BACKGROUNDThe effectiveness of therapeutic drug monitoring (TDM) of mycophenolic acid (MPA) trough levels in children with steroid-dependent or frequently relapsing nephrotic syndrome (SDNS/FRNS) treated with mycophenolate mofetil (MMF) has not been adequately assessed.METHODSWe performed an international, retrospective study including children with SDNS/FRNS, treated with MMF as the first-line steroid-sparing agent, and a follow-up of more than six months. Patients were categorized into two groups: TDM, if MPA trough levels were monitored, and No-TDM, if not. In the TDM group, MMF doses were adjusted to maintain MPA trough levels of more than 3 µg/ml, unless toxicity occurred. The primary outcome was relapse-free survival.RESULTSA total of 167 patients were observed, 90 in the TDM and 77 in the No-TDM group. Relapse-free survival over the total follow-up was significantly longer in the TDM group (p=0.001, log-rank test) with an estimated relapse-free survival at six months of 73% for the TDM and 55% for the No-TDM group. After correcting for potential confounders, the association remained statistically significant (p<0.001). TDM patients also received lower doses of prednisone after MMF introduction. In the TDM group, children were more likely to modify their initial dose (90% vs 9%; p<0.001). While MMF dose was not associated with relapse (median 1186 vs 1298 mg/m2; p=0.14), MPA trough levels were significantly higher in children who did not relapse (4.0 vs 2.7 µg/ml, p=0.001). Among children maintaining mean MPA levels more than 2.9 µg/ml, relapse-free survival at 6 months was 86%. Reported side effects were similar in both groups.CONCLUSIONSMonitoring MPA trough levels was associated with an approximately 20% higher MMF effectiveness in maintaining remission at six months in children with SDNS/FRNS. Personalized MMF dosing, adjusted to maintain MPA levels more than 2.9 µg/ml, was both safe and effective. We recommend including MPA trough level monitoring in future studies comparing MMF with other steroid-sparing agents in SDNS/FRNS children.
背景：在接受霉酚酸酯（MMF）治疗的类固醇依赖或频繁复发肾病综合征（SDNS/FRNS）患儿中，治疗性药物监测（TDM）霉酚酸（MPA）谷底水平的有效性尚未得到充分评估。方法：我们进行了一项国际回顾性研究，包括SDNS/FRNS患儿，接受MMF作为一线类固醇保留剂治疗，随访超过6个月。患者分为两组：TDM组（如果监测MPA低谷水平）和non -TDM组（如果没有监测）。在TDM组中，调整MMF剂量以维持大于3µg/ml的MPA谷水平，除非发生毒性。主要终点为无复发生存期。结果共观察167例患者，其中TDM组90例，非TDM组77例。TDM组的无复发生存期比总随访期明显更长（p=0.001， log-rank检验），TDM组6个月无复发生存期估计为73%，无TDM组为55%。在校正了潜在的混杂因素后，相关性仍然具有统计学意义（p<0.001）。TDM患者在引入MMF后也接受了较低剂量的强的松治疗。在TDM组中，儿童更有可能修改初始剂量（90% vs 9%; p<0.001）。虽然MMF剂量与复发无关（中位1186 vs 1298 mg/m2， p=0.14），但未复发儿童的MPA低谷水平显著较高（4.0 vs 2.7µg/ml, p=0.001）。在平均MPA水平高于2.9 μ g/ml的儿童中，6个月无复发生存率为86%。两组报告的副作用相似。结论：监测MPA谷底水平与MMF维持SDNS/FRNS患儿6个月缓解的有效性提高约20%相关。调整个体化MMF剂量以维持大于2.9 μ g/ml的MPA水平，既安全又有效。我们建议在未来的研究中，比较MMF与其他类固醇保留剂对SDNS/FRNS儿童的影响时，纳入MPA槽水平监测。
{"title":"Effectiveness of Mycophenolate Mofetil Trough Level Monitoring in Children with Relapsing Nephrotic Syndrome.","authors":"William Morello,Silvia Bernardi,Giuseppe Puccio,Anita Bellotti,Evgenia Preka,Mathilde Grapin,Maud Prévot,Marina Charbit,Teresa Nittoli,Maurizio Gallieni,Luciana Ghio,Alberto Edefonti,Olivia Boyer,Giovanni Montini","doi":"10.2215/cjn.0000000824","DOIUrl":"https://doi.org/10.2215/cjn.0000000824","url":null,"abstract":"BACKGROUNDThe effectiveness of therapeutic drug monitoring (TDM) of mycophenolic acid (MPA) trough levels in children with steroid-dependent or frequently relapsing nephrotic syndrome (SDNS/FRNS) treated with mycophenolate mofetil (MMF) has not been adequately assessed.METHODSWe performed an international, retrospective study including children with SDNS/FRNS, treated with MMF as the first-line steroid-sparing agent, and a follow-up of more than six months. Patients were categorized into two groups: TDM, if MPA trough levels were monitored, and No-TDM, if not. In the TDM group, MMF doses were adjusted to maintain MPA trough levels of more than 3 µg/ml, unless toxicity occurred. The primary