Mammalian Cell Genotoxicity of Potable Reuse and Conventional Drinking Waters.

Potable reuse water is increasingly part of the water supply portfolio for municipalities facing water shortages, and toxicity assays can be useful for evaluating potable reuse water quality. We examined the Chinese hamster ovary cell acute direct genotoxicity of potable reuse waters contributed by disinfection byproducts (DBPs) and anthropogenic contaminants and used the local conventional drinking waters as benchmarks for evaluating potable reuse water quality. Our results showed that treatment trains based on reverse osmosis (RO) were more effective than RO-free treatment trains for reducing the genotoxicity of influent wastewaters. RO-treated reuse waters were less genotoxic than the local tap water derived from surface water, whereas reuse waters not treated by RO were similarly genotoxic as the local drinking waters when frequent replacement of granular activated carbon limited contaminant breakthrough. The genotoxicity contributed by nonvolatile, uncharacterized DBPs and anthropogenic contaminants accounted for ≥73% of the total genotoxicity. The (semi)volatile DBPs of current research interest contributed 2-27% toward the total genotoxicity, with unregulated DBPs being more important genotoxicity drivers than regulated DBPs. Our results underscore the need to look beyond known, (semi)volatile DBPs and the importance of determining whole water toxicity when assessing the quality of disinfected waters.

Persistence and free chlorine disinfection of human coronaviruses and their surrogates in water.

The coronavirus disease 2019 pandemic illustrates the importance of understanding the behavior and control of human pathogenic viruses in the environment. Exposure via water (drinking, bathing, and recreation) is a known route of transmission of viruses to humans, but the literature is relatively void of studies on the persistence of many viruses, especially coronaviruses, in water and their susceptibility to chlorine disinfection. To fill that knowledge gap, we evaluated the persistence and free chlorine disinfection of human coronavirus OC43 (HCoV-OC43) and its surrogates, murine hepatitis virus (MHV) and porcine transmissible gastroenteritis virus (TGEV), in drinking water and laboratory buffer using cell culture methods. The decay rate constants of human coronavirus and its surrogates in water varied, depending on virus and water matrix. In drinking water without disinfectant addition, MHV showed the largest decay rate constant (estimate ± standard error, 2.25 ± 0.09 day-1) followed by HCoV-OC43 (0.99 ± 0.12 day-1) and TGEV (0.65 ± 0.06 day-1), while in phosphate buffer without disinfectant addition, HCoV-OC43 (0.51 ± 0.10 day-1) had a larger decay rate constant than MHV (0.28 ± 0.03 day-1) and TGEV (0.24 ± 0.02 day-1). Upon free chlorine disinfection, the inactivation rates of coronaviruses were independent of free chlorine concentration and were not affected by water matrix, though they still varied between viruses. TGEV showed the highest susceptibility to free chlorine disinfection with the inactivation rate constant of 113.50 ± 7.50 mg-1 min-1 L, followed by MHV (81.33 ± 4.90 mg-1 min-1 L) and HCoV-OC43 (59.42 ± 4.41 mg-1 min-1 L). IMPORTANCE: This study addresses an important knowledge gap on enveloped virus persistence and disinfection in water. Results have immediate practical applications for shaping evidence-based water policies, particularly in the development of disinfection strategies for pathogenic virus control.

Pharmaceuticals, pesticides, and ultraviolet filters in wastewater discharges to San Francisco Bay as drivers of ecotoxicity.

