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Over the past 65 years, kidney transplantation has evolved into the optimal treatment for patients with kidney failure, dramatically reducing suffering through improved survival and quality of life. However, access to transplant is still limited by organ supply, opportunities for transplant are inequitably distributed, and lifelong transplant survival remains elusive. To address these persistent needs, the National Kidney Foundation convened an expert panel to define an agenda for future research. The key priorities identified by the panel center on the needs to develop and evaluate strategies to expand living donation, improve waitlist management and transplant readiness, maximize use of available deceased donor organs, and extend allograft longevity. Strategies targeting the critical goal of decreasing organ discard that warrant research investment include educating patients and clinicians about potential benefits of accepting nonstandard organs, use of novel organ assessment technologies and real-time decision support, and approaches to preserve and resuscitate allografts before implantation. The development of personalized strategies to reduce the burden of lifelong immunosuppression and support "one transplant for life" was also identified as a vital priority. The panel noted the specific goal of improving transplant access and graft survival for children with kidney failure. This ambitious agenda will focus research investment to promote greater equity and efficiency in access to transplantation, and help sustain long-term benefits of the gift of life for more patients in need.

Aim Predicting progression in diabetic kidney disease (DKD) is critical to improving outcomes. We sought to develop/validate a machine-learned, prognostic risk score (KidneyIntelX™) combining electronic health records (EHR) and biomarkers. Methods This is an observational cohort study of patients with prevalent DKD/banked plasma from two EHR-linked biobanks. A random forest model was trained, and performance (AUC, positive and negative predictive values [PPV/NPV], and net reclassification index [NRI]) was compared with that of a clinical model and Kidney Disease: Improving Global Outcomes (KDIGO) categories for predicting a composite outcome of eGFR decline of ≥5 ml/min per year, ≥40% sustained decline, or kidney failure within 5 years. Results In 1146 patients, the median age was 63 years, 51% were female, the baseline eGFR was 54 ml min−1 [1.73 m]−2, the urine albumin to creatinine ratio (uACR) was 6.9 mg/mmol, follow-up was 4.3 years and 21% had the composite endpoint. On cross-validation in derivation (n = 686), KidneyIntelX had an AUC of 0.77 (95% CI 0.74, 0.79). In validation (n = 460), the AUC was 0.77 (95% CI 0.76, 0.79). By comparison, the AUC for the clinical model was 0.62 (95% CI 0.61, 0.63) in derivation and 0.61 (95% CI 0.60, 0.63) in validation. Using derivation cut-offs, KidneyIntelX stratified 46%, 37% and 17% of the validation cohort into low-, intermediate- and high-risk groups for the composite kidney endpoint, respectively. The PPV for progressive decline in kidney function in the high-risk group was 61% for KidneyIntelX vs 40% for the highest risk strata by KDIGO categorisation (p event for the high-risk group was 41% (p Conclusions KidneyIntelX improved prediction of kidney outcomes over KDIGO and clinical models in individuals with early stages of DKD. Graphical abstract

Multiple clinical guidelines recommend an ACE (angiotensin-converting enzyme) inhibitor or angiotensin II receptor blocker (ARB) in patients with elevated albuminuria, which can be measured through urine albumin-to-creatinine ratio (ACR), protein-to-creatinine ratio, or dipstick. However, how albuminuria test results relate to the prescription of ACE inhibitor/ARB is uncertain. We identified individuals with an ACR measurement between January 1, 2004, and June 30, 2018, and no contraindications or allergy to ACE inhibitor/ARB. We performed multivariable logistic regression analyses to evaluate the association between ACR level and prescription of ACE inhibitor/ARB within 6 months after the test. We applied similar methods to investigate the association of protein-to-creatinine ratio and dipstick measurement results with the prescription of ACE inhibitor/ARB. Among 67 237 individuals with an ACR measurement, 47.7% were already taking an ACE inhibitor or ARB at the time of first ACR measurement. Among the 35 138 individuals who were not on ACE inhibitor/ARB, those with higher ACR levels were more likely to be prescribed ACE inhibitor/ARB in the following 6 months, with steep increases in prescriptions until ACR 300 mg/g, after which the association plateaued. The majority (80.9%) of ACE inhibitor/ARB prescriptions were made by family medicine and internal medicine. A similar pattern held in the cohorts tested by protein-to-creatinine ratio and dipstick measurement. Our study provides evidence that albuminuria test results change patient care, suggesting that adherence to albuminuria testing is a key step in optimal medical management.

BackgroundHyperkalemia is a potentially life-threatening electrolyte abnormality that often requires urgent treatment. Clinicians should distinguish true hyperkalemia from pseudohyperkalemia and reverse pseudohyperkalemia (RPK). RPK has exclusively been described in case reports of patients with hematologic malignancies (HMs) and extreme leukocytosis [white blood cell (WBC) count >200 × 103/mL].MethodsThis single-center retrospective study analyzed laboratory data from the Mount Sinai Data Warehouse between 1 January 2010 and 31 December 2016 for plasma potassium and serum potassium samples drawn within 1 h of each other, with plasma potassium ≥1 mEq/L of the serum potassium. Only plasma potassium ≥5 mEq/L were included. Samples that were documented to be hemolyzed or contaminated were excluded. Clinical history and laboratory data were collected from the identified cases.ResultsAfter applying the inclusion/exclusion criteria to 485 potential cases, the final cohort included 45 cases from 41 patients. There were 24 men and 17 women with a mean age of 52 years. The median plasma potassium was 6.1 mEq/L and serum potassium was 4.4 mEq/L. The median WBC count was 9.35 × 103/mL (interquartile range 6.5–19.7 × 103/mL). Only 44% of the samples had leukocytosis, defined as WBC >11 × 103/mL.Seven patients had a HM and comprised 11 of the cases (24%) with a median WBC of 181.8 × 103µL. There was no difference in their plasma and serum potassium levels when compared with the total cohort, despite a higher median WBC count. Thirty-eight percent of the cases required medical management.ConclusionsThe literature on RPK is limited to case reports and series associated with extreme leukocytosis. This is the first study characterizing RPK predominantly associated with normal leukocyte counts. Further investigation is required to more precisely characterize factors associated with RPK and to elucidate RPK mechanisms.

Introduction Albuminuria is a sign of kidney disease and associated with adverse outcomes. However, most individuals with albuminuria are unaware of it. The Kidney Disease Screening and Awareness Program (KDSAP) aims for early detection and raising awareness of albuminuria, targeting underserved populations in communities. This study will assess the prevalence and awareness of albuminuria and identify associated risk factors among KDSAP participants. Methods KDSAP participants ≥18 years old without a history of dialysis or kidney transplant were included. Albuminuria was identified by dipstick urinalysis. Individuals with albuminuria who answered yes to either of the following 2 questions were defined as being aware: (i) Have you ever had protein in the urine? (ii) Do you have kidney disease? Results Among 2304 participants, 461 (20.0%) had albuminuria: 16.3% with trace or 1+ (low degree) and 3.7% with 2+ or more (high degree). Correlating factors of albuminuria included young age, male sex, African American descent, self-reported diabetes, hypertension, family history of kidney disease, and smoking. Overall albuminuria awareness was 15.8%, but awareness inversely correlated to younger age groups: 7.0% for ages 18–39 years, 13.5% for ages 40–59 years, and 24.0% for ages ≥60 years (P < 0.001). A high degree of albuminuria (vs. low, odds ratio: 5.04, P < 0.001) and concurrent hematuria (odds ratio: 2.12, P=0.024) were both associated with higher awareness; conversely, risk factors for low awareness included African American and better self-assessments of health. Conclusions There was a high albuminuria prevalence among KDSAP participants, yet low awareness. KDSAP can potentially be a useful model for detecting albuminuria and raising awareness in communities., Graphical abstract

