Appraising prediction research: a guide and meta-review on bias and applicability assessment using the Prediction model Risk Of Bias ASsessment Tool (PROBAST).

Over the past few years, a large number of prediction models have been published, often of poor methodological quality. Seemingly objective and straightforward, prediction models provide a risk estimate for the outcome of interest, usually based on readily available clinical information. Yet, using models of substandard methodological rigour, especially without external validation, may result in incorrect risk estimates and consequently misclassification. To assess and combat bias in prediction research the prediction model risk of bias assessment tool (PROBAST) was published in 2019. This risk of bias (ROB) tool includes four domains and 20 signalling questions highlighting methodological flaws, and provides guidance in assessing the applicability of the model. In this paper, the PROBAST will be discussed, along with an in-depth review of two commonly encountered pitfalls in prediction modelling that may induce bias: overfitting and composite endpoints. We illustrate the prevalence of potential bias in prediction models with a meta-review of 50 systematic reviews that used the PROBAST to appraise their included studies, thus including 1510 different studies on 2104 prediction models. All domains showed an unclear or high ROB; these results were markedly stable over time, highlighting the urgent need for attention on bias in prediction research. This article aims to do just that by providing (1) the clinician with tools to evaluate the (methodological) quality of a clinical prediction model, (2) the researcher working on a review with methods to appraise the included models, and (3) the researcher developing a model with suggestions to improve model quality.

[Nephrology: where we stand and where we should go].

In the last year, the Italian National Health Service as a whole and the Nephrology community have been severely challenged by the pandemic. It has been a dramatic stress test for the entire healthcare system, not only in Italy but worldwide. The general organization of our Nephrology units and our models of care were put under extreme pressure, and we had to quickly adopt unprecedented clinical practice recommendations and organizational models to overcome the impasse caused by the pandemic. The time has come to evaluate these new experiences, ask how we could have been better prepared and look for change. In this editorial, we outline a few proposals and suggestions for the future, weighing the information gathered in the 2018 Nephrology Census against the new organizational requirements imposed by the COVID-19 pandemic.

[The management of nephropathic patients during the Covid-19 pandemic: the experience of Ragusa].

The public emergency caused by Covid-19 has forced health services to reorganize in order to separate positive patients from negative ones. In nephrology, this reorganization involves several levels of assistance concerning hospitalizations, ambulatory care and haemodialysis. Within the Complex Unit of Nephrology in Ragusa, the distribution of nephro-dialytic resources has involved four different hospitals, hence ensuring haemodialysis services for asymptomatic and pauci-symptomatic Covid-19 patients as well as for patients in Covid-Unit, Sub-Intensive Therapy and Intensive Care Unit. In this complex context, we had to create a common protocol involving all the professionals who provide assistance in our Unit, across the different structures. We also report some encouraging data that seem to indicate the effectiveness of the protocols put in place.

Countermeasures against COVID-19: how to navigate medical practice through a nascent, evolving evidence base - a European multicentre mixed methods study.

