Female Reproductive Health and Contraception Use in CKD: An International Mixed-Methods Study

Blood Pressure Goals: How Low Is Safe in CKD?

Hip fracture is a significant health problem and is associated with increased mortality. Patients with chronic kidney disease (CKD) are more at risk of hip fracture than the general population, but the hip fracture risk is not evident among non-dialysis CKD stage 5 patients. This study aims to assess the risk of hip fracture in patients with non-dialysis CKD stage 5 comparing to those with CKD stages 1–4. Patients with non-dialysis CKD stage 5 and CKD stages 1–4 were retrieved from Taiwan longitudinal health insurance database 2011–2014. All patients were followed to the end of 2018 for the development of hip fractures. We analyze the risk of hip fracture of propensity score-matched patients with CKD stage 5 compared to patients with CKD stages 1–4 using stepwise Cox regression and competing risks regression. We analyzed 5649 propensity score-matched non-dialysis CKD 1–4 patients and non-dialysis CKD 5 patients between 2011 and 2014. All patients were followed to the end of 2018, 229 (4.1%) of CKD 1–4 patients in 21,899 patient-year, and 290 (5.1%) of CKD 5 patients had hip fractures in 18,137 patient-year. CKD 5 patients had a higher risk of hip fracture than patients with CKD stages 1–4. The adjusted HR was 1.53 (95% CI 1.08–1.54) in the Cox regression with adjustments for age, gender, comorbidity, and history of fracture. In the competing risks regression, the subdistribution hazard ratio was 1.29 (95% CI 1.08–1.54). Female gender, age, history of fractures, and Charlson–Deyo comorbidity index were independently associated with increased hip fracture risks. Non-dialysis CKD 5 patients had a higher risk of hip fracture than patients with CKD stages 1–4. This association is independent of patients’ age, female gender, history of fractures, and comorbidities.

Background and Aims Chronic kidney disease (CKD) is often a silent condition, with symptoms typically not appearing until a large proportion of kidney function has been lost. Therapeutic interventions, e.g., disease-modifying medications, blood pressure and diabetes control, and lifestyle changes, can delay CKD progression, particularly if instigated early. However, psychological distress can reduce adherence to interventions. It is important patients are adequately informed about their diagnosis to improve adherence and reduce the impact of distress. Multinational, real-world data on patient experiences with CKD, particularly about clinical management, treatment patterns and quality of life, are limited. This DISCOVER CKD sub-study aimed to capture the emotions elicited by patients at CKD diagnosis and their perceptions of the information received. Method DISCOVER CKD (NCT04034992) is a multinational cohort study that aims tocharacterise the epidemiology of CKD and describe patient characteristics, CKD progression, clinical outcomes, the patient journey, practice patterns, and clinical management. The current analysis includes a subset of patients from the USA, UK, Japan, and Spain, who participated in 1-2-1 telephone interviews about their CKD experience, including their disease journey and interactions with the healthcare system. Interview topics in DISCOVER CKD were informed by a pilot study that utilised data from PatientsLikeMe, an online network for patients to share personal stories and health data. Qualitative interviews, conducted in the local language by trained interviewers, January–June 2023, lasted ∼60–90 minutes. Transcribed interviews were translated into English for coding (MAXQDA Plus 2022 v22.3.0) and analysis. The study received research ethics board approval and all participants provided written informed consent. Results 103 patients (mean age 63.1 years; 42.7% female; 51.5% with type 2 diabetes) were interviewed. Most had CKD stage 3A (22.3%) or 3B (28.2%); 26.2% had stage 4 or 5 no dialysis and 9.7% were stage 4 (n = 1) or 5 on dialysis. Average time since diagnosis was 9.5 years. Over one-third (38.8%; n = 40/103) of participants did not recall any specific symptoms or signs of CKD prior to diagnosis. Of the pre-diagnosis symptoms reported, the most common was fatigue (21.4%; n = 22/103), then high blood pressure (15.5%; n = 16/103) and swelling (11.7%; n = 12/103). With respect to patient experiences, 55.2% (n = 32/58) said they did not feel sufficient information about CKD was provided at diagnosis and 59.2% (n = 45/76) said no information about their CKD stage was shared. Participants felt overwhelmed and confused about the diagnostic process and struggled to understand the information provided to them, including information about kidney function and symptoms. To supplement their understanding, participants reported using additional sources of information, including the internet (52.9%; n = 36/68), other healthcare professionals (HCPs) (19.1%; n = 13/68), books/printed information (11.8%; n = 8/68) and patient support groups (8.8%; n = 6/68). The most common emotions experienced at the time of diagnosis were worry and fear (28.2%; n = 29/103), then shock/surprise (25.2%; n = 26/103) (Figure). For those reporting no reaction (27.2%; n = 28/103), many stated the condition had no discernible effect on their daily lives. Reasons for fear or worry were related to the potential for disease progression. Conclusion Many patients expressed dissatisfaction with the information they received at their CKD diagnosis. This suggests that HCPs could dedicate more time to explaining the diagnosis, the characteristics and severity of CKD, likelihood of progression, and the benefits of self-management and adherence to intervention. This could be particularly important for those without symptoms at the time of diagnosis, and patients who rely on HCPs as their primary source of information. Patients should be asked what information they want to receive and be directed to trusted sources. The diagnostic process was a highly emotional experience for many patients and counselling or psychological therapy should be considered.

