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Purpose: To systematically evaluate the decision effectiveness of patient decision aids (PtDAs) on the decision-making effect of patients with advanced chronic kidney disease. Method: Two authors independently searched ten electronic databases [Web of science, PubMed, the Cochrane Library, Embase, CINAHL, EBSCO, CBM, CNKI, WanFang DATA and Vip database], to include randomized controlled trials of interventions through PtDAs in patients with advanced chronic kidney disease published from the inception of the database until April 2024. Two authors conducted a comprehensive quality evaluation (Cochrane 5.1.0) before independently extracting and analyzing the data with RevMan 5.2. Results: The study included 11 randomized controlled trials with a total of 1613 patients. According to the results, PtDAs can improve the decision knowledge [SMD = 0.53, 95% CI (0.26, 0.80), P = 0.0002] and decision preparation [SMD = 2.34, 95% CI (2.04, 2.65), P < 0.00001] of patients with advanced chronic kidney disease. Additionally, there was a substantial decrease in the levels of decision regret [SMD = − 1.33, 95% CI (− 2.11, − 0.55), P < 0.05] and decision conflict [SMD = − 0.88, 95% CI (− 1.47, − 0.28), P = 0.004]. Conclusion: The current available evidence indicates that PtDAs can significantly enhance the decision knowledge and decision preparation of patients with advanced chronic kidney disease. Additionally, PtDAs can reduce the levels of decision regret and decision conflict. Trial Registry: CRD42023433798. [ABSTRACT FROM AUTHOR]

Abstract Background Pregnancy in women with chronic kidney disease (CKD) is associated with an increased risk of adverse maternal and fetal outcomes, including worsening renal function, hypertension, proteinuria, preeclampsia, preterm delivery, stillbirth, and intrauterine growth restriction. Some pregnant women with CKD may require dialysis after conception. Clinical guidelines provide recommendations for optimal hemodialysis prescription in pregnant women undergoing maintenance hemodialysis for end-stage kidney disease. However, the timing of initiation and optimal doses of hemodialysis for pregnant women with non-dialysis advanced CKD remain uncertain. Case presentation We describe the case of a 29-year-old woman with a history of CKD for at least 2 years. She was referred to our department with a serum creatinine level of 2.48 mg/dL and an estimated glomerular filtration rate of 20 mL/min/1.73 m2. Because she was found to be pregnant at the initial visit, she was referred to the Department of Obstetrics. At 23 weeks’ gestation, she was admitted due to threatened premature delivery and urinary tract infection, which were managed with ritodrine hydrochloride and antibiotics. Owing to maternal weight loss and asymmetrical fetal growth restriction, daily protein intake was increased from 40 g/day to 60–80 g/day. Additionally, supportive hemodialysis (three times per week) was initiated at 26 weeks’ gestation, and the pre-dialysis blood urea nitrogen (BUN) level was consistently maintained

Resumen: Introducción: La influencia de los determinantes sociales de la salud en la elección de las técnicas de tratamiento renal sustitutivo (TRS) en la enfermedad renal crónica avanzada (ERCA) ha sido escasamente explorada, pudiendo generar problemas de inequidad, frecuentemente desapercibidos en la asistencia sanitaria. El objetivo de este estudio es identificar las desigualdades sociales y económicas que influyen en la elección de TRS en una consulta de ERCA en España. Material y métodos: Análisis retrospectivo incluyendo el total de pacientes atendidos en la consulta de ERCA en un hospital terciario desde 2009 a 2020. La inclusión en la consulta de ERCA comenzaba por un proceso de toma de decisiones, conducido por una enfermera específicamente instruida. Las variables consideradas para el estudio fueron: edad, sexo, etiología de la ERC, nivel de dependencia para las actividades básicas de la vida diaria (escala de Barthel) y actividades instrumentales de la vida diaria (escala de Lawton y Brody), nacionalidad española versus extranjera, nivel socioeconómico y barrera idiomática. El nivel socioeconómico se extrapoló según el domicilio y el distrito sanitario por centro de atención primaria al que pertenecían los pacientes. Resultados: Un total de 673 personas fueron atendidas en la consulta de ERCA en el periodo de estudio, de los cuales 400 (59,4%) optaron por la técnica de hemodiálisis (HD), 156 (23,1%) por diálisis peritoneal (DP), 4 (0,5%) por trasplante renal de donante vivo anticipado y 113 (16,7%) eligieron tratamiento conservador (TC). La elección de DP como técnica de TRS elegida (frente a HD) se asoció a personas con nivel socioeconómico alto (38,7 vs. 22,5%) (p = 0,002), a la nacionalidad española (91 vs. 77,7%) (p

Alterations in the body's nutritional status or composition may be observed as the kidney disease advances, which could influence the kidney's functional capacity and, consequently, could increase the risk of mortality. The aim of the study is to determine the influence of functional capacity on mortality assessed by different functional tests in patients with advanced chronic kidney disease (ACKD). A prospective observational study was designed, which included 225 patients followed for 8 years in a CKD clinic. The study assessed functional capacity by using a range of tests, which included the Short Physical Performance Battery, the 6 minutes walking gait test, the timed up and go, and the four versions of the sit-to-stand test. Additionally, body composition and nutritional conditions were considered, taking into consideration various biochemical indicators such as albumin, prealbumin, c-reactive protein (CRP), lymphocytes, and transferrin, muscle strength, comorbidity, and frailty. The relationship between functionality and all-cause mortality was investigated using a Cox proportional hazard model. A total of fifty patients died during the duration of the study. Patients who performed worse on the function and muscle strength tests showed a worse body composition and nutritional status, and exhibited a reduced life expectancy. Inflammation (CRP) was associated with an increased risk of mortality (model 1: hazard ratio (HR) = 1.246; 95% confidence interval (95% CI = 1.014–1.531; model 2: HR = 1.333; 95% CI = 1.104–1.610). Good functional capacity as determined by the SPPB test decreased the risk of mortality (model 1: HR = 0.764; 95% CI = 0.683–0.855; model 2 HR = 0.778; 95% CI = 0.695–0.872). Cut-off points of maximum sensitivity and specificity for mortality were obtained with different tests. The study demonstrated that functional capacity influences mortality in patients with ACKD, being higher in those patients with impaired functionality regardless of the test used, although the SPPB allows a larger number of patients to be assessed. Therefore, it is essential to incorporate the assessment of functionality into the comprehensive care of patients with CKD. [ABSTRACT FROM AUTHOR]

Phase angle (PhA), a marker of nutritional status obtained by bioelectrical impedance analysis (BIA), is associated with the integrity of cell membranes. Damage to muscle fiber membranes can impact muscle strength, which is related to adverse outcomes in adults with advanced chronic kidney disease (CKD). The main objective of this study was to determine the usefulness of the PhA in identifying muscle weakness in candidates for kidney transplants (KTs). Secondly, it aimed to examine the associations of PhA with other parameters of body composition, exercise performance, and muscle structure. Sensitivity, specificity, and area under the receiver operating characteristics curve were used to evaluate the PhA (index test) as a biomarker of muscle weakness. Muscle strength was estimated with maximal voluntary isometric contraction of the quadriceps (MVCI-Q) of the dominant side. Muscle weakness was defined as MVIC-Q < 40% of body weight. A total of 119 patients were evaluated (mean age 63.7 years, 75.6% men). A phase angle cut-off of 5.1° was identified to classify men with a higher likelihood of having low muscle strength in upper limbs (MVIC-Q 40% of their body weight). Male KT candidates with PhA < 5.1° had poorer exercise capacity, lower muscle strength, less muscle mass, and smaller muscle size. A PhA < 5.1° was significantly associated with an eight-fold higher muscle weakness risk (OR = 8.2, 95%CI 2.3–29.2) in a binary regression model adjusted by age, frailty, and hydration status. Remarkably, PhA is an easily obtainable objective parameter in CKD patients, requiring no volitional effort from the individual. The associations of PhA with aerobic capacity, physical activity, muscle mass, and muscle size underscore its clinical relevance and potential utility in the comprehensive evaluation of these patients. [ABSTRACT FROM AUTHOR]

Copyright of Nefrologia is the property of Revista Nefrologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

