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Circulating cell-free mitochondrial DNA (ccf-mtDNA) may induce systemic inflammation, a common condition in chronic kidney disease (CKD), by acting as a damage-associated molecular pattern. We hypothesized that in patients with moderate to severe CKD, aerobic exercise would reduce ccf-mtDNA levels. We performed a post hoc analysis of a multicenter randomized trial (NCT01150851) measuring plasma concentrations of ccf-mtDNA at baseline and 2 and 4 mo after aerobic exercise and caloric restriction. A total of 99 participants had baseline ccf-mtDNA, and 92 participants completed the study. The median age of the participants was 57 yr, 44% were female and 55% were male, 23% had diabetes, and 92% had hypertension. After adjusting for demographics, blood pressure, body mass index, diabetes, and estimated glomerular filtration rate, median ccf-mtDNA concentrations at baseline, 2 mo, and 4 mo were 3.62, 3.08, and 2.78 pM for the usual activity group and 2.01, 2.20, and 2.67 pM for the aerobic exercise group, respectively. A 16.1% greater increase per month in ccf-mtDNA was seen in aerobic exercise versus usual activity (P = 0.024), which was more pronounced with the combination of aerobic exercise and caloric restriction (29.5% greater increase per month). After 4 mo of intervention, ccf-mtDNA increased in the aerobic exercise group by 81.6% (95% confidence interval: 8.2−204.8, P = 0.024) compared with the usual activity group and was more marked in the aerobic exercise and caloric restriction group (181.7% increase, 95% confidence interval: 41.1−462.2, P = 0.003). There was no statistically significant correlation between markers of oxidative stress and inflammation with ccf-mtDNA. Our data indicate that aerobic exercise increased ccf-mtDNA levels in patients with moderate to severe CKD. NEW & NOTEWORTHY The effects of prolonged exercise on circulating cell-free mitochondrial DNA (ccf-mtDNA) have not been explored in patients with chronic kidney disease (CKD). We showed that 4-mo aerobic exercise is associated with an increase in plasma ccf-mtDNA levels in patients with stages 3 or 4 CKD. These changes were not associated with markers of systemic inflammation. Future studies should determine the mechanisms by which healthy lifestyle interventions influence biomarkers of inflammation and oxidative stress in patients with CKD.

Chronic kidney disease (CKD)-associated pruritus (CKD-aP) is an underdiagnosed yet severely distressing condition that impacts 60% of patients on dialysis and many nondialysis patients with Stages 3–5 CKD. However, despite its high prevalence, there are currently limited treatment options available for these patients and a lack of treatment guidelines for clinicians. In this manuscript, we reviewed the available literature in order to evaluate the current management and treatment options for CKD-aP, including dialysis management, topical treatments, gabapentinoids, opioids and alternative medicine. We also review the available data on CKD-aP treatments in development and propose new guidelines for managing patients with CKD-aP.

Kidney involvement in patients with coronavirus disease 2019 (COVID-19) is common, and can range from the presence of proteinuria and haematuria to acute kidney injury (AKI) requiring renal replacement therapy (RRT; also known as kidney replacement therapy). COVID-19-associated AKI (COVID-19 AKI) is associated with high mortality and serves as an independent risk factor for all-cause in-hospital death in patients with COVID-19. The pathophysiology and mechanisms of AKI in patients with COVID-19 have not been fully elucidated and seem to be multifactorial, in keeping with the pathophysiology of AKI in other patients who are critically ill. Little is known about the prevention and management of COVID-19 AKI. The emergence of regional ‘surges’ in COVID-19 cases can limit hospital resources, including dialysis availability and supplies; thus, careful daily assessment of available resources is needed. In this Consensus Statement, the Acute Disease Quality Initiative provides recommendations for the diagnosis, prevention and management of COVID-19 AKI based on current literature. We also make recommendations for areas of future research, which are aimed at improving understanding of the underlying processes and improving outcomes for patients with COVID-19 AKI., COVID-19-associated AKI (COVID-19 AKI) is associated with high mortality and is an independent risk factor for all-cause in-hospital death in patients with COVID-19. This Consensus Statement from the Acute Disease Quality Initiative provides recommendations for the diagnosis, prevention and management of COVID-19 AKI and for areas of future research, with the aim of improving understanding of the underlying processes and outcomes for patients with COVID-19 AKI.

Chronic kidney disease negatively impacts the lives of a significant number of Americans. Unlike patients who suffer from chronic illnesses such as cardiovascular disease and pulmonary disease, renal patients currently do not have access to rehabilitation services specifically tailored to their ailments. Implementing renal rehabilitation services has the potential to attenuate further progression of kidney disease and improve the quality of life of patients. Providing properly structured renal rehabilitation services to kidney patients should be a future goal of the medical community.

