State of the Science and Ethical Considerations for Preimplantation Genetic Testing for Monogenic Cystic Kidney Diseases and Ciliopathies.

There is a broad phenotypic spectrum of monogenic polycystic kidney diseases (PKDs). These disorders often involve cilia-related genes and lead to the development of fluid-filled cysts and eventual kidney function decline and failure. Preimplantation genetic testing for monogenic (PGT-M) disorders has moved into the clinical realm. It allows prospective parents to avoid passing on heritable diseases to their children, including monogenic PKD. The PGT-M process involves embryo generation through in vitro fertilization, with subsequent testing of embryos and selective transfer of those that do not harbor the specific disease-causing variant(s). There is a growing body of literature supporting the success of PGT-M for autosomal-dominant and autosomal-recessive PKD, although with important technical limitations in some cases. This technology can be applied to many other types of monogenic PKD and ciliopathies despite the lack of existing reports in the literature. PGT-M for monogenic PKD, like other forms of assisted reproductive technology, raises important ethical questions. When considering PGT-M for kidney diseases, as well as the potential to avoid disease in future generations, there are regulatory and ethical considerations. These include limited government regulation and unstandardized consent processes, potential technical errors, high cost and equity concerns, risks associated with pregnancy for mothers with kidney disease, and the impact on all involved in the process, including the children who were made possible with this technology.

Posthospital Multidisciplinary Care for AKI Survivors: A Feasibility Pilot.

Rationale & Objective: Innovative models are needed to address significant gaps in kidney care follow-up for acute kidney injury (AKI) survivors. Study Design: This quasi-experimental pilot study reports the feasibility of the AKI in Care Transitions (ACT) program, a multidisciplinary approach to AKI survivor care based in the primary care setting. Setting & Participants: The study included consenting adults with stage 3 AKI discharged home without dialysis. Interventions: The ACT intervention included predischarge education from nurses and coordinated postdischarge follow-up with a primary care provider and pharmacist within 14 days. ACT was implemented in phases (Usual Care, Education, ACT). Outcomes: The primary outcome was feasibility. Secondary outcomes included process and clinical outcomes. Results: In total, 46 of 110 eligible adults were enrolled. Education occurred in 18/18 and 14/15 participants in the Education and ACT groups, respectively. 30-day urine protein evaluation occurred in 15%, 28%, and 87% of the Usual Care, Education, and ACT groups, respectively (P < 0.001). Cumulative incidence of provider (primary care or nephrologist) and laboratory follow-up at 14 and 30 days was different across groups (14 days: Usual care 0%, Education 11%, ACT 73% [P < 0.01]; 30 days: 0%, 22%, and 73% [P < 0.01]). 30-day readmission rates were 23%, 44%, and 13% in the Usual Care, Education, and ACT groups, respectively (P = 0.13). Limitations: Patients were not randomly assigned to treatment groups. The sample size limited the ability to detect some differences or perform multivariable analysis. Conclusions: This study demonstrated the feasibility of multidisciplinary AKI survivor follow-up beginning in primary care. We observed a higher cumulative incidence of laboratory and provider follow-up in ACT participants. Trial Registration: ClinicalTrials.gov (NCT04505891). Plain-Language Summary: Abrupt loss of kidney function in hospitalized patients, acute kidney injury (AKI), increases the chances of long-term kidney disease and a worse health care experience for patients. One out of 3 people who experience AKI do not get the follow-up kidney care they need. We performed a pilot study to test whether a program that facilitates structured AKI follow-up in primary care called the AKI in Care Transitions (ACT) program was possible. ACT brings together the unique expertise of nurses, doctors, and pharmacists to look at the patient's kidney health plan from all angles. The study found that the ACT program was possible and led to more complete kidney care follow-up after discharge than the normal approach to care.

Impact of Aging and Cellular Senescence in the Pathophysiology of Preeclampsia.

