Editor’s Note: We asked authors of Original Investigations to provide short plain-language 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 valuable in helping them keep up with the latest research in the field of nephrology. From the August 2019 issue:
Anxiety Symptoms, Mortality, and Hospitalization in Patients Receiving Maintenance Dialysis: A Cohort Study by Robbert W. Schouten, et al [Open Access]
From the authors: Patients with end-stage kidney disease rely on dialysis therapy to survive. Kidney disease and dialysis therapy are associated with a psychological symptoms of depression and anxiety, which are very common in these patients. Depression is known to be related to a decreased quality of life as well as an increased number of hospital admissions and shortened survival. These associations have not been thoroughly investigated for anxiety among dialysis patients. This study showed that anxiety symptoms are related to hospital admissions and mortality, independent of depressive symptoms. These findings highlight the importance of assessing anxiety in patients on dialysis therapy. Future studies should investigate the effect of treatment for this important mental health condition.
Editorial Anxiety Symptoms in Patients Treated With Hemodialysis: Measurement and Meaning by Paul L. Kimmel and Daniel Cukor [FREE]
From the authors: Patients with advanced chronic kidney disease often experience clusters of symptoms and impaired health-related quality of life (HRQOL) as their kidney function deteriorates. Remote electronic monitoring of patients’ symptoms may facilitate communication between patients and the clinical team, and allow early interventions to manage symptoms; potentially delaying deterioration in kidney function and improving HRQOL. To ensure that our ePROM system met stakeholder needs we interviewed patients and clinicians to seek their opinions regarding system design as well and barriers and facilitators to implementation. Clinicians and patients were supportive of the proposed system suggesting that a renal ePROM system may play a supportive role in the clinical management of patients with advanced kidney disease.
Editorial Patient-Reported Outcome Measures in CKD Care: The Importance of Demonstrating Need and Value by Meghan J. Elliott and Brenda R. Hemmelgarn [FREE]
From the authors: Fatigue is a critically important outcome for some patients on hemodialysis. Yet, the nature and pervasive impact of fatigue on the lives of affected patients may be under-recognized. We aimed to describe patients’ perspectives on the nature, meaning, and impact of fatigue among in patients on hemodialysis patients who experience fatigue. We conducted a comprehensive review of existing studies and identified and summarized 65 studies that involved 1713 patients. These studies revealed that patients who reported experiencing fatigue on hemodialysis often felt debilitated and exhausted by the burden of dialysis treatments, restricted in their ability to participate in life, diminished in their capacity to fulfill relationship roles, and misunderstood by others. Effective strategies to manage and improve fatigue in affected patients on hemodialysis are needed.
Editorial Toward Developing a Patient-Reported Outcome Measure for Fatigue in Hemodialysis by Devika Nair and Fredric O. Finkelstein [FREE]
Vascular Access Choice, Complications, and Outcomes in Children on Maintenance Hemodialysis: Findings From the International Pediatric Hemodialysis Network (IPHN) Registry by Dagmara Borzych-Duzalka, et al
From the authors: Arteriovenous fistulae (AVF) are the recommended vascular access for maintenance hemodialysis (HD). In 552 children prospectively monitored in the International Pediatric HD Network, 72% of 870 vascular accesses placed were central venous catheters (CVC). The use of CVCs was greater among younger children and those expecting early living related transplantation. One third of children receiving an AVF required a transient CVC until their fistula was suitable for dialysis, suggesting adverse vascular access planning. CVC use was associated with lower blood flow rates, and lower rates of removal of solutes. CVCs were used for a median of 14 months until transplantation and were associated with access revision and replacement risks that were almost two- and three-fold greater than for AVFs. These findings suggest a need for a re-evaluation of pediatric CVC use and practices.
Editorial Catheter Craze Continues for Pediatric Hemodialysis Vascular Access: The Need to Move From Catheter First to Catheter Last by Rudolph P. Valentini and Deepa H. Chand [FREE]
Predictors of Net Acid Excretion in the Chronic Renal Insufficiency Cohort (CRIC) Study by Landon Brown, et al
From the authors: Even early in the course of autosomal dominant polycystic kidney disease (ADPKD), vascular dysfunction, featuring impaired vascular endothelial function and increased large-elastic artery stiffness, is evident. Aldosterone excess has been implicated in the development of vascular dysfunction. In a prospective, randomized, controlled, double-blind clinical trial in 61 adults with early-stage ADPKD receiving a renin angiotensin aldosterone system inhibitor, we tested whether 24 weeks of treatment with the aldosterone antagonist spironolactone would improve vascular endothelial function (brachial artery flow-mediated dilation; primary endpoint) or reduce arterial stiffness (carotid-femoral pulse-wave velocity; secondary endpoint). As compared to placebo, treatment failed to change either endothelial function or arterial stiffness, despite lowering blood pressure.
