Pub Date : 2024-10-18DOI: 10.1016/j.xkme.2024.100923
Changyuan Yang , Xiaoxuan Hu , Xitao Ling , Cuixia Xiao , Ruolan Duan , Jiamei Qiu , Qin Li , Xindong Qin , Jiahao Zeng , La Zhang , Haijing Hou , Yu Peng , Yuan Xu , Jingxu Su , Xusheng Liu , Bengt Lindholm , David W. Johnson , Fuhua Lu , Guobin Su
<div><h3>Rationale & Objective</h3><div>Hypokalemia is common and potentially life-threatening in patients undergoing peritoneal dialysis (PD). However, the current literature has produced varying results. This study aimed to evaluate the prevalence and adverse outcomes of hypokalemia and the role of potassium supplementation in patients receiving PD.</div></div><div><h3>Study Design</h3><div>Systematic review and meta-analysis of randomized controlled trials and observational studies.</div></div><div><h3>Setting & Study Populations</h3><div>Adults receiving maintenance PD.</div></div><div><h3>Selection Criteria for Studies</h3><div>Studies that investigated the prevalence and adverse outcomes of hypokalemia and the effect of potassium supplementation.</div></div><div><h3>Data Extraction</h3><div>Two independent reviewers evaluated studies for eligibility and extracted relevant data.</div></div><div><h3>Analytical Approach</h3><div>Random effects meta-analysis was conducted to pool hazard ratios (HRs) and 95% CIs for the outcomes of interest. The certainty of findings was rated according to the Grading of Recommendations Assessment, Development and Evaluation criteria.</div></div><div><h3>Results</h3><div>Of 3,632 reports identified, 24 studies involving 60,313 participants met the inclusion criteria. The prevalence of hypokalemia was 37.9% (95% CI, 27.2%-52.7%), 17.7% (95% CI, 12.0%-25.9%), and 4.4% (95% CI, 1.9%-10.2%) in patients with potassium level<!--> <!--><4.0, 3.5, and 3.0<!--> <!-->mmol/L, respectively. Hypokalemia, according to the study’s definition, was associated with increased risks of all-cause mortality (HR, 1.49; 95% CI, 1.18-1.89), cardiovascular mortality (HR, 1.50; 95% CI, 1.19-1.88), and PD-associated peritonitis (HR, 1.42; 95% CI, 1.17-1.73). These associations were consistent but with low to very low certainty. The effect of correcting hypokalemia with potassium supplementation in patients undergoing PD remains uncertain.</div></div><div><h3>Limitations</h3><div>Heterogeneity persisted across most of the examined subgroups, and observational studies preclude causation.</div></div><div><h3>Conclusions</h3><div>Hypokalemia is common and portends poorer survival and a higher risk of peritonitis among patients undergoing PD. Further research into the optimal prevention and treatment strategies for hypokalemia is warranted to improve outcomes.</div></div><div><h3>Registration</h3><div>Registered at PROSPERO with registration number CRD42022358236.</div></div><div><h3>Plain-Language Summary</h3><div>Hypokalemia is common and can be fatal in patients undergoing peritoneal dialysis (PD). The reported prevalence of hypokalemia in patients undergoing PD varies significantly across studies, and there is inconsistency regarding the relationship between hypokalemia and adverse outcomes. This systematic review and meta-analysis showed that hypokalemia is prevalent and associated with decreased survival rates and higher risk o
{"title":"Hypokalemia in Peritoneal Dialysis: A Systematic Review and Meta-analysis of Prevalence, Treatment, and Outcomes","authors":"Changyuan Yang , Xiaoxuan Hu , Xitao Ling , Cuixia Xiao , Ruolan Duan , Jiamei Qiu , Qin Li , Xindong Qin , Jiahao Zeng , La Zhang , Haijing Hou , Yu Peng , Yuan Xu , Jingxu Su , Xusheng Liu , Bengt Lindholm , David W. Johnson , Fuhua Lu , Guobin Su","doi":"10.1016/j.xkme.2024.100923","DOIUrl":"10.1016/j.xkme.2024.100923","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>Hypokalemia is common and potentially life-threatening in patients undergoing peritoneal dialysis (PD). However, the current literature has produced varying results. This study aimed to evaluate the prevalence and adverse outcomes of hypokalemia and the role of potassium supplementation in patients receiving PD.</div></div><div><h3>Study Design</h3><div>Systematic review and meta-analysis of randomized controlled trials and observational studies.