Editor’s Note: In an effort to improve the understanding of Original Investigation articles published in AJKD, we asked authors to provide short nontechnical summaries that would briefly summarize what inspired their study, the basic approach taken, what was learned, and why it matters. We hope our readers will find this service valuable in helping them to keep up with the latest research in the field of nephrology.
From the authors: Several electronic alert systems for AKI have been introduced; however, their effects on clinical outcomes require further investigation. We tried to link AKI alerts with changes in the behavior of clinicians by allowing generation of automated consultation notes within our electronic medical record system with just a few mouse clicks. We anticipated that early consultation with nephrologists after AKI would increase and that early specialist intervention would improve clinical prognosis. After implementation of the system, clinicians were more likely to consult the nephrology department sooner and to perform follow-up blood tests after AKI. Furthermore, the incidence of severe AKI events reduced, and the AKI recovery rate improved. Therefore, the adoption of an AKI alert system linked to early specialist consultation could be considered in hospitals to improve the prognoses of patients with AKI.
Editorial Electronic Alerts for Acute Kidney Injury by Paul M. Palevsky [FREE]
From the authors: Several chronic diseases, including type 2 diabetes and coronary heart disease, have their origins in early life. It is believed that nonoptimal conditions, including malnutrition, during fetal life program the developing organism. One marker of fetal malnutrition is a small body size at birth. A small body size at birth has been associated with an increased risk for type 2 diabetes and elevated blood pressure. It has also been associated with kidneys with fewer nephrons. This could increase the risk for developing CKD later in life. We have shown that a small body size at birth is associated with an increased risk of CKD among men. These findings support the importance of early life factors in the development of CKD.
Editorial Developmental Origins of CKD: Big Problems From Small Packages by Jennifer R. Charlton & Robert L. Chevalier [FREE]
From the authors: Vascular calcification is common in CKD and associated with mortality. Low bone mineral density is also common in CKD and associated with vascular calcification. The bile acid deoxycholic acid (DCA) is elevated in CKD and causes vascular calcification in animals. To explore whether DCA contributes to vascular calcification in human CKD, we analyzed the relationship between baseline DCA levels and coronary artery calcification and bone mineral density at baseline and the change after nine months among patients with moderate to severe CKD. Higher DCA levels were associated with higher coronary artery calcification and lower bone mineral density at baseline. There was no association of DCA with change in coronary artery calcification or bone mineral density after nine months. DCAis a potential biomarker for vascular calcification in CKD. Additional studies are needed to assess whether lowering DCA could treat vascular calcification in CKD.
From the authors: Kidney disease is underdiagnosed and undertreated in the community. Heart disease and stroke are among the main causes of death in patients with kidney disease. Community pharmacists are primary healthcare providers who see patients with chronic conditions (for example, high blood pressure, diabetes, and kidney disease) frequently. As such they can help identify people who are at high risk for kidney disease and help them calculate their heart disease and stroke risk and manage that risk. In this study, community pharmacists recruited patients with kidney disease and designed individual treatment plans for each patient to achieve their treatment targets. Pharmacists helped patients reduce their heart disease and stroke risk. They also helped them control their blood pressure, blood sugar, cholesterol, and to stop smoking. This represents a promising approach for identification and management of patients with kidney disease, which could have major public health implications.
From the authors: In some living donor kidney transplant programs, a donor can donate a kidney to an anonymous recipient. The preference for anonymity was demonstrated in the early days of these programs; however, experience in daily practice has shown that some recipients and donors question this principle. There is little up-to-date research on patients’ views and experiences. Therefore, we conducted a questionnaire among Dutch and Swedish anonymous donors and recipients. Findings showed that most donors and recipients were satisfied with their own experience of anonymity, but felt that if both parties agreed, there should be the choice of revoking anonymity and that this decision should be their own. Donors agreed to a greater extent with the principle of anonymity than recipients, and more recipients wanted to meet than donors. In light of these findings, we recommend reassessing current policy of absolute anonymity; the pros and cons generated from the study can help educate and counsel donors and recipients on this issue.
