Therapy In Chronic Kidney Disease Patients Research Articles

Resistance physical exercise modulates metabolic adipokines, decreases body weight, and improves glomerular filtration in patients with chronic kidney disease in hemodialysis.

Chronic kidney disease (CKD) is a condition characterized by abnormalities in kidney structure and function that persist for more than 3months. It is estimated that more than 800 million people in the world have a diagnosis of CKD. To remove the harmful metabolic substances from the body, people with CKD need to perform hemodialysis. Due to their beneficial effects against a wide range of clinical conditions, physical exercise is considered a non-pharmacological therapy. This study aimed to evaluate the beneficial effects of resistance exercise during hemodialysis on metabolic adipokines, myokines, body weight, and glomerular filtration rate in patients living with CKD. Briefly, the blood samples were collected in two moments: immediately before the start of the resistance exercise protocol and 1week after the end of the protocol. Resistance exercise protocol was performed thrice a week for 12weeks and applied during hemodialysis sessions. Here, resistance exercise increases the circulating irisin (14.56%; p = 0.0112), handgrip strength (5.70%; p = 0.0036), glomerular filtration rate (25.9%; p = 0.022) and significantly decreases adiponectin (- 55.7%; p = 0.0044), body weight (- 3.7%; p = 0.0001), glucose (- 22%; p = 0.009), and albumin levels (- 9.55%; p = 0.0001). Conversely, leptin levels (- 10.9%; p = 0.38), iron (3.05%; p = 0.705), ferritin (3.24%; p = 0.880), hemoglobin (- 0.52%; p = 0.75), total cholesterol (7.9%; p = 0.19), LDL (- 9.99%; p = 0.15) and HDL (- 4.8%; p = 0.45), did not change after resistance exercise. Interestingly, 1,25 hydroxyvitamin D levels were significantly increased (14.5%; p = 0.01) following resistance exercise. Considering the effect of sex (males vs. females), we found that irisin levels increased in females but not in males after the resistance exercise protocol. Furthermore, handgrip strength and body weight were different, indicating that males had the highest strength and weight. We demonstrated that both males and females had lower albumin levels after the resistance exercise protocol. In conclusion, we suggest that resistance exercise has beneficial effects in the CKD population by modulating adipokines and metabolic myokines and therefore can be used as a non-pharmacological adjunctive therapy in CKD patients undergoing HD.

#2970 Heart failure with preserved ejection fraction on chronic kidney patients: innocent bystander? A cohort study in Portuguese population