Research in the United States evaluating ecotoxic risk to receiving waters posed by contaminants occurring in wastewater discharges typically has focused on measurements of pharmaceuticals and personal care products (PPCPs), with limited evaluations of UV filters and phenylpyrazole and neonicotinoid pesticides. In this study, concentrations of 5 representative pharmaceuticals, 11 pesticides or pesticide degradation products, and 5 ultraviolet filters were measured in 24 h composite samples of six wastewater discharges representing ∼70% of the total wastewater discharged to San Francisco Bay during the summer and fall of 2021. No significant difference was observed between concentrations measured on weekdays vs. weekends. A hydrodynamic model of San Francisco Bay was used to estimate annual average dilution factors associated with different subembayments. With and without considering dilution effects, Risk Quotients were calculated using the 90th percentile of measured concentrations in wastewater effluents and threshold concentrations associated with ecotoxicity. Risk Quotients were highest for the neonicotinoid pesticide, imidacloprid, and exceeded ecotoxicity thresholds in the lower South Bay by a factor of 2.4, even when considering dilution. Compared to commonly measured pharmaceuticals, Risk Quotients for imidacloprid were higher than those for carbamazepine, trimethoprim and diclofenac, and comparable to those for propranolol and metoprolol. Risk Quotients for the pesticide, fipronil, and the UV filter, oxybenzone, were higher than for carbamazepine. The results highlight the need to incorporate pesticides and UV filters with high Risk Quotients into studies in the United States evaluating ecotoxic risk associated with contaminants in municipal wastewater discharges.

Purified Chlorine Dioxide as an Alternative to Chlorine Disinfection to Minimize Chlorate Formation During Postharvest Produce Washing.

The washwater used to wash produce within postharvest washing facilities frequently contains high chlorine concentrations to prevent pathogen cross-contamination. To address concerns regarding the formation and uptake of chlorate (ClO3-) into produce, this study evaluated whether switching to chlorine dioxide (ClO2) could reduce chlorate concentrations within the produce. Because ClO2 exhibits lower disinfectant demand than chlorine, substantially lower concentrations can be applied. However, ClO3- can form through several pathways, particularly by reactions between ClO2 and the chlorine used to generate ClO2 via reaction with chlorite (ClO2-) or chlorine that forms when ClO2 reacts with produce. This study demonstrates that purging ClO2 from the chlorine and ClO2- mixture used for its generation through a trap containing ClO2- can scavenge chlorine, substantially reducing ClO3- concentrations in ClO2 stock solutions. Addition of low concentrations of ammonia to the produce washwater further reduced ClO3- formation by binding the chlorine produced by ClO2 reactions with produce as inactive chloramines without scavenging ClO2. While chlorate concentrations in lettuce, kale, and broccoli exceeded regulatory guidelines during treatment with chlorine, ClO3- concentrations were below regulatory guidelines for each of these vegetables when treated with ClO2 together with these two purification measures. Switching to purified ClO2 also reduced the concentrations of lipid-bound oleic acid chlorohydrins and protein-bound chlorotyrosines, which are exemplars of halogenated byproducts formed from disinfectant reactions with biomolecules within produce.

Chronic kidney disease promotes atrial fibrillation via inflammasome pathway activation.

Chronic kidney disease (CKD) is associated with a higher risk of atrial fibrillation (AF). The mechanistic link between CKD and AF remains elusive. IL-1ß, a main effector of NLR family pyrin domain-containing 3 (NLRP3) inflammasome activation, is a key modulator of conditions associated with inflammation, such as AF and CKD. Circulating IL-1ß levels were elevated in patients with CKD who had AF (versus patients with CKD in sinus rhythm). Moreover, NLRP3 activity was enhanced in atria of patients with CKD. To elucidate the role of NLRP3/IL-1ß signaling in the pathogenesis of CKD-induced AF, Nlrp3-/- and WT mice were subjected to a 2-stage subtotal nephrectomy protocol to induce CKD. Four weeks after surgery, IL-1ß levels in serum and atrial tissue were increased in WT CKD (WT-CKD) mice versus sham-operated WT (WT-sham) mice. The increased susceptibility to pacing-induced AF and the longer AF duration in WT-CKD mice were associated with an abbreviated atrial effective refractory period, enlarged atria, and atrial fibrosis. Genetic inhibition of NLRP3 in Nlrp3-/- mice or neutralizing anti-IL-1ß antibodies effectively reduced IL-1ß levels, normalized left atrial dimensions, and reduced fibrosis and the incidence of AF. These data suggest that CKD creates a substrate for AF development by activating the NLRP3 inflammasome in atria, which is associated with structural and electrical remodeling. Neutralizing IL-1ß antibodies may be beneficial in preventing CKD-induced AF.

