Pub Date : 2025-11-01DOI: 10.1053/j.jrn.2025.05.006
Fabiola Martín-del-Campo PhD , Andrea Arriaga-Verduzco MSc , Ari Cisneros-Hernández MSc , Norma García-Galindo MSc , Francisco Gerardo Yanowsky-Escatell PhD , Leonardo Pazarín-Villaseñor PhD , Jorge Andrade-Sierra PhD
Objectives
This study explored the access, use, and acceptance of technological devices for nutritional counseling in patients with diabetic kidney disease (DKD) in a low socioeconomic setting.
Methods
In this cross-sectional study, 80 adult patients with DKD from an underserved population, attending the nephrology service of a tertiary-care teaching hospital were included. All patients had a clinical, nutritional, and biochemical evaluation; a direct questionnaire was applied to evaluate access and use of technological devices for nutritional counseling as well as their acceptance (knowledge and perception about benefits, barriers, needs, and easy to use).
Results
Eighty-seven percent of patients had access to a smartphone, whereas 20% and 6% to a computer and tablet, respectively; 40% use technological devices for health/nutrition search. Knowledge (1 [1-2]) and barriers (1.4 [1-1.8]) scores were low; scores for benefits (3.7 [3-4]), needs (4.4 [3.7-5]), and easy to use (4.2 [3.7-4.5]) were high. Higher perceptions of the benefits, needs, and willingness to receive nutritional counseling via telemedicine and lower barriers perception were associated with higher easy to use score.
Conclusions
Despite advanced age and low educational level, patients had good access to smartphones and perceived their possible benefits and need for nutritional counseling. Regardless of low knowledge, perception of barriers was very low. Telemedicine via smartphones may be a good option to improve nutritional knowledge and skills of patients with DKD.
{"title":"Technological Devices for Nutritional Counseling in Patients With Diabetic Kidney Disease","authors":"Fabiola Martín-del-Campo PhD , Andrea Arriaga-Verduzco MSc , Ari Cisneros-Hernández MSc , Norma García-Galindo MSc , Francisco Gerardo Yanowsky-Escatell PhD , Leonardo Pazarín-Villaseñor PhD , Jorge Andrade-Sierra PhD","doi":"10.1053/j.jrn.2025.05.006","DOIUrl":"10.1053/j.jrn.2025.05.006","url":null,"abstract":"<div><h3>Objectives</h3><div><span>This study explored the access, use, and acceptance of technological devices for nutritional counseling in patients with </span>diabetic kidney disease (DKD) in a low socioeconomic setting.</div></div><div><h3>Methods</h3><div><span>In this cross-sectional study, 80 adult patients with DKD from an underserved population, attending the </span>nephrology service of a tertiary-care teaching hospital were included. All patients had a clinical, nutritional, and biochemical evaluation; a direct questionnaire was applied to evaluate access and use of technological devices for nutritional counseling as well as their acceptance (knowledge and perception about benefits, barriers, needs, and easy to use).</div></div><div><h3>Results</h3><div>Eighty-seven percent of patients had access to a smartphone, whereas 20% and 6% to a computer and tablet, respectively; 40% use technological devices for health/nutrition search. Knowledge (1 [1-2]) and barriers (1.4 [1-1.8]) scores were low; scores for benefits (3.7 [3-4]), needs (4.4 [3.7-5]), and easy to use (4.2 [3.7-4.5]) were high. Higher perceptions of the benefits, needs, and willingness to receive nutritional counseling via telemedicine and lower barriers perception were associated with higher easy to use score.</div></div><div><h3>Conclusions</h3><div>Despite advanced age and low educational level, patients had good access to smartphones and perceived their possible benefits and need for nutritional counseling. Regardless of low knowledge, perception of barriers was very low. Telemedicine via smartphones may be a good option to improve nutritional knowledge and skills of patients with DKD.</div></div>","PeriodicalId":50066,"journal":{"name":"Journal of Renal Nutrition","volume":"35 6","pages":"Pages 734-740"},"PeriodicalIF":3.2,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144288075","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1053/j.jrn.2025.10.001
Linda W. Moore PhD, RDN, Giacomo Garibotto MD
{"title":"The Relentless Challenge of Dietary Salt Restriction for Hypertension and Kidney Disease","authors":"Linda W. Moore PhD, RDN, Giacomo Garibotto MD","doi":"10.1053/j.jrn.2025.10.001","DOIUrl":"10.1053/j.jrn.2025.10.001","url":null,"abstract":"","PeriodicalId":50066,"journal":{"name":"Journal of Renal Nutrition","volume":"35 6","pages":"Pages 697-699"},"PeriodicalIF":3.2,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145282486","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1053/j.jrn.2024.12.002
Seyedeh-Masomeh Derakhshandeh-Rishehri PhD , Luciana Peixoto Franco MS , Hermann Kalhoff MD , Stefan A. Wudy MD , Thomas Remer PhD
Objectives
Uromodulin is the most abundant urinary protein in healthy subjects, which under physiological conditions protects against kidney stone formation. Acid-base imbalances, especially states with acidic urine, increase the risk for uric acid and oxalate stones, but lower it for phosphate (PO4)-containing stones. Whether habitual high acid loads and high dietary phosphorus intake (P-In) themselves may influence plasma uromodulin concentrations in the long-term is not known.