In this case report, we describe a patient who presented with chronic symptoms and signs of uremia and persistent accelerated idioventricular rhythm (AIVR) on electrocardiogram. Findings from blood tests, echocardiography, renal ultrasound, and renal scan were suggestive of heart failure with reduced ejection fraction and chronic kidney disease, and attendance of daily hemodialysis sessions led to the restoration of sinus rhythm. Typically, AIVR has a favorable prognosis and, if necessary, medical intervention focuses on addressing the underlying responsible causes. Accumulation of uremic toxins has the potential to trigger the formation of AIVR and clearance of small solutes through conventional hemodialysis may contribute to sinus rhythm restoration. [ABSTRACT FROM AUTHOR]

Rationale & Objective: Engaging patients with advanced chronic kidney disease (CKD) in goals of care (GOC) conversations is essential to align life-sustaining treatments with patient preferences. This pilot study described the feasibility of engaging older Veterans with advanced CKD in GOC conversations via telehealth by (1) comparing patient characteristics, including life-sustaining treatment note completion rates and preferences by visit modality, and (2) exploring Veteran and clinician perspectives surrounding telehealth GOC conversations. Study Design: Mixed-method convergent design including a prospective, quantitative observational cohort analysis (n = 40) and qualitative, semi-structured interviews with 4 clinicians and 11 Veterans. Descriptive statistics were used to describe the quantitative data. An inductive, rapid analytic approach and the constant comparison were used to analyze and interpret qualitative data. Quantitative and qualitative data were triangulated to identify practical suggestions to optimize GOC conversations via telehealth. Setting & Participants: Study participants included Veteran patients aged ≥70 years with advanced CKD stage 4 or 5 from a Veterans Affairs hospital nephrology clinic. Results: The cohort (n = 40) had a high probability of death, hospitalization, or both occurring within 90 days or 1 year. Across visit modalities, patient characteristics did not differ significantly. Two interrelated themes emerged from interviews: (1) GOC conversation feasibility varies by key personal and environmental factors (barriers and facilitators) across visit modalities, although overarching barriers include lack of non-palliative care provider engagement and uncertainty or lack of understanding surrounding illness trajectory, and (2) engaging Veterans in GOC conversations has a positive impact by creating a sense of reassurance regardless of visit modality. Limitations: The sample size was small (n = 40), and the study was unable to detect statistically significant differences in patient characteristics and clinical outcomes between visit modalities. Furthermore, future studies with larger and more diverse samples may be better equipped to identify differences by demographic characteristics. Conclusions: The findings suggest that it is feasible to engage older patients with advanced CKD in GOC conversations via telehealth, as patients wishing to complete a telehealth GOC conversation were able to. Factors increasing the ease of accessing GOC conversations may also increase their benefits, irrespective of visit modality. Plain-Language Summary: Goals of care (GOC) conversations for older patients with advanced chronic kidney disease (CKD) are important to align medical care with patient goals. Telehealth may be used to facilitate GOC conversations for these patients. We studied the feasibility of engaging older patients with advanced CKD in GOC conversations via telehealth. We compared demographic characteristics and visit outcomes between patients who completed telehealth versus in-person visits. We also interviewed patients and clinicians regarding their perspectives. The findings suggest that telehealth visits can be used for a select group of patients who prefer them to in-person visits. However, there are barriers and benefits with both modalities. There is no one-size-fits-all modality; rather, the needs of each patient should determine the most suitable visit modality.

Abstract Background Advanced chronic kidney disease (ACKD) is associated with a high risk of adverse cardiovascular and renal events and has a significant impact on quality of life and life expectancy. Several studies have identified areas for improvement in their management in primary care. Some professional and environmental factors can act as key barriers to appropriate care. Objective To analyse attitudes, subjective norms, and perceived behavioural control among primary care professionals related to the implementation of an evidence-based approach for individuals with ACKD in primary care. Methodology This was a qualitative study using an interpretative phenomenological approach based on the theory of planned behaviour. Two aspects of the evidence-based approach were explored: the implementation of clinical practice guidelines and the utilisation of electronic kidney disease records within the scope of this study. Primary care nurses and physicians participated in a previous pilot interview and five focus groups. Subsequently, a thematic analysis of the gathered data was conducted. Findings Thirty-three primary care professionals participated. The emerging themes included: experiences in the management of ACKD (highlighting a distinct profile of older, frail patients with comorbidities masking CKD and a CKD follow-up primarily focused on analytical monitoring and drug adjustment); factors in the professional environment influencing the use of scientific evidence (such as time constraints, excessive electronic health records, and unfamiliar reference guidelines); attitudes towards the application of recommendations on ACKD (recognising limitations of computer systems despite considering them as guidance); and capacities to implement evidence-based recommendations (acknowledging formative needs and challenges in coordinating care with nephrology services). Conclusions Several psychological elements identified through the TBP hinder the adequate implementation of an evidence-based approach for individuals with CKD. Attitudes have been identified as factors modulating the use of standardised electronic records. Instead, subjective norms (influences from the professional environment) and perceived behavioral control (perception of capabilities) acted as barriers to the proper application of clinical practice guidelines and standardised records. Implications for practice Strategies aimed at optimising the management of people with ACKD should focus not only on training but also on improving attitudes, organisational structures, IT systems and coordination between primary care and nephrology.

Resumen: La encefalopatía por contraste es una complicación neurológica relacionada con el contraste utilizado en procedimientos endovasculares o tomografía computarizada (TC). Los principales factores de riesgo son la hipertensión arterial, la diabetes mellitus, la enfermedad renal crónica (ERC), contrastes hiperosmolares, cantidad de contraste infundida y su infusión directa en el territorio cerebral posterior, o patologías que cursen con daño de barrera hematoencefálica. La sintomatología es inespecífica y puede presentarse como alteración del nivel de conciencia, focalidad neurológica o crisis comiciales. El diagnóstico es de exclusión tras haber descartado los accidentes cerebrovasculares (ACV) isquémicos o hemorrágicos; el TC o la resonancia magnética (RM) son de utilidad para su diferenciación. Generalmente aparece poco tiempo tras la exposición y la sintomatología dura 48-72 h con recuperación completa, aunque se han descrito casos con persistencia de los síntomas o mayor duración. El tratamiento es la monitorización con medidas de soporte y la terapia de sustitución renal con hemodiálisis (HD) en aquellos pacientes en programa crónico. Es importante que el nefrólogo conozca esta entidad, dada la susceptibilidad del paciente en HD, así como su potencial papel terapéutico en estos pacientes. Abstract: Contrast-induced encephalopathy is a neurological complication related to contrast used in endovascular procedures or computed tomography (CT). The main risk factors are arterial hypertension, diabetes mellitus, chronic kidney disease (CKD), hyperosmolar contrasts, the amount of infused contrast and its direct infusion in the posterior cerebral territory, or pathologies with blood–brain barrier damage. Symptomatology is non-specific and may present as altered level of consciousness, neurological focality or seizures. Diagnosis is done by exclusion after ischemic or hemorrhagic stroke has been ruled out; CT or MRI are useful for differentiation. Generally, it appears shortly after exposure and the symptoms lasts 48–72 h with complete recovery, although cases with persistence of symptoms or longer duration have been described. Treatment consists of monitoring, supportive measures and renal replacement therapy (RRT) with hemodialysis (HD) in patients in chronic RRT program. It is important for the nephrologist to be aware of this entity given the susceptibility of the patient on HD as well as its potential therapeutic role in these patients.