Background and aims: Obesity is a pro-inflammatory risk factor for progression of CKD and cardiovascular disease. We hypothesized that implementation of caloric restriction and endurance exercise would improve adipocytokine profiles in patients with moderate to severe CKD. Methods and results: We enrolled patients with moderate to severe CKD through a multi-center pilot randomized trial of diet and exercise in a 4-arm design (dietary restriction of 10%-15% reduction in caloric intake, exercise three times/week, combined diet and exercise, and control) (NCT01150851). Adipocytokines (adiponectin and leptin) were measured at the beginning and end of the study period as secondary outcomes. Treatment effect was analyzed in a multivariable model adjusted for baseline outcome values, age, gender, site and diabetes. A total of 122 participants were consented, 111 were randomized (42% female, 25% diabetic, and 91% hypertensive), 104 started intervention and 92 completed the study (Figure 1). Plasma adiponectin levels increased significantly in response to diet by 23% (95% CI: 0.2%, 49.8%, p = 0.048) among participants randomized to the caloric restriction and usual activity arm but not to exercise, whereas circulating leptin did not change by either treatment. Conclusion: Our data suggest that dietary caloric restriction increases plasma adiponectin levels in stage 3-4 CKD patients, with limited effect on leptin levels. These findings suggest the potential for improving the metabolic milieu of CKD with moderate calorie restriction. (C) 2020 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved. National Institutes of Health from National Heart, Lung, and Blood InstituteUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USANIH National Heart Lung & Blood Institute (NHLBI) [R01HL070938]; National Institute of Diabetes and Digestive and Kidney DiseasesUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USANIH National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK) [K24DK62849, P30DK020593, P30DK035816]; National Institute of Environmental Health SciencesUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USANIH National Institute of Environmental Health Sciences (NIEHS) [P30ES000267]; National Center for Advancing Translational SciencesUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USANIH National Center for Advancing Translational Sciences (NCATS) [UL1-TR000445, UL1TR000423] This study was in part supported by National Institutes of Health grants R01HL070938 from National Heart, Lung, and Blood Institute; K24DK62849, P30DK020593, and P30DK035816 from National Institute of Diabetes and Digestive and Kidney Diseases; P30ES000267 from the National Institute of Environmental Health Sciences; and Clinical Translational Science Awards UL1-TR000445 and UL1TR000423 from the National Center for Advancing Translational Sciences. WOS:000572853200016 2-s2.0-85086927317 PubMed: 32571614

In patients with advanced-stage chronic kidney disease (CKD), progressive kidney function decline leads to increased risk for hyperkalemia (serum potassium > 5.0 or >5.5 mEq/L). Medications such as renin-angiotensin-aldosterone system inhibitors pose an additional hyperkalemia risk, especially in patients with CKD. When hyperkalemia develops, clinicians often recommend a diet that is lower in potassium content. This review discusses the barriers to adherence to a low-potassium diet and the impact of dietary restrictions on adverse clinical outcomes. Accumulating evidence indicates that a diet that incorporates potassium-rich foods has multiple health benefits, which may also be attributable to the other vitamin, mineral, and fiber content of potassium-rich foods. These benefits include blood pressure reductions and reduced risks for cardiovascular disease and stroke. High-potassium foods may also prevent CKD progression and reduce mortality risk in patients with CKD. Adjunctive treatment with the newer potassium-binding agents, patiromer and sodium zirconium cyclosilicate, may allow for optimal renin-angiotensin-aldosterone system inhibitor therapy in patients with CKD and hyperkalemia, potentially making it possible for patients with CKD and hyperkalemia to liberalize their diet. This may allow them the health benefits of a high-potassium diet without the increased risk for hyperkalemia, although further studies are needed.

Introduction Patients are often instructed to engage in multiple weekly sessions of exercise to increase physical activity. We aimed to determine whether assignment to a supervised exercise regimen increases overall weekly activity in individuals with chronic kidney disease (CKD). Methods We performed a secondary analysis of a pilot randomized 2 × 2 factorial design trial examining the effects of diet and exercise (10%−15% reduction in caloric intake, 3 supervised exercise sessions/wk, combined diet restriction/exercise, and control). Activity was measured as counts detected by accelerometer. Counts data were collected on all days for which an accelerometer was worn at baseline, month 2, and month 4 follow-up. The primary outcome was a relative change from baseline in log-transformed counts/min. Generalized estimating equations were used to compare the primary outcome in individuals in the exercise group and the nonexercise group. Results We examined 111 individuals randomized to aerobic exercise or usual activity (n = 48 in the exercise group and n = 44 controls). The mean age was 57 years, 42% were female, and 28% were black. Median overall adherence over all time was 73%. Median (25th, 75th percentile) counts/min over nonsupervised exercise days at months 2 and 4 were 237.5 (6.5, 444.4) for controls and 250.9 (7.7, 529.8) for the exercise group (P = 0.74). No difference was observed in the change in counts/min between the exercise and control groups over 3 time points (β [fold change], 0.96, 95% confidence interval [CI], 0.91, 1.02). Conclusion Engaging in a supervised exercise program does not increase overall weekly physical activity in individuals with stage 3 to 4 CKD., Graphical abstract

Background: There are few studies of patient-facing decision aids that include supportive kidney care as an option. We tested the efficacy of a video decision aid on knowledge of supportive kidney care among older patients with advanced CKD. Methods: Participants (age ≥ 65 years with advanced CKD) were randomized to receive verbal or video education. Primary outcome was knowledge of supportive kidney care (score range 0–3). Secondary outcomes included preference for supportive kidney care, and satisfaction and acceptability of the video. Results: Among all participants (n = 100), knowledge of supportive kidney care increased significantly after receiving education (p < 0.01); however, there was no difference between study arms (p = 0.68). There was no difference in preference for supportive kidney care between study arms (p = 0.49). In adjusted analyses, total health literacy score (aOR 1.08 [95% CI: 1.003–1.165]) and nephrologists’ answer of “No” to the Surprise Question (aOR 4.87 [95% CI: 1.22–19.43]) were associated with preference for supportive kidney care. Most felt comfortable watching the video (96%), felt the content was helpful (96%), and would recommend the video to others (96%). Conclusions: Among older patients with advanced CKD, we did not detect a significant difference between an educational verbal script and a video decision aid in improving knowledge of supportive kidney care or preferences. However, patients who received video education reported high satisfaction and acceptability ratings. Future research will determine the effectiveness of a supportive kidney care video decision aid on real-world patient outcomes. Trial Registration: NCT02698722 (ClinicalTrials.gov).

