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Background: Monitoring of serum alkaline phosphatase (ALP) is recommended in the management of chronic kidney disease (CKD)-mineral bone disorder (MBD) because of associations with poor outcome among dialysis patients. However, such associations may have changed with several advances in the management of CKD-MBD over the last decade.

Methods: Baseline data for 241,670 dialysis patients (mean age, 69 ± 12 years; male, 65.9%; median dialysis duration, 68 months) were extracted from a nationwide dialysis registry in Japan at the end of 2019. Outcomes, including all-cause and cardiovascular (CV) mortality and hip fracture, were evaluated using the registry at the end of 2020 and 2021. All-cause mortality was assessed using Cox regression analysis, whereas CV mortality and new hip fracture were assessed using competing-risks regression analysis. Multiple imputation for missing values was performed.

Results: Within the 2-year study period, a total of 40,449 patients (16.7%) died, including 13,562 (5.6%) CV deaths. Of the 168,836 patients with no history of hip fracture at the end of 2019, 4,136 (2.4%) suffered hip fracture within 2 years. Higher serum ALP was independently associated with higher all-cause and CV mortality and new hip fracture, but the association with CV mortality was marginal (hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.18-1.24; sub-HR [SHR] 1.07, 95%CI 1.03-1.12; and SHR 1.28, 95%CI 1.19-1.38, respectively). There is a linier association between serum ALP and all-cause mortality among the lower- parathyroid hormone (PTH) group, whereas lower serum ALP tended to have higher all-cause mortality than intermediate serum ALP among patients in the higher-PTH group.

Conclusions: Higher serum ALP was independently and linearly associated with higher all-cause and CV mortality and new hip fracture in Japanese dialysis patients. Higher serum ALP and higher intact PTH were synergistic in increasing all-cause and CV mortality but not with new hip fracture.

Background: Nephrology has seen an uptake in transition to remote care delivery. The impact of telenephrology care on chronic kidney disease (CKD) progression is not well defined.

Methods: We analyzed data from patients naturally selected for telenephrology versus standard, in-person visits. Patients were seen across 4,230 visits over a 2-year period at a nephrology clinic within the Veterans Affairs health system. Baseline characteristics and health profile data were assessed based on grouping of individuals to the telenephrology group (>50% virtual visits) or in-person group (≤50% virtual visits). The slope of eGFR change over time was estimated for each patient using a random effects regression model and compared across groups using weighted linear regression models.

Results: A total of 1,098 patients comprised the final analysis. The groups were similar across baseline demographics and health profiles, although more cardiovascular disease, congestive heart failure, and diabetes mellitus were present in the in-person group. There was no significant difference in eGFR decline between groups, though those in telenephrology group trended toward less steep decline compared to those seen predominately in-person (telenephrology slope versus in-person slope; difference = 0.81mL/min/1.73 m2; 95% CI: -0.447, 2.08; p=0.21). Those seen primarily in-person had a similar degree of proteinuria compared to those in telenephrology (p=0.12). All-cause mortality and incidence of outpatient renal replacement therapy initiation was similar. Telenephrology patients had an average of 1.3 fewer emergency department visits per individual compared to their in-person counterpart (2.17 versus 3.44, p<0.001), as well as fewer hospital admissions (1.59 versus 2.08, p=0.02). Those in the in-person group were more often prescribed SGLT-2 inhibitors, statins, NSAIDs, and potassium supplements.

Conclusions: Data from this observational study within a VA healthcare system suggests that medically complex, multi-morbid CKD patients can expect a similar rate of eGFR decline when care is delivered via a hybrid system that includes a majority of telenephrology when compared to those managed in face-to-face visits. Further studies are needed to corroborate findings and ensure generalizability outside of this VA system.

The lack of non-invasive urine and blood-based biomarkers for the diagnosis of acute kidney injury (AKI) in patients with cancer is an area of significant unmet clinical need. Traditional non-invasive diagnostic tools that are currently utilized in the clinic, such as creatinine and cystatin C-based eGFR measurements, urinalysis, urine sediment exam, urine protein quantification, and urine electrolyte measurement, lack the sensitivity and specificity to distinguish between the various underlying etiologies of AKI in patients with cancer. Imaging-based diagnostics can be helpful to rule out urinary obstruction, but also lack sensitivity and specificity to diagnose the etiology of AKI. Kidney biopsy is often required for definitive diagnosis. As our scientific understanding of the biological pathways that are dysregulated in AKI has advanced, there has been considerable interest in developing new biomarkers for AKI. For example, the diagnosis of acute interstitial nephritis (AIN), which can occur in patients treated with immune checkpoint inhibitors (ICIs), promises to be revolutionized by the incorporation of urinary testing for inflammatory biomarkers such as C-X-C motif ligand 9 (CXCL9), tumor necrosis factor alpha (TNF-α), and interleukin 9 (IL-9). In the case of cisplatin administration, biomarkers such as neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule 1 (KIM-1) may improve prognostication, differentiating between persistent AKI resulting from acute tubular injury versus pre-renal azotemia. The development and validation of blood, urine and imaging biomarkers into widely utilized diagnostic tests will require a concerted effort, but could improve diagnosis, management and prognostication for a growing group of patients who are at high risk of developing AKI during the course of their illness.