</div></div><div><h3>Setting & Study Populations</h3><div>Adults receiving maintenance PD.</div></div><div><h3>Selection Criteria for Studies</h3><div>Studies that investigated the prevalence and adverse outcomes of hypokalemia and the effect of potassium supplementation.</div></div><div><h3>Data Extraction</h3><div>Two independent reviewers evaluated studies for eligibility and extracted relevant data.</div></div><div><h3>Analytical Approach</h3><div>Random effects meta-analysis was conducted to pool hazard ratios (HRs) and 95% CIs for the outcomes of interest. The certainty of findings was rated according to the Grading of Recommendations Assessment, Development and Evaluation criteria.</div></div><div><h3>Results</h3><div>Of 3,632 reports identified, 24 studies involving 60,313 participants met the inclusion criteria. The prevalence of hypokalemia was 37.9% (95% CI, 27.2%-52.7%), 17.7% (95% CI, 12.0%-25.9%), and 4.4% (95% CI, 1.9%-10.2%) in patients with potassium level<!--> <!--><4.0, 3.5, and 3.0<!--> <!-->mmol/L, respectively. Hypokalemia, according to the study’s definition, was associated with increased risks of all-cause mortality (HR, 1.49; 95% CI, 1.18-1.89), cardiovascular mortality (HR, 1.50; 95% CI, 1.19-1.88), and PD-associated peritonitis (HR, 1.42; 95% CI, 1.17-1.73). These associations were consistent but with low to very low certainty. The effect of correcting hypokalemia with potassium supplementation in patients undergoing PD remains uncertain.</div></div><div><h3>Limitations</h3><div>Heterogeneity persisted across most of the examined subgroups, and observational studies preclude causation.</div></div><div><h3>Conclusions</h3><div>Hypokalemia is common and portends poorer survival and a higher risk of peritonitis among patients undergoing PD. Further research into the optimal prevention and treatment strategies for hypokalemia is warranted to improve outcomes.</div></div><div><h3>Registration</h3><div>Registered at PROSPERO with registration number CRD42022358236.</div></div><div><h3>Plain-Language Summary</h3><div>Hypokalemia is common and can be fatal in patients undergoing peritoneal dialysis (PD). The reported prevalence of hypokalemia in patients undergoing PD varies significantly across studies, and there is inconsistency regarding the relationship between hypokalemia and adverse outcomes. This systematic review and meta-analysis showed that hypokalemia is prevalent and associated with decreased survival rates and higher risk o","PeriodicalId":17885,"journal":{"name":"Kidney Medicine","volume":"6 12","pages":"Article 100923"},"PeriodicalIF":3.2,"publicationDate":"2024-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142703304","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.2024.100917
Cameron E. Comrie , Katherine He , Jolene Wong , Anil K. Chandraker , Naoka Murakami , Joshua R. Lakin , Amanda J. Reich
<div><h3>Rationale & Objective</h3><div>Nearly half of kidney transplant recipients develop allograft failure within 10 years of transplantation and experience high mortality, significant symptom burden, and complex communication challenges. These patients may benefit from palliative care, but palliative care is infrequently provided in this population. This study explores palliative care perceptions and needs among patients with poorly functioning and declining kidney allografts.</div></div><div><h3>Study Design</h3><div>A qualitative study using semistructured interviews.</div></div><div><h3>Setting & Participants</h3><div>Adult kidney transplant recipients with a glomerular filtration rate of<!--> <!--><20<!--> <!-->mL/min/1.73m<sup>2</sup> followed at a single transplant center were interviewed from April 2022 to November 2022.</div></div><div><h3>Analytical Approach</h3><div>An interdisciplinary team, including nephrology, palliative care, and surgery, conducted a thematic analysis.