Pub Date : 2024-06-19DOI: 10.1053/j.ajkd.2024.04.017
<div><h3>Rationale & Objective</h3><div>We conducted a prespecified examination of the efficacy and safety of allopurinol and febuxostat administered using a treat-to-target strategy in trial participants with chronic kidney disease (CKD).</div></div><div><h3>Study Design</h3><div>Prespecified subcohort analysis of a randomized controlled trial.</div></div><div><h3>Setting & Participants</h3><div>A substudy of the STOP Gout Trial in participants with CKD. CKD was defined as an estimated glomerular filtration rate (eGFR) 30-59<!--> <!-->mL/min/1.73<!--> <!-->m<sup>2</sup> at baseline.</div></div><div><h3>Exposure</h3><div>Trial participants with CKD and gout and serum urate (SUA) concentration of<!--> <!-->≥6.8<!--> <!-->mg/dL were randomized 1:1 to receive allopurinol or febuxostat. Urate-lowering therapy (ULT) was titrated during weeks 0-24 to achieve a goal SUA of<!--> <!--><6.0<!--> <!-->mg/dL (<5.0<!--> <!-->mg/dL with tophi) (phase 1) and maintained during weeks 25-48 (phase 2). Gout flare was assessed between weeks 49-72 (phase 3).</div></div><div><h3>Outcome</h3><div>Gout flare between weeks 49-72 (phase 3) was the primary outcome. Secondary outcomes included SUA goal achievement and ULT dosing at end of phase 2, and serious adverse events.</div></div><div><h3>Analytical Approach</h3><div>Outcomes between treatment groups were compared using logistic regression models for binary outcomes, and Poisson regression for flare rates. Multivariable models were subsequently used, adjusting for factors identified to be imbalanced by treatment arm.</div></div><div><h3>Results</h3><div>CKD was present in 351 of 940 participants; 277 were assessed for the primary outcome. Fewer patients randomized to allopurinol had a flare during phase 3 (32% vs 45%; <em>P</em> <!-->=<!--> <!-->0.02) despite similar attainment of the SUA goal (79% vs 81%; <em>P</em> <!-->=<!--> <!-->0.6) by the end of phase 2. Acute kidney injury was more common in participants with stage 3 CKD randomized to allopurinol compared with febuxostat.</div></div><div><h3>Limitations</h3><div>Limited power to assess infrequent safety events, largely male, older population.</div></div><div><h3>Conclusions</h3><div>Allopurinol and febuxostat are similarly efficacious and well-tolerated in the treatment of gout in people with CKD when used in a treat-to-target regimen with lower incidence of gout flares in participants randomized to allopurinol.</div></div><div><h3>Plain-Language Summary</h3><div>The STOP Gout Trial was a multicenter, randomized, double-blind, noninferiority, comparative effectiveness trial, which found that allopurinol was noninferior to febuxostat in gout flare prevention and that both medications were similarly efficacious in reaching a serum urate goal when used as part of a treat-to-target approach. A significant proportion of patients with chronic kidney disease (CKD) are afflicted by gout, yet there is a lack of high-quality comparative effectiveness data
理论依据和目标：我们对患有慢性肾脏病（CKD）的试验参与者采用靶向治疗策略服用别嘌醇和非布索坦的疗效和安全性进行了预设检查：随机对照试验的预设子队列分析：STOP痛风试验的一项子研究，研究对象为慢性肾脏病患者。暴露：患有慢性肾脏病和痛风且血清尿酸盐（sUA）浓度≥6.8 mg/dL的试验参与者按1:1比例随机接受别嘌醇或非布司他治疗。降尿酸盐疗法（ULT）在第0-24周期间进行滴定，以达到目标sUA结果：第 49-72 周（第 3 阶段）痛风复发是主要结果。次要结果包括sUA目标的实现、第二阶段结束时的ULT剂量以及严重不良事件（SAE）：分析方法：采用逻辑回归模型对二元结局进行比较，采用泊松回归对复发率进行比较。随后使用多变量模型，对已确定的治疗组失衡因素进行调整：940名参与者中有351人（37.3%）患有慢性肾功能衰竭，其中277人接受了主要结果评估。尽管在第二阶段结束时达到sUA目标的比例相似（79% vs. 81%; p=0.6），但随机接受别嘌醇治疗的患者在第三阶段病情发作的比例较低（32% vs. 45%; p=0.02）。与非布司他相比，急性肾损伤（AKI）在随机接受别嘌醇治疗的CKD 3期患者中更为常见：局限性：评估不常见安全事件的能力有限，主要为男性和老年人群：结论：别嘌醇和非布司他在治疗慢性肾脏病患者痛风的疗效相似，且耐受性良好。