Abstract Background and Aims Heart failure (HF) consists in a significant public health challenge, with high prevalence worldwide and a substantial impact on morbidity and mortality. In chronic kidney disease (CKD), HF can act both as a risk factor and a complication, exacerbating the overall outcomes for affected individuals. This study aims to elucidate the prevalence of distinct types of heart failure, encompassing preserved ejection fraction (HFpEF), mid-range ejection fraction (HFmrEF), and reduced ejection fraction (HFrEF) in CKD patients. Moreover, we purpose to identify the potential of these subtypes to influence the outcomes of mortality and start of kidney replacement therapy (KRT), as a different therapeutic approach is suitable for each. Method Observational retrospective cohort study of 3008 CKD patients, with follow-up in Nephrology out-patient clinic in a Portuguese hospital, from February, 2012 to October, 2019. Ejection fraction was accessed by echocardiogram and information was collected from health records. To access mortality, patients who started KRT along the study were excluded. Results A total of 3008 patients, of which 91.7% Caucasians and 54.5% males, with an average age of 68.2 (±15.9) years was enrolled in the study. The mean follow-up time was 3.21 (±1.97) years and the mean estimated glomerular filtration rate at baseline was 47.63 ± 33.1 ml/min/1.73 m2. Among the participants, 769 individuals (25.5%) were diagnosed with HF. Specifically, 319 patients (41.5%) exhibited HFpEF; 85 patients (11%) had HFmrEF, and 117 patients (15.2%) had HFrEF, while the ejection fraction (EF) was unknown in 32.2% of cases. In the HF group, the incidence of diabetes was 55.6%, compared to 37.5% in the non-HF group. As for hypertension, the prevalence of was 91.8% in the HF group and 78.6% in the non-HF group. When assessing all-cause mortality during the follow-up, the hazard ratio (HR) for the HF group was 3.54 (95% CI, 2.94-4.26) compared to the non-HF group. Furthermore, for the initiation of KRT, the HR was 1.57 (95% CI, 1.19-2.06), favoring patients without heart failure. Across different types of HF, in comparison to the group without HF, the hazard ratio during follow up were notably different. Specifically, the HR was 5.39 (95% CI, 3.66-7.94) for patients with HFrEF, 3.43 (95% CI, 2.18-5.40) for patients with HFmrEF and 2.99 (95% CI, 2.32-3.87) for the HFpEF. When assessing the initiation of kidney replacement therapy (KRT), HFrEF and HFpEF also exhibited statistically different data comparing to those without HF. Specifically, HFrEF showed a HR of 2.14 (95%, 1.27-3.63), while HFpEF had a HR of 1.79 (95%, 1.25-2.56). The Kaplan-Meier analysis demonstrated a steeper descent curve for both survival and start of KRT for the HF group compared to the non-HF group (log-rank p < 0.0001) over the study period. Within the HF group, the worst survival outcomes were observed in the HFrEF subgroup, followed by HFmrEF and HFpEF (log-rank p < 0.0001). Conclusion Heart failure is a prevalent condition in CKD patients and worsens outcomes. Our analysis of real-world data suggests a threefold higher risk of mortality among for patients with HF, and a fivefold increase in the subgroup of HFrEF, comparing to patients without HF. Notably, preserved EF yielded a HR of 3.3 for mortality when compared to those without heart failure, underscoring the importance of clinical accurate assessment, since both entities may present with preserved ejection fraction in echocardiogram. Despite the study's sample limitations and the fact that it is unicentric, we believe this work holds significance as it highlights the importance of the establishment of different degrees of HF as it can change the prognosis in terms of mortality and progression to kidney replacement therapy in CKD patients. In addition to the established association between reduced EF and mortality, the HFpEF showed to exert a notable influence on outcomes comparing to patients without HF. This emphasizes the importance of not neglecting this entity, as it should treated appropriately.

Ionized and total magnesium levels in patients with chronic kidney disease: associated factors and outcomes.

The association between hypo- and/or hypermagnesaemia and cardiovascular (CV) outcomes or mortality has shown conflicting results in chronic kidney disease (CKD) and has been conducted on total magnesium (tMg) levels. Thus, the objectives of the present study were to (i) describe the serum ionized Mg (iMg) concentration in patients at various CKD stages, (ii) measure the correlation between iMg and tMg concentrations, (iii) identify their associated factors and (iv) determine whether serum tMg and/or iMg concentrations are associated with major adverse cardiovascular events (MACE) and mortality before kidney replacement therapy in CKD patients. Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) is a prospective cohort of CKD patients with an estimated glomerular filtration rate (eGFR) <60mL/min/1.73 m2. Baseline iMg and tMg serum concentrations were centrally measured. Adjusted cause-specific Cox proportional hazard models were used to estimate hazard ratios (HRs) for first MACE and for mortality. Of the 2419 included patients, median age was 68years, and the mean eGFR was 34.8mL/min/1.73 m2. Concentrations of serum iMg and tMg were strongly correlated (r=0.89, P<.001) and were independently associated with eGFR. The adjusted HR [95% confidence interval (CI)] for MACE associated with the baseline serum tMg level was 1.27 (0.95; 1.69) for patients in Tertile 1 and 1.56 (1.18; 2.06) for patients in Tertile 3, relative to patients in Tertile 2. The HR (95% CI) of death according to serum tMg concentration was increased in Tertile 3 [1.48 (1.11; 1.97)]. The adjusted risk for MACE and mortality (all-cause or CV) associated with the baseline serum iMg level was not significantly different between tertiles. Our analysis of a large cohort of patients with moderate-to-advanced CKD demonstrated that individuals with higher serum tMg concentrations, although still within the normal range, had a greater likelihood of MACE and mortality. However, serum iMg levels were not associated with these outcomes.

