Distinguishing between transient and sustained subtypes of acute kidney injury (AKI) among hospitalized patients is valuable for clinical management and risk stratification. This study developed and validated a pragmatic electronic phenotype (e-phenotype) for the diagnosis, staging, and subtyping of AKI using electronic health record (EHR) data. Development of a computable rule-based algorithm to diagnose, stage, and subtype AKI using longitudinal changes of serum creatinine values recorded in an EHR. Assessment of the test characteristics of these algorithm-based diagnoses was implemented using a set of patients admitted to the emergency department (ED) with or without clinically diagnosed AKI. Validation of AKI diagnoses was implemented in 2 ways: using a set of patients hospitalized for COVID-19 and using a dataset of patients hospitalized for any cause following an ED visit. These analyses examined the associations of AKI stage and subtype with mortality. Assessment of the test characteristics of the algorithm-based diagnoses: 90 ED visits for AKI and 376 visits without clinical evidence of AKI at Columbia University. Validation in the setting of COVID-19: EHR data from 117,514 instances of COVID-19 infection diagnosed at Columbia University Medical Center throughout the pandemic. Validation in the setting of general hospital admissions: 405,467 general hospital admissions at Beth Israel Medical Center in Boston, Massachusetts. The algorithm-based diagnosis, stage, and subtype of AKI were compared with the clinically adjudicated AKI diagnosis, stage, and subtype. AKI detected, staged, and subtyped by an electronic algorithm, and 30-day mortality. The AKI e-phenotype had a positive predictive value of 95.4%, sensitivity of 69.0%, specificity of 99.2%, and overall accuracy of 93.4%. In COVID-19 patients, pre-existing CKD was an independent predictor of AKI. COVID-19-related AKI was associated with mortality in a stage-dependent manner. The subtype of sustained AKI was associated with higher mortality compared with transient AKI within and across all pandemic waves. These results were reproducible in the dataset of patients hospitalized for any condition. Reliance on serum creatinine patterns alone and the inability to incorporate urine output or molecular markers to diagnose and subtype AKI. The AKI e-phenotype is accurate, scalable, and generalizable to diverse EHR datasets with reproducible associations with mortality. Acute kidney injury (AKI) is a common and serious complication in hospitalized patients, but identifying and tracking it accurately in electronic health records is challenging. We developed an algorithm that uses patterns in kidney function test data to detect, classify, and distinguish AKI subtypes. After testing and validating the method, we applied it to 2 large hospital databases: one including patients hospitalized with COVID-19 and another including hospital admissions for any cause. Our approach reliably identified AKI and its association with poor outcomes. Patients with more severe or sustained AKI were more likely to die. This tool may help researchers study kidney injury more consistently across different health care settings.
Glucagon-like peptide 1 (GLP-1) receptor agonist treatment is associated with a lower risk for incident chronic kidney disease (CKD) and death relative to treatment with a dipeptidyl peptidase 4 inhibitor or sulfonylurea. This study examined within class effects of GLP-1 receptor agonists on kidney outcomes in type 2 diabetes mellitus (T2DM) and moderate cardiovascular risk. Retrospective observational study using the target trial emulation framework. This study used claims data from OptumLabs Data Warehouse and 100% sample of Medicare fee-for-service claims. Participants were adults ≥21 years of age, at moderate cardiovascular risk, who filled a new prescription for a GLP-1 receptor agonist between January 1, 2019 and December 31, 2021. GLP-1 receptor agonists dulaglutide, exenatide, liraglutide, or semaglutide. A primary kidney composite outcome inclusive of incident diagnosis codes for CKD stages 3-4 and kidney failure (inclusive of CKD stage 5 and kidney replacement therapy). A secondary kidney composite outcome included the elements of the primary composite outcome plus death from any cause. Components of the kidney composite outcomes were also evaluated independently. Random treatment assignment was emulated using inverse probability of treatment weighting (IPTW) with propensity scores estimated using the SuperLearner ensemble method. Primary analyses were time-to-event models under the intention-to-treat framework using cause-specific IPTW Cox proportional hazards models. There was no difference among dulaglutide, exenatide, liraglutide, and semaglutide with respect to the primary outcome. When compared to dulaglutide and exenatide, semaglutide was associated with a reduced risk for the secondary kidney composite outcome by 8% (HR, 0.92 [95% CI, 0.87-0.97]) and 12% (HR, 0.88 [95% CI, 0.79-0.99]), respectively. Compared to dulaglutide, semaglutide was also associated with reduced risk of death (HR, 0.81 [95% CI, 0.70-0.93]). Potential for residual confounding, lack of hemoglobin A1c and weight data, and uncertainty about the indication for GLP-1 receptor agonist prescriptions. No differences were observed among different GLP-1 receptor agonists for the primary outcome, but semaglutide initiation was associated with a lower risk of the secondary kidney composite outcome and of death. Chronic kidney disease (CKD) is a common complication of diabetes that increases the risk for poor health outcomes. Glucagon-like peptide-1 (GLP-1) receptor agonists were found to improve kidney outcomes in people with type 2 diabetes mellitus (T2DM) and moderate cardiovascular risk when compared with dipeptidyl peptidase-4 inhibitors and sulfonylureas. Although there has been no head-to-head comparison of individual GLP-1 receptor agonists, randomized controlled trials have suggested that there may be variation among members of this drug class on kidney disease outcomes. In this study, we tested whether there were differences in kidney outcomes when comparing individual GLP-1 receptor agonist medications. We found that semaglutide compared favorably to other drugs in the class and may represent the preferred GLP-1 receptor agonist for delaying or preventing CKD in this population.
