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Rationale & Objective Persons with chronic kidney disease (CKD) are often unaware of their disease status. Efforts to improve CKD awareness may be most effective if focused on persons at highest risk for progression to kidney failure. Study Design Serial cross-sectional surveys. Setting & Participants Nonpregnant adults (aged ≥20 years) with CKD glomerular filtration rate categories 3-4 (G3-G4) who participated in the National Health and Nutrition Examination Survey from 1999 to 2016 (n = 3,713). Predictor 5-year kidney failure risk, estimated using the Kidney Failure Risk Equation. Predicted risk was categorized as minimal ( Outcome CKD awareness, defined by answering “yes” to the question “Have you ever been told by a doctor or other health professional that you had weak or failing kidneys?” Analytical Approach Prevalence of CKD awareness was estimated within each risk group using complex sample survey methods. Associations between Kidney Failure Risk Equation risk and CKD awareness were assessed using multivariable logistic regression. CKD awareness was compared with awareness of hypertension and diabetes during the same period. Results In 2011 to 2016, unadjusted CKD awareness was 9.6%, 22.6%, 44.7%, and 49.0% in the minimal-, low-, intermediate-, and high-risk groups, respectively. In adjusted analyses, these proportions did not change over time. Awareness of CKD, including among the highest risk group, remains consistently below that of hypertension and diabetes and awareness of these conditions increased over time. Limitations Imperfect sensitivity of the “weak or failing kidneys” question for ascertaining CKD awareness. Conclusions Among adults with CKD G3-G4 who have 5-year estimated risks for kidney failure of 5%

The Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure, an important risk factor for chronic kidney disease (CKD) and end-stage renal disease (ESRD). However, it is unclear whether adherence to a DASH diet confers protection against future ESRD, especially among those with pre-existing CKD and hypertension. We examined whether a DASH diet is associated with lower risk of ESRD among 1,110 adults aged ≥ 20 years with hypertension and CKD (estimated glomerular filtration rate, eGFR 30-59 ml/min/1.73 m2) enrolled in the National Health and Nutrition Examination Survey (1988-1994). Baseline DASH diet accordance score was assessed using a 24-hour dietary recall questionnaire. ESRD was ascertained by linkage to the U.S. Renal Data System registry. We used the Fine-Gray competing risks method to estimate the relative hazard (RH) for ESRD after adjusting for sociodemographics, clinical and nutritional factors, eGFR, and albuminuria. Over a median follow-up of 7.8 years, 18.4% of subjects developed ESRD. Compared to the highest quintile of DASH diet accordance, there was a greater risk of ESRD among subjects in quintiles 1 (RH=1.7; 95% CI 1.1-2.7) and 2 (RH 2.2; 95% CI 1.1-4.1). Significant interactions were observed with diabetes status and race/ethnicity, with the strongest association between DASH diet adherence and ESRD risk observed in individuals with diabetes and in non-Hispanic blacks. Low accordance to a DASH diet is associated with greater risk of ESRD in adults with moderate CKD and hypertension, particularly in non-Hispanic blacks and persons with diabetes.

Background Poor access to food among low-income adults has been recognized as a risk factor for chronic kidney disease (CKD), but there are no data for the impact of food insecurity on progression to end-stage renal disease (ESRD). We hypothesized that food insecurity would be independently associated with risk for ESRD among persons with and without earlier stages of CKD. Study Design Longitudinal cohort study. Setting & Participants 2,320 adults (aged ≥ 20 years) with CKD and 10,448 adults with no CKD enrolled in NHANES III (1988-1994) with household income ≤ 400% of the federal poverty level linked to the Medicare ESRD Registry for a median follow-up of 12 years. Predictor Food insecurity, defined as an affirmative response to the food-insecurity screening question. Outcome Development of ESRD. Measurements Demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. Dietary acid load was estimated from 24-hour dietary recall. We used a Fine-Gray competing-risk model to estimate the relative hazard (RH) for ESRD associated with food insecurity after adjusting for covariates. Results 4.5% of adults with CKD were food insecure. Food-insecure individuals were more likely to be younger and have diabetes (29.9%), hypertension (73.9%), or albuminuria (90.4%) as compared with their counterparts ( P P =0.05). Food-insecure adults were more likely to develop ESRD (RH, 1.38; 95% CI, 1.08-3.10) compared with food-secure adults after adjustment for demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. In the non-CKD group, 5.7% were food insecure. We did not find a significant association between food insecurity and ESRD (RH, 0.77; 95% CI, 0.40-1.49). Limitations Use of single 24-hour diet recall; lack of laboratory follow-up data and measure of changes in food insecurity over time; follow-up of cohort ended 10 years ago. Conclusions Among adults with CKD, food insecurity was independently associated with a higher likelihood of developing ESRD. Innovative approaches to address food insecurity should be tested for their impact on CKD outcomes.