Methods
We prospectively examined biomarker based on the associations of P-In and endogenous acid loads of 3-17-year-old healthy participants (n = 358) of the Dortmund Nutritional and Anthropometric Longitudinally Designed study (Dortmund, Germany), with their circulating uromodulin levels later in adulthood. Urinary (PO4)excretion, net acid excretion (NAE), potential renal acid load (uPRAL), and pH were analyzed in 24-hour urine samples repeatedly collected during growth. Circulating uromodulin was analyzed in adult fasting blood samples. Individual means of age- and sex-stratified standard deviation scores of growth- and nutritional biomarker-related parameters were calculated. Multilinear regression models adjusted for anthropometric, renal, and blood parameters were conducted to examine the prospective relationships of preadulthood urinary biomarkers with adult circulating uromodulin.
Results
Uromodulin associated inversely with NAE (Pfor-trend < .03) and positively with urinary pH (Pfor-trend = .05; lowest pH-quintile vs. highest quintile: P = .03), but not significantly with uPRAL and (PO4) excretion during growth.
Conclusions
The known increased urolithiasis risk associated with high endogenous acid production may be further augmented by a high NAE-related reduction of the stone-formation inhibitor uromodulin. Despite not observing a significant association with uPRAL, the potential of habitual low-PRAL diets to raise uromodulin needs to be further studied.
{"title":"Higher Renal Net Acid, but Not Higher Phosphate Excretion During Growth Associates With Lower Adult Circulating Uromodulin","authors":"Seyedeh-Masomeh Derakhshandeh-Rishehri PhD , Luciana Peixoto Franco MS , Hermann Kalhoff MD , Stefan A. Wudy MD , Thomas Remer PhD","doi":"10.1053/j.jrn.2024.12.002","DOIUrl":"10.1053/j.jrn.2024.12.002","url":null,"abstract":"<div><h3>Objectives</h3><div>Uromodulin is the most abundant urinary protein in healthy subjects, which under physiological conditions protects against kidney stone formation. Acid-base imbalances, especially states with acidic urine, increase the risk for uric acid and oxalate stones, but lower it for phosphate (PO<sub>4</sub>)-containing stones. Whether habitual high acid loads and high dietary phosphorus intake (P-In) themselves may influence plasma uromodulin concentrations in the long-term is not known.</div></div><div><h3>Methods</h3><div>We prospectively examined biomarker based on the associations of P-In and endogenous acid loads of 3-17-year-old healthy participants (n = 358) of the Dortmund Nutritional and Anthropometric Longitudinally Designed study (Dortmund, Germany), with their circulating uromodulin levels later in adulthood. Urinary (PO<sub>4</sub>)excretion, net acid excretion (NAE), potential renal acid load (uPRAL), and pH were analyzed in 24-hour urine samples repeatedly collected during growth. Circulating uromodulin was analyzed in adult fasting blood samples. Individual means of age- and sex-stratified standard deviation scores of growth- and nutritional biomarker-related parameters were calculated. Multilinear regression models adjusted for anthropometric, renal, and blood parameters were conducted to examine the prospective relationships of preadulthood urinary biomarkers with adult circulating uromodulin.</div></div><div><h3>Results</h3><div>Uromodulin associated inversely with NAE (<em>P</em><sub><em>for-trend</em></sub> < .03) and positively with urinary pH (<em>P</em><sub><em>for-trend</em></sub> = .05; lowest pH-quintile vs. highest quintile: <em>P</em> = .03), but not significantly with uPRAL and (PO<sub>4</sub>) excretion during growth.</div></div><div><h3>Conclusions</h3><div>The known increased urolithiasis risk associated with high endogenous acid production may be further augmented by a high NAE-related reduction of the stone-formation inhibitor uromodulin. Despite not observing a significant association with uPRAL, the potential of habitual low-PRAL diets to raise uromodulin needs to be further studied.</div></div>","PeriodicalId":50066,"journal":{"name":"Journal of Renal Nutrition","volume":"35 6","pages":"Pages 726-733"},"PeriodicalIF":3.2,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142808455","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1053/j.jrn.2025.06.005
Andrew Davenport MD
Objective
Kidney dialysis patients are at an increased risk of sarcopenia and mortality. Although there are many potential causes, the effect of chronic inflammation on changes in body composition in peritoneal dialysis (PD) over time was reviewed.
Methods
Changes in body composition were measured by multifrequency bioimpedance in PD outpatients attending routine clinic review with sustained normal or raised C reactive protein (CRP) concentrations, excluding patients with peritonitis, and other acute hospitalizations.
Results
Body composition was measured; median 12 (11-14) months apart in 427 PD outpatients (59.5% male, 37.2% diabetic), median dialysis vintage 12 months, 215 sustained normal CRP, and (≤5 mg/L) versus 212 sustained raised CRP (9 [6-19] mg/L). Body composition did not differ initially, but over time whereas there were no changes in fat mass, fat-free mass index remained stable in the normal CRP group (17.8 ± 2.3 vs 17.9 ± 2.4) but decreased in the raised CRP group (18.0 ± 2.6 vs 14.4 ± 2.6, P < .05), and over time serum albumin was lower in the raised CRP group (36.8 ± 4.7 vs 38.8 ± 4.0, P < .001). Estimated dietary protein intake declined over time in both groups but remained lower in the raised CRP group (0.83 ± 0.32 vs 0.87 ± 0.21 g/kg/day, P < .05). In a multivariable model, loss of lean body tissue was associated with persistently raised CRP (odds ratio 2.6, 95% confidence intervals 1.58-4.2, P < .001).
Conclusion
Sustained low-grade inflammation leads to a loss of lean body tissue in PD outpatients. Studies are required to determine whether treating the causes of, and reducing, low-grade inflammation results in prevention of lean tissue loss.