Background: Patients with end-stage renal disease are sedentary, frail, and have low functional ability (FA) compared to healthy age-matched controls. The purpose of this study was to examine the effects of an intradialytic, supervised, 8-week resistance training (RT) program on strength (ST), FA, and quality of life (QOL) in a sample of patients with end-stage renal disease. Methods: Twenty hemodialysis patients were randomized to an exercise (E, n = 12) or control (C, n = 8) group. Patients randomized to E received intradialytic RT immediately before and during treatment, 3 d per week for 8 weeks. Patients randomized to C received usual care and no exercise. ST and FA were assessed at baseline and at 4 and 8 weeks with manual muscle testing and the Short Physical Performance Battery. QOL was assessed at baseline and 8 weeks with the 36-item Short Form Health Survey (SF-36). Mixed factorial ANOVAs were used to determine the effects of RT on ST, FA, and QOL. Results: Significant interactions were found for ST for the right (p = 0.006) and left (p = 0.008) gastrocnemius, right quadriceps (p = 0.003), right (p = 0.005) and left (p = 0.004) hamstrings, and right adductor (p = 0.020). ST improved for E but not C across time (p < 0.05). Significant time effects for FA were found for chair (p = 0.001) and total (p = 0.008) SPPB scores but were not different between groups (p > 0.05). Similar effects were found for the physical performance component of the SF-36 (p = 0.023). Conclusion: A supervised 8-week, intradialytic RT program improved lower body ST in patients with end-stage renal disease; however, these improvements did not impact FA or QOL.

Rationale & Objective Fatigue is a highly prevalent and debilitating symptom in patients on hemodialysis therapy due to the uremic milieu, the hemodialysis treatment itself, and other comorbid conditions. However, fatigue remains underrecognized and the consequences are underappreciated because it may not be visible in clinical settings. This study aims to describe the experience that patients undergoing maintenance hemodialysis have with fatigue. Study Design Systematic review and thematic synthesis of qualitative studies. Setting & Study Populations Patients undergoing hemodialysis. Search Strategy & Sources MEDLINE, Embase, PsycINFO, CINAHL, reference lists, and PhD dissertations were searched from inception to October 2018. Data Extraction All text from the results/conclusion of the primary studies. Analytical Approach Thematic synthesis. Results 65 studies involving 1,713 participants undergoing hemodialysis were included. We identified 4 themes related to fatigue: debilitating and exhausting burden of dialysis (bodily depletion, trapped in a vicious cycle of postdialysis exhaustion, vigilance and worry inhibiting rest, tiresome and agonizing regimen, and without remedy and relief), restricted life participation (deprived of time, managing energy reserves, frustrating need to rest, and joys foregone), diminishing capacities to fulfil relationship roles (losing ability to work and provide for family, failing as a parent, lacking stamina for sexual intimacy, and relying on others), and vulnerable to misunderstanding (being criticized for the need to rest and failing to meet expectations). Limitations Non-English articles were excluded and most studies were conducted in high-income countries. Conclusions For patients undergoing hemodialysis who experience fatigue, fatigue is a profound and relentless exhaustion that pervades the entire body and encompasses weakness. The fatigue drains vitality in patients and constrains their ability to do usual activities and fulfill their roles and meet personal aspirations. Explicit recognition of the impact of fatigue and establishing additional effective interventions to improve fatigue are needed.

OBJECTIVES: There are approximately 660,000 end-stage renal disease (ESRD) patients in the USA, with hemodialysis (HD) the primary form of treatment. High ultrafiltration rates (UFRs) are associated with intradialytic hypotension, a complication associated with adverse clinical outcomes including mortality. Individualized UFR profiles could reduce the incidence of intradialytic hypotension. METHODS: The patient’s fluid dynamics during HD is described by a nonlinear model comprising intravascular and interstitial pools, whose parameters are given by the patient’s estimated nominal parameter values with uncertainty ranges; the output measurement is hematocrit. We design UFR profiles that minimize the maximal UFR needed to remove a prescribed volume of fluid within a set time, with hematocrit not exceeding a specified time-varying critical profile. RESULTS: We present a novel approach to designing individualized UFR profiles, and give theoretical results guaranteeing that the system remains within a pre-defined physiologically plausible region and does not exceed a specified time-invariant critical hematocrit level for all parameters in the uncertainty ranges. We test the performance of our design using a real patient data example. The designed UFR maintains the system below a time-varying critical hematocrit profile in the example. CONCLUSION: Theoretical results and simulations show that our designed UFR profiles can remove the target amount of fluid in a given time period while keeping the hematocrit below a specified critical profile. SIGNIFICANCE: Individualization of UFR profiles is now feasible using current HD technology and may reduce the incidence of intradialytic hypotension.

