precision rate of 85%, an AU-ROC score of 92%, and an AU-PR score of 81%. Regarding variable importance, our model identifies creatinine as the most critical feature, followed by eGFR. Conclusion: Our findings indicate that machine learning models hold promise in predicting CKD progression with substantial discriminative capabilities, as evidenced by high AUROC curves. This suggests their potential utility in real-world clinical settings for identifying patients at risk of transitioning from mild to severe stages of CKD.

Patient-Reported Outcomes Measures, Polycystic Kidney Disease Burden, and Outcomes in Autosomal Dominant Polycystic Kidney Disease

Rationale & ObjectiveUsing OVERTURE (NCT01430494) study data on patient-perceived health, healthcare utilization, and productivity in autosomal dominant polycystic kidney disease (ADPKD), this research was conducted to characterize the burden of illness in ADPKD patients and assess whether patient-reported outcomes (PRO) assessment scores predict clinical and health-economic outcomes. Study DesignAnalyses of data from a prospective, observational study. Setting & ParticipantsThe study cohort comprised 3409 individuals with ADPKD in 20 countries, ages 12–78 years, in chronic kidney disease (CKD) stages G1–G5 and Mayo risk subclasses 1A–1E. PredictorsScores on PRO instruments, including disease-specific assessments (ADPKD-Impact Scale [ADPKD-IS], ADPKD-Urinary Impact Scale [ADPKD-UIS]) and generic measures. OutcomesClinical variables (e.g., height-adjusted total kidney volume [htTKV], estimated glomerular filtration rate [eGFR], abdominal girth) and health-economic outcomes. Analytical ApproachAssociations among variables were evaluated using Spearman correlations, logistic regression, and generalized linear mixed-effects repeated-measures models. ResultsBaseline CKD stage and Mayo risk classification showed little correlation with baseline PRO scores, although scores on disease-specific instruments and measures of physical functioning were worse at more severe CKD stages. PRO scores predicted hospitalizations and sick days at 6–18 months, with associations strongest for the ADPKD-IS. Whereas PRO scores were not associated with htTKV and eGFR, worse PRO scores were associated with greater abdominal girth. Poor baseline ADPKD-IS scores were positively associated with occurrence of ADPKD-related symptoms up to 18 months, including kidney pain (odds ratio [OR] 5.30, 95% confidence interval [CI] 2.75–10.24), hematuria (OR 4.58, 95% CI 1.99–10.53), and urinary tract infection (OR 4.41, 95% CI 1.93–10.11; P<0.001 for all). LimitationsMaximum 18 months of follow-up to assess outcomes. ConclusionsPRO scores predicted clinical and health-economic outcomes such as hospitalization and absence from work, underscoring the importance of quality of life assessment of individuals with ADPKD.

Effect of serum creatinine difference between the Jaffe and the enzymatic method on kidney disease detection and staging.

Serum creatinine (SCr), mainly determined by the Jaffe or an enzymatic method, is the central marker to assess kidney function. Deviations between these two methods may affect the diagnosis and staging of acute kidney injury (AKI) and chronic kidney disease (CKD). The results of the first parallel SCr measurement (Jaffe and enzymatic method) of adult in- and outpatients in the same serum sample at the University Hospital Essen (Essen, Germany) between 2020-2022 were retrospectively evaluated. A Bland-Altman plot with 95% limits of agreement (LoAs) was used to assess the difference between the Jaffe and the enzymatic SCr (eSCr) method. We used the 2009 Chronic Kidney Disease Epidemiology Collaboration equation for determination of estimated glomerular filtration rate (eGFR) according to the Kidney Disease: Improving Global Outcomes guidelines. A total of 41144 parallel SCr measurements were evaluated. On average, Jaffe SCr was 0.07mg/dl higher than eSCr (LoA -0.12; 0.25mg/dl). In 19% of all cases there was a different CKD stage when comparing eGFR between both SCr methods, of which 98% resulted in a more severe CKD stage determined with Jaffe SCr. In 1.6% of all cases Jaffe SCr was ≥0.3mg/dl higher than eSCr. The present study showed that methods of SCr measurement may affect both the diagnosis and staging of AKI and CKD. This must be taken into account when interpreting measurements of renal function in everyday clinical practice, but also when planning and comparing studies on renal diseases. One should therefore stay with one method for SCr measurement, preferably with the enzymatic method.

