Chronic Kidney Disease in the Older Adult Patient with Diabetes.

Diabetes mellitus (DM) and chronic kidney disease (CKD) are common in middle aged and older adult individuals. DM may accelerate the aging process, and the age-related declines in the estimated glomerular filtration rate (eGFR) can pose a challenge to diagnosing diabetic kidney disease (DKD) using standard diagnostic criteria especially with the absence of severe albuminuria among older adults. In the presence of CKD and DM, older adult patients may need multidisciplinary care due to susceptibility to various health issues, e.g., cognitive decline, auditory or visual impairment, various comorbidities, complex medical regimens, and increased sensitivity to medication adverse effects. As a result, it can be challenging to apply recent therapeutic advancements for the general population to older adults. We review the evidence that the benefits from these newer therapies apply equally to older and younger patients with CKD and diabetes type 2 and propose a comprehensive management. This framework will address nonpharmacological measures and pharmacological management with renin angiotensin system inhibitors (RASi), sodium glucose co-transporter 2 inhibitors (SGLT2i), non-steroidal mineralocorticoids receptor antagonists (MRAs), and glucagon like peptide 1 receptor agonists (GLP1-RAs).

Rapid implementation of an emergency on-site CKRT dialysate production system during the COVID-19 pandemic.

BACKGROUND: On December 29, 2021, during the delta wave of the Coronavirus Disease 2019 (COVID-19) pandemic, the stock of premanufactured solutions used for continuous kidney replacement therapy (CKRT) at the University of New Mexico Hospital (UNMH) was nearly exhausted with no resupply anticipated due to supply chain disruptions. Within hours, a backup plan, devised and tested 18 months prior, to locally produce CKRT dialysate was implemented. This report describes the emergency implementation and outcomes of this on-site CKRT dialysate production system. METHODS: This is a single-center retrospective case series and narrative report describing and reporting the outcomes of the implementation of an on-site CKRT dialysate production system. All adults treated with locally produced CKRT dialysate in December 2021 and January 2022 at UNMH were included. CKRT dialysate was produced locally using intermittent hemodialysis machines, hemodialysis concentrate, sterile parenteral nutrition bags, and connectors made of 3-D printed biocompatible rigid material. Outcomes analyzed included dialysate testing for composition and microbiologic contamination, CKRT prescription components, patient mortality, sequential organ failure assessment (SOFA) scores, and catheter-associated bloodstream infections (CLABSIs). RESULTS: Over 13 days, 22 patients were treated with 3,645 L of locally produced dialysate with a mean dose of 20.0 mL/kg/h. Fluid sample testing at 48 h revealed appropriate electrolyte composition and endotoxin levels and bacterial colony counts at or below the lower limit of detection. No CLABSIs occurred within 7 days of exposure to locally produced dialysate. In-hospital mortality was 81.8% and 28-day mortality was 68.2%, though illness severity was high, with a mean SOFA score of 14.5. CONCLUSIONS: Though producing CKRT fluid with IHD machines is not novel, this report represents the first description of the rapid and successful implementation of a backup plan for local CKRT dialysate production at a large academic medical center in the U.S. during the COVID-19 pandemic. Though conclusions are limited by the retrospective design and limited sample size of our analysis, our experience could serve as a guide for other centers navigating similar severe supply constraints in the future.

Ambulatory blood pressure monitoring and peri-hemodialysis blood pressures in a southeast US hemodialysis unit.

AIMS: End-stage renal disease (ESRD) patients on dialysis are perceived to have difficult-to-control blood pressure (BP) and commonly treated with complex antihypertensive regimens. Our hypothesis was that peri-dialysis BP will overestimate the true burden of hypertension in these patients. SUBJECTS AND METHODS: We performed 44-h ambulatory blood pressure monitoring (ABPM) in 43 patients recruited from the University of Mississippi outpatient dialysis unit. Data collected included routine peri-dialysis blood systolic blood pressure (SBP), diastolic blood pressure (DBP), weight gain, and demographic information. We investigated whether the pre-dialysis or post-dialysis blood pressure would better correspond to the ABPM results. RESULTS: The mean age of participants was 50.5 ± 12.05 years, 95% African-American, and 44% diabetic with an average dialysis vintage of 31.1 ± 30 months. The mean SBP and DBP were 164.6/87.9 mmHg ± 22.3/15 before dialysis, 151.5/81.3 mmHg ± 24.1/13 after dialysis and 136/80.6 mmHg ± 23.5/14.7 during ABPM. There were wide limits of agreements between peri-dialysis BP and ABPM, the largest with pre-dialysis SBP (28.5 ± 16.6 mmHg) and the least with post-dialysis DBP (0.7 ± 10 mmHg). With both peri-dialysis BP measurements as explanatory variables in a linear regression model, only the post-dialysis SBP (ß 0.716; p < 0.001) but not pre-dialysis SBP (ß 0.157; p = 0.276) had a significant independent association with ABPM systolic BP. For DBP, both pre-dialysis (ß 0.543; p = 0.001) and post-dialysis (ß 0.317; p = 0.037) values retained correlation with DBP on ABPM. CONCLUSION: Peri-dialysis measurements overestimated true BP burden in this Southeastern U.S. cohort of ESRD patients. When BP readings from outside the dialysis unit are notavailable, assessment of BP control should focus pre-dialysis on DBP and post-dialysison both SBP and DBP.