Patients seen by nephrologists are highly complex, and clinical experience suggests this complexity has increased over time. This study compared temporal trends in the complexity profiles of inpatients seen by nephrologists to those seen by other physicians. Retrospective-cohort study. Adult inpatients hospitalized between 2011 and 2020 in Alberta, Canada. (1) Physician groups involved during hospitalization and (2) calendar time. Ten markers of complexity were evaluated before hospital admission, and 2 outcomes (death and placement in long-term care) were assessed after hospitalization. Generalized linear models to estimate absolute changes over the study period. Between 2011 and 2020, there were 1,621,630 hospital admissions among 971,051 patients. The number of nephrology inpatients seen annually rose by 44%, an increase larger than observed with other specialties (95% CI, 28.9-59.8). The percentage of inpatients seen by nephrologists in 2020 with complexity markers related to the number of specialty caregivers, number of physician caregivers, number of prescriptions, emergency department visits, and number of drug reactions increased by 6.1% (95% CI, 5.0-7.1), 6.0% (95% CI, 4.9-7.1) 1.9% (95% CI, 1.0-2.8), 1.5% (95% CI, 0.9-2.1), and 1.2% (95% CI, 0.4-2.0), respectively. The percentage of inpatients with frailty seen by nephrologists and with low primary-care attachment increased by 5.1% (95% CI, 4.2-6.0) and 3.5% (95% CI, 2.4-4.6), respectively. Except for frailty and number of prescriptions, the magnitude of the increases in these markers was larger for nephrology inpatients than for those cared for by other physicians. Secular changes in complexity were largely due to increases in characteristics other than age. Risks of death or placement in long-term care within 1 year of discharge decreased to a greater extent for inpatients cared for by nephrologists than among those cared for by other physicians. Various markers of patient complexity were not evaluated. Volume and complexity of inpatients cared for by nephrologists have increased over time, a trend not explained by the increasing age of the population. However, the risks of death or need for long-term care fell more among patients cared for by nephrologists. Patients seen by nephrologists are highly complex, and clinical experience suggests that this complexity has increased over time. This study evaluated changes in various markers of patient complexity among hospitalized patients seen by nephrologists in Alberta, Canada, between 2011 and 2020. This study found increasing clinical complexity among patients seen by nephrologists, with changes greater than those observed among patients seen by other physician groups. Despite these changes showing increasing complexity among patients cared for by nephrologists, the risks of death or placement in long-term care within a year of hospital discharge decreased over time, and the decrease was greater among patients seen by nephrologists.
With the demonstrated cardiovascular- and kidney-protective benefits of medications such as sodium/glucose cotransporter 2 inhibitors, renin-angiotensin-aldosterone system inhibitors, and mineralocorticoid receptor antagonists, there are increased rates of initiation and use of combinations of these agents. The same mechanisms that allow for the reduction of glomerular hypertension and blood pressure limit the ability to maintain kidney perfusion in the setting of volume depletion and relative hypotension and, as a result, increase the risk of development of acute kidney injury (AKI) and the severity of AKI. "Sick-day" medication guidance that provides recommendations for holding medications in the setting of illness to mitigate the risk of AKI has not been widely adopted by practitioners. Confusion regarding the criteria to define a sick day, lack of clarity as to how long to hold the medications and when to resume treatment, concerns that this information drives patient hesitancy to use the medications, lack of data demonstrating the benefit of holding medication, and concerns that patients will lose out on the therapeutic benefits of these agents as a result of constant interruption have fueled arguments against the regular use of these sick-day medication guidelines. In this perspective, sick-day medication guidance will be shown to be a valuable tool in counseling patients about the use of medications that reduces the risk of and costs associated with an AKI episode and ultimately promotes more consistent use of these important medications.