#6823 THE NUTRITIONAL AND NEPHROLOGICAL IMPACT OF A LOW-NORMAL PROTEIN HIGH CALORIE DIET ON THE ONCOLOGICAL SOLITARY KIDNEY: TIME FOR A NEW PERSPECTIVE?

Abstract Background and Aims Nutritional therapy (NT) based on controlled protein intake represents a cornerstone in the management of chronic kidney disease (CKD). However the international guidelines do not precisely define an adequate protein intake for nephrological patients affected by cancer, the onco-nephrological ones. Among them, there is a precise asset where a personalized nutritional strategy can make the difference; the oncological patients who remain with a solitary kidney due to a radical nephrectomy for renal cancer. In fact, the acute decrease of GFR due to the loss of an entire kidney leads these patients to develop a mild to severe stage of CKD and this pathological condition should require a nephrological diet with protein restriction based upon GFR levels. However, in routinary clinical practice this cohort of patients tend to be followed by oncologists who apply a completely opposite nutritional approach with a high protein diet for the presence of cancer in order to avoid catabolism, malnutrition and sarcopenia. The aim of our study was to investigate whether a Low-Normal Protein High Calorie (LNPHC) diet in a nephrologist-nutritionist combined approach (NNCA) and aimed at CKD patients can also be effective in improving the nutritional status in solitary cancer kidney patients without compromising the renal function and metabolism. Method A consecutive cohort of 44 pts was enrolled in the Urological Department at San Raffaele Scientific Institute between 2018-2021. Inclusion criteria were: Age (&amp;gt;18 years old), eGFR (&amp;lt;60 ml/min/1.73), Malnutritional Screening Tool (MST&amp;lt;2), Solitary kidney for radical nephrectomy for renal cancer, informed consent (signed). Each patient underwent an initial nephrological and nutritional evaluation and was subsequently subjected to a conventional CKD LNPHC diet integrated with aproteic foods (0,7-1 g/Kg/die: calories: 30-35 kcal per kg body weight/die) for a period of 6 months (+/- 2 moths). The diet was based on the estimated Glomerular Filtration Rate (CKD-EPI 2021 Creatinin formula), comorbidities and nutritional status. MST, Body Mass Index (BMI), Phase Angle (PA), Fat Mass percentage (FM%), Fat-Free Mass Index (FFMI), body cell mass index (BCMI), extracellular/intracellular water ratio (ECW/ICW), waist/hip circumference ratio (WHC), lab test exams and clinical variables were examined at baseline and after 6 months. Statistical analysis: Kruskal-Wallis rank sum test; Data analysis: R programming language and RStudio integrated development environment. Results Descriptive analysis is showed in Table 1. Our results clearly highlighted that LNPHC was able to generate a significant improvement in all the investigated nutritional parameters (Table 2 and 3) avoiding malnutrition or catabolism. Moreover, regarding the nephrological asset, LNPHC was responsible for a significant decrease of urea, the most important parameter influencing general status. The non-significant increase of serum creatinine and therefore decrease of eGFR was related to the augmented muscle mass (Table 4). Conclusion LNPHC represents a new important therapeutic strategy to apply in the onco-nephrological patients with solitary kidney due to renal cancer.