目的：肾透析患者发生肌肉减少症和死亡的风险增加。尽管有许多潜在的原因，慢性炎症对腹膜透析（PD）中身体成分随时间变化的影响进行了综述。方法：对C反应蛋白（CRP）浓度持续正常或升高的PD门诊患者（不包括腹膜炎和其他急性住院患者）进行常规临床复查，通过多频生物阻抗测量其体成分的变化。结果：测量体成分，427例PD门诊患者（59.5%为男性，37.2%为糖尿病患者）中位间隔12（11-14）个月，中位透析时间12个月；215例CRP维持正常（≤5mg /L）， 212例CRP升高（9 (6-19)mg/L）。身体组成最初没有差异，但随着时间的推移，脂肪量没有变化，无脂质量指数（FFMI）在正常CRP组保持稳定（17.8±2.3 vs 17.9±2.4），但在CRP升高组下降（18.0±2.6 vs 14.4±2.6）。结论：持续的低度炎症导致PD门诊患者瘦体组织的损失。需要进行研究来确定治疗病因和减少低度炎症是否能预防瘦组织的损失。
{"title":"The Effect of Low-grade Inflammation on Body Composition in Peritoneal Dialysis Patients","authors":"Andrew Davenport MD","doi":"10.1053/j.jrn.2025.06.005","DOIUrl":"10.1053/j.jrn.2025.06.005","url":null,"abstract":"<div><h3>Objective</h3><div>Kidney dialysis patients are at an increased risk of sarcopenia and mortality. Although there are many potential causes, the effect of chronic inflammation on changes in body composition in peritoneal dialysis (PD) over time was reviewed.</div></div><div><h3>Methods</h3><div>Changes in body composition were measured by multifrequency bioimpedance in PD outpatients attending routine clinic review with sustained normal or raised C reactive protein (CRP) concentrations, excluding patients with peritonitis, and other acute hospitalizations.</div></div><div><h3>Results</h3><div>Body composition was measured; median 12 (11-14) months apart in 427 PD outpatients (59.5% male, 37.2% diabetic), median dialysis vintage 12 months, 215 sustained normal CRP, and (≤5 mg/L) versus 212 sustained raised CRP (9 [6-19] mg/L). Body composition did not differ initially, but over time whereas there were no changes in fat mass, fat-free mass index remained stable in the normal CRP group (17.8 ± 2.3 vs 17.9 ± 2.4) but decreased in the raised CRP group (18.0 ± 2.6 vs 14.4 ± 2.6, <em>P</em> < .05), and over time serum albumin was lower in the raised CRP group (36.8 ± 4.7 vs 38.8 ± 4.0, <em>P</em> < .001). Estimated dietary protein intake declined over time in both groups but remained lower in the raised CRP group (0.83 ± 0.32 vs 0.87 ± 0.21 g/kg/day, <em>P</em> < .05). In a multivariable model, loss of lean body tissue was associated with persistently raised CRP (odds ratio 2.6, 95% confidence intervals 1.58-4.2, <em>P</em> < .001).</div></div><div><h3>Conclusion</h3><div>Sustained low-grade inflammation leads to a loss of lean body tissue in PD outpatients. Studies are required to determine whether treating the causes of, and reducing, low-grade inflammation results in prevention of lean tissue loss.</div></div>","PeriodicalId":50066,"journal":{"name":"Journal of Renal Nutrition","volume":"35 6","pages":"Pages 787-794"},"PeriodicalIF":3.2,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144532778","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1053/j.jrn.2025.06.007
Yinhui Li MD, Baoling Liu MD, Liqian Dong MD, Heng Sang BD, Ni Kang BD
Objectives
This study aimed to assess the knowledge, attitude, and practice (KAP) of patients with chronic kidney disease (CKD) and their spouses toward low-salt diets.
Methods
This cross-sectional study enrolled patients with CKD and their spouses at the outpatient nephrology clinic of our hospital between September 2023 and February 2024.
Results
The study enrolled 443 patients and 499 spouses of patients. The mean KAP scores for patients were 13.64 ± 3.1, 35.19 ± 5.98, and 29.44 ± 7.58, respectively. Spouses of patients had mean scores of 14.39 ± 3.22, 31.66 ± 4.70, and 30.56 ± 6.52, respectively. Path analysis demonstrated that among patients, education, duration of CKD, and income had direct effects on knowledge. Knowledge, gender, marital status, duration of CKD, and residence had direct effects on attitude. Knowledge, attitude, education, CKD stage, employment, and type of medical insurance had direct effects on practice. For the spouses, duration of CKD had direct effect on knowledge; knowledge, residence, and education had direct effects on attitude; knowledge, attitude, residence, education, employment, CKD stage, and dialysis had direct effects on practice.
Conclusion
Both patients with CKD and their spouses demonstrated sufficient knowledge, positive attitude, and proactive practice toward low-salt diets. Clinicians should emphasize education and support programs targeting patients and their spouses to reinforce positive attitude and encourage sustained adherence to low-salt diets, particularly focusing on socioeconomic factors influencing KAP.
