Effectiveness of patient decision aids in patients with advanced kidney disease: a meta-analysis based on randomized controlled trials.

PURPOSE: To systematically evaluate the decision effectiveness of patient decision aids (PtDAs) on the decision-making effect of patients with advanced chronic kidney disease. METHOD: Two authors independently searched ten electronic databases [Web of science, PubMed, the Cochrane Library, Embase, CINAHL, EBSCO, CBM, CNKI, WanFang DATA and Vip database], to include randomized controlled trials of interventions through PtDAs in patients with advanced chronic kidney disease published from the inception of the database until April 2024. Two authors conducted a comprehensive quality evaluation (Cochrane 5.1.0) before independently extracting and analyzing the data with RevMan 5.2. RESULTS: The study included 11 randomized controlled trials with a total of 1613 patients. According to the results, PtDAs can improve the decision knowledge [SMD = 0.53, 95% CI (0.26, 0.80), P = 0.0002] and decision preparation [SMD = 2.34, 95% CI (2.04, 2.65), P < 0.00001] of patients with advanced chronic kidney disease. Additionally, there was a substantial decrease in the levels of decision regret [SMD = - 1.33, 95% CI (- 2.11, - 0.55), P < 0.05] and decision conflict [SMD = - 0.88, 95% CI (- 1.47, - 0.28), P = 0.004]. CONCLUSION: The current available evidence indicates that PtDAs can significantly enhance the decision knowledge and decision preparation of patients with advanced chronic kidney disease. Additionally, PtDAs can reduce the levels of decision regret and decision conflict. TRIAL REGISTRY: CRD42023433798.

Accelerated idioventricular rhythm as a manifestation of chronic renocardiac syndrome: A case report.

In this case report, we describe a patient who presented with chronic symptoms and signs of uremia and persistent accelerated idioventricular rhythm (AIVR) on electrocardiogram. Findings from blood tests, echocardiography, renal ultrasound, and renal scan were suggestive of heart failure with reduced ejection fraction and chronic kidney disease, and attendance of daily hemodialysis sessions led to the restoration of sinus rhythm. Typically, AIVR has a favorable prognosis and, if necessary, medical intervention focuses on addressing the underlying responsible causes. Accumulation of uremic toxins has the potential to trigger the formation of AIVR and clearance of small solutes through conventional hemodialysis may contribute to sinus rhythm restoration.

Contrast-induced encephalopathy in patients with advanced chronic kidney disease: What the nephrologist needs to know.

Contrast-induced encephalopathy is a neurological complication related to contrast used in endovascular procedures or computed tomography (CT). The main risk factors are arterial hypertension, diabetes mellitus, chronic kidney disease (CKD), hyperosmolar contrasts, the amount of infused contrast and its direct infusion in the posterior cerebral territory, or pathologies with blood-brain barrier damage. Symptomatology is non-specific and may present as altered level of consciousness, neurological focality or seizures. Diagnosis is done by exclusion after ischemic or hemorrhagic stroke has been ruled out; CT or MRI are useful for differentiation. Generally, it appears shortly after exposure and the symptoms lasts 48-72h with complete recovery, although cases with persistence of symptoms or longer duration have been described. Treatment consists of monitoring, supportive measures and kidney replacement therapy (KRT) with hemodialysis (HD) in patients in chronic KRT program. It is important for the nephrologist to be aware of this entity given the susceptibility of the patient on HD as well as its potential therapeutic role in these patients.

Multi-year population-based analysis of Asian patients with acute decompensated heart failure and advanced chronic kidney disease.

