Pub Date : 2024-11-01DOI: 10.1016/j.xkme.2024.100909
Elaine Ku , Sabrina Legaspi , Timothy P. Copeland , Deborah B. Adey , Adrian M. Whelan , Garrett R. Roll , Charles E. McCulloch , Brian K. Lee , Kirsten L. Johansen
<div><h3>Rationale & Objective</h3><div>Given the organ shortage in the United States, increasing living donation is vital to improving access to kidney transplantation, but many donor candidates do not complete the donor evaluation. Our objective was to understand potential living donors’ perceived health and its association with the likelihood of completing the donor evaluation process.</div></div><div><h3>Study Design</h3><div>Potential donors’ self-reported health was ascertained using the Patient Reported Outcomes Measurement Information System (PROMIS) global physical and mental health and the Davies and Ware Health Perceptions surveys.</div></div><div><h3>Setting & Participants</h3><div>Potential living donors who expressed interest in donation at a single medical center were recruited prospectively between 2017 and 2022.</div></div><div><h3>Exposure</h3><div>Donors' self-reported health and health perceptions.</div></div><div><h3>Outcomes</h3><div>Completion of the donor evaluation.</div></div><div><h3>Analytical Approach</h3><div>Adjusted linear and logistic regression models were used to examine the association between self-reported health and health perceptions with outcomes.</div></div><div><h3>Results</h3><div>A total of 1,347 individuals were included for study; 46% (N<!--> <!-->=<!--> <!-->613) were<!--> <!--><<!--> <!-->40 years of age, 71% (n<!--> <!-->=<!--> <!-->951) were female, 22% (n<!--> <!-->=<!--> <!-->294) were of Hispanic ethnicity, and 16% (n<!--> <!-->=<!--> <!-->215) completed the donor evaluation. The mean PROMIS global physical health (17.0<!--> <!-->±<!--> <!-->1.9) and mental health (15.5<!--> <!-->±<!--> <!-->2.7) raw scores were higher among donor candidates proceeding to completion of the donor evaluation when compared with those who withdrew early in the process (16.3<!--> <!-->±<!--> <!-->2.2 for physical health and 14.9<!--> <!-->±<!--> <!-->3.1 for mental health). Every z-score change in the PROMIS physical health score was associated with 1.48-fold higher odds of completing the donor evaluation (95% CI, 1.19-1.85). Fully adjusted models incorporating the PROMIS scores for predicting the completion of donor evaluations had a c-statistic of 0.70. Potential donors’ Davies and Wares health perceptions did not predict the likelihood of completing the donor evaluation in fully adjusted models.</div></div><div><h3>Limitations</h3><div>Data are derived from a single center and may not generalize to the donor evaluation process at other transplant centers.</div></div><div><h3>Conclusions</h3><div>Donor candidates’ self-reported physical health may serve as a predictor of the likelihood of completing the donor evaluation process and a potential avenue for future interventions.</div></div><div><h3>Plain Language Summary</h3><div>This study was designed to understand the health perceptions of living donor candidates. We found that donor candidates’ self-reported physical health strongly predicted their lik
{"title":"Living Donor Candidates’ Self-reported Health and Health Perceptions and Completion of Donor Evaluation: A Cohort Study","authors":"Elaine Ku , Sabrina Legaspi , Timothy P. Copeland , Deborah B. Adey , Adrian M. Whelan , Garrett R. Roll , Charles E. McCulloch , Brian K. Lee , Kirsten L. Johansen","doi":"10.1016/j.xkme.2024.100909","DOIUrl":"10.1016/j.xkme.2024.100909","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>Given the organ shortage in the United States, increasing living donation is vital to improving access to kidney transplantation, but many donor candidates do not complete the donor evaluation. Our objective was to understand potential living donors’ perceived health and its association with the likelihood of completing the donor evaluation process.</div></div><div><h3>Study Design</h3><div>Potential donors’ self-reported health was ascertained using the Patient Reported Outcomes Measurement Information System (PROMIS) global physical and mental health and the Davies and Ware Health Perceptions surveys.</div></div><div><h3>Setting & Participants</h3><div>Potential living donors who expressed interest in donation at a single medical center were recruited prospectively between 2017 and 2022.</div></div><div><h3>Exposure</h3><div>Donors' self-reported health and health perceptions.</div></div><div><h3>Outcomes</h3><div>Completion of the donor evaluation.</div></div><div><h3>Analytical Approach</h3><div>Adjusted linear and logistic regression models were used to examine the association between self-reported health and health perceptions with outcomes.</div></div><div><h3>Results</h3><div>A total of 1,347 individuals were included for study; 46% (N<!--> <!-->=<!--> <!-->613) were<!--> <!--><<!--> <!-->40 years of age, 71% (n<!--> <!-->=<!--> <!-->951) were female, 22% (n<!--> <!-->=<!--> <!-->294) were of Hispanic ethnicity, and 16% (n<!--> <!-->=<!--> <!-->215) completed the donor evaluation. The mean PROMIS global physical health (17.0<!--> <!-->±<!--> <!-->1.9) and mental health (15.5<!--> <!-->±<!--> <!-->2.7) raw scores were higher among donor candidates proceeding to completion of the donor evaluation when compared with those who withdrew early in the process (16.3<!--> <!-->±<!--> <!-->2.2 for physical health and 14.9<!--> <!-->±<!--> <!-->3.1 for mental health). Every z-score change in the PROMIS physical health score was associated with 1.48-fold higher odds of completing the donor evaluation (95% CI, 1.19-1.85). Fully adjusted models incorporating the PROMIS scores for predicting the completion of donor evaluations had a c-statistic of 0.70. Potential donors’ Davies and Wares health perceptions did not predict the likelihood of completing the donor evaluation in fully adjusted models.</div></div><div><h3>Limitations</h3><div>Data are derived from a single center and may not generalize to the donor evaluation process at other transplant centers.</div></div><div><h3>Conclusions</h3><div>Donor candidates’ self-reported physical health may serve as a predictor of the likelihood of completing the donor evaluation process and a potential avenue for future interventions.</div></div><div><h3>Plain Language Summary</h3><div>This study was designed to understand the health perceptions of living donor candidates. We found that donor candidates’ self-reported physical health strongly predicted their lik","PeriodicalId":17885,"journal":{"name":"Kidney Medicine","volume":"6 11","pages":"Article 100909"},"PeriodicalIF":3.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142554192","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Acute kidney injury secondary to methotrexate therapy for hematologic malignancies is relatively uncommon. Methotrexate crystals in these cases are rarely seen on kidney biopsy, and in particular, their appearance in tissue prepared for transmission electron microscopy has not been described. A male patient with recurrent primary central nervous system lymphoma received high-dose methotrexate and rituximab for treatment. On day 2 of cycle 3, one day after the infusion of high-dose methotrexate, the patient was found to have high levels of serum methotrexate. Shortly after, he developed acute kidney injury. A kidney biopsy was performed, which showed methotrexate crystals only on tissue submitted for electron microscopy. To our knowledge, this is the first report to characterize methotrexate crystals on toluidine blue-stained thick sections and their ultrastructure on transmission electron microscopy.