OBJECTIVES: In a previously published Delphi exercise the European Pediatric Dialysis Working Group (EPDWG) reported widely variable counteractive responses to COVID-19 during the first week of statutory public curfews in 12 European countries with case loads of 4-680 infected patients per million. To better understand these wide variations, we assessed different factors affecting countermeasure implementation rates and applied the capability, opportunity, motivation model of behaviour to describe their determinants. DESIGN: We undertook this international mixed methods study of increased depth and breadth to obtain more complete data and to better understand the resulting complex evidence. SETTING: This study was conducted in 14 paediatric nephrology centres across 12 European countries during the COVID-19 pandemic. PARTICIPANTS: The 14 participants were paediatric nephrologists and EPDWG members from 12 European centres. MAIN OUTCOME MEASURES: 52 countermeasures clustered into eight response domains (access control, patient testing, personnel testing, personal protective equipment policy, patient cohorting, personnel cohorting, suspension of routine care, remote work) were categorised by implementation status, drivers (expert opinion, hospital regulations) and resource dependency. Governmental strictness and media attitude were independently assessed for each country and correlated with relevant countermeasure implementation factors. RESULTS: Implementation rates varied widely among response domains (median 49.5%, range 20%-71%) and centres (median 46%, range 31%-62%). Case loads were insufficient to explain response rate variability. Increasing case loads resulted in shifts from expert opinion-based to hospital regulation-based decisions to implement additional countermeasures despite increased resource dependency. Higher governmental strictness and positive media attitude towards countermeasure implementation were associated with higher implementation rates. CONCLUSIONS: COVID-19 countermeasure implementation by paediatric tertiary care centres did not reflect case loads but rather reflected heterogeneity of local rules and of perceived resources. These data highlight the need of ongoing reassessment of current practices, facilitating rapid change in 'institutional behavior' in response to emerging evidence of countermeasure efficacy.

Reflexiones sobre la necesidad de Unidades de Referencia de Nefropatología / Reflections on the need for Nephropathology Reference Units

1. La ERC tiene una elevada incidencia y prevalencia con un alto impacto sobre la calidad de vida y mortalidad de los pacientes, lo que supone un importante consumo de recursos sanitarios. 2. En un porcentaje relevante de pacientes no se dispone de un diagnóstico etiológico de la ERC, lo que limita sus posibilidades de tratamiento y curación. 3. Las acciones dirigidas a mejorar el diagnóstico permitirán favorecer un mejor conocimiento de las causas de la ERC y optimizar el tratamiento. 4. La biopsia renal, constituye el procedimiento necesario para el estudio histopatológico del tejido renal que permitirá establecer el diagnóstico, las posibilidades de tratamiento y el pronóstico del daño renal. 5. El trasplante renal constituye la mejor opción de TRS. La causa más frecuente de pérdida del injerto renal es el rechazo. La biopsia renal es el único método para establecer el tipo de rechazo e iniciar el tratamiento más adecuado. 6. La planificación del tratamiento de la enfermedad renal se establece con base en un diagnóstico preciso y este se basa en el diagnóstico histológico. La falta de una adecuada interpretación diagnóstica, bien por inexperiencia del patólogo, bien por falta de medios diagnósticos (microscopia electrónica), condiciona y limita las opciones de tratamiento en perjuicio del enfermo

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Improving hepatitis B vaccination rates for advanced chronic kidney disease patients: a quality improvement initiative.

INTRODUCTION: Chronic kidney disease (CKD) patients are vulnerable to hepatitis B, and immunization prior to end stage kidney disease is recommended to optimize seroconversion. Our institution undertook a process improvement approach to increase hepatitis B vaccination in stage 4 and 5 CKD patients. METHODS: Four strategies were utilized such as: (1) Electronic health record (EHR)-based CKD registry to identify patients, (2) EHR-based physician/nurse reminders, (3) a co-located nurse appointment for vaccine administration, and (4) information sharing and provider awareness effort. The CKD registry was utilized to identify patients with stage 4 or 5 CKD, with at least two clinic visits in the prior 2 years, who had not received the hepatitis B vaccine or did not have serologic evidence of immunity. Target monthly vaccination rate was set at 75%, based on clinic leadership, nephrologist, and nurse consensus. RESULTS: A total of 239 patients were included in the study period, from November 2018 to January 2019 (observation period) and from February 2019 to September 2019 (intervention period). Monthly vaccination rate improved from 48% in November 2018 to the target rate of 75% by the end of the intervention (August and September 2019). There was a statistically significant increase from the rate of vaccination at a unique patient level in the first month of the baseline period, compared to the last month of the intervention period (51 vs. 75% p = 0.03). CONCLUSIONS: Utilizing a nurse-led approach to hepatitis B vaccination, coupled with EHR-based tools, along with continuous monitoring of performance, helped to improve hepatitis B vaccination among CKD stage 4 and 5 patients.