outcome was relapse-free survival.RESULTSA total of 167 patients were observed, 90 in the TDM and 77 in the No-TDM group. Relapse-free survival over the total follow-up was significantly longer in the TDM group (p=0.001, log-rank test) with an estimated relapse-free survival at six months of 73% for the TDM and 55% for the No-TDM group. After correcting for potential confounders, the association remained statistically significant (p<0.001). TDM patients also received lower doses of prednisone after MMF introduction. In the TDM group, children were more likely to modify their initial dose (90% vs 9%; p<0.001). While MMF dose was not associated with relapse (median 1186 vs 1298 mg/m2; p=0.14), MPA trough levels were significantly higher in children who did not relapse (4.0 vs 2.7 µg/ml, p=0.001). Among children maintaining mean MPA levels more than 2.9 µg/ml, relapse-free survival at 6 months was 86%. Reported side effects were similar in both groups.CONCLUSIONSMonitoring MPA trough levels was associated with an approximately 20% higher MMF effectiveness in maintaining remission at six months in children with SDNS/FRNS. Personalized MMF dosing, adjusted to maintain MPA levels more than 2.9 µg/ml, was both safe and effective. We recommend including MPA trough level monitoring in future studies comparing MMF with other steroid-sparing agents in SDNS/FRNS children.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"50 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145071859","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jeremy Puthumana,Justin M Belcher,Guadalupe Garcia-Tsao,Arun J Sanyal,Jesse C Seegmiller,Pranav S Garimella,Chirag R Parikh,Joachim H Ix
BACKGROUNDAcute kidney injury (AKI) is a common and severe complication among hospitalized patients with cirrhosis. The most common causes of AKI in cirrhosis are prerenal azotemia (PRA), hepatorenal syndrome (HRS), and acute tubular necrosis (ATN), and treatment depends upon its causes. Kidney proximal tubular secretion is an essential mechanism for elimination of many drugs and toxins and may be affected in AKI. We hypothesized that assessing secretion would help distinguish between structural tubular injury (ATN) and hemodynamic perturbations (PRA and HRS).METHODSWe collected paired plasma and spot urine specimens from 76 hospitalized patients with cirrhosis and AKI from four tertiary care centers in North America. A panel of endogenous metabolites known to be secreted was measured in blood and urine by tandem mass spectrometry, and a summary secretion score was calculated by averaging the standardized spot urine-to-plasma ratios of the endogenous secretion markers, with higher urine-to-plasma ratios reflecting greater tubular secretion. The summary secretion score was assessed for its ability to discriminate ATN from non-ATN.RESULTSAmong the 76 patients with cirrhosis and AKI, 39 (51%) had PRA, 13 (17%) had HRS, and 24 (32%) had ATN. Median secretion scores were significantly lower in ATN (50.3, 95% confidence intervals [CI] 42.2-61.2) compared with PRA (61.7, 95% CI 55.4-75.4) or HRS (62.5, 95% CI 55.6-66.5) (p=0.007). In models adjusted for clinical characteristics, baseline estimated glomerular filtration rate (eGFR), and Model for End Stage Liver Disease (MELD) score, higher summary secretion score was associated with lower odds of ATN (odds ratio per standard deviation higher secretion score: 0.34, 95% CI 0.15-0.67). The summary secretion score showed good discriminative ability in diagnosing ATN versus other causes of AKI (Area Under the Receiver Operating Curve 0.73, 95% CI 0.60-0.85).CONCLUSIONSIn patients with cirrhosis and AKI, substantially lower tubular secretion was observed among inpatients with ATN relative to those with PRA and HRS. These results support the use of tubular secretion for the differential diagnosis of AKI in cirrhosis and may have important therapeutic and prognostic implications.
