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 November 2021 issue:
From the authors: Diagnosis and management of hypertension in hemodialysis was traditionally based on peridialytic blood pressure (BP) readings. Ambulatory BP monitoring (ABPM) is considered the gold standard for hemodialysis patients because of its association with clinical outcomes, but several factors reduce its widespread application. This study examined the diagnostic accuracy of different types of BP metrics, comparing them with 44-hour ABPM. It showed that intradialytic BP, intradialytic plus pre/postdialysis BP, and scheduled BP recordings in the out-of-dialysis day performed with better sensitivity/speciﬁcity, higher measures of agreement (κ-statistic), and higher area under the curve in receiver operating characteristic (ROC) analyses for 44-hour BP than predialysis or postdialysis BP. These 3 index metrics represent promising approaches for the diagnosis of elevated BP in hemodialysis.
Editorial: In the Right Place at the Right Time: Growing Evidence for Out-of-Office Blood Pressure Measurement in Hemodialysis Patients by Jordana B. Cohen [FREE]
Financial Hardship Among Nonelderly Adults With CKD in the United States by Isaac Acquah et al
From the authors: Due to their chronic nature and rising health care costs, adults with diseases like diabetes mellitus and cardio-vascular disease often have difﬁculty paying their medical bills. This ﬁnancial hardship has not been extensively explored among patients with chronic kidney disease (CKD). We used nationally representative data from the National Health Interview Survey to explore this phenomenon. Our ﬁndings show that 1 in 2 nonelderly adults with CKD in the United States either have difﬁculty paying their medical bills or cannot pay them at all. Although the uninsured were more likely to report this problem, individuals who were insured also face this challenge. These ﬁndings suggest that measures to reduce ﬁnancial hardships in this population are needed.
Editorial: The Financial Burden of Inadequate Health Insurance Coverage by Talar W. Markossian and Timothy Classen [FREE]
From the authors: Mechanisms underlying the variable course of disease progression in patients with chronic kidney disease (CKD) are incompletely understood. We aimed to identify biomarkers of adverse kidney outcomes and mortality in patients with CKD to gain insights into pathophysiologic mechanisms and their prediction. Through a systematic screen of urine metabolites in patients with CKD, we identiﬁed 55 urine metabolites whose levels were signiﬁcantly associated with adverse kidney outcomes and/or mortality. Metabolites were found to cluster within speciﬁc pathways, especially the phosphatidylcholine pathway, to a greater degree than would be expected by chance. We demonstrated improvement of the prediction of kidney failure when metabolites were added to the well-established Kidney Failure Risk Equation. Our comprehensive screen rep-resents a valuable resource for future studies of bio-markers of CKD progression.
From the authors: In patients with atrial ﬁbrillation (AF) and chronic kidney disease stages 3-5D, the relative efﬁcacy and safety of different oral anticoagulant agents (OACs) remains unclear. We conducted a systematic review and pairwise network meta-analysis, with results suggesting that, in patients with AF with an glomerular ﬁltration rate of 15-60 mL/min, direct OACs are superior to warfarin in preventing thromboembolic events and reducing the risk of bleeding. This study could not identify a preferred direct OAC. Notably, the use of OACs in dialysis recipients with AF may increase bleeding events without signiﬁcant beneﬁts. These ﬁndings may provide valuable insights to help clinicians.
Patient Education for Kidney Failure Treatment: A Mixed-Methods Study by Susan Koch-Weser et al
From the authors: There are several treatment options for people whose kidneys are failing. Doctors and patients need to choose the treatment together, and patient education should prepare people to do this. To learn about what happens in patient education sessions, we observed them, interviewed session leaders, and reviewed the slide presentations they used. We found that information patients need to make decisions was missing from some sessions. Session leaders said some people come only when the decision they have to make is urgent. These ﬁndings suggest that improvement of patient education requires that all topics patients need to understand should be covered and that doctors and session leaders should work together more closely to make sure patients attend these sessions before the choice of a treatment becomes urgent.
Mortality, Kidney Failure, and Hospitalization Among Medicare Beneficiaries With CKD and Pulmonary Hypertension by Sankar D. Navaneethan et al
From the authors: Pulmonary hypertension (PH) is common and has been linked to adverse cardiovascular outcomes in patients with kidney disease. In this study of Medicare beneﬁciaries with CKD (aged ≥67 years), we examined the associations of pulmonary hypertension with mortality, kidney failure, and hospitalization. The presence of pulmonary hypertension was associated with a higher risk of death during the follow-up period. A higher rate of all-cause, cardiovascular, and noncardiovascular hospitalization was noted among those with PH compared with those without PH. During follow-up years 1 and 2-3, a higher risk of kidney failure was noted after PH, which is partly due to the higher incidence of acute kidney injury events and acute kidney injury requiring dialysis support. Further studies examining the mechanisms that explain the observed associations and therapeutic interventions to address underlying reasons for PH in the setting of CKD are needed.
Special Report from the November 2021 Issue:
From the authors: The National Kidney Foundation convened an interdisciplinary international workshop in March 2019 to discuss the potential role of a new class of agents for the treatment of anemia in patients with chronic kidney disease (CKD): the hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs). International experts with expertise in physiology, biochemistry, structural chemistry, translational medicine, and clinical management of anemia participated. Participants reviewed the unmet needs of current anemia treatment, the biology of hypoxia-inducible factor, the pharmacology of prolyl hydroxylase inhibitors, and the results of phase 2 clinical trials of HIF-PHIs among patients with CKD, both those treated by dialysis and those not receiving kidney replacement therapy. Participants in the workshop developed a number of recommendations for further examination of HIF-PHIs, including long-term safety issues, potential benefits, and practical considerations for implementation including patient and provider education.
On the Cover: The November 2021 cover features vibrant murals painted on the pillars of the Coronado Bridge in San Diego, which was to have been the host city of this year’s Kidney Week. Part of Chicano Park, the murals celebrate and commemorate the history and culture of Mexican Americans and Chicanos, connecting the past with the present. While the ongoing COVID-19 pandemic has certainly impacted professional society gatherings, the spirit of Kidney Week as a time to connect with colleagues near and far, new and old, remains strong. The theme of connection on the cover resonates with a poignant essay entitled “The Bridge”, in which Dr Izmaylov describes how one patient redefined their goals at the time of dialysis initiation.
The photograph “Chicano Park” is by bikesharedude on Flickr and was released into the public domain.
AJKD is celebrating its 40th year in 2021. In this special collection, the editors highlight landmark papers on chronic kidney disease that have been published in the journal over the past four decades.