There are limited data evaluating chronic nonsteroidal anti-inflammatory drug (NSAID) exposure and decline in kidney function in primary care practice where rates of NSAID prescribing are high (1,2). The majority of published observational studies have evaluated the association of prescription NSAID use with AKI using claims data in focused geographic areas outside of the United States (1). It is estimated that >36 million Americans use over-the-counter (OTC) NSAIDs and data suggest that many users, regardless of age, exceed the recommended dose (1,3,4). Education materials for prescription ( e.g ., Food and Drug Administration Medication Guide) and OTC (label) NSAIDs have also been noted to have content that is not aligned with the universal precautions for health literacy. Poor literacy around NSAID education materials has been documented among primary care patients with CKD (5). This study sought to evaluate eGFR changes associated with chronic NSAID exposure in a large, geographically vast, primary care cohort using data from the DARTNet Practice Performance Registry receiving prescription and OTC NSAIDs (6). This project was determined to not require oversight by the University of Michigan Institutional Review Board. This determination was based on the fact that the data set analyzed had no protected health information. Eligible patients were ≥18 years old and had at least two eGFR measurements (between 29 ml/min per 1.73 m2) at least 3 months apart. Baseline was defined as the first qualifying eGFR during the study period of January 1, …

Introduction The uptake of the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 chronic kidney disease (CKD) Guideline is not fully described in real-world nephrology practice across the world. Methods We used baseline data from the CKD Outcomes and Practice Patterns Study (2013–2017), a 4-country cohort of patients with estimated glomerular filtration rate, Graphical abstract

Rationale & Objective Patients experience various symptoms during hemodialysis. We aimed to assess the frequency and severity of symptoms during hemodialysis and whether intradialytic symptoms are associated with recovery time postdialysis. Study Design An online questionnaire was sent to 10,000 patients in a National Kidney Foundation database. Setting & Participants Adult patients receiving in-center hemodialysis 3 times weekly for 3 or more months. Exposure Online questionnaire. Analytic Approach Tabulation of frequency and severity of events and recovery time as percent of respondents, construction of a total symptom score, followed by rank correlation analysis of symptom characteristics with total recovery time. Outcomes Patient-reported intradialytic symptoms and recovery time postdialysis. Results 359 patients met screening criteria and completed the questionnaire. Mean age was 62.5 ± 13.8 years, 207 (58%) were men, 74 (21%) were black/African American, 132 (37%) had diabetes, 252 (70%) had hypertension, and 102 (28%) had a history of myocardial infarction, heart surgery, or stent placement. 311 (87%) patients had symptoms during dialysis in the previous week, with mean severity of 2.7 (range for each symptom, 1-5). The most common symptoms were fatigue/feeling washed out (62%), cramps (44%), and symptoms of low blood pressure (42%). Median time to recovery was 3 (range, 0-24) hours, and this correlated with the incidence and severity of intradialytic symptoms (P < 0.0001). 40% of patients had time to recovery times of 4 hours or longer. 1 in 3 patients reported having stopped dialysis early for intradialytic symptoms and 6% reported skipping dialysis at least once because of intradialytic symptoms. Limitations Recall-based self-reported data with a relatively low response rate. Conclusions A majority of patients receiving in-center hemodialysis experience symptoms such as feeling washed out, fatigue, and cramping; these may be severe and are correlated with longer recovery time following hemodialysis, as well as shortened and skipped hemodialysis sessions., Graphical abstract

The primary laboratory tests for diagnosis of chronic kidney disease (CKD)9 are serum/plasma/blood creatinine with calculation of estimated glomerular filtration rate (eGFR) and urine albumin–creatinine ratio (UACR). Cystatin C is becoming a secondary test for estimating eGFR in some clinical situations. Urine total protein and the protein–creatinine ratio are also used to monitor patients with more advanced CKD. The US Renal Data System 2018 reports that data from the National Health and Nutrition Examination Survey provide an estimate that 15% of the US population meet the laboratory criteria for CKD based on the Kidney Disease Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline definition of GFR 30 mg/g (3 mg/mmol). In the years from 2010 to 2018, 80%–90% of laboratories in the US have reported eGFR along with creatinine, yet patient awareness of having CKD continues to be poor. In the 2013–2016 US National Health and Nutrition Examination Survey data, only 8% of people with eGFR 30 mg/g (3 mg/mmol) were aware of having CKD. In this Q&A, a panel of experts in laboratory medicine and in nephrology examine laboratory ordering, testing, and reporting practices and recommend how those practices can be improved to better serve patients with CKD. What is a kidney profile and when should it be ordered? Joseph Vassalotti: The American Diabetes Association, KDIGO, and the National Kidney Foundation (NKF)'s Kidney Disease Outcomes Quality Initiative recommend eGFR and UACR as the tests for CKD targeted for the major risk groups, including diabetes and hypertension. The combination of eGFR and UACR guides therapeutic interventions and predicts risk for CKD progression as well as cardiovascular events, and mortality. The UACR is …

Despite the high prevalence and economic burden of chronic kidney disease (CKD) in the United States, federal funding for kidney-related research, prevention, and education activities under the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) remains substantially lower compared to other chronic diseases. More federal support is needed to promote critical research that will expand knowledge of kidney health and disease, develop new and effective therapies, and reduce health disparities. In 2021, the National Kidney Foundation (NKF) convened 2 Research Roundtables (preclinical and clinical research), comprising nephrology leaders from prominent US academic institutions and the pharmaceutical industry, key bodies with expertise in research, and including individuals with CKD and their caregivers and kidney donors. The goal of these roundtables was to identify priorities for preclinical and clinical kidney-related research. The research priorities identified by the Research Roundtables and presented in this position statement outline attainable opportunities for groundbreaking and critically needed innovations that will benefit patients with kidney disease in the next 5-10 years. Research priorities fall within 4 preclinical science themes (expand data science capability, define kidney disease mechanisms and utilize genetic tools to identify new therapeutic targets, develop better models of human disease, and test cell-specific drug delivery systems and utilize gene editing) and 3 clinical science themes (expand number and inclusivity of clinical trials, develop and test interventions to reduce health disparities, and support implementation science). These priorities in kidney-related research, if supported by additional funding by federal agencies, will increase our understanding of the development and progression of kidney disease among diverse populations, attract additional industry investment, and lead to new and more personalized treatments.