Deep learning-based electrocardiographic screening for chronic kidney disease

BackgroundUndiagnosed chronic kidney disease (CKD) is a common and usually asymptomatic disorder that causes a high burden of morbidity and early mortality worldwide. We developed a deep learning model for CKD screening from routinely acquired ECGs.MethodsWe collected data from a primary cohort with 111,370 patients which had 247,655 ECGs between 2005 and 2019. Using this data, we developed, trained, validated, and tested a deep learning model to predict whether an ECG was taken within one year of the patient receiving a CKD diagnosis. The model was additionally validated using an external cohort from another healthcare system which had 312,145 patients with 896,620 ECGs between 2005 and 2018.ResultsUsing 12-lead ECG waveforms, our deep learning algorithm achieves discrimination for CKD of any stage with an AUC of 0.767 (95% CI 0.760–0.773) in a held-out test set and an AUC of 0.709 (0.708–0.710) in the external cohort. Our 12-lead ECG-based model performance is consistent across the severity of CKD, with an AUC of 0.753 (0.735–0.770) for mild CKD, AUC of 0.759 (0.750–0.767) for moderate-severe CKD, and an AUC of 0.783 (0.773–0.793) for ESRD. In patients under 60 years old, our model achieves high performance in detecting any stage CKD with both 12-lead (AUC 0.843 [0.836–0.852]) and 1-lead ECG waveform (0.824 [0.815–0.832]).ConclusionsOur deep learning algorithm is able to detect CKD using ECG waveforms, with stronger performance in younger patients and more severe CKD stages. This ECG algorithm has the potential to augment screening for CKD.

Assessment of Pulmonary Hypertension in Chronic Kidney Disease Patients using Doppler Echocardiography.

The incidence of chronic kidney disease (CKD) is increasing globally and is associated with significant morbidity and mortality related to the cardiovascular system. There is limited data on pulmonary hypertension (PH) in CKD patients, especially from developing and underdeveloped countries. PH leads to hypoxia which is a significant cause of dyspnea in CKD patients with or without pulmonary edema. Hence, we planned this study to assess the PH in CKD patients using two-dimensional (2D) color Doppler echocardiography. This is an observational cross-sectional study. A total of 100 CKD patients on hemodialysis or conservative management were enrolled in the study. Following the collection of demographic data, and routine/specific investigations, these patients were assessed for PH using 2D color Doppler echocardiography. PH was found in 47% of patients with CKD. Left ventricular (LV) hypertrophy, systolic and diastolic dysfunction, dilated right atrium/right ventricular and left atrial/LV chambers, and valvular hypertrophy were other echocardiography findings recorded in these patients. Low hemoglobin levels, high urea/creatinine levels, and duration of hemodialysis in CKD patients were found to be significantly associated with the presence of PH. The majority of CKD patients have PH at various stages of disease-causing unexplained dyspnea in these patients. PH is common in end-stage CKD as compared to patients with a less severe stage of CKD. Hence, CKD patients should be evaluated for PH, especially in the presence of intractable dyspnea.

New Insights into Adiponectin and Leptin Roles in Chronic Kidney Disease

Chronic kidney disease (CKD) is commonly associated with a high burden of comorbidities and poor clinical outcomes. Malnutrition–inflammation–atherosclerosis syndrome is common in the more severe stages of CKD, suggesting a close interplay for these three comorbid conditions. Both malnutrition and obesity are associated with a disturbed adipokine profile and inflammation, contributing to a higher risk of cardiovascular disease (CVD) events. Adiponectin and leptin have important roles in carbohydrate and lipid metabolism, and in the inflammatory process. The effects of adiponectin and leptin alterations in CKD, which are usually increased, and their association with the different comorbidities found in CKD, will be focused on to understand their crosstalk with the risk of CVD events. Nonetheless, although adiponectin and leptin contribute to a higher risk of CVD events, further studies are warranted to fully clarify their roles, especially when different comorbidities exist.