Cytotoxicity Comparison between Drinking Water Treated by Chlorination with Postchloramination versus Granular Activated Carbon (GAC) with Postchlorination.

Granular activated carbon treatment with postchlorination (GAC/Cl2) and chlorination followed by chloramination (Cl2/NH2Cl) represent two options for utilities to reduce DBP formation in drinking water. To compare the total cytotoxicity of waters treated by a pilot-scale GAC treatment system with postchlorination (and in some instances with prechlorination upstream of GAC (i.e., (Cl2)/GAC/Cl2)) and chlorination/chloramination (Cl2/NH2Cl) at ambient and elevated Br- and I- levels and at three different GAC ages, we applied the Chinese hamster ovary (CHO) cell cytotoxicity assay to whole-water extracts in conjunction with calculations of the cytotoxicity contributed by the 33 (semi)volatile DBPs lost during extractions. At both ambient and elevated Br- and I- levels, GAC/Cl2 and Cl2/NH2Cl achieved comparable reductions in the formation of regulated trihalomethanes (THMs) and haloacetic acids (HAAs). Nonetheless, GAC/Cl2 always resulted in lower total cytotoxicity than Cl2/NH2Cl, even at up to 65% total organic carbon breakthrough. Prechlorination formed (semi)volatile DBPs that were removed by the GAC, yet there was no substantial difference in total cytotoxicity between Cl2/GAC/Cl2 and GAC/Cl2. The poorly characterized fraction of DBPs captured by the bioassay dominated the total cytotoxicity when the source water contained ambient levels of Br- and I-. When the water was spiked with Br- and I-, the known, unregulated (semi)volatile DBPs and the uncharacterized fraction of DBPs were comparable contributors to total cytotoxicity; the contributions of regulated THMs and HAAs were comparatively minor.

Making waves: Opportunities and challenges of applying far-UVC radiation in controlling micropollutants in water.

Concerns over human health risks associated with chemical contaminants (micropollutants) in drinking waters are rising due to the increased use of reclaimed water or water supplies impacted by upstream wastewater discharges. Ultraviolet (UV)-driven advanced oxidation processes (UV-AOPs) using radiation sources that emit at 254 nm have been developed as advanced treatments to degrade contaminants, while those UV-AOPs can be improved towards higher radical yields and lower byproduct formation. Several previous studies have suggested that Far-UVC radiation (200-230 nm) is a promising radiance source to drive UV-AOPs because the direct photolysis of micropollutants and production of reactive species from oxidant precursors can both be improved. In this study, we summarize from the literature the photodecay rate constants of five micropollutants by direct UV photolysis, which are higher at 222 than 254 nm. We experimentally determine the molar absorption coefficients at 222 and 254 nm of eight oxidants commonly used in water treatment and present the quantum yields of the oxidant photodecay. Our experimental results also show that the concentrations of HO·, Cl·, and ClO· generated in the UV/chlorine AOP can be increased by 5.15-, 15.76-, and 2.86-fold, respectively, by switching the UV wavelength from 254 to 222 nm. We also point out the challenges of applying Far-UVC for micropollutant abatement in water treatment, including the strong light screening effect of matrix components (e.g., carbonate, nitrate, bromide, and dissolved organic matter), the formation of byproducts via new reaction pathways, and the needs to improve the energy efficiency of the Far-UVC radiation sources.

Lysine and Arginine Reactivity and Transformation Products during Peptide Chlorination.

