Pub Date : 2025-02-01DOI: 10.1053/j.ajkd.2024.07.014
David C. Cron , Arnold E. Kuk , Layla Parast , S. Ali Husain , Kristen L. King , Miko Yu , Sumit Mohan , Joel T. Adler
<div><h3>Rationale & Objective</h3><div>The kidney allocation system (KAS250), using circle-based distribution, attempts to address geographic disparities through broader sharing of deceased-donor kidney allografts. This study evaluated the association between KAS250 and likelihood of deceased-donor kidney transplantation (DDKT) among wait-listed candidates, and whether the policy has differentially affected centers with shorter versus longer waiting time.</div></div><div><h3>Study Design</h3><div>Retrospective cohort study.</div></div><div><h3>Setting & Participants</h3><div>160,941 candidates waitlisted at 176 transplant centers between March 2017 and March 2024.</div></div><div><h3>Exposure</h3><div>KAS250 allocation policy.</div></div><div><h3>Outcome</h3><div>Rate of DDKT.</div></div><div><h3>Analytical Approach</h3><div>Multivariable Cox regression, modeling KAS250 as a time-dependent variable.</div></div><div><h3>Results</h3><div>KAS250 was not independently associated with likelihood of DDKT overall (HR, 1.01 vs pre-KAS250 [95% CI, 0.97-1.04]). KAS250’s association with likelihood of DDKT varied across centers from HR, 0.18 (DDKT less likely after KAS250), to HR, 17.12 (DDKT more likely) and varied even among neighboring centers. KAS250 was associated with decreased DDKT at 25.6% and increased DDKT at 18.2% of centers. Centers with previously <em>long</em> median waiting times (57+<!--> <!-->months) experienced <em>increased</em> likelihood of DDKT after KAS250 (HR, 1.20 [95% CI, 1.15-1.26]) whereas centers with previously <em>short</em> median waiting times (6-24 months; HR, 0.88 [95% CI, 0.84-0.92]) experienced <em>decreased</em> likelihood of DDKT.</div></div><div><h3>Limitations</h3><div>Retrospective study of allocation policy changes, confounded by multiple changes over the study time frame.</div></div><div><h3>Conclusions</h3><div>Association between KAS250 and DDKT varied across centers. For 1 in 4 centers, DDKT was less likely after KAS250 relative to pre-KAS250 trends. Candidates at centers with previously long waiting times experienced an increased likelihood of DDKT after KAS250. Thus, broader distribution of kidneys may be associated with improved equity in access to DDKT, but additional strategies may be needed to minimize disparities between centers.</div></div><div><h3>Plain-Language Summary</h3><div>This study examines how a recent policy change, KAS250, aimed at broadening the geographic sharing of deceased-donor kidneys, has impacted likelihood of kidney transplantation in the United States. Historically, kidney allocation occurred within local geographic boundaries, leading to unequal rates of transplantation across regions. KAS250, implemented in March 2021, replaced this system with a broader allocation radius of 250 miles around the donor hospital. Using national registry data, the study found that while there was no overall significant increase in the likelihood of transplantation nationally under KAS250, t
{"title":"Associations Among Circle-Based Kidney Allocation, Center Waiting Time, and Likelihood of Deceased-Donor Kidney Transplantation","authors":"David C. Cron , Arnold E. Kuk , Layla Parast , S. Ali Husain , Kristen L. King , Miko Yu , Sumit Mohan , Joel T. Adler","doi":"10.1053/j.ajkd.2024.07.014","DOIUrl":"10.1053/j.ajkd.2024.07.014","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>The kidney allocation system (KAS250), using circle-based distribution, attempts to address geographic disparities through broader sharing of deceased-donor kidney allografts. This study evaluated the association between KAS250 and likelihood of deceased-donor kidney transplantation (DDKT) among wait-listed candidates, and whether the policy has differentially affected centers with shorter versus longer waiting time.</div></div><div><h3>Study Design</h3><div>Retrospective cohort study.</div></div><div><h3>Setting & Participants</h3><div>160,941 candidates waitlisted at 176 transplant centers between March 2017 and March 2024.</div></div><div><h3>Exposure</h3><div>KAS250 allocation policy.</div></div><div><h3>Outcome</h3><div>Rate of DDKT.