Kidney360最新文献

Background: While AKI requiring renal replacement therapy (AKI-RRT) is associated with increased mortality in heterogeneous inpatient populations, the epidemiology of AKI-RRT in hospitalized patients with cirrhosis is not fully known. Herein, we evaluated the association of etiology of AKI with mortality in hospitalized patients with cirrhosis and AKI-RRT in a multicentric contemporary cohort.

Methods: This is a multicenter retrospective cohort study using data from the HRS-HARMONY consortium, which included 11 U.S. hospital network systems. Consecutive adult patients admitted in 2019 with cirrhosis and AKI-RRT were included. The primary outcome was 90-day mortality, and the main independent variable was AKI etiology, classified as hepatorenal syndrome (HRS-AKI) vs. other (non-HRS-AKI). AKI etiology was determined by at least two independent adjudicators. We performed Fine and Gray sub-distribution hazard analyses adjusting for relevant clinical variables.

Results: Of 2,063 hospitalized patients with cirrhosis and AKI, 374 (18.1%) had AKI-RRT. Among these, 65 (17.4%) had HRS-AKI and 309 (82.6%) non-HRS-AKI, which included ATN in most cases (62.6%). Continuous RRT (CRRT) was used as the initial modality in 264 (71%) of patients, while intermittent hemodialysis (IHD) was utilized in 108 (29%). The HRS-AKI (vs. non-HRS-AKI) group received more vasoconstrictors for HRS management (81.5% vs. 67.9%), while the non-HRS-AKI group received more mechanical ventilation (64.3% vs. 50.8%) and more CRRT (vs. IHD) as the initial RRT modality (73.9% vs. 56.9%). In the adjusted model, HRS-AKI (vs. non-HRS-AKI) was not independently associated with increased 90-day mortality (sHR=1.36, 95% CI: 0.95-1.94).

Conclusions: In this multicenter contemporary cohort of hospitalized adult patients with cirrhosis and AKI-RRT, HRS-AKI was not independently associated with an increased risk of 90-day mortality when compared to other AKI etiologies. The etiology of AKI appears less relevant than previously considered when evaluating the prognosis of hospitalized adult patients with cirrhosis and AKI requiring RRT.

Background: Patient activation, defined as an individual's readiness, willingness, and ability to manage their own health and health care, is associated with healthy behaviors and improved outcomes. Patients undergoing in-center hemodialysis (HD) have low activation, but the association of patient activation with clinical outcomes among dialysis patients is unclear. We investigated the association between patient activation and outcomes in HD patients.

Methods: This cohort included 925 prevalent, in-center HD patients among 10 facilities in a mid-sized dialysis provider. All patients who completed the Patient Activation Measure 13-item (PAM-13) survey during a previous study were included, and their records were cross-referenced with data from the electronic heath system. Patients were followed for 180 days after completion of the survey for the primary outcomes of time to (1) death and (2) time to hospitalization. Markers of non-adherence during the month before and the month after completion of the PAM survey were examined as secondary outcomes, including (1) serum potassium >5.0 mEq/L; (2) serum phosphorus >5.5 mg/dL; (3) missed dialysis treatment due to absence (not hospitalization); and (4) interdialytic weight gain >4.0%. Univariate and adjusted regression models were fit to estimate associations of a 3-point increment in PAM-13 score with the outcomes of interest; adjustment factors comprised age, sex, dialysis vintage, serum albumin, diabetes, and hospitalization history.

Results: A 3-point increment in PAM score was associated with lower hazard of death (univariate HR=0.89, 95% CI: 0.84-0.94; adjusted HR=0.90, 95% CI: 0.85-0.96), but not with hospitalization (univariate HR=0.99, 95% CI: 0.96-1.02; adjusted HR=0.99, 95% CI: 0.96-1.02). Higher scores were associated with increased odds of having high phosphorus levels in the unadjusted analysis, but this was attenuated and not significant in adjusted models. There were no significant relationships between a 3-point increment in PAM score and any of the other secondary outcomes in univariate and adjusted analyses.

Conclusion: In a cohort of prevalent, in-center HD patients, low activation was associated with mortality but not with hospitalization or measures of non-adherence.

Background: Few studies have explored the impact of socioeconomic position on chronic kidney disease (CKD). This study aims to fill this gap using a large Italian cohort of CKD patients.

Methods: We analyzed a cohort of incident CKD cases from the Lazio regional Health Information System from 1 January 2012 to 31 December 2021. We used the deprivation index (DI), a 5-category census-block indicator that integrates several dimensions of disadvantage. The outcomes were mortality and end-stage kidney disease (ESKD). We characterized the health status of patients in the two years before CKD identification and followed each subject from the index date to the end of follow-up, i.e., the date of the outcome, of emigration, or 31 December 2022, whichever came first. We used Cox proportional hazard models to investigate the association between DI and outcomes (HR, 95% CI).

Results: From 2012 to 2021, 127,457 new cases (55.9% men) were diagnosed. The average age was 72.2 (± 13.7) for men and 74.4 (± 14.8) for women. During an average follow-up of 4.3 years (± 3.2), 57,158 patients (45%) died, and 5,994 developed ESKD (5%). The age-adjusted association between DI and mortality was higher in men than in women (p-value interaction = 0.02), HRs for the extreme categories of DI (very high vs. very low) were 1.16, 95% CI 1.12-1.21 for men, and 1.08, 95% CI 1.04-1.13, for women). There was no evidence of association between DI and ESKD.

Conclusions: In this population, socioeconomic disadvantage is associated with a higher risk of death but not of ESKD in CKD patients.