Preeclampsia and gestational hypertension affect over 1 in 8 pregnancies in the US. Gestational hypertension differs, in part, from preeclampsia by not being associated with proteinuria. However, it is unclear whether these two conditions differ in their risk of subsequent kidney disease. We studied the postpartum risks of kidney disease, comparing individuals with a history of gestational hypertension to those with prior preeclampsia. Retrospective cohort study. Pregnant patients aged 15 to 54 with in-hospital deliveries in the United States, 2010 to 2020, complicated by a hypertensive disorder of pregnancy and identified in the Healthcare Cost and Utilization Project's Nationwide Readmissions Database. New-onset hypertensive disease in pregnancy, classified either as gestational hypertension, preeclampsia without severe features, or preeclampsia with severe features. Hospital readmissions within one calendar year of delivery for acute or chronic kidney disease. Multivariable Cox proportional hazards regression. 3,425,221 deliveries were complicated by a new onset hypertensive disease of pregnancy. The readmission rate for patients with new hypertensive disease in pregnancy was 1.3% for kidney disease complications. Kidney disease hospitalization rates for gestational hypertension, preeclampsia without severe features, and preeclampsia with severe features were 246, 407, and 648 per 100,000 delivery hospitalizations, respectively. Compared to those with gestational hypertension, preeclampsia without severe features was associated with an increased hazard of any kidney disease (adjusted hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.41-1.71), acute kidney injury (HR 1.49, 95% CI 1.31-1.6), and chronic kidney disease (HR 2.31, 95% CI 1.70-3.13). Compared to gestational hypertension, patients with preeclampsia with severe features had a yet higher hazard of hospitalization for any kidney disease (HR 2.44, 95% CI 2.23-2.68) and chronic kidney disease (HR 6.03, 95% CI 4.54-8.01). Potential underreporting of kidney disease diagnoses and incomplete data on confounders. This population-based study suggests that preeclampsia is associated with a substantial increase in the hazard of subsequent kidney disease compared to gestational hypertension in the first year postpartum. These findings may inform clinical surveillance strategies following the occurrence of hypertensive disorders of pregnancy, in particular, preeclampsia.
The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the KDIGO 2024 Clinical Practice Guideline for the Management of Lupus Nephritis (LN). The management of LN has become increasingly individualized, and treatment options are expanding; for example, since the release of the KDIGO guideline, the US Food and Drug Administration has approved obinutuzumab in addition to belimumab and voclosporin for the treatment of LN, and the enrollment of patients in chimeric antigen receptor (CAR) T-cell therapy clinical trials is changing the treatment landscape for autoimmune diseases including systemic lupus erythematosus. The use of combination therapy and the trend toward lower doses of corticosteroids for LN management are also part of this transformation. The KDOQI work group reviewed the KDIGO guideline statements and practice points and provides perspectives for implementation within the context of clinical practice in the United States. This commentary is the product of the KDOQI work group and presents the recommendations and practice points from the KDIGO guideline, followed by commentary and brief notes on clinical utility, implementation, and challenges.
The impact of iodinated contrast media (ICM) on kidney outcomes remains debated, especially among patients recovering from dialysis-requiring acute kidney injury (AKI-D). Despite apparent clinical recovery, these individuals may remain vulnerable to repeat kidney insults. Retrospective cohort study. Adults recovering from AKI-D were identified using Taiwan's National Health Insurance Research Database between January 2015 and December 2022. Intravenous ICM. The primary kidney event was recurrent treatment with dialysis; the secondary was persistent kidney dysfunction, defined as at least 0.3 mg/dL or 50% increase in serum creatinine from post-AKI recovery levels at one year after index date. Observational analysis using inverse probability of treatment weighting (IPTW) within a target trial emulation framework to compare patients exposed to ICM with unexposed counterparts. Among 23,263 patients recovering from dialysis after AKI-D (mean age, 69.6 years; 58.5 % men), 1,551 (6.7 %) received contrast-enhanced computed tomography in the first 30 days. After IPTW, ICM was independently associated with a higher hazard of recurrent treatment with dialysis (subdistribution hazard ratio (sHR) 1.37 [95 % CI, 1.20-1.56]) and persistent kidney dysfunction (sHR 1.11 [95 % CI, 1.01-1.23]). Generalized-additive modeling showed that the risk for kidney events were greatest when the post-AKI-D estimated glomerular filtration rate (eGFR) fell below 36 mL/min/1.73 m2 in the patients who received contrast, compared with 22.8 mL/min/1.73 m2 in patients who did not. External validation in an independent, multi-hospital cohort of 1,195 AKI-D survivors confirmed the excess risk of kidney events after contrast exposure. The observational nature of this study precludes definitive causal inference. Among adults recently recovering from AKI-D and no longer dependent on dialysis, ICM exposure was associated with an increased risk of a recurrent treatment with dialysis and persistent kidney dysfunction. These findings inform clinical management of these patients and the use of contrast in this high-risk population. The effects of iodinated contrast on kidney function remain controversial and are even less well understood in patients recovering from dialysis-requiring acute kidney injury (AKI-D). In this nationwide observational study using a target trial emulation framework, we evaluated adults with AKI-D whose recovery permitted discontinued dialysis. We found that patients who underwent contrast-enhanced CT scans within 30 days of dialysis cessation were more likely to require dialysis again and to develop persistent kidney dysfunction compared with those who did not receive contrast. These findings suggest that kidney function may remain vulnerable after apparent recovery and support careful consideration of contrast use in this high-risk population.