OBJECTIVE An estimated 37 million Americans have chronic kidney disease (CKD). Nearly 90% do not know about their condition because of low awareness about the importance of CKD testing and diagnosis among practitioners and people at risk for CKD. This study uses data from a national clinical laboratory to identify guideline-recommended CKD testing rates across the U.S. RESEARCH DESIGN AND METHODS Patients with Laboratory Corporation of America Holdings (Labcorp) testing between 2013 and 2019 were defined as at risk for CKD if they had any testing ordered with diagnosis codes for diabetes and/or hypertension. Guideline-concordant CKD assessment was defined by estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (uACR) testing within the study year. RESULTS We identified 28,295,982 at-risk patients (mean age 60.6 ± 14.8 years; 53.6% women): 16.2% had diabetes, 63.8% had hypertension, and 20.1% had both comorbidities. Of these, 80.3% did not receive guideline-concordant assessment during the study period. Furthermore, only 21.0% had uACR testing versus 89.6% with eGFR. CKD assessment occurred at least once in 28.7% of patients with diabetes, 10.5% of patients with hypertension, and 41.4% of patients with both conditions. In a state-by-state comparison, annual testing rates ranged from 5 to 30%. The nationwide rate increased modestly each year between 2013 and 2018 (from 10.7% to 15.2%). CONCLUSIONS Despite guideline recommendations, testing for CKD with uACR and eGFR in U.S. adults with diabetes and hypertension is low in routine clinical care. These data highlight the need for strategies to improve routine CKD assessment nationwide.

Background A majority of diabetic kidney disease (DKD) patients receive medical care in the primary care setting, making it an important opportunity to improve patient management. There is limited evidence evaluating whether primary care physicians (PCPs) are equipped to effectively manage these patients in routine clinical practice. The present study was undertaken to identify gaps in primary care and unmet needs in the diagnosis and monitoring of DKD in type 2 diabetes (T2D) patients among PCPs. Methods This was a qualitative analysis based on 30–45-min interviews with PCPs treating T2D patients. PCPs were recruited via email and were board-certified, in practice for more than 3 years, spent most of their time in direct clinical care, and provided care for more than three T2D patients in a week. Descriptive data analysis was conducted to identify and examine themes that were generated by interviews. Two reviewers evaluated interview data to identify themes and developed consensus on the priority themes identified. Results A total of 16 PCPs satisfying the inclusion criteria were recruited for qualitative interviews. Although the PCPs recognized kidney disease as an important comorbidity in T2D patients, testing for kidney disease was not consistently top of mind, with 56% reportedly performing kidney function testing in their T2D patients. PCPs most frequently reported using estimated glomerular filtration rate (eGFR) alone to monitor and stage DKD; only 25% PCPs reported testing for albuminuria. Most PCPs incorrectly believed that a majority of DKD patients are diagnosed in early stages. Also, early stages of DKD emerged as ambiguous areas of decision-making, wherein treatments prescribed greatly varied among PCPs. Lastly, early and accurate risk stratification of DKD patients emerged as the most important unmet need; which, if it could be overcome, was consistently identified by PCPs as a key to monitoring, appropriate nephrologist referrals, and intervening to improve outcomes in patients with DKD. Conclusions Our study highlights important unmet needs in T2D DKD testing, staging, and stratification in the PCP setting that limit effective patient care. Health systems and insurers in the U.S. should prioritize the review and approval of new strategies that can improve DKD staging and risk stratification.

Chronic kidney disease (CKD) causes substantial global morbidity and increases cardiovascular and all-cause mortality. Unlike other chronic diseases with established strategies for screening, there has been no consensus on whether health systems and governments should prioritize early identification and intervention for CKD. Guidelines on evaluating and managing early CKD are available but have not been universally adopted in the absence of incentives or quality measures for prioritizing CKD care. The burden of CKD falls disproportionately upon persons with lower socioeconomic status, who have a higher prevalence of CKD, limited access to treatment, and poorer outcomes. Therefore, identifying and treating CKD at the earliest stages is an equity imperative. In 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a controversies conference entitled "Early Identification and Intervention in CKD." Participants identified strategies for screening, risk stratification, and treatment for early CKD and the key health system and economic factors for implementing these processes. A consensus emerged that CKD screening coupled with risk stratification and treatment should be implemented immediately for high-risk persons and that this should ideally occur in primary or community care settings with tailoring to the local context.

OBJECTIVE Clinical guidelines for people with diabetes recommend chronic kidney disease (CKD) testing at least annually using estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (uACR). We aimed to understand CKD testing among people with type 2 diabetes in the U.S. RESEARCH DESIGN AND METHODS Electronic health record data were analyzed from 513,165 adults with type 2 diabetes receiving primary care from 24 health care organizations and 1,164 clinical practice sites. We assessed the percentage of patients with both one or more eGFRs and one or more uACRs and each test individually in the 1, 2, and 3 years ending September 2019 by health care organization and clinical practice site. Elevated albuminuria was defined as uACR ≥30 mg/g. RESULTS The 1-year median testing rate across organizations was 51.6% for both uACR and eGFR, 89.5% for eGFR, and 52.9% for uACR. uACR testing varied (10th–90th percentile) from 44.7 to 63.3% across organizations and from 13.3 to 75.4% across sites. Over 3 years, the median testing rate for uACR across organizations was 73.7%. Overall, the prevalence of detected elevated albuminuria was 15%. The average prevalence of detected elevated albuminuria increased linearly with uACR testing rates at sites, with estimated prevalence of 6%, 15%, and 30% at uACR testing rates of 20%, 50%, and 100%, respectively. CONCLUSIONS While eGFR testing rates are uniformly high among people with type 2 diabetes, testing rates for uACR are suboptimal and highly variable across and within the organizations examined. Guideline-recommended uACR testing should increase detection of CKD.

Rationale & Objective The Kidney Disease Outcome Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) chronic kidney disease (CKD) classification systems published in 2002 and 2012, respectively, are recommended worldwide and based on strong epidemiologic data. However, their impact on CKD recognition and management is not well evaluated in clinical practice, and we therefore investigated whether they help physicians recognize and appropriately care for patients with CKD. Study Design Randomized vignette experiment with fractional factorial design based on 6 kidney-related scenarios and 3 laboratory presentation methods reflecting the CKD guidelines. Participants evaluated 1 of 3 subsets of the 18 vignettes (ie, 6 vignettes each with 4 answer alternatives). Setting & Participants 249 interns, general practitioners, and residents/fellows attending postgraduate meetings and courses in Norway and the United States. Intervention Kidney-related results (serum creatinine level and urinary albumin excretion) were presented as the “minimal data” (high/low levels), KDOQI-2002 (estimated glomerular filtration rate [eGFR] reported automatically), or KDIGO-2012 (eGFR + albuminuria categorization + risk for complications) laboratory report. Outcome CKD management choice by physicians. Results When kidney laboratory data were presented as the KDOQI-2002 report (automatic eGFR calculation), there was a significantly higher odds for correct patient management decisions compared with the minimal data report (OR, 1.57; P < 0.001). Additional significant improvement was obtained with the KDIGO-2012 report (OR, 2.28 for correct answer vs minimal data report [P < 0.001]; OR, 1.45 compared to KDOQI-2002 report [P = 0.005]). The KDIGO classification system improved physician management in 4 of the 6 clinical scenarios covering a wide range of kidney-related topics. Interaction analysis showed that general practitioners and those with 1 to 3 years of internal medicine experience had the greatest improvements with the new presentation techniques. Limitations Physicians’ management was evaluated by theoretical scenarios rather than direct patient care. Conclusions Automatic GFR estimation, albuminuria categorization, and notification of the associated risk for complications improve most physicians` recognition and management of a wide range of CKD clinical scenarios., Graphical abstract

