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 March 2022 issue:
From the authors: Children, adolescents, and young adults face many barriers to taking medication as prescribed. After an organ transplant, failure to address these barriers can lead to transplant rejection and organ failure. In our kidney transplant clinic, we implemented an approach to help patients identify barriers to taking medication and to partner with clinical team members to overcome them. After full implementation of the new system in our clinic over 15 months, acute rejection in our patients decreased by nearly half. These results need to be replicated by studies in other clinics and settings, but this approach may help clinicians know how to improve health outcomes by partnering with patients who have chronic illness to overcome the barriers to taking medication.
Editorial: A Multifaceted Medication Adherence Promotion System to Reduce Late Kidney Allograft Rejection in Children and Young Adults by Andrew J. Benintende et al [FREE]
From the authors: Kidney disease guidelines for nephrology referral are transitioning from recommending referral based on laboratory value thresholds to using risk of kidney failure to guide referrals, but the impact on health care systems is not known. Using data from the Veterans Health Administration, we estimated the potential volume of nephrology referrals based on laboratory data, the estimated risk of kidney failure, or a combination of both. We report that referral based on a 2-year risk of kidney failure of 1% or higher would result in a similar number of referrals as current laboratory-based guidelines but would identify patients at higher median risk for kidney failure.
Editorial: Too Many for Too Few: Finding Appropriate Nephrology Referrals for Patients With CKD That Optimize Outcomes by Chi D. Chu et al [FREE]
Etelcalcetide Utilization, Dosing Titration, and Chronic Kidney Disease–Mineral and Bone Disease (CKD-MBD) Marker Responses in US Hemodialysis Patients by Angelo Karaboyas et al [OPEN ACCESS]
From the authors: Randomized trials have demonstrated the efﬁcacy of etelcalcetide, a calcimimetic approved for US commercial use in 2017, to reduce parathyroid hormone (PTH) levels in hemodialysis patients, but we speculated that its real-world effectiveness outside a controlled trial setting may differ. Studying 2,596 dialysis patients across the United States, we found that the majority of patients starting etelcalcetide had PTH levels well beyond the KDIGO-recommended upper limit, and they experienced large reductions in PTH levels over the subsequent year into the target range. Serum calcium levels also declined, but the use of active vitamin D and calcium-based phosphate binders increased, and the risk of severe hypocalcemia remained low. Intravenously administered etelcalcetide is an effective therapy for PTH reduction and has the potential to improve adherence and decrease pill burden for patients receiving in-center hemodialysis.
From the authors: High anion gap acidosis frequently occurs in individuals with advanced chronic kidney disease (CKD) due to the accumulation of uremic solutes. Its impact on the risk of progression to kidney failure with replacement therapy (KFRT) has not been well studied. This retrospective cohort study sought to assess the association between anion gap and the risk of progression to KFRT in advanced CKD. We found that high anion gap, regardless of its deﬁnition, was associated with an increased risk of progression to KFRT and mortality. High anion gap might be a potential therapeutic target although it has received little attention in current clinical practice for CKD. Our ﬁndings are applicable to patients with advanced CKD given the distribution of kidney function of our cohort.
From the authors: The cardiac biomarkers N-terminal pro–brain natri-uretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hsTnT) are frequently used clinically to evaluate patients for suspected acute heart failure or myocardial infarction. However, the utility of conventional upper reference limits (URL) for NT-proBNP and hsTnT in chronic kidney disease (CKD) remains debated. We analyzed the distribution of hsTnT and NT-proBNP in ambulatory CKD participants to examine how conventional URL apply to this population. In this ambulatory CKD population with no self-reported history of cardiovascular disease, we found that the majority of participants had concentrations of NT-proBNP and hsTnT above the conventional URL. Developing thresholds for these commonly used cardiac biomarkers when used in the setting of CKD may improve their utility for evaluation of suspected heart failure and myocardial infarction.
From the authors: Staphylococcus aureus (S aureus) bacteremia (SAB) is a leading cause of morbidity and mortality in patients with kidney failure on hemodialysis. The clinical characteristics and the characteristics of the S aureus isolates have changed over time, but it is unknown how these changes have affected patient outcomes. In this study, we examined these changing characteristics and their associations with clinical outcomes among 453 patients receiving maintenance hemodialysis who were hospitalized with SAB over a period of 21 years. The most common suspected sources of infection changed over time. Additionally, virulent strains of S aureus became more prevalent. These changes were associated with worse outcomes, including SAB-attributable mortality, persistent bacteremia, and tissue infections, all of which increased over time.
From the authors: Critically ill patients with COVID-19 often develop acute kidney injury (AKI). This study of 4,221 patients demonstrated that more severe AKI was associated with greater in-hospital mortality and poorer kidney function at hospital discharge. Among the 876 patients who required dialysis for AKI, almost two-thirds died. Among those who survived to discharge, about two-thirds recovered kidney function and were discharged without the need for dialysis. Lower baseline kidney function and reduced urine output were associated with nonrecovery of kidney function. Identiﬁcation of such predictors is important in assessing prognosis among these critically ill patients and has implications for clinical care of individuals critically ill with COVID-19.
Timing of Kidney Support Therapy in Acute Kidney Injury: What Are We Waiting For? by Josée Bouchard and Ravindra L. Mehta [FREE]
From the authors: The optimal timing of kidney support therapy in critically ill patients with acute kidney injury (AKI) without life-threatening complications related to AKI is controversial. Recent multicenter, randomized, controlled studies have questioned the need for earlier initiation of therapy, despite one study showing a benefit in survival and others with no differences in mortality based on the timing of kidney support therapy initiation. These findings reflect the uncertainties in decisions to initiate kidney support therapy, which should ideally be individualized according to the patient’s comorbidities, severity of illness, trajectory of kidney function, and urine output as well as requirements for fluid balance and solute removal. A delayed approach could translate into a potentially reduced burden of dialysis dependence in addition to saving health resources. However, we must ascertain what constitutes the waiting period and the benefits and risks associated with this approach. This article reviews the concept of timing of dialysis in AKI, performs a critical assessment of the most important clinical trials in this topic, discusses ongoing research and knowledge gaps, and defines key research issues to address in the future.
On the Cover: AJKD is honored to present the 10th annual NephMadness, organized by Executive Team members Joel Topf, Matthew Sparks, Timothy Yau, Anna Burgner, Samira Farouk, Pascale Khairallah, and Anna Vinnikova. This annual educational initiative highlights 8 important nephrology topics and encourages participants to select the one most likely to change kidney disease care in the next 5 years. US-based physicians can claim up to 8.0 CME credits and MOC points for this activity. Join the fun and learning at www.AJKDBlog.org.
The NephMadness 2022 logo is created by Graham T. Gipson, © AJKD
In celebration of World Kidney Day on March 10, AJKD presents this special collection of recent publications from around the world addressing a variety of important aspects of kidney disease research. All articles are freely available until March 31, 2022.