Administrative health data are increasingly used to identify individuals receiving maintenance dialysis. We systematically reviewed literature on the accuracy of administrative data in recording dialysis treatments and the performance of case definitions for identifying recipients of maintenance dialysis. Systematic review of studies included in MEDLINE and Embase from inception to June 13, 2025. Studies of individuals with kidney failure treated with maintenance dialysis. Studies assessed the accuracy of administrative data in recording dialysis treatments or in identifying recipients of maintenance dialysis. Two investigators independently screened studies and extracted data. Narrative synthesis of study characteristics, data sources, case definitions, and reference standards. Performance metrics included sensitivity, positive predictive value, and F1 score (range of 0-1, the higher the better). Nine studies were included. One study reported high accuracy in documenting initial and 90-day dialysis modalities in claims versus medical records. Eight studies evaluated various case definitions for maintenance dialysis using inpatient data (n = 1), outpatient claims (n = 2), or both (n = 5). Three studies used procedural codes alone, and 5 used procedural and diagnostic codes. Two studies included incident cases only. Reference standards were kidney replacement therapy registries or data from kidney care programs in 7 studies and from medical records in 1. The median positive predictive value was 85.9% (25th and 75th percentiles, 74.4%-92.9%; 37 case definitions), median sensitivity was 75.8% (63.5%-83.8%; 18 case definitions), and median F1 score was 79.5% (70.2%-81.9%; 18 case definitions). Findings were based on studies from high-income countries; lack of studies using contemporary data. Performance of case definitions for identifying maintenance dialysis recipients in administrative data is context-dependent and varies across definitions. Existing definitions may guide the development of updated, locally adapted methods, ideally validated against medical records as the reference standard for future studies. Registered at PROSPERO with identification code CRD42024582507. Administrative health data such as hospital records and billing information are often used to identify individuals receiving long-term dialysis. Different methods have been developed to identify these patients in the data, but it is unclear how accurate these methods are, and a critical assessment of the literature is lacking. We conducted a systematic review to compare the accuracy of these methods. We found that most methods were reasonably accurate, but many were tested using outdated data or were compared against a reference standard, which may not have accurately identified all patients. Our findings inform the development of more reliable methods for accurately identifying dialysis recipients in administrative data and for planning health care services.
A cancer diagnosis is associated with complex risks for patients that may influence survival and access to transplantation. This study characterized the probability and timing of cancer-related death, noncancer death, and transplantation among patients with an incident cancer diagnosis after dialysis initiation. Longitudinal cohort study. In Australia and New Zealand, 2000-2021, 3,052 patients receiving dialysis, identified via the Australia and New Zealand Dialysis and Transplant Registry, with cancer diagnosed after they had started dialysis. Cancer, categorized by type and stage. Transplantation as well as cancer-related death and noncancer death for the 5 most common cancer types. Parametric mixture competing risk models to estimate event probabilities and timing, stratified by age and cancer stage. Among 3,052 dialysis patients with incident cancer followed for a median of 1.3 years after diagnosis, 1,245 died from cancer, 1,127 died from other causes, and 204 received a transplant. The most common cancers were lung (n = 396), colorectal (n = 323), prostate (n = 269), liver (n = 249), and kidney (n = 242). For localized/regional prostate, kidney, and colorectal cancers, the probability of cancer-related death ranged from 0.09 to 0.32 while the probability of noncancer death was higher, ranging from 0.32 to 0.73. In contrast, cancer-related death predominated in the setting of metastatic disease, with a median time to death of 0.1 years for lung and liver cancers. Among patients aged under 70 with localized or regional prostate cancer, the probability of transplantation was 0.60 (95% CI, 0.48-0.71), which exceeded that of cancer-related death, 0.09 (95% CI, 0.06-0.12), and noncancer death, 0.32 (95% CI, 0.23-0.41). Analogous probabilities for kidney cancer were 0.52 (95% CI, 0.43-0.60), 0.12 (95% CI, 0.09-0.16), and 0.36 (95% CI, 0.29-0.43). Among those under 70 years with localized/regional prostate, kidney, or colorectal cancers, the risk of cancer-related death fell below that of noncancer death within 1 year of diagnosis. Data on cancer staging were incomplete, residual confounding, and potential outcome misclassification. Among patients receiving dialysis with a localized or regional cancer diagnosis, the risk of cancer-related death is low and may be exceeded by noncancer mortality within 1 year of the cancer diagnosis. These findings support consideration of earlier transplantation for some patients with cancer and highlight the need for individualized approaches to defining transplant eligibility. People receiving dialysis who develop cancer are often excluded from kidney transplantation because of concerns about cancer-related survival. However, it is unclear how often people with cancer on dialysis die from cancer itself, die from other causes, or receive a transplant. Using registry data from Australia and New Zealand, we examined outcomes after a cancer diagnosis among people already receiving dialysis. We found that for several common cancers diagnosed at an early stage, death from cancer was uncommon and often occurred less frequently than death from other causes. In younger patients with certain cancers, transplantation was more likely than cancer-related death. These findings support earlier and more individualized consideration of transplantation in selected patients with a cancer diagnosis.
