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Home dialysis modalities (home hemodialysis [HD] and peritoneal dialysis [PD]) are associated with greater patient autonomy and treatment satisfaction compared with in-center modalities, yet the level of home-dialysis use worldwide is low. Reasons for limited utilization are context-dependent, informed by local resources, dialysis costs, access to healthcare, health system policies, provider bias or preferences, cultural beliefs, individual lifestyle concerns, potential care-partner time, and financial burdens. In May 2021, KDIGO (Kidney Disease: Improving Global Outcomes) convened a controversies conference on home dialysis, focusing on how modality choice and distribution are determined and strategies to expand home-dialysis use. Participants recognized that expanding use of home dialysis within a given health system requires alignment of policy, fiscal resources, organizational structure, provider incentives, and accountability. Clinical outcomes across all dialysis modalities are largely similar, but for specific clinical measures, one modality may have advantages over another. Therefore, choice among available modalities is preference-sensitive, with consideration of quality of life, life goals, clinical characteristics, family or care-partner support, and living environment. Ideally, individuals, their care-partners, and their healthcare teams will employ shared decision-making in assessing initial and subsequent kidney failure treatment options. To meet this goal, iterative, high-quality education and support for healthcare professionals, patients, and care-partners are priorities. Everyone who faces dialysis should have access to home therapy. Facilitating universal access to home dialysis and expanding utilization requires alignment of policy considerations and resources at the dialysis-center level, with clear leadership from informed and motivated clinical teams.

National strategies for addressing chronic kidney disease (CKD) are crucial to improving kidney health. We sought to describe country-level variations in non-communicable disease (NCD) strategies and CKD-specific policies across different regions and income levels worldwide. The International Society of Nephrology Global Kidney Health Atlas (GKHA) was a multinational cross-sectional survey conducted between July and October 2018. Responses from key opinion leaders in each country regarding national NCD strategies, the presence and scope of CKD-specific policies, and government recognition of CKD as a health priority were described overall and according to region and income level. 160 countries participated in the GKHA survey, comprising 97.8% of the world’s population. Seventy-four (47%) countries had an established national NCD strategy, and 53 (34%) countries reported the existence of CKD-specific policies, with substantial variation across regions and income levels. Where CKD-specific policies existed, non-dialysis CKD care was variably addressed. 79 (51%) countries identified government recognition of CKD as a health priority. Low- and low-middle income countries were less likely to have strategies and policies for addressing CKD and have governments which recognise it as a health priority. The existence of CKD-specific policies, and a national NCD strategy more broadly, varied substantially across different regions around the world but was overall suboptimal, with major discrepancies between the burden of CKD in many countries and governmental recognition of CKD as a health priority. Greater recognition of CKD within national health policy is critical to improving kidney healthcare globally.

Chronic kidney disease (CKD) affects about 10% of all populations worldwide, with about 2 million people requiring dialysis. Although patients with CKD are at high risk of cardiovascular disease and events, they are often underrepresented or excluded in clinical trials, leading to important knowledge gaps about how to treat these patients. KDIGO (Kidney Disease: Improving Global Outcomes) convened the fourth clinical Controversies Conference on the heart, kidney and vasculature in Dublin, Ireland, in February 2020, entitled Central and Peripheral Arterial Diseases in Chronic Kidney Disease. A global panel of multidisciplinary experts from the fields of nephrology, cardiology, neurology, surgery, radiology, vascular biology, epidemiology, and health economics attended. The objective was to identify key issues related to the optimal detection, management, and treatment of cerebrovascular diseases, central aortic disease, renovascular disease, and peripheral artery disease in the setting of CKD. This report outlines the common pathophysiology of these vascular processes in the setting of CKD, describes best practices for their diagnosis and management, summarizes areas of uncertainty, addresses ongoing controversial issues, and proposes a research agenda to address key gaps in knowledge that, when addressed, could improve patient care and outcomes.

AIM Darbepoetin alpha is available as Aranesp® and NESP®, which differ in the inactive component and maximum dose-strength of prefilled syringes. We conducted an observational cohort study to investigate optimal conversion strategies and the feasibility of extending dosing intervals with higher-dose preparations in dialysis patients converting from Aranesp® to NESP®. METHODS Adult dialysis patients on Aranesp® with stable haemoglobin of 9-12 g/dL were converted to NESP® at the same monthly total dose according to one of three conversion regimens. Group A included patients on ≤80 mcg/month of Aranesp® who converted with dosing regimen unchanged. Group B patients converted to NESP® with extended dosing intervals using higher individual dose preparations. Group C were patients on 100 mcg Aranesp® who converted to NESP® 120 mcg with extended dosing intervals. Patients were observed for 6 months. RESULTS Fifty patients were included. All 24 Group A patients maintained stable haemoglobin. In Group B, 10 patients (50%) maintained stable haemoglobin with extension of dosing interval from 1.04 ± 0.14 to 3.03 ± 1.28 weeks. Factors associated with success in extending dosing interval included a lower prevalence of cardiovascular disease and a higher Kt/Vurea in peritoneal dialysis patients. Four patients (80%) in Group C maintained stable haemoglobin after conversion to NESP® 120 mcg with extended dosing interval. The use of NESP® 120 mcg was well tolerated, and was associated with reduced patient-reported pain score and 38% reduction of drug cost. CONCLUSION Dialysis patients on Aranesp® can be successfully converted to NESP® and the dosing interval can be extended successfully in a significant proportion of patients, which could reduce discomfort and drug cost.

Introduction Hypokalemia, including normal range values, Graphical abstract

Background Randomized trials can provide evidence to inform decision-making but this may be limited if the outcomes of importance to patients and clinicians are omitted or reported inconsistently. We aimed to assess the scope and heterogeneity of outcomes reported in trials in peritoneal dialysis (PD). Methods We searched the Cochrane Kidney and Transplant Specialized Register for randomized trials in PD. We extracted all reported outcome domains and measurements and analyzed their frequency and characteristics. Results From 128 reports of 120 included trials, 80 different outcome domains were reported. Overall, 39 (49%) domains were surrogate, 23 (29%) patient-reported and 18 (22%) clinical. The five most commonly reported domains were PD-related infection [59 (49%) trials], dialysis solute clearance [51 (42%)], kidney function [45 (38%)], protein metabolism [44 (37%)] and inflammatory markers/oxidative stress [42 (35%)]. Quality of life was reported infrequently (4% of trials). Only 14 (12%) trials included a patient-reported outcome as a primary outcome. The median number of outcome measures (defined as a different measurement, aggregation and metric) was 22 (interquartile range 13–37) per trial. PD-related infection was the most frequently reported clinical outcome as well as the most frequently stated primary outcome. A total of 383 different measures for infection were used, with 66 used more than once. Conclusions Trials in PD include important clinical outcomes such as infection, but these are measured and reported inconsistently. Patient-reported outcomes are infrequently reported and nearly half of the domains were surrogate. Standardized outcomes for PD trials are required to improve efficiency and relevance.