Quality of Life and Depression in CKD: Improving Hope and Health

BACKGROUND AND AIMS A frequent complication of chronic kidney disease (CKD) is iron deficiency anaemia. This affects not only patient mortality, morbidity and disease progression, but also quality of life. Patient-related outcome measures and functional status are important measures of assessment in modern research. Evidence from patients with heart failure have demonstrated that treatment of iron deficiency leads to improved functional status, whilst in observational studies in non-dialysis dependent CKD (ND-CKD) iron replenishment has led to improvement in quality of life. As newer intravenous (IV) iron products [e.g. ferric carboxymaltose (FCM) and ferric derisomaltose (FDI)] are now in use, allowing efficacious and quick iron supplementation, a differential effect on phosphate has been noted. Phosphate is a key element involved in energy production and mitochondrial function. Therefore, the comparative effect between such compounds needs to be explored. METHOD The exploratory single-center double-blinded randomized controlled trial ‘Iron and Phosphaturia—ExplorIRON-CKD’ assessed the differential effects of FCM and FDI on fibroblast growth factor 23 and phosphate. Non-dialysis patients with CKD and iron deficiency with/without anaemia defined as serum ferritin <200 µg/L or transferrin saturation ≤ 20% and serum ferritin 200–299 µg/L were recruited and randomized in a 1:1 ratio. Participants received 1000 mg at baseline and 500–1000 mg at 1 month to achieve replenishment. Quality of life was assessed using the Short-Form (SF)-36 questionnaire, whilst fatigue severity was monitored using the fatigue severity scale (FSS) utilizing both a scored questionnaire and a visual analogue scale. Functional status was evaluated using the Duke Activity Status Index (DASI) and the 1-minute-sit-to-stand test at baseline, 1 month, 2 months and 3 months. RESULTS Twenty-six patients were recruited; 14 were randomized to receive FDI and 12 to receive FCM. All patients received at least one iron dose (1000 mg), 10 patients received two FDI doses and 11 received two FCM doses. Quality of life measures (SF-36 and FSS) improved in the whole population and in each IV iron group after 3 months. Seven out of eight of the SF-36 domains improved numerically. Fatigue severity scale scores improved by ∼20% in both groups within 1 month lasting until the end of the study, whilst an improvement in the visual analogue scale was observed, which was greater in the FDI group [FDI: baseline: 3.0 (6.0); 3 months: 7.0 (4.5) versus FCM: baseline: 4.5 (2.0); 3 months: 5.0 (2.5); P-value 3 months: 0.16) (Figure 1). The DASI remained largely unaffected following IV iron. One-minute-sit-to-stand improved in the total population and within each group [mean % change baseline to 3 months: 52.5 (53.7)%], with values remaining higher than baseline throughout the study (Figure 2). No significant differences were found between the two groups in either quality of life or functional status. CONCLUSION In this study, patients with non-dialysis CKD and iron deficiency with/without anaemia who received a high dose of either FDI or FCM had numerical improvements in measures of quality of life and functional status. The beneficial effects on these patient-related outcomes and functional status were similar between the IV iron groups, irrespective of the potential for hypophosphataemia that FCM therapy poses. This may be due to the potential decreased hypophosphataemic effect in CKD, secondary to impaired phosphate excretion. This exploratory study, despite the small sample size highlighting the importance of caution upon generalization of results, suggests that IV iron in non-dialysis CKD is associated with improvement in patient-related outcome measures, likely secondary to improvement in haematinic parameters.