BACKGROUND: Data on disparities in outcomes and risk factors in Asian patients with advanced chronic kidney disease admitted for heart failure are scare. METHODS: This was a retrospective cohort study that utilized data from the National Inpatient Sample between January 2016 and December 2019. Patients who had a primary diagnosis of acute decompensated heart failure and a concomitant diagnosis of advanced CKD were included. The primary outcome of interest was in-hospital mortality. Secondary outcomes include hospital cost, length of stay, and other clinical outcomes. Weighted multivariable logistic regression was used to adjust for comorbidities. RESULTS: There were 251,578 cases of ADHF with advanced CKD, out of which 2.6 % were from individuals of Asian ethnicity. Asian patients exhibited a higher burden of comorbidities in comparison to other UREM patients, but a lower burden than White patients. Regardless of differences in comorbidity burden, Asian patients exhibited a higher likelihood of experiencing severe consequences. After adjusting for comorbidies, White (OR:1.11; 95 % CI 1.03-1.20;0.009) patients had higher odds of mortality than Asian patients. However, Blacks (OR: 0.58; 95 % CI 0.53 to 0.63; p < 0.001) and Hispanics (OR: 0.69; 95 % CI 0.62 to 0.78; p < 0.001) had lower odds of mortality. CONCLUSION: This first population-based studies shows that Asian patients with advanced CKD admitted for ADHF have greater comorbidity burden and poorer outcomes Black and Hispanic patients. This data underscores the importance of comprehensive approaches in phenotyping, and ethnic specific interventions.

Exploring the factors influencing evidence-based approaches to advanced chronic kidney disease: a qualitative study involving nurses and physicians.

BACKGROUND: Advanced chronic kidney disease (ACKD) is associated with a high risk of adverse cardiovascular and renal events and has a significant impact on quality of life and life expectancy. Several studies have identified areas for improvement in their management in primary care. Some professional and environmental factors can act as key barriers to appropriate care. OBJECTIVE: To analyse attitudes, subjective norms, and perceived behavioural control among primary care professionals related to the implementation of an evidence-based approach for individuals with ACKD in primary care. METHODOLOGY: This was a qualitative study using an interpretative phenomenological approach based on the theory of planned behaviour. Two aspects of the evidence-based approach were explored: the implementation of clinical practice guidelines and the utilisation of electronic kidney disease records within the scope of this study. Primary care nurses and physicians participated in a previous pilot interview and five focus groups. Subsequently, a thematic analysis of the gathered data was conducted. FINDINGS: Thirty-three primary care professionals participated. The emerging themes included: experiences in the management of ACKD (highlighting a distinct profile of older, frail patients with comorbidities masking CKD and a CKD follow-up primarily focused on analytical monitoring and drug adjustment); factors in the professional environment influencing the use of scientific evidence (such as time constraints, excessive electronic health records, and unfamiliar reference guidelines); attitudes towards the application of recommendations on ACKD (recognising limitations of computer systems despite considering them as guidance); and capacities to implement evidence-based recommendations (acknowledging formative needs and challenges in coordinating care with nephrology services). CONCLUSIONS: Several psychological elements identified through the TBP hinder the adequate implementation of an evidence-based approach for individuals with CKD. Attitudes have been identified as factors modulating the use of standardised electronic records. Instead, subjective norms (influences from the professional environment) and perceived behavioral control (perception of capabilities) acted as barriers to the proper application of clinical practice guidelines and standardised records. IMPLICATIONS FOR PRACTICE: Strategies aimed at optimising the management of people with ACKD should focus not only on training but also on improving attitudes, organisational structures, IT systems and coordination between primary care and nephrology.

Association between stopping renin-angiotensin system inhibitors immediately before hemodialysis initiation and subsequent cardiovascular events.

It is controversial whether renin-angiotensin system inhibitors (RASIs) should be stopped in patients with advanced chronic kidney disease (CKD). Recently, it was reported that stopping RASIs in advanced CKD was associated with increased mortality and cardiovascular (CV) events; however, it remains unclear whether stopping RASIs before dialysis initiation affects clinical outcomes after dialysis, which this study aimed to evaluate. In this multicenter prospective cohort study in Japan, we included 717 patients (mean age, 67 years; 68% male) who had a nephrology care duration ≥90 days, initiated hemodialysis, and used RASIs 3 months before hemodialysis initiation. The multivariable adjusted Cox models were used to compare mortality and CV event risk between 650 (91%) patients who continued RASIs until hemodialysis initiation and 67 (9.3%) patients who stopped RASIs. During a median follow-up period of 3.5 years, 170 (24%) patients died and 228 (32%) experienced CV events. Compared with continuing RASIs, stopping RASIs was unassociated with mortality (adjusted hazard ratio [aHR]: 0.82; 95% confidence interval [CI]: 0.50-1.34) but was associated with higher CV events (aHR: 1.59; 95% CI: 1.06-2.38). Subgroup analyses showed that the risk of stopping RASIs for CV events was particularly high in patients aged <75 years, with a significant interaction between stopping RASIs and age. This study revealed that patients who stopped RASIs immediately before dialysis initiation were associated with subsequent higher CV events. Active screening for CV disease may be especially beneficial for these patients.

