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 January 2020 issue:
From the authors: Cardiac dysfunction is associated with adverse outcomes in hemodialysis patients. This sub-study of a randomized trial evaluated the effect of lung-ultrasound-guided dry-weight reduction on left and right heart chamber dimensions as well as systolic and diastolic function in clinically euvolemic hypertensive hemodialysis patients. The active intervention group’s volume removal was guided by lung ultrasound (US-B lines) and the usual care group was treated using standard-of-care processes that did not include acquisition of lung ultrasound data. After 8-weeks half of patients in the active group and 14% of those in the usual care group had reductions in their dry-weight. Inferior vena cava diameter, as well as left and right atrial dimensions fell more in the active group. This was accompanied by a greater decrease in left ventricular filling pressures in the active compared to the usual care group. In multivariable analysis US-B line reduction was associated with reductions in LV filling pressures. Use of lung-ultrasound data to guide fluid removal on hemodialysis may represent an effective strategy for optimizing identification of dry-weight.
Extravascular Lung Water Assessment by Ultrasound to Guide Dry Weight Changes: Ready for Prime Time? by Rajiv Agarwal et al [FREE]
From the authors: Certain medications called angiotensin-converting enzyme (ACE) inhibitors are known to improve survival in patients with heart failure with reduced ejection fraction (HFrEF). They can be associated with reductions in one measurement of kidney function called estimated glomerular filtration rate (eGFR) in the short-term, but the longer-term effects on eGFR in patients with HFrEF are unknown. Using two large trials of HFrEF patients, we observed that being randomized to ACE-inhibitor therapy did lead to an initial reduction in eGFR but that this effect did not persist over the longer term. These findings may encourage clinicians that ACE inhibitors will not only promote survival but also have no detrimental, albeit also no beneficial, longer-term effect on kidney function in patients with HFrEF.
An Implanted Blood Vessel Support Device for Arteriovenous Fistulas: A Randomized Controlled Trial by Nikolaos Karydis et al [Open Access]
From the authors: Arteriovenous fistulas created between arteries and veins for dialysis are known to narrow and occlude over time, with or without abnormal growth of cells of the inner walls of blood vessels. This process is caused, in part, by changes in the dynamics of blood flow caused by the direct connection between an artery and a vein. Physical support of this connection applied to the exterior vessel wall has the potential to reduce the extent of these processes and to prevent some of the complications associated with the disturbed flow at the junction between the artery and the vein. Here, we tested VasQ, an implanted device that is applied to the exterior wall of blood vessels and that stabilizes the junction between the artery and vein. It is comprised of two parts: a brace that wraps around the artery and the junction and maintains a 40-50% angle between the artery and the vein, as well as a mesh braid that reduces the tension of the vein wall over the first 25mm to reduce blood flow disturbances. We found that the use of the implant was safe and may be effective in maintaining the internal blood vessel diameter at 3 and 6 months following surgery.
APOL1 Nephropathy Risk Alleles and Mortality in African American Adults: A Cohort Study by Orlando M. Gutiérrez et al
From the authors: APOL1 nephropathy risk alleles are associated with the development of chronic kidney disease in African Americans. Chronic kidney disease is a strong risk factor for mortality, suggesting that carriage of APOL1 nephropathy risk alleles may shorten survival in African Americans. In the current paper, African Americans with two APOL1 nephropathy risk alleles had lower all-cause mortality risk than African Americans with zero or one risk allele in fully adjusted models. In addition, whereas African Americans with zero or one risk allele had lower survival than white Americans, African Americans with two APOL1 risk alleles had similar survival to white Americans. Understanding the reasons for these findings may uncover novel biologic factors that underlie disparities in mortality risk in African Americans.
From the authors: Acute kidney injury is very common in today’s intensive care units (ICUs) and has major ramifications for patient outcomes, making collaboration between nephrology consultants and ICU teams highly important. While there has been considerable debate about how nephrology consultants and ICU teams should collaborate, communicative dynamics between the two parties remain poorly understood. This study used a qualitative approach to examine interactions between nephrology consultants and ICU teams across three ICUs in a large academic hospital. Particularly in the surgical ICUs, consultants and teams had discordant preferences about the aggressiveness of dialysis, leading to some collaborative difficulties. These findings stress the need for medical teamwork research and intervention to address issues stemming from disciplinary siloing.
From the authors: Evidence suggests that the standard-dose influenza vaccine (SDV) may not prevent influenza-related outcomes in patients with end-stage renal disease (ESRD). Yet, little is known about the comparative effectiveness of SDV versus high-dose influenza vaccine (HDV) in this population. Using data from the United States Renal Data System, our large comparative study failed to demonstrate that HDV has superior effectiveness versus SDV for preventing all-cause mortality and influenza-related outcomes among patients with ESRD, overall or within subgroups. Given the findings of this population-level study, along with the substantially higher cost and side-effect profiles of HDV versus SDV, it appears that HDV should not conclusively be considered the standard of care at the present time for influenza immunization of patients with ESRD.
Special Report from the January 2020 Issue:
Change in Albuminuria and GFR as End Points for Clinical Trials in Early Stages of CKD: A Scientific Workshop Sponsored by the National Kidney Foundation in Collaboration With the US Food and Drug Administration and European Medicines Agency by Andrew S. Levey et al [FREE temporarily]
The FDA and EMA are currently willing to consider a 30% to 40% glomerular filtration rate (GFR) decline as a surrogate end point for kidney failure for clinical trials of kidney disease progression under appropriate conditions. However, these end points may not be practical for early stages of kidney disease. In March 2018, the National Kidney Foundation sponsored a scientific workshop in collaboration with the FDA and EMA to evaluate changes in albuminuria or GFR as candidate surrogate end points. Three parallel efforts were presented: meta-analyses of observational studies (cohorts), meta-analyses of clinical trials, and simulations of trial design.
Change in Estimated GFR and Albuminuria as End Points in Clinical Trials: A Viewpoint From the FDA by Aliza Thompson et al [FREE]
On the Cover: In the late 1700s, Lazzaro Spallanzani, an Italian physiologist and biologist, observed bats navigating effortlessly in the dark. More than a century later came the discovery that bats produce high frequency sounds in flight to localize objects using reflected echoes of their own cries – echolocation. These observations undoubtedly motivated early pioneers of medical ultrasound, Douglas Howry, a radiologist working with engineers William Roderick Bliss and George Posakony, to build in 1949 the first pulse-echo ultrasonic scanner capable of making two-dimensional images. This invention launched decades of technology development leading to our modern tools of ultrasonographic imaging. In this month’s issue of AJKD, Loutradis et al examine the use of lung ultrasound-guided dry weight reduction in clinically euvolemic hemodialysis patients on echo cardio-graphic indices of left ventricular function.
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