Increased Cardiovascular Risk in Young Patients with CKD and the Role of Lipid-Lowering Therapy.

Chronic kidney disease (CKD) is associated with a significantly increased risk of cardiovascular disease (CVD). This review summarizes known risk factors, pathophysiological mechanisms, and current therapeutic possibilities, focusing on lipid-lowering therapy in CKD. Novel data on lipid-lowering therapy in CKD mainly stem from clinical trials and clinical studies. In addition to traditional CVD risk factors, patients with CKD often present with non-traditional risk factors that include, e.g., anemia, proteinuria, or calcium-phosphate imbalance. Dyslipidemia remains an important contributing CVD risk factor in CKD, although the mechanisms involved differ from the general population. While statins are the most commonly used lipid-lowering therapy in CKD patients, some statins may require dose reduction. Importantly, statins showed diminished beneficial effect on cardiovascular events in patients with severe CKD and hypercholesterolemia despite high CVD risk and effective reduction of LDL cholesterol. Ezetimibe enables the reduction of the dose of statins and their putative toxicity and, in combination with statins, reduces CVD endpoints in CKD patients. The use of novel drugs such as PCSK9 inhibitors is safe in CKD, but their potential to reduce cardiovascular events in CKD needs to be elucidated in future studies.

PENGARUH ERITROPOETIN TERHADAP TINGKAT KEBERHASILAN TERAPI ANEMIA PADA PASIEN ANEMIA PADA PASIEN CHRONIC KIDNEY DISEASE DI RSUD ULIN BANJARMASIN

Chronic kidney disease (CKD) is kidney damage for more than 3 months. The medical in hospital taken was hemodialysis. The aim of this study was to determine the success rate of anemia therapy, the incidence of anemia in CKD patients, and determine the effect of erythropoietin administration on the success rate of anemia therapy in CKD patients at Ulin Hospital, Banjarmasin. This research is a non-experimental research, observational in nature. Data collection was carried out prospectively. The sample used in this study was patient hemoglobin data in medical records that met the inclusion and exclusion criteria. The sample selection method used was total sampling. The measurement of therapeutic success used is the patient's hemoglobin data after being given erythropoietin. The research data obtained is displayed descriptively analytically. The research results of 90 patients with CKD (Chronic Kidney Disease). The results obtained were that 50 patients (55.55%) achieved success in anemia therapy and 40 patients (45.45%) did not achieve success in anemia therapy. The incidence of anemia was 90 patients (100%). Based on the analysis of data obtained, there is an influence of erythropoietin on the success of anemia therapy in Chronic Kidney Disease (CKD) at Ulin Regional Hospital, Banjarmasin.

Obstructive sleep apnea in chronic kidney disease patients undergoing hemodialysis. Prevalence, severity, and treatment. A narrative review