{"title":"Methotrexate Crystals on Electron Microscopy of Kidney Biopsy for Acute Kidney Injury","authors":"Diana Fang MD , Noah Poznanski MD , Lois J. Arend MD, PhD","doi":"10.1016/j.xkme.2024.100924","DOIUrl":"10.1016/j.xkme.2024.100924","url":null,"abstract":"<div><div>Acute kidney injury secondary to methotrexate therapy for hematologic malignancies is relatively uncommon. Methotrexate crystals in these cases are rarely seen on kidney biopsy, and in particular, their appearance in tissue prepared for transmission electron microscopy has not been described. A male patient with recurrent primary central nervous system lymphoma received high-dose methotrexate and rituximab for treatment. On day 2 of cycle 3, one day after the infusion of high-dose methotrexate, the patient was found to have high levels of serum methotrexate. Shortly after, he developed acute kidney injury. A kidney biopsy was performed, which showed methotrexate crystals only on tissue submitted for electron microscopy. To our knowledge, this is the first report to characterize methotrexate crystals on toluidine blue-stained thick sections and their ultrastructure on transmission electron microscopy.</div></div>","PeriodicalId":17885,"journal":{"name":"Kidney Medicine","volume":"6 12","pages":"Article 100924"},"PeriodicalIF":3.2,"publicationDate":"2024-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142654936","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-18DOI: 10.1016/j.xkme.2024.100925
Anna E. Williams MD , Erin B. Chang MPH , Rasheed A. Gbadegesin MBBS, MD , Clarissa J. Diamantidis MD, MHS
{"title":"Pediatric Acute Kidney Injury Care: A Qualitative Study of Clinicians","authors":"Anna E. Williams MD , Erin B. Chang MPH , Rasheed A. Gbadegesin MBBS, MD , Clarissa J. Diamantidis MD, MHS","doi":"10.1016/j.xkme.2024.100925","DOIUrl":"10.1016/j.xkme.2024.100925","url":null,"abstract":"","PeriodicalId":17885,"journal":{"name":"Kidney Medicine","volume":"6 12","pages":"Article 100925"},"PeriodicalIF":3.2,"publicationDate":"2024-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142654937","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<div><h3>Rational & Objective</h3><div>Diabetes and uric acid kidney stones are strongly associated. Patients with calcium kidney stones also have higher risk of developing diabetes compared with nonkidney stone patients yet this has not been further investigated. We aimed to characterize insulin resistance in calcium kidney stone patients.</div></div><div><h3>Study Design</h3><div>Observational.</div></div><div><h3>Setting & Population</h3><div>This study was performed in the University of Chicago Clinical Research Center. Kidney stone patients (N<!--> <!-->=<!--> <!-->42) were selected for having idiopathic hypercalciuria and calcium stones with no other medical conditions, and controls (N<!--> <!-->=<!--> <!-->27) were healthy.</div></div><div><h3>Exposures</h3><div>All participants presented to the Clinical Research Center in a fasting state and at least 2 timed fasting blood and urine collections were collected before a fixed breakfast. Six additional timed blood and urine collections were performed after breakfast.</div></div><div><h3>Outcomes</h3><div>We compared fasting and fed indices of insulin resistance between the groups.</div></div><div><h3>Analytic Approach</h3><div>We used <em>t</em> tests and multivariable linear regression models. A sensitivity analysis removing all patients who had ever been on a thiazide diuretic was also performed.</div></div><div><h3>Results</h3><div>In separate multivariable linear models, kidney stone patients had higher fasting serum insulin levels (24 (3-46<!--> <!-->pmol/L), <em>P</em> <!-->=<!--> <!-->0.03) and higher homeostatic model of insulin resistance (HOMA-IR) (1.0 (0.2-1.8), <em>P</em> <!-->=<!--> <!-->0.02). In separate multivariable linear models, kidney stone patients had higher fed serum glucose levels (10 (2-18<!--> <!-->mg/dL), <em>P</em> <!-->=<!--> <!-->0.01). Results were similar in a sensitivity analysis removing all patients who had ever been on a thiazide diuretic. There were no differences in urine composition based on HOMA-IR levels.</div></div><div><h3>Limitations</h3><div>Single institution. Small sample size limited subanalyses by different calcium stone types.</div></div><div><h3>Conclusions</h3><div>Calcium kidney stone patients without diabetes or other medical conditions demonstrated signs of insulin resistance compared with healthy matched controls.</div></div><div><h3>Plain-Language Summary</h3><div>Diabetes is strongly associated with kidney stones, particularly uric acid kidney stones. However, patients who form calcium kidney stones may also have an increased risk of developing diabetes, but this has not been further explored. We collected markers of insulin resistance in otherwise healthy patients with calcium kidney stones and healthy control volunteers to evaluate for early signs of insulin resistance in patients with calcium kidney stones. Compared to healthy control participants, we found that patients with calcium kidney stones are more likely to have ins