</div></div><div><h3>Analytical Approach</h3><div>Multivariable Cox regression, modeling KAS250 as a time-dependent variable.</div></div><div><h3>Results</h3><div>KAS250 was not independently associated with likelihood of DDKT overall (HR, 1.01 vs pre-KAS250 [95% CI, 0.97-1.04]). KAS250’s association with likelihood of DDKT varied across centers from HR, 0.18 (DDKT less likely after KAS250), to HR, 17.12 (DDKT more likely) and varied even among neighboring centers. KAS250 was associated with decreased DDKT at 25.6% and increased DDKT at 18.2% of centers. Centers with previously <em>long</em> median waiting times (57+<!--> <!-->months) experienced <em>increased</em> likelihood of DDKT after KAS250 (HR, 1.20 [95% CI, 1.15-1.26]) whereas centers with previously <em>short</em> median waiting times (6-24 months; HR, 0.88 [95% CI, 0.84-0.92]) experienced <em>decreased</em> likelihood of DDKT.</div></div><div><h3>Limitations</h3><div>Retrospective study of allocation policy changes, confounded by multiple changes over the study time frame.</div></div><div><h3>Conclusions</h3><div>Association between KAS250 and DDKT varied across centers. For 1 in 4 centers, DDKT was less likely after KAS250 relative to pre-KAS250 trends. Candidates at centers with previously long waiting times experienced an increased likelihood of DDKT after KAS250. Thus, broader distribution of kidneys may be associated with improved equity in access to DDKT, but additional strategies may be needed to minimize disparities between centers.</div></div><div><h3>Plain-Language Summary</h3><div>This study examines how a recent policy change, KAS250, aimed at broadening the geographic sharing of deceased-donor kidneys, has impacted likelihood of kidney transplantation in the United States. Historically, kidney allocation occurred within local geographic boundaries, leading to unequal rates of transplantation across regions. KAS250, implemented in March 2021, replaced this system with a broader allocation radius of 250 miles around the donor hospital. Using national registry data, the study found that while there was no overall significant increase in the likelihood of transplantation nationally under KAS250, t","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":"85 2","pages":"Pages 187-195"},"PeriodicalIF":9.4,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142374970","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}
Pub Date : 2025-02-01DOI: 10.1053/j.ajkd.2024.07.017
Melandrea L. Worsley , Jingbo Niu , Kevin F. Erickson , Neal R. Barshes , Wolfgang C. Winkelmayer , L. Parker Gregg
Rationale & Objective
Race and ethnicity differences exist in the type of arteriovenous access (AVA, including fistulas and grafts) used at hemodialysis (HD) initiation. The preferred anatomic location for the creation of an initial HD AVA is typically in the forearm We evaluated race and ethnicity differences in the use of an AVA in the forearm location at HD initiation.
Study Design
Retrospective cohort study.
Setting & Participants
Using records from DaVita Kidney Care linked to the US Renal Data System (USRDS), we evaluated patients aged ≥16 years who initiated in-center HD with an AVA between 2006 and 2019.
Predictor
Race and ethnicity, categorized as non-Hispanic White, non-Hispanic Black, Hispanic, or Other.
Outcome
Forearm versus upper arm AVA location.
Analytical Approach
Multivariable modified Poisson regression to estimate adjusted trends in AVA location over time and race and ethnicity differences in AVA location. Nested models helped assess the relative confounding by groups of variables on estimates of race and ethnicity differences.
Results
Among 70,147 patients (51.7% White, 28.8% Black, 12.6% Hispanic, 6.9% Other), White patients were older and more likely to have peripheral vascular disease but less likely to have diabetes compared with the other groups. The proportion initiating HD using a forearm AVA decreased from 49% in 2006 to 29% in 2019 and by 3.6% (95% CI, 3.3%-3.9%) annually, with no difference in this trend among groups (race and ethnicity by calendar year interaction P = 0.32). Black patients were 13% (95% CI, 10%-15%) less likely and Hispanic patients were 5% (95% CI, 1%-9%) less likely than White patients to initiate HD with a forearm AVA.
Limitations
Findings may not apply to home HD.