Chlorine reactions with peptide-bound amino acids form disinfection byproducts and contribute to pathogen inactivation by degrading protein structure and function. Peptide-bound lysine and arginine are two of the seven chlorine-reactive amino acids, but their reactions with chlorine are poorly characterized. Using N-acetylated lysine and arginine as models for peptide-bound amino acids and authentic small peptides, this study demonstrated conversion of the lysine side chain to mono- and dichloramines and the arginine side chain to mono-, di-, and trichloramines in ≤0.5 h. The lysine chloramines formed lysine nitrile and lysine aldehyde at ∼6% yield over ∼1 week. The arginine chloramines formed ornithine nitrile at ∼3% yield over ∼1 week but not the corresponding aldehyde. While researchers hypothesized that the protein aggregation observed during chlorination arises from covalent Schiff base cross-links between lysine aldehyde and lysine on different proteins, no evidence for Schiff base formation was observed. The rapid formation of chloramines and their slow decay indicate that they are more relevant than the aldehydes and nitriles to byproduct formation and pathogen inactivation over timescales relevant to drinking water distribution. Previous research has indicated that lysine chloramines are cytotoxic and genotoxic to human cells. The conversion of lysine and arginine cationic side chains to neutral chloramines should alter protein structure and function and enhance protein aggregation by hydrophobic interactions, contributing to pathogen inactivation.

Dissolved Methane Recovery and Trace Contaminant Fate Following Mainstream Anaerobic Treatment of Municipal Wastewater.

Anaerobic treatment of municipal wastewater with the staged anaerobic fluidized bed membrane bioreactor (SAF-MBR) shows promise to transform secondary wastewater treatment into an energy-positive process. However, the dissolved methane in SAF-MBR effluent needs to be recovered to reach net energy positive. To recover this methane for energy generation, an air stripping system was constructed downstream of a pilot-scale SAF-MBR facility and operated for over 80 days. The process removed 98% of effluent dissolved methane, and with the addition of intermittent disinfection recovered an average of 90% of the dissolved methane. The exit gas from air-stripping comprised 1.5-2.5% methane and could be utilized by blending with biogas produced from primary solids digestion and the SAF-MBR in an on-site combustion process. The direct energy costs for air stripping methane are <1% of the energy recoverable from the dissolved methane, not accounting for siloxane or sulfide scrubbing. Only siloxanes were observed at levels impacting combustion in this study, with 1.6 mg Si/m3 present in the blended biogas and air stripping mixture. The fate of a subset of trace organic contaminants was examined across the air stripping unit to check for aerobic degradation by methanotrophs or other opportunistic aerobes. Only 1,4-dioxane and benzotriazole showed statistically significant removal among 17 compounds screened, with 0.53 ± 0.13 and 0.34 ± 0.15 fraction removal, respectively. Our results indicate that air stripping is an energy efficient and robust technology for dissolved methane removal and onsite utilization for heat and electricity generation from anaerobic treatment of municipal wastewater.

Electrochemical Dechlorination of Municipal Wastewater Effluent.

The use of sodium bisulfite as an electron donor to quench chloramine disinfectant residuals in municipal wastewater effluents prior to discharge incurs the cost of purchasing and transporting bisulfite to the utility and increases the loading of salts to the receiving water. In this study, degradation of chloramine residuals within authentic municipal wastewater effluents was achieved within a 30 min timescale using a reductive electrochemical reactor, which supplied electrons via a stainless-steel cathode under galvanostatic conditions without an ion exchange membrane separating the cathode and anode. Application of a 0.26 mA/cm2 cathodic current density reduced chloramines to ammonia and avoided oxidation at the IrO2-coated titanium anode of chloride to chlorine or chlorate and of ammonia to nitrite or nitrate. Net chloramine production was observed at a higher current density (2 mA/cm2). Chloramine degradation rates and Coulombic efficiencies were highest and electrical energy per order (EEO) values were lowest for the 304-grade stainless-steel cathode, which contains the highest nickel content, and for a stainless-steel cathode with a high surface area. Differences in ionic strength and pH were less important. For chloraminated municipal wastewater samples, the highest Coulombic efficiency was 4.1% and the lowest EEO value was 0.08 kWh/m3. An initial comparison indicated that the electricity cost associated with this EEO value would be comparable to the cost of sodium bisulfite for areas with low electricity costs.

Muscle Atrophy in CKD: A Historical Perspective of Advancements in Its Understanding.