Rationale & Objective: There is a concern regarding increased risk of vascular calcification with the use of calcium-based phosphorus binders. This study aimed to compare the effects of sevelamer used as a second-line, low-dose therapy with calcium-based phosphorus binders with those of sevelamer used as a first-line, high-dose therapy on coronary artery and heart valve calcification, aortic pulse wave velocity (PWV), and calcification propensity over 2 years in patients with hyperphosphatemia receiving peritoneal dialysis (PD). Study Design: A 2-year-long prospective, multicenter, open-label, randomized pilot study. Setting & Participants: Prevalent patients with hyperphosphatemia receiving PD from 2 university-affiliated hospitals in Hong Kong. Interventions: The patients were randomized to receive sevelamer either as a first-line therapy at a high dose of 800 mg thrice daily (can titrate up to 1,200 mg thrice daily as required) or a second-line therapy at a low dose of 400 mg thrice daily with calcium carbonate to achieve a serum phosphorus target of ≤5.5 mg/dL. Outcomes: The primary endpoints were changes in coronary artery calcium score and aortic PWV over 104 weeks. The secondary endpoints were changes in heart valve calcium scores, calcification propensity measure, and biochemical parameters of chronic kidney disease–mineral bone disease over 104 weeks. Results: Among 60 prevalent patients receiving PD, with a mean age of 53 ± 10 years and with 57% men, changes in the coronary artery calcium score (median [interquartile range], 225 [79-525] vs 223 [56-1,212], respectively; P = 0.21), aortic PWV (mean ± standard error, 0.3 ± 0.1 vs 0.8 ± 0.2 m/s, respectively; P = 0.31), heart valve calcium score, maturation or transformation time, serum calcium levels, and phosphorus levels over 104 weeks were similar for the second-line, low-dose and first-line, high-dose sevelamer groups. Alkaline phosphatase and intact parathyroid hormone levels increased and low-density lipoprotein cholesterol decreased in both the groups, with no significant between-group differences. Limitations: The sample size was small, and the dropout rates were relatively high. Conclusions: Low-dose sevelamer used as a second-line therapy for hyperphosphatemia in combination with a calcium-based phosphorus binder had similar effects on vascular calcification, valvular calcification, and arterial stiffness compared with high-dose sevelamer used as a first-line therapy. This approach may be considered in resource-constrained countries to minimize calcium loading. Funding: The study was supported by a competitive grant from SK Yee Medical Foundation. T50 assays and other biochemical assays were funded by a research grant from Sanofi Renal Corporation. Trial Registration: NCT00745589.

Background: Peritoneal dialysis (PD) can offer patients more autonomy and flexibility compared with in-center hemodialysis (HD). However, burnout – defined as mental, emotional, or physical exhaustion that leads to thoughts of discontinuing PD – is associated with an increased risk of transfer to HD. We aimed to describe the perspectives of burnout among patients on PD and their caregivers. Methods: In this focus group study, 81 patients and 45 caregivers participated in 14 focus groups from 9 dialysis units in Australia, Hong Kong, and the United States. Transcripts were analyzed thematically. Results: We identified two themes. Suffering an unrelenting responsibility contributed to burnout, as patients and caregivers felt overwhelmed by the daily regimen, perceived their life to be coming to a halt, tolerated the PD regimen for survival, and had to bear the burden and uncertainty of what to expect from PD alone. Adapting and building resilience against burnout encompassed establishing a new normal, drawing inspiration and support from family, relying on faith and hope for motivation, and finding meaning in other activities. Conclusions: For patients on PD and their caregivers, burnout was intensified by perceiving PD as an unrelenting, isolating responsibility that they had no choice but to endure, even if it held them back from doing other activities in life. More emphasis on developing strategies to adapt and build resilience could prevent or minimize burnout.

Background Hyperphosphatemia is associated with increased fibroblast growth factor 23 (FGF23), arterial calcification, and cardiovascular mortality. Effects of phosphate-lowering medication on vascular calcification and arterial stiffness in CKD remain uncertain.Methods To assess the effects of non-calcium-based phosphate binders on intermediate cardiovascular markers, we conducted a multicenter, double-blind trial, randomizing 278 participants with stage 3b or 4 CKD and serum phosphate >1.00 mmol/L (3.10 mg/dl) to 500 mg lanthanum carbonate or matched placebo thrice daily for 96 weeks. We analyzed the primary outcome, carotid-femoral pulse wave velocity, using a linear mixed effects model for repeated measures. Secondary outcomes included abdominal aortic calcification and serum and urine markers of mineral metabolism.Results A total of 138 participants received lanthanum and 140 received placebo (mean age 63.1 years; 69% male, 64% White). Mean eGFR was 26.6 ml/min per 1.73m(2); 45% of participants had diabetes and 32% had cardiovascular disease. Mean serum phosphate was 1.25 mmol/L (3.87 mg/dl), mean pulse wave velocity was 10.8 m/s, and 81.3% had abdominal aortic calcification at baseline. At 96 weeks, pulse wave velocity did not differ significantly between groups, nor did abdominal aortic calcification, serum phosphate, parathyroid hormone, FGF23, and 24-hour urinary phosphate. Serious adverse events occurred in 63 (46%) participants prescribed lanthanum and 66 (47%) prescribed placebo. Although recruitment to target was not achieved, additional analysis suggested this was unlikely to have significantly affected the principle findings.Conclusions In patients with stage 3b/4 CKD, treatment with lanthanum over 96 weeks did not affect arterial stiffness or aortic calcification compared with placebo. These findings do not support the role of intestinal phosphate binders to reduce cardiovascular risk in patients with CKD who have normophosphatemia.

Trials in children with chronic kidney disease do not consistently report outcomes that are critically important to patients and caregivers. This can diminish the relevance and reliability of evidence for decision making, limiting the implementation of results into practice and policy. As part of the Standardized Outcomes in Nephrology—Children and Adolescents (SONG-Kids) initiative, we convened 2 consensus workshops in San Diego, California (7 patients, 24 caregivers, 43 health professionals) and Melbourne, Australia (7 patients, 23 caregivers, 49 health professionals). This report summarizes the discussions on the identification and implementation of the SONG-Kids core outcomes set. Four themes were identified; survival and life participation are common high priority goals, capturing the whole child and family, ensuring broad relevance across the patient journey, and requiring feasible and valid measures. Stakeholders supported the inclusion of mortality, infection, life participation, and kidney function as the core outcomes domains for children with chronic kidney disease.

Sources of dietary phosphate differentially contribute to hyperphosphatemia in maintenance haemodialysis (MHD) patients. This cross-sectional study in Malaysia investigated association between dietary patterns and serum phosphorus in MHD patients. Dietary patterns were derived by principal component analysis, based on 27 food groups shortlisted from 3-day dietary recalls of 435 MHD patients. Associations of serum phosphorus were examined with identified dietary patterns. Three dietary patterns emerged: Home foods (HFdp), Sugar-sweetened beverages (SSBdp), and Eating out noodles (EO-Ndp). The highest tertile of patients in HF (T3-HFdp) pattern significantly associated with higher intakes of total protein (p = 0.002), animal protein (p = 0.001), and animal-based organic phosphate (p dp patients had significantly higher intakes of total energy (p p p = 0.001). T3-EO-Ndp patients had significantly higher intakes of total energy (p = 0.033), total protein (p = 0.003), plant protein (p p = 0.009). T3-SSBdp patients had significantly higher serum phosphorus (p = 0.006). The odds ratio of serum phosphorous > 2.00 mmol/l was significantly 2.35 times higher (p = 0.005) with the T3-SSBdp. The SSBdp was associated with greater consumption of inorganic phosphate and higher serum phosphorus levels.

In 2018, Kidney Disease: Improving Global Outcomes (KDIGO) published a clinical practice guideline on the prevention, diagnosis, evaluation, and treatment of hepatitis C virus (HCV) infection in chronic kidney disease (CKD). The guideline synthesized recent advances, especially in HCV therapeutics and diagnostics, and provided clinical recommendations and suggestions to aid healthcare providers and improve care for CKD patients with HCV. To gain insight into the extent that the 2018 guideline has been adopted in Asia, KDIGO convened an HCV Implementation Summit in Hong Kong. Participants included nephrologists, hepatologists, and nurse consultants from 8 Southeast Asian countries or regions with comparable high-to-middle economic ranking by the World Bank: mainland China, Hong Kong, Japan, Malaysia, Singapore, South Korea, Taiwan, and Thailand. Through presentations and discussions, meeting participants described regional practice patterns related to the KDIGO HCV in CKD guideline, identified barriers to implementing the guideline, and developed strategies for overcoming the barriers in Asia and around the world.