Electrochemical sensing of the secretion of indoxyl sulfate in a rat intestinal loop using a self-assembled monolayer-modified gold bead electrode

Indoxyl sulfate is a uremic toxin that accumulates in the plasma after a decline in renal function that might progress to chronic kidney disease (CKD). This accumulation is associated with the onset of dialysis and exacerbation of CKD and cardiovascular diseases. In this study, we aimed to demonstrate intestinal secretion as an excretion pathway of indoxyl sulfate in the severe stage of CKD using electrochemical sensing. A self-assembled monolayer (SAM) of 2-mercaptobenzimidazole on gold beads was successfully used for the separate sensing of indoxyl sulfate, uric acid (UA), and ascorbic acid. This electrode could detect indoxyl sulfate at concentrations as low as 50 nM in the presence of UA. No indoxyl sulfate secretion was observed in the intestinal loop of healthy rats or those intravenously administered saline. However, indoxyl sulfate secretion was detected in the 5/6 nephrectomized rats that showed high serum indoxyl sulfate levels, which also occurs in patients with CKD stage 4 or 5 and the healthy rats intravenously injected with indoxyl sulfate. These results suggest that indoxyl sulfate is excreted through the intestine when serum indoxyl sulfate level is high. The results of the present study showed that the SAM-modified gold bead electrode can be used as an easy and sensitive method for evaluating indoxyl sulfate secreted in the intestine over time.

Urinary thrombin as a marker of local disseminated intravascular coagulation in patients with chronic kidney disease

The aim of this research was to study the diagnostic markers of nonovert local disseminated intravascular coagulation (DIC) syndrome in the urine of patients with chronic kidney disease (CKD). We conducted a prospective study involving 140 patients with CKD, of these patients, 100 patients (71.4%; 95% CI 53.4-76.7) had glomerulonephritis (GN) and 40 patients (28.6%; 95% CI 21.3-36.8) had diabetic nephropathy (DN). We diagnosed overt DIC syndrome on the International Society of Thrombosis and Haemostasis (ISTH) scale (&gt;5 points) in 18.6 % of patients. We determined the level of thrombin in the urine of patients who had &lt;5 points on ISTH scale for the diagnosis of local nonovert DIC syndrome in the kidneys. In the urine of healthy individuals, the level of thrombin did not exceed 1 ng/ml, so we found no thrombinuria at a thrombin level &lt;1 ng/ml. In 56.1% of patients, we found urinary thrombin levels &gt;1 ng/ml. The average level of thrombin in the urine of these patients was 6.5 (4.8; 10.6) ng/ml. In our opinion, the presence of thrombinuria indicates the intensity of monocytic-macrophage inflammation in the glomeruli and may be a criterion for nonovert, local DIC syndrome in the kidneys. The association of overt DIC syndrome with decreased blood albumin, reduced glomerular filtration rate (GFR), increased daily protein excretion (DPE) indicates its occurrence in severe underlying disease, in the presence of nephrotic syndrome and in the severe stages of CKD. Early diagnosis of nonovert local DIC syndrome would be more useful, since the process is still reversible and controlled, and timely use of antiplatelet and anticoagulant therapy would affect the course and the progression of CKD.

Dysgeusia and Dysosmia in Chronic Kidney Disease: NHANES 2011-2014

Dysgeusia and dysosmia are known to be associated with end-stage renal disease. Whether dysgeusia and dysosmia are associated with nondialysis-requiring chronic kidney disease (CKD) is unknown. We utilized data from the National Health and Nutrition Examination Survey during years 2011-14. We classified CKD by stage using standard criteria for the estimated glomerular filtration rate and the urine albumin-to-creatinine ratio. We used multivariable logistic regression analysis to determine the independent associations among CKD, CKD stage, and dysgeusia and dysosmia using a ChemoSensory Questionnaire. After adjusting for the residual effects of age, sex, self-reported race, and diabetes, nondialysis-requiring CKD was significantly associated with dysgeusia ([odds ratio, 95% confidence interval] 1.34 [1.05, 1.70]); the association with dysosmia was of borderline significance, odds ratio 1.27 (0.97, 1.68). Odds of dysgeusia were higher at more severe CKD stages. Nondialysis-requiring CKD is significantly associated with self-reported dysgeusia.