背景：急性肾损伤（AKI）是肝硬化住院患者中一种常见且严重的并发症。肝硬化AKI最常见的原因是肾前氮质血症（PRA）、肝肾综合征（HRS）和急性肾小管坏死（ATN），治疗取决于其原因。肾近端小管分泌是消除许多药物和毒素的重要机制，并可能在AKI中受到影响。我们假设评估分泌将有助于区分结构性小管损伤（ATN）和血流动力学扰动（PRA和HRS）。方法：我们收集了来自北美4个三级医疗中心的76例肝硬化合并AKI住院患者的配对血浆和尿样。通过串联质谱法测量血液和尿液中已知分泌的内源性代谢物，并通过平均内源性分泌标记物的标准化点尿浆比来计算总分泌评分，较高的尿浆比反映了更多的小管分泌。总结分泌评分评估其区分ATN和非ATN的能力。结果76例肝硬化合并AKI患者中，39例（51%）有PRA， 13例（17%）有HRS， 24例（32%）有ATN。与PRA （61.7, 95% CI 55.4-75.4）或HRS （62.5, 95% CI 55.6-66.5）相比，ATN的中位分泌评分（50.3,95%可信区间[CI] 42.2-61.2）显著降低（p=0.007）。在调整了临床特征、基线估计肾小球滤过率（eGFR）和终末期肝病模型（MELD）评分的模型中，较高的总分泌评分与较低的ATN几率相关（每标准差较高的分泌评分的比值比：0.34,95% CI 0.15-0.67）。综合分泌评分在诊断ATN与其他原因AKI方面具有良好的鉴别能力（受试者工作曲线下面积0.73,95% CI 0.60-0.85）。结论在合并肝硬化和AKI的住院患者中，ATN患者的肾小管分泌明显低于PRA和HRS患者。这些结果支持将肾小管分泌用于肝硬化AKI的鉴别诊断，并可能具有重要的治疗和预后意义。
{"title":"Kidney Tubule Secretion Can Discriminate the Cause of Acute Kidney Injury in Cirrhosis.","authors":"Jeremy Puthumana,Justin M Belcher,Guadalupe Garcia-Tsao,Arun J Sanyal,Jesse C Seegmiller,Pranav S Garimella,Chirag R Parikh,Joachim H Ix","doi":"10.2215/cjn.0000000814","DOIUrl":"https://doi.org/10.2215/cjn.0000000814","url":null,"abstract":"BACKGROUNDAcute kidney injury (AKI) is a common and severe complication among hospitalized patients with cirrhosis. The most common causes of AKI in cirrhosis are prerenal azotemia (PRA), hepatorenal syndrome (HRS), and acute tubular necrosis (ATN), and treatment depends upon its causes. Kidney proximal tubular secretion is an essential mechanism for elimination of many drugs and toxins and may be affected in AKI. We hypothesized that assessing secretion would help distinguish between structural tubular injury (ATN) and hemodynamic perturbations (PRA and HRS).METHODSWe collected paired plasma and spot urine specimens from 76 hospitalized patients with cirrhosis and AKI from four tertiary care centers in North America. A panel of endogenous metabolites known to be secreted was measured in blood and urine by tandem mass spectrometry, and a summary secretion score was calculated by averaging the standardized spot urine-to-plasma ratios of the endogenous secretion markers, with higher urine-to-plasma ratios reflecting greater tubular secretion. The summary secretion score was assessed for its ability to discriminate ATN from non-ATN.RESULTSAmong the 76 patients with cirrhosis and AKI, 39 (51%) had PRA, 13 (17%) had HRS, and 24 (32%) had ATN. Median secretion scores were significantly lower in ATN (50.3, 95% confidence intervals [CI] 42.2-61.2) compared with PRA (61.7, 95% CI 55.4-75.4) or HRS (62.5, 95% CI 55.6-66.5) (p=0.007). In models adjusted for clinical characteristics, baseline estimated glomerular filtration rate (eGFR), and Model for End Stage Liver Disease (MELD) score, higher summary secretion score was associated with lower odds of ATN (odds ratio per standard deviation higher secretion score: 0.34, 95% CI 0.15-0.67). The summary secretion score showed good discriminative ability in diagnosing ATN versus other causes of AKI (Area Under the Receiver Operating Curve 0.73, 95% CI 0.60-0.85).CONCLUSIONSIn patients with cirrhosis and AKI, substantially lower tubular secretion was observed among inpatients with ATN relative to those with PRA and HRS. These results support the use of tubular secretion for the differential diagnosis of AKI in cirrhosis and may have important therapeutic and prognostic implications.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"35 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145071656","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Atlee Baker,Koyal Jain,Anna M Burgner,Bharvi Oza-Gajera,Sam Kant,Chyi Chyi Chong,Dalia Dawoud,Christopher R Ramos,Bharat Sachdeva,Adina Voiculescu,Jeffrey Hull,Kerry A Leigh,Joseph Kessler,Prabir Roy Chaudhury,Matthew A Sparks,Vandana Dua Niyyar