ImportanceDiabetic kidney disease (DKD) is the leading cause of kidney failure in the United States and predicting progression is necessary for improving outcomes.ObjectiveTo develop and validate a machine-learned, prognostic risk score (KidneyIntelX™) combining data from electronic health records (EHR) and circulating biomarkers to predict DKD progression.DesignObservational cohort studySettingTwo EHR linked biobanks: Mount Sinai BioMe Biobank and the Penn Medicine Biobank.ParticipantsPatients with prevalent DKD (G3a-G3b with all grades of albuminuria (A1-A3) and G1 & G2 with A2-A3 level albuminuria) and banked plasma.Main outcomes and measuresPlasma biomarkers soluble tumor necrosis factor 1/2 (sTNFR1, sTNFR2) and kidney injury molecule-1 (KIM-1) were measured at baseline. Patients were divided into derivation [60%] and validation sets [40%]. The composite primary end point, progressive decline in kidney function, including the following: rapid kidney function decline (RKFD) (estimated glomerular filtration rate (eGFR) decline of ≥5 ml/min/1.73m2/year), ≥40% sustained decline, or kidney failure within 5 years. A machine learning model (random forest) was trained and performance assessed using standard metrics.ResultsIn 1146 patients with DKD the median age was 63, 51% were female, median baseline eGFR was 54 ml/min/1.73 m2, urine albumin to creatinine ratio (uACR) was 61 mg/g, and follow-up was 4.3 years. 241 patients (21%) experienced progressive decline in kidney function. On 10-fold cross validation in the derivation set (n=686), the risk model had an area under the curve (AUC) of 0.77 (95% CI 0.74-0.79). In validation (n=460), the AUC was 0.77 (95% CI 0.76-0.79). By comparison, the AUC for an optimized clinical model was 0.62 (95% CI 0.61-0.63) in derivation and 0.61 (95% CI 0.60-0.63) in validation. Using cutoffs from derivation, KidneyIntelX stratified 46%, 37% and 16.5% of validation cohort into low-, intermediate- and high-risk groups, with a positive predictive value (PPV) of 62% (vs. PPV of 37% for the clinical model and 40% for KDIGO; p < 0.001) in the high-risk group and a negative predictive value (NPV) of 91% in the low-risk group. The net reclassification index for events into high-risk group was 41% (pConclusions and RelevanceA machine learned model combining plasma biomarkers and EHR data improved prediction of progressive decline in kidney function within 5 years over KDIGO and standard clinical models in patients with early DKD.

Background Kidney transplantation remains the optimal therapy for patients with end stage kidney disease (ESKD), though a small fraction of patients on dialysis are on organ waitlists. An important barrier to both preemptive kidney transplantation and successful waitlisting is timely referral to a kidney transplant center. We implemented a quality improvement strategy to improve outpatient kidney transplant referrals in a single center academic outpatient nephrology clinic. Methods Over a 3 month period (July 1–September 30, 2016), we assessed the baseline kidney transplantation referral rate at our outpatient nephrology clinic for patients 18–75 years old with an estimated glomerular filtration rate (eGFR) of less than 20 mL/min/1.73m2 (2 values over 90 days apart). Charts were manually reviewed by two reviewers to look for kidney transplant referrals and documentation of discussions about kidney transplantation. We then performed a root cause analysis to explore potential barriers to kidney transplantation. Our intervention began on July 1, 2017 and included the implementation of a column in the electronic medical record (EMR) which displayed the patient’s last eGFR as part of the clinic schedule. In addition, physicians were given a document listing their patients to be seen that day with an eGFR of 2. Annual education sessions were also held to discuss the importance of timely kidney transplant referral. Results At baseline, 54 unique patients with eGFR ≤20 ml/min/1.73 m2 were identified who were seen in the Clinic between July 1, 2016 and September 30, 2016. 29.6% (16) eligible patients were referred for kidney transplantation evaluation. 69.5% (37) of these patients were not referred for kidney transplant evaluation. 46.3% (25) did not have documentation regarding kidney transplant in the EMR. nephrologist’s most recent note. Following the intervention, 66 unique patients met criteria for eligibility for kidney transplant evaluation. Kidney transplant referrals increased to 60.6% (p Conclusions Our pilot implementation study of a strategy to improve outpatient kidney transplant referrals showed that a free, simple, scalable intervention can significantly improve kidney transplant referrals in the outpatient setting. This intervention targeted the nephrologist’s role in the transplant referral, and facilitated the process of patient recognition and performing the referral itself without significantly interrupting the workflow. Next steps include further investigation to study the impact of early referral to kidney transplant centers on preemptive and living donor kidney transplantation as well as successful waitlisting.

ImportancePreliminary reports indicate that acute kidney injury (AKI) is common in coronavirus disease (COVID)-19 patients and is associated with worse outcomes. AKI in hospitalized COVID-19 patients in the United States is not well-described.ObjectiveTo provide information about frequency, outcomes and recovery associated with AKI and dialysis in hospitalized COVID-19 patients.DesignObservational, retrospective study.SettingAdmitted to hospital between February 27 and April 15, 2020.ParticipantsPatients aged ≥18 years with laboratory confirmed COVID-19ExposuresAKI (peak serum creatinine increase of 0.3 mg/dL or 50% above baseline).Main Outcomes and MeasuresFrequency of AKI and dialysis requirement, AKI recovery, and adjusted odds ratios (aOR) with mortality. We also trained and tested a machine learning model for predicting dialysis requirement with independent validation.ResultsA total of 3,235 hospitalized patients were diagnosed with COVID-19. AKI occurred in 1406 (46%) patients overall and 280 (20%) with AKI required renal replacement therapy. The incidence of AKI (admission plus new cases) in patients admitted to the intensive care unit was 68% (553 of 815). In the entire cohort, the proportion with stages 1, 2, and 3 AKI were 35%, 20%, 45%, respectively. In those needing intensive care, the respective proportions were 20%, 17%, 63%, and 34% received acute renal replacement therapy. Independent predictors of severe AKI were chronic kidney disease, systolic blood pressure, and potassium at baseline. In-hospital mortality in patients with AKI was 41% overall and 52% in intensive care. The aOR for mortality associated with AKI was 9.6 (95% CI 7.4-12.3) overall and 20.9 (95% CI 11.7-37.3) in patients receiving intensive care. 56% of patients with AKI who were discharged alive recovered kidney function back to baseline. The area under the curve (AUC) for the machine learned predictive model using baseline features for dialysis requirement was 0.79 in a validation test.Conclusions and RelevanceAKI is common in patients hospitalized with COVID-19, associated with worse mortality, and the majority of patients that survive do not recover kidney function. A machine-learned model using admission features had good performance for dialysis prediction and could be used for resource allocation.Key PointsQuestionWhat is incidence and outcomes of acute kidney injury (AKI) in patients hospitalized with COVID-19?FindingsIn this observational study of 3,235 hospitalized patients with COVID-19 in New York City, AKI occurred in 46% of patients and 20% of those patients required dialysis. AKI was associated with increased mortality. 44% of patients discharged alive had residual acute kidney disease. A machine learned predictive model using baseline features for dialysis requirement had an AUC Of 0.79.MeaningAKI was common in patients with COVID-19, associated with increased mortality, and nearly half of patients had acute kidney disease on discharge.