Background: Chronic kidney disease (CKD), also known as chronic renal insufficiency (CRI), can be defined by a glomerular filtration rate (GFR) less than 60mL/min/1.73m^2 associated with an albumin-to-creatinine ratio greater than 30mg of albumin per 1g of creatinine. CKD is a significant factor leading to a decline in the quality of life, increased morbidity, and a substantial reduction in life expectancy. Currently, it is estimated that there are 3.9 million patients worldwide on renal replacement therapy for CKD. Recent data indicates that in the United States of America (USA), more than 500,000 people suffer from renal failure or insufficiency. In Brazil, epidemiological data is incomplete and outdated. In 2016, there were 122,825 patients in Brazil on renal replacement therapy. Objectives: This literature review aims to assess the prevalence, severity, and therapeutic recommendations for obstructive sleep apnea (OSA) in patients with CKD undergoing hemodialysis. Methods: A literature review was conducted using PubMed, Web of Science, and SciELO databases with keywords including "Obstructive Sleep Apnea", "Chronic kidney disease", "End-stage renal disease", "sleep disorders", "hemodialysis", "CPAP", "Continuous positive airway pressure", and "Physiotherapy." Only studies published in the last twenty years and in the English language were included. Results: Despite scientific evidence demonstrating a high prevalence of OSA in CKD patients undergoing hemodialysis, there are still a lack of studies examining the effects of Continuous positive airway pressure (CPAP) therapy on the clinical outcomes of these patients. In the scientific literature, only three randomized clinical trials were found that investigated the impact of CPAP therapy on improving kidney function. Consequently, there is a critical need for clinical studies to assess the effects of CPAP therapy in CKD patients undergoing hemodialysis. It is also essential to highlight the role of physiotherapy in managing sleep disorders and aiding in the adaptation and monitoring of patients undergoing CPAP therapy. Conclusion: This literature review concluded that more randomized controlled studies are necessary to better define the optimal therapy for OSA in CKD patients, with the goal of preventing a decline in GFR progression, reducing morbidity and mortality, and enhancing overall quality of life.

Hypoxia controls expression of kidney-pathogenic MUC1 variants.

The interplay between genetic and environmental factors influences the course of chronic kidney disease (CKD). In this context, genetic alterations in the kidney disease gene MUC1 (Mucin1) predispose to the development of CKD. These variations comprise the polymorphism rs4072037, which alters splicing of MUC1 mRNA, the length of a region with variable number of tandem repeats (VNTR), and rare autosomal-dominant inherited dominant-negative mutations in or 5' to the VNTR that causes autosomal dominant tubulointerstitial kidney disease (ADTKD-MUC1). As hypoxia plays a pivotal role in states of acute and chronic kidney injury, we explored the effects of hypoxia-inducible transcription factors (HIF) on the expression of MUC1 and its pathogenic variants in isolated primary human renal tubular cells. We defined a HIF-binding DNA regulatory element in the promoter-proximal region of MUC1 from which hypoxia or treatment with HIF stabilizers, which were recently approved for an anti-anemic therapy in CKD patients, increased levels of wild-type MUC1 and the disease-associated variants. Thus, application of these compounds might exert unfavorable effects in patients carrying MUC1 risk variants.

The Role of Nutritional Therapy in Inhibiting the Progression of Chronic Kidney Disease: A Narrative Literature Review

The need for proper nutrition and diet is fundamental in every stage of chronic kidney disease. The principle of nutritional therapy is slowing the progression of chronic kidney disease, delaying patients with CKD (chronic kidney disease) from getting kidney replacement therapy. In CKD patients, there is a disturbance of protein homeostasis, disturbance in metabolism protein, acid-base disorders, and hormonal dysfunctions. As the progression of CKD increases, nitrogen-containing products accumulate, causing a decrease in appetite. In CKD patients, intestinal absorption is also impaired because uremia causes microbiota disturbance and damage to the intestinal epithelium. These various things cause nutritional status to become often irregular, and protein energy wasting frequently occurs, thus requiring dietary adjustments in patients with CKD. In conclusion, each individual with CKD has a different nutritional therapy approach depending on the disease conditions and nutritional status of the individual. Appropriate nutritional therapy in CKD patients can reduce disease progression.

Guidelines for hypertension management in patients with chronic kidney disease in China (2023)

The population of chronic kidney disease (CKD) with hypertension in China is characterized by complex etiology, high incidence rate, low awareness and control rate. How to diagnose and treat hypertension in CKD patients properly and improve their prognosis is particularly urgent. Several clinical guidelines or expert consensus on the diagnosis, treatment and management of hypertension have been issued. Some of them involve the diagnosis and treatment of hypertension in CKD patients, but they still can not meet the demand for diagnosis and treatment of hypertension in CKD patients. Based on the situation of hypertension in CKD patients in China, the Chinese Society of Nephrology organized an expert group to formulate this guideline. This guideline systematically introduces the diagnostic criteria, epidemiology, risk factors, poor prognosis of hypertension, the purpose, timing and control goals of antihypertensive therapy in CKD patients, as well as blood pressure control goals for special populations, non drug treatment and drug treatment of hypertension. This guideline aims to further strengthen the management of hypertension in CKD patients, standardize the diagnosis and treatment standards, formulate reasonable treatment plans, effectively control hypertension, reduce complications, so as to delay the progress of kidney diseases and improve the long-term prognosis of hypertension in Chinese CKD patients.

