American Journal of Kidney Diseases最新文献

Rationale & objective: Coronary artery calcification (CAC) progresses rapidly in people with chronic kidney disease (CKD) compared with the general population. We studied the association between CAC progression and higher risks of atherosclerotic cardiovascular disease (CVD), congestive heart failure, and all-cause mortality among adults with CKD.

Study design: Prospective cohort study.

Setting: & Participants: 1,310 participants in the Chronic Renal Insufficiency Cohort (CRIC) Study who had at least one CAC scan with no prior history of CVD and with observed or imputed data on changes in CAC over time.

Exposure: Observed or imputed CAC progression, categorized as incident CAC among participants with zero CAC on the baseline scan, or progressive CAC when the baseline scan demonstrated CAC and there was an increase in CAC ≥50 Agatston units per year.

Outcomes: Atherosclerotic CVD (myocardial infarction or stroke), congestive heart failure, and all-cause mortality.

Analytical approach: Cause-specific Cox proportional hazards regression, stratified by presence of CAC at baseline.

Results: A total of 545 participants without and 765 with prevalent CAC at baseline were included. During a mean 3.3 years between CAC assessments, 177 (32.5%) participants without baseline CAC developed incident CAC while 270 participants (35.3%) with baseline CAC developed a ≥50 Agatston units per year increase in CAC. After multivariable adjustment, incident CAC was associated with 2.42-fold higher rate of atherosclerotic CVD (95% confidence interval [CI]: 1.23-4.79) and 1.82-fold higher rate of all-cause mortality (95% CI: 1.03-3.22). Progressive CAC (≥50 units per year) was not associated with atherosclerotic CVD (hazard ratio [HR]: 1.42; 95% CI: 0.85-2.35) but was associated with a 1.73-fold higher rate of all-cause mortality (95% CI: 1.31-2.28). Progressive CAC was not associated with incident heart failure.

Limitations: Residual confounding and limited statistical power for some outcomes.

Conclusions: Among adults with CKD stages 2-4, CAC progression over a mean 3.3 years was associated with higher risk of atherosclerotic CVD and all-cause mortality. The associations were strongest among participants without CAC at baseline.

Rationale & objective: Formalized peer support is a promising approach for addressing the emotional and practical needs of people living with chronic kidney disease (CKD). We aimed to systematically identify and summarize peer support interventions studied in individuals with CKD with or without kidney replacement therapy (KRT).

Sources of evidence: We searched electronic databases and grey literature sources in March 2023.

Eligibility criteria: Studies of any design were eligible if they reported sufficient detail on peer support interventions and outcomes for adults with CKD with or without KRT and/or their caregivers.

Charting methods: We extracted information on study and intervention characteristics and reported outcomes using established frameworks. We summarized quantitative data descriptively and qualitative data thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews.

Results: We included 77 studies describing 56 unique peer support interventions. Most reports were program evaluations (39%) or randomized controlled trials (27%) published after 2013. Two thirds of interventions focused on in-centre hemodialysis or mixed CKD populations, and three quarters were integrated within a kidney care clinic or program. Whereas most peer interactions centered on informational support, few programs offered focused support in areas such as transplant navigation or dialysis modality selection. Only one third of outcomes were assessed against a comparator group, with results suggesting improvements in psychological health with peer support.

Limitations: Heterogeneity of included studies; lack of rigorous program evaluation.

Conclusions: This review suggests recent growth in peer support programming with a variety of formats and delivery methods to address the diverse needs of people living with kidney disease. Notable gaps in peer support availability for transplant and home dialysis recipients and the lack of rigorous evaluations present opportunities to expand the reach and impact of peer support in the kidney care context.

Older Latino adults (65+) comprise the fastest growing minoritized group among the older population in the US and experience a disproportionate burden of kidney failure as well as disparities in kidney care compared to non-Hispanic White individuals. Despite significant need and barriers uniquely faced by this population, few educational resources or decision aids are available to meet the language and cultural needs of Latino patients. Decision aids are designed to improve knowledge and empower individuals to engage in shared decision-making and have been shown to improve decisional quality and goal-concordant care among older patients with CKD. In this commentary, we examine the barriers faced by older Latino people with CKD who must make dialysis initiation decisions. We conclude that there is a need for culturally concordant decision aids tailored for older Latino patients with CKD to overcome barriers in access to care and improve patient-centered care for older Latino CKD patients.

Rationale & objective: Case-mix adjusted hemodialysis mortality has decreased since 1998. Many factors that influence mortality may have contributed to this trend and these associations may differ by continental region. We studied changes in hemodialysis facility practices over time and their potential role in mediating changes in patient survival.

Study design: Observational prospective cohort study.

Setting & participants: Adult hemodialysis patients treated in hemodialysis 500 facilities participating in the Dialysis Outcomes Practice Patterns Study (DOPPS) between 1999 and 2015 in the US, Japan, and 4 four European countries: Germany, Italy, Spain, and UK.

Predictors: Four practice measures at each facility: the percentages of patients with Kt/V>1.2, interdialytic weight gain [IDWG]<5.7%, phosphorus<6 mg/dL, and using AV fistulae.

Outcomes: Patient survival.

Analytical approach: Mediation analyses, adjusted for case mix, were conducted using 3-year study phase as the exposure and facility practice measures as potential mediators.

Results: In Europe, we observed a 13% improvement in overall case-mix adjusted survival per decade. Trends in facility practice measures, especially Kt/V and phosphorus, explained 10% improvement in case-mix survival per decade, representing 77% (10% explained of 13% improvement) of the observed improvement. In Japan, 73% of the observed 12%/decade improvement in case-mix adjusted survival could be attributed to facility practices, especially Kt/V and IDWG. In the US, 56% of the observed 47%/decade improvement in case-mix adjusted survival could be attributed to facility practices, especially AV fistula use and phosphorus control.

Limitations: Unmeasured changes in the characteristics of the patient population over this period may confound the observed associations.

Conclusion: The improvements in adjusted hemodialysis patient survival in Europe, Japan, and the US from 1999 to 2015 can be largely explained by improvements in specific facility practices. Future changes in patient survival may be responsive to further evolution in the implementation of common clinical practices.