Glomerular kidney disorders account for a significant proportion of chronic kidney disease and end-stage renal disease worldwide. Nevertheless, major obstacles make breakthrough progress in diagnosis and cure an ongoing challenge. Here we report the creation of a “grassroots” initiative that aims to provide new opportunities for nephrologists, pathologists, basic and clinical scientists, patients, and industry partners to collaborate in the field of glomerular kidney disease. Members of the medical community, including trainees, nephrologists, and nephropathologists, can participate in the open-access, Web-based, multidisciplinary clinical video case conferences, which provide “peer-to-peer” exchange of clinical and pathological expertise combined with a formal didactic curriculum. Participants can also join other aspects of the broader initiative. These include the participation in a multisite research study to facilitate enrollment of patients into a longitudinal clinical data and biorepository for glomerular kidney disorders. Items included in this prospective registry include the following: an ontology-based patient medical history, which is regularly updated; interval collection and storage of blood and urine samples; DNA collection; and a contact registry for patients who wish to participate in clinical trials. Participating sites and external scientists can leverage access to the database to pursue genetic, biomarker, epidemiological, and observational clinical effectiveness studies. Patients can independently sign up for a supplementary contact registry to participate in clinical trials if eligible. The broad spectrum of activities within this initiative will foster closer collaboration among trainees, practicing nephrologists, pathologists, and researchers, and may help to overcome some of the barriers to progress in the field of glomerular kidney disease. Keywords: disease registry, glomerular kidney disease, nephrology education, observational clinical studies

IntroductionOlder patients with advanced chronic kidney disease (CKD) often are inadequately prepared to make informed decisions about treatments including dialysis and cardiopulmonary resuscitation. Further, evidence shows that patients with advanced CKD do not commonly engage in advance care planning (ACP), may suffer from poor quality of life, and may be exposed to end-of-life care that is not concordant with their goals. We aim to study the effectiveness of a video intervention on ACP, treatment preferences and other patient-reported outcomes.Methods and analysisThe Video Images about Decisions for Ethical Outcomes in Kidney Disease trial is a multi-centre randomised controlled trial that will test the effectiveness of an intervention that includes a CKD-related video decision aid followed by recording personal video declarations about goals of care and treatment preferences in older adults with advancing CKD. We aim to enrol 600 patients over 5 years at 10 sites.Ethics and disseminationRegulatory and ethical aspects of this trial include a single Institutional Review Board mechanism for approval, data use agreements among sites, and a Data Safety and Monitoring Board. We intend to disseminate findings at national meetings and publish our results.Trial registration numberNCT04347629.

Background Guiding patients with advanced chronic kidney disease (CKD) through advance care planning about future treatment obliges an assessment of prognosis. A patient-specific integrated model to predict mortality could inform shared decision-making for patients with CKD. Methods Patients with Stages 4 and 5 CKD from Massachusetts (749) and West Virginia (437) were prospectively evaluated for clinical parameters, functional status [Karnofsky Performance Score (KPS)] and their provider’s response to the Surprise Question (SQ). A predictive model for 12-month mortality was derived with the Massachusetts cohort and then validated externally on the West Virginia cohort. Logistic regression was used to create the model, and the c-statistic and Hosmer–Lemeshow statistic were used to assess model discrimination and calibration, respectively. Results In the derivation cohort, the SQ, KPS and age were most predictive of 12-month mortality with odds ratios (ORs) [95% confidence interval (CI)] of 3.29 (1.87–5.78) for a ‘No’ response to the SQ, 2.09 (95% CI 1.19–3.66) for fair KPS and 1.41 (95% CI 1.15–1.74) per 10-year increase in age. The c-statistic for the 12-month mortality model for the derivation cohort was 0.80 (95% CI 0.75–0.84) and for the validation cohort was 0.74 (95% CI 0.66–0.83). Conclusions Our integrated prognostic model for 12-month mortality in patients with advanced CKD had good discrimination and calibration. This model provides prognostic information to aid nephrologists in identifying and counseling advanced CKD patients with poor prognosis who are facing the decision to initiate dialysis or pursue medical management without dialysis.

Introduction: The safety and efficacy of extended-release calcifediol (ERC) as a treatment for secondary hyperparathyroidism (SHPT) in adults with stage 3 or 4 chronic kidney disease (CKD) and vitamin D insufficiency (VDI) has been demonstrated in prospective randomized clinical trials (RCTs). ERC (Rayaldee®) was approved by the Food and Drug Administration in 2016 on the basis of these prospective RCTs. The current retrospective study assessed the postlaunch data available with respect to ERC’s efficacy and safety in increasing serum 25-hydroxyvitamin D (25D) and reducing parathyroid hormone (PTH) in the indicated population. Materials and Methods: Medical records of 174 patients who met study criteria from 15 geographically representative United States nephrology clinics were reviewed for 1 year before and after initiation of ERC treatment. Enrolled subjects had ages ≥18 years, stage 3 or 4 CKD, and a history of SHPT and VDI. Key study variables included patient demographics, medication usage, and laboratory results, including serial 25D and PTH determinations. Results: The enrolled subjects had a mean age of 69.0 years, gender and racial distributions representative of the indicated population, and were balanced for CKD stage. Most (98%) received 30 mcg of ERC/day during the course of treatment (mean follow-up: 24 weeks). Baseline 25D and PTH levels averaged 20.3 ± 0.7 (standard error) ng/mL and 181 ± 7.4 pg/mL, respectively. ERC treatment raised 25D by 23.7 ± 1.6 ng/mL (p < 0.001) and decreased PTH by 34.1 ± 6.6 pg/mL (p < 0.001) with nominal changes of 0.1 mg/dL (p > 0.05) in serum calcium (Ca) and phosphorus (P) levels. Discussion/Conclusion: Analysis of postlaunch data confirmed ERC’s effectiveness in increasing serum 25D and reducing PTH levels without statistically significant or notable impact on serum Ca and P levels. A significant percentage of these subjects achieved 25D levels ≥30 mg/mL and PTH levels which decreased by at least 30% from baseline. Dose titration to 60 mcgs was rarely prescribed. Closer patient monitoring and appropriate dose titration may have led to a higher percentage of subjects achieving an increase in 25D levels to at least 50 ng/mL and a reduction in PTH levels of at least 30%.