{"title":"Knowledge, Attitude, and Practice Toward Low-Salt Diets Among Patients With Chronic Kidney Disease and Their Spouses: A Cross-Sectional Study","authors":"Yinhui Li MD, Baoling Liu MD, Liqian Dong MD, Heng Sang BD, Ni Kang BD","doi":"10.1053/j.jrn.2025.06.007","DOIUrl":"10.1053/j.jrn.2025.06.007","url":null,"abstract":"<div><h3>Objectives</h3><div>This study aimed to assess the knowledge, attitude, and practice (KAP) of patients with chronic kidney disease (CKD) and their spouses toward low-salt diets.</div></div><div><h3>Methods</h3><div>This cross-sectional study enrolled patients with CKD and their spouses at the outpatient nephrology clinic of our hospital between September 2023 and February 2024.</div></div><div><h3>Results</h3><div>The study enrolled 443 patients and 499 spouses of patients. The mean KAP scores for patients were 13.64 ± 3.1, 35.19 ± 5.98, and 29.44 ± 7.58, respectively. Spouses of patients had mean scores of 14.39 ± 3.22, 31.66 ± 4.70, and 30.56 ± 6.52, respectively. Path analysis demonstrated that among patients, education, duration of CKD, and income had direct effects on knowledge. Knowledge, gender, marital status, duration of CKD, and residence had direct effects on attitude. Knowledge, attitude, education, CKD stage, employment, and type of medical insurance had direct effects on practice. For the spouses, duration of CKD had direct effect on knowledge; knowledge, residence, and education had direct effects on attitude; knowledge, attitude, residence, education, employment, CKD stage, and dialysis had direct effects on practice.</div></div><div><h3>Conclusion</h3><div>Both patients with CKD and their spouses demonstrated sufficient knowledge, positive attitude, and proactive practice toward low-salt diets. Clinicians should emphasize education and support programs targeting patients and their spouses to reinforce positive attitude and encourage sustained adherence to low-salt diets, particularly focusing on socioeconomic factors influencing KAP.</div></div>","PeriodicalId":50066,"journal":{"name":"Journal of Renal Nutrition","volume":"35 6","pages":"Pages 700-707"},"PeriodicalIF":3.2,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144532760","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1053/j.jrn.2025.06.004
Diana S. Kalantar BS , Rina Takahashi MD, PhD , Jenny I. Shen MD , Diana Tran MPH , Adnan Ismail BS , Erika Lopez Pena BS , Mayara Abichequer-Beer RD , Fridtjof Thomas PhD , Jun Ling Lu MD , Keiichi Sumida MD , Kamyar Kalantar-Zadeh MD, MPH, PhD , Csaba P. Kovesdy MD , Connie M. Rhee MD, MSc
Objectives
Gastrointestinal symptoms can significantly impact patients' nutritional status. Effective management using antiemetics is crucial for maintaining adequate nutrition. However, the effect of antiemetics on long-term renal function remains unclear. This study aimed to examine the association of antiemetics with the incident chronic kidney disease (CKD) in patients with normal renal function.
Methods
In a historical cohort study involving 323,970 US Veterans with normal estimated glomerular filtration rate, we identified 13,154 Veterans initiating antiemetics. The Cox proportional hazards model adjusted for demographics, major comorbidities, and laboratory measurements was used to estimate the relationship between antiemetics and the incident CKD, defined as estimated glomerular filtration rate <60 mL/min/1.73 m2 on two occasions, separated by ≥ 90 days. Propensity score (PS) matching and PS overlap weighting were also performed.
Results
The mean age of nonusers and users of antiemetics was 64.1 ± 14.2 and 62.1 ± 12.9 years. Antiemetic users were more likely to be female, smokers, and had a higher prevalence of comorbidities. Antiemetic use was associated with an increased risk of incident CKD across various models: unmatched adjusted (hazard ratio [HR] 1.26; 95% confidence interval [CI] 1.22-1.31), PS matched (HR 1.22; 95% CI 1.17-1.28), and PS overlap weighting (HR 1.28; 95% CI 1.18-1.46).
Conclusions
Antiemetic use is associated with a higher risk of incident CKD in individuals without preexisting kidney disease. This association appears robust across different analytical models. While antiemetics are essential for managing gastrointestinal symptoms—potentially improving nutritional status—the results underscore the necessity for careful monitoring of renal function in patients prescribed antiemetics.
目的：胃肠道症状可显著影响患者的营养状况。使用止吐药的有效管理对于维持足够的营养至关重要。然而，止吐药对长期肾功能的影响尚不清楚。本研究旨在探讨止吐药与肾功能正常的慢性肾脏疾病（CKD）发生的关系。方法：在一项涉及323,970名肾小球滤过率（eGFR）正常的美国退伍军人的历史队列研究中，我们确定了13,154名退伍军人服用止吐药。采用Cox比例风险模型对人口统计学、主要合并症和实验室测量进行调整，以估计止吐药与CKD事件之间的关系，两次定义为eGFR 2，间隔≥90天。倾向得分（PS）匹配和PS重叠加权。结果：未使用止吐药和使用止吐药的平均年龄分别为64.1±14.2岁和62.1±12.9岁。止吐药使用者更有可能是女性、吸烟者，并且有更高的合并症患病率。在各种模型中，止吐药的使用与CKD发生风险增加相关：未匹配调整(风险比[HR] 1.26；95%可信区间[CI] 1.22-1.31)， PS匹配(HR 1.22；95% CI 1.17-1.28)， PS重叠加权(HR 1.28；95% ci 1.18-1.46)。结论：止吐药的使用与先前没有肾脏疾病的个体发生CKD的高风险相关。这种关联似乎在不同的分析模型中都很强大。虽然止吐药对控制胃肠道症状至关重要——可能改善营养状况——但结果强调了在服用止吐药的患者中仔细监测肾功能的必要性。
{"title":"The Association of Antiemetics Use With Incident Chronic Kidney Disease","authors":"Diana S. Kalantar BS , Rina Takahashi MD, PhD , Jenny I. Shen MD , Diana Tran MPH , Adnan Ismail BS , Erika Lopez Pena BS , Mayara Abichequer-Beer RD , Fridtjof Thomas PhD , Jun Ling Lu MD , Keiichi Sumida MD , Kamyar Kalantar-Zadeh MD, MPH, PhD , Csaba P. Kovesdy MD , Connie M. Rhee MD, MSc","doi":"10.1053/j.jrn.2025.06.004","DOIUrl":"10.1053/j.jrn.2025.06.004","url":null,"abstract":"<div><h3>Objectives</h3><div>Gastrointestinal symptoms can significantly impact patients' nutritional status. Effective management using antiemetics is crucial for maintaining adequate nutrition. However, the effect of antiemetics on long-term renal function remains unclear. This study aimed to examine the association of antiemetics with the incident chronic kidney disease (CKD) in patients with normal renal function.</div></div><div><h3>Methods</h3><div>In a historical cohort study involving 323,970 US Veterans with normal estimated glomerular filtration rate, we identified 13,154 Veterans initiating antiemetics. The Cox proportional hazards model adjusted for demographics, major comorbidities, and laboratory measurements was used to estimate the relationship between antiemetics and the incident CKD, defined as estimated glomerular filtration rate <60 mL/min/1.73 m<sup>2</sup> on two occasions, separated by ≥ 90 days. Propensity score (PS) matching and PS overlap weighting were also performed.