{"title":"Insulin Resistance in Hypercalciuric Calcium Kidney Stone Patients","authors":"Megan Prochaska , Gloria Adeola , Noah Vetter , Raghavendra G. Mirmira , Fredric Coe , Elaine Worcester","doi":"10.1016/j.xkme.2024.100922","DOIUrl":"10.1016/j.xkme.2024.100922","url":null,"abstract":"<div><h3>Rational & Objective</h3><div>Diabetes and uric acid kidney stones are strongly associated. Patients with calcium kidney stones also have higher risk of developing diabetes compared with nonkidney stone patients yet this has not been further investigated. We aimed to characterize insulin resistance in calcium kidney stone patients.</div></div><div><h3>Study Design</h3><div>Observational.</div></div><div><h3>Setting & Population</h3><div>This study was performed in the University of Chicago Clinical Research Center. Kidney stone patients (N<!--> <!-->=<!--> <!-->42) were selected for having idiopathic hypercalciuria and calcium stones with no other medical conditions, and controls (N<!--> <!-->=<!--> <!-->27) were healthy.</div></div><div><h3>Exposures</h3><div>All participants presented to the Clinical Research Center in a fasting state and at least 2 timed fasting blood and urine collections were collected before a fixed breakfast. Six additional timed blood and urine collections were performed after breakfast.</div></div><div><h3>Outcomes</h3><div>We compared fasting and fed indices of insulin resistance between the groups.</div></div><div><h3>Analytic Approach</h3><div>We used <em>t</em> tests and multivariable linear regression models. A sensitivity analysis removing all patients who had ever been on a thiazide diuretic was also performed.</div></div><div><h3>Results</h3><div>In separate multivariable linear models, kidney stone patients had higher fasting serum insulin levels (24 (3-46<!--> <!-->pmol/L), <em>P</em> <!-->=<!--> <!-->0.03) and higher homeostatic model of insulin resistance (HOMA-IR) (1.0 (0.2-1.8), <em>P</em> <!-->=<!--> <!-->0.02). In separate multivariable linear models, kidney stone patients had higher fed serum glucose levels (10 (2-18<!--> <!-->mg/dL), <em>P</em> <!-->=<!--> <!-->0.01). Results were similar in a sensitivity analysis removing all patients who had ever been on a thiazide diuretic. There were no differences in urine composition based on HOMA-IR levels.</div></div><div><h3>Limitations</h3><div>Single institution. Small sample size limited subanalyses by different calcium stone types.</div></div><div><h3>Conclusions</h3><div>Calcium kidney stone patients without diabetes or other medical conditions demonstrated signs of insulin resistance compared with healthy matched controls.</div></div><div><h3>Plain-Language Summary</h3><div>Diabetes is strongly associated with kidney stones, particularly uric acid kidney stones. However, patients who form calcium kidney stones may also have an increased risk of developing diabetes, but this has not been further explored. We collected markers of insulin resistance in otherwise healthy patients with calcium kidney stones and healthy control volunteers to evaluate for early signs of insulin resistance in patients with calcium kidney stones. Compared to healthy control participants, we found that patients with calcium kidney stones are more likely to have ins","PeriodicalId":17885,"journal":{"name":"Kidney Medicine","volume":"6 12","pages":"Article 100922"},"PeriodicalIF":3.2,"publicationDate":"2024-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142654847","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-16DOI: 10.1016/j.xkme.2024.100920
Carolina Lopez-Silva , Aditya Surapaneni , Insa M. Schmidt , Dhairya Upadhyay , Anand Srivastava , Ragnar Palsson , Isaac E. Stillman , Eugene P. Rhee , Sushrut S. Waikar , Morgan E. Grams
Rationale & Objective
Diabetic kidney disease (DKD) is one of the leading causes of end-stage kidney disease globally. We aim to identify proteomic and metabolomic correlates of histologically confirmed DKD that may improve our understanding of its pathophysiology.
Study Design
A cross-sectional study.
Setting & Participants
A total of 434 Boston Kidney Biopsy Cohort participants.
Predictors
Histopathological diagnosis of DKD on biopsy.
Outcomes
Proteins and metabolites associated with DKD.
Analytical Approach
We performed linear regression to identify circulating proteins and metabolites associated with a histopathological diagnosis of DKD (n = 81) compared with normal or thin basement membrane (n = 27), and other kidney diseases without diabetes (n = 279). Pathway enrichment analysis was used to explore biological pathways enriched in DKD. Identified proteins were assessed for their discriminative ability in cases of DKD versus a distinct set of 48 patients with diabetes but other kidney diseases.
Results
After adjusting for age, sex, estimated glomerular filtration, and albuminuria levels, there were 8 proteins and 1 metabolite that differed between DKD and normal/thin basement membrane, and 84 proteins and 11 metabolites that differed between DKD and other kidney diseases without diabetes. Five proteins were significant in both comparisons: C-type mannose receptor 2, plexin-A1, plexin-D1, renin, and transmembrane glycoprotein NMB. The addition of these proteins improved discrimination over clinical variables alone of a histopathological diagnosis of DKD on biopsy among patients with diabetes (change in area under the curve 0.126; P = 0.008).
Limitations
A cross-sectional approach and lack of an external validation cohort.
Conclusions
Distinct proteins and biological pathways are correlated with a histopathological diagnosis of DKD.
Plain-Language Summary
In the following study, we aimed to identify proteins, metabolites, and biological pathways that are associated with a diagnosis of diabetic kidney disease on biopsy. After adjusting for demographic characteristics and baseline renal function, we identified 5 proteins that were significantly associated with diabetic kidney disease, both in comparison to individuals without kidney disease and those with nondiabetic kidney disease: C-type mannose receptor 2, plexin-A1, plexin-D1, renin, and transmembrane glycoprotein NMB. We also found that these proteins may enhance our ability to distinguish between diabetic kidney disease and other causes of kidney disease in a group of patients with diabetes.