Volume-related weight gain and subsequent mortality in acute renal failure patients treated with continuous renal replacement therapy.

Fluid overload is a frequent finding in critically ill patients suffering from acute kidney injury (AKI). To assess the impact of fluid overload on the mortality of AKI patients treated with continuous renal replacement therapy (CRRT), we used a registry of 81 critically ill patients with AKI initiated on CRRT assembled over an 18-month period to conduct a cross- sectional analysis using volume-related weight gain (VRWG) of > or =10% and > or =20% of body weight and oliguria (< or =20 ml/h) as the principal variables, with the primary outcome measure being mortality at 30 days. Mean Apache II scores were 27.5 +/- 6.9 with overall cohort mortality of 50.6%. Mean (+/-SD) VRWG was 8.3 +/- 9.6 kg, representing a 10.2% +/- 13.5% increase since admission. Oliguria was present in 65.4% of patients. Odds ratio (OR) for mortality on univariate analysis was increased to 2.62 [95% confidence interval (CI): 1.07-6.44] by a VRWG > or =10% and to 3.22 (95% CI: 1.23-8.45) by oliguria. VRWG > or =20% had OR of 3.98 (95% CI: 1.01-15.75; p = 0.049) for mortality. Both VRWG > or =10% (OR 2.71, p = 0.040) and oliguria (OR 3.04, p = 0.032) maintained their statistically significant association with mortality in multivariate models that included sepsis and Apache II score. In conclusion, fluid overload is an important prognostic factor for survival in critically ill AKI patients treated with CRRT. Further studies are needed to elicit mechanisms and develop appropriate interventions.

Mentoring for subspecialty training program directors: an unrecognized, unmet need?

BACKGROUND: The benefits of mentoring residents have been studied, but there is no research about mentoring new program directors. Program directors' responsibilities have become increasingly complicated, and they may not be adequately prepared for their role at the time of appointment without the benefit of mentoring that is specific to their new role. OBJECTIVE: To assess whether nephrology subspecialty program directors were specifically mentored and whether they felt prepared for the educational and administrative aspects of this role. METHODS: We conducted an electronic needs assessment survey of the nephrology subspecialty program directors through the American Society of Nephrology listserv for program directors. RESULTS: The survey response rate was 42% (58 of 139). Of the respondents, 58% did not feel adequately prepared when they first became subspecialty program directors, and only 32% reported having formal or informal mentoring for the role. Individuals who had served as associate program directors (34%) were more likely to report mentoring than those who had not (P  =  .02). Eighty percent of respondents reported that mentoring from another nephrology program director would have been beneficial during their first several years. CONCLUSIONS: This appears to be the first study specifically evaluating mentoring experiences relevant to the role of nephrology program director. As a result of this survey, the American Society of Nephrology Training Program Director Executive Committee recognized the need to provide opportunities for mentoring new nephrology program directors and formed a New Training Program Director Training and Mentoring Work Group to recommend initiatives for mentoring and training new program directors. Further investigation is needed to assess whether mentoring benefits subspecialty program directors and whether these findings can be generalized to other specialties and subspecialties.

Potential renal sequelae in survivors of hantavirus cardiopulmonary syndrome.