The incidence of hypertensive disorders of pregnancy is increasing, which may be due to several factors, including an increased age at pregnancy and more comorbid health conditions during reproductive years. Preeclampsia, the most severe hypertensive disorder of pregnancy, has been associated with an increased risk of future disease, including cardiovascular and kidney diseases. Cellular senescence, the process of cell cycle arrest in response to many physiologic and maladaptive stimuli, may play an important role in the pathogenesis of preeclampsia and provide a mechanistic link to future disease. In this article, we will discuss the pathophysiology of preeclampsia, the many mechanisms of cellular senescence, evidence for the involvement of senescence in the development of preeclampsia, as well as evidence that cellular senescence may link preeclampsia to the risk of future disease. Lastly, we will explore how a better understanding of the role of cellular senescence in preeclampsia may lead to therapeutic trials. © 2023 American Physiological Society. Compr Physiol 13:5077-5114, 2023.

Development and Implementation of an Acute Kidney Injury Remote Patient Monitoring Program: Research Letter.

Acute kidney injury (AKI) survivors have a dynamic posthospital course which warrants close monitoring. Remote patient monitoring (RPM) could be used to improve quality and efficiency of AKI survivor care. Objective: The objective of this report was to describe the development and preliminary feasibility of an AKI RPM program launched in October 2021. Setting: Academic medical center. Patients: Patients enrolled in the AKI RPM program were those who experienced AKI during a hospitalization and underwent nephrology consultation. Measurements/Methods: At enrollment, patients were provided with home monitoring technology and underwent weekly laboratory assessments. Nurses evaluated the data daily and adhered to prespecified protocols for management and escalation of care if needed. Results: Twenty patients were enrolled in AKI RPM in the first 5 months. Median duration of program participation was 36 (31, 40) days. Eight patients (40%) experienced an unplanned readmission, or an emergency department visit, half (N = 4) of which were attributed to AKI and related circumstances. Of the 9 postgraduation survey respondents, all were satisfied with the RPM program and 89% would recommend RPM to other patients with similar health conditions. Limitations: Acute kidney injury RPM was made possible by the existing infrastructure in our integrated health system and the robust resources available in the Mayo Clinic Center for Digital Health. Such infrastructure may not be universally available which could limit scale and generalizability of such a program. Conclusions: Remote patient monitoring can offer a unique opportunity to bridge the care transition from hospital to home and increase access to quality care for the AKI survivors.

Les survivants d'un épisode d'insuffisance rénale aiguë (IRA) ont un parcours post-hospitalier dynamique qui justifie une surveillance étroite. La télésurveillance des patients (TSP) pourrait être employée pour améliorer la qualité et l'efficacité des soins pour les survivants de l'IRA. Objectif: L'objectif de ce rapport était de décrire le développement et la faisabilité préliminaire d'un programme de TSP-IRA (télésurveillance des patients atteints d'IRA) en octobre 2021. Cadre: Centre médical universitaire. Sujets: Les patients inscrits au programme de TSP-IRA étaient des patients qui avaient vécu un épisode d'IRA lors d'une hospitalisation et obtenu une consultation en néphrologie. Mesures et méthodologie: Au moment de l'inclusion, les patients ont reçu un dispositif de surveillance à domicile et se sont soumis à des évaluations de laboratoire hebdomadaires. Les infirmières ont évalué les données quotidiennement et ont respecté des protocoles prédéfinis pour la gestion et l'escalade des soins si nécessaire. Résultats: Vingt patients ont été inclus dans le programme de TSP-IRA au cours des cinq premiers mois. La durée médiane de participation au programme était de 36 (31, 40) jours. Huit patients (40%) ont dû être réadmis de façon non planifiée ou ont dû faire une visite aux urgences; pour la moitié d'entre eux (N = 4) en raison de l'IRA et de circonstances connexes. Parmi les neuf répondants qui ont répondu au sondage à la complétion du programme, tous se sont dits satisfaits du programme de TSP et 89% le recommanderaient à d'autres patients ayant des problèmes de santé similaires. Limites: Le programme de TSP-IRA a été rendu possible grâce à l'infrastructure existante dans notre système de santé intégré et aux ressources robustes disponibles au Mayo Clinic Center for Digital Health. Une telle infrastructure n'est peut-être pas universellement disponible, ce qui pourrait limiter l'ampleur et la généralisabilité d'un tel programme. Conclusion: La TSP peut offrir une occasion unique de faciliter la transition des soins entre l'hôpital et le domicile et d'accroître l'accès à des soins de qualité pour les survivants d'un épisode d'IRA.