{"title":"Circulating Protein and Metabolite Correlates of Histologically Confirmed Diabetic Kidney Disease","authors":"Carolina Lopez-Silva , Aditya Surapaneni , Insa M. Schmidt , Dhairya Upadhyay , Anand Srivastava , Ragnar Palsson , Isaac E. Stillman , Eugene P. Rhee , Sushrut S. Waikar , Morgan E. Grams","doi":"10.1016/j.xkme.2024.100920","DOIUrl":"10.1016/j.xkme.2024.100920","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>Diabetic kidney disease (DKD) is one of the leading causes of end-stage kidney disease globally. We aim to identify proteomic and metabolomic correlates of histologically confirmed DKD that may improve our understanding of its pathophysiology.</div></div><div><h3>Study Design</h3><div>A cross-sectional study.</div></div><div><h3>Setting & Participants</h3><div>A total of 434 Boston Kidney Biopsy Cohort participants.</div></div><div><h3>Predictors</h3><div>Histopathological diagnosis of DKD on biopsy.</div></div><div><h3>Outcomes</h3><div>Proteins and metabolites associated with DKD.</div></div><div><h3>Analytical Approach</h3><div>We performed linear regression to identify circulating proteins and metabolites associated with a histopathological diagnosis of DKD (n<!--> <!-->=<!--> <!-->81) compared with normal or thin basement membrane (n<!--> <!-->=<!--> <!-->27), and other kidney diseases without diabetes (n<!--> <!-->=<!--> <!-->279). Pathway enrichment analysis was used to explore biological pathways enriched in DKD. Identified proteins were assessed for their discriminative ability in cases of DKD versus a distinct set of 48 patients with diabetes but other kidney diseases.</div></div><div><h3>Results</h3><div>After adjusting for age, sex, estimated glomerular filtration, and albuminuria levels, there were 8 proteins and 1 metabolite that differed between DKD and normal/thin basement membrane, and 84 proteins and 11 metabolites that differed between DKD and other kidney diseases without diabetes. Five proteins were significant in both comparisons: C-type mannose receptor 2, plexin-A1, plexin-D1, renin, and transmembrane glycoprotein NMB. The addition of these proteins improved discrimination over clinical variables alone of a histopathological diagnosis of DKD on biopsy among patients with diabetes (change in area under the curve 0.126; <em>P</em> <!-->=<!--> <!-->0.008).</div></div><div><h3>Limitations</h3><div>A cross-sectional approach and lack of an external validation cohort.</div></div><div><h3>Conclusions</h3><div>Distinct proteins and biological pathways are correlated with a histopathological diagnosis of DKD.</div></div><div><h3>Plain-Language Summary</h3><div>In the following study, we aimed to identify proteins, metabolites, and biological pathways that are associated with a diagnosis of diabetic kidney disease on biopsy. After adjusting for demographic characteristics and baseline renal function, we identified 5 proteins that were significantly associated with diabetic kidney disease, both in comparison to individuals without kidney disease and those with nondiabetic kidney disease: C-type mannose receptor 2, plexin-A1, plexin-D1, renin, and transmembrane glycoprotein NMB. We also found that these proteins may enhance our ability to distinguish between diabetic kidney disease and other causes of kidney disease in a group of patients with diabetes.</div></div>","PeriodicalId":17885,"journal":{"name":"Kidney Medicine","volume":"6 12","pages":"Article 100920"},"PeriodicalIF":3.2,"publicationDate":"2024-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142654846","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-16DOI: 10.1016/j.xkme.2024.100919
Dipal M. Patel , Bryce M. Churilla , Timmy C. Lee , Mae Thamer , Yi Zhang , Michael Allon , Deidra C. Crews
Rationale & Objective
Arteriovenous fistula (AVF) use among US hemodialysis (HD) patients is suboptimal, especially among Black patients. We interviewed a group of predominantly Black HD patients to probe experiences and perspectives surrounding steps along the AVF care continuum, which includes placement, maturation, and use of AVFs.
Study Design
Individual semistructured interviews.
Setting & Participants
Patients with kidney failure receiving HD in Birmingham, Alabama.
Analytical Approach
Transcripts were coded and thematically analyzed.
Results
We interviewed 53 Black and 6 White patients at different steps of the AVF care continuum: 29 were dialyzing with a central venous catheter (15 had not undergone AVF placement, 9 had a maturing AVF, and 5 had a nonfunctional AVF) and 30 were dialyzing with an AVF. We coded transcripts using qualitative thematic analysis. Three themes emerged: (1) the circumstances of dialysis initiation sometimes altered the timeline of AV access placement; (2) patients had variable levels of knowledge of steps along the AVF continuum; and (3) the life impacts of dialysis access were a significant factor in patients’ experience of dialysis.
Limitations
Single-institution study; low number of non-Black participants limited comparison of patient experiences by race.
Conclusions
Among a group of predominantly Black HD patients, perspectives surrounding the AVF care continuum included consideration of the circumstances of dialysis initiation, patient knowledge, and the life impacts of dialysis access. These findings may inform targeted interventions aimed at optimizing dialysis access use and addressing disparities across the AVF continuum.
Plain-Language Summary
People with kidney failure receiving hemodialysis (HD) rely on vascular access to undergo HD treatments. Though arteriovenous fistulas (AVFs) are preferred over tunneled dialysis catheters, AVF use is suboptimal especially among Black people with kidney failure. We interviewed 59 predominantly Black people with kidney failure who were at various stages of having an AVF placed. We aimed to understand their perspectives and experiences surrounding AVF placement, maintenance, and use. We learned that the circumstances of dialysis initiation, patient knowledge, and perceived life impacts of dialysis access contributed to perspectives on AVFs. These findings can help guide interventions that may address disparities in use of AVFs and optimize patient experiences around dialysis access.