BACKGROUND: Effective co-management of patients with chronic kidney disease (CKD) between primary care physicians (PCPs) and nephrologists is increasingly recognized as a key strategy to ensure the delivery of efficient and high-quality CKD care. However, the co-management of patients with CKD remains suboptimal. OBJECTIVE: We aimed to identify PCPs’ perceptions of key barriers and facilitators to effective co-management of patients with CKD at the PCP-nephrology interface. STUDY DESIGN: Qualitative study SETTING AND PARTICIPANTS: Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC; and San Francisco, CA APPROACH: We conducted four focus groups of PCPs. Two members of the research team coded transcribed audio-recorded interviews and identified major themes. KEY RESULTS: Most of the 32 PCPs (59% internists and 41% family physicians) had been in practice for > 10 years (97%), spent ≥ 80% of their time in clinical care (94%), and practiced in private (69%) or multispecialty group practice (16%) settings. PCPs most commonly identified barriers to effective co-management of patients with CKD focused on difficulty developing working partnerships with nephrologists, including (1) lack of timely adequate information exchange (e.g., consult note not received or CKD care plan unclear); (2) unclear roles and responsibilities between PCPs and nephrologists; and (3) limited access to nephrologists (e.g., unable to obtain timely consultations or easily contact nephrologists with concerns). PCPs expressed a desire for “better communication tools” (e.g., shared electronic medical record) and clear CKD care plans to facilitate improved PCP-nephrology collaboration. CONCLUSIONS: Interventions facilitating timely adequate information exchange, clear delineation of roles and responsibilities between PCPs and nephrologists, and greater access to specialist advice may improve the co-management of patients with CKD.

This analysis assessed healthcare costs associated with progression of chronic kidney disease (CKD) in patients with type 2 diabetes (T2D). Adults (90 days later. Non-progression required an eGFR indicating same stage within 12 months and eGFR confirmation of same stage >12 months post-index. Per-patient per-month (PPPM) healthcare costs evaluated from index to the earliest of end of eligibility or data were compared between progressors and non-progressors by baseline CKD Stage, and adjusted costs were compared using multivariate linear regressions. Of the 204,767 patients selected, 4.8% progressed ≥1 CKD Stage within a year. Progressors were older (72.5 vs. 64.5 years), more likely to be female (55.6% vs. 51.2%) and had a higher Diabetes Complications Severity Index (2.12 vs. 1.17) compared to non-progressors. Healthcare costs PPPM for progressors vs. non-progressors were $2,685 vs. $1,659 for baseline normal eGFR, $3,131 vs. $2,003 for G3a, $5,138 vs. $2,396 for G3b and $14,400 vs. $3,475 for G4. Among patients with confirmed progression status, progressors represented 4.1%, 8.5%, 5.5% and 4.2% of those from normal eGFR, G3a, G3b and G4, respectively. Controlling for baseline characteristics, the adjusted incremental post-index healthcare costs associated with progressors were $674 for baseline normal eGFR, $947 for G3a, $2,625 for G3b, and $10,704 for G4. All comparisons tested at p Disclosure L. Blonde: Consultant; Self; Gilead Sciences, Inc., Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi US. Research Support; Self; Janssen Pharmaceuticals, Inc., Lexicon Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi US. Speaker's Bureau; Self; Janssen Pharmaceuticals, Inc., Novo Nordisk Inc., Sanofi US. J.A. Vassalotti: Advisory Panel; Self; Merck & Co., Inc. Consultant; Self; Janssen Pharmaceuticals, Inc., KPMG. D. Pilon: Other Relationship; Self; Janssen Scientific Affairs, LLC., Novartis Pharmaceuticals Corporation. W. Wynant: Consultant; Self; AbbVie Inc., Bristol-Myers Squibb Company, Daiichi Sankyo Company, Limited, Genentech, Inc., GlaxoSmithKline plc., Janssen Scientific Affairs, LLC., Novartis Pharmaceuticals Corporation, Novartis Pharmaceuticals Corporation, Taiho Pharmaceutical Co., Ltd. M. Zhdanava: Other Relationship; Self; Janssen Scientific Affairs, LLC., Novartis Pharmaceuticals Corporation. P. Lefebvre: Research Support; Self; Janssen Scientific Affairs, LLC. J. Voelker: Consultant; Self; Janssen Scientific Affairs, LLC. R. Bailey: Employee; Self; Janssen Scientific Affairs, LLC. Stock/Shareholder; Self; Johnson & Johnson. M. Durkin: Employee; Self; Janssen Scientific Affairs, LLC. Funding Janssen Scientific Affairs, LLC

Author(s): Harding, Kimberly; Mersha, Tesfaye B; Pham, Phuong-Thu; Waterman, Amy D; Webb, Fern A; Vassalotti, Joseph A; Nicholas, Susanne B | Abstract: BackgroundThe persistent challenges of bridging healthcare disparities for African Americans (AAs) in need of kidney transplantation continue to be unresolved at the national level. This healthcare disparity is multifactorial: stemming from limited kidney donors suitable for AAs; inconsistent care coordination and suboptimal risk factor control; social determinants, low socioeconomic status, reduced access to care; and mistrust of clinicians and the healthcare system.SummaryThere are numerous opportunities to significantly lessen the disparities in kidney transplantation for AAs through the following measures: the adoption of new care and patient engagement models that include education, enhanced practice-level cultural sensitivity, and timely referral as well as increased research on the impact of the environment on genetic risk, and implementation of new transplantation-related policies. Key Messages: This systematic review describes pretransplant concerns related to access to kidney transplantation, posttransplant complications, and policy interventions to address the challenging issues associated with kidney transplantation in AAs.

OBJECTIVES The positive predictive value (PPV) of a single assessment of estimated glomerular filtration rate (eGFR) in the diagnosis of chronic kidney disease (CKD) is not known. Our objective was to determine the PPV of a single assessment of eGFR among adults with at least one eGFR

CKD progression is introduced broadly, including definitions to distinguish related conditions (such as rapid CKD progression from AKI), common pathways for loss of kidney function, as well as validated ESRD prediction models to risk stratify patients and populations. Interventions to slow CKD progression are hypertension control in the context of current blood pressure target controversies, use of RAAS blockade for hypertension with albuminuria (A3) or proteinuria, glycemic control in diabetes, diabetic kidney disease therapy with a focus on recent and ongoing interventional trials and alkali therapy for CKD metabolic acidosis. Other less evidenced-based treatments (retrospective and observational trials, as well as secondary outcomes of RCT) to slow CKD progression are also discussed. These include the folic acid supplementation in the deficient population, SGLT-2 inhibitors for type-2 diabetes, intervention for obstructive sleep apnea, prevention of AKI, early nephrology referral and implementation of the multi-disciplinary approach to slowing CKD progression.

Chronic Kidney Disease (CKD), is highly prevalent in the United States. Epidemiological systems for surveillance of CKD rely on data that are based solely on the NHANES survey, which does not include many patients with the most severe and less frequent forms of CKD. We investigated the feasibility of estimating CKD prevalence from the large-scale community disease detection Kidney Early Evaluation and Program (KEEP, n = 127,149). We adopted methodologies from the field of web surveys to address the self-selection bias inherent in KEEP. Primary outcomes studied were CKD Stage 3–5 (estimated glomerular filtration rate [eGFR] 2, and CKD Stage 4-5 (eGFR 2). The unweighted prevalence of Stage 4-5 CKD was higher in KEEP (1.00%, 95%CI: 0.94–1.05%) than in NHANES (0.51%, 95% CI: 0.43–0.59%). Application of a selection model that used variables related to demographics, recruitment and socio-economic factors resulted in estimates similar to NHANES (0.55%, 95% CI: 0.50–0.60%). Weighted prevalence of Stages 3–5 CKD in KEEP was 6.45% (95% CI: 5.70–7.28%) compared to 6.73% (95% CI: 6.30–7.19%) for NHANES. Application of methodologies that address the self-selection bias in the KEEP program may allow the use of this large, geographically diverse dataset for CKD surveillance.