{"title":"Transforming Dialysis Access Together (TDAT) Dialysis Access Training: Recommendations for Nephrology Fellows.","authors":"Atlee Baker,Koyal Jain,Anna M Burgner,Bharvi Oza-Gajera,Sam Kant,Chyi Chyi Chong,Dalia Dawoud,Christopher R Ramos,Bharat Sachdeva,Adina Voiculescu,Jeffrey Hull,Kerry A Leigh,Joseph Kessler,Prabir Roy Chaudhury,Matthew A Sparks,Vandana Dua Niyyar","doi":"10.2215/cjn.0000000899","DOIUrl":"https://doi.org/10.2215/cjn.0000000899","url":null,"abstract":"","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"64 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145071861","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Anuradha Wadhwa,Scott Reule,Kerri L Cavanaugh,Michael J Fischer,Karen Mackichan,Arjun D Sinha,Paul M Palevsky,Susan T Crowley,Linda F Fried,Ashutosh M Shukla
Peritoneal dialysis (PD) use among the United States (US) Veteran population is lower than in the non-Veteran kidney failure population. Enhancing access to PD within the Veteran Healthcare Administration (VHA) may be crucial for achieving the Advancing American Kidney Health Executive Order goals. The VHA Home Dialysis Committee conducted a nationwide survey of nephrology stakeholders to assess Veterans' access to PD across the VHA and identify barriers and opportunities for the growth of VHA-affiliated PD services. Participants were invited via email and completed an electronic questionnaire consisting of seventeen PD access items and fifteen respondent characteristic items. Of the 141 eligible centers, 117 (83%) responded, including 97 facilities that provide nephrology services. Respondents indicated that PD could ideally serve 25% (interquartile range IQR: 15%, 40%) of Veterans with kidney failure. Most (62%) of the nephrology service-providing centers offered outpatient hemodialysis; however, only 28% reported providing outpatient PD services, with a median census of 10 Veterans. Among those lacking, 30% expressed a desire to establish outpatient PD services. The availability of comprehensive kidney replacement therapy KRT-directed pre-kidney failure education, an inpatient PD program, or respondents' perceptions of Veteran interest in PD were positively associated (p<0.05) with their desire to establish outpatient PD services. System-related challenges, such as limited space and capital costs of establishing a program, alongside staff-related issues like insufficient availability of trained nurses and support staff, were frequently cited barriers to PD programs. Respondents commonly cited the need for formal VHA-specific policies and procedural standards, administrative guides to establish local PD and patient education programs, and VHA-based PD nurse training assistance as strategies to address PD underutilization. Our findings suggest that the Veterans' lack of access to VHA-based PD programs may be an underrecognized barrier to their PD utilization. VHA nephrology stakeholders have a high desire to establish PD services but require local and system-based support to address PD underuse across the VHA.
{"title":"Barriers and Opportunities in Access to Peritoneal Dialysis across Veterans Healthcare Administration.","authors":"Anuradha Wadhwa,Scott Reule,Kerri L Cavanaugh,Michael J Fischer,Karen Mackichan,Arjun D Sinha,Paul M Palevsky,Susan T Crowley,Linda F Fried,Ashutosh M Shukla","doi":"10.2215/cjn.0000000826","DOIUrl":"https://doi.org/10.2215/cjn.0000000826","url":null,"abstract":"Peritoneal dialysis (PD) use among the United States (US) Veteran population is lower than in the non-Veteran kidney failure population. Enhancing access to PD within the Veteran Healthcare Administration (VHA) may be crucial for achieving the Advancing American Kidney Health Executive Order goals. The VHA Home Dialysis Committee conducted a nationwide survey of nephrology stakeholders to assess Veterans' access to PD across the VHA and identify barriers and opportunities for the growth of VHA-affiliated PD services. Participants were invited via email and completed an electronic questionnaire consisting of seventeen PD access items and fifteen respondent characteristic items. Of the 141 