Rare diseases of phosphate and calcium metabolism: Crossing glances between nephrology and endocrinology.

Rare diseases of phosphate/calcium metabolism correspond to a wide and heterogeneous spectrum of diseases. Recent knowledge in physiology and genetics has made it possible to better characterize them and to propose attractive therapeutic approaches based on the underlying pathophysiology. These diseases are often at the interface between nephrology and endocrinology. In this spirit of a multidisciplinary care, each specialty can bring its own critical point of view and its own specificities to improve patient care. The objective of this manuscript is to "read" with a nephrologist's point of view the main frameworks of diseases of phosphate/calcium metabolism, to illustrate the three crucial messages of nephro-protection sent to endocrinologists. First, calciuria must be interpreted both in absolute value (concentration hypercalciuria) and in ratio (flow hypercalciuria). Second, renal monitoring of therapies inducing hypercalciuria on kidneys with normal renal function (e.g. active vitamin D analogs or teriparatide) should be systematic. Last, hyperphosphatemia, often latent in hypoparathyroidism and pseudo-hypoparathyroidism, should be detected and at least benefit from dietary measures, in the context of Western diets rich in phosphate hidden in food additives.

Acute Kidney Injury and Special Considerations during Renal Replacement Therapy in Children with Coronavirus Disease-19: Perspective from the Critical Care Nephrology Section of the European Society of Paediatric and Neonatal Intensive Care.

Children seem to be less severely affected by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) as compared to adults. Little is known about the prevalence and pathogenesis of acute kidney injury (AKI) in children affected by SARS-CoV-2. Dehydration seems to be the most common trigger factor, and meticulous attention to fluid status is imperative. The principles of initiation, prescription, and complications related to renal replacement therapy are the same for coronavirus disease (COVID) patients as for non-COVID patients. Continuous renal replacement therapy (CRRT) remains the most common modality of treatment. When to initiate and what modality to use are dependent on the available resources. Though children are less often and less severely affected, diversion of all hospital resources to manage the adult surge might lead to limited CRRT resources. We describe how these shortages might be mitigated. Where machines are limited, one CRRT machine can be used for multiple patients, providing a limited number of hours of CRRT per day. In this case, increased exchange rates can be used to compensate for the decreased duration of CRRT. If consumables are limited, lower doses of CRRT (15-20 mL/kg/h) for 24 h may be feasible. Hypercoagulability leading to frequent filter clotting is an important issue in these children. Increased doses of unfractionated heparin, combination of heparin and regional citrate anticoagulation, or combination of prostacyclin and heparin might be used. If infusion pumps to deliver anticoagulants are limited, the administration of low-molecular-weight heparin might be considered. Alternatively in children, acute peritoneal dialysis can successfully control both fluid and metabolic disturbances. Intermittent hemodialysis can also be used in patients who are hemodynamically stable. The keys to successfully managing pediatric AKI in a pandemic are flexible use of resources, good understanding of dialysis techniques, and teamwork.

The Vanderbilt O'Brien Kidney Center.

The Vanderbilt O'Brien Kidney Center (VOKC) is one of the eight National Institutes of Health P30-funded centers in the United States. The mission of these core-based centers is to provide technical and conceptual support to enhance and facilitate research in the field of kidney diseases. The goal of the VOKC is to provide support to understand mechanisms and identify potential therapies for acute and chronic kidney disease. The services provided by the VOKC are meant to help the scientific community to have the right support and tools as well as to select the right animal model, statistical analysis, and clinical study design to perform innovative research and translate discoveries into personalized care to prevent, diagnose, and cure kidney disease. To achieve these goals, the VOKC has in place a program to foster collaborative investigation into critical questions of kidney disease, to personalize diagnosis and treatment of kidney disease, and to disseminate information about kidney disease and the benefits of VOKC services and research. The VOKC is complemented by state-of-the-art cores and an education and outreach program whose goals are to provide an educational platform to enhance the study of kidney disease, to publicize information about services available through the VOKC, and to provide information about kidney disease to patients and other interested members of the community. In this review, we highlight the major services and contributions of the VOKC.