Impact of Removing Race Adjustment When Estimating GFR on Chronic Kidney Disease Staging

Abstract Introduction/Objective Determination of glomerular filtration rate (GFR) is essential in assessment of kidney function, particularly in patients with chronic kidney disease (CKD). Formulas were developed to calculate estimated GFR (eGFR), as direct measurement is cumbersome and not amenable to routine monitoring. CKD-EPI is the most widely used formula for eGFR, using parameters of serum creatinine, gender, race, and age. A race adjustment was added from an unfounded assumption that Black patients have more muscle mass, increasing their eGFR by about 16%. There is concern on the impact of “correcting” for Black race on patient management, utility of eGFR, and its possible contribution to healthcare disparities. This study examined the impact of eliminating race adjustment from the CKD- EPI formula on CKD staging in patients at a large safety-net hospital in an academic medical center. Methods/Case Report 80090 serum creatinine values from 56676 adult patients (31.4% Black, 67.5% female, median age 51 yrs) were collected from the electronic medical record (Epic, Verona, WI) over a 16-month timeframe. Values were excluded if they lacked age, gender, self-identified race, or serum creatinine. eGFR was calculated using the CKD-EPI equation with and without race modifier, and CKD staging was performed using 2012 Kidney Disease: Improving Global Outcomes guidelines. Results (if a Case Study enter NA) In our cohort, only 50.8% of Black patients are in CKD1, indicative of no CKD, compared to 67.9% of non-Black patients. Given that these two cohorts are demographically similar, this shows a discrepancy in kidney function even before removing the race adjustment. After removal of the race modifier, 28.1% of Black patients were reclassified into a more severe CKD stage. The most restaging occurred from CKD3A to 3B (39%). Conclusion Many Black patients in our study were reclassified to a more severe CKD stage, with the highest percentage of patients restaged to CKD3B, which would have attracted clinical attention for nephrology referral. We recommend removal of the race adjustment in eGFR, given its basis in the incorrect belief in biological differences between races. It perpetuates systemic racism and discrimination in healthcare, and its removal will provide more equitable care and reduce healthcare disparities. Future studies should examine the increase in resources required to provide adequate medical care to patients who will be placed into a more severe CKD stage.

Состояние функции почек у больных туберкулезом легких

Objective: to evaluate the functional state of the kidneys in patients with various clinical variants of pulmonary tuberculosis. Material and methods. 60 patients with pulmonary tuberculosis were examined: 32 people with disseminated forms (53.3%), 16 people with infiltrative pulmonary tuberculosis (26.6%) and 12 people with other forms of pulmonary tuberculosis (20.0%). The average age of patients was 54.3 ± 3.3 years. The examination included a complete clinical, laboratory and instrumental examination. The glomerular filtration rate (GFR) was evaluated using the CKD-EPI formula, followed by an assessment of the stage of chronic kidney disease (CKD) in accordance with National Clinical Guidelines (Moscow, 2019). Results and discussion. As a result of the examination, CKD of various stages was detected in all observed patients with pulmonary tuberculosis. CKD of stage C2 (35.0%) and C3a (31.6%) was most often detected, less often C3b (6.6%), C4 (15%) and C5 (11.6%). At the same time, patients with disseminated forms of pulmonary tuberculosis were more likely to have more severe stages of CKD (C3b – C5) – 18.2%, than in patients with infiltrative forms (6.5%) and in patients with other forms of pulmonary tuberculosis (8.3%). The development of CKD in patients with pulmonary tuberculosis can contribute to the formation of morphofunctional changes in the lung tissue with fibrosis phenomena and subsequent violations of ventilation and perfusion mechanisms. Conclusion. The results obtained require mandatory assessment of kidney function in patients with pulmonary tuberculosis with the determination of the glomerular filtration rate by the calculated method, followed by the isolation of the CKD stage, especially in patients with a disseminated form of the disease, and timely measures to slow the progression of CKD.