Conclusions
Use of a forearm AVA for HD initiation has declined and racial differences have persisted, with Black and Hispanic patients being less likely than White patients to have an AVA in the forearm location. Research toward understanding the causes and consequences of these trends and disparities is warranted.
{"title":"Forearm Versus Upper Arm Location of Arteriovenous Access Used at Hemodialysis Initiation: Temporal Trends and Racial Disparities","authors":"Melandrea L. Worsley , Jingbo Niu , Kevin F. Erickson , Neal R. Barshes , Wolfgang C. Winkelmayer , L. Parker Gregg","doi":"10.1053/j.ajkd.2024.07.017","DOIUrl":"10.1053/j.ajkd.2024.07.017","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>Race and ethnicity differences exist in the type of arteriovenous access (AVA, including fistulas and grafts) used at hemodialysis (HD) initiation. The preferred anatomic location for the creation of an initial HD AVA is typically in the forearm We evaluated race and ethnicity differences in the use of an AVA in the forearm location at HD initiation.</div></div><div><h3>Study Design</h3><div>Retrospective cohort study.</div></div><div><h3>Setting & Participants</h3><div>Using records from DaVita Kidney Care linked to the US Renal Data System (USRDS), we evaluated patients aged<!--> <!-->≥16 years who initiated in-center HD with an AVA between 2006 and 2019.</div></div><div><h3>Predictor</h3><div>Race and ethnicity, categorized as non-Hispanic White, non-Hispanic Black, Hispanic, or Other.</div></div><div><h3>Outcome</h3><div>Forearm versus upper arm AVA location.</div></div><div><h3>Analytical Approach</h3><div>Multivariable modified Poisson regression to estimate adjusted trends in AVA location over time and race and ethnicity differences in AVA location. Nested models helped assess the relative confounding by groups of variables on estimates of race and ethnicity differences.</div></div><div><h3>Results</h3><div>Among 70,147 patients (51.7% White, 28.8% Black, 12.6% Hispanic, 6.9% Other), White patients were older and more likely to have peripheral vascular disease but less likely to have diabetes compared with the other groups. The proportion initiating HD using a forearm AVA decreased from 49% in 2006 to 29% in 2019 and by 3.6% (95% CI, 3.3%-3.9%) annually, with no difference in this trend among groups (race and ethnicity by calendar year interaction <em>P</em> <!-->=<!--> <!-->0.32). Black patients were 13% (95% CI, 10%-15%) less likely and Hispanic patients were 5% (95% CI, 1%-9%) less likely than White patients to initiate HD with a forearm AVA.</div></div><div><h3>Limitations</h3><div>Findings may not apply to home HD.</div></div><div><h3>Conclusions</h3><div>Use of a forearm AVA for HD initiation has declined and racial differences have persisted, with Black and Hispanic patients being less likely than White patients to have an AVA in the forearm location. Research toward understanding the causes and consequences of these trends and disparities is warranted.</div></div>","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":"85 2","pages":"Pages 226-235.e1"},"PeriodicalIF":9.4,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142436111","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}
Pub Date : 2025-02-01DOI: 10.1053/j.ajkd.2024.10.004
Jung-Im Shin , Antoine Créon , Juan-Jesus Carrero
{"title":"Metformin in People With Diabetes and Advanced CKD: Should We Dare?","authors":"Jung-Im Shin , Antoine Créon , Juan-Jesus Carrero","doi":"10.1053/j.ajkd.2024.10.004","DOIUrl":"10.1053/j.ajkd.2024.10.004","url":null,"abstract":"","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":"85 2","pages":"Pages 184-186"},"PeriodicalIF":9.4,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142811841","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}
Pub Date : 2025-02-01DOI: 10.1053/j.ajkd.2024.05.021
Charmaine E. Lok , Theodore Yuo , Timmy Lee
The majority of patients with kidney failure requiring replacement therapy will need the support of hemodialysis during their journey with kidney failure. A reliable functioning vascular access is required to provide hemodialysis. This Core Curriculum reviews the major forms of vascular access (arteriovenous fistula, arteriovenous graft, and central venous catheter) as well as the planning, preparation, creation, use, and maintenance of vascular access, requiring a P-L-A-N (Patient ESKD Life-Plan first then Access Needs) for each patient. The end-stage kidney disease Patient Life-Plan focuses on a strategy for kidney replacement modalities, while the Access Needs are the corresponding dialysis access(es) and management plans. The Access Needs include a vessel preservation plan, creation plan, contingency (complications) plan, and access succession plan. Stenosis and thrombosis are common problems with arteriovenous accesses, and dysfunction and infection are common problems with central venous catheters. Underrecognized and underreported but potentially life-threatening situations include arteriovenous access rupture and high-output cardiac failure. Effective management of these and other vascular access problems requires a coordinated multidisciplinary effort that is patient centered while preserving vascular access.
