In 2017, we established an annual celebration of articles that our editorial team designated as “Editors’ Choice” selections. Over the last year, AJKD published close to a hundred Original Investigations that expand our understanding of the field of nephrology. The editors are delighted to recognize the four articles listed below that have been selected to receive the 2019 Editors’ Choice Award. These articles will be freely available at AJKD.org until January 15, 2020. Congratulations to all the authors!

Acute Kidney Injury in Sugarcane Workers at Risk for Mesoamerican Nephropathy by Joseph Kupferman, Oriana Ramírez-Rubio, Juan José Amador, Damaris López-Pilarte, Elissa H. Wilker, Rebecca L. Laws, Caryn Sennett, Ninoska Violeta Robles, Jorge Luis Lau, Alejandro José Salinas, James S. Kaufman, Daniel E. Weiner, Madeleine K. Scammell, Michael D. McClean, Daniel R. Brooks, and David J. Friedman (October 2018)

From the authors: Mesoamerican nephropathy is an epidemic of kidney disease of unknown cause affecting young people in Central America. Sugarcane workers and other manual laborers are at high risk, and investigators suspect that kidney injury occurring during strenuous physical work may lead to permanent damage. We studied a group of over 300 Nicaraguan sugarcane workers with previously normal kidney function. We found that kidney function decreased to abnormal levels over the course of a sugarcane harvest season in about 10% of workers. Cane cutters were at highest risk for worsening kidney function. At follow-up evaluations 6 and 12 months later, kidney function remained impaired in some of these workers and met the definition of chronic kidney disease. Our results suggest that short term kidney injury is common in sugarcane workers and may progress to irreversible kidney damage in some cases.

DOI: 10.1053/j.ajkd.2018.04.014

Editorial Untangling Mesoamerican Nephropathy by Diego Aguilar-Ramirez and Magdalena Madero [FREE]

Missed Hemodialysis Treatments: International Variation, Predictors, and Outcomes in the Dialysis Outcomes and Practice Patterns Study (DOPPS) by Issa Al Salmi, Maria Larkina, Mia Wang, Lalita Subramanian, Hal Morgenstern, Stefan H. Jacobson, Raymond Hakim, Francesca Tentori, Rajiv Saran, Takashi Akiba, Natalia A. Tomilina, Friedrich K. Port, Bruce M. Robinson, and Ronald L. Pisoni (November 2018) OPEN ACCESS

From the authors: A challenge to providing quality care to hemodialysis (HD) patients is that patients sometimes miss one or more of their thrice-weekly scheduled HD treatments. We asked how missing HD treatment(s) differs across countries, and relates to patient characteristics and outcomes. We used 2012-2015 Dialysis Outcomes and Practice Patterns Study (DOPPS) data from 8501 patients at 439 facilities in 20 countries. Missing ≥1 HD treatment(s) over 4 months varied greatly across countries (<1% in Italy & Japan; 24% in US), across facilities, by particular patient factors, and was associated with poorer outcomes (hospitalization, quality of life, lab measure achievement, 1.7-fold higher mortality). These findings encourage further examination of patient- and system-level reasons for high missed treatment rates in some facilities/countries, and what approaches may yield greater treatment adherence and associated benefits for patients.

DOI: 10.1053/j.ajkd.2018.04.019

Editorial Missed Hemodialysis Treatments: A Modifiable But Unequal Burden in the World by Steven Menez and Bernard G. Jaar [FREE]

Effects of Intensive Blood Pressure Lowering on Kidney Tubule Injury in CKD: A Longitudinal Subgroup Analysis in SPRINT by Rakesh Malhotra, Timothy Craven, Walter T. Ambrosius, Anthony A. Killeen, William E. Haley, Alfred K. Cheung, Michel Chonchol, Mark Sarnak, Chirag R. Parikh, Michael G. Shlipak, and Joachim H. Ix on behalf of the SPRINT Research Group (January 2019)

From the authors: Intensive blood pressure (BP) lowering in hypertensive patients reduced the risk of cardiovascular disease and mortality in SPRINT. However, it also worsened kidney function which has led to concerns about implementing intensive BP lowering; however, it was unclear if this was due to real kidney damage, or rather a hemodynamic (blood flow) effect without intrinsic kidney damage. Using 8 distinct urine biomarkers of kidney tubule function, injury, and repair measured repeatedly over 1 year, we evaluated the effect of intensive BP lowering on the kidney in a subset of SPRINT trial participants. We demonstrated that while intensive SBP lowering resulted in reductions in kidney function, there was no evidence that intensive SBP induced kidney tubule cell damage. The pattern of several biomarkers clearly reflected hemodynamic changes rather than intrinsic kidney cell injury. These findings should provide greater reassurance to clinicians to institute or continue intensive BP lowering in hypertensive persons, to garner the cardiovascular and mortality benefits despite a short-term change in blood tests that suggest worsening of kidney function.

DOI: 10.1053/j.ajkd.2018.07.015

Editorial Estimated GFR Decline and Tubular Injury Biomarkers With Intensive Blood Pressure Control by Carl P. Walther et al [FREE]

Allocation of the Highest Quality Kidneys and Transplant Outcomes Under the New Kidney Allocation System by Supreet Sethi, Reiad Najjar, Alice Peng, James Mirocha, Ashley Vo, Suphamai Bunnapradist, Stanley C. Jordan, and Edmund Huang (May 2019)

Percentage of kidneys in each kidney donor profile index (KDPI) category used for recipients with calculated panel-reactive antibody (cPRA) levels ≥ 99% compared to the representation of candidates with cPRA levels ≥ 99% on the waitlist. Waitlist percentage represents the percentage of the deceased donor waitlist comprising candidates with cPRA levels ≥ 99% on January 1 of each respective year. Calculations for column graph series are as shown for this example: [# of KDPI ≤ 20% kidneys used for cPRA ≥ 99% candidates/total # of KDPI ≤ 20% kidneys] × 100. Figure 1 from Sethi et al, AJKD, © National Kidney Foundation.

From the authors: Highly sensitized candidates have benefited greatly from policy changes enacted by the Kidney Allocation System (KAS) in 2014 and have experienced a dramatic increase in access to transplantation. We studied trends in utilization of the highest quality kidneys (defined as kidney donor profile index [KDPI] <20%) versus other kidneys following implementation of KAS and investigated whether KDPI impacts clinical outcomes differently for sensitized and non-sensitized candidates. There was a four-fold increase in utilization of lower KDPI kidneys in highly sensitized candidates after implementation of KAS, while there was no change in utilization of high KDPI kidneys. We also found that KDPI has a similar relationship with patient survival and graft loss across all levels of recipient allosensitization. The transplant community should examine the impact of the redistribution of higher quality kidneys away from less sensitized recipients.

DOI: 10.1053/j.ajkd.2018.12.036

Blog Post The New Kidney Allocation System: How Is It Performing? by Andrew Malone [FREE]