Pharmacological interventions versus placebo, no treatment or usual care for osteoporosis in people with chronic kidney disease stages 3-5D.

Chronic kidney disease (CKD) is an independent risk factor for osteoporosis and is more prevalent among people with CKD than among people who do not have CKD. Although several drugs have been used to effectively treat osteoporosis in the general population, it is unclear whether they are also effective and safe for people with CKD, who have altered systemic mineral and bone metabolism. To assess the efficacy and safety of pharmacological interventions for osteoporosis in patients with CKD stages 3-5, and those undergoing dialysis (5D). We searched the Cochrane Kidney and Transplant Register of Studies up to 25 January 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Randomised controlled trials comparing any anti-osteoporotic drugs with a placebo, no treatment or usual care in patients with osteoporosis and CKD stages 3 to 5D were included. Two review authors independently selected studies, assessed their quality using the risk of bias tool, and extracted data. The main outcomes were the incidence of fracture at any sites; mean change in the bone mineral density (BMD; measured using dual-energy radiographic absorptiometry (DXA)) of the femoral neck, total hip, lumbar spine, and distal radius; death from all causes; incidence of adverse events; and quality of life (QoL). Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Seven studies involving 9164 randomised participants with osteoporosis and CKD stages 3 to 5D met the inclusion criteria; all participants were postmenopausal women. Five studies included patients with CKD stages 3-4, and two studies included patients with CKD stages 5 or 5D. Five pharmacological interventions were identified (abaloparatide, alendronate, denosumab, raloxifene, and teriparatide). All studies were judged to be at an overall high risk of bias. Among patients with CKD stages 3-4, anti-osteoporotic drugs may reduce the risk of vertebral fracture (RR 0.52, 95% CI 0.39 to 0.69; low certainty evidence). Anti-osteoporotic drugs probably makes little or no difference to the risk of clinical fracture (RR 0.91, 95% CI 0.79 to 1.05; moderate certainty evidence) and adverse events (RR 0.99, 95% CI 0.98 to 1.00; moderate certainty evidence). We were unable to incorporate studies into the meta-analyses for BMD at the femoral neck, lumbar spine and total hip as they only reported the percentage change in the BMD in the intervention group. Among patients with severe CKD stages 5 or 5D, it is uncertain whether anti-osteoporotic drug reduces the risk of clinical fracture (RR 0.33, 95% CI 0.01 to 7.87; very low certainty evidence). It is uncertain whether anti-osteoporotic drug improves the BMD at the femoral neck because the certainty of this evidence is very low (MD 0.01, 95% CI 0.00 to 0.02). Anti-osteoporotic drug may slightly improve the BMD at the lumbar spine (MD 0.03, 95% CI 0.03 to 0.04, low certainty evidence). No adverse events were reported in the included studies. It is uncertain whether anti-osteoporotic drug reduces the risk of death (RR 1.00, 95% CI 0.22 to 4.56; very low certainty evidence). Among patients with CKD stages 3-4, anti-osteoporotic drugs may reduce the risk of vertebral fracture in low certainty evidence. Anti-osteoporotic drugs make little or no difference to the risk of clinical fracture and adverse events in moderate certainty evidence. Among patients with CKD stages 5 and 5D, it is uncertain whether anti-osteoporotic drug reduces the risk of clinical fracture and death because the certainty of this evidence is very low. Anti-osteoporotic drug may slightly improve the BMD at the lumbar spine in low certainty evidence. It is uncertain whether anti-osteoporotic drug improves the BMD at the femoral neck because the certainty of this evidence is very low. Larger studies including men, paediatric patients or individuals with unstable CKD-mineral and bone disorder are required to assess the effect of each anti-osteoporotic drug at each stage of CKD.