{"title":"Hemodialysis Vascular Access: Core Curriculum 2025","authors":"Charmaine E. Lok , Theodore Yuo , Timmy Lee","doi":"10.1053/j.ajkd.2024.05.021","DOIUrl":"10.1053/j.ajkd.2024.05.021","url":null,"abstract":"<div><div>The majority of patients with kidney failure requiring replacement therapy will need the support of hemodialysis during their journey with kidney failure. A reliable functioning vascular access is required to provide hemodialysis. This Core Curriculum reviews the major forms of vascular access (arteriovenous fistula, arteriovenous graft, and central venous catheter) as well as the planning, preparation, creation, use, and maintenance of vascular access, requiring a P-L-A-N (<em>P</em>atient ESKD <em>L</em>ife-Plan first then <em>A</em>ccess <em>N</em>eeds) for each patient. The end-stage kidney disease Patient Life-Plan focuses on a strategy for kidney replacement modalities, while the Access Needs are the corresponding dialysis access(es) and management plans. The Access Needs include a vessel preservation plan, creation plan, contingency (complications) plan, and access succession plan. Stenosis and thrombosis are common problems with arteriovenous accesses, and dysfunction and infection are common problems with central venous catheters. Underrecognized and underreported but potentially life-threatening situations include arteriovenous access rupture and high-output cardiac failure. Effective management of these and other vascular access problems requires a coordinated multidisciplinary effort that is patient centered while preserving vascular access.</div></div>","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":"85 2","pages":"Pages 236-252"},"PeriodicalIF":9.4,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142765506","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}
Pub Date : 2025-02-01DOI: 10.1053/j.ajkd.2024.07.010
Cédric Villain , Natalie Ebert , Richard J. Glassock , Nina Mielke , Tim Bothe , Muhammad Helmi Barghouth , Anna Pöhlmann , Anne-Katrin Fietz , John S. Gill , Elke Schaeffner
Rationale & Objective
The benefits of kidney transplantation compared with treatment with dialysis, including in older adults, are primarily limited by the number of donated kidneys. We studied the potential to expand the use of older living kidney donors.
Study Design
Secondary analysis of the Berlin Initiative Study, a population-based cohort.
Setting & Participants
2,069 adults aged ≥70 years in Germany.
Exposure
Age and sex.
Outcome
Suitability for living donation assessed by the absence of kidney-related exclusions for donation including albuminuria and low estimated glomerular filtration rate (eGFR) as well as absence of other medical exclusions. Willingness for living and deceased kidney donation assessed by participant survey.
Analytical Approach
Descriptive analysis.
Results
Among the 2,069 participants (median age 80 years, 53% women, median eGFR 63 mL/min/1.73 m2), 93% had ≥1 medical contraindication for living donation at study entry unrelated to eGFR or albuminuria. Using 2 published eGFR and albuminuria thresholds for donor acceptance, 38% to 54% of participants had kidney-related exclusions for donation. Among the 5% to 6% of participants with neither medical nor kidney-related exclusions for living donation at baseline, 11% to 12% remained suitable for donation during 8 years of follow-up. Willingness for living or deceased donation was high (73% and 60%, respectively).
Limitations
GFR was not measured, and medical exclusions unrelated to eGFR and albuminuria were assessed using a cohort database complemented by claims data.
Conclusions
One in 20 older adults were potentially suitable for living kidney donation, and willingness for living donation was high. Further studies are warranted to define the feasibility of expanding living kidney donation among older adults.
