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Publisher: Elsevier   (Total: 3184 journals)

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Showing 1 - 200 of 3184 Journals sorted alphabetically
Academic Pediatrics     Hybrid Journal   (Followers: 37, SJR: 1.655, CiteScore: 2)
Academic Radiology     Hybrid Journal   (Followers: 26, SJR: 1.015, CiteScore: 2)
Accident Analysis & Prevention     Partially Free   (Followers: 100, SJR: 1.462, CiteScore: 3)
Accounting Forum     Hybrid Journal   (Followers: 28, SJR: 0.932, CiteScore: 2)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 40, SJR: 1.771, CiteScore: 3)
Achievements in the Life Sciences     Open Access   (Followers: 6)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 7)
Acta Astronautica     Hybrid Journal   (Followers: 434, SJR: 0.758, CiteScore: 2)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 2)
Acta Biomaterialia     Hybrid Journal   (Followers: 28, SJR: 1.967, CiteScore: 7)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription   (Followers: 3)
Acta de Investigación Psicológica     Open Access   (Followers: 3)
Acta Ecologica Sinica     Open Access   (Followers: 11, SJR: 0.18, CiteScore: 1)
Acta Histochemica     Hybrid Journal   (Followers: 3, SJR: 0.661, CiteScore: 2)
Acta Materialia     Hybrid Journal   (Followers: 308, SJR: 3.263, CiteScore: 6)
Acta Mathematica Scientia     Full-text available via subscription   (Followers: 5, SJR: 0.504, CiteScore: 1)
Acta Mechanica Solida Sinica     Full-text available via subscription   (Followers: 9, SJR: 0.542, CiteScore: 1)
Acta Oecologica     Hybrid Journal   (Followers: 12, SJR: 0.834, CiteScore: 2)
Acta Otorrinolaringologica (English Edition)     Full-text available via subscription  
Acta Otorrinolaringológica Española     Full-text available via subscription   (Followers: 2, SJR: 0.307, CiteScore: 0)
Acta Pharmaceutica Sinica B     Open Access   (Followers: 1, SJR: 1.793, CiteScore: 6)
Acta Poética     Open Access   (Followers: 4, SJR: 0.101, CiteScore: 0)
Acta Psychologica     Hybrid Journal   (Followers: 25, SJR: 1.331, CiteScore: 2)
Acta Sociológica     Open Access   (Followers: 1)
Acta Tropica     Hybrid Journal   (Followers: 6, SJR: 1.052, CiteScore: 2)
Acta Urológica Portuguesa     Open Access  
Actas Dermo-Sifiliograficas     Full-text available via subscription   (Followers: 3, SJR: 0.374, CiteScore: 1)
Actas Dermo-Sifiliográficas (English Edition)     Full-text available via subscription   (Followers: 2)
Actas Urológicas Españolas     Full-text available via subscription   (Followers: 3, SJR: 0.344, CiteScore: 1)
Actas Urológicas Españolas (English Edition)     Full-text available via subscription   (Followers: 1)
Actualites Pharmaceutiques     Full-text available via subscription   (Followers: 7, SJR: 0.19, CiteScore: 0)
Actualites Pharmaceutiques Hospitalieres     Full-text available via subscription   (Followers: 3)
Acupuncture and Related Therapies     Hybrid Journal   (Followers: 8)
Acute Pain     Full-text available via subscription   (Followers: 15, SJR: 2.671, CiteScore: 5)
Ad Hoc Networks     Hybrid Journal   (Followers: 11, SJR: 0.53, CiteScore: 4)
Addictive Behaviors     Hybrid Journal   (Followers: 18, SJR: 1.29, CiteScore: 3)
Addictive Behaviors Reports     Open Access   (Followers: 9, SJR: 0.755, CiteScore: 2)
Additive Manufacturing     Hybrid Journal   (Followers: 11, SJR: 2.611, CiteScore: 8)
Additives for Polymers     Full-text available via subscription   (Followers: 23)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 184, SJR: 4.09, CiteScore: 13)
Advanced Engineering Informatics     Hybrid Journal   (Followers: 12, SJR: 1.167, CiteScore: 4)
Advanced Powder Technology     Hybrid Journal   (Followers: 17, SJR: 0.694, CiteScore: 3)
Advances in Accounting     Hybrid Journal   (Followers: 9, SJR: 0.277, CiteScore: 1)
Advances in Agronomy     Full-text available via subscription   (Followers: 17, SJR: 2.384, CiteScore: 5)
Advances in Anesthesia     Full-text available via subscription   (Followers: 29, SJR: 0.126, CiteScore: 0)
Advances in Antiviral Drug Design     Full-text available via subscription   (Followers: 2)
Advances in Applied Mathematics     Full-text available via subscription   (Followers: 11, SJR: 0.992, CiteScore: 1)
Advances in Applied Mechanics     Full-text available via subscription   (Followers: 11, SJR: 1.551, CiteScore: 4)
Advances in Applied Microbiology     Full-text available via subscription   (Followers: 24, SJR: 2.089, CiteScore: 5)
Advances In Atomic, Molecular, and Optical Physics     Full-text available via subscription   (Followers: 15, SJR: 0.572, CiteScore: 2)
Advances in Biological Regulation     Hybrid Journal   (Followers: 4, SJR: 2.61, CiteScore: 7)
Advances in Botanical Research     Full-text available via subscription   (Followers: 2, SJR: 0.686, CiteScore: 2)
Advances in Cancer Research     Full-text available via subscription   (Followers: 33, SJR: 3.043, CiteScore: 6)
Advances in Carbohydrate Chemistry and Biochemistry     Full-text available via subscription   (Followers: 9, SJR: 1.453, CiteScore: 2)
Advances in Catalysis     Full-text available via subscription   (Followers: 5, SJR: 1.992, CiteScore: 5)
Advances in Cell Aging and Gerontology     Full-text available via subscription   (Followers: 5)
Advances in Cellular and Molecular Biology of Membranes and Organelles     Full-text available via subscription   (Followers: 14)
Advances in Chemical Engineering     Full-text available via subscription   (Followers: 29, SJR: 0.156, CiteScore: 1)
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 10, SJR: 0.713, CiteScore: 1)
Advances in Chronic Kidney Disease     Full-text available via subscription   (Followers: 10, SJR: 1.316, CiteScore: 2)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 26, SJR: 1.562, CiteScore: 3)
Advances in Colloid and Interface Science     Full-text available via subscription   (Followers: 20, SJR: 1.977, CiteScore: 8)
Advances in Computers     Full-text available via subscription   (Followers: 14, SJR: 0.205, CiteScore: 1)
Advances in Dermatology     Full-text available via subscription   (Followers: 15)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 13)
Advances in Digestive Medicine     Open Access   (Followers: 12)
Advances in DNA Sequence-Specific Agents     Full-text available via subscription   (Followers: 7)
Advances in Drug Research     Full-text available via subscription   (Followers: 26)
Advances in Ecological Research     Full-text available via subscription   (Followers: 44, SJR: 2.524, CiteScore: 4)
Advances in Engineering Software     Hybrid Journal   (Followers: 29, SJR: 1.159, CiteScore: 4)
Advances in Experimental Biology     Full-text available via subscription   (Followers: 8)
Advances in Experimental Social Psychology     Full-text available via subscription   (Followers: 51, SJR: 5.39, CiteScore: 8)
Advances in Exploration Geophysics     Full-text available via subscription   (Followers: 1)
Advances in Fluorine Science     Full-text available via subscription   (Followers: 9)
Advances in Food and Nutrition Research     Full-text available via subscription   (Followers: 66, SJR: 0.591, CiteScore: 2)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 17)
Advances in Genetics     Full-text available via subscription   (Followers: 21, SJR: 1.354, CiteScore: 4)
Advances in Genome Biology     Full-text available via subscription   (Followers: 10, SJR: 12.74, CiteScore: 13)
Advances in Geophysics     Full-text available via subscription   (Followers: 7, SJR: 1.193, CiteScore: 3)
Advances in Heat Transfer     Full-text available via subscription   (Followers: 26, SJR: 0.368, CiteScore: 1)
Advances in Heterocyclic Chemistry     Full-text available via subscription   (Followers: 11, SJR: 0.749, CiteScore: 3)
Advances in Human Factors/Ergonomics     Full-text available via subscription   (Followers: 24)
Advances in Imaging and Electron Physics     Full-text available via subscription   (Followers: 3, SJR: 0.193, CiteScore: 0)
Advances in Immunology     Full-text available via subscription   (Followers: 36, SJR: 4.433, CiteScore: 6)
Advances in Inorganic Chemistry     Full-text available via subscription   (Followers: 10, SJR: 1.163, CiteScore: 2)
Advances in Insect Physiology     Full-text available via subscription   (Followers: 2, SJR: 1.938, CiteScore: 3)
Advances in Integrative Medicine     Hybrid Journal   (Followers: 6, SJR: 0.176, CiteScore: 0)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 3)
Advances in Life Course Research     Hybrid Journal   (Followers: 9, SJR: 0.682, CiteScore: 2)
Advances in Lipobiology     Full-text available via subscription   (Followers: 1)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 8)
Advances in Marine Biology     Full-text available via subscription   (Followers: 21, SJR: 0.88, CiteScore: 2)
Advances in Mathematics     Full-text available via subscription   (Followers: 12, SJR: 3.027, CiteScore: 2)
Advances in Medical Sciences     Hybrid Journal   (Followers: 8, SJR: 0.694, CiteScore: 2)
Advances in Medicinal Chemistry     Full-text available via subscription   (Followers: 6)
Advances in Microbial Physiology     Full-text available via subscription   (Followers: 5, SJR: 1.158, CiteScore: 3)
Advances in Molecular and Cell Biology     Full-text available via subscription   (Followers: 24)
Advances in Molecular and Cellular Endocrinology     Full-text available via subscription   (Followers: 8)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 7, SJR: 0.182, CiteScore: 0)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 5)
Advances in Oncobiology     Full-text available via subscription   (Followers: 2)
Advances in Organ Biology     Full-text available via subscription   (Followers: 2)
Advances in Organometallic Chemistry     Full-text available via subscription   (Followers: 18, SJR: 1.875, CiteScore: 4)
Advances in Parallel Computing     Full-text available via subscription   (Followers: 7, SJR: 0.174, CiteScore: 0)
Advances in Parasitology     Full-text available via subscription   (Followers: 5, SJR: 1.579, CiteScore: 4)
Advances in Pediatrics     Full-text available via subscription   (Followers: 27, SJR: 0.461, CiteScore: 1)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 18)
Advances in Pharmacology     Full-text available via subscription   (Followers: 17, SJR: 1.536, CiteScore: 3)
Advances in Physical Organic Chemistry     Full-text available via subscription   (Followers: 9, SJR: 0.574, CiteScore: 1)
Advances in Phytomedicine     Full-text available via subscription  
Advances in Planar Lipid Bilayers and Liposomes     Full-text available via subscription   (Followers: 3, SJR: 0.109, CiteScore: 1)
Advances in Plant Biochemistry and Molecular Biology     Full-text available via subscription   (Followers: 10)
Advances in Plant Pathology     Full-text available via subscription   (Followers: 6)
Advances in Porous Media     Full-text available via subscription   (Followers: 5)
Advances in Protein Chemistry     Full-text available via subscription   (Followers: 19)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 20, SJR: 0.791, CiteScore: 2)
Advances in Psychology     Full-text available via subscription   (Followers: 66)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 6, SJR: 0.371, CiteScore: 1)
Advances in Radiation Oncology     Open Access   (Followers: 1, SJR: 0.263, CiteScore: 1)
Advances in Small Animal Medicine and Surgery     Hybrid Journal   (Followers: 3, SJR: 0.101, CiteScore: 0)
Advances in Space Biology and Medicine     Full-text available via subscription   (Followers: 6)
Advances in Space Research     Full-text available via subscription   (Followers: 420, SJR: 0.569, CiteScore: 2)
Advances in Structural Biology     Full-text available via subscription   (Followers: 5)
Advances in Surgery     Full-text available via subscription   (Followers: 13, SJR: 0.555, CiteScore: 2)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 37, SJR: 2.208, CiteScore: 4)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 20)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 15)
Advances in Virus Research     Full-text available via subscription   (Followers: 6, SJR: 2.262, CiteScore: 5)
Advances in Water Resources     Hybrid Journal   (Followers: 53, SJR: 1.551, CiteScore: 3)
Aeolian Research     Hybrid Journal   (Followers: 6, SJR: 1.117, CiteScore: 3)
Aerospace Science and Technology     Hybrid Journal   (Followers: 382, SJR: 0.796, CiteScore: 3)
AEU - Intl. J. of Electronics and Communications     Hybrid Journal   (Followers: 8, SJR: 0.42, CiteScore: 2)
African J. of Emergency Medicine     Open Access   (Followers: 6, SJR: 0.296, CiteScore: 0)
Ageing Research Reviews     Hybrid Journal   (Followers: 12, SJR: 3.671, CiteScore: 9)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 472, SJR: 1.238, CiteScore: 3)
Agri Gene     Hybrid Journal   (Followers: 1, SJR: 0.13, CiteScore: 0)
Agricultural and Forest Meteorology     Hybrid Journal   (Followers: 18, SJR: 1.818, CiteScore: 5)
Agricultural Systems     Hybrid Journal   (Followers: 31, SJR: 1.156, CiteScore: 4)
Agricultural Water Management     Hybrid Journal   (Followers: 45, SJR: 1.272, CiteScore: 3)
Agriculture and Agricultural Science Procedia     Open Access   (Followers: 4)
Agriculture and Natural Resources     Open Access   (Followers: 3)
Agriculture, Ecosystems & Environment     Hybrid Journal   (Followers: 58, SJR: 1.747, CiteScore: 4)
Ain Shams Engineering J.     Open Access   (Followers: 5, SJR: 0.589, CiteScore: 3)
Air Medical J.     Hybrid Journal   (Followers: 7, SJR: 0.26, CiteScore: 0)
AKCE Intl. J. of Graphs and Combinatorics     Open Access   (SJR: 0.19, CiteScore: 0)
Alcohol     Hybrid Journal   (Followers: 12, SJR: 1.153, CiteScore: 3)
Alcoholism and Drug Addiction     Open Access   (Followers: 11)
Alergologia Polska : Polish J. of Allergology     Full-text available via subscription   (Followers: 1)
Alexandria Engineering J.     Open Access   (Followers: 2, SJR: 0.604, CiteScore: 3)
Alexandria J. of Medicine     Open Access   (Followers: 1, SJR: 0.191, CiteScore: 1)
Algal Research     Partially Free   (Followers: 11, SJR: 1.142, CiteScore: 4)
Alkaloids: Chemical and Biological Perspectives     Full-text available via subscription   (Followers: 2)
Allergologia et Immunopathologia     Full-text available via subscription   (Followers: 1, SJR: 0.504, CiteScore: 1)
Allergology Intl.     Open Access   (Followers: 5, SJR: 1.148, CiteScore: 2)
Alpha Omegan     Full-text available via subscription   (SJR: 3.521, CiteScore: 6)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 10, SJR: 0.201, CiteScore: 1)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 54, SJR: 4.66, CiteScore: 10)
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring     Open Access   (Followers: 6, SJR: 1.796, CiteScore: 4)
Alzheimer's & Dementia: Translational Research & Clinical Interventions     Open Access   (Followers: 6, SJR: 1.108, CiteScore: 3)
Ambulatory Pediatrics     Hybrid Journal   (Followers: 5)
American Heart J.     Hybrid Journal   (Followers: 58, SJR: 3.267, CiteScore: 4)
American J. of Cardiology     Hybrid Journal   (Followers: 63, SJR: 1.93, CiteScore: 3)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 46, SJR: 0.604, CiteScore: 1)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 12)
American J. of Geriatric Psychiatry     Hybrid Journal   (Followers: 14, SJR: 1.524, CiteScore: 3)
American J. of Human Genetics     Hybrid Journal   (Followers: 37, SJR: 7.45, CiteScore: 8)
American J. of Infection Control     Hybrid Journal   (Followers: 29, SJR: 1.062, CiteScore: 2)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 36, SJR: 2.973, CiteScore: 4)
American J. of Medicine     Hybrid Journal   (Followers: 50)
American J. of Medicine Supplements     Full-text available via subscription   (Followers: 3, SJR: 1.967, CiteScore: 2)
American J. of Obstetrics and Gynecology     Hybrid Journal   (Followers: 249, SJR: 2.7, CiteScore: 4)
American J. of Ophthalmology     Hybrid Journal   (Followers: 66, SJR: 3.184, CiteScore: 4)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 5, SJR: 0.265, CiteScore: 0)
American J. of Orthodontics and Dentofacial Orthopedics     Full-text available via subscription   (Followers: 6, SJR: 1.289, CiteScore: 1)
American J. of Otolaryngology     Hybrid Journal   (Followers: 25, SJR: 0.59, CiteScore: 1)
American J. of Pathology     Hybrid Journal   (Followers: 32, SJR: 2.139, CiteScore: 4)
American J. of Preventive Medicine     Hybrid Journal   (Followers: 28, SJR: 2.164, CiteScore: 4)
American J. of Surgery     Hybrid Journal   (Followers: 39, SJR: 1.141, CiteScore: 2)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 12, SJR: 0.767, CiteScore: 1)
Ampersand : An Intl. J. of General and Applied Linguistics     Open Access   (Followers: 7)
Anaerobe     Hybrid Journal   (Followers: 4, SJR: 1.144, CiteScore: 3)
Anaesthesia & Intensive Care Medicine     Full-text available via subscription   (Followers: 66, SJR: 0.138, CiteScore: 0)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 24, SJR: 0.411, CiteScore: 1)
Anales de Cirugia Vascular     Full-text available via subscription   (Followers: 1)
Anales de Pediatría     Full-text available via subscription   (Followers: 3, SJR: 0.277, CiteScore: 0)
Anales de Pediatría (English Edition)     Full-text available via subscription  
Anales de Pediatría Continuada     Full-text available via subscription  
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 5, SJR: 4.849, CiteScore: 10)
Analytica Chimica Acta     Hybrid Journal   (Followers: 44, SJR: 1.512, CiteScore: 5)
Analytica Chimica Acta : X     Open Access  
Analytical Biochemistry     Hybrid Journal   (Followers: 208, SJR: 0.633, CiteScore: 2)
Analytical Chemistry Research     Open Access   (Followers: 13, SJR: 0.411, CiteScore: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 14)
Anesthésie & Réanimation     Full-text available via subscription   (Followers: 2)
Anesthesiology Clinics     Full-text available via subscription   (Followers: 25, SJR: 0.683, CiteScore: 2)
Angiología     Full-text available via subscription   (SJR: 0.121, CiteScore: 0)
Angiologia e Cirurgia Vascular     Open Access   (Followers: 1, SJR: 0.111, CiteScore: 0)
Animal Behaviour     Hybrid Journal   (Followers: 218, SJR: 1.58, CiteScore: 3)
Animal Feed Science and Technology     Hybrid Journal   (Followers: 6, SJR: 0.937, CiteScore: 2)
Animal Reproduction Science     Hybrid Journal   (Followers: 7, SJR: 0.704, CiteScore: 2)