INTRODUCTION: Estimated dry weight is used to guide fluid removal during outpatient hemodialysis sessions. Errors in estimated dry weight can result in intradialytic hypotension and interdialytic fluid overload. The goal of this study was to assess the accuracy of estimated dry weight by comparing it to the two-week post-transplant weight in two cohorts of hemodialysis patients. METHODS: This observational, multi-center, retrospective cohort study included maintenance hemodialysis patients who underwent kidney transplantation at two medical centers in Massachusetts. The relationship between estimated dry weight pre-transplant and weight at week 2 post-transplant in patients with good allograft function (serum creatinine ≤ 1.5 mg/dL) was analyzed. Estimated dry weight was considered accurate if it was within ±2% of the week 2 post-transplant weight. RESULTS: Fifty seven patients with good allograft function were identified: mean age 54±14 years, 32 (58%) from deceased donors, 22 (38.6%) females. 38 were Caucasian (66.7%), 11 Hispanic (19.3%), 3 black (5.3%), and 5 others (8.8%). 2-week mean post transplantation serum creatinine was 1.2±0.2 mg/dL. Mean (SD) estimated dry weight was 71.4±15.9. Before transplantation, only 14 (24.6%) patients were within ±2% of the 2-week post-transplant weight; 23 (40.3%) were above and 20 (35.1%) were below. CONCLUSIONS: Our point of view, based on the assumption that the weight of patients with good allograft function at 2 weeks post-transplant approaches their accurate dry weight, is that a majority of maintenance hemodialysis patients (75.4%) are hypervolemic or hypovolemic prior to renal transplantation. This highlights the importance of finding novel tools to achieve euvolemia in patients undertaking dialysis. Timely feedback regarding achieved weight 2 weeks post-transplant to treating nephrologists and dialysis centers may be a starting point for assessing accuracy of dry weight.

Kidney involvement in patients with coronavirus disease 2019 (COVID-19) is common, and can range from the presence of proteinuria and haematuria to acute kidney injury (AKI) requiring renal replacement therapy (RRT; also known as kidney replacement therapy). COVID-19-associated AKI (COVID-19 AKI) is associated with high mortality and serves as an independent risk factor for all-cause in-hospital death in patients with COVID-19. The pathophysiology and mechanisms of AKI in patients with COVID-19 have not been fully elucidated and seem to be multifactorial, in keeping with the pathophysiology of AKI in other patients who are critically ill. Little is known about the prevention and management of COVID-19 AKI. The emergence of regional 'surges' in COVID-19 cases can limit hospital resources, including dialysis availability and supplies; thus, careful daily assessment of available resources is needed. In this Consensus Statement, the Acute Disease Quality Initiative provides recommendations for the diagnosis, prevention and management of COVID-19 AKI based on current literature. We also make recommendations for areas of future research, which are aimed at improving understanding of the underlying processes and improving outcomes for patients with COVID-19 AKI.

Background Chronic kidney disease (CKD) is characterized by dysbiosis, elevated levels of uremic toxins, systemic inflammation, and increased markers of oxidative stress. These factors lead to an increased risk of cardiovascular disease (CVD) which is common among CKD patients. Supplementation with high amylose maize resistant starch type 2 (RS-2) can change the composition of the gut microbiota, and reduce markers of inflammation and oxidative stress in patients with end-stage renal disease. However, the impact of RS-2 supplementation has not been extensively studied in CKD patients not on dialysis. Aerobic exercise training lowers certain markers of inflammation in CKD patients. Whether combining aerobic training along with RS-2 supplementation has an additive effect on the aforementioned biomarkers in predialysis CKD patients has not been previously investigated. Methods The study is being conducted as a 16-week, double-blind, placebo controlled, parallel arm, randomized controlled trial. Sixty stage 3–4 CKD patients (ages of 30–75 years) are being randomized to one of four groups: RS-2 & usual care, RS-2 & aerobic exercise, placebo (cornstarch) & usual care and placebo & exercise. Patients attend four testing sessions: Two baseline (BL) sessions with follow up visits 8 (wk8) and 16 weeks (wk16) later. Fasting blood samples, resting brachial and central blood pressures, and arterial stiffness are collected at BL, wk8 and wk16. A stool sample is collected for analysis of microbial composition and peak oxygen uptake is assessed at BL and wk16. Blood samples will be assayed for p-cresyl sulphate and indoxyl sulphate, c-reactive protein, tumor necrosis factor α, interleukin 6, interleukin 10, monocyte chemoattractant protein 1, malondialdehyde, 8-isoprostanes F2a, endothelin-1 and nitrate/nitrite. Following BL, subjects are randomized to their group. Individuals randomized to conditions involving exercise will attend three supervised moderate intensity (55–65% peak oxygen uptake) aerobic training sessions (treadmills, bikes or elliptical machine) per week for 16 weeks. Discussion This study has the potential to yield information about the effect of RS-2 supplementation on key biomarkers believed to impact upon the development of CVD in patients with CKD. We are examining whether there is an additive effect of exercise training and RS-2 supplementation on these key variables. Trial registration Clinicaltrials.gov Trial registration#NCT03689569. 9/28/2018, retrospectively registered.