Plain-Language Summary
Although potentially beneficial, kidney transplantation remains infrequent among older adults aged ≥70 years with kidney failure. Study evaluated the potential to increase living kidney donation among older adults, including their medical suitability as well as willingness to donate. Among 2,069 community-dwelling older adults (median age 80 years), 5% to 6% had no exclusion to donation. Among these individuals, 11% to 12% remained suitable for donation during 8 years of follow-up. Most exclusions were not related to eGFR and albuminuria. Willingness to living donation was high (73%). These findings highlight the potential benefits from expanding the pool of transplantable kidneys through the use of living donation in older adults.
{"title":"Medical Suitability and Willingness for Living Kidney Donation Among Older Adults","authors":"Cédric Villain , Natalie Ebert , Richard J. Glassock , Nina Mielke , Tim Bothe , Muhammad Helmi Barghouth , Anna Pöhlmann , Anne-Katrin Fietz , John S. Gill , Elke Schaeffner","doi":"10.1053/j.ajkd.2024.07.010","DOIUrl":"10.1053/j.ajkd.2024.07.010","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>The benefits of kidney transplantation compared with treatment with dialysis, including in older adults, are primarily limited by the number of donated kidneys. We studied the potential to expand the use of older living kidney donors.</div></div><div><h3>Study Design</h3><div>Secondary analysis of the Berlin Initiative Study, a population-based cohort.</div></div><div><h3>Setting & Participants</h3><div>2,069 adults aged<!--> <!-->≥70 years in Germany.</div></div><div><h3>Exposure</h3><div>Age and sex.</div></div><div><h3>Outcome</h3><div>Suitability for living donation assessed by the absence of kidney-related exclusions for donation including albuminuria and low estimated glomerular filtration rate (eGFR) as well as absence of other medical exclusions. Willingness for living and deceased kidney donation assessed by participant survey.</div></div><div><h3>Analytical Approach</h3><div>Descriptive analysis.</div></div><div><h3>Results</h3><div>Among the 2,069 participants (median age 80 years, 53% women, median eGFR 63<!--> <!-->mL/min/1.73<!--> <!-->m<sup>2</sup>), 93% had<!--> <!-->≥1 medical contraindication for living donation at study entry unrelated to eGFR or albuminuria. Using 2 published eGFR and albuminuria thresholds for donor acceptance, 38% to 54% of participants had kidney-related exclusions for donation. Among the 5% to 6% of participants with neither medical nor kidney-related exclusions for living donation at baseline, 11% to 12% remained suitable for donation during 8 years of follow-up. Willingness for living or deceased donation was high (73% and 60%, respectively).</div></div><div><h3>Limitations</h3><div>GFR was not measured, and medical exclusions unrelated to eGFR and albuminuria were assessed using a cohort database complemented by claims data.</div></div><div><h3>Conclusions</h3><div>One in 20 older adults were potentially suitable for living kidney donation, and willingness for living donation was high. Further studies are warranted to define the feasibility of expanding living kidney donation among older adults.</div></div><div><h3>Plain-Language Summary</h3><div>Although potentially beneficial, kidney transplantation remains infrequent among older adults aged<!--> <!-->≥70 years with kidney failure. Study evaluated the potential to increase living kidney donation among older adults, including their medical suitability as well as willingness to donate. Among 2,069 community-dwelling older adults (median age 80 years), 5% to 6% had no exclusion to donation. Among these individuals, 11% to 12% remained suitable for donation during 8 years of follow-up. Most exclusions were not related to eGFR and albuminuria. Willingness to living donation was high (73%). These findings highlight the potential benefits from expanding the pool of transplantable kidneys through the use of living donation in older adults.</div></div>","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":"85 2","pages":"Pages 205-214.e1"},"PeriodicalIF":9.4,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142370734","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}