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Similar Journals
Journal Cover
American Journal of Kidney Diseases
Journal Prestige (SJR): 2.973
Citation Impact (citeScore): 4
Number of Followers: 36  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 0272-6386 - ISSN (Online) 1523-6838
Published by Elsevier Homepage  [3184 journals]
  • Timing of Recovery From Moderate to Severe AKI and the Risk for Future
           Loss of Kidney Function
    • Abstract: Publication date: Available online 16 September 2019Source: American Journal of Kidney DiseasesAuthor(s): Edward D. Siew, Khaled Abdel-Kader, Amy M. Perkins, Robert A. Greevy, Sharidan K. Parr, Jeffrey Horner, Andrew J. Vincz, Jason Denton, Otis D. Wilson, Adriana M. Hung, Cassianne Robinson-Cohen, Michael E. MathenyRationale & ObjectiveThe extent of recovery of kidney function following acute kidney injury (AKI) is known to be associated with future chronic kidney disease. Less is known about how the timing of recovery affects the rate of future loss of kidney function.Study DesignWe performed a retrospective cohort study examining the independent association between the timing of recovery from moderate to severe AKI and future loss of kidney function.Setting & Participants47,903 adult US veterans with stage 2 or 3 AKI who recovered to within 120% of baseline creatinine level within 90 days of peak injury.ExposureThe timing of recovery of kidney function from peak inpatient serum creatinine level grouped into 1 to 4, 5 to 10, 11 to 30, and 31 to 90 days.OutcomeA sustained 40% decline in estimated glomerular filtration rate below that calculated from the last serum creatinine level available during the 90-day recovery period or kidney failure (2 outpatient estimated glomerular filtration rates  90 days apart, kidney transplantation, or registry within the US Renal Data System).Analytical ApproachTime to the primary outcome was examined using multivariable Cox proportional hazards regression.ResultsAmong 47,903 patients, 29,316 (61%), 10,360 (22%), 4,520 (9%), and 3,707 (8%) recovered within 1 to 4, 5 to 10, 11 to 30, and 31 to 90 days, respectively. With a median follow-up of 42 months, unadjusted incidence rates for the kidney outcome were 2.01, 3.55, 3.86, and 3.68 events/100 person-years, respectively. Compared with 1 to 4 days, recovery within 5 to 10, 11 to 30, and 31 to 90 days was associated with increased rates of the primary outcome: adjusted HRs were 1.33 (95% CI, 1.24-1.43), 1.41 (95% CI, 1.28-1.54), and 1.58 (95% CI, 1.43-1.75), respectively.LimitationsPredominately male population, residual confounding, and inability to make causal inferences because of the retrospective observational study design.ConclusionsThe timing of recovery provides an added dimension to AKI phenotyping and prognostic information regarding the future occurrence of loss of kidney function. Studies to identify effective interventions on the timing of recovery from AKI are warranted.
       
  • Patient Navigation: Addressing Social Challenges in Dialysis Patients
    • Abstract: Publication date: Available online 9 September 2019Source: American Journal of Kidney DiseasesAuthor(s): Lilia Cervantes, Romana Hasnain-Wynia, John F. Steiner, Michel Chonchol, Stacy FischerMembers of racial and ethnic minority groups make up nearly 50% of US patients with end-stage kidney disease and face a disproportionate burden of socioeconomic challenges (ie, low income, job insecurity, low educational attainment, housing instability, and communication challenges) compared with non-Hispanic whites. Patients with end-stage kidney disease who face social challenges often have poor patient-centered and clinical outcomes. These challenges may have a negative impact on quality-of-care performance measures for dialysis facilities caring for primarily minority and low-income patients. One path toward improving outcomes for this group is to develop culturally tailored interventions that provide individualized support, potentially improving patient-centered, clinical, and health system outcomes by addressing social challenges. One such approach is using community-based culturally and linguistically concordant patient navigators, who can serve as a bridge between the patient and the health care system. Evidence points to the effectiveness of patient navigators in the provision of cancer care and, to a lesser extent, caring for people with chronic kidney disease and those who have undergone kidney transplantation. However, little is known about the effectiveness of patient navigators in the care of patients with kidney failure receiving dialysis, who experience a number of remediable social challenges.
       
  • Characteristics Associated With Peritoneal Dialysis Technique Failure: Are
           We Asking the Right Questions'
    • Abstract: Publication date: Available online 9 September 2019Source: American Journal of Kidney DiseasesAuthor(s): Annie-Claire Nadeau-Fredette, Joanne M. Bargman
       
  • Cefepime as Empirical Peritoneal Dialysis–Associated Peritonitis
           Treatment: Something to Dwell On'
    • Abstract: Publication date: Available online 9 September 2019Source: American Journal of Kidney DiseasesAuthor(s): Muthana Al Sahlawi, Adrian Liew, Jeffrey Perl
       
  • Early Antibody-Mediated Kidney Transplant Rejection Associated With
           Anti-Vimentin Antibodies: A Case Report
    • Abstract: Publication date: Available online 9 September 2019Source: American Journal of Kidney DiseasesAuthor(s): Christie Rampersad, James Shaw, Ian W. Gibson, Chris Wiebe, David N. Rush, Peter W. Nickerson, Julie HoImproving precision in predicting alloreactivity is an important unmet need and may require individualized consideration of non-HLA antibodies. We report a 21-year-old man with kidney failure from immunoglobulin A nephropathy who met all traditional criteria for a “low-risk” transplant for immune memory. He was unsensitized and received a haplotype-matched living donor kidney transplant from his mother. There were no anti-HLA donor-specific antibodies and flow cross-match was negative. After immediate function, he developed delayed graft function on postoperative day 2. The transplant biopsy specimen was suggestive of antibody-mediated rejection and acute tubular injury with increased vimentin proximal tubular expression compared to the implantation biopsy specimen. He had a history of juvenile idiopathic arthritis, and non-HLA antibody screening demonstrated preformed anti-vimentin antibody. He was successfully treated with plasmapheresis, intravenous immunoglobulin, antithymocyte globulin, and methylprednisolone, with renal recovery. The follow-up biopsy specimen demonstrated decreased vimentin expression with decreased alloinflammation, and graft function remains stable at 1 year posttransplantation (estimated glomerular filtration rate, 62 mL/min/1.73 m2). We postulate that preformed anti-vimentin autoantibodies bound to vimentin expressed on apoptotic tubular epithelial cells induced by ischemia-reperfusion injury and to constitutively expressed vimentin on peritubular capillaries and podocytes. Our case is suggestive of the involvement of anti-vimentin antibody, for which the pathogenic epitopes may be exposed during ischemia-reperfusion injury.
       
  • The Argument for Abolishing Cardiac Screening of Asymptomatic Kidney
           Transplant Candidates
    • Abstract: Publication date: Available online 3 September 2019Source: American Journal of Kidney DiseasesAuthor(s): Adnan SharifCardiovascular disease is the leading cause of death for individuals with end-stage renal disease. Due to concern about cardiac fitness, international guidelines support screening algorithms based on clinical risk factors for people with kidney failure who wish to consider kidney transplantation surgery. The stated aim of cardiac screening is to identify asymptomatic kidney transplantation candidates with potentially significant pathology that either allows risk stratification or facilitates intervention. This will enable some to proceed toward kidney transplant listing while others will be denied kidney transplantation due to perceived risks. The ultimate aim is to attenuate the risk for peri- or early postoperative cardiovascular mortality after kidney transplantation while maximizing the utility of scarce donor organs. However, heterogeneous recommendations for cardiac screening from international professional and/or society guidelines reflect the lack of evidence base to support published advice. Currently established screening strategies lack evidence for efficacy, incur substantial expense, and can be associated with significant risk for harm. In this Perspective article, the argument is made that current cardiac screening algorithms for asymptomatic kidney transplantation candidates are overzealous, counterproductive, and not in the best interests of the majority of people living with kidney failure and should be abolished.
       
  • CKD in China: Evolving Spectrum and Public Health Implications
    • Abstract: Publication date: Available online 3 September 2019Source: American Journal of Kidney DiseasesAuthor(s): Chao Yang, Haibo Wang, Xinju Zhao, Kunihiro Matsushita, Josef Coresh, Luxia Zhang, Ming-Hui ZhaoDiabetes is the leading cause of kidney failure worldwide, whereas glomerulonephritis has been predominant in developing countries such as China. The prevalence of obesity and diabetes has increased dramatically in developing countries, substantially affecting the patterns of chronic kidney disease (CKD) observed in these regions. Using data from the Hospital Quality Monitoring System to evaluate changes in the spectrum of non–dialysis-dependent CKD in China, we have observed an increase in the percentage of patients with CKD due to diabetes, which has exceeded that of CKD due to glomerulonephritis since 2011, as well as an increase in hypertensive nephropathy and, in some regions, obstructive kidney disease (mostly associated with kidney stones). The growth of noncommunicable diseases under profound societal and environmental changes has shifted the spectrum of CKD in China toward patterns similar to those of developed countries, which will have enormous impacts on the Chinese health care system. There is much to be done regarding public health interventions, including the establishment of a national CKD surveillance system, improvement in the management of diabetes and hypertension, and enhancement of the affordability and accessibility of kidney replacement therapy. Reducing the burden of CKD will require joint efforts from government, the medical community (including practitioners other than nephrologists), and the public.
       
