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 2022 issue:

Hyperkalemia-Related Discontinuation of Renin-Angiotensin-Aldosterone System Inhibitors and Clinical Outcomes in CKD: A Population-Based Cohort Study by Sylvia J. Leon et al 

From the authors: Hyperkalemia in patients with chronic kidney disease (CKD) is common and potentially life-threatening. After an episode of renin-angiotensin-aldosterone system (RAAS) inhibitor–related hyperkalemia, discontinuation or dose reduction of the RAAS inhibitor is a common practice. In this retrospective population-based cohort study, RAAS inhibitor discontinuation was associated with higher risk of all-cause mortality and cardiovascular events. These associations were dose dependent and were consistent in 2 geographic areas in Canada. Our findings underpin the importance of RAAS inhibitors in patients with CKD. Strategies to maintain RAAS inhibitor continuity after hyperkalemia may improve clinical outcomes.

DOI: 10.1053/j.ajkd.2022.01.002

Editorial: Managing Hyperkalemia to Enable Guideline-Recommended Dosing of Renin-Angiotensin-Aldosterone System Inhibitors by Biff F. Palmer and Deborah J. Clegg [FREE] 

Self-reported Race, Serum Creatinine, Cystatin C, and GFR in Children and Young Adults With Pediatric Kidney Diseases: A Report From the Chronic Kidney Disease in Children (CKiD) Study by Derek K. Ng et al 

From the authors: Increased discussion about use of race in estimation of glomerular filtration rate (GFR) in adults motivated this investigation in children using self-/parental-reported race and measured GFR data from the Chronic Kidney Disease in Children (CKiD) study. Self-reported Black race was systematically associated with slightly higher GFR after adjustment for serum creatinine in children older than 6 years and young adults. We observed a smaller and opposite difference when adjusting for cystatin C. The “U25” (ie, age under 25 years) GFR estimation equations, which are race independent, yielded a significant but small bias in the serum creatinine–only equation for self-reported Black race but when averaged with the U25 cystatin C equation was unbiased. Our results are consistent with adult studies, and we recommend inclusion of children for future investigations of biomarkers to estimate GFR.

DOI: 10.1053/j.ajkd.2021.10.013

Editorial: Including Race in Pediatric Estimated GFR Equations: Is This a Genuine Need? by Ana Catalina Alvarez-Elías and Guido Filler [FREE] 

Epidemiology and Risk Factors for Hemodialysis Access–Associated Infections in Children: A Prospective Cohort Study From the SCOPE Collaborative by Rebecca L. Ruebner et al

From the authors: Dialysis access–associated infections are a major cause of morbidity and death among children receiving maintenancehemodialysis(HD).TheStandardizing Care to Improve Outcomes in Pediatric End-Stage Kidney Disease (SCOPE) Collaborative is a multi-center quality-improvement initiative aimed at reducing dialysis-associated infections through implementation of standardized care practices. In this study of 1,277 children receiving HD at 35 pediatric dialysis centers, risk factors for catheter-associated bloodstream infections included mupirocin use or no antibiotic agent use at the catheter exit site. Dialysis centers that demonstrated improved adherence to SCOPE HD care practices over time had a significant reduction in catheter-associated bloodstream infection rates. Consistent improvement in compliance with standardized HD care practices can lead to a reduction in the risk of dialysis-associated infections.

DOI: 10.1053/j.ajkd.2021.11.008

Nonalbuminuric Diabetic Kidney Disease and Risk of All-Cause Mortality and Cardiovascular and Kidney Outcomes in Type 2 Diabetes: Findings From the Hong Kong Diabetes Biobank by Qiao Jin et al [OPEN ACCESS]

From the authors: Nonalbuminuric diabetic kidney disease (DKD) has become the prevailing DKD phenotype, and distinct clinicopathological characteristics have been reported. We assessed the risks of adverse outcomes (all-cause mortality, cardiovascular disease, heart failure hospitalization, and kidney disease progression) among patients with nonalbuminuric DKD compared with patients with other DKD phenotypes in a multicenter prospective cohort study of type 2 diabetes that included 19,025 individuals. We found that patients with nonalbuminuric DKD had increased risks of death, hospitalization for heart failure, and chronic kidney disease progression compared with those without DKD, and the risks of all adverse outcomes were higher among individuals with albuminuric DKD after adjustment for a wide range of confounders. Further studies are warranted to explore possible mechanisms explaining these observations that will help to tailor the clinical management of nonalbuminuric DKD.

DOI: 10.1053/j.ajkd.2021.11.011

The Relationship Between Neighborhood Disadvantage and Kidney Disease Progression in the Chronic Kidney Disease in Children (CKiD) Cohort by Sarah A. Boynton et al 

From the authors: Neighborhood poverty is associated with adverse health outcomes in children, but the specific effects on the health of children with chronic kidney disease have not been studied. We used data from participants enrolled in the Chronic Kidney Disease in Children (CKiD) study linked to US Census data to explore the association between neighborhood poverty and health characteristics in this population. Children living in areas with the lowest neighborhood income were more likely to be hospitalized and more likely to visit the emergency department for care than were children living in higher-income neighborhoods, even after accounting for the participants’ race and family income. These markers of socioeconomic status were not associated with kidney disease progression. These findings may reflect barriers to health care in lower income neighborhoods.