Despite growing interest in conservative kidney management (CKM) for older adults with advanced chronic kidney disease (CKD), little is known about the lived experiences of those involved in CKM care. This study aimed to explore the perceptions and experiences of patients, informal caregivers, nephrologists, and healthcare professionals participating in a coordinated home-based CKM pathway in France. Multicenter qualitative study using grounded theory. Participants were recruited from a regional, coordinated home-based CKM pathway involving 20 nephrology centers and a multidisciplinary care network across urban and semi-rural areas in northern France. Semi-structured interviews explored experiential themes and the perceived value of CKM in four stakeholder groups. Analysis used grounded theory with open, axial, and selective coding. Fifty-three participants were interviewed: 12 patients, 12 informal caregivers, 15 nephrologists, and 14 home-care professionals. Three interrelated themes emerged. First, CKM was perceived as a meaningful and legitimate alternative to dialysis, centered on remaining at home, preserving autonomy, and prioritizing quality of life. The decision not to dialyze was usually described as patient-driven and grounded in a rejection of dependence and hospitalization. Second, communication, decision-making, and coordination emerged as central but uneven pillars of the pathway. Introducing conservative care and discussing end-of-life preferences remained difficult, whereas the coordinating nurse consistently appeared as the key structural link between patients, caregivers, nephrologists, and community professionals. Third, informal caregivers occupied a central yet vulnerable position, combining emotional support, practical coordination, and symptom monitoring; although increasingly involved in organizing care, they frequently experienced substantial burden, anticipatory distress, and mutual protective silences within families. Single-region study; limited generalizability; possible selection bias. Conservative kidney management involves complex relational, emotional, and practical dynamics. Incorporating the perspectives of various stakeholders may help optimize coordinated, home-based care pathways tailored to older adults with advanced CKD.
Time in target range (TTR) for systolic blood pressure (SBP) and hemoglobin A1c (HbA1c) integrates information about average and variability of levels over time. Their impact on kidney outcomes has not been fully evaluated. This study aimed to investigate the association of HbA1c-TTR and SBP-TTR, individually and jointly, with kidney outcomes among patients with type 2 diabetes and hypertension. Post hoc observational cohort analysis of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial data. 6,542 ACCORD participants with ≥ 3 HbA1c and SBP measurements during the first 12 months. HbA1c-TTR and SBP-TTR during the first 12 months after randomization, each categorized separately as either 100% or in tertiles among the remaining study participants. In addition, four categories jointly assessing TTR for HbA1c and SBP were created: both HbA1c-TTR and SBP-TTR ≤ 80%, HbA1c-TTR ≤ 80% and SBP-TTR > 80%, HbA1c-TTR > 80% and SBP-TTR ≤ 80%, and both HbA1c-TTR and SBP-TTR > 80%. A composite kidney outcome, defined as incident albuminuria, estimated glomerular filtration rate (eGFR) decline ≥ 40% from baseline, or kidney failure. Associations of HbA1c-TTR and SBP-TTR, individually and in combination with kidney outcomes, were analyzed using Cox proportional hazards models. Compared to HbA1c-TTR of ≤ 49.6% (lowest tertile), HbA1c-TTR of 100% was associated with 20% lower risk of composite kidney outcome (HR 0.80 [95% CI, 0.68-0.94]). Compared to SBP-TTR of ≤ 50.7% (lowest tertile), SBP-TTR of 100% was associated with 32% lower risk of composite kidney outcome (HR 0.68 [95% CI, 0.58-0.80]). Participants with both HbA1c-TTR and SBP-TTR > 80% had a 29% (HR 0.71 [95% CI, 0.61-0.83]) lower risk of the composite kidney outcome compared with participants with both HbA1c-TTR and SBP-TTR ≤ 80%. Limited duration of follow-up and low number of kidney failure events. Longer time with HbA1c and SBP within target range was associated with a lower risk of adverse kidney events.
Pericarditis and pericardial effusions may complicate the clinical course of people with kidney failure receiving dialysis. However, few recent data exist on their incidence or associated outcomes and costs. This study characterized hospitalizations among a nationally representative set of US patients receiving maintenance dialysis who experienced pericarditis or pericardial effusion. Retrospective cohort study. Adults with dialysis-dependent kidney failure, represented in the National Inpatient Sample (NIS) (2016-21), a database of ∼20% of non-federal acute care hospitalizations in the US, with pericarditis or pericardial effusions identified using administrative codes. Calendar year, pericardial drainage procedures, and cardiac tamponade or cardiogenic shock. Trends in in-hospital mortality, costs, and repeat pericardial drainage procedures. Survey methods with weighted least squares regression to characterize trends. Logistic regression for the risk of repeat pericardial drainage. In-hospital mortality was characterized as a proportion of hospital stays. Cost estimation was based on hospitalization charges and cost-to-charge ratios. 18,535 hospitalizations were identified in the NIS sample, representing a total of 92,675 (95% CI, 90,674-94,676) non-federal acute care hospital stays. Mean age was 57 years and 49% were female. Pericardial tamponade or shock was diagnosed in 11.1% (95% CI, 10.6-11.6) of hospitalizations, pericardial drainage procedures were performed in 13.1% (95% CI, 12.6-13.6%), and in-hospital mortality was 7.8% (95% CI, 7.4-8.2%). The counts of hospitalizations increased by an average of 1,370 (95% CI, 1108-1631; P<0.001) per year and percutaneous drainage procedures by an average of 131 (95% CI, 15-246; P=0.04) per year. The rate of hospitalization increased from 2.3 (95% CI, 2.2-2.4) per 100 person-years in 2016 to 3.5 (95% CI, 3.4-3.7) in 2021 (P for trend=0.001). Hospital costs increased from $347 million (95% CI, $316-378 million) in 2016 to $591 million (95% CI, $545-637 million) in 2021 (P=0.001). Administrative data. Hospitalization for pericarditis or pericardial effusion among patients on dialysis have increased in recent years, with a corresponding increase in pericardial drainage procedures. More than 1 in 10 hospitalizations were complicated by tamponade or shock. Identifying actionable drivers of the increase in this morbidity over time warrants further investigation.