eligible centers, 117 (83%) responded, including 97 facilities that provide nephrology services. Respondents indicated that PD could ideally serve 25% (interquartile range IQR: 15%, 40%) of Veterans with kidney failure. Most (62%) of the nephrology service-providing centers offered outpatient hemodialysis; however, only 28% reported providing outpatient PD services, with a median census of 10 Veterans. Among those lacking, 30% expressed a desire to establish outpatient PD services. The availability of comprehensive kidney replacement therapy KRT-directed pre-kidney failure education, an inpatient PD program, or respondents' perceptions of Veteran interest in PD were positively associated (p<0.05) with their desire to establish outpatient PD services. System-related challenges, such as limited space and capital costs of establishing a program, alongside staff-related issues like insufficient availability of trained nurses and support staff, were frequently cited barriers to PD programs. Respondents commonly cited the need for formal VHA-specific policies and procedural standards, administrative guides to establish local PD and patient education programs, and VHA-based PD nurse training assistance as strategies to address PD underutilization. Our findings suggest that the Veterans' lack of access to VHA-based PD programs may be an underrecognized barrier to their PD utilization. VHA nephrology stakeholders have a high desire to establish PD services but require local and system-based support to address PD underuse across the VHA.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"93 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145068399","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Verônica T Costa E Silva,Meghan E Sise,Lesley A Inker,Lea Mantz Cand Med,Tianqi Ouyang,Fernando Louzada Strufaldi,Luiz A Gil-Jr,Renato A Caires,George Coura-Filho,Marcelo T Sapienza,Emmanuel A Burdmann,Florian J Fintelmann
BACKGROUNDSarcopenia and obesity are common in patients with cancer and may reduce the accuracy of estimated glomerular filtration rate (eGFR) equations. We evaluated the performance of recommended eGFR equations based on creatinine or cystatin C, and novel GFR markers β2-microglobulin (B2M) and β-trace protein (BTP) according to body composition derived from computed tomography (CT).METHODSProspective cohort study of adult patients with solid tumors recruited between May 2015 and October 2017 who had a CT scan within 90 days of measured GFR (mGFR) using plasma clearance of 51Cr-EDTA. eGFR was calculated with the CKD-EPI equations using either creatinine (eGFRCR); cystatin C (eGFRCYS); creatinine and cystatin (eGFRCR-CYS); creatinine and B2M (eGFRCR-B2M), cystatin, B2M, and BTP (eGFRCYS-B2M-BTP); or creatinine, cystatin, B2M, and BTP (eGFRCR-CYS-B2M-BTP). Bias was assessed as the median of the differences between mGFR and eGFR. Accuracy was assessed as the percentage of estimates that differed by more than 30% from the mGFR (1-P30). 1-P30 < 10%, 10-20%, and > 20% are considered optimal, acceptable, and poor accuracy, respectively. Skeletal muscle index (SMI) was quantified on CT and calculated by dividing the skeletal muscle cross-sectional area by the patient's height squared.RESULTSOf 465 patients included, 157 (34%) met criteria for sarcopenia. Bias varied by magnitude of SMI. In patients with sarcopenia, the accuracy of eGFRCR and eGFRCYS was poor (1-P30 42.0% [95% CI 34.4, 49.6] and 20.4% [95% CI 14.0, 26.8], respectively). eGFRCR-CYS had acceptable accuracy (1-P30: 14.0 [8.3, 19.1] %) whereas eGFRCYS-B2M-BTP and eGFRCR-CYS-B2M-BTP had optimal accuracy (1-P30: 7.0 [3.2, 10.8] % and 8.3 [3.8, 12.3] %, respectively). Obesity did not significantly affect bias or accuracy.CONCLUSIONSGFR estimates based on eGFRCR and eGFRCYS are not sufficiently accurate in patients with cancer and sarcopenia. Body composition analysis can identify patients in need of more accurate GFR assessment.
