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The chronic and excessive use of alcohol adversely affects the healthcare system, work productivity, and familial and social relationships. Alcohol misuse accounts for 85,000 deaths per year in the United States, and the overall financial costs related to alcohol dependence are more than $100 billion annually. The reduction of alcohol misuse can be measured as an increase in the frequency of abstinence or a reduction in the frequency of relapses. The recommendation for alcohol dependence treatment is a combination of psychosocial support therapy and pharmacologic treatment. Currently, there are only 3 FDA-approved agents for the treatment of alcohol dependence: naltrexone, acamprosate, and disulfiram. The literature suggests that there may be varying expectations for the potential beneficial outcomes associated with each of these medications. Treatment with naltrexone has consistently demonstrated a decrease in overall alcohol consumption and fewer relapses when compared with placebo. Acamprosate has been associated with an improvement in maintaining abstinence and more total days of continuous abstinence compared with placebo. Disulfiram treatment has yielded inconsistent results in reducing alcohol consumption when compared with placebo, and observed administration may be the only way to ensure compliance. In general, since disulfiram treatment has not demonstrated long-term efficacy and because of its risk for causing hepatotoxicity, it is not considered a first-line medication option. Other pharmacologic options with differing effects on neurotransmitters also are being studied. Each agent, with its unique mechanism of action, seems to play a role in treating alcohol dependence, either as monotherapy or as part of polypharmacy. Future research is necessary to help specify which patient characteristics will predict the most effective pharmacologic treatment plan for the management of alcohol dependence. [ABSTRACT FROM AUTHOR]

The Merit-based Incentive Payment System (MIPS) is a mandatory pay-for-performance program through the Centers for Medicare & Medicaid Services (CMS) that aims to incentivize high-quality care, promote continuous improvement, facilitate electronic exchange of information, and lower health care costs. Previous research has highlighted several limitations of the MIPS program in assessing nephrology care delivery, including administrative complexity, limited relevance to nephrology care, and inability to compare performance across nephrology practices, emphasizing the need for a more valid and meaningful quality assessment program. This article details the iterative consensus-building process used by the American Society of Nephrology Quality Committee from May 2020 to July 2022 to develop the Optimal Care for Kidney Health MIPS Value Pathway (MVP). Two rounds of ranked-choice voting among Quality Committee members were used to select among nine quality metrics, 43 improvement activities, and three cost measures considered for inclusion in the MVP. Measure selection was iteratively refined in collaboration with the CMS MVP Development Team, and new MIPS measures were submitted through CMS's Measures Under Consideration process. The Optimal Care for Kidney Health MVP was published in the 2023 Medicare Physician Fee Schedule Final Rule and includes measures related to angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use, hypertension control, readmissions, acute kidney injury requiring dialysis, and advance care planning. The nephrology MVP aims to streamline measure selection in MIPS and serves as a case study of collaborative policymaking between a subspecialty professional organization and national regulatory agencies., (Copyright © 2023 by the American Society of Nephrology.)

Introduction: Sodium zirconium cyclosilicate (SZC) is a selective potassium (K+) binder for hyperkalemia management that provides rapid and sustained correction of hyperkalemia. The NEUTRALIZE study is investigating whether SZC, in addition to correcting hyperkalemia and maintaining normal serum K+, can provide sustained increases in serum bicarbonate (HCO3-) in patients with hyperkalemia and metabolic acidosis associated with chronic kidney disease (CKD)., Methods: This is a prospective, randomized, double-blind, placebo-controlled phase 3b study of US adults with stage 3-5 CKD not on dialysis with hyperkalemia (K+ >5.0-≤5.9 mmol/L) and low-serum HCO3- (16-20 mmol/L). In the open-label correction phase, all eligible patients receive SZC 10 g three times daily for up to 48 h. Patients who achieve normokalemia (K+ ≥3.5-≤5.0 mmol/L) are then randomized 1:1 to once-daily SZC 10 g or placebo for a 4-week, double-blind, placebo-controlled maintenance phase. The primary endpoint is the proportion of patients with normokalemia at the end of treatment (EOT) without rescue therapy for hyperkalemia. Key secondary endpoints include mean change in serum HCO3-, the proportion of patients with an increase in serum HCO3- of ≥2 or ≥3 mmol/L without rescue therapy for metabolic acidosis, and the proportion of patients with serum HCO3- ≥22 mmol/L at EOT., Conclusions: NEUTRALIZE will establish whether SZC can provide sustained increases in serum HCO3- while lowering serum K+ in patients with hyperkalemia and CKD-associated metabolic acidosis and may provide insights on the mechanism(s) underlying the increased serum HCO3- with SZC treatment., (The Author(s). Published by S. Karger AG, Basel.)