  • Nephrology in the Academic Intensive Care Unit: A Qualitative Study of
           Interdisciplinary Collaboration
    • Abstract: Publication date: Available online 3 September 2019Source: American Journal of Kidney DiseasesAuthor(s): Justin T. Clapp, Sushmitha P. Diraviam, Meghan B. Lane-Fall, Julia E. Szymczak, Madhavi Muralidharan, Jamison J. Chung, Jacob T. Gutsche, Martha A.Q. Curley, Jeffrey S. Berns, Lee A. FleisherRationale & ObjectiveCollaboration between nephrology consultants and intensive care unit (ICU) teams is important in light of the high incidence of acute kidney injury in today’s ICUs. Although there is considerable debate about how nephrology consultants and ICU teams should collaborate, communicative dynamics between the 2 parties remain poorly understood. This article describes interactions between nephrology consultants and ICU teams in the academic medical setting.Study DesignFocused ethnography using semi-structured interviews and participant observation.Setting & ParticipantsPurposive sampling was used to enroll nephrologists, nephrology fellows, and ICU practitioners across several roles collaborating in 3 ICUs (a medical ICU, a surgical ICU, and a cardiothoracic surgical ICU) of a large urban US academic medical center. Participant observation (150 hours) and semi-structured interviews (35) continued until theoretical saturation.Analytical ApproachInterview and fieldnote transcripts were coded in an iterative team-based process. Explanation was developed using an abductive approach.ResultsNephrology consultants and surgical ICU teams exhibited discordant preferences about the aggressiveness of renal replacement therapy based on different understandings of physiology, goals of care, and acuity. Collaborative difficulties resulting from this discordance led to nephrology consultants often serving as dialysis proceduralists rather than diagnosticians in surgical ICUs and to consultants sometimes choosing not to express disagreements about clinical care because of the belief that doing so would not lead to changes in the course of care.LimitationsAspects of this single-site study of an academic medical center may not be generalizable to other clinical settings and samples. Surgical team perspectives would provide further detail about nephrology consultation in surgical ICUs. The effects of findings on patient care were not examined.ConclusionsDifferences in approach between internal medicine–trained nephrologists and anesthesia- and surgery-trained intensivists and surgeons led to collaborative difficulties in surgical ICUs. These findings stress the need for medical teamwork research and intervention to address issues stemming from disciplinary siloing rooted in long-term socialization to different disciplinary practices.
       
  • Patient-Reported Outcome Measures for Adults With Kidney Disease: Current
           Measures, Ongoing Initiatives, and Future Opportunities for Incorporation
           Into Patient-Centered Kidney Care
    • Abstract: Publication date: Available online 3 September 2019Source: American Journal of Kidney DiseasesAuthor(s): Devika Nair, F. Perry WilsonTools that measure patients’ experiences and perceptions of disease are increasingly being recognized as important components of a multidisciplinary personalized approach to care. These patient-reported outcome measures (PROMs) have the ability to provide clinicians, researchers, and policymakers with valuable insights into patients’ symptoms and experiences that are unable to be ascertained by laboratory markers alone. If developed rigorously, studied systematically, and used judiciously, PROMs can effectively incorporate the patient voice into clinical care, clinical trials, and health care policy. PROMs have continued to gain attention and interest within the nephrology community, but key challenges and opportunities for their seamless uptake and integration remain. In this narrative overview, we provide nephrologists with a comprehensive list of existing PROMs developed for adults with kidney disease with information on their gaps and limitations; a rationale to support the continued incorporation of PROMs into nephrology clinical trials, clinical care, and health care policy; and a summary of ongoing initiatives and future opportunities to do so.
       
  • Alkali Therapy for Respiratory Acidosis: A Medical Controversy
    • Abstract: Publication date: Available online 28 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Horacio J. Adrogué, Nicolaos E. MadiasAlkali therapy for certain organic acidoses remains a topic of ongoing controversy, but little attention has been given to a related medical controversy, namely the prescription of alkali for respiratory acidosis. We first describe the determinants of carbon dioxide retention in the 2 types of respiratory failure; hypercapnic respiratory failure and hypoxemic respiratory failure with coexisting hypercapnia. We then highlight the deleterious consequences of severe acidemia for several organ systems, particularly the cardiovascular and central nervous systems. We argue that alkali therapy is not indicated for respiratory acidosis as a simple acid-base disturbance. Notwithstanding, we recommend prescription of alkali for severe acidemia caused by mixed acidosis (ie, combined respiratory and metabolic acidosis) or permissive hypercapnia. We examine the utility of alkali therapy in various clinical scenarios incorporating respiratory acidosis. We conclude that controlled studies will be required to test the impact of alkali therapy on clinical outcomes of these clinical settings. Such studies should also examine the optimal mode of administering alkali (amount, rate, and tonicity) and the blood pH to be targeted. The development of new buffers should be explored, especially systems that do not generate carbon dioxide or even consume it.
       
  • The Controversy of Contrast-Induced Nephropathy With Intravenous Contrast:
           What Is the Risk'
    • Abstract: Publication date: Available online 28 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Michael R. Rudnick, Amanda K. Leonberg-Yoo, Harold I. Litt, Raphael M. Cohen, Susan Hilton, Peter P. ReeseContrast-induced nephropathy (CIN) has long been observed in both experimental and clinical studies. However, recent observational studies have questioned the prevalence and severity of CIN following intravenous contrast exposure. Initial studies of acute kidney injury following intravenous contrast were limited by the absence of control groups or contained control groups that did not adjust for additional acute kidney injury risk factors, including prevalent chronic kidney disease, as well as accepted prophylactic strategies. More contemporary use of propensity score–adjusted models have attempted to minimize the risk for selection bias, although bias cannot be completely eliminated without a prospective randomized trial. Based on existing data, we recommend the following CIN risk classification: patients with estimated glomerular filtration rates (eGFRs) ≥ 45 mL/min/1.73 m2 are at negligible risk for CIN, while patients with eGFRs 
       
  • In Reply to ‘Urinary Concentration Capacity, Glomerular Filtration Rate,
           and Mortality in the General American Population’
    • Abstract: Publication date: Available online 26 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Nahid Tabibzadeh, Bénédicte Stengel, Jean-Philippe Haymann
       
  • Urinary Concentration Capacity, Glomerular Filtration Rate, and Mortality
           in the General American Population
    • Abstract: Publication date: Available online 26 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Jacob J.E. Koopman
       
  • Targeting the Gut for Early Diagnosis, Prevention, and Cure of Diabetic
           Kidney Disease: Is the Phenyl Sulfate Story Another Step Forward'
    • Abstract: Publication date: Available online 23 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Enrico Fiaccadori, Carmela Cosola, Alice Sabatino
       
  • Treatment of Membranous Nephropathy in Patients With THSD7A Antibodies
           Using Immunoadsorption
    • Abstract: Publication date: Available online 23 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Julia Weinmann-Menke, Stefan Holtz, Daniel Sollinger, Mara Dörken, Simone Boedecker, Beate Schamberger, Frederick Pfister, Kerstin Amann, Jens LutzAntibodies against THSD7A (thrombospondin type 1 domain-containing protein 7A) have been proposed to play a causal role in the development of nephrotic syndrome in patients with THSD7A antibody–positive membranous nephropathy. We hypothesized that removal of these antibodies from plasma could lead to a rapid reduction in proteinuria. Using immunoadsorption to reduce THSD7A antibodies led to a rapid reduction in proteinuria in 2 patients with THSD7A antibody–positive membranous nephropathy. Moreover, our findings support and strengthen the pathogenic role of the antibodies in the development of nephrotic syndrome in patients with THSD7A antibody–positive membranous nephropathy. Taken together, these 2 cases suggest that immunoadsorption could be a useful tool in the treatment of patients with THSD7A antibody–positive membranous nephropathy.
       
  • Artificial Intelligence in Nephrology: Core Concepts, Clinical
           Applications, and Perspectives
    • Abstract: Publication date: Available online 23 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Olivier Niel, Paul BastardArtificial intelligence is playing an increasingly important role in many fields of medicine, assisting physicians in most steps of patient management. In nephrology, artificial intelligence can already be used to improve clinical care, hemodialysis prescriptions, and follow-up of transplant recipients. However, many nephrologists are still unfamiliar with the basic principles of medical artificial intelligence. This review seeks to provide an overview of medical artificial intelligence relevant to the practicing nephrologist, in all fields of nephrology. We define the core concepts of artificial intelligence and machine learning and cover the basics of the functioning of neural networks and deep learning. We also discuss the most recent clinical applications of artificial intelligence in nephrology and medicine; as an example, we describe how artificial intelligence can predict the occurrence of progressive immunoglobulin A nephropathy. Finally, we consider the future of artificial intelligence in clinical nephrology and its impact on medical practice, and conclude with a discussion of the ethical issues that the use of artificial intelligence raises in terms of clinical decision making, physician-patient relationship, patient privacy, and data collection.
       
  • An Implanted Blood Vessel Support Device for Arteriovenous Fistulas: A
           Randomized Controlled Trial
    • Abstract: Publication date: Available online 22 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Nikolaos Karydis, Paul Bevis, Timothy Beckitt, Daniel Silverberg, Moshe Halak, Francis CalderRationale & ObjectiveReducing turbulent blood flow through dialysis arteriovenous fistulas (AVFs) and radial stretching of their venous wall may attenuate hyperplasia and stenosis and improve AVF outcomes in hemodialysis patients. The goal of this study was to evaluate the safety and efficacy of the VasQ implant, which intervenes on these mechanisms by physically supporting the surgical arteriovenous anastomosis.Study DesignProspective, randomized, controlled, multicenter study.Settings & Participants40 consecutive patients with kidney failure referred for creation of a brachiocephalic fistula in 4 vascular access centers in the United Kingdom and Israel.InterventionsAVF surgical creation with placement of the VasQ implant (treatment) versus AVF placement without the implant (control).OutcomesSafety assessed as percentage of severe device-related adverse events was the primary outcome. Secondary outcomes were efficacy assessments including: (1) AVF maturation at 3 months, defined as cephalic vein diameter ≥ 5 mm and flow ≥ 500 mL/min; (2) functional cumulative patency, defined as successful 2-needle cannulation for two-thirds or more of all dialysis runs for 1 month in study participants receiving dialysis; (3) cephalic vein diameter and blood flow; and (4) primary and cumulative patency at 6 months.ResultsNo severe device-related adverse events were observed. There was no significant difference in maturation at 3 months or primary patency at 6 months between treatment and control (85% vs 80% and 80% vs 66%). Significantly larger vein luminal diameters were observed in the treatment group versus controls at 3 and 6 months (8.27 ± 2.2 vs 6.69 ± 1.8 mm [P = 0.03] and 9.6 ± 2.5 vs 7.56 ± 2.7 mm [P = 0.03]). Functional patency at 6 months was significantly greater in the treatment group (100% vs 56% [P = 0.01]).LimitationsSmall sample size, limited power for secondary end points.ConclusionsNo safety signals were detected for the VasQ external support of brachiocephalic AVFs. Higher functional patency and vein luminal diameters were achieved with the device at 3 and 6 months. VasQ may safely intervene on mechanisms associated with the disturbed hemodynamic profile in the juxta-anastomotic region.FundingFunded by Laminate Medical Technologies Ltd.Trial RegistrationRegistered at ClinicalTrials.gov with study number NCT02112669.
       
  • Effects of Sevelamer Carbonate in Patients With CKD and Proteinuria: The
           ANSWER Randomized Trial
    • Abstract: Publication date: September 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 3Author(s): Barbara Ruggiero, Matias Trillini, Lida Tartaglione, Silverio Rotondi, Elena Perticucci, Rocco Tripepi, Carolina Aparicio, Veruska Lecchi, Annalisa Perna, Francesco Peraro, Davide Villa, Silvia Ferrari, Antonio Cannata, Sandro Mazzaferro, Francesca Mallamaci, Carmine Zoccali, Antonio Bellasi, Mario Cozzolino, Giuseppe Remuzzi, Piero RuggenentiRationale & ObjectiveHyperphosphatemia is associated with increased risk for chronic kidney disease (CKD) progression and reduced antiproteinuric effects of renin-angiotensin system (RAS) blockers. We investigated whether the phosphate binder sevelamer carbonate may enhance the antiproteinuric effect of RAS inhibitors in patients with CKD.Study DesignPhase 2, randomized, controlled, open-label, crossover trial.Setting & ParticipantsBetween November 2013 and December 2014, we enrolled 53 patients with CKD with estimated glomerular filtration rates (eGFRs) > 15 mL/min/1.73 m2 and residual proteinuria with protein excretion ≥ 0.5 g/24 h despite maximal tolerated ramipril and/or irbesartan therapy from 2 nephrology units in Italy.InterventionAfter stratification by serum phosphate level, ≤4 or >4 mg/dL, patients were randomly assigned to 3 months of sevelamer (1,600 mg thrice daily) treatment followed by 3 months without sevelamer separated by a 1-month washout period or 3 months without sevelamer followed by 3 months with sevelamer, also separated by a 1-month washout period.OutcomesThe primary outcome was 24-hour proteinuria (n = 49 patients). Secondary outcomes included measured GFR (using iohexol plasma clearance), office blood pressure (BP), serum lipid levels, levels of inflammation and bone metabolism biomarkers, urinary electrolyte levels, and arterial stiffness.ResultsChanges in proteinuria during the 3-month treatment with (from 1.36 [IQR, 0.77-2.51] to 1.36 [IQR, 0.77-2.60] g/24 h) or without (from 1.36 [IQR, 0.99-2.38] to 1.48 [IQR, 0.81-2.77] g/24 h) sevelamer were similar (P = 0.1). Sevelamer reduced urinary phosphate excretion without affecting serum phosphate levels. Sevelamer reduced C-reactive protein (CRP), glycated hemoglobin, and total and low-density lipoprotein cholesterol levels and increased high-density lipoprotein cholesterol levels without affecting levels of office BP, measured GFR, fibroblast growth factor 23, klotho, intact parathyroid hormone, serum vitamin D, or other urinary electrolytes. Results were similar in the low- and high-phosphate groups. Sevelamer was well tolerated. Adverse events were comparable between treatment periods. One case of transient hypophosphatemia was observed during treatment with sevelamer.LimitationsShort treatment duration, lower pretreatment proteinuria than expected.Conclusions3-month sevelamer treatment did not reduce proteinuria in patients with CKD on maximal RAS blockade. Amelioration of inflammation and dyslipidemia with sevelamer treatment raises the possibility that it may confer benefit in patients with CKD beyond reduction of proteinuria.FundingSanofi (Milan, Italy).Trial RegistrationRegistered at ClinicalTrials.gov with study number NCT01968759.
       
