Acute Kidney Injury
30-Day Outcomes Poor Following Discharge from the ED with AKI
Clinical Journal of the American Nephrology Society. 2017, doi: 10.2215/CJN.10431016
Rey R. Acedillo, MD, and colleagues conducted a population-based retrospective cohort study designed to examine the characteristics and outcomes of patients discharged home from an emergency department (ED) with acute kidney injury (AKI). The cohort included 6346 patients ≥40 years of age in Ontario, Canada, who were discharged from the ED with AKI defined using serum creatinine values from 2003 to 2012.
The outcomes of interest were all-cause mortality, receipt of acute dialysis, and hospitalization within 30 days following discharge from the ED. The researchers matched 4379 discharged patients to 4379 patients who were hospitalized from the ED with similar stage of AKI. They also matched 6188 discharged patients to 6188 patients who were discharged home from the ED with no AKI.
Of the 63465 patients discharged with AKI, 95% (n=6012) had stage 1 AKI, 5% (n=290) had stage 2, and 0.7% (n=44) had stage 3. Within 30 days of discharge from the ED, 2% with stage 1 AKI (n=127), 5% with stage 2 AKI (n=15), and 16% of those with stage 3 AKI (n=7), died; 0.3% (n=22) received acute dialysis; and 16% (n=1032) were hospitalized.
There was an association with lower morality among those who were discharged from the ED versus those who were hospitalized (3% vs 12%; relative risk [RR], 0.3; 95% confidence interval [CI], 0.2-0.3). There was an association with higher mortality among those discharged from the ED with a diagnosis of AKI versus those discharged without a diagnosis of AKI (2% vs 1%; RR, 1.5; 95% CI, 1.2-2.0).
In conclusion, the researchers said, “Patients discharged home from the emergency department with AKI are at risk of poor 30-day outcomes. A better understanding of care in this at-risk population is warranted, as are testing strategies to improve care.”
Nephrologists’ Role in Follow-Up Care for Patients with AKI
Advances in Chronic Kidney Disease. doi:org/10.1053/j.ackd.2017.05.008
Acute kidney injury (AKI) is associated with long-term health outcomes. When AKI is severe or persistent, it is associated with all-cause mortality, chronic kidney disease, end-stage renal disease, cardiovascular events, and reductions in quality of life.
Data from a previous study found that patients with AKI that requires dialysis therapy benefit from nephrologist care. However, other studies have demonstrated that the majority of patients with AKI do not seek care from a nephrologist, raising questions about the elements of care that may improve outcomes in survivors of AKI and which survivors would benefit from nephrologist care.
Samuel A. Silver, MD, and colleagues reviewed the evidence supporting patient follow-up after AKI. The researchers also described the current state of follow-up care and examined strategies to improve long-term outcomes among AKI patients.
Possible opportunities to improve care, according to Dr. Silver et al., include appropriate risk stratification, closer monitoring of kidney function, management of complications related to chronic kidney disease, blood pressure control, reconciliation of medication, and patient education. Nephrologists are in the best position to “lead and advocate for outpatient pathways for survivors of AKI,” the researchers said.
CHRONIC KIDNEY DISEASE
Treating Patients with Kidney Disease and HCV Infection
World Journal of Hepatology. 2019;9(19):833-839
Among patients with chronic kidney disease and end-stage renal disease, the prevalence of hepatitis C virus (HCV) infection is greater than that in the general population. Direct-acting antiviral agents have been shown to achieve higher sustained virologic response rates than protocols based on interferon therapy.
According to Marco Ladino, MD, and colleagues, when treating patients with reduced kidney function, glomerular filtration rate <30 mL/min/1.73 m2 may make therapy with some direct-acting antivirals unadvisable. However, there are now direct-acting antivirals approved by the US FDA for treatment of patients with kidney disease and reduced renal function. Those agents have been shown to be effective with sustained viral response rates comparable to the general population with good safety profiles.
“A disease that was only recently considered to be very challenging to treat in patients with kidney dysfunction is now curable with these medications,” the researchers said.