Treatment of Chronic Heart Failure in Advanced Chronic Kidney Disease: The HAKA Multicenter Retrospective Real-World Study.

INTRODUCTION: Chronic heart failure (HF) has high rates of mortality and hospitalization in patients with advanced chronic kidney disease (aCKD). However, randomized clinical trials have systematically excluded aCKD population. We have investigated current HF therapy in patients receiving clinical care in specialized aCKD units. METHODS: The Heart And Kidney Audit (HAKA) was a cross-sectional and retrospective real-world study including outpatients with aCKD and HF from 29 Spanish centers. The objective was to evaluate how the treatment of HF in patients with aCKD complied with the recommendations of the European Society of Cardiology Guidelines for the diagnosis and treatment of HF, especially regarding the foundational drugs: renin-angiotensin system inhibitors (RASi), angiotensin receptor blocker/neprilysin inhibitors (ARNI), beta-blockers (BBs), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2i). RESULTS: Among 5,012 aCKD patients, 532 (13%) had a diagnosis of HF. Of them, 20% had reduced ejection fraction (HFrEF), 13% mildly reduced EF (HFmrEF), and 67% preserved EF (HFpEF). Only 9.3% of patients with HFrEF were receiving quadruple therapy with RASi/ARNI, BB, MRA, and SGLT2i, but the majority were not on the maximum recommended doses. None of the patients with HFrEF and CKD G5 received quadruple therapy. Among HFmrEF patients, approximately half and two-thirds were receiving RASi and/or BB, respectively, while less than 15% received ARNI, MRA, or SGLT2i. Less than 10% of patients with HFpEF were receiving SGLT2i. CONCLUSIONS: Under real-world conditions, HF in aCKD patients is sub-optimally treated. Increased awareness of current guidelines and pragmatic trials specifically enrolling these patients represent unmet medical needs.

Pruritus associated with chronic kidney disease in hemodialysis patients: a survey in French nephrologists / Prurit associé à la maladie rénale chronique chez les patients hémodialysés : une enquête auprès des néphrologues français

Background: Chronic kidney disease-associated pruritus (CKD-aP) is common in hemodialysis patients and severely impairs their quality of life, but the practices of nephrologists remain poorly known. Methods: The objective of this on-line survey was to describe the management of CKD-aP in French nephrologists affiliated with the French-speaking Society of Nephrology, Dialysis and Transplantation (SFNDT) and involved in hemodialysis. Results: In total, 122 questionnaires were completed and 100 were usable. Nephrologists reported they personally managed a median of 52 patients; they estimated that the CKD-aP prevalence in their hemodialysis patients was a median of 10% (IQR, 6.3-17.2); 6% of nephrologists reported not following any patient with CKD-aP. In case of CKD-aP, the first-intention intervention was the evaluation of phosphocalcic metabolism (53.5%) and verification of dialysis adequacy (52%). For moderate-to-severe CKD-aP, the first-line prescription was topical therapy (71.3%), antihistamine (23.2%) and membrane change (15.9%). Patients were referred to a dermatologist mainly in case of treatment failure (86.9%) or scratching lesions (40.4%). Available treatments were considered ineffective for 50.5% of nephrologists, partially effective for 45.5% and effective for only 4%. Conclusion: These results show that according to the opinion of nephrologists, the pruritus prevalence is low in dialysis patients. This is inconsistent with studies based on systematic patient interviews, thus suggesting that pruritus is a symptom overlooked by nephrologists. In the context of the arrival of a new drug for pruritus, patients should be more questioned about this symptom in order to propose this treatment.