Introduction Advanced chronic kidney disease (CKD) is common among patients with coronary artery disease (CAD), and angiotensin‑converting enzyme inhibitors (ACEI) or angiotensin‑receptor blockers (ARB) can improve cardiac and renal function, but whether ACEI/ARB therapy improves long-term prognosis remains unclear among these high-risk patients. Therefore, this research aimed to investigate the relationship between ACEI/ARB therapy and long-term prognosis among CAD patients with advanced CKD.Methods CAD patients with advanced CKD were included in five hospitals. Advanced CKD was defined as estimated glomerular filtration rate (eGFR)

Background: Advanced chronic kidney disease (ACKD) is associated with a high risk of adverse cardiovascular and renal events and has a significant impact on quality of life and life expectancy. Several studies have identified areas for improvement in their management in primary care. Some professional and environmental factors can act as key barriers to appropriate care. Objective: To analyse attitudes, subjective norms, and perceived behavioural control among primary care professionals related to the implementation of an evidence-based approach for individuals with ACKD in primary care. Methodology: This was a qualitative study using an interpretative phenomenological approach based on the theory of planned behaviour. Two aspects of the evidence-based approach were explored: the implementation of clinical practice guidelines and the utilisation of electronic kidney disease records within the scope of this study. Primary care nurses and physicians participated in a previous pilot interview and five focus groups. Subsequently, a thematic analysis of the gathered data was conducted. Findings: Thirty-three primary care professionals participated. The emerging themes included: experiences in the management of ACKD (highlighting a distinct profile of older, frail patients with comorbidities masking CKD and a CKD follow-up primarily focused on analytical monitoring and drug adjustment); factors in the professional environment influencing the use of scientific evidence (such as time constraints, excessive electronic health records, and unfamiliar reference guidelines); attitudes towards the application of recommendations on ACKD (recognising limitations of computer systems despite considering them as guidance); and capacities to implement evidence-based recommendations (acknowledging formative needs and challenges in coordinating care with nephrology services). Conclusions: Several psychological elements identified through the TBP hinder the adequate implementation of an evidence-based approach for individuals with CKD. Attitudes have been identified as factors modulating the use of standardised electronic records. Instead, subjective norms (influences from the professional environment) and perceived behavioral control (perception of capabilities) acted as barriers to the proper application of clinical practice guidelines and standardised records. Implications for practice: Strategies aimed at optimising the management of people with ACKD should focus not only on training but also on improving attitudes, organisational structures, IT systems and coordination between primary care and nephrology. [ABSTRACT FROM AUTHOR]

Copyright of Nefrologia is the property of Revista Nefrologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract In this case report, we describe a patient who presented with chronic symptoms and signs of uremia and persistent accelerated idioventricular rhythm (AIVR) on electrocardiogram. Findings from blood tests, echocardiography, renal ultrasound, and renal scan were suggestive of heart failure with reduced ejection fraction and chronic kidney disease, and attendance of daily hemodialysis sessions led to the restoration of sinus rhythm. Typically, AIVR has a favorable prognosis and, if necessary, medical intervention focuses on addressing the underlying responsible causes. Accumulation of uremic toxins has the potential to trigger the formation of AIVR and clearance of small solutes through conventional hemodialysis may contribute to sinus rhythm restoration.

This study investigated the risk factors of abdominal aortic calcification (AAC) in patients with stage 5 chronic kidney disease (CKD) and the effects of AAC and different dialysis methods on the 3-year survival rate of patients with stage 5 CKD. A retrospective cohort study was conducted on stage 5 CKD patients who received dialysis treatment. The general data were collected, and all fasting venous blood samples were harvested before the first dialysis to detect biochemical markers. The AAC was evaluated by lateral abdominal X-ray. The patients were followed up with a cut-off date of March 31, 2022, with all-cause mortality as the endpoint event. A total of 205 patients were included. multivariable Cox regression analysis confirmed that AAC (hazard ratio (HR) = 2.173, 95% CI 1.029–4.588, p = 0.042), advanced age (HR = 1.061, 95% CI 1.031–1.093, p < 0.001), duration of dialysis (HR = 1.015, 95% CI 1.007–1.032, p < 0.001), diabetes (HR = 3.966, 95% CI 2.164–7.269, p < 0.001), and hypertension (HR = 1.897, 95% CI 1.089–3.303, p = 0.024) were independent risk factors for 3-year mortality. However, peritoneal dialysis (HR = 0.366, 95% CI 0.165–0.812, p = 0.013), high albumin (HR = 0.882, 95% CI 0.819–0.950, p = 0.001), and high hemoglobin (HR = 0.969, 95% CI 0.942–0.997, p = 0.031) were protective factors for 3-year mortality in stage 5 CKD patients. Increased age, long-term dialysis, high level of intact parathyroid hormone, diabetes, and hypertension are closely related to the occurrence of AAC in patients with stage 5 CKD. In addition, AAC is an independent risk factor for all-cause mortality in patients with stage 5 CKD. [ABSTRACT FROM AUTHOR]

Abstract Background The French Renal Epidemiology and Information Network (REIN) registry collect dialysis initiation context for each patient starting dialysis with a flawed definition of urgent start dialysis (USD). The main objective of this study was to identify factors associated with USD in patients regularly followed-up by a nephrologist using a classification of USD considering the preparation to renal replacement therapy. Methods This retrospective cohort study included adult patients who started dialysis between 2012 and 2018 in the Franche-Comté region of France after a minimum of two nephrology consultations. We classified dialysis initiation context as follows: USD for patients with no dialysis access (DA) created or planned, unplanned non urgent start dialysis (UNUSD) for patients starting with a recent or non-functional DA and planned start dialysis (PSD) for those starting with a functional and mature DA. Results Four hundred and sixty-five patients met inclusion criteria. According to REIN registry, 94 (20.3%) patients were urgent starters (US) whereas with our classification 80 (17.2%) and 73 (15.7%) where respectively US and unplanned non urgent starters (UNUS). The factors independently associated with USD in our classification were: stroke (odds ratio(OR) = 2.76, 95% confidence interval (95%CI)=[1.41–5.43]), cardiac failure (OR = 1.78, 95%CI=[1.07–2.96]) and the number of nephrology consultations prior dialysis onset (OR = 0.73, 95%CI=[0.64–0.83]). Thirty-one patients died during the first year after dialysis start. According to our classification, we observed significantly different survival probabilities: 95.7%, 89.5% and 83.4% respectively for planned starters, UNUS and US (p = 0.001). Conclusion The two factors independently associated with USD were cardiac failure and stroke.

BackgroundPatients with advanced chronic kidney disease (CKD), end-stage kidney disease (ESKD), and kidney transplants (KT) are at an elevated risk for COVID-19 infection, hospitalization, and mortality. A comprehensive comparison of morbidity and mortality between these populations with kidney disease and individuals without any kidney disease is lacking.MethodsWe analysed the 2020 Nationwide Inpatient Sample (NIS) database for non-elective adult COVID-19 hospitalizations, categorizing patients into advanced CKD, ESKD, KT, and kidney disease-free cohorts. Our analysis included a description of the distribution of comorbidities across the entire spectrum of CKD, ESKD, and KT. Additionally, we investigated in-hospital mortality, morbidity, and resource utilization, adjusting for potential confounders through multivariable regression models.ResultsThe study included 1,018,915 adults hospitalized for COVID-19 in 2020. The incidence of advanced CKD, ESKD, and KT in this cohort was 5.8%, 3.8%, and 0.4%, respectively. Patients with advanced CKD, ESKD, and KT exhibited higher multimorbidity burdens, with 90.3%, 91.0%, and 75.2% of patients in each group having a Charlson comorbidity index (CCI) equal to or greater than 3. The all-cause in-hospital mortality ranged from 9.3% in kidney disease-free patients to 20.6% in advanced CKD, 19.4% in ESKD, and 12.4% in KT patients. After adjusting for potential confounders at both the patient and hospital levels, CKD stages 3–5; ESKD; and KT were found to be associated with increased odds of mortality, with adjusted odds ratios (aOR) of 1.34, 1.80, 2.66, 1.97, and 1.69, respectively.ConclusionPatients hospitalized for COVID-19 with advanced CKD, ESKD, or KT demonstrated a higher burden of comorbidities and increased mortality rates compared to those without kidney disease. After adjusting for confounders, CKD stages 3–5; ESKD; and KT were identified as independent risk factors for in-hospital mortality, illustrating a dose-response relationship between the odds of mortality and adverse outcomes as CKD progressed from stages 3 to 5. Our study highlights the necessity for enhanced management of comorbidities, targeted interventions, and vigorous vaccination efforts to mitigate the risk of adverse outcomes in the vulnerable populations of patients with CKD, ESKD, and KT.