Pub Date : 2025-02-01DOI: 10.1053/j.ajkd.2024.08.012
Emilie J. Lambourg , Edouard L. Fu , Stuart McGurnaghan , Bryan R. Conway , Neeraj Dhaun , Christopher H. Grant , Ewan R. Pearson , Patrick B. Mark , John Petrie , Helen Colhoun , Samira Bell
<div><h3>Rationale & Objective</h3><div>Despite a lack of supporting evidence, current guidance recommends against the use of metformin in people with advanced kidney impairment. This observational study compared the outcomes of patients with type 2 diabetes who continued versus stopped metformin after developing stage 4 chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR]<!--> <!--><<!--> <!-->30<!--> <!-->mL/min/1.73<!--> <!-->m<sup>2</sup>).</div></div><div><h3>Study Design</h3><div>Nationwide observational cohort study.</div></div><div><h3>Setting & Participants</h3><div>All adults with type 2 diabetes and incident stage 4 CKD in Scotland who were treated with metformin between January 2010 and April 2019.</div></div><div><h3>Exposure</h3><div>Stopping versus continuing metformin within 6 months following incident stage 4 CKD.</div></div><div><h3>Outcome</h3><div>Primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiovascular events (MACE).</div></div><div><h3>Analytical Approach</h3><div>Target trial emulation with clone-censor-weight design and marginal structural models fit for sensitivity analyses.</div></div><div><h3>Results</h3><div>In a population of 371,742 Scottish residents with a diagnosis of type 2 diabetes before April 30, 2019, 4,278 were identified as prevalent metformin users with incident CKD stage 4. Within 6 months of developing CKD stage IV, 1,713 (40.1%) individuals discontinued metformin. Compared with continuing metformin, stopping metformin was associated with a lower 3-year survival (63.7% [95% CI, 60.9-66.6] vs 70.5% [95% CI, 68.0-73.0]; HR, 1.26 [95% CI, 1.10-1.44]), and the incidence of MACE was similar between both strategies (HR, 1.05 [95% CI, 0.88-1.26]). Marginal structural models confirmed the higher risk of all-cause mortality and similar risk of MACE in patients who stopped versus continued metformin (all-cause mortality: HR, 1.34 [95% CI, 1.08-1.67]; MACE: HR, 1.04 [95% CI, 0.81-1.33]).</div></div><div><h3>Limitations</h3><div>Residual confounding.</div></div><div><h3>Conclusions</h3><div>The continued use of metformin may be appropriate when eGFR falls below 30<!--> <!-->mL/min/1.73<!--> <!-->m<sup>2</sup>. Randomized controlled trials are needed to confirm these findings.</div></div><div><h3>Plain-Language Summary</h3><div>Current guidance recommends against the use of metformin in people with advanced kidney impairment despite a lack of evidence. It is therefore currently unclear how the decision to stop versus continue metformin in patients who reach stage 4 CKD impacts their risk of mortality and cardiovascular events. This study showed that stopping metformin after reaching stage 4 CKD was associated with reduced survival that did not appear to be mediated by an increase in adverse cardiovascular outcomes. These findings may support the continued use of metformin in patients with advanced kidney impairment, but further research is neede
理由与目标：尽管缺乏支持性证据，但目前的指南建议肾功能损害晚期患者不要使用二甲双胍。这项观察性研究旨在比较2型糖尿病患者在发展到慢性肾脏病（CKD）4期（eGFR 2）后继续使用二甲双胍与停止使用二甲双胍的结果：全国观察性队列研究：研究设计：全国观察性队列研究。研究地点和参与者：苏格兰所有在2010年1月至2019年4月期间接受二甲双胍治疗的2型糖尿病和偶发4期慢性肾脏病成人患者。暴露：在偶发4期慢性肾脏病后6个月内停用二甲双胍与继续使用二甲双胍：主要结果为全因死亡率。次要结果包括主要不良心血管事件（MACE）：分析方法：目标试验模拟，采用克隆张量加权设计和边际结构模型进行敏感性分析：在2019年4月30日前确诊为2型糖尿病的371,742名苏格兰居民中，有4,278人被确定为二甲双胍的普遍使用者，并出现了CKD 4期。在出现 CKD IV 期的 6 个月内，有 1713 人（40.1%）停用了二甲双胍。与继续服用二甲双胍相比，停用二甲双胍与较低的 3 年生存率相关（63.7%，95% CI 60.9 至 66.6 对 70.5%，95% CI 68.0 至 73.0；HR=1.26，95% CI 1.10 至 1.44），而两种策略的 MACE 发生率相似（HR=1.05，95% CI 0.88 至 1.26）。边际结构模型证实，停用二甲双胍与继续使用二甲双胍的患者全因死亡风险较高，MACE风险相似（全因死亡率：HR=1.34，95% CI 1.08至1.67；MACE：HR=1.04，95% CI 0.81至1.33）：结论结论：当 eGFR 低于 30 ml/min/1.73m2 时，继续使用二甲双胍可能是合适的。需要进行随机对照试验来证实这些发现。