Introduction: Le prurit associé à l'insuffisance rénale chronique (Pa-IRC) est fréquent chez les patients hémodialysés et altère gravement leur qualité de vie, mais les pratiques des néphrologues restent mal connues. Méthodes: L'objectif de cette enquête en ligne était de décrire la prise en charge du Pa-IRC par les néphrologues français hémodialyseurs affiliés à la Société francophone de néphrologie, dialyse et transplantation (SFNDT). Résultats: Au total, 122 questionnaires ont été remplis et 100 étaient utilisables. Les néphrologues suivaient personnellement 52 patients (médiane). Ils estimaient que la prévalence du Pa-IRC chez ces patients était de 10 % (médiane ; écart interquartile : 6,3-17,2) ; 6 % des néphrologues ont déclaré ne suivre aucun patient atteint de Pa-IRC. En cas de Pa-IRC, l'intervention de première intention était l'évaluation du métabolisme phosphocalcique (53,5 %) et la vérification de la qualité de dialyse (52 %). Pour le Pa-IRC modéré à sévère, la prescription de première intention était un traitement topique (71,3 %), un antihistaminique (23,2 %) et un changement de membrane (15,9 %). Les traitements disponibles étaient considérés comme inefficaces pour 50,5 % des néphrologues, partiellement efficaces pour 45,5 % et efficaces pour seulement 4 %. Conclusion: Ces résultats montrent que selon l'opinion des néphrologues, la prévalence du prurit est faible chez les patients dialysés. Ceci est en contradiction avec les études basées sur des entretiens systématiques avec les patients, suggérant ainsi que le prurit est un symptôme sous-estimé par les néphrologues. Dans le contexte de l'arrivée d'un nouveau médicament pour le prurit, les patients devraient être davantage interrogés sur ce symptôme afin de proposer ce traitement.

Nationwide in-hospital mortality and morbidity analysis of COVID-19 in advanced chronic kidney disease, dialysis and kidney transplant recipients.

Background: Patients with advanced chronic kidney disease (CKD), end-stage kidney disease (ESKD), and kidney transplants (KT) are at an elevated risk for COVID-19 infection, hospitalization, and mortality. A comprehensive comparison of morbidity and mortality between these populations with kidney disease and individuals without any kidney disease is lacking. Methods: We analysed the 2020 Nationwide Inpatient Sample (NIS) database for non-elective adult COVID-19 hospitalizations, categorizing patients into advanced CKD, ESKD, KT, and kidney disease-free cohorts. Our analysis included a description of the distribution of comorbidities across the entire spectrum of CKD, ESKD, and KT. Additionally, we investigated in-hospital mortality, morbidity, and resource utilization, adjusting for potential confounders through multivariable regression models. Results: The study included 1,018,915 adults hospitalized for COVID-19 in 2020. The incidence of advanced CKD, ESKD, and KT in this cohort was 5.8%, 3.8%, and 0.4%, respectively. Patients with advanced CKD, ESKD, and KT exhibited higher multimorbidity burdens, with 90.3%, 91.0%, and 75.2% of patients in each group having a Charlson comorbidity index (CCI) equal to or greater than 3. The all-cause in-hospital mortality ranged from 9.3% in kidney disease-free patients to 20.6% in advanced CKD, 19.4% in ESKD, and 12.4% in KT patients. After adjusting for potential confounders at both the patient and hospital levels, CKD stages 3-5; ESKD; and KT were found to be associated with increased odds of mortality, with adjusted odds ratios (aOR) of 1.34, 1.80, 2.66, 1.97, and 1.69, respectively. Conclusion: Patients hospitalized for COVID-19 with advanced CKD, ESKD, or KT demonstrated a higher burden of comorbidities and increased mortality rates compared to those without kidney disease. After adjusting for confounders, CKD stages 3-5; ESKD; and KT were identified as independent risk factors for in-hospital mortality, illustrating a dose-response relationship between the odds of mortality and adverse outcomes as CKD progressed from stages 3 to 5. Our study highlights the necessity for enhanced management of comorbidities, targeted interventions, and vigorous vaccination efforts to mitigate the risk of adverse outcomes in the vulnerable populations of patients with CKD, ESKD, and KT.

Gaps in Modern Heart Failure and Chronic Kidney Disease Research.

Heart failure and chronic kidney disease are common conditions and often coexist. Modern clinical trials are not entirely representative of heart failure patients in the community with respect to age and sex. Despite this, another group of heart failure patients, those with advanced chronic kidney disease, are even less represented in modern clinical trials. This review summarises the evidence for heart failure therapies across age, sex and severity of chronic kidney disease, and outlines the need for further research in these populations.