ObjectivesTo investigate the association between chronic kidney disease (CKD) and dementia diagnosis in a real-world primary care setting in England.DesignMatched cohort study.SettingsEnglish primary care in the Clinical Practice Research Datalink.ParticipantsPeople...

Objective: To analyze diagnosis rate of chronic kidney disease (CKD) in hospitalized pediatric patients in a single center and understand pediatricians' awareness of CKD. Methods: This was a cross-sectional study. Children who were admitted to the Division of Pediatric Nephrology, Peking University First Hospital from January 1, 2008 to December 31, 2017 and met the diagnostic criteria of CKD (kidney disease: improving global outcomes 2012 guideline) were recruited. A total of 4 472 cases were enrolled. Original CKD diagnosis was collected from the home page of medical records. Actual CKD diagnosis was validated and corrected by reviewing medical records and recalculating glomerular filtration rate. The diagnosis rate and influencing factors of pediatric CKD, the distribution and etiology of actual CKD were analyzed. The comparison between groups were performed with χ(2) test. Results: In 4 472 cases, there were 3 470 cases in actual CKD stage 1, among which only 24 cases were in original CKD stage 1. There were 543 cases in actual CKD stage 2-3, among which only 181 cases were in original CKD stage 2-3. Three hundred and one cases were in actual CKD stage 4-5, including 290 cases in original CKD stage 4-5. In addition, there were 43 cases with unknown CKD stage and 115 cases with acute kidney injury. Compared to original CKD diagnosis, the diagnosis rates of CKD stage 1-5 were 0.7% (24/3 470), 16.7% (58/348), 63.1% (123/195), 90.7% (78/86) and 98.6% (212/215), respectively. The proportions of actual CKD stage 1-5 were 80.4% (3 470/4 314), 8.1% (348/4 314), 4.5% (195/4 314), 2.0% (86/4 314) and 5.0% (215/4 314). The etiology of actual CKD included primary glomerular disease (62.2%, 2 686/4 314), secondary glomerular disease (19.7%, 849/4 314), hereditary kidney disease (9.1%, 391/4 314), congenital abnormalities of the kidney and urinary tract (CAKUT) (3.1%, 135/4 314), tubulointerstitial disease (2.2%, 94/4 314) and etiology uncertain (2.1%, 89/4 314). The leading cause of end stage renal disease was etiology uncertain (31.1%, 67/215), followed by hereditary kidney disease (24.2%, 52/215), CAKUT (16.3%, 35/215) and primary glomerular disease (16.3%, 35/215). Conclusions: Among actual CKD hospitalized pediatric patients, the diagnosis rate of CKD given by physicians at discharge was relatively low, especially patients in earlier CKD stages, which reflected serious lack of physicians' awareness of CKD.

Abstract. The purpose of the study was to establish an ultrasonographic picture of the upper urinary system in cats with chronic kidney disease at different stages and their prognostic significance. Research methods. The study involved 40 cats of different sex, age and breed with an established diagnosis of chronic kidney disease from stage 1 to stage 4, 10 animals in each group. The staging of the stage was based on the concentration of the serum creatinine level. All animals underwent ultrasonographic examination of the urinary system on the ChisonQBit 11 apparatus with a high-frequency linear sensor in longitudinal and cross sections. The nature of structural changes in the kidneys as a result of ultrasonographic examination were correlated with the stage of the disease. Scientific novelty. Chronic kidney disease is one of the most common pathologies in cats older than 7 years. The disease is progressive, which proves the need for early detection and preparation of therapeutic and diagnostic measures to prolong and improve the life of the animal. Ultrasound diagnostics is included in the diagnostic plan, which allows to identify animals with structural changes in the kidneys, but is not decisive in the diagnosis and stage of chronic kidney disease in cats. Results. In cats at stage 1 of chronic kidney disease, ultrasound changes in the structure of the kidneys were absent in 60 % of cases, ultrasound signs of polycystic and hyperechogenic medullary rim (ring) were detected in 10 % of cases. In cats at stage 2, ultrasound changes of the kidneys were absent in 30 % of cases, signs of nephrolithiasis (concretions in the projection of the pelvis without signs of obstruction) were found in 20 % of cases, and signs of nephrosclerosis/hypoplasia unilaterally were found in 10 % of cases. At stage 3, diffuse kidney changes were detected in 100 % of cases, signs of nephrosclerosis/hypoplasia in 40 % of cases, nephrolithiasis in 20 %, polycystic disease in 10 % of cases. At stage 4, diffuse changes were present in 100 %, signs of nephrosclerosis/hypoplasia in 30 %, and nephrolithiasis in 10 % of cases. Thus, there are no specific signs that allow us to establish the stage of chronic kidney disease in cats according to the results of ultrasonographic examination.