DOI: 10.1053/j.ajkd.2021.12.008

Perspectives of Patients, Nurses, and Nephrologists About Electronic Symptom Monitoring With Feedback in Hemodialysis Care by Andrea K. Viecelli et al 

From the authors: Patients who need dialysis can have severe symptoms like anxiety, pain, appetite loss, itching, and disturbed sleep. We are conducting a large clinical trial called SWIFT to learn whether electronic symptom monitoring with feedback to clinicians will reduce patients’ symptoms and improve their well-being. We asked patients, doctors, and nurses who participated in the pilot study of SWIFT about their perspectives on collecting information on symptoms to improve the pro-cess. Patients and clinicians thought that electronic symptom monitoring with feedback was feasible and suggested strategies to strengthen the SWIFT trial design. These included nurse champions to support patients with survey completion, language options, reliable technology, timely symptom feedback, and effective symptom management.

DOI: 10.1053/j.ajkd.2021.12.007

Twice-Weekly Hemodialysis With Adjuvant Pharmacotherapy and Transition to Thrice-Weekly Hemodialysis: A Pilot Study by Mariana Murea et al [FREE] 

From the authors: At dialysis initiation some patients have substantial levels of residual kidney function and may not require full-dose thrice-weekly hemodialysis. We performed a randomized pilot study to assess the feasibility of incremental-start hemodialysis in the incident hemodialysis population. The intervention group received twice-weekly hemodialysis with pharmacoadjuvant therapy for 6 weeks and then changed to thrice-weekly hemodialysis (n = 23). The conventional group received thrice-weekly hemodialysis (n = 25). We found that 41%of the patients met the preliminary eligibility criteria, 66% consented, 96% adhered to protocol-defined frequency of hemodialysis treatments, and all adhered to protocol-defined timed urine collections. Larger multi-center clinical trials are indicated to determine the efficacy and safety of incremental hemodialysis with individualized periods of twice-weekly hemodialysis.

DOI: 10.1053/j.ajkd.2021.12.001

Blog Post: Incremental Hemodialysis: Can and Should We Do it? by Shabnam Hamidi and Bourne Auguste [FREE] 

Perspectives of Clinicians on Shared Decision Making in Pediatric CKD: A Qualitative Study by Jasmijn Kerklaan et al  [OPEN ACCESS]

From the authors: Heavy metals are known to induce kidney damage, and transplanted kidneys may be particularly susceptible. Recent evidence showed that plasma concentrations of the heavy metals cadmium and arsenic are associated with increased risk of kidney graft failure. It is unknown if this association is also true for plasma lead concentrations. We measured plasma lead concentrations in 670 kidney transplant recipients with a functioning graft for ≥1 year who were followed for approximately 5 years at our outpatient clinic in Groningen, The Netherlands. Plasma lead concentrations were independently associated with an increased risk of late kidney graft failure, suggesting that lead-targeted interventions could be examined in future research as novel strategies to decrease the burden of kidney allograft failure.

DOI: 10.1053/j.ajkd.2021.12.009

Perspective from the August 2022 Issue:

A Novel Approach for Managing Protein-Energy Wasting in People With Kidney Failure Undergoing Maintenance Hemodialysis: Rationale and Call for Trials by David E. St-Jules and Denis Fouque

From the authors: Protein-energy wasting (PEW) is a unique presentation of protein-energy malnutrition in people with kidney disease that is characterized by body protein catabolism exceeding anabolism. PEW is especially common in patients undergoing maintenance hemodialysis (HD) treatment. Dietary guidelines for managing PEW in HD patients primarily focus on protein adequacy and typically promote the intake of animal-based protein foods. Although intake of protein and essential amino acids is important for protein synthesis, the emphasis on protein adequacy largely fails to address—and may actually exacerbate—many of the root causes of PEW. This perspective examines the dietary determinants of PEW in people undergoing HD treatment, with an emphasis on upstream disease-related factors that reduce dietary protein utilization and impair dietary intakes. From this, we present a theoretical diet model for managing PEW that includes etiology-based dietary strategies to address barriers to intake and treat disease-related factors, as well as supportive dietary strategies to promote adequate energy and protein intakes. Given the complexity of diet-disease interactions in the pathogenesis of PEW, and its ongoing burden in HD patients, interventional trials are urgently needed to evaluate alternative diet therapy approaches for PEW in this population.

DOI: 10.1053/j.ajkd.2021.10.012

On the Cover: The Danakil Depression in Ethiopia is a geological phenomenon that results from the continental drift of three tectonic plates and contains geologic structures that appear to not be of this world. Geothermally heated water rises to the surface and leads to rapid crystallization of potassium salts as the water evaporates, coloring the Danakil landscape. The eerie beauty of this potassium-rich environment can be contrasted with the impediment elevated potassium represents in optimizing treatment with renin-angiotensin-aldosterone system inhibitors (RAASi), a mainstay of treatment for chronic kidney disease. In this month’s issue of AJKD, Leon et al investigated the adverse outcomes of RAASi discontinuation due to hyperkalemia.

Photo by Daniele Levis Pelusi on Unsplash.

Special Collection: HIGHLY CITED Original Investigations

We are delighted to highlight the top cited Original Investigations published in 2019 and 2020 that contributed to AJKD’s 2021 Impact Factor of 11.072, our highest IF yet. This diverse set of articles includes systematic reviews and qualitative studies, and of course, COVID-19 studies. We would like to thank all the authors and reviewers who helped AJKD achieve this milestone.