Hallazgos por ecografía Doppler arterial oftálmica en pacientes con enfermedad renal crónica avanzada / Ophthalmic Arterial Doppler Ultrasound Findings in Patients with Advanced Chronic Kidney Disease

Objetivo: Determinar los hallazgos por ecografía Doppler arterial oftálmica en pacientes con enfermedad renal crónica avanzada. Métodos: Se efectuó un estudio observacional descriptivo y transversal con 212 órbitas de 106 pacientes con enfermedad renal crónica avanzada (estadios 4 y 5 en tratamiento dialítico). Por interrogatorio y examen físico se identificaron los factores de riesgo aterosclerótico. Además, se realizó ultrasonido orbitario y Doppler carotídeo, y solo en caso de resultar normales, se procedió a evaluar mediante ecografía Doppler las arterias oftálmicas. Resultados: Predominaron los pacientes mayores de 50 años, el sexo masculino, el color mestizo de piel y los normopesos; mientras que la hipertensión arterial, el tabaquismo y la diabetes mellitus tipo 2 fueron los factores de riesgo aterosclerótico mayoritarios. En todos los enfermos renales crónicos se demostró un incremento de la velocidad del flujo y de la resistencia vascular a nivel de las arterias oftálmicas, en tanto los casos con hipertensión arterial y diabetes mellitus tipo 2, así como los hipertensos exclusivos, mostraron los valores hemodinámicos más elevados. Conclusiones: La evaluación de las arterias oftálmicas mediante ecografía Doppler permite hacer un estudio y seguimiento más integral de los pacientes con enfermedad renal crónica avanzada(AU)

Objective: To determine ophthalmic arterial Doppler ultrasound findings in patients with advanced chronic kidney disease. Methods: A descriptive and cross-sectional observational study was carried out with 212 orbits of 106 patients with advanced chronic kidney disease (stages 4 and 5 in dialysis treatment). Atherosclerotic risk factors were identified by interrogation and physical examination. In addition, orbital ultrasound and carotid Doppler were performed, and only if they were normal, the ophthalmic arteries were evaluated by Doppler ultrasound. Results: Patients older than 50 years, male sex, mestizo skin color and normal weight predominated, while arterial hypertension, smoking and type 2 diabetes mellitus were the main atherosclerotic risk factors. An increase in flow velocity and vascular resistance at the level of the ophthalmic arteries was demonstrated in all chronic renal patients, while cases with arterial hypertension and type 2 diabetes mellitus, as well as exclusive hypertensives, showed the highest hemodynamic values. Conclusions: The evaluation of the ophthalmic arteries by Doppler ultrasound allows a more comprehensive study and follow-up of patients with advanced chronic kidney disease(AU)

Electronic Phenotype for Advanced Chronic Kidney Disease in a Veteran Health Care System Clinical Database: Systems-Based Strategy for Model Development and Evaluation.