Access to kidney transplantation (KT) for Hispanic patients with advanced chronic kidney disease (CKD) is often attributed to spoken languages different from their healthcare providers. Effective communication, however, is not limited to language, and involves consideration of social context and background; and if successful, can lead to better engagement. Understanding patients' perspectives on the communication and engagement with their providers regarding KT may inform clinical practice and this was the objective of this study. Cross-sectional qualitative study SETTING & PARTICIPANTS: Hispanic individuals with advanced CKD who identified Spanish as their primary language. Bilingual staff conducted 1:1 semi-structured interviews using a guide based on published literature on healthcare disparities. Berlo's Communication Framework was used to guide analysis of the interviews. Twenty participants from five states (age 57±11 years, 50% female) were interviewed; 18 were receiving maintenance dialysis, and 11 had diabetes. Participants reported that communication regarding eligibility for KT and the KT process was insufficient to make an informed decision, especially when the information was provided outside of transplant clinic setting. During the discussions for treatment options with their clinical providers, participants experienced inadequate consideration of their socioemotional well-being. Participants often felt that healthcare providers did not provide sufficient information. While discordance in spoken language between patients and clinicians was a barrier, it was largely mitigated by interpreters. Lack of representation from all parts of the country. This study identified several areas of suboptimal patient-provider communication and patient engagement for Hispanic patients with advanced CKD. These findings may inform strategies to improve communication and patient engagement, thereby addressing barriers to accessing KT for Hispanic patients.
The survival benefit of deceased donor kidney transplantation (DDKT) versus continued dialysis among patients aged ≥75 years remains uncertain due to a lack of randomized trials and limitations of observational study. This study estimated the causal effect of DDKT on survival using a target trial emulation. Target trial emulation with sequential trials framework. Transplant-eligible adults aged ≥75 years who initiated dialysis and were listed in the Organ Procurement and Transplantation Network registry (2015-2023) for kidney-only transplantation. DDKT versus remaining on dialysis. Restricted mean survival time (RMST) at 3 and 5 years. The stacked dataset from all auxiliary trials analyzed using weighted Cox proportional hazards regression. Inverse probability of treatment and censoring weights incorporated to address confounding and immortal time bias. Among 2,670 patients (mean age, 76.8 years; 70.7% male; 49% with diabetes), 1,012 (37.9%) received DDKT. The framework generated 511 auxiliary trials with 505,438 person-trial observations. DDKT recipients experienced early mortality risk (HR, 2.29 [95% CI, 1.50-3.49] for days 0-90) transitioning to survival benefit beyond 1 year (HR, 0.34 [95% CI, 0.26-0.45] after 3 years). At 3 years, the break-even point, survival was equivalent between groups (RMST difference, 2.0 days; P = 0.9). By 5 years, DDKT conferred a 111-day survival advantage ([95% CI, 65.6-156.4], P < 0.001). Patients without diabetes experienced a numerically greater benefit than patients with diabetes (133.6 vs 81.2 days; P interaction = 0.3), as did those who received ≥2 years dialysis versus <2 years (156.1 vs 107.9 days; P interaction = 0.3). Unmeasured confounding, generalizability limited to wait-listed patients, most covariates measured at listing rather than updated over time, lack of data on quality of life, symptom burden, or patient-reported outcomes. DDKT confers a survival benefit to wait-listed patients aged ≥75 years although this benefit emerges only after 3 years, providing a critical benchmark for patient counseling. The modest 5-year advantage for DDKT should be weighed against earlier elevated risks of mortality. These findings support individualized decision-making and highlight dialysis as a reasonable alternative to DDKT. Kidney transplantation is the preferred treatment for kidney failure, but whether it benefits patients aged 75 and older remains unclear. Previous studies in this age group have been limited by biased methods. This study used target trial emulation to mimic a randomized trial using national registry data, allowing estimation of transplantation's true effect on patient survival. We found that transplant recipients face a higher mortality risk in the first few months after surgery, but those who survive this early period live longer than patients continuing to receive dialysis. This survival advantage becomes clear after about 3 years of follow-up. These findings can help elderly patients and their nephrologists make more informed decisions and emphasize that age alone should not exclude patients from consideration for kidney transplantation.