{"title":"Efficacy and Safety of Allopurinol and Febuxostat in Patients With Gout and CKD: Subgroup Analysis of the STOP Gout Trial","authors":"","doi":"10.1053/j.ajkd.2024.04.017","DOIUrl":"10.1053/j.ajkd.2024.04.017","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>We conducted a prespecified examination of the efficacy and safety of allopurinol and febuxostat administered using a treat-to-target strategy in trial participants with chronic kidney disease (CKD).</div></div><div><h3>Study Design</h3><div>Prespecified subcohort analysis of a randomized controlled trial.</div></div><div><h3>Setting & Participants</h3><div>A substudy of the STOP Gout Trial in participants with CKD. CKD was defined as an estimated glomerular filtration rate (eGFR) 30-59<!--> <!-->mL/min/1.73<!--> <!-->m<sup>2</sup> at baseline.</div></div><div><h3>Exposure</h3><div>Trial participants with CKD and gout and serum urate (SUA) concentration of<!--> <!-->≥6.8<!--> <!-->mg/dL were randomized 1:1 to receive allopurinol or febuxostat. Urate-lowering therapy (ULT) was titrated during weeks 0-24 to achieve a goal SUA of<!--> <!--><6.0<!--> <!-->mg/dL (<5.0<!--> <!-->mg/dL with tophi) (phase 1) and maintained during weeks 25-48 (phase 2). Gout flare was assessed between weeks 49-72 (phase 3).</div></div><div><h3>Outcome</h3><div>Gout flare between weeks 49-72 (phase 3) was the primary outcome. Secondary outcomes included SUA goal achievement and ULT dosing at end of phase 2, and serious adverse events.</div></div><div><h3>Analytical Approach</h3><div>Outcomes between treatment groups were compared using logistic regression models for binary outcomes, and Poisson regression for flare rates. Multivariable models were subsequently used, adjusting for factors identified to be imbalanced by treatment arm.</div></div><div><h3>Results</h3><div>CKD was present in 351 of 940 participants; 277 were assessed for the primary outcome. Fewer patients randomized to allopurinol had a flare during phase 3 (32% vs 45%; <em>P</em> <!-->=<!--> <!-->0.02) despite similar attainment of the SUA goal (79% vs 81%; <em>P</em> <!-->=<!--> <!-->0.6) by the end of phase 2. Acute kidney injury was more common in participants with stage 3 CKD randomized to allopurinol compared with febuxostat.</div></div><div><h3>Limitations</h3><div>Limited power to assess infrequent safety events, largely male, older population.</div></div><div><h3>Conclusions</h3><div>Allopurinol and febuxostat are similarly efficacious and well-tolerated in the treatment of gout in people with CKD when used in a treat-to-target regimen with lower incidence of gout flares in participants randomized to allopurinol.</div></div><div><h3>Plain-Language Summary</h3><div>The STOP Gout Trial was a multicenter, randomized, double-blind, noninferiority, comparative effectiveness trial, which found that allopurinol was noninferior to febuxostat in gout flare prevention and that both medications were similarly efficacious in reaching a serum urate goal when used as part of a treat-to-target approach. A significant proportion of patients with chronic kidney disease (CKD) are afflicted by gout, yet there is a lack of high-quality comparative effectiveness data ","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":null,"pages":null},"PeriodicalIF":9.4,"publicationDate":"2024-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141436550","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 : 2024-06-18DOI: 10.1053/j.ajkd.2024.05.003
{"title":"In Reply to “Considerations on Potential Modifiers of Glycated Albumin Levels in Patients With CKD”","authors":"","doi":"10.1053/j.ajkd.2024.05.003","DOIUrl":"10.1053/j.ajkd.2024.05.003","url":null,"abstract":"","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":null,"pages":null},"PeriodicalIF":9.4,"publicationDate":"2024-06-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0272638624008345/pdfft?md5=21b660eda8a78924f5f75a514a775f04&pid=1-s2.0-S0272638624008345-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141433758","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 : 2024-06-18DOI: 10.1053/j.ajkd.2024.04.016