Current Best Practice for High-Quality CRRT Delivery
Advances in Chronic Kidney Diseases. doi:10.1053/j.ackd.2017.05.003
The use of continuous renal replacement therapy (CRRT) is expanding worldwide; however, despite improvements in technology, CRRT remains a complex intervention, according to Michael J. Connor, Jr, MD, and Nithin Karakala, MD.
CRRT requires the close cooperation of a multidisciplinary team, including critical care clinicians, nephrologists, nurses, pharmacists, and nutritionists. A growing evidence base supports evolving best practice and consensus to define high-quality CRRT.
Drs. Connor and Karakala reviewed the current best practice on several aspects of CRRT delivery, including optimal CRRT dose, anticoagulation, dialysis vascular access, fluid management, and drug dosing.
Treating CKD Patients with SOF-Based HCV Therapy
Clinical and Molecular Hepatology. doi:org.10.3350/chm.2016.0087
It is essential to treat chronic hepatitis C virus (HCV) infection in patients with chronic kidney disease (CKD). The availability of direct-acting antiviral (DAA) therapy has improved overall HCV cure rates, but there are few data on DDA therapy use in patients with CKD.
Hyun Phil Shin, MD, and colleagues recently conducted a retrospective analysis of all patients treated with a regimen based on sofosbuvir (SOF) from December 2013 through September 2015 at Virginia Mason Medical Center. Data on HCV G1 patients with stage 3 CKD was collected.
During the study period, 28 patients with HCV G1 and stage 3 CKD were treated with a SOF-based regimen. Of those, 21 had stage 3A CKD, defined as estimated glomerular filtration rate (eGFR) 45 to 60 mL/min/1.73 m2, and seven had stage 3B CKD, defined as eGFR 30 to 45 mL/min/1.73 m2. After 12 weeks of SOF-based therapy, the overall sustained virologic response (SVR12) rate was 85.7% (n=24/28 patients). Among patients with 3A CKD, the SVR12 rate was 81.0% (n=17/21) and among stage 3B CKD patients, the SVR12 rate was 100% (n=7/7). More than 30% reduction in eGFR was seen in 5 of the 28 patients.
In conclusion, the researchers said, “SOF-based regimens resulted in high SVR12 rates in patients with moderately impaired renal function. During therapy, HCV patients with CKD should be carefully monitored for worsening renal function.”
Education Intervention Improves Nutritional Status in Spanish Study
Journal of Renal Nutrition. doi:org/10.1053/j.jrn.2017.02.004
In patients with chronic kidney disease, protein-energy wasting (PEW) is associated with increased morbidity and mortality as well as a rapid deterioration of kidney function. According to Almudena Pérez-Torres, MS, and colleagues, there are few data available on the effect of nutrition intervention in that patient population.
The Spanish researchers conducted a 6-month, longitudinal, prospective, and interventional study designed to evaluate the efficacy and safety of a nutrition education program (NEP) in patients with non–dialysis-dependent CKD (NDD-CKD), based on the diagnostic criteria for PEW proposed by the International Society of Renal Nutrition and Metabolism. The study period was March 2008 to September 2011.
Of the 160 NDD-CKD patients who started the NEP, 128 completed it. The NEP included design of an individualized diet plan based on the patient’s nutritional status at baseline, as well as four sessions devoted to nutrition education. The primary outcome measures were changes in nutritional status (PEW) and parameters of biochemical, anthropometric, and body composition.
Following 6 months of intervention, there were decreases in levels of potassium and inflammation and improvement in lipid profile. In men, there were decreased levels of albumin and prealbumin, and in women, there were decreased levels of proteinuria. Overall, the prevalence of PEW decreased (27/3% to 10.9%); in men, the decrease was from 29.5% to 6.5% and in women, the decrease was from 25.4% to 14.9%.
“The NEP in NDD-CKD generally improved nutritional status as measured by PEW parameters, but individual poorer results indicated the need to pay special attention to female sex and low body mass index at the start of the program,” the researchers said.