Background and objectives Shared decision making in patients with glomerular disease remains challenging because outcomes important to patients remain largely unknown. We aimed to identify and prioritize outcomes important to patients and caregivers and to describe reasons for their choices. Design, setting, participants, & measurements We purposively sampled adult patients with glomerular disease and their caregivers from Australia, Hong Kong, the United Kingdom, and the United States. Participants identified, discussed, and ranked outcomes in focus groups using the nominal group technique; a relative importance score (between zero and one) was calculated. Qualitative data were analyzed thematically. Results Across 16 focus groups, 134 participants (range, 19–85 years old; 51% women), including 101 patients and 33 caregivers, identified 58 outcomes. The ten highest-ranked outcomes were kidney function (importance score of 0.42), mortality (0.29), need for dialysis or transplant (0.22), life participation (0.18), fatigue (0.17), anxiety (0.13), family impact (0.12), infection and immunity (0.12), ability to work (0.11), and BP (0.11). Three themes explained the reasons for these rankings: constraining day-to-day experience, impaired agency and control over health, and threats to future health and family. Conclusions Patients with glomerular disease and their caregivers highly prioritize kidney health and survival, but they also prioritize life participation, fatigue, anxiety, and family impact.

International audience; Blood pressure (BP) and volume control are critical components of dialysis care and have substantial impacts on patient symptoms, quality of life, and cardiovascular complications. Yet, developing consensus best practices for BP and volume control have been challenging, given the absence of objective measures of extracellular volume status and the lack of high-quality evidence for many therapeutic interventions. In February of 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference titled Blood Pressure and Volume Management in Dialysis to assess the current state of knowledge related to BP and volume management and identify opportunities to improve clinical and patient-reported outcomes among individuals receiving maintenance dialysis. Four major topics were addressed: BP measurement, BP targets, and pharmacologic management of suboptimal BP; dialysis prescriptions as they relate to BP and volume; extracellular volume assessment and management with a focus on technology-based solutions; and volume-related patient symptoms and experiences. The overarching theme resulting from presentations and discussions was that managing BP and volume in dialysis involves weighing multiple clinical factors and risk considerations as well as patient lifestyle and preferences, all within a narrow therapeutic window for avoiding acute or chronic volume-related complications. Striking this challenging balance requires individualizing the dialysis prescription by incorporating comorbid health conditions, treatment hemodynamic patterns, clinical judgment, and patient preferences into decision-making, all within local resource constraints.

International audience; Outcomes reported in randomized controlled trials in peritoneal dialysis (PD) are diverse, are measured inconsistently, and may not be important to patients, families, and clinicians. The Standardized Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD) initiative aims to establish a core outcome set for trials in PD based on the shared priorities of all stakeholders. We convened an international SONG-PD stakeholder consensus workshop in May 2018 in Vancouver, Canada. Nineteen patients/caregivers and 51 health professionals attended. Participants discussed core outcome domains and implementation in trials in PD. Four themes relating to the formation of core outcome domains were identified: life participation as a main goal of PD, impact of fatigue, empowerment for preparation and planning, and separation of contributing factors from core factors. Considerations for implementation were identified: standardizing patient-reported outcomes, requiring a validated and feasible measure, simplicity of binary outcomes, responsiveness to interventions, and using positive terminology. All stakeholders supported inclusion of PD-related infection, cardiovascular disease, mortality, technique survival, and life participation as the core outcome domains for PD.

Life participation requiring physical activity and physical function is a key patient-reported outcome for people receiving peritoneal dialysis (PD). Clinician guidance is required from multidisciplinary sources regarding exercise and activity advice to address the specific needs of this group. From August 2020 through to June 2021, the Global Renal Exercise Network and the International Society for Peritoneal Dialysis reviewed the published literature and international clinical experience to develop a set of clinical practice points. A set of questions relevant to physical activity and exercise were developed from the perspective of a person receiving PD and were the basis for the practice point development. The GRADE framework was used to evaluate the quality of evidence and to guide clinical practice points. The review of the literature found sparse quality evidence, and thus the clinical practice points are generally based on the expert consensus of people receiving PD, PD exercise expert clinicians and experienced PD exercise researchers. Clinical practice points address timing of exercise and activity (post-catheter insertion, peritoneal space empty or full), the uptake of specific activities (work, sex, swimming, core exercise), potential adverse outcomes related to activity and exercise (exit site care, perspiration, cardiovascular compromise, fatigue, intra-abdominal pressure), the effect of exercise and activity on conditions of interest (mental health, obesity, frailty, low fitness) and exercise nutrition. (Figure presented.). Refereed/Peer-reviewed

Background Health information systems (HIS) are fundamental tools for the surveillance of health services, estimation of disease burden and prioritization of health resources. Several gaps in the availability of HIS for kidney disease were highlighted by the first iteration of the Global Kidney Health Atlas. Methods As part of its second iteration, the International Society of Nephrology conducted a cross-sectional global survey between July and October 2018 to explore the coverage and scope of HIS for kidney disease, with a focus on kidney replacement therapy (KRT). Results Out of a total of 182 invited countries, 154 countries responded to questions on HIS (85% response rate). KRT registries were available in almost all high-income countries, but few low-income countries, while registries for non-dialysis chronic kidney disease (CKD) or acute kidney injury (AKI) were rare. Registries in high-income countries tended to be national, in contrast to registries in low-income countries, which often operated at local or regional levels. Although cause of end-stage kidney disease, modality of KRT and source of kidney transplant donors were frequently reported, few countries collected data on patient-reported outcome measures and only half of low-income countries recorded process-based measures. Almost no countries had programs to detect AKI and practices to identify CKD-targeted individuals with diabetes, hypertension and cardiovascular disease, rather than members of high-risk ethnic groups. Conclusions These findings confirm significant heterogeneity in the global availability of HIS for kidney disease and highlight important gaps in their coverage and scope, especially in low-income countries and across the domains of AKI, non-dialysis CKD, patient-reported outcomes, process-based measures and quality indicators for KRT service delivery.