From the authors: Diabetic kidney disease is a leading cause of death in type 2 diabetes (T2D). Insulin resistance, a hallmark of T2D, may contribute to the development of diabetic kidney disease in T2D. Early diabetic kidney disease, including hyperfiltration and elevated albumin excretion, is common in youth with T2D. In fact, youth-onset T2D carries a greater risk of diabetic kidney disease compared to adult-onset T2D. In this observational analysis of data from the TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth) study, we demonstrate that worse insulin resistance carries a greater risk of developing hyperfiltration, but not elevated albumin excretion. These findings suggest that hyperfiltration and increased albumin excretion may be associated with discrete risk factors reflecting their underlying pathophysiology.
Phosphate Kinetic Models in Hemodialysis: A Systematic Review by Sisse H. Laursen et al
From the authors: Hyperphosphatemia is a challenging condition in dialysis patients. Different physiological models have been proposed to improve insight into phosphate kinetics and overcome this challenge. The present review addresses the complexity of existing phosphate models within hemodialysis therapy and hopefully sheds new light on this important issue. The review provides information about each individual model and validation approach, evaluates the quality and potential of the models, and clarifies what has been done and what needs to be done. Nine models were identified through thorough database and hand searches of the literature. The models were then evaluated, and the quality of each model was assessed against 14 quality indicators relating to the model and validation approaches. It was found that some models could potentially be used in clinical practice. However, the validation results in the field of phosphate modeling tend to be unclear and the issue needs further attention.
Longitudinal Estimated GFR Trajectories in Patients With and Without Type 2 Diabetes and Nephropathy by Misghina Weldegiorgis et al
From the authors: In clinical trials, changes in serum creatinine are used to evaluate changes in kidney function. It has been assumed that these changes follow a linear pattern when serum creatinine is converted to eGFR. However, the paradigm that kidney function declines linearly over time has been questioned by studies showing either linear or nonlinear patterns. To assess the potential impact of this nonlinearity on kidney end points in clinical trials, we determined eGFR trajectories in six clinical trials of patients with and without diabetes and kidney disease. We found that the majority of patients show a more or less linear eGFR decline, although the proportion of patients with a nonlinear eGFR trajectory is higher in the diabetic compared to the non-diabetic populations. These data support the paradigm that in diabetic and nondiabetic kidney disease, eGFR decline progresses linearly over time during a clinical trial period.
Blog Post Creatinine Linearity – Connecting the Dots Has Never Been So Complicated by Ed Gould
Impact of Diabetes Mellitus on the Association of Vascular Disease Before Transplantation With Long-term Transplant and Patient Outcomes After Kidney Transplantation: A Population Cohort Study by Wai H. Lim et al
From the authors: Individuals with ESKD who undergo kidney transplantation live longer than those who do not. However, the benefits of transplantation on long-term outcomes of people with ESKD who also have vascular disease are unclear. In this study of 7,128 patients with ESKD who received a kidney transplant from a deceased donor, the negative impact of pretransplantation vascular disease burden on long-term survival was observed only in the absence of diabetes. Among people without diabetes, the presence of vascular disease before transplantation was associated with over a 30% greater risk of graft loss and death. In contrast, among people with diabetes, the presence of vascular disease before transplantation had no significant impact on graft or patient outcomes. Therefore, knowledge of the presence or absence of both diabetes and vascular disease before transplantation may assist in stratifying patients according to their risks of important clinical outcomes.
Association Between Gestational Diabetes and Incident Maternal CKD: The CARDIA Study by Elizabeth W. Dehmer et al
From the authors: Gestational diabetes mellitus (GDM) is associated with development of diabetes, metabolic syndrome, and cardiovascular disease in women following delivery. This study aimed to determine if GDM is also associated with subsequent maternal CKD. We studied 820 women who participated in the CARDIA (Coronary Artery Risk Development in Young Adults) study who had never been pregnant, delivered at least one pregnancy, and had kidney function measures available during follow-up. We determined the rate of CKD following a GDM pregnancy and observed that GDM was associated with development of CKD in black women, but not white women. Hypotheses to explain the elevated risk only in black women include post-pregnancy diabetes, post-pregnancy hypertension, genetics, differences in lactation practices, or differences in GDM severity. Following a GDM pregnancy, black women may benefit from counseling about ways to reduce their future risk of CKD.
Blog Post Gestational Diabetes Mellitus: A Race Effect on the Kidneys by Anna Burgner