Evaluation of Therapies for Secondary Hyperparathyroidism Associated with Vitamin D Insufficiency in Chronic Kidney Disease

Introduction: Parathyroid hormone-lowering responses after administration of three different therapies capable of raising serum total 25-hydroxyvitamin D (25OHD) were evaluated in patients with secondary hyperparathyroidism (SHPT), vitamin D insufficiency (VDI), and stage 3 or 4 chronic kidney disease (CKD). Methods: Sixty-nine adult subjects with intact parathyroid hormone (iPTH) ≥85 and <500 pg/mL and VDI (25OHD <30 ng/mL) were randomized after ≥4-week washout to 2 months of open-label treatment with: (1) extended-release calcifediol (ERC) 60 μg/day; (2) immediate-release calcifediol (IRC) 266 μg/month; (3) high-dose cholecalciferol (HDC) 300,000 IU/month; or (4) paricalcitol plus low-dose cholecalciferol (PLDC) 1 or 2 μg and 800 IU/day, used as reference hormone replacement therapy. Serum 25OHD, calcium (Ca), phosphorus (P), plasma iPTH, and adverse events were monitored weekly. No clinically significant differences were observed at baseline between treatment groups. Results: Sixty-two subjects completed the study per protocol (PP; 14–17 per group). Mean (SD) 25OHD and iPTH at baseline were 20.6 (6.6) ng/mL and 144.8 (90) pg/mL, respectively. Mean 25OHD increased at end of treatment (EOT) to 82.9 (17.0) ng/mL with ERC (p < 0.001) and 30.8 (11.6) ng/mL with HDC (p < 0.05), but remained unchanged with IRC and PLDC. EOT 25OHD levels reached ≥30 ng/mL in all subjects treated with ERC and in 44% with HDC. All subjects attained EOT 25OHD levels ≥50 ng/mL with ERC versus none with other therapies. iPTH response rates at EOT (≥10, 20 or 30% below baseline) were similar for ERC and PLDC; rates for IRC and HDC were much lower. No significant changes from baseline were observed in ionized or corrected total Ca or P in any group. One episode of hypercalcemia (>10.3 mg/dL) occurred with PLDC. Hyperphosphatemia (>5.5 mg/dL) occurred once with ERC, eight times with HDC, 3 times with IRC, and twice with PLDC. Conclusion: ERC was highly effective in both raising serum 25OHD and decreasing iPTH in patients with SHPT, VDI, and stage 3 or 4 CKD. iPTH-lowering response rates with ERC were similar to daily PLDC, the reference therapy; rates with IRC or HDC were significantly lower. ERC is an attractive alternative to vitamin D hormone therapy in CKD patients.

Vitamin D and Secondary Hyperparathyroidism in Chronic Kidney Disease: A Critical Appraisal of the Past, Present, and the Future.

The association between vitamin D deficiency and especially critical shortage of active vitamin D (1,25-dihydroxyvitamin D, calcitriol) with the development of secondary hyperparathyroidism (sHPT) is a well-known fact in patients with chronic kidney disease (CKD). The association between sHPT and important clinical outcomes, such as kidney disease progression, fractures, cardiovascular events, and mortality, has turned the prevention and the control of HPT into a core issue of patients with CKD and on dialysis. However, vitamin D therapy entails the risk of unwanted side effects, such as hypercalcemia and hyperphosphatemia. This review summarizes the developments of vitamin D therapies in CKD patients of the last decades, from calcitriol substitution to extended-release calcifediol. In view of the study situation for vitamin D insufficiency and sHPT in CKD patients, we conclude that the nephrology community has to solve three core issues: (1) What is the optimal parathyroid hormone (PTH) target level for CKD and dialysis patients? (2) What is the optimal vitamin D level to support optimal PTH titration? (3) How can sHPT treatment support reduction in the occurrence of hard renal and cardiovascular events in CKD and dialysis patients?