{"title":"Impact of CT-Derived Body Composition Analysis on the Performance of GFR Estimating Equations in Patients with Cancer.","authors":"Verônica T Costa E Silva,Meghan E Sise,Lesley A Inker,Lea Mantz Cand Med,Tianqi Ouyang,Fernando Louzada Strufaldi,Luiz A Gil-Jr,Renato A Caires,George Coura-Filho,Marcelo T Sapienza,Emmanuel A Burdmann,Florian J Fintelmann","doi":"10.2215/cjn.0000000878","DOIUrl":"https://doi.org/10.2215/cjn.0000000878","url":null,"abstract":"BACKGROUNDSarcopenia and obesity are common in patients with cancer and may reduce the accuracy of estimated glomerular filtration rate (eGFR) equations. We evaluated the performance of recommended eGFR equations based on creatinine or cystatin C, and novel GFR markers β2-microglobulin (B2M) and β-trace protein (BTP) according to body composition derived from computed tomography (CT).METHODSProspective cohort study of adult patients with solid tumors recruited between May 2015 and October 2017 who had a CT scan within 90 days of measured GFR (mGFR) using plasma clearance of 51Cr-EDTA. eGFR was calculated with the CKD-EPI equations using either creatinine (eGFRCR); cystatin C (eGFRCYS); creatinine and cystatin (eGFRCR-CYS); creatinine and B2M (eGFRCR-B2M), cystatin, B2M, and BTP (eGFRCYS-B2M-BTP); or creatinine, cystatin, B2M, and BTP (eGFRCR-CYS-B2M-BTP). Bias was assessed as the median of the differences between mGFR and eGFR. Accuracy was assessed as the percentage of estimates that differed by more than 30% from the mGFR (1-P30). 1-P30 < 10%, 10-20%, and > 20% are considered optimal, acceptable, and poor accuracy, respectively. Skeletal muscle index (SMI) was quantified on CT and calculated by dividing the skeletal muscle cross-sectional area by the patient's height squared.RESULTSOf 465 patients included, 157 (34%) met criteria for sarcopenia. Bias varied by magnitude of SMI. In patients with sarcopenia, the accuracy of eGFRCR and eGFRCYS was poor (1-P30 42.0% [95% CI 34.4, 49.6] and 20.4% [95% CI 14.0, 26.8], respectively). eGFRCR-CYS had acceptable accuracy (1-P30: 14.0 [8.3, 19.1] %) whereas eGFRCYS-B2M-BTP and eGFRCR-CYS-B2M-BTP had optimal accuracy (1-P30: 7.0 [3.2, 10.8] % and 8.3 [3.8, 12.3] %, respectively). Obesity did not significantly affect bias or accuracy.CONCLUSIONSGFR estimates based on eGFRCR and eGFRCYS are not sufficiently accurate in patients with cancer and sarcopenia. Body composition analysis can identify patients in need of more accurate GFR assessment.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"104 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145068378","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Beyond Rural versus Urban: Telemedicine as a Lifeline for All Kidney Transplant Patients.","authors":"Kevin Mott","doi":"10.2215/cjn.0000000873","DOIUrl":"https://doi.org/10.2215/cjn.0000000873","url":null,"abstract":"","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"24 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145043645","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Tomonori Takeuchi,Seda Babroudi,Lama Ghazi,Elizabeth Baker,Gabriela R Oates,Lucia D Juarez,Ariann F Nassel,Samuel A Silver,Orlando M Gutierrez,Javier A Neyra
BACKGROUNDIndividual- and neighborhood-level social determinants of health (SDOH) measures have been associated with higher incidence of acute kidney injury (AKI), lower likelihood of recovery, and higher risk of mortality following AKI. The association of SDOH measures with post-hospitalization AKI follow-up care is unknown.METHODSUsing a retrospective cohort design, we evaluated the association of individual- (insurance status, race, ethnicity) and neighborhood-level (socioeconomic deprivation, rurality, residential segregation, and social vulnerability to natural or human-caused disasters) SDOH measures with receipt of post-hospitalization follow-up for AKI within three months of hospital discharge among intensive care unit (ICU) survivors with AKI stage 2 or 3 hospitalized between 2012 and 2023 at a major academic medical center. The primary outcome, post-hospitalization AKI follow-up, was defined as the occurrence of at least one of the following within three months of hospital discharge: a nephrology outpatient visit, serum creatinine measurement, or urine protein measurement. We utilized pooled logistic regression models with inverse probability of censoring weighting to adjust for demographics, comorbidities, and hospitalization characteristics and to account for the competing risks of death, re-hospitalization, or dialysis initiation.RESULTSAmong 13,392 adult ICU survivors with AKI stages 2 or 3, 5,970 (45%) were female, 4,488 (34%) were of Black race, and 1,561 (12%) were uninsured. A total of 7,316 (61%) received post-hospitalization follow-up for AKI within three months of hospital discharge. Uninsured individuals (adjusted odds ratio (aOR) 0.77, 95% confidence interval (CI) 0.70-0.84), individuals residing in a neighborhood with greater socioeconomic deprivation (aOR 0.86, 95% CI 0.81-0.92), greater rurality (aOR 0.86, 95% CI 0.81-0.92), greater segregation (aOR 0.92, 95% CI 0.87-0.98), and greater social vulnerability (aOR 0.83, 95% CI 0.77-0.89) all experienced significantly lower odds of post-hospitalization AKI care.CONCLUSIONSBoth individual- and neighborhood-level SDOH were associated with lower odds of post-AKI follow-up among ICU survivors with severe AKI.
背景：个体和社区层面的健康社会决定因素（SDOH）措施与急性肾损伤（AKI）发生率较高、恢复可能性较低以及AKI后死亡风险较高相关。SDOH措施与住院后AKI随访护理的关系尚不清楚。方法采用回顾性队列设计，我们评估了个人（保险状况、种族、民族）与社区水平(社会经济剥夺、乡村性、居住隔离、2012年至2023年在一家主要学术医疗中心住院的重症监护病房（ICU） 2期或3期AKI幸存者出院后3个月内AKI住院随访的SDOH措施。主要结局，住院后AKI随访，定义为出院后三个月内至少发生以下一项：肾脏病门诊就诊，血清肌酐测量或尿蛋白测量。我们使用具有逆概率审查权重的混合逻辑回归模型来调整人口统计学、合并症和住院特征，并考虑死亡、再次住院或开始透析的竞争风险。结果13392例急性肾损伤2期或3期成人ICU幸存者中，女性5970例（45%），黑人4488例（34%），无保险1561例（12%）。共有7316人（61%）在出院后3个月内接受了AKI的住院后随访。未参保个体（调整优势比（aOR） 0.77, 95%可信区间（CI） 0.70-0.84）、居住在社会经济剥夺程度较高的社区的个体（aOR 0.86, 95% CI 0.81-0.92）、较大的乡村性（aOR 0.86, 95% CI 0.81-0.92）、较大的隔离性（aOR 0.92, 95% CI 0.87-0.98）和较大的社会脆弱性（aOR 0.83, 95% CI 0.77-0.89）住院后AKI护理的几率均显著降低。结论在重症AKI存活患者中，个体和社区水平的SDOH均与AKI后随访的低几率相关。