Sleep-related problems, which have been associated with poor health outcomes, have not been investigated thoroughly in people with chronic kidney disease (CKD). We examined the prevalence of a variety of sleep-related problems in persons with and without CKD.National cross-sectional survey (National Health and Nutrition Examination Survey 2005-2008).Community-based survey of 9,110 noninstitutionalized US civilian residents 20 years or older.CKD, defined as estimated glomerular filtration rate (eGFR) of 15-59 mL/min/1.73 m(2) (stages 3 and 4) or eGFR ≥60 mL/min/1.73 m(2) and albumin-creatinine ratio ≥30 mg/g (stages 1 and 2).Sleep quality, defined using self-report in a multi-item sleep questionnaire including items from previously validated instruments.Albuminuria and eGFR assessed from urine and blood samples; sleep, demographics, and comorbid conditions assessed using a standardized questionnaire.Inadequate sleep (≤6 hours per night) differed by CKD severity (37.4%, 43.0%, and 30.9% for no CKD, CKD stages 1 and 2, and CKD stages 3 and 4, respectively; P = 0.003). Frequent sleeping pill use (8.4%, 9.9%, and 16.6%), leg symptoms (39.2%, 48.0%, and 50.9%), and nocturia (20.9%, 35.2%, and 43.6%; P0.001 for all) also differed by CKD severity. After adjustment for age, sex, race/ethnicity, obesity, diabetes, and cardiovascular disease, the prevalence of these sleep-related problems remained higher in people with CKD stages 1 and 2 relative to no CKD. Most other measures of sleep quality, disorder, and functional outcomes did not differ by CKD.Inability to establish causality and possible unmeasured confounding.Providers should be aware of early sleep-related CKD manifestations, including inadequate sleep, leg symptoms, and nocturia, and of the high rate of reported sleep medication use in this population.

The prevalence in the United States of dietary supplement use that may be harmful to those with chronic kidney disease (CKD) is unknown. We sought to characterize potentially harmful supplement use by individual CKD status.Cross-sectional national survey (National Health and Nutrition Examination Survey, 1999-2008).Community-based survey of 21,169 nonpregnant noninstitutionalized US civilian adults (aged ≥20 years).CKD status (no CKD, at risk of CKD [presence of diabetes, hypertension, and/or cardiovascular disease], stages 1/2 [albuminuria only (albumin-creatinine ratio ≥30 mg/g)], or stages 3/4 [estimated glomerular filtration rate of 15-59 mL/min/1.73 m(2)]).Self-reported use of dietary supplements containing any of 37 herbs the National Kidney Foundation identified as potentially harmful in the setting of CKD.Albuminuria and estimated glomerular filtration rate assessed from urine and blood samples; demographics and comorbid conditions assessed by standardized questionnaire.An estimated 8.0% of US adults reported potentially harmful supplement use within the last 30 days. A lower crude estimated prevalence of potentially harmful supplement use was associated with higher CKD severity (no CKD, 8.5%; at risk, 8.0%; stages 1/2, 6.1%; and stages 3/4, 6.2%; P0.001). However, after adjustment for confounders, those with or at risk of CKD were as likely to use a potentially harmful supplement as those without CKD: at-risk OR, 0.93 (95% CI, 0.79-1.09); stages 1/2 OR, 0.83 (95% CI, 0.64-1.08); and stages 3/4 OR, 0.87 (95% CI, 0.63-1.18); all versus no CKD.Herb content was not available and the list of potentially harmful supplements examined is unlikely to be exhaustive.The use of dietary supplements potentially harmful to people with CKD is common regardless of CKD status. Health care providers should discuss the use and potential risks of supplements with patients with and at risk of CKD.