Background and objectives Fatigue is a very common and debilitating symptom and identified by patients as a critically important core outcome to be included in all trials involving patients receiving hemodialysis. A valid, standardized measure for fatigue is needed to yield meaningful and relevant evidence about this outcome. This study validated a core patient-reported outcome measure for fatigue in hemodialysis. Design, setting, participants, & measurements A longitudinal cohort study was conducted to assess the validity and reliability of a new fatigue measure (Standardized Outcomes in Nephrology-Hemodialysis Fatigue [SONG-HD Fatigue]). Eligible and consenting patients completed the measure at three time points: baseline, a week later, and 12 days following the second time point. Cronbach α and intraclass correlation coefficient were calculated to assess internal consistency, and Spearman rho was used to assess convergent validity. Confirmatory factor analysis was also conducted. Hemodialysis units in the United Kingdom, Australia, and Romania participated in this study. Adult patients aged 18 years and over who were English speaking and receiving maintenance hemodialysis were eligible to participate. Standardized Outcomes in Nephrology-Hemodialysis, the Visual Analog Scale for fatigue, the 12-Item Short Form Survey, and Functional Assessment of Chronic Illness Therapy–Fatigue were used. Results In total, 485 participants completed the study across the United Kingdom, Australia, and Romania. Psychometric assessment demonstrated that Standardized Outcomes in Nephrology-Hemodialysis is internally consistent (Cronbach α =0.81–0.86) and stable over a 1-week period (intraclass correlation coefficient =0.68–0.74). The measure demonstrated convergence with Functional Assessment of Chronic Illness Therapy–Fatigue and had moderate correlations with other measures that assessed related but not the same concept (the 12-Item Short Form Survey and the Visual Analog Scale). Confirmatory factor analysis supported the one-factor model. Conclusions SONG-HD Fatigue seems to be a reliable and valid measure to be used in trials involving patients receiving hemodialysis.

There are numerous case reports and a handful of single1–5 center studies reporting on COVID‐19 in kidney transplant recipients. Most reports arise from the epicenters of where the SARS‐CoV‐2 virus was first detected such as New York City1,2,5 and Europe3,4. We in UNOS Region 1 experienced COVID‐19 weeks to a month later and questioned whether our experience was different. The programs within UNOS Region 1 have had a long history of sharing information in an attempt to mitigate the effect of viruses on our patients.

Most patients with advanced chronic kidney disease and end-stage kidney disease want to know their prognosis. Nephrologists report discomfort in communicating prognostic information to their patients and tend to avoid these discussions. This contributes to prognostic misperceptions among patients and overtreatment for patients for whom treatment benefit is questionable. Decisional regret and withdrawal rates are very high, especially among elderly dialysis patients. Prognosis lies at the center of good discussions about treatment goals that, in turn, facilitate shared decision-making. Good prognostic discussions thus have the potential to promote patient autonomy and facilitate goal concordant care. Several validated tools and frameworks are available to guide clinicians in these important conversations.

Background and Aims Extended-release calcifediol (ERC), active vitamin D analogs (VDA), and nutritional vitamin D (NVD) are the predominant vitamin D therapies (VDTs) commonly used for treatment (Tx) of secondary hyperparathyroidism (SHPT) in adults with stage 3 or 4 non-dialysis chronic kidney disease (ND-CKD) and vitamin D insufficiency (VDI). Clinical trials have demonstrated varying efficacy on serum total 25-hydroxyvitamin D (25D) and intact parathyroid hormone (iPTH) across VDTs. This study aimed to descriptively assess the real-world experience of various VDTs in increasing 25D, reducing iPTH, and modifying serum calcium (Ca). Method Medical records of the first 376 adult patients with stage 3 or 4 CKD and a history of SHPT and VDI who met study criteria from 18 geographically representative United States nephrology clinics were reviewed from 1 year before through 1 year after initiation of VDT. Key study variables included patient demographics, medication usage, and laboratory results. The study population had a mean age of 69.5 years with gender and racial distributions representative of the US ND-CKD population. Patients were stratified into cohorts based on their index therapy at index date: ERC (n=174), VDA (n=55) and NVD (n=147). Results Patients treated with NVD were predominantly CKD Stage 3 (69.4%), while CKD Stage 4 were the majority of those treated with ERC (53.4%) and VDA (61.8%). The ERC Tx’ed subjects demonstrated an increase in 25D by 23.7 ± 1.6 ng/mL (p Conclusion Clinical effectiveness and safety varied across VDTs. ERC was the only VDT which significantly reduced mean iPTH in the real world setting despite highest mean levels at baseline among the three cohorts. Additionally, subjects treated with ERC demonstrated the largest mean increase in 25D and ERC was the only VDT which raised mean 25D to the normal range (>30 ng/mL). Patients treated with ERC and NVD saw no statistically significant impact on serum Ca and P levels; however, those treated with VDAs saw a small, but statistically significant increase in serum Ca levels.