Introduction Patients with glomerular disease experience symptoms that impair their physical and mental health while managing their treatments, diet, appointments and monitoring general and specific indicators of health and their illness. We sought to describe the perspectives of patients and their care partners on self-management in glomerular disease. Methods We conducted 16 focus groups involving adult patients with glomerular disease (n = 101) and their care partners (n = 34) in Australia, Hong Kong, the United Kingdom, and United States. Transcripts were analyzed thematically. Results We identified the following 4 themes: empowered in autonomy (gaining confidence through understanding, taking ownership of disease and treatment, learning a positive health approach); overwhelmed by compounding treatment burdens (financially undermined and depleted, demoralized by side effects and harms, frustrated by fragmented and inflexible care, fear of possible drug harms); striving for stability and normalcy (making personal sacrifices, maximizing life participation, attentiveness to bodily signs, avoiding precarious health states, integrating medicines into routines); and necessity of health-sustaining relationships (buoyed by social support, fulfilling meaningful responsibilities, sharing and normalizing experiences, seeking a trusting and respectful alliance). Conclusion Patients with glomerular disease and their care partners value their capacity for autonomy and disease ownership, stability of their health, and relationships that support self-management. Strategies directed at strengthening these factors may increase self-efficacy and improve the care and outcomes for patients with glomerular disease., Graphical abstract

Anemia is a highly prevalent complication in patients with chronic kidney disease (CKD) and its severity and prevalence increase with increasing CKD severity. Many factors contribute to anemia in CKD, of which a hallmark feature is erythropoietin deficiency. The availability of erythropoietin-stimulating agents (ESAs) has revolutionized anemia management in CKD patients in the last two decades. However, the cardiovascular safety of ESA treatment in CKD came into question some years ago when ESA trials that targeted hemoglobin (Hb) >13 g/dL showed greater risks for death, cardiovascular events, and stroke than a lower Hb target. This led to revision of the recommended Hb target by the different international guidelines to no more than 11.5–12 g/dL for CKD 3–5D patients. On the other hand, the discovery of the hypoxia-inducible factor (HIF) transcription complex in 1992 has unfolded important novel mechanisms that regulate erythropoietin gene and erythropoietin production in the kidneys in response to hypoxia or anemia. This led to development of a new class of drugs called HIF stabilizers, or HIF prolyl hydroxylase domain (PHD) inhibitors that prevent the proteasomal degradation of HIF-α, thereby inducing upregulation of erythropoietin gene. The PHD inhibitors can be orally administered and represent a novel paradigm for anemia management in CKD. Currently, several of them are undergoing phase III clinical trials in adults. The PHD inhibitors may have better cardiovascular safety profile in that they induce lower erythropoietin production, lower hepcidin levels, increase iron absorption and mobilization, lower cholesterol level, and have a neutral effect on blood pressure than ESA. However, the long-term safety of this new class of drugs remains to be tested as the PHD inhibitors also stimulate angiogenic factors such as vascular endothelial growth factor and glycolytic factors. In this chapter, we also review other key nutrition factors involved in anemia in CKD, including iron, carnitine, vitamin C, vitamin D, folate, and several other B group vitamins. We specifically review iron homeostasis, iron balance and management, interrelations between the HIF pathway and iron, and hepcidin. We also discuss erythropoietin hyporesponsiveness in CKD patients.

International audience; In chronic kidney disease, anemia and disordered iron homeostasis are prevalent and associated with significant adverse consequences. In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) issued an anemia guideline for managing the diagnosis, evaluation, and treatment of anemia in chronic kidney disease. Since then, new data have accrued from basic research, epidemiological studies, and randomized trials that warrant a re-examination of previous recommendations. Therefore, in 2019, KDIGO decided to convene 2 Controversies Conferences to review the latest evidence, explore new and ongoing controversies, assess change implications for the current KDIGO anemia guideline, and propose a research agenda. The first conference, described here, focused mainly on iron-related issues, including the contribution of disordered iron homeostasis to the anemia of chronic kidney disease, diagnostic challenges, available and emerging iron therapies, treatment targets, and patient outcomes. The second conference will discuss issues more specifically related to erythropoiesis-stimulating agents, including epoetins, and hypoxia-inducible factor-prolyl hydroxylase inhibitors. Here we provide a concise overview of the consensus points and controversies resulting from the first conference and prioritize key questions that need to be answered by future research.

Author(s): Yeung, Emily; Bello, AK; Levin, Adeera; Lunney, Meaghan; Osman, Mohamed A; Ye, Feng; Ashuntantang, Gloria; Bellorin-Font, Ezequiel; Benghanem Gharbi, Mohammed; Davison, Sara; Ghnaimat, Mohammad; Harden, Paul; Jha, Vivekanand; Kalantar-Zadeh, Kamyar; Kerr, Peter; Klarenbach, Scott; Kovesdy, Csaba; Luyckx, Valerie; Neuen, Brendon; O'Donoghue, Donal; Ossareh, Shahrzad; Perl, Jeffrey; Ur Rashid, Harun; Rondeau, Eric; See, Emily; Saad, Syed; Sola, Laura; Tchokhonelidze, Irma; Tesar, Vladimir; Tungsanga, Kriang; Turan Kazancioglu, Rumeyza; Wang, Angela Yee-Moon; Wiebe, Natasha; Yang, Chih-Wei; Zemchenkov, Alexander; Zhao, Minhui; Jager, Kitty J; Caskey, Fergus; Perkovic, Vlado; Jindal, Kailash; Okpechi, Ikechi G; Tonelli, Marcello; Feehally, John; Harris, David Ch; Johnson, David | Abstract: ObjectivesThe Global Kidney Health Atlas (GKHA) is a multinational, cross-sectional survey designed to assess the current capacity for kidney care across all world regions. The 2017 GKHA involved 125 countries and identified significant gaps in oversight, funding and infrastructure to support care for patients with kidney disease, especially in lower-middle-income countries. Here, we report results from the survey for the second iteration of the GKHA conducted in 2018, which included specific questions about health financing and oversight of end-stage kidney disease (ESKD) care worldwide.SettingA cross-sectional global survey.ParticipantsKey stakeholders from 182 countries were invited to participate. Of those, stakeholders from 160 countries participated and were included.Primary outcomesPrimary outcomes included cost of kidney replacement therapy (KRT), funding for dialysis and transplantation, funding for conservative kidney management, extent of universal health coverage, out-of-pocket costs for KRT, within-country variability in ESKD care delivery and oversight systems for ESKD care. Outcomes were determined from a combination of desk research and input from key stakeholders in participating countries.Results160 countries (covering 98% of the world's population) responded to the survey. Economic factors were identified as the top barrier to optimal ESKD care in 99 countries (64%). Full public funding for KRT was more common than for conservative kidney management (43% vs 28%). Among countries that provided at least some public coverage for KRT, 75% covered all citizens. Within-country variation in ESKD care delivery was reported in 40% of countries. Oversight of ESKD care was present in all high-income countries but was absent in 13% of low-income, 3% of lower-middle-income, and 10% of upper-middle-income countries.ConclusionSignificant gaps and variability exist in the public funding and oversight of ESKD care in many countries, particularly for those in low-income and lower-middle-income countries.

International audience; Shared decision-making about clinical care options in end-stage kidney disease is limited by inconsistencies in the~reporting of outcomes and the omission of patient-important outcomes in trials. Here we generated a consensus-based prioritized list of outcomes to be reported during trials in peritoneal dialysis (PD). In an international, online, three-round Delphi survey, patients/caregivers and health professionals rated the importance of outcomes using a 9-point Likert scale (with 7-9 indicating critical importance) and provided comments. Using a Best-Worst Scale (BWS), the relative importance of outcomes was estimated. Comments were analyzed thematically. In total, 873 participants (207 patients/caregivers and 666 health professionals) from 68 countries completed round one, 629 completed round two and 530 completed round three. The top outcomes were PD-related infection, membrane function, peritoneal dialysis failure, cardiovascular disease, death, catheter complications, and the ability to do usual activities. Compared with health professionals, patients/caregivers gave higher priority to six outcomes: blood pressure (mean difference, 0.4), fatigue (0.3), membrane function (0.3), impact on family/friends (0.1), peritoneal thickening (0.1) and usual activities (0.1). Four themes were identified that underpinned the reasons for ratings: contributing to treatment longevity, preserving quality of life, escalating morbidity, and irrelevant and futile information and treatment. Patients/caregivers and health professionals gave highest priority to clinical outcomes. In contrast to health professionals, patients/caregivers gave higher priority to lifestyle-related outcomes including the impact on family/friends and usual activities. Thus, prioritization will inform a core outcome set to improve the consistency and relevance of outcomes for trials in PD.

