Clinical Journal of the American Society of Nephrology最新文献

There is a global interest in expanding home dialysis utilization among patients with ESKD. Home hemodialysis (HHD) is an appealing KRT option for this population because of its multiple clinical and quality of life benefits. Central to successful HHD is the establishment and maintenance of a functioning vascular access that serves as a patient's lifeline while on therapy. While the selection of a vascular access type is influenced by individual patient circumstances, the arteriovenous fistula is generally the preferred access method. Training patients to use their dialysis access requires attention to safety, risk management, and monitoring for complications to minimize adverse events and technique failure. Policies incorporating systematic frameworks for quality improvement and assurance, in conjunction with the measurement of metrics relating to vascular access, are tools that should be used by HHD programs to enhance the value of care delivered. In this perspective, we aim to describe what is currently known about the various vascular access options in HHD and to elucidate what needs to be taken into consideration in the selection and care of this access.

Background: People living with chronic kidney disease (CKD) are at higher risk of cognitive impairment. Exercise may improve cognitive function. This systematic review and meta-analysis of randomized controlled trials (RCTs) was completed to determine the efficacy and harms of exercise in improving cognitive function in people living with CKD.

Methods: A systematic literature review identified RCTs of people with any stage of CKD, with an intervention that exercised large-muscle groups, and with a validated outcome measure of cognitive function. First, harms were analyzed. Then a random-effects meta-analysis was completed with subsequent planned subgroup analyses to investigate heterogeneity between CKD stages and treatments, between different exercise types, durations and intensities, and between different outcome methodologies. Finally, quality of evidence was rated.

Results: Nineteen trials randomized 1160 participants. Harms were reported on 94 occasions in intervention groups vs. 83 in control. The primary analysis found that exercise had a small but statistically significant effect on cognition in CKD (effect size (ES) = 0.22; 95% confidence intervals (CI95) = 0.00, 0.44; P = 0.05). However, the quality of evidence was rated as low. Subgroup analyses found that type of exercise moderated the effect on cognition (χ2 = 7.62; P = 0.02), with positive effects only observed following aerobic exercise (ES = 0.57; CI95 = 0.21, 0.93; P = 0.002).

Conclusions: Across the spectrum of CKD, exercise had a small but positive and clinically meaningful effect on cognitive function and did not appear to be harmful. Aerobic exercise was particularly beneficial. However, results must be interpreted cautiously due to the low quality of evidence. Nevertheless, care teams may choose to recommend aerobic exercise interventions to prevent cognitive decline. Researchers should design unbiased studies to clarify what intensity and duration of exercise is required to maximize efficiency of such exercise interventions.

Glomerular disease is a leading cause of CKD and ESKD. Although diabetic kidney disease is the most common cause of glomerular disease, nondiabetic causes include malignancy, systemic autoimmune conditions, drug effects, or genetic conditions. Nondiabetic glomerular diseases are rare diseases, with a paucity of high-quality clinical trials in this area. Furthermore, late referral can result in poor patient outcomes. This article reviews the current management of nondiabetic glomerular disease and explores the latest developments in drug treatment in this area. Current treatment of nondiabetic glomerular disease aims to manage complications (edema, hypertension, proteinuria, hyperlipidemia, hypercoagulability, and thrombosis) as well as target the underlying cause of glomerular disease. Treatment options include renin-angiotensin-aldosterone system inhibitors, statins/nonstatin alternatives, loop diuretics, anticoagulation agents, immunosuppressives, and lifestyle and dietary modifications. Effective treatment of nondiabetic glomerular disease is limited by heterogeneity and a lack of understanding of the disease pathogenesis. Sodium-glucose cotransporter-2 inhibitors and nonsteroidal mineralocorticoid receptor antagonists (ns-MRAs, such as finerenone), with their broad anti-inflammatory and antifibrotic effects, have emerged as valuable therapeutic options for a range of cardiorenal conditions, including CKD. ns-MRAs are an evolving drug class of particular interest for the future treatment of nondiabetic glomerular disease, and there is evidence that these agents may improve kidney prognosis in various subgroups of patients with CKD. The benefits offered by ns-MRAs may present an opportunity to reduce the progression of CKD from a spectrum of glomerular disease. Several novel ns-MRA are in clinical development for both diabetic and nondiabetic CKD.

Background: Many nephrology providers express difficulty in discussing care options for patients who forgo kidney replacement therapy (KRT), which hampers their ability to help patients make decisions about their current and future treatment of kidney disease.

Methods: We conducted a qualitative study using interviews with a national sample of nephrology providers (i.e., physicians and advanced practice providers) who participated in US professional societies between July and December 2022. We performed a thematic analysis of interviews to identify emergent themes reflecting providers' experiences discussing care for patients who forgo KRT.

Results: There were 21 providers (age 54±13years, female 81%, White 32%) who participated in interviews, of which 43% were physicians and most (57%) practiced in academic settings. Three dominant themes emerged from interviews: 1) Inconsistent terminology: while providers sought to use terms to describe care for patients who forgo KRT that affirmed patients' decision, clearly conveyed that KRT would not be pursued, and were familiar to patients and other providers, they disagreed about which terms satisfied these priorities; 2) Blurred distinctions between KRT and its alternative: providers' descriptions of their care practices suggested that differences in their approaches to caring for patients who forgo KRT and those who are planning to pursue KRT could be opaque; and, 3) Deciphering patients' decision to forgo KRT: providers did not readily accept patients' expressed preferences to forgo KRT at face value and described using a variety of methods to assess whether patients would follow through with their decision.

Conclusions: Providers used different, inconsistent terms to describe care for patients who forgo KRT. They disagreed about what this care entailed and were uncertain about what patients might mean when they express not wanting to undergo KRT.