Background The urinary cell cycle arrest biomarkers (UBs) insulin-like growth factor-binding protein-7 and tissue inhibitor of metalloproteinases-2 provide early detection of kidney stress, and elevations may predict cardiac surgery–associated acute kidney injury (CS-AKI). We sought to determine whether known clinical risk factors for CS-AKI correlated with increased UB values. Methods UBs were measured over a 12-month period the morning after on-pump cardiac surgery. Patients with a preoperative serum creatinine level greater than 2.0 mg/dL or patients undergoing dialysis were excluded. Known clinical AKI risk factors in patients with elevated UB (>0.3 (ng/mL)2/1000), that is known to correlate with kidney stress, were compared with patients with low scores (≤0.3 (ng/mL)2/1000) by using logistic regression; the analysis was repeated with UB as a continuous variable. Results A total of 412 patients met inclusion criteria. Unadjusted results demonstrated a clinically similar CS-AKI risk profile in patients with either elevated or low UB values. The Pearson correlation between preoperative estimated glomerular filtration rate and UB was low (r = 0.16). Clinical risk factors for CS-AKI were not associated with elevated UB values in the logistic regression model, thus producing an area under the receiver operating characteristic curve of 0.63. Linear regression analysis also found few associations between CS-AKI clinical risk factors and UB when measured as a continuous variable, (R2) = 0.15. Conclusions Traditional CS-AKI clinical risk factors do not differ between patients with normal or elevated UB values. This UB test may identify patients at increased risk for AKI who otherwise would appear to be at low risk by traditional metrics.

The optimal use of erythropoiesis stimulating agents to treat anemia of end-stage renal disease remains difficult due to reported associations with adverse events. A patient's hemoglobin response to these agents cannot be accurately described using population-level models due to many individual factors including chronic inflammation, red blood cell lifespan, and acute blood loss. As a consequence, it is generally understood that current one-size-fits-all anemia management protocols result in suboptimal outcomes. In this paper, we report on our collaboration with the medical community in designing anemia management protocols. In clinical implementation, these new dosing protocols have led to improved outcomes due to their use of control-relevant modelling, model parameter identification, and principles of feedback control. This is an example of medical professionals and control engineers working together to positively affect the performance of anemia management protocols in end-stage renal disease.

IntroductionLifestyle interventions have been shown to produce favorable changes in some health outcomes in patients with chronic kidney disease (CKD). However, few such studies, employing “real world” methods have been completed in patients with CKD.ObjectiveThis study tested the effectiveness of a comprehensive, multicomponent, lifestyle intervention, delivered through individualized counseling on a variety of health outcomes in pre-dialysis CKD patients.MethodsEligible patients were assigned randomly to the intervention (TR) or usual care group (UC). A six-month home-based program involving personalized counseling to increase physical activity to recommended levels among stage G3a to G4 CKD patients while exchanging plant proteins for animal proteins was implemented. Physical function, cardiovascular function, dietary intake, medication use, and health-related quality of life (HRQOL) were assessed at baseline and after 1-month, 3-months (M3) and 6-months (M6).ResultsForty-two, patients (age 60.2 ± 9.2, BMI 34.5 ± 7.8) participated in this study (TR=27 UC=15). The intervention reduced (pConclusionsThis personalized multi-component lifestyle intervention enabled CKD patients to self-report fewer concerns with how CKD affected their daily lives independent of changes in physical function.

Background and Objectives Since 25 May 2010, all donors at our blood centre who tested false-positive for HIV, HBV, HCV or syphilis are eligible for re-entry after further testing. Donors who have a second false-positive screening test, either during qualification for or after re-entry, are deferred for life. This study reports on factors associated with the occurrence of such deferrals. Materials and Methods Rates of second false-positive results were compared by year of deferral, transmissible disease marker, gender, age, donor status (new or repeat) and testing platform (same or different) both at qualification for re-entry and afterwards. Chi-square tests were used to compare proportions. Cox regression was used for multivariate analyses. Results Participation rates in the re-entry programme were 42·1%: 25·6% failed to qualify for re-entry [different platform: 2·7%; same platform: 42·9% (P < 0·0001)]. After re-entry, rates of deferral for second false-positive results were 8·4% after 3 years [different platform: 1·8%; same platform: 21·4% (P < 0·0001)]. Deferral rates were higher for HIV and HCV than for HBV at qualification when tested on the same platform. The risk, when analysed by multivariate analyses, of a second deferral for a false-positive result, both at qualification and 3 years after re-entry, was lower for donors deferred on a different platform; this risk was higher for HIV, HCV and syphilis than for HBV and for new donors if tested on the same platform. Conclusion Re-entry is more often successful when donors are tested on a testing platform different from the one on which they obtained their first false-positive result.

Background Fatigue is a prevalent and debilitating symptom in patients receiving hemodialysis. We aimed to identify and evaluate the characteristics and psychometric properties of patient-reported outcome measures for fatigue in patients receiving hemodialysis, to inform the selection of a robust and feasible measure for use in randomized trials in hemodialysis. Study Design Systematic review of outcome measures for fatigue. Setting & Population Patients receiving hemodialysis. Search Strategy & Sources MEDLINE, Embase, PsycINFO, and CINAHL from inception to April 2017 were searched for all studies that reported fatigue in patients receiving hemodialysis. Analytical Approach With a focus on addressing methods, items (individual questions) from all measures were categorized into content and measurement dimensions of fatigue. We assessed the general characteristics (eg, number of items and cost) and psychometric properties of all measures. Results From 123 studies, we identified 43 different measures: 24 (55%) were developed specifically for the hemodialysis population (of which 18 were nonvalidated author-developed measures for use in their study only), 17 (40%) for other populations, and 2 (5%) for chronic kidney disease (all stages). The measures assessed 11 content dimensions of fatigue, the 3 most frequent being level of energy (19 [44%]), tiredness (15 [35%]), and life participation (14 [33%]); and 4 measurement dimensions: severity (34 [79%]), frequency (10 [23%]), duration (4 [9%]), and change (1 [2%]). The vitality subscale of the 36-Item Short Form Health Survey (SF-36) was the most frequently used (19 [15%] studies), but has only been tested for reliability in hemodialysis. Of the fatigue-specific measures, the Chalder Fatigue Scale was the only one evaluated in hemodialysis, but the full psychometric robustness remains uncertain. Limitations For feasibility, we searched for validation studies in the hemodialysis population using the names of measures identified in the primary search strategy. Conclusions A very wide range of measures have been used to assess fatigue in patients receiving hemodialysis, each varying in content and length. Many have limited validation data available in this population. A standardized and psychometrically robust measure that captures dimensions of fatigue that are important to patients is needed to estimate and improve this disabling complication of hemodialysis.