{"title":"Association of Individual- and Neighborhood-Level Social Determinants of Health with Post-Hospitalization Acute Kidney Injury Care.","authors":"Tomonori Takeuchi,Seda Babroudi,Lama Ghazi,Elizabeth Baker,Gabriela R Oates,Lucia D Juarez,Ariann F Nassel,Samuel A Silver,Orlando M Gutierrez,Javier A Neyra","doi":"10.2215/cjn.0000000856","DOIUrl":"https://doi.org/10.2215/cjn.0000000856","url":null,"abstract":"BACKGROUNDIndividual- and neighborhood-level social determinants of health (SDOH) measures have been associated with higher incidence of acute kidney injury (AKI), lower likelihood of recovery, and higher risk of mortality following AKI. The association of SDOH measures with post-hospitalization AKI follow-up care is unknown.METHODSUsing a retrospective cohort design, we evaluated the association of individual- (insurance status, race, ethnicity) and neighborhood-level (socioeconomic deprivation, rurality, residential segregation, and social vulnerability to natural or human-caused disasters) SDOH measures with receipt of post-hospitalization follow-up for AKI within three months of hospital discharge among intensive care unit (ICU) survivors with AKI stage 2 or 3 hospitalized between 2012 and 2023 at a major academic medical center. The primary outcome, post-hospitalization AKI follow-up, was defined as the occurrence of at least one of the following within three months of hospital discharge: a nephrology outpatient visit, serum creatinine measurement, or urine protein measurement. We utilized pooled logistic regression models with inverse probability of censoring weighting to adjust for demographics, comorbidities, and hospitalization characteristics and to account for the competing risks of death, re-hospitalization, or dialysis initiation.RESULTSAmong 13,392 adult ICU survivors with AKI stages 2 or 3, 5,970 (45%) were female, 4,488 (34%) were of Black race, and 1,561 (12%) were uninsured. A total of 7,316 (61%) received post-hospitalization follow-up for AKI within three months of hospital discharge. Uninsured individuals (adjusted odds ratio (aOR) 0.77, 95% confidence interval (CI) 0.70-0.84), individuals residing in a neighborhood with greater socioeconomic deprivation (aOR 0.86, 95% CI 0.81-0.92), greater rurality (aOR 0.86, 95% CI 0.81-0.92), greater segregation (aOR 0.92, 95% CI 0.87-0.98), and greater social vulnerability (aOR 0.83, 95% CI 0.77-0.89) all experienced significantly lower odds of post-hospitalization AKI care.CONCLUSIONSBoth individual- and neighborhood-level SDOH were associated with lower odds of post-AKI follow-up among ICU survivors with severe AKI.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"61 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145043757","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Harnessing the Potential of Technology for Learners in Nephrology and Medicine.","authors":"Pedram Fatehi","doi":"10.2215/cjn.0000000874","DOIUrl":"https://doi.org/10.2215/cjn.0000000874","url":null,"abstract":"","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"34 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145043643","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Krister Cromm,Ngoc Pham,Tom Yuen,Hanna Jaha,Valeria Saglimbene,Jörgen Hegbrant,Mark Woodward,Andrew Davenport,Bernard Canaud,Claudia Barth,Matthias Rose,Peter J Blankestijn,Michiel L Bots,Giovanni Fm Strippoli,
BACKGROUNDSelection criteria in randomized trials (RCTs) can lead to differences in key characteristics between trial participants and real-life populations. We evaluated reporting of population characteristics in existing RCTs of hemodiafiltration (HDF) and in real-life populations included in kidney registries to descriptively identify key differences.METHODSWe used systematic review methodology to identify existing RCTs of HDF vs hemodialysis (HD) (1966 to May 2024). We also searched the Fresenius Quantitative Market Analysis team registry database (2024 update) for existing registries from Europe, the Asia-Pacific region and America including populations on HDF. Patient characteristics from RCTs and registries were extracted, summarized and compared descriptively.RESULTSEleven RCTs (N=5108) and eight registries (N=1,147,167) were identified. There were no RCTs in the United States and only two small RCTs from Australia (N=124) and Brazil (N=195). Most trials were from Europe. Key characteristics consistently reported in both RCTs and registries were only age, sex, diabetes, cardiovascular disease, vascular access type and dialysis vintage. There was moderate to high heterogeneity for these patient characteristics in RCTs, indicating enrolment of a broad array of people. The proportion of people with diabetes was 26% in RCTs and 43% in registries. The prevalence of arteriovenous fistulas/graft was 90% in RCTs and 70% in registries.CONCLUSIONSThere was a broad but incomplete array of patient characteristics in existing RCTs and real-world registries of HDF vs HD. Data were primarily limited to Europe and only a core set of demographic and clinical variables. Apart for age, sex, diabetes, cardiovascular disease, vascular access type and dialysis vintage, other patient and treatment relevant characteristics were erratically or not at all reported in RCTs as well as in real-world registries. With potential differences in patient populations, we support the need for studies examining HDF in real world settings, e.g. with target emulation trials.
