Secular Trend in GFR Decline in Non-Dialysis CKD Based on Observational Data From Standard of Care Arms of Trials.

RATIONALE & OBJECTIVE: The standard of care (SoC) group of randomized controlled trials (RCTs) is a useful setting to explore the secular trends in kidney disease progression because implementation of best clinical practices is pursued for all patients enrolled in trials. This meta-analysis evaluated the secular trend in the change of glomerular filtration rate (GFR) decline in the SoC arm of RCTs in chronic kidney disease (CKD) published in the last 30 years. STUDY DESIGN: Systematic review and meta-analysis of the SoC arms of RCTs analyzed as an observational study. SETTING & STUDY POPULATIONS: Adult patients with CKD enrolled in the SoC arm of RCTs. SELECTION CRITERIA FOR STUDIES: Phase 3 RCTs evaluating GFR decline as an outcome in SoC arms. DATA EXTRACTION: Two independent reviewers evaluated RCTs for eligibility and extracted relevant data. ANALYTICAL APPROACH: The mean of GFR declines extracted in the SoC arm of selected RCTs were pooled by using a random effects model. Meta-regression analyses were performed to identify factors that may explain heterogeneity. RESULTS: The SoC arms from 92 RCTs were included in the meta-analysis with a total of 32,202 patients. The overall mean GFR decline was-4.00 (95% CI, -4.55 to-3.44) mL/min/1.73m2 per year in the SoC arms with a high level of heterogeneity (I2, 98.4% [95% CI, 98.2-98.5], P<0.001). Meta-regression analysis showed an association between publication year (ß estimate, 0.09 [95% CI, 0.032-0.148], P=0.003) and reduction in GFR over time. When evaluating publication decade categorically, GFR decline was-5.44 (95% CI, -7.15 to-3.73), -3.92 (95% CI, -4.82 to-3.02), and -3.20 (95% CI, -3.75 to -2.64) mL/min/1.73m2 per year during 1991-2000, 2001-2010, and 2011-2023, respectively. Using meta-regression, the heterogeneity of GFR decline was mainly explained by age and proteinuria. LIMITATIONS: Different methods assessing GFR in selected trials and observational design of the study. CONCLUSIONS: In the last 3 decades, GFR decline has decreased over time in patients enrolled in RCTs who received the standard of care. TRIAL REGISTRATION: Registered at PROSPERO with record number CRD42022357704. PLAIN-LANGUAGE SUMMARY: This study evaluated the secular trend in the change in glomerular filtration rate (GFR) decline in the placebo arms of randomized controlled trials (RCTs) that were studying approaches to protect the kidneys in the setting of chronic kidney disease. The placebo groups of RCTs are useful for examining whether the rate of progression of kidney disease has changed over time. We found an improvement in the slope of change in GFR over time. These findings suggest that adherence to standards of kidney care as implemented in clinical trials may be associated with improved clinical outcomes, and these data may inform the design of future RCTs in nephrology.

Volume-Independent Sodium Toxicity in Peritoneal Dialysis: New Insights from Bench to Bed.

Sodium overload is common in end-stage kidney disease (ESKD) and is associated with increased cardiovascular mortality that is traditionally considered a result of extracellular volume expansion. Recently, sodium storage was detected by Na23 magnetic resonance imaging in the interstitial tissue of the skin and other tissues. This amount of sodium is osmotically active, regulated by immune cells and the lymphatic system, escapes renal control, and, more importantly, is associated with salt-sensitive hypertension. In chronic kidney disease, the interstitial sodium storage increases as the glomerular filtration rate declines and is related to cardiovascular damage, regardless of the fluid overload. This sodium accumulation in the interstitial tissues becomes more significant in ESKD, especially in older and African American patients. The possible negative effects of interstitial sodium are still under study, though a higher sodium intake might induce abnormal structural and functional changes in the peritoneal wall. Interestingly, sodium stored in the interstial tissue is not unmodifiable, since it is removable by dialysis. Nevertheless, the sodium removal by peritoneal dialysis (PD) remains challenging, and new PD solutions are desirable. In this narrative review, we carried out an update on the pathophysiological mechanisms of volume-independent sodium toxicity and possible future strategies to improve sodium removal by PD.

[Peritoneal dialysis catheter infection with abscess of the abdominal wall in a ADPKD patient].

Infections to the peritoneal catheter are common in Peritoneal Dialysis (PD). We report the clinical case of a 49-year-old male patient in PD, who showed an atypical manifestation of tunnel infection caused by Staphylococcus aureus. The infection was characterized by a little abscess, on the left pararectal abdominal line, 6 cm far from exit-site of the peritoneal catheter. The diagnosis was made using ultrasonography (US), which showed a fistulous communication from subcutaneous cuff to the skin. We treated the infection conservatively by performing cuff-shaving and drainage of the abscess, associated to antibiotic therapy (teicoplanin). Due to the persistence of the infection, we added oral and topical rifampicin, and advanced medication with freez-dried collagen plant impregnated with extended-release gentamicin. The complete resolution of the infection allowed us to avoid removing the catheter.

[Role of Ambulatory Blood Pressure Monitoring (ABPM) in chronic kidney patients: a review].

About 90%of patients with chronic kidney disease (CKD) have arterial hypertension; the main international guidelines recommend maintaining blood pressure (BP) values below 130/80 mmHg to reduce the cardio-renal risk in this population. Twenty-four-hour Ambulatory Blood Pressure Monitoring (ABPM) is the golden standard for the identification of the BP profiles and patterns, as well as for the assessment of the circadian rhythm and BP variability. The correct interpretation of ABPM allows to optimize anti-hypertensive treatment and to reduce cardio-renal risk in CKD patient. In fact, in patients with CKD, the ABPM has a greater role in terms of renal and cardio-vascular prognosis when compared to clinical BP measurements. Patients with ABPM in target present a low cardio-renal risk, regardless of clinical BP values; on the contrary, if the clinical PA is normal and the ABPM not in target, this risk increases significantly. Moreover, in the CKD population, non-dipping is associated with a higher risk of cardiovascular events and end stage renal disease (ESRD), making identifying nocturnal hypertension greatly important. Therefore, ABPM is an instrument of primary importance in the diagnostic and therapeutic work-out of renal patients.