</div></div><div><h3>Results</h3><div>The mean age of nonusers and users of antiemetics was 64.1 ± 14.2 and 62.1 ± 12.9 years. Antiemetic users were more likely to be female, smokers, and had a higher prevalence of comorbidities. Antiemetic use was associated with an increased risk of incident CKD across various models: unmatched adjusted (hazard ratio [HR] 1.26; 95% confidence interval [CI] 1.22-1.31), PS matched (HR 1.22; 95% CI 1.17-1.28), and PS overlap weighting (HR 1.28; 95% CI 1.18-1.46).</div></div><div><h3>Conclusions</h3><div>Antiemetic use is associated with a higher risk of incident CKD in individuals without preexisting kidney disease. This association appears robust across different analytical models. While antiemetics are essential for managing gastrointestinal symptoms—potentially improving nutritional status—the results underscore the necessity for careful monitoring of renal function in patients prescribed antiemetics.</div></div>","PeriodicalId":50066,"journal":{"name":"Journal of Renal Nutrition","volume":"35 6","pages":"Pages 749-755"},"PeriodicalIF":3.2,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144532762","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1053/j.jrn.2025.07.007
Andrea C. Sczip MSc , Jyana G. Morais PhD , Adaiane Calegari MSc , Tatiana S. Kruger , Jorgiane C. Oliveira , Natália K. Scatone MSc , Rafaela G. dos Santos , Fellype C. Barreto MD, PhD , Fabiana B. Nerbass PhD
Objective
We aimed to investigate the role of dietary diversity of unprocessed and minimally processed foods and the intake of ultraprocessed foods (UPFs), along with their respective phosphorus source subgroups, in hyperphosphatemia among patients on chronic hemodialysis.
Methods
This is a secondary analysis of a multicenter cross-sectional study conducted in seven dialysis units in Southern Brazil. Two validated questionnaires were used: a dietary diversity questionnaire to assess the intake of unprocessed and minimally processed foods, and a UPFs consumption questionnaire to evaluate the intake of UPFs. Dietary intake was assessed on 2 separate days—1 dialysis day and 1 nondialysis day. From these instruments, scores were calculated for overall dietary diversity, total UPFs consumption, and phosphorus sources subgroups.
Results
A total of 297 patients participated (age: 52.1 ± 14.1 years; 57.9% men; 42% with hyperphosphatemia). While unprocessed and minimally processed phosphorus sources were more commonly consumed, multivariate analysis revealed that UPFs, particularly those from animal-based sources, were independently associated with hyperphosphatemia. Each one-point increase in intake of UPFs scores corresponded to an increased likelihood of hyperphosphatemia: 25% for total UPF, 76% for animal-based UPFs, and 24% for other UPF sources.
Conclusion
Our findings indicate that although phosphorus sources from UPFs were consumed less frequently than those from unprocessed and minimally processed foods, consumption of UPFs—especially those from animal-based sources—was an independent determinant of hyperphosphatemia. These results highlight the need for dietary interventions that prioritize healthy food choices in the management of hyperphosphatemia.
{"title":"Hyperphosphatemia in Patients on Hemodialysis May be Driven by the Consumption of Ultraprocessed Foods","authors":"Andrea C. Sczip MSc , Jyana G. Morais PhD , Adaiane Calegari MSc , Tatiana S. Kruger , Jorgiane C. Oliveira , Natália K. Scatone MSc , Rafaela G. dos Santos , Fellype C. Barreto MD, PhD , Fabiana B. Nerbass PhD","doi":"10.1053/j.jrn.2025.07.007","DOIUrl":"10.1053/j.jrn.2025.07.007","url":null,"abstract":"<div><h3>Objective</h3><div>We aimed to investigate the role of dietary diversity of unprocessed and minimally processed foods and the intake of ultraprocessed foods (UPFs), along with their respective phosphorus source subgroups, in hyperphosphatemia among patients on chronic hemodialysis.</div></div><div><h3>Methods</h3><div>This is a secondary analysis of a multicenter cross-sectional study conducted in seven dialysis units in Southern Brazil. Two validated questionnaires were used: a dietary diversity questionnaire to assess the intake of unprocessed and minimally processed foods, and a UPFs consumption questionnaire to evaluate the intake of UPFs. Dietary intake was assessed on 2 separate days—1 dialysis day and 1 nondialysis day. From these instruments, scores were calculated for overall dietary diversity, total UPFs consumption, and phosphorus sources subgroups.</div></div><div><h3>Results</h3><div>A total of 297 patients participated (age: 52.1 ± 14.1 years; 57.9% men; 42% with hyperphosphatemia). While unprocessed and minimally processed phosphorus sources were more commonly consumed, multivariate analysis revealed that UPFs, particularly those from animal-based sources, were independently associated with hyperphosphatemia. Each one-point increase in intake of UPFs scores corresponded to an increased likelihood of hyperphosphatemia: 25% for total UPF, 76% for animal-based UPFs, and 24% for other UPF sources.</div></div><div><h3>Conclusion</h3><div>Our findings indicate that although phosphorus sources from UPFs were consumed less frequently than those from unprocessed and minimally processed foods, consumption of UPFs—especially those from animal-based sources—was an independent determinant of hyperphosphatemia. These results highlight the need for dietary interventions that prioritize healthy food choices in the management of hyperphosphatemia.</div></div>","PeriodicalId":50066,"journal":{"name":"Journal of Renal Nutrition","volume":"35 6","pages":"Pages 780-786"},"PeriodicalIF":3.2,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144700947","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1053/j.jrn.2024.09.004
Miriam Menacho-Roman BSc , Martin Fabregate-Fuente BSc , Laura Caja-Guayerbas BSc , Sergio Jiménez-Sánchez BSc , Javier Soto BSc , Ignacio Arribas-Gómez PhD, MD
Introduction
The measurement of urinary sodium excretion provides valuable information about an individual's sodium balance and can help in the management of various medical conditions. However, the collection of 24-hour urine samples is subject to errors. Spot urine sodium (uNa) measurements are a reliable alternative to 24-hour urine collections for estimating urinary sodium excretion.