The Autosomal Dominant Polycystic Kidney Disease (ADPKD) Centers of Excellence Program, launched by the Polycystic Kidney Disease Foundation in 2022, aims to bridge the gap in specialized care for individuals with ADPKD. This program seeks to enhance the availability of specialized clinicians and simplify the process for patients seeking expert care. It is founded on three pillars: improving care for all individuals with ADPKD, educating and empowering the community, and advancing PKD research. The program draws inspiration from successful models in other diseases, such as cystic fibrosis and muscular dystrophy, which have demonstrated the effectiveness of standardized care centers in improving patient outcomes. Patient and clinician stakeholder interviews have identified key areas where a national program could make a significant impact, including the need for a core care team with defined referral processes, mentorship and shared care models, patient navigation services, and education around expert consensus and care guidelines. The program introduces two designations: "Center of Excellence" and "Partner Clinic" to accommodate diverse care settings and enhance patient access to specialists. The Partner Clinic designation ensures that patients in smaller community practices have access to specialized care through mentorship and guidance from experts at Centers of Excellence. The program also emphasizes the importance of specialized services, especially in underserved communities experiencing health disparities, to manage the complexities of ADPKD care. Patient focus groups have highlighted the need for care navigation services, centralized sources of knowledge, and access to local care. The program aims to address these needs by providing a structured framework for care coordination, enhancing patient self-advocacy, and improving overall outcomes for individuals with ADPKD.

Background: Elevated levels of fibroblast growth factor 23 (FGF23) are associated with left ventricular hypertrophy and heart failure (HF) in individuals with and without kidney disease. Prior studies investigated the association of FGF23 and structural cardiac changes using conventional echocardiography, which is limited in its ability to detect early cardiac dysfunction. We investigated the relationship between FGF23 levels and cardiac dynamics using two-dimensional speckle tracking echocardiography (2D-STE), a novel imaging modality.

Methods: This was a cross-sectional analysis of data from the Cardiovascular Health Study, an ongoing prospective, population-based cohort study. The study population included 506 participants from CHS with available c-terminal (cFGF23) and intact FGF23 (iFGF23) measurements from 1996-1997 and 2D-STE images from 1994-1995. Forty two percent of the study population had CKD, defined as an eGFR < 60 ml/min/1.73m2, and the mean eGFR was 63 ml/min/1.73m2. The primary exposures were cFGF23 and iFGF23. The primary outcomes were six 2D-STE parameters performed at the 1994-1995 study visit. Linear regression models were used to examine the independent associations of FGF23 with six cardiac 2D-STE indices adjusting for demographics, cardiovascular risk factors, markers of kidney disease severity, and inflammation.

Results: cFGF23 levels were moderately correlated with iFGF23 levels in the CHS population. In fully adjusted models, cFGF23 was associated with left atrial dysfunction, but no other cardiac imaging parameter (β estimate -2.47; 95% Confidence Interval -4.68, -0.25; Table 2 ). iFGF23 was not associated with any of the six 2D-STE indices. Limitations include small sample size and noncurrent FGF23 measurements and 2D-STE imaging.

Conclusions: In a limited sample of individuals enrolled in the CHS with c- and i-FGF23 measurements, we did not find consistent associations between FGF23 levels and 2D-STE parameters. Further investigations in a larger population with concurrent 2D-STE are needed to better understand the associations of FGF23 with early changes in cardiac mechanics.

Background: National strategies to address chronic kidney disease (CKD) are crucial to support kidney health. Lack of political support in the form of policy decisions and funding leads to fragmentation of kidney care and catastrophic health expenditure. This study used data from the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) to obtain a global overview of the existence and reach of national strategies for kidney care.

Methods: We leveraged data from an international survey of stakeholders (clinicians, policymakers, and patient advocates) conducted by the ISN between July and September 2022. Data were extracted on existence and scope of national non-communicable disease (NCD) and/or CKD-specific strategies and policies, as well as recognition of kidney disease as a national health priority through participant perception and existence of CKD advocacy groups.

Results: Overall, stakeholders from 167 countries responded to the survey representing 97.4% of the global population. National strategies for NCDs were reported by 56% of countries. In 29% of countries CKD was addressed within an NCD strategy while 25% of countries reported CKD-specific strategies. Countries with CKD-specific strategies were more likely to address all CKD populations (non-dialysis dependent CKD, chronic dialysis and kidney transplantation) compared to those with NCD strategies only (51.2% versus 19%). Of the 54% of countries with any CKD strategy 89% reported public funding of the full spectrum of CKD care compared to 64% of those with no CKD strategy. KF, CKD and AKI were reported to be recognized as national health priorities by 63%, 48% and 19% of countries respectively.

Conclusions: The inclusion of CKD and kidney failure within national health strategies is frequently lacking. Countries with CKD-specific policies tend to include a broader spectrum of kidney disease populations and to fund kidney care more than those with CKD policies integrated within NCD strategies. Greater global and national prioritization of kidney health are required to reduce global inequities in access to kidney care.