BACKGROUND: Identifying advanced (stages 4 and 5) chronic kidney disease (CKD) cohorts in clinical databases is complicated and often unreliable. Accurately identifying these patients can allow targeting this population for their specialized clinical and research needs. OBJECTIVE: This study was conducted as a system-based strategy to identify all prevalent Veterans with advanced CKD for subsequent enrollment in a clinical trial. We aimed to examine the prevalence and accuracy of conventionally used diagnosis codes and estimated glomerular filtration rate (eGFR)-based phenotypes for advanced CKD in an electronic health record (EHR) database. We sought to develop a pragmatic EHR phenotype capable of improving the real-time identification of advanced CKD cohorts in a regional Veterans health care system. METHODS: Using the Veterans Affairs Informatics and Computing Infrastructure services, we extracted the source cohort of Veterans with advanced CKD based on a combination of the latest eGFR value ≤30 ml·min-1·1.73 m-2 or existing International Classification of Diseases (ICD)-10 diagnosis codes for advanced CKD (N18.4 and N18.5) in the last 12 months. We estimated the prevalence of advanced CKD using various prior published EHR phenotypes (ie, advanced CKD diagnosis codes, using the latest single eGFR <30 ml·min-1·1.73 m-2, utilizing two eGFR values) and our operational EHR phenotypes of a high-, intermediate-, and low-risk advanced CKD cohort. We evaluated the accuracy of these phenotypes by examining the likelihood of a sustained reduction of eGFR <30 ml·min-1·1.73 m-2 over a 6-month follow-up period. RESULTS: Of the 133,756 active Veteran enrollees at North Florida/South Georgia Veterans Health System (NF/SG VHS), we identified a source cohort of 1759 Veterans with advanced nondialysis CKD. Among these, 1102 (62.9%) Veterans had diagnosis codes for advanced CKD; 1391(79.1%) had the index eGFR <30 ml·min-1·1.73 m-2; and 928 (52.7%), 480 (27.2%), and 315 (17.9%) Veterans had high-, intermediate-, and low-risk advanced CKD, respectively. The prevalence of advanced CKD among Veterans at NF/SG VHS varied between 1% and 1.5% depending on the EHR phenotype. At the 6-month follow-up, the probability of Veterans remaining in the advanced CKD stage was 65.3% in the group defined by the ICD-10 codes and 90% in the groups defined by eGFR values. Based on our phenotype, 94.2% of high-risk, 71% of intermediate-risk, and 16.1% of low-risk groups remained in the advanced CKD category. CONCLUSIONS: While the prevalence of advanced CKD has limited variation between different EHR phenotypes, the accuracy can be improved by utilizing two eGFR values in a stratified manner. We report the development of a pragmatic EHR-based model to identify advanced CKD within a regional Veterans health care system in real time with a tiered approach that allows targeting the needs of the groups at risk of progression to end-stage kidney disease.

The 'Phosphorus Week': involvement of Spanish nephrologists in the control of phosphorus blood levels.

BACKGROUND: The adequate control of phosphorus levels is a major concern for professionals involved in the care of patients with chronic kidney disease (CKD), since high phosphorus levels are directly related to an increase in mortality. OBJECTIVES: To know the perception and involvement of Spanish nephrologists on the control of phosphorus levels, the so-called 'Phosphorus Week' was organized (November 13-17, 2017). METHODS: All members of the Spanish Society of Nephrology were invited to participate in an online survey, which included questions on aspects related to phosphorus control in patients with advanced CKD (aCKD) (glomerular filtration rate <30 ml/min/1, 73 m2) and in the different modalities of renal replacement therapies [peritoneal dialysis (PD), hemodialysis (HD) and renal transplantation (KT)]. RESULTS: 72 data entries were obtained in the survey with an inclusion of 7463 patients. Of them, 35.4% were on HD, 34.8% were KT, 24.2% had aCKD and 5.5% were on PD. The serum phosphorus level target for the four groups of patients was 4.5 mg/dl, with minimal variations depending on the area of ​​the national territory. The patients with better control of phosphataemia were patients with KT (93.3% had phosphorus values ​​<4.5 mg/dl), followed by patients with aCKD (65.6% with phosphorus <4.5 mg/dl). Only 53.6% of the patients on HD and 39.4% of those on PD reached the phosphorus goal <4.5 mg/dl. The group of patients on dialysis was the one in whom phosphorus binders prescribed the most (73.5% and 75.6% in HD and PD, respectively), being less frequent in patients with patients with aCKD (39.9%) and only 4.5 % in KT. CONCLUSIONS: The objectives of the Spanish nephrologists are in line with those recommended by the national and international clinical guidelines; however, there is still a wide room for improvement to achieve these goals, especially in HD and PD patients.

Analysis of risk factors for abdominal aortic calcification in dialysis patients and its influence on long-term recovery.