Introduction Dialysis patients are frequently advised to restrict fruit and vegetable intake due to their high potassium content. This study aimed to evaluate the association between dietary fiber intake and major adverse cardiovascular events (MACE) among dialysis patients. Methods A total of 219 prevalent dialysis patients were prospectively recruited from a major university teaching hospital and regional dialysis center in Hong Kong. Dietary fiber intake estimated using a 7-day locally validated food frequency questionnaire was examined in relation to a primary composite outcome of MACE over a follow-up period of 4 years. Results A total of 127 patients were complicated with 1 or more MACE. In the multivariable Cox regression analysis, every 1 g higher fiber intake, and every 1 g/d per 1000 kcal higher fiber intake density were associated with an 11% (95% confidence interval [CI]: 0.81–0.97) and a 13% lower risk of MACE (95% CI: 0.77–0.99), respectively, independent of clinical, demographic, biochemical, hemodynamic, adequacy parameters, dietary protein, energy intake, inflammatory, and cardiac markers. Patients in the lower tertile of fiber intake density showed an increased hazard for MACE (adjusted hazard ratio: 1.78; 95% CI: 1.13–2.80) than those in the upper tertile. Conclusion Higher fiber intake and higher fiber intake density may be associated with less inflammation, less myocardial hypertrophy, injury, and lower risk of MACE in dialysis patients. These data form an important basis for a randomized controlled trial to examine fiber supplementation on cardiovascular outcomes in the dialysis population., Graphical abstract

Contains fulltext : 203024.pdf (Publisher’s version ) (Open Access) In November 2017, the Kidney Disease: Improving Global Outcomes (KDIGO) initiative brought a diverse panel of experts in glomerular diseases together to discuss the 2012 KDIGO glomerulonephritis guideline in the context of new developments and insights that had occurred over the years since its publication. During this KDIGO Controversies Conference on Glomerular Diseases, the group examined data on disease pathogenesis, biomarkers, and treatments to identify areas of consensus and areas of controversy. This report summarizes the discussions on primary podocytopathies, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated nephritis, complement-mediated kidney diseases, and monoclonal gammopathies of renal significance.

International audience; BACKGROUND AND OBJECTIVES: The absence of accepted patient-centered outcomes in research can limit shared decision-making in peritoneal dialysis (PD), particularly because PD-related treatments can be associated with mortality, technique failure, and complications that can impair quality of life. We aimed to identify patient and caregiver priorities for outcomes in PD, and to describe the reasons for their choices. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Patients on PD and their caregivers were purposively sampled from nine dialysis units across Australia, the United States, and Hong Kong. Using nominal group technique, participants identified and ranked outcomes, and discussed the reasons for their choices. An importance score (scale 0-1) was calculated for each outcome. Qualitative data were analyzed thematically. RESULTS: Across 14 groups, 126 participants (81 patients, 45 caregivers), aged 18-84 (mean 54, SD 15) years, identified 56 outcomes. The ten highest ranked outcomes were PD infection (importance score, 0.27), mortality (0.25), fatigue (0.25), flexibility with time (0.18), BP (0.17), PD failure (0.16), ability to travel (0.15), sleep (0.14), ability to work (0.14), and effect on family (0.12). Mortality was ranked first in Australia, second in Hong Kong, and 15th in the United States. The five themes were serious and cascading consequences on health, current and impending relevance, maintaining role and social functioning, requiring constant vigilance, and beyond control and responsibility. CONCLUSIONS: For patients on PD and their caregivers, PD-related infection, mortality, and fatigue were of highest priority, and were focused on health, maintaining lifestyle, and self-management. Reporting these patient-centered outcomes may enhance the relevance of research to inform shared decision-making.

Background and Aims Icodextrin is designed to maintain ultrafiltration during the long dwell, especially when there is a risk of increased fluid reabsorption (fast peritoneal solute transfer rate, PSTR), without the need for excessive use of high glucose. Randomized trials have demonstrated these benefits but are insufficiently powered to investigate a clear impact on survival. We aimed to establish international prescription practices and their relationship to clinical outcomes. Method The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) is an international prospective cohort study in collaboration with the International Society for Peritoneal Dialysis. The current analysis was drawn from A/NZ, Canada, Japan, UK, and US in PDOPPS phases 1-2 (2014-2019). Patient demographics, comorbidities, lab measurements, clinic blood pressure, membrane function (both solute transport rate and ultrafiltration capacity), dialysis prescription details, urine and 24-hour ultrafiltration volumes were captured at study enrollment. Mortality and permanent transfer to HD (HDT) events were collected during study follow-up [median (IQR) = 1.1 yrs (0.6, 1.7)]. Linear and logistic models were used to analyze the association between icodextrin and blood pressure. Cox regression, stratified by country, was used to analyze the association of icodextrin with time from study enrollment to (a) death and (b) HDT, and adjusted for demographics, 13 comorbidities, transplant waitlisting, serum albumin, urine volume, facility size and % APD use, study phase, while accounting for facility clustering. Results Icodextrin was prescribed in 1,929 (35%) of 5,432 patients studied, but this proportion differed by country, being >44% in all except the US, where it was 17%, and by facility within countries. Patients on icodextrin were more likely to have coronary artery disease and diabetes, have lower residual 24-hour urine volume and function, use less high glucose, have faster PSTR and reduced ultrafiltration capacity, and have been on PD longer (PD vintage: median 1.19, IQR 0.50-2.76). Despite this, patients using icodextrin achieved equivalent ultrafiltration to those using glucose at every level of residual urine volume (see figure). The low use of icodextrin in the US was more than compensated for by much greater use of high glucose and overall higher ultrafiltration volumes at each level of urine volume. Icodextrin use was not associated with blood pressure (effects: 0.90 mmHg, 95% CI: -0.68, 2.47), mortality (Hazard ratio [HR] 1.01, 95% CI: 0.83, 1.23) and HDT (HR 1.05, 95% CI: 0.90, 1.23). Conclusion There are important national and facility differences in the prescription of icodextrin, with the US a clear outlier, with less icodextrin and more high glucose use, resulting in higher ultrafiltration volumes. These practices and the targeting of patients with less efficient membranes for fluid removal may mask any potential survival advantage associated with icodextrin.

Made available in DSpace on 2021-06-25T10:28:52Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-01-01 Background: Peritoneal dialysis (PD) technique survival is an important outcome for patients, caregivers and health professionals, however, the definition and measures used for technique survival vary. We aimed to assess the scope and consistency of definitions and measures used for technique survival in studies of patients receiving PD. Method: MEDLINE, EMBASE and CENTRAL databases were searched for randomised controlled studies (RCTs) conducted in patients receiving PD reporting technique survival as an outcome between database inception and December 2019. The definition and measures used were extracted and independently assessed by two reviewers. Results: We included 25 RCTs with a total of 3645 participants (41–371 per trial) and follow up ranging from 6 weeks to 4 years. Terminology used included ‘technique survival’ (10 studies), ‘transfer to haemodialysis (HD)’ (8 studies) and ‘technique failure’ (7 studies) with 17 different definitions. In seven studies, it was unclear whether the definition included transfer to HD, death or transplantation and eight studies reported ‘transfer to HD’ without further definition regarding duration or other events. Of those remaining, five studies included death in their definition of a technique event, whereas death was censored in the other five. The duration of HD necessary to qualify as an event was reported in only four (16%) studies. Of the 14 studies reporting causes of an event, all used a different list of causes. Conclusion: There is substantial heterogeneity in how PD technique survival is defined and measured, likely contributing to considerable variability in reported rates. Standardised measures for reporting technique survival in PD studies are required to improve comparability. School of Medicine Keele University Department of Nephrology Princess Alexandra Hospital Australasian Kidney Studies Network The University of Queensland Translational Research Institute Department of Renal Medicine Auckland City Hospital Polycystic Kidney Disease International Polycystic Kidney Disease Charity Department of Medicine The University of Hong Kong Queen Mary Hospital Department of Medicine Western University Botucatu School of Medicine University of Sao Paulo State—UNESP Clinical Innovation and Business Unit South Western Sydney Local Health District Faculty of Nursing University of Sydney UNSW Faculty of Medicine University of New South Wales School of Health Science University of Tasmania Maisonneuve-Rosemont Research Centre and Hospital The Kidney and Transplant Practice Mount Elizabeth Novena Hospital Medical School University of Western Australia Sydney School of Public Health University of Sydney and Centre for Kidney Research The Children’s Hospital at Westmead Division of Nephrology St Michael’s Hospital and the Keenan Research Centre in the Li Ka Shing Knowledge Institute St Michael’s Hospital University of Toronto Botucatu School of Medicine University of Sao Paulo State—UNESP