Background Catheter-associated urinary tract infections (CAUTIs) can be fatal, and are a source of avoidable expense for patients and hospitals. Prolonged catheterization increases infection risk, and avoiding catheters is crucial for infection prevention. Male external urinary catheters are recommended as a tool to prevent the need for indwelling catheterization. Female external urinary catheters (FEUCs) have intermittently been marketed without wide adoption; one has recently become available but published data is limited. Objective This retrospective observational study was conducted to investigate the effect of FEUCs on indwelling catheter use and female CAUTIs. Methods FEUCs were introduced to intensive care units. CAUTI rates and indwelling catheter days were obtained before and after the introduction of the devices. Results  CAUTI rates decreased from 3.14 per 1000 catheter days to 1.42 per 1000 catheter days (p=0.013). Female indwelling catheter days decreased, while overall intensive care patient days increased. Conclusions Introduction of a FEUC was associated with a statistically significant decrease in CAUTI rate among female intensive care patients. The FEUC may prevent the need for indwelling catheters in some situations., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Zavodnick et al.)

Introduction: Large interdialytic weight gain (IDWG) is associated with increased morbidity and mortality in chronic hemodialysis patients. Over 50% of patients at our inner city tertiary academic center dialysis unit had IDWG and target weights (TW) above goal. We conducted an open-label nonrandomized study to explore the effects of an individualized dialysate sodium (DNa) prescription using Na gradients in patients at high risk for large IDWG. Thirty-three patients receiving chronic hemodialysis received individualized DNa prescriptions with a DNa bath of 0 to -2 meq/L below their serum Na level in the intervention group, while patients in the control group were prescribed the standard dialysate Na at 138 mmol/L. Serum Na level, predialysis SBP, symptomatic hypotensive episodes, and %hemodialysis treatments with large IDWG (%TxAIDWG) and above TW(%TxATW) were recorded before and three months after the intervention. We used student t tests to compare continuous variables and Chi-square tests to compare binary variables between the groups at baseline and after the intervention. Age- and sex-adjusted linear regression models were also constructed to assess the differences in each continuous outcome between the groups. Multivariable logistic regression models were conducted by modeling IDWG decrease and above estimated-dry-weight (EDW) decrease as binary dependent variables with adjustment for age, sex, and EDW change., Findings: Patients with individualized DNa concentrations had 3.6 times greater odds of having lower IDWG than those with standard dialysate Na concentration. This significant association remained after adjustment for age, sex, and changes in EDW (OR: 3.63; 95% CI, 1.03-12.9). There was no difference in predialysis BP or symptomatic hypotensive episodes between the two groups., Discussion: Individualized DNa prescriptions appeared to be well tolerated and may be effective for optimal fluid management in high-risk hemodialysis patients., (© 2020 International Society for Hemodialysis.)