Advancing Nephrology: Division Leaders Advise ASN.

New treatments, new understanding, and new approaches to translational research are transforming the outlook for patients with kidney diseases. A number of new initiatives dedicated to advancing the field of nephrology-from value-based care to prize competitions-will further improve outcomes of patients with kidney disease. Because of individual nephrologists and kidney organizations in the United States, such as the American Society of Nephrology, the National Kidney Foundation, and the Renal Physicians Association, and international nephrologists and organizations, such as the International Society of Nephrology and the European Renal Association-European Dialysis and Transplant Association, we are beginning to gain traction to invigorate nephrology to meet the pandemic of global kidney diseases. Recognizing the timeliness of this opportunity, the American Society of Nephrology convened a Division Chief Retreat in Dallas, Texas, in June 2019 to address five key issues: (1) asserting the value of nephrology to the health system; (2) productivity and compensation; (3) financial support of faculty's and divisions' educational efforts; (4) faculty recruitment, retention, diversity, and inclusion; and (5) ensuring that fellowship programs prepare trainees to provide high-value nephrology care and enhance attraction of trainees to nephrology. Herein, we highlight the outcomes of these discussions and recommendations to the American Society of Nephrology.

Impacto de la pandemia COVID-19 en los servicios de Nefrología españoles / Impact of the COVID-19 pandemic on Spanish Nephrology Services

La pandemia de la infección por el coronavirus tipo2 del síndrome respiratorio agudo grave o SARS-CoV-2, causante de la enfermedad por coronavirus de 2019 (COVID-19), ha precisado una transformación drástica de los hospitales y, por consiguiente, de los servicios de Nefrología de España. Desde la Sociedad Española de Nefrología se ha realizado una encuesta a los jefes de servicios de Nefrología de España abordando la reorganización de los servicios de Nefrología y la actividad en la época de mayor afectación por COVID-19. Hemos preguntado por la integración de los nefrólogos en equipos COVID-19, la actividad asistencial de hospitalización de Nefrología (ingresos programados, biopsias renales), la realización de cirugías programadas como los accesos vasculares o la implantación de catéteres peritoneales, la suspensión o no del programa de trasplante renal y la transformación de las consultas externas de Nefrología. En el trabajo actual se detallan la adaptación y la transformación de los servicios de Nefrología en la pandemia COVID-19 en España. Durante dicho periodo se han suspendido los ingresos programados en los servicios de Nefrología, la realización de cirugías/biopsias programadas y ha disminuido en más de un 75% el programa de trasplante renal. Es de interés mencionar que las consultas externas de Nefrología se han realizado mayoritariamente telefónicamente. En conclusión, la pandemia ha impactado claramente en la actividad clínica en los servicios de Nefrología españoles disminuyendo la actividad programada y los trasplantes renales y modificando la actividad en consultas externas. Un plan de transformación asistencial e implementación de telemedicina en Nefrología parece necesario y de gran utilidad en un futuro próximo

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has required a rapid and drastic transformation of hospitals, and consequently also of Spanish Nephrology Units, to respond to the critical situation. The Spanish Society of Nephrology conducted a survey directed to the Heads of Nephrology Departments in Spain that addressed the reorganisation of Nephrology departments and activity during the peak of COVID-19 pandemic. The survey has been focused on the integration of nephrologists in COVID-19 teams, nephrology inpatient care activities (elective admissions, kidney biopsies), the performance of elective surgeries such as vascular accesses or implantation of peritoneal catheters, the suspension of kidney transplantation programmes and the transformation of nephrology outpatient clinics. This work details the adaptation and transformation of nephrology services during the COVID-19 pandemic in Spain. During this period, elective admissions to Nephrology Services, elective surgeries and biopsies were suspended, and the kidney transplant programme was scaled back by more than 75%. It is worth noting that outpatient nephrology consultations were carried out largely by telephone. In conclusion, the pandemic has clearly impacted clinical activity in Spanish Nephrology departments, reducing elective activity and kidney transplants, and modifying activity in outpatient clinics. A restructuring and implementation plan in Nephrology focused on telemedicine and/or virtual medicine would seem to be both necessary and very useful in the near future

Current State of the Workforce in Nephrology.