{"title":"Patient Perspectives on Arteriovenous Fistula Placement, Maturation, and Use: A Qualitative Study","authors":"Dipal M. Patel , Bryce M. Churilla , Timmy C. Lee , Mae Thamer , Yi Zhang , Michael Allon , Deidra C. Crews","doi":"10.1016/j.xkme.2024.100919","DOIUrl":"10.1016/j.xkme.2024.100919","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>Arteriovenous fistula (AVF) use among US hemodialysis (HD) patients is suboptimal, especially among Black patients. We interviewed a group of predominantly Black HD patients to probe experiences and perspectives surrounding steps along the AVF care continuum, which includes placement, maturation, and use of AVFs.</div></div><div><h3>Study Design</h3><div>Individual semistructured interviews.</div></div><div><h3>Setting & Participants</h3><div>Patients with kidney failure receiving HD in Birmingham, Alabama.</div></div><div><h3>Analytical Approach</h3><div>Transcripts were coded and thematically analyzed.</div></div><div><h3>Results</h3><div>We interviewed 53 Black and 6 White patients at different steps of the AVF care continuum: 29 were dialyzing with a central venous catheter (15 had not undergone AVF placement, 9 had a maturing AVF, and 5 had a nonfunctional AVF) and 30 were dialyzing with an AVF. We coded transcripts using qualitative thematic analysis. Three themes emerged: (1) the circumstances of dialysis initiation sometimes altered the timeline of AV access placement; (2) patients had variable levels of knowledge of steps along the AVF continuum; and (3) the life impacts of dialysis access were a significant factor in patients’ experience of dialysis.</div></div><div><h3>Limitations</h3><div>Single-institution study; low number of non-Black participants limited comparison of patient experiences by race.</div></div><div><h3>Conclusions</h3><div>Among a group of predominantly Black HD patients, perspectives surrounding the AVF care continuum included consideration of the circumstances of dialysis initiation, patient knowledge, and the life impacts of dialysis access. These findings may inform targeted interventions aimed at optimizing dialysis access use and addressing disparities across the AVF continuum.</div></div><div><h3>Plain-Language Summary</h3><div>People with kidney failure receiving hemodialysis (HD) rely on vascular access to undergo HD treatments. Though arteriovenous fistulas (AVFs) are preferred over tunneled dialysis catheters, AVF use is suboptimal especially among Black people with kidney failure. We interviewed 59 predominantly Black people with kidney failure who were at various stages of having an AVF placed. We aimed to understand their perspectives and experiences surrounding AVF placement, maintenance, and use. We learned that the circumstances of dialysis initiation, patient knowledge, and perceived life impacts of dialysis access contributed to perspectives on AVFs. These findings can help guide interventions that may address disparities in use of AVFs and optimize patient experiences around dialysis access.</div></div>","PeriodicalId":17885,"journal":{"name":"Kidney Medicine","volume":"6 12","pages":"Article 100919"},"PeriodicalIF":3.2,"publicationDate":"2024-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142654849","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-16DOI: 10.1016/j.xkme.2024.100915
Taesoo Kim , Dirk M. Hentschel , David B. Mount , Katherine Scovner Ravi
{"title":"Undetected Air Embolism During Hemodialysis from a Defective Central Venous Catheter Causing Intradialytic Cardiac Arrest: An Imaging Teaching Case","authors":"Taesoo Kim , Dirk M. Hentschel , David B. Mount , Katherine Scovner Ravi","doi":"10.1016/j.xkme.2024.100915","DOIUrl":"10.1016/j.xkme.2024.100915","url":null,"abstract":"","PeriodicalId":17885,"journal":{"name":"Kidney Medicine","volume":"6 11","pages":"Article 100915"},"PeriodicalIF":3.2,"publicationDate":"2024-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142537384","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-15DOI: 10.1016/j.xkme.2024.100918
Benjamin R. Griffin , Avinash Mudireddy , Benjamin D. Horne , Michel Chonchol , Stuart L. Goldstein , Michihiko Goto , Michael E. Matheny , W. Nick Street , Mary Vaughan-Sarrazin , Diana I. Jalal , Jason Misurac
<div><h3>Rationale and Objective</h3><div>Acute kidney injury (AKI) is a common complication among hospitalized adults, but AKI prediction and prevention among adults has proved challenging. We used machine learning to update the nephrotoxic injury negated by just-in time action (NINJA), a pediatric program that predicts nephrotoxic AKI, to improve accuracy among adults.</div></div><div><h3>Study Design</h3><div>A retrospective cohort study.</div></div><div><h3>Setting and Population</h3><div>Adults admitted for<!--> <!-->><!--> <!-->48 hours to the University of Iowa Hospital from 2017 to 2022.</div></div><div><h3>Exposure</h3><div>A NINJA high-nephrotoxin exposure (≥3 nephrotoxins on 1<!--> <!-->day or intravenous aminoglycoside or vancomycin for<!--> <!-->≥3 days).</div></div><div><h3>Outcomes</h3><div>AKI within 48 hours of high-nephrotoxin exposure.</div></div><div><h3>Analytical Approach</h3><div>We collected 85 variables, including demographics, laboratory tests, vital signs, and medications. AKI was defined as a serum creatinine increase of<!--> <!-->≥0.3<!--> <!-->mg/dL. A gated recurrent unit (GRU)-based recurrent neural network (RNN) was trained on 85% of the data, and then tested on the remaining 15%. Model performance was evaluated with precision, recall, negative predictive value, and area under the curve. We used an artificial neural network to determine risk factor importance.</div></div><div><h3>Results</h3><div>There were 14,480 patients, 18,180 admissions, and 37,300 high-nephrotoxin exposure events meeting inclusion criteria. In the testing cohort, 29% of exposures developed AKI within 48 hours. The RNN-GRU model predicted AKI with a precision of 0.60, reducing the number of false alerts from 2.5 to 0.7 per AKI case. Lowest hemoglobin, lowest blood pressure, and highest white blood cell count were the most important variables in the artificial neural network model. Acyclovir, piperacillin-tazobactam, calcineurin inhibitors, and angiotensin-converting enzyme inhibitor/angiotensin receptor blockers were the most important medications.</div></div><div><h3>Limitations</h3><div>Clinical variables and medications were not exhaustive, drug levels or dosing were not incorporated, and Iowa’s racial makeup may limit generalizability.</div></div><div><h3>Conclusions</h3><div>Our RNN-GRU model substantially reduced the number of false alerts for nephrotoxic AKI, which may facilitate NINJA translation to adult hospitals by providing more targeted intervention.</div></div><div><h3>Plain-Language Summary</h3><div>Nephrotoxic acute kidney injury (AKI) is common and can potentially be prevented through preemptive adjustments of medications, as demonstrated by the success of the nephrotoxic injury negated by just-in time action (NINJA) program in pediatric populations. Translation of NINJA to the adult population has been challenging, and major barriers include high alert volume in adults that can lead to high resource utilization and alert