{"title":"Considerations on Potential Modifiers of Glycated Albumin Levels in Patients With CKD","authors":"","doi":"10.1053/j.ajkd.2024.04.016","DOIUrl":"10.1053/j.ajkd.2024.04.016","url":null,"abstract":"","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":null,"pages":null},"PeriodicalIF":9.4,"publicationDate":"2024-06-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0272638624008333/pdfft?md5=921fbdd8d57565b5973797f5814ed069&pid=1-s2.0-S0272638624008333-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141433757","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 : 2024-06-18DOI: 10.1053/j.ajkd.2024.04.005
{"title":"The Case for Incremental Thinking About Kidney Stone Disease","authors":"","doi":"10.1053/j.ajkd.2024.04.005","DOIUrl":"10.1053/j.ajkd.2024.04.005","url":null,"abstract":"","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":null,"pages":null},"PeriodicalIF":9.4,"publicationDate":"2024-06-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0272638624007583/pdfft?md5=7340a62db2f6b394da8df7655082c67c&pid=1-s2.0-S0272638624007583-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141417211","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 : 2024-06-12DOI: 10.1053/j.ajkd.2024.04.010
Rationale & Objective
Exposure to extreme heat events has been linked to increased morbidity and mortality in the general population. Patients receiving maintenance dialysis may be vulnerable to greater risks from these events, but this is not well understood. We characterized the association of extreme heat events and the risk of death among patients receiving dialysis in the United States.
Study Design
Retrospective cohort study.
Setting & Participants
Data from the US Renal Data System were used to identify adults living in US urban settlements prone to extreme heat who initiated maintenance dialysis between 1997 and 2016.
Exposure
An extreme heat event, defined as a time-updated heat index (a humid-heat metric) exceeding 40.6°C for ≥2 days or 46.1°C for ≥1 day.
Outcome
Death.
Analytical Approach
Cox proportional hazards regression to estimate the elevation in risk of death during a humid-heat event adjusted for age, sex, year of dialysis initiation, dialysis modality, poverty level, and climate region. Interactions between humid-heat and these same factors were explored.
Results
Among 945,251 adults in 245 urban settlements, the mean age was 63 years, and 44% were female. During a median follow-up period of 3.6 years, 498,049 adults were exposed to at least 1 of 7,154 extreme humid-heat events, and 500,025 deaths occurred. In adjusted models, there was an increased risk of death (hazard ratio 1.18 [95% CI, 1.15-1.20]) during extreme humid-heat exposure. The relative mortality risk was higher among patients living in the Southeast (P < 0.001) compared with the Southwest.
Limitations
Possibility of exposure misclassification, did not account for land use and air pollution co-exposures.
Conclusions
This study suggests that patients receiving dialysis face an increased risk of death during extreme humid-heat exposure.
Plain-Language Summary
Patients who receive dialysis are vulnerable to extreme weather events, and rising global temperatures may bring more frequent extreme heat events. We sought to determine whether extreme heat exposure was associated with an increased risk of death in urban-dwelling patients receiving dialysis across the United States. We found that people receiving dialysis were more likely to die during extreme humid-heat events, defined by a heat index exceeding 40.6°C (105°F) for ≥2 days or 46.1°C (115°F) for ≥1 day. These findings inform the nephrology community about the potential importance of protecting patients receiving maintenance dialysis from the risks associated with extreme heat.