Objective
To assess whether 24-h urinary sodium excretion (24 h uNa) can be estimated from spot samples in adult patients who attend hospital clinics.
Design and Methods
A cross-sectional study with a development (284 patients) and a validation cohort (229 patients) was conducted at our hospital. A multivariate linear regression model was built which was compared with former models. Concordance analyses and comparison of the ability to correctly classify each patient against a prespecified uNa cutoff value of 130 mmol/24 h were performed, assessed by the C-statistic.
Results
The model was well calibrated (slope [95% confidence interval] in internal validation: 0.965 [0.947-0.987], showing good discrimination, and performed robustly in an external validation cohort (slope: 0.811 [0.675-0.946]). The mean bias between the measured and the estimated 24 h uNa by NaRYC was 24.85 mmol/24 h [17.06-32.63]. The NaRYC had the highest values of Pearson coefficient (0.613 P < .0001), accuracy (the percentage of estimated 24 h uNa results within 30% deviation of measured 24 h uNa): 56.8%, and area under the receiver operating characteristic curve: 0.822 [0.766-0.869] as compared to other seven equations.
Conclusion
Although the mean bias of the results is quite acceptable, the variability observed in the 95% confidence interval makes not recommend the general use of a spot as a substitute of the 24-hour urine in order to estimate the total urine excretion of Na in a single subject basis.
{"title":"Development and Validation of a Prediction Model for Estimating 24-Hour Urinary Sodium Excretion Using Spot Urine Samples in Adult Patients","authors":"Miriam Menacho-Roman BSc , Martin Fabregate-Fuente BSc , Laura Caja-Guayerbas BSc , Sergio Jiménez-Sánchez BSc , Javier Soto BSc , Ignacio Arribas-Gómez PhD, MD","doi":"10.1053/j.jrn.2024.09.004","DOIUrl":"10.1053/j.jrn.2024.09.004","url":null,"abstract":"<div><h3>Introduction</h3><div>The measurement of urinary<span><span><span> sodium excretion provides valuable information about an individual's sodium balance and can help in the management of various medical conditions. However, the collection of 24-hour urine samples is subject to errors. Spot </span>urine sodium (uNa) measurements are a reliable alternative to 24-hour urine collections for estimating </span>urinary sodium excretion.</span></div></div><div><h3>Objective</h3><div>To assess whether 24-h urinary sodium excretion (24 h uNa) can be estimated from spot samples in adult patients who attend hospital clinics.</div></div><div><h3>Design and Methods</h3><div>A cross-sectional study with a development (284 patients) and a validation cohort (229 patients) was conducted at our hospital. A multivariate linear regression model was built which was compared with former models. Concordance analyses and comparison of the ability to correctly classify each patient against a prespecified uNa cutoff value of 130 mmol/24 h were performed, assessed by the C-statistic.</div></div><div><h3>Results</h3><div>The model was well calibrated (slope [95% confidence interval] in internal validation: 0.965 [0.947-0.987], showing good discrimination, and performed robustly in an external validation cohort (slope: 0.811 [0.675-0.946]). The mean bias between the measured and the estimated 24 h uNa by NaRYC was 24.85 mmol/24 h [17.06-32.63]. The NaRYC had the highest values of Pearson coefficient (0.613 <em>P</em> < .0001), accuracy (the percentage of estimated 24 h uNa results within 30% deviation of measured 24 h uNa): 56.8%, and area under the receiver operating characteristic curve: 0.822 [0.766-0.869] as compared to other seven equations.</div></div><div><h3>Conclusion</h3><div>Although the mean bias of the results is quite acceptable, the variability observed in the 95% confidence interval makes not recommend the general use of a spot as a substitute of the 24-hour urine in order to estimate the total urine excretion of Na in a single subject basis.</div></div>","PeriodicalId":50066,"journal":{"name":"Journal of Renal Nutrition","volume":"35 6","pages":"Pages 756-763"},"PeriodicalIF":3.2,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142331379","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Limited studies exist on prevalence of Protein energy wasting (PEW) in children with chronic kidney disease. The study aimed to determine the prevalence of PEW in children aged 2-18 years with CKD stage 2-5D, compare various diagnostic criteria and describe clinical characteristics of children with PEW.
