Our shared responsibility: the urgent necessity of global environmentally sustainable kidney care.

In response to Earth's accelerating climate crisis, we, an international group of nephrologists, call on our global community to unite and align kidney care in accordance with United Nation's 26th Conference of the Parties health sector principles. We announce a global and inclusive initiative, "GREEN-K": Global Environmental Evolution in Nephrology and Kidney Care, with a vision of "sustainable kidney care for a healthy planet and healthy kidneys" and mission to "promote and support environmentally sustainable and resilient kidney care globally through advocacy, education, and collaboration." A patient-centric approach that permits climate change mitigation and adaptation is proposed. Multi-stakeholder GREEN-K action and focus areas will include education, sustainable clinical care, and advances toward environmentally sustainable innovations, procurement, and infrastructure. Mindful of the disproportionately high climate impact of kidney therapies, we welcome the opportunity to work together in shared accountability to patients and Earth's natural systems.

Redesigning Kidney Care for the Anthropocene: A New Framework for Planetary Health in Nephrology.

Climate change is one of the greatest threats to human health in the 21st century. The human health impacts of climate change contribute to approximately 1 in 4 deaths worldwide. Health care itself is responsible for approximately 5% of annual global greenhouse gas (GHG) emissions. Canada is a recent signatory of the 26th United Nations Climate Change Conference (COP26) health agreement that is committed to developing low carbon and climate resilient health systems. Kidney care services have a substantial environmental impact and there is opportunity for the kidney care community to climate align clinical care. We introduce a framework of redesigned kidney care and describe examples of low carbon kidney disease management strategies to expand our duty of care to the environment which completes the triple bottom line of optimal patient outcomes and cost effectiveness in the Anthropocene.

Moxifloxacin-Induced Immune-Mediated Thrombocytopenia in a Chronic Kidney Disease Patient Receiving Hemodialysis.

OBJECTIVE: To alert clinicians to a serious complication from a commonly prescribed medication, moxifloxacin. CASE SUMMARY: A 65-year-old male, septic, hemodialysis patient developed thrombocytopenia following exposure to vancomycin, ceftazidime, and moxifloxacin. Drug-specific immunoglobulin testing showed positive autoantibodies against only moxifloxacin, and the probability stratification proposed by Naranjo et al would give this case a score of 7-a probable association between moxifloxacin and the adverse event. DISCUSSION: Idiopathic thrombocytopenic purpura (ITP) results in immune-mediated platelet destruction, with bleeding risk frequently manifested by purpuric skin and mucosal lesions. Although many drugs are associated with ITP, moxifloxacin has only been characterized in 2 previous case reports. This is the first case report where specific immunoglobulin antibody testing showed a positive association between ITP and moxifloxacin. CONCLUSIONS: Moxifloxacin is a commonly prescribed medication because of its wide spectrum of activity, high bioavailability, and convenient dose schedule. Clinicians need to be aware of this little-known side effect of this commonly prescribed antibiotic.

C-reactive protein levels in patients on maintenance hemodialysis: reliability and reflection on the utility of single measurements.

BACKGROUND: Single C-reactive protein (CRP) values have been associated with death and cardiovascular disease in dialysis patients. We prospectively obtained multiple CRP values in stable patients, hypothesizing that values would remain stable in the absence of disease and that a single CRP value would be a reliable marker of risk. METHODS: Four CRP values per week for three consecutive weeks were obtained in 10 clinically stable patients receiving conventional HD. Using prespecified cutoffs of 2.2 and 4.4 mg/l, the frequency of risk misclassification relative to the lowest CRP value obtained was determined. Within and between patient variability was also calculated. RESULTS: The median age was 54 years, and the average duration of dialysis was 41 months. Nine out of ten patients had at least one abnormal CRP value (>2.2 mg/l), six had all values elevated, and seven had an abnormal median CRP. The overall coefficient of reliability was 0.63 (95% CI 0.42-0.87). The misclassification rate varied with cutoff, and ranged from 0-83% and 0-58% using upper limit of normal (ULN) and twice ULN, respectively. The within patient variability was 0.37 for the entire cohort, and 0.33 when three patients with intercurrent acute inflammation were excluded. CONCLUSIONS: CRP exhibits short term variability in HD patients, resulting in a risk of misclassification depending on sampling time and chosen cutoff point. Single CRP values must be interpreted with caution, and multiple measurements, or use of other biomarkers, should be considered.

