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 August 2020 issue:

Adiposity, Sex, and Cardiovascular Disease Risk in Children With CKD: A Longitudinal Study of Youth Enrolled in the Chronic Kidney Disease in Children (CKiD) Study by Tammy M Brady et al 

From the authors: Children with chronic kidney disease are at greater risk for cardiovascular disease than their peers without kidney disease. It is unclear how much of a role obesity plays in this elevated risk and it is unknown if the association of obesity with cardiovascular risk differs by sex. Longitudinal analyses of over 700 children with chronic kidney disease revealed that adiposity is not only independently associated with indicators of cardiac damage, but has a significantly greater association among girls than among boys. These findings may have significant clinical implications for this group of children at high risk for cardiovascular disease morbidity and mortality.

DOI: 10.1053/j.ajkd.2020.01.011

Editorial: Obesity and Cardiovascular Outcomes in Children With CKD: Does Sex Matter? by Kristen Sgambat and Asha Moudgil [FREE] 

CKD Awareness Among US Adults by Future Risk of Kidney Failure by Chi D Chu et al 

From the authors: Patients are often unaware of their CKD status. Using nationally representative survey data from 1999-2016, self-reported CKD awareness was examined and compared to hypertension and diabetes awareness. Overall CKD awareness was consistently <15% and stable over time. Even among individuals with high predicted risk of kidney failure (≥15% within 5 years, using the Kidney Failure Risk Equation), CKD awareness was only 49%—less than awareness of hypertension and diabetes (both 60%-80%, improving from 1999-2016 with statistically significant trends). This work underscores the urgent need for intensified efforts to improve CKD awareness, particularly among patients at highest risk of kidney failure.

DOI: 10.1053/j.ajkd.2020.01.007

Editorial: Knowledge Is Power: Patient Education as a Tool for Patient Activation by Jennifer Chen et al [FREE] 

Association of Opioids and Nonsteroidal Anti-inflammatory Drugs With Outcomes in CKD: Findings From the CRIC (Chronic Renal Insufficiency Cohort) Study by Min Zhan et al [Open Access] 

From the authors: Pain is common in patients with chronic kidney disease (CKD) but the best drugs to treat pain are not known. In an existing cohort of patients with CKD, we prospectively examined the comparative harm of two important classes of drugs to treat pain: non-steroidal anti-inflammatory drugs (NSAIDs) and opioids. Both drug classes have distinct adverse effects. The results suggest opioids use was associated with an increased risk of kidney failure, hospitalization, and death when compared to cohort participants not using these drugs. NSAID use had a much weaker association with these outcomes. We conclude that opioid use may have a greater risk than NSAIDs in CKD.

DOI: 10.1053/j.ajkd.2019.12.010

Plasma Soluble Urokinase Plasminogen Activator Receptor (suPAR) and CKD Progression in Children by Darcy K Weidemann et al 

From the authors: Soluble urokinase-type plasminogen activator receptor (suPAR) is a new biomarker which may be associated with chronic kidney disease (CKD), although this remains understudied in children. A longitudinal prospective analysis using lognormal regression methods was performed of 565 participants enrolled in the Chronic Kidney Disease in Children study looking at CKD progression based on their levels of plasma suPAR. We found that participants in the highest quartile of suPAR experienced 54% faster time to a combined event (renal replacement therapy or a halving of their eGFR), as compared to the lowest quartile after adjustment for traditional CKD risk factors. This relationship seemed to be most affected by baseline eGFR, with strongest associations observed at milder stages of kidney disease.