Patients with non-dialysis chronic kidney disease (CKD) are at greater risk of early mortality and decreased physical function with an advance in the stage of CKD. However, the effect of exercise in these patients is unclear. This meta-analysis aimed to determine the effects of physical exercise training on the risk of mortality, kidney and physical functions, and adverse events in patients with non-dialysis CKD. The meta-analysis conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement and the Cochrane Handbook recommendations. On 16 August 2019, the PubMed, CINAHL, Cochrane Library databases, and Embase were electronically searched, with no restrictions for date/time, language, document type, or publication status, for eligible randomized controlled trials (RCTs) investigating the effects of exercise on mortality and kidney and physical function in patients with non-dialysis CKD. Eighteen trials (28 records), including 848 patients, were analyzed. The effects of exercise on all-cause mortality and estimated glomerular filtration rate were not significantly different from that of usual care. Exercise training improved peak/maximum oxygen consumption compared to usual care. Regular exercise improves physical and walking capacity for patients with non-dialysis CKD. Effect on leg muscle strength was unclear.

Background: Controlling blood pressure is critical for patients with non-dialysis chronic kidney disease to prevent the rapid progression to end-stage renal disease and sudden cardiac death. However, only a limited number of these patients achieve the blood pressure target. No previous study has been observed to evaluate the status of blood pressure control and its determinants among Myanmar patients with non-dialysis chronic kidney disease.Purpose: This study aimed to identify the rate of blood pressure control and its determinants among patients with non-dialysis chronic kidney disease in Myanmar.Methods: A total of 150 patients with non-dialysis chronic kidney disease attending the clinics at a tertiary hospital in Myanmar participated in this cross-sectional, correlational predictive study. They were recruited by a convenience sampling method. Data were collected by using Sodium Consumption Behavior Questionnaire, Family-Friends Support Subscale and Doctor-Health Care Team Support Subscale of Chronic Illness Resources Survey, demographic and clinical characteristics data form, and by measuring blood pressure against the target level of less than 130/80 mmHg. Descriptive statistics, Chi-square, Fisher’s exact test, and binary logistic regression analysis were performed.Results: Only 44% of the participants had their blood pressure controlled. Overweight (OR=0.170, 95% CI: 0.058-0.495), obese (OR=0.071, 95% CI: 0.017-0.305), and chronic kidney disease stage 5 (OR=0.070, 95% CI: 0.020-0.244) were the determinants associated with poorly controlled blood pressure. Low sodium consumption behavior (OR=9.065, 95% CI: 3.251-25.277) and high family support (OR=7.799, 95% CI: 2.738-22.215) were the determinants associated with well-controlled blood pressure.Conclusion: The blood pressure control rate in Myanmar patients with non-dialysis chronic kidney disease was suboptimal. Determinant findings serve as an input to endorse family-based lifestyle modification interventions such as weight control and low sodium dietary for optimizing blood pressure control. Further investigation of other determinants and of lifestyle intervention programs is warranted.