{"title":"Extreme Humid-Heat Exposure and Mortality Among Patients Receiving Dialysis","authors":"","doi":"10.1053/j.ajkd.2024.04.010","DOIUrl":"10.1053/j.ajkd.2024.04.010","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>Exposure to extreme heat events has been linked to increased morbidity and mortality in the general population. Patients receiving maintenance dialysis may be vulnerable to greater risks from these events, but this is not well understood. We characterized the association of extreme heat events and the risk of death among patients receiving dialysis in the United States.</div></div><div><h3>Study Design</h3><div>Retrospective cohort study.</div></div><div><h3>Setting & Participants</h3><div>Data from the US Renal Data System were used to identify adults living in US urban settlements prone to extreme heat who initiated maintenance dialysis between 1997 and 2016.</div></div><div><h3>Exposure</h3><div>An extreme heat event, defined as a time-updated heat index (a humid-heat metric) exceeding 40.6°C for<!--> <!-->≥2 days or 46.1°C for<!--> <!-->≥1<!--> <!-->day.</div></div><div><h3>Outcome</h3><div>Death.</div></div><div><h3>Analytical Approach</h3><div>Cox proportional hazards regression to estimate the elevation in risk of death during a humid-heat event adjusted for age, sex, year of dialysis initiation, dialysis modality, poverty level, and climate region. Interactions between humid-heat and these same factors were explored.</div></div><div><h3>Results</h3><div>Among 945,251 adults in 245 urban settlements, the mean age was 63 years, and 44% were female. During a median follow-up period of 3.6 years, 498,049 adults were exposed to at least 1 of 7,154 extreme humid-heat events, and 500,025 deaths occurred. In adjusted models, there was an increased risk of death (hazard ratio 1.18 [95% CI, 1.15-1.20]) during extreme humid-heat exposure. The relative mortality risk was higher among patients living in the Southeast (<em>P</em> <!--><<!--> <!-->0.001) compared with the Southwest.</div></div><div><h3>Limitations</h3><div>Possibility of exposure misclassification, did not account for land use and air pollution co-exposures.</div></div><div><h3>Conclusions</h3><div>This study suggests that patients receiving dialysis face an increased risk of death during extreme humid-heat exposure.</div></div><div><h3>Plain-Language Summary</h3><div>Patients who receive dialysis are vulnerable to extreme weather events, and rising global temperatures may bring more frequent extreme heat events. We sought to determine whether extreme heat exposure was associated with an increased risk of death in urban-dwelling patients receiving dialysis across the United States. We found that people receiving dialysis were more likely to die during extreme humid-heat events, defined by a heat index exceeding 40.6°C (105°F) for<!--> <!-->≥2 days or 46.1°C (115°F) for<!--> <!-->≥1<!--> <!-->day. These findings inform the nephrology community about the potential importance of protecting patients receiving maintenance dialysis from the risks associated with extreme heat.</div></div>","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":null,"pages":null},"PeriodicalIF":9.4,"publicationDate":"2024-06-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141320427","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 : 2024-06-12DOI: 10.1053/j.ajkd.2024.04.012
<div><h3>Rationale & Objective</h3><div>Prolonged end-stage kidney disease (ESKD) is a risk factor for frailty, and the number of patients in Japan receiving maintenance dialysis for more than 20 years is large and growing. This study characterized the association of dialysis vintage and frailty among patients receiving dialysis in Japan.</div></div><div><h3>Study Design</h3><div>Cross-sectional study.</div></div><div><h3>Setting & Participants</h3><div>Patients with ESKD aged over 50 years who received maintenance dialysis in 2018 as represented in the JSDT Renal Data Registry database (n = 227,136).</div></div><div><h3>Exposure</h3><div>Dialysis vintage categorized as: 0-<5 years, 5-<10 years, 10-<20 years, 20-<30 years, and over 30 years.</div></div><div><h3>Outcome</h3><div>Frailty and bedridden status were defined as graded<!--> <!-->≥2 and graded 4, respectively, according to the Eastern Cooperative Oncology Group Performance Status scale.</div></div><div><h3>Analytical Approach</h3><div>Poisson regression models with robust error variance adjusted for potential covariates were used to estimate the adjusted prevalence ratios (APRs) for frailty and bedridden status. Clinical characteristics of patients undergoing dialysis for<!