American Journal of Kidney Diseases最新文献

Sleep disorders are highly prevalent in patients with chronic kidney disease (CKD) but are often under-recognized. The most common sleep disturbances in people with CKD include insomnia, sleep apnea syndrome, restless leg syndrome, and periodic limb movement disorder. The presence of sleep disorders in CKD can further worsen the burden of high morbidity and mortality in a patient population with already high mortality rates. The detection and management of sleep disorders in patients with CKD are often challenging since the classic symptoms of sleep disorders (poor concentration, daytime sleepiness, and insomnia) overlap with CKD symptomatology. The treatment of one symptom may have a negative impact on others; hence treatment of these disorders is challenging and may need to be individualized and modified based on the response to treatment and the development of adverse effects. However, treatment of sleep disorders may have significant clinical benefits leading to improved health-related quality of life. This article presents an overview of sleep disorders in patients with CKD, with emphasis on relevant pathophysiology, diagnosis and treatment strategies.

Rationale & objective: Driven by expanding indications, topiramate and zonisamide utilization has increased over time. This trend may be associated with greater occurrence of kidney stones given the effects of these medications on urine chemistries. We sought to examine the relationship between topiramate and zonisamide use and kidney stone risk.

Study design: Retrospective cohort study.

Setting & participants: Individuals in Optum's de-identified Clinformatics® Data Mart Database (CDM) and Medicare enrollees with at least one prescription filled for topiramate or zonisamide between January 1, 2011 and September 30, 2019, and age- and sex-matched controls.

Exposure: New topiramate or zonisamide use.

Outcome: Symptomatic stone event defined as an emergency department visit, hospitalization, or surgery for kidney stones.

Analytical approach: Cox proportional hazards regression.

Results: Among 1,122,301 study participants, 187,032 filled a prescription for topiramate or zonisamide at some point during the study period. The unadjusted cumulative incidence of symptomatic stone events between three months and three years after the first filled prescription were 2.9% and 2.0% among users of topiramate or zonisamide versus 1.2% and 1.3% among nonusers in the CDM and Medicare cohorts, respectively (P<0.001 for each comparison). After controlling for covariates, users had a significantly higher hazard than nonusers of experiencing a symptomatic stone event (CDM cohort: hazard ratio [HR], 1.58 [95% confidence interval {CI}, 1.49 to 1.68]; Medicare cohort: HR, 1.22 [95% CI, 1.11 to 1.34]). There was a stronger association with stone risk among younger adults receiving either topiramate or zonisamide and the hazard of a symptomatic stone event increased with higher topiramate doses.

Limitations: Potential bias in unmeasured differences between users of topiramate or zonisamide and nonusers. Participants may have been diagnosed with kidney stone disease prior to the study period.

Conclusions: Use of Topiramate or zonisamide was associated with an increased hazard of symptomatic stone events. These finding inform the consideration of risks and benefits of these medications.

Rationale & objective: Women with kidney failure have reduced access to kidney transplantation compared to men. We examined trends in sex inequities in access to transplantation over time.

Study design: Retrospective cohort study.

Setting & participants: 2.3 million adults identified within the United States Renal Data System, aged 18-79 years, who initiated kidney replacement therapy (KRT) between 1997 and 2020.

Exposures: Era of KRT (1997-2000, 2001-2004, 2005-2008, 2009-2012, 2013-2016, or 2017-2020), Sex (male or female).

Outcomes: Placement onto the kidney transplant waitlist or LDKT among all individuals initiating KRT, and DDKT among patients on the waitlist.

Analytical approach: Multivariable cause-specific hazard models to analyze the association between sex and placement onto the waitlist, LDKT, and DDKT, by era, overall, and by categories of age, race, and cause of kidney failure.

Results: Sex inequities in waitlisting became less pronounced over time. During 1997-2000 the adjusted hazard ratio comparing men to women was 0.81; 95%CI: [0.79-0.83]) and by 2017-2020, narrowed to 0.86 [0.85-0.87]). For the outcome of LDKT, during 1997-2000, the adjusted hazard ratio comparing men to women was (0.89 [0.85-0.93]) and by 2017-2020, widened to 0.79 [0.76-0.82]). For the outcome of DDKT, during 1997-2000, the adjusted hazard ratio comparing men to women was (0.92 [0.89-0.95]) and by 2017-2020, widened to (1.16 [1.14-1.19]). Sex inequities in waitlisting and LDKT were greatest in women (vs. men) with diabetes (27% and 37%, respectively in 2017-2020) and older adults 60-79 years (24% and 34%, respectively in 2017-2020), but broadly similar across race groups.

Limitations: Residual confounding; unknown true medical eligibility for transplant.

Conclusions: Since 1997, sex inequities in waitlisting have improved but remain significant, especially for women who are older, and with diabetes-attributed kidney failure. Worsening sex inequities in LDKT among women and DDKT among waitlisted men, warrant further study.