This study investigated the risk factors of abdominal aortic calcification (AAC) in patients with stage 5 chronic kidney disease (CKD) and the effects of AAC and different dialysis methods on the 3-year survival rate of patients with stage 5 CKD. A retrospective cohort study was conducted on stage 5 CKD patients who received dialysis treatment. The general data were collected, and all fasting venous blood samples were harvested before the first dialysis to detect biochemical markers. The AAC was evaluated by lateral abdominal X-ray. The patients were followed up with a cut-off date of March 31, 2022, with all-cause mortality as the endpoint event. A total of 205 patients were included. multivariable Cox regression analysis confirmed that AAC (hazard ratio (HR) = 2.173, 95% CI 1.029-4.588, p = 0.042), advanced age (HR = 1.061, 95% CI 1.031-1.093, p < 0.001), duration of dialysis (HR = 1.015, 95% CI 1.007-1.032, p < 0.001), diabetes (HR = 3.966, 95% CI 2.164-7.269, p < 0.001), and hypertension (HR = 1.897, 95% CI 1.089-3.303, p = 0.024) were independent risk factors for 3-year mortality. However, peritoneal dialysis (HR = 0.366, 95% CI 0.165-0.812, p = 0.013), high albumin (HR = 0.882, 95% CI 0.819-0.950, p = 0.001), and high hemoglobin (HR = 0.969, 95% CI 0.942-0.997, p = 0.031) were protective factors for 3-year mortality in stage 5 CKD patients. Increased age, long-term dialysis, high level of intact parathyroid hormone, diabetes, and hypertension are closely related to the occurrence of AAC in patients with stage 5 CKD. In addition, AAC is an independent risk factor for all-cause mortality in patients with stage 5 CKD.

Association between GLIM-defined malnutrition and hospitalizations in kidney transplant candidates: A post hoc analysis of a cohort study.

BACKGROUND: Malnutrition is frequent in patients with chronic kidney disease (CKD) and has a negative impact on morbidity, mortality, and quality of life. The objective of this study was to assess the value of the Global Leadership Initiative for Malnutrition (GLIM) criteria to predict hospitalizations and mortality in candidates to kidney transplant during their first year on the waiting list. METHODS: This was a post hoc analysis of 368 patients with advanced CKD. The main study variables were malnutrition, according to the GLIM criteria; number of hospital admissions during the first year on the waiting list; and mortality at the end of follow-up. Kaplan-Meier survival curves and binary logistic regression were performed, adjusting for age, frailty status, handgrip strength, and Charlson Index as potential confounders. RESULTS: The prevalence of malnutrition was 32.6%. Malnutrition was associated with increased risk of hospitalizations during the first year on the waiting list (odds ratio [OR] = 3.33 [95% CI = 1.34-8.26]), which persisted after adjustment for age and frailty status (adjusted OR = 3.61 [95% CI = 1.38-10.7]), age and handgrip strength (adjusted OR = 3.39 [95% CI = 1.3-8.85]), and age and Charlson Index (adjusted OR = 3.25 [95% CI = 1.29-8.13]). CONCLUSION: Malnutrition according to the GLIM criteria was highly prevalent in patients with CKD and was associated with a threefold increased risk of hospitalizations during the first year on the waiting list; these associations remained significant after adjusting for age, frailty status, handgrip strength, and comorbidities.

Determinants of urgent start dialysis in a chronic kidney disease cohort followed by nephrologists.

BACKGROUND: The French Renal Epidemiology and Information Network (REIN) registry collect dialysis initiation context for each patient starting dialysis with a flawed definition of urgent start dialysis (USD). The main objective of this study was to identify factors associated with USD in patients regularly followed-up by a nephrologist using a classification of USD considering the preparation to renal replacement therapy. METHODS: This retrospective cohort study included adult patients who started dialysis between 2012 and 2018 in the Franche-Comté region of France after a minimum of two nephrology consultations. We classified dialysis initiation context as follows: USD for patients with no dialysis access (DA) created or planned, unplanned non urgent start dialysis (UNUSD) for patients starting with a recent or non-functional DA and planned start dialysis (PSD) for those starting with a functional and mature DA. RESULTS: Four hundred and sixty-five patients met inclusion criteria. According to REIN registry, 94 (20.3%) patients were urgent starters (US) whereas with our classification 80 (17.2%) and 73 (15.7%) where respectively US and unplanned non urgent starters (UNUS). The factors independently associated with USD in our classification were: stroke (odds ratio(OR) = 2.76, 95% confidence interval (95%CI)=[1.41-5.43]), cardiac failure (OR = 1.78, 95%CI=[1.07-2.96]) and the number of nephrology consultations prior dialysis onset (OR = 0.73, 95%CI=[0.64-0.83]). Thirty-one patients died during the first year after dialysis start. According to our classification, we observed significantly different survival probabilities: 95.7%, 89.5% and 83.4% respectively for planned starters, UNUS and US (p = 0.001). CONCLUSION: The two factors independently associated with USD were cardiac failure and stroke.

