Highlights from the June 2021 Issue

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 2021 issue:

Joint Associations of Maternal-Fetal APOL1 Genotypes and Maternal Country of Origin With Preeclampsia Risk by Xiumei Hong et al

From the authors: Preeclampsia, characterized by increased blood pressure after 20 weeks of pregnancy, as well as other abnormalities (eg, protein in the urine), is dangerous to mothers and their infants. Previous studies found that individuals with African ancestry may carry APOL1 genetic variants that increase risk for chronic kidney dis-ease. This study found that fetal high-risk APOL1 genotypes and maternal-fetal APOL1 genotype discordance independently contribute to preeclampsia risk in African American mothers. This association was not observed in Haitian mother-infant pairs possibly because of different environmental exposures and cultural milieu. Additional studies are required to under-stand why APOL1 associations with preeclampsia differ by maternal country of origin and to improve management of mothers at risk for preeclampsia.

DOI: 10.1053/j.ajkd.2020.10.020

Editorial: APOL1 and Preeclampsia: Intriguing Links, Uncertain Causality, Troubling Implications by John R. Sedor et al [FREE] 

Estimation of Prevalence of Kidney Disease Treated With Dialysis in China: A Study of Insurance Claims Data by Chao Yang et al  

From the authors: The national prevalence of dialysis in China has not been well studied due to its large population and limited resources. Insurance claims data provide a unique opportunity to understand the burden of kidney failure and have been used to characterize dialysis patients in the United States. Using a large nationwide claims database, the age- and sex-standardized prevalence of kidney disease treated with dialysis in China was estimated between 2013 and 2017. In addition, we predicted the prevalence trend over time to estimate a rising prevalence through 2025. Kidney failure has become a major public health problem in China. It is imperative to develop prevention and control strategies to reduce the escalating burden of advanced kidney disease.

DOI: 10.1053/j.ajkd.2020.11.021

Editorial: One Step Closer to Developing a National Dialysis Registry in China by Samaya Javed Anumudu et al [FREE] 

Prevention of Urinary Stones With Hydration (PUSH): Design and Rationale of a Clinical Trial by Charles D. Scales Jr. et al

From the authors: Increasing fluid intake in urinary stone formers with low urine volume is essential to prevent stone recurrence but difficult to achieve in clinical practice. The Prevention of Urinary Stones With Hydration (PUSH) Study is a randomized clinical trial that uses a smart water bottle to track fluid intake and examines whether a combination of behavioral interventions (including a fluid prescription, financial incentives, and coaching) improves adherence to higher fluid intake and reduces stone recurrence. We describe the rationale and design of this large multicenter randomized trial currently enrolling 1,642 stone formers, with outcomes including symptomatic stone recurrence, asymptomatic (radiographic) stone disease progression, and urinary parameters associated with disease.

DOI: 10.1053/j.ajkd.2020.09.016

Blog Post A Patient Behavior Modification to Increase Fluid Intake: The PUSH Trial by Shubha Mathur and Edgar V. Lerma [FREE] 

Change in Cardiac Biomarkers and Risk of Incident Heart Failure and Atrial Fibrillation in CKD: The Chronic Renal Insufficiency Cohort (CRIC) Study by Nisha Bansal et al 

From the authors: Patients with chronic kidney disease are at higher risk of developing heart failure and atrial fibrillation for reasons that are not completely understood. Cardiac bio-markers measured in the blood may provide insight into possible mechanisms that contribute to the higher risk of heart failure and atrial fibrillation. In this study, we examined changes in cardiac biomarkers over time and their association with development of heart failure and atrial fibrillation. We found that increases over a period of 2 years in 2 of these cardiac biomarkers (NT-proBNP and sST2) were significantly associated with higher risk of heart failure, and increases in sST2 were associated with higher risk of atrial fibrillation.

DOI: 10.1053/j.ajkd.2020.09.021

Design and Rationale of HiLo: A Pragmatic, Randomized Trial of Phosphate Management for Patients Receiving Maintenance Hemodialysis by Daniel L. Edmonston et al [Open Access] 

From the authors: Citing observational and preclinical studies that link hyperphosphatemia to adverse clinical outcomes, current clinical practice guidelines recommend reduction of serum phosphate “toward the normal range” in patients with kidney failure undergoing hemodialysis. However, no randomized clinical trials have tested whether lowering serum phosphate levels improves clinical outcomes. HiLo is a pragmatic cluster-randomized clinical trial that will test the effects of targeting a “Hi” or a “Lo” serum phosphate level (≥6.5 vs <5.5 mg/dL) on the hierarchical composite outcome of all-cause mortality and all-cause hospitalization. HiLo incorporates multiple pragmatic features including liberal eligibility criteria, cluster randomization, electronic informed consent, dietitian-implemented interventions, remote study monitoring, real-world data collection from existing electronic health records, and a novel hierarchical composite outcome.