Feedback on Salt Intake Improves Reduction Efforts in CKD Patients
Journal of Renal Nutrition. doi:org/10.1053/j.jrn.2017.04.005
Reduction in dietary salt intake in patients with chronic kidney disease (CKD) can help reduce hypertension, cardiovascular events, CKD progression, and mortality. However, according to Kiyotaka Uchiyama, MD, and colleagues, it is difficult to recommend salt reduction for patients whose actual sodium intake is unknown. The researchers conducted a prospective cohort study to measure dietary sodium intake in 127 adult outpatients with CKD.
The primary outcome of interest was estimated salt excretion; a secondary outcome was the urinary protein to creatinine ratio (UPCR). Patients’ spot urine-estimated salt intake was measured each time they visited the outpatient clinic. Patients were urged to achieve their salt restriction goal based on the collected data.
During a follow-up of 12 months, the median number of patient visits was seven. There was significant reduction in the estimated salt intake from 7.98 g/day to 6.77 g/day. There was also reduction in median UPCR from 0.20 to 0.10. In multiple regression analysis, there was a positive association between a reduction in UPCR and baseline UPCR and a reduction in systolic blood pressure. There was a positive correlation with a reduction in the estimated salt intake.
In conclusion, the researchers said, “Providing spot urine-estimated salt intake feedback effectively motivated CKD patients to reduce their salt intake. Spot urine-guided salt reduction may slow CKD progression through decreased urinary protein excretion.”
Outcomes and Characteristics of Deceased-Donor Kidney Offers
Clinical Journal of the American Society of Nephrology. 2017;12(8):1311-1320
Researchers led by Anne M. Huml, MD, conducted a cohort study aimed at determining outcomes of offers of deceased donor kidneys and the association of the outcomes with characteristics of waitlisted patients and organ donors. Data from the United Network of Organ Sharing database were used to examine all seven million deceases-donor adult kidney offers in the United States from 2007 to 2012 that led to eventual transplantation.
The study cohort included 178,625 patients who were waitlisted for a deceased-donor kidney transplant and 31,230 deceased donors. Kidneys from deceased donors were offered to transplantation centers a median of seven times before being accepted for transplantation. Refusals were most commonly made due to donor-related factors (age or organ quality; 3.2 million offers; 45.0%) and transplant center bypass (minimal criteria not met; 3.2 million offers, 44.0%).
Following adjustment for characteristics of waitlisted patients, organ donors, and transplantation centers, male and Hispanic waitlisted donors were less likely to have an offer accepted than female and white patients, respectively. There was wide variation across transplantation centers in the likelihood of offer acceptance.
In conclusion, the researchers said, “Transplant centers frequently refuse deceased-donor kidneys. Such refusals differ by patient and donor characteristics, may contribute to disparities in access to transplantation, and vary greatly across transplant centers.”
Induction Treatment of IL-2RAb in Pediatric Transplantation Recipients
The benefits of induction of interleukin-2-receptor antibody (IL-2RAb) in reducing the risk of acute rejection in adult recipients of kidney transplantation is well established; however, there are few data on a similar benefit in pediatric kidney transplantation recipients. In a recent study, Christine Marie Mincham, MBBS, and colleagues sought to assess the efficacy of IL-2RAb in reducing acute rejection in pediatric and adolescent recipients ≤21 years of age. Data from the Australia and New Zealand Dialysis and Transplant registry were used in the study.
Between 2001 and 2012, there were 658 eligible transplant recipients; follow-up continued for a median of 5.5 years. There was an association between the use of IL-2RAb induction and adjusted odds rations of 0.61 (95% confidence interval [CI], 0.41-0.91; P=.007) for any rejection, and 0.57 (95% CI, 0.35-0.92; P=.020) for early rejection, defined as occurring in the first 6 months following transplant.
The associations were attenuated in a propensity score analysis, but remained statistically significant. Adjusted odds ratios were 0.65 (95% CI, 0.49-0.87) for any rejection and 0.64 (95% CI, 0.44-0.93) for early rejection. There were no associations between induction, graft loss, and incident cancer.
“Induction treatment with IL-2RAb in pediatric and adolescent kidney transplant recipients is associated with at least a 40% reduction in the odds of acute rejection, independent of age, era, immunological status, and initial immunosuppression,” the researchers said.