  • A Case of Iatrogenic Dehydration
    • Abstract: Publication date: September 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 3Author(s): Pascale Khairallah, Pietro A. Canetta
       
  • Self-reported Urine Volume in Hemodialysis Patients: Predictors and
           Mortality Outcomes in the International Dialysis Outcomes and Practice
           Patterns Study (DOPPS)
    • Abstract: Publication date: September 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 3Author(s): Manfred Hecking, Keith P. McCullough, Friedrich K. Port, Brian Bieber, Hal Morgenstern, Hiroyasu Yamamoto, Rita S. Suri, Michel Jadoul, Loreto Gesualdo, Jeffrey Perl, Bruce M. Robinson
       
  • Oxalosis Associated With High-Dose Vitamin C Ingestion in a Peritoneal
           Dialysis Patient
    • Abstract: Publication date: September 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 3Author(s): Matthew R. D’Costa, Nelson S. Winkler, Dawn S. Milliner, Suzanne M. Norby, LaTonya J. Hickson, John C. LieskeWe report a case of systemic oxalosis involving the eyes and joints due to long-term use of high-dose vitamin C in a patient receiving maintenance peritoneal dialysis (PD). This 76-year-old woman with autosomal dominant polycystic kidney disease underwent living unrelated kidney transplantation 10 years earlier. The transplant failed 6 months before presentation, and she initiated hemodialysis therapy before transitioning to PD therapy 4 months later. During the month before presentation, the patient noted worsening arthralgias and decreased vision. Ophthalmologic examination revealed proliferative retinopathy and calcium oxalate crystals. Plasma oxalate level was markedly elevated at 187 (reference range, 
       
  • Person-Centered Care for Older Adults With Kidney Disease: Core Curriculum
           2019
    • Abstract: Publication date: September 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 3Author(s): Natalie Freidin, Ann M. O’Hare, Susan P.Y. WongThis Core Curriculum article models a person-centered approach to care for older adults with kidney disease. We provide background information on the principles of person-centered care and outline ways in which this approach contrasts with the more disease-based approaches that dominate current medical education and practice. Using hypothetical cases, we discuss 3 clinical scenarios that arise commonly when caring for older adults with kidney disease: (1) a moderate reduction in estimated glomerular filtration rate, (2) new-onset nephrotic-range proteinuria, and (3) the prospect of starting dialysis. For each scenario, we summarize relevant available evidence and model what a person-centered approach might look like. In discussing each scenario, we highlight: (1) the considerable heterogeneity in clinical presentation, circumstances, priorities, and values that exist among older adults with kidney disease; (2) the importance of interpreting available evidence and clinical practice guidelines in the context of what is relevant to each patient; (3) methods for grounding discussions about care and treatment options in the realities of each patient’s situation and what is most meaningful to them; and (4) the importance of setting aside one’s own biases and practice style to ensure that patients’ own values and goals guide their care.
       
  • The Use of Patient-Reported Outcomes in Patients Treated With Maintenance
           Hemodialysis: A Perspective
    • Abstract: Publication date: September 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 3Author(s): Nicola Elizabeth Anderson, Melanie Calvert, Paul Cockwell, Mary Dutton, Derek KyteThere is increasing interest in the integration of patient-reported outcomes (PROs) into health care research and clinical practice for the benefit of patients with end-stage kidney disease receiving hemodialysis. In a research setting, PROs can be used as a patient-centered primary or secondary outcome in clinical studies. In routine care, PRO data may be used to support service delivery through benchmarking and audit or inform and enhance the care of the individual patient by improving patient-clinician communication. Despite evidence demonstrating the potential benefits of PROs and prioritization of these outcomes by patients, their use in kidney disease remains limited. Although there are significant methodological and operational challenges for the widespread integration of PROs, there is now consensus that this area should be at the forefront of clinical research and implementation science. We discuss the current use of PROs for patients with end-stage kidney disease receiving hemodialysis and identify a roadmap for increasing the evidence base and introducing PROs into mainstream clinical practice.
       
  • Quality Metrics in Kidney Transplantation: Current Landscape, Trials and
           Tribulations, Lessons Learned, and a Call for Reform
    • Abstract: Publication date: September 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 3Author(s): Jesse D. Schold, Rachel E. Patzer, Timothy L. Pruett, Sumit MohanQuality metrics have a long history in the field of kidney transplantation. These metrics are highly visible, with significant ramifications to transplantation centers based on their use in regulatory review and other stakeholders. In this perspective, we review the history of quality metrics in this field, discuss the perceptions and empirical evidence evaluating the impact of metrics on care delivery, and summarize the current landscape of quality oversight. Based on the research findings and opinions of the transplantation community, we suggest that significant reforms are needed for the evaluation of quality in the field based on more appropriately aligning metrics with optimizing patient outcomes. Moreover, there are vast potential uses of the current data that should be emphasized in a learning environment rather than a highly punitive system. In our view, these reforms would enhance care delivery, improve patient care, and better align incentives for providers of care that treat transplantation patients.
       
  • Reduced Estimated GFR and Cardiac Remodeling: A Population-Based Autopsy
           Study
    • Abstract: Publication date: September 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 3Author(s): Kensuke Izumaru, Jun Hata, Toshiaki Nakano, Yutaka Nakashima, Masaharu Nagata, Masayo Fukuhara, Yoshinao Oda, Takanari Kitazono, Toshiharu NinomiyaRationale & ObjectiveEvidence suggests that cardiac remodeling, including left ventricular hypertrophy and myocardial fibrosis, develops with progression of kidney disease. Few studies have examined cardiac pathology across a range of estimated glomerular filtration rates (eGFRs), which was the objective of this investigation.Study DesignPopulation-based cross-sectional study of deceased patients undergoing autopsy.Setting & Participants334 of 694 consecutive deceased patients undergoing autopsy with available cardiac tissue, with a prior health examination within 6 years and without a prior diagnosis of heart disease.ExposureeGFR.OutcomesThe thickness of the left ventricular wall, sizes of cardiac cells, and percentages of fibrosis, estimated from pathology examination of autopsy samples.Analytical ApproachGeneralized estimating equations.ResultsLower eGFRs were associated with greater left ventricular wall thickness. Deceased patients with eGFRs ≥ 60, 45 to 59, 30 to 44, and 
       
  • Effects of Water Loading on Observed and Predicted Plasma Sodium, and
           Fluid and Urine Cation Excretion in Healthy Individuals
    • Abstract: Publication date: September 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 3Author(s): Rosa D. Wouda, Shosha E.I. Dekker, Joelle Reijm, Rik H.G. Olde Engberink, Liffert VogtRationale & ObjectiveThe discovery of sodium storage without concurrent water retention suggests the presence of an additional compartment for sodium distribution in the body. The osmoregulatory role of this compartment under hypotonic conditions is not known.Study DesignExperimental interventional study.Setting & ParticipantsSingle-center study of 12 apparently healthy men.InterventionTo investigate whether sodium can be released from its nonosmotic stores after a hypotonic fluid load, a water-loading test (20 mL water/kg in 20 minutes) was performed.OutcomesDuring a 240-minute follow-up, we compared the observed plasma sodium concentration ([Na+]) and fluid and urine cation excretion with values predicted by the Barsoum-Levine and Nguyen-Kurtz formulas. These formulas are used for guidance of fluid therapy during dysnatremia, but do not account for nonosmotic sodium stores.Results30 minutes after water loading, mean plasma [Na+] decreased 3.2 ± 1.6 (SD) mmol/L, after which plasma [Na+] increased gradually. 120 minutes after water loading, plasma [Na+] was significantly underestimated by the Barsoum-Levine (−1.3 ± 1.4 mmol/L; P = 0.05) and Nguyen-Kurtz (−1.5 ± 1.5 mmol/L; P = 0.03) formulas. In addition, the Barsoum-Levine and Nguyen-Kurtz formulas overestimated urine volume, while cation excretion was significantly underestimated, with a cation gap of 57 ± 62 (P = 0.009) and 63 ± 63 mmol (P = 0.005), respectively. After 240 minutes, this gap was 28 ± 59 (P = 0.2) and 34 ± 60 mmol (P = 0.08), respectively.LimitationsThe compartment from which the mobilized sodium originated was not identified, and heterogeneity in responses to water loading was observed across participants.ConclusionsThese data suggest that healthy individuals are able to mobilize osmotically inactivated sodium after an acute hypotonic fluid load. Further research is needed to expand knowledge about the compartment of osmotically inactivated sodium and its role in osmoregulation and therapy for dysnatremias.FundingThis investigator-initiated study was partly supported by a grant from Unilever Research and Development Vlaardingen, The Netherlands B.V. (MA-2014-01914).
       
  • Prediction and Risk Stratification of Kidney Outcomes in IgA Nephropathy
    • Abstract: Publication date: September 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 3Author(s): Tingyu Chen, Xiang Li, Yingxue Li, Eryu Xia, Yong Qin, Shaoshan Liang, Feng Xu, Dandan Liang, Caihong Zeng, Zhihong LiuRationale & ObjectiveImmunoglobulin A nephropathy (IgAN) is common worldwide and has heterogeneous phenotypes. Predicting long-term outcomes and stratifying risk are important for clinical decision making and designing future clinical trials.Study DesignMulticenter retrospective cohort study of 2,047 patients with IgAN.Setting & ParticipantsDerivation and validation cohorts composed of 1,022 Chinese patients with IgAN from a single center and 1,025 patients with IgAN from 18 renal centers, respectively.Predictors36 characteristics, including demographic, clinical, and pathologic variables.OutcomesCombined event of end-stage kidney disease or 50% reduction in estimated glomerular filtration rate within 5 years after diagnostic kidney biopsy.Analytical ApproachA gradient tree boosting method implemented in the eXtreme Gradient Boosting (XGBoost) system was used to select the 10 most important variables from 36 candidate variables. Stepwise Cox regression analysis was used to derive a simplified scoring scale model (SSM) based on these 10 variables. Model discrimination and calibration were assessed using the C statistic and Hosmer-Lemeshow test. Risk stratification of the SSM was evaluated using Kaplan-Meier analysis.ResultsIn the derivation and validation cohorts, 74 and 114 patients reached the outcome, respectively. XGBoost predicted the outcome with a C statistic of 0.84 (95% CI, 0.80-0.88) for the validation cohort. The SSM included 3 variables: urine protein excretion, global sclerosis, and tubular atrophy/interstitial fibrosis. Using Kaplan-Meier analysis, the SSM identified significant risk stratification (P < 0.001).LimitationsRetrospective study design, application for other ethnic groups needs to be verified.ConclusionsA prediction model using routinely available characteristics and based on the combination of a machine learning algorithm and survival analysis can stratify risk for kidney disease progression in the setting of IgAN. An online calculator, the Nanjing IgAN Risk Stratification System, permits easy implementation of this model.
       
  • The AJKD Editorial Internship: Insights From the Inaugural Class
           of Editorial Interns
    • Abstract: Publication date: September 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 3Author(s): Samantha L. Gelfand, Pascale Khairallah, Devika Nair, Adrian M. Whelan
       
  • Announcement
    • Abstract: Publication date: September 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 3Author(s):
       
  • Single Measurements of Carboxy-Terminal Fibroblast Growth Factor 23 and
           Clinical Risk Prediction of Adverse Outcomes in CKD
    • Abstract: Publication date: Available online 21 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Daniel Edmonston, Daniel Wojdyla, Rupal Mehta, Xuan Cai, Claudia Lora, Debbie Cohen, Raymond R. Townsend, Jiang He, Alan S. Go, John Kusek, Matthew R. Weir, Tamara Isakova, Michael Pencina, Myles Wolf, Lawrence J. Appel, Harold I. Feldman, James P. Lash, Panduranga S. Rao, Mahboob Rahman, Matthew R. WeirRationale & ObjectiveAn elevated fibroblast growth factor 23 (FGF-23) level is independently associated with adverse outcomes in populations with chronic kidney disease, but it is unknown whether FGF-23 testing can improve clinical risk prediction in individuals.Study DesignProspective cohort study.Setting & ParticipantsParticipants in the Chronic Renal Insufficiency Cohort (CRIC) Study (n = 3,789).ExposureBaseline carboxy-terminal FGF-23 (cFGF-23) level.OutcomesAll-cause and cardiovascular (CV) mortality, incident end-stage renal disease (ESRD), heart failure (HF) admission, and atherosclerotic events at 3, 5, and 8 years.Analytical ApproachWe assessed changes in model performance by change in area under the receiver operating characteristic curve (ΔAUC), integrated discrimination improvement (IDI), relative IDI, and net reclassification index (NRI) above standard clinical factors. We performed sensitivity analyses, including an additional model comparing the addition of phosphate rather than cFGF-23 level and repeating our analyses using an internal cross-validation cohort.ResultsAddition of a single baseline value of cFGF-23 to a base prediction model improved prediction of all-cause mortality (ΔAUC, 0.017 [95% CI, 0.001-0.033]; IDI, 0.021 [95% CI, 0.006-0.036]; relative IDI, 32.7% [95% CI, 8.5%-56.9%]), and HF admission (ΔAUC, 0.008 [95% CI, 0.0004-0.016]; IDI, 0.019 [95% CI, 0.004-0.034]; relative IDI, 10.0% [95% CI, 1.8%-18.3%]), but not CV mortality, ESRD, or atherosclerotic events at 3 years of follow-up. The NRI did not reach statistical significance for any of the 3-year outcomes. The incremental predictive utility of cFGF-23 level diminished in analyses of the 5- and 8-year outcomes. The cFGF-23 models outperformed the phosphate model for each outcome.LimitationsPower to detect increased CV mortality likely limited by low event rate. The NRI is not generalizable without accepted prespecified risk thresholds.ConclusionsAmong individuals with CKD, single measurements of cFGF-23 improve prediction of risks for all-cause mortality and HF admission but not CV mortality, ESRD, or atherosclerotic events. Future studies should evaluate the predictive utility of repeated cFGF-23 testing.
       