CKD is steadily increasing along with obesity worldwide. Furthermore, obesity is a proinflammatory risk factor for progression of CKD and cardiovascular disease. We tested the hypothesis that implementation of caloric restriction and aerobic exercise is feasible and can improve the proinflammatory metabolic milieu in patients with moderate to severe CKD through a pilot, randomized, 2×2 factorial design trial. Of 122 participants consented, 111 were randomized to receive caloric restriction and aerobic exercise, caloric restriction alone, aerobic exercise alone, or usual care. Of those randomized, 42% were women, 25% were diabetic, and 91% were hypertensive; 104 started intervention, and 92 completed the 4-month study. Primary outcomes were a change from baseline in absolute fat mass, body weight, plasma F 2 -isoprostane concentrations, and peak oxygen uptake (VO 2 peak ). Compared with usual care, the combined intervention led to statistically significant decreases in body weight and body fat percentage. Caloric restriction alone also led to significant decreases in these measures, but aerobic exercise alone did not. The combined intervention and each independent intervention also led to significant decreases in F 2 -isoprostane and IL-6 concentrations. No intervention produced significant changes in VO 2 peak , kidney function, or urine albumin-to-creatinine ratio. In conclusion, 4-month dietary calorie restriction and aerobic exercise had significant, albeit clinically modest, benefits on body weight, fat mass, and markers of oxidative stress and inflammatory response in patients with moderate to severe CKD. These results suggest healthy lifestyle interventions as a nonpharmacologic strategy to improve markers of metabolic health in these patients.

Background: Fluid management remains a major challenge of hemodialysis (HD) care, with serious implications for morbidity and mortality. Intradialytic fluid management is typically guided by blood pressure, an indirect resultant of hemodynamics status. Direct measurements of hemodynamic parameters may improve cardiovascular outcomes by providing rational bases for intervention. We compare stroke volume (SV) measurements using a noninvasive, regional biompedance cardiography device (NiCaS) with Doppler echocardiography (Echo) in HD setting. Methods: Stroke volumes were simultaneously measured using the devices in 17 patients receiving maintenance HD. Measurements were made during 2 weekly HD treatments, and twice within each HD treatment during the first and last hour of each treatment, for a total of 64 SV measurements. Agreement between devices was assessed using linear regression, a Pearson's correlation coefficient, and a Bland-Altman plot all adjusted for repeated measures within patients. Results: Echo and NiCaS SV mean and 95% CIs were 58.0 (50.1, 65.8) and 56.7 (49.4, 64.0) mL, respectively. NiCaS SV correlated strongly with Echo SV during the first and last hours of treatments (r = 0.93, P

Background Chronic kidney disease (CKD) is associated with abnormal lipid profiles and altered high-density lipoprotein (HDL) particle size patterns. Lower levels of the larger, cardioprotective HDL particles found in CKD may play a role in the increased risk for cardiovascular disease in these patients. The current study was designed to assess the effects of short-term moderate-intensity aerobic exercise training on the HDL particle pattern and overall lipid profiles in stage 3 CKD patients. Methods Forty-six men and women with stage 3 CKD were randomized to either exercise (EX, n = 25) or control (CON, n = 21). Those in the EX group completed 16 weeks of supervised moderate-intensity aerobic exercise three times per week. Serum total cholesterol, HDL cholesterol (HDL-C), triglycerides (TGs), low-density lipoprotein cholesterol (LDL-C), HDL particle size, estimated glomerular filtration rate (eGFR), body composition and peak oxygen uptake (VO2peak) were assessed at baseline and week 16. Results The rate of compliance in the EX group was 97 ± 7.2%. No change was observed in eGFR over time in either group. There was an 8.2% improvement in VO2peak in the EX group (P = 0.05), while VO2peak decreased in the CON group. HDL-C, TGs, HDL particle size and body composition remained unchanged in both groups. A trend was found for lower total cholesterol (TC) (P = 0.051) and LDL-C (P = 0.07) in the CON group. Conclusion Our findings indicate that a short-term aerobic exercise training intervention in stage 3 CKD patients does not induce changes in HDL particle size or favorable lipid profile modifications.

Aim The current study was designed to determine if a relationship exists between acute and chronic blood pressure responses to aerobic exercise in pre-dialysis patients. Methods Pre-dialysis kidney patients attended four sessions before being randomized to the treatment (n = 25) or control group (n = 21). In session 1, resting blood pressure was recorded, and these measurements were repeated during the second visit when peak oxygen uptake (VO2peak) was assessed. In the third and fourth sessions, blood pressures were taken prior to a 40 min walk or period of seated rest. After the 40 min walk or seated rest, blood pressures were monitored for 60 min in the laboratory and for the subsequent 24 h. After session 4, subjects in the treatment group trained aerobically at a moderate intensity, three times per week for 16 weeks. Control subjects were asked to be sedentary. All measurements were repeated after 16 weeks of training or sedentary living. Results Training increased VO2peak (mL/kg per minute) in the treatment group (baseline 19.6 ± 6.7 vs 21.2 ± 7.7, P