Summary Background and objectives Recent studies suggest an overall association between chronic kidney disease (CKD) and periodontal disease, but it is unknown whether this association is similar across various subpopulations. Design, setting, participants, & measurements This study was a cross-sectional analysis of 2001 to 2004 National Health and Nutrition Examination Survey data. CKD was defined as a urinary albumin-to-creatinine ratio ≥30 mg/g or estimated GFR of 15 to 59 ml/min per 1.73 m2. Adjusted odds ratios were calculated using multivariable logistic regression with U.S. population-based weighting. Results These analyses included 6199 dentate adult participants (aged 21 to 75 years) with periodontal exams. The estimated prevalences of moderate/severe periodontal disease and CKD were 5.3% and 10.6%, respectively. Periodontal disease was associated with >2-fold higher risk of CKD that was moderately attenuated after adjustment for age, gender, race/ethnicity, tobacco use, hypertension, diabetes, educational attainment, poverty index ratio, and dental care use. There were no statistically significant interactions between periodontal disease and race/ethnicity, educational attainment, or poverty status. Less-than-recommended dental care use was associated with periodontal disease and CKD and was increasingly prevalent among nonwhites, lower educational attainment, and lower poverty status. Conclusions The association between periodontal disease and CKD is not significantly different among subgroups. However, because nonwhites, those with a lower educational level, and the poor less frequently report use of recommended dental care, the association between periodontal disease and kidney function over time may become stronger among these groups and warrants further investigation.

Background Little is known about disability in early-stage chronic kidney disease (CKD). Study Design Cross-sectional national survey (National Health and Nutrition Examination Survey 1999-2006). Setting & Participants Community-based survey of 16,011 noninstitutionalized US civilian adults (aged ≥20 years). Predictor CKD, categorized as no CKD, stages 1 and 2 (albuminuria and estimated glomerular filtration rate [eGFR] ≥60 mL/min/1.73 m 2 ), and stages 3 and 4 (eGFR, 15-59 mL/min/1.73 m 2 ). Outcome Self-reported disability, defined by limitations in working, walking, and cognition and difficulties in activities of daily living (ADL), instrumental ADL, leisure and social activities, lower-extremity mobility, and general physical activity. Measurements Albuminuria and eGFR assessed from urine and blood samples; disability, demographics, access to care, and comorbid conditions assessed using a standardized questionnaire. Results Age-adjusted prevalence of reported limitations generally was significantly greater with CKD: for example, difficulty with ADL was reported by 17.6%, 24.7%, and 23.9% of older (≥65 years) and 6.8%, 11.9%, and 11.0% of younger (20-64 years) adults with no CKD, stages 1 and 2, and stages 3 and 4, respectively. CKD also was associated with greater reported limitations and difficulty in other activities after age adjustment, including instrumental ADL, leisure and social activities, lower-extremity mobility, and general physical activity. Other demographics, socioeconomic status, and access to care generally only slightly attenuated the observed associations, particularly in older individuals; adjustment for cardiovascular disease, arthritis, and cancer attenuated most associations such that statistical significance no longer was achieved. Limitations Inability to establish causality and possible unmeasured confounding. Conclusion CKD is associated with a higher prevalence of disability in the United States. Age and other comorbid conditions account for most, but not all, of this association.

Recent guidelines recommending more aggressive blood pressure control in patients with chronic kidney disease have unknown impact. We assessed trends in and predictors of blood pressure control in 8829 adult National Health and Nutrition Examination Survey 1999–2006 participants with hypertension (self-report, measured blood pressure, or use of antihypertensive medications), without (n=7178) and with (n=1651) chronic kidney disease. Uncontrolled blood pressure was defined as follows: general definition, systolic blood pressure ≥140 mm Hg and diastolic blood pressure ≥90 mm Hg, and disease-specific definition, systolic blood pressure ≥130 mm Hg and diastolic blood pressure ≥85 mm Hg (1999–2002) and systolic blood pressure ≥130 mm Hg and diastolic blood pressure ≥80 mm Hg (2003–2006) for those with chronic kidney disease (estimated glomerular filtration rate: 2 ) or diabetes mellitus (self-report). Proportions with uncontrolled blood pressure in 1999–2006 were greater in those with chronic kidney disease versus those without chronic kidney disease (51.5% versus 48.7% [general definition: P =0.122] and 68.8% versus 51.7% [disease-specific definition: P P =0.011]). With adjustment for demographic, socioeconomic, and clinical variables, older age ( P P P =0.002) was associated in those without chronic kidney disease, whereas female sex ( P =0.030) was associated in those with chronic kidney disease. Multiple medications ( P P =0.001) were associated with less uncontrolled blood pressure. Although some improvement has occurred over time, uncontrolled blood pressure remains highly prevalent, especially in subjects with chronic kidney disease and in nonwhites, older persons, and women. Therapy appears suboptimal.