Background: Sodium zirconium cyclosilicate (SZC) and patiromer (PAT) are potassium binders that differ by exchange ion, sodium, and calcium, respectively. There is limited data on whether using sodium exchange could impact the risks of hospitalizations for heart failure (HHF) or severe edema in patients with hyperkalemia.

Objectives: To assess the occurrence rates of pre-specified major encounters potentially related to electrolyte-/fluid-related imbalances (including HHF, edema) among new users of PAT or SZC.

Methods: Using Cerner Real World Data, we conducted a retrospective cohort study among adults (≥18 years) who were newly initiated on SZC or PAT between June 1, 2018, and December 31, 2021. Based on baseline demographic and clinical characteristics, 1 PAT initiator was propensity score matched with 2 SZC initiators. Primary outcomes were any HHF, primary HHF, major edema encounter (MEE), or death. Cox Proportional Hazard regression models were used to estimate the association between SZC or PAT use and each outcome in the overall population and subgroups with/without prior heart failure (HF).

Results: The final cohort included 9,929 PAT initiators matched to 19, 849 SZC initiators. Mean age was 66 years old; about 50% had a history of chronic kidney disease stages 3-5, and 34% a history of HF. Incidence rates (IR) were significantly higher in the SZC cohort when compared to the PAT cohort for all outcomes. Risks of HHF (any/primary) (adjusted Hazard ratios, HR: 1.373; 95% CI: 1.337-1.410), MEE (HR: 1.330; 95% CI: 1.298-1.363), and death (HR: 1.287; 95% CI: 1.255-1.320) were also significantly higher in the SZC cohort compared to the PAT cohort (p<0.05). These findings were consistent among subgroups with/without prior HF.

Conclusions: SZC use (vs. PAT) was associated with increased risk of pre-specified encounters potentially sodium-/fluid-related, including among patients with/without pre-existing HF.

Background: Obesity is an independent risk factor for incident and recurrent nephrolithiasis. The impact of weight loss through glucagon-like peptide 1 (GLP-1) receptor agonists and dual GLP-1/ gastric inhibitory polypeptide receptor agonists (GLP-based therapies) on nephrolithiasis is not well-understood. This study examined the changes in 24-hour urine chemistry assessing for stone risk during weight loss through GLP-based therapies.

Methods: This retrospective analysis identified adult stone formers followed at our academic institution's weight wellness clinic between September 2015 and August 2023 and included patients with at least two 24-hour urine collections for stone risk assessment. 24-hour urine parameters before and during weight loss in patients on GLP-based therapies were compared.

Results: Forty-four obese patients with nephrolithiasis experienced significant weight reduction (-6.6±7.3 kg, p<0.001) over a median 1.1 years of follow-up with GLP-based therapies. During this period, there was a significant decrease in 24-hour urine oxalate (40±16 to 32±11 mg/day, p=0.002), sulfate (21±10 to 17±9 mmol/day, p=0005), and ammonium (35±22 to 29±15 mEq/day, p=0.01). There were non-significant changes in urine calcium, citrate, uric acid, pH, phosphorus, sodium, potassium, magnesium, chloride, creatinine or total volume. Additionally, there was no statistical difference in urine supersaturation indices with respect to calcium oxalate, calcium phosphate and uric acid.

Conclusion: Our results indicate that weight loss through GLP-based therapies is not associated with pro-lithogenic changes in 24-hour urine chemistry in patients with nephrolithiasis, unlike what happens with other weight loss modalities.

Background: Multiple studies have shown that females are living donors for kidney transplantation at higher rates than males. However, the underlying reasons for this observation are not well-understood. We examined the living donor evaluation process to determine the point at which sex imbalance arises. Based on a previous study, we hypothesized that both sexes are equally likely to become approved as living donors, but females are more likely to follow through with donation.

Methods: Single institution retrospective chart review of self-referrals for living donor evaluation between 1/2009 - 12/2022. Self-referrals identified using the Organ Transplant Tracking Record database and cross referenced with billing data. Exclusion at each stage of evaluation was recorded and compared between sexes using log binomial regression; unadjusted and adjusted (for donor age, race, ethnicity, relationship to recipient, and recipient sex) risk ratios (RRs) with 95% confidence interval (CI) were determined.

Results: 1,861 self-referrals were reviewed, including 1,214 (65.2%) females and 647 (34.8%) males, resulting in 146 approvals and 125 donations (76/125, 60.8% females, 49/125 39.2% males). Adjusted RRs indicated no significant differences between sexes in completing medical and/or psychosocial workup, having medical and/or psychosocial contraindications, being approved for donation, and proceeding with donation. The top medical contraindications for both sexes were obesity, hypertension, and nephrolithiasis.

Conclusion: Female overrepresentation among living donors is likely due to the 1.9 times higher rate of self-referral for evaluation. After this point, both sexes were equally likely to complete workup, be approved, and follow through with donation. Increased efforts to engage males at the initial self-referral stage has the potential to expand access to living donor kidney transplantation.

The Hispanic population of the US is the second largest racial or ethnic group comprising 18.7% of the population. However, this population is incredibly heterogeneous differing in genetic traits, cultural upbringing, educational backgrounds, and financial status. The impact of this heterogeneity on the prevalence and outcomes of renal disease and kidney transplantation is understudied compared to non-Hispanic whites and African Americans. What is known appears to be underrecognized. This review aims to critically assess current medical literature on Hispanic individuals, focusing on etiological factors, disease progression, and outcomes related to chronic kidney disease (CKD) and kidney transplantation. By doing so, we aim to underscore key areas for further in-depth investigation.