Decreased Risk of Preeclampsia in Women with Inflammatory Bowel Disease on Anti-Tumor Necrosis Factor Therapy.

BACKGROUND: Evidence suggests that upregulation of tumor necrosis factor-alpha (TNF-α) plays a role in immune dysregulation in both preeclampsia and inflammatory bowel disease (IBD). AIMS: We aimed to investigate whether anti-TNF therapy during pregnancy decreases the risk of preeclampsia in women with IBD. METHODS: The study population included women with IBD and pregnancies who were followed at a tertiary care center from 2007 to 2021. Cases of preeclampsia were compared with controls with a normotensive pregnancy. Data on patient demographics, disease type and activity, pregnancy complications, and additional risk factors for preeclampsia were collected. The association between anti-TNF therapy and preeclampsia was analyzed using univariate analysis and multivariate logistic regression. RESULTS: Women with preeclampsia were more likely to have a preterm delivery (44% vs. 12%, p < 0.001). More women without preeclampsia were exposed to anti-TNF therapy during pregnancy than women with preeclampsia (55% vs. 30%, p = 0.029). The majority of women (32/44) on anti-TNF therapy, either adalimumab or infliximab, continued to have some degree of exposure during the third trimester. Though not significant, multivariate analysis showed a trend towards a protective effect of anti-TNF therapy against developing preeclampsia if exposed during the third trimester (OR 0.39; 95% CI 0.14-1.12, p = 0.08). CONCLUSIONS: In this study, anti-TNF therapy exposure was higher in IBD patients who did not develop preeclampsia than in those who did. While not significant, there was a trend towards a protective effect of anti-TNF therapy against preeclampsia if exposed during the third trimester.

Risk of Adult Hypertension in Offspring From Pregnancies Complicated by Hypertension: Population-Based Estimates.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) have been associated with an increased risk of chronic hypertension for both mothers and offspring. We sought to quantify the incidence of chronic hypertension in offspring from HDP-affected pregnancies in a large, population-based cohort study. Furthermore, we evaluate the association of HDP exposure in utero and maternal chronic hypertension in offspring. METHODS: We performed a population-based cohort study of 8755 individuals born during 1976 to 1982 to 7544 women who all resided in the same community at the time of delivery. HDP were identified using a previously validated algorithm. Diagnosis of chronic hypertension in mothers and their offspring was determined using diagnostic codes. Cox proportional hazards regression was used to assess the association between HDP and chronic hypertension. RESULTS: HDP exposure (hazard ratio, 1.50 [95% CI, 1.18-1.90]) and maternal chronic hypertension (hazard ratio, 1.73 [95% CI, 1.48-2.02]) were both associated with a significant increased risk for chronic hypertension in offspring. Both risk factors remained significantly associated with increased risk of hypertension in offspring when included together in a multivariate model. Having both exposures was associated with a 2.4-fold increase in the risk of hypertension in offspring, suggesting a synergistic additive interaction. CONCLUSIONS: HDP exposure in gestation and maternal hypertension are both independently associated with an increased risk of chronic hypertension in offspring. Our results suggest that HDP exposure in utero, in addition to maternal chronic hypertension, may lead to a greater risk for the development of hypertension in offspring.

Comprehensive Acute Kidney Injury Survivor Care: Protocol for the Randomized Acute Kidney Injury in Care Transitions Pilot Trial.