Taiwan has the world's highest burden of end-stage kidney disease, and farmers face elevated risk of chronic kidney disease of non-traditional causes (CKDnt). This study explored mechanisms linking heat stress to acute kidney injury (AKI) among agricultural workers. Pre-post study with repeated measures. 119 agricultural workers in Taiwan (2023-2024). Occupational heat stress characterized by the physiological strain index (PSI). Pre- and post-work shift serum creatinine; urine biomarkers, including monocyte chemotactic protein-1 (MCP-1), N-acetyl-beta-D-glucosaminidase (NAG), and 8-hydroxy-2-deoxyguoanosine (8-OHdG); and the renal artery resistance index (RI). AKI was defined as a rise in post-shift serum creatinine of ≥0.3 mg/dL. Difference-in-differences (DiD) analysis to evaluate biomarker changes by AKI status. AKI occurred in 24 participants (20.2%) and was associated with higher peak core temperature and lower post-shift urinary pH (both P = 0.02). Higher PSI was associated with greater declines in eGFR (β = -1.27, P = 0.01). After a single workday under heat stress, the AKI group showed significant increases in urinary NAG/SG (P = 0.008), MCP-1/SG (P = 0.002), and RI (P = 0.03). DiD analysis demonstrated a significantly higher increase in urine NAG (P = 0.04) and MCP-1 (P = 0.001) in the AKI group. Urine acidification was significantly associated with increases in MCP-1/SG (P < 0.001). No information on the persistence of kidney dysfunction after acute declines in post-work kidney function. Heat stress was associated with acute kidney injury accompanied by elevated core temperature, inflammation, urine acidification, and renal ischemia, suggesting potential mechanisms underlying heat-related acute declines in kidney function. Outdoor workers face increasing risks to their kidney health as global temperatures continue to rise. In this study, agricultural workers were followed during a typical summer workday to examine how heat stress affected their kidneys. Before and after work, we measured their physical strain, renal artery resistance, kidney function, and several blood and urine biomarkers. We found that heat exposure was associated with impaired kidney function, with urinary acidification, and with inflammation. These results underscore the need for stronger protection, monitoring, and education for people working in hot environments as extreme heat events become more frequent.
A certain proportion of patients with Mendelian diseases are overlooked, although substantial technical advances in molecular genetics have been achieved. Massively parallel sequencing (MPS) increasingly identifies genetic variants of unknown significance, which may remain clinically unhelpful. Furthermore, difficult niches in the genome exist, which cannot be solved by standard MPS. In the reported family autosomal dominant kidney disease leading to renal failure in middle adulthood runs through the maternal and paternal family. Comprehensive genetic analyses and customized functional evaluation solved the genetic etiologies: autosomal dominant polycystic kidney disease (ADPKD-PKD1, maternal) and autosomal dominant tubulointerstitial kidney disease (ADTKD-UMOD, paternal), with the index patient suffering from both diseases. The pathogenic variant in PKD1 (c.2180T>C, p.(Leu727Pro)) was not identified by exome sequencing (ES) but was unveiled by traditional long-range amplification protocols and whole genome sequencing. The ease of use of MPS increasingly tempts non-specialized genetic laboratories to perform broad analyses of numerous diseases, which in specific cases may worsen the quality of investigations, i.e. for the relatively frequent ADPKD.
Hospital readmissions represent a significant burden for children with chronic kidney disease (CKD), but the epidemiology and drivers of readmission remain poorly understood. We evaluated 30-day all-cause readmission rates among US pediatric patients with kidney disease and examined associations with clinical and social factors. Retrospective cohort study. Children no older than 18 years of age with a diagnosis of CKD discharged from 49 tertiary care centers participating in the Pediatric Health Information System between January 1, 2016, and June 30, 2021. Primary or comorbid CKD identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision diagnostic codes. All-cause 30-day hospital readmission. Multivariable logistic regression adjusting for demographic, clinical, and social factors. Among 48,228 pediatric patients with CKD (median age, 5.8 years [IQR, 1.0-12.5]; 46.7% female; 50.2% non-Hispanic White), 6,172 (12.8%) were readmitted within 30 days. Among children with kidney failure, 22.3% experienced readmission. In adjusted analyses, higher readmission risk was associated with glomerular CKD etiology (OR, 1.34; 95% CI, 1.23-1.46), complex chronic disease (OR, 6.13; 95% CI, 4.53-8.29), increasing illness severity by All Patient Refined Diagnosis-Related Group (OR, 2.10; 95% CI, 1.84-2.40), longer duration of hospital stay (OR, 1.50; 95% CI, 1.39-1.63), and mental health comorbidity (OR, 1.16; 95% CI, 1.03-1.30). CKD-related index admissions were associated with lower odds of readmission (OR, 0.85; 95% CI, 0.80-0.92). Urban residence was independently associated with readmission (OR, 1.18; 95% CI, 1.08-1.29), whereas insurance type, neighborhood income, and Child Opportunity Index were not. Laboratory data were not available. Approximately 1 in 8 children with CKD and 1 in 5 with kidney failure were readmitted within 30 days. Readmission risk was driven primarily by clinical complexity, illness severity, and mental health comorbidity. These findings inform integrated transitional care strategies and targeted interventions addressing medical and behavioral health needs to reduce preventable hospital use in pediatric CKD. Hospital readmissions place a significant burden on children with chronic kidney disease (CKD) and their families. In the United States, approximately 1 in 8 children with CKD and 1 in 5 children with end-stage kidney disease are readmitted to the hospital within 30 days of discharge. Factors associated with these readmissions remain poorly understood. In this study, we examined hospitalizations of children (age ≤18 years) with CKD across 49 hospitals in the United States to identify factors linked to 30-day readmission. Mental health comorbidities, glomerular cause of CKD, greater illness severity, longer initial hospital stays, and urban residence were associated with higher odds of readmission. Identifying children at higher risk of readmission may help improve discharge planning, follow-up care, and support for families.