Although other hantaviruses are associated with renal manifestations, hantavirus cardiopulmonary syndrome (HCPS) has not been associated with such sequelae. The HCPS survivors were prospectively evaluated for renal complications. Subjects underwent yearly evaluation, laboratory studies, and 24-hour urine collection. Thirty subjects were evaluated after recovery from HCPS with the first follow-up at a median of 7.4 months after discharge. Subjects were a wide age range (18-51) but had an equal gender composition. Eighteen of 30 (60%) returned for > 1 evaluation. Half (15/30) had a 24-hour urine collection with > 150 mg of total protein and 6 had > 300 mg. Seven had a Cockcroft-Gault creatinine clearance (CrClCG) < 90 mL/min/1.73 m2 and 2 were < 60. Fifty-three percent met the definition of chronic kidney disease. Those treated with extracorporeal membrane oxygenation had less renal sequelae (P = 0.035). Our data suggest that renal sequelae may occur in HCPS. Further study of renal complications of New World hantavirus infections are needed.

C-reactive Protein among Community-Dwelling Hypertensives on Single-agent Antihypertensive Treatment.

BACKGROUND: C-reactive protein is a predictor of adverse cardiovascular outcomes. The effect of antihypertensive therapy on C-reactive protein levels is largely unknown. METHOD: We undertook a cross-sectional study of CRP levels among participants with primary hypertension on single-agent anti-hypertensive therapy in the community-based biracial Genetic Epidemiology Network of Arteriopathy cohort. Linear regression models were used to assess the association of anti-hypertensive medication class with log-transformed C-reactive protein after adjustment for age, gender, ethnicity, body mass index, smoking, diabetes, HMG-Co-A reductase inhibitor use, achieved blood pressure control (<140/90 mmHg), serum creatinine and urine albumin-to-creatinine ratios. RESULTS: There were 662 participants in the cohort taking single-agent therapy for hypertension. Median C-reactive protein levels differed across participants: 0.40 mg/dL for those on diuretics, 0.34 mg/dL on calcium channel blockers, 0.25 mg/dL on beta blockers and 0.27 mg/dL on renin-angiotensin-aldosterone system inhibitors (p<0.001). With multivariable adjustment, the group on renin-angiotensin-aldosterone system inhibitors had a 20% lower mean CRP on average than the group on diuretics (p=0.044), differences between other medication classes were not apparent. Heart rate had a strong association with C-reactive protein (p < 0.001). CONCLUSIONS: Antihypertensive medication class may influence inflammation, particularly in patients on RAAS inhibitors.

Pathogenesis and treatment of encapsulating peritoneal sclerosis: basic and translational research.

Encapsulating peritoneal sclerosis is a devastating condition in long-term peritoneal dialysis patients. Animal models have employed chemical insults to simulate its pathology and have provided insights into its pathophysiology, which appears to include inflammation, angiogenesis, and fibrosis. Monitoring of biomarkers and interruption of molecular pathways have provided potential interventions to slow or prevent the disease process. However, there remain many questions concerning the trigger that alters chronic peritoneal inflammation in peritoneal dialysis to severe sclerosis, peritoneal adhesions, and bowel obstruction. Further advances in therapy will likely require an effective means of an early diagnosis through related biomarkers, which in turn will require further advances in the understanding of the pathogenesis of this disease process.

Classification of the degree of obesity by body mass index or by deviation from ideal weight.

BACKGROUND: The purpose of this study was to compare classifications of subjects as underweight, normal weight, or obese by body mass index (BMI) and the ratio of body weight to ideal weight (W/IW). METHODS: We performed a theoretical comparison of the 2 indices. We compared classifications of the degree of obesity in 1839 women and 5914 men who were followed up in the primary care clinics of a United States federal hospital. Information was extracted from computerized records. Subjects were classified as underweight (BMI < 18.5 kg/m2, W/IW < 0.9), obese (BMI > or = 30.0 kg/m2, W/IW > or = 1.2), or normal weight (BMI, W/IW values between the cutoff values for underweight and obesity). W/IW values were computed assuming small, medium, and large skeletal frame for all. We compared the classifications of subjects as underweight, normal weight, or obese by BMI and W/IW. We used Cohen's kappa ratio to evaluate the agreement between these classifications. RESULTS: Theoretically, the cutoff values of BMI and W/IW for underweight and obesity are not in agreement. Patient data revealed substantial differences in the classifications of subjects as underweight, normal weight, or obese. Kappa ratios ranged between 0.18 (poor agreement) and 0.71 (reasonable, but not high degree of agreement). In general, kappa ratios were higher when assuming large or medium skeletal frame versus small frame. CONCLUSIONS: There are substantial discrepancies in classifying the subjects of a population as underweight, normal weight, or obese by BMI or W/IW. These discrepancies may cause confusion when 2 or more indices are used simultaneously to classify the degree of obesity.