BACKGROUND: Innovative care models are needed to address gaps in kidney care follow-up among acute kidney injury (AKI) survivors. We developed the multidisciplinary AKI in Care Transitions (ACT) program, which embeds post-AKI care in patients' primary care clinic. OBJECTIVE: The objective of this randomized pilot trial is to test the feasibility and acceptability of the ACT program and study protocol, including recruitment and retention, procedures, and outcome measures. METHODS: The study will be conducted at Mayo Clinic in Rochester, Minnesota, a tertiary care center with a local primary care practice. Individuals who are included have stage 3 AKI during their hospitalization, do not require dialysis at discharge, have a local primary care provider, and are discharged to their home. Patients unable or unwilling to provide informed consent and recipients of any transplant within 100 days of enrollment are excluded. Consented patients are randomized to receive the intervention (ie, ACT program) or usual care. The ACT program intervention includes predischarge kidney health education from nurses and coordinated postdischarge laboratory monitoring (serum creatinine and urine protein assessment) and follow-up with a primary care provider and pharmacist within 14 days. The usual care group receives no specific study-related intervention, and any aspects of AKI care are at the direction of the treating team. This study will examine the feasibility of the ACT program, including recruitment, randomization and retention in a trial setting, and intervention fidelity. The feasibility and acceptability of participating in the ACT program will also be examined in qualitative interviews with patients and staff and through surveys. Qualitative interviews will be deductively and inductively coded and themes compared across data types. Observations of clinical encounters will be examined for discussion and care plans related to kidney health. Descriptive analyses will summarize quantitative measures of the feasibility and acceptability of ACT. Participants' knowledge about kidney health, quality of life, and process outcomes (eg, type and timing of laboratory assessments) will be described for both groups. Clinical outcomes (eg, unplanned rehospitalization) up to 12 months will be compared with Cox proportional hazards models. RESULTS: This study received funding from the Agency for Health Care Research and Quality on April 21, 2021, and was approved by the Institutional Review Board on December 14, 2021. As of March 14, 2023, seventeen participants each have been enrolled in the intervention and usual care groups. CONCLUSIONS: Feasible and generalizable AKI survivor care delivery models are needed to improve care processes and health outcomes. This pilot trial will test the ACT program, which uses a multidisciplinary model focused on primary care to address this gap. TRIAL REGISTRATION: ClinicalTrials.gov NCT05184894; https://www.clinicaltrials.gov/ct2/show/NCT05184894. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/48109.

Explainable Preoperative Automated Machine Learning Prediction Model for Cardiac Surgery-Associated Acute Kidney Injury.

BACKGROUND: We aimed to develop and validate an automated machine learning (autoML) prediction model for cardiac surgery-associated acute kidney injury (CSA-AKI). METHODS: Using 69 preoperative variables, we developed several models to predict post-operative AKI in adult patients undergoing cardiac surgery. Models included autoML and non-autoML types, including decision tree (DT), random forest (RF), extreme gradient boosting (XGBoost), and artificial neural network (ANN), as well as a logistic regression prediction model. We then compared model performance using area under the receiver operating characteristic curve (AUROC) and assessed model calibration using Brier score on the independent testing dataset. RESULTS: The incidence of CSA-AKI was 36%. Stacked ensemble autoML had the highest predictive performance among autoML models, and was chosen for comparison with other non-autoML and multivariable logistic regression models. The autoML had the highest AUROC (0.79), followed by RF (0.78), XGBoost (0.77), multivariable logistic regression (0.77), ANN (0.75), and DT (0.64). The autoML had comparable AUROC with RF and outperformed the other models. The autoML was well-calibrated. The Brier score for autoML, RF, DT, XGBoost, ANN, and multivariable logistic regression was 0.18, 0.18, 0.21, 0.19, 0.19, and 0.18, respectively. We applied SHAP and LIME algorithms to our autoML prediction model to extract an explanation of the variables that drive patient-specific predictions of CSA-AKI. CONCLUSION: We were able to present a preoperative autoML prediction model for CSA-AKI that provided high predictive performance that was comparable to RF and superior to other ML and multivariable logistic regression models. The novel approaches of the proposed explainable preoperative autoML prediction model for CSA-AKI may guide clinicians in advancing individualized medicine plans for patients under cardiac surgery.

Renin Production by Juxtaglomerular Cell Tumors and Clear Cell Renal Cell Carcinoma and the Role of Angiotensin Signaling Inhibitors.