Background: Most people with chronic kidney disease (CKD) are not aware of their condition. Objectives: To assess screening criteria in identifying a population with or at high risk for CKD and to determine their level of control of CKD risk factors. Method: CKD Health Evaluation Risk Information Sharing (CHERISH), a demonstration project of the Centers for Disease Control and Prevention, hosted screenings at 2 community locations in each of 4 states. People with diabetes, hypertension, or aged ≥50 years were eligible to participate. In addition to CKD, screening included testing and measures of hemoglobin A1C, blood pressure, and lipids. ­Results: In this targeted population, among 894 people screened, CKD prevalence was 34%. Of participants with diabetes, 61% had A1C < 7%; of those with hypertension, 23% had blood pressure < 130/80 mm Hg; and of those with high cholesterol, 22% had low-density lipoprotein < 100 mg/dL. Conclusions: Using targeted selection criteria and simple clinical measures, CHERISH successfully identified a population with a high CKD prevalence and with poor control of CKD risk factors. CHERISH may prove helpful to state and local programs in implementing CKD detection programs in their communities.

Introduction: As chronic kidney disease (CKD) is among the most prevalent chronic diseases in the world with various rate of progression among patients, identifying its phenotypic subtypes is important for improving risk stratification and providing more targeted therapy and specific treatments for patients having different trajectories of the disease progression.Problem Definition and Data: The rapid growth and adoption of electronic health records (EHR) technology has created a unique opportunity to leverage the abundant clinical data, available as EHRs, to find meaningful phenotypic subtypes for CKD. In this study, we focus on extracting disease severity profiles for CKD while accounting for other confounding factors.Probabilistic Subtyping Model: We employ a probabilistic model to identify precise phenotypes from EHR data of patients who have chronic kidney disease. Using this model, patient’s eGFR trajectory is decomposed as a combination of four different components including disease subtype effect, covariate effect, individual long-term effect and individual short-term effect.Experimental Results: The discovered disease subtypes obtained by Probabilistic Subtyping Model for CKD are presented and their clinical relevance is analyzed.Discussion: Several clinical health markers that were found associated with disease subtypes are presented with suggestion for further investigation on their use as risk predictors. Several assumptions in the study are also clarified and discussed.Conclusion: The large dataset of EHRs can be used to identify deep phenotypes retrospectively. Directions for further expansion of the model are also discussed.

Author(s): Sperati, C John; Soman, Sandeep; Agrawal, Varun; Liu, Yang; Abdel-Kader, Khaled; Diamantidis, Clarissa J; Estrella, Michelle M; Cavanaugh, Kerri; Plantinga, Laura; Schell, Jane; Simon, James; Vassalotti, Joseph A; Choi, Michael J; Jaar, Bernard G; Greer, Raquel C; National Kidney Foundation Education Committee | Abstract: BackgroundGiven the high prevalence of chronic kidney disease (CKD), primary care physicians (PCPs) frequently manage early stage CKD. Nonetheless, there are challenges in providing optimal CKD care in the primary care setting. This study sought to understand PCPs' perceptions of barriers and facilitators to the optimal management of CKD.Study designMixed methods study.Settings and participantsCommunity-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC and San Francisco, CA.MethodologyWe used a self-administered questionnaire and conducted 4 focus groups of PCPs (n = 8 PCPs/focus group) in each city to identify key barriers and facilitators to management of patients with CKD in primary care.Analytic approachWe conducted descriptive analyses of the survey data. Major themes were identified from audio-recorded interviews that were transcribed and coded by the research team.ResultsOf 32 participating PCPs, 31 (97%) had been in practice for g10 years, and 29 (91%) practiced in a non-academic setting. PCPs identified multiple barriers to managing CKD in primary care including at the level of the patient (e.g., low awareness of CKD, poor adherence to treatment recommendations), the provider (e.g., staying current with CKD guidelines), and the health care system (e.g., inflexible electronic medical record, limited time and resources). PCPs desired electronic prompts and lab decision support, concise guidelines, and healthcare financing reform to improve CKD care.ConclusionsPCPs face substantial but modifiable barriers in providing care to patients with CKD. Interventions that address these barriers and promote facilitative tools may improve PCPs' effectiveness and capacity to care for patients with CKD.

The 3SITES study randomly assigned a nontunneled central venous catheter site in over 3000 adults treated in intensive care units. The subclavian site was associated with a lower rate of short-term complications, including catheter-related bloodstream infection and deep venous thrombosis, compared to the femoral or internal jugular site. Nephrologists should be aware of this study and should continue to advocate for alternatives to subclavian vein catheter placement in patients with chronic kidney disease who are expected to require arteriovenous access for dialysis in the future.

Despite the availability of blood pressure (BP)-lowering medications and dietary education, hypertension is still poorly controlled in the chronic kidney disease (CKD) population. As glomerular filtration rate declines, the number of medications required to achieve BP targets increases, which may lead to reduced patient adherence and therapeutic inertia by the clinician. Home BP monitoring (HBPM) has emerged as a means of improving diagnostic accuracy, risk stratification, patient adherence, and therapeutic intervention. The definition of hypertension by HBPM is an average BP >135/85 mm Hg. Twelve readings over the course of 3-5 days are sufficient for clinical decision making. Diagnostic accuracy is especially important in the CKD population as approximately half of these patients have either white coat hypertension or masked hypertension. Preliminary data suggest that HBPM outperforms office BP monitoring in predicting progression to end-stage renal disease or death. When combined with additional support such as telemonitoring, medication titration, or behavioral therapy, HBPM results in a sustained improvement in BP control. HBPM must be adapted to provide information on the phenomena of nondipping (absence of nocturnal fall in BP) and reverse dipping (paradoxical increase in BP at night). These diurnal patterns are more prevalent in the CKD population and are important cardiovascular risk factors. Ambulatory BP monitoring provides nocturnal BP readings and unlike HBPM may be reimbursed by Medicare when certain criteria are met. Further studies are needed to determine whether HBPM is cost-effective in the current US healthcare system.

Interventional trials of dietary sodium reduction have demonstrated improvements in blood pressure, cardiovascular events, and chronic kidney disease (CKD). Furthermore, public health initiatives to reduce population sodium intake in Finland and Japan have shown similar benefit in blood pressure and stroke reduction. Recent follow-up data from large cohort trials that suggest increased mortality among individuals with lower urinary sodium excretion have generated controversy regarding the optimal sodium intake. This paper reviews the evidence for the reduction of dietary sodium to prevent and manage chronic diseases, including hypertension, cardiovascular disease, and CKD.

Background and objectives Patients on hemodialysis have high 30-day unplanned readmission rates. Using a national all-payer administrative database, we describe the epidemiology of 30-day unplanned readmissions in patients on hemodialysis, determine concordance of reasons for initial admission and readmission, and identify predictors for readmission. Design, setting, participants, & measurements This is a retrospective cohort study using the Nationwide Readmission Database from the year 2013 to identify index admissions and readmission in patients with ESRD on hemodialysis. The Clinical Classification Software was used to categorize admission diagnosis into mutually exclusive clinically meaningful categories and determine concordance of reasons for admission on index hospitalizations and readmissions. Survey logistic regression was used to identify predictors of at least one readmission. Results During 2013, there were 87,302 (22%) index admissions with at least one 30-day unplanned readmission. Although patient and hospital characteristics were statistically different between those with and without readmissions, there were small absolute differences. The highest readmission rate was for acute myocardial infarction (25%), whereas the lowest readmission rate was for hypertension (20%). The primary reasons for initial hospitalization and subsequent 30-day readmission were discordant in 80% of admissions. Comorbidities that were associated with readmissions included depression (odds ratio, 1.10; 95% confidence interval [95% CI], 1.05 to 1.15; P Conclusions In patients with ESRD on hemodialysis, nearly one quarter of admissions were followed by a 30-day unplanned readmission. Most readmissions were for primary diagnoses that were different from initial hospitalization. A small proportion of patients accounted for a disproportionate number of readmissions.