Background: People with kidney failure typically receive kidney replacement therapy (KRT) in the form of dialysis or transplantation. However, studies have suggested that not all patients with kidney failure are best suited for KRT. Additionally, KRT is costly and not always accessible in resource-restricted settings. Conservative kidney management is an alternate kidney failure therapy, which focuses on symptom management, psychological health, spiritual care and family and social support. Despite the importance of conservative kidney management in kidney failure care, several barriers exist that impact its uptake and quality. Methods: The Global Kidney Health Atlas is an ongoing initiative of the International Society of Nephrology (ISN), which aims to monitor and evaluate the status of global kidney care worldwide. This study reports on findings from the 2018 Global Kidney Health Atlas survey, specifically addressing the availability, accessibility, uptake and quality of conservative kidney management. Results: Respondents from 160 countries completed the survey and 154 answered questions pertaining to conservative kidney management. Of these, 124 (81%) stated that conservative kidney management was available. Accessibility was low worldwide, particularly in low-income countries. Less than half of countries utilized multidisciplinary teams (46%), shared decision-making (32%), or provided psychological, cultural, or spiritual support (36%). One quarter provided relevant healthcare providers with training on conservative kidney management delivery.Conclusions: Overall, conservative kidney management is available in most countries; however, it is not optimally accessible or of the highest quality.

Clinical Background and Epidemiology: Nutrition and obesity are both important and common clinical issues in chronic kidney disease (CKD). Protein-energy wasting predicts adverse clinical outcomes in CKD. Obesity is associated with poor health outcomes. Nutrition management, specifically a protein-restricted diet, has been shown to ameliorate glomerular injury and progressive CKD by reducing glomerular hyperfiltration and hypertension. A protein-restricted diet has favorable metabolic and hemodynamic effects and effects on CKD-mineral bone disease that may favorably impact patients' outcomes. On the other hand, obesity may adversely affect kidney function both directly by placing an increased metabolic demand on the kidneys and indirectly through various humoral mechanisms mediated via adiponectin, leptin, and resistin that lead to hyperinsulinemia, insulin resistance, abnormal lipid metabolism, activation of renin-angiotensin aldosterone system, chronic inflammation, and oxidative stress, and could result in the development of obesity-related glomerulopathy. It is therefore important to raise more awareness of the two clinical issues and promote a healthy lifestyle with proper nutrition and exercise in CKD management. Challenges and Solutions: There are global shortage of dietitians and challenges in accessibility and availability of renal dietitians in many emerging countries as well as lack of reimbursement of dietitians' consultations. Many patients may not have the opportunity to be monitored and reviewed by dieticians on a regular basis. In addition, there are practical challenges in enforcing patients' adherence to a protein-restricted diet. Patients and nephrologists from developed countries may\not appreciate the need to adopt a protein restricted diets as dialysis is readily available. Furthermore, keto-analogues or nutrition supplements are not reimbursed in many parts of the world. Increased government advocacy, prioritization of renal nutrition care, and more trained renal dietitians are required in many parts of the world. More government resource allocation is required to increase renal dietitians' manpower in nephrology centers so to enable multidisciplinary nutrition management in CKD and end-stage kidney disease. On the other hand, prevention and treatment of obesity require lifestyle modifications including calorie restriction and adequate exercise, and they need to be maintained lifelong. Such changes may be difficult in modern societies with the "fast food culture" and increasing prevalence of sedentary lifestyles. Changes in lifestyle may become even more difficult as long-term complications such as diabetes and cardiovascular disease set in, which may further limit patients' mobility. To tackle the obesity epidemic, we need a global action plan to prevent and control non-communicable diseases. We need a concerted population-wide intervention by national governments, health policy planners, and professional organizations to target obesity and CKD by promoting healthy lifestyle factors and healthy diets. Pharmacologic and surgical interventions such as bariatric surgery for obesity require further evaluation in CKD.

Rationale & Objective: Approximately 11% of people with kidney failure worldwide are treated with peritoneal dialysis (PD). This study examined PD use and practice patterns across the globe. Study Design: A cross-sectional survey. Setting & Participants: Stakeholders including clinicians, policy makers, and patient representatives in 182 countries convened by the International Society of Nephrology between July and September 2018. Outcomes: PD use, availability, accessibility, affordability, delivery, and reporting of quality outcome measures. Analytical Approach: Descriptive statistics. Results: Responses were received from 88% (n = 160) of countries and there were 313 participants (257 nephrologists [82%], 22 non-nephrologist physicians [7%], 6 other health professionals [2%], 17 administrators/policy makers/civil servants [5%], and 11 others [4%]). 85% (n = 156) of countries responded to questions about PD. Median PD use was 38.1 per million population. PD was not available in 30 of the 156 (19%) countries responding to PD-related questions, particularly in countries in Africa (20/41) and low-income countries (15/22). In 69% of countries, PD was the initial dialysis modality for ≤10% of patients with newly diagnosed kidney failure. Patients receiving PD were expected to pay 1% to 25% of treatment costs, and higher (>75%) copayments (out-of-pocket expenses incurred by patients) were more common in South Asia and low-income countries. Average exchange volumes were adequate (defined as 3-4 exchanges per day or the equivalent for automated PD) in 72% of countries. PD quality outcome monitoring and reporting were variable. Most countries did not measure patient-reported PD outcomes. Limitations: Low responses from policy makers; limited ability to provide more in-depth explanations underpinning outcomes from each country due to lack of granular data; lack of objective data. Conclusions: Large inter- and intraregional disparities exist in PD availability, accessibility, affordability, delivery, and reporting of quality outcome measures around the world, with the greatest gaps observed in Africa and South Asia.

Outcomes relevant to treatment decision-making are inconsistently reported in trials involving glomerular disease. Here, we sought to establish a consensus-derived set of critically important outcomes designed to be reported in all future trials by using an online, international two-round Delphi survey in English. To develop this, patients with glomerular disease, caregivers and health professionals aged 18 years and older rated the importance of outcomes using a Likert scale and a Best-Worst scale. The absolute and relative importance was assessed and comments were analyzed thematically. Of 1198 participants who completed Round 1, 734 were patients/caregivers while 464 were health care professionals from 59 countries. Of 700 participants that completed Round 2, 412 were patients/caregivers and 288 were health care professionals. Need for dialysis or transplant, kidney function, death, cardiovascular disease, remission-relapse and life participation were the most important outcomes to patients/caregivers and health professionals. Patients/caregivers rated patient-reported outcomes higher while health care professionals rated hospitalization, death and remission/relapse higher. Four themes explained the reasons for their priorities: confronting death and compounded suffering, focusing on specific targets in glomerular disease, preserving meaning in life, and fostering self-management. Thus, consistent reporting of these critically important outcomes in all trials involving glomerular disease is hoped to improve patient-centered decision-making.