OBJECTIVE: To profile juxtaglomerular cell tumors (JXG) and histologic mimics by analyzing renin expression; to identify non-JXG renin-producing tumors in The Cancer Genome Atlas (TCGA) data sets; and to define the prevalence of hypertension (HTN) and patient outcomes with angiotensin signaling inhibitor (ASI) use in tumors of interest. PATIENTS AND METHODS: Thirteen JXGs and 10 glomus tumors (GTs), a histologic mimic, were evaluated for clinicopathologic features; TCGA data were analyzed to identify non-JXG renin-overexpressing tumors. An institutional registry was queried to determine the incidence of HTN, the use of ASIs in hypertensive patients, and the impact of ASIs on outcomes including progression-free survival (PFS) in a tumor type with high renin expression (clear cell renal cell carcinoma [CC-RCC] diagnosed between January 1, 2005, and December 31, 2012). RESULTS: We found an association between renin production and HTN in JXG compared with GT. Analysis of TCGA data found that a subset of CC-RCCs overexpress renin relative to 29 other tumor types. Furthermore, analysis of our institutional registry revealed a high prevalence (64%) of HTN among 1203 patients treated with radical or partial nephrectomy for nonmetastatic CC-RCC. On multivariable Cox regression, patients with HTN treated with ASIs (34%) had improved PFS (hazard ratio, 0.76; 95% CI, 0.57 to 1.00; P=.05) compared with patients with HTN not treated with ASIs (30%). CONCLUSION: The identification of renin expression in a subset of CC-RCC may provide a biologic rationale for the high prevalence of HTN and improved PFS with ASI use in hypertensive patients with nonmetastatic CC-RCC.

Development and Feasibility of a Multidisciplinary Approach to AKI Survivorship in Care Transitions: Research Letter.

Background: Acute kidney injury (AKI) survivors are at heightened risk for poor short- and long-term health outcomes. Even among those who recover after an AKI episode, the risk for chronic kidney disease is 4- to 6-fold higher than in patients without AKI, underscoring the importance of identifying methods to improve AKI survivorship. Objective: The purpose of this report was to describe the development and feasibility of a novel multidisciplinary approach to caring for AKI survivors at care transitions (ACT). Design: Observational process improvement initiative. Setting: Single academic medical center in the United States. Patients: The studied population was adults with stage 3 AKI not discharging on dialysis who were established with a primary care provider (PCP) at our institution. Methods: An electronic health record tool was developed prior to implementation to identify AKI survivors. The ACT program encompassed engaging patients in the hospital, delivering education by nephrology-trained nurses before discharge, completing recommended laboratory testing after discharge, and conducting structured kidney-focused follow-up with a pharmacist and a PCP within 7 to 14 days after discharge. Patients could be referred for nephrology evaluation at the discretion of the PCP. Results: Preliminary data demonstrated that most AKI survivors of interest could be identified, educated, and followed up with this model. This strategy appeared feasible, scalable, and maximized the unique expertise of each member of the multidisciplinary team. Limitations: Small sample size, future assessment of process, clinical, and patient-reported outcomes needed. Conclusions: The multidisciplinary ACT workflow supported by clinical decision support was feasible and addressed gaps in existing care transition models. Team-based care delivery in primary care appears to be a mechanism to extend the capacity for kidney health monitoring for AKI survivors.