DOI: 10.1053/j.ajkd.2019.11.004

Efficacy of Furosemide, Oral Sodium Chloride, and Fluid Restriction for Treatment of Syndrome of Inappropriate Antidiuresis (SIAD): An Open-label Randomized Controlled Study (The EFFUSE-FLUID Trial) by Parajee Krisanapan et al [FREE temporarily]

DOI: 10.1053/j.ajkd.2019.11.012

Associations of Systolic Blood Pressure With Incident CKD G3-G5: A Cohort Study of South Korean Adults by Tae Ik Chang et al 

From the authors: For the general population, clinical practice guidelines recommend a target blood pressure <130/80 mmHg in order to reduce cardiovascular risk. However, the optimal blood pressure to prevent development of chronic kidney disease (CKD) is unclear and has been a matter of debate. We studied the associations of systolic blood pressure and incident kidney disease using a large national cohort of 10.5 million Korean adults with preserved kidney function. We note that higher systolic blood pressure levels (>130 mm Hg) were associated with an increased risk of incident CKD in a graded manner. This linear association between systolic blood pressure level and the risk of incident CKD was robust and consistent in analyses incorporating blood pressure measured once and those incorporating time-updated blood pressure measurements. These findings support future evaluation of SBP lowering strategies to reduce the development of CKD.

DOI: 10.1053/j.ajkd.2020.01.013

Association of NT-proBNP and BNP With Future Clinical Outcomes in Patients With ESKD: A Systematic Review and Meta-analysis by Tyrone G Harrison et al [Open Access]  

From the authors: In this meta-analysis, we examined the associations between varying threshold elevations of BNP (Brain Natriuretic Peptide) and NT-proBNP (N-terminal pro-fragment of BNP) with future cardiovascular (CV) events, CV mortality, and all-cause mortality in patients with end-stage kidney disease (ESKD). NT-proBNP and BNP thresholds were identified that were associated with significantly increased risks of CV mortality and all-cause mortality. Graded increases in the risk of CV mortality and all-cause mortality were observed with higher NT-proBNP and BNP thresholds. Thresholds of natriuretic peptide elevations above those used in populations with normal kidney function are required to identify patients with ESKD at increased risk of future clinical events. These findings may assist clinicians with interpreting these peptide levels in this population.

DOI: 10.1053/j.ajkd.2019.12.017

This month’s Policy Forum:

Moral Distress in Nephrology: Perceived Barriers to Ethical Clinical Care by Kathryn Ducharlet et al

Moral distress occurs when individuals are unable to act in accordance with what they believe to be ethically correct or just. It results from a discrepancy between a clinician’s perception of “the right thing to do” and what is actually happening and is perpetuated by perceived constraints that limit the individual from speaking up or enacting change. Moral distress is reported by many clinicians in caring for patients with serious illness, including chronic kidney disease and kidney failure. This article offers an international perspective on moral distress in nephrology in diverse contexts and health care systems and offer suggestions for interventions from individual provider, facility, and health care systems perspectives to reduce the impact of moral distress on nephrology providers.

DOI: 10.1053/j.ajkd.2019.09.018

Strategies for addressing moral distress in nephrology. Figure 1 from Ducharlet et al, AJKD © National Kidney Foundation

Blog Post Impact of Moral Distress on Nephrology Providers: An Interview [FREE]

On the Cover: Opium, derived from the poppyplant, has been used recreationally and medicinally to treat pain since 6000 BCE. In the early 1800s, the German apothecary Friedrich Wilhelm Adam Sertürner isolated an opiate alkaloid from poppy and named it ‘Morphium’ after the Greek god of sleep and dreams. Since this breakthrough in medicinal chemistry and, in particular, over the past 20 years, we have observed the enormous risks of opioid addiction. Despite these concerns, treating pain in patients with chronic kidney disease can be complex and difficult because of the fear of nephrotoxicity from nonsteroidal anti-inflammatory drugs (NSAIDs). While both opioids and NSAIDs are efficacious analgesics, concerns regarding the safety of both medication classes influence their utilization. In this month’s issue of AJKD, Fink et al analyzed data from the Chronic Renal Insufficiency Cohort (CRIC) Study and compared the association of kidney failure and other adverse events with the use of opioids to the association with use of NSAIDs. Their novel findings reveal that opioids may actually be more harmful than NSAIDs in patients with CKD.

Image by tuku released under the Pixabay license (https://pixabay.com/service/license/).

Special Collection: Patient-Centered Research