</div></div><div><h3>Results</h3><div>Twelve participants (3 women, 9 men; 9 White, 2 Black, and 1 Hispanic patient) were interviewed. The median age of participants was 59 (IQR 48-73). At 6 months postinterview, 7 participants had resumed dialysis, 1 participant had been retransplanted, and 1 participant was deceased. Most participants had not heard of palliative care and those who had equated it with end-of-life care. Participants reported that emotional distress, particularly pervasive concern about the worsening of their kidney disease, was their most significant priority related to unmet palliative care needs. They also desired more discussion with their care team about future quality of life and lifespan. Participants described high trust in their transplant teams, suggesting that palliative care integration with these teams would be well-received.</div></div><div><h3>Limitations</h3><div>Limitations include recruitment from a single institution, lack of subject familiarity with palliative care, and limited racial and ethnic diversity among participants.</div></div><div><h3>Conclusions</h3><div>Patients with declining kidney allografts have heterogeneous, unmet palliative care needs, including emotional symptoms and a desire for better prognostic awareness. Our results suggest that patients are largely unaware of palliative care and may benefit from practice models in which transplant teams integrate palliative care education and timely palliative care engagement.</div></div><div><h3>Plain-Language Summary</h3><div>Nearly half of patients with kidney transplants experience failure of their transplant within a decade, leading to high mortality, significant symptoms, and communication challenges. Palliative care can help address these issues but is not frequently provided to these patients. We interviewed 12 patients whose kidney transplants were no longer working well to understand their perspectives on palliative care and palliative care needs. Mo
{"title":"Perceptions of Palliative Care Among Patients With Kidney Allograft Dysfunction: A Qualitative Study","authors":"Cameron E. Comrie , Katherine He , Jolene Wong , Anil K. Chandraker , Naoka Murakami , Joshua R. Lakin , Amanda J. Reich","doi":"10.1016/j.xkme.2024.100917","DOIUrl":"10.1016/j.xkme.2024.100917","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>Nearly half of kidney transplant recipients develop allograft failure within 10 years of transplantation and experience high mortality, significant symptom burden, and complex communication challenges. These patients may benefit from palliative care, but palliative care is infrequently provided in this population. This study explores palliative care perceptions and needs among patients with poorly functioning and declining kidney allografts.</div></div><div><h3>Study Design</h3><div>A qualitative study using semistructured interviews.</div></div><div><h3>Setting & Participants</h3><div>Adult kidney transplant recipients with a glomerular filtration rate of<!--> <!--><20<!--> <!-->mL/min/1.73m<sup>2</sup> followed at a single transplant center were interviewed from April 2022 to November 2022.</div></div><div><h3>Analytical Approach</h3><div>An interdisciplinary team, including nephrology, palliative care, and surgery, conducted a thematic analysis.</div></div><div><h3>Results</h3><div>Twelve participants (3 women, 9 men; 9 White, 2 Black, and 1 Hispanic patient) were interviewed. The median age of participants was 59 (IQR 48-73). At 6 months postinterview, 7 participants had resumed dialysis, 1 participant had been retransplanted, and 1 participant was deceased. Most participants had not heard of palliative care and those who had equated it with end-of-life care. Participants reported that emotional distress, particularly pervasive concern about the worsening of their kidney disease, was their most significant priority related to unmet palliative care needs. They also desired more discussion with their care team about future quality of life and lifespan. Participants described high trust in their transplant teams, suggesting that palliative care integration with these teams would be well-received.</div></div><div><h3>Limitations</h3><div>Limitations include recruitment from a single institution, lack of subject familiarity with palliative care, and limited racial and ethnic diversity among participants.</div></div><div><h3>Conclusions</h3><div>Patients with declining kidney allografts have heterogeneous, unmet palliative care needs, including emotional symptoms and a desire for better prognostic awareness. Our results suggest that patients are largely unaware of palliative care and may benefit from practice models in which transplant teams integrate palliative care education and timely palliative care engagement.