Background: Malnutrition is frequent in patients with chronic kidney disease (CKD) and has a negative impact on morbidity, mortality, and quality of life. The objective of this study was to assess the value of the Global Leadership Initiative for Malnutrition (GLIM) criteria to predict hospitalizations and mortality in candidates to kidney transplant during their first year on the waiting list. Methods: This was a post hoc analysis of 368 patients with advanced CKD. The main study variables were malnutrition, according to the GLIM criteria; number of hospital admissions during the first year on the waiting list; and mortality at the end of follow‐up. Kaplan‐Meier survival curves and binary logistic regression were performed, adjusting for age, frailty status, handgrip strength, and Charlson Index as potential confounders. Results: The prevalence of malnutrition was 32.6%. Malnutrition was associated with increased risk of hospitalizations during the first year on the waiting list (odds ratio [OR] = 3.33 [95% CI = 1.34–8.26]), which persisted after adjustment for age and frailty status (adjusted OR = 3.61 [95% CI = 1.38–10.7]), age and handgrip strength (adjusted OR = 3.39 [95% CI = 1.3–8.85]), and age and Charlson Index (adjusted OR = 3.25 [95% CI = 1.29–8.13]). Conclusion: Malnutrition according to the GLIM criteria was highly prevalent in patients with CKD and was associated with a threefold increased risk of hospitalizations during the first year on the waiting list; these associations remained significant after adjusting for age, frailty status, handgrip strength, and comorbidities. [ABSTRACT FROM AUTHOR]

Background: The French Renal Epidemiology and Information Network (REIN) registry collect dialysis initiation context for each patient starting dialysis with a flawed definition of urgent start dialysis (USD). The main objective of this study was to identify factors associated with USD in patients regularly followed-up by a nephrologist using a classification of USD considering the preparation to renal replacement therapy. Methods: This retrospective cohort study included adult patients who started dialysis between 2012 and 2018 in the Franche-Comté region of France after a minimum of two nephrology consultations. We classified dialysis initiation context as follows: USD for patients with no dialysis access (DA) created or planned, unplanned non urgent start dialysis (UNUSD) for patients starting with a recent or non-functional DA and planned start dialysis (PSD) for those starting with a functional and mature DA. Results: Four hundred and sixty-five patients met inclusion criteria. According to REIN registry, 94 (20.3%) patients were urgent starters (US) whereas with our classification 80 (17.2%) and 73 (15.7%) where respectively US and unplanned non urgent starters (UNUS). The factors independently associated with USD in our classification were: stroke (odds ratio(OR) = 2.76, 95% confidence interval (95%CI)=[1.41–5.43]), cardiac failure (OR = 1.78, 95%CI=[1.07–2.96]) and the number of nephrology consultations prior dialysis onset (OR = 0.73, 95%CI=[0.64–0.83]). Thirty-one patients died during the first year after dialysis start. According to our classification, we observed significantly different survival probabilities: 95.7%, 89.5% and 83.4% respectively for planned starters, UNUS and US (p = 0.001). Conclusion: The two factors independently associated with USD were cardiac failure and stroke. [ABSTRACT FROM AUTHOR]

Background: Metabolic acidosis is a common complication in patients with chronic kidney disease (CKD). Oral sodium bicarbonate is often used to treat metabolic acidosis and prevent CKD progression. However, there is limited information about the effect of sodium bicarbonate on major adverse cardiovascular events (MACE) and mortality in patients with pre-dialysis advanced CKD. Method: 25599 patients with CKD stage V between January 1, 2001 and December 31, 2019 were identified from the Chang Gung Research Database (CGRD), a multi-institutional electronic medical record database in Taiwan. The exposure was defined as receiving sodium bicarbonate or not. Baseline characteristics were balanced using propensity score weighting between two groups. Primary outcomes were dialysis initiation, all-cause mortality, and major adverse cardiovascular events (MACE) (myocardial infarction, heart failure, stroke). The risks of dialysis, MACE, and mortality were compared between two groups using Cox proportional hazards models. In addition, we performed analyzes using Fine and Gray sub-distribution hazard models that considered death as a competing risk. Result: Among 25599 patients with CKD stage V, 5084 patients (19.9%) were sodium bicarbonate users while 20515 (80.1%) were sodium bicarbonate nonusers. The groups had similar risk of dialysis initiation (hazard ratio (HR): 0.98, 95% confidence interval (CI): 0.95-1.02, p < 0.379). However, taking sodium bicarbonate was associated with a significantly lower risks of MACE (HR: 0.95, 95% CI 0.92-0.98, p < 0.001) and hospitalizations for acute pulmonary edema (HR: 0.92, 95% CI 0.88-0.96, p < 0.001) compared with non-users. The mortality risks were significantly lower in sodium bicarbonate users compared with sodium bicarbonate non-users (HR: 0.75, 95% CI 0.74-0.77, p < 0.001). Conclusion: This cohort study revealed that in real world practice, use of sodium bicarbonate was associated with similar risk of dialysis compared with non-users among patients with advanced CKD stage V. Nonetheless, use of sodium bicarbonate was associated with significantly lower rate of MACE and mortality. Findings reinforce the benefits of sodium bicarbonate therapy in the expanding CKD population. Further prospective studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Background: Despite the frequent coexistence of heart failure (HF) in patients with advanced chronic kidney disease (CKD), it has been understudied, and little is known about its prevalence and prognostic relevance. Methods: A retrospective study of 217 patients with advanced CKD (stages 4 and 5) who did not undergo renal replacement therapy (RRT). The patients were followed up for two years. The primary outcome was all-cause death or the need for RRT. Results: Forty percent of patients had a history of HF. The mean age was 78.2 ± 8.8 years and the mean eGFR was 18.4 ± 5.5 mL/min/1.73 m2. The presence of previous HF identified a subgroup of high-risk patients with a high prevalence of cardiovascular comorbidities and was significantly associated with the composite endpoint of all-cause hospitalization or need for RRT (66.7% vs. 53.1%, HR 95% CI 1.62 (1.04–2.52), p = 0.034). No differences were found in the need for RRT (27.6% vs. 32.2%, p = 0.46). Nineteen patients without HF at baseline developed HF during the follow-up and all-cause death was numerically higher (36.8 vs. 19.8%, p = 0.1). Conclusions: Patients with advanced CKD have a high prevalence of HF. The presence of previous HF identified a high-risk population with a worse prognosis that required close follow-up. [ABSTRACT FROM AUTHOR]

Copyright of Nefrologia is the property of Revista Nefrologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Malnutrition has a negative impact on patients with chronic diseases and its early identification is a priority. The primary objective of this diagnostic accuracy study was to assess the performance of the phase angle (PhA), a bioimpedance analysis (BIA)-derived parameter, for malnutrition screening using the Global Leadership Initiative for Malnutrition (GLIM) criteria as the reference standard in patients with advanced chronic kidney disease (CKD) waiting for kidney transplantation (KT); criteria associated with low PhA in this population were also analyzed. Sensitivity, specificity, accuracy, positive and negative likelihood ratios, predictive values, and area under the receiver operating characteristic curve were calculated for PhA (index test) and compared with GLIM criteria (reference standard). Of 63 patients (62.9 years old; 76.2% men), 22 (34.9%) had malnutrition. The PhA threshold with the highest accuracy was ≤4.85° (sensitivity 72.7%, specificity 65.9%, and positive and negative likelihood ratios 2.13 and 0.41, respectively). A PhA ≤ 4.85° was associated with a 3.5-fold higher malnutrition risk (OR = 3.53 (CI95% 1.0–12.1)). Considering the GLIM criteria as the reference standard, a PhA ≤ 4.85° showed only fair validity for detecting malnutrition, and thus cannot be recommended as a stand-alone screening tool in this population. [ABSTRACT FROM AUTHOR]

Resumen: Introducción y objetivos: La elección del tratamiento sustitutivo renal (TSR) es una decisión importante que determina la calidad de vida y la supervivencia. La mayoría de los pacientes cambiará de una modalidad de TSR a otra para adaptarla a sus necesidades dentro de lo que se conoce como modelo de TSR integrado. En estas circunstancias surgen nuevas preguntas sobre la mejor secuencia de técnicas o las consecuencias de las transiciones. Material y métodos: Describimos las transiciones entre técnicas de TSR y su impacto en la supervivencia a partir del Registro Madrileño de Enfermos Renales (REMER), durante un periodo de 11 años. Se utilizaron los modelos de riesgos proporcionales y de riesgos competitivos para realizar un análisis por intención de tratar (ITT) según su 1.er tratamiento y como tratado (AT) considerando la 1.ª transición. Resultados: Un total de 8.971 pacientes iniciaron su primer TSR durante este periodo en Madrid (6,6 millones habitantes): 7.207 (80,3%) en hemodiálisis (HD), 1.401 (15,6%) en diálisis peritoneal (DP) y 363 (4,1%) recibieron un trasplante renal anticipado (TXR). En el análisis ITT, los pacientes incidentes en HD eran mayores (HD 65,3 años (DE 15,3) vs. DP 58,1 años [DE 14,8] vs. TXR 52,0 años (DE 17,2); p