Methods
A cross-sectional study (September 2023 to February 2024) conducted at the pediatric nephrology services of a tertiary-care center investigated children aged 2-18 years diagnosed with CKD stages 2-5D for PEW. Demographic, clinical, biochemical details and growth parameters were recorded at enrollment. The study employed three 3 PEW definitions: minimal, standard, and modified. Descriptive statistics were performed using STATA 14.0.
Results
The study enrolled 150 children (79.4% boys) in CKD 2-5D with a median (interquartile range) age of 10.6 (7,13.1) years. Congenital anomalies of kidney and urinary tract were the most common etiology in 104 (69.4%) children. The median estimated glomerular filtration rate at enrollment was 23.2 (12.7, 40) mL/min/1.73 m2. Seventy (46.7%) children satisfied minimal PEW definition, 20 (13.3%) children met standard PEW definition, and 40 (27.3%) satisfied pediatric tailored modified PEW definition. There was an increasing prevalence of modified PEW with advancing CKD stage (P =.04). Among individual parameters contributing to diagnosis of PEW, reduced muscle mass was a consistent finding, while serum albumin, short stature, and reduced body mass varied with CKD severity (P < .05). Children with modified PEW were more likely to be severely wasted and/or severely underweight. Infection-related hospitalization rate was significantly higher in children with PEW (P = .008).
Conclusion
The prevalence of PEW ranged from 13.3% to 46.7% depending on the definition used. Importantly, the prevalence increased with advancing stages of CKD. Age-appropriate criteria, like anthropometry, are crucial and highlight the need for tailored nutritional assessment in children.
{"title":"Assessment of Protein Energy Wasting in Children With Chronic Kidney Disease: A Cross-Sectional Study","authors":"Mohammed Kaif K. Mulla MBBS, Bobbity Deepthi MD Pediatrics, Madhileti Sravani MD Pediatrics, FPN, Sudarsan Krishnasamy MD Pediatrics, DM Pediatric Nephrology, Sriram Krishnamurthy MD Pediatrics, FIPNA","doi":"10.1053/j.jrn.2025.06.009","DOIUrl":"10.1053/j.jrn.2025.06.009","url":null,"abstract":"<div><h3>Objectives</h3><div>Limited studies exist on prevalence of Protein energy wasting (PEW) in children with chronic kidney disease. The study aimed to determine the prevalence of PEW in children aged 2-18 years with CKD stage 2-5D, compare various diagnostic criteria and describe clinical characteristics of children with PEW.</div></div><div><h3>Methods</h3><div>A cross-sectional study (September 2023 to February 2024) conducted at the pediatric nephrology services of a tertiary-care center investigated children aged 2-18 years diagnosed with CKD stages 2-5D for PEW. Demographic, clinical, biochemical details and growth parameters were recorded at enrollment. The study employed three 3 PEW definitions: minimal, standard, and modified. Descriptive statistics were performed using STATA 14.0.</div></div><div><h3>Results</h3><div>The study enrolled 150 children (79.4% boys) in CKD 2-5D with a median (interquartile range) age of 10.6 (7,13.1) years. Congenital anomalies of kidney and urinary tract were the most common etiology in 104 (69.4%) children. The median estimated glomerular filtration rate at enrollment was 23.2 (12.7, 40) mL/min/1.73 m<sup>2</sup>. Seventy (46.7%) children satisfied minimal PEW definition, 20 (13.3%) children met standard PEW definition, and 40 (27.3%) satisfied pediatric tailored modified PEW definition. There was an increasing prevalence of modified PEW with advancing CKD stage (<em>P</em> =.04). Among individual parameters contributing to diagnosis of PEW, reduced muscle mass was a consistent finding, while serum albumin, short stature, and reduced body mass varied with CKD severity (<em>P</em> < .05). Children with modified PEW were more likely to be severely wasted and/or severely underweight. Infection-related hospitalization rate was significantly higher in children with PEW (<em>P</em> = .008).</div></div><div><h3>Conclusion</h3><div>The prevalence of PEW ranged from 13.3% to 46.7% depending on the definition used. Importantly, the prevalence increased with advancing stages of CKD. Age-appropriate criteria, like anthropometry, are crucial and highlight the need for tailored nutritional assessment in children.</div></div>","PeriodicalId":50066,"journal":{"name":"Journal of Renal Nutrition","volume":"35 6","pages":"Pages 718-725"},"PeriodicalIF":3.2,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144556527","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-01DOI: 10.1053/j.jrn.2025.07.006
Anum Akbar MBBS, PhD , Rebecca Drakowski PhD , Matthew VanOrmer PhD , Rebekah Rapoza BS , Taija Hahka MS , Colman Freel BS , Sathish Kumar Natarajan PhD , Melissa Thoene RD, PhD , Corrine Hanson RD, PhD , Ann Anderson-Berry MD, PhD , Teri Mauch MD, PhD
<div><h3>Objective</h3><div>Vitamin A (retinol) is essential for fetal organ development, with preclinical studies associating maternal vitamin A deficiency (VAD) with reduced nephron numbers, smaller kidneys, and higher chronic kidney disease risk later in life. However, similar findings in humans are limited, and no studies in Nebraska have examined maternal VAD's effect on fetal and infant kidney development, despite 10% of mothers being deficient at delivery. Additionally, the impact of provitamin A compounds (α-carotene, β-carotene, β-cryptoxanthin) on kidney size remains unexplored. This study addresses these gaps by analyzing maternal plasma retinol and provitamin A carotenoids' relationship with fetal and infant kidney sizes.