理论依据和目标急性肾损伤（AKI）是成人住院患者中常见的并发症，但事实证明，成人AKI的预测和预防具有挑战性。我们利用机器学习更新了及时行动（NINJA）（一种预测肾毒性 AKI 的儿科程序）所否定的肾毒性损伤，以提高成人中的准确性。研究设计回顾性队列研究设置和人群2017 年至 2022 年期间，爱荷华大学医院收治了 > 48 小时的成人。暴露A NINJA高肾毒素暴露（1天内≥3种肾毒素或静脉注射氨基糖苷类或万古霉素≥3天）.结果高肾毒素暴露48小时内AKI.分析方法我们收集了85个变量，包括人口统计学、实验室检查、生命体征和药物。AKI 的定义是血清肌酐升高≥0.3 mg/dL。基于门控递归单元（GRU）的递归神经网络（RNN）在 85% 的数据上进行了训练，然后在剩余 15% 的数据上进行了测试。模型性能通过精确度、召回率、负预测值和曲线下面积进行评估。我们使用人工神经网络来确定风险因素的重要性。结果符合纳入标准的患者有 14,480 人，入院人数有 18,180 人，高肾毒素暴露事件有 37,300 起。在测试队列中，29%的接触者在 48 小时内发生了 AKI。RNN-GRU 模型预测 AKI 的精确度为 0.60，将每例 AKI 的误报数量从 2.5 降至 0.7。最低血红蛋白、最低血压和最高白细胞计数是人工神经网络模型中最重要的变量。局限性临床变量和药物未穷尽，药物水平或剂量未纳入其中，爱荷华州的种族构成可能会限制其普遍性。结论我们的 RNN-GRU 模型大大降低了肾毒性 AKI 的错误警报数量，通过提供更有针对性的干预措施，这可能有助于将 NINJA 移植到成人医院。将 NINJA 移植到成人中一直是个挑战，主要障碍包括成人的高警报量会导致资源利用率高和警报疲劳。为了解决这一问题，我们开发了一种针对成人肾毒性 AKI 的机器学习模型，该模型可将每次 AKI 事件的错误警报次数从 2.5 次减少到 0.7 次，这可以通过减少警报次数和提高资源利用效率来进行更有针对性的干预，从而加强未来 NINJA 在成人中的实施。
{"title":"Predicting Nephrotoxic Acute Kidney Injury in Hospitalized Adults: A Machine Learning Algorithm","authors":"Benjamin R. Griffin , Avinash Mudireddy , Benjamin D. Horne , Michel Chonchol , Stuart L. Goldstein , Michihiko Goto , Michael E. Matheny , W. Nick Street , Mary Vaughan-Sarrazin , Diana I. Jalal , Jason Misurac","doi":"10.1016/j.xkme.2024.100918","DOIUrl":"10.1016/j.xkme.2024.100918","url":null,"abstract":"<div><h3>Rationale and Objective</h3><div>Acute kidney injury (AKI) is a common complication among hospitalized adults, but AKI prediction and prevention among adults has proved challenging. We used machine learning to update the nephrotoxic injury negated by just-in time action (NINJA), a pediatric program that predicts nephrotoxic AKI, to improve accuracy among adults.</div></div><div><h3>Study Design</h3><div>A retrospective cohort study.</div></div><div><h3>Setting and Population</h3><div>Adults admitted for<!--> <!-->><!--> <!-->48 hours to the University of Iowa Hospital from 2017 to 2022.</div></div><div><h3>Exposure</h3><div>A NINJA high-nephrotoxin exposure (≥3 nephrotoxins on 1<!--> <!-->day or intravenous aminoglycoside or vancomycin for<!--> <!-->≥3 days).</div></div><div><h3>Outcomes</h3><div>AKI within 48 hours of high-nephrotoxin exposure.</div></div><div><h3>Analytical Approach</h3><div>We collected 85 variables, including demographics, laboratory tests, vital signs, and medications. AKI was defined as a serum creatinine increase of<!--> <!-->≥0.3<!--> <!-->mg/dL. A gated recurrent unit (GRU)-based recurrent neural network (RNN) was trained on 85% of the data, and then tested on the remaining 15%. Model performance was evaluated with precision, recall, negative predictive value, and area under the curve. We used an artificial neural network to determine risk factor importance.</div></div><div><h3>Results</h3><div>There were 14,480 patients, 18,180 admissions, and 37,300 high-nephrotoxin exposure events meeting inclusion criteria. In the testing cohort, 29% of exposures developed AKI within 48 hours. The RNN-GRU model predicted AKI with a precision of 0.60, reducing the number of false alerts from 2.5 to 0.7 per AKI case. Lowest hemoglobin, lowest blood pressure, and highest white blood cell count were the most important variables in the artificial neural network model. Acyclovir, piperacillin-tazobactam, calcineurin inhibitors, and angiotensin-converting enzyme inhibitor/angiotensin receptor blockers were the most important medications.</div></div><div><h3>Limitations</h3><div>Clinical variables and medications were not exhaustive, drug levels or dosing were not incorporated, and Iowa’s racial makeup may limit generalizability.</div></div><div><h3>Conclusions</h3><div>Our RNN-GRU model substantially reduced the number of false alerts for nephrotoxic AKI, which may facilitate NINJA translation to adult hospitals by providing more targeted intervention.</div></div><div><h3>Plain-Language Summary</h3><div>Nephrotoxic acute kidney injury (AKI) is common and can potentially be prevented through preemptive adjustments of medications, as demonstrated by the success of the nephrotoxic injury negated by just-in time action (NINJA) program in pediatric populations. Translation of NINJA to the adult population has been challenging, and major barriers include high alert volume in adults that can lead to high resource utilization and alert ","PeriodicalId":17885,"journal":{"name":"Kidney Medicine","volume":"6 12","pages":"Article 100918"},"PeriodicalIF":3.2,"publicationDate":"2024-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142654848","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<div><h3>Rationale & Objective</h3><div>A response “no” (SQ-No) to the surprise question (SQ) of whether a clinician would be surprised if a dialysis patient died in the next 6 months is associated with a higher risk of all-cause death. It is uncertain what domains are intuitively assessed with the SQ. We hypothesized that the SQ would assess the patient’s frailty, malnutrition, or patient-perceived health-related quality of life in a cohort of patients on maintenance hemodialysis.</div></div><div><h3>Study Design</h3><div>Cohort study.</div></div><div><h3>Setting & Participants</h3><div>A multicenter study including 994 patients on maintenance hemodialysis in Japan.</div></div><div><h3>Predictors</h3><div>(1) SQ answered by nurses; (2) frailty by modified Cardiovascular Health Study criteria; (3) malnutrition as evaluated by Geriatric Nutritional Risk Index (GNRI); and (4) patient-perceived health-related quality of life examined by the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS).</div></div><div><h3>Outcomes</h3><div>All-cause mortality.</div></div><div><h3>Analytical Approach</h3><div>Cox proportional hazard models.</div></div><div><h3>Results</h3><div>Median age and dialysis vintage were 66 and 5.9 years, respectively, 35.8% were women, and 39.6% had diabetic kidney disease. The prevalence of SQ-No and frailty was 19.7% and 45.9%. Median GNRI and SF-36 PCS scores were 96.3 and 36.9, respectively. During the 5-year follow-up, 247 patients died. SQ-No, being frail, low GNRI, and low SF-36 PCS were each significant predictors of a higher risk for mortality independent of potential confounders. SQ-No remained a significant predictor after further adjustment for frailty or GNRI, but SQ-No was no longer significant when adjusted for SF-36 PCS.