Does Mediterranean Adequacy Index Correlate with Cardiovascular Events in Patients with Advanced Chronic Kidney Disease? An Exploratory Study.

The Mediterranean Diet (MD) is a healthy dietary pattern, demonstrated to reduce the risk of cancer, diabetes, cardiovascular and neurodegenerative diseases, and early death. The Mediterranean Adequacy Index (MAI) is used to measure adherence to the MD in perspective studies in the general population and correlates with cardiovascular events. The aim of this study was to calculate the MAI among patients with advanced chronic kidney disease (CKD) and correlate it with traditional uremic, microbiota-derived, and proatherogenic toxins as well as nutritional status, quality of life, and cardiovascular events. A total of 60 adult patients with advanced CKD were enrolled and their MAI was calculated. According to the median value, patients were divided into lower (l-MAI, <1.80) and higher (h-MAI, ≥1.80) MAI groups. Biochemical parameters, microbiota-derived and proatherogenic toxins (p-Cresyl sulphate, Indoxyl-sulphate, and Lipoprotein-associated phospholipase A2), nutritional status, quality of life, and cardiovascular events that occurred in the previous three years were recorded. The mean value of the MAI was 2.78 ± 2.86. The MAI was significantly higher in foreigners (median (IQR) 6.38 (8.98) vs. 1.74 (1.67), p < 0.001) and diabetic patients. The l-MAI and h-MAI groups had similar routinary blood, p-Cresyl-sulphate, Indoxyl-sulphate, and Lp-PLA2 as well as nutritional status and quality of life parameters. The MAI was not associated with previous cardiovascular events and did not correlate with cardiovascular events in CKD patients. New and nephro-tailored indexes are warranted to evaluate nutritional therapy in CKD patients.

Monitoring Kidney Function Through the Use of Candesartan, Telmisartan or Valsartan Antihypertensive Therapy towards Patients CKD

Chronic Kidney Disease (CKD) lower kidney function caused by an irreversible reduction in normal nephron function. Globally, CKD contributes to the cause of death. Activation of the Renin-Angiotensin-Aldosterone system is involved in the pathogenesis. ARBs have a cardiorenal protective effect. The purpose of this study was to determine the changes in kidney function with the use of Candesartan, Telmisartan or Valsartan antihypertensive therapies in CKD patients. This research method was a prospective observational cohort study looking at changes in kidney function (BUN and Serum Creatinine) at 1 and 6 months of using Antihypertensive Drugs Valsartan, Telmisartan, and Candesartan and tested by statistical analysis. The number of samples in this study was 72 patients which are 24 patients (Candesartan), 27 patients (Telmisartan), and 21 patients (Valsartan). The results showed that the Candesartan group experienced a decrease in average BUN of 0.13±0.85 mg/dl and serum creatinine of 0.004±0.09 mg/dl with independent t-test p=0.479 (p&gt;0.05), Serum Creatinine p= 0.809 (p&gt;0.05). The Telmisartan group experienced a decrease in average BUN of 4.74±5.16 mg/dl and serum creatinine of 0.33±0.20 mg/dl with Wilcoxon BUN test results p=0.000 (p&lt;0.05), Serum Creatinine p=0.000 (p&lt;0.05). In contrast, in the valsartan group, there was no change. So, it can be said that telmisartan has the highest effectiveness in kidney function (BUN and Serum Creatinine).