The Impact of Chronic Kidney Disease on Peripheral Artery Disease and Peripheral Revascularization.

Chronic kidney disease (CKD) is a clinical condition characterized by high morbidity and mortality. Globally, CKD is also increasing in prevalence and incidence. The two principal kidney measures namely estimated glomerular filtration rate (eGFR) and albuminuria have been found to be predictors of renal and cardiovascular (CV) endpoints including peripheral artery disease (PAD). The prevalence of PAD was increased in CKD patients and, particularly, in patients with more severe CKD stages. Despite the fact that revascularization strategies are suitable in CKD patients in similar fashion to non-CKD patients, few CKD patients underwent these procedures. In fact, if it is true that revascularization improves prognosis in PAD patients irrespective of baseline eGFR, it was also demonstrated that CKD patients, who underwent revascularization, were at higher risk for amputations, mortality, re-intervention and perioperative complications. With the present review article, we have examined the association between CKD, PAD and peripheral revascularization highlighting data about epidemiology, pathophysiologic mechanisms, and results from previous observational and intervention studies. We have also examined the future perspectives and challenges of research around the association between CKD and PAD.

Excess healthcare costs in patients with autosomal dominant polycystic kidney disease by renal dysfunction stage

Aim To build upon previous outdated studies by comprehensively assessing the direct healthcare burden of autosomal dominant polycystic kidney disease (ADPKD). Materials and methods Patients with ≥2 diagnoses for ADPKD (ADPKD cohort) were identified in the US fee-for-use IBM Truven Health Analytics MarketScan Commercial Claims and Encounters and IBM Truven Health Analytics MarketScan Medicare Supplemental databases (01 January 2015–31 December 2017) and matched (1:3) to controls without ADPKD (non-ADPKD cohort). The index date was the last calendar date followed by 12 months continuous enrollment (study period). Patients with ADPKD were stratified into one of seven mutually exclusive groups based on chronic kidney disease (CKD) stages (I–V), end-stage renal disease requiring renal replacement therapy (ESRD-RRT), and unknown stage. Results During the 12-month study period, patients with ADPKD incurred significantly higher total healthcare costs than those without ADPKD (mean cost difference = $22,879 per patient per year [PPPY]; p < .001). Besides CKD stages I and II, total healthcare cost differences increased as patients progressed beyond CKD stage III, with the greatest difference observed among patients with ESRD-RRT. Total healthcare cost differences between cohorts were more pronounced in subgroups of patients with hypertension ($29,347) and with high risk of rapid progression ($39,976). Similar results were observed in the Medicare Supplemental population, with a total mean cost difference of $42,694 PPPY (p < .001); cost difference was also higher in the hypertension ($46,461 PPPY) and high risk of rapid progression ($45,708 PPPY) subgroups. Limitations Results may not be representative of the overall ADPKD US population; CKD stage was based on diagnosis and procedure codes; criteria used to identify ADPKD at risk of rapid progression did not rely on laboratory values; there may be billing inaccuracies and omissions in health insurance claims data. Conclusions This study demonstrated the substantial healthcare costs associated with ADPKD, which increased as patients progressed through more severe CKD stages.

Intellectual Functioning of Pediatric Patients with Chronic Kidney Disease: Results from the KNOW-Ped CKD.