{"title":"Stopping Versus Continuing Metformin in Patients With Advanced CKD: A Nationwide Scottish Target Trial Emulation Study","authors":"Emilie J. Lambourg , Edouard L. Fu , Stuart McGurnaghan , Bryan R. Conway , Neeraj Dhaun , Christopher H. Grant , Ewan R. Pearson , Patrick B. Mark , John Petrie , Helen Colhoun , Samira Bell","doi":"10.1053/j.ajkd.2024.08.012","DOIUrl":"10.1053/j.ajkd.2024.08.012","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>Despite a lack of supporting evidence, current guidance recommends against the use of metformin in people with advanced kidney impairment. This observational study compared the outcomes of patients with type 2 diabetes who continued versus stopped metformin after developing stage 4 chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR]<!--> <!--><<!--> <!-->30<!--> <!-->mL/min/1.73<!--> <!-->m<sup>2</sup>).</div></div><div><h3>Study Design</h3><div>Nationwide observational cohort study.</div></div><div><h3>Setting & Participants</h3><div>All adults with type 2 diabetes and incident stage 4 CKD in Scotland who were treated with metformin between January 2010 and April 2019.</div></div><div><h3>Exposure</h3><div>Stopping versus continuing metformin within 6 months following incident stage 4 CKD.</div></div><div><h3>Outcome</h3><div>Primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiovascular events (MACE).</div></div><div><h3>Analytical Approach</h3><div>Target trial emulation with clone-censor-weight design and marginal structural models fit for sensitivity analyses.</div></div><div><h3>Results</h3><div>In a population of 371,742 Scottish residents with a diagnosis of type 2 diabetes before April 30, 2019, 4,278 were identified as prevalent metformin users with incident CKD stage 4. Within 6 months of developing CKD stage IV, 1,713 (40.1%) individuals discontinued metformin. Compared with continuing metformin, stopping metformin was associated with a lower 3-year survival (63.7% [95% CI, 60.9-66.6] vs 70.5% [95% CI, 68.0-73.0]; HR, 1.26 [95% CI, 1.10-1.44]), and the incidence of MACE was similar between both strategies (HR, 1.05 [95% CI, 0.88-1.26]). Marginal structural models confirmed the higher risk of all-cause mortality and similar risk of MACE in patients who stopped versus continued metformin (all-cause mortality: HR, 1.34 [95% CI, 1.08-1.67]; MACE: HR, 1.04 [95% CI, 0.81-1.33]).</div></div><div><h3>Limitations</h3><div>Residual confounding.</div></div><div><h3>Conclusions</h3><div>The continued use of metformin may be appropriate when eGFR falls below 30<!--> <!-->mL/min/1.73<!--> <!-->m<sup>2</sup>. Randomized controlled trials are needed to confirm these findings.</div></div><div><h3>Plain-Language Summary</h3><div>Current guidance recommends against the use of metformin in people with advanced kidney impairment despite a lack of evidence. It is therefore currently unclear how the decision to stop versus continue metformin in patients who reach stage 4 CKD impacts their risk of mortality and cardiovascular events. This study showed that stopping metformin after reaching stage 4 CKD was associated with reduced survival that did not appear to be mediated by an increase in adverse cardiovascular outcomes. These findings may support the continued use of metformin in patients with advanced kidney impairment, but further research is neede","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":"85 2","pages":"Pages 196-204.e1"},"PeriodicalIF":9.4,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142611763","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1053/j.ajkd.2024.07.008
Samantha L. Gelfand , Joshua R. Lakin , Mallika L. Mendu
{"title":"Leveraging the End-Stage Renal Disease Patient Life Goals Survey (PaLS) to Improve Quality of Care: Avoiding a “Checkbox Measure”","authors":"Samantha L. Gelfand , Joshua R. Lakin , Mallika L. Mendu","doi":"10.1053/j.ajkd.2024.07.008","DOIUrl":"10.1053/j.ajkd.2024.07.008","url":null,"abstract":"","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":"85 2","pages":"Pages 177-181"},"PeriodicalIF":9.4,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142370733","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}
Pub Date : 2025-02-01DOI: 10.1053/j.ajkd.2024.06.013
Christina Miranda BS
{"title":"Considering Dialysis in Octogenarians and Nonagenarians Living With Kidney Failure","authors":"Christina Miranda BS","doi":"10.1053/j.ajkd.2024.06.013","DOIUrl":"10.1053/j.ajkd.2024.06.013","url":null,"abstract":"","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":"85 2","pages":"Page A12"},"PeriodicalIF":9.4,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142379881","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}