Outcomes after percutaneous coronary interventions in patients with CKD: improved outcome in the stenting era.

BACKGROUND: Percutaneous coronary intervention (PCI) with stenting reduces adverse events in the general population compared with balloon angioplasty. The benefit of stents in high-risk patients normally excluded from clinical trials has not been well studied. Outcomes after PCIs in patients with chronic kidney disease (CKD) before and after widespread use of stents were compared. METHODS: All patients undergoing PCIs at our center within 2 periods selected for high and low stent use were included. Demographic, kidney and cardiac function, and PCI data were collected. Kaplan-Meier curves were constructed, and Cox proportional hazards analysis was used to assess the effect of high stent use on major adverse cardiac event, a composite of cardiac revascularization, myocardial infarction, or death 3 years after PCI. RESULTS: A total of 1,879 patients (780 patients, low stent use; 1,099 patients, high stent use; 18% and 94.1% stent use, respectively) with a mean age of 63 years, 73% men, and 26% of patients with a glomerular filtration rate less than 60 mL/min were included. At baseline, there was a greater prevalence of severe CKD, cardiac risk factors, and cardiovascular disease in the high-stent-use cohort. Major adverse cardiac events were reduced in the contemporary cohort (hazard ratio, 0.61; 95% confidence interval, 0.52 to 0.72); this benefit extended across all stages of kidney function. CONCLUSION: Patients with CKD undergoing PCI in the stenting era show improved outcomes. Additional studies are needed to determine optimal revascularization strategies in patients with CKD.

What's new in peritoneal dialysis: biocompatibility and continuous flow peritoneal dialysis.

PURPOSE OF REVIEW: This review examines recent developments in the understanding of the effect of conventional, bioincompatible peritoneal dialysis fluids on structural and functional changes in the peritoneal membrane. Emphasis is placed on the clinically relevant outcome of failure of long-term peritoneal dialysis. Therapeutic strategies to prevent technique failure, including the use of new peritoneal dialysis fluids and continuous flow peritoneal dialysis, are explored. RECENT FINDINGS: Long-term (greater than 6 months) exposure to new peritoneal dialysis fluids with physiologic pH, lower lactate concentrations, or lower concentrations of glucose degradation products results in improved leukocyte cytokine release, ultrafiltration, and mesothelial cell mass, respectively. Continuous flow peritoneal dialysis allows efficient small molecule removal using dialysate with lower glucose concentration and possibly less glucose degradation products. Recent technical advances include creation of a double-lumen peritoneal dialysis catheter, and methods of monitoring intra-abdominal pressure and ultrafiltration. SUMMARY: Though initial reports with biocompatible peritoneal dialysis fluids are promising, the efficacy of these new solutions in preventing long-term peritoneal dialysis failure is unproven. Conditions in which new peritoneal dialysis fluids may be beneficial are suggested. Continuous flow peritoneal dialysis requires substantial technical improvements before this technique can be widely accepted.

Should hemoglobin be normalized in patients with chronic kidney disease?

In the last decade the nephrology community has learned much about the impact of anemia on patients with kidney disease. Therapy of anemia can correct many of the symptoms which seriously compromise patient function. Despite the obvious benefits, controversy continues regarding the optimal target hemoglobin concentration both in patients prior to dialysis and in dialysis populations. In this editorial we review the clinical data that contribute to this controversy and the physiologic concepts underlying the treatment of anemia. Furthermore, we discuss the need to individualize hemoglobin targets for specific patient populations and the importance of early identification and treatment of anemia in patients with kidney disease. The economic impact of normalizing hemoglobin with the use of erythropoietin and intravenous or oral iron has affected clinical practice over the last decade. Current guidelines published by Kidney Disease Outcomes and Quality Initiative (KDOQI), the European Working Group on Anemia Management, and the Canadian Society of Nephrology all recommend target hemoglobin concentrations and thresholds for initiation of therapy and also suggest the need for reevaluation of current targets in light of new evidence. This editorial supports those guidelines and challenges the reader to critically evaluate current practice in the context of the accumulating data and the physiologic principles discussed herein. The therapy of anemia in patients with chronic kidney disease (CKD) is becoming increasingly sophisticated and is an essential component of care in patients with CKD. However, the effects of therapy will be most impressive when accompanied by the optimal care of all hemodynamic and metabolic abnormalities that are associated with CKD.