  • Straight Versus Coiled Peritoneal Dialysis Catheters: A Randomized
           Controlled Trial
    • Abstract: Publication date: Available online 21 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Kai Ming Chow, Steve Siu Man Wong, Jack Kit Chung Ng, Yuk Lun Cheng, Chi Bon Leung, Wing Fai Pang, Winston Wing Shing Fung, Cheuk Chun Szeto, Philip Kam Tao LiRationale & ObjectiveDespite a recent meta-analysis favoring straight catheters, the clinical benefits of straight versus coiled peritoneal dialysis catheters remain uncertain. We conducted a randomized controlled study to compare the complication rates associated with these 2 types of double-cuffed peritoneal dialysis catheters.Study DesignMulticenter, open-label, randomized, controlled trial.Setting & Participants308 adult continuous ambulatory peritoneal dialysis patients.InterventionParticipants were randomly assigned to receive either straight or coiled catheters.OutcomesThe primary outcome was the incidence of catheter dysfunction requiring surgical intervention. Secondary outcomes included time to catheter dysfunction requiring intervention, catheter migration with dysfunction, infusion pain measured using a visual analogue scale, peritonitis, technique failure, and peritoneal catheter survival.Results153 patients were randomly assigned to straight catheters; and 155, to coiled catheters. Among randomly assigned patients who underwent peritoneal dialysis, during a mean follow-up of 21 months, the primary outcome of catheter dysfunction or drainage failure occurred in 9 (5.8%) patients who received a coiled catheter and 1 (0.7%) patient who received a straight catheter. Straight catheters had 5.1% lower risk for catheter dysfunction (95% CI, 1.2%-9.1%; P = 0.02). The HR of the primary outcome for coiled versus straight catheters was 8.69 (95% CI, 1.10-68.6; P = 0.04). Patients who received a coiled catheter had similar risk for peritonitis but reported higher infusion pain scores than those who received straight catheters.LimitationsGeneralizability to other peritoneal dialysis centers with lower volumes and other races and nationalities.ConclusionsUse of straight Tenckhoff catheters compared with coiled catheters reduced the rate of catheter dysfunction requiring surgical intervention.FundingFunded by the Chinese University of Hong Kong.Trial RegistrationRegistered at ClinicalTrials.gov with study number NCT02479295.
       
  • Sex Differences in the Progression of CKD Among Older Patients: Pooled
           Analysis of 4 Cohort Studies
    • Abstract: Publication date: Available online 10 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Roberto Minutolo, Francis B. Gabbai, Paolo Chiodini, Michele Provenzano, Silvio Borrelli, Carlo Garofalo, Vincenzo Bellizzi, Domenico Russo, Giuseppe Conte, Luca De Nicola, Collaborative Study Group on the Conservative Treatment of CKD of the Italian Society of NephrologyRationale & ObjectiveData for the association of sex with chronic kidney disease (CKD) progression are conflicting, a relationship this study sought to examine.Study DesignPooled analysis of 4 Italian observational cohort studies.Setting & Participants1,311 older men and 1,024 older women with estimated glomerular filtration rate (eGFR) 
       
  • The Use of Erythropoiesis-Stimulating Agents in Patients With CKD and
           Cancer: A Clinical Approach
    • Abstract: Publication date: Available online 5 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Sumeska Thavarajah, Michael J. ChoiErythropoiesis-stimulating agents (ESAs) have been used to manage anemia in chronic kidney disease (CKD) to reduce transfusion requirements and anemia symptoms. Lack of objective benefit of normalizing hemoglobin (Hb) levels and increased evidence of ESA-induced complications in persons with anemia has resulted in clinicians generally attempting to maintain Hb levels in the 10- to 11-g/dL range. In 2000, concerns in patients with cancer arose attributable to associations of ESA use with increased mortality, thrombotic complications, and cerebrovascular accidents led to a change in US Food and Drug Administration oncology guidelines regarding limitation of ESA use for chemotherapy-induced anemia. No guidance was rendered for individuals with CKD and cancer. Persons with CKD with remote or active malignancy should receive the lowest ESA doses possible that achieve a maximum Hb level of 10 g/dL. Based on current data, although ESAs may promote progression or worsen outcomes in some cancers, we lack data that ESAs increase the likelihood of developing new cancers in patients on dialysis or earlier stages of CKD.
       
  • Missing the Forest and the Trees: Challenges and Opportunities in Ensuring
           Timely Follow-up of Abnormal Estimated GFR
    • Abstract: Publication date: Available online 1 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Salman Ahmed, Gearoid M. McMahon, Mallika L. Mendu
       
  • Cognitive Impairment in CKD: Pathophysiology, Management, and Prevention
    • Abstract: Publication date: Available online 1 August 2019Source: American Journal of Kidney DiseasesAuthor(s): David A. Drew, Daniel E. Weiner, Mark J. SarnakPatients with chronic kidney disease (CKD) are at substantially higher risk for developing cognitive impairment compared with the general population, and both lower glomerular filtration rate and the presence of albuminuria are associated with the development of cognitive impairment and poorer cognitive function. Given the excess of vascular disease seen in individuals with CKD, cerebrovascular disease is likely the predominant pathology underlying these associations, though impaired clearance of uremic metabolites, depression, sleep disturbance, anemia, and polypharmacy may also contribute. Modification of vascular disease risk factors may be helpful in limiting decline, though definite data are lacking. Specific to CKD, targeting a low blood pressure and reduction in albuminuria with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may slow cognitive decline, albeit modestly. Initiation of dialysis can improve severe impairment associated with uremia but does not appear to affect more subtle chronic cognitive impairment. In contrast, kidney transplantation appears to lead to improved cognitive function in many transplant recipients, suggesting that dialysis methods do not provide the same cognitive benefits as having a functioning kidney. Management of patients with both CKD and cognitive impairment should include a comprehensive plan including more frequent follow-up visits; involvement of family in shared decision making; measures to improve compliance, such as written instruction and pill counts; and a focus on advance directives in conjunction with an emphasis on understanding an individual patient’s life goals. Further research is needed on novel therapies, including innovative dialysis methods, that aim to limit the development of cognitive impairment, slow decline in those with prevalent impairment, and improve cognitive function.
       
  • Collapsing Lesions and Focal Segmental Glomerulosclerosis in Pregnancy: A
           Report of 3 Cases
    • Abstract: Publication date: Available online 1 August 2019Source: American Journal of Kidney DiseasesAuthor(s): Oralia Alejandra Orozco Guillén, Ricardo Iván Velazquez Silva, Bernardo Moguel Gonzalez, Tomas Becerra Gamba, Alfredo Gutiérrez Marín, Norberto Reyes Paredes, Jorge Arturo Cardona Pérez, Virgilia Soto Abraham, Giorgina Barbara Piccoli, Magdalena MaderoThe relationship between focal segmental glomerulosclerosis (FSGS) and pregnancy is complex and not completely elucidated. Pregnancy in patients with FSGS poses a high risk for complications, possibly due to hemodynamic factors, imbalance between angiogenic and antiangiogenic factors, and hormonal conditioning. Although poor clinical outcomes associated with collapsing FSGS are common outside of pregnancy, the prognosis during pregnancy is not well documented. We report 3 patients who developed collapsing FSGS during pregnancy, 2 of whom had presumed underlying FSGS. Two patients underwent biopsy during pregnancy, and 1, during the puerperium. None of the 3 patients improved spontaneously after delivery, and 1 experienced a rapid deterioration in kidney function and proteinuria after delivery. Aggressive immunosuppressive therapy led to a full response in 1 case (without chronic lesions) and to partial responses in the remaining 2 cases. These cases suggest that collapsing lesions should be considered in patients with FSGS who develop a rapid increase in serum creatinine level or proteinuria during pregnancy and that these lesions may at least partially respond to treatment.
       
  • Novel Detection of CALR-Mutated Cells in Myeloproliferative
           Neoplasm-Related Glomerulopathy With Interstitial Extramedullary
           Hematopoiesis: A Case Report
    • Abstract: Publication date: Available online 31 July 2019Source: American Journal of Kidney DiseasesAuthor(s): Keisuke Maruyama, Naoki Nakagawa, Ayana Suzuki, Maki Kabara, Motoki Matsuki, Motohiro Shindo, Sari Iwasaki, Yayoi Ogawa, Naoyuki HasebeMyeloproliferative neoplasms (MPNs) are associated with somatic mutations of genes including JAK2, CALR, or MPL in hematopoietic stem cells. Various glomerular lesions are known to be involved in MPN-related glomerulopathy, including mesangial hypercellularity, segmental sclerosis, features of chronic thrombotic microangiopathy, and intracapillary hematopoietic cell infiltration. Renal extramedullary hematopoiesis (EMH) is uncommon, but it is reported to occur in the setting of MPN; however, to our knowledge, there have been no reports of renal EMH with pathologically verified mutations. We report the case of a 65-year-old woman with MPN who had a CALR mutation and developed nephrotic syndrome. Kidney biopsy showed the typical findings of MPN-related glomerulopathy. CALR mutation–specific immunostaining of the kidney revealed immunopositive cells in the EMH lesion of the interstitium, indicating that renal EMH was caused by CALR-mutated cells. Based on these findings, we diagnosed nephrotic syndrome caused by MPN-related glomerulopathy. After initiation of steroid therapy, the patient’s proteinuria gradually decreased and she achieved an incomplete remission. Additionally, the patient was prescribed the JAK inhibitor ruxolitinib and maintained incomplete remission. There is no established treatment for MPN-related glomerulopathy; therefore, further studies are needed to elucidate its pathophysiology.
       
  • Targeting Zero Infections in Hemodialysis
    • Abstract: Publication date: Available online 30 July 2019Source: American Journal of Kidney DiseasesAuthor(s): Alan S. Kliger, Renee Garrick
       
  • Transplant Center Volume: Is Bigger Better'
    • Abstract: Publication date: Available online 26 July 2019Source: American Journal of Kidney DiseasesAuthor(s): John R. Montgomery, Randall S. Sung, Kenneth J. Woodside
       
  • ANCA-Associated Vasculitis: Core Curriculum 2020
    • Abstract: Publication date: Available online 26 July 2019Source: American Journal of Kidney DiseasesAuthor(s): Duvuru Geetha, J. Ashley JeffersonAntineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of disorders characterized by inflammation and destruction of small- and medium-sized blood vessels and the presence of circulating ANCA. Clinical disease phenotypes include granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis, and renal-limited vasculitis. Serologic classification of AAV into proteinase 3–ANCA disease and myeloperoxidase-ANCA disease correlates with a number of disease characteristics. AAV has a predilection for the kidney, with>75% of patients having renal involvement characterized by rapidly progressive glomerulonephritis. The cause and pathogenesis of AAV are multifactorial and influenced by genetics, environmental factors, and responses of the innate and adaptive immune system. Randomized controlled trials in the past 2 decades have refined the therapy of AAV and transformed AAV from a fatal disease to a chronic illness with relapsing course and associated morbidity. This article in AJKD’s Core Curriculum in Nephrology series provides a detailed review of the epidemiology, pathogenesis, diagnosis, and advances in the management of AAV.
       
  • Low Birth Weight and Kidney Function in Middle-Aged Men and Women: The
           Netherlands Epidemiology of Obesity Study
    • Abstract: Publication date: Available online 26 July 2019Source: American Journal of Kidney DiseasesAuthor(s): Kevin Esmeijer, Aiko P. de Vries, Dennis O. Mook-Kanamori, Johan W. de Fijter, Frits R. Rosendaal, Ton J. Rabelink, Roelof A.J. Smit, Renée de Mutsert, Ellen K. HoogeveenRationale & ObjectiveChronic kidney disease (CKD), defined as estimated glomerular filtration rate (eGFR) 
       
  • Cognitive Impairment and Mortality in Patients Receiving Hemodialysis:
           Implications and Future Research Avenues
    • Abstract: Publication date: Available online 24 July 2019Source: American Journal of Kidney DiseasesAuthor(s): Katharine L. Cheung, Michael A. LaMantia
       
  • Osmotically Inactivated Sodium in Acute Hyponatremia: Stay With Edelman
    • Abstract: Publication date: Available online 23 July 2019Source: American Journal of Kidney DiseasesAuthor(s): Horacio J. Adrogué, Nicolaos E. Madias
       
  • Announcement
    • Abstract: Publication date: August 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 2Author(s):
       
  • Nephropathy Progression in African Americans With a Family History of
           ESKD: Implications for Clinical Trials in APOL1-Associated Nephropathy
    • Abstract: Publication date: August 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 2Author(s): Barry I. Freedman, Mitzie Spainhour, Pamela J. Hicks, Jolyn Turner, Julia Robertson, Carl D. Langefeld, Mariana Murea, Jasmin Divers
       
  • The Impact of Whole-Exome Sequencing on Kidney Disease Ontology: The Tip
           of the Iceberg'
    • Abstract: Publication date: August 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 2Author(s): Abdallah S. Geara, Staci Kallish, Jonathan J. Hogan
       
  • Heavy Chain Fibrillary Glomerulonephritis: A Case Report
    • Abstract: Publication date: August 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 2Author(s): Samih H. Nasr, Christophe Sirac, Frank Bridoux, Vincent Javaugue, Sebastien Bender, Alexia Rinsant, Sihem Kaaki, Emilie Pinault, Surendra Dasari, Mariam P. Alexander, Samar M. Said, Jonathan J. Hogan, Angela Dispenzieri, Guy Touchard, Ellen D. McPhail, Nelson LeungHeavy chain amyloidosis and heavy chain deposition disease are the only known kidney diseases caused by the deposition of truncated immunoglobulin heavy chains. Fibrillary glomerulonephritis typically results from deposition of DNAJB9 (DnaJ heat shock protein family [Hsp40] member B9) and polytypic immunoglobulin G (IgG). We describe a patient with monoclonal gammopathy (IgG with λ light chain) who developed DNAJB9-negative fibrillary glomerulonephritis leading to end-stage kidney disease, with recurrence in 2 kidney allografts. Pre- and postmortem examination showed glomerular deposition of Congo red–negative fibrillar material that was determined to be immunoglobulin heavy chain. We propose the term “heavy chain fibrillary glomerulonephritis” to describe this lesion, which appears to be a rare kidney complication of monoclonal gammopathy. The diagnosis should be suspected when the kidney biopsy shows fibrillary glomerulonephritis with negative staining for immunoglobulin light chains and DNAJB9; the diagnosis can be confirmed using immunochemical and molecular studies.
       