The incidence of hypocalcemia is high in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) undergoing denosumab treatment. Since 2018, we have carried out a "multidisciplinary integrated care program for osteoporosis among patients with CKD and ESRD" in our hospital. The aim of this study was to compare the incidence of denosumab-associated hypocalcemia among patients with advanced CKD and ESRD before and after the integrated care program. We retrospectively reviewed the records of patients on their first dose of denosumab treatment from January 2012 to December 2021. A total of 3208 patients were included in our study. Among the 3208 patients, there were 101 dialysis patients, 150 patients with advanced CKD (stage 4 and 5), and 2957 patients with an estimated glomerular filtration rate (eGFR) higher than or equal to 30. The incidence of post-treatment severe hypocalcemia (corrected calcium level less than 7.0 mg/dl) within 30 days was significantly higher in the dialysis and advanced CKD group than in patients with an eGFR higher than or equal to 30 (6.9% vs. 2.0% vs. 0.1%, respectively, p < 0.001). Based on the results of the multivariate regression model, poor renal function (p < 0.05) and lower baseline corrected calcium level (p < 0.05) were associated with severe hypocalcemia within 30 days following the first dose of denosumab treatment. The incidence of post-treatment severe hypocalcemia within 30 days in advanced CKD and dialysis patients was significantly lower after the integrated care program (6.8% vs. 0.8%, p < 0.05). Our study shows that multidisciplinary integrated care may reduce the incidence rate of denosumab-associated severe hypocalcemia among patients with advanced CKD and ESRD. [ABSTRACT FROM AUTHOR]

BackgroundNutritional and inflammation status are significant predictors of morbidity and mortality risk in advanced chronic kidney disease (ACKD). To date, there are a limited number of clinical studies on the influence of nutritional status in ACKD stages 4–5 on the choice of renal replacement therapy (RRT) modality.AimThis study aimed to examine relationships between comorbidity and nutritional and inflammatory status and the decision-making on the choice of RRT modalities in adults with ACKD.MethodsA retrospective cross-sectional study was conducted on 211 patients with ACKD with stages 4–5 from 2016 to 2021. Comorbidity was assessed using the Charlson comorbidity index (CCI) according to severity (CCI: ≤ 3 and >3 points). Clinical and nutritional assessment was carried out by prognosis nutritional index (PNI), laboratory parameters [serum s-albumin, s-prealbumin, and C-reactive protein (s-CRP)], and anthropometric measurements. The initial decision-making of the different RRT modalities [(in-center, home-based hemodialysis (HD), and peritoneal dialysis (PD)] as well as the informed therapeutic options (conservative treatment of CKD or pre-dialysis living donor transplantation) were recorded. The sample was classified according to gender, time on follow-up in the ACKD unit (≤ 6 and >6 months), and the initial decision-making of RRT (in-center and home-RRT). Univariate and multivariate regression analyses were carried out for evaluating the independent predictors of home-based RRT.ResultsOf the 211 patients with ACKD, 47.4% (n = 100) were in stage 5 CKD, mainly elderly men (65.4%). DM was the main etiology of CKD (22.7%) together with hypertension (96.6%) as a CV risk factor. Higher CCI scores were significantly found in men, and severe comorbidity with a CCI score > 3 points was 99.1%. The mean time of follow-up time in the ACKD unit was 9.6 ± 12.8 months. A significantly higher CCI was found in those patients with a follow-up time > 6 months, as well as higher mean values of eGFR, s-albumin, s-prealbumin, s-transferrin, and hemoglobin, and lower s-CRP than those with a follow-up 3.8 g/dl was found in 71.1% (n = 150), and values of s-CRP ≤ 1 mg/dl were 82.9% (n = 175). PEW prevalence was 15.2%. The initial choice of RRT modality was higher in in-center HD (n = 119 patients; 56.4%) than in home-based RRT (n = 81; 40.5%). Patients who chose home-based RRT had significantly lower CCI scores and higher mean values of s-albumin, s-prealbumin, s-transferrin, hemoglobin, and eGFR and lower s-CRP than those who chose in-center RRT (p 6 months (OR: 0.440) were significantly associated with the likelihood of decision-making to choose a home-based RRT modality (all, at least p

Functional capacity of chronic kidney disease (CKD) patients is compromised by their nutrition-inflammation status. We evaluated the functional capacity of advanced chronic kidney disease (ACKD) patients and the influence of the nutrition-inflammation status. In a cross-sectional study, which included ACKD patients from the nephrology department of the Hospital Universitario de la Princesa in Madrid, Spain, we assessed: functional capacity with the Short Physical Performance Battery (SPPB) test, interpreting a result <7 in the test as low functionality; body composition with monofrequency bioimpedance; muscular strength with hand grip strength; nutritional and inflammatory status using biochemical parameters and the Malnutrition Inflammation Scale (MIS). A total of 255 patients with ACKD were evaluated, 65.8% were men, their mean age was 70.65 ± 11.97 years and 70.2% of the patients had an age >65 years. The mean score of SPPB was 8.50 ± 2.81 and 76.4% of the patients presented a score ≥7, with a higher percentage in the group of men. The percentage of patients with limitations increased with age. The patients with SPPB values higher than 7 showed high values of albumin and low soluble C-reactive protein (s-CRP) and MIS. We found better functionality in well-nourished patients. A multivariate logistic regression model established an association of high albumin values with a better functional capacity (OR: 0.245 CI: 0.084–0.714 p < 0.010), while another model showed an association between CRP values and decreased functionality (OR: 1.267 CI: 1.007–1.594 p = 0.044). Conclusion: nutritional status and body composition influence on the functional capacity of patients with ACKD. [ABSTRACT FROM AUTHOR]

Nutritional status is a predictor of adverse outcomes and mortality in patients with advanced chronic kidney disease (ACKD). This study aimed to explore and evaluate risk factors related to nutritional status, body composition, and inflammatory profile in patients with ACKD compared with age- and sex-matched controls in a Mediterranean cohort of the Spanish population. Out of 200 volunteers recruited, 150 participants (64%) were included, and a case-control study was conducted on 75 ACKD patients (stages 4–5), matched individually with controls at a ratio of 1:1 for both age and sex. At enrolment, demographic, clinical, anthropometric, and laboratory parameters were measured. Bioimpedance analysis (BIA) was used to assess both body composition and hydration status. ACKD patients had lower body cell mass (BCM%), muscle mass (MM%) phase angle (PA), s-albumin, and higher C-reactive protein (s-CRP) than controls (at least, p < 0.05). PA correlated positively with BCM% (cases: r = 0.84; controls: r = 0.53, p < 0.001), MM% (cases: r = 0.65; controls: r = 0.31, p < 0.001), and inversely with s-CRP (cases: r = −0.30, p < 0.001; controls: r = −0.31, p = 0.40). By univariate and multivariate conditional regression analysis, total body water (OR: 1.186), extracellular mass (OR: 1.346), s-CRP (OR: 2.050), MM% (OR: 0.847), PA (OR: 0.058), and s-albumin (OR: 0.475) were significantly associated among cases to controls. Nutritional parameters and BIA-derived measures appear as prognostic entities in patients with stage 4–5 ACKD compared to matched controls in this Mediterranean cohort. [ABSTRACT FROM AUTHOR]

Objective: Hyperuricemia is a risk factor for cardiovascular disease complications in patients with chronic kidney disease. The impact of febuxostat on cardiovascular disease in advanced chronic kidney disease remains unclear. This study aimed to explore the cardiovascular benefits of xanthine oxidase inhibitors, particularly febuxostat and allopurinol, in patients with advanced chronic kidney disease., Methods: A retrospective population-based cohort study was conducted using data from Taiwan's National Health Insurance Research Database (NHIRD) (2012-2020). The TriNetX dataset served as an external validation dataset. The study involved 13,187 patients with advanced chronic kidney disease treated with febuxostat or allopurinol. After propensity score matching, a balanced cohort of 976 patients (488 in each arm) was created. Hazard ratios (HRs) were calculated for all-cause mortality and hospitalizations, utilizing the competing risk regression model., Results: Febuxostat was associated with lower all-cause mortality (HR, 0.79; 95% confidence interval [CI], 0.64-0.98) and fewer hospitalizations (HR, 0.53; 95% CI, 0.44-0.63) than allopurinol. After adjustments, febuxostat also reduced hospitalizations for heart failure (HR, 0.59; 95% CI, 0.43-0.80) and infection (HR, 0.65; 95% CI, 0.52-0.82). This cardiovascular benefit of febuxostat was consistently observed in the TriNetX dataset. Moreover, subgroup analysis revealed that febuxostat was better in reducing death and heart failure events than allopurinol across most of the subgroups., Conclusions: Febuxostat may confer cardioprotective effects in patients with advanced chronic kidney disease compared with allopurinol, thereby making it potentially useful in reducing cardiovascular risks in this high-risk population., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Copyright of Nefrologia is the property of Revista Nefrologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

