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 June 2020 issue:
Icodextrin Versus Glucose Solutions for the Once-Daily Long Dwell in Peritoneal Dialysis: An Enriched Systematic Review and Meta-analysis of Randomized Controlled Trials by Käthe Goossen et al [Open Access]
From the authors: Peritoneal dialysis (PD) is a common and effective form of dialysis. Usual PD is performed with dialysis solutions containing glucose as the main ingredient, although other types of sugars are available. In this study, we combine the results of 20 randomized controlled trials that compared usual PD (glucose) to PD using another type of sugar (icodextrin). The trials were all of acceptable technical quality. Among the 1714 patients that we included, those randomly assigned to icodextrin PD had better outcomes relative to those randomly assigned to usual PD. Icodextrin PD resulted in greater fluid removal, fewer episodes of fluid overload, reduced daily sugar absorption and probably increased overall survival. Further research will be needed to confirm our results that suggest icodextrin has clinical benefit for select patients, including those not meeting targets for care and at risk of fluid overload.
Editorial: Enriching the Evidence Base for Icodextrin by Simon J. Davies [FREE]
Blog Post: Icodextrin vs Glucose for the Long Daytime Dwell? by Shubha Mathur, Yara Shams, and Edgar Lerma [FREE]
From the authors: The SUBLIME lifestyle intervention aimed to reduce sodium intake and blood pressure in hypertensive patients with chronic kidney disease (CKD). Hypertension is common in patients with CKD and is usually treated with multiple medications. High sodium intake is a major contributor to hypertension, but is not effectively targeted in routine care. This is partially because improving dietary habits and reduction of sodium intake is not easy for most people, and requires substantial coaching and costs to achieve. SUBLIME helped patients to reduce their sodium intake. However, over time the effects somewhat diminished, and further research is needed to improve its effectiveness in the long term.
Editorial: A Web-Based Self-management Sodium Intervention in Individuals With CKD by Cheryl A.M. Anderson et al [FREE]
From the authors: Only a small proportion of patients with kidney failure receive kidney transplants. In large part, this is due to the imbalance between supply and demand for organs. A significant proportion of kidneys are discarded due to donors’ infection with the hepatitis C virus. Yet, aside from infection with hepatitis C, many of these donors are young and healthy and their organs could provide a recipient with many years of life. In addition, the wait to get a kidney transplant can be many years. There has been a marked increase in the number of hepatitis C infected organs available that could shorten the wait for a transplant. This study used a computer model to analyze the clinical and economic outcomes for end stage kidney disease patients considering accepting transplantation with such an organ. It demonstrates that transplanting kidneys from HCV-viremic donors into HCV-uninfected recipients increased quality-adjusted life expectancy and reduced costs compared with a strategy of transplanting kidneys from HCV-unexposed donors.
Editorial: HCV-Infected Deceased Donor Kidney Transplantation—Time to Take Up the Offer by Yuvaram N.V. Reddy et al [FREE]
Blog post: How Cost-Effective is Transplanting Hepatitis C Positive Kidneys? by Anju Yadav [FREE]
From the authors: Although the impact of chronic kidney disease (CKD) on patients’ quality of life and well-being is increasingly being evaluated, the degree to which quality of life falls with CKD is unclear. After adjusting for demographic, social, and comorbidity factors, this study compared self-perceived health and health-related quality of life between the general population and patients with different stages of kidney disease, including those with moderate to advanced CKD not receiving renal replacement therapy, those on dialysis, and those with a functioning kidney transplant. We observed significantly lower physical health in patients with kidney disease, including those with CKD not yet dependent on renal replacement therapies. We only observed a lower level of mental health among patients on maintenance dialysis.
Arteriovenous Fistula Use in the United States and Dialysis Facility–Level Comorbidity Burden by Claudia Dahlerus et al
From the authors: While fistulas are the preferred form of vascular access for hemodialysis patients, it can be difficult to create fistulas in sicker patients. However, some dialysis units with patients who have many other illnesses have a high proportion of patients with a fistula for hemodialysis access. We studied how much variation in fistula rates exists across dialysis units based on the overall illness burden across their patients. There was little variation in fistula rates among dialysis units even after taking into account the average number of medical problems among patients. Variations in the proportion of sicker patients did not explain why some dialysis units had lower fistula rates than others. Instead, these differences may be related to variations in processes of care across dialysis units, but more investigation is needed to fully understand these patterns.