--> <!-->≥<!--> <!-->30 years were also described.</div></div><div><h3>Results</h3><div>Among the study cohort, 5,510 patients (2.4%) had been undergoing dialysis for 30 years or more. The prevalence of frailty in the group with over 30 years of dialysis history was 36.2%, and the rate of being bedridden was 6.4%. Compared with<!--> <!--><5 years, dialysis vintages of 5-<10 years, 10-<20 years, 20-<30 years, and over 30 years were associated with frailty (APR, 1.06 [95% CI, 1.05-1.08], 1.10 [95% CI, 1.08-1.11], 1.14 [95% CI, 1.10-1.17], and 1.67 [95% CI, 1.60-1.73]), respectively. Compared with<!--> <!--><5 years, dialysis vintages of 5-<10 years, 10-<20 years, 20-<30 years, and over 30 years were associated with being bedridden (APR, 1.17 [95% CI, 1.13-1.22], 1.26 [95% CI, 1.20-1.31], 1.17 [95% CI, 1.08-1.26], and 1.66 [95% CI, 1.49-1.86], respectively.</div></div><div><h3>Limitations</h3><div>Patients receiving short-term dialysis may have more unmeasured comorbidities compared with patients receiving long-term dialysis.</div></div><div><h3>Conclusions</h3><div>Long-term dialysis therapy, particularly exceeding 30 years, is associated with deterioration of physical function and frailty.</div></div><div><h3>Plain-Language Summary</h3><div>End-stage kidney disease increases the risk of frailty. Understanding how long-term dialysis affects physical function may help patients and caregivers plan their lives better. Our research explores the relationship between duration of maintenance dialysis and frailty. We found that longer durations of maintenance dialysis, especially longer than 30 years, were associated with a higher risk of frailty and being bedridden among Japanese pati
{"title":"Frailty and Duration of Maintenance Dialysis: A Japanese Nationwide Cross-Sectional Study","authors":"","doi":"10.1053/j.ajkd.2024.04.012","DOIUrl":"10.1053/j.ajkd.2024.04.012","url":null,"abstract":"<div><h3>Rationale & Objective</h3><div>Prolonged end-stage kidney disease (ESKD) is a risk factor for frailty, and the number of patients in Japan receiving maintenance dialysis for more than 20 years is large and growing. This study characterized the association of dialysis vintage and frailty among patients receiving dialysis in Japan.</div></div><div><h3>Study Design</h3><div>Cross-sectional study.</div></div><div><h3>Setting & Participants</h3><div>Patients with ESKD aged over 50 years who received maintenance dialysis in 2018 as represented in the JSDT Renal Data Registry database (n = 227,136).</div></div><div><h3>Exposure</h3><div>Dialysis vintage categorized as: 0-<5 years, 5-<10 years, 10-<20 years, 20-<30 years, and over 30 years.</div></div><div><h3>Outcome</h3><div>Frailty and bedridden status were defined as graded<!--> <!-->≥2 and graded 4, respectively, according to the Eastern Cooperative Oncology Group Performance Status scale.</div></div><div><h3>Analytical Approach</h3><div>Poisson regression models with robust error variance adjusted for potential covariates were used to estimate the adjusted prevalence ratios (APRs) for frailty and bedridden status. Clinical characteristics of patients undergoing dialysis for<!--> <!-->≥<!--> <!-->30 years were also described.</div></div><div><h3>Results</h3><div>Among the study cohort, 5,510 patients (2.4%) had been undergoing dialysis for 30 years or more. The prevalence of frailty in the group with over 30 years of dialysis history was 36.2%, and the rate of being bedridden was 6.4%. Compared with<!--> <!--><5 years, dialysis vintages of 5-<10 years, 10-<20 years, 20-<30 years, and over 30 years were associated with frailty (APR, 1.06 [95% CI, 1.05-1.08], 1.10 [95% CI, 1.08-1.11], 1.14 [95% CI, 1.10-1.17], and 1.67 [95% CI, 1.60-1.73]), respectively. Compared with<!--> <!--><5 years, dialysis vintages of 5-<10 years, 10-<20 years, 20-<30 years, and over 30 years were associated with being bedridden (APR, 1.17 [95% CI, 1.13-1.22], 1.26 [95% CI, 1.20-1.31], 1.17 [95% CI, 1.08-1.26], and 1.66 [95% CI, 1.49-1.86], respectively.</div></div><div><h3>Limitations</h3><div>Patients receiving short-term dialysis may have more unmeasured comorbidities compared with patients receiving long-term dialysis.</div></div><div><h3>Conclusions</h3><div>Long-term dialysis therapy, particularly exceeding 30 years, is associated with deterioration of physical function and frailty.</div></div><div><h3>Plain-Language Summary</h3><div>End-stage kidney disease increases the risk of frailty. Understanding how long-term dialysis affects physical function may help patients and caregivers plan their lives better. Our research explores the relationship between duration of maintenance dialysis and frailty. We found that longer durations of maintenance dialysis, especially longer than 30 years, were associated with a higher risk of frailty and being bedridden among Japanese pati","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":null,"pages":null},"PeriodicalIF":9.4,"publicationDate":"2024-06-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141320428","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 : 2024-06-10DOI: 10.1053/j.ajkd.2024.06.001