Chronic kidney disease (CKD) in heart failure (HF) patients is common, present in 49%, and is associated with a higher mortality hazard ratio [2.34 (95% confidence interval 2.20–2.50); P

Lay summary The International Society for Peritoneal Dialysis last published a guideline on prescribing peritoneal dialysis (PD) in 2006. This focused on clearance of toxins and used a measure of waste product removal by dialysis using urea as an example. This guideline suggested that a specific quantity of small solute removal was needed to achieve dialysis `adequacy'. It is now generally accepted, however, that the well-being of the person on dialysis is related to many different factors and not just removal of specific toxins. This guideline has been written with the focus on the person doing PD. It is proposed that dialysis delivery should be `goal-directed'. This involves discussions between the person doing PD and the care team (shared decision-making) to establish care goals for dialysis delivery. The aims of these care goals are (1) to allow the person doing PD to achieve his/her own life goals and (2) to promote the provision of high-quality dialysis care by the dialysis team.Key recommendations 1. PD should be prescribed using shared decision-making between the person doing PD and the care team. The aim is to establish realistic care goals that (1) maintain quality of life for the person doing PD as much as possible by enabling them to meet their life goals, (2) minimize symptoms and treatment burden while (3) ensuring high-quality care is provided. 2. The PD prescription should take into account the local country resources, the wishes and lifestyle considerations of people needing treatment, including those of their families/caregivers', especially if providing assistance in their care. 3. A number of assessments should be used to help ensure the delivery of high-quality PD care. a. Patient reported outcome measures - this is a measure of how a person doing PD is experiencing life and his/her feeling of well-being. It should take into account the person's symptoms, impact of the dialysis regimen on the person's life, mental health and social circumstances. b. Fluid status is an important part of dialysis delivery. Urine output and fluid removed by dialysis both contribute to maintaining good fluid status. Regular assessment of fluid status, including blood pressure and clinical examination, should be part of routine care. c. Nutrition status should be assessed regularly through evaluation of the patient's appetite, clinical examination, body weight measurements and blood tests (potassium, bicarbonate, phosphate, albumin). Dietary intake of potassium, phosphate, sodium, protein, carbohydrate and fat may need to be assessed and adjusted as well. d. Removal of toxins. This can be estimated using a calculation called Kt/Vurea and/or creatinine clearance. Both are measures of the amount of dialysis delivered. There is no high-quality evidence regarding the need or benefit associated with the achievement of a specific target value for these measures. 4. The amount of kidney function that continues to remove waste products and the remaining urine volume should be known for all individuals doing PD. Management should focus on preserving this as long as possible. 5. For some people who require dialysis and who are old, frail or have a poor prognosis, there may be a quality of life benefit from a reduced dialysis prescription to minimize the burden of treatment. 6. In low and lower middle-income countries, every effort should be made to conform to the framework of these statements, taking into account resource limitations. 7. The principles of prescribing and assessing delivery of high-quality PD to children are the same as for adults. In all cases, the PD prescription should be designed to meet the medical, mental health social and financial needs of the individual child and family

Background: We describe peritoneal dialysis (PD) prescription variations among Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) participants on continuous ambulatory PD (CAPD) and automated PD (APD; n = 4657) from Australia/New Zealand (A/NZ), Canada, Japan, Thailand, United Kingdom (UK), and United States (US). Results: CAPD was more commonly used in Thailand and Japan, while APD predominated over CAPD in A/NZ, Canada, the US, and the UK. Total prescribed PD volume normalized to the surface area was the highest in Thailand and the lowest in Japan (for both APD and CAPD) and the UK (for CAPD). PD patients from Thailand had the lowest residual urine volume and residual renal urea clearance, yet achieved the highest dialysis urea clearance. Japanese patients had the lowest dialysis urea clearances for both APD and CAPD. Despite having similar urine volumes to patients in A/NZ, Canada, Japan, and the UK, US CAPD and APD patients used 2.5% and 3.86% glucose PD solutions more frequently, whereas fewer than 25% of these patients used icodextrin. Over half of the patients in A/NZ, Canada, the UK, and Japan used icodextrin, whereas it was hardly used in Thailand. Japan and Thailand were more likely to use 1.5% glucose solutions for their PD prescription. Conclusions: There are considerable international variations in PD modality use and prescription patterns that translate into important differences in achieved dialysis clearances. Ongoing recruitment of additional PDOPPS participants and accrual of follow-up time will allow us to test the associations between specific PD prescription regimens and clinical and patient-reported outcomes.

Background: Appropriate volume control is one of the key goals in a peritoneal dialysis (PD) prescription. As such it is an important component of the International Society of Peritoneal Dialysis (ISPD) guideline for “High-quality PD prescription” necessitating a review of the literature on volume management. The workgroup recognized the importance of including within its scope measures of volume status and blood pressure in prescribing high-quality PD therapy. Methods: A Medline and PubMed search for publications addressing volume status and its management in PD since the publication of the 2015 ISPD Adult Cardiovascular and Metabolic Guidelines, from October 2014 through to July 2019, was conducted. Results: There were no randomized controlled trials on blood pressure intervention and six randomized trials of bioimpedance-guided volume management. Generally, all studies were of small sample size, short duration, and used surrogate markers as primary outcomes. As a consequence, only “practice points” were drawn. High-quality goal-directed PD prescription should aim to achieve and maintain clinical euvolemia taking residual kidney function and its preservation into account, so that both fluid removal from peritoneal ultrafiltration and urine output are considered and residual kidney function is not compromised. Blood pressure should be included as a key objective parameter in assessing the quality of PD prescription but there is currently no evidence for a specific target in PD. Clinical examination remains the keystone of routine clinical care. Conclusions: High-quality goal-directed PD prescription should include volume management as one of the key dimensions.

Background While peritoneal dialysis (PD) can offer patients more independence and flexibility compared with in-center hemodialysis, managing the ongoing and technically demanding regimen can impose a burden on patients and caregivers. Patient empowerment can strengthen capacity for self-management and improve treatment outcomes. We aimed to describe patients’ and caregivers’ perspectives on the meaning and role of patient empowerment in PD. Methods Adult patients receiving PD (n = 81) and their caregivers (n = 45), purposively sampled from nine dialysis units in Australia, Hong Kong and the USA, participated in 14 focus groups. Transcripts were thematically analyzed. Results We identified six themes: lacking clarity for self-management (limited understanding of rationale behind necessary restrictions, muddled by conflicting information); PD regimen restricting flexibility and freedom (burden in budgeting time, confined to be close to home); strength with supportive relationships (gaining reassurance with practical assistance, comforted by considerate health professionals, supported by family and friends); defying constraints (reclaiming the day, undeterred by treatment, refusing to be defined by illness); regaining lost vitality (enabling physical functioning, restoring energy for life participation); and personal growth through adjustment (building resilience and enabling positive outlook, accepting the dialysis regimen). Conclusions Understanding the rationale behind lifestyle restrictions, practical assistance and family support in managing PD promoted patient empowerment, whereas being constrained in time and capacity for life participation outside the home undermined it. Education, counseling and strategies to minimize the disruption and burden of PD may enhance satisfaction and outcomes in patients requiring PD.