OBJECTIVE: This perspective reviews the seminal clinical and experimental observations that led to today's current mechanistic model of muscle protein loss (wasting) in patients with chronic kidney disease (CKD). RESULTS AND CONCLUSION: Early International Society of Renal Nutrition and Metabolism (ISRNM) meetings facilitated discussions and hypotheses about the causes of muscle wasting in CKD. It became widely recognized that wasting is common and correlated with increased risks of mortality and morbidity. Although anorexia and dietary restrictions contribute to muscle loss, several features of CKD-associated wasting cannot be explained by malnutrition alone. The protein catabolism-inducing actions of metabolic acidosis, inflammation, insulin resistance, endocrine disorders and uremic toxins were progressively identified. Continued research to understand the interactions of inflammation, anabolic resistance, mitochondrial dysfunction, exercise, and nutrition on muscle protein turnover in patients with CKD will hopefully accelerate discoveries and treatments to ameliorate muscle wasting as well as the progression of CKD.

Electrochemical Reduction of Halogenated Alkanes and Alkenes Using Activated Carbon-Based Cathodes.

Granular activated carbon (GAC) is used to sorb a broad range of halogenated contaminant classes, but spent GAC disposal is costly. Taking advantage of GAC's conductivity, this study evaluated the conversion of the GAC to cathodes for electrochemical reductive dehalogenation of 15 halogenated alkanes and alkenes exhibiting a diversity of structures (type of halogen, number of halogens, functional groups) and including contaminants of practical importance (e.g., trichloroethylene). Alkane degradation rates increased with the number of halogens and in the order: chlorine < bromine < iodine. Quantitative structure-activity relationships (QSARs) correlating experimental first-order degradation rate constants for alkanes with molecular descriptors associated with an outer-sphere one-electron transfer calculated using density functional theory indicated that correlations with molecular descriptors improved in the order: aqueous phase reduction potentials (E0,aq) < energy of the substrate's lowest unoccupied molecular orbital (ELUMO) < Marcus theory activation free energies (ΔG‡) ∼ gas-phase standard reduction free energies (ΔG0,gas). Chlorinated alkene degradation rates increased with decreasing number of chlorines, and QSAR correlations were opposite those of alkanes, indicating a different reaction mechanism. Degradation timescales ranged from 1 min to 3 h with halides as predominant products. These results suggest that the electrochemical reduction of halogenated alkanes and alkenes can be used to regenerate spent GAC.

SIRPα Mediates IGF1 Receptor in Cardiomyopathy Induced by Chronic Kidney Disease.

BACKGROUND: Chronic kidney disease (CKD) is characterized by increased myocardial mass despite near-normal blood pressure, suggesting the presence of a separate trigger. A potential driver is SIRPα (signal regulatory protein alpha)-a mediator impairing insulin signaling. The objective of this study is to assess the role of circulating SIRPα in CKD-induced adverse cardiac remodeling. METHODS: SIRPα expression was evaluated in mouse models and patients with CKD. Specifically, mutant, muscle-specific, or cardiac muscle-specific SIRPα KO (knockout) mice were examined after subtotal nephrectomy. Cardiac function was assessed by echocardiography. Metabolic responses were confirmed in cultured muscle cells or cardiomyocytes. RESULTS: We demonstrate that SIRPα regulates myocardial insulin/IGF1R (insulin growth factor-1 receptor) signaling in CKD. First, in the serum of both mice and patients, SIRPα was robustly secreted in response to CKD. Second, cardiac muscle upregulation of SIRPα was associated with impaired insulin/IGF1R signaling, myocardial dysfunction, and fibrosis. However, both global and cardiac muscle-specific SIRPα KO mice displayed improved cardiac function when compared with control mice with CKD. Third, both muscle-specific or cardiac muscle-specific SIRPα KO mice did not significantly activate fetal genes and maintained insulin/IGF1R signaling with suppressed fibrosis despite the presence of CKD. Importantly, SIRPα directly interacted with IGF1R. Next, rSIRPα (recombinant SIRPα) protein was introduced into muscle-specific SIRPα KO mice reestablishing the insulin/IGF1R signaling activity. Additionally, overexpression of SIRPα in myoblasts and cardiomyocytes impaired pAKT (phosphorylation of AKT) and insulin/IGF1R signaling. Furthermore, myotubes and cardiomyocytes, but not adipocytes treated with high glucose or cardiomyocytes treated with uremic toxins, stimulated secretion of SIRPα in culture media, suggesting these cells are the origin of circulating SIRPα in CKD. Both intracellular and extracellular SIRPα exert biologically synergistic effects impairing intracellular myocardial insulin/IGF1R signaling. CONCLUSIONS: Myokine SIRPα expression impairs insulin/IGF1R functions in cardiac muscle, affecting cardiometabolic signaling pathways. Circulating SIRPα constitutes an important readout of insulin resistance in CKD-induced cardiomyopathy.