Monkeypox (mpox) is an orthopoxviral zoonotic disease with a similar but less severe clinical presentation as smallpox. However, immunocompromised patients such as solid organ transplant recipients are at higher risk of developing severe forms of the disease. Herein, we describe the case of a 43-year-old female kidney transplant recipient that manifested severe skin ulcers alongside nodular lung opacities and pleural effusion attributed directly to the monkeypox virus. Notwithstanding the initiation of early treatment with tecovirimat, a satisfactory response was not achieved until a reduction in immunosuppression to everolimus monotherapy, coupled with the transition to cidofovir for antiviral treatment. In conclusion, mpox has the potential to produce a severe form of systemic infection in individuals who have undergone solid organ transplantation, demanding a meticulous approach involving sequential antiviral treatment and modifications to immunosuppressive regimens in order to achieve complete healing.
{"title":"Severe Presentation of Mpox With Skin, Lung and Pleural Involvement in a Non–HIV-Infected Kidney Transplant Recipient","authors":"","doi":"10.1053/j.ajkd.2024.06.001","DOIUrl":"10.1053/j.ajkd.2024.06.001","url":null,"abstract":"<div><div>Monkeypox (mpox) is an orthopoxviral zoonotic disease with a similar but less severe clinical presentation as smallpox. However, immunocompromised patients such as solid organ transplant recipients are at higher risk of developing severe forms of the disease. Herein, we describe the case of a 43-year-old female kidney transplant recipient that manifested severe skin ulcers alongside nodular lung opacities and pleural effusion attributed directly to the monkeypox virus. Notwithstanding the initiation of early treatment with tecovirimat, a satisfactory response was not achieved until a reduction in immunosuppression to everolimus monotherapy, coupled with the transition to cidofovir for antiviral treatment. In conclusion, mpox has the potential to produce a severe form of systemic infection in individuals who have undergone solid organ transplantation, demanding a meticulous approach involving sequential antiviral treatment and modifications to immunosuppressive regimens in order to achieve complete healing.</div></div>","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":null,"pages":null},"PeriodicalIF":9.4,"publicationDate":"2024-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141309418","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 : 2024-06-06DOI: 10.1053/j.ajkd.2024.04.008
Benjamin A Goldstein, Dinushika Mohottige, Sophia Bessias, Michael P Cary
There has been a steady rise in the use of clinical decision support (CDS) tools to guide nephrology as well as general clinical care. Through guidance set by federal agencies and concerns raised by clinical investigators, there has been an equal rise in understanding whether such tools exhibit algorithmic bias leading to unfairness. This has spurred the more fundamental question of whether sensitive variables such as race should be included in CDS tools. In order to properly answer this question, it is necessary to understand how algorithmic bias arises. We break down 3 sources of bias encountered when using electronic health record data to develop CDS tools: (1) use of proxy variables, (2) observability concerns and (3) underlying heterogeneity. We discuss how answering the question of whether to include sensitive variables like race often hinges more on qualitative considerations than on quantitative analysis, dependent on the function that the sensitive variable serves. Based on our experience with our own institution's CDS governance group, we show how health system-based governance committees play a central role in guiding these difficult and important considerations. Ultimately, our goal is to foster a community practice of model development and governance teams that emphasizes consciousness about sensitive variables and prioritizes equity.