Urate-lowering therapy for CKD patients with asymptomatic hyperuricemia without proteinuria elucidated by attribute-based research in the FEATHER Study

Attribute-based medicine is essential for patient-centered medicine. To date, the groups of patients with chronic kidney disease (CKD) requiring urate-lowering therapy are clinically unknown. Herein, we evaluated the efficacy of febuxostat using a cross-classification, attribute-based research approach. We performed post hoc analysis of multicenter, randomized, double-blind, placebo-controlled trial data for 395 patients with stage 3 CKD and asymptomatic hyperuricemia. Participants were divided into febuxostat or placebo groups and subcohorts stratified and cross-classified by proteinuria and serum creatinine concentrations. In patients stratified based on proteinuria, the mean eGFR slopes were significantly higher in the febuxostat group than in the placebo group (P = 0.007) in the subcohort without proteinuria. The interaction between febuxostat treatment and presence of proteinuria in terms of eGFR slope was significant (P for interaction = 0.019). When cross-classified by the presence of proteinuria and serum creatinine level, the mean eGFR slopes significantly differed between the febuxostat and placebo groups (P = 0.040) in cross-classified subcohorts without proteinuria and with serum creatinine level ≥ median, but not in the cross-classified subcohorts with proteinuria and serum creatinine level < median. Febuxostat mitigated the decline in kidney function among stage 3 CKD patients with asymptomatic hyperuricemia without proteinuria.

Cost Consequence Analysis of the Management of Hyperkalemia by Patiromer and Optimization of Renin-Angiotensin-Aldosterone System Inhibitors Therapy in Chronic Kidney Disease Patients in Saudi Arabia

Renin-angiotensin-aldosterone system inhibitors (RAASi) have been shown to improve outcomes in chronic kidney disease (CKD) patients but are associated with an increased risk of hyperkalemia in this vulnerable population. Hyperkalemia often leads to patients' downtitrating or discontinuing RAASi which can result in sub-optimal health outcomes. The objective is to evaluate the cost and health benefits of maintaining normokalemia using patiromer, an oral potassium binder while optimizing RAASi therapy in CKD patients in the Kingdom of Saudi Arabia. The medium-to long-term costs and health outcomes of patients with CKD stage 3-4 and raised serum potassium levels (≥5.5 mmol/L) at baseline were estimated, from a Saudi Arabia payer perspective, using a Markov state-transition model simulating the natural progression of CKD depending on patients' serum potassium level and usage of RAASi at different dosages. The analysis demonstrated that appropriate management of hyperkalemia, enabling optimization of RAASi, leads to cost and health benefits. The cost of patiromer is offset by 68% due to a reduction in management costs associated with CKD progression, hyperkalemia-related hospitalization, and cardiovascular (CV) events. Over a 10-year time horizon, a pool of 300 patients treated with patiromer experience increased life-expectancy [+3.78 life-years (LYs)] and slower disease progression, with decreased time spent in end-stage renal disease (-9.59 LYs). Patiromer may deliver value to both CKD patients and payers in Saudi Arabia, leading to better health outcomes for the former and reduced cost of management of CKD progression and CV events at low additional costs for the latter.

Are Antioxidants Useful in Preventing the Progression of Chronic Kidney Disease?

Chronic kidney disease (CKD) is a progressive impairment of renal function for more than three months that affects 15% of the adult population. Because oxidative stress is involved in its pathogenesis, antioxidants are under study for the prophylaxis of CKD progression. The objective of this work was to meta-analyze the efficacy of antioxidant therapy in CKD patients and to identify the most effective candidate antioxidants. Our meta-analysis showed that, despite being quite heterogeneous, overall antioxidant therapy apparently reduced CKD progression. Pentoxifylline and bardoxolone methyl demonstrated a robust and statistically significant protection, while other products showed a favorable but non-significant tendency, due to a high interindividual variability. Off-target (i.e., antioxidant-independent) effects, such as body weight reduction and heart failure-associated blood dilution, might totally or partially explain the protection provided by effective antioxidants. This potential pleiotropy introduces uncertainty on the role of oxidative stress in CKD progression and on antioxidant therapy in its prevention, which needs to be further investigated. Independently, identification of factors determining the nephroprotective effect of each candidate on each patient is thus necessary for a prospectively personalized antioxidant therapy. Finally, pentoxifylline should be further explored for the prophylaxis of CKD progression.

Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy.

Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.

Coronavirus disease 2019 in chronic kidney disease.

The clinical spectrum of coronavirus disease 2019 (COVID-19) infection ranges from asymptomatic infection to severe pneumonia with respiratory failure and even death. More severe cases with higher mortality have been reported in older patients and in those with chronic illness such as hypertension, diabetes or cardiovascular diseases. In this regard, patients with chronic kidney disease (CKD) have a higher rate of all-type infections and cardiovascular disease than the general population. A markedly altered immune system and immunosuppressed state may predispose CKD patients to infectious complications. Likewise, they have a state of chronic systemic inflammation that may increase their morbidity and mortality. In this review we discuss the chronic immunologic changes observed in CKD patients, the risk of COVID-19 infections and the clinical implications for and specific COVID-19 therapy in CKD patients. Indeed, the risk for severe COVID-19 is 3-fold higher in CKD than in non-CKD patients; CKD is 12-fold more frequent in intensive care unit than in non-hospitalized COVID-19 patients, and this ratio is higher than for diabetes or cardiovascular disease; and acute COVID-19 mortality is 15–25% for haemodialysis patients even when not developing pneumonia.

Current Therapy in CKD Patients Can Affect Vitamin K Status.

Chronic kidney disease (CKD) patients have a higher risk of cardiovascular (CVD) morbidity and mortality compared to the general population. The links between CKD and CVD are not fully elucidated but encompass both traditional and uremic-related risk factors. The term CKD-mineral and bone disorder (CKD-MBD) indicates a systemic disorder characterized by abnormal levels of calcium, phosphate, PTH and FGF-23, along with vitamin D deficiency, decreased bone mineral density or altered bone turnover and vascular calcification. A growing body of evidence shows that CKD patients can be affected by subclinical vitamin K deficiency; this has led to identifying such a condition as a potential therapeutic target given the specific role of Vitamin K in metabolism of several proteins involved in bone and vascular health. In other words, we can hypothesize that vitamin K deficiency is the common pathogenetic link between impaired bone mineralization and vascular calcification. However, some of the most common approaches to CKD, such as (1) low vitamin K intake due to nutritional restrictions, (2) warfarin treatment, (3) VDRA and calcimimetics, and (4) phosphate binders, may instead have the opposite effects on vitamin K metabolism and storage in CKD patients.

Health Literacy in Kidney Disease: Associations with Quality of Life and Adherence.

Health literacy (HL) is a multidimensional concept with significance for self-management and health outcomes in patients with chronic kidney disease (CKD); however, research with a multidimensional perspective on HL is scarce. This study aimed to explore the relationship between multidimensional HL, quality of life (QoL) and adherence to long-term therapy in CKD patients. A descriptive single-centre cross-sectional study. Patients with CKD in stages 3-5 were recruited from the nephrology unit in a Norwegian hospital. The Health Literacy Questionnaire (HLQ) was used to assess HL, QoL was measured by the Short Form-12 (SF-12) and a Visual Analogue Scale (VAS-QoL). Adherence to long-term therapy was measured by the Medical Adherence Rating Scale 5 (MARS-5), participants' prescription withdrawals from pharmacies, and a VAS (VAS-adherence). Hierarchical cluster analysis was performed to group patients with similar HLQ scores, and multiple linear regression analysis was performed to identify the HL dimensions that were associated with QoL and adherence to long-term therapy. A total of 187 patients were included, 65% were male, and the mean (SD) age was 67 (13) years. The high-level HL group (N = 52) had significantly better QoL than patients in the mid-level (N = 106) and low-level (N = 27) HL groups. The HL dimensions "actively managing health," "actively engage with healthcare providers," "ability to find good health information" and "ability to understand health information" were predictive of QoL and adherence to long-term therapy. HL seems to be important for both QoL and adherence to long-term therapy.