Purpose of Review: To examine available clinical data on the differences between premenopausal and postmenopausal women with hypertension (HTN). Clinical conditions related to HTN and reproductive status differ in younger women compared with older women. Due to recent changes in the definition of HTN, the prevalence of HTN has increased significantly in all women. Rising rates of obesity among women of all ages increase the risk for HTN., Recent Findings: Among younger women, long-term vascular consequences of preeclampsia, the under-reported prevalence of fibromuscular dysplasia, and widespread use of oral contraceptive pills in women with contraindications confer unique risks for HTN-related cardiovascular risk. For older women, insights on vascular aging and hormonal changes with menopause are shown to be gender-specific causal factors for HTN. Assessment of risk factors unique to premenopausal and postmenopausal women can facilitate the management of HTN and improve long-term outcomes. Further studies in women are needed to accurately stratify women risk based on these risk factors.

The authors aimed to improve the rate of pre-dialysis arteriovenous (AV) access placement for hospitalized patients with advanced chronic kidney disease. The authors developed and implemented a protocol for hospitalized adult patients with an estimated glomerular filtration rate <20 mL/min to streamline the workflow for obtaining AV access. The protocol was piloted on 5 inpatient medical services over 3 months at 1 institution. Specific-Measurable-Achievable-Realistic-Timely (SMART) aims, Fishbone diagrams, Plan-Do-Study-Act cycles, and run charts were used to assess the process and outcomes of the intervention. There were 22 patients in the baseline group and 27 patients in the intervention group. Pre-dialysis AV access increased from 23% to 46%. Length of stay did not differ significantly between the baseline group (8.31 days) and the intervention group (8.4 days). Pathways can improve pre-dialysis AV access without significantly increasing length of stay.

Pregnancy in the setting of the uremic milieu of renal disease has a lower success rate than in the normal population and is a rare event. While intensified renal replacement therapy (RRT) during pregnancy can lead to improved outcomes, most studies have focused on nocturnal hemodialysis as the main RRT in pregnancy. Although thousands of patients use the home NxStage System One short daily hemodialysis (SDHD) machine in the United States, pregnancy outcomes with this therapy are unknown. The NxStage System One uses low-volume dialysate and hence small and middle molecule clearance may differ compared to conventional therapies and affect pregnancy outcomes. We report a case of a successful conception and pregnancy using the home NxStage system. The NxStage system may provide an alternative to the more routinely used NHD or standard SDHD therapies for women of childbearing age.

Background: The optimal regimen for prophylaxis of cytomegalovirus (CMV) disease after kidney and/or pancreas transplantation remains unclear. We compared the effectiveness of three months of oral ganciclovir (3 g/day) versus low-dose valganciclovir (450 mg/day) for CMV prophylaxis., Methods: We performed a retrospective cohort study of patients at our center who received kidney and/or pancreas transplants between January 2000 and April 2003. We used a Cox proportional hazards model to examine the relationship between baseline covariates, including type of CMV prophylaxis, and time to development of CMV disease., Results: Of the 500 patients (295 ganciclovir, 205 valganciclovir), 22 patients (4.4%) developed CMV disease (mean time to CMV disease, 163+/-85 days). Sixteen of the ganciclovir patients (5.4%) and six of the valganciclovir patients (2.9%) developed CMV disease (P=0.18). By CMV serostatus, the incidence of CMV disease during the first posttransplant year was 8.5% among donor-seropositive, recipient-seronegative (D+/R-) patients, 8.6% among D+/R+ patients, 2.9% among D-/R+ patients, 1.0% among D-/R- patients, and 0.9% among patients for whom documentation of CMV serostatus was incomplete. In the unadjusted Cox proportional hazards analysis, race/ethnicity, type of transplant, type of antiviral prophylaxis, CMV serostatus, and use of mycophenolate mofetil were each associated with risk of developing CMV disease. In the adjusted, multivariable model, only CMV serostatus was associated with development of CMV disease., Conclusions: Three months of low-dose valganciclovir (450 mg/day) was as effective as ganciclovir (3 g/day) for prophylaxis of CMV disease after kidney and/or pancreas transplantation.