{"title":"Enhancing Clinical Decision Support in Nephrology: Addressing Algorithmic Bias Through Artificial Intelligence Governance.","authors":"Benjamin A Goldstein, Dinushika Mohottige, Sophia Bessias, Michael P Cary","doi":"10.1053/j.ajkd.2024.04.008","DOIUrl":"10.1053/j.ajkd.2024.04.008","url":null,"abstract":"<p><p>There has been a steady rise in the use of clinical decision support (CDS) tools to guide nephrology as well as general clinical care. Through guidance set by federal agencies and concerns raised by clinical investigators, there has been an equal rise in understanding whether such tools exhibit algorithmic bias leading to unfairness. This has spurred the more fundamental question of whether sensitive variables such as race should be included in CDS tools. In order to properly answer this question, it is necessary to understand how algorithmic bias arises. We break down 3 sources of bias encountered when using electronic health record data to develop CDS tools: (1) use of proxy variables, (2) observability concerns and (3) underlying heterogeneity. We discuss how answering the question of whether to include sensitive variables like race often hinges more on qualitative considerations than on quantitative analysis, dependent on the function that the sensitive variable serves. Based on our experience with our own institution's CDS governance group, we show how health system-based governance committees play a central role in guiding these difficult and important considerations. Ultimately, our goal is to foster a community practice of model development and governance teams that emphasizes consciousness about sensitive variables and prioritizes equity.</p>","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":null,"pages":null},"PeriodicalIF":9.4,"publicationDate":"2024-06-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141293006","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 : 2024-06-06DOI: 10.1053/j.ajkd.2024.03.030
The global burden of kidney disease is increasing, paralleled by a rising number of natural and man-made crises. During these tumultuous times, accessing vital health care resources becomes challenging, posing significant risks to individuals, particularly those with kidney disease. This review delves into the impact of crises on kidney disease, with a particular focus on acute kidney injury (AKI), kidney failure, and kidney transplant. Patients experiencing crush injuries leading to AKI may encounter delayed diagnosis due to the chaotic nature of disasters and limited availability of resources. In chronic crises such as conflicts, patients with kidney failure are particularly affected, and deviations from dialysis standards are unfortunately common, impacting morbidity and mortality rates. Additionally, crises also disrupt access to kidney transplants, potentially compromising transplant outcomes. This review underscores the critical importance of preparedness measures and proactive management for kidney disease in crisis settings. Collaborative efforts among government bodies, rescue teams, health care providers, humanitarian agencies, and nongovernmental organizations are imperative to ensure equitable and reasonable care for kidney disease patients during times of crises, with the aim of saving lives and improving outcomes.
{"title":"Kidney Care in Times of Crises: A Review","authors":"","doi":"10.1053/j.ajkd.2024.03.030","DOIUrl":"10.1053/j.ajkd.2024.03.030","url":null,"abstract":"<div><div>The global burden of kidney disease is increasing, paralleled by a rising number of natural and man-made crises. During these tumultuous times, accessing vital health care resources becomes challenging, posing significant risks to individuals, particularly those with kidney disease. This review delves into the impact of crises on kidney disease, with a particular focus on acute kidney injury (AKI), kidney failure, and kidney transplant. Patients experiencing crush injuries leading to AKI may encounter delayed diagnosis due to the chaotic nature of disasters and limited availability of resources. In chronic crises such as conflicts, patients with kidney failure are particularly affected, and deviations from dialysis standards are unfortunately common, impacting morbidity and mortality rates. Additionally, crises also disrupt access to kidney transplants, potentially compromising transplant outcomes. This review underscores the critical importance of preparedness measures and proactive management for kidney disease in crisis settings. Collaborative efforts among government bodies, rescue teams, health care providers, humanitarian agencies, and nongovernmental organizations are imperative to ensure equitable and reasonable care for kidney disease patients during times of crises, with the aim of saving lives and improving outcomes.</div></div>","PeriodicalId":7419,"journal":{"name":"American Journal of Kidney Diseases","volume":null,"pages":null},"PeriodicalIF":9.4,"publicationDate":"2024-06-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141293008","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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