Comprehensive conservative care for the management of advanced chronic kidney disease / Le traitement conservateur dans la prise en charge de la maladie rénale chronique

Comprehensive "conservative care" is defined as any active therapeutic procedure for the management of stage 5 chronic kidney disease without recourse to dialysis. This therapeutic option is discussed in elderly, frail patients whose anticipated life expectancy is reduced with dialysis. The decision for conservative management primarily relies on an informed choice by the patient and his caregivers. This holistic approach, focused on quality of life, requires a multidisciplinary approach. The goals are to slow the progression of kidney disease, prevent complications, anticipate the risks of decompensation, provide support for the patient and his caregivers to maintain the best possible quality of life at home. This article describes the principles of conservative management, highlights various barriers to this care pathway, and proposes potential solutions.

Le « traitement conservateur ¼ se définit comme toute procédure thérapeutique active de prise en charge de la maladie rénale chronique au stade 5, sans recours à la suppléance par dialyse. Cette option thérapeutique est discutée chez des patients âgés, fragiles, dont l'espérance de vie anticipée est réduite en cas de recours à la dialyse. La décision de traitement conservateur repose avant tout sur un choix éclairé du patient et de son entourage. Cette prise en charge holistique, centrée sur la qualité de vie, nécessite une approche multidisciplinaire. Les objectifs sont de ralentir la progression de la maladie rénale, d'en prévenir les complications, d'anticiper les risques de décompensation, d'assurer un soutien au patient et à ses aidants afin de maintenir une qualité de vie la plus acceptable possible à domicile. Cet article décrit les principes du traitement conservateur. Nous mettons en perspective différents freins à ce parcours de soins, ainsi que les solutions qui pourraient être envisagées.

Effect of sodium bicarbonate on cardiovascular outcome and mortality in patients with advanced chronic kidney disease.

Background: Metabolic acidosis is a common complication in patients with chronic kidney disease (CKD). Oral sodium bicarbonate is often used to treat metabolic acidosis and prevent CKD progression. However, there is limited information about the effect of sodium bicarbonate on major adverse cardiovascular events (MACE) and mortality in patients with pre-dialysis advanced CKD. Method: 25599 patients with CKD stage V between January 1, 2001 and December 31, 2019 were identified from the Chang Gung Research Database (CGRD), a multi-institutional electronic medical record database in Taiwan. The exposure was defined as receiving sodium bicarbonate or not. Baseline characteristics were balanced using propensity score weighting between two groups. Primary outcomes were dialysis initiation, all-cause mortality, and major adverse cardiovascular events (MACE) (myocardial infarction, heart failure, stroke). The risks of dialysis, MACE, and mortality were compared between two groups using Cox proportional hazards models. In addition, we performed analyzes using Fine and Gray sub-distribution hazard models that considered death as a competing risk. Result: Among 25599 patients with CKD stage V, 5084 patients (19.9%) were sodium bicarbonate users while 20515 (80.1%) were sodium bicarbonate non-users. The groups had similar risk of dialysis initiation (hazard ratio (HR): 0.98, 95% confidence interval (CI): 0.95-1.02, p < 0.379). However, taking sodium bicarbonate was associated with a significantly lower risks of MACE (HR: 0.95, 95% CI 0.92-0.98, p < 0.001) and hospitalizations for acute pulmonary edema (HR: 0.92, 95% CI 0.88-0.96, p < 0.001) compared with non-users. The mortality risks were significantly lower in sodium bicarbonate users compared with sodium bicarbonate non-users (HR: 0.75, 95% CI 0.74-0.77, p < 0.001). Conclusion: This cohort study revealed that in real world practice, use of sodium bicarbonate was associated with similar risk of dialysis compared with non-users among patients with advanced CKD stage V. Nonetheless, use of sodium bicarbonate was associated with significantly lower rate of MACE and mortality. Findings reinforce the benefits of sodium bicarbonate therapy in the expanding CKD population. Further prospective studies are needed to confirm these findings.