From the authors: Influenza vaccination is particularly important for older adults and those with high risk conditions including reduced kidney function. In this study, we assessed the effectiveness of influenza vaccination among older adults with and without reduced kidney function. We found that nearly 40% of older adults with and without reduced kidney function were not vaccinated, and receiving an influenza vaccination reduced the risk of hospitalization relevant to influenza by approximately 10% when kidney function was preserved or mild to moderately reduced, but the benefit was not evident when kidney function was severely reduced. Thus, the uptake of influenza vaccination should be improved, while further studies are needed to determine the optimal influenza vaccination strategies for individuals with severely reduced kidney function.
US Trends in Hospitalizations for Dialysis-Requiring Acute Kidney Injury in People With Versus Without Diabetes by Jessica Lee Harding et al [FREE temporarily]
From the authors: In the United States, the incidence of dialysis-requiring acute kidney injury (AKI-D) has risen substantially in the last decade. Whether this differs in adults with vs. without diabetes, and whether these increases are associated with changes in comorbidities, is unclear. Using nationally representative data, we show that rates of AKI-D increased significantly between 2000 and 2015, especially in young adults with diabetes, with rates remaining more than five times higher in adults with diabetes compared to adults without diabetes. In both populations, the proportion of AKI-D hospitalizations with liver, rheumatic and renal comorbidities increased, while most cardiovascular comorbidities decreased. This study highlights the need for greater AKI risk factor mitigation above and beyond traditional cardiovascular prevention and management, especially in young adults with diabetes.
From the authors: Observational studies that measured fibroblast growth factor 23 (FGF23) at a single time point reported independent associations between elevated FGF23 levels and increased risk of end stage renal disease (ESRD) in some but not in all studies. Using up to 5 FGF23 measurements, this prospective case-cohort study within the Chronic Renal Insufficiency Cohort (CRIC) Study demonstrated that rising FGF23 levels were associated with ESRD risk independent of time-updated covariates. Additional clinical studies are needed to confirm our findings and further preclinical studies are needed to demonstrate if FGF23 has a mechanistic role in the progression of chronic kidney disease (CKD) to ESRD.
Long-term Mortality Risks Among Living Kidney Donors in Korea by Yaerim Kim et al
From the authors: Living kidney donors have been reported to have a possibly higher rate of death and end-stage kidney disease. This study investigated the long-term mortality experience of living kidney donors by comparing them to a similarly healthy component of the Korean population that excluded individuals with risk factors that would have rendered them ineligible for kidney donation. A complementary approach compared donors to the general population matched on age, sex, BMI, era and other characteristics. Neither analysis demonstrated any difference in mortality between kidney donors and the general healthy population.
This month’s Special Report:
Overcoming Barriers for Uptake and Continued Use of Home Dialysis: An NKF-KDOQI Conference Report by Christopher T. Chan et al [FREE temporarily]
Home dialysis is used in a minority of patients with kidney failure in the United States. How can the United States increase the uptake of home dialysis therapies? The 2018 NKF-KDOQI Home Dialysis Conference built on the goals of the first such conference held a year earlier, which focused on identifying barriers to home dialysis in terms of initiating home therapies and in retention of home dialysis patients. The focus of the second conference was to develop practical action points that would benefit not only home dialysis programs but also patients and their care partners.
On the Cover: The 3D computer-generated rendering of the influenza virus on this month’s cover hides the fierceness with which these microscopic organisms infect humans, as was so apparent following the emergence of SARS-CoV-2 and, even more so, as we cope with the COVID-19 pandemic. Three of the influenza virus’ eight ribonucleoproteins encode surface proteins (HA, NA, and M) that are used to type the virus, and serve as targets for vaccines that activate a T cell immune response. Patients with kidney disease are particularly susceptible to influenza-related diseases, but the efficacy of influenza vaccination in patients with kidney disease is not clear. In this month’s issue, Ishigami et al sought to bridge this gap by studying the prevalence of influenza vaccination across stages of CKD as well as the associated incidence of influenza-related hospitalizations. Vaccination lowered the odds of influenza-related hospitalization in moderate but not severe CKD, reinforcing the need to study optimal vaccination strategies in the setting of advanced kidney disease.
Image by Dan Higgins from the CDC Public Health Image Library (Public Domain).
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