In patients with advanced (estimated glomerular filtration rate

Background: The characteristics of patients with advanced chronic kidney disease (CKD) who are recipients of public assistance in Japan, and the adequacy of their medical care have not been reported previously.The records of patients with CKD stage G5 who visited nine facilities in Japan from April to June 2013 were retrospectively reviewed to compare the characteristics and care of recipients of public assistance with those of non-recipients. Receiving a presentation of kidney replacement therapy (KRT) options and polypharmacy were used as indicators of suboptimal medical care.Of the 592 patients included in this analysis (mean age, 69.6 years; male, 59.3%), 56 (9.5%) were recipients of public assistance and 536 (90.5%) were non-recipients of public assistance. The prevalence of diabetes mellitus, unmarried status, and living alone were higher in recipients of public assistance. In multivariable logistic regression analysis, compared with non-recipients of public assistance, recipients of public assistance were less likely to receive a presentation of KRT options (adjusted odds ratio [aOR], 0.31; 95% confidence interval [CI], 0.17–0.56), and were more likely to receive ≥ 10 (aOR, 1.92; 95% CI, 1.05–3.51), and ≥ 15 (aOR, 2.78; 95% CI, 1.23–6.26) types of medication.Patients with advanced CKD receiving public assistance were less likely to receive a presentation of KRT options and more likely to receive ≥ 10 and ≥ 15 types of medication, suggesting that recipients of public assistance are more likely to receive suboptimal medical care.Methods: The characteristics of patients with advanced chronic kidney disease (CKD) who are recipients of public assistance in Japan, and the adequacy of their medical care have not been reported previously.The records of patients with CKD stage G5 who visited nine facilities in Japan from April to June 2013 were retrospectively reviewed to compare the characteristics and care of recipients of public assistance with those of non-recipients. Receiving a presentation of kidney replacement therapy (KRT) options and polypharmacy were used as indicators of suboptimal medical care.Of the 592 patients included in this analysis (mean age, 69.6 years; male, 59.3%), 56 (9.5%) were recipients of public assistance and 536 (90.5%) were non-recipients of public assistance. The prevalence of diabetes mellitus, unmarried status, and living alone were higher in recipients of public assistance. In multivariable logistic regression analysis, compared with non-recipients of public assistance, recipients of public assistance were less likely to receive a presentation of KRT options (adjusted odds ratio [aOR], 0.31; 95% confidence interval [CI], 0.17–0.56), and were more likely to receive ≥ 10 (aOR, 1.92; 95% CI, 1.05–3.51), and ≥ 15 (aOR, 2.78; 95% CI, 1.23–6.26) types of medication.Patients with advanced CKD receiving public assistance were less likely to receive a presentation of KRT options and more likely to receive ≥ 10 and ≥ 15 types of medication, suggesting that recipients of public assistance are more likely to receive suboptimal medical care.Results: The characteristics of patients with advanced chronic kidney disease (CKD) who are recipients of public assistance in Japan, and the adequacy of their medical care have not been reported previously.The records of patients with CKD stage G5 who visited nine facilities in Japan from April to June 2013 were retrospectively reviewed to compare the characteristics and care of recipients of public assistance with those of non-recipients. Receiving a presentation of kidney replacement therapy (KRT) options and polypharmacy were used as indicators of suboptimal medical care.Of the 592 patients included in this analysis (mean age, 69.6 years; male, 59.3%), 56 (9.5%) were recipients of public assistance and 536 (90.5%) were non-recipients of public assistance. The prevalence of diabetes mellitus, unmarried status, and living alone were higher in recipients of public assistance. In multivariable logistic regression analysis, compared with non-recipients of public assistance, recipients of public assistance were less likely to receive a presentation of KRT options (adjusted odds ratio [aOR], 0.31; 95% confidence interval [CI], 0.17–0.56), and were more likely to receive ≥ 10 (aOR, 1.92; 95% CI, 1.05–3.51), and ≥ 15 (aOR, 2.78; 95% CI, 1.23–6.26) types of medication.Patients with advanced CKD receiving public assistance were less likely to receive a presentation of KRT options and more likely to receive ≥ 10 and ≥ 15 types of medication, suggesting that recipients of public assistance are more likely to receive suboptimal medical care.Conclusions: The characteristics of patients with advanced chronic kidney disease (CKD) who are recipients of public assistance in Japan, and the adequacy of their medical care have not been reported previously.The records of patients with CKD stage G5 who visited nine facilities in Japan from April to June 2013 were retrospectively reviewed to compare the characteristics and care of recipients of public assistance with those of non-recipients. Receiving a presentation of kidney replacement therapy (KRT) options and polypharmacy were used as indicators of suboptimal medical care.Of the 592 patients included in this analysis (mean age, 69.6 years; male, 59.3%), 56 (9.5%) were recipients of public assistance and 536 (90.5%) were non-recipients of public assistance. The prevalence of diabetes mellitus, unmarried status, and living alone were higher in recipients of public assistance. In multivariable logistic regression analysis, compared with non-recipients of public assistance, recipients of public assistance were less likely to receive a presentation of KRT options (adjusted odds ratio [aOR], 0.31; 95% confidence interval [CI], 0.17–0.56), and were more likely to receive ≥ 10 (aOR, 1.92; 95% CI, 1.05–3.51), and ≥ 15 (aOR, 2.78; 95% CI, 1.23–6.26) types of medication.Patients with advanced CKD receiving public assistance were less likely to receive a presentation of KRT options and more likely to receive ≥ 10 and ≥ 15 types of medication, suggesting that recipients of public assistance are more likely to receive suboptimal medical care. [ABSTRACT FROM AUTHOR]

Data on disparities in outcomes and risk factors in Asian patients with advanced chronic kidney disease admitted for heart failure are scare. This was a retrospective cohort study that utilized data from the National Inpatient Sample between January 2016 and December 2019. Patients who had a primary diagnosis of acute decompensated heart failure and a concomitant diagnosis of advanced CKD were included. The primary outcome of interest was in-hospital mortality. Secondary outcomes include hospital cost, length of stay, and other clinical outcomes. Weighted multivariable logistic regression was used to adjust for comorbidities. There were 251,578 cases of ADHF with advanced CKD, out of which 2.6 % were from individuals of Asian ethnicity. Asian patients exhibited a higher burden of comorbidities in comparison to other UREM patients, but a lower burden than White patients. Regardless of differences in comorbidity burden, Asian patients exhibited a higher likelihood of experiencing severe consequences. After adjusting for comorbidies, White (OR:1.11; 95 % CI 1.03-1.20;0.009) patients had higher odds of mortality than Asian patients. However, Blacks (OR: 0.58; 95 % CI 0.53 to 0.63; p < 0.001) and Hispanics (OR: 0.69; 95 % CI 0.62 to 0.78; p < 0.001) had lower odds of mortality. This first population-based studies shows that Asian patients with advanced CKD admitted for ADHF have greater comorbidity burden and poorer outcomes Black and Hispanic patients. This data underscores the importance of comprehensive approaches in phenotyping, and ethnic specific interventions. Central Illustration. Racial Disparities in Clinical Comorbidities of Patients with Heart Failure and Advanced Chronic Kidney Disease Asian patients had higher ischemic cardiovascular comorbidities and age than UREM patients but lower than White patients [Display omitted]. [ABSTRACT FROM AUTHOR]