Pub Date : 2025-02-01DOI: 10.1053/j.ajkd.2024.08.003
Sankar D. Navaneethan , Nisha Bansal , Kerri L. Cavanaugh , Alexander Chang , Susan Crowley , Cynthia Delgado , Michelle M. Estrella , Cybele Ghossein , T. Alp Ikizler , Holly Koncicki , Wendy St. Peter , Katherine R. Tuttle , Jeffrey William
The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the 2024 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for the management of chronic kidney disease (CKD). The KDOQI Work Group reviewed the KDIGO guideline statements and practice points and provided perspective for implementation within the context of clinical practice in the United States. In general, the KDOQI Work Group concurs with several recommendations and practice points proposed by the KDIGO guidelines regarding CKD evaluation, risk assessment, and management options (both lifestyle and medications) for slowing CKD progression, addressing CKD-related complications, and improving cardiovascular outcomes. The KDOQI Work Group acknowledges the growing evidence base to support the use of several novel agents such as sodium/glucose cotransporter 2 inhibitors for several CKD etiologies, and glucagon-like peptide 1 receptor agonists and nonsteroidal mineralocorticoid receptor antagonists for type 2 CKD in setting of diabetes. Further, KDIGO guidelines emphasize the importance of team-based care which was also recognized by the work group as a key factor to address the growing CKD burden. In this commentary, the Work Group has also assessed and discussed various barriers and potential opportunities for implementing the recommendations put forth in the 2024 KDIGO guidelines while the scientific community continues to focus on enhancing early identification of CKD and discovering newer therapies for managing kidney disease.
{"title":"KDOQI US Commentary on the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD","authors":"Sankar D. Navaneethan , Nisha Bansal , Kerri L. Cavanaugh , Alexander Chang , Susan Crowley , Cynthia Delgado , Michelle M. Estrella , Cybele Ghossein , T. Alp Ikizler , Holly Koncicki , Wendy St. Peter , Katherine R. Tuttle , Jeffrey William","doi":"10.1053/j.ajkd.2024.08.003","DOIUrl":"10.1053/j.ajkd.2024.08.003","url":null,"abstract":"<div><div>The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the 2024 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for the management of chronic kidney disease (CKD). The KDOQI Work Group reviewed the KDIGO guideline statements and practice points and provided perspective for implementation within the context of clinical practice in the United States. In general, the KDOQI Work Group concurs with several recommendations and practice points proposed by the KDIGO guidelines regarding CKD evaluation, risk assessment, and management options (both lifestyle and medications) for slowing CKD progression, addressing CKD-related complications, and improving cardiovascular outcomes. The KDOQI Work Group acknowledges the growing evidence base to support the use of several novel agents such as sodium/glucose cotransporter 2 inhibitors for several CKD etiologies, and glucagon-like peptide 1 receptor agonists and nonsteroidal mineralocorticoid receptor antagonists for type 2 CKD in setting of diabetes. Further, KDIGO guidelines emphasize the importance of team-based care which was also recognized by the work group as a key factor to address the growing CKD burden. In this commentary, the Work Group has also assessed and discussed various barriers and potential opportunities for implementing the recommendations put forth in the 2024 KDIGO guidelines while the scientific community continues to focus on enhancing early identification of CKD and discovering newer therapies for managing kidney disease.</div></div>","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":"85 2","pages":"Pages 135-176"},"PeriodicalIF":9.4,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142646814","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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