Kidney disease affects approximately half of patients with multiple myeloma (MM), and kidney failure is associated with poor prognosis. Kidney transplantation is rarely pursued in MM owing to concerns of relapse, infection, and allograft rejection. However, advances in therapy, including B-cell maturation antigen-directed chimeric antigen receptor (CAR) T-cell therapy, have led to deep and durable hematologic responses, creating new opportunities for transplantation in select patients. We report a 71-year-old man with stage III MM and high-risk cytogenetics [del(17p)] who developed end-stage kidney disease requiring hemodialysis during his treatment course. Despite multiple lines of therapy, he had never achieved a deep remission until he received ciltacabtagene autoleucel (cilta-cel) CAR T-cell therapy, which led to minimal residual disease (MRD)-negative disease status. One year following CAR T-cell therapy, he underwent living donor kidney transplantation with basiliximab induction, and tacrolimus/mycophenolate maintenance immunosuppression. His course was complicated by hypogammaglobulinemia, cytopenia, BK viremia, and acute rejection, all managed with immunosuppression adjustment and supportive therapies. At 17 months post-transplant, allograft function remains stable (creatinine 1.8 mg/dL), and he has achieved an MRD-negative, complete hematologic remission. This case highlights both the feasibility and the challenges of kidney transplantation after CAR T-cell therapy in MM.
Peritubular capillary (PTC) rarefaction occurs in chronic kidney disease (CKD), but the independent association of PTC histological features with CKD progression is uncertain. Assessment of this relationship was the principal aim of this study. Historical cohort study. Patients who underwent radical nephrectomy for a kidney tumor. PTC histological features including density, mean area, major axis length, and circularity, were defined in the cortex (excluding regions of interstitial fibrosis and tubular atrophy [IFTA]) and medulla using previously developed deep learning models. Progressive CKD was defined as the composite of dialysis, kidney transplantation, a sustained decline in estimated glomerular filtration rate (eGFR) of ≥30%, or a sustained eGFR <10 mL/min/1.73 m2 that was ≥5 mL/min/1.73 m2 lower that the post-nephrectomy value. Cox proportional hazards analysis where follow-up was censored at death, cancer recurrence, or the last serum creatinine value adjusted for chronic histological changes (IFTA, glomerulosclerosis, arteriosclerosis, and arteriolar hyalinosis), and the CKD risk factors of age, sex, body mass index, hypertension, diabetes, eGFR, and proteinuria. 94 (6.1%) of 1553 patients, followed for a mean of 4.3 years, experienced progressive CKD. A mean of 28,055 PTCs and 332 glomeruli were detected in each wedge section. In cortical and medullary tissue, a lower density of PTCs and PTCs that were more circular and less elongated were associated with progressive CKD in analyses adjusted for kidney function and CKD risk factors. After additional adjustment for chronic histological changes, only cortical PTCs that were more circular and less elongated were associated with progressive CKD. Study limited to patients who underwent a radical nephrectomy for a tumor. Reduction and simplification of the microvasculature in non-scarred regions of cortex and medulla are associated with progressive CKD.
Ketoacidosis is a metabolic state characterized by overproduction and accumulation of ketone bodies (ketoacids), leading to potentially life-threatening drops in blood pH. Common to these disorders is a reduction in the insulin-glucagon ratio signaling a lack of available cellular fuel. This change promotes lipolysis and subsequent hepatic β-oxidation of fatty acids, yielding acetyl-CoA that is converted into ketone bodies (acetoacetate, β-hydroxybutyrate, and acetone). Additionally, increased levels of other counterregulatory hormones (eg, catecholamines, cortisol, and growth hormone) often play a key role in exacerbating ketogenesis and the catabolic state. This core curriculum explores the physiological and pathological spectrum of ketoacidosis, beginning with the benign state of starvation ketosis. Diabetic ketoacidosis is a severe complication of diabetes mellitus resulting from profound absolute or relative insulin deficiency and counterregulatory hormone excess. Other forms discussed include pregnancy-associated ketoacidosis (often triggered by starvation or illness), alcoholic ketoacidosis (resulting from the metabolism of alcohol in association with reduced food intake), ketoacidosis associated with chronic salicylate poisoning, sodium/glucose cotransporter 2 inhibitor-induced ketoacidosis, and development of euglycemic ketoacidosis in patients undergoing continuous kidney replacement therapy. Understanding the distinct pathophysiology of each condition is crucial for accurate diagnosis and timely, targeted therapeutic intervention.