Background: Chronic kidney disease is a progressive disease, which terminates in end-stage renal diseases (ESRD) that requires either dialysis or kidney transplantation for the patient to survive. There is an alarming trend in the disparities of ESRD in African Americans (AAs). Currently, AAs represent more than 30% of incident ESRD cases, yet they constitute 15% of the overall US population. Despite the reductions in mortality, increases in access to patient-centered home dialysis and preemptive kidney transplantation for the overall US ESRD population over the last decade, disparities in the care of AAs with ESRD remain largely unaffected. Summary: This review discusses patient-, community-, and practitioner-related factors that contribute to disparities in ESRD care for AAs. In particular, the review addresses issues related to end-of-life support, the importance of Apolipoprotein-1 gene variants, and the advent of pharmacogenomics toward achieving precision care. The need for accessible clinical intelligence for the ESRD population is discussed. Several interventions and a call to action to address the disparities are presented. Key Messages: Significant disparities in ESRD care exist for AAs. Strategies to enhance patient engagement, education, accountable partnerships, and clinical intelligence may reduce these disparities.

Background: African Americans (AAs) suffer the widest gaps in chronic kidney disease (CKD) outcomes compared to Caucasian Americans (CAs) and this is because of the disparities that exist in both health and healthcare. In fact, the prevalence of CKD is 3.5 times higher in AAs compared to CAs. The disparities exist at all stages of CKD. Importantly, AAs are 10 times more likely to develop hypertension-related kidney failure and 3 times more likely to progress to kidney failure compared to CAs. Summary: Several factors contribute to these disparities including genetic and social determinants, late referrals, poor care coordination, medication adherence, and low recruitment in clinical trials. Key Messages: The development and implementation of CKD-related evidence-based approaches, such as clinical and social determinant assessment tools for medical interventions, more widespread outreach programs, strategies to improve medication adherence, safe and effective pharmacological treatments to control or eliminate CKD, as well as the use of health information technology, and patient-engagement programs for improved CKD outcomes may help to positively impact these disparities among AAs

An arteriovenous fistula (AVF) is the optimal vascular access for hemodialysis (HD), because it is associated with prolonged survival, fewer infections, lower hospitalization rates, and reduced costs. The AVF First breakthrough initiative (FFBI) has made dramatic progress, effectively promoting the increase in the national AVF prevalence since the program's inception from 32% in May 2003 to nearly 60% in 2011. Central venous catheter (CVC) use has stabilized and recently decreased slightly for prevalent patients (treated more than 90 days), while CVC usage in the first 90 days remains unacceptably high at nearly 80%. This high prevalence of CVC utilization suggests important specific improvement goals for FFBI. In addition to the current 66% AVF goal, the initiative should include specific CVC usage target(s), based on the KDOQI goal of less than 10% in patients undergoing HD for more than 90 days, and a substantially improved initial target from the current CVC proportion. These specific CVC targets would be disseminated through the ESRD networks to individual dialysis facilities, further emphasizing CVC avoidance in the transition from advanced CKD to chronic kidney failure, while continuing to decrease CVC by prompt conversion of CVC-based hemodialysis patients to permanent vascular access, utilizing an AVF whenever feasible.

KEEP is the world’s only sustained chronic disease screening and awareness program. Its success is partially attributable to the continued dedication and commitment of stakeholders (the National Kidney Foundation, local affiliates, and the academic community), but also to a unique set of methods that balance detail with simplicity and place efficiency and patient care at a premium. Early access to health care through primary care or nephrology referral is critical to improving CKD-related outcomes. However, our understanding of barriers to such care is limited. KEEP participants appear to experience lack of adequate health care access and nephrology care. This finding may be influenced by the nature of a large-scale screening program dedicated to providing some level of access to participants who are concerned about the personal possibility of CKD. Not surprisingly, we observed a low rate of CKD awareness among participants with CKD newly recognized through the KEEP screening, findings not modified by insurance or prescription drug coverage. However, the strongest association occurred between perceived difficulty obtaining access to care and greater CKD awareness. These findings may partially explain the findings of high-level cardiovascular risk factors and mortality in patients receiving nephrologist care. The KEEP Steering Committee continues to work to expand understanding of barriers to care, awareness of CKD, and measures to improve cardiovascular and renal risk (Figure 1). We anticipate that future findings from our longitudinal program will continue to shape our understanding of CKD and the complex interface between recognition of the disease, navigation of the health care system, and related consequences. Open in a separate window Figure 1 Factors that impact KEEP screening and nephrology care. CKD, chronic kidney disease; KEEP, Kidney Early Evaluation Program. Source of kidney image: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

Background Diabetes is a leading cause of chronic kidney disease (CKD). Whether reclassification of CKD stages based on glomerular filtration rate estimated using the CKD Epidemiology Collaboration (CKD-EPI) equation versus the Modification of Diet in Renal Disease (MDRD) Study equation modifies estimates of prevalent risk factors across stages is unknown. Methods This is a cross-sectional analysis of data from the Kidney Early Evaluation Program (KEEP), a community-based health screening program targeting individuals 18 years and older with diabetes, hypertension, or a family history of diabetes, hypertension, or kidney disease. Of 109,055 participants, 68.2% were women and 31.8% were African American. Mean age was 55.3 ± 0.05 years. Clinical, demographic, and laboratory data were collected from August 2000 through December 2009. Glomerular filtration rate was estimated using the CKD-EPI and MDRD Study equations. Results CKD was present in 25.6% and 23.5% of the study population using the MDRD Study and CKD-EPI equations, respectively. Diabetes was present in 42.4% and 43.8% of participants with CKD, respectively. Prevalent risk factors for diabetes included obesity (body mass index >30 kg/m 2 ), 44.0%; hypertension, 80.5%; cardiovascular disease, 23.2%; family history of diabetes, 55.9%; and dyslipidemia, 43.0%. In a logistic regression model after adjusting for age and other risk factors, odds for diabetes increased significantly compared with no CKD with each CKD stage based on the CKD-EPI equation and similarly with stages based on the MDRD Study equation. Using a CKD-EPI–adjusted model, ORs were: stage 1, 2.08 (95% CI, 1.90-2.27); stage 2, 1.86 (95% CI, 1.72-2.02); stage 3, 1.23 (95% CI, 1.17-1.30); stage 4, 1.69 (95% CI, 1.42-2.03); and stage 5, 2.46 (95% CI, 1.46-4.14). Conclusions Using the CKD-EPI equation led to a lower prevalence of CKD but to similar diabetes prevalence rates associated with CKD across all stages compared with the MDRD Study equation. Diabetes and other CKD risk factor prevalence was increased compared with the non-CKD population.