</div></div><div><h3>Design and Methods</h3><div>An institutional review board–approved prospective cohort study enrolled 120 pregnant women in Nebraska prior to their anatomy scans (18-20 weeks of gestation). The high-performance liquid chromatography–tandem mass spectrometry evaluated the retinol and provitamin A carotenoid concentrations at 24-28 weeks of gestation (n = 79) and at delivery in maternal circulation (n = 79) and umbilical cord (n = 79). Ultrasounds were used to assess fetal kidney length, volume, and parenchymal thickness at 18-20 weeks and infant kidney measurements within 48-72 hours of birth. Spearman's correlation evaluated the relationship between maternal plasma levels and kidney sizes. Linear regression analysis was performed, adjusting for maternal hypertension, diabetes, and smoking status. A Kruskal–Wallis test was performed to examine kidney size differences across retinol adequate, insufficient, and deficient groups, and a <em>P</em> value of <0.05 was considered statistically significant.</div></div><div><h3>Results</h3><div>Ten percent of mothers (n = 8) and 19% of mothers (n = 15) had VAD during 24-28 weeks of gestation and at delivery, respectively. Maternal retinol at 24-28 weeks or at delivery was not associated with fetal or infant kidney size, and fetal kidney size did not differ between maternal retinol groups. However, maternal α- and β-carotene at 24-28 gestational weeks were significantly positively associated with fetal kidney lengths (right (R) kidney length with α-carotene: β = 0.279, <em>P</em> = .022, left (L) kidney length with α-carotene: β = 0.475, <em>P</em> < .001, L kidney length with β-carotene: β = 0.255, <em>P</em> = .029). Cord retinol was not associated with infant kidney size, nor did infant kidney size differ between cord retinol groups. In contrast cord α-carotene was significantly positively associated with infant kidney lengths (R kidney length: β = 0.178, <em>P</em> = .029, L kidney length: β = 0.168, <em>P</em> = .040). Lastly, the change in maternal plasma retinol from gestation to delivery was not associated with the change in fetal kidney size from gestation to birth. On the other hand, the changes in maternal α-carotene and β-carotene were signi
{"title":"Relationship Between Maternal Plasma Retinol and Provitamin A Carotenoids With Fetal and Infant Kidney Development: A Comprehensive Analysis","authors":"Anum Akbar MBBS, PhD , Rebecca Drakowski PhD , Matthew VanOrmer PhD , Rebekah Rapoza BS , Taija Hahka MS , Colman Freel BS , Sathish Kumar Natarajan PhD , Melissa Thoene RD, PhD , Corrine Hanson RD, PhD , Ann Anderson-Berry MD, PhD , Teri Mauch MD, PhD","doi":"10.1053/j.jrn.2025.07.006","DOIUrl":"10.1053/j.jrn.2025.07.006","url":null,"abstract":"<div><h3>Objective</h3><div>Vitamin A (retinol) is essential for fetal organ development, with preclinical studies associating maternal vitamin A deficiency (VAD) with reduced nephron numbers, smaller kidneys, and higher chronic kidney disease risk later in life. However, similar findings in humans are limited, and no studies in Nebraska have examined maternal VAD's effect on fetal and infant kidney development, despite 10% of mothers being deficient at delivery. Additionally, the impact of provitamin A compounds (α-carotene, β-carotene, β-cryptoxanthin) on kidney size remains unexplored. This study addresses these gaps by analyzing maternal plasma retinol and provitamin A carotenoids' relationship with fetal and infant kidney sizes.</div></div><div><h3>Design and Methods</h3><div>An institutional review board–approved prospective cohort study enrolled 120 pregnant women in Nebraska prior to their anatomy scans (18-20 weeks of gestation). The high-performance liquid chromatography–tandem mass spectrometry evaluated the retinol and provitamin A carotenoid concentrations at 24-28 weeks of gestation (n = 79) and at delivery in maternal circulation (n = 79) and umbilical cord (n = 79). Ultrasounds were used to assess fetal kidney length, volume, and parenchymal thickness at 18-20 weeks and infant kidney measurements within 48-72 hours of birth. Spearman's correlation evaluated the relationship between maternal plasma levels and kidney sizes. Linear regression analysis was performed, adjusting for maternal hypertension, diabetes, and smoking status. A Kruskal–Wallis test was performed to examine kidney size differences across retinol adequate, insufficient, and deficient groups, and a <em>P</em> value of <0.05 was considered statistically significant.</div></div><div><h3>Results</h3><div>Ten percent of mothers (n = 8) and 19% of mothers (n = 15) had VAD during 24-28 weeks of gestation and at delivery, respectively. Maternal retinol at 24-28 weeks or at delivery was not associated with fetal or infant kidney size, and fetal kidney size did not differ between maternal retinol groups. However, maternal α- and β-carotene at 24-28 gestational weeks were significantly positively associated with fetal kidney lengths (right (R) kidney length with α-carotene: β = 0.279, <em>P</em> = .022, left (L) kidney length with α-carotene: β = 0.475, <em>P</em> < .001, L kidney length with β-carotene: β = 0.255, <em>P</em> = .029). Cord retinol was not associated with infant kidney size, nor did infant kidney size differ between cord retinol groups. In contrast cord α-carotene was significantly positively associated with infant kidney lengths (R kidney length: β = 0.178, <em>P</em> = .029, L kidney length: β = 0.168, <em>P</em> = .040). Lastly, the change in maternal plasma retinol from gestation to delivery was not associated with the change in fetal kidney size from gestation to birth. On the other hand, the changes in maternal α-carotene and β-carotene were signi","PeriodicalId":50066,"journal":{"name":"Journal of Renal Nutrition","volume":"35 6","pages":"Pages 708-717"},"PeriodicalIF":3.2,"publicationDate":"2025-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144700948","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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