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 May 2020 issue:

Peripheral Artery Disease: Its Adverse Consequences With and Without CKD by Mathieu Bourrier et al 

From the authors: In clinical practice, peripheral artery disease (PAD) and subsequent lower limb complications (amputations and foot ulcers) are often seen in patients with reduced kidney function and those on dialysis. These complications are devastating for patients and are associated with high morbidity and mortality. Our study sought to quantify the relationship between PAD and these adverse outcomes, in individuals both with normal kidney function and those with chronic kidney disease and kidney failure. We found a strong association between PAD and all cause death, cardiovascular disease and adverse lower limb complications in patients with normal kidney function and those with CKD. Rates of lower limb complications were found to be extremely high in the dialysis population. Further research is now required to identify ways to improve the lower limb outcomes for this at risk population.

DOI: 10.1053/j.ajkd.2019.08.028

Editorial: Peripheral Artery Disease in CKD: Anatomically Peripheral But Clinically Central by Manabu Hishida et al [FREE] 

Pulmonary Hypertension Subtypes and Mortality in CKD by Daniel L. Edmonston et al 

From the authors: Pulmonary hypertension (PH) commonly affects patients with chronic kidney disease (CKD), but the pathophysiology remains unclear. Right heart catheterization provides sufficient hemodynamic data to discern among the PH subtypes: pre-capillary (increased pulmonary vascular resistance), post-capillary (increased left-sided pressures), and combined pre- and post-capillary PH (combination of increased pulmonary vascular resistance and elevated left-sided pressures). We sought to estimate the prevalence and consequences of PH subtypes in the setting of CKD by reviewing 15 years of right heart catheterization data from over 12,000 patients stratified by severity of CKD. After categorization by PH subtype, we evaluated the association of each subtype with mortality. In patients with CKD, post-capillary and combine pre- and post-capillary PH were the most common subtypes compared to a predominance of pre-capillary PH in patients without CKD. Combined pre- and post-capillary PH was associated with the highest risk of mortality in patients with CKD whereas pre-capillary PH conferred the highest risk of mortality in patients without CKD. Our findings support further investigation into mechanisms of increased pulmonary vascular resistance in patients with CKD.

DOI: 10.1053/j.ajkd.2019.08.027

Editorial: Classification of Pulmonary Hypertension in CKD by Sankar D. Navaneethan et al [FREE] 

Outcomes From Right Versus Left Deceased-Donor Kidney Transplants: A US National Cohort Study by Sanjay Kulkarni et al

From the authors: An individual’s right kidney tends to be smaller with a shorter vein than their left kidney. A study of the US transplant database showed right-sided living-donor kidney transplants were less often performed and at increased risk for poor outcomes compared with left-sided transplants. In this US database study of deceased-donor kidney transplants, we evaluated right and left kidney recipient pairs to control for all other donor factors. Right-sided recipients had slightly increased risk for delayed graft function and graft failure in the first 6 months but had similar long-term outcomes compared with left-sided recipients from the same donors. Quantifying these minor associations suggests other donor-recipient considerations should take precedence when deciding to accept or decline individual deceased-donor kidney offers.

DOI: 10.1053/j.ajkd.2019.08.018

Heavy Chain Deposition Disease: Clinicopathologic Characteristics of a Chinese Case Series by Yuan Zhang et al 

From the authors: Heavy chain deposition disease (HCDD) is one of the kidney disease manifestations of monoclonal immunoglobulin deposition disease, characterized by the deposition of monoclonal heavy chains without associated light chains. Twenty-five Chinese patients with biopsy-proven HCDD were retrospectively studied. Patients presented with hypertension, anemia, proteinuria, hematuria and reduced kidney function. Laboratory evaluation revealed only the IgG subtype of disease among all patients studied. As most patients treated with chemotherapy achieved good clinical responses, our case series suggests that chemotherapy should be considered for HCDD, especially for individuals with an early stage of the disease.

DOI: 10.1053/j.ajkd.2019.08.013

Medical Record Documentation of Goals-of-Care Discussions Among Older Veterans With Incident Kidney Failure by Christina L. Bradshaw et al 

From the authors: Despite the ubiquity of dialysis as a treatment for end-stage kidney failure, the decision to initiate it is a weighty decision. Documentation surrounding this decision is imperative to ensuring delivery of care that aligns with patient values. We examined the medical records of Veterans approaching end-stage kidney failure who received care in the Veteran’s Affairs Health System to describe documentation of discussions pertaining to dialysis treatment, including discussions of treatment alternatives like supportive care. We found that documentation of these discussions occurred infrequently, even among patients who were at high risk of mortality with dialysis. Dialysis may not be regularly presented as a choice, potentially indicating that patients’ goals for care may not be fully elicited and documented.