</div></div><div><h3>Limitations</h3><div>We did not assess the agreement of responses to the SQ between different raters.</div></div><div><h3>Conclusions</h3><div>The predictive ability of the SQ was closely related to SF-36 PCS in hemodialysis patients. Nurses’ answer to the SQ appears to assess the physical domain of patient-perceived health-related quality of life rather than objectively assessed frailty or malnutrition.</div></div><div><h3>Plain Language Summary</h3><div>“Would I be surprised if this patient died in the next 6 months?” This question posed to a clinician is called the “surprise question” (SQ) and the answer “no” (SQ-No) has been shown to predict a higher risk of mortality in patients undergoing hemodialysis. We examined which domains are intuitively assessed with the SQ, such as frailty, malnutrition, and patient-perceived quality of life in a cohort of hemodialysis patients. We found that the association between the SQ response and mortality was independent of frailty and malnutrition but was closely related to the physical domain of patient-perceived quality of life. The results suggest that the SQ appears to assess the physical domain of patient-per
{"title":"The Surprise Question in Hemodialysis, Frailty, Nutrition, Patient-reported Quality of Life, and All-Cause Mortality: The Osaka Dialysis Complication Study (ODCS)","authors":"Tetsuo Shoji , Daijiro Kabata , Seiichi Kimura , Yuki Nagata , Katsuhito Mori , Shinya Nakatani , Hisako Fujii , Tomoaki Morioka , Masanori Emoto","doi":"10.1016/j.xkme.2024.100914","DOIUrl":"10.1016/j.xkme.2024.100914","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>A response “no” (SQ-No) to the surprise question (SQ) of whether a clinician would be surprised if a dialysis patient died in the next 6 months is associated with a higher risk of all-cause death. It is uncertain what domains are intuitively assessed with the SQ. We hypothesized that the SQ would assess the patient’s frailty, malnutrition, or patient-perceived health-related quality of life in a cohort of patients on maintenance hemodialysis.</div></div><div><h3>Study Design</h3><div>Cohort study.</div></div><div><h3>Setting & Participants</h3><div>A multicenter study including 994 patients on maintenance hemodialysis in Japan.</div></div><div><h3>Predictors</h3><div>(1) SQ answered by nurses; (2) frailty by modified Cardiovascular Health Study criteria; (3) malnutrition as evaluated by Geriatric Nutritional Risk Index (GNRI); and (4) patient-perceived health-related quality of life examined by the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS).</div></div><div><h3>Outcomes</h3><div>All-cause mortality.</div></div><div><h3>Analytical Approach</h3><div>Cox proportional hazard models.</div></div><div><h3>Results</h3><div>Median age and dialysis vintage were 66 and 5.9 years, respectively, 35.8% were women, and 39.6% had diabetic kidney disease. The prevalence of SQ-No and frailty was 19.7% and 45.9%. Median GNRI and SF-36 PCS scores were 96.3 and 36.9, respectively. During the 5-year follow-up, 247 patients died. SQ-No, being frail, low GNRI, and low SF-36 PCS were each significant predictors of a higher risk for mortality independent of potential confounders. SQ-No remained a significant predictor after further adjustment for frailty or GNRI, but SQ-No was no longer significant when adjusted for SF-36 PCS.</div></div><div><h3>Limitations</h3><div>We did not assess the agreement of responses to the SQ between different raters.</div></div><div><h3>Conclusions</h3><div>The predictive ability of the SQ was closely related to SF-36 PCS in hemodialysis patients. Nurses’ answer to the SQ appears to assess the physical domain of patient-perceived health-related quality of life rather than objectively assessed frailty or malnutrition.</div></div><div><h3>Plain Language Summary</h3><div>“Would I be surprised if this patient died in the next 6 months?” This question posed to a clinician is called the “surprise question” (SQ) and the answer “no” (SQ-No) has been shown to predict a higher risk of mortality in patients undergoing hemodialysis. We examined which domains are intuitively assessed with the SQ, such as frailty, malnutrition, and patient-perceived quality of life in a cohort of hemodialysis patients. We found that the association between the SQ response and mortality was independent of frailty and malnutrition but was closely related to the physical domain of patient-perceived quality of life. The results suggest that the SQ appears to assess the physical domain of patient-per","PeriodicalId":17885,"journal":{"name":"Kidney Medicine","volume":"6 12","pages":"Article 100914"},"PeriodicalIF":3.2,"publicationDate":"2024-10-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142594064","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-11DOI: 10.1016/j.xkme.2024.100913
Dilaram Acharya , Fanar Ghanim , Tyrone G. Harrison , Tayler Dawn Scory , Nusrat Shommu , Paul E. Ronksley , Meghan J. Elliott , David Collister , Neesh Pannu , Matthew T. James
<div><h3>Rationale & Objective</h3><div>Cilastatin is an inhibitor of drug metabolism in the proximal tubule that demonstrates nephroprotective effects in animals. It has been used in humans in combination with the antibiotic imipenem to block imipenem’s renal metabolism. This systematic review and meta-analysis evaluated the nephroprotective effects of cilastatin in humans.</div></div><div><h3>Study Design</h3><div>Systematic review and meta-analysis of observational (comparative effectiveness) studies or randomized clinical trials (RCTs).</div></div><div><h3>Setting & Study Populations</h3><div>People of any age at risk of acute kidney injury (AKI).</div></div><div><h3>Selection Criteria for Studies</h3><div>We systematically searched MEDLINE, Embase, Web of Science, and the Cochrane Controlled Trials registry from database inception to November 2023 for observational studies or RCTs that compared kidney outcomes among groups treated with cilastatin, either alone or as combination imipenem-cilastatin, versus an inactive or active control group not treated with cilastatin.</div></div><div><h3>Data Extraction</h3><div>Two reviewers independently evaluated studies for inclusion and risk of bias.