Recovery of Clean Water and Ammonia from Domestic Wastewater: Impacts on Embodied Energy and Greenhouse Gas Emissions.

Treatment of domestic wastewater can recover valuable resources, including clean water, energy, and ammonia. Important metrics for these systems are greenhouse gas (GHG) emissions and embodied energy, both of which are location- and technology-dependent. Here, we determine the embodied energy and GHG emissions resulting from a conventional process train, and we compare them to a nonconventional process train. The conventional train assumes freshwater conveyance from a pristine source that requires energy for pumping (US average of 0.29 kWh/m3), aerobic secondary treatment with N removal as N2, and Haber-Bosch synthesis of ammonia. Overall, we find that this process train has an embodied energy of 1.02 kWh/m3 and a GHG emission of 0.77 kg-CO2eq/m3. We compare these metrics to those of a nonconventional process train that features anaerobic secondary treatment technology followed by further purification of the effluent by reverse osmosis and air stripping for ammonia recovery. This "short-cut" process train reduces embodied energy to 0.88 kWh/m3 and GHG emissions to 0.42 kg-CO2eq/m3, while offsetting demand for ammonia from the Haber-Bosch process and decreasing reliance upon water transported over long distances. Finally, to assess the potential impacts of nonconventional nitrogen removal technology, we compared the embodied energy and GHG emissions resulting from partial nitritation/anammox coupled to anaerobic secondary treatment. The resulting process train enabled a lower embodied energy but increased GHG emissions, largely due to emissions of N2O, a potent greenhouse gas.

Conversion of oxybenzone sunscreen to phototoxic glucoside conjugates by sea anemones and corals.

The reported toxicity of oxybenzone-based sunscreens to corals has raised concerns about the impacts of ecotourist-shed sunscreens on corals already weakened by global stressors. However, oxybenzone's toxicity mechanism(s) are not understood, hampering development of safer sunscreens. We found that oxybenzone caused high mortality of a sea anemone under simulated sunlight including ultraviolet (UV) radiation (290 to 370 nanometers). Although oxybenzone itself protected against UV-induced photo-oxidation, both the anemone and a mushroom coral formed oxybenzone-glucoside conjugates that were strong photo-oxidants. Algal symbionts sequestered these conjugates, and mortality correlated with conjugate concentrations in animal cytoplasm. Higher mortality in anemones that lacked symbionts suggests an enhanced risk from oxybenzone to corals bleached by rising temperatures. Because many commercial sunscreens contain structurally related chemicals, understanding metabolite phototoxicity should facilitate the development of coral-safe products.

Disinfection byproducts formed during drinking water treatment reveal an export control point for dissolved organic matter in a subalpine headwater stream.