BackgroundChronic kidney disease (CKD) has a negative impact on growth and development in children and is a risk factor for neurocognitive impairment; however, there is limited research on the cognitive function of children and adolescents with CKD. This study therefore aimed to investigate the mean intelligence and risk factors for low intelligence in children and adolescents with CKD.MethodsEighty-one patients with CKD under 18 years old were included in the KoreaN cohort study for Outcomes in patients With Pediatric Chronic Kidney Disease (KNOW-Ped CKD). Participants completed either the Wechsler Intelligence Scale for Children (6–16 years), or Wechsler Adult Intelligence Scale (> 16 years).ResultsThe mean full-scale intelligence quotient (IQ) was 91 ± 19; 24.7% of participants scored a full-scale IQ below 80. Participants with a short stature (height Z scores < −1.88), failure to thrive (weight Z scores < −1.65), more severe CKD stage (≥ IIIb), longer duration of CKD (≥ 5 years), and those who were Medicare or Medicaid beneficiaries, had significantly lower mean full-scale IQs.ConclusionOn linear regression analysis, the association between the full-scale IQ, and longer duration of CKD and growth failure, remained significant after controlling for demographic and clinical variables. It is therefore necessary to investigate cognitive impairment in pediatric patients with CKD who exhibit growth failure or for a longer postmorbid period. It is believed that early interventions, such as kidney transplantation, will have a positive effect on IQ in children with CKD, as the disease negatively affects IQ due to poor glomerular filtration rate over time.Trial RegistrationClinicalTrials.gov Identifier: NCT02165878

Association of impaired oral health status with chronic kidney disease in post-acute rehabilitation.

Despite the growing interest in oral health and chronic disease in geriatric medicine, the evidence of an association between the two variables is limited. This study sought to examine the association between oral health status and chronic kidney disease (CKD) in this setting. This retrospective study included consecutive post-acute patients in a rehabilitation hospital. Oral health status was evaluated using the Revised Oral Assessment Guide (ROAG). Renal function or CKD stage was assessed by measurement of the estimated glomerular filtration rate (eGFR). Multivariate logistic regression analysis was used to determine which subcategories of ROAG were independently associated with advanced CKD stages (vs. early CKD stages). Multiple linear regression analysis was used to clarify whether eGFR on admission was independently associated with ROAG score after adjusting for potential confounders. A total of 1056 (mean age 70years; 52% women) were included in the analysis. Slight and moderate-to-severe oral health problems were detected in 57.7% and 15.4% of patients, respectively. Patients with oral problems had a more severe stage of CKD (P=.036) and a lower eGFR (P=.028). Among subitems of ROAG, tongue (OR=1.40, P=.041), saliva (OR=1.72, P=.039) and oral cavity mucosa (OR=1.37, P=.013) status was independently associated with the presence of CKD stages 3, 4 and 5. Furthermore, eGFR was independently associated with ROAG score (β=-0.180, P=.034) after adjusting for possible confounders. Impaired oral health status is common and closely associated with CKD in post-acute inpatients.

PUK12 Using Real-World DATA to Improve the Accuracy of Economic Models; Experience from the Swedish Renal Register

When data from clinical trials is lacking economic models typically obtain their estimates from published literature, which is often derived from non-representative populations, with varying confounders and observation periods. To inform economic models in the setting of chronic kidney disease (CKD), we generated reliable estimates on transition probabilities during the disease progression cycle using real-world data from the nationwide Swedish Renal Register. Observational analysis from all nephrologist-referred patients with CKD stages 3-5 in Sweden during 2010-2016, with complete capture of disease progression and death events. Using Markov processes, we estimated the annual probability of dying or progressing to a more severe CKD stage. The six possible states were CKD stages 3, 4 and 5, chronic dialysis, kidney transplant and death. We also evaluated the transition probability by CKD state in individuals with high (>130 pg/mL) and low (= <130 pg/mL) serum levels of parathyroid hormone (PTH). In total 17,679 patients fulfilled our inclusion and exclusion criteria. Median age was 73 years, and 35% were women. The annual probability of transitioning to more severe CKD stages was 51% in stage 3 and 44% in stage 4 and 5; the probability of dying increased from 4% in stage 3, to 22% in stage 5 and 20% in patients on dialysis. 8,246 patients had high PTH levels, and their annual probability of transitioning to death or the next severity stage of CKD was between 40-60% significantly higher compared to patients with low PTH. Data from rich and representative patient registers can improve the estimation of reliable risk estimates to inform economic models. Our observed transition probabilities of patients with CKD can be of use to any future studies on this disease.