Background The National Kidney Foundation has recommended that the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation replace the Modification of Diet in Renal Disease (MDRD) Study equation. Before implementing this change in the Kidney Early Evaluation Program (KEEP), we compared characteristics of reclassified individuals and mortality risk predictions using the new equation. Methods Of 123,704 eligible KEEP participants, 116,321 with data available for this analysis were included. Glomerular filtration rate (GFR) was estimated using the MDRD Study (eGFR MDRD ) and CKD-EPI (eGFR CKD-EPI ) equations with creatinine level calibrated to standardized methods. Participants were characterized by eGFR category: >120, 90-119, 60-89, 45-59, 30-44, and 2 . Clinical characteristics ascertained included age, race, sex, diabetes, hypertension, coronary artery disease, congestive heart failure, cerebrovascular disease, peripheral vascular disease, and anemia. Mortality was determined over a median of 3.7 years of follow-up. Results The prevalence of eGFR CKD-EPI 2 was 14.3% compared with 16.8% using eGFR MDRD . Using eGFR CKD-EPI , 20,355 participants (17.5%) were reclassified to higher eGFR categories, and 3,107 (2.7%), to lower categories. Participants reclassified upward were younger and less likely to have chronic conditions, with a lower risk of mortality. A total of 3,601 deaths (3.1%) were reported. Compared with participants classified to eGFR of 45-59 mL/min/1.73 m 2 using both equations, those with eGFR CKD-EPI of 60-89 mL/min/1.73 m 2 had a lower mortality incidence rate (6.4 [95% CI, 5.1-7.7] vs 18.5 [95% CI, 17.1-19.9]). Results were similar for all eGFR categories. Net reclassification improvement was 0.159 ( P Conclusions The CKD-EPI equation reclassifies people at lower risk of CKD and death into higher eGFR categories, suggesting more accurate categorization. The CKD-EPI equation will be used to report eGFR in KEEP.

The asymptomatic nature of chronic kidney disease (CKD) makes explicit screening strategies for individuals at risk as the only means of early detection. This will allow more time for interventions to alter the natural history of the disease by delaying or preventing kidney disease progression and its complications. Patient awareness of CKD remains low. Utilization of CKD tests for patients at risk and interpretation of those tests to detect CKD by primary care physicians remain suboptimal. There is insufficient evidence to support general population screening. Diabetes, hypertension, and age 60 or greater are the primary CKD screening target conditions, based on assessments representative of the general populations in America and Norway. Although cardiovascular disease, family history of CKD, and ethnic and racial minorities are important predictors of CKD risk, they do not contribute significantly beyond the scope of diabetes, hypertension, and older age. Challenges remain to define the roles in the community of the primary physician and nephrologist to implement intensive blood pressure control, use of renin-angiotensin system blockers for proteinuric patients and nephrology referral as indicated. The electronic medical record holds the most promise in CKD screening through improvements in the flow of information and application of clinical decision support.

To address the highly complex interrelated nature of chronic kidney disease (CKD) and diabetes, hypertension, and cardiovascular disease, we examined CKD prevalence by the predictive effect of demographic factors, comorbid conditions, and CKD risk factors by using National Health and Nutrition Examination Survey (NHANES) 1999-2004 data. NHANES is a nationally representative cross-sectional series of surveys with a complex stratified multistage sampling design. NHANES 1999-2004 participants (n = 15,332; ageor = 20 years) were interviewed in their homes and asked to participate in standardized medical examinations in mobile centers and provide samples for laboratory tests. Weighted logistic regression modeling was used to assess the importance of individual CKD risk factors. Multiple logistic regressions were performed on patient cohorts, with increasing levels of CKD severity defined by means of estimated glomerular filtration rate. A branching diagram was constructed to address the distribution of CKD grouped by diabetes, hypertension, and cardiovascular disease status. CKD prevalence increases with age (39.2% for ageor = 60 years). For ages 20 to 59 years, CKD prevalence was greater for participants with diabetes (33.8%) than for those without diabetes (8.2%) and for participants with both diabetes and hypertension (43%) than for diabetic participants without hypertension (25.5%) or nondiabetic participants with hypertension (15.2%). The prevalence was 6.8% for nondiabetic participants without hypertension. Effects of cardiovascular disease are less dramatic when hypertension and diabetes are considered. A CKD screening approach targeting individuals 60 years and older or those with diabetes or hypertension likely would be useful from a public health standpoint.

Few previous studies have reported on the outcome of patients with renal failure (RF) undergoing valvular surgery, particularly with regard to choice of valve prosthesis.We retrospectively analyzed prospectively collected data from 155 patients with RF (mean age 62 +/- 14, 42% female) who underwent left-sided valve surgery from January 1998 to December 2006. Patients were divided into two groups: Group 1 (non-dialysis-dependent renal failure (NDRF); creatinine2.5 mg/dl; n = 47, 40%) and Group 2 (renal failure dialysis (DRF); n = 108, 60%). Mechanical valves were implanted in 50 (32%) patients and bioprostheses in 63 (41%). Isolated mitral valve reconstruction was performed in 27% (n = 42) of patients. Outcome measures included hospital mortality, major postoperative complications, length of hospital stay, discharge planning and late survival.The overall hospital mortality was 19.3% (n = 30) and was not different between Groups 1 (23%) and 2 (18%). Ejection fraction, peripheral vascular disease, aortic valve replacement and reoperation were independent predictors of hospital mortality. One- and five-year survival rates were 74.4 +/- 7.8% and 53.1 +/- 10.1% in Group 1 and 75.8 +/- 4.6% and 49.1 +/- 7.1% in Group 2 (P = ns), respectively. According to the type of prostheses, hospital mortality and freedom from reoperation were similar in patients with mechanical and biological valves. Five-year survival rate was 51 +/- 10.7 for biological valves versus 55 +/- 8.4 for mechanical valves (P = ns).Hospital mortality and morbidity remain high in patients with RF undergoing valvular surgery and it is not different in NDRF and DRF patients. This study suggests that the type of valve prosthesis does not appear to have an impact on early and late survival but is limited by sample size. It may be that bioprostheses should be more widely used in patients with RF requiring valve replacement.

Background and objectives: Despite emerging evidence that preemptive transplantation is the best treatment modality for patients reaching end-stage renal disease (ESRD), it is underutilized. Nephrologists’ views on preemptive transplantation are explored herein. Design, setting, participants, & measurements: A web-based survey elicited barriers to preemptive transplantation as perceived by nephrologists as well as demographic and practice variables associated with a favorable attitude toward preemptive transplantation. Results: Four hundred seventy-six of 5,901 eligible nephrologists responded (8% participation rate). Seventy-one percent of respondents agreed that preemptive transplantation is the best treatment modality for eligible chronic kidney disease (CKD) patients reaching ESRD, 69% reported that late referrals did not allow enough time for patients to be evaluated for preemptive transplantation, and 50% stated that there was too much delay between a patient9s referral and the time the patient was seen at the transplant center. Nephrologists agreed to a lesser extent that they should be held accountable for CKD patients’ education (26%) and preemptive transplant referrals (23%). The most important patient factors considered when deciding not to discuss preemptive transplant were poor health status (70%), lack of compliance (69%), other medical problems (51%), being too old (40%), lack of prescription coverage (37%), and lack of health insurance to cover the costs of the procedure (36%). Conclusions: Surveyed nephrologists consider preemptive transplantation as the optimal treatment modality for eligible patients. Late referral, patient health and insurance status, and delayed transplant center evaluation are perceived as major barriers to preemptive transplantation.