</div></div><div><h3>Plain-Language Summary</h3><div>Nearly half of patients with kidney transplants experience failure of their transplant within a decade, leading to high mortality, significant symptoms, and communication challenges. Palliative care can help address these issues but is not frequently provided to these patients. We interviewed 12 patients whose kidney transplants were no longer working well to understand their perspectives on palliative care and palliative care needs. Mo","PeriodicalId":17885,"journal":{"name":"Kidney Medicine","volume":"6 12","pages":"Article 100917"},"PeriodicalIF":3.2,"publicationDate":"2024-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142703324","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.2024.100921
Teresa K. Chen , Aditya L. Surapaneni , Insa M. Schmidt , Sushrut S. Waikar , Josef Coresh , Hongbo Liu , Katalin Susztak , Eugene P. Rhee , Celina Liu , Pascal Schlosser , Morgan E. Grams
<div><h3>Rationale & Objective</h3><div>Individuals with chronic kidney disease (CKD) are at increased risk of morbidity and mortality, particularly as they progress to kidney failure. Identifying circulating proteins that underlie kidney failure development may guide the discovery of new targets for intervention.</div></div><div><h3>Study Design</h3><div>Prospective cohort.</div></div><div><h3>Setting & Participants</h3><div>703 African American Study of Kidney Disease and Hypertension (AASK) and 434 Boston Kidney Biopsy Cohort (BKBC) participants with baseline proteomics data.</div></div><div><h3>Exposures</h3><div>Circulating proteins measured using SomaScan.</div></div><div><h3>Outcomes</h3><div>Kidney failure, defined as dialysis initiation or kidney transplantation.</div></div><div><h3>Analytical Approach</h3><div>Using adjusted Cox models, we studied associations of 6,284 circulating proteins with kidney failure risk separately in AASK and BKBC and meta-analyzed results. We then performed gene set enrichment analyses to identify underlying perturbations in biological pathways. In separate data sets with kidney-tissue level gene expression, we ascertained dominant regions of expression and correlated kidney tubular gene expression with fibrosis and estimated glomerular filtration rate (eGFR).</div></div><div><h3>Results</h3><div>Over median follow-up periods of 8.8 and 3.1 years, 210 AASK (mean age: 55 years, 39% female, mean GFR: 46<!--> <!-->mL/min/1.73<!--> <!-->m<sup>2</sup>) and 115 BKBC (mean age: 54 years, 47% female, mean eGFR: 51<!--> <!-->mL/min/1.73<!--> <!-->m<sup>2</sup>) participants developed kidney failure, respectively. We identified 143 proteins that were associated with incident kidney failure, of which only 1 (Testican-2) had a lower risk. Notable proteins included those related to vascular permeability (endothelial cell-selective adhesion molecule), glomerulosclerosis (ephrin-A1), glomerular development (ephrin-B2), intracellular sorting/transport (vesicular integral-membrane protein VIP36), podocyte effacement (pigment epithelium-derived factor), complement activation (complement decay-accelerating factor), and fibrosis (ephrin-A1, ephrin-B2, and pigment epithelium-derived factor). Gene set enrichment analyses detected overrepresented pathways that could be related to CKD progression, such as ephrin signaling, cell-cell junctions, intracellular transport, immune response, cell proliferation, and apoptosis. At the kidney level, glomerular expression predominated for genes corresponding to circulating proteins of interest, and several gene expression levels were correlated with eGFR and/or fibrosis.</div></div><div><h3>Limitations</h3><div>Possible residual confounding.</div></div><div><h3>Conclusions</h3><div>Multimodal data identified proteins and pathways associated with the development of kidney failure.</div></div><div><h3>Plain-Language Summary</h3><div>Circulating proteins that underlie the development of
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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。
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