DOI: 10.1053/j.ajkd.2020.10.008

Blog Post Could High Be Better Than Low? Targeting Phosphate in Trials by Swapnil Hiremath [FREE] 

Psychosocial Factors, Intentions to Pursue Arteriovenous Dialysis Access, and Access Outcomes: A Cohort Study by Jace Ming Xuan Chia et al 

From the authors: Many patients start hemodialysis with temporary vascular access despite regular kidney care and predialysis education. Delay is often related to patient choice, but research on patients’ perspectives is limited and no measure of attitudes toward hemodialysis preparation presently exists. In this study, we surveyed predialysis patients and their family members about their perceptions of chronic kidney disease and their intentions to undergo access creation. We also report on a new survey instrument to measure attitudes toward hemodialysis preparation. Domains covered in the instrument included perceptions about the value of vascular access as well as concerns, including those about the need for dialysis and costs. Beliefs about value of vascular access predicted patients’ intentions to pre-pare for hemodialysis as well as their access outcomes.

DOI: 10.1053/j.ajkd.2020.09.019

Mobile Health (mHealth) Technology: Assessment of Availability, Acceptability, and Use in CKD by Sarah J. Schrauben et al 

From the authors: Mobile health (mHealth) technology improves patient-provider communication and increases access to information. We wanted to explore how extensively patients are using mHealth technology, what they think about using it, and how proficient they are using it. Our study focused on a group of 932 individuals with chronic kidney disease (CKD). We found that 70% currently used internet, email, and smartphones and that 35% used health specific applications. Less than one-third of our patients reported proficient use of mHealth technology. Individuals who were under 65 years of age, had more education, and higher income were more likely to use mHealth technology and had a greater interest in it. Black and Hispanic individuals used technology less overall but were more interested in using mHealth technology. mHealth technology presents an opportunity to engage individuals with CKD.

DOI: 10.1053/j.ajkd.2020.10.013

Podcast Is Mobile Health the Way of the Future? Interview with Dr Schrauben [FREE] 

Policy Forum from the June 2021 Issue:

Racism and Kidney Health: Turning Equity Into a Reality by Dinushika Mohottige et al 

From the authors: It is time to repair the effects of racism on kidney health. In recent years, profound racial and ethnic kidney health disparities  in the United Sates have been magnified by a number of factors, including the coronavirus disease 2019 (COVID-19) pandemic. These disparities have been well described over the past decade, providing overwhelming evidence of the inextricable links between unequal resources, opportunities, and social contexts shaped by racialization/racism and poor kidney health. Black individuals who have borne a disproportionate burden of racism-driven inequality have greater prevalence of chronic kidney disease (CKD) risk factors, are 2-4–fold more likely than White individuals to have kidney failure, and experience persistently worse access to kidney transplants, compounded by decreasing rates of access to living-donor kidney transplants. There is an urgent ethical imperative for the nephrology community to disrupt this incessant trajectory of inequity. In this perspective, we reference transdisciplinary scholarship to advance a dialog on how the field of nephrology can chart a path toward kidney health equity.

DOI: 10.1053/j.ajkd.2021.01.010

On the Cover: When ripe, winter cherries blaze like bright flames within skeletal outer “lanterns”. The immature green berries are less striking and have an unpleasant taste, but would be familiar to readers of Nicholas Culpeper’s The English Physitian of 1652 as a preventive for kidney stones. Presumably this property derived from the berries’ atropinic compounds, which could aid in the passage of ureteric stones by relaxing the smooth muscle of the walls of the ureter. Less desirable would have been the other possible consequences of ingesting the unripe fruit, including dry mouth, hallucinations, and death. In this month’s issue of AJKD, Scales et al describe a more refined approach to the prevention of urinary stones, reporting the design and rationale of the PUSH clinical trial, which involves use of a smart water bottle to encourage hydration.

The photograph “Physalis alkekengi L. Rosaceae” is by Dr Henry Oakeley. From the Wellcome Collection, available under CC BY license.


With diabetes mellitus being a leading cause of kidney failure and earlier stages of CKD throughout much of the world, understanding how diabetes affects the kidneys and exploring new treatment options is of critical importance. The last few years have brought new treatments to the clinical arena, in particular, SGLT-2 inhibitors, the focus of several publications assembled in this special collection on Diabetes and Kidney Disease (FREE until July 31, 2021).



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