DOI: 10.1053/j.ajkd.2019.07.024

Coffee Consumption and Kidney Function: A Mendelian Randomization Study by Oliver J. Kennedy et al [FREE temporarily] 

Image from Pixabay / PublicDomainPhotos

From the authors: Chronic kidney disease (CKD) is increasing worldwide and represents a major cause of death, disability and healthcare expenditure. However, there are few effective options for prevention or treatment. Coffee is a complex mixture of hundreds of chemical compounds, some of which could have beneficial effects on health. Some observational studies link drinking more coffee to a lower risk of developing CKD. In this Mendelian randomization study, we used measured variation in genetics, rather than self-reported data, to examine the causal effect of coffee on CKD. We showed that among coffee consumers, drinking more coffee appeared to protect against CKD. Further work is now needed to demonstrate whether a coffee-based intervention is effective for the prevention or treatment of CKD.

DOI: 10.1053/j.ajkd.2019.08.025

Blog Post: Coffee Consumption and Kidney Function [FREE] by Paul Phelan

Obstetric Deliveries in US Women With ESKD: 2002-2015 by Andrea L. Oliverio et al

From the authors: Pregnancy in women with end stage kidney disease (ESKD) is a challenging and rare clinical scenario. We used a comprehensive US database to determine delivery rates among women with ESKD, from 2002 to 2015, and examined associations between clinical characteristics and delivery, preterm delivery, and cesarean delivery. We found that the delivery rate in women treated with hemodialysis or kidney transplantation increased over the study period. Women with a kidney transplant were less likely to deliver preterm but more likely to deliver via cesarean when compared to women on hemodialysis. Increasing time on hemodialysis is now recommended for pregnant women with ESKD on hemodialysis. In 2012-2015, few women were observed to have been prescribed increased outpatient hemodialysis time 30 days prior to delivery. These findings draw attention to rising trend of obstetric delivery among those with ESKD that could help guide both patient counseling and future research on management of women with ESKD who are of childbearing age.

DOI: 10.1053/j.ajkd.2019.08.029

Screening for Asymptomatic Coronary Artery Disease in Waitlisted Kidney Transplant Candidates: A Cost-Utility Analysis by Tracey Ying et al

Cardiovascular disease is common in patients with kidney failure, and clinical practice guidelines recommend regular screening for asymptomatic coronary artery disease (CAD) in patients on the kidney transplant waitlist. To date, the cost-effectiveness of such screening has not been evaluated. In this article, Tracey Ying and colleagues conducted a cost-utility analysis to determine the cost-effectiveness of no further screening versus regular screening for asymptomatic CAD, and evaluated potential influential variables that may affect results of the economic evaluation.

DOI: 10.1053/j.ajkd.2019.10.001

Editorial: The Cost of Screening Kidney Transplant Candidates for Coronary Artery Disease by Allyson Hart et al [FREE] 

This month’s In Practice:

A Guide to Management of Sleepiness in ESKD by Jennifer Y. So et al 

Daytime sleepiness is common among patients receiving maintenance dialysis and following successful kidney transplantation. Unrecognized and untreated sleep disorders are associated with substantial morbidity and mortality among patients with end-stage kidney disease. Effective management of sleepiness can improve quality of life in patients with kidney disease, and awareness of these disorders by treating nephrologists is crucial. This review focuses on the principal causes of sleepiness in patients with end-stage kidney disease, and provides a systematic approach to guide providers through the recognition, early diagnosis, and treatment of sleepiness.

DOI: 10.1053/j.ajkd.2019.09.010

On the Cover: The short-eared owl is a stealthy predator owing, in part, to the paired anatomy of its eyes, facial plumage, and ears. Despite not being able to move its eyes within the orbits, a forward symmetrical gaze provides the depth of field necessary to judge distance from prey. Highly symmetrical and satellite shaped rings of facial feathers, the facial disk, collect and funnel sounds to ears with exquisite auditory acuity. Hidden ear openings located asymmetrically behind the eyes enable the owl to distinguish if prey is approaching from above or below. The imperfect anatomical symmetry of human kidneys has raised the question of whether the right and left kidneys yield different transplantation outcomes. In this issue of AJKD, Kulkarni et al examine this question.

The photograph “IMG_9969-001” is by Nigel on Flickr, released under CC BY 2.0 license.

In the face of the unprecedented public health crisis posed by the current pandemic, this special collection gathers COVID-19–related publications from the NKF family of journals. All articles in the collection are freely available.