C5 Convertase Blockade in Membranoproliferative Glomerulonephritis: A Single-Arm Clinical Trial by Piero Ruggenenti, et al
Membranoproliferative glomerulonephritis (MPGN) is a rare primary glomerulopathy characterized by complement dysregulation. MPGN progresses rapidly to kidney failure when it is associated with nephrotic syndrome driven by complement dysregulation that, when associated with nephrotic syndrome, rapidly progresses to kidney failure. In this explorative study of ten patients with MPGN and nephrotic syndrome, we evaluated the effect of treatment with the terminal complement pathway inhibitor eculizumab of over two 48-week treatment periods with the terminal complement pathway inhibitor eculizumab, divided by 12-week washout, in ten patients with MPGN and nephrotic syndrome. Only three patients achieved persistent remission of proteinuria and kidney function stabilization up to study end. C3 nephritic factors were undetectable in all of them. Future larger studies are needed to assess whether screening for C3 nephritic factors might help identifying patients with MPGN who might benefit from eculizumab. Significant results in this study require further studies that are adequately powered to confirm the findings.
Prevalence and Risk Factors for CKD Among Brickmaking Workers in La Paz Centro, Nicaragua by Lyanne Gallo-Ruiz, et al [FREE]
Chronic kidney disease (CKD) of non-traditional etiology is a leading cause of death in Nicaragua. Most prevalence studies have focused on agricultural workers. This study included 224 artisanal brick and tile workers in Northwestern Nicaragua, where CKD rates are high. We measured kidney function at two time points to determine the prevalence of CKD according to international guidelines. We also examined social, economic and occupational factors that may influence kidney health. Prevalence of CKD was high among these workers and was not evenly distributed. Kidney function was lower at baseline among oven workers, workers with low education, and among workers who had a family member with CKD. Oven workers and workers who lacked education were more likely to develop CKD.
Blog Post Mesoamerican Mysteries: CKD Among Brickmaking Workers in Nicaragua by Pablo Garcia
On the Cover: The brick is one of the oldest known building materials, with the earliest record of use dating back to 7000 BC. Rarely is consideration given to how they are made or the occupational risks brickmakers experience. Building on the knowledge we have gained in recent years about kidney disease among agricultural laborers, potentially from prolonged and chronic heat exposure, we increasingly must consider similar risks from other occupational and industrial exposures. In this issue of AJKD, Gallo-Ruiz et al explore how the work environment, in combination with more traditional factors, influence the health status of artisanal brick and tile workers in Nicaragua, among whom CKD is a leading cause of death. This work extends our understanding of how occupational exposures to high temperature environments may influence the occurrence of kidney disease.
“Life in Red | A brick factory workers life” Photograph by Saravanan Dhandapani © Saravanan Dhandapani.
Perspective from the August 2019 Issue:
Repository Corticotropin Versus Glucocorticoid for Nephrotic Syndrome: When Will We See the Evidence? by Daniel M. Hartung et al
Despite little evidence supporting its superiority to glucocorticoid therapy, use and expenditures for repository corticotropin (rACTH) injection (H.P. Acthar Gel; Mallinckrodt) have increased dramatically in the last 5 years, particularly among a small number of nephrologists, rheumatologists, and neurologists. Recently, the manufacturer justified the extremely high and rapidly increasing cost of rACTH by citing the ongoing need to generate clinical data to support its use. We test this assertion by investigating the quality and provenance of the evidence likely to emerge in the foreseeable future.
Blog Post ACTH Gel: Excessive Extravagance But No Evidence by Swapnil Hiremath
Metabolic Acidosis in CKD: Core Curriculum 2019 by Kalani L. Raphael [FREE]
Maintenance of normal acid-base homeostasis is one of the most important kidney functions. In chronic kidney disease, the capacity of the kidneys to excrete the daily acid load as ammonium and titratable acid is impaired, resulting in acid retention and metabolic acidosis. The prevalence of metabolic acidosis increases with declining glomerular filtration rate. Metabolic acidosis is associated with several clinically important complications, including chronic kidney disease progression, bone demineralization, skeletal muscle catabolism, and mortality. To mitigate these adverse consequences, clinical practice guidelines suggest treating metabolic acidosis with oral alkali in patients with chronic kidney disease. However, large clinical trials to determine the efficacy and safety of correcting metabolic acidosis with oral alkali in patients with chronic kidney disease have yet to be conducted. In this Core Curriculum article, established and emerging concepts regarding kidney acid-base regulation and the pathogenesis, risk factors, diagnosis, and management of metabolic acidosis in chronic kidney disease are discussed.
Recognizing the efficiency losses to authors and reviewers when a manuscript turned down by a high-profile journal is submitted to a new journal, AJKD is excited to offer a new expedited consideration process for manuscripts that meet the following criteria:
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