Clinical Kidney Journal最新文献

[This corrects the article DOI: 10.1093/ckj/sfae322.].

Background: Multiple studies have identified risk factors for acute kidney injury (AKI) in hospitalized patients, but less is known about factors associated with AKI severity, including non-recovery of AKI.

Methods: Retrospective cohort study of adults (≥18 years) hospitalized between 2014 and 2017 at three US academic medical centers. Study outcomes included incidence of AKI and non-recovery from AKI at hospital discharge in those who survived hospitalization. AKI was defined by KDIGO serum creatinine criteria. Non-AKI recovery was defined as persistent AKI stage ≥1 at time of discharge. Multivariable models assessed the association of risk factors for each outcome, focusing on race, diabetes, and obesity (BMI ≥ 30 versus <30 kg/m²), and adjusting for potential confounders.

Results: Among 56 056 patients included in the study (mean age 57, 25% Black, 48% women), 12 954 (23%) developed AKI. In adjusted models, Black race [odds ratio (OR) 1.26, 95% confidence interval (CI): 1.20, 1.32], diabetes (OR 1.14, 95% CI: 1.08, 1.19) and obesity (OR 1.14, 95% CI: 1.10, 1.20) were all associated with incident AKI. A total of 3591 of the 11 672 (30.8%) patients with AKI who survived until discharge had AKI non-recovery. In adjusted models, obesity (OR 1.27, 95% CI: 1.17, 1.39) was independently associated with higher risk of AKI non-recovery at hospital discharge.

Conclusions: Black race, diabetes, and obesity were associated with the development of AKI in hospitalized patients, but only obesity was associated with non-recovery from AKI at hospital discharge. These findings emphasize the growing relevance of obesity as an epidemiological risk factor of AKI.

A multitude of challenges exist when supporting older adults in deciding on the optimal kidney replacement therapy (KRT), including frailty, comorbidity, cognitive impairment, dialysis modality, as well as local availability of services. The combination of these factors can determine treatment outcomes and quality of life (QoL), and as such the care of older people should be tailored to take these into account. Frailty in older people with chronic kidney disease (CKD) leads to higher rates of hospitalization, increased mortality, and a diminished QoL, while cognitive impairment, present in up to 50% of people with CKD, exacerbates these challenges and affects decision making. Dialysis, particularly haemodialysis, can accelerate physical and cognitive decline in frail older adults. Conversely, peritoneal dialysis (PD) presents a home-based alternative that may better support QoL, particularly for people wanting to prioritize treatment flexibility and independence. Assisted PD programmes have emerged as a valuable option for older people who cannot manage home-based care independently, improving access to KRT. Ultimately shared decision making should be employed when discussing KRT, incorporating patient goals, prognostic awareness, and QoL measures. There is also the emerging role of the geriatrician and the need for an integrated Comprehensive Geriatric Assessment. These elements support older adults to make informed choices that align with the individuals' values and health needs. In designing future health services to meet the needs of increasing numbers of older people, there needs to be increased access to assisted PD as well as multidisciplinary working to ensure patient-focused care surrounding KRT in older adults.

Background: The slope of estimated glomerular filtration rate (eGFR) is a promising surrogate endpoint in patients with chronic kidney disease (CKD). However, current evidence is mainly derived from Western populations with CKD stages 1-3. In addition, stage-by-stage analysis has never been formally performed.

Methods: We analyzed data from the Chronic Kidney Disease Japan Cohort Study, which included a large proportion of patients with CKD stages 4 and 5. We estimated eGFR slopes over three evaluation periods (0.5, 1, and 2 years) using mixed effects models and examined their associations with kidney failure with replacement therapy across CKD stages.

Results: Of 2713 patients with an available 1-year eGFR slope, 985 subsequently initiated kidney replacement therapy. Overall, a slower eGFR decline was strongly associated with a lower risk of subsequent kidney failure with replacement therapy. The association was pronounced with higher baseline CKD stages and attenuated with shorter evaluation periods. The estimated deceleration in eGFR decline over 1 year associated with a 20% lower risk of subsequent kidney failure with replacement therapy was 1.91 (1.60-2.37), 1.12 (1.00-1.28), and 1.06 (0.81-1.60) ml/min/1.73 m² per year in patients with CKD stages 3, 4, and 5, respectively.

Conclusion: Our results support the potential of eGFR slope as a surrogate across different stages of CKD in Asians and suggest that a shorter evaluation period than 2 years may be feasible for patients with late-stage CKD. Our findings provide valuable insights for the future design of clinical trials in CKD patients, especially those with more advanced CKD.