International audience; The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for nutrition in kidney diseases since 1999. Since the publication of the first KDOQI nutrition guideline, there has been a great accumulation of new evidence regarding the management of nutritional aspects of kidney disease and sophistication in the guidelines process. The 2020 update to the KDOQI Clinical Practice Guideline for Nutrition in CKD was developed as a joint effort with the Academy of Nutrition and Dietetics (Academy). It provides comprehensive up-to-date information on the understanding and care of patients with chronic kidney disease (CKD), especially in terms of their metabolic and nutritional milieu for the practicing clinician and allied health care workers. The guideline was expanded to include not only patients with end-stage kidney disease or advanced CKD, but also patients with stages 1-5 CKD who are not receiving dialysis and patients with a functional kidney transplant. The updated guideline statements focus on 6 primary areas: nutritional assessment, medical nutrition therapy (MNT), dietary protein and energy intake, nutritional supplementation, micronutrients, and electrolytes. The guidelines primarily cover dietary management rather than all possible nutritional interventions. The evidence data and guideline statements were evaluated using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

International audience; The Academy of Nutrition and Dietetics and the National Kidney Foundation collaborated to provide an update to the Clinical Practice Guidelines (CPG) for nutrition in chronic kidney disease (CKD). These guidelines provide a valuable update to many aspects of the nutrition care process. They include changes in the recommendations for nutrition screening and assessment, macronutrients, and targets for electrolytes and minerals. The International Society of Renal Nutrition and Metabolism assembled a special review panel of experts and evaluated these recommendations prior to public review. As one of the highlights of the CPG, the recommended dietary protein intake range for patients with diabetic kidney disease is 0.6-0.8 g/kg/day, whereas for CKD patients without diabetes it is 0.55-0.6 g/kg/day. The International Society of Renal Nutrition and Metabolism endorses the CPG with the suggestion that clinicians may consider a more streamlined target of 0.6-0.8 g/kg/day, regardless of CKD etiology, while striving to achieve intakes closer to 0.6 g/kg/day. For implementation of these guidelines, it will be important that all stakeholders work to detect kidney disease early to ensure effective primary and secondary prevention. Once identified, patients should be referred to registered dietitians or the region-specific equivalent, for individualized medical nutrition therapy to slow the progression of CKD. As we turn our attention to the new CPG, we as the renal nutrition community should come together to strengthen the evidence base by standardizing outcomes, increasing collaboration, and funding well-designed observational studies and randomized controlled trials with nutritional and dietary interventions in patients with CKD.

International audience; Cardiovascular disease (CVD) affects more than two-thirds of patients receiving hemodialysis and is the leading cause of death in this population, yet CVD outcomes are infrequently and inconsistently reported in trials in patients receiving hemodialysis. As part of the Standardised Outcomes in Nephrology-Haemodialysis (SONG-HD) initiative, we convened a consensus workshop to discuss the potential use of myocardial infarction and sudden cardiac death as core outcome measures for CVD for use in all trials in people receiving hemodialysis. Eight patients or caregivers and 46 health professionals from 15 countries discussed selection and implementation of the proposed core outcome measures. Five main themes were identified: capturing specific relevance to the hemodialysis population (acknowledging prevalence, risk, severity, unique symptomology, and pathophysiology), the dilemmas in using composite outcomes, addressing challenges in outcome definitions (establishing a common definition and addressing uncertainty in the utility of biomarkers in hemodialysis), selecting a meaningful metric for decision making (to facilitate comparison across trials), and enabling and incentivizing implementation (by ensuring that cardiologists are involved in the development and integration of the outcome measure into registries, trial design, and reporting guidelines). Based on these themes, participants supported the use of myocardial infarction and sudden cardiac death as core outcome measures of CVD to be reported in all hemodialysis trials.

International audience; Patients on long-term hemodialysis are at very high risk for cardiovascular disease but are usually excluded from clinical trials conducted in the general population or in at-risk populations. There are no universally agreed cardiovascular outcomes for trials conducted specifically in the hemodialysis population. In this review, we highlight that trials reporting cardiovascular outcomes in hemodialysis patients are usually of short duration (median 3 to 6~months) and are small (59% of trials have~

Summary: Chronic kidney disease (CKD) is a global public health burden. Dialysis is not only costly but may not be readily available in developing countries. Even in highly developed nations, many patients may prefer to defer or avoid dialysis. Thus, alternative options to dialysis therapy or to complement dialysis are needed urgently and are important objectives in CKD management that could have huge clinical and economic implications globally. The role of nutritional therapy as a strategy to slow CKD progression and uremia was discussed as early as the late 19th and early 20th century, but was only seriously explored in the 1970s. There is a revival of interest recently owing to encouraging data as well as the increase of precision medicine with an emphasis on a personalized approach to CKD management. Although part of the explanation for the inconclusive data may relate to variations in study design and dietary prescription, diversity in genetic make-up, variations in the non-nutritional management of CKD, intra-individual variations in responses to dietary and nondietary treatment, psychosocial factors, and dietary compliance issues, these all may contribute to the heterogeneous data and responses. This brings in the evolving concept of precision medicine, in which disease management should be tailored and individualized according not only to clinical manifestations but also to the genetic make-up and biologic responses to therapy, which may vary depending on genetic composition. Precision nutrition management also should take into account patient demographics, social, psychological, education, and compliance factors, which all may influence the therapeutic needs and responses to the nutritional therapy prescribed. In this review, we provide a novel concept of precision medicine in nutritional management in end-stage kidney disease with a transition to dialysis and propose how this may be the way forward for nutritional therapy in the CKD population.

Evidence-based cinical practice guidelines improve delivery of uniform care to patients with and at risk of developing kidney disease, thereby reducing disease burden and improving outcomes. These guidelines are not well-integrated into care delivery systems in most low- and middle-income countries (LMICs). The KDIGO Controversies Conference on Implementation Strategies in LMIC reviewed the current state of knowledge in order to define a road map to improve the implementation of guideline-based kidney care in LMICs. An international group of multidisciplinary experts in nephrology, epidemiology, health economics, implementation science, health systems, policy, and research identified key issues related to guideline implementation. The issues examined included the current kidney disease burden in the context of health systems in LMIC, arguments for developing policies to implement guideline-based care, innovations to improve kidney care, and the process of guideline adaptation to suit local needs. This executive summary serves as a resource to guide future work, including a pathway for adapting existing guidelines in different geographical regions.

Renin–angiotensin–aldosterone system inhibitors (RAASi) are now a standard treatment in most patients with cardiovascular disease, especially in those with heart failure (HF). The European Society of Cardiology and the American College of Cardiology/American Heart Association gave a Class IA recommendation for the use of RAASi in the treatment of Classes II–IV symptomatic HF with reduced ejection fraction (HFREF), based on their strong clinical benefits of lowering all-cause mortality and HF hospitalizations in these subjects. However, RAASi therapy or adding mineralocorticoid receptor antagonists in subjects receiving background angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may be associated with an increased risk of hyperkalemia (HK), especially in those with reduced kidney function. As a result, a significant proportion of these subjects either have RAASi dose reduced or more often discontinued when they develop HK. Discontinuation of RAASi in patients hospitalized with HFREF was associated with higher postdischarge mortality and rehospitalization rates, while optimal dosing of RAASi significantly reduced median hospital stays, outpatient visits and related costs. Thus, effective treatment is required to lower potassium level and maintain normokalemia in subjects with HF and reduced kidney disease who develop or are at risk of HK, thus enabling them to continue their RAASi therapy and maximize benefits from RAASi. In this review, we provide an up-to-date review of the prevalence and significance of HK in patients with cardiorenal syndrome, as well as their optimal management of HK with recent novel therapies.