On Being Better Kidney Doctors: Understanding Trajectories, Probabilities, Predictability, and People

4539 Background: VHL disease is an inherited condition associated with tumors in multiple organs; RCC may affect up to 70% of patients with VHL. Patients often need many tumor reduction procedures (TRP) to manage renal neoplasms. This study evaluated TRP treatment patterns, costs, and complications among patients with VHL-RCC. Methods: Using an algorithm based on VHL manifestations, patients with VHL were identified from the Optum Clinformatics claims database. Patients were then selected with a prior RCC diagnosis. Minimum continuous enrollment of 12 months before and 3 months after first observed RCC diagnosis was required. TRPs for RCC included nephrectomy, renal ablation, and cryotherapy. Time to first TRP from initial observed RCC diagnosis was estimated using Kaplan-Meier analysis. Mean hospitalization costs per TRP type were estimated. Costs associated with TRP complications were estimated via linear regression; the explanatory variable was the presence of a given complication. Short-term complications were evaluated for 4 weeks post-TRP; long-term ones were evaluated over 6 months. Renal function was evaluated using chronic kidney disease (CKD) stages before and after TRPs, using diagnosis codes and eGFR lab values. Results: 160 patients with VHL-RCC were identified; mean follow-up time was 34.1 months. 115 (71.8%) patients incurred ≥1 RCC TRP over their study period. 68.4% had a TRP in the first year after RCC diagnosis and 76.5% had TRPs by year 5. Of the 125 observed TRPs, 97 (77.6%) were nephrectomies and 28 (22.4%) were ablation/cryotherapy. The mean costs for nephrectomy were nominally higher vs. ablation/cryotherapy ($29,313 vs. $18,290). The most common short-term complications were respiratory related (20.8%) and vascular injury/anemia (13.6%). The most common long-term complications were CKD stage 1-5 (24.0%) and end-stage renal disease (chronic dialysis dependence) (4.0%). The most expensive complications were related to impaired renal function: acute renal failure ($21,013 over 4 weeks), CKD ($26,032 over 6 months) and end stage renal disease ($65,338 over 6 months). At baseline, the proportion of patients with a diagnosis of CKD ≥ stage 3 was similar between patients who had TRPs (n = 115) and those who did not have TRPs (n = 45): 24.3% and 24.4%, respectively. After the first TRP, the proportion of patients with CKD ≥ stage 3 increased from 24.3% to 41.7%. Conclusions: Patients with VHL-RCC incur a significant clinical and economic burden related to TRPs for managing their renal tumors. This is in addition to the burden that VHL-RCC patients incur from the management of other VHL tumors. This study underscores the need for novel effective therapies to prevent or delay the recurrence of VHL-related renal neoplasms to mitigate the burden of morbidity and long-term medical management related to VHL.

BackgroundWe sought to study longer term survival in patients with aortic stenosis (AS) and nondialysis chronic kidney disease (CKD).Methods and ResultsWe studied 839 patients (aged 78±9 years and 51% male) with CKD and AS on echocardiogram from 2005 to 2012. Longer term all‐cause and cardiovascular mortality was compared with a CKD group without AS, propensity matched for age, sex, race, left ventricular ejection fraction and CKD stage. Cox models were used to evaluate all‐cause mortality and competing‐risks regression models censored at time of aortic valve replacement to evaluate cardiac mortality in patients with AS and CKD. Overall, 511 (61%), 252 (30%), and 76 (9%) patients had CKD stages 3a, 3b, and 4, respectively; 93% had hypertension, 28% had diabetes mellitus, and 37% had coronary artery disease. In total, 185 (22%) had mild AS, 355 (42%) had moderate AS, and 299 (36%) had severe AS (66 symptomatic). Patients with CKD and AS had higher cardiac and all‐cause mortality compared with controls with CKD and no AS (P<0.001). Among patients with AS and CKD, there were 156 (19%) aortic valve replacements and 454 (54%) deaths (203 cardiac deaths) at 4.0±2.3 years of follow‐up. Lower estimated glomerular filtration rate (hazard ratio per 10 mL/min per 1.73 m2: 1.18; 95% CI, 1.08–1.29) was associated with increased risk of all‐cause mortality but not cardiac mortality (hazard ratio: 1.12; 95% CI, 0.97–1.30; P=0.13). Of patients undergoing aortic valve replacement, 61% had improvement in estimated glomerular filtration rate within 1 year (median percentage change=+2.8% per month).ConclusionsAmong patients with nondialysis CKD, AS is associated with significantly higher cardiac and all‐cause mortality; lower estimated glomerular filtration rate is associated with increased mortality, and aortic valve replacement was associated with improved survival.

Using GFR, Albuminuria, and Their Changes in Clinical Trials and Clinical Care

Consensus document. Recommendations on assessing proteinuria during the diagnosis and follow-up of chronic kidney disease.