{"title":"Characteristics of Populations Included in Randomized Controlled Trials of Hemodiafiltration and Registry Real-Life Populations: A Systematic Review.","authors":"Krister Cromm,Ngoc Pham,Tom Yuen,Hanna Jaha,Valeria Saglimbene,Jörgen Hegbrant,Mark Woodward,Andrew Davenport,Bernard Canaud,Claudia Barth,Matthias Rose,Peter J Blankestijn,Michiel L Bots,Giovanni Fm Strippoli, ","doi":"10.2215/cjn.0000000855","DOIUrl":"https://doi.org/10.2215/cjn.0000000855","url":null,"abstract":"BACKGROUNDSelection criteria in randomized trials (RCTs) can lead to differences in key characteristics between trial participants and real-life populations. We evaluated reporting of population characteristics in existing RCTs of hemodiafiltration (HDF) and in real-life populations included in kidney registries to descriptively identify key differences.METHODSWe used systematic review methodology to identify existing RCTs of HDF vs hemodialysis (HD) (1966 to May 2024). We also searched the Fresenius Quantitative Market Analysis team registry database (2024 update) for existing registries from Europe, the Asia-Pacific region and America including populations on HDF. Patient characteristics from RCTs and registries were extracted, summarized and compared descriptively.RESULTSEleven RCTs (N=5108) and eight registries (N=1,147,167) were identified. There were no RCTs in the United States and only two small RCTs from Australia (N=124) and Brazil (N=195). Most trials were from Europe. Key characteristics consistently reported in both RCTs and registries were only age, sex, diabetes, cardiovascular disease, vascular access type and dialysis vintage. There was moderate to high heterogeneity for these patient characteristics in RCTs, indicating enrolment of a broad array of people. The proportion of people with diabetes was 26% in RCTs and 43% in registries. The prevalence of arteriovenous fistulas/graft was 90% in RCTs and 70% in registries.CONCLUSIONSThere was a broad but incomplete array of patient characteristics in existing RCTs and real-world registries of HDF vs HD. Data were primarily limited to Europe and only a core set of demographic and clinical variables. Apart for age, sex, diabetes, cardiovascular disease, vascular access type and dialysis vintage, other patient and treatment relevant characteristics were erratically or not at all reported in RCTs as well as in real-world registries. With potential differences in patient populations, we support the need for studies examining HDF in real world settings, e.g. with target emulation trials.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"36 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145043758","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Leilani Dodgen,Brittany Ajoku,Heather Kitzman,Aisha Montgomery,Anne Marie Strauss,Patricia Allison,Donald Wesson
BACKGROUNDChronic kidney disease (CKD) disproportionately affects African American persons with incidence rates 2-4 times that of White persons. Structural inequities like limited access to healthy foods and lower socioeconomic status might be contributing factors. The Fruits and Vegetables for Kidney Health Study was a randomized controlled trial in African American persons with CKD that demonstrated reductions in urine albumin-to-creatinine ratio when participants were given free fruits and vegetables (FV) over six months with or without a six-week cooking class. This qualitative study aimed to understand participant experiences in each group, using Social Cognitive Theory (SCT) to identify program components that contributed to FV intake and can inform future interventions.METHODSFocus groups were held virtually and in-person. Focus group questions were informed by SCT to evaluate study participation, changes to self-efficacy, barriers and benefits to individual and community-level FV intake. An applied thematic analysis approach was utilized for data analysis with trained staff using MAXQDA.RESULTSSix focus groups were conducted (N=40; 100% African American persons; mean age 63 years; 83% female; 58% with annual income <$25,000). Primary themes included: 1) study participation empowered participants to change food-related behaviors; 2) care and accountability from staff positively influenced participant engagement, 3) barriers impact the sustainability of recently acquired skills and health habits; and 4) enhance program reach through intergenerational social connections and social media.CONCLUSIONSAccess to both FV alone and with cooking classes had positive impacts on reported FV intake, although cooking class participants reported greater benefits. Sustainability of changes, particularly after access to free produce ends remains challenging. Participants indicated that integrating community health workers and staff skilled in diverse populations promoted participant trust and long-term engagement. Lastly, expanding intervention targets to include family and social media could further enhance reach and support for kidney health promoting foods.
{"title":"Qualitative Perspectives from African American Adults with Chronic Kidney Disease on Community-Based Fruit and Vegetable Promotion.","authors":"Leilani Dodgen,Brittany Ajoku,Heather Kitzman,Aisha Montgomery,Anne Marie Strauss,Patricia Allison,Donald Wesson","doi":"10.2215/cjn.0000000838","DOIUrl":"https://doi.org/10.2215/cjn.0000000838","url":null,"abstract":"BACKGROUNDChronic kidney disease (CKD) disproportionately affects African American persons with incidence rates 2-4 times that of White persons. Structural inequities like limited access to healthy foods and lower socioeconomic status might be contributing factors. The Fruits and Vegetables for Kidney Health Study was a randomized controlled trial in African American persons with CKD that demonstrated reductions in urine albumin-to-creatinine ratio when participants were given free fruits and vegetables (FV) over six months with or without a six-week cooking class. This qualitative study aimed to understand participant experiences in each group, using Social Cognitive Theory (SCT) to identify program components that contributed to FV intake and can inform future interventions.METHODSFocus groups were held virtually and in-person. Focus group questions were informed by SCT to evaluate study participation, changes to self-efficacy, barriers and benefits to individual and community-level FV intake. An applied thematic analysis approach was utilized for data analysis with trained staff using MAXQDA.RESULTSSix focus groups were conducted (N=40; 100% African American persons; mean age 63 years; 83% female; 58% with annual income <$25,000). Primary themes included: 1) study participation empowered participants to change food-related behaviors; 2) care and accountability from staff positively influenced participant engagement, 3) barriers impact the sustainability of recently acquired skills and health habits; and 4) enhance program reach through intergenerational social connections and social media.CONCLUSIONSAccess to both FV alone and with cooking classes had positive impacts on reported FV intake, although cooking class participants reported greater benefits. Sustainability of changes, particularly after access to free produce ends remains challenging. Participants indicated that integrating community health workers and staff skilled in diverse populations promoted participant trust and long-term engagement. Lastly, expanding intervention targets to include family and social media could further enhance reach and support for kidney health promoting foods.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"31 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2025-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145043644","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"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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