Despite the high prevalence of chronic kidney disease (CKD) and its high cardiovascular risk, patients with CKD, especially those with advanced CKD (stages 4–5 and patients on kidney replacement therapy), are excluded from most cardiovascular clinical trials. It is particularly relevant in patients with advanced CKD and heart failure (HF) who have been underrepresented in many pivotal randomized trials that have modified the management of HF. For this reason, there is little or no direct evidence for HF therapies in patients with advanced CKD and treatment is extrapolated from patients without CKD or patients with earlier CKD stages. The major consequence of the lack of direct evidence is the under-prescription of HF drugs to this patient population. As patients with advanced CKD and HF represent probably the highest cardiovascular risk population, the exclusion of these patients from HF trials is a serious deontological fault that must be solved. There is an urgent need to generate evidence on how to treat HF in patients with advanced CKD. This article briefly reviews the management challenges posed by HF in patients with CKD and proposes a road map to address them. [ABSTRACT FROM AUTHOR]

Objective: This study aimed at determining the feasibility of conducting a large-scale pragmatic effectiveness study on the implementation of multidisciplinary care (MDC) program for patients with advanced chronic kidney disease (CKD). Methods: This is a single-arm pre-post intervention design pilot study over 12 months. Participants with an estimated glomerular filtration rate (eGFR) between 11 and 20 ml/min/1.73m2 were screened and recruited at the initial MDC clinic visit and followed for 12 months. Clinical parameters, KDQOL™-36, questionnaires, and interviews were collected, administered, and analysed for enrolment and completion rates, baseline characteristics, implementation fidelity, adherence to CKD interventions, eGFR decline, CKD complications, health-related quality of life, and participants' acceptability of the program. Results: The study enrolment and completion rates were 43.1% (50/116 screened) and 66.0% (33/50 recruited) respectively. The participants had a mean age of 68.5 years (SD9.0) and a mean eGFR of 15.4 ml/min/1.73m2(3.2). After 12 months of MDC program, there was increased adherence to CKD interventions (difference − 0.6(1.0), 95%CI − 1.1, − 0.1, p = 0.02). There was good participants' acceptability of the program with participants being more satisfied with the waiting time and having a better understanding of kidney failure after attending the program. No difference in the eGFR decline noted (difference 0.0 ml/min/1.73m2(5.3), 95%CI − 1.9, 1.9, p = 1.00). Conclusion: Our pilot data suggest increased adherence to CKD interventions and good acceptability to MDC program, albeit no difference in eGFR decline probably because of the small sample size. However, reasons for overall low enrolment and completion rates need to be explored and addressed while designing a future large-scale randomised controlled trial. [ABSTRACT FROM AUTHOR]

Introduction: Advanced chronic kidney disease (CKD) is common among patients with coronary artery disease (CAD), and angiotensin‑converting enzyme inhibitors (ACEI) or angiotensin‑receptor blockers (ARB) can improve cardiac and renal function, but whether ACEI/ARB therapy improves long-term prognosis remains unclear among these high-risk patients. Therefore, this research aimed to investigate the relationship between ACEI/ARB therapy and long-term prognosis among CAD patients with advanced CKD., Methods: CAD patients with advanced CKD were included in five hospitals. Advanced CKD was defined as estimated glomerular filtration rate (eGFR)<30 ml/min per 1.73 m 2 . Cox regression models and competing risk Fine and Gray models were used to examine the relationship between ACEI/ARB therapy and all-cause and cardiovascular death, respectively., Results: Of 2527 patients, 47.6% population of our cohort was discharged on ACEI/ARB. The overall all-cause and cardiovascular mortality were 38.6% and 24.7%, respectively. Multivariate Cox regression analyses indicated that ACEI/ARB therapy was found to be associated with lower rates of both all-cause mortality (hazard ratio (HR)=0.836, 95% confidence interval (CI): 0.738-0.948, p  = 0.005) and cardiovascular mortality (HR = 0.817, 95%CI: 0.699-0.956, p  = 0.011). In the propensity-matched cohort, the survival benefit was consistent, and significantly better survival was observed for all-cause mortality (HR = 0.856, 95%CI: 0.752-0.974, p  = 0.019) and cardiovascular mortality (HR = 0.830, 95%CI: 0.707-0.974, p  = 0.023) among patients treated with ACEI/ARB., Conclusion: ACEI/ARB therapy showed a better survival benefit among high-risk CAD patients with advanced CKD at long-term follow-up, which manifested that strategies to maintain ACEI/ARB treatment may improve clinical outcomes among these high-risk populations.

BackgroundMedication nonadherence is a known risk factor for adverse outcomes in the general population. However, little is known about the association of predialysis medication adherence among patients with advanced chronic kidney disease and mortality following their transition to dialysis.Study designObservational study.Setting & participants32,348 US veterans who transitioned to dialysis during 2007 to 2011.PredictorsAdherence to treatment with cardiovascular drugs, ascertained from pharmacy database records using proportion of days covered (PDC) and persistence during the predialysis year.OutcomesPost-dialysis therapy initiation all-cause and cardiovascular mortality, using Cox models with adjustment for confounders.ResultsMean age of the cohort was 72±11 (SD) years; 96% were men, 74% were white, 23% were African American, and 69% had diabetes. During a median follow-up of 23 (IQR, 9-36) months, 18,608 patients died. Among patients with PDC>80%, there were 14,006 deaths (mortality rate, 283 [95% CI, 278-288]/1,000 patient-years]); among patients with PDC>60% to 80%, there were 3,882 deaths (mortality rate, 294 [95% CI, 285-304]/1,000 patient-years); among patients with PDC≤60%, there were 720 deaths (mortality rate, 291 [95% CI, 271-313]/1,000 patient-years). Compared with patients with PDC>80%, the adjusted HR for post-dialysis therapy initiation all-cause mortality for patients with PDC>60% to 80% was 1.12 (95% CI, 1.08-1.16), and for patients with PDC≤60% was 1.21 (95% CI, 1.11-1.30). In addition, compared with patients showing medication persistence, adjusted HR risk for post-dialysis therapy initiation all-cause mortality for patients with nonpersistence was 1.11 (95% CI, 1.05-1.16). A similar trend was detected for cardiovascular mortality and in subgroup analyses.LimitationsLarge number of missing values; results may not be generalizable to women or the general US population.ConclusionsPredialysis cardiovascular medication nonadherence is an independent risk factor for postdialysis mortality in patients with advanced chronic kidney disease transitioning to dialysis therapy. Further studies are needed to assess whether interventions targeting adherence improve survival after dialysis therapy initiation.

Advanced chronic kidney disease is a serious and common medical condition with significant treatment choices incurring varying high treatment burdens. Better understanding on how to best collect quality of life (QoL) in this unique situation may help guide critical decisions. This study investigates the acceptability of digital QoL questionnaires completed during routine haemodialysis sessions. Qualitative data was collected from patient (n=23) and clinical researcher (n=2) interviews alongside analysis of data from questionnaires completed by patients (n=101) during a 6-week validation study. Interviews refined the content and format of digital QoL questionnaires and provided novel insights regarding how patients assessed and completed QoL questions. This study suggests collecting QoL data using digital tablet technology during routine haemodialysis clinics is both feasible and acceptable to patients and has provided novel insights that are not routinely available with traditional methods. [ABSTRACT FROM AUTHOR]