  • Metabolic Acidosis in CKD: Core Curriculum 2019
    • Abstract: Publication date: August 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 2Author(s): Kalani L. RaphaelMaintenance of normal acid-base homeostasis is one of the most important kidney functions. In chronic kidney disease, the capacity of the kidneys to excrete the daily acid load as ammonium and titratable acid is impaired, resulting in acid retention and metabolic acidosis. The prevalence of metabolic acidosis increases with declining glomerular filtration rate. Metabolic acidosis is associated with several clinically important complications, including chronic kidney disease progression, bone demineralization, skeletal muscle catabolism, and mortality. To mitigate these adverse consequences, clinical practice guidelines suggest treating metabolic acidosis with oral alkali in patients with chronic kidney disease. However, large clinical trials to determine the efficacy and safety of correcting metabolic acidosis with oral alkali in patients with chronic kidney disease have yet to be conducted. In this Core Curriculum article, established and emerging concepts regarding kidney acid-base regulation and the pathogenesis, risk factors, diagnosis, and management of metabolic acidosis in chronic kidney disease are discussed.
       
  • Repository Corticotropin Versus Glucocorticoid for Nephrotic Syndrome:
           When Will We See the Evidence'
    • Abstract: Publication date: August 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 2Author(s): Daniel M. Hartung, Kirbee Johnston, Atul Deodhar, Dennis N. Bourdette, David M. CohenDespite little evidence supporting its superiority to glucocorticoid therapy, use and expenditures for repository corticotropin (rACTH) injection (H.P. Acthar Gel; Mallinckrodt) have increased dramatically in the last 5 years, particularly among a small number of nephrologists, rheumatologists, and neurologists. Recently, the manufacturer justified the extremely high and rapidly increasing cost of rACTH by citing the ongoing need to generate clinical data to support its use. We test this assertion by investigating the quality and provenance of the evidence likely to emerge in the foreseeable future. We identified all completed, in-progress, and proposed studies of rACTH registered at ClinicalTrials.gov. 75 studies representing 2,953 participants met inclusion criteria. Studies addressed primarily nephrologic (n = 23), rheumatologic (n = 28), and neurologic (n =22) indications. Of the 23 studies proposed for renal indications (enrollment, 33 ± 49 [mean ± SD]), 11 were not randomized, 8 compared only different rACTH treatment regimens, and 4 compared rACTH to placebo. No studies of rACTH proposed for renal indications included an rACTH-free arm receiving active treatment (ie, another form of immunosuppression). We conclude that evidence emerging in the foreseeable future is unlikely to broadly support rACTH use over lower-cost glucocorticoid-based alternatives for renal indications.
       
  • Prevalence and Risk Factors for CKD Among Brickmaking Workers in La Paz
           Centro, Nicaragua
    • Abstract: Publication date: August 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 2Author(s): Lyanne Gallo-Ruiz, Caryn M. Sennett, Mauricio Sánchez-Delgado, Ana García-Urbina, Tania Gámez-Altamirano, Komal Basra, Rebecca L. Laws, Juan José Amador, Damaris Lopez-Pilarte, Yorghos Tripodis, Daniel R. Brooks, Michael D. McClean, Joseph Kupferman, David Friedman, Aurora Aragón, Marvin González-Quiroz, Madeleine K. ScammellRationale & ObjectiveIn Central America, there is a high prevalence of chronic kidney disease (CKD) of nontraditional etiology often observed among agricultural workers. Few studies have assessed CKD prevalence among workers in nonagricultural occupations, which was the objective of this investigation.Study DesignProspective cohort study.Setting & ParticipantsMale and female workers (n = 224) employed by artisanal brickmaking facilities in La Paz Centro, Nicaragua.PredictorsAge, sex, education, smoking status, body mass index, alcohol consumption, water consumption, first-degree relative(s) with CKD, years worked, hours worked per week, job category, study visit (baseline and follow-up), and self-reported hypertension and diabetes.OutcomesCKD defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 at 2 time points 4 months apart and CKD stage.Analytical ApproachA linear mixed-effects model with an unstructured covariance matrix was used to evaluate the association between demographics, occupational risk factors, and eGFR at baseline. The interaction between risk factors and time with change in eGFR was also evaluated. Multivariable logistic regression models were used to evaluate predictors of CKD.ResultsThe CKD prevalence was 12.1% (n = 27), 100% of cases were male, 30% had stage 5 CKD (eGFR < 15 mL/min/1.73 m2), and 22% were younger than 35 years. Proportions of participants with eGFRs < 60 mL/min/1.73 m2 at baseline and follow-up were 13.8% and 15.2%, respectively. Linear regression analysis demonstrated significant predictors of lower kidney function at baseline including oven work, older age, lack of education, and having an immediate family member with CKD. Predictors of CKD identified using logistic regression analysis included oven work and lack of education.LimitationsCrude job classification measures, loss to follow-up, self-reported exposures.ConclusionsThe prevalence of CKD is high in this population of brick workers, suggesting that the epidemic of CKD affecting Mesoamerica is not limited to agricultural workers. These results are consistent with the hypothesis that occupational heat exposure is a risk factor for kidney disease in this region.
       
  • Mineralocorticoid Antagonism and Vascular Function in Early Autosomal
           Dominant Polycystic Kidney Disease: A Randomized Controlled Trial
    • Abstract: Publication date: August 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 2Author(s): Kristen L. Nowak, Berenice Gitomer, Heather Farmer-Bailey, Wei Wang, Mikaela Malaczewski, Jelena Klawitter, Zhiying You, Diana George, Nayana Patel, Anna Jovanovich, Michel ChoncholRationale & ObjectiveVascular dysfunction, characterized by impaired vascular endothelial function and increased large-elastic artery stiffness, is evident early in autosomal dominant polycystic kidney disease (ADPKD) and is an important predictor of cardiovascular events and mortality. Aldosterone excess has been implicated in the development of endothelial dysfunction and arterial stiffness, in part by causing increased oxidative stress and inflammation. We hypothesized that aldosterone antagonism would reduce vascular dysfunction in patients with early-stage ADPKD.Study DesignProspective, randomized, controlled, double-blind, clinical trial.Setting & Participants61 adults aged 20 to 55 years with ADPKD, estimated glomerular filtration rate ≥ 60 mL/min/1.73 m2, and receiving a renin-angiotensin-aldosterone system inhibitor.InterventionSpironolactone (maximum dose, 50 mg/d) or placebo for 24 weeks.OutcomesChange in brachial artery flow-mediated dilation (FMDBA) was the primary end point and change in carotid-femoral pulse-wave velocity (CFPWV) was the secondary end point.Results60 participants completed the trial. Participants had a mean age of 34 ± 10 (SD) years, 54% were women, and 84% were non-Hispanic white. Spironolactone did not change FMDBA (8.0% ± 5.5% and 7.8% ± 4.3% at baseline and 24 weeks, respectively, vs corresponding values in the placebo group of 8.4% ± 6.2% and 8.0% ± 4.6%; P = 0.9 for comparison of change between groups) or CFPWV (640 ± 127 and 603 ± 101 cm/s at baseline and 24 weeks, respectively, vs corresponding values in the placebo group of 659 ± 138 and 658 ± 131 cm/s; P = 0.1). Brachial systolic blood pressure was reduced with spironolactone (median change, −6 [IQR, −15, 1] vs −2 [IQR, −7, 10] mm Hg in the placebo group; P = 0.04). Spironolactone did not change the majority of circulating and/or endothelial cell markers of oxidative stress/inflammation and did not change vascular oxidative stress.LimitationsLow level of baseline vascular dysfunction; lack of aldosterone measurements.Conclusions24 weeks of aldosterone antagonism reduced systolic blood pressure without changing vascular function in patients with early-stage ADPKD.FundingNIDDK, NIH National Center for Advancing Translational Sciences, and the Zell Family Foundation.Trial RegistrationRegistered at ClinicalTrials.gov with study number NCT01853553.
       
  • Predictors of Net Acid Excretion in the Chronic Renal Insufficiency Cohort
           (CRIC) Study
    • Abstract: Publication date: August 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 2Author(s): Landon Brown, Alison Luciano, Jane Pendergast, Pascale Khairallah, Cheryl A.M. Anderson, James Sondheimer, L. Lee Hamm, Ana C. Ricardo, Panduranga Rao, Mahboob Rahman, Edgar R. Miller, Daohang Sha, Dawei Xie, Harold I. Feldman, John Asplin, Myles Wolf, Julia J. Scialla, Lawrence J. Appel, Harold I. Feldman, Alan S. GoRationale & ObjectiveHigher urine net acid excretion (NAE) is associated with slower chronic kidney disease progression, particularly in patients with diabetes mellitus. To better understand potential mechanisms and assess modifiable components, we explored independent predictors of NAE in the CRIC (Chronic Renal Insufficiency Cohort) Study.Study DesignCross-sectional.Setting & ParticipantsA randomly selected subcohort of adults with chronic kidney disease enrolled in the CRIC Study with NAE measurements.PredictorsA comprehensive set of variables across prespecified domains including demographics, comorbid conditions, medications, laboratory values, diet, physical activity, and body composition.Outcome24-hour urine NAE.Analytical ApproachNAE was defined as the sum of urine ammonium and calculated titratable acidity in a subset of CRIC participants. 22 individuals were excluded for urine pH < 4 (n = 1) or ≥7.4 (n = 19) or extreme outliers of NAE values (n = 2). From an analytic sample of 978, we identified the association of individual variables with NAE in the selected domains using linear regression. We estimated the percent variance explained by each domain using the adjusted R2 from a domain-specific model.ResultsMean NAE was 33.2 ± 17.4 (SD) mEq/d. Multiple variables were associated with NAE in models adjusted for age, sex, estimated glomerular filtration rate (eGFR), race/ethnicity, and body surface area, including insulin resistance, dietary potential renal acid load, and a variety of metabolically active medications (eg, metformin, allopurinol, and nonstatin lipid agents). Body size, as indicated by body surface area, body mass index, or fat-free mass; race/ethnicity; and eGFR also were independently associated with NAE. By domains, more variance was explained by demographics, body composition, and laboratory values, which included eGFR and serum bicarbonate level.LimitationsCross-sectional; use of stored biological samples.ConclusionsNAE relates to several clinical domains including body composition, kidney function, and diet, but also to metabolic factors such as insulin resistance and the use of metabolically active medications.Graphical abstractGraphical abstract for this article
       
  • Patient and Clinician Perspectives on Electronic Patient-Reported Outcome
           Measures in the Management of Advanced CKD: A Qualitative Study
    • Abstract: Publication date: August 2019Source: American Journal of Kidney Diseases, Volume 74, Issue 2Author(s): Olalekan Lee Aiyegbusi, Derek Kyte, Paul Cockwell, Tom Marshall, Mary Dutton, Natalie Walmsley-Allen, Anita Slade, Christel McMullan, Melanie CalvertRationale & ObjectiveChronic kidney disease (CKD) can substantially affect patients’ health-related quality of life. Electronic patient-reported outcome measures (ePROMs) may capture symptoms and health-related quality of life and assist in the management of CKD. This study explored patient and clinician views on the use of a renal ePROM system.Study DesignQualitative study.Setting & Participants12 patients with stage 4 or 5 CKD (non–dialysis dependent); 22 clinicians (6 CKD community nurses, 1 clinical psychologist, 10 nephrologists, 3 specialist registrars, and 2 renal surgeons) in the United Kingdom.Analytical ApproachSemi-structured interviews and focus group discussion during which patients received paper versions of the Kidney Disease Quality of Life-36 and the Integrated Patient Outcome Scale-Renal to exemplify the type of content that could be included in an ePROM. Thematic analysis of interview transcripts.Results4 themes were identified: (1) general opinions of PROMs, (2) potential benefits and applications of an ePROM system, (3) practical considerations for the implementation of ePROMs, and (4) concerns, barriers, and facilitators. Patients were willing to complete ePROMs on a regular basis as part of their care despite clinician concerns about patient burden. Patients assessed the questionnaires favorably. Clinicians suggested that the extent of adoption of renal ePROM systems in routine clinical settings should be based on evidence of significant impact on patient outcomes. Clinicians were concerned that an ePROM system may raise patient expectations to unrealistic levels and expose clinicians to the risk for litigation. Patients and clinicians identified potential benefits and highlighted issues and concerns that need to be addressed to ensure the successful implementation of the renal ePROM system.LimitationsTransferability of the findings may be limited because only English-speaking participants were recruited to the study.ConclusionsA renal ePROM system may play a supportive role in the routine clinical management of patients with advanced CKD if the concerns of clinicians and patients can be sufficiently addressed.
       
  • Pathophysiology and Management of Hyperammonemia in Organ Transplant
           Patients
    • Abstract: Publication date: Available online 27 April 2019Source: American Journal of Kidney DiseasesAuthor(s): Harish Seethapathy, Andrew Z. FenvesNeurologic complications are common after solid-organ transplantation, occurring in one-third of patients. Immunosuppression-related neurotoxicity (involving calcineurin inhibitors and corticosteroids), opportunistic central nervous system infections, seizures, and delirium are some of the causes of neurologic symptoms following solid-organ transplantation. An uncommon often missed complication posttransplantation involves buildup of ammonia levels that can lead to rapid clinical deterioration even when treated. Ammonia levels are not routinely checked due to the myriad of other explanations for encephalopathy in a transplant recipient. A treatment of choice for severe hyperammonemia involves renal replacement therapy (RRT), but there are no guidelines on the mode or parameters of RRT for reducing ammonia levels. Hyperammonemia in a transplant recipient poses specific challenges beyond the actual condition because the treatment (RRT) involves significant hemodynamic fluctuations that may affect the graft. In this review, we describe a patient with posttransplantation hyperammonemia and discuss the pathways of ammonia metabolism, potential factors underlying the development of hyperammonemia posttransplantation, and choice of appropriate therapeutic options in these patients.
       