Changes in climate, season, and vegetation can alter organic export from watersheds. While an accepted tradeoff to protect public health, disinfection processes during drinking water treatment can adversely react with organic compounds to form disinfection byproducts (DBPs). By extension, DBP monitoring can yield insights into hydrobiogeochemical dynamics within watersheds and their implications for water resource management. In this study, we analyzed temporal trends from a water treatment facility that sources water from Coal Creek in Crested Butte, Colorado. These trends revealed a long-term increase in haloacetic acid and trihalomethane formation over the period of 2005-2020. Disproportionate export of dissolved organic carbon and formation of DBPs that exceeded maximum contaminant levels were consistently recorded in association with late spring freshet. Synoptic sampling of the creek in 2020 and 2021 identified a biogeochemical hotspot for organic carbon export in the upper domain of the watershed that contained a prominent fulvic acid-like fluorescent signature. DBP formation potential analyses from this domain yielded similar ratios of regulated DBP classes to those formed at the drinking water facility. Spectrometric qualitative analyses of pre and post-reacted waters with hypochlorite indicated lignin-like and condensed hydrocarbon-like molecules were the major reactive chemical classes during chlorine-based disinfection. This study demonstrates how drinking water quality archives combined with synoptic sampling and targeted analyses can be used to identify and understand export control points for dissolved organic matter. This approach could be applied to identify and characterize analogous watersheds where seasonal or climate-associated organic matter export challenge water treatment disinfection and by extension inform watershed management and drinking water treatment.

The Kidney Diet Challenge: An Experiential Educational Experience.

Background: Health care providers who care for patients with CKD must be able to provide effective counseling about a kidney-friendly diet. Nutrition is underemphasized in medical curricula, and the kidney diet is one of the most challenging diets. We hypothesized that participation in an experiential educational program in kidney diet would result in improved knowledge of the underlying principles behind it and provide concrete examples of how to explain this diet to patients. Methods: The first part of this study was a knowledge assessment administered to all US nephrology fellows during the 2020 National Board of Medical Examiners Nephrology In-Training Examination. We later opened the assessment to a broader, global audience via social media. Respondents included trainees, practicing nephrologists, dieticians, and other health professionals. Participants self-identified willingness to participate in the second part of the study, the Kidney Diet Challenge (KDC). The 5-day challenge included daily webinars by experts in nutrition. Daily surveys captured self-reported adherence to the diet. Social media was used to engage with participants. All participants received a follow-up knowledge assessment. Results: Among the nephrology fellows (n=317), the median pretest score was 2 out of 5 (40%) questions correct, and results did not differ by year of training (P=0.31). Of the participants (n=70) who completed the 5-day challenge and responded to the post-challenge survey, the distribution of the number of correct answers improved after the KDC (median [25th, 75th percentile]: 3 [2, 3] versus 3 [2, 4]; P<0.001). Statistics from our official hashtag for this study (#kidneydietchallenge) showed that we achieved 406,241 reaches and 1,004,799 impressions, with a total of 974 posts using this hashtag. Conclusions: The KDC is an immersive, experiential educational tool that enabled a global population to learn how to counsel their patients better about adherence to a complex kidney diet.

Pathophysiological mechanisms leading to muscle loss in chronic kidney disease.

Loss of muscle proteins is a deleterious consequence of chronic kidney disease (CKD) that causes a decrease in muscle strength and function, and can lead to a reduction in quality of life and increased risk of morbidity and mortality. The effectiveness of current treatment strategies in preventing or reversing muscle protein losses is limited. The limitations largely stem from the systemic nature of diseases such as CKD, which stimulate skeletal muscle protein degradation pathways while simultaneously activating mechanisms that impair muscle protein synthesis and repair. Stimuli that initiate muscle protein loss include metabolic acidosis, insulin and IGF1 resistance, changes in hormones, cytokines, inflammatory processes and decreased appetite. A growing body of evidence suggests that signalling molecules secreted from muscle can enter the circulation and subsequently interact with recipient organs, including the kidneys, while conversely, pathological events in the kidney can adversely influence protein metabolism in skeletal muscle, demonstrating the existence of crosstalk between kidney and muscle. Together, these signals, whether direct or indirect, induce changes in the levels of regulatory and effector proteins via alterations in mRNAs, microRNAs and chromatin epigenetic responses. Advances in our understanding of the signals and processes that mediate muscle loss in CKD and other muscle wasting conditions will support the future development of therapeutic strategies to reduce muscle loss.