American Journal of Kidney Diseases最新文献

Rational & objective: People with glomerular disease (GN) may be at an increased risk of cancer, but existing studies have not accurately clarified the cancer risk in patients with GN. A better understanding of these risks may inform cancer screening strategies and identify potentially modifiable risk factors. This study sought to identify risk factors for cancer among Canadian patients with GN.

Study design: Retrospective observational cohort study.

Setting & participants: Adults with diagnosed GN (n=4,039) identified using a centralized pathology registry in British Columbia, Canada between 2000 and 2020.

Exposures: Known cancer risk factors, including age, sex, ethnicity, smoking, alcohol abuse, obesity, diabetes, dyslipidemia, hypertension, and cardiovascular disease, as well as GN-related potential risk factors, including GN disease type, estimated glomerular filtration rate (eGFR), and level of proteinuria.

Outcomes: All-cause cancer, excluding non-melanoma skin cancer.

Analytical approach: Standardized incidence ratios (SIRs) were calculated using an age- and sex-matched general population. The time to the first cancer event was modeled using a cause-specific hazards model, with death considered as a competing event.

Results: The mean age of the cohort was 51 years, with 52% of the participants being male. During a median of 7.8 years of follow-up, 384 (9.5%) developed de novo cancer. The 20-year cancer risk was 23%, with an incidence rate 30% higher than the general population (SIR 1.3, 95% CI 1.2-1.4). The risk was most pronounced in patients under 40 years old, almost three-fold higher than the general population (SIR 2.9, 95% CI 1.6-4.6). Significant increases in cancer incidence were observed for lymphoma (SIR 3.5), kidney (SIR 2.6), colorectal (SIR 2.4), and lung cancers (SIR 1.5). Elevated risk was observed both before and after the onset of end-stage kidney disease (ESKD). Age, male sex, baseline eGFR, and GN disease type were independently associated with cancer risk.

Limitations: The lack of immunosuppression data.

Conclusions: Patients with GN have a substantially increased risk of cancer compared to the general population, particularly younger patients who are typically excluded from current screening programs. These findings suggest the need to raise awareness of the cancer risk among people with GN and may inform the further development of tailored cancer screening and prevention strategies, especially among younger adults with GN.

Rationale & objective: Transplant failure is associated with a morbidity burden, increased mortality, and poor quality of life. We have a limited understanding of how patients prepare for transplant failure, when they do so, and what experiences and priorities are relevant to clinical management decisions when transplants are failing. This study investigated the experiences of living with and managing kidney transplant failure among patients, families and friends, and healthcare professionals (HCPs).

Study design: Qualitative semi-structured interview study.

Setting & participants: Three groups of adults sampled from 3 UK hospitals: a) People with a failing kidney transplant or one that had failed in the last year; b) family/friends of group (a); b) kidney transplant HCPs.

Analytical approach: Inductive analysis based in constructivist grounded theory.

Results: 41 participants were interviewed (15 people with failing/failed transplants, 9 family/friends, 17 HCPs). We identified 8 theoretical categories under 3 headings. First, the experience of waiting: 1) a constant threat: anticipation of failure; 2) lack of preparedness; 3) liminality: an indeterminate and in-between state. Second, shaping conversations about failing transplants: 4) navigating uncertainty; 5) responsibility and control; 6) failing to acknowledge failure: 'the elephant in the room'. Third, the focus on the failing transplant: 7) maximizing mileage and missed opportunities; 8) the ripple effect of failure and family suffering. 'Duality' emerged as the core category describing findings which appeared to be in opposition, but which were experienced or delivered simultaneously. Patients experienced failure as an inevitability and a surprise, and felt both responsible for and a lack of control over the transplant outcome. HCPs identified a need for parallel planning; simultaneously prolonging transplant survival and planning post-transplant treatment.

Limitations: Adult participants only.

Conclusions: Our study identified targets for improving the experiences of people with transplant failure, related to explicit communication, navigating uncertainty, and parallel planning.

Rationale & objective: Inconsistencies in the association of acute declines in kidney function with longer-term cardiovascular (CV) and kidney outcomes in patients with acute heart failure (AHF) may be due to different approaches to assessing the timing of the decline. This study examined the influence of the timing of acute kidney function decline among patients with AHF on the associations of these declines with mortality, CV outcomes, and long-term kidney function.

Study design: Observational analysis of clinical trial data.

Setting & participants: Participants in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial hospitalized for AHF.

Exposures: Kidney function decline (defined by creatinine increase by ≥0.3 mg/dl, creatinine increase by >50%, and percent creatinine change) at 3 different time points (3-days, 7-days, and 14-days after randomization).

Outcomes: Mortality, a composite of CV mortality or heart failure (HF) hospitalization, incident estimated glomerular filtration rate (eGFR) <30 ml/min/1.73 m², and a >40% eGFR decline.

Analytical approach: Multivariable cause-specific proportional hazards regression models.

Results: Among 3931 patients over a median follow-up of 9.9 months, acute kidney function decline at 3 days was not associated with mortality (HR=0.98 [95% CI 0.88, 1.09] per 30% creatinine increase) or with the composite outcome of CV mortality and HF hospitalization (HR=0.96 [0.89, 1.05]). In contrast, acute kidney function decline at 7 days after randomization was associated with a higher risk of mortality (HR=1.19 [1.10, 1.30] per 30% creatinine increase) and the composite outcome (HR=1.10 [1.03, 1.18]). Acute kidney function decline at 14 days after randomization was also associated with higher risk of mortality (HR=1.27 [1.16, 1.38] per 30% creatinine increase) and the composite outcome (HR=1.15 [1.08, 1.23]). Acute kidney function declines at 3 days, 7 days, and 14 days after randomization were all associated with significantly higher risk of incident eGFR<30 ml/min/1.73 m² and >40% eGFR decline.

Limitations: Limited generalizability from the study of clinical trial participants.

Conclusions: Among patients hospitalized for AHF, incorporating the timing of acute kidney function declines may inform prognostic assessment of CV endpoints. Acute declines in kidney function at all studied time points were associated with longer-term kidney function.