Background: In peritoneal dialysis (PD) patients, determining energy expenditure is essential for recommending energy intake in nutrition management.

Objective: We aimed to develop and validate a resting energy expenditure (REE) equation for patients with PD and compare it to previously available REE equations in dialysis patients.

Design: This cross-sectional study enrolled 200 patients with PD from two hospitals in Beijing, China. Stepwise linear regression analysis was used to derive a new REE equation (eREE-PD) based on actual REE (aREE) measured using indirect calorimetry (IC) in the development dataset. The eREE-PD value was then validated with aREE in the validation dataset and compared with values from existing equations obtained in general populations and those developed for chronic kidney disease and dialysis patients, in terms of bias, precision, and accuracy.

Results: The bias, precision, and accuracy of the eREE-PD equation were significantly better than those of the Harris-Benedict, WHO, and Schofield equations (P < .005) and comparable to the Mifflin equation (P = .541 for bias, .988 for precision, and .359 for accuracy), with IC as the reference method. Either bias, precision or accuracy of the eREE-PD were significantly better than eREE-V, eREE-B_scr, and eREE-C_FFM equations significantly (P < .005) and similar to eREE-CKD, eREE-B_crp, and eREE-C_weighht equations (P > .05 for bias, precision, and accuracy). The bias, precision, and accuracy of the eREE-PD equation were consistent across subgroups categorized by hs-CRP levels.

Conclusion: The eREE-PD equation, based on age, sex, and weight data, may serve as a reliable and practical tool for estimating REE in patients with PD, aiding in individualized nutritional management. However, external validation in other populations is required to confirm its generalizability beyond the studied cohort.

Background: The role of parathyroid gland (PTG) ultrasonography in the management of secondary hyperparathyroidism after the introduction of calcimimetics remains unclear. Recent investigations have prompted renewed interest in the use of PTG ultrasonography for assessing treatment resistance to calcimimetics and determining the optimal timing for surgical intervention. This study aimed to explore the hypothesis that the PTG volume correlates with the calcimimetic dose.

Methods: We retrospectively observed outpatients undergoing haemodialysis at baseline and a 4-year follow-up. PTG volume was measured using ultrasonography between January and December 2017 and January and December 2021. We examined the association between baseline PTG volume and calcimimetic doses after 4 years.

Results: Of the 121 patients {median age 64 years [interquartile range (IQR) 54-72]}, 71 had PTG nodules on ultrasonography and the median total PTG volume was 34 mm³ (IQR 0-178). In the short dialysis vintage group, baseline parathyroid hormone levels tended to correlate with baseline calcimimetic doses; however, this trend was not observed in the extended dialysis vintage group. Baseline PTG volume correlated with the cinacalcet-equivalent calcimimetic dose (correlation coefficient 0.46; P < .001) after 4 years. The calcimimetic dose in the group with an estimated PTG volume >500 mm³ was ≈80 mg/day higher than that in the non-PTG nodule group after 4 years. In multivariate linear regression analysis, PTG volume >500 mm³ was associated with a high calcimimetic dose at 4 years in all analysis models.

Conclusions: Assessing PTG volume using ultrasonography may help predict high calcimimetic doses.

Background: Acute kidney injury (AKI) is common in hospitalized children. A post-AKI outcomes prediction model is important for the early detection of important clinical outcomes associated with AKI so that early management of pediatric AKI patients can be initiated.

Methods: Three retrospective cohorts were set up based on two pediatric hospitals in China, in which 8205 children suffered AKI during hospitalization. Two clinical outcomes were evaluated, i.e. hospital mortality and dialysis within 28 days after AKI occurrence. A Genetic Algorithm was used for feature selection, and a Random Forest model was built to predict clinical outcomes. Subsequently, a temporal validation set and an external validation set were used to evaluate the performance of the prediction model. Finally, the stratification ability of the prediction model for the risk of mortality was compared with a commonly used mortality risk score, the pediatric critical illness score (PCIS).

Results: The prediction model performed well for the prediction of hospital mortality with an area under the receiver operating curve (AUROC) of 0.854 [95% confidence interval (CI) 0.816-0.888], and the AUROC was >0.850 for both temporal and external validation. For the prediction of dialysis, the AUROC was 0.889 (95% CI 0.871-0.906). In addition, the AUROC of the prediction model for hospital mortality was superior to that of PCIS (P < .0001 in both temporal and external validation).

Conclusions: The new proposed post-AKI outcomes prediction model shows potential applicability in clinical settings.