Contexte: Les patients qui survivent à un épisode d'insuffisance rénale aiguë (IRA) courent un risque plus élevé de mauvais résultats cliniques à court et à long terme. Même chez les patients qui se rétablissent, le risque de progression vers l'insuffisance rénale chronique (IRC) demeure de quatre à six fois plus élevé que chez les patients n'ayant jamais eu d'épisode d'IRA. Il est donc essentiel d'identifier des méthodes permettant d'améliorer la survie à un épisode d'IRA. Objectif: L'objectif de cette étude était de décrire l'élaboration et la faisabilité d'une nouvelle approche multidisciplinaire pour la prise en charge des survivants d'un épisode d'IRA en transition de soins (Approche multidisciplinaire en Transition de Soins­AmTS). Type d'étude: Initiative d'amélioration des processus menée par observation. Cadre: Un seul centre médical universitaire aux États-Unis. Sujets: La population étudiée était constituée d'adultes atteints d'IRA de stade 3 sans traitements de dialyse à leur sortie et qui avaient été mis en contact avec un fournisseur de soins primaires (FSP) dans l'établissement. Méthodologie: Avant la mise en œuvre de l'intervention, un outil de dossier de santé électronique a été développé pour identifier les survivants à un épisode d'IRA. Le programme de l'AmTS comprenait la participation des patients pendant leur séjour à l'hôpital, une formation donnée par des infirmières formées en néphrologie avant le congé, les tests de laboratoire recommandés après la sortie de l'hôpital et un suivi structuré axé sur la santé rénale avec un pharmacien et un FSP dans les 7 à 14 jours suivant la sortie de l'hôpital. Il a été laissé à la discrétion des FSP d'aiguiller ou non leurs patients pour une évaluation en néphrologie. Résultats: Des données préliminaires ont démontré qu'il était possible d'identifier, d'informer et d'assurer le suivi de la plupart des sujets d'intérêt (des survivants à un épisode d'IRA) avec ce modèle. Cette stratégie a semblé réalisable, évolutive et apte à optimiser l'expertise individuelle des membres de l'équipe multidisciplinaire. Limites: Faible taille de l'échantillon; une évaluation future du processus, des résultats cliniques et des résultats rapportés par les patients est nécessaire. Conclusion: Le processus de cette AmTS soutenue par une aide à la prise de décision clinique s'est avéré réalisable et a permis de combler les lacunes des modèles de transition des soins existants. Dans le contexte des soins primaires, la prestation de soins en équipe semble être un mécanisme permettant d'étendre la capacité de surveillance de la santé rénale des survivants à un épisode d'IRA.

Provider Perspectives and Clinical Outcomes with Inpatient Telenephrology.

BACKGROUND AND OBJECTIVES: Despite the dramatic increase in the provision of virtual nephrology care, only anecdotal reports of outcomes without comparators to usual care exist in the literature. This study aimed to provide objective determination of clinical noninferiority of hybrid (telenephrology plus face-to-face) versus standard (face-to-face) inpatient nephrology care. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective study compares objective outcomes in patients who received inpatient hybrid care versus standard nephrology care at two Mayo Clinic Health System community hospitals. Outcomes were then additionally compared with those patients receiving care at another Mayo Clinic Health System site where only standard care is available. Hospitalized adults who had nephrology consults from March 1, 2020 to February 28, 2021 were considered. Regression was used to assess 30-day mortality, length of hospitalization, readmissions, odds of being prescribed dialysis, and hospital transfers. Sensitivity analysis was performed using patients who had ≥50% of their care encounters via telenephrology. Structured surveys were used to understand the perspectives of non-nephrology hospital providers and telenephrologists. RESULTS: In total, 850 patients were included. Measured outcomes that included the number of hospital transfers (odds ratio, 1.19; 95% confidence interval, 0.37 to 3.82) and 30-day readmissions (odds ratio, 0.97; 95% confidence interval, 0.84 to 1.06), among others, did not differ significantly between controls and patients in the general cohort. Telenephrologists (n=11) preferred video consults (82%) to phone for communication. More than half (64%) of telenephrologists spent less time on telenephrology compared with standard care. Non-nephrology hospital providers (n=21) were very satisfied (48%) and satisfied (29%) with telenephrology response time and felt telenephrology was as safe as standard care (67%), while providing them enough information to make patient care decisions (76%). CONCLUSIONS: Outcomes for in-hospital nephrology consults were not significantly different comparing hybrid care versus standard care. Non-nephrology hospital providers and telenephrologists had favorable opinions of telenephrology and most perceived it is as safe and effective as standard care. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_04_11_CJN13441021.mp3.

Telehealth versus face-to-face visits: A comprehensive outpatient perspective-based cohort study of patients with kidney disease.