The number of individuals with CKD and end-stage kidney disease continues to rise as the interest in nephrology as a career choice is declining among internal medicine residents. Simultaneously, the emergence of integrated healthcare delivery models encompassing multiple levels of nonphysician healthcare workers plus advanced technological capabilities offer innovative mechanisms for the delivery of optimal care for patients at risk for and suffering from CKD. Critical to the success of these models is the identification of aspects of nephrology care specific to and appropriate for each type of kidney care professional and the development of organizational structures that both define and facilitate the flow of patient care. However, several factors in addition to the declining interest in nephrology pose significant obstacles to the development of the optimal nephrology work force including gender imbalance in leadership and nonleadership positions, gender disparity in compensation, inadequate diversity in ethnicity of nephrologists, and perceptions of inadequate compensation and a poor work life balance. Recent studies suggest that some, but not all, of these challenges are being addressed, though full resolution will require creative and concerted efforts.

[Impact of the COVID-19 pandemic on Spanish Nephrology Services]. / Impacto de la pandemia COVID-19 en los servicios de Nefrología españoles.

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has required a rapid and drastic transformation of hospitals, and consequently also of Spanish Nephrology Units, to respond to the critical situation. The Spanish Society of Nephrology conducted a survey directed to the Heads of Nephrology Departments in Spain that addressed the reorganisation of Nephrology departments and activity during the peak of COVID-19 pandemic. The survey has been focused on the integration of nephrologists in COVID-19 teams, nephrology inpatient care activities (elective admissions, kidney biopsies), the performance of elective surgeries such as vascular accesses or implantation of peritoneal catheters, the suspension of kidney transplantation programmes and the transformation of nephrology outpatient clinics. This work details the adaptation and transformation of nephrology services during the COVID-19 pandemic in Spain. During this period, elective admissions to Nephrology Services, elective surgeries and biopsies were suspended, and the kidney transplant programme was scaled back by more than 75%. It is worth noting that outpatient nephrology consultations were carried out largely by telephone. In conclusion, the pandemic has clearly impacted clinical activity in Spanish Nephrology departments, reducing elective activity and kidney transplants, and modifying activity in outpatient clinics. A restructuring and implementation plan in Nephrology focused on telemedicine and/or virtual medicine would seem to be both necessary and very useful in the near future.

Covid-19 pandemic: from carnival masks to surgical masks.

Given the high transmissibility of SARS-CoV-2, COVID-19 pandemic has a huge impact on our health system. Even in developed countries, strategic resources soon become insufficient. Although people over 60 and with comorbidities are at greater risk of developing severe forms, younger people may also require precious and scarce care. Hence, the World Health Organization recommend tests - PCR and serological tests - for detecting infected people on a large scale. The most common symptoms are fever, fatigue, dry cough, anorexia, myalgia, and dyspnea, with tomographic pulmonary findings being frequent even in asymptomatic cases. The Brazilian Society of Nephrology has published guidelines for the management of hypertensive, diabetic, dialysis, and transplant patients. In its alerts, care and precautions in dialysis units are also being detailed, both for the health team and for the patients. Although important renal manifestations are not yet evident in the admission of positive cases, recent studies with renal patients and performed in nephrology services are listed here. This pandemic lead us to learn from its progress in order to face new challenges in dialysis clinics, transplant services, and intensive care services.