  • Intraperitoneal Cefepime Monotherapy Versus Combination Therapy of
           Cefazolin Plus Ceftazidime for Empirical Treatment of CAPD-Associated
           Peritonitis: A Multicenter, Open-Label, Noninferiority, Randomized,
           Controlled Trial
    • Abstract: Publication date: Available online 19 July 2019Source: American Journal of Kidney DiseasesAuthor(s): Thidarat Kitrungphaiboon, Pongpratch Puapatanakul, Piyatida Chuengsaman, Krittaya Tiskajornsiri, Guttiga Halue, Monchai Siribamrungwong, Saraporn Matayart, Kamonrat Chongthanakorn, Ussanee Poonvivatchaikarn, Chanchana Boonyakrai, Wanida Somboonsilp, Pisut Katavetin, Kearkiat Praditpornsilpa, Somchai Eiam-Ong, David W. Johnson, Talerngsak KanjanabuchRationale & ObjectiveCompared to combination therapy, intraperitoneal (IP) cefepime monotherapy for continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis may provide potential benefits in lowering staff burden, shortening time-consuming antibiotic preparation, and reducing bag contamination risk. This study sought to evaluate whether cefepime monotherapy is noninferior to combination regimens.Study DesignMulticenter, open-label, noninferiority, randomized, controlled trial.Setting & ParticipantsAdult incident peritoneal dialysis (PD) patients with CAPD-associated peritonitis in 8 PD centers in Thailand.InterventionsRandom assignment to either IP monotherapy of cefepime, 1 g/d, or IP combination of cefazolin and ceftazidime, 1 g/d, both given as continuous dosing.OutcomesPrimary end point: resolution of peritonitis at day 10 (primary treatment response). Secondary outcomes: initial response (day 5), complete cure (relapse/recurrence-free response 28 days after treatment completion), relapsing/recurrent peritonitis, and death from any cause. Noninferiority would be confirmed for the primary outcome if the lower margin of the 1-sided 95% CI was not less than −10% for difference in the primary response rate. A 2-sided 90% CI was used to demonstrate the upper or lower border of the 1-sided 95% CI.ResultsThere were 144 eligible patients with CAPD-associated peritonitis, of whom 70 and 74 patients were in the monotherapy and combination-therapy groups, respectively. Baseline demographic and clinical characteristics were not different between the groups. The primary response was 82.6% in the monotherapy group and 81.1% in the combination-therapy group (treatment difference, 1.5%; 90% CI, −9.1% to 12.1%; P = 0.04). There was no significant difference in the monotherapy group compared with the combination-therapy group in terms of initial response rate (65.7% vs 60.8%; treatment difference, 4.9%; 95% CI, −10.8% to 20.6%; P = 0.5) and complete cure rate (80.0% vs 80.6%; treatment difference, −0.6%; 95% CI, −13.9% to 12.8%; P = 0.7). Relapsing and recurrent peritonitis occurred in 4.6% and 4.6% of the monotherapy group and 4.2% and 5.6% of the combination-therapy group (P = 0.9 and P = 0.8, respectively). There was nominally higher all-cause mortality in the monotherapy group (7.1% vs 2.7%; treatment difference, 4.4%; 95% CI, −2.6% to 11.5%), but this difference was not statistically significant (P = 0.2).LimitationNot double blind.ConclusionsIP cefepime monotherapy was noninferior to conventional combination therapy for resolution of CAPD-associated peritonitis at day 10 and may be a reasonable alternative first-line treatment.FundingThis study is supported by The Kidney Foundation of Thailand (R5879), Thailand; Rachadaphiseksompotch Fund (RA56/006) and Rachadaphicseksompotch Endorsement Fund (CU-GRS_61_06_30_01), Chulalongkorn University, Thailand; National Research Council of Thailand (156/2560), Thailand; and Thailand Research Foundation (IRG5780017), Thailand.Trial RegistrationRegistered at ClinicalTrials.gov with study number NCT02872038.
       
  • Dysproteinemia and the Kidney: Core Curriculum 2019
    • Abstract: Publication date: Available online 19 July 2019Source: American Journal of Kidney DiseasesAuthor(s): Jonathan J. Hogan, Miriam Priya Alexander, Nelson LeungDysproteinemic kidney diseases occur when B- or plasma cell clones produce pathogenic monoclonal immunoglobulins or light chains that cause kidney damage. The clinical presentation of these disorders ranges from sub–nephrotic-range proteinuria or microscopic hematuria with preserved kidney function to severe nephrotic syndrome to severe acute kidney injury or rapidly progressive glomerulonephritis. These monoclonal immunoglobulins can cause a variety of histologic patterns of injury, including cast nephropathy, glomerular and tubular deposition diseases, amyloidosis, and inflammatory glomerulonephritis. The underlying clonal disorder may meet criteria for overt multiple myeloma or systemic lymphoma. In recent years, there has been increased recognition and study of dysproteinemic kidney diseases that occur in the setting of smaller clonal plasma and B-cell populations, which are classified as monoclonal gammopathies of renal significance. Regardless of clonal cell burden, the goal of treatment is to achieve a hematologic response (ie, improvement or resolution of the monoclonal protein) by eradicating the underlying clone. Organ-specific responses are dependent on achieving hematologic response. Without appropriate treatment, many of these disorders are associated with high rates of progressive kidney disease and end-stage kidney disease. In this insstallment of AJKD's Core Curriculum in Nephrology, we review the pathogenesis, diagnosis, and treatment of dysproteinemic kidney diseases.
       
  • The Association Between Kidney Disease and Diabetes Remission in Bariatric
           Surgery Patients With Type 2 Diabetes
    • Abstract: Publication date: Available online 19 July 2019Source: American Journal of Kidney DiseasesAuthor(s): Allon N. Friedman, Junyao Wang, Abdus S. Wahed, Neil G. Docherty, Erin Fennern, Alfons Pomp, Jonathan Q. Purnell, Carel W. le Roux, Bruce WolfeRationale & ObjectiveThe association between bariatric surgery, type 2 diabetes, and chronic kidney disease (CKD) is poorly understood. We studied whether remission of type 2 diabetes induced by bariatric surgery influences markers of kidney disease, if CKD is associated with remission of diabetes after bariatric surgery, and if baseline levels of gut hormones and peptides modify these associations.Study DesignProspective observational study.Study Participants737 bariatric surgery patients with type 2 diabetes who participated in a multicenter cohort study for up to 5 years.PredictorsDemographics, blood pressure, medications, type of bariatric surgery, anthropometrics, markers of kidney disease, and circulating levels of gut hormones and peptides.OutcomesEstimated glomerular filtration rate (eGFR), urinary albumin excretion, prognostic risk for CKD, and remission of diabetes.Analytical ApproachLinear mixed models for eGFR; generalized linear mixed models with logit link for albuminuria, prognostic risk for CKD, and diabetes remission.ResultsRemission of diabetes at 5 years post–bariatric surgery was not independently associated with eGFR but was associated with lower risk for moderate/severe increase in albuminuria (risk ratio, 0.66; 95% CI, 0.48-0.90) and stabilization in prognostic risk for CKD. These findings were modified by baseline ghrelin level. Lower preoperative eGFR and greater prognostic risk for CKD were independently associated with reduced likelihood of diabetes remission. The association with preoperative GFR was modified by C-peptide level. Higher baseline circulating ghrelin level was independently associated with a lower prognostic risk for CKD.LimitationsA minority of participants had baseline CKD; lack of comparison group; no information on duration of diabetes, other clinical end points, or kidney biopsy results.ConclusionsRemission of type 2 diabetes 5 years after bariatric surgery was associated with improvements in albuminuria and stabilized prognostic risk for CKD, but not with eGFR. Lower kidney function and greater prognostic risk at the time of bariatric surgery was linked to a lower likelihood of diabetes remission. These results highlight the need to identify the mechanisms through which bariatric surgery may delay the long-term progression of CKD in type 2 diabetes.
       
  • Supplement Use by US Adults With CKD: A Population-Based Study
    • Abstract: Publication date: Available online 18 July 2019Source: American Journal of Kidney DiseasesAuthor(s): Shaheen Kurani, LaTonya J. Hickson, Bjorg Thorsteinsdottir, Erin F. Barreto, Jordan D. Haag, Nilay D. Shah, Rozalina G. McCoy
       
  • Trends in Kidney Function Outcomes Following RAAS Inhibition in Patients
           With Heart Failure With Reduced Ejection Fraction
    • Abstract: Publication date: Available online 11 July 2019Source: American Journal of Kidney DiseasesAuthor(s): Wendy McCallum, Hocine Tighiouart, Elaine Ku, Deeb Salem, Mark J. SarnakRationale & ObjectiveAngiotensin-converting enzyme (ACE) inhibitors are beneficial in heart failure with reduced ejection fraction (HFrEF). We sought to describe longitudinal trends in estimated glomerular filtration rate (eGFR) in HFrEF and how ACE-inhibitor therapy influences these changes.Study DesignPost hoc analysis of trial data.Settings & ParticipantsSymptomatic (Treatment Trial, n = 2,423) and asymptomatic (Prevention Trial, n = 4,094) patients from the Studies of Left Ventricular Dysfunction (SOLVD).ExposureEnalapril versus placebo.OutcomesEarly and long-term eGFR slope (ie, within and after the first 6 weeks) and 4 kidney end points: (1) serum creatinine level increase by ≥0.3 mg/dL, (2) >30% eGFR decline, (3) >40% eGFR decline, and (4) incident eGFR  30%; 2.60 [95% CI, 1.30-5.21] for eGFR decline > 40%; and 4.71 [95% CI, 1.78-12.50] for eGFR 
       
  • Kidney Complications of Immune Checkpoint Inhibitors: A Review
    • Abstract: Publication date: Available online 11 July 2019Source: American Journal of Kidney DiseasesAuthor(s): Roman Shingarev, Ilya G. GlezermanImmunologic control of malignancy has long been recognized as an important determinant of disease progression. Recent advances in immunology have led to the focus on several mechanisms that can be targeted to achieve tumor suppression. In particular, checkpoint inhibition has evolved in less than a decade to become one of the most important strategies in cancer therapy, with a meaningful improvement in patient survival. Six agents have been approved for clinical use to date and many more are in the industry pipeline. The spectrum of malignancies responsive to immunotherapy ranges from advanced melanoma, for which the first immune checkpoint inhibitor ipilimumab was approved, to Hodgkin lymphoma, non–small cell lung cancer, renal cell carcinoma, and others. Notwithstanding its clinical benefits, checkpoint inhibition carries a risk for significant off-target toxicity stemming from the immune system activation. In this review, we discuss general principles of checkpoint inhibition, mechanisms of toxicity, and kidney complications of the treatment and propose diagnostic and treatment strategies when kidney injury occurs.
       
  • Major Advancements in Slowing Diabetic Kidney Disease Progression: Focus
           on SGLT2 Inhibitors
    • Abstract: Publication date: Available online 28 June 2019Source: American Journal of Kidney DiseasesAuthor(s): George L. Bakris
       
  • Glucose Control and the Effect of Empagliflozin on Kidney Outcomes in Type
           2 Diabetes: An Analysis From the EMPA-REG OUTCOME Trial
    • Abstract: Publication date: Available online 27 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Mark E. Cooper, Silvio E. Inzucchi, Bernard Zinman, Stefan Hantel, Maximilian von Eynatten, Christoph Wanner, Audrey Koitka-Weber
       
  • More Evidence to Suggest a Relation of Blood Pressure to Long-term
           Progression of Kidney Disease: Is It Causal'
    • Abstract: Publication date: Available online 27 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Wendy McCallum, Elaine Ku, Mark J. Sarnak
       
  • Are There Consequences of Adolescent Blood Pressure on Kidney Function in
           Adulthood'
    • Abstract: Publication date: Available online 27 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Douglas L. Blowey, Joseph T. Flynn, Bradley A. Warady
       
  • Transplanting the Untransplantable
    • Abstract: Publication date: Available online 27 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Courtenay M. Holscher, Kyle R. Jackson, Dorry L. SegevWith implementation of the Kidney Allocation System, the growth of kidney paired donation programs, and advances in desensitization and immunosuppression, the outlook for “untransplantable” kidney transplantation candidates has never been more promising. The Kidney Allocation System prioritized compatible matches for candidates with calculated panel-reactive antibody levels of 98%, 99%, or 100% and broadened allocation of non-A1 and non–A1-B subgroup kidneys to blood group type B candidates. Concurrently, the growth of kidney paired donation programs and use of incompatible transplantation as part of kidney paired donation to achieve “more compatible” kidney transplantation has improved options for candidates with an incompatible living donor. Finally, advances in desensitization and immunosuppression have strengthened the ability to manage donor-specific antibodies and antibody-mediated rejection. Although no patient should be labeled “untransplantable” due to blood group type or donor-specific antibody, all candidates should be provided with individualized and realistic counseling regarding their anticipated wait times for deceased donor or kidney paired donation matching, with early referral to expert centers when needed. In this Perspective, we consider blood group type ABO incompatibility, HLA antigen incompatibility, antibody-mediated rejection, kidney paired donation, and recent developments in incompatible transplantation in more depth and recommend an approach to the sensitized candidate.
       