Resumen: Antecedentes y objetivo: Recientemente, se han desarrollado en España las Unidades de Enfermedad Renal Crónica Avanzada (UERCA) con el objetivo de ofrecer una mayor calidad de vida a los pacientes con ERCA, mejorar su supervivencia y disminuir la morbilidad en esta fase de la enfermedad. Al día de hoy, hay poca evidencia en la literatura española e internacional con respecto a la estructura y cómo conseguir estos objetivos en las UERCA. Desde el grupo de trabajo ERCA de la Sociedad Española de Nefrología (SEN) se impulsa este proyecto para mejorar la atención a los pacientes ERCA a través de la definición de estándares de calidad para el funcionamiento de las UERCA. Material y métodos: Se conformó una propuesta inicial de estándares de calidad sobre el funcionamiento de las UERCA a través de la consulta de principales fuentes de referencias y el asesoramiento de un grupo de trabajo de expertos a través de reuniones presenciales y no presenciales. A partir de esta propuesta inicial de estándares, se diseñó y envío una encuesta vía correo electrónico a 121 especialistas de nefrología y profesionales de enfermería con experiencia en UERCA españolas para conocer entre otros, la idoneidad de cada estándar, es decir, su obligatoriedad o recomendación como estándar. Se permitió acceso a la encuesta entre el 16 de julio de 2018, hasta el 26 de septiembre de 2018. Resultados: Participaron un total de 95 (78,5%) profesionales de los 121 que fueron invitados a participar. De éstos, 80 fueron especialistas en nefrología y 15 profesionales de enfermería, obteniéndose una variada representación de profesionales de la geografía española. Tras analizar las opiniones de estos participantes, los estándares quedaron definidos a un total de 68, 37 de ellos (54,4%) obligatorios y 31 de ellos (45,5%) recomendables. Además, se observó que el volumen de pacientes atendidos en las UERCA se sitúa usualmente por encima de los 100 pacientes, y que el criterio de derivación por regla general está por debajo de 25-29 mL/min/1,73 m2 de filtración glomerular. Conclusiones: Este trabajo constituye una primera propuesta de estándares de calidad para el funcionamiento de una UERCA en España. La definición de estos estándares ha permitido establecer las bases para la estandarización de la organización de las UERCA, y trabajar posteriormente en la configuración de un manual de estándares para la acreditación de estas Unidades. Abstract: Background and objective: Recently, the Advanced Chronic Kidney Disease Units (UERCA, in Spanish) have been developed in Spain to offer a better quality of life to patients with advanced chronic kidney disease (ACKD), improving their survival and reducing morbidity in this phase of the disease. Nowadays, there is not much evidence in the Spanish and international literature regarding the structure and how to achieve these objectives in the UERCA. From the ERCA working group of the Spanish Society of Nephrology (SEN), this project is promoted to improve care for ERCA patients through the definition of quality standards for the operation of the UERCA. Material and methods: An initial proposal for quality standards concerning the operation of the UERCA was configured through consultation with the main sources of references and the advice of an expert working group through face-to-face and telematic meetings. Base on this initial proposal of standards, a survey was conducted and sent it via email to 121 nephrology specialist and nursing professionals with experience in Spanish UERCA to find out, among others, the suitability of each standards, that is, its mandatory nature or recommendation as standards. The access to the survey was allowed between July 16th, 2018, until September 26th, 2018. Results: A total of 95 (78.5%) professionals participated out of the 121 who were invited to participate. Of these, 80 of the participants were nephrology specialists and 15 nursing professionals, obtaining a varied representation of professionals from the Spanish geography. After analyzing the opinions of these participants, the standards were defined to a total of 68, 37 of them (54.4%) mandatory and 31 of them (45.5%) recommended. Besides, it was observed that the volume of patients attended in the UERCA is usually above 100 patients, and the referral criteria is generally below 25-29 mL/min/1.73 m2 of glomerular filtration. Conclusions: This work constitutes a first proposal of quality standards for the operation of UERCA in Spain. The definition of these standards has made it possible to establish the bases for the standardization of the organization of UERCA, and to subsequently work on the configuration of a standards manual for the accreditation of ERCA Units.

Introduction: The influence of socioeconomic and cultural barriers in the choice of renal replacement therapy (RRT) techniques in advanced chronic kidney disease (ACKD) has been scarcely explored, which can generate problems of inequity, frequently unnoticed in health care. The aim of this study is to identify the "non-medical" barriers that influence the choice of RRT in an advanced chronic kidney disease (ACKD) consultation in Spain., Material and Methods: Retrospective analysis including the total number of patients seen in the ACKD consultation in a tertiary hospital from 2009 to 2020. Inclusion in the ACKD consultation began with an eligibility test and a decision-making process, conducted by a specifically trained nurse. The variables considered for the study were: age, sex, etiology of CKD, level of dependence for basic activities of daily living (Barthel Scale) and instrumental activities of daily living (Lawton and Brody Scale), Spanish versus foreign nationality, socioeconomic level and language barrier. The socioeconomic level was extrapolated according to home and health district by primary care center to which the patients belonged., Results: A total of 673 persons were seen in the ACKD consultation during the study period, of whom 400 (59.4%) opted for hemodialysis (HD), 156 (23.1%) for peritoneal dialysis (PD), 4 (0.5%) for early living donor renal transplantation (LDRT) and 113 (16.7%) chose conservative care (CC). The choice of PD as the chosen RRT technique (vs. HD) was associated with people with a high socioeconomic level (38.7% vs. 22.5%) (p = 0.002), Spanish nationality (91% vs. 77.7%) (p < 0.001), to a lower language barrier (0.6% vs 10.5%) (p < 0.001), and to a higher score on the Barthel scale (97.4 vs 92.9) and on the Lawton and Brody scale (7 vs 6.1) (p < 0.001). Neither age nor sex showed significant differences in the choice of both techniques. Patients who opted for CC were significantly older (81.1 vs 67.7 years; p < 0.001), more dependent (p < 0.001), with a higher proportion of women (49.6% vs 35.2%; p = 0.006) and a higher proportion of Spaniards (94.7% vs 81%, p = 0.001) in relation to the choice of other techniques (PD and HD). Socioeconomic level did not influence the choice of CC., Conclusion: Despite a regulated decision-making process, there are factors such as socioeconomic status, migration, language barrier and dependency of the population that influence the type of RRT chosen. To address these aspects that may cause inequity, an intersectoral and multilevel intervention is required with interdisciplinary teams that include, among others, social workers, to provide a more holistic and person-centered assessment., (Copyright © 2023 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

Patients with heart failure (HF) and advanced chronic kidney disease (CKD) constitute a special population that experience poor outcomes due to poor adherence to established therapies because of potential safety concerns. Role of newer agents like angiotensin–receptor neprilysin inhibitors (ARNI) in early stages of CKD is well elucidated. We report two cases of HF with reduced ejection fraction, who received ARNI in advanced stage of CKD (stage 5) and achieved remarkable outcomes in terms of quality of life and longevity. [ABSTRACT FROM AUTHOR]

Introduction: Despite the high prevalence of advanced chronic kidney disease for elderly, survival and symptom burden are uncertain for patients commencing renal replacement therapy versus patients managed with supportive care without dialysis (RSC-NFD). We examined these outcomes in both treatment modalities. Methods: Prospective cohort study of RSCNFD and renal replacement therapy patients older than 75-years-old. A survival analysis and Symptoms were measured using POS-S Renal Scale in a multidisciplinary RSC-NFD clinic and in renal replacement therapy units. Results: 82 RSC-NFD patients and 37 renal replacement therapy patients were included in the study. RSC-NFD patients presented significant comorbidity (Charlson) and worse functional situation (Karnofsky). Median survival in the RSC-NFD treatment was 26.9 months (95%CI 19.6-34.2) vs mean 30.5 months (95% CI 27.46-33.67) in renal replacement therapy group (p 0.014 in favour of dialysis). Both treatments presented a wide variety of symptoms, being weakness the most prevalent and intense in both groups (97% renal replacement therapy and 98% RSC-NFD). The evaluation at 0,12 and 24 months showed that the number and intensity of symptoms remained stable in both therapies and there were no clinical differences. Conclusions: Dialysis is associated with a survival advantage from RSC-NFD. However, the perceived symptoms in advanced chronic kidney disease are highly prevalent and we didn't appreciate differences comparing both treatments. Routine symptom assessment by a multidisciplinary team can be useful in clinical practice of patients in renal replacement therapy and RSC-NFD. [ABSTRACT FROM AUTHOR]

Objective: To determine the prevalence and severity of symptoms of patients with Chronic Kidney Disease Stage 5 managed conservately, and their association with the comorbidities and functional status. Methods: A cross-sectional, descriptive, and correlational design was used. Symptom data were collected using the Spanish modified version of Palliative care Outcome Scale-Symptoms Renal. Comorbidity was collected and scored according to the modified Charlson Comorbidity Index. For the evaluation of functional status, the Barthel index was used. Results: 60 patients were included in this study. More than 50% of patients described weakness, pain, difficulty for sleeping, poor appetite and mouth problems. Diabetes, coronary artery disease, and peripheral vascular disease, and tumor, were the main comorbid conditions of these patients. The mean score of Barthel index was 88±14.2. There was no significant correlation between comorbidities and symptoms (p=0.43). There was a significant correlation between symptoms and functional decline (p=0.001). Conclusions: Patients with Chronic Kidney Disease Stage 5 experience a high level of symptom burden. Weakness was the most prevalent symptom in this sample population. Symptom burden correlated with functional decline. Further longitudinal studies are needed that analyse the impact of symptoms and their management in this population. [ABSTRACT FROM AUTHOR]