BACKGROUND: Telenephrology has become an important health care delivery modality during the COVID-19 pandemic. However, little is known about patient perspectives on the quality of care provided via telenephrology compared to face-to-face visits. We aimed to use objective data to study patients' perspectives on outpatient nephrology care received via telenephrology (phone and video) versus face-to-face visits. METHODS: We retrospectively studied adults who received care in the outpatient Nephrology & Hypertension division at Mayo Clinic, Rochester, from March to July 2020. We used a standardized survey methodology to evaluate patient satisfaction. The primary outcome was the percent of patients who responded with a score of good (4) or very good (5) on a 5-point Likert scale on survey questions that asked their perspectives on access to their nephrologist, relationship with care provider, their opinions on the telenephrology technology, and their overall assessment of the care received. Wilcoxon rank sum tests and chi-square tests were used as appropriate to compare telenephrology versus face-to-face visits. RESULTS: 3,486 of the patient encounters were face-to-face, 808 phone and 317 video visits. 443 patients responded to satisfaction surveys, and 21% of these had telenephrology encounters. Established patients made up 79.6% of telenephrology visits and 60.9% of face-to-face visits. There was no significant difference in patient perceived access to health care, satisfaction with their care provider, or overall quality of care between patients cared for via telenephrology versus face-to-face. Patient satisfaction was also equally high. CONCLUSIONS: Patient satisfaction was equally high amongst those patients seen face-to-face or via telenephrology.

Subtyping hospitalized patients with hypokalemia by machine learning consensus clustering and associated mortality risks.

BACKGROUND: Hospitalized patients with hypokalemia are heterogeneous and cluster analysis, an unsupervised machine learning methodology, may discover more precise and specific homogeneous groups within this population of interest. Our study aimed to cluster patients with hypokalemia at hospital admission using an unsupervised machine learning approach and assess the mortality risk among these distinct clusters. METHODS: We performed consensus clustering analysis based on demographic information, principal diagnoses, comorbidities and laboratory data among 4763 hospitalized adult patients with admission serum potassium ≤3.5 mEq/L. We calculated the standardized mean difference of each variable and used the cutoff of ±0.3 to identify each cluster's key features. We assessed the association of the hypokalemia cluster with hospital and 1-year mortality. RESULTS: Consensus cluster analysis identified three distinct clusters that best represented patients' baseline characteristics. Cluster 1 had 1150 (32%) patients, cluster 2 had 1344 (28%) patients and cluster 3 had 1909 (40%) patients. Based on the standardized difference, patients in cluster 1 were younger, had less comorbidity burden but higher estimated glomerular filtration rate (eGFR) and higher hemoglobin; patients in cluster 2 were older, more likely to be admitted for cardiovascular disease and had higher serum sodium and chloride levels but lower eGFR, serum bicarbonate, strong ion difference (SID) and hemoglobin, while patients in cluster 3 were older, had a greater comorbidity burden, higher serum bicarbonate and SID but lower serum sodium, chloride and eGFR. Compared with cluster 1, cluster 2 had both higher hospital and 1-year mortality, whereas cluster 3 had higher 1-year mortality but comparable hospital mortality. CONCLUSION: Our study demonstrated the use of consensus clustering analysis in the heterogeneous cohort of hospitalized hypokalemic patients to characterize their patterns of baseline clinical and laboratory data into three clinically distinct clusters with different mortality risks.

Impact of Pregnancy on GFR Decline and Kidney Histology in Kidney Transplant Recipients.

INTRODUCTION: Women with advanced kidney disease are advised to wait until after transplant to pursue pregnancy, but the impact of pregnancy on estimated glomerular filtration rate (eGFR) decline and kidney histology is unclear. METHODS: We identified a cohort of women aged 18 to 44 years at transplant from 1996 to 2014 at our 3-site program (N = 816) and determined whether they had a pregnancy >20 weeks gestation post-transplant by chart review. Outcomes included rate of change in eGFR after pregnancy, changes in kidney histology before and after pregnancy, graft failure, and 50% reduction in eGFR. RESULTS: There were 37 women with one or more pregnancies lasting longer than 20 weeks gestation post-transplant. Comparing women with and without pregnancy post-transplant, there was a significant increase in the rate of eGFR decline after pregnancy (-2.4 ml/min per 1.73 m2 per year vs. -1.9 ml/min per 1.73 m2 per year in women with no pregnancy, P < 0.001). Pregnancy did not affect the risk of graft failure, death-censored graft failure, or 50% reduction in eGFR. CONCLUSION: Pregnancy affects the rate of eGFR decline in the allograft. Postpregnancy biopsy findings revealed an increase in vascular injury, which could be a potential mechanism. We did not find a significant increase in risk of graft failure or reduction in eGFR by 50% owing to pregnancy.