  • Second-Chance Placement of Hemodialysis Patients After Involuntary
           Discharge for Disruptive Behavior
    • Abstract: Publication date: Available online 27 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Michael Allon, Denyse Thornley-Brown, Dana V. Rizk, Arlene J. CarrasquilloA small subset of hemodialysis patients exhibits persistently disruptive behavior. When all reasonable attempts to stop such behavior have been exhausted, they may undergo involuntary discharge from their dialysis unit. Such patients typically present repeatedly to the emergency department for urgent inpatient dialysis. We describe a novel approach to achieve a successful “second-chance” placement at a new outpatient dialysis unit. The patients were required to dialyze in the inpatient unit for a minimum of 3 months, during which their compliance and behavior were observed closely. In parallel, an experienced social worker in the emergency department applied a structured protocol. The approach included debriefing about the incident leading to the discharge, coaching about building a trusting relationship with the nephrologist and dialysis staff, education about constructive handling of grievances, and arranging a face-to-face office interview with the medical director to determine their potential acceptance. Finally, the emergency department social worker conducted a formal handoff with the social worker at the accepting facility. During a 4-year period, we accrued 12 patients with an involuntary discharge. Following this protocol, 7 of them have been successfully placed at a new outpatient dialysis unit for 77 to 650 days without recurrence of disruptive behavior.
       
  • Implantable Defibrillators for Primary Prevention of Sudden Death in
           Patients on Dialysis
    • Abstract: Publication date: Available online 27 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Patrick H. Pun, Sana M. Al-Khatib
       
  • Comparative Effectiveness of Medical Therapy, Percutaneous
           Revascularization, and Surgical Coronary Revascularization in
           Cardiovascular Risk Subgroups of Patients With CKD: A Retrospective Cohort
           Study of Medicare Beneficiaries
    • Abstract: Publication date: Available online 27 June 2019Source: American Journal of Kidney DiseasesAuthor(s): David M. Charytan, Tanya Natwick, Craig A. Solid, Shuling Li, Tingting Gong, Charles A. HerzogRationale & ObjectivePrior studies suggesting that medical therapy is inferior to percutaneous (percutaneous coronary intervention [PCI]) or surgical (coronary artery bypass grafting [CABG]) coronary revascularization in chronic kidney disease (CKD) have not adequately considered medication optimization or baseline cardiovascular risk and have infrequently evaluated progression to kidney failure. We compared, separately, the risks for kidney failure and death after treatment with PCI, CABG, or optimized medical therapy for coronary disease among patients with CKD stratified by cardiovascular disease risk.Study DesignRetrospective cohort study.Setting & Participants34,385 individuals with CKD identified from a national 20% Medicare sample who underwent angiography or diagnostic stress testing without (low risk) or with (medium risk) prior cardiovascular disease or who presented with acute coronary syndrome (high risk).ExposuresPCI, CABG, or optimized medical therapy (defined by the addition of cardiovascular medications in the absence of coronary revascularization).OutcomesDeath, kidney failure, composite outcome of death or kidney failure.Analytical ApproachAdjusted relative rates of death, kidney failure, and the composite of death or kidney failure estimated from Cox proportional hazards models.ResultsAmong low-risk patients, 960 underwent PCI, 391 underwent CABG, and 6,426 received medical therapy alone; among medium-risk patients, 1,812 underwent PCI, 512 underwent CABG, and 9,984 received medical therapy alone; and among high-risk patients, 4,608 underwent PCI, 1,330 underwent CABG, and 8,362 received medical therapy alone. Among low- and medium-risk patients, neither CABG (HRs of 1.22 [95% CI, 0.96-1.53] and 1.08 [95% CI, 0.91-1.29] for low- and medium-risk patients, respectively) nor PCI (HRs of 1.14 [95% CI, 0.98-1.33] and 1.02 [95% CI, 0.93-1.12], respectively) were associated with reduced mortality compared with medical therapy, but in low-risk patients, CABG was associated with a higher rate of the composite, death or kidney failure (HR, 1.25; 95% CI, 1.02-1.53). In high-risk patients, CABG and PCI were associated with lower mortality (HRs of 0.57 [95% CI, 0.51-0.63] and 0.70 [95% CI, 0.66-0.74], respectively). Also, in high-risk patients, CABG was associated with a higher rate of kidney failure (HR, 1.40; 95% CI, 1.16-1.69).LimitationsPossible residual confounding; lack of data for coronary angiography or left ventricular ejection fraction; possible differences in decreased kidney function severity between therapy groups.ConclusionsOutcomes associated with cardiovascular therapies among patients with CKD differed by baseline cardiovascular risk. Coronary revascularization was not associated with improved survival in low-risk patients, but was associated with improved survival in high-risk patients despite a greater observed rate of kidney failure. These findings may inform clinical decision making in the care of patients with both CKD and cardiovascular disease.
       
  • Ethical Issues in Pragmatic Cluster-Randomized Trials in Dialysis
           Facilities
    • Abstract: Publication date: Available online 19 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Cory E. Goldstein, Charles Weijer, Monica Taljaard, Ahmed A. Al-Jaishi, Erika Basile, Jamie Brehaut, Charles L. Cook, Jeremy M. Grimshaw, Eduardo Lacson, Craig Lindsay, Meg Jardine, Laura M. Dember, Amit X. GargA pragmatic cluster-randomized trial (CRT) is a research design that may be used to efficiently test promising interventions that directly inform dialysis care. While the Ottawa Statement on the Ethical Design and Conduct of Cluster Randomized Trials provides general ethical guidance for CRTs, the dialysis setting raises additional considerations. In this article, we outline ethical issues raised by pragmatic CRTs in dialysis facilities. These issues may be divided into 7 key domains: justifying the use of cluster randomization, adopting randomly allocated individual-level interventions as a facility standard of care, conducting benefit-harm analyses, gatekeepers and their responsibilities, obtaining informed consent from research participants, patient notification, and including vulnerable participants. We describe existing guidelines relevant to each domain, illustrate how they were considered in the Time to Reduce Mortality in End-Stage Renal Disease (TiME) trial (a prototypical pragmatic hemodialysis CRT), and highlight remaining areas of uncertainty. The following is the first step in an interdisciplinary mixed-methods research project to guide the design and conduct of pragmatic CRTs in dialysis facilities. Subsequent work will expand on these concepts and when possible, argue for a preferred solution.
       
  • Physiology and Pathophysiology of Potassium Homeostasis: Core Curriculum
           2019
    • Abstract: Publication date: Available online 19 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Biff F. Palmer, Deborah J. CleggTotal-body potassium (K+) content and appropriate distribution of K+ across the cell membrane is vitally important for normal cellular function. Total-body K+ content is determined by changes in excretion of K+ by the kidneys in response to intake levels. Under normal conditions, insulin and β-adrenergic tone also make important contributions in maintaining internal distribution of K+. However, despite these homeostatic pathways, disorders of altered K+ homeostasis are common. Appreciating the pathophysiology and regulatory influences that determine the internal distribution and external balance of K+ is critical in designing effective treatments to restore K+ homeostasis. We provide an up-to-date review of the regulatory aspects of normal K+ physiology as a preface to highlighting common disorders in K+ homeostasis and their treatment. This review of K+ homeostasis is designed as a resource for clinicians and a tool for educators who are teaching trainees to understand the pivotal factors involved in K+ balance.
       
  • Direct Delivery of Kidney Transplant Education to Black and Low-Income
           Patients Receiving Dialysis: A Randomized Controlled Trial
    • Abstract: Publication date: Available online 19 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Amy D. Waterman, John Devin Peipert, Anna-Michelle McSorley, Christina J. Goalby, Jennifer L. Beaumont, Leanne PeaceRationale & ObjectiveCompared with others, black and low-income patients receiving dialysis are less likely to receive kidney transplantation (KT) education within dialysis centers. We examined the efficacy of 2 supplementary KT education approaches delivered directly to patients.Study DesignProspective, 3-arm parallel-group, randomized, controlled trial.Settings & ParticipantsAdult, black, and white low-income patients receiving dialysis in Missouri.InterventionPatients were randomly assigned to 1 of 3 educational conditions: (1) standard of care, usual KT education provided in dialysis centers (control); (2) Explore Transplant @ Home patient-guided, 4 modules of KT education sent directly to patients using print, video, and text messages; and (3) Explore Transplant @ Home educator-guided, the patient-guided intervention plus 4 telephonic discussions with an educator.OutcomesPrimary: patient knowledge of living (LDKT) and deceased donor KT (DDKT). Secondary: informed decision making, change in attitudes in favor of LDKT and DDKT, and change in the number of new steps taken toward KT.ResultsIn intent-to-treat analyses, patients randomly assigned to educator- and patient-guided interventions had greater knowledge gains (1.4 point increase) than control patients (0.8 point increase; P = 0.02 and P = 0.01, respectively). Compared with control patients, more patients randomly assigned to educator- and patient-guided interventions were able to make informed decisions about starting KT evaluation (82% vs 91% and 95%; P = 0.003), pursuing DDKT (70% vs 84% and 84%; P = 0.003), and pursuing LDKT (73% vs 91% and 92%; P 
       
  • Genetics of Blood Pressure Regulation: Possible Paths in the Labyrinth
    • Abstract: Publication date: Available online 17 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Luisa Foco, Cristian Pattaro
       
  • Women’s Reproductive Health for the Nephrologist
    • Abstract: Publication date: Available online 17 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Anna Burgner, Michelle A. HladunewichWomen with chronic kidney disease (CKD) are faced with complex decisions and significant challenges during their reproductive years. Contraceptive choices have a variety of side effects that can disproportionately affect women with CKD, limiting choice. CKD itself and the therapies needed to treat severe disease can affect future fertility. When conception is desired, young women with CKD must plan meticulously because an ill-timed pregnancy can result in disease progression or flare and exposure of an unborn child to potentially teratogenic medications. Among women with CKD, pregnancy risks are substantial, with up to 10-fold higher risk for preeclampsia and 6-fold higher risk for preterm delivery. These pregnancy complications associated with inadequate placentation also increase maternal and newborn risks for cardiovascular morbidity and mortality and progression to kidney failure later in life. As such, it is the obligation of every nephrologist caring for women of reproductive age to provide guidance in the choice of methods to prevent unplanned pregnancies, to choose treatments that preserve fertility, and to participate in shared decision making that optimizes pregnancy timing and outcomes. In this perspective, we review the many challenges associated with reproductive counseling in women with CKD.
       
  • Patient-Reported Outcome Measures in CKD Care: The Importance of
           Demonstrating Need and Value
    • Abstract: Publication date: Available online 11 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Meghan J. Elliott, Brenda R. Hemmelgarn
       
  • Catheter Craze Continues for Pediatric Hemodialysis Vascular Access: The
           Need to Move From Catheter First to Catheter Last
    • Abstract: Publication date: Available online 11 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Rudolph P. Valentini, Deepa H. Chand
       
  • Anxiety Symptoms in Patients Treated With Hemodialysis: Measurement and
           Meaning
    • Abstract: Publication date: Available online 11 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Paul L. Kimmel, Daniel Cukor
       
  • Machine Learning in Glomerular Diseases: Promise for Precision Medicine
    • Abstract: Publication date: Available online 11 June 2019Source: American Journal of Kidney DiseasesAuthor(s): Girish N. Nadkarni, Kumardeep Chaudhary, Steven G. Coca
       
  • Toward Developing a Patient-Reported Outcome Measure for Fatigue in
           Hemodialysis
    • Abstract: Publication date: Available online 30 May 2019Source: American Journal of Kidney DiseasesAuthor(s): Devika Nair, Fredric O. Finkelstein
       
  • Association Between Weight Loss Before Deceased Donor Kidney
           Transplantation and Posttransplantation Outcomes
    • Abstract: Publication date: Available online 21 May 2019Source: American Journal of Kidney DiseasesAuthor(s): Meera Nair Harhay, Karthik Ranganna, Suzanne M. Boyle, Antonia M. Brown, Thalia Bajakian, Lissa B. Levin Mizrahi, Gary Xiao, Stephen Guy, Gregory Malat, Dorry L. Segev, David Reich, Mara McAdams-DeMarcoRationale & ObjectiveThere is debate on whether weight loss, a hallmark of frailty, signals higher risk for adverse outcomes among recipients of deceased donor kidney transplantation (DDKT).Study DesignRetrospective cohort study.Setting & ParticipantsUsing national Organ Procurement and Transplantation Network data, we included all DDKT recipients in the United States between December 4, 2004, and December 3, 2014, who were adults (aged ≥ 18 years) when listed for DDKT.ExposuresRelative pre-DDKT weight change as a continuous predictor and categorized as
       
  • Safety and Effectiveness of Bexagliflozin in Patients With Type 2 Diabetes
           Mellitus and Stage 3a/3b CKD
    • Abstract: Publication date: Available online 14 May 2019Source: American Journal of Kidney DiseasesAuthor(s): Andrew S. Allegretti, Wenbin Zhang, Wenjiong Zhou, Tara K. Thurber, Scott P. Rigby, Cynthia Bowman-Stroud, Carlos Trescoli, Pierre Serusclat, Mason W. Freeman, Yuan-Di C. HalvorsenRationale & ObjectiveHyperglycemia exacerbates the progression of chronic kidney disease (CKD), but most glucose-lowering therapies do not address morbidities associated with CKD. Sodium/glucose cotransporter 2 (SGLT2) inhibitors offer potential benefits to patients with diabetes and CKD, but their effectiveness may be diminished with decreased kidney function. We aimed to evaluate the safety and effectiveness of bexagliflozin, a novel SGLT2 inhibitor, in patients with type 2 diabetes and CKD.Study DesignPhase 3, double-blind, placebo-controlled, multicenter, multinational, randomized trial.Setting & Participants54 sites across 4 countries. Patients with CKD stage 3a or 3b, type 2 diabetes mellitus, and hemoglobin A1c level of 7.0% to 10.5% and estimated glomerular filtration rate (eGFR) of 30 to 59 mL/min/1.73 m2 who were taking oral hypoglycemic agents for 8 weeks.InterventionsBexagliflozin, 20 mg, daily versus placebo for 24 weeks.OutcomesPrimary outcome was change in percent hemoglobin A1c from baseline to week 24. Secondary end points included changes in body weight, systolic blood pressure, albuminuria, and hemoglobin A1c level stratified by CKD stage.Results312 patients across 54 sites were analyzed. Bexagliflozin lowered hemoglobin A1c levels by 0.37% (95% CI, 0.20%-0.54%); P 
       
 
 
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