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 December 2019 issue:
From the authors: Continuous renal replacement therapy (CRRT) is a form of continuous dialysis used in critically ill patients, often in the intensive care unit. National guidelines recommend that CRRT be prescribed at a dose of 20-25 mL/kg/hr, however, prescription practices are variable. Inconsistent prescribing patterns among providers may lead to errors in dosing of medications such as antibiotics, and increase rates of blood chemistry abnormalities. This study describes a quality improvement initiative to increase compliance with national guidelines for CRRT dosing. Over the course of one year, multiple interventions to improve compliance were implemented, including modifications to the electronic medical record, modifications to the procedure note and CRRT order templates, and education of providers regarding proper prescribing practices. Following these interventions, the rate of administration of CRRT using dosing consistent with national guidelines doubled from 33% to 66%.
A Quality Improvement Initiative Targeting CRRT Delivered Dose: The What, the How, and the Why by Javier A Neyra and Ashita J Tolwani [FREE]
Antibiotic Use and Risk of Incident Kidney Stones in Female Nurses by Pietro Manuel Ferraro et al
Editorial Antibiotics and Kidney Stones: Perturbation of the Gut-Kidney Axis by Gregory Tasian et al [FREE]
Idiopathic Retroperitoneal Fibrosis: Long-term Risk and Predictors of Relapse by Francesca Raffiotta et al
From the authors: Idiopathic retroperitoneal fibrosis (IRF) is a rare disorder of unknown origin. We prospectively followed 50 patients with IRF to evaluate their response to medical therapy as well as the rate and predictors of IRF relapse. Most patients achieved remission of IRF after one year of medical therapy. However, one-third of patients experienced at least one relapse. Relapses may occur after a long period of remission and were more frequent in men. Corticosteroids alone or in conjunction with tamoxifen were associated with a lower rate of relapse. Patients with circulating antinuclear-antibodies had the highest rate of relapse supporting the hypothesis that altered autoimmunity plays a role in the pathogenesis of IRF. Antinuclear antibodies may also represent a biomarker, indicative of an elevated probability of relapse.
From the authors: Low birth weight has been associated with reduced kidney function, due to development of a lower number of glomeruli. We hypothesized that individuals with lower birth weight may have an increased risk to develop chronic kidney disease in middle age. We studied 6,671 individuals and found no relationship between self-reported birth weight and kidney function, but found such a relationship using genetic markers of birthweight. Based on genetic markers, every 500 gram lower birth weight was associated with 3.7 mL/min/1.73m2 lower kidney levels of the glomerular filtration rate. However, we were not able to confirm this finding among 133,814 individuals studied by the CKDGen Consortium.
From the authors: Type 2 diabetes is closely linked to obesity and is the main cause of chronic kidney disease (CKD) worldwide, but the relationship between CKD, diabetes, and obesity needs further exploration. We, therefore, studied if bariatric surgery is associated with improvements in CKD measures and if the presence of CKD at time of bariatric surgery influences the likelihood of remission of diabetes after surgery. Among 737 patients with type 2 diabetes undergoing bariatric surgery and followed for 5 years, improvements in certain parameters of CKD were observed. Patients with CKD were less likely to achieve remission of diabetes after bariatric surgery. These observations warrant further study to understand the mechanistic pathways that underlie them and that could guide development of treatment strategies.
From the authors: Building on previously-demonstrated associations between FGF23 and adverse outcomes in CKD, our study evaluates the utility of FGF23 for individual risk prediction of these outcomes above standard clinical data. We developed models to predict all-cause mortality, CV mortality, incident ESRD, HF admissions, and atherosclerotic events in the prospective, CRIC study. We compared the predictive performance of this model for each outcome before and after addition of FGF23. To benchmark the FGF23 effects, we repeated these analyses after the addition of serum phosphate. FGF23 significantly improved prediction of all-cause mortality and HF admission but not CV mortality, incident ESRD, or atherosclerotic events. The FGF23 model outperformed the phosphate models for each outcome. Our study supports inclusion of FGF23 into future studies evaluating prognostic biomarkers of mortality and heart failure events.
On the Cover: Winding through the Mojave Desert, a motorcyclist takes in vistas of the rock formations, cliffs, deep canyons, and serene valleys, whose contours and colors form the Valley of Fire State Park in Nevada. This stunning landscape appears as a tapestry woven of bright red Aztecs and stone outcrops nestled within gray and tan limestone rock formations. Just as such landscapes are composed of many individual elements, effective quality improvement initiatives also rely on the combination of multiple individual approaches to enhance clinical practice. In this issue of AJKD, Griffin et al discuss a quality improvement intervention in which education and systematic changes in documentation doubled the number of critically ill patients receiving the appropriate dosing of continuous renal replacement therapy.
The photograph “Valley of Fire State Park, Overton, United States” is by Jannes Glas on Unsplash. Released under the Unsplash license.
Case Report from the December 2019 Issue:
Collapsing Lesions and Focal Segmental Glomerulosclerosis in Pregnancy: A Report of 3 Cases by Oralia Alejandra Orozco Guillén et al [Open Access]
These cases suggest that collapsing lesions should be considered in patients with FSGS who develop a rapid increase in serum creatinine level or proteinuria during pregnancy and that these lesions may at least partially respond to treatment.
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