</div></div><div><h3>Analytical Approach</h3><div>Treatment effects were estimated using random-effects models, and heterogeneity was quantified using the <em>I</em><sup>2</sup> statistic.</div></div><div><h3>Results</h3><div>We identified 10 studies (5 RCTs, n<!--> <!-->=<!--> <!-->531<!--> <!-->patients; 5 observational studies, n<!--> <!-->=<!--> <!-->6,321 participants) that met the inclusion criteria, including 4 studies with comparisons to inactive controls and 6 studies with comparisons to alternate antibiotics. Based on pooled results from 7 studies, the risk of AKI was lower with imipenem-cilastatin (risk ratio [RR], 0.52; 95% confidence intervals [CI], 0.40-0.67; <em>I</em><sup>2</sup> <!-->=<!--> <!-->26.5%), with consistent results observed in RCTs (3 RCTs, RR, 0.26; 95% CI, 0.09-0.77; <em>I</em><sup>2</sup> <!-->=<!--> <!-->44.4%) and observational studies (4 studies, RR, 0.54; 95% CI, 0.41-0.72; <em>I</em><sup>2</sup> <!-->=<!--> <!-->44.4%). Based on results from 6 studies, serum creatinine concentration was lower following treatment with imipenem-cilastatin than comparators (weighted mean difference in serum creatinine<!--> <!-->−0.14 mg/dL (95% CI, −0.21 to<!--> <!-->−0.07; <em>I</em><sup>2</sup> <!-->=<!--> <!-->0%). The overall certainty of the evidence was low due to heterogeneity of the results, high risk of bias, and indirectness among the identified studies.</div></div><div><h3>Limitations</h3><div>Clinical and statistical heterogeneity could not be fully explained due to a limited number of studies.</div></div><div><h3>Conclusions</h3><div>Patients treated with imipenem-cilastatin developed AKI less frequently and had lower serum creatinine concentration following treatment than control groups or those who had received compar
理由与amp; 目的西司他丁是一种近端肾小管药物代谢抑制剂，在动物体内具有保护肾脏的作用。在人体中，它与抗生素亚胺培南联合使用，可阻断亚胺培南的肾脏代谢。本系统综述和荟萃分析评估了西司他丁对人类肾脏的保护作用。研究设计系统综述和荟萃分析观察性（比较效应）研究或随机临床试验（RCT）。研究的筛选标准我们系统地检索了MEDLINE、Embase、Web of Science和Cochrane对照试验登记系统中从数据库开始到2023年11月的所有研究，以寻找对单用西司他丁或亚胺培南-西司他丁联合治疗组与未用西司他丁治疗的非活性或活性对照组的肾脏结果进行比较的观察性研究或RCT。结果我们确定了10项符合纳入标准的研究（5项RCT，n=531名患者；5项观察性研究，n=6321名参与者），其中包括4项与非活性对照组进行比较的研究和6项与替代抗生素进行比较的研究。根据 7 项研究的汇总结果，亚胺培南-西司他丁的 AKI 风险较低（风险比 [RR]，0.52；95% 置信区间 [CI]，0.40-0.67；I2 = 26.5%），在 RCT（3 项 RCT，RR，0.26；95% CI，0.09-0.77；I2 = 44.4%）和观察性研究（4 项研究，RR，0.54；95% CI，0.41-0.72；I2 = 44.4%）中观察到的结果一致。根据6项研究的结果，使用亚胺培南-西司他丁治疗后，血清肌酐浓度低于对照组（血清肌酐的加权平均差异为-0.14 mg/dL (95% CI, -0.21 to -0.07；I2 = 0%)。结论与对照组或接受了对比抗生素治疗的患者相比，接受亚胺培南-西司他丁治疗的患者发生AKI的频率较低，治疗后血清肌酐浓度也较低。为确定西司他丁预防 AKI 的疗效，需要进行更大规模的临床试验，以降低因缺乏分配隐藏和盲法而导致的检测偏倚风险。本系统综述和荟萃分析确定了 10 项亚胺培南-西司他丁研究（5 项随机对照试验和 5 项观察性研究），涉及有 AKI 风险的人群。对治疗效果的汇总估计表明，与对比组相比，接受亚胺培南-西司他丁治疗的患者的 AKI 发生率较低，治疗后血清肌酐浓度也较低。尽管这些研究结果很有希望，但由于研究之间存在异质性、高偏倚风险以及数据的间接性，证据的总体确定性较低。尽管西司他丁似乎是一种很有前景的预防 AKI 的药物，但还需要更大规模、设计合理的试验来确定其有效性。
{"title":"Nephroprotective Effects of Cilastatin in People at Risk of Acute Kidney Injury: A Systematic Review and Meta-analysis","authors":"Dilaram Acharya , Fanar Ghanim , Tyrone G. Harrison , Tayler Dawn Scory , Nusrat Shommu , Paul E. Ronksley , Meghan J. Elliott , David Collister , Neesh Pannu , Matthew T. James","doi":"10.1016/j.xkme.2024.100913","DOIUrl":"10.1016/j.xkme.2024.100913","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>Cilastatin is an inhibitor of drug metabolism in the proximal tubule that demonstrates nephroprotective effects in animals. It has been used in humans in combination with the antibiotic imipenem to block imipenem’s renal metabolism. This systematic review and meta-analysis evaluated the nephroprotective effects of cilastatin in humans.</div></div><div><h3>Study Design</h3><div>Systematic review and meta-analysis of observational (comparative effectiveness) studies or randomized clinical trials (RCTs).</div></div><div><h3>Setting & Study Populations</h3><div>People of any age at risk of acute kidney injury (AKI).</div></div><div><h3>Selection Criteria for Studies</h3><div>We systematically searched MEDLINE, Embase, Web of Science, and the Cochrane Controlled Trials registry from database inception to November 2023 for observational studies or RCTs that compared kidney outcomes among groups treated with cilastatin, either alone or as combination imipenem-cilastatin, versus an inactive or active control group not treated with cilastatin.</div></div><div><h3>Data Extraction</h3><div>Two reviewers independently evaluated studies for inclusion and risk of bias.</div></div><div><h3>Analytical Approach</h3><div>Treatment effects were estimated using random-effects models, and heterogeneity was quantified using the <em>I</em><sup>2</sup> statistic.</div></div><div><h3>Results</h3><div>We identified 10 studies (5 RCTs, n<!--> <!-->=<!--> <!-->531<!--> <!-->patients; 5 observational studies, n<!--> <!-->=<!--> <!-->6,321 participants) that met the inclusion criteria, including 4 studies with comparisons to inactive controls and 6 studies with comparisons to alternate antibiotics. Based on pooled results from 7 studies, the risk of AKI was lower with imipenem-cilastatin (risk ratio [RR], 0.52; 95% confidence intervals [CI], 0.40-0.67; <em>I</em><sup>2</sup> <!-->=<!--> <!-->26.5%), with consistent results observed in RCTs (3 RCTs, RR, 0.26; 95% CI, 0.09-0.77; <em>I</em><sup>2</sup> <!-->=<!--> <!-->44.4%) and observational studies (4 studies, RR, 0.54; 95% CI, 0.41-0.72; <em>I</em><sup>2</sup> <!-->=<!--> <!-->44.4%). Based on results from 6 studies, serum creatinine concentration was lower following treatment with imipenem-cilastatin than comparators (weighted mean difference in serum creatinine<!--> <!-->−0.14 mg/dL (95% CI, −0.21 to<!--> <!-->−0.07; <em>I</em><sup>2</sup> <!-->=<!--> <!-->0%). The overall certainty of the evidence was low due to heterogeneity of the results, high risk of bias, and indirectness among the identified studies.</div></div><div><h3>Limitations</h3><div>Clinical and statistical heterogeneity could not be fully explained due to a limited number of studies.</div></div><div><h3>Conclusions</h3><div>Patients treated with imipenem-cilastatin developed AKI less frequently and had lower serum creatinine concentration following treatment than control groups or those who had received compar","PeriodicalId":17885,"journal":{"name":"Kidney Medicine","volume":"6 12","